The effects of gender transitioning, particularly the effects of testosterone exposure in transgender men, on the oocyte and embryo development are largely unknown. Based on prior studies suggesting that the extracellular RNAs secreted by the ovarian follicle cells reflect the oocyte and embryo biological state, the investigators propose to use these extracellular RNAs to gain insights into the effects of testosterone exposure in transgender men on their oocyte and embryo without impacting the clinical IVF process.

Background:

MicroRNAs are small RNA molecules that control gene expression in the cell. micro RNAs are also found in the body fluids in vesicles known as exosomes that interact with cellular membranes, release their contents, thus responsible for cell-to-cell contact.

The ovarian follicle fluid contains various substances, including micro RNAs, which are secreted by the various follicle cells and plays an important role in the development and maturation of the oocyte. Recent studies have found that micro RNAs found in the follicle fluid play an important role in the maturation of the oocyte, fertilization, embryo quality, and implantation.

Transgenderism is an umbrella term describing people whose gender identity and/or expression does not align with their sex assigned at birth. A transgender man is a man who was assigned female at birth. The medical interventions for transgender men include hormonal (testosterone) treatment that can negatively affect fertility, and fertility preservation is an option to overcome this potential damage. The fertility preservation options for transmen include oocyte and embryo cryopreservation. The American Society for Reproductive Medicine (ASRM) recommends that: 1. All transgender patients will be counseled regarding the fertility options prior to initiating the medical transition. 2. Transgenders have to preserve gametes (cryopreservation) before starting hormonal therapy. 3. Transgenders that are already using cross-sex hormone treatment have to stop hormone treatment for at least 3 months before fertility preservation. The aim of the current study is to compare the micro RNA profile of the follicle fluid of IVF patients exposed to high testosterone levels with IVF patients with normal testosterone levels and examine the possible association between testosterone exposure and fertility potential.

Specific aims:

1. To characterize the profile of extracellular RNAs in the follicle fluid of transgender patients treated with testosterone.
2. To determine the association of the follicle fluid RNA profile in these patients with the number and quality of oocyte, fertilization potential and the quality of the embryos.

Research plan

Research Location:

IVF Unit, Lis Maternity Hospital, The Tal Aviv Sourasky Medical Center (TASMC) Department of Reproductive Medicine, Division of Maternal Fetal Medicine, University of California, San Diego (UCSD)

Estimated duration: 5 years

Study size: 40 IVF patients: 10 transgender men after testosterone therapy, 10 transgender men before testosterone therapy, 10 patients with the polycystic ovarian syndrome and high endogenic testosterone levels, 10 egg donors

Research design and methods

1. Patients who are intended to participate in the study will receive a detailed explanation of the study and will sign a consent form.

2. IVF patients included in the study will be referred to all tests routinely required prior to IVF procedure, including blood tests for hormonal profile and testosterone levels, and ultrasound for antral follicle count (AFC). Testosterone levels in transgender patients will be tested before and after testosterone therapy is stopped.

3. Patients will get an IVF protocol including hormonal therapy which will be followed by the oocyte retrieval.

4. During oocyte retrieval, follicular fluids will be collected from IVF cycles of 10 transgender patients exposed to testosterone and 30 control patients not exposed to external testosterone (10 transgender men before testosterone therapy, 10 patients with the polycystic ovarian syndrome and high endogenic testosterone levels, 10 egg donors). These biofluids will be discarded materials obtained during the course of clinical IVF cycles.

   The samples of the follicular fluid will be subjected to unrecognized samples with a running number, encoded, thus eliminating any possibility of establishing contact with the particular patient.

5. The follicular fluid will undergo centrifugation and the supernatant will be maintained at -80 degrees in the IVF unit, TASMC.

6. Follicular fluid from clinical IVF cycles from enrolled transgender subjects and controls, along with non-identifiable patient information associated with each follicular fluid and embryo culture fluid sample, including patient age, BMI, use of testosterone, cause of IVF treatment, number of oocytes, number of fertilized oocytes and the quality of embryos, will be transferred from the Amir group at TASMC to the Laurent group at UCSD.

7. At UCSD, extracellular RNA will be isolated from the follicle fluid samples using The Norgen and The ExoRNeasy methods (followed by qRT-PCR validation) and subjected to RNA sequencing analysis using NEBNext multiple small RNAseq library preparation kits.

8. The resulting RNAseq data will be analyzed to identify changes in micro RNA expression associated with clinical variables, including the cause of IVF, testosterone treatment, and embryo quality.

Steps 1-6, 8 will be performed in TASMC. Steps 7-8 will be performed in UCSD.

Inclusion criteria:

* Patients aged 18 and older

Exclusion criteria:

• Patients under 18 years old
• Patients who did not respond to hormone therapy and the IVF cycle was discontinued.

Inclusion Criteria:

* Patients aged 18 and older.

Exclusion Criteria:

• Patients under 18 years old.
• Patients who did not respond to hormone therapy and the IVF cycle was discontinued.

Female undergoing IVF treatments for fertility preservation/infertility/egg donation

Transgender men before testosterone therapy Transgender men after testosterone therapy, Patients with polycystic ovarian syndrome (PCOS) and high testosterone levels undergoing IVF treatments Egg donors undergoing IVF treatments