Infertility Centre, University Hospital Ghent, De Pintelaan 185, B-9000 Gent, Belgium.
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Abstract |
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Key words: gamete preservation/reproduction/sperm freezing/transsexual/transgender
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Introduction |
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Until recently, transition to the desired gender and reproduction seemed to be mutually exclusive for transsexual people. To many, loss of reproductive potential seems the `price to pay' for transition. Even today, many medical expertseven those involved in the care for transsexual and transgendered peopleare still critical when discussing possible procreation after gender reassignment. However, recent publications have opened the ethical debate as to whether transsexual people should be helped in their possible wish for children in relationships occurring after transition (Brothers and Ford, 2000; Jones, 2000
). The debate has only just started amongst fertility experts and currently only deals with donor inseminations in female partners of transsexual men (female-to-male transsexual patients). The question posed is whether transsexual people can be `good' parents, without negative influence on the gender and/or sexual orientation of the child-to-be, a discussion that was held many years ago for homosexual people (Hanscombe, 1983
). As it was to homosexuals then, this question may be considered to be an insult to transsexual people, and we rather believe that the debate should be broadened and discuss the possibilities of how to help fulfil the wish for children by transsexual people, rather than whether to help them or not. The overall wellbeing of transsexual people after gender reassignment therapy has been well documented in recent studies (Cohen-Kettenis and Gooren, 1999
) and many of these people have normal relationships with children from their previous relationships or from their current partners.
More and more, people are diagnosed and treated for their transsexuality at an early age, when they still do not have any children nor possibly any wish for children. Recent reproductive techniques, however, have made it possible to preserve germ cells for future use, so that in theory transsexual people may make use of their germ cells after transition. A few years ago Lawrence et al. discussed the `reproductive needs' of the transsexual patient (Lawrence et al., 1996), taking Lawrence's ideas further, the purpose of this paper is to discuss what is already technically possible now, and what may be possible tomorrow. Of course, we may expect that the medical and ethical debate will continue before these new techniques may be implemented routinely.
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The right to procreate |
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In short we will discuss the various theoretical options that are available. It is worthwhile to mention that although most transsexual people will form heterosexual relationships after transition, many will not, illustrating the well known fact that sexual orientation and gender identity are quite different entities. Therefore, not all options are available for all transsexual people alike.
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Sperm banking in transsexual women (male-to-female transsexual patients) |
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In case of a future male partner the situation is the same as with homosexual men today, and there is little help available except when an oocyte donor and surrogate mother are involved. Since many transsexual women are, however, sexually oriented towards women after transition (and therefore identify as lesbians), sperm banking should routinely be offered to people considering hormonal and/or surgical gender reassignment treatment. Any man undergoing a treatment that will damage his reproductive potential (such as chemo- or radiotherapy for a malignancy) is now offered the opportunity to bank spermatozoa, and the transsexual woman should be no exception to this.
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Transsexual men |
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Oocyte banking |
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Embryo banking |
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Ovarian tissue banking |
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Ovarian tissue banking would also require donor spermatozoa and a recipient uterus of a future female partner or a surrogate mother in case of a male partner. The problem of ovarian tissue banking is not the freezing but the question of what to do with the tissue after thawing. One has the option to graft the ovarian tissue into the patient himself (Shaw et al., 2000) (of course this is not an option for transsexual men), in another patient (leading to possible problems of immune rejection) or in another animal (such as the mouse, but here may arise some serious ethical objections). In these three scenarios follicular growth and ovulation should still be induced (Oktay and Karlikaya, 2000
) and IVF would be needed to obtain fertilization and pregnancy. As another possibility, in-vitro culture of the tissue fragments, with follicular growth and oocyte maturation in vitro still seems to lead to poor results so far (Smitz and Cortvrindt, 1999
) and intermediate approaches are being explored, combining grafting and in-vitro maturation (Liu et al., 2000
). So, although ovarian tissue banking seems to be the option to choose, much research will still be needed to bring this in practice for transsexual men.
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The future |
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Conclusion |
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Notes |
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References |
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