Ep 102: ART Therapy For Transgender Males with Dr. Atoosa Ghofranian
Fertility Forward Episode 102:
Transgender patients are still a largely marginalized group, but thanks to people like Dr. Atoosa Ghofranian, more and more research is being done to improve their medical experience. Dr. Ghofranian is a fourth-year obstetrics and gynecology resident at the Icahn school in New York with an interest in improving IVF outcomes and expanding access to ART in underserved communities. She joins us today to talk about the study she’s presenting at ASRM, “Assisted Reproductive Technology Treatment Outcomes in Transgender Males with History of Gender-Affirming Hormone Therapy.” Tune in to hear about the objectives and reassuring findings of this critical study!
Rena: Hi everyone. We are Rena and Dara and welcome to Fertility Forward. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our Fertility Foward podcast brings together advice for medical professionals, mental health specialists, wellness experts, and patients because knowledge is power and you are your own best advocate.
Rena: I am so excited to welcome to Fertility Forward today, Dr. Atoosa Ghofranian. She is a current fourth year Obstetrics and Gynecology resident at the Icahn School of Medicine at Mount Sinai in New York. She is interested in improving IVF outcomes and expanding access to ART in underserved communities. She attended the University of California at San Diego for college and Georgetown University School of Medicine for medical school. And I should mention, she is currently on night float and normally sleeps 8:30 to 5 and so nicely woke up in the middle of the day to do this podcast for us. So thank you so much for joining us today.
Ghofranian: Of course. Any time. Thank you for having me.
Rena: So I'm super excited to talk to you about your study that you will be presenting at ASRM in just a couple of weeks or even next week I guess. Yeah?
Ghofranian: Yeah, yeah. It's coming out soon, Monday.
Rena: Very soon. Oh my gosh. Time flies. So tell us, so the title of your abstract is Assisted Reproductive Technology Treatment Outcomes and Transgender Males With History of Gender Affirming Hormone Therapy.
Rena: Ok. So long title - can you break that down for us and tell us sort of what you were studying for this?
Ghofranian: Yeah, sure. So, and I guess I'll start a little bit just with the background. So, you know, transgender patients are still very much a marginalized group, but recent advances in reproductive rights have really expanded access to healthcare for them. And they do have kind of a broadly defined gender affirming care, which can be divided into surgical care and medical care. Medical care kind of includes puberty blockers, hormone therapy, while surgical care can cover a really wide spectrum from voice surgery to genital reconstructive surgery. So obviously certain surgical therapies like removing your ovaries or removing your uterus would really render somebody permanently in fertile whereas it's pretty, you know, I don't wanna say ambiguous, but there really isn't enough data on what the effects of medical therapy are, particularly like testosterone therapy for transgender males. So, you know, we looked at background research and there's conflicting studies. So, some studies show that, you know, the ovaries that they look at after being removed from a patient who was previously on testosterone therapy look very, you know, atrophic and they don't really have follicles anymore. And that those findings went on to be confirmed by multiple investigators whereas more recently people have found that yes, there are some, you know, features that show, you know, the ovarian cortex, for example, in stroma look like a patient with polycystic ovaries, but it doesn't have like the full morphology, meaning the number of follicles that they saw were actually the same still. So that's really all to say that there's conflicting studies still. And more recently there was some studies that showed similar to, you know, the study that I'm doing now that people were able to have, you know, successful outcomes with ART despite a history of testosterone therapy. So that's kind of everything that brought us to this point.
Rena: Okay. So the objective of your study is to evaluate the effect of testosterone therapy in transgender males and ART treatment outcome.
Rena: So your findings were conclusive that if someone had undergone, undergone testosterone therapy, that they could then have success with ART?
Ghofranian: Yeah, so again, it's a very small cohort of people. So we looked at all of the patients who presented to RMA who either had, you know, a chart alert that said this patient is a transgender patient or they're a partner of a transgender patient, or you know, it, it just had the key words like transgender or trans male in their chart and there was, we started with about 77 patients, but that kind of dwindled down to 11 who had a history of testosterone therapy and then proceeded with treatment. So based on our findings, yes, you know, there were live births with IVF, every single patient who underwent IUI was able to get pregnant and people who underwent embryo freezing, egg freezing had successful outcomes. So yeah, it was very reassuring. You know, we can't really make generalizations obviously based on a group of 11 people, but it definitely contributes to the literature showing that it is possible.
Rena: Yeah, I was curious because when I was reading your abstract, I noticed, you know, you that your sample size was 77. So I was curious how you found the sample size and then, so how did it dwindle from 77 to 11?
Ghofranian: So that's a really good question. There was a breakdown that we saw, so about 46 patients went through fertility preservation or family building counseling, and the remaining 31 were partners of cisgender patients who were undergoing treatment. And then from that 46 who underwent fertility preservation counseling, only 16 actually proceeded to treatment. And then 11 of those 16 actually had a history of testosterone therapy. So, you know, going from 46 to 16 is obviously a big, you know, there was a large attrition rate that we saw only 20% of patients who presented initially actually ended up, you know, undergoing fertility treatment. So, you know, that's something that we're definitely looking into to see what were those kind of prohibiting factors? Was it insurance or was it, you know, a fear of discontinuing testosterone therapy? Because you know, the guidelines, ASRM and the European Society of Reproduction, the Endocrine Society here, they all recommend stopping testosterone therapy for at least three months prior to treatment. So, so yeah, so the numbers really did dwindle down, but you know, that's an area that we wanna look at in the future to see, you know, what were the reasons specifically because they weren't necessarily cited, you know, during this chart review. But it's something that we would definitely want to look into going forward, like by doing patient surveys, for example.
Rena: Yeah, I mean, I'm curious, obviously, you know, myself, the mental health perspective, was any of that, you know, discussed with patients and what sort of the, if any, mental health ramifications there were with discontinuing, you know, the treatment to, to do this?
Ghofranian: Yeah, yeah. So I mean as far as the patients that we looked at, there was no documentation of, you know, any sort of gender dysphoria being triggered by discontinuing their testosterone therapy. Some patients had already been off of it for like, like two years prior to starting to cycle, but some people were only off of it for about two to three weeks. But as far as we know, everybody tolerated being off of it. Well, there was no documentation otherwise. But again, it's somewhere, you know, that we need to look, something we need to look at in the future as far as having like a streamline documentation, you know, about how, how did they feel? Because there definitely are studies out there that show that people can have a really tough time being off of their testosterone therapy. And that's, you know, ultimately, ultimately in the future, you know, I'm hoping that we can create normative data for this group of patients so that hopefully we can, you know, not even have them discontinue testosterone therapy in the future. Hopefully they can continue it. And there is, you know, a few cases where that has been done. One of them was published by us and the Mount Sinai Center for Transgender Medicine and Surgery of a patient who did continue their testosterone therapy actually throughout their controlled ovarian stimulation cycle and they did reciprocal IVF, co-IVF and transferred an embryo into their partner and they had a live birth! So, you know, it, we have, you know, reassuring data that this is possible. We just, you know, need more numbers. So our goal is really to be able to do multi-center studies in the future so we can really get that large n.
Rena: So is that where the future of this is going, to be able to allow someone to continue testosterone therapy while undergoing ART?
Ghofranian: Yes. That, that would be our goal.
Rena: So what needs to be done to, to get the treatment there so that people can, you know, do both in parallel?
Ghofranian: So like I said earlier, the guidelines right now recommend stopping testosterone therapy, but I think what it's gonna take is just multicenter studies, a lot of patients, a lot of, you know, good data to show that people can have great outcomes even while continuing their testosterone therapy. So, you know, we plan on collaborating with other institutions to get a bigger n so that we can really show this and again, do the patients surveys and see, you know, how did patients tolerate it? Is it, is this, you know, feasible? Was it significantly better than stopping their testosterone therapy? But yeah, it's just gonna take some more numbers. We can get there.
Rena: Well it sounds like, I mean, what you're doing is gonna be huge and make a big difference to people undergoing treatment just to allow them to able to maintain, you know, their quality of life.
Ghofranian: Yeah, definitely. I mean that's the hope. So hopefully we can get there.
Rena: Was anything for you specifically surprising when you did this study or, or not really?
Ghofranian: I wouldn't say necessarily surprising, but definitely reassuring that this was consistent with prior studies that have been done. You know, 2019 and 2020, there was a couple of studies that also looked at essentially the same thing. They didn't look at the entire breadth of treatment, like from IVF to egg and embryo freezing and everything in between whereas we were able to capture all of that. But again, it was reassuring that we had similar outcomes. So, so yeah. And you know, again, I think, I don't wanna say people are surprised by it. I think there is definitely a lot of data out there to show what the possible reasons are for patients not, you know, with that high attrition rate, not being able to, you know, pursue their treatment, whether it's cost, insurance coverage, you know, gender dysphoria triggering, but you know, it's just something that keeps me curious and wants to, you know, keep going and find out what those answers are.
Rena: Yeah. Well so what does the future hold for you in terms of work?
Ghofranian: Yeah, so I mean, continuing to do research, planning to do an REI fellowship, expanding these, these research ideas to multi-centers and larger sample sizes and yeah, just exploring, you know, how we can really streamline this process for these patients as far as referral and you know, making the process just easy and as easy as, you know, it can be for anybody else to go through these cycles and, you know, feel like we're really accommodating the patient.
Rena: Sure. Well I think that's wonderful and I think, you know, again, sort of from my perspective, the mental health perspective, I think what my dream is is that it's really a collaborative, integrative approach in that, you know, every patient undergoing treatment then has in tandem, you know, mental health services to be a part of it as well because I think, you know, for anyone going undergoing fertility treatment, I think that's just so necessary.
Ghofranian: A hundred percent. I completely agree with you. It's definitely it needs to be a multidisciplinary approach for sure.
Rena: Well, I'm so happy that we have someone like you in the field to help push this research and expand and try and, you know, make patient experience all the better.
Ghofranian: Thank you, I appreciate that.
Rena: So I guess anything else that you wanna say about this study or anything else that you're working on?
Ghofranian: I dunno, I don't think
Rena: I know it's the middle of the night for you, so
Ghofranian: I'm getting to my end, but no, I mean, I think again, in, you know, in the future we just wanna be able to do multi-center studies to be better equipped to really assess fertility treatment outcomes for this patient population. And you know, my goal is really to be able to help these patients balance their desires for family-building while simultaneously transitioning to or maintaining their gender identity.
Rena: I think that's amazing and I think, you know, again, if they're so lucky to have you, the field's so lucky to have you and you know, physicians and and professionals to do this research to help grow and expand the field and, and provide compassionate patient care. You know, I think since I've been in this field which has been about six years now, which is crazy, you know, I think there is such a, a broader understanding and deeper understanding, you know, as patients, as individuals. And of course, you know, now with the different populations we treat to really meet people where they're at and look at this, you know, from a multidisciplinary approach. And you know, that's why I love RMA because I think that is how we view patients, that's how we work and so it's been such a pleasure to interview different physicians and people that have done, you know, abstracts for ASRM to see what everyone's been working on. You know, it's really incredible.
Ghofranian: Yeah, it's, it's really exciting. Yeah, I'm excited definitely to go to ASRM and see what everybody's been up to. So yeah, it's fun and it's an amazing group, so.
Rena: Well thank you so much for coming on and again, waking up in the middle of your night to do this
Ghofranian: Anytime. It's been great. Thank you so much.
Rena: So the way we like to conclude our episodes is by sharing a gratitude. So something that you are grateful for.
Ghofranian: Oh my gosh, I am grateful for my two little kittens for bringing me joy and when I'm on nights and cuddling with me throughout the day.
Rena: Oh, that's such a good one. I guess I will say then I will say I'm grateful for my little dog, Charlie, who's over there on the couch having a stretch break from her taxing day of napping, but there's nothing like it, you know, just to keep me company and definitely. So yes, every day I wake up and I say to her, I say, Charlie, I'm so grateful for you.
Rena: So thank you so much for coming on and looking forward to seeing what you do next and what comes next, you know, in terms of this study.
Ghofranian: Yeah, yeah. I'm excited. Stay tuned. So there will be more.
Rena: Definitely. Well, thank you.
Ghofranian: Yeah, of course. Thank you so much.
Dara: Thank you so much for listening today. And always remember, practice gratitude, give a little love to someone else and yourself, and remember - you are not alone. Find us on Instagram @fertility_forward and if you're looking for more support, visit us at www.rmany.com and tune in next week for more fertility.