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Reproductive Medicine for the Transgender Patient: Q&A with Dr. Jacqueline Gutmann

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Fertility and family planning are life-changing considerations for transgender people, just as significant as these decisions can be for cisgender people. Increasingly, transgender patients are seeking physician guidance in reproductive endocrinology in order to build families in ways strikingly similar to their cisgender counterparts, but there are unique aspects of their care that physicians and their teams must take into account. 

Doximity consults with Dr. Jacqueline Gutmann, Reproductive Endocrinologist and Fertility Specialist with IV-IRMA Global and Clinical Associate Professor at Thomas Jefferson University Hospitals, who recently spoke on the topic at the Philadelphia Trans Wellness Conference 2019.

Doximity: Banking egg cells and sperm cells: What’s the gist of this process for a transgender patient?

Dr. Jacqueline Gutmann: Ultimately there’s not a ton of data with respect to what happens to eggs or sperm after medical transition. Certainly, lack of exposure to exogenous hormones is ideal. That being said, there is some data that looks at eggs after a year of testosterone, and suggests that the eggs actually look okay. Our own experience, though not extensive (and the literature certainly doesn’t have anything extensive) suggests that even after six, seven, eight years of testosterone, we’ve been able to have men actually achieve pregnancy, and we’ve been able to have men freeze their eggs or make embryos. So having [been on] testosterone does not preclude obtaining eggs or achieving a pregnancy. The same holds true for sperm, though it appears that the sperm don’t recover perhaps as well.

Dox: In pediatric patients who may be starting hormone replacement therapy (HRT) at an early age, is this something you see as being a worthwhile conversation with adolescents and teenagers regarding their reproductive health?

JG: That’s extraordinarily complicated, unfortunately. We are not particularly expert at this time at taking prepubertal tissue and freezing it and ultimately being able to use it. The best case scenario is that a young person — a child, really — or a very young adolescent who has not entered puberty goes on hormone blockers to block their birth-sex puberty, and then ultimately goes on hormones that are gender-affirming. So, [ideally], you take out a piece of ovary or a piece of testicle and freeze the tissue before they go through puberty so that they never have to go through their birth-sex puberty. But we’re not great at working with those cells yet. Certainly, if an adolescent has gone through puberty, that would be the time to have the discussion, before they start hormones. In the ideal world, it happens before they go through puberty, but again, from a scientific standpoint, the technology is not fully there, and that is considered at this point to be experimental.

Dox: Do you think with younger patients that you see, there needs to be a more conscious effort to talk to trans patients about contraceptives, especially in regard to what they know is possible after hormone therapy?

JG: One of the things I touched on in my lecture is that I work to get people pregnant — that’s my job. But, in fact, we have a responsibility to let individuals know that in the absence of contraception, they can get pregnant. There’s ample literature looking at trans men who have achieved pregnancy — now typically, that’s in the setting of not having used hormones at all, or using hormones intermittently — but yes, absolutely, [trans] people need to plan for, or protect against, unplanned pregnancy like anybody else, if they are sexually active such that a pregnancy could be achieved. 

Dox: Would you say that that’s a comparable concern for trans women as well?

JG: There may be some issue with achieving and maintaining an erection. There is definitely data suggesting that their sperm is negatively impacted. When we’re worried about pregnancy, I think we need to think about the people who are less compliant with their medication regimen. And, in all honesty, when you get pregnant, you know that you are pregnant. When you get somebody pregnant, you may or may not know that. And that holds true for cis or trans. That is a bias in terms of collecting the data.

Dox: What do you think other clinicians may be apprehensive about in terms of advising transgender patients about reproductive health?

JG: I’m in the middle of Philadelphia, and I don’t think that’s at all an issue here. And I certainly don’t think it’s an issue for any of my personal colleagues, regardless of where they live. Is it possible that there are reproductive endocrinologists in the country who are not comfortable with this? I guess, but I honestly don’t know. My job is to help people build their families, and that is where my commitment lies — and I would hope the same holds true for all of us.

Dox: What advice would you give to your colleagues — care management teams of physicians, NPs, PAs, and others — to provide the best care possible for your trans patients?

JG: The recommendations are from WPATH [World Professional Organization for Transgender Health] and the American Society for Reproductive Medicine, and the American Endocrine Society, and each of these organizations have guidelines that are established in terms of recommending that fertility is discussed with individuals who are considering transitioning. So, theoretically, everybody who is in that situation should be speaking with their provider about freezing eggs, freezing sperm, what the different options might be, and what those processes would entail. It’s not the patient’s responsibility to ask those questions, it’s the provider’s responsibility to ensure that that is something that is discussed. Unfortunately, it doesn’t happen as often as it should, and there’s ample data that supports that. But the recommendation is, in fact, that all individuals receive that counsel.

View the Doximity Collection on Transgender Health in Endocrinology

View the Doximity Collection on Transgender Health in Urology & Gynecology

Interview conducted by Kyler Koons, Doximity Editor.

Image by Panchenko Vladimir / Shutterstock.

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