Clinical Pregnancy Rate by Age in Natural Cycle IUI versus Ovulation Induction IUI
P-value comparing
Clinical
Age Natural Pregnancy NC Pregnancy
(years) Cycles from NC per Cycle
<35 2346 402 17.1%
35-37 1033 164 15.9%
38-40 767 73 9.5%
41-42 212 14 6.6%
O-44 Monday, October 8, 2018 11:00 AM
THE EFFICACY OF TESTOSTERONE OR ESTRADIOL
THERAPY WITHOUT A GNRH AGONIST OR PROGES-
TIN TO SUPPRESS ENDOGENOUS GONADAL ACTIV-
ITY IN TRANSGENDER PATIENTS. I. I. Stewart,a
L. V. Spratt,a W. Craig,b J. S. Olshan,c D. I. Spratt.a aThe Department of
Obstetrics and Gynecology, Division of Reproductive Endocrinology and
Infertility, Maine Medical Center, Portland, ME; bMaine Medical Center
Research Institute, Scarborough, ME; cThe Department of Pediatrics, Divi-
sion of Pediatric Endocrinology, Maine Medical Center, Portland, ME.
OBJECTIVE: To determine the efficacy of testosterone (T) or estradiol
(E2) therapy alone, without a GnRH agonist or progestin, to suppress endog-
enous gonadal activity in female-to-male (FTM) or male-to-female (MTF)
transgender patients.
DESIGN: A retrospective cohort study of transgender patients undergoing
routine therapy in the Reproductive Endocrinology Clinic at Maine Medical
Center.
MATERIALS AND METHODS: Data were collected from all transgender
patients seen in the outpatient clinic between 03/2013 and 01/2018 who met
inclusion criteria: 1) age 18-40 years for FTM and 18-50 years for MTF; 2)
normal reproductive function prior to therapy; 3) total T within the normal
adult male range (348-1197 ng/dL) in FTM patients while on T therapy; 4)
serum E2 greater than 100 pg/mL in MTF patients while on E2 therapy unless
T was adequately suppressed at lower serum E2 concentrations; 5) no concur-
rent therapy with a progestin or GnRH agonist; and 6) no history of oopho-
rectomy or orchiectomy. Consistent with Endocrine Society guidelines,
effective suppression of ovarian function in FTM patients was assessed by
cessation of menses and a serum E2 of (<50 pg/mL). In MTF patients, testic-
ular suppression was assessed by total serum T concentrations below the up-
per limit of the premenopausal adult female normal range (<55 ng/mL)1.
RESULTS: FTM patients (n¼50) were aged 26.25.9 years and received
T through subcutaneous (SC, n¼58) or intramuscular (IM, n¼2) injections. T
doses ranged from 40-100 mg per week. All FTM patients were amenorrheic
on T therapy alone. The mean serum E2 concentration was 39.821.4 pg/
mL. Among these 50 patients, 36 (72%) had serum E2 <50 pg/mL. The me-
dian serum E2 value for the 14 patients with E2 R50 pg/mL was 55 pg/mL
(range, 55-130). Thus, 36 out of 50 (72%) FTM patients had effective
biochemical suppression of ovarian function without a GnRH agonist or pro-
gestin therapy and all FTM patients had clinical suppression of ovarian func-
tion (amenorrhea). MTF patients (n¼24) were aged 29.79.0 years and
received oral (n¼25), SC (n¼1), or IM (n¼1) E2 as well as spironolactone.
Oral E2 doses ranged from 3-12 mg per day. Serum total T values for the 24
MTF patients were all within the target range (median 8.2, range 2.7-36 ng/
dL). Thus, all MTF patients had effective biochemical suppression of testic-
ular function without GnRH agonist or progestin therapy.
CONCLUSIONS: Our results indicate that most transgender patients do
not need GnRH agonist or progestin treatment in addition to T or E2 therapy
to suppress endogenous gonadal activity. Additional unnecessary endocrine
therapies to suppress ovarian or testicular function incur a significant expense
and potential adverse effects without providing a clear change in clinical
outcome.
References:
1. J Clin Endocrinol Meta (2017), 102:3869-3903.
O-45 Monday, October 8, 2018 11:15 AM
DEVELOPMENT OF A MOUSE MODEL TO INVESTI-
GATE THE REPRODUCTIVE EFFECTS OF TESTOS-
TERONE (T) ADMINISTRATION IN TRANSGENDER
MEN. M. B. Moravek,a H. M. Kinnear,b E. S. Constance,a
FERTILITY & STERILITYÒ
Ovulation Clinical Clinical Pregnancies
Induction Pregnancy OI Pregnancy from NC vs.
Cycles from OI per Cycle OI IUI (chi square)
2120 400 18.9% 0.13
911 142 15.6% 0.86
729 103 14.1% 0.006
197 14 7.1% 0.84
A. David,b E. E. Marsh,a V. Padmanabhan,c A. Shikanov.b aObstetrics &
Gynecology, University of Michigan, Ann Arbor, MI; bBiomedical Engineer-
ing, University of Michigan, Ann Arbor, MI; cPediatrics, University of Mich-
igan, Ann Arbor, MI.
OBJECTIVE: Multiple national and international medical organizations,
including ASRM, recommend fertility preservation counseling prior to start-
ing gender-affirming hormone therapy in transgender patients; however,
there is a paucity of data on the reproductive effects of long-term hormone
therapy, particularly in transgender men. The objective of this study was to
develop a mouse model to investigate reproductive effects of T administra-
tion for female-to-male (FTM) gender transition.
DESIGN: Translational animal study.
MATERIALS AND METHODS: Fifteen 8-9 week old adult female
C57BL/6J mice were injected with 0.9 mg, 0.45mg, or 0.225mg of T enan-
thate in sesame oil twice weekly; 10 controls were injected with vehicle.
Daily vaginal cytology and weekly serum hormone analysis were performed.
Mice were sacrificed after 6 weeks of injections, serum collected, and organs
harvested. Data were analyzed with t-tests, Mann-Whitney, ANOVA, or
Kruskal-Wallis with post-hoc tests, as appropriate, and nQuery Advisor
used to calculate sample size with 85% power.
RESULTS: Estrous cycles ceased in all T-treated mice within 1 week of
initiating injections, while controls continued cycling normally. Mean termi-
nal T level (ng/mL) was increased in all T-treated mice (5.3, 5.7, and 7.7 for
0.225mg, 0.45mg, 0.9mg T groups, respectively) compared to controls (0.05,
p<0.05), and LH (ng/mL) was suppressed (0.04, 0.04, and 0.05 for 0.225mg,
0.45mg, 0.9mg T groups, respectively) compared to controls (0.27, p<0.05).
AMH levels were increased in the 0.225mg (1.6x) and 0.45mg (1.5x) T
groups, compared to controls (p<0.05). There were no differences in FSH,
estradiol, or progesterone levels. Clitoral area was significantly increased
in T-treated mice compared to controls (9.5 vs 5.2mm2, p<0.0001). Ovaries
of all T-treated mice had a multi-follicular appearance and complete absence
of corpora lutea. Liver weight was significantly increased in mice receiving
0.45 or 0.9mg T (1.1 and 1.18g, respectively, vs 0.96g in controls, p<0.05).
There were no significant differences between groups in body weight change,
or uterine, ovarian or brain weights. Two mice in the 0.9mg T group had
vaginal prolapse.
CONCLUSIONS: T treatment of adult female mice mimicking hormone
therapy in FTM patients resulted in reproductive as well as metabolic pertur-
bations, manifested at the level of the ovaries and liver. Due to vaginal pro-
lapse in the 0.9mg T group, possibly due to higher serum T levels, 0.225mg or
0.45mg T are more suitable for a FTM mouse model, which can be used to
further elucidate the consequences of chronic T administration on fertility
and metabolic health, for which there is currently only sparse data.
O-46 Monday, October 8, 2018 11:30 AM
FEMALE TO MALE TRANSGENDER PATIENTS HAVE
GOOD EGG YIELDS WITH CONTROLLED OVARIAN
HYPERSTIMULATION. A. Leung,a,b D. Sakkas,a
S. Pang,a K. Thornton,a,c N. Resetkova.a,c aBoston IVF, Wal-
tham, MA; bOb/Gyn, Beth Israel Deaconess Medical Center, Boston, MA;
c
Ob/Gyn, Beth Israel Deaconess Medical Center, Boston, MA.
OBJECTIVE: The transgender population is increasingly seeking access
to assisted reproductive technologies (ART). However, there are no studies
of substantial sample size that examines ovarian hyperstimulation outcomes
in this underserved patient population. Given the increasing demand for ART
services by transgender patients and lack of information for providers treat-
ing these patients, we seek to inform this area of medicine. This information
will serve to counsel transgender patients and their providers on ART out-
comes in this population.
e21
 DESIGN: This study is a retrospective analysis that investigated a female
to male transgender cohort who underwent ART services and compared their
outcomes with matched controls.
MATERIALS AND METHODS: We identified 25 controlled ovarian hy-
perstimulation cycles completed by female-to-male (FTM) transgender pa-
tients who sought care at a large academic-affiliated IVF (in vitro
fertilization) clinic from 2013-2017. Each transgender patient was matched
with three control patients with tubal factor infertility, using the following
factors: age, body mass index (BMI), and anti-mullerian hormone (AMH)
levels. Patients with polycystic ovary syndrome (PCOS) were excluded.
Oocyte retrieval outcomes were compared, and statistical analysis was per-
formed using student’s t-test.
RESULTS: 25 cycles completed by 22 FTM transgender patients were
matched with 75 cycles completed by controls. Only ovarian stimulation out-
comes were examined, as the majority of the transgender group underwent
ART for the purpose of oocyte cryopreservation. Therefore, no embryo
data or pregnancy outcomes were analyzed. Mean total gonadotropin dose
used for stimulation and peak estradiol levels were the same between the
two groups (p¼0.11; p¼0.098). The mean number of oocytes retrieved in
the transgender group was 19.7 (SD¼8.7) compared to 13.2 (SD¼7.7) in
the control group (p¼0.002). Similarly, the transgender group had higher
numbers of mean mature oocytes (14.6, SD¼7.9) compared to the control
group (10.6, SD¼5.4; p¼0.026). Among the minority of transgender patients
who proceeded to oocyte fertilization (n¼11), the mean number of fertilized
oocytes was not significantly different from those in the control group
(p¼0.297).
CONCLUSIONS: This is the first study of this size investigating ART out-
comes in transgender patients. Our results show that transgender men have
excellent controlled ovarian hyperstimulation outcomes, in many cases
exceeding those of patients with tubal factor infertility.
References:
1. Armuand, G. et al. (2017) Human Reproduction (Oxford, England) 32
(2):383-90.
2. Light, Alexis D. at al. (2014) Obstetrics & Gynecology 124 (6):1120-27.
3. Maxwell, Susan at al. (2017) Obstetrics & Gynecology 129 (6):1031-34.
Supported by: No disclosures.
O-47 Monday, October 8, 2018 11:45 AM
TOTAL MOTILE SPERM IN TRANSGENDER WOMEN
SEEKING HORMONE THERAPY: A CASE-CONTROL
STUDY. M. McCracken,a A. K. Nangia,b K. Roby,c
H. McLaren,c M. Gray,c C. A. Marsh.c aUniversity of Kansas,
Overland Park, KS; bUniversity of Kansas Health System, Saint Barthelemy;
c pregnancy rates between members of SSF couples and the general heterosex-
OBGYN, University of Kansas, Overland Park, KS.
OBJECTIVE: This pilot study was undertaken to compare semen quality,
hormonal status, and social factors in transgender women seeking fertility
preservation with those of cis-men. Long range goals are to establish standard
practice measures to ensure optimum semen quality for cryopreservation and
fertility preservation in transgender women.
DESIGN: This is an IRB-approved fully consented case-control study car-
ried out at an academic medical center. Semen parameters in transgender
women (cases; n¼11) at the time of fertility preservation were measured
and compared to those of cis-men recently fathering a child (controls;
n¼16). Exclusion criteria included use of hormones in the prior three months.
All participants completed a questionnaire which included the Depression
Anxiety Stress Scales 21 Survey (DASS-21). Follicle stimulating hormone,
estradiol and testosterone and risk factors that may alter semen parameters
were measured and compared.
MATERIALS AND METHODS: Complete semen analysis was carried
out in a clinical andrology laboratory according to WHO guidelines. Hor-
mones were analyzed by LCMSMS at Quest Diagniostics. Study participants
completed a questionnaire via a secure online portal. Data were analyzed by
Mann-Whitney or Student t-test.
RESULTS: Sperm concentration was significanctly lower in transgender
women compared to controls (28.97.8 vs 71.420.2 million; p¼0.023).
In addition, total motile sperm in transgender women was significantly lower
than controls (43.214.7 vs 110.122.6 million; p<0.05). Other semen pa-
rameters were not different between groups. FSH, estradiol and testosterone
concentrations were not different between groups. The DASS-21 survey indi-
cated transgender women were more likely to have symptoms of depression,
anxiety and stress (p<0.01) compared to controls. Additonal survey results
indicated greater use of tucking and tight undergarments by transgender
e22 ASRM Abstracts
women (p<0.05), however both groups reported a similar number of ejacu-
lations per week.
CONCLUSIONS: Sperm concentration and total motile sperm in trans-
gender women prior to hormone treatment were lower compared to cis-
men that recently fathered a child. Although sperm counts were low, cryo-
preservation of sperm prior to the initiation of hormone therapy is a viable
option for fertility preservation. The etiology of the differences in semen pa-
rameters is not known, but use of tight undergarments may play a role in
reducing sperm production and enhanced education related to behaviors prior
to cryopreservation may improve future fertility potential. On going studies
seek to further substantiate the present pilot findings and to investigate the
underlying mechanisms leading to oligospermia in order to design interven-
tions ensuring transgender women the opportunity for optimum fertility pres-
ervation.
References:
1: Wierckx K, Stuyver I, Weyers S, Hamada A, Agarwal A, De Sutter P,
T’Sjoen G. Sperm freezing in transsexual women. Arch Sex Behav. 2012
Oct;41(5):1069-71. https://doi.org/10.1007/s10508-012-0012-x. PubMed
PMID: 22968492.
Supported by: University of Kansas Frontiers Pilot Grant
O-48 Monday, October 8, 2018 12:00 PM
MORE TO THE STORY THAN SPERM: PREGNANCY
RATES WITH IN VITRO FERTILIZATION IN SAME-
SEX FEMALE COUPLES. A. Napleton, B. M. Steinberg,
L. Grimm, R. Jeelani, A. Beltsos. Vios Fertility Institute, Chi-
cago, IL.
OBJECTIVE: For same-sex female (SSF) couples, assisted reproductive
technology (ART) is prevalent as a means to family building. These couples
may face significant burdens in finding insurance coverage for ART,
choosing a sperm donor, and taking on the second parent adoption process
in many states. Previous reports have compared pregnancy success rates us-
ing intrauterine insemination (IUI) between the general infertility population
and members of same-sex female couples and have shown up to 67% cumu-
lative pregnancy rates over 12 cycles.1 Of all evolving assisted reproductive
technology, in vitro fertilization (IVF) provides the best overall chance of
pregnancy. Additionally, IVF lends the unique opportunity for both members
of a SSF couple to have involvement in treatment as either oocyte source or
recipient. In order to best treat same-sex female couples, a population-spe-
cific criteria for prognosis should be established for IVF. The success of
SSF in IVF treatment compared to the general infertility population is not
yet established. We sought to determine if there exists a difference in IVF
ual infertility population.
DESIGN: Retrospective chart review at a private infertility center.
MATERIALS AND METHODS: All IVF treatment cycles performed on
patients in SSF relationships from 2016 to 2018 were analyzed. Both fresh
and frozen transfers were identified, and we divided the data set into 2
groups, for female patients in same-sex and heterosexual couples. A bino-
mial test was used to analyze the data using SPSS 21.0 (SPSS Inc., Chi-
cago, IL, USA).
RESULTS: A total of 205 treatment cycles were identified: 51 transfer cy-
cles (42 frozen and 9 fresh) for SSF and 154 treatment cycles for heterosexual
population (115 frozen and 39 fresh). Baseline characteristics between the
SSF group and control group were the same, with a mean age in the SSF cou-
ples of 35.9 years old compared to 37.5 in the heterosexual group (p > 0.05).
We found that the clinical pregnancy rate in the SSF population was signif-
icantly lower than the heterosexual patient population (39.2% vs. 55.8%,
p ¼ .025).
CONCLUSIONS: Our analysis shows that patients in same-sex female re-
lationships do not show a higher pregnancy rate with ART than the general
infertility population. Given that this population showed a higher pregnancy
rate with IUI than the general infertility population, we had expected a higher
pregnancy rate with IVF as well. This data can be utilized to establish clinical
guidelines in managing patient expectations about the outcomes of their
treatment. Treating physicians need to look at SSF couples trying for preg-
nancy with ART with a very open mind when it comes to exploring all pos-
sibilities for care and exercise caution to not assume better pregnancy
outcomes with IVF among this population. ART has the power to redefine
modern family-building; a realistic view of all reproductive options can
empower same-sex female couples to make the best treatment choices
possible.
Vol. 110, No. 4, Supplement, September 2018