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
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hic_the_female_reproductive_system.aspx
3
New Jersey Natural Family Planning. Human Reproduction and the Signs of
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signsoffertility.php
4
University of California San Francisco Medical Center. Conception: How it Works.
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conception_how_it_works/
5
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MedlinePlus. Sperm. Retrieved on July 16, 2014, from http://www.nlm.nih.gov/
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MayoClinic.com (2012) Getting Pregnant. Retrieved July 10, 2014, from
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pregnancy/faq-20058504
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family-building-options/ivf-art.html
12
University of California San Francisco Medical Center. FAQ: Intracytoplasmic
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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
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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
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popular_legal_problems_proliferate
19
Council for Responsible Genetics: Surrogacy in America 2010
20
Human Rights Campaign. (2010). Adoption. Retrieved July 16, 2014, from
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21
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22
American Society for Reproductive Medicine. (2006). Medications for Inducing
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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
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risk-factors/con-20033441
25
Anderson, L., Lewis, S. E. M., & McClure, N. (1998). The effects of coital lubricants
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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.
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29
Human Rights Campaign.(2010). Surrogacy Laws: State by State. Retrieved July 15,
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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
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