Most people who hope to become parents plan to have children who are genetically related to them. But for homosexuals, this process is complicated and expensive. Carrying it out involves the collaboration of a fertility doctor, a lawyer, a gestational carrier (aka surrogate mother) and an egg donor. The process takes about two years and costs about $200,000 per child — and expectant gay fathers don’t qualify for most health insurance plans’ fertility benefits, though that’s starting to change.
Brent MonseurMD, recently helped lead a study to document the details of how gay men use assisted reproductive technologies to build their families, including issues such as how many children they want to have and how often their efforts are successful. Monseur, who is completing her postdoctoral fellowship at Stanford Medicine in reproductive endocrinology and infertility, spoke to science writer Erin Digitale about the research, which appeared Aug. 4 in Fertility and Sterility Reports.
How was this study born?
A refrain that many LGBTQ people, myself included, heard after coming out was “You can never have a family.” Fortunately, it’s less common now, but for a long time this comment reflected prevailing social norms and a misconception that reproductive science was not advanced enough for LGBTQ people to become parents.
As a gay man growing up in a conservative environment, this was a challenge I thought about. I don’t know if I want to have kids, but I didn’t want anyone to tell me I couldn’t. So I looked for how I could start a family. As a youngster, it was really hard to find this information. (That was about 20 years ago, I’m 35 now.) There was nothing in the library and very little on the internet, but I figured that would probably involve a doctor.
At Johns Hopkins graduate school, before going to medical school, I worked with fertility doctors. I asked them how I could start a family as a homosexual. They explained the whole process; it was super complicated. Then they said, “You wouldn’t be able to be a patient here. We don’t deal with homosexuals… but we should. I’ve decided, I’m going to go to medical school and become a doctor who provides reproductive care to all LGBTQ people.
Your article provides historical context on how changing attitudes towards LGBTQ families have changed the climate for gay men who want to become fathers. Can you summarize?
The simplest way to put it is that LGBTQ families have gone from a paradox to a possibility. We have gone from criminalized and pathologized to more accepted.
Much of the scientific literature has focused on whether children do well if they have gay parents. There is no data to suggest anything detrimental to children having gender or sexual minority parents. Not only is it now socially “OK” for LGBTQ people to have children, but there are also people who are now advocating for LGBTQ families. In my own field, the professional organization that sets practice guidelines for fertility doctors says everyone should have access to fertility care. Many institutions whose fertility clinics didn’t treat everyone before — including Johns Hopkins, where I did my graduate work — now do.
But there are still barriers. Some fertility clinics in this country still do not support LGBTQ patients, and most health insurance plans that offer fertility benefits use a clinical definition of infertility based on a heterosexual couple trying to conceive for 12 months without pregnancy. A New York state gay couple recently filed a lawsuit claiming the criteria were discriminatory.
Why is it important that the experiences of gay men seeking fertility care be reflected in the scientific literature?
Most work in reproductive medicine has focused on infertile cisgender heterosexual women. Cisgender gay men are almost never included in this research, so as physicians we know nothing about their characteristics as reproductive health patients, even basic information such as their demographics, clinical decision or their results.
Our article used data from one of the few fertility benefit companies that offers fertility coverage to gay men. It gave us a window into a nationwide group of 119 cisgender men, including five single men and 57 same-sex couples, who had unique fertility benefits. Although this study is still relatively small, it is the largest study of American men going through this process to date. I’ve often started my patient consultations by saying “There really isn’t any research on how to do this”, but now we can say “You’re in the literature. Your decision-making and results have been studied.”
According to our data, the success rates for finally having a child are really high for this population. At the time of the study, approximately 70% of people in our study population had completed both egg donation and embryo transfer to a gestational carrier, with a live birth rate of 85%. It’s important to keep in mind that our data reflects the experiences of people who can afford reproductive medical care because their employer-sponsored fertility benefits cover them, and this is again an unusual situation. for gay men.
These data served as the basis for a grant application we have just obtained to conduct a much larger population-based study that will give us access to information on approximately 2,000 embryo transfers per year among gay men.
What are the most important aspects of your findings?
It’s a group that has extremely successful birth rates, and in fertility medicine, that’s unusual. Many people see a fertility doctor because they have an underlying medical problem, whereas same-sex couples usually have two possible sperm sources, a young egg donor and a gestational carrier who has had pregnancies before. successful. I believe that because of these medical factors, same-sex couple birth rates could serve as a modern standard for judging the success of IVF labs.
The other thing, consistent with the results for lesbian/bisexual women, is that there is a high rate of twin pregnancies. In our study, the transfer rate of more than one embryo to the gestational carrier did not meet the standard of care, which strongly recommends transferring a single embryo; it was much higher. We recognize that this may be because many gay men ask for twins or may ultimately want two children, and fertility doctors may transfer two embryos to try and save their patients money so that they only have to go through the fertility treatment process once. But we have to ask ourselves: are we putting gestational carriers at unnecessary risk of twin pregnancies and putting same-sex couples at unnecessary risk of having babies in the NICU? I believe that better insurance coverage for fertility care for LGBTQ people would be a safer and healthier way to deal with financial pressure.
Before becoming a gynecologist-obstetrician, I thought: “It’s a problem of access to health, and if gay men want twins, we must respect their autonomy. But once you deal with complicated pregnancies and realize the risks, it becomes clear that your goal is not to rush. The goal is one healthy baby at a time.
What does it add to have physician-scientists like you, who are gay themselves, answering research questions about this population of future parents?
Research shows that patients do better when their doctor is of the same race. I suspect the same logic applies to members of the LGBTQ community. I’m currently on a scholarship, and I have patients who come to see me specifically, not because I’m the most amazing doctor, but because I’m gay and they want a gay doctor. Also, it’s important because I’m publishing the first study in this area — sometimes, if you don’t have lived experience, you don’t consider what people in that community are doing or what’s important to them. The job just isn’t done any other way.
picture by Davide Zanin