Such high graft failure risk was not observed in female-to-male LT with > 40 years donors (decreased systemic estrogen secretion in the lack of ovarian reserve [infertility] or macrosteatotic donors (decreased hepatic estrogen receptor expression) despite worse graft quality12–15, 18, supporting the role of hepatic sex hormonal mismatch in the inferiority of female-to-male LT. Here, ESR1 is linked to Infertility.