Cheng Philip J, Pastuszak Alexander W, Myers Jeremy B, Goodwin Isak A, Hotaling James M
Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA.
Division of Plastic Surgery, Department of Surgery, University of Utah, Salt Lake City, UT, USA.
Transl Androl Urol. 2019 Jun;8(3):209-218. doi: 10.21037/tau.2019.05.09.
Transgender individuals who undergo gender-affirming medical or surgical therapies are at risk for infertility. Suppression of puberty with gonadotropin-releasing hormone agonist analogs (GnRHa) in the pediatric transgender patient can pause the maturation of germ cells, and thus, affect fertility potential. Testosterone therapy in transgender men can suppress ovulation and alter ovarian histology, while estrogen therapy in transgender women can lead to impaired spermatogenesis and testicular atrophy. The effect of hormone therapy on fertility is potentially reversible, but the extent is unclear. Gender-affirming surgery (GAS) that includes hysterectomy and oophorectomy in transmen or orchiectomy in transwomen results in permanent sterility. It is recommended that clinicians counsel transgender patients on fertility preservation (FP) options prior to initiation of gender-affirming therapy. Transmen can choose to undergo cryopreservation of oocytes or embryos, which requires hormonal stimulation for egg retrieval. Uterus preservation allows transmen to gestate if desired. For transwomen, the option for FP is cryopreservation of sperm either through masturbation or testicular sperm extraction. Experimental and future options may include cryopreservation and maturation of ovarian or testicular tissue, which could provide prepubertal transgender youth an option for FP since they lack mature gametes. Successful uterus transplantation with subsequent live birth is a new medical breakthrough for cisgender women with uterus factor infertility. Although it has not yet been performed in transgender women, uterus transplantation is a potential solution for those who wish to get pregnant. The transgender population faces many barriers to care, such as provider discrimination, lack of information, legal barriers, scarcity of fertility centers, financial burden, and emotional cost. Further research is necessary to investigate the feasibility of experimental FP options, provide better evidence-based information to clinicians and transgender patients alike, and to improve access to and quality of reproductive services for the transgender population.
接受性别确认医学或手术治疗的跨性别者存在不孕风险。儿科跨性别患者使用促性腺激素释放激素激动剂类似物（GnRHa）抑制青春期可使生殖细胞成熟暂停，从而影响生育潜力。跨性别男性接受睾酮治疗可抑制排卵并改变卵巢组织学，而跨性别女性接受雌激素治疗可导致精子发生受损和睾丸萎缩。激素治疗对生育的影响可能是可逆的，但程度尚不清楚。性别确认手术（GAS），包括跨性别男性的子宫切除术和卵巢切除术或跨性别女性的睾丸切除术，会导致永久性不育。建议临床医生在开始性别确认治疗前，就生育力保存（FP）选项为跨性别患者提供咨询。跨性别男性可以选择进行卵母细胞或胚胎冷冻保存，这需要进行激素刺激以获取卵子。保留子宫可使有意愿的跨性别男性怀孕。对于跨性别女性，FP的选择是通过手淫或睾丸精子提取进行精子冷冻保存。实验性和未来的选择可能包括卵巢或睾丸组织的冷冻保存和成熟，这可以为青春期前的跨性别青少年提供FP选项，因为他们缺乏成熟的配子。成功的子宫移植并随后活产是子宫因素不孕的顺性别女性的一项新医学突破。虽然尚未在跨性别女性中进行，但子宫移植是那些希望怀孕的人的一种潜在解决方案。跨性别群体在获得医疗服务方面面临许多障碍，如提供者歧视、信息缺乏、法律障碍、生育中心稀缺、经济负担和情感成本。有必要进行进一步研究，以调查实验性FP选项的可行性，为临床医生和跨性别患者提供更好的循证信息，并改善跨性别群体获得生殖服务的机会和服务质量。
