149 Use of fertility preservation among a cohort of transgirls in the Netherlands 8 Early pubertal phase precluded FP for a number of transgirls. Adolescents and physicians are faced with this dilemma between the wish for early treatment to avoid virilization on the one hand, and the wish for FP on the other hand, more often now that increasing numbers of adolescents are referred for hormonal treatment at younger ages. Research on in vitro maturation of spermatozoa might provide future solutions for these early pubertal adolescents (Wallace, Blough, & Kondapalli, 2014). The need to masturbate was another reason to decline FP. Alternative options for extracting sperm such as testicular sperm extraction or electroejaculation stimulation could be used to facilitate FP. In the case report and literature review by Lau, Li and Soh (2014), electroejaculation appeared to be relatively safe. However, in the Netherlands, this procedure is currently only offered by some clinics to adolescents starting cancer treatment when it can be combined with a procedure that already requires anaesthesia such as placement of a central venous catheter. Differences in costs of the procedure and health insurance coverage may explain some of the difference in use of FP between studies. Although costs were mentioned as a barrier by only 5% of transgirls in the retrospective study by Nahata and colleagues (2017), the reason for refusal of FP was unknown in 26%; therefore, costs may have been an important factor for more adolescents. In the present study, none of the patients had mentioned costs as a reason to decline FP probably because most insurance will cover most of the costs of FP. When thinking of pregnancy/conception options, transgirls attracted to women might be more likely to cryopreserve their sperm than those attracted to men because this would allow them to conceive a child with their female partner. A previous study did indeed find that lesbian or bisexual transwomen were more likely to state that they would, if possible, have cryopreserved sperm than asexual or heterosexual transwomen (de Sutter et al., 2002). However, we did not find such a correlation, but this may have been because of the small group size and missing data, as only four transgirls stated they were attracted to women. Furthermore, sexual orientation is difficult to assess with certainty at a young age, so these results need to be interpreted with caution. In addition, transgirls who are attracted to men may also wish to use FP to allow them to have children with the help of a surrogate mother. Surrogacy (if not commercial) is legal in the Netherlands. Caucasian transgirls were more likely to decline FP than adolescents with other ethnicities, but the latter were older than Caucasian transgirls (15.9 ± 1.5 years vs. 14.4 ± 1.9 years), so this association may be confounded by age. On the other hand, there may be a true association with ethnicity because of the differences in reproductive pressure and importance given to reproduction in different cultures. This is supported by a study by Schmid, Kirchengast, Vytiska-Binstorfer, and Huber (2004) where cisgender infertile women