Same-sex couples and babies: Q&A with Dr. Briana Rudick
While the decision and process to have a baby for a heterosexual couple may be relatively straightforward, for same sex couples, the path to parenthood is quite different. But knowledge is power. Dr. Briana Rudick, Assistant Professor of Obstetrics and Gynecology at Columbia University Irving Medical Center explains this process, and the steps these couples can take in order to have their own little bundle of joy.
How often do same sex female couples come to Columbia University Fertility Center for consultation/treatment?
They are one of my biggest demographics in terms of patients. I would say multiple people are coming in every day.
What methods of insemination are discussed with these couples?
I review intravaginal, intracervical, and intrauterine insemination. In general, the higher up in the female reproductive tract you go with the catheter, the higher the chance of success. We only do intrauterine insemination unless there’s some reason to do intracervical (which is rare). We don’t do intravaginal insemination, but some couples do try this at home. These are just the methods of insemination. There is always IVF treatment (if need be), and something called co-maternity, in which one female partner donates her eggs for the other female partner to carry.
What fears/doubts do these couples usually have about insemination?
The biggest fear that I see is fear of over-medicalization. I think these couples still want getting pregnant to be as “natural” a process as possible, but because they have to deal with the medical and financial aspects of treatment, they worry that it won’t be a special process.
What is the simplest way to conceive for lesbian couples?
The simplest way is through donor sperm intrauterine insemination (without any medication). We call that a “natural cycle with intrauterine insemination (IUI).” Even though it sounds simple, there is still a lot of testing that goes into starting treatment, and there is the decision about how to choose donor sperm. You can use anonymous versus non-anonymous donor sperm. Lots of people are under the misconception that using someone who you know is easier. It’s actually much, much harder. It requires legal and psychiatric clearance, as well as a six-month quarantine of the sperm.
Which is the fastest and the least expensive way to conceive for lesbian couples?
We never know the true answer to this question, especially since fastest and least expensive may not be the same thing. Technically, IVF would be the fastest treatment to actually do, because it carries with it the highest chance of success per month. But it’s certainly not the least expensive. Natural cycle/IUI is the least expensive, but it may not be the fastest since you’re dealing with, at maximum, a 20 percent pregnancy rate per month.
If one of the partners wishes to carry the baby, how is this decided – by medical history or the couple themselves?
It’s really a combination of both. Usually same sex couples will have already initiated this conversation before they get to us since one of them has to decide to be the “patient” and the other the partner. Usually, it’s the “patient” who will ultimately carry. However, I do obtain a medical and gynecological history on both partners, and I inquire about their desire to carry since we can include that in the family planning discussion. Sometimes, there will be medical problems in one partner that will make it either harder for her to carry or more dangerous. This is all stuff we discuss, since they have more options than your average couple (two uteri, two sets of ovaries).
How often do same sex male couples come to Columbia for consultation/treatment?
We rarely see them because they need a surrogate, and surrogacy is not contract enforceable in the state of New York. So for legal reasons, we usually recommend that they seek treatment in New Jersey or Connecticut, or in a state in which surrogacy contracts are enforceable. New York state law is a little behind in this aspect.
What options do male same sex partners have when trying to have a baby?
They have two options. The first is to use a surrogate. This means that they would choose a woman who serves as the source of both the egg and the uterus. She could get pregnant just with intrauterine insemination. But again, the legal aspects of this are tricky, and I think this has fallen out of favor when compared to the second option. The second option would be to choose one woman as the egg donor, and a second different woman as the surrogate. I think this is slightly better in terms of legal issues, but only in states in which surrogacy contracts are upheld. They could theoretically use an egg donor who is known to them or an anonymous one.
What fears/doubts do these couples usually have about this process?
I think they tend to be less afraid of over medicalization, because they are already aware of how much they would have to go through to get this done. Legal issues tend to become tantamount.
What effect does the gestational carrier have on the genetic composition of a baby?
I tell people to think of genetics as like a blueprint to a house. Your genetics come from your genetic mother (egg donor). The gestational carrier is more like an environmental influence on your genetics. In the blueprint to the house, some rooms get built and others don’t. Some of that is determined by the blueprint, but some of that is environmental as well. So the health of the gestational carrier is important, and leaves a very long lasting fingerprint on the baby’s health. There are various aspects of a gestational carrier that need to be considered: An ideal gestational carrier should have no previous cesarean deliveries, because it places all subsequent pregnancies at a higher risk of complications. Prior full term vaginal deliveries should be a prerequisite for a gestational carrier. Also, there should be no toxic habits such as smoking, and a healthy lifestyle is a must.
If the couple finds a gestational carrier, what else needs to be done from a medical point of view for the male same sex couple? How about for the gestational carrier?
The male same sex couple needs to decide whose sperm is going to be used. I have seen a few cases in which half of the eggs are fertilized with one partner’s sperm and the other half fertilized with the other partner’s sperm, but that is getting kind of fancy. The important thing is that the partner’s sperm needs to be screened, which is a much more rigorous screening from an FDA standpoint in terms of infectious disease testing. Additionally, there are many types of genetic screening (for autosomal recessive diseases) that could be offered. A routine semen analysis will let us know how aggressive we have to be with fertilization when it comes to the actual IVF treatment. For a gestational carrier, issues of the uterus are the most important, starting with previous obstetrical history. Standard prenatal labs and uterine cavity evaluation are the most important. We evaluate the uterine cavity through a saline sonogram, in which we put saline into the uterus at the same time that we do a transvaginal ultrasound. When it comes to treatment, the only medications that the uterus needs to get ready for embryo implantation is estrogen (oral or patch), followed by progesterone (vaginal or intramuscular injection). The timing of these medications, however, is crucial for success.
What are your personal thoughts about same sex couples having children?
For any couple having children, including same sex couples, it’s an amazing adventure. It’s the single hardest, yet most rewarding, experience they will ever have. That makes all the treatment worth it! I admire same sex couples who embark on this journey, because it’s clear that it costs them so much more in the beginning stages just to get pregnant from both a medical and a legal perspective. And with medical treatments come a lot of ups and downs. They don’t have the luxury of just “letting things happen”. They really do have to be a bit more pro-active and analytic about everything. But it’s this same level of devotion which will serve them in good stead when there’s a little one around.
How does Columbia University Fertility Center accommodate and treat couples from the LBGT community who would like to become parents?
Columbia Fertility treats the LGBT community the same as we do any other patient: we individualize care. Some want more intervention, some want less. Our job is to figure out when more medical intervention is needed, and to help them figure out some of the initial stages of their family building process: pros and cons of various donor sperm options, and referrals for legal counsel when necessary.
Is the consultation different for LGBT couples than “regular” couples? If so, how? What is discussed?
It’s different in that we are frequently focusing on fertility issues and not so much infertility issues. There is a lot more focus on lifestyle and minimal intervention. We also consider which tests to do and when – for infertility couples, they have already been trying for a while so we typically do all of our testing at once, whereas for same sex couples, we are counseling them assuming that they are fertile, not infertile. So chances of success every month with IUI are higher than for our infertile patients. We also counsel them that just as 15 percent of heterosexual couples have infertility, 15 percent of same-sex couples will also have infertility. Fortunately, they are already familiar with the process should they happen to fall into that category. Additionally, I do take the opportunity to talk to them about co-maternity, a very special arrangement for a female same sex couple in which genetic and biologic maternity is shared. No other type of couple gets to have that kind of arrangement.
Do you ever hear doubts from patients about having children while in a gay relationship? What do you tell these patients?
I hear doubts in general about having kids and how much work it will be, but in general by the time same sex couples get to this point, they are already very certain that they want to start a family. If they did have any doubts, I could review with them all the literature that is out there on “alternative family building” and how the love and attention children receive is ultimately more important for their psychological well-being than the presence of a mother and a father. There are also numerous children’s books on where families come from and the many ways to make a family. I think most of our same sex couples are confident that they will make great parents. The one thing I definitely discourage is two female partners getting pregnant at the same time. It’s too much and a good percent of those couples end up getting divorced.
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