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This blog post is written by Dr. Lucky Sekhon, reproductive endocrinologist, infertility specialist, board certified OBGYN, at RMA of New York. Dr. Sekhon has particular expertise in fertility preservation (egg freezing), LGBTQ family building, and in vitro fertilization.
Having the opportunity to build one’s family is an important, basic right. Assisted Reproductive Technologies (ART) provide the LGBTQ community with a a wide array of family building options. As a fertility doctor, I consider LGTBQ patients as a unique group of patients who do not have proven fertility or infertility – their needs are unique and present specific challenges. When it comes to building one’s family as a same sex couple or transgender person, there are distinct strategic, physical, emotional, and financial challenges to consider.
Before pursuing treatment to start building one’s family, a thorough evaluation is necessary to determine the most efficient, effective, and practical path forward.
The basic fertility work up involves testing:
- Sperm quality of a partner with testes or any individual looking to act as a ‘known or designated sperm donor’: a sample is collected via ejaculation and then analyzed under a microscope for it’s volume, concentration, motility, and morphology (the overall proportion of sperm with a normal shape).
- Fallopian tubes should be examined for scar tissue or blockages using a hysterosalpingogram (HSG), an x-ray of the pelvis.
- The uterus can be examined with an ultrasound or on the HSG test (see above) to make sure there is no structural issues (ie. scar tissue, fibroids, polyps) that could get in the way of an embryo implanting.
- Ovaries can be assessed for egg quantity by looking at the number of follicles (fluid filled spaces that each hold a single egg) visible on an ultrasound of the ovaries and by measuring the levels of antimullerian hormone (AMH) in the blood. Egg quantity correlates with the potential response to IVF treatment and the number of eggs yielded in a single IVF or egg freezing cycle. Ultrasound of the ovaries can also confirm that ovulation has taken place. Measuring progesterone levels a week or so after ovulation can also confirm that ovulation occurred.
- Genetic testing: If using a sperm or egg donor, one should have genetic testing to determine what mutations are carried in order to choose a donor without that particular mutation. Most of the types of gene mutations tested on these panels require that both copies of a gene should be mutated to result in manifestation of the actual disease. If known to carry a particular mutation, a patient should choose a donor tested and confirmed negative for that mutation to minimize the risk of having an affected child with two mutated copies.
- Infectious disease screening: Patients and donors used should be screened for infection diseases and cytomegalovirus (CMV). If using a donor, it is important to know if one is immune to CMV, which is a common virus that causes cold and flu like symptoms, but can cause major birth defects if infection occurs during pregnancy. If found to be non-immune, it is best to use a CMV negative donor to minimize the risk of contracting this virus around the time of pregnancy.
Unlike heterosexual couples who have typically spent months to years trying to conceive on their own prior to presenting to a fertility clinic, same sex couples should not be assumed to be infertile. For same sex female couples, the lack of ability to conceive stems from lack of exposure to sperm. Despite this, patients are encouraged to seek out early testing to reduce the risk of wasting time by engaged in ineffective treatments and to utilize resources wisely. Most importantly, speaking to a fertility specialist can help to ensure a treatment approach that facilitates both short and long-term family building goals.
Family building options for same-sex female couples:
Donor sperm options
A known/designated donor, who is familiar to an individual or couple, will need to be screened for infectious diseases, prior to collecting and then quarantining sperm samples for 3-6 months. Sperm then needs to be retested before the samples can be released from quarantine and used to conceive. This screening and quarantine process adds to the overall cost of treatment and will delay the ability to begin treatment. There are also major legal considerations with known donors, where parental rights should be established and protected to minimize questions about custody and financial support later on.
An anonymous sperm donor can be found through a licensed sperm bank which takes on the testing/screening and quarantining of the sperm. Anonymous donors have no parental rights and privacy is protected.
***It is important realize that no donor can be truly anonymous given the use of at-home DNA tests, where data generated can be publicly available. For any parent who used a donor to conceive, one should think through when and how they plan to disclose this information to their children.
- Donor sperm intrauterine insemination (IUI): Sperm must enter the reproductive track within a few days before ovulation. A donor sperm insemination can be done in a natural cycle, where only 1 egg is released. Older patients with lower egg quality, those with irregular and long cycles, and those who have failed natural cycle inseminations may opt to use medications. Clomid and letrozole work by potentially releasing more than 1 egg to increase the odds of pregnancy. In individuals with irregular menses, these medications can be used to promote regular ovulation. Intrauterine insemination with and without medications is considered a more laid back treatment option, with success rates that lie between 5-15%.
Advantages of 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 IUI: multiple pregnancy (twins) risk is ~3-8%, doesn’t change the miscarriage due to egg/embryo quality issues, does not allow for embryo freezing to preserve fertility, estimating the number of donor sperm vials needed can be complicated as it is impossible to predict whether inseminations will work for one or both partners, and how many cycles may be required.
- In vitro fertilization (IVF):
This is the most successful, efficient, and aggressive treatment approach. The ovaries undergo stimulation to mature eggs before they are retrieved in a minor surgery where a long, thin needle is passed vaginally. Eggs are then fertilized with sperm and grown into embryos which either be transferred, frozen, or samples to perform genetic testing before they are frozen. Embryos are then transferred to the uterine cavity.
- Co-IVF/Reciprocal IVF:
Reciprocal IVF, also known as co-IVF, involves one partner undergoing ovarian stimulation and egg retrieval to create embryos that are then transferred into the other partner’s uterus. This allows both members of a same sex female couple to play major role in creating the pregnancy.
Advantages of IVF: high success rates, reduced odds of twins (most clinics will only transfer a single embryo at a time, lower risk of miscarriage if embryo transferred is genetically normal, IVF allows for freezing embryos for fertility preservation, allows for reciprocal IVF, minimizes the number of the donor sperm vials needed (a single vial of sperm to inseminate all eggs retrieved in a single IVF cycle).
Disadvantages of IVF: expensive, may not be covered by insurance – or may only be covered after a minimum number of IUI cycles, more invasive- requiring daily injections for 8-10 days a minor surgery under anesthesia to retrieve eggs.
Family building options for same-sex male couples:
- Same sex male couples can use an egg donor (known or anonymous) to with either partner’s sperm. The resulting embryos can be transferred into the uterus of a gestational carrier (a woman who agrees to carry the pregnancy and deliver the baby).
Adoption is a family building option for all individuals/couples, regardless of their biology or sexual orientation/gender identity.
Despite significant improvements and expansion of the family building options available, there is much work to be done. Access to care remains a challenge, with many insurance policies using outdated definitions and technical criteria for infertility coverage that do not apply to same sex couples. Thankfully, in some states, laws are being enacted to rectify this issue and mandate broader infertility coverage. Recently, NY state mandated 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.
Anyone interested in learning more about LGBTQ family building should seek out a fertility expert and have a reproductive check-up early in the process. It is important to discuss and determine your overall family goals (ie. how many children? How will each partner contribute (who will carry the pregnancy or provide the egg/sperm)? Undergoing basic fertility testing can help to identify potential barriers to successful treatment as early as possible. It is never too early to start the conversation.
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