There are many options. The best treatment choice will depend on several factors, including sperm quality, surrogate mother options and finances.
The initial step for any man starting a family is to have his sperm analyzed. His physician can order this test, or he can consult with a fertility specialist who will discuss the results and recommend the best pathway to pregnancy.
A semen analysis shows how healthy the sperm are by are revealing the concentration of sperm, the percent that are moving (motility) and the shape of the sperm heads (morphology). These three parameters—concentration, motility and morphology—reflect the ability of the sperm to fertilize an egg and influence the choice of fertility treatments. If the semen analysis is normal, then inseminations of sperm into the uterus may be a viable and cost effective option. If the sperm variables are abnormal, the chance for normal fertilization is reduced, and in vitro fertilization with assisted fertilization, where the eggs are fertilized by injection of sperm into eggs in a laboratory, will be the best treatment option.
With this information in hand, your next step is to explore surrogacy. There are two general types of surrogacy arrangements: traditional surrogacy and gestational surrogacy. In traditional surrogacy, the woman who will carry the pregnancy also contributes the egg to be fertilized and thus has a genetic link to the child. In gestational surrogacy, donor eggs and the intended parent’s sperm are used to make embryos that are transferred into the surrogate’s uterus. Thus there is no genetic link between a gestational surrogate mother and the child. This distinction between the two types of surrogacy has legal significance and should be discussed with a reproductive attorney before starting on the journey to parenthood.
If traditional surrogacy is considered, a gay man must plan on storing sperm for up to six months before it can be used for conception. The semen samples can be released for insemination only after the sperm provider has been re-screened for transmittable infectious diseases after a quarantine period. Depending on the requirements of the program, that period can be of up to six months. The quarantine period allows for the time between infection exposure and positive test results and helps to insure against transmission of infection to the surrogate mother and unborn child. The sperm storage laboratory then conducts a post-thaw analysis to provide information on the survival of the sperm after the freezing and thawing process. The quantity and quality of the defrosted sperm determines the adequacy of the sperm for insemination procedures.
The traditional surrogate conceives through an intrauterine insemination (IUI). She begins by monitoring her cycle for ovulation using an ovulation predictor kit. This urinary dipstick test detects the surge in luteinizing hormone that occurs twenty-four hours prior to release of the egg. Once the surge of hormone is detected, the insemination procedure is scheduled for the following day. An hour before the procedure, the frozen semen sample is thawed and washed to remove semen and non-viable sperm, leaving behind the motile, normally shaped sperm. These sperm are then suspended in a small volume of a salt solution. The IUI is performed in an examination room by passing a narrow, flexible catheter through the cervix and into the uterine cavity, where the sperm are released. Within five minutes of the procedure, there are thousands of sperm in the fallopian tubes searching for an egg to fertilize. A pregnancy test may be performed 12 days later.
The pregnancy rates for IUI using thawed sperm will be approximately 10 percent per cycle. These rates will depend on the age of the surrogate and the receptiveness of her uterus, as well as the overall quality of the sperm. The intended parent should allow at least six months for pregnancy to occur. If conception has not occurred within this time, he should consult with his fertility doctor about what factors may be preventing pregnancy from occurring and consider additional diagnostic tests before planning further treatment cycles.
The second main treatment option is to use the assisted reproductive technique of in vitro fertilization (IVF). This technique uses donor eggs and transfers the embryos created into a gestational surrogate mother. The donor may be known to the sperm provider, or she may be anonymous, selected through an egg donor agency. The combination of donor eggs and a gestational surrogate who carries the child provides some of the highest pregnancy rates possible in reproductive medicine today. The high success rates are attributed to the young age of the egg donors and the normal, receptive uterine environments of the gestational carriers. Approved surrogates have had at least one normal pregnancy and no prior history of infertility, thus providing the best possible conditions for conception to occur.
One of the most important factors affecting the outcome of IVF is the age of the woman producing the eggs. The ideal age for an egg donor is between the ages of 21 and 34. Once the donor is selected, she undergoes an intensive screening that includes medical, psychological, genetic and infectious disease screening tests. The egg donor also meets with a reproductive attorney to review and sign a contract, which specifies that the eggs and embryos will become the legal property of the intended parents.
The gestational carrier is usually found through an agency that recruits, screens and organizes the arrangement. The agency’s attorneys provide separate legal representation for the intended parents and surrogate mother and file a declaration of parenthood prior to the birth of the child. Before being matched with an intended parent, the surrogate candidate undergoes comprehensive physical and psychological screening. The medical exam includes a thorough review of past obstetrical history and ultrasound evaluation of the uterus and uterine cavity as well as infectious disease and urine drug screening of the candidate and her sexual partner.
Once the egg donor has been screened, the intended parent has been matched with a gestational carrier, and all contracts have been signed, medical treatment is started. The goal is have the gestational carrier’s uterus in the receptive phase of the menstrual cycle when the embryos are ready. To accomplish this, medication is used to “turn off” the ovarian cycles of both egg donor and surrogate. Estrogen is then started in the surrogate mother to build up her uterine lining in preparation for pregnancy. Several days later, ovarian stimulating hormones are started in the egg donor to induce her ovaries to produce multiple eggs. The egg donor is carefully monitored through serial ultrasound exams and blood hormone levels to determine when the eggs are mature and ready for harvest. The eggs are removed through a simple surgical procedure in which a needle is placed through the upper vaginal wall into the ovary to aspirate the eggs from the ovarian follicles. The harvested eggs are then transferred to a petri dish in the laboratory where fertilization will take place. If there are two sperm providers, the eggs can be separated into two groups and some fertilized with each partner’s sperm.
In cases of sub-optimal sperm quality, an assisted fertilization procedure called intracytoplasmic sperm injection (ICSI) is used to increase the chance for fertilization. In the ICSI procedure, a single sperm is injected into each egg using a special microscope. ICSI bypasses several steps in the spontaneous fertilization process and produces near normal fertilization rates. The technique is used when there is a problem with the sperm, when there are not many eggs, or simply to prevent an unexplained failed fertilization.
On the third day of petri dish life, the best two or three embryos are transferred into the surrogate mother’s uterus in a simple, non-surgical procedure. Any extra healthy embryos can be frozen and stored for use in future cycles.
During the last six years, we have performed a couple of hundred egg donor and surrogacy treatments for gay men. The pregnancy rate has been approximately 65 percent per fresh embryo transfer cycle. The pregnancy rate with transfer of thawed frozen embryos is approximately 45 percent per cycle.
When comparing pregnancy rates of intrauterine insemination (IUI) and in vitro fertilization (IVF) procedures, the difference between them is dramatic: 10 percent per cycle with IUI versus 65 percent per cycle with IVF. The time to achieve pregnancy can vary greatly as well. It may take six procedures over between six and 12 months for conception to occur with IUI compared to one or two procedures over between one and three months for a pregnancy by IVF. There is a significant difference in the medical treatment costs between these two options. The costs for an IUI cycle can be several hundred dollars compared to between twelve and fifteen thousand dollars for an IVF cycle. (These costs do not include the surrogacy costs.)
The process of finding an egg donor, surrogate candidate and reproductive attorney can be difficult and time consuming. Gay men should start by choosing a surrogacy agency that can facilitate and organize the endeavor. It takes a team of dedicated professionals to make all of this happen, and it is crucial not to cut corners in the process. The agency recruits, screens and educates the surrogate mother, refers the client to established egg donor agencies and fertility centers, and provides appropriate legal consultation. In addition to providing medical and legal referrals, the agency can provide emotional guidance and support during the treatment process.
Gay men can become fathers. It takes commitment, patience, faith and unlimited love for your future child.
Dr. Guy Ringler is a board certified physician in both Obstetrics and Gynecology and Reproductive Endocrinology and Infertility. He is a partner with California Fertility Partners.