Fertility and Family Building in LGBTQ Families

Evaluation:

The initial evaluation for same sex female couples includes a detailed transvaginal pelvic ultrasound of the uterus and ovaries.  Frequently the woman's egg reserve is assessed with (1) AMH (antimullerian hormone) level which is the most commonly used blood test to check a woman's "egg count" (2) antral follicle count (AFC) which determines the number of small follicles in each ovary.  Both of these tests predict whether a woman has a robust, average or low egg supply. Preconceptual lab work is obtained including a prenatal or OB panel on the woman undergoing treatment and an infectious disease screen on her partner.  The same preconceptual bloodwork is obtained for heterosexual couples.  The couple has the option of obtaining genetic carrier screening for the woman who is planning on conceiving. 

You May Be Fertile

The majority of same sex female couples are not infertile.  They simply lack exposure to sperm.  Depending upon the woman's past gynecologic history, a detailed evolution of the uterus and fallopian tubes may be done at the outset or performed later if she failed to become pregnant following three cycles of  IUI with donor sperm. The two tests used to evaluate the uterus and fallopian tubes are (1) HSG or hysterosalpingogram (2) hysteroscopy.  Both of these tests are important and complement one another to allow a thorough evaluation of the pelvic structures. 

HSG

A hysterosalpingogram or HSG is a radiographic procedure (x-ray) which is performed in the early portion of the cycle. Typically this is scheduled once the woman has stopped her menstrual flow but no later than cycle day 10. The test may cause some discomfort similar to menstrual cramps.  It is advisable to take NSAIDs (Aleve, Motrin, Ibuprofen, etc.) about 20 to 30 minutes before the scheduled procedure to aid in decreasing the cramping.  A small tube is placed through the cervix to allow the dye to be injected.  Arriving at the Center with a semi full bladder will allow this tube to be placed more easily.  HSGs are performed Monday through Friday at either our Bedford or Fort Worth location and may be performed by any one of our physicians.  This test typically lasts about five minutes.  The physician performing the HSG will review the results with you.  The HSG may not detect small amounts of scar tissue or endometriosis; however, a normal HSG should be viewed reassuringly.  Hysteroscopy involves the placement of a small telescope through the cervix to allow direct visualization of the inside of the uterus (endometrial cavity). 

Hysteroscopy

The same guidelines outlined for the HSG regarding timing of the test in relation to the menstrual cycle, arriving with a semi full bladder and taking NSAIDs (Aleve, Motrin, Ibuprofen, etc.) prior to the test apply for hysteroscopy as well.  The patient has two options for scheduling the hysteroscopy (1) diagnostic procedure in the office setting (2) diagnostic / therapeutic procedure in the operating room.  The diagnostic procedure in the office involves using a small (3 mm in diameter) telescope and typically is done without the placement of a speculum and lasts less than five minutes.  The majority of patients tolerate this option well.  If an abnormality is found, a hysteroscopy in the operating room to correct or treat the problem will need to be scheduled on a different day.  Patients may opt to schedule the hysteroscopy in the operating room at the outset if they desire or if the physician suspects an abnormality is present at ultrasound or HSG.   This likely is the optimal choice for individuals who have a low pain tolerance.

Ordering Donor Sperm

Donor sperm may be ordered from any accredited commercial sperm bank.  One of our andrology staff will be happy to assist you in the ordering process.  CARE Fertility has large liquid nitrogen storage tanks on site.  One vial of donor sperm is needed for each treatment cycle.

Natural Cycle Donor IUI 

The most commonly utilized treatment option for same sex female couples is artificial insemination (also known as IUI or intrauterine insemination) with donor sperm.  If the woman undergoing treatment has predictable menstrual cycles, the insemination is performed in a natural cycle without the use of fertility medications.  This minimizes the risk of multiple pregnancy (twins) and yields pregnancy rates close to the age-matched fertile population.  The IUI is timed with ultrasound and the use of an ovulation predictor kit. 

Clomiphene Citrate (clomid) Donor IUI

For women with irregular cycles and normal to high “egg counts”, natural cycle donor IUI is not an option.  After eliminating medical causes for irregular cycles, clomiphene citrate may be used to attempt to induce normal ovulation.  The main risk of clomiphene citrate (clomid) is an increased risk of multiple pregnancy, primarily an approximately 10% risk of twins.  Similar to natural cycle donor IUI, the IUI is timed with ultrasound and the use of an ovulation predictor kit  

In Vitro Fertilization (IVF)

IVF (in vitro fertilization) is a treatment option which involves the use of fertility injections to stimulate the ovaries to increase egg production in a given treatment cycle.  The eggs are harvested using transvaginal ultrasound guidance.  This procedure usually takes 10 to 15 minutes and is performed in an operating room with intravenous sedation.  The sedation is administered by a board certified anesthesiologist.  Afterwards the sperm and egg are combined in the laboratory.  The embryo transfer is typically performed five days later through a process which is similar to IUI.  CARE Fertility follows the ASRM/SART guidelines regarding numbers of embryos to transfer.  The majority of women have a single embryo transferred which minimizes the risk of multiple pregnancy such as twins or triplets.  Extra heathy embryos (if available) are stored for future use.  Some couples may opt to begin with IVF rather than donor IUI because of the higher rate of pregnancy, potentially shorter duration to conceive, control over multiple birth and the potential to have extra embryos to expand their family in the future.  Most same sex female couples are candidates for a simplified IVF process pioneered by CARE Fertility called effortless IVFTM.  This revolutionary IVF treatment involves a lower dosage of the fertility injections and just two to three sonograms during the IVF cycle.  No blood tests are needed.  This greatly reduces the time burden and financial cost for the couple.  If you are interested, please go to effortless IVFTM.com to learn more about this option.

Reciprocal IVF

Same sex male couples can have their biological child through the use of an egg donor and a gestational carrier.  This process is more complex than a same sex female couple pursuing reciprocal IVF.  The FDA views the exchange of reproductive tissue (sperm, eggs or embryos) as a tissue donation and this requires more testing.  Either or both male partner's sperm may be used to inseminate the donor's eggs.

FDA Screening of the Sperm Source

The FDA stipulates that an FDA physical exam, bloodwork and Risk Assessment Questionnaire must be completed within a 7 day window of when the semen is collected.  CARE performs this testing and freezing of the semen sample(s) prior to beginning the treatment cycle.

Egg Donor

One option is to use a frozen egg bank.  This reduces the cost and simplifies the process since there is no wait time to identify, screen and stimulate the donor.  Pregnancy rates with frozen eggs are lower than with a fresh egg donor.  This is likely due to the lower number of eggs being used and the variability in frozen eggs surviving the freeze/thaw process.  The most common way an egg donor is located is through a donor agency.  Our office will be happy to provide you with a list of donor agencies we have worked with previously or a couple may locate an agency on their own.  Characteristics of a good egg donor are: age 21 to 32, normal weight and BMI, no significant health issues and a good to excellent egg count.  The donor's screening includes genetic carrier screening, evaluation by a mental health professional with knowledge of reproductive issues and a physical exam with ultrasound.  An AMH (antimullerian hormone) blood test is performed to measure her egg reserve or "egg count".  This information is used to plan the stimulation of her eggs.  The egg donor is required to undergo an FDA physical exam, bloodwork and Risk Assessment Questionnaire within a 30 day window of the egg harvest. 

Gestational Carrier

Similar to egg donors, gestational carriers are typically located through agencies.  Again, our staff will provide you with a list of agencies that we have previously worked with or a couple may locate their own gestational carrier.  An ideal gestational carrier is under the age of 38, has previously delivered a term baby and has no history of prior pregnancy complications.  The carrier ideally should be of average body weight, have an unremarkable medical history and be a non-smoker.  The gestational carrier's evaluation will focus on her uterus.  Three tests will be performed in addition to a physical exam.  These include a pelvic ultrasound, hysterosalpingogram (HSG) and hysteroscopy.  The transvaginal pelvic ultrasound is non-invasive and gives us information regarding the size and shape of her uterus.  It does not provide detailed information about the inside of the uterus where the baby grows nor does it provide information about the fallopian tubes.  Utilizing hysteroscopy, the interior of the uterus where the baby will grow is thoroughly evaluated. The HSG provides information about the configuration of the inside of the uterus and information about the fallopian tubes.

Number of Embryos to Transfer

Single embryo transfer is performed when an egg donor is utilized.  If a couple chooses to each have their own biological child, sequential pregnancies would be undertaken.