Transgender and gender diverse (TGD) people are those who have a gender identity – the internal and individual sense of being male, female, both, neither or something else – that is not fully aligned with their sex assigned at birth1. Although not all TGD individuals choose to undergo medical or surgical interventions to improve physical alignment with their gender identity, those who do may face significant impairment to their fertility. Notwithstanding, data on this topic are limited in the literature2. Use of pharmacologic gender-affirming interventions, including puberty suppressants such as gonadotropin hormone releasing agonists (GnRHA) androgen receptor blockers, 5-alphareductase inhibitors and gender-affirming hormones such as estrogen or testosterone therapies, are likely to impair fertility. Gender-affirming surgeries to remove the gonads results in permanent, while hysterectomy results in absolute uterine factor infertility,4,5. The World Professional Association of Transgender Health (WPATH), amongst other medical societies, recommend that physicians counsel TGD individuals prior to their transition about the impact that hormone therapy or surgery may have on fertility and their options for fertility preservation3,6. To begin the process of fertility preservation for interested patients, a referral to a Reproductive Endocrinology and Infertility (REI) clinic for consultation with a specialist is a first important step. At the initial REI consultation, fertility preservation options as well as effects of gender-affirming treatments on fertility are discussed. Fertility preservation services differ depending on sex assigned at birth, Individuals assigned male sex at birth (AMAB) may pursue sperm banking, while first line fertility preservation option for individuals assigned female sex at birth (AFAB) is oocyte cryopreservation5,8,9.

The choice to participate in fertility preservation is a highly personal decision and may be especially fraught for TGD youth10. This choice requires the ability to weigh the personal benefit of future biological children against any procedural risk, the costs of treatment, and long-term storage of eggs or sperm. The process of fertility preservation, with its delayed treatments, may exacerbate the sensations of gender incongruence and gender dysphoria.

As demonstrated in a recent meta-analysis, a majority (49-67%) of TGD adolescents expressed a future desire to have children, with a large proportion considering adoption11. Many TGD patients (9-35.9%) did feel that having biological children was important to them11. Conversely, many TGD patients do not expect that they will be able to achieve parenthood with a biological child12.

Access to fertility counseling is limited for TGD patients who have reported interest in fertility preservation, with limited utilization (10% in one report) of fertility preservation services13. A retrospective review of patients seen in the Stanford Pediatric & Adolescent Gender Clinic from October 2015 through March 2019 found that 24% of patients accepted a REI consultation and only 6.8% of individuals underwent fertility preservation14. The most cited barrier of fertility preservation in TGD adolescents is cost and lack of insurance coverage for fertility preservation12.

Although data from the gender health clinic (GHC) at the Milton S Hershey Medical Center — a program with a wide catchment encompassing rural, urban, and suburban patients — demonstrates that TGD adolescents and adults are capable of articulating goals of care at the initiation of medical treatment, the uptake of REI consultation and fertility preservation services in rural settings has not been previously characterized15. The goal of this study was to assess desire for and utilization of fertility preservation services among TGD adolescents and young adults at the start of medical services for gender affirmation. A secondary study objective was to investigate the factors associated with completion of a fertility preservation procedure. We hypothesized that AMAB transgender participants would complete fertility preservation procedures at a higher rate than AFAB transgender patients.