Schneider Florian Josef, Scheffer Bettina, Kliesch Sabine, Cremers Jann-Frederik
Center for Reproductive Medicine and Andrology, Department of Clinical and Surgical Andrology, University Hospital Münster, Munster, Germany.
University Hospital Münster, Center of Transgender Health, Münster, Germany.
Aktuelle Urol. 2025 Apr;56(2):150-157. doi: 10.1055/a-2490-4059. Epub 2025 Feb 5.
According to current guidelines, patients with gender incongruence seeking treatment must receive appropriate education and counselling from healthcare professionals on the various options for fertility preservation. Gender-affirming hormonal treatment leads in persons assigned male at birth to a reduction of LH, FSH, and testosterone, which is associated with a regression of spermatogenesis (up to complete loss) and subsequent testicular atrophy. Individuals starting gender-affirming hormonal treatment after having experienced male puberty may provide an ejaculate sample for sperm cryopreservation. In cases where no sperm is detected in the ejaculate due to gender-affirming hormonal treatment, or if the sampling of ejaculate is no longer possible or causes excessive psychological distress, (microsurgical) testicular sperm extraction [(m)TESE] should be offered. Electroejaculation under anaesthesia is rarely effective, as hormonal treatment impairs spermatogenesis. Similarly, microsurgical epididymal sperm aspiration (MESA) is not typically effective for the same reason. If adolescents with gender incongruence undergo puberty blockade and/or gender-affirming hormonal treatment at an early stage of puberty (possible from Tanner stage 2), this prevents the maturation of spermatogonial stem cells into mature sperm. Puberty blockade with GnRH reduces the secretion of LH and FSH by the pituitary gland, which, in turn, suppresses the production of testosterone in the Leydig cells and the stimulation of spermatogenesis in the testicles. In such cases, the cryopreservation of spermatogonial stem cells is possible, similar to how it is offered in some countries for peri-pubertal patients prior to necessary germ cell-toxic treatments. In Germany, there is a relevant network (Androprotect), which was founded in Münster in 2012. Via Androprotect, this procedure is also offered for adolescent individuals with gender incongruence. This approach is considered experimental as no established treatment exists for the refertilisation of affected adults at a later stage, although several procedures for in-vitro sperm maturation and tissue transplantation are under development. The care of patients with gender incongruence should include individual counselling provided by experienced professionals in an interdisciplinary treatment team. Individual treatment approaches should be offered to facilitate shared decision-making (based on informed consent) to ensure that each individual can make an informed and appropriate decision regarding fertility preservation.
根据现行指南，寻求治疗的性别认同障碍患者必须接受医疗保健专业人员就各种生育力保存选项提供的适当教育和咨询。对于出生时被指定为男性的人，性别肯定激素治疗会导致促黄体生成素（LH）、促卵泡生成素（FSH）和睾酮水平降低，这与精子发生的消退（直至完全丧失）以及随后的睾丸萎缩有关。在经历男性青春期后开始接受性别肯定激素治疗的个体可以提供射精样本用于精子冷冻保存。如果由于性别肯定激素治疗在射精中未检测到精子，或者如果不再可能采集射精样本或导致过度的心理困扰，则应提供（显微外科）睾丸精子提取术[（m）TESE]。麻醉下的电射精很少有效，因为激素治疗会损害精子发生。同样，出于相同原因，显微外科附睾精子抽吸术（MESA）通常也无效。如果性别认同障碍的青少年在青春期早期（可能从坦纳2期开始）接受青春期阻断和/或性别肯定激素治疗，这会阻止精原干细胞成熟为成熟精子。使用促性腺激素释放激素（GnRH）进行青春期阻断会减少垂体分泌的LH和FSH，这反过来又会抑制睾丸间质细胞中睾酮的产生以及睾丸中精子发生的刺激。在这种情况下，可以进行精原干细胞的冷冻保存，类似于一些国家在必要的生殖细胞毒性治疗之前为青春期前患者提供的方式。在德国，有一个相关网络（Androprotect），它于2012年在明斯特成立。通过Androprotect，也为有性别认同障碍的青少年提供这种程序。这种方法被认为是实验性的，因为目前尚无针对受影响成年人后期恢复生育能力的确立治疗方法，尽管几种体外精子成熟和组织移植程序正在研发中。对性别认同障碍患者的护理应包括由跨学科治疗团队中经验丰富的专业人员提供的个性化咨询。应提供个性化的治疗方法，以促进共同决策（基于知情同意），确保每个人都能就生育力保存做出明智和适当的决定。
