Extended sperm search and microfreeze for fertility preservation after long-term hormone therapy in transgender women: a report of three cases.

Background: Many barriers prevent transgender women (TW) from fertility preservation (FP) prior to initiating gender-affirming hormones. The decision to move forward with gender affirming bottom surgery presents the last opportunity for these patients to preserve their ability to have genetically related children. However, oftentimes these patients will have azoospermia even after stopping their hormone therapy for an extended period due to the negative effects of these hormones on fertility. The objective of this case report is to investigate a novel method of FP in TW on longstanding gender-affirming hormone therapy who present with azoospermia on conventional semen analysis. Case Description: Three TW on gender-affirming hormone therapy for between 6-21 years presented for FP prior to gender affirming vaginoplasty with simultaneous orchiectomy. All three patients had azoospermia on conventional semen analysis. Extended sperm search and microfreeze (ESSM) was conducted on semen samples. Results, including sperm count, number of vitrified sperm, and number of SpermVDs, were obtained. Conventional testicular sperm extraction (TESE) was also performed on two of the patients. Two out of three patients successfully retrieved and cryopreserved sperm after ESSM procedure. One patient had a successful ESSM despite not having any sperm on testicular tissue analysis. Conclusions: The findings from this case study underscore the potential use for ESSM as a tool for FP in TW who have undergone multiple years of hormonal therapy and have unsuccessful semen analyses and testicular extractions. Future studies with larger cohorts are necessary to validate the efficacy of ESSM and explore its potential application as a standard practice in transgender healthcare, particularly for those who cannot completely cease hormone therapy.