Figure 4.

Different options for fertility preservation depending on the time point of Gender confirming hormone therapy (GCHT) and spermatogenic status. During the transition, the histological state of the testes shows a regression of spermatogenesis to severely impaired spermatogenesis or even spermatogonial arrest. Depending on the most advanced germ cell type, different procedures can be offered to preserve germ cells. Before and during cross-sex hormone treatment, masturbation is the most favorable non-invasive option. Following masturbation, semen samples are processed by swim up and sperm are cryopreserved. Alternatively, microsurgical testicular sperm extraction (mTESE) can be performed. After mTESE, sperm need to be extracted prior to cryopreservation, and the same applies for sperm extraction after orchiectomy. Cryopreserved sperm can be used for ICSI (intracytoplasmic sperm injection). Testicular tissues with spermatogonial stem cells (SSC) can also be cryopreserved although this procedure is still experimental. Abbreviations are: mTESE: Microsurgical testicular sperm extraction, ICSI: Intracytoplasmic sperm injection, SSCs: Spermatogonial stem cells. *mTESE can be offered if masturbation is psychologically distressing.