Most frequently, same-gender couples in general and lesbian couples in particular are seeking out fertility centers to help them start or expand their families by means of artificial insemination, ovarian stimulation, in vitro fertilization, donor eggs or surrogacy.
There are some unique aspects associated with the care rendered to same-sex couples. One of the foremost is an honest self-assessment by the healthcare team about its own comfort level in relating to the needs of patients with what are considered alternative lifestyles. Some, but not all, lesbian women may feel marginalized by the healthcare system and perhaps even more so with respect to the unfamiliar territory of assisted reproductive technologies. The lesbian patient may also feel higher anxiety levels about the team’s acceptance of her sexuality and how the team will interact with her and her partner and/or extended family. The approach to all patients should be one of sensitivity and patience and kindness in word and deed as well as the time for patients to ask questions and feel welcomed.
We invite new patients to bring their partners for the initial examination in order to establish an environment of respect and trust. A vaginal ultrasound at this time helps the patient to understand female anatomy and how treatments will be performed.
Level One testing is the basic assessment we perform for our patients and can be completed in one menstrual cycle. Ovarian function and reserve is checked on the third or fourth cycle day with a simple blood panel (FSH, LH, Estradiol and TSH) to uncover polycystic ovaries, menstrual disorders and thyroid problems. We also advise a hysterosalpingoram (HSG), an x-ray study to check the uterine anatomy and any tubal problems that may prevent the egg/embryo from reaching the uterus.
At this time, we also discuss the different types of inseminations and how the sperm donor selection should be made. To have a reasonable chance of pregnancy, there must be good sperm concentration (more than 30 million/ml), good motility (more than 60 percent) and rapid speed (grade 3 or 4). The sperm shape (morphology) must be adequate. Semen obtained from reputable sperm banks has undergone rigorous screening for sexually transmitted diseases (STD) and a health risk questionnaire is completed by the donor and reviewed by trained personnel. The semen is frozen and quarantined for six months and the donor is then re-tested for STDs. If he is not infected, the semen samples are made available for artificial insemination (AI).
About 30 percent of lesbian couples we treat have undertaken home inseminations without success. A word of caution: Some patients prefer using the semen of a personal friend or acquaintance. This practice is strongly discouraged unless the individual has undergone rigorous screening. Not doing so may have grave, even deadly consequences, especially if the donor is from a high-risk behavior group.
If all parameters are normal, AI will succeed at a rate of 15 percent per month in women less than 35 years of age. After six unsuccessful attempts, we recommend a consultation with the patient to review ovulation quality, timing and semen parameters. If ovulation is unpredictable, medications can be used to regulate ovulation. If this is unsuccessful after three attempts, or if other symptoms are present, a laparoscopy may be indicated. This is a surgical procedure to evaluate the internal reproductive organs with a slender instrument attached to a camera. Endometriosis, pelvic adhesions, tubal blockage and fibroids can be diagnosed and treated with laparoscopic techniques. Then, if conditions are right, AI can resume for three additional cycles.
Assisted reproductive technologies
If obstacles to pregnancy cannot be overcome with AI or laparoscopic techniques, consideration must then be given to in vitro fertilization (IVF), the most frequently used of the assisted reproductive technologies (ART) procedures.
Briefly, IVF overcomes the hurdles of not knowing why the egg and sperm are unable to join in the fallopian tube as occurs naturally. In IVF, the egg sacs located within the ovaries are stimulated to grow using follicle stimulating hormone (FSH) for approximately 12 days. The patient’s response is checked with ultrasound and estrogen blood tests every four days until follicle maturity is confirmed. Using the ultrasound probe, the fluid in the egg sacs is removed vaginally while the patient is under intravenous anesthesia. The egg collection is performed in the doctor’s office. No surgical incisions are necessary, and the procedure lasts approximately 45 minutes. The embryology laboratory then begins combining the freshly collected eggs with the donor sperm sample. Each step of the IVF process is documented, and daily phone calls are made to update the couple about the lab developments. Fertilized eggs become embryos composed of cells that are graded according to their shape and appearance—competition begins early, doesn’t it?
Two or three days later, the woman and her partner return to the center to review the total number and quality of their embryos and to make a decision about how many to replace into the uterus. The embryo transfer (ET) is guided by ultrasound technique, is painless, and the partner can observe the transfer from a private observation room. Bed rest is advised for several days, followed by a pregnancy test after two weeks. Surplus embryos, or unfertilized eggs, can be frozen and stored in case the first attempt is not successful.
As explained above, IVF is a very well controlled treatment in which our patients play an interactive role. We actively seek the input of our patients as our partners in their own treatment.
Complications may occur in any medical procedure. In IVF, serious complications occur in less than one percent of cases. Careful attention to detail and customized treatment plans help to minimize the risks.
A word about multiple births is warranted: We take into account each patient’s risk tolerance regarding the number of embryos they wish to transfer. In women of less than 35 years of age, two embryos of excellent quality will yield a pregnancy rate of 45 percent. Replacing more embryos will result in higher pregnancy rates, but the risk of triplets is 10 percent. This is not considered a favorable outcome, because of a number of maternal and fetal complications. Selective removal of one embryo at 12 weeks is an option chosen by some patients who conceive triplets. Patient involvement is crucial, and detailed written informed consents are given to all patients advising them of the risks.
Special ART procedures
Women of advanced maternal age (more than 37 years) who are not successful may need to resort to egg donation, so named because the eggs are collected from a directed or an anonymous egg donor. Some lesbian couples decide to use the eggs of the younger partner and transfer the resulting embryos into the older partner. This method actively involves both partners and achieves good results. In cases of uterine problems such as fibroids or scarring, the uterus of another woman, a surrogate, can be used to carry the embryos of the intended mothers.
I am often asked about gender selection for the intended child. Most couples are thrilled to simply achieve a healthy pregnancy. However, some lesbian couples strongly request a female baby if possible. Preimplantation genetic diagnosis (PGD) is used to screen not only for the health of the embryos but it can also determine the gender with 99 percent accuracy. The procedure is done during IVF and carries an additional cost.
A Personal Perspective
Recently, I had the pleasure of a visit from one of my first IVF cases, a lovely woman named “S” who gave birth to twin boys, now 16 years old. This is from a beautiful narrative explaining her struggle for motherhood.
“It is hard to get pregnant if you aren’t sleeping with men. It would be a lot easier if we could. What to ask the doctor? I would say everything about the time and cost involved. It is all worth it, but you must be financially able to support a child.
There is a [general feeling that] gay people should not become parents. You always have to think about the kids and what will make them the most comfortable when they start school. Most important is the love and devotion given by both parents to raise the child in an alternative life style.”
David G. Diaz, M.D., F.A.C.O.G. is founder and medical director of West Coast Fertility Centers. Dr. Diaz can be reached at West Coast Fertility Center at (714) 513-1399 or at http://www.ivfbaby.com.