## 4 Discussion  
Our institution established the GPP in 2016 to provide multidisciplinary care for TGNB patients with a focus on reproductive health and fertility preservation. Following its inception, we found a significant increase in the number of FP referrals per year for our TGNB-AMAB patients. The implementation of this formalized PF program allowed our institution to maintain a high rate of sperm cryopreservation among patients who completed the referral process. We also demonstrated an expeditious referral process with a time from referral to sperm banking of only two weeks and a similarly short delay from referral to the initiation of GAHT of approximately one month. Lastly, we found no \begin{table}
\begin{tabular}{c c c c c} \hline \hline  & **Overall** & **\textless{}18 Years Old** & \(\geq\)**18 Years Old** & _p_**-Value** \\  & **(N = 154)** & **(n = 71)** & **(n = 83)** & **(<0.05)** \\ \hline Age at referral (years) & 20.5 \(\pm\) 5.7 & 16.1 \(\pm\) 1.6 & 24.3 \(\pm\) 5.3 & **<0.001** \\ Prior hormonal therapy & 36 (23.4) & 10 (14.1) & 26 (31.3) & **0.01** \\
**Referal Characteristics** & & & & \\ Completed referral & 131 (85.1) & 61 (85.9) & 70 (84.3) & 0.78 \\ (saw MD/APP) & 124 (80.5) & 54 (76.1) & 70 (84.3) & 0.20 \\ Sperm banking & 2.1 \(\pm\) 1.5 & 2.4 \(\pm\) 1.4 & 1.9 \(\pm\) 1.6 & 0.12 \\ Vials per bank & 4.4 \(\pm\) 3.1 & 2.8 \(\pm\) 2.2 & 5.7 \(\pm\) 3.2 & **<0.001** \\
**Semen Parameters** & & & & \\ Ejaculate volume (mL) & 2.7 \(\pm\) 1.7 & 1.9 \(\pm\) 1.1 & 3.4 \(\pm\) 1.7 & **<0.001** \\ Sperm concentration (M/mL) & 36.0 \(\pm\) 31.6 & 30.7 \(\pm\) 29.5 & 40.1 \(\pm\) 32.9 & 0.10 \\ Sperm motility (\%) & 56.8 \(\pm\) 19.0 & 53.9 \(\pm\) 19.9 & 59.0 \(\pm\) 18.0 & 0.13 \\ Sperm morphology (\%) & 4.7 \(\pm\) 2.9 & 4.0 \(\pm\) 2.9 & 5.2 \(\pm\) 2.7 & **0.03** \\ Total motile sperm count (M) & 61.4 \(\pm\) 57.3 & 36.4 \(\pm\) 41.1 & 80.9 \(\pm\) 60.7 & **<0.001** \\ Serum Hormonal Values & & & & \\ Testosterone (ng/dL) & 407.4 \(\pm\) 188.6 & 412.3 \(\pm\) 184.5 & 402.7 \(\pm\) 194.1 & 0.81 \\ FSH (mIU/mL) & 3.3 \(\pm\) 3.4 & 2.9 \(\pm\) 1.6 & 3.6 \(\pm\) 4.6 & 0.48 \\ \hline \hline \end{tabular} APP = advanced practice provider, FSH = follicle-stimulating hormone, MD = medical doctor.  
\end{table} 
Table 2: Cohort demographics and clinical characteristics overall and between pediatric and adult patients. \begin{table}
\begin{tabular}{l c c} \hline \hline  & **Prior GAHT** & **No Prior GAHT** & _p_**-Value** \\  & **(n = 30)** & **(n = 94)** & **(<0.05)** \\ \hline Ejaculate volume (mL) & 2.7 \(\pm\) 1.3 & 2.7 \(\pm\) 1.8 & 0.95 \\ Sperm concentration (M/mL) & 26.8 \(\pm\) 23.5 & 38.1 \(\pm\) 33.5 & 0.09 \\ Sperm motility (\%) & 51.5 \(\pm\) 20.2 & 58.5 \(\pm\) 18.4 & 0.08 \\ Sperm morphology (\%) & 4.2 \(\pm\) 3.3 & 4.8 \(\pm\) 2.8 & 0.24 \\ Total motile sperm count (M) & 51.2 \(\pm\) 63.3 & 62.7 \(\pm\) 55.4 & 0.34 \\ \hline \hline \end{tabular}
\end{table} 
Table 3: Comparison of semen parameters between patients with and without prior GAHT who completed sperm cryopreservation. difference in semen parameters between patients with or without prior GAHT. Our study demonstrates that a formalized FP program can adequately address the reproductive needs of TGNB-AMAB patients planning to undergo gender affirmation. Our FP program saw an increase in the number of annual referrals from 5 patients in 2016 to 42 patients in 2023. In the state of Illinois, transgender FP became covered by insurance under H.B. 2617 as medical fertility preservation on 1 January 2019, which amended the Illinois insurance code to \"provide that a policy of accident or health insurance shall provide coverage for medically necessary expenses for standard fertility preservation services when a necessary medical treatment may directly or indirectly cause iatrogenic infertility to an enrollee\" [19]. While this legislation likely helped increase referrals, the number of referrals per year had already doubled prior to its enactment.