reproductive health and obstetric care in transgender patients...donor's. all that matters is...
TRANSCRIPT
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Reproductive Health and Obstetric Care in Transgender
Patients
Rebekah P. Viloria, MDObstetrician & Gynecologist
Fenway Health
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Continuing Medical Education Disclosure Program Faculty: Rebekah P. Viloria, MD Current Positions: Obstetrician & Gynecologist, Fenway Health Disclosure: No relevant financial relationships.
It is the policy of The National LGBT Health Education Center, Fenway Health that all CME planning committee/faculty/authors/editors/staffdisclose relationships with commercial entities upon nomination/invitation of participation. Disclosure documents are reviewed for potentialconflicts of interest and, if identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interestor who agree to an identified resolution process prior to their participation were involved in this CME activity.
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OBJECTIVES Brief overview of fertility preservation
Brief overview of reproductive options
Brief overview of transmen experience with pregnancy and chestfeeding
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The Reproductive Conversation WPATH: “…it is desirable for patients to make decisions
concerning fertility before starting hormone therapy or undergoing surgery to remove/alter their reproductive organs…”
UCSF: “It is recommended that prior to transition all transgender persons be counseled on the effects of transition on their fertility as well as regarding options for fertility preservation and reproduction”
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Reproductive WishSurvey of 50 transmen after GRS 22% participants already had children 8 had partners conceived with donor sperm 3 conceived prior to GRS
54% were interested in having children at time of study
37.5% would have considered fertility preservation if available
Wierckx K, Van Caenegem E, Pennings G, Elaut E, Dedecker D, Van de Peer F, et al. Reproductive wish in transsexual men. Hum Reprod 2012;27:483–7
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Contraception“Because infertility is not absolute or universal in transgender people undergoing hormone therapy, all transgender people who have gonads and engage in sexual activity that could result in pregnancy should be counseled on the need for contraception. Gender affirming hormone therapy alone is not a reliable form of contraception, and testosterone is a teratogen that is contraindicated in pregnancy.“
UCSF Center of Excellence for Transgender Health
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MTF: Estrogen Effect Estrogen therapy decreases testosterone production
sperm count and motility
Stopping estrogen therapy may/may not reverse effects
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MTF: Fertility Preservation Sperm cryopreservation
Testicular sperm extraction
Testicular tissue preservation
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FTM: Testosterone Effect Testosterone therapy usually leads to anovulation and
amenorrhea
Stopping testosterone therapy may/may not reverse effects
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Egg/Embryo PreservationOocyte Cryopreservation Hormone-induced ovulation Ultrasound guided retrieval under anesthesia
Embryo Banking Egg retrieval with immediate fertilization with chosen
donor sperm
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TABLE 1
Pregnancy Outcomes After Fertility Preservation in Transgender MenMaxwell, Susan; Noyes, Nicole; Keefe, David; Berkeley, Alan S.; Goldman, Kara N.Obstetrics & Gynecology. 129(6):1031-1034, June 2017.doi: 10.1097/AOG.0000000000002036
Table 1. Fertility Preservation Options for Adolescent Transgender Boys and Adult Transgender Men
Copyright © 2017 by The American College of Obstetricians and Gynecologists
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Family Building Options
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Adoption Alternative insemination (donor sperm) Assisted Reproductive Treatment (IVF) Donor sperm/egg Cryopreserved sperm/egg Surrogacy
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The Basics of Reproduction
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“In order to make a baby, you need sperm, an egg, and a uterus for the embryo to grow in.Any one of those can be your own, your partner's, or a donor's. All that matters is that the sperm meets the egg, and the fertilized embryo implants and then grows inside the uterus. How and where the magic happens is ultimately a matter of logistics and planning.”
20 Things Transgender People Might Want To Know About Fertility. BuzzFeed. Carolyn Kylstra. June 23,2015
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Cost
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Donor sperm: $500 per vial Sperm banking and FDA testing: $1,000 Intrauterine insemination: $400 In vitro fertilization: $15,000 per cycle In vitro fertilization with egg donation: $25,000 per cycle Oocyte/embryo cryopreservation: $10,000 Gestational surrogacy: $50,000 - $100,000
P. Amato MD. Fertility Options for Transgender Persons. Endocrine Society Annual Meeting, San Diego, CA March 2015
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Legal Considerations
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Contracts when using donor/surrogate Financial obligations Visitation agreement Child custody Varying state laws/policies
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Reproductive Health
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Obesity Hypertension Polycystic Ovarian Syndrome Tobacco/Drug use Sexually transmitted infections Anatomic pathology
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Preconception Counseling
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Healthy diet Prenatal vitamin with folic acid Routine screening Medications Menstrual calendar
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Preconception Considerations
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When to start/stop Testosterone Return of normal/spontaneous menses Regular vs irregular bleeding Pelvic ultrasound, endometrial biopsy
Labs Testosterone, Cycle day 3 labs, CBC, Hgb a1c and LFT
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Pregnancy in Transmen
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Transgender Men Who Experienced Pregnancy After Female-to-Male Gender Transitioning
Alexis D. Light, MD, MPH, Juno Obedin-Maliver, MD, MPH, Jae M. Sevelius, PhD, and Jennifer L. Kerns, MD, MPH
Obstetrics & Gynecology Vol. 124, NO. 6 , Dec 2014
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Cross Sectional Survey
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March –Dec 2013 Online survey >18 y.o. Self identified as male BEFORE pregnancy Delivered within 10 years Testosterone therapy or gender affirming surgery not
required
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Results: 41 Participants
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61% used pre-pregnancy T 68% planned pregnancy 32% unplanned 58% conceived within 6 months No difference in pregnancy, delivery or birth outcomes
in those with prior T use
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Pregnancy Experience
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Feeling of isolation common “Lack of resources available to pregnant transgender men”
Varying degrees of gender dysphoria “It was relieving to feel comfortable in the body I’d been
born with” “Heavy time, having a baby, not passing as male, all the
changes and a society telling me to just be happy”
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Pregnancy Experience
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Positive experience associated with proper use of gender-related language by health care team
Negative experience due to improper pronouns and denial of services
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Chestfeeding
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Transmasculine individuals’ experiences with lactation, chestfeeding, and gender identity: a qualitative study
Trevor MacDonald, Joy Noel-Weiss, Diana West, Michelle Walks, MaryLynne Biener, Alanna Kibbe and Elizabeth Myler
BMC Pregnancy and Childbirth, May 2016
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Results: 22 Responders
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9 with prior chest surgery No discussion with surgeon regarding future infant feeding
choices
16 chose to chest feed 7 had gender dysphoria 11 chest fed for more than 1 year 7 received donor milk 1 resumed testosterone therapy
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Chestfeeding after Top Surgery
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9 with prior chest surgery 6 experienced some growth in chest tissue 2 reported chest tissue grew back to original size 2 experienced engorgement and mastitis post-partum
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Testosterone and Chestfeeding
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Safety of maternal testosterone therapy during breast feeding
Single case report 100 mg of implantable testosterone No significant increase in testosterone in breast milk No detectable increase in testosterone and no apparent deleterious
effects in infant
Glaser, et al; Int J Pharm Compd. 2009 Jul-Aug;13(4):314-7.
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Chestfeeding Support
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Use non-gendered language Avoid touching without permission Privacy is important Support all decisions around feeding
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OB/GYN Care of Trans Men
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Need fertility preservation counseling Need preconception counseling & care Need comprehensive guidelines for care Need trained & affirming care & supports
Use of name, parental role, and pronouns is KEY
Ellis et al., 2015; Light et al., 2014; Nixon, 2013; Trum et al., 2015; Unger, 2015; Wallace et al., 2014; Wierckx et al., 2012.
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Take Home Points
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Discuss fertility and contraception before starting gender affirming hormone therapy or surgery
Assisted reproductive options are expensive, potentially complex
Transmen should have preconception counseling & care
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Take Home Points
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Pregnancy and chestfeeding are options for transgender men
Variable gender dysphoria occurs during pregnancy and chestfeeding
Gender-affirming language/care/support improves transgender patient experience
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What do you like to be called?
What pronouns do you use?
What words do you use to talk about
your body and body parts?
Just Ask!
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What term(s) have you chosen for your parental role that you want us to use when referring to your relationship to your baby?
What name and pronoun have you chosen for your baby?
What infant feeding choices are you considering?
Keep Asking…
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