Partial rejuvenation of the spermatogonial stem cell niche after gender-affirming hormone therapy in trans women

Reviewer #1 (Public Review):

Summary:

This is a nice paper taking a broad range of aspects and endpoints into account. The effect of GAHT in girls has been nicely worked out. Changes in Sertoli and peritubular cells appear valid, less strong evidence is provided for Leydig cell development. The recovery of SSCs appears an overjudgement and should be rephrased. The multitude and diversity of datasets appear a strength and a weakness as some datasets were not sufficiently critically reviewed and a selection of highlights provides a certain bias to the interpretation and conclusion of the study.

The authors need to indicate that the subset of data on SSCs has been reported previously (Human Reprod 36: 5-15 (2021) and is simply re-incorporated in the present paper. as Fig. 1C. There are sufficient new results to publish the remaining datasets as a separate paper. Authors could refer to the SSC data with reference to the previous publication.

Strengths:

The patient cohort is impressive and is nicely characterized. Here, histological endpoints and endocrine profiles were analyzed appropriately for most endpoints. The paper is well-written and has many new findings.

Weaknesses:

The patients and controls are poorly separated in regard to pubertal status. Here additional endpoints (e.g. Tanner status) would have been helpful especially as the individual patient history is unknown. Pre- and peri-puberty is a very rough differentiation. The characterization and evaluation of Leydig cells is the weakest histological endpoint. Here, additional markers may be required. Fig. 1 suffers from suboptimal micrograph quality.

Reviewer #2 (Public Review):

Summary:

The study is devoted to the deep investigation of the spermatogonial stem cell (SSC) niche in trans women after gender-affirming hormone therapy (GAHT). Both cellular structure and functionality of the niche were studied. The authors evidently demonstrated that all cellular components of SSC niche were affected by hormone therapy. Interestingly, the signs of "rejuvenation" within the niche were also observed indicating the possible reverse to the immature condition.

Strengths:

The obtained findings are important for the better understanding of hormonal regulation of testis and SSC niche and provide some clues for using the biomaterials from these specific and even unique donors for biomedical research.

Weaknesses:

This study has some limitations. Many studies can't be done using the testes cells of trans women, since their cells are significantly different from adult man cells and less from prepubertal and pubertal cells. The authors themselves identify some of the limitations: this material is suitable only for studying prepubertal processes in the testis. However, the authors also report large variability in data due to different hormonal therapy regimens and, apparently, age. Accordingly, not all material obtained from trans women can also be used for studies of prepubertal processes.

Author response:

The authors express their gratitude to the reviewers for their insightful comments.

Reviewer #1: We are uncertain about the reference to an overjudgement of the recovery of spermatogonial stem cells, as we did not draw any conclusions on this in the current study. Additionally, we have received feedback mentioning the multitude and diversity of datasets as both a strength and a weakness. However, we would appreciate clarification on which datasets may have been insufficiently reviewed and how our selection of highlights may have introduced bias to the interpretation and conclusion of the study. It is important to note that we did not select any patients/ data; all patient data were incorporated into our results section. We acknowledge the need for clarification regarding our study population for the germ cell stainings. As stated in our Materials and Methods section, our current study population includes the cohort from our previous publication (Vereecke et al., 2020), supplemented by nine additional participants, totaling n=106 trans women. While Fig. 1C incorporates both previous and new data on germ cells, we understand the need to clarify this to avoid confusion. Additionally, we will include information on the Tanner stages of the trans women in our cohort (all G5), as well as details on the selection criteria for our controls and their Tanner stages. As briefly touched upon in the discussion, a marker such as delta-like homolog 1 would indeed be valuable to assess the presence of truly immature Leydig cells. Unfortunately, our attempts to optimize the immunofluorescence protocol for this marker were unsuccessful, resulting in a double staining instead of a triple staining for the Leydig cells. The suboptimal resolution of Fig.1 will be solved.

Reviewer #2 raises concerns regarding the suitability of rejuvenated testicular tissue for research purposes. However, we emphasize that this tissue source holds significant value. Although there is a wide availability of adult testicular tissue (coming from prostate cancer patients or vasectomy reversal patients), we are especially looking for alternatives for the scarce prepubertal/ pubertal tissue for research on in vitro spermatogenesis. While we acknowledge that transgender tissue with severe hyalinization or without spermatogonia may not be suitable for such research, the abundance of transgender tissue without these issues emphasizes the value of this tissue source.