Semen parameters in transgender women and gender-diverse people assigned male at birth using gender-affirming hormones: cohort study and scoping review

Abstract

Objective

To assess semen parameters, hormone levels, and the psychological experience of transgender (TG) women and gender-diverse (GD) people assigned male at birth using gender-affirming hormones (GAH) and to summarize the current literature on this topic.

Design

Cohort study and scoping review.

Patients

Fifteen people assigned male at birth identifying as TG or GD using GAH (12 TG women and 3 GD people).

Exposure

Gender-affirming hormone therapy (estradiol, antiandrogen, +/- progesterone).

Main Outcome Measures

The primary outcomes of the cohort study were semen parameters (volume, concentration, motility, and total motile count). Secondary outcomes included serum levels of gonadotropins, estradiol, and testosterone. Secondary outcomes also included qualitative data about the specimen collection experience. The primary outcome of the scoping review was to evaluate the current literature on semen parameters of TG women and GD people on GAH by determining the number of studies, key objectives, and findings.

Results

Cohort study: Fifteen participants attempted to produce a semen sample. Thirteen participants (87%) produced a specimen for analysis; 8 were azoospermic (61.5%) and 5 contained sperm (38.5%). Of all included participants, only 4 participants (26.7%) were able to produce a sample with motile sperm. The median concentration was 25.0 million/mL (range: 0.2–99.0), motility 22% (range: 0–70%), and total motile count 2.5 million (range: 0–70.0). All participants with motile sperm had luteinizing hormone (median: 3.8 IU/L, interquartile range [IQR]: 1.9–5.2) and testosterone levels (median: 193 ng/dL, IQR: 94.5–330.5) that were significantly higher than the remainder of the cohort. Estradiol (median: 147 pg/mL, IQR: 100.5–410) and follicle-stimulating hormone (median: 0.4, IQR: 0.2–1.55) levels among participants with motile sperm did not differ significantly compared with the remainder of the cohort. Producing a specimen was rated as moderately difficult physically (median: 4.0, IQR: 2.0–7.5) and psychologically (median: 4.0, IQR: 2.0–6.0) (where 1=easy, 9=difficult). Participants advised that assuring sound-proofed collection rooms or home collection could improve the collection experience.

Scoping review

682 abstracts were eligible for screening. 12 sources were included in the final analysis. Most studies demonstrated that GAH negatively impacted semen parameters. One case report, and no cohort studies, examined hormonal profiles at the time of specimen collection.

Conclusion

Consistent with prior limited data, in a cohort of TG women and GD people assigned male at birth using gender-affirming hormones, semen parameters were abnormal and often azoospermic. The ability to produce motile sperm may be associated with less hypothalamic suppression (higher luteinizing hormone and testosterone levels). Providing an inclusive and private environment may ease some of the challenges associated with collection.