In people with gender incongruence/gender dysphoria who decide to undergo gender affirming surgery, which can include bilateral orchiectomy (testis removal) and hysterectomy/ovariectomy (uterus and ovaries removal), fertility gets irreversibly compromised. Furthermore gender affirming hormonal therapy can compromise fertility and reproductive capability. Even if more studies are needed to better clarify this point, a protracted therapy with testosterone or oestrogens may irreversibly compromise both spermatogenesis and ovulation, even after therapy is stopped. In particular, several scientific societies including American College of Obstetrics and Gynecology (ACOG), American Society of Reproductive Medicine (ASRM) and Endocrine Society, recommend to adequately inform and counsel young people before starting gender affirming hormonal treatment or undergoing surgery.

Sperm cryopreservation can be proposed to assigned male at birth transgender people (cryopreservation is a lab procedure in which cells or tissues are conserved at very low temperatures). Sperm cryopreservation should then be done before starting of the hormonal therapy with oestrogens and/or antiandrogens, in order to avoid potential consequences of the latter on fertility. Anyway, it is possible to perform this procedure also after the initiation of the hormonal therapy; in this case it is necessary to stop it for at least three months. The quality of the preserved biological material could anyway be compromised by the previous therapy. Sperm collection can be done through masturbation within dedicated structures where a sperm bank is available. If masturbation is source of intense discomfort or for any other reason is not feasible, sperm can be collected after a vibratory stimulation on the penis surface (vibromassage). Alternatively, an aspiration, through a needle, of sperm cells from the testicle or a sperm cells surgical extraction via a small incision on the testis can be performed. Finally, reproductive potential can be preserved through the cryopreservation of testicular tissue obtained at the time of the bilateral orchiectomy.

In regards to assigned female at birth transgender people, oocytes cryopreservation can be proposed. Such procedure needs frequent gynecological checks and an hormonal treatment that stimulates feminine hormones production, in order to increase oocytes count. The latter will be subsequently extracted transvaginally (through a needle that through the vagina reaches ovaries) under sedation (the presence of an anesthetist is then necessary). Another possibility is cryopreservation of the ovarian tissue which requires the surgery; the ovarian tissue can be obtained during hysteroannessiectomy   or even separately from this. Preliminary studies suggest that these procedures’ success is satisfactory even when testosterone therapy has already started. From the withdrawn and cryopreserved ovarian tissue it is theoretically possible to induce oocytes maturation. This procedure as of today has been demonstrated effective only after the transplantation of ovarian tissue on the patient’s arm or pelvis; this implies anyway female hormones production restart, which can be source of psychological distress.

Cryopreserved gametes (oocytes or sperm) can be used with the help of assisted reproduction techniques in order to induce a pregnancy. Regarding consent to treatments for people who undergo gender-affirming procedures, a particular attention must be dedicated to fertility preservation. It is fundamental to be aware  that female gametes cryopreservation (oocytes) needs a medical procedure (including an hormonal stimulation), which, as such, can be associated with health risks. It needs also to be pointed out that the Italian law (Legge n. 40/2004) allows access to Assisted Reproductive Technologies (ART) only to married or cohabitant couples with different gender. This means that individuals and homosexual couples cannot receive this treatment.

Bibliography 

De Roo C, Lierman S, Tilleman K, et al. Ovarian tissue cryopreservation in female-to-male transgender people: insights into ovarian histology and physiology after prolonged androgen treatment. Reprod Biomed Online. 2017;34(6):557-66.

De Roo C, Tilleman K, T'Sjoen G, et al. Fertility options in transgender people. Int Rev Psychiatry. 2016; 28(1):112-9.

Martinez F; International Society for Fertility Preservation–ESHRE–ASRM Expert Working Group. Update on fertility preservation from the Barcelona International Society for Fertility Preservation-ESHRE-ASRM 2015 expert meeting: indications, results and future perspectives. Fertil Steril. 2017; 108(3):407-415.

Mattawanon N, Spencer JB, Schirmer DA 3rd, Tangpricha V, et al. Fertility preservation options in transgender people: A review. Rev Endocr Metab Disord. 2018;19(3):231-242.