Family planning can be challenging and stressful for anyone. For the LGBTQ community, it's that and more.
Iris Insogna
"LGBTQ is a unique patient population that deserves additional consideration when it comes to fertility," says Iris Insogna, MD, a Columbia OB/GYN who specializes in reproductive endocrinology. "Even in resource rich settings like New York City, where you think access to fertility care is easy, there are still barriers to care."
Barriers like financial limitations (including discriminatory insurance coverage), fears due to prior negative experiences with the medical community, and misconceptions, like the assumption having children was not a priority, or not possible.
As a doctor, Insogna knows the physical, emotional, and psychological challenges of family planning. As a former reproductive medicine patient, she understands it. A fact so significant she shares her own experience when appropriate to reinforce support.
"When I tell patients I did IVF, or that my wife and I used reciprocal IVF for our second child, the connection helps them to feel more at ease, share their concerns, and even be more accepting of obstacles," says Insogna. "It's so important for patients to feel comforted and considered."
Insogna helped us create this resource.
When to talk to a fertility specialist
Ask yourself if having a child is a priority. If you're 25 or older and you know you want a child sometime in your life, it's not too soon to talk to a fertility specialist. Don't wait to seek out care.
Trans people and fertility
Before transition, talk to a fertility specialist. It is often easiest to freeze sperm or eggs before starting gender-affirming hormone therapy, but in many cases it is still possible to retrieve sperm or eggs even after starting hormones. If you are considering surgery, however, it may result in the permanent inability to have a biological child, so consider freezing sperm or eggs in advance.
Counseling, mental health, and family planning
There's a lot to think about when creating family, from the health of parents to options like adoption, surrogacy, egg freezing, fertility preservation for transgender individuals, and reproductive treatment. "It's not always easy to choose the course that's right for you," Insogna says. "And after that decision is made, there are many others to make and more challenges to navigate. At every turn you need to work with professionals who understand your specific needs."
At Columbia, OB/GYN doctors often work in conjunction with family medicine doctors, social workers, and psychologists who specialize in family planning and LGBTQ needs.
How do you find an egg, embryo, or sperm donor? How do you find a surrogate? How do you adopt? Prospective parents must also determine what they will tell friends, family, and the child.
Same-sex female couples must consider who wants to contribute an egg and who wants to carry the pregnancy. Who wants their genetic material to be involved?
LGBTQ women and couples who need fertility treatment may have additional mental health needs. How do you deal with discrimination from people who say your infertility is not real because you are a same-sex couple. And when using a donor egg from a friend or acquaintance, a psychological screening is required. "These cases have another level of complexity, requiring legal contracts to protect parental rights and psychosocial screening to plan for disclosures to future children," Insogna says.
A fertility lawyer can create legal agreements for parentage of the baby after it is born.
The financial burden of fertility treatment
"The financial barriers to family planning cannot be underestimated," Insogna says. "Fertility treatment is expensive." Financially it's out of reach for many people, particularly if they do not have insurance coverage. This is especially true for male same-sex couples because treatment involving donor eggs and gestational carriers is considerably more expensive than those involving donor sperm and is not covered by insurance.
Donor sperm can be obtained for $1000 to $1800 a vial. Though insurance companies will not pay for donor sperm, some will pay for intrauterine insemination or IVF. Donor eggs can be $25,000 to $40,000. Gestational carriers can be $100,000 to $200,000. These costs are almost always out of pocket.
It's important to assess your financial situation before starting the journey. New York is a state with an insurance mandate, so many policies include partial or full coverage for fertility treatment.
Fertility options
When prospective parents work with an egg, embryo, or sperm donor, or a surrogate, the arrangement is known as third-party reproduction. Third-party options can help individuals and couples build a family when they cannot do so on their own. "The best option is the one that's right for you. Having a conversation with a fertility doctor can help clarify. For example, insemination with donor sperm can happen at home or in a clinic, but typically is safer and more effective in a clinic setting," Insogna says.
Intrauterine insemination (IUI)
Sperm is place directly in a woman's uterus.
In vitro fertilization (IVF)
Eggs are retrieved from a woman's body then fertilized with sperm to develop embryos that are placed in the woman's uterus.
Reciprocal IVF
One same-sex female partner provides the eggs to create the embryo; the other partner undergoes an embryo transfer and carries the pregnancy.
Gestational carrier (also called surrogate)
A woman who carries a pregnancy, but has no genetic relationship to the pregnancy. Embryos are created using IVF and then transferred into a gestational carrier.
For same-sex male couples, embryos can be created using donor eggs and sperm from one or both male partners. Embryos can stay frozen for future use in case a couple wants to use one partner's embryo first and the other's in the future.
"With two dads, an egg donor, and a gestational carrier, these types of fertility arrangements can become very complex," Insogna says. "Advance counseling and legal planning are essential."
Egg, embryo and sperm donor options
- Anonymous /non-identified donor
- Known donor (friend or family)
- Fresh v. frozen eggs or sperm
How to choose a donor
Before seeking egg, embryo, or sperm donation, talk to your doctor. There are many considerations-personal, medical, and more-to discuss and determine in advance. It can also be helpful to discuss with people you know who have gone through fertility treatment. There are a variety of banks and agencies in the United States so having some guidance can be helpful.
Find a health care provider who is able and willing to be part of this journey with you. Family planning, like other journeys that require medical assistance, can feel isolating, like you're on your own. Find networks of people, support groups, other people going through the same thing.
References
Iris Insogna, MD, is a reproductive endocrinologist at ColumbiaDoctors and the Columbia University Fertility Center and assistant professor of obstetrics and gynecology at Columbia University Vagelos College of Physicians and Surgeons. Her research interests include bioethics, improving access to care, LGBTQIA+ fertility, and third-party reproduction, including the use of donor egg, donor sperm, and gestational carriers.
Learn more: LGBTQ fertility services at Columbia Universitys Fertility Center
