Same-sex couples and transgender people face unique challenges when building a family. Here’s our guide to LGBTQ fertility options—pros, cons, and what to expect.
LGBTQ fertility treatment with donor sperm
For couples in which both partners have ovaries (lesbian couples, or couples in which one or more partners are trans men), it will be necessary to use donor sperm for fertility treatments.
Donor sperm from a sperm bank
One route to find a donor is to use a sperm bank. Sperm banks sell vials of frozen sperm from an anonymous donor (although with the advent of at-home DNA testing kits, anonymity cannot be guaranteed).
The pros of working with a sperm bank: The sperm you’re buying has been analyzed for health and fertility, as well as screened for infectious disease and quarantined for at least 6 months for HIV testing. Additionally, when working with a sperm bank, the donor is out of the picture legally and practically; the sperm bank handles the legal paperwork with both the donor and the intended parents.
The primary con of donor sperm is the cost. Vials of donor sperm typically cost $800–$1,000, and doctors typically recommend 1–2 vials per pregnancy attempt, and it could take several attempts to be successful—so it can add up. Additionally, some people would prefer that their child have a connection to the donor, which would not happen in the case of a sperm bank.
Known donor sperm
“Known donors” are sperm donors that are not anonymous and are often friends or family members of one of the intended parents. When working with a known donor, you can use “fresh” sperm for a home insemination, or frozen sperm for an insemination in a doctor’s office. (More on the differences below.) If you use “fresh” sperm, it won’t be screened for fertility or infectious disease. Frozen sperm will need to be screened, and then must be quarantined and the donor retested for HIV after 6 months, before it can be used in an in-office insemination.
Many people will prefer a known donor who has a genetic connection to the child. For example, one partner’s brother or cousin may donate sperm to be used in an insemination of the other partner. It’s also less expensive, although infectious disease and genetic screening is recommended (and, in the case of frozen sperm for an in-office procedure, required) and may come with additional costs.
The cons of using a known donor are that, unless you have the sperm frozen, tested, and quarantined, you don’t know if it’s healthy or free of STIs, including HIV. Using a known donor is more legally complicated—contracts drawn up with a lawyer and notarized may be recommended or required—and can come with emotional complications, as well, about the role of the donor in the child’s life.
Sometimes known as the “turkey baster” method, this is the most common LGBTQ fertility treatment. You can use either fresh or frozen sperm for at-home insemination; frozen sperm vials should be allowed to thaw for about 30 minutes before use, depending on instructions from the bank. (If purchasing frozen sperm for at-home insemination, it’s recommended that you buy “ICI” vials, which are unwashed—meaning the sperm are not isolated from the semen.)
The advantage of at-home insemination is that it’s less expensive and fairly easy. You’ll simply use a needleless syringe to draw up the sperm sample and insert it into the vagina, near the cervix. The only costs involved are the costs of the sperm or sperm testing.
The cons? At-home insemination has lower success rates—around 10–15% per attempt, according to the Seattle Sperm Bank—which may be undesirable especially if you’re working with donor sperm purchased for $1,000 or more. Additionally, at-home insemination requires you to accurately pinpoint your day of ovulation on your own, assuming that you do ovulate regularly (ovulation trackers such as Natural Cycles can be helpful for this). And unless you see a doctor prior to attempting insemination, you really won’t know if there are any other potential obstacles to conception, such as endometriosis or another reproductive disorder.
An intrauterine insemination or “IUI” is a procedure done by a doctor (typically a reproductive endocrinologist, though some OB/GYNs also offer this service). During an IUI, sperm that’s “washed” or isolated from semen is inserted directly into the uterus to increase chances of pregnancy. An IUI cycle can either be unmedicated or paired with medication to induce ovulation, further increasing the success rates.
The main perk of in-office IUI is just that—a higher chance of success. Success rates for lesbian couples using IUI with donor sperm are around 24% for those under 35 (the sample included both medicated and unmedicated cycles). When you do an IUI with a fertility specialist, ovulation is predicted and confirmed using blood tests and ultrasound, so you know you’re doing the insemination on the correct day—the day of ovulation.
The downside is the cost: an IUI cycle, even without medication, can cost around $1,000. But, if you’re purchasing sperm for $800+ per vial, the increased chance of success may be worth it.
Moving on to IVF
If no pregnancy is achieved with IUI, you may consider moving to IVF (in vitro fertilization), a more powerful fertility treatment. IVF is more involved than IUI. Whereas IUI may be medicated or unmedicated, IVF involves the use of injectable hormone medications that stimulate the ovaries to produce multiple eggs in one cycle.
After 8–11 days of medication, the eggs are removed from the ovaries in a minimally invasive surgical procedure known as an egg retrieval. Then, they’re fertilized in a laboratory using donor sperm, to create embryos. The embryos can then be transferred for potential pregnancy or frozen to use later or to await the results of embryo genetic testing. Success rates for IVF depend primarily on your age, but are around twice that of IUI. In addition, extra embryos could be stored for sibling pregnancies down the line.
IVF is a more expensive procedure, averaging around $12,000 per cycle plus the cost of medications. (In NY, 2020 legislation required many insurance carriers to cover IVF for all members, regardless of sexual orientation, gender identity, or marital status.) When or if to move on to IVF is a decision to be made between you and your doctor, depending on your age, individual fertility health, budget, insurance coverage, and more; many patients choose to move on to IVF after 3–6 cycles of IUI.
Learn more about the cost of IVF.
Reciprocal IVF (in vitro fertilization) is an option that allows lesbian or trans men partners in a couple to both participate, biologically and emotionally, in a pregnancy. Also known as partner-assisted reproduction, shared motherhood, partner IVF, co-IVF, or ROPA (reception of oocytes from partner), reciprocal IVF is a process in which one partner acts as an egg donor to the other.
In reciprocal IVF, one partner goes through the process of stimulation with hormone medications, and their eggs are retrieved and fertilized with donor sperm. Then, the embryo is transferred into the uterus of the other partner. Medically speaking, it’s the same process used when a woman works with an egg donor, or when a couple works with a gestational carrier.
Success rates of reciprocal IVF will depend primarily on the age of the “donor,” but it’s a powerful LGBTQ fertility treatment; in one study from 2017, 60% of couples with an average “donor” age of 32 achieved pregnancy. The benefits of this treatment are clear, but it’s expensive, with a price tag of around $20,000 per cycle not including medication, and in states without legalized same-sex marriage, the legal parenting arrangments can be complex.
Learn more about reciprocal IVF for LGBTQ couples.
Surrogacy is the only LGBTQ fertility option for couples in which both partners have testes. Surrogacy involves working with a surrogate or “carrier,” the person who carries the pregnancy, and sometimes with an egg donor, separately.
Who should be a surrogate? You could ask someone you know or find a surrogate on your own, but it may be less complicated—legally and otherwise—to work with a surrogacy agency. An agency will screen a surrogate for health, fertility, and mental preparedness, and will help you handle all the contractual paperwork. In the case that you want to do it on your own, you should work with a lawyer experienced in surrogacy.
Surrogacy is an expensive option. It typically costs over $100,000, but costs can vary widely depending on whether you work with a traditional surrogate or a gestational surrogate.
“Traditional” surrogacy is a process in which the surrogate is inseminated with sperm from one of the intended parents; the surrogate is the biological mother of the baby. In New York State, it’s illegal for a traditional surrogate to be compensated—they must be what’s known as “altruistic” surrogates. This approach is often less expensive, because it involves only paying for the insemination and the surrogate’s medical care throughout the pregnancy.
However, it may be more difficult to find a surrogate who will agree to this, since it involves a lot of risk and no compensation. It also may be more legally complicated due to the carrier’s genetic tie to the child. In NYS, a traditional surrogate must consent to the adoption of the baby by the intended parents.
Gestational surrogacy involves several parties: the carrier, an egg donor, and the intended parents, one of which is typically the genetic father of the baby. The egg donor is usually anonymous.
In this scenario, the egg donor will undergo the process of ovarian stimulation used in IVF; the eggs will be retrieved and fertilized in vitro with sperm, and one of the resulting embryo(s) will be inserted into the carrier’s uterus for a hopeful pregnancy. With the advances made in the egg freezing technology, there are now egg banks where donated eggs are readily available for purchase. In this type of surrogacy, the carrier does not have any genetic connection to the baby.
Gestational surrogacy for compensation is newly legal in New York; in April 2020, NYS ended its ban on commercial gestational surrogacy. It’s less complicated, legally, as the birthing mother has no “claim” to the baby. Additionally, because gestational surrogacy uses IVF, embryos can be frozen and/or genetically tested—both valuable options that aren’t available in traditional surrogacy.
It will come as no surprise that this option is also the most expensive, as it typically involves compensating the surrogate as well as the cost of donated eggs, paying for IVF (in addition to possible embryo freezing and genetic testing), paying for all medical costs associated with the pregnancy, and paying lawyers and/or an agency to ensure all legalities are taken care of.
Egg freezing for trans men
While not all trans men choose to transition medically, many will undergo hormone replacement therapy (HRT) with testosterone to align their secondary sexual characteristics, including facial/body hair, muscle mass and a deeper voice, with their gender identity.
Over time, testosterone therapy usually leads to anovulation (no ovulation) and amenorrhea (no menstrual periods). While it’s certainly possible for trans men who stop taking testosterone for a period of time to get pregnant and have healthy babies, the effect of long-term testosterone treatment on fertility is mostly unknown. That’s why transgender men who want to have genetically related families in the future may consider egg freezing either prior to starting testosterone or early in hormone therapy.
Egg freezing involves using hormone injections to stimulate the ovaries to produce multiple mature eggs, as opposed to the single egg typically produced during a menstrual cycle. Then, the eggs are retrieved and immediately frozen in a specialized lab. Once frozen, the eggs remain healthy and high quality until you’re ready to use them. Egg freezing offers trans men many options for family building down the road—they can carry the pregnancy themselves, “donate” their eggs to a female partner through reciprocal IVF, or use a gestational surrogate.
Learn more about egg freezing for trans men.
Questions about LGBTQ fertility services? We’re here for you.
We know it’s extremely important—especially for the LGBTQ community—to work with a team that’s inclusive and considerate. Extend Fertility was founded with the express purpose of democratizing fertility preservation and treatment. Many of our staff has undergone training with Family Equality to work more effectively and sensitively with same-sex couples and trans/nonbinary patients, and we take pride in making every person who walks through our door feel comfortable and cared for.