Testicular Functions and Clinical Characterization of Patients with Gender Dysphoria (GD) Undergoing Sex Reassignment Surgery (SRS) Florian Schneider,

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Testicular Functions and Clinical Characterization of Patients with Gender Dysphoria (GD) Undergoing Sex Reassignment Surgery (SRS) Florian Schneider, MD, Nina Neuhaus, PhD, Joachim Wistuba, PhD, Michael Zitzmann, MD, Jochen Heß, MD, Dorothee Mahler, MD, Hermann van Ahlen, MD, Stefan Schlatt, PhD, Sabine Kliesch, MD The Journal of Sexual Medicine Volume 12, Issue 11, Pages 2190-2200 (January 2015) DOI: 10.1111/jsm.13022 Copyright © 2015 International Society for Sexual Medicine Terms and Conditions

Figure 1 Blood serum hormone levels of luteinizing hormone (LH) (A), follicle-stimulating hormone (FSH) (B), testosterone (C), sex hormone-binding globuline (SHBG) (D), free testosterone (E), estradiol (F), and prolactin (G) in total values. Data are presented as mean with standard error of the mean (SEM) (A1-G1). Blood serum hormone levels according to the clinic of origin (A2–G2) of n = 80 patients. The blue line marks the male and the red line marks the female reference line. Significant differences are indicated as *P < 0.05, if **P < 0.005, if ***P < 0.0001, and if ****P < 0.00001 The Journal of Sexual Medicine 2015 12, 2190-2200DOI: (10.1111/jsm.13022) Copyright © 2015 International Society for Sexual Medicine Terms and Conditions

Figure 2 Weight of testicular tissue with capsule ing according to the level of spermatogenesis (A). Results for subjects with complete spermatogenesis (CS), meiotic arrest (MA), spermatogonial arrest (SPG-A), Sertoli-cell-only syndrome (SCO), and tubular shadows (TS) are shown as mean with SEM. Significant differences are presented as *P < 0.05, if **P < 0.005, if ***P < 0.0001, and if ****P < 0.00001. B and C show the correlation of testicular weight (with capsule in g) and testosterone (nmol/L) and free testosterone (pmol/L), respectively The Journal of Sexual Medicine 2015 12, 2190-2200DOI: (10.1111/jsm.13022) Copyright © 2015 International Society for Sexual Medicine Terms and Conditions

Figure 3 Micrographs of representative periodic acid-Schiff (PAS)-stained testicular tissues (A) with tubular shadows (A1), Sertoli-cell-only (SCO) (A2), spermatogonial arrest (A3), meiotic arrest (A4) and complete spermatogenesis (A5). The scale bar represents 20 μm. Total number of tissues with a specific state of spermatogenesis (B). Number of subjects with a specific state of spermatogenesis according to the clinic of origin (C). Black bars represent clinic A, dark grey bars, clinic B and light grey bars clinic C The Journal of Sexual Medicine 2015 12, 2190-2200DOI: (10.1111/jsm.13022) Copyright © 2015 International Society for Sexual Medicine Terms and Conditions

Figure 4 Intratesticular testosterone (ITT) measurements in pmol/g (n = 159) according to the level of spermatogenesis (A) and according to the clinic of origin (B). Data are presented as mean with standard error of the mean (SEM). CS, complete spermatogenesis; MA, meiotic arrest; SPG-A, spermatogonial arrest; TS, tubular shadows. The red lines indicates the reference lines at 8,000–12,000 pmol/g. Significant differences are marked as *P < 0.05, if **P < 0.005, if ***P < 0.0001, and if ****P < 0.00001 The Journal of Sexual Medicine 2015 12, 2190-2200DOI: (10.1111/jsm.13022) Copyright © 2015 International Society for Sexual Medicine Terms and Conditions

Figure 5 Correlation of luteinizing hormone (LH) receptor positive (in %, A) and negative cells (in %; B) according to intratesticular testosterone (ITT) levels (pmol/g) and histological stainings (C). Control (C1) and complete spermatogenesis (C2). The scale bar represents 20 μm The Journal of Sexual Medicine 2015 12, 2190-2200DOI: (10.1111/jsm.13022) Copyright © 2015 International Society for Sexual Medicine Terms and Conditions