Amanda Roth, Timothy Murphy
State University of New York at Geneseo
University of Illinois College of Medicine
Access to fertility treatment by lesbian, gay, bisexual, transgender, and queer (LGBTQ) people has improved considerably in recent years, as a matter of ethics standards and practice. Various commentators have defended the right of lesbian and gay people to fertility treatment (1,2). The Ethics Committee of the American Society of Reproductive Medicine declares the “the ethical duty to treat persons with equal respect requires that fertility programs treat single persons and gay and lesbian couples equally to heterosexual married couples in determining which services to provide” (3). The American Congress of Obstetricians and Gynecologists has expressed objection to conscience exemptions as the basis for declining to treat patients on the basis of sexual orientation (4). As more LGBTQ people express interest in having children, some clinics have opened their practices to them by, for example, offering such services as reciprocal IVF, in which one woman gestates and the other provides the egg (5). While these advances are important, additional room remains for improving clinical practice for LBQ women.
The Experiences of LBQ Women in the Clinic
Some LBQ women take do-it-yourself approaches to insemination, relying on guidance from the lesbian community and employing basal body temperatures charts, ovulation kits, and donor sperm, all without the help of clinicians (6). Others turn to clinicians for assistance. As LBQ women turn to reproductive endocrinology clinicians, they can encounter care framed by assumptions better suited to the needs of different-sex couples facing infertility.
Current guidelines recommend that male-female couples with no known fertility problems pursue fertility intervention only after failure to conceive for one year (or six months, in the case of women over age 35) (7). Typically, women in male-female relationships approach fertility clinics only after failing to secure pregnancy over a meaningful amount of time (8). After that time, an assumption of need for medical evaluation and clinical treatment is generally warranted. By contrast, LBQ women entering the clinic are not infertile in the same sense; they have not necessarily ‘tested’ their fertility before turning to clinical help. Historically, advocates pressing the case for broader access to assisted reproductive treatments for LGB people embraced the notion of the ‘situational’ infertility of same-sex couples (9). This approach was politically helpful at the time, but it effectively enfolded the reproductive needs of LGBT people under a medical paradigm. At this point in history, it is important to avoid interpreting lesbian and queer sexuality as a proxy for sub- or infertility itself.
Consider a number of examples of LBQ women known to us. In one case, a woman described being “scared” into using fertility medication by a reproductive endocrinologist; that clinician advised IVF after suggesting that the use of frozen sperm for insemination would be less successful. A clinician recommended that another healthy woman receive ultrasonography to detect follicle growth, a human chorionic gonadotropin trigger injection, and IUI in the clinic; she left that clinician and sought less aggressive treatment through midwives (10). In a third situation, a woman approached a clinic looking for information about do-it-yourself options. The clinician steered the woman toward an HSG (given a fibroid in her gynecological history) and recommended fertility drugs after a finding of low progesterone; the clinician offered no discussion of the risks of these options. Objecting to the unexpected escalation of testing and treatment, the woman left that clinician and successfully conceived twins on her first unmedicated home insemination. In another case, a reproductive endocrinologist advised a woman and her partner to have IUI in the same month since the partner was having trouble conceiving through IVF. Though the women did not wish to have two children simultaneously, each conceived that very month (11).
We must be cautious when it comes to interpreting anecdotal cases. It is worth noting, however, that in three of the four cases above -- the last being the outlier -- none of the women had previously attempted to conceive, had prior evidence of an obstacle to fertility, or were aged 35 or over. Further, while financial considerations might suggest a more aggressive approach -- to lower the number of cycles needed to conceive -- in some cases women prefer a more conservative approach and dislike pressure to accept more interventions and risk (8, 12, 13). These concerns indicate that certain assumptions that are better suited to the care of different-sex couples are being carried over to LBQ women.
The Case against Medical Interventions as Frontline Treatment
A variety of reasons support differentiating LBQ women from others in clinical evaluation and treatment.
While it is true that same-sex couples must always reach outside their relationship for gametes, it is not true that either member of that couple must have anatomical or physiological obstacles to conception. In fact, many might need only medical evaluation of their fitness to conceive and bear children or guidance regarding do-it-yourself techniques, or help in securing gametes. Some may want physician involvement for legal reasons, to ensure parental rights when donor gametes are involved. Less intensive medical care can also make assisted reproduction more accessible and safer overall. For example, IVI and ICI do not require specialized training and are less risky than ovulation stimulating drugs or IVF (14, 15). They certainly avoid the complications of IVF (16). Unmedicated in-clinic IUIs involve comparatively little risk of serious complication, although uterine infection and perforation are possible (17). Reliance on these techniques can also be less costly than other options.
Risks of overly aggressive treatment are not the only issues facing LBQ women; the experience of the encounter matters too. Some queer and straight Canadian single mothers who conceived through DI at a fertility clinic objected to “the expectation among fertility doctors that…women would largely surrender their decision-making capacity and bodies to the doctors” (12). Other women reported seeing themselves as “medically problematized” because of “more and more investigative tests and use of drugs at what seemed to them quite an early stage in their [reproductive] attempts” (8). Some LBQ women see do-it-yourself approaches as more in line with their values, identities, and politics (15, 18).
These considerations do not mean that clinically supervised efforts are not valuable for some women. Clinically supervised care may reduce the total number of attempts necessary to secure pregnancy, saving effort and money. Moreover, some women may prefer IUI and/or ovulation induction in order to maximize the chance of conception in just one or two cycles. Others might desire reciprocal IVF in order to both contribute physically and biologically to the pregnancy and resulting child (15). Others might prefer standard IVF, perhaps to produce embryos for freezing in anticipation of future pregnancies.
The relevant point here is that patients deserve to be informed of all choices available, including do-it-yourself options, without pressure to accept unwanted testing or interventions. Any presumption that a full-scale medical evaluation and treatment is the only appropriate option certainly fails as a matter of informed consent.
Given the shifting mix of financial considerations, personal preferences, legal implications, and medical risks involved in pursuing a pregnancy, no single treatment paradigm fits all LBQ women. However, practices that make clinical testing and treatment the frontline approach to LBQ women’s reproduction deserve closer scrutiny.
One possible way to respond to LBQ patients is to ‘escalate’ the scale of intervention according to need and interest. For example, some commentators have suggested that primary care clinicians -- not fertility clinicians -- supervise donor-insemination, whether at home or in the clinic, with referral to a fertility specialist reserved for cases in which a diagnosis of infertility is suspected (10, 18). Shifting the assumption from presumed infertility to presumed fertility for LBQ women might pose some difficulties for those women who do have anatomical and/or physiological obstacles to conception. (Some studies report that interruption of normal ovulation by PCOS is more common in LBQ women than in straight women (20); other studies have failed to confirm a significant difference in rates of PCOS by sexuality (21, 22). Shifting reproductive treatment to primary care providers might lead to a longer time to achieve pregnancy for some women, along with potentially higher costs, and more stress, compared to the use of medications or IVF immediately. Some LBQ women might wish to be treated by fertility specialists on the assumption that they will be better situated to address the legal implications of their reproductive choices. Even so, an escalating approach would do its part to avoid ‘overtreatment’ and unnecessary risks and costs.
The foregoing considerations make clear the need for closer attention to the interests of LBQ women and the dynamics of elinical encounters. It makes little sense to assume that LBQ women turning to clinicians need the same initial evaluation and treatment appropriate to different-sex couples with demonstrated infertility. We therefore hope for more conversation about balancing the relevant considerations for LBQ women: respect for autonomy, informed consent, risk minimization, and cost containment.
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