New technique may increase trans women’s chances of having children

Claire always knew she wanted to start a family. But as a transgender woman who just turned 41, she also knew it could be difficult.

Claire and her partner discussed having a baby together and, if possible, wanted to use their partner’s sperm and egg. But Claire, who spoke on condition of anonymity to protect the family’s privacy, had been on estrogen therapy for 18 years, and the chances of doctors finding any viable sperm were slim.

At the same time, Claire was scheduled to have her gender confirmation surgery, a vaginoplasty. The procedure would remove your penis and testicles and create a functioning vagina, permanently shutting down your body’s sperm production.

Transgender women take medications to suppress testosterone production and increase estrogen, which tends to decrease sperm production and often eliminate it altogether. But a new procedure called extended search and sperm microfreezing, or ESSM, makes it possible to retrieve that sperm unless production has stopped completely.

Using the ESSM, Dr. Michael Werner, a urologist specializing in sexual and reproductive health, was able to find and freeze over 200 of Claire’s viable sperm. Her procedure was the first time that doctors were able to recover viable sperm in a transgender woman after more than two years of hormone treatments.

Dr Arie Berkovitz, an obstetrician and gynecologist specializing in male fertility at Assuta Hospital in Rishon LeZion, Israel, created the ESSM technique in 2017 as a treatment for men with low sperm count.

Sperm production requires consistent production of testosterone in the testes; 40 million per ejaculation is considered normal.

ESSM does not increase sperm production. With ESSM, doctors can find and freeze small amounts of sperm from ejaculate without side effects; finding such samples can be difficult in people who have been on long-term hormone therapy.

Previously, patients with low sperm counts or those who had no sperm had to undergo invasive surgery, in which sperm was removed through a needle inserted into the testicle. The process can be painful and can damage the testicles.

“I was going to do this for peace of mind, so I could be sure I had tried everything,” Claire said of the procedure. “When I got the call that not only was there sperm, but there were so many, it was amazing and wonderful.”

In the ESSM, the semen sample is divided into small droplets and scanned using a high-powered microscope for several hours. Any sperm found are individually placed into a special device called a SpermVD and cryopreserved. More than 90% of them survive the freezing and thawing process.

Dr Joshua Safer, executive director of the Mount Sinai Health System’s Center for Transgender Medicine and Surgery, said the surgery’s success is promising for transgender women who would like to start a family later in life.

“My reaction is twofold: I’m surprised and impressed,” he said. Referring to the surgery, he added: “As an endocrinologist, we don’t know what the limits are.”

Prior to her procedure, Claire visited a fertility clinic in Boston, at her doctor’s suggestion, to see if the bank could retrieve and store her sperm before surgery. The clinic could not find any gametes, or sperm, in her ejaculate, even though she had stopped taking hormones ten months earlier.

Her urologist in New York referred her to Maze Men’s Sexual Health, a fertility clinic and sperm bank headed by Werner. At this point, the vaginoplasty was just a day away, and rescheduling could take a long time, given the waiting list. ESSM seemed like a long shot, so she was surprised by the result.

Dr. Eric K. Seaman, a urologist specializing in male reproductive health in Millburn, New Jersey, said Claire’s success is rare.

“It’s a miracle they found any sperm after 18 years of hormone therapy,” he said.

Claire, who lives in Massachusetts, is one of an estimated 1.6 million people in the United States who identify as transgender. For transgender women who wish to undergo genital surgery, ESSM may be an option to preserve sperm.

Safer, who is also a past president of the American Professional Association for Transgender Health, said he believes this technology can benefit many of his patients. Since starting the Mount Sinai Health System’s Center for Transgender Medicine and Surgery in 2016, he has seen an increase in the number of transgender people seeking hormone therapy and surgery. The center performs 800 to 900 gender-affirming surgeries a year, he said.

“More and more people are feeling safe to identify as transgender, receive hormones and have medical interventions,” he said. “But in the world of gender-affirming treatments our clinics need to do a better job of getting young people to preserve fertility before they start taking hormones.”

Seaman said he was concerned, however, that there could be an increase in the rate of abortions related to ESSM use. Sperm retrieved by the technique tends to be more fragile due to the extra time it takes to travel through the epididymis, part of the duct systems of the male reproductive organs, compared to surgical removal of the testes, where the sperm and its DNA are more robust.

As long as transgender women have normal sperm production, ESSM should not interfere with the production of a healthy baby, Berkovitz said.

“In this case, she didn’t have a low sperm count,” he said. “Genetically, her sperm was normal,” so her fertility would be preserved for future use.

Doctors managed to freeze enough of Claire’s sperm for her to have 30 IVF cycles in the future.

“It’s a second chance for transgender patients,” he said. “We can offer them fertility preservation without any pain or discomfort and without an invasive procedure or operation.”

Still, Werner encourages young transgender people to store their sperm before any medical intervention to avoid the potential risks of fertility loss and leave their options open for the future.

“Unfortunately, the vast majority of trans women who are transitioning don’t have the option to store their sperm, and once they’re given hormones and have their testicles surgically removed, their options are gone,” he said.

^{Translated by Luiz Roberto M. Gonçalves}