## 4 Discussion
We also observed a proportional rise in patients completing their referral consultation and pursuing sperm banking. During each year of our formalized FP program, more than 70% of the referred patients completed sperm cryopreservation, showing that programs such as this with adequate staffing (including fertility preservation navigators to coordinate referrals, and reproductive urologists and APPs) can be scaled to accommodate a growing patient volume. While data on fertility preservation rates in TGNB-AMAB patients is limited, our finding are comparable with prior studies that report sperm banking utilization rates between 40 and 85% [20,21]. In a systematic review by [PERSON] et al. that evaluated psychosocial, attitudinal, and systemic factors associated with pursuing FP, the authors found a significantly higher rate of FP utilization among patients referred for fertility consultation at specialty fertility centers than among those without these resources [22]. Overall, our results contribute to the existing literature that shows formal FP programs and referrals are effective at increasing FP completion rates among TGNB-AMAB patients. The FP referral process, which consists of a screening telephone interview by our Fertility Preservation Program Manager followed by referral consultation to a reproductive urology MD/APP, provides minimal delay to both sperm banking and time to initiation of GAHT after banking. The delay in the initiation of hormonal therapy is often cited as a significant concern and barrier to care in TGNB-AMAB patients wishing to undergo FP [23,24]. Consequently, prioritizing FP at the expense of delaying the initiation of GAHT for gender dysphoria is a dilemma often faced by TGNB-AMAB patients. Our study found a median time of two weeks from referral to sperm banking and of less than one month from initial referral to the initiation of GAHT. In a prior survey study by [PERSON] et al., the authors found that less than 5% of transgender and gender-diverse youth respondents would delay GAHT by more than three months in order to undergo FP [25]. The relatively short duration from referral to the initiation of GAHT among patients undergoing FP in our study indicates that delays in the initiation of GAHT can be avoided when a formalized FP program is established. We found no significant difference in the rate of referral completion or rate of pursuing sperm banking between pediatric/adolescent and adult patients. Pediatric/adolescent patients had a significantly lower average number of vials per sperm banking procedure, lower ejaculate volume, sperm morphology, and TMSC than adults. However, the average TMSC among pediatric patients was above the requisite clinical threshold for intrauterine insemination or other ART procedures such as in vitro fertilization [26]. These data support prior studies that show adolescents pursuing FP to have significantly lower semen parameters than adults [27]. Previous studies also show that over 70% of young adolescent TGNB-AMAB patients wished to be the sole decision-maker (without parental input) on whether to pursue FP [25]. Taken together, our findings underscore the importance of providing age-appropriate counseling for pediatric patients. They pursue FP at a similar rate to adults when allowedaccess to a formal FP program and can provide semen samples with adequate parameters to become biological parents in the future. Lastly, our study found no difference in semen parameters between patients with and without prior use of GAHT. However, prior studies show conflicting results. [PERSON] et al. analyzed semen parameters among 28 TGNB-AMAB patients without prior GAHT (n = 18), prior GAHT (n = 3), and current GAHT use (n = 7). In their cohort, TGNB-AMAB patients with prior and current GAHT use had significantly lower semen parameters than patients without prior GAHT, even following a median discontinuation time of 4.4 months (range: 3-6.5 months) among the cohort with prior exposure [15]. Similarly, [PERSON] et al.