in the - Fertility Lifelines
Transcription
in the - Fertility Lifelines
Brought to you by in the know What No One Tells You About Family Building Options for LGBTQ Couples © 2014 EMD Serono, Inc. All rights reserved. US-NON-0714-0022 EMD Serono, Inc. is a subsidiary of Merck KGaA, Darmstadt, Germany. 17 American Society for Reproductive Medicine. Mature Oocyte cryopreservation: a guideline. 2012. Retrieved on July 16, 2014, from http://www.asrm.org/ uploadedFiles/ASRM_Content/News_and_Publications/Practice_Guidelines/ Committee_Opinions/Ovarian_tissue_and_oocyte(1).pdf 18 ABA Journal, Mar 1, 2011. Retrieved on July 16, 2014 , from http://www.abajournal.com/magazine/article/as_surrogacy_becomes_more_ popular_legal_problems_proliferate 19 Council for Responsible Genetics: Surrogacy in America 2010 20 Human Rights Campaign. (2010). Adoption. Retrieved July 16, 2014, from http://www.hrc.org/resources/entry/adoption-options-overview 21 RESOLVE. Diagnosis and Management. Retrieved July 15, 2014, from http://www.resolve.org/diagnosis-management/ 22 American Society for Reproductive Medicine. (2006). Medications for Inducing Ovulation: A Guide for Parents. Retrieved September 7, 2010, from http://asrm.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/ Fact_Sheets_and_Info_Booklets/ovulation_drugs.pdf 23 Mayo Clinic. Infertility. Retrieved July 16, 2014, from http://www.mayoclinic.org/ diseases-conditions/infertility/basics/causes/con-20034770 24 Mayo Clinic. Low Sperm Count, Retrieved July 16, 2014, from http://www.mayoclinic.org/diseases-conditions/low-sperm-count/basics/ risk-factors/con-20033441 25 Anderson, L., Lewis, S. E. M., & McClure, N. (1998). The effects of coital lubricants on sperm motility in vitro. Human Reproduction, 13(12): 3351-3356. 26 Weng, X.,Odouli, R. & Li, D-K. (2008).Material caffeine consumption during pregnancy and the risk of miscarriage: A prospective cohort study. American Journal of Obstetrics andGynecology, 198 (3), 279-281. 27 McCusker, R. R., Goldberger, B. A., & Cone, E. J. (2003). Caffeine content of specialty coffees. Journal of Analytical Toxicology, 27, 520-522. 28 The American Fertility Association (2010). Brisman, M. & Halm,W. Legal Issues for the LGBT Community: Forming Your Family through Assisted Reproduction. Retrieved August 23, 2010, from http://www.theafa.org/article/legal-issues-for-thelgbt-community-forming-your-family-through-assistedreproduction/ 29 Human Rights Campaign.(2010). Surrogacy Laws: State by State. Retrieved July 15, 2010, from http://www.hrc.org/resources/entry/surrogacy-laws-and-legal-considerations 30 American Academy of Pediatrics. (2002). Coparent or Second-Parent Adoption by LGBTQ Parents. Committee on Psychosocial Aspects of Child and Family Health. Pediatrics, Vol. 109 No. 2. 31 Perrin, E.C. (2002). Technical report: Coparent or second-parent adoption by LGBTQ parents. Pediatrics, 109(2), 341-344. Retrieved July 14, 2010, from http://aappolicy.aappublications.org/cgi/content/full/pediatrics;109/2/341. starting a family can be daunting; but there’s good news. There are up to nine million children in the United States with gay or lesbian parents1 and today there are more options available for LGBTQ couples to explore starting a family than ever before. Even though it might seem overwhelming, there are resources and tools available to help you and your partner navigate the many considerations in your family building journey. The first step is to have open discussions with your partner about what your mutual expectations are for parenthood, including whether you want a genetically related child or an adopted child. You’ll also want to begin familiarizing yourself with the legal and financial implications associated with your different choices. And of course, it’s important to understand the medical procedures that might be available to you, along with the risks and benefits of each one. In recent years, family building options have expanded for LGBTQ couples, in part because of increased fertility treatment options. This booklet explores options for LGBTQ couples, reviews the biology that affects fertility and helps navigate obstacles that are unique to LGBTQ couples who want to start or grow their family. It’s also important to remember that LGBTQ couples may encounter some of the same infertility issues as heterosexual couples, but a Fertility Specialist known as a Reproductive Endocrinologist can help. There are treatments available for many of these infertility issues, so the sooner you seek treatment for infertility, the greater the chances may be of successfully conceiving. Congratulations on taking this first step in your family building journey. chapter one Bio 101 A s just about every adult knows, it takes an egg from a woman and sperm from a man to make a baby. Regardless of the path you and your healthcare provider choose, understanding the process of fertility and conception will shed some light on how the male and female reproductive systems play into your family building options. For more help understanding reproductive terminology, browse the glossary on www.FertilityLifeLines.com. FEMALE REPRODUCTIVE SYSTEM The ovaries store a woman’s lifetime supply of immature eggs – about 300,0002 – and produce the female hormones estrogen and progesterone, which are both needed for menstruation and pregnancy. 2 chapter one The sperm and egg meet for fertilization in the fallopian tubes. A fertilized egg attaches itself to the lining of the uterus (the endometrium) and develops in the uterus. The vagina is the passage that leads from the outside of the body to the cervix, the opening to the uterus. Menstrual Cycle2 A regular menstrual cycle is an important element of successful conception. The menstrual cycle refers to the maturation and release of an egg as well as the preparation of the uterus to receive and nurture the fertilized egg (embryo). The hormones released during the menstrual cycle control the sequence of events that lead to pregnancy. On the first day of the cycle, when menstruation, or a “period,” begins, the uterus sheds its lining from the previous cycle. The typical menstrual cycle lasts for about 28 days and is divided into the following three distinct phases. Follicular Phase – Days 1 to 132 During this phase, the pituitary glands in the brain release a hormone known as follicle stimulating hormone (FSH). FSH stimulates the development of a follicle, which is a tiny fluidfilled sac in each ovary containing a maturing egg. Follicular Phase Ovulatory Phase Days 1-13 of your cycle 14 Days BEFORE next cycle begins Ovulatory Phase for next cycle Day one of menstruation The follicle also secretes estrogen, which produces midcycle changes in the cervical mucus. These changes help prepare the cervical mucus to receive and nourish sperm. Luteal Phase Days 15-28* of your cycle Menstrual Cycle *based on a typical 28-day cycle 3 Bio 101 Ovulatory Phase – Approx. 14 Days Before Your Next Cycle Starts2 The ovulatory phase begins when the level of luteinizing hormone (LH), also released by the pituitary gland, drastically increases or surges. LH causes the follicle to break open and release the mature egg into the fallopian tube. During her reproductive years, a woman usually releases a single mature egg each month. This process is known as ovulation. Cervical mucus is most receptive to sperm around this time and a woman has the best chances of conceiving right before and during ovulation. It is a common misconception that the ovulatory phase begins around day 14 of a woman’s cycle; in fact, it can more easily be determined by 14 days prior to the start of a woman’s cycle, which may not be an exact 28 days. A cycle begins on the first day that a woman experiences regular flow. Once it’s determined how long a personal cycle lasts, a woman should subtract 14 days from the predicted end of the cycle to determine time of ovulation. Luteal Phase – Days 15 to 282 During this phase, the follicle that produced the egg becomes a functioning gland called the corpus luteum. The corpus luteum produces progesterone, which prepares the endometrium (lining of the uterus) for the implantation of the fertilized egg. Fertilization3,4 The ovulatory phase of the menstrual cycle is the optimal time for fertilization. During insemination, sperm swim through the cervical mucus, into the uterus and along the fallopian tube, where they meet the egg. Although millions of sperm can be released, only one sperm can fertilize an egg. The egg has the capacity to be fertilized for about 24 hours after it is released from the follicle. (If fertilization does not occur, the egg passes through the uterus, and the corpus luteum ceases to function on about day 26. The uterine lining then breaks down and is shed several days later as the next menstrual cycle begins.) 4 chapter one Implantation4 After fertilization, the embryo travels through the fallopian tube toward the uterus. Inside the uterus, the embryo implants itself into the lining on about the 20th day of the cycle and continues to grow into an embryo and eventually a fetus. The corpus luteum continues to produce progesterone to preserve the uterine lining and help maintain pregnancy. MALE REPRODUCTIVE SYSTEM Sperm Production5,6 Similar to the female reproductive system, normal anatomy of the male reproductive organs and balanced hormones are important for fertility. The same hormones that regulate female reproductive functions also regulate the production of sperm in the male. FSH stimulates sperm production and LH stimulates the production of testosterone, which helps to maintain sperm production. Sperm are highly specialized cells comprised of a head where chromosomes are stored, and a tail, which enables movement. Sperm are produced by the testes glands (testicles) located in the scrotum. The scrotum maintains a lower than normal body temperature to help sperm develop properly. As sperm are produced, they pass from the testes to the epididymis, an organ that stores and nourishes sperm as they mature. When a man ejaculates, sperm from the epididymis combine with a fluid from the seminal vesicles and prostate gland to create semen. The fluid can be deposited into the woman’s vagina. Sperm can live for 3-5 days within the female reproductive tract, while retaining the ability to fertilize an egg.7 5 chapter two Family Building Options I n recent years, fertility treatment options have expanded for LGBTQ couples. For female couples, your options ultimately depend on the age and health of each partner, as well as the desire of each partner to carry a child. For gay male couples looking to start or build a family, your best option will depend on several factors, including sperm quality, surrogacy options, and finances. A good first step for many men is to have their semen analyzed, which can help determine the viability of various fertility treatment options and next steps.8 Before you agree to undergo any kind of treatment, take some time to talk to your healthcare provider about its likelihood of success and its risks. You may also wish to inquire about a timeline for each phase of treatment. That way, if a certain treatment isn’t working, you’ll know when it may be appropriate to consider more advanced treatments. Following are some options that may be available for LGBTQ couples looking to start or build their family, which may be applicable to one or both of the partners or a surrogate. 6 chapter two Advanced Treatments Ovulation Induction (OI)9 – If fertility testing reveals an ovulatory problem and clomiphene citrate – a prescription medication used to induce ovulation – proves to be ineffective, or was not appropriate to begin with, other fertility medications may be used to induce follicle development and ovulation. A Fertility Specialist, also known as a Reproductive Endocrinologist, usually recommends these prescription medications, which are given in the form of injections. Artificial Insemination (AI)10 AI is a procedure in which the healthcare provider inserts the male partner’s or donor’s sperm directly into a woman’s reproductive tract. A common AI procedure is intrauterine insemination (IUI), in which the healthcare provider inserts sperm directly into the uterus near the time of ovulation. The healthcare provider may also consider cervical insemination, when semen is released through a soft catheter to the cervical opening. Assisted Reproductive Technologies (ART)11 ART is the umbrella term for a variety of medical procedures used to bring eggs and sperm together without sexual intercourse. In Vitro Fertilization (IVF)11 is the most common ART procedure. During IVF, medications are often used to stimulate the development and release of a woman’s eggs. The eggs and sperm are then collected and placed together in a laboratory dish to fertilize. If the eggs are successfully fertilized, the embryos are transferred into a woman’s uterus. Hopefully, one of the fertilized eggs will implant and begin to develop. 7 Family Building Options In Reciprocal IVF, the procedure is performed using the eggs of one partner and the womb of the other. For lesbian couples, reciprocal IVF can help both women feel an equal biological tie to the child.12 Intracytoplasmic Sperm Injection (ICSI)13 is used in conjunction with IVF in which a laboratory technician, using a microscope, attempts to inject a single sperm directly into each egg. ICSI is often used if the male has very low sperm count, low sperm motility or poor-quality sperm. If fertilization occurs after ICSI, the embryo(s) are transferred into the uterus. Egg and Sperm Donation. For lesbian couples, egg donation involves one woman (a donor) “donating” her eggs to another woman. IVF is performed in the usual manner, except that the donor receives fertility medications to stimulate the production of multiple eggs in her ovaries. At the same time, the recipient (the intended mother) also receives medications so that her cycle mirrors the cycle of the donor and her body is prepared to receive the embryo(s). The eggs are then fertilized in a laboratory and the embryos are transferred into the recipient’s uterus. For women utilizing donor sperm, it’s important to know that anonymous sperm donation is regulated by the U.S. Food and Drug Administration (FDA). Sperm donors are required to be tested for certain infections14 and also may need to meet other criteria as determined by the sperm bank. Even though the FDA only requires that anonymous sperm donors be screened for transmittable diseases, the American Society for Reproductive Medicine (ASRM) believes it is important that both anonymous donors and those known to the recipient undergo the same initial and periodic screening and testing process.15 For gay male couples, the egg donor may be known or selected anonymously through an egg donor agency. The age of the egg donor is one of the most important factors affecting the 8 chapter two outcome of IVF. Because fertility declines with age, the donor should ideally be between the ages of 21 and 34. Once selected, the donor will undergo an intensive screening that includes medical, psychological, genetic and infectious disease tests, and also meet with an independent reproductive attorney.8 Egg and Embryo Freezing.16,17 Cryopreservation, also known as “freezing,” involves storing embryos at a very low temperature so they can be thawed and used later. Many fertility clinics now offer this option. Some clinics have begun to offer egg freezing as well. Things to Consider: It’s important to know that advanced fertility treatment can be stressful for couples. Your Fertility Specialist will help set expectations, provide injection training, monitor treatment response, and check for side effects. Patient response and pregnancy success rates can vary. Follow doctors’ orders and report any adverse events such as severe abdominal pain, which can be serious. Multiple births are common with the use of fertility treatment. Remember, these treatments were designed to bring you closer to starting or building your family. 9 Family Building Surrogacy Options An estimated 22,000 babies have been born through surrogacy since the mid-70s18 and the number of babies born to gestational surrogates grew 89 percent from 2004 – 2008.19 Surrogacy agencies are available to recruit, screen and educate the surrogate mother, refer partners to established egg donor agencies and fertility centers and provide appropriate legal advice. The agency can also give emotional guidance and support during the treatment process.8 There are two types of surrogacy: • In traditional surrogacy, the woman who will carry the pregnancy contributes her own eggs to be fertilized with the sperm and will share a genetic link to the child. In these cases, conception is achieved through IUI, in which a healthcare provider places sperm directly into the uterus through the cervix using a catheter.8 • In gestational surrogacy, donor eggs and sperm are used to make embryos that are transferred into the surrogate’s uterus. In these cases, the surrogate has no genetic bond to the child. When donor eggs are used, the healthcare provider will recommend using IVF, during which the eggs and sperm are collected and placed together in a laboratory dish to fertilize.8 Considerations for HIV Positive Prospective Parents If you or your partner is HIV-positive, speak to your healthcare provider or an HIV specialist for more information about your options and risks. Adoption Several options for adopting children can be explored by LGBTQ couples. Each route has its own challenges and advantages, so consult with an attorney to get familiar with the laws in your state as they relate to each option. Adoption options vary depending on the parenting laws in your state, but can include: state or public agency adoption, in which the child is adopted from the public 10 chapter two child welfare system; an agency open adoption; an open independent adoption, in which you find birth parents who want or need to place their child in an adoption and complete that adoption through an attorney; and an international adoption.20 Fertility Considerations In addition to understanding ART options as they relate to the family building process, it’s also important to remember that anyone can be affected by infertility, and for LGBTQ couples, fertility issues may be uncovered after starting the family building process with ART. FEMALE FACTORS There are a number of biological issues that can cause infertility in women. The most common definition of infertility is if a woman is younger than 35 and unable to conceive after a year of regular, unprotected intercourse, or older than 35 and unable to conceive after six months of trying.21 This may or may not be an issue for you or your surrogate. Ovulatory Issues Approximately 25% of all infertile women have problems with ovulation.22 The normal ovarian cycle is so complex22 that even small changes may disrupt the cycle and prevent ovulation. In the majority of cases, the problem is caused by hormonal imbalances (e.g., not having enough of a certain hormone or not releasing a hormone at the right time). This can be caused by faulty communication between the brain and the glands responsible for releasing the hormone. Sometimes, abnormal ovulation may also be associated with significant changes in weight (loss or gain) including extremely low body weight or being overweight. Physical Issues23 Then there are some physical problems that can cause fertility issues in women: • Blocked fallopian tubes – though there are many causes for this, including past infections or sexually transmitted 11 Family Building Options diseases (STDs), blockages can prevent the sperm and egg from uniting or they can prevent embryo implantation • Cervical disorders – some cervical problems can prevent the sperm from entering the uterus • Endometriosis – this disease causes cells that normally line the uterine cavity to also implant outside the uterus on the ovaries or other pelvic organs and is found in about 35% of women who have no other diagnosable infertility problem • Polycystic Ovarian Syndrome (PCOS) – one of the leading causes of infertility in women. PCOS is a condition in which cysts develop in the ovaries due to abnormal hormone levels, sometimes causing the ovaries to enlarge History Here are some red flags just for women: • Over age 35 • Irregular or absent periods • Two or more miscarriages • Prior use of an intrauterine device (IUD) • Endometriosis/painful menstruation • Breast discharge • Excessive acne or hirsutism (body hair) • Prior use of the birth control pill and no subsequent menstruation MALE FACTORS23 While gay men may think female fertility issues don’t affect them, it’s important to remember that surrogates may also experience difficulty carrying a child, despite extensive screening. It’s also important to know that there are a number of factors that can lead to fertility issues in men. Sperm Issues Many male fertility issues are related to sperm disorders. Disorders of sperm quantity or quality will generally be detected during the preliminary screening process when considering AI, 12 chapter two IVF, or surrogacy. Many factors play a role in whether or not sperm will succeed: • Sperm count (number of sperm) • Motility (ability to move) • Morphology (size and shape) impacts forward progression, quality of movement Physical Issues There are some physical problems that can cause fertility issues in men. If any of these issues apply to you, then you should contact your healthcare provider: • Erectile dysfunction – inability to get or sustain an erection • Undescended testis – testis has not reached its normal position in the scrotum, causing it to function abnormally and potentially not produce sperm • Retrograde ejaculation – ejaculate containing the sperm flows backwards into the bladder instead of leaving the penis • Scrotal varicocele – the most common cause of identifiable male infertility, this occurs when a varicose vein is around a testicle, which may hinder sperm production Medical and Family History Always speak to your healthcare provider about any potential issues you may have. If you’re a male, talk to your healthcare provider, and discuss any of the following male-specific issues that can lead to trouble conceiving: • Mumps after puberty • Previous urologic surgery • Prostate infection • Family history of cystic fibrosis or other genetic disorders 13 Family Building Options FACTORS THAT MAY AFFECT BOTH There are some factors that may cause fertility issues in both men and women: • History of sexually transmitted disease • History of pelvic/genital infection • Previous abdominal surgery • Reversal of surgical sterilization • Chronic medical condition (e.g., diabetes, high blood pressure) • History of chemotherapy or radiation therapy Lifestyle24 Keep in mind that certain lifestyle choices can affect your fertility. You might want to consider talking to your doctor if any of these apply: • Alcohol consumption and smoking have been shown to compromise fertility of both men and women. • Being underweight, overweight or obese may reduce a woman’s fertility. • Prolonged exposure to high heat from hot baths and steam rooms can lower sperm quality. • Lubricants such as petroleum jelly or vaginal creams may affect sperm quality.25 • Higher amounts of caffeine (more than 200 mg/day or about 2 cups) have been shown in some studies to increase the risk of miscarriage.26 Be aware that some coffeehouse drinks can have up to 560 mg in a single beverage.27 • Exposure to toxic substances on the job, such as pesticides, radioactivity, X-rays, and electromagnetic or microwave emissions, may lead to sperm abnormalities. • Some drugs for heart disease and high blood pressure may cause infertility in men. The bottom line is: If you feel like some of these apply to you or your partner, then talk to your doctor. Don’t dread and prolong making the call; most of the causes of infertility listed are treatable. 14 chapter three Help Getting A Fertility Specialist known as a Reproductive Endocrinologist (RE) can help you during your family building process, because REs specialize in treating reproductive issues and can offer a full range of options. REs have completed the same education and medical requirements as OB/GYNs, and in addition, they have finished a two- to three-year fellowship in reproductive endocrinology, passed specialized examinations (if board certified) and completed a two-year practice in reproductive endocrinology. It may also be recommended that you or your partner visit a Urologist or Andrologist, or have an independent sperm workup. The Role of the Reproductive Endocrinologist (RE) The role of an RE is to help those wishing to get pregnant, including coordinating AI and IVF procedures for LGBTQ couples looking to build their families. REs can also help identify and treat fertility issues in men and women. 15 Getting Help The Role of the Urologist A Urologist can help men, in particular, during the family building process, because urologists are specialists in the reproductive system of males. Urologists are trained to diagnose, treat, and manage patients with urological disorders. Finding a Fertility Specialist Check with a fertility center or office before you make an appointment to confirm it offers relevant options for LGBTQ couples. When seeking care from an RE, it’s important to verify that he or she is board certified by the American Board of Obstetrics and Gynecology (ABOG). Visit the American Society for Reproductive Medicine’s Web site (asrm.org) to search for a RE, or find an RE or Urologist by zip code at www.FamilyBuildingOptions.com. To find a specialist near you visit: www.FamilyBuildingOptions.com What questions should I discuss with my partner before my medical visit? • If you are a female couple, will one of you be providing the egg and where will you get the sperm? Who is going to carry the baby? • For men, will one of you contribute the sperm? Where will you get the egg and/or surrogate? • Will both partners be tested for fertility issues? You may also make these decisions after speaking with your healthcare provider. 16 chapter three What questions should I ask during my medical visit? Being prepared with questions will ensure you get the most out of your visit. How many times have you left a doctor’s office only to remember that question you meant to ask? Don’t be shy and if you don’t understand the answers, don’t hesitate to ask your healthcare provider to repeat them or to put them in layman’s terms. Possible Questions for your RE (For Lesbians and Gay Male Couples) • Based on my test results, do I have potential fertility issues? • If I do have potential fertility issues, how will this impact who will carry the baby? • Based on the test results, what are my treatment options, and how much do they cost? – Will my insurance pay for the testing and/or treatments? – Will your clinic help me determine what my insurance will cover for infertility? • What is your IVF success rate for gestational carriers? • What can you tell me about the risks associated with each of these procedures? • How will I communicate with you during this whole process? • Does your clinic provide emotional counseling, or can you refer me to a counselor who deals with LGBTQ couples? • Do you recommend any complementary healthcare practices such as massage or acupuncture? Here are some additional questions that may help you, your partner or your surrogate if undergoing OI and/or IVF. 17 Getting Help Ovulation Induction • How many OI cycles do you recommend before moving to IVF? • At what point would you convert me/her to IVF or cancel my OI cycle? • What are the risks involved? In Vitro Fertilization • What is the success rate for IVF in terms of live births per embryo transfer? • What are the risks involved? • How many embryos do you typically transfer per cycle? • Can you help us access donor egg, embryo or sperm programs? Questions for Advocacy Organizations • What kinds of programs and services do you offer? • Do you have a local chapter or any upcoming events in my area? • Do you offer any financial assistance programs? Where to Turn for Help Always speak to your doctor first. Additionally, here are some resources that can provide information and support: FamilyBuildingOptions.com www.FamilyBuildingOptions.com The American Fertility Association www.theafa.org RESOLVE: The National Infertility Association www.resolve.org American Society for Reproductive Medicine www.asrm.org 18 Society for the Study of Male Reproduction www.ssmr.org The Gay and Lesbian Medical Association www.glma.org other Factors to consider chapter four Having Realistic Expectations about Getting Pregnant For LGBTQ couples who want to start or build a family, setting realistic expectations about having a baby can be critical to your peace of mind. Even if you don’t have fertility issues, a LGBTQ relationship makes the use of reproductive technologies necessary for a pregnancy in most cases, which can take time and may require numerous attempts. The good news is that LGBTQ couples can have biological children and appear to be doing so in increasing numbers, but you’ll need patience and knowledge of what to expect during your journey. 19 other Factors Dollars and Sense Having a child is expensive in itself, but using AI, ART, or surrogates to conceive and carry a child to birth can add significant costs above and beyond what is normally incurred. Other costs, such as legal and administration fees, may not be included, and each clinic will have its own prices. Medical insurance may not cover a lot of these costs, except in the case of infertility, which varies from state to state. It is important to check with your health insurance provider and recognize that different companies will have different policies, even if they are in the same state. Insurance Some insurance companies cover fertility treatments and surrogacy options for LGBTQ couples, but coverage is by no means universal; it varies within each state and plan. You should consult with your insurance agent or human resources department to determine your coverage. Fertility LifeLines™ can also help you determine and verify your coverage by visiting www.FertilityLifeLines.com or calling the hotline at 1-866-LETS-TRY (1-866-538-7879). All calls are free and confidential. As you study your policy, here are some pointers to think about: 1. Get approval in advance – and in writing. This is called preauthorization or predetermination. Your coverage may impact what kind of healthcare provider you see, the kinds of tests you undergo, the sequence of the testing and what treatments will be covered. 2. Try to get a list of Fertility Specialists and clinics that are part of your insurance plan and determine that the clinic or office works with surrogates and gestational carriers. 3. Look at both your medical and prescription coverage. What is the definition of infertility in the contract? Are there restrictions on the type of healthcare provider that can 20 chapter four perform fertility services? Are infertility drugs covered under the pharmacy or medical benefit? Also, try to find out in advance what the submission process is, what forms you need and what the deadlines are for submission. 4. Have you read your policy for the fourth time and still don’t know what is covered? You are not alone. Fertility benefits aren’t always clearly spelled out in policies. What’s not written can be just as important as what is. In most policies there’s usually room for interpretation. If your claim has been denied, you may appeal. In fact, resubmissions are common. The key is to be prepared to address the issues that led to the denial. The more specific information you have, the better you’ll be able to respond to your insurer’s request. It can also benefit you to learn how the medical industry codes treatments. A few digits can be the difference as to whether or not you’re covered! 5. Don’t get discouraged. Being an advocate for your fertility coverage can get frustrating. At these times, it’s important to remember your rights, your state laws/coverage and your goals. It can also be helpful to talk with your healthcare provider in advance about your coverage. 6. Find out if your company or your partner’s company has access to any benefits, programs or resources that might be helpful, such as Employee Assistance Programs and Health Savings Accounts. Other Payment Options 1. Loans – Banks and financing companies may make loans that enable patients to pay for their treatment in manageable monthly installments. Some fertility clinics have relationships with financing companies. 2. IVF Center Programs – Some IVF centers offer their patients alternate payment plans as an option for paying for their IVF procedures, including programs that offer multiple cycles for a set cost. Many centers also make more traditional financing plans available to their patients. Your healthcare provider can tell you if they offer any payment programs. 21 other Factors LEGAL ASPECTS TO CONSIDER Donor Sperm or Eggs There are important legal considerations when using donor eggs or sperm or a surrogate, so it’s a good idea to consult an attorney, even if you think you have everything covered. Whether you choose surrogacy, egg, or sperm donation, it’s important to make arrangements in a state where the arrangements are legal and a contract can be enforced. Laws regarding the parental rights of sperm and egg donors vary widely from state to state, so it’s important to fully evaluate your state’s landscape before making decisions.28 Surrogacy There is no national policy regarding surrogacy and the laws governing surrogacy agreements vary from state to state, and state laws sometimes depend on the type of surrogacy agreement – gestational or traditional. Qualified professionals can help you navigate the emotional and legal issues that LGBTQ couples can face when starting a family.29 Defining Parental Roles Another thing you may want to consider is how to divide parental roles before the child is born and to check with a lawyer to determine the laws in your state regarding the rights that come with your specific union or partnership. Coparenting Some couples may also consider a co-parenting arrangement. Check with an attorney in your state to determine whether children who are born to or adopted by one member of a LGBTQ couple can have the security of having two legally recognized parents.30 Always speak to your healthcare provider and/or attorney about your specific situation. 22 chapter four Addressing Societal Stereotypes The question inevitably arises, “To tell or not to tell?” As a LGBTQ couple planning to start or build a family, you may be walking around with a tremendous burden on your shoulders. Face it, a lot of people in society still don’t get it when it comes to gay or lesbian couples having kids, let alone expressing the desire to have them. Some of those people may be members of your own family. Therefore, you may want to confide only in people you feel comfortable with, if any. Remember, you don’t owe anyone an explanation for your decision to start a family, especially if you also have fertility issues. These topics are personal. It is up to you and your spouse or partner if you want to share this information. Unfortunately, some stigmas may exist regarding homosexuality, which can lead to false assumptions about parental abilities and the resulting well-being of the children. But when the time comes to tell your family or even your boss, you have science on your side. If necessary, you can explain that studies show children of lesbian and gay parents fare as well as those of heterosexual couples in terms of emotional, cognitive, social, and sexual functioning.31 It is the nature of the familial relationships and family interactions that have a greater influence on the development of the child – not your sexual orientation. Remember that having children is one of our most innate drives as human beings, and every couple should have the right to build their own family. While the process is no doubt more complicated for LGBTQ couples, it may be possible in today’s society for you to become parents, and of genetically related children. 23 References 1 Position Statement on Parenting of Children by Lesbian, Gay, and Bisexual Adults. CWLA. Accessed August 23, 2011. 2 Cleveland Clinic. The Female Reproductive System. Retrieved on July 15, 2014, from http://my.clevelandclinic.org/anatomy/female_reproductive_system/ hic_the_female_reproductive_system.aspx 3 New Jersey Natural Family Planning. Human Reproduction and the Signs of Fertility. Retrieved on July 15, 2014 from http://www.njnfp.org/resources/ signsoffertility.php 4 University of California San Francisco Medical Center. Conception: How it Works. Retrieved on July 15, 2014, from http://www.ucsfhealth.org/education/ conception_how_it_works/ 5 Urology Care Foundation. Male Infertility. Retrieved on July 16, 2014, from http://www.urologyhealth.org/urology/index.cfm?article=102&display=1 6 MedlinePlus. Sperm. Retrieved on July 16, 2014, from http://www.nlm.nih.gov/ medlineplus/ency/imagepages/19471.htm 7 MayoClinic.com (2012) Getting Pregnant. Retrieved July 10, 2014, from http://www.mayoclinic.org/healthy-living/getting-pregnant/expert-answers/ pregnancy/faq-20058504 8 The American Fertility Association. (2010). Ringler, Guy, M.D. Gay Man, Gay Dad: Gay Men Can Become Fathers. Retrieved July 27, 2013, from http://www.theafa.org/article/gay-man-gay-dad-gay-men-can-become-fathers/ 9 RESOLVE. Ovulation Induction. Retrieved on July 16, 2014, from http://www.resolve.org/family-building-options/ovulation-induction.html 10 RESOLVE. IUI. Retrieved on July 16, 2014, from http://www.resolve.org/ cp-test/family-building-options/iui.html#.U8aU4fmzEhE 11 RESOLVE. IVF/ART. Retrieved on July 16, 2014, from http://www.resolve.org/ family-building-options/ivf-art.html 12 University of California San Francisco Medical Center. FAQ: Intracytoplasmic Sperm Injection Retrieved on July 16, 2014, from http://www.ucsfhealth.org/ education/intracytoplasmic_sperm_injection/ 13 Pelka, S. (2009) Sharing motherhood: Maternal jealousy among lesbian co-mothers. Journal of Homosexuality, 56, 195-217. 14 U.S. Food and Drug Administration. (2010). CFR - Code of Federal Regulations Title 21. Retrieved July 14, 2010, from http://www.accessdata.fda.gov/scripts/cdrh/ cfdocs/cfcfr/CFRSearch.cfm?fr=1271.85 15 American Society for Reproductive Medicine. (2006). Third-Party Reproduction. Retrieved July 16, 2014, from http://www.asrm.org/BOOKLET_Third-party_ Reproduction/ 16 American Society for Reproductive Medicine. Press Release Oct. 19, 2012. Retrieved on July 16, 2014, from http://asrm.org/news/article.aspx?id=10358 17 American Society for Reproductive Medicine. Mature Oocyte cryopreservation: a guideline. 2012. Retrieved on July 16, 2014, from http://www.asrm.org/ uploadedFiles/ASRM_Content/News_and_Publications/Practice_Guidelines/ Committee_Opinions/Ovarian_tissue_and_oocyte(1).pdf 18 ABA Journal, Mar 1, 2011. Retrieved on July 16, 2014 , from http://www.abajournal.com/magazine/article/as_surrogacy_becomes_more_ popular_legal_problems_proliferate 19 Council for Responsible Genetics: Surrogacy in America 2010 20 Human Rights Campaign. (2010). Adoption. Retrieved July 16, 2014, from http://www.hrc.org/resources/entry/adoption-options-overview 21 RESOLVE. Diagnosis and Management. Retrieved July 15, 2014, from http://www.resolve.org/diagnosis-management/ 22 American Society for Reproductive Medicine. (2006). Medications for Inducing Ovulation: A Guide for Parents. Retrieved September 7, 2010, from http://asrm.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/ Fact_Sheets_and_Info_Booklets/ovulation_drugs.pdf 23 Mayo Clinic. Infertility. Retrieved July 16, 2014, from http://www.mayoclinic.org/ diseases-conditions/infertility/basics/causes/con-20034770 24 Mayo Clinic. Low Sperm Count, Retrieved July 16, 2014, from http://www.mayoclinic.org/diseases-conditions/low-sperm-count/basics/ risk-factors/con-20033441 25 Anderson, L., Lewis, S. E. M., & McClure, N. (1998). The effects of coital lubricants on sperm motility in vitro. Human Reproduction, 13(12): 3351-3356. 26 Weng, X.,Odouli, R. & Li, D-K. (2008).Material caffeine consumption during pregnancy and the risk of miscarriage: A prospective cohort study. American Journal of Obstetrics andGynecology, 198 (3), 279-281. 27 McCusker, R. R., Goldberger, B. A., & Cone, E. J. (2003). Caffeine content of specialty coffees. Journal of Analytical Toxicology, 27, 520-522. 28 The American Fertility Association (2010). Brisman, M. & Halm,W. Legal Issues for the LGBT Community: Forming Your Family through Assisted Reproduction. Retrieved August 23, 2010, from http://www.theafa.org/article/legal-issues-for-thelgbt-community-forming-your-family-through-assistedreproduction/ 29 Human Rights Campaign.(2010). Surrogacy Laws: State by State. Retrieved July 15, 2010, from http://www.hrc.org/resources/entry/surrogacy-laws-and-legal-considerations 30 American Academy of Pediatrics. (2002). Coparent or Second-Parent Adoption by LGBTQ Parents. Committee on Psychosocial Aspects of Child and Family Health. Pediatrics, Vol. 109 No. 2. 31 Perrin, E.C. (2002). Technical report: Coparent or second-parent adoption by LGBTQ parents. Pediatrics, 109(2), 341-344. Retrieved July 14, 2010, from http://aappolicy.aappublications.org/cgi/content/full/pediatrics;109/2/341. Brought to you by in the know What No One Tells You About Family Building Options for LGBTQ Couples © 2014 EMD Serono, Inc. All rights reserved. US-NON-0714-0022 EMD Serono, Inc. is a subsidiary of Merck KGaA, Darmstadt, Germany.