LGBTQ couples face unique challenges when considering starting a family. The most common questions and concerns revolve around how third party reproduction and assisted reproductive technology (ART) help members of the LGBTQ community have a family or plan for the future.
Here’s a basic primer, breaking down the various approaches—from insemination to assisted reproductive technology and how they might help.
Insemination: for an individual–whether single or in a lesbian relationship- who wishes to conceive and doesn’t have any underlying infertility issues, donor sperm insemination is a fairly simple method to help with conception. Frozen sperm from a sperm bank—either from an anonymous or known source—can be inserted into the uterus/cervix/upper vagina right around the time of ovulation using a thin catheter and syringe (absolutely no needles required!). Insemination can be done both at home or in the doctor’s office—though for those using known donor sperm, legal experts frequently advise pursuing insemination in a physician’s office to cover some of the legal issues surrounding known donor sperm use. Certain infertility problems such as blocked fallopian tubes or older aged eggs may prevent donor insemination from being successful.
IVF (in vitro fertilization): IVF can help individuals conceive if donor (or partner) insemination is unsuccessful or if the person has certain types of infertility which do not respond to insemination. Typically, 9-12 days of daily hormone injections are used to help mature a group of eggs within the ovaries. The eggs are then surgically vacuumed from the ovaries. In a laboratory, an embryologist uses sperm to fertilize the eggs. The fertilized eggs are then incubated in the lab for 3-6 days. Embryos that grow successfully can then be placed into a person’s uterus or frozen for future use.
In some lesbian relationships, one partner may undergo IVF so she can “donate” her eggs to the other partner (the “recipient”). The resultant embryo (s) are then placed into the “recipient” partner’s uterus to help her conceive.
Transgender males who have not undergone gender-affirming surgery but who are on hormone therapy may consider temporarily stopping use of hormone therapy to try an IVF procedure and create embryos using donor sperm or partner sperm. Resultant embryos can then be placed into the patient’s uterus or a female partner’s uterus or a gestational carrier for pregnancy attempts. Occasionally, pregnancy can result via conception attempts with a male partner or via donor sperm insemination.
Transgender females who are on hormone therapy but who have not undergone gender-affirming surgery should consult with a urologist specializing in fertility. Transgender hormone therapy needs to stop to allow sperm production to resume and this may take anywhere from a few months to two years, according to Dr. Peter Stahl, Assistant Professor of Urology and Director of Male Reproductive & Sexual Medicine at Columbia University. Additionally, Stahl counsels that different hormones may need to be prescribed to help promote sperm generation. The resultant sperm can then be used via insemination therapy or IVF to help with pregnancy attempts. Occasionally, pregnancy can result via natural conception attempts with a female partner.
Donor IVF: donor eggs (either previously harvested, frozen and purchased from a donor egg bank or freshly harvested from an egg donor) can be fertilized with sperm from a single male or, occasionally, from both male partners in a gay couple. The resultant embryo(s) can then be frozen or---if a gestational carrier (a woman who has agreed to carry a pregnancy for an individual or couple) is already available—placed directly into the uterus of the carrier.
Fertility preservation: for those not yet ready to have a child, but seeking to maintain the possibility in the future, egg or embryo freezing are options to consider. Normal aging can dramatically lower fertility potential as women age—particularly as they advance into their late 30s and 40s. Using the techniques applied in IVF treatment, a person may be able to freeze eggs (or embryos) for future attempts at conception.
Transgender males wishing to maintain future fertility potential should discuss fertility preservation options such as egg and embryo freezing with a reproductive endocrinologist prior to starting hormone therapy and/or undergoing gender-affirming surgery.
Transgender females who may want to try and conceive children in the future should consider sperm freezing prior to starting any hormone therapy and/ or gender-affirming surgery.
Freezing doesn’t seem to increase the risk of birth defects in future resultant pregnancies and offers a few more options down the road when an individual/couple are ready to start a family.
Lastly, don’t forget to consult with a lawyer well versed in third party reproduction.
Individuals and couples using a gestational carrier should consult with a reproductive lawyer in the state where the gestational carrier is intending to deliver. “Couples want to ensure that both partners will be legally recognized as the parents of the child,” says Denise Seidelman, partner at Rumbold and Seidelman, a New York law firm concentrating on reproductive and adoption law. And it’s important to recognize that not all states uphold gestational carrier contracts.
Same sex couples should also seek legal advice regarding second parent adoption.
“Even though all states are required to recognize same sex marriage, some states do not apply the marital presumption to same sex couples. In those cases, the presumption that the child is the “child” of the non-gestating mother can be rebutted through DNA testing,” explains Seidelman.
For more information on these various approaches to family building/fertility preservation, please consider these resources:
Reproductive Facts - ReproductiveFacts.org
Trans Fertility Resource - Trans Health
New York Essential Guide to Lesbian Conception, Pregnancy, and Birth – This book by Stephanie Brill is one of very few the LGBTQ community, and is an indispensable guide for specific conception know-how, tools and skills.