LGBT Assisted Reproduction: Current Practice and Future Possibilities

The availability and type of lesbian, gay, bisexual, transgender, and queer content on sperm, oocyte, and embryo provider websites

PURPOSE

To evaluate and quantify the character and amount of lesbian, gay, bisexual, transgender, and queer (LGBTQ +) content on sperm, oocyte, and embryo provider websites in the USA.

METHODS

Websites with LGBTQ + information were categorized into "minimal," "moderate," and "significant" content. The presence and type (category) of LGBTQ + content were assessed in its relationship to geographic regions, in vitro fertilization (IVF) cycles/year, and website types. Interobserver reliability was assessed for the categorization system created.

RESULTS

Out of 373 unique websites, 191 (51.2%) had LGBTQ + content of any kind. Regarding the amount of content, websites were categorized as "none" (48.8%), "minimal" (8.0%), "moderate" (28.4%), and "significant" (14.8%). "Private fertility clinic" websites were more likely to have LGBTQ + content and a significantly increased amount of content compared to other website types ("academic hospital" and "sole sperm, oocyte, and embryo provider" websites) (p < 0.0001). Fertility clinics with more IVF cycles/year were more likely to have increased amount of LGBTQ + content compared to those with fewer IVF cycles/year (OR = 4.280; 95% CI, 1.952-9.388). Northeast, West, South, and Midwest regions showed no statistically significant difference in presence and type of content (p = 0.06 and p = 0.13, respectively).

CONCLUSION

Approximately half of websites had LGBTQ + content. Private fertility clinics and fertility clinics with increased IVF cycles/year show a positive relationship to the presence and type of LGBTQ + content, while LGBTQ + website content was similar across four geographic regions.

Lesbian shared IVF: the ROPA method: a systematic review

The ROPA (Reception of Oocytes from PArtner) method, also known as lesbian shared IVF (in vitro fertilization), is an assisted reproduction technique for female couples, in which one of the women provides the oocytes (genetic mother) and the other receives the embryo and gestates (gestational mother). As a double parented method, it is the only way lesbian women may biologically share motherhood. This is a narrative review of data concerning ROPA published in PubMed, Scopus, and Cochrane Library. A total of 35 articles were included, 10 about motivations for undergoing ROPA, 13 about ethics or legislation, 4 about motherhood, and 8 studies reporting clinical outcomes. Despite being used for more than a decade, there is a paucity of data regarding this technique in scientific literature. Most women choose this technique to share biological motherhood, but medical issues may also justify its use. Many ethical and legal issues are still to be solved. Despite the small number of studies, data regarding the outcomes of this technique and the resulting motherhood are reassuring.

Fertility preservation for transgender children and young people in paediatric healthcare: a systematic review of ethical considerations

BACKGROUND

While fertility preservation is recommended practice for paediatric oncology patients, it is increasingly being considered for transgender children and young people in paediatric care. This raises ethical issues for clinicians, particularly around consent and shared decision-making in this new area of healthcare.

METHODS

A systematic review of normative literature was conducted across four databases in June 2020 to capture ethical considerations related to fertility counselling and preservation in paediatric transgender healthcare. The text of included publications was analysed inductively, guided by the Qualitative Analysis Guide of Leuven.

RESULTS

Twenty-four publications were identified for inclusion. Four key ethical considerations emerged from this literature: access to fertility preservation, conscientious objection, decision-making capacity of children and young people, and shared decision-making.

CONCLUSION

In the identified literature, there is consensus that transgender children and young people should not be refused access to fertility preservation services solely due to their gender identity, and that clinicians with conscientious objections to fertility preservation for this group have an obligation to refer on to willing providers. Factors that create ethical complexity in this area of paediatric care include the child's age, mental health, and parents' views.

Similar reproductive outcomes between lesbian-shared IVF (ROPA) and IVF with autologous oocytes

PURPOSE

To compare reproductive outcomes of the ROPA method (reception of oocytes from partner) to IVF with autologous oocytes. To study the impact of the absence of a genetic link between the embryo and its recipient in reproductive outcomes.

METHODS

Retrospective multicentric cohort study performed from January 2011 to December 2020 in 18 fertility clinics in Spain. A total of 99 ROPA (73 couples) and 2929 non-ROPA cycles (2334 couples or single patients) of women younger than 38 years old with no known female fertility disorder were included. Clinical outcomes were compared between both groups and included positive pregnancy test, clinical pregnancy, miscarriage, ectopic pregnancy, pre-term birth, live birth, weeks of gestation at birth, and newborn weight at birth.

RESULTS

No differences were found between groups in clinical outcomes. The total clinical pregnancy rates per embryo transfer were 57% and 50.2% (p = 0.15) and the live-birth rates were 46.1% and 40.9% (p = 0.14) for the ROPA and non-ROPA groups, respectively. When adjusted to age and BMI of donors and recipients, there were also no differences in live-birth rates between both groups. The cumulative live-birth rate per ROPA cycle was 73.7% and the cumulative live-birth rate per couple was 78.3%.

CONCLUSION

Clinical outcomes following the ROPA method and IVF with autologous oocytes were found to be similar. These findings suggest no impact of the absence of genetic ties between the embryo and the uterus on reproductive treatments' outcomes. Data regarding the outcomes of the ROPA method are reassuring.

Laboring to Conceive: Reducing Barriers to Fertility Care for Same-Sex Mothers Pursuing Parenthood

Infertility clinics and providers in the United States have made efforts to become LGBTQ-inclusive, yet patients in same-sex partnerships continue to face disproportionate barriers to accessing fertility services when pursuing parenthood. This narrative case study of a same-sex couple’s “labor to conceive” illustrates some of the structural barriers to family building that lesbian mothers face when seeking fertility care, including insurance coverage of fertility treatments, federal regulations for sperm donation, and legal definitions of parenthood. Exclusionary medical and legal systems are discussed, as are the informal strategies that this same-sex couple utilized to negotiate and circumvent these barriers. A patient-centered model of advocacy that facilitates access to and protection of same-sex partners seeking (in)fertility services is presented. Intervention points at the (1) Logistical and (2) Societal levels are considered with respect to three domains of same-sex reproduction: (A) insurance; (B) sperm donation; (C) legal adoption.

LGBTQ2S+ childbearing individuals and perinatal mental health: A systematic review

BACKGROUND

The perinatal period may uniquely impact the mental health and wellbeing of lesbian, gay, bisexual, transgender, queer, and Two-Spirit (LGBTQ2S+) childbearing individuals.

OBJECTIVES

To characterise and synthesise the experiences of LGBTQ2S+ childbearing individuals regarding perinatal mental health, including symptomatology, access to care and care-seeking.

SEARCH STRATEGY

We conducted and reported a systematic review following PRISMA guidelines of eight databases (EMBASE, MEDLINE-OVID, CINAHL, Scopus, Web of Science: Core Collection, Sociological Abstracts, Social Work Abstract, and PsycINFO) from inception to 1 March 2021.

SELECTION CRITERIA

Original, peer-reviewed research related to LGBTQ2S+ mental health was eligible for inclusion if the study was specific to the perinatal period (defined as pregnancy planning, conception, pregnancy, childbirth, and first year postpartum; includes miscarriages, fertility treatments and surrogacy).

DATA COLLECTION AND ANALYSIS

Findings were synthesised qualitatively via meta-aggregation using the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI), and the ConQual approach.

MAIN RESULTS

Our systematic search included 26 eligible studies encompassing 1199 LGBTQ2S+ childbearing participants. Using the JBI SUMARI approach, we reported 65 results, which we synthesised as six key findings. The studies described unique considerations for LGBTQ2S+ individuals' perinatal mental health, including heteronormativity, cisnormativity, isolation, exclusion from traditional pregnancy care, stigma, and distressing situations from the gendered nature of pregnancy. Many participants described a lack of knowledge from healthcare providers related to care for LGBTQ2S+ individuals. In addition, LGBTQ2S+ individuals described barriers to accessing mental healthcare and gaps in health systems. Strategies to improve care include provider education, avoidance of gendered language, documentation of correct pronouns, trauma-informed practices, cultural humility training and tailored care for LGBTQ2S+ people.

CONCLUSIONS

Pregnancy, postpartum, and the perinatal period uniquely impacts the mental health and wellbeing of LGBTQ2S+individuals, largely due to systems-level inequities and exclusion from perinatal care. Healthcare providers should implement the identified strategies to improve perinatal care and address inequities.

Successful In Vitro Fertilization in a Cisgender Female Carrier Using Oocytes Retrieved From a Transgender Man Maintained on Testosterone

Background

Health care providers routinely discontinue testosterone in transgender men undergoing oocyte retrieval. To date, there is little literature to support such discontinuation. The sudden drop in testosterone levels can be distressing for transgender men. The objective of this report was to describe a case study of successful reciprocal in vitro fertilization (IVF) using oocytes retrieved from a transgender man who remained on testosterone during the entire course of gonadotropin controlled ovarian stimulation and retrieval.

Case Report

A 33-year-old gravida 0 transgender man and his partner, a 42-year-old gravida 0 cisgender woman, presented to an outpatient clinic in 2017 seeking reciprocal IVF. Both patients were healthy with no significant past medical history. The transgender patient reported a 10-year history of testosterone hormone therapy. Both patients reported no other medication use. The transgender man underwent a 14-day course of ovarian stimulation before oocytes were retrieved. An oocyte was then fertilized and implanted into the uterus of the patient’s cisgender female partner. The reciprocal IVF resulted in an uncomplicated, full-term pregnancy with vaginal delivery. The child is now 2 years old and developmentally normal.

Discussion

To our knowledge, this is the first report of a live birth from an oocyte retrieved from a transgender man who continued to use testosterone throughout assisted reproduction.

Conclusion

Fertility preservation options for transmasculine people may include stimulated egg retrieval if the ovaries are left in place even when the patients remain on testosterone therapy.

Ethical Considerations of Fertility Preservation for Transmasculine and Nonbinary Youth

An increasing number of young adolescents who identify as transgender or nonbinary are presenting to the health care system for gender affirmation therapy before the full progression of puberty. Gender-affirming therapy may impair future fertility, but options exist for fertility preservation. This perspective reviews these options for transmasculine and nonbinary youth, and explores related ethical considerations. The authors support the right of transgender and nonbinary youth to utilize available reproductive technologies, provide recommendations for treating health professionals, and advocate for increased research efforts and tools to aid patient decision making.

Double intrauterine insemination (IUI) of no benefit over single IUI among lesbian and single women seeking to conceive

PURPOSE

To explore clinical benefit of performing two intrauterine inseminations (IUI) 24 h apart-a double IUI vs. a single IUI among lesbian and single women.

METHODS

Retrospective cohort study using electronic medical record review during a 17-year period (11/1999-3/2017). A total of 11,396 patients at a single academic-affiliated private practice were included in this study. All cycles with a single or double IUI were included. A sub-analysis of first cycles only (n = 10,413) was also performed. Canceled IVF cycles converted to IUI were excluded. T tests and Wilcoxon rank-sum tests were used for continuous data, and chi-square for categorical data. Multivariable logistic regression controlled for patient age, day 3 follicle-stimulating hormone (D3 FSH), body mass index (BMI), peak estradiol (E2), and post-wash total motile sperm counts to model the association between IUI number and ongoing pregnancy rate (OPR) according to sperm source (autologous vs. donor). Generalized estimating equations and mixed effect models accounted for multiple cycles from the same woman. Adjusted odds ratio (AOR) with 95% CI was determined. Sub-analyses of sexual orientation and partner status were performed to compare heterosexual couples with proven infertility to women with lesbian and single women.

RESULTS

During the study period, 22,452 cycles met inclusion criteria (single IUI 1283 vs. double IUI 21,169). Mean patient age and BMI were similar between groups. For couples using autologous sperm, OPR was significantly higher with double IUI (12.0% vs. 14.1%; p = 0.0380). A similar increase was observed for donor sperm OPR among heterosexual couples (14.4% vs. 16.2%), though this did not reach statistical significance (p = 0.395). A sub-analysis restricted to donor sperm demonstrates a clinical benefit of second IUI in heterosexual couples, 8.5% vs. 17.6% OPR (AOR 2.94; CI 1.00-10.99; p = 0.0496). When lesbian and single patients were evaluated, there was no difference (17.2% vs. 15.2%; AOR 0.99; CI 0.59-1.70; p = 0.0958).

CONCLUSIONS

Double IUI is associated with a significantly higher OPR for heterosexual couples using an autologous or donor sperm source. The benefit of a second IUI is less clear in patients with undocumented fertility status using donor sperm, such as single and lesbian women.

Genetics in LGB Assisted Reproduction: Two Flipped Classroom, Progressive Disclosure Cases

INTRODUCTION

There have been several educational reforms calling for increasing lesbian, gay, bisexual, and transgender (LGBT) education materials, application of basic sciences to clinical medicine, and active engagement of students. While the amount of educational materials for LGBT clinical cases is increasing, this session for preclinical medical students uniquely combines basic science population genetics, cisgender lesbian, gay, and bisexual (LGB) cultural issues and reproductive endocrinology in a 1.5-hour flipped classroom session.

METHODS

Students were assigned a prediscussion video and reading. Facilitators attended a 1.5-hour training session prior to discussion. Each classroom of 30 students with small groups of six was led by a third- or fourth-year medical student facilitator who taught from a PowerPoint that included discussion questions. An audience response system was used to show aggregated, real-time anonymous responses to case questions, a pre- and postsurvey was used to analyze changes in student attitudes and knowledge of assisted reproduction services for same-sex couples, and course evaluations captured overarching student impressions.

RESULTS

All first-year students (N = 180) attended this mandatory session. Audience response questions showed a high level of knowledge of population genetics concepts. Voluntary surveys showed a higher number of assisted reproduction recommendations for LGB patients compared to heterosexual patients before discussion, with this difference disappearing after the discussion. This may indicate a shift in student attitudes and knowledge of LGB patient barriers and assisted reproduction. Course evaluations showed appreciation of LGB material integration within the course.

DISCUSSION

Educators will be able to successfully integrate the application of population genetics, assisted reproduction cases, and an examination of cultural barriers in health care for LGB patients with this session.

Lesbian, gay, bisexual, transgender content on reproductive endocrinology and infertility clinic websites

OBJECTIVE

To assess geographical distribution and practice characteristics of fertility clinics inclusive of lesbian, gay, bisexual, and transgender (LGBT) patients.

DESIGN

Cross-sectional analysis.

SETTING

Not applicable.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Prevalence and geographical distribution of fertility clinic websites with LGBT-specific content, indicated by keywords and home page cues specific to the LGBT patient population. Assessment of relationship between LGBT-specific content and clinic characteristics, including U.S. region, clinic size, private versus academic setting, and state-mandated fertility insurance coverage.

RESULT(S)

Of 379 websites analyzed, 201 (53%) contained LGBT content. Clinics with the highest proportion of LGBT website content were in the Northeast (59/82, 72%) and West (63/96, 66%), while the lowest proportion was in the Midwest (29/74, 39%) and South (50/127, 39%). Most frequently used terms included lesbian (72%), LGBT/LGBTQ (69%), and gay (68%), while less used terms included trans/transgender (32%) and bisexual (15%). Larger clinic size was associated with LGBT-specific website content (odds ratio, 4.42; 95% confidence interval, 2.07-9.67). Practice type and state-mandated fertility insurance coverage were not associated with a clinic website having LGBT content.

CONCLUSION(S)

Over half of Society for Assisted Reproductive Technology member fertility clinics included LGBT content on their websites, yet those in the Midwest and South were significantly less likely to do so. Predictive factors for having LGBT website content included location in northeastern and western regions and increasing clinic size. Further studies are needed to evaluate whether inclusion of LGBT content on clinic websites impacts use of reproductive services by the LGBT patient population.