The attitudes of transgender and gender-diverse adolescents and their parents regarding fertility, parenthood, and fertility preservation before the start of puberty suppression or gender-affirming hormone therapy

BACKGROUND: Gender-affirming treatment for transgender and gender-diverse (TGD) adolescents can consist of puberty suppression (PS) and gender-affirming hormone treatment (GAHT), which may affect fertility. AIM: This study aims to evaluate the attitudes and decision-making regarding parenthood and fertility preservation from TGD adolescents and their parents and analyze the fertility preservation use and outcome before the start of treatment. METHODS: Adolescents under 18 starting PS or GAHT between November 2021 and March 2024 were enrolled in a multicenter prospective cohort study "ENIGI adolescents," conducted at Amsterdam University Medical Centre, Ghent University Hospital, and Florence University Hospital. Adolescents and parents were asked to complete the "Transgender Youth Fertility Attitudes Questionnaire" and the "Decision Conflict Scale." Information about fertility preservation use and outcomes was extracted from electronic patient files. OUTCOMES: Attitudes from TGD adolescents and their parents regarding desire for children, fertility preservation use, outcomes, and decision-making. RESULTS: A total of 316 adolescents were counseled about fertility options; 100 (49%) registered female at birth (RFAB) and 50 (48%) registered male at birth (RMAB) adolescents expressed a future desire for children. More than 1/3 had interest in or are still undecided about having a genetic offspring. None of the RFAB TGD adolescents underwent fertility preservation. In total, 20 (22%) RMAB adolescents pursued fertility preservation, 14 before PS and 6 before GAHT. Before PS, three performed testicular sperm extraction (TESE). All others performed semen cryopreservation. The post-thawed semen quality was low. The testicular volume and Tanner stage in the semen cryopreservation group were significantly higher compared to TESE, P = .013 and P = .021, respectively. There was no significant difference in age between those groups.Adolescents experience moderate to high decisional conflict about their fertility choices. RFAB adolescents experience a significantly higher conflict in decision-making compared to RMAB adolescents (40/100 vs 34/100 95% CI 2.1-9.4). Younger RFAB adolescents experienced more decisional conflict (B =-1,25, 95% CI -2,25, -0.25). In RMAB this was not significant. CLINICAL IMPLICATIONS: This study helps to further understand TGD adolescents' needs and can further improve the development of tailored fertility counseling. STRENGTHS AND LIMITATIONS: This is the first European collaborative study on transgender healthcare in adolescents. A limitation of our study is the relatively low response rate to the questionnaires, which varied between 25% and 62%. CONCLUSION: Many TGD adolescents express a desire for future parenthood yet experience decisional conflict about their reproductive options, even after receiving comprehensive fertility counseling prior to PS or GAHT.