An Introduction to LGBTQ Fertility and Family Building

One of the great joys of my profession is being able to leverage modern assisted reproductive technology techniques to provide LGBTQ couples with a myriad of family building options. As a fertility doctor, I recognize my LGBTQ patients as a distinct group of patients who have unique needs and face specific challenges. I put together this article to provide LGBTQ individuals and their allies with a broad overview of the major points to consider when it comes to building one’s family as a same sex couple or transgender person and to highlight that there are distinct strategic, physical, emotional, and financial challenges to overcome.

Pre-treatment testing

For any LGBTQ couple seeking to build a family, it is important to undergo a medical evaluation to figure out the most successful, efficient, and cost-effective path forward prior to starting any treatment-based options.

The basic fertility work up involves testing the following:

• Sperm quality should be tested in a partner with testes or any individual looking to act as a ‘known or designated sperm donor’: this involves collecting a sample via ejaculation and then looking at sperm under the microscope to assess the volume, concentration, how well the sperm moves in a forward direction, and the overall proportion of normally shaped sperm

• Fallopian tubes can be checked for scarring or blockages with a hysterosalpingogram (HSG) which is an x-ray of the pelvis while dye is injected into the uterus, with observation to confirm whether the dye spilled from either Fallopian tube.

• The uterus can be viewed on ultrasound or on the HSG test (see above) to ensure that the inner lining is smooth and not interrupted by scar tissue, fibroids, polyps, or any other structural factor that could prevent an embryo from successfully implanting.

• Ovaries can be tested for the quantity of eggs by counting the number of follicles (fluid filled spaces that each hold a single egg) seen in the ovaries and by measuring a hormone in the blood called antimullerian hormone (AMH). The number of eggs you have is important to know how many potential eggs we can access in a given IVF or egg freezing cycle. You can also assess the ovaries to confirm whether ovulation has taken place by viewing a ruptured follicle on ultrasound scan or checking progesterone levels a few days and up until a week post-ovulation.

• Genetic testing: If planning to use a sperm or egg donor to conceive, it is imperative to undergo genetic testing to determine what mutations you carry so that you can select a donor who is confirmed to NOT carry the same mutation. It is extremely common to have a single mutated gene – most of these types of gene mutations require both copies of a gene to be mutated to cause actual disease. Therefore, if an individual carries a single copy, it is prudent to choose a donor tested and confirmed negative for that mutation to minimize the risk of having a child with two mutated copies of the same gene, a scenario where the child would be affected by the disease.

• Infectious disease screening: Donors are also screened for infection diseases and cytomegalovirus (CMV). For those using donor sperm to conceive and carry a pregnancy, it is important to know if they are immune to CMV. If found to be non-immune, it is advisable to use a CMV negative donor to minimize the risk of contracting this virus around the time of pregnancy, as it can cause major birth defects in pregnancy.

Many doctors have differing opinions on how much testing to do upfront in LGBTQ couples prior to them initiating treatment. Unlike heterosexual couples who may present to a fertility clinic after months to years of trying to conceive, there is no reason to assume a same sex female couple would have blocked tubes as the logical assumption regarding the underlying cause of fertility is that it stems from lack of exposure to sperm. Despite this, I most often encourage patients to seek out early testing, even in the context of being in a same sex relationship. The reason I recommend thorough testing early in the process is to minimize the risk of wasting one’s time on ineffective treatments, to ensure that resources are being used wisely and that the treatment strategy is in line with overall big picture goals for the patient/couple.

Family building options for same-sex female couples:

Designated vs Anonymous sperm donors

A known/designated donor is a donor an individual or couple chooses. This individual will need to be screened for infectious diseases, submit samples of sperm that can be quarantined for 3-6 months and then be retested at the end of the quarantine to ensure that they still are negative for infectious disease before the samples can be released for use in a cycle. This screening and quarantine process can cost a few thousand dollars and adds to the overall cost of treatment and will delay being able to start one’s treatment journey until the quarantine ends. Additionally, there should be a legal agreement set up between both parties to ensure that parental rights are protected and that there are no debates regarding custody of children or obligations for financial support in the future.

An anonymous sperm donor works directly with a licensed sperm bank which performs the testing/screening and quarantines the sperm. An anonymous donor has no parental rights and protects your privacy.

***It is important realize that no donor can be truly anonymous in today’s age of DNA testing with results which can be posted to publicly available databases. It is important to be aware of this fact and for any parent who used a donor to conceive to mentally prepare for whether, how, and when they plan to discuss this with their child in the future.

Intrauterine Insemination (IUI):

IUI involves getting sperm into the reproductive track 1-2 days prior to ovulation of an egg. A donor sperm insemination can be done using the single egg ovulated in a natural cycle. This is a good option for patients who are young, with regular menstrual cycles, who are strongly opposed to the risk of twins that is seen when using medication to ovulate multiple eggs, and those who have risk factors for a high risk pregnancy who want to minimize the risk of twins. Patients who are older with lesser egg quality, have irregular and long cycles, and those who ave failed natural cycle inseminations may opt to use medications such as Clomid or Letrozole to provide their body with the opportunity to release more than 1 egg to increase the odds of success. In general, insemination is considered a lower efficacy, more laid back option. The success rates tend to hover between 5-15% as there is a lot left up to chance (ie. will the sperm and egg interact, fertilize, turn into a healthy embryo, and find the right spot to implant in the uterine cavity?)

Advantages of Donor Sperm IUI: cheaper, more likely to be covered by insurance, laid back/less invasive, if taking medications mainly requires oral pills +/- a single injection.

Disadvantages of Donor Sperm IUI: risk of multiple pregnancy (twins) is ~3-8%, doesn’t modify or improve risk of miscarriage due to egg/embryo quality issues, does not allow for freezing embryos for future use, knowing how many vials of donor sperm to purchase for oneself and potentially to be used by another female partner can be complicated as it is impossible to predict whether inseminations will work and how many rounds may be required.

Co-IVF or Reciprocal IVF:

Co-IVF, or Reciprocal IVF, is the most aggressive and involved treatment option which also tends to be the most successful. IVF involves stimulating the ovaries to mature and then extract eggs (a quick and minor procedure that is done vaginally), and then fertilize them with donor sperm. The fertilized eggs are grown into embryos over the course of 1 week and at that stage the embryos can either be transferred, frozen, or biopsied for genetic testing before undergoing freezing. The embryo is then placed at the top of the uterus, or ‘transferred’. About 8-9 days post transfer, patients will be able to find out if they are pregnant.

Co-IVF involves one partner undergoing ovarian stimulation and egg retrieval to then have their eggs fertilized with donor sperm and turned into embryos. The embryos will then be transferred into the other partner’s uterus, so they can carry the pregnancy. This is a great option for same sex female couples who both want to play integral role in creating the pregnancy.

Advantages of Co-IVF: high success rates (up to 60-65% chance of live birth if using a genetically normal embryo), low chance of twins (most clinics will only use 1 embryo at a time if a patient is young and/or used a genetically normal embryo with a high chance of success – the chance of an embryo splitting into twins is less than 2-3%), lower risk of miscarriage if a genetically tested embryo is used, the ability to freeze embryos for future use from a single cycle as a form of fertility preservation, allows for reciprocal IVF with a female partner who wants to carry the pregnancy, simplifies the problem of knowing how much donor sperm to purchase (since one can use a single vial of sperm to inseminate all eggs retrieved in a single IVF cycle).

Disadvantages of IVF: not guaranteed to be successful (particularly if starting with low egg count or poor egg quality), expensive, usually not covered by insurance right away without doing 6-12 rounds of ‘less effective’ treatments such as IUI, more involved (daily injections for 8-10 days and a procedure requiring anesthesia to extract eggs).

Family building options for same-sex male couples:

Egg Donation and Gestational Surrogacy

For same-sex male couples, an IVF-based approach requires both the use of an egg donor to create an embryo with either partner’s sperm and then the implanting of the resulting embryo into the uterus of a gestational carrier (a woman who agrees to carry the pregnancy and deliver the baby). With a gestational carrier, there is no genetic link between the embryo and the carrier.

Traditional Surrogacy

This involves a surrogate mother who carries and gives birth to a child for the couple. Unlike a gestational carrier, with traditional surrogacy the surrogate’s egg is used, making her the biological mother of the child. With traditional surrogacy, either an IUI or IVF based approach may be used depending on the circumstances.

Embryo Adoption

In this less common scenario, embryos that were created by couples undergoing IVF but were not used are sometimes available for “adoption.” The adopted embryo is then implanted into a surrogate mother.

Adoption

This is one of the most common methods. It involves the legal process of taking on parental responsibility for a child that is not biologically one’s own. Adoption can be from within the country (domestic adoption) or from another country (international adoption).

Remember, laws and regulations regarding these options can vary widely, both within countries and between them. It’s essential to consult with legal experts and fertility specialists in your area to understand what your options are, what the process involves, and the potential costs.

Despite significant strides in improving the family building options available, there is much work to be done. Access to care remains a critical problem, with many insurance policies requiring patients to meet a technical criteria for infertility that is discriminatory and does not apply to same sex couples before treatments will be covered. Same sex couples often must pay out of pocket for 6 to 12 months of fertility testing and treatment (ie. donor sperm insemination) before they qualify for IVF coverage. Thankfully, laws are being enacted to rectify this issue and mandate broader infertility coverage. Just this year, NY state began to mandate that insurers provide immediate coverage for fertility treatment for same sex couples, without them having to prove that they meet the definition of infertility based on the duration of time they have been trying to conceive.

My advice to anyone interested in exploring their options and learning more about LGBTQ family building options is to see a fertility expert early in the process. Discuss your overall family goals (ie. How many children do you want? If part of a couple, how will each partner contribute (who will carry the pregnancy or provide the egg/sperm) and don’t be afraid of undergoing basic fertility testing to identify any potential barriers to successful treatment as early as possible. It is never too early to start the conversation.