Egg harvest and T
The transgender patients were aged 14-39 years, with an average age at cycle start of 28 years. Some patients had not yet undergone any form of medical transition but planned to do so after ART.
The majority (61%) had received testosterone hormonal therapy, and a small number had undergone surgery, for example mastectomy and reconstruction, but none had undergone a hysterectomy or ovary removal (so-called “bottom” or gender-reassignment surgery).
Prior to ART, all patients taking testosterone came off the hormone on average 4 months prior to starting treatment. The mean time on testosterone before seeking ART treatment was 3.7 years and ranged from 3 months to 17 years.
“All patients had intact uterus and ovaries, and all patients had gone through puberty and had not received puberty blocking. This was required for ovarian stimulation and egg freezing,” Dr. Resetkova explained in an interview.
Researchers tracked patient records for outcomes, including oocyte yield, number of mature oocytes, total gonadotropin dose, and peak estradiol levels.
A mean of 19.9 +/– 8.7 oocytes were retrieved per cycle in the transgender cohort, compared with 15.9 +/– 9.6 in the cisgender female group; peak estradiol levels were similar between the two groups. However, the total dose of gonadotropins used was higher in the transgender group compared with the cisgender group (3,892 IU vs. 2,599 IU).
Of the 26 transgender men, 16 had egg preservation (oocyte banking) only. Seven couples had fresh or frozen embryo transfers, with all achieving live births.
Among the patients who planned for IVF with embryo transfer, two intended to carry the pregnancy themselves and the remaining five transferred embryos to their cisgender female partner.
The authors noted that many of the transgender patients who ultimately did not choose to proceed with treatment did so because of the need to stop testosterone therapy before initiating a cycle or the burden of cost.
“For many transgender patients, stopping androgen therapy can be both physically and psychologically distressing, especially because many experience the resumption of menses,” they observed.
“A logical follow-up question is whether ovarian stimulation can be done with any measure of success without the cessation of testosterone,” they noted.
“Although our findings are certainly reassuring for patients who have already initiated androgens, they were still all required to stop therapy to proceed with stimulation. This is a barrier to access that should be investigated, and if overcome may increase utilization of ART by transgender male patients,” they wrote.
Dr. Safer said that, to his knowledge, “a couple of fertility groups ... have been clear that the egg harvest could take place while the transgender men were using testosterone.”
Higher yield
The results with regard to the use of testosterone prior to ART were particularly enlightening, said Dr. Resetkova, who noted that testosterone therapy did not seem to affect ovarian stimulation.
“Before this study, we did not know if long-term testosterone use had a negative impact on egg reserve but, remarkably, testosterone does not appear to have an effect on the ovarian reserve as measured by egg count,” she noted, although she acknowledged that the “study is small.”
“In fact, in some ways, it looks like testosterone might even have a beneficial effect on egg count with a trend towards a higher number of eggs in the transmales who used it,” she added.
But this is “speculative,” she acknowledged, given the low numbers.
Reflecting on why long-term testosterone use may have shown a trend towards greater egg retrieval, Dr. Resetkova explained that the environment might be more similar to an individual with underlying elevated testosterone as seen in polycystic ovarian syndrome, and she noted these patients typically have a higher egg yield during IVF therapy.
Commenting on the higher doses of gonadotropins used in transgender patients, Dr. Resetkova suggested there could be various reasons for this, given that dosing was at the physician’s discretion, including the possibility that they knew the patient only had one chance and therefore higher doses of gonadotropins may have been administered.
Furthermore, each round of treatment is expensive. The researcher stressed, however, there was no conclusion in this respect based on their data.