Providing fertility services to lesbian couples: the lesbian baby boom☆

Clinical issues 

When lesbian couples choose DI as a means to become parents, they must decide who will carry the baby. Some factors that come into play are within the domain of a physician's advice, including the impact of age of each partner, and medical and gynecological history. Lesbian women should be advised of the increased risk of infertility, miscarriage, and chromosomal defects with increasing age. Couples will also consider the desire of each to be pregnant or not, insurance and medical benefits, attitudes of extended family, and the presence of existing children.

Women who wish to become pregnant using DI choose either an anonymous sperm donor or a known donor. There are pros and cons to each option. If the known donor is altruistic and is giving the sperm, costs may be reduced. If desired, a known donor can develop a relationship with the child, but it is also true that he may have a legal advantage in some states to obtaining a relationship with the child even if the mom(s) don't wish it. A known donor can be a family member of the nonbiological mother, ensuring her some biological connection to the child. Having a known donor means sharing some decisions that would otherwise be the parents' decision alone, such as if and when to disclose to the child the use of a donor and who the donor is, and perhaps what to do with excess embryos if IVF is used. (Many known donors would prefer that excess gametes and embryos not be given to others.)

Several sperm banks now offer an identity-release option, whereby the donors agree that the sperm bank can contact them in the future to pass along requests such as asking for an update on medical history and that the sperm bank can provide identifying information to adult offspring (18 years or older) who request it. Some banks have donors who agree that the bank can contact them in the future and pass along requests from adult offspring, and the donor will decide at that point in his life if he can be helpful. The rationale for this increasing openness is that the genealogical bewilderment experienced by adopted people may be shared by donor-conceived people. Also, donor offspring may desire reassurance that their donors are normal, average people, and having access may allow them this reassurance. If the parents of donor-conceived children are open with their children, (and almost all lesbian parents are), part of their task is to help the children understand that although a donor is a genetic relative, he is not a dad. He did not have a child and give it for adoption, and in most cases he doesn't even know of the existence of the child. Most open donors are not expecting or desiring an ongoing relationship with the offspring, but are accepting an adult responsibility for their choice to be a donor.

Because of the risk of sexually transmitted diseases (STDs), the use of fresh sperm is not advised, even in the case of a known donor. All donor sperm should be frozen and quarantined for 6 months to allow for retesting of the donor. The ASRM recommends that all sperm donors undergo a semen analysis, a medical history and physical examination, genetic evaluation, and laboratory testing including testing for HIV and other STDs. Ideally, donors have been counseled to carefully consider this choice they are making, and challenged to consider why they believe they can be comfortable in the long run with the choice.

The ASRM guidelines for sperm donation recommend that psychological counseling be offered to all persons receiving DI. This counseling may be conceptualized as an extension of the informed consent process, whereby patients are given information about the pros, cons, and ramifications of their alternative choices (4). The ASRM also recommends that the female recipient undergoes a medical and reproductive history, physical examination, standard preconceptual screening, testing and counseling including blood type, Rh factor, and antibody screening, rubella and varicella titers, HIV testing, and testing for other STDs such as hepatitis B surface antigen, hepatitis C antibody, cytomegalovirus (CMV) antibody, and serologic test for syphilis. Cervical cultures for gonorrhea and chlamydia may be obtained at the discretion of the physician (this is routine in the author's practice). Guidelines for genetic evaluation such as testing for cystic fibrosis carrier should be discussed and implemented. As with all women planning to conceive, the lesbian patient should be advised to take daily prenatal vitamins containing at least 400 μg of folic acid starting 3 months before attempting to conceive to decrease the risk of birth defects. In addition, depending on state law, many patients should consult a legal expert regarding donor or co-parenting agreements.

Reproductive abnormalities identified in the history and physical examination may warrant a more detailed evaluation and treatment before insemination. A study of women undergoing IUI found that the prevalence of polycystic ovary syndrome (PCOS) was significantly higher in lesbian women compared with heterosexual women (42% vs. 14%) (5).

The cumulative pregnancy success rate after 12 cycles of DI in 2,193 nulliparous women with azoospermic partners was 73%, 61%, and 54% for women aged under 31, 31–35, and >35 years, respectively (6). A study of lesbian-parented pregnancies found that a mean of three inseminations were needed to achieve pregnancy (7). If a lesbian patient fails to conceive with 3–6 cycles of well-timed inseminations, it is reasonable to consider an hysterosalpingogram (HSG) to document tubal patency. Consideration may also be given to performing an HSG before inseminations, particularly if the history and physical examination reveal risk factors for tubal or uterine pathology. Special consideration should be exercised before the empiric use of ovarian hyperstimulation with either clomiphene citrate (CC) or gonadotropins if pregnancy does not occur within 3–6 cycles, as 3–6 failed cycles of insemination with frozen sperm does not necessarily classify a woman as technically “infertile.” As with all patients, lesbian recipients should be advised of the increased risk of multiple pregnancy and possibility of ovarian hyperstimulation syndrome (OHSS) with fertility medications.

When a physician begins to offer these services to lesbians, a number of adaptations to office procedures can be helpful. These include educating the entire medical and office staff about the reasons for the changes in policy and addressing any discomfort or concerns they may have; revising educational materials and consent forms to refer to partners and unions rather than spouses and marriages; letting lesbian recipients know that all donor recipients are referred for psychological counseling and they are not being singled out; and enlarging your resource lists to include materials for lesbian women.

Legal issues 

Each state has its own laws governing adoption, custody, visitation, and surrogacy. It is important to advise all lesbian couples to consult a lawyer and have documents prepared outlining their intentions regarding co-parenting and what they want to happen in the event of death or separation. They should be made aware of options in their state regarding second-parent adoption (also called co-parent adoption).

Second-parent adoption allows a same-sex parent to adopt her or his partner's biological or adoptive child without terminating the first parent's legal status as parent. Second-parent adoption protects the best interests of the children and of both parents, by ensuring that the children and the parents have legally recognized relationships with one another, with all the rights and responsibilities that accompany those parent–child relationships. This is not only important to the child's emotional well-being and sense of safety, but to the family's well-being should the biological (or original adoptive parent) die or become incapacitated, and it protects the relationship of the child to the nonbiological parent should the couple's relationship end.

As of this writing, only Connecticut has a state statute legalizing second-parent adoptions, but other states, including California, Connecticut, Washington, DC, Illinois, Massachusetts, Pennsylvania, New York, New Jersey, and Vermont, have appellate court decisions allowing it. Second-parent adoptions have also been granted by trial court judges in Alabama, Alaska, Delaware, Hawaii, Indiana, Iowa, Louisiana, Maryland, Minnesota, Nevada, New Mexico, Oregon, Rhode Island, Texas, and Washington.

In November 2003, the Massachusetts Supreme Judicial Court ruled that denial of marriage for same-sex couples is unconstitutional and that same- and opposite-sex couples must be given equal civil marriage rights under the state constitution. At present, a partner in a same-sex partnership will not automatically get child custody, wrongful death benefits, or visitation rights. Thus, it is a part of the informed consent process to advise lesbian couples to obtain legal advice about how to proceed.

Summary