Fertility Care for the LGBTQIA+ Community

Fertility and family planning are deeply personal and meaningful journeys for many individuals and couples, including within the LGBTQIA+ community. Fortunately, advances in medical technology have opened a world of possibilities for fertility for our LGBTQIA+ patients and their families.

For individuals and couples embarking on the path to parenthood, there are options and considerations. 

1. Intercourse: If one partner has sperm and a penis, another partner has eggs, a vagina, and a uterus and is willing to be pregnant, and both are okay with having penetrative intercourse, they can have sex and try for a baby.
2. Fostering and adoption: Welcoming a child through fostering and/or adoption is another way to build a family. However, there can be significant financial costs, as well as barriers to single individuals, members of the LGBTQIA+ community, and people with chronic illnesses from being able to participate in these systems.
3. Assisted Reproductive Technologies (ART): In simplest terms, there are three things that one needs to make a baby: eggs, sperm, and a uterus. ART includes all types of fertility treatments in which sperm, eggs, and/or embryos are handled outside of the body and put back in the uterus. They have revolutionized family building for LGBTQIA+ individuals. ART will be the focus of this blog.  

What are Assisted Reproductive Technologies (ART)?

1. Artificial Insemination: Artificial insemination can come in several different forms, including intravaginal, intracervical (ICI), or intrauterine insemination (IUI). These are all options for individuals who have an egg and a uterus and need sperm from a donor. The first two could be done at home. For intrauterine insemination (IUI), the sperm is washed and prepared before being directly inserted into the uterus to facilitate fertilization – this is usually done in a clinic setting. 
2. In Vitro Fertilization (IVF): IVF is the process in which eggs from one individual are combined with sperm from another individual in a laboratory to create embryos. One of these embryos is then put back into the uterus of the person who wishes to carry the pregnancy. For example, Natasha and Ashley are a same-sex, cis-gender female couple. Natasha would like to be the source of the egg and Ashley wants to carry the pregnancy. Natasha would undergo a process of stimulating her ovaries and retrieving her eggs. Those eggs would be combined in the lab with sperm from a donor. An embryo created in this way would then be put into Ashley’s uterus. Ashley would then carry the pregnancy and deliver their baby. 
3. Gestational Surrogacy: This is a process in which a person carries a pregnancy and gives birth to a baby for another individual or couple. The gestational carrier is not genetically related to the baby. This is an option for single males, same-sex male couples, and other individuals who do not have a uterus or have illnesses that make it unsafe to carry a pregnancy. Using IVF (see above), sperm and/or egg from the intended parent(s) and/or donor (if necessary) are combined to create an embryo that is then transferred into the gestational carrier’s uterus. 

Where do you find sperm, egg, or embryo donors and/or gestational surrogates?

What is Fertility Preservation? 

• Electively for personal or professional reasons.
• Medical reasons, such as before undergoing chemotherapy for cancer treatment or before starting gender-affirming hormones or having gender-affirming surgery. 

1. Sperm Banking: Sperm banking involves an individual, who has gone through puberty, masturbating for ejaculation into a cup. The semen sample is then processed, and the sperm is frozen for future use for inseminations (IUI) or in vitro fertilization (IVF). 
   
   • Sperm Banking for transgender female and transfeminine people (assigned male at birth):          We typically recommend banking sperm before starting gender-affirming hormone therapy. Individuals on testosterone blockers and feminizing hormones often stop producing sperm. Although sperm production can recover after stopping medications, it can take months. Sperm banking must happen before testicular removal. 
2. Egg Banking: Like individuals who produce sperm, individuals who produce eggs must have gone through puberty to be able to harvest and freeze eggs. This process involves the first half of IVF – stimulating the ovaries with hormones and having an egg retrieval. These eggs are frozen and can then be thawed and used in the future for IVF to create embryos which could then be transferred into a uterus.
   • Egg Banking for transgender males and transmasculine people (assigned female at birth):        Like our transfeminine patients, we recommend transmasculine individuals undergo egg banking before starting gender-affirming hormone therapy. However, we are learning over time that it may be safe to go through the process of egg banking while staying on testosterone. Egg banking must happen before removing ovaries.
3. Embryo Banking: This is most often done for patients who are already partnered but not ready to have a child. To undergo embryo banking, patients go through the same process of ovarian stimulation and egg retrieval, fertilize those eggs using partner or donor sperm, and then freeze any resulting embryos for future use. When they’re ready to use those embryos, the person can carry the pregnancy themselves, have their partner carry, or use a gestational carrier.

NOTE: There are some caveats to fertility preservation. Fertility preservation is NOT an insurance policy. Unlike your car insurance or home insurance policies which usually pay out, we can never promise somebody they will get pregnant or have a genetically related baby.  

What are other factors to consider?

1. The experience can be especially challenging emotionally and psychologically; seeking support from LGBTQIA+-friendly healthcare providers and support groups can be invaluable.
2. There are legal aspects of family building, from gestational carrier agreements to parental rights, that are unique and require a lawyer’s involvement.
3. This process can be expensive. While some health insurance may cover family-building options, others do not, and the same goes for fertility preservation. There are some financial assistance options out there, including for members of the LGBTQIA+ community.

Conclusion