By Dennis Thompson
WEDNESDAY, Feb. 27, 2019 (HealthDay News) -- You're a 14-year-old transgender boy who has opted to block normal female puberty before it can begin.
What happens if you and your parents decide to preserve some of your eggs, in case you want to have children later in life?
In this real-life case, doctors were able to retrieve and freeze four viable eggs from the patient, who was born a girl, but identified as male. The findings were published in a report in the Feb. 28 issue of the New England Journal of Medicine.
The process was anything but simple, as hormone blockers being used to halt female puberty clashed with fertility medications used to stimulate egg production.
The teen wound up experiencing menstruation for the first time and some slight breast development, a "distressing" side effect for a person who identifies as male, his doctors said.
"He and mom had been warned this would likely happen," said report author Dr. Selma Witchel, director of pediatric endocrinology with UPMC Children's Hospital of Pittsburgh, who has been overseeing his hormone therapy. "I think when it happened, even though he was prepared for it, it was shocking for him and uncomfortable."
The patient went through a brief bout of depression that included some suicidal thoughts, but he is now is healthy and going through male puberty with the help of testosterone therapy, doctors report.
Parenting in the future?
Preservation of fertility is a choice that transgender teens must struggle with as they undergo hormone therapy to align their bodies with their sexual identities.
Doctors are encouraged to bring up the issue as they counsel adolescent transgender patients, Witchel said.
"I'm seeing more and more youth with gender dysphoria," Witchel said. "Most of them are not thinking ahead of the future and they themselves aren't interested in fertility preservation. Their parents are, but the teenager generally is not."
Dr. Joshua Safer, executive director of the Mount Sinai Health System's Center for Transgender Medicine and Surgery, said it is "typical for transgender people to begin treatment without delaying for a fertility preservation maneuver."
In this case, the teen and his parents came to Witchel asking for advice. "The initial focus was stopping the progression of the natal [birth] gender, female, so he would not be exposed to female hormones," Witchel said.
The teen started taking hormone blockers so that female puberty could not begin.
Deciding to preserve eggs
Witchel then brought up fertility preservation. After some back-and-forth, the patient and his parents decided they wanted to try to retrieve and freeze eggs.
Witchel turned to reproductive experts at UPMC for help.
"There are more and more of these patients who are being treated, but there's very little published in the literature. There's little guidance," said report co-author Dr. Stephanie Rothenberg, a reproductive endocrinology and infertility fellow with UPMC Magee-Women's Hospital. She participated in the fertility preservation process.
"This patient's case was even more complicated because he hadn't completed his female puberty, so we weren't sure whether or not freezing eggs was even an option for him," Rothenberg said.
"Normally, to freeze eggs, these patients need to complete their puberty to get eggs that are mature and able to be fertilized. His puberty had been halted," she noted.
The teen and his family were told that the most reliable method would be for him to stop his hormone blocker and progress into female puberty, Rothenberg said. Naturally developed eggs could be then harvested and frozen.
Troubling side effects
The patient rejected that approach, having no interest in female puberty, so he and his family took a "leap of faith that we might potentially be able to have success in getting eggs that could be frozen," Rothenberg said.
Doctors started the teen on medication to stimulate egg production, but also maintained his hormone-blocking therapy.
He experienced routine side effects from the process, but for him they were anything but routine, said report co-author Dr. Marie Menke, division director of UPMC Magee-Women's Hospital.
"His side effects were uniquely related to his diagnosis and his identification as a transgender male," Menke said. "The reason he was on this hormone blocker was to minimize the exposure to female puberty, but by virtue of going through stimulation for egg freezing, your estrogen levels go pretty high. He actually had some transient breast development and menstruation, which was distressing for him, understandably."
Witchel said, "He talked about maybe doing something to hurt himself, but as far as I'm aware he did nothing more than sort of mention how sad he was and how hard this period of time was for him. He didn't do anything actively to hurt himself."
The breast development regressed within three months, Witchel said.
Transitioning through puberty
Once the process of egg retrieval was completed, the teen started on testosterone and is now experiencing male puberty, Rothenberg said.
Safer, who wasn't involved with the report, called the case study "important, because it draws attention to a real tension with regard to transgender medical care.
"Even when we get to a reality where transgender individuals have timely, respectful care, the current treatment options can put fertility at risk," Safer said. "Although they are imperfect, strategies to protect fertility are important to consider."
Unfortunately, only transgender people from well-off families typically have the opportunity to even consider fertility preservation, Menke said.
"It's generally not covered by insurance, which is a shame," Menke said. "In an ideal world, I think the adolescents would benefit by having this as a covered procedure."
The University of California, San Francisco, has more about fertility options for transgender persons.
SOURCES: Selma Witchel, M.D., director, pediatric endocrinology, UPMC Children's Hospital of Pittsburgh; Joshua Safer, M.D., executive director, Mount Sinai Health System's Center for Transgender Medicine and Surgery, New York City; Stephanie Rothenberg, M.D., reproductive endocrinology and infertility fellow, UPMC Magee-Women's Hospital; Marie Menke, M.D., M.P.H., division director, UPMC Magee-Women's Hospital; Feb. 28, 2019, New England Journal of Medicine
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