Spermatogenesis present in some transgender women pre-orchiectomy

More than one-third of transgender women on gender-affirming hormone therapy have some or intact spermatogenesis when they’re about to undergo bilateral simple orchiectomy, according to research presented at the AUA annual meeting in Chicago.

It’s a finding that has important implications when urologists counsel these patients, many of whom want to preserve fertility.

Urologists play an important role in the care of transgender patients. One example: Urologists do gender-affirming bilateral simple orchiectomy-a procedure they typically offer transgender women, according to lead author Tristan Nicholson, MD, PhD, a urology resident at the University of Washington, Seattle, working with Thomas J. Walsh, MD, MS, and colleagues.

One way individuals who are born with male sex characteristics but identify as female can better align their physical appearance with their gender identity is to take a combination of hormones, said Dr. Nicholson.

“These are known as feminizing hormones, and it’s typically a combination of estradiol and an antiandrogen. That’s one step toward a physical transition,” she said. “Another step is the surgical removal of both testicles. After their testicles are removed, patients can typically reduce their estradiol dosing and often stop antiandrogen therapy.”

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Previous research suggests that up to half of transgender individuals are interested in future fertility, but historically these patients’ reproductive needs have been largely ignored, according to Dr. Nicholson.

Urologists and others caring for transgender patients should address fertility concerns and desires, and international guidelines recommend that providers and patients have the discussion, she said.

“One question that we had was how does hormone therapy affect the testicles and specifically fertility. We did a retrospective study of pathology reports at our institution for patients who had undergone this surgery,” Dr. Nicholson said.

She and colleagues examined 52 transgender women who had bilateral simple orchiectomy and assessed the presence or absence of spermatogenesis in the testis tissue that was removed at the time of surgery. All patients were on feminizing hormones, and all are living as women.

The researchers found intact spermatogenesis in 13.5%, hypo-spermatogenesis in 23.1%, and no spermatogenesis in 51.9%. In 11.5% of testis specimens, spermatogenesis wasn’t reported, according to the study.

They found no difference in estimated testis volume among testes that did versus didn’t have spermatogenesis.

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“Our finding that about a third of patients had some evidence of spermatogenesis in the testes at the time of bilateral simple orchiectomy indicates that there is at least some fertility potential in these patients. Our study did not evaluate whether there was sperm in the ejaculate or the true fertility potential, but we think this information is really important when we counsel our patients before they undergo any surgical therapy for gender transition,” Dr. Nicholson said.

Part of Dr. Nicholson’s standard counseling for transgender women who are presenting for surgery is that this is a sterilizing surgery and it’s irreversible.

“We do talk with them about the potential for fertility preservation. But this should ideally be done prior to starting feminizing hormones, which is typically before most urologists would see these patients,” she said.

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Regardless of whether these patients have started feminizing hormone therapy or not, the potential for fertility exists and patients should know that, she said.

“We think this is a starting point for a prospective study. We’re interested in evaluating how different hormone regimens affect fertility potential and the biology of the testis. We’re specifically interested in how the feminizing hormones affect the supporting cells of the testis. We’re also very interested in how this particular surgery, bilateral simple orchiectomy, may affect the quality of life of our patients, both before and after, as well as their perception of how well their physical appearance aligns with their gender identity,” Dr. Nicholson said.