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Research Letter
April 13, 2020

Rates of Fertility Preservation Use Among Transgender Adolescents

Author Affiliations
  • 1Royal Children’s Hospital, Melbourne, Victoria, Australia
  • 2Murdoch Children’s Research Institute, Parkville, Victoria, Australia
  • 3Department of Obstetrics & Gynaecology, University of Melbourne, Royal Women’s Hospital Parkville, Victoria, Australia
JAMA Pediatr. 2020;174(9):890-891. doi:10.1001/jamapediatrics.2020.0264

Transgender adolescents are increasingly seeking hormonal intervention to achieve a body consistent with their gender identity. These treatments include gonadotropin-releasing hormone agonists (GnRHa) to suppress puberty and the gender-affirming hormones testosterone and estrogen. Given that these interventions affect reproductive function, current treatment guidelines recommend prior fertility counseling and access to fertility preservation (FP).1 However, despite a previous report that 36% of transgender adolescents want biological children in the future,2 3 recent North American studies3-5 identified that less than 5% of transgender adolescents accessed FP. Whether these low rates reflect service barriers (eg, cost and availability), unwillingness to delay hormonal treatment for FP, and/or an intrinsic lack of desire for FP is unclear.

We performed a retrospective review to examine FP use among transgender adolescents receiving hormonal intervention at our pediatric gender service in Australia. We hypothesized that the nature of our clinic, which is publicly funded and located alongside a pediatric oncofertility center, might reduce barriers and increase FP uptake.


Our statewide service sees transgender individuals who are 18 years or younger. To assess FP use, we conducted a retrospective review of all individuals with gender dysphoria who had commenced receiving GnRHa and/or gender-affirming hormones from January 1, 2003, until June 1, 2017. Information on birth-assigned sex, age, hormonal treatment, fertility counseling, and FP use was extracted from the medical record. The Royal Children’s Hospital Human Research Ethics Committee approved the study, which included a waiver of informed consent because the study was a secondary use of medical data. Data were analyzed between August 2017 and July 2019. The P value threshold considered significant was .05 (2-tailed), and statistical analysis was performed using Prism version 7.0 (GraphPad).


One hundred two patients received fertility counseling from their pediatrician prior to commencing hormones. Of 53 individuals who were assigned male at birth (AMAB), 23 received counseling prior to taking GnRHa and 30 prior to taking estrogen, and 14 received additional consultation from an andrologist. Of 49 individuals assigned female at birth (AFAB), 3 received counseling prior to taking GnRHa and 46 prior to taking testosterone, and 47 received additional consultation from a gynecologist. The mean age at counseling was 15.6 years (range, 10.8-18.3 years), with no significant difference between sexes.

Among 49 individuals who were AFAB, none attempted FP, with 16 stating no reason; among the other 33, the main reason was a plan to reassess fertility options when older (Figure). Conversely, 33 of 53 individuals who were AMAB (62%) pursued FP (Table), of whom 22 successfully froze sperm after providing a masturbatory sample (mean [SD] age, 15.6 [1.4] years). The remaining 11 underwent testicular biopsy (which is well suited to those in early puberty), and this group was significantly younger (mean [SD] age, 13.9 [1.5] years; P = .003). Five of these 11 individuals were found to have mature sperm, while the other 6 had germ cells only, all of which were cryopreserved.

Figure.  Reasons for Declining Fertility Preservation
Reasons for Declining Fertility Preservation

To understand why some patients chose not to pursue fertility preservation, we examined reasons recorded in the medical record. Of the 49 young people assigned female at birth (AFAB) who declined FP, 16 gave no reason. The remaining 33 gave a variety of responses, the proportions of which are displayed. Of the 19 young people assigned male at birth (AMAB) who declined FP, 9 gave no reason. The remaining 10 gave a variety of responses, the proportions of which are displayed. The item “experimental nature of procedure” refers to the procedure for those in early puberty who have yet to start producing mature gametes, in whom cryopreservation of immature testicular or ovarian tissue harvested via biopsy is offered within a governed pathway that emphasizes that this practice is experimental and requires further technological advances for the tissue to be successfully used for reproductive purposes.

Table.  Rates of Cryopreservation Between Patients Assigned Male or Female at Birth
Rates of Cryopreservation Between Patients Assigned Male or Female at Birth


Whereas all our patients who were AFAB declined FP, 62% of patients who were AMAB pursued FP, suggesting that most transfeminine adolescents have an intrinsic desire to preserve their fertility. This result stands in stark contrast to recent North American studies in which FP rates among the AMAB population were 0% to 14%.3-5 Given that our cohort had a similar age and rate of andrology consultation as those in previous reports, the most likely explanation is differences in FP access. Specifically, patients who were AMAB within our service obtain FP in a timely manner (<1 week for masturbatory specimens; <1-2 months for testicular biopsies). This is probably important, given an unwillingness to delay hormone treatment is a common reason for forgoing FP.2,3,5 Furthermore, FP costs for patients who were AMAB at our clinic are relatively affordable (testicular biopsy is free, semen analysis costs approximately $66 [AU $100], and annual sperm storage costs approximately $132 [AU $200]). Consistent with this, a recent Dutch study in which FP costs were also largely covered by insurance observed that 12 of 32 transgender individuals who were AMAB (38%) froze sperm prior to starting hormones.6 Notably, this rate was still considerably lower than ours. One likely reason is that testicular biopsy, which is likely to be less dysphoria-inducing than masturbation and also more suitable for younger adolescents, was not an option for the patients in the Netherlands, highlighting the importance of providing different FP options.

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Article Information

Accepted for Publication: October 10, 2020.

Corresponding Author: Kenneth C. Pang, MBBS(Hons), BMedSc, PhD, Murdoch Children’s Research Institute, 50 Flemington Rd, Parkville, VIC 3052, Australia (ken.pang@mcri.edu.au).

Published Online: April 13, 2020. doi:10.1001/jamapediatrics.2020.0264

Author Contributions: Dr Pang and Mr Peri had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Pang, Telfer, Elder.

Acquisition, analysis, or interpretation of data: Pang, Peri, Chung, Grover, Jayasinghe.

Drafting of the manuscript: Pang, Chung, Grover.

Critical revision of the manuscript for important intellectual content: Pang, Peri, Telfer, Elder, Grover, Jayasinghe.

Statistical analysis: Pang, Peri, Chung.

Administrative, technical, or material support: Pang, Peri, Chung, Jayasinghe.

Supervision: Pang, Telfer, Elder, Grover.

Conflict of Interest Disclosures: Dr Jayasinghe reported grants from University of Melbourne during the conduct of the study and grants from National Health and Medical Research Council, Victorian Cancer Agency, Royal Children's Hospital Foundation, University of Melbourne, and Merck outside the submitted work. Dr Pang reported funding from the Royal Children's Hospital Foundation. No other disclosures were reported.

Additional Contributions: The authors would like to thank Charlie Cooper, BA, Murdoch Children's Research Institute, and Timothy Lai, BBiomed, Royal Children's Hospital, for conducting literature searches; Debra Gook, BSc, PhD, Department of Obstetrics & Gynaecology, University of Melbourne, Royal Women's Hospital, and Harold Bourne, BSc, MRepSci, Reproductive Services/Melbourne In Vitro Fertilization, Royal Women’s Hospital, for processing and analyzing semen samples and testicular biopsies; Michael Nightingale, MB, ChB, Royal Children's Hospital, Murdoch Children’s Research Institute and Department of Paediatrics, University of Melbourne, for performing testicular biopsies; Melanie Engel, MD, Royal Children's Hospital, for data extraction; and the staff of the Royal Children's Hospital Gender Service for their contributions and support during the course of this study. These individuals were not compensated for their contributions.

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