Introduction: If desired, options for gender affirming treatment in transgender individuals may involve gender affirming hormonal therapy. However, the effects on fertility and testicular function are less known. Several studies have been performed with variable results regarding germ cell maturation and testicular function in this population. In order to give correct information to all transgender women, we find it important as a referral center for transgender care, to compare results of earlier studies with our population.
Material and Methods: This prospective cohort study was part of the European Network for the Investigation of Gender Incongruence (ENIGI). Ninety-seven transgender women who initiated gender affirming hormonal therapy (HT) according to the ENIGI protocol and who proceeded with gonadectomy at the Ghent University Hospital, were selected for this substudy. Testicular tissue retrieved during gonadectomy was processed and stained for four different markers. Subsequent immunohistochemical staining was performed for Melanoma-Associated antigen A4 (MAGE-A4), BOLL, CAMP Responsive Element Modulator (CREM), and acrosin. The number of MAGE-A4+ spermatogonia and primary spermatocytes were counted per square millimeter. Healthy controls were used for comparison. Serum levels of sex steroids were measured prior to surgery.
Results: An adequately suppressed testosterone level (<50 ng/dl) was found in ninety-two percent (89/97) of the participants prior to surgery. The mean time between initiation of HT and surgery was 685 days. In 88% (85/97) of the sections, MAGE-A4 staining was positive. Further immunohistochemical staining could not reveal complete spermatogenesis in any of the participants. There was a positive correlation between serum testosterone levels and number of spermatogonia counted per mm2.
Conclusion: Gender affirming hormonal therapy with cyproterone acetate plus estrogens leads to complete suppression of spermatogenesis in transgender women. Therefore, it is important to discuss sperm preservation before the start of hormone therapy, as stated in the WPATH guidelines.
21 Oct 2019
Belgian Endocrine Society