Dear Dr Sedgwick. Thank you for referring Oscar for fertility preservation counselling prior to gender-affirming hormone treatment. Oscar is a transfeminine individual who uses she her pronouns. Oscar works in theatre and is also an artist involved in performance and drag. She reported that she feels supported both at home and at work. She identifies her sexual orientation as queer and is in a stable relationship of three years. She has had insertive penetrative intercourse in the past but has never previously investigated her fertility. She is happy to receive letters by post. She has no formal diagnosis of neurodiversity. She has not yet started gender affirming hormone therapy and is currently on the waiting list for the Tavistock service. We discussed the potential impact of gender affirming hormone therapy on gonadal function, including reduced spermatogenesis and the possibility of azoospermia after a period of treatment. We also discusssed that libido may be affected. I advised her not to start gender affirming hormone therapy until fertility preservation has been completed. She understands that gender affirming hormone therapy is not a form of contraception. We discussed gamete cryopreservation in detail, including the process, limitations and the fact that future use of stored gametes would depend on her circumstances at that time. We also discussed that NHS-funded fertility treatment is usually limited to couples of opposite biologicacl sex, depending on prevailing local and national funding criteria. I advised that she should attend at least two sessions for sample production, if feasible, in order to mazimise the chance of successful sperm cryopreservation. We also discussed the implications of future name change and consent. If she changes her name in future, newer consent forms can be issued to reflect this. We also discussed that if she wished a future partner or next of kin to have access to decision-making rights in relation to stored gametes, this would ned to be clearly documented on updated consent forms. Consent forms have been ompleted and sent. Blood tests were taken today, including virology screening and hormonal profile. Counselling was offered, and written information together with contact details was provded. We will arrange cryopreservation appointments once the relevant GIC letter has been received and funding has been secured. I hope she found this appointment useful.

Fertility preservation for trans women and non-binary people. Overview. Gender transition can involve hormone therapy and surgery. These treatments can be alled gender affirming hormone therapy (GAHT) and gender affirming surgery (GAS). Both hormone therapy can lead to not being able to produce children (infertility). Your fertility might only be temporarily affected with hormone therapy, meaning that sterility could be reversible. However, this is not guaranteed and can depend on how long you have hormone therapy. Surgery can lead to permanent sterility. If you want to naturally produce children, fertility preservation could store some of your reproductive cells giving you an opportunity to use them in the future. Although fertility preservation can be discussed at any stage of transition, we generally advise havin fertility preservation treatment before any gender affirming therapy. We cannot offer fertility preservation if you have already had gender affirming surgery such as bilateral gonad removal (orchidectomy) as this results in permanent sterility. The NHS website has more information about treatment options for gender dysphoria.

as far as possible, we use non-binary biological terms throughout this information to make reading as comfortable for you as possible. However, we know that medical terms can sometimes be more confusing, so we've included the following list that you can use as a guide if you need to.

1. Gonads: circular organs in the reproductive system which contain reproductive cells (gametes). Ovaries and testicles are gonads. 2. Gametes: reproductive cells in different stages of development in a gonad. Gametes include oocytes (developing eggs in the ovary) and sperm (cells in the testicles). 3. Embryo: an egg successfully fertilised with sperm to allow potential development of a baby. 4. Egg collection: a procedure under sedation where gametes are retrieved. 5. Sperm freezing: freezing of ejaculate gametes after masturbation, or surgery in some cases.

Discussing fertility preservation while on hormone therapy. You can be referred to the fertility specialist to discuss the options of preserving fertility while on gender affirming hormonal therapy. Based on your individual management so far, the consultant will discuss and advise treatment that is appropriate for you. A full medical history, screening, blood tests and all the relevant consent forms need to be completed by you before starting treatment. Stopping hormone therapy temporarily. Currently, there is limited robust data about fertility preservation offered in transgender people while on hormone therapy. Most trans women who take oestrogen or anti-androgens (7 out of 10) stop making reproductive cells. To make sure sterility is reversed, we advise you to consider temporarily stopping hormone therapy for 3 to 6 months before fertility preservation treatment. Your doctor can help you understand how your reproductive function is affected by hormones and together you can plan your care.

A full medical history, screening, blood tests and all the relevant consent forms need to be completed by you before treatment is commenced. Your doctor can discuss each option in detail with you, and give you written information to take away.

In theory, there's a risk of viral cross-contamination between samples that are stored in liquid nitrogen. There has never been a report of this happening but, because of the theoretical risk, you (and your partner, where appropriate) must be screened for HIV, and hepatitis B and C. We cannot freeze any samples until we've had the results of these tests. Our assisted contraception unit currently cannot offer storage if you or your partner test positive for HIV or hepatitis B or C at this time, but we will be able to advise where this service is available.

Under the terms of the human fertilisation and embryology act (1990), you are required to give written consent about 1. the storage of your gametes, 2. the length of time they may be stored for, 3. the purposes your gametes can be used for, 4. your wishes over any gametes stored, 5. what should be done with your gametes in the event of your death, or if you become incapable of changing or cancelling your consent. If your circumstances change, and you want to update your consent, you must contact us. Please call us on 020 7188 2300 or 020 7188 7188 extension 50426 to arrange an appointment to change your consent forms, or for any further consultations.

NHS funding criteria for fertility preservation is set by local commissioning authorities known as integrated care boards (ICB). This will be assessed when your doctor refers you for fertility preservation. If you are eligible, funding will be provided for the fertility preservation of your gametes for a specific period of time. Continued storage after this point may incur a charge. A letter from a NHS gender identity clinic will be required to proceed with fertility preservation. We strive for inclusive care for all patients, and we will support you as much as we can. Please note that it is not the medical or administrative teams at Guy's and St Thomas's assisted contraception unit that make decisions on funding, and we have no authority to grant it! If you are not eligible for NHS funding for fertility preservation, you can still have this treatment with us on a private basis. There will be a charge for consultaiton, screening tests, treatment cycle and storage of gametes. Our admin team can give you more information and a price list. If you require fertility treatment to achieve a pregnncy, your consultant or GP will have to refer you for assisted contraception. At the moment, there is no special funding for fertility treatment for transgender patients. The eligibility criteria for funding are the same as for any other person seeking fertility treatment. If you do not meet these criteria, fertility treatment will have to be self-funded

Freezing (cryopreservatio involves storing samples of your reproductive cells (gametes) at a very low temperature in liquid nitrogen. Gametes stored this way can be thawed out in the future for fertility treatment. Before fertility preservaiton, you'll need to be tested for HIV and hepatitis B and C. Your reproductive cells will also need to be analysed so we know the quality, as this might affect your chances of having a baby in the future. Before we can store your samples, you have a consultation with a doctor or nurse in the fertility unit to talk about storing your gametes, and to complete the relevant consent forms. We'll ask you to produce a samplle, complete consent forms, and have a blood test. We know that this proces smght feel difficult for you, but we are here to support you and will be happy to answer any questions you have. A gamete sample is usually produced by masturbating. There are facilities in the fertility unit, where you can produce a sample in a separate, private area. We understand that this might be embarrasing and difficult for some people, but we're here to support you and answer any questions you may have. Sometimes it is possible to produce a sample at ome, using the sterile pot provided, and bring it to the fertility clinic. This is only possible if you can get the sample back to the clinic within 1 hour. Analysis will tell us the quality of your gametes. Some people, especially people on hormone therapy, might have lower quality or quantity of reproductive cells. Even if the quality is poor, you might still want to store samples for future use. Some fertility procedures only require aa small number of viable or 'good' cells to fertilise eggs. This includes intra-cytoplasmic sperm injection (ICS) where a single sperm is injected into each egg. The doctor can talk to you more about your options when the results of the analysis are available. Your sample can be used in simple insemination procedures, such as intra-uterine insemination (IUI), or more complex assisted conception treatments, such as IVF or ICSI. We'll give you advice about the best procedure depending on the quality and quantity of the reproductive cells, and your preferred way of building a family. The statutory (legal) maximum time period for storing gametes for medical reasons is 55 years. Our policy is for you to give permision (Consent) for us to store gametes for 10 years. If you want to continue to store your gametes after this time, you must contact us in writing and one of the doctors will assess if there are still medical grounds to continue storage of your gametes. It's very important that we can keep in regular contact with you. If we cannot contact you to find out if you want us to continue to store your gametes, by law samples have to be destroyed.