A Conversation About LGBTQIA+ Fertility Options

What are the different paths to parenthood available to LGBTQIA+ individuals or couples, and how can a fertility specialist (like yourself) help navigate these options?

The great news for LGBTQIA+ individuals is that there are a great number of ways to build one's family. To conceive you need an egg, a sperm, and a uterus and each of these components can be contributed by one or more partners or by a third party. For individuals or couples that do not have or are not able to produce one of these components, they can utilize donor eggs and/or donor sperm to help create an embryo. Additionally, a gestational carrier (often referred to as a surrogate) can be used to carry a pregnancy when there is no uterus available. Other options include the use of donor embryo or adoption. With these methods, the offspring do not have any genetic relation to the parent(s).

The most important thing for these individuals who are interested in learning about family building options is to talk with a fertility specialist (REI Physician) to learn how they can best accomplish their family building goals. The first question I want an individual or a couple to consider is how they envision building their family. Who will contribute the eggs, the sperm, and the uterus for the pregnancy? 

In the case of same-sex couples, sometimes both partners will contribute eggs or sperm in order for each partner to have at least one child that is genetically related to them. For couples where both partners have sperm, one or both partners can contribute sperm to fertilize donor eggs to create an embryo that can be implanted in a gestational carrier. For couples where both partners have a uterus and ovaries, one partner can both contribute the eggs and carry the pregnancy. In these cases, IUI or IVF treatment with donor sperm are options. Another option is for one partner to contribute eggs and the other partner to carry the pregnancy. This is referred to as reciprocal IVF or co-IVF and, as the name implies, involves IVF with donor sperm.

Because there are so many options and important things to consider when navigating this journey, I encourage LGBTQIA+ individuals to meet with a fertility specialist as soon as they are ready to think about planning their family. Individuals with a female sex assigned at birth that are not sure if or when they want to become a parent should also consider meeting with a fertility specialist before age 34 to learn more about fertility preservation options. Transgender individuals should meet with a fertility specialist before beginning gender affirming hormone therapy or undergoing gender affirming surgery that may permanently impact their ability to conceive using their own gametes including removal of the uterus, ovaries, or testicles.

How does the process of using donor sperm, eggs or embryos work for LGBTIA+ individuals or couples interested in building their families?

Individuals that are interested in using donor sperm, donor eggs, or donor embryos should first meet with a fertility specialist for a consult to review their reproductive and medical history. Patients then receive counseling regarding these options as well as education about raising a donor conceived person. Psychosocial experts with experience in third party reproduction can also be part of this conversation to provide additional support to ensure that individuals are fully informed before conceiving with donor gametes. 

For donor sperm, recipients will first undergo a fertility evaluation. Specific blood work that is often done to help pick a sperm donor candidate includes genetic carrier screening to minimize the risk of passing down a genetic condition to the child as well as testing for prior exposure to a common virus called cytomegalovirus which helps minimize the risk of developing an infection during pregnancy that can be harmful to the fetus. Recipients will then search donor sperm bank databases online where they will have access to a sufficient amount of background information for each donor including race, education/occupation, interests, personality, medical and genetic history, and prior pregnancy history. Once a sperm donor is selected, patients can choose to undergo treatment with IUI or IVF depending on their history and family building goals.

For donor egg, recipients will first undergo a fertility evaluation. Specific blood work that is often done to help pick an egg donor candidate includes genetic carrier screening to minimize the risk of passing down a genetic condition to the child. Recipients will then work with their fertility clinic to match with an egg donor or select from a donor egg database where they will have access to a sufficient amount of background information for each donor including race, education/occupation, interests, personality, medical and genetic history, and prior pregnancy history. Patients can choose between using fresh or frozen eggs and must also decide on the number of eggs to receive. The fertility physician will help to guide these decisions based on the family building goals of the individual or couple and the desired family size. Once eggs are received, they can be fertilized with sperm to create embryos which can then be transferred to the uterus of the individual or to a gestational carrier when needed.

For donor embryo, recipients will first undergo a fertility evaluation. Recipients will then work with their fertility clinic to review and select from a donor embryo database where they will have access to the information that is available from the embryo donor. Donor embryos are most often donated by individuals are couples that originally created the embryos for their own family building but are no longer needed for this purpose and instead were altruistically donated. The amount of information available for each donor embryo is dependent on the amount of fertility screening that was originally completed by the donor and this can vary between different donor embryos. Once donor embryos are received, they can be transferred to the individual or to a gestational carrier when needed.

What are the unique challenges faced by LGBTQIA+ individuals or couples when seeking fertility treatment?

Challenges that can be faced by LQBTQIA+ individuals or couples when seeking fertility treatment can include finding a fertility specialist and clinic that is welcoming, inclusive, and able to provide comprehensive evaluation and counseling regarding the full panel of treatment options.

LQBTQIA+ individuals must be aware of the reproductive laws in their state where they are receiving care and where they plan to live and it is generally recommended that they meet with an experienced reproductive law professional for advice specific to the individuals family building plans.

Finally, disparities in access to care remains an area where LGBTQIA+ individuals may face barriers related to insurance coverage for treatment compared to their cisgender and heterosexual peers. Fertility clinics that are experienced in providing counseling for LGBTQIA+ individuals will be able to help you understand your fertility coverage benefits and provide financial counseling and support.

In what ways can fertility clinics and specialists continue to support and advocate for the diverse needs of the LGBTQIA+ community in family building?

One lauded change that is already helping with LGBTQIA+ fertility advocacy is a recent update to the definition of infertility, published by the American Society for Reproductive Medicine (ASRM). The new definition adds that infertility is characterized by “the need for medical intervention, including, but not limited to, the use of donor gametes or donor embryos in order to achieve a successful pregnancy either as an individual or as a partner”. This more inclusive terminology helps to recognize the fertility barriers often faced by LGBTQIA+ individuals or couples and will assist with ongoing efforts to continue to improve fertility mandates and insurance coverage for this population.

Speaking for fertility specialists, we constantly strive to create an environment for our patients that is welcoming, safe, and inclusive. Importantly, we must continue to listen to and support our LGBTQIA+ patients and continuously work toward reproductive health equity where everyone has the access and ability to create the family they desire. This work is done through a large collaboration between fertility clinics, professional infertility organizations like ASRM, and advocacy and education organizations like Resolve and Family Equality.

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