Understudied and Under‐Reported: Fertility Issues in Transgender Youth—A Narrative Review

Abstract

I nfertility, or the concern for infertility, has been shown in many studies to be associated with psychosocial distress among affected adults, and may result from numerous genetic or pediatric conditions and treatments. Fertility preservation technologies have been developed to expand future parenthood options for youth and others at risk for infertility. Although these rapid technological advances have facilitated improvements in clinical care, significant knowledge gaps exist with regard to who is at risk and could benefit from fertility preservation technologies, which methods have adequate evidence to support integration in clinical care, and how to optimize access to, and utilization of, established options. Much of the work in this area has been conducted in pediatric oncology, as chemotherapy and radiation are known to impair gonadal function, and research has informed dosespecific risk assessments for many of the most common treatments. An important limitation of this research is that sexual orientation or gender identity are rarely assessed within study populations, and 1 study has suggested perspectives on parenthood may be different in those within the lesbian, gay, bisexual, transgender, or questioning (LGBTQ) population compared with non-LGBTQ identified cancer survivors. Organizations such as the American Academy of Pediatrics, American Society of Pediatric Oncology, and American Society for Reproductive Medicine have published guidelines urging providers to counsel youth with cancer about their infertility risk; discuss fertility preservation options, distinguishing those that are established (sperm, oocyte, and embryo cryopreservation), from those that are experimental (testicular and ovarian tissue cryopreservation); and to document these discussions and referrals in the medical record. Using this framework, increasing attention has been paid to other populations at risk for infertility, including the rapidly expanding transgender population seeking hormonal therapies. Though little is known about long-term fertility outcomes after these treatments, the American Society for Reproductive Medicine Endocrine Society, and World Professional Association for Transgender Health recently published guidelines highlighting the need to discuss infertility risk and fertility preservation options with youth prior to hormonal interventions. The purpose of the narrative review was to identify what is known about fertility implications related to hormonal treatments in youth (estrogen, testosterone, and gonadotropin-releasing hormone [GnRH] agonists), fertility preservation options in pediatrics, and transgender youths’ attitudes toward biological parenthood. This article will report on the results of the narrative review; discuss appropriate fertility preservation options for youth with gender dysphoria; and propose medical and psychological recommendations for best practices related to fertility counseling and intervention, based on the known literature to date. A literature search was conducted to inform this narrative review, based on applicable PRISMA items. We searched PubMed, Google Scholar, Medline, Web of Science, and PsycInfo databases for English-language studies (no date restrictions on publication year), with the following search terms: transgender, gender identity disorder, gender dysphoria, transsexual, reproductive health, fertility, fertility preservation, ovarian stimulation, prepubertal ovaries, testes, gender-affirming hormones, cross-sex hormones, pubertal suppression, GnRH agonist, testosterone, estrogen, antimullerian hormone (AMH), adolescent, parent, pregnancy, and attitudes. Search results included a variety of publication types including guidelines, commentaries, case series, qualitative, and quantitative research. We also manually searched the references of each selected article. All authors agreed upon which articles to include. Given the dearth of research in this area, inclusion was broad and based on assessment of relevance of content, utility of findings, and appraisal of study methodology and reporting. Human studies were prioritized for inclusion, though relevant animal studies were also included as they related to hormone functioning and fertility.