THIRD-PARTY REPRODUCTION IN NON-INFERTILE PATIENTS: Building Mono-parental and Shared-motherhood Families
By Sònia Gayete Lafuente, MD, PhD, who is a Foundation for Reproductive Medicine (FRM) postdoctoral research fellow at the CHR and can be reached through The Reproductive Times at Hello@ReproductiveTimes.com or directly at sgayete@thechr.com.
Briefing: Increasing numbers of women and men with no evidence of traditional infertility problems are seeking out standard infertility treatments, either desirous of fertility preservation into older ages, single parenthood, or because of being in same sex relationships. The author of this article offers some important insights into the individualized treatments such patients require.
INTRODUCTION
As reproductive technologies have evolved, the use of egg and sperm donation has broadened beyond outright clinical indications to encompass fertility options in a variety of non-clinical scenarios. These include supporting uniparental families, diverse LGBTIQ+ family structures, and adjusting medical and technical aspects of fertility assessment and treatments to these predominantly non-infertile populations. Understanding these highly individual circumstances and their respective treatment implications is of great importance in order to properly manage third-party reproductive practices.
While access to fertility treatments for single mothers and same sex couples has been improving in many parts of the world, legal, cultural, religious, and other systemic societal factors still greatly vary. In the U.S. and in many other countries with more advanced health care systems, medical insurance coverage still often quite distinctively differentiates between coverage of infertility in heterosexual couples and coverage of medical services to achieve pregnancy for non-infertile individuals who need treatments because of being single and/or being in same-sex relationships. Though such coverage has also been improving in recent years in the U.S., other countries, such as Spain, the U.K., and especially Belgium, are considerably ahead of the U.S.
Non-infertile women requiring fertility-related medical services also include women seeking what is widely called social or planned egg freezing in attempts to preserve their fertility chances with their own eggs into more advanced ages. While this is generally not a covered benefit in most health insurance plans, some typically larger companies – especially those in very competitive industries for staff recruitments – have started to offer financial contributions for such services, though usually not full or unlimited coverage. This area of fertility practice, therefore, represents an evolving landscape of changing policies, deserving of review.
STRIVING FOR MONO-PARENTAL and LGBTIQ+ FAMILIES
Several studies have demonstrated that a strong primary motivation for social egg-freezing is the concern of single women about not finding a suitable partner in time. At the same time, especially in the U.S., young women have also been exposed to at times hard-driving marketing campaigns by a quickly developing egg-freezing industry, which often argue that every young woman (and man) should cryopreserve gametes at peak fertility in their mid-twenties.
Whether this, because of potential risks (as small as they may be) and quite significant costs, is an ethically defensible position, is not the subject of this communication, though it may be one day because the subject has remained controversial. As here at the CHR we do not believe that there exists any medical treatment that should be applied to “everybody,” this, in our opinion, also applies to fertility preservation through egg-freezing. But the choice, of course, should always be the patient’s!
At the same time, becoming a single mother with the help of (in most cases in the U.S. still anonymous) semen donations has become socially more acceptable and is, therefore, quickly increasing. Studies on the subject suggested that single women proceeding with donor sperm either though intrauterine inseminations (IUIs) or in vitro fertilization (IVF) rather than freezing their eggs, tend to have a historically longer desire for motherhood, live closer to family, and report stronger social support compared to those choosing egg freezing. Men, interestingly, opt for single parenthood through egg donation and use of a gestational carrier (often mistakenly called a surrogate) much less frequently.
Lesbian female couples must also rely on sperm donation to build their families, while gay male couples, of course, require donor eggs and the availability of a gestational carrier, with the latter being extraordinarily expensive, unless one is lucky enough to recruit a friend or family member who does it for free. The use of donor gametes and gestational carriers, moreover, in several even otherwise medically very advanced countries, is still forbidden. Laws usually only change once adoptions by gay couples are allowed.
Though in the U.S. all these options are available, it is important to note that third-party gamete donation is very closely regulated by the FDA. IVF clinics, therefore, have to follow very strict rules and are regularly inspected by FDA inspectors in surprise visits.
THE TREATMENTS
In countries where third-party gamete donation for single and same-sex female couples are allowed, about 25% of sperm donation cycles occur in single women, 50% by same-sex female couples, and only 25% by heterosexual couples with male factor infertility. In other words, a large majority of donor sperm cycles are actually performed in absence of what traditionally has been defined as “infertility.”
Single women undergoing fertility treatments are significantly older than same-sex female couples (aged around 37 vs 32 years) and more often chose IVF as their initial treatment, while lesbian couples more often prefer donor sperm IUI, particularly in natural cycles. Despite these differences, after adjusting for age, live birth rates in those groups are comparable.
… donor sperm IUI vs. IVF in non-infertile women
Simple logic suggests that fertility clinics must approach non-infertile women in here discussed circumstances differently from obviously infertile women where the assumption is that there exists a medical problem that must be overcome. In non-infertile women – at least at relatively young ages – such an assumption does not exist. The assumption, indeed, must be (unless, of course, there exists history that suggests otherwise) that, once egg and sperm are allowed to meet in presence of a uterus, pregnancy should happen at age-dependent speed.
A recently published study demonstrated that the cumulative clinical pregnancy rate of up to 4 donor sperm IUIs in a non-infertile population is approximately 45%, with most pregnancies occurring within the first two attempts. Interestingly, this pregnancy chance also did not differ between age-comparable women with AMH ≥ 1.1 ng/mL and < 1.1 ng/mL.
Non-infertile patients even with low functional ovarian reserve – unless, of course at extremely diminished levels – therefore, still deserve at least several IUI cycles before IVF is initiated. A widely accepted consensus exists that in more depth fertility evaluations in preparation for IVF should only be considered after up to 4 failed IUI attempts.
As with infertile women, ovarian stimulation protocols and other IVF strategies should be individualized in non-infertile patient populations based on age, ovarian reserve, and other hormonal as well as uterine parameters.
… the ROPA method in shared motherhood IVF
Among same-sex female couples, a new option for shared motherhood is becoming increasingly popular, the so-called Reciprocal IVF or ROPA (Reception of Oocytes from Partner) method. It allows for both female partners to be actively involved in the conception and birth of their children. With ROPA one of the two female partner undergoes ovarian stimulation to produce eggs which, after retrieval, are inseminated with donor sperm, producing embryos for transfer into the uterus of the other female partner, who technically now becomes the gestational carrier for the transferred embryo(s). She has no genetic connection to the fetus growing in her (the genetic mother will be the partner who produced the eggs), but she will be the biological mother of the child. In other words, both female partners can claim motherhood of the newborn child.
Among female couples using ROPA, the gestational carriers tend to have had more previous fertility treatments and be generally more parous than the egg providers, who generally have slightly higher ovarian reserve markers. In non-infertile females, ROPA has comparable success rates to fully autologous IVF. It is, therefore, a safe and effective treatment with reassuring obstetric and perinatal outcomes.
After we have navigated fertility treatment options for single mothers and same sex female couples, we would love to be part of yours. Whether you are exploring donor sperm IUI, IVF, or the innovative ROPA method, at CHR our expert team is here to guide you through your journey to motherhood, committed to offering comprehensive and tailored fertility solutions to meet your wishes and needs. Visit us to discuss your family-building options!
CONCLUSIONS
Non-infertile individuals seeking out fertility treatments – whether women or men – often find themselves in an unexpected framework, akin to a healthy individual entering an emergency room. This feeling of “not-belonging” is often further accented by fertility clinics treating these individuals as if the treatments they were receiving were not really fertility treatments.
But they, of course are exactly the same treatments truly infertile patients receive and they, therefore, must be appreciated as such. An IUI or IVF cycle is the same IUI or IVF cycle in heterosexual and same-sex couples. Under both circumstances, treatments dispensed by fertility clinics, therefore, have the same obligations of maximizing outcomes for their patient in every treatment cycle.
In other words, even though an egg-freezing cycle in a 25-year-old will not include fertilization of her eggs and/or immediate transfer of an embryo as a regular IVF cycle usually entails, her cycle still requires a careful assessment of her overall health ahead of cycle start, determination of how her ovaries are best stimulated to safely obtain the largest possible egg numbers for cryopreservation, administration of intravenous sedation by certified anesthesiologists for the egg retrieval, and a needle entering (under ultrasound vision) her pelvic cavity. In other words, she receives real treatment, with potentially real (though fortunately rare) complications, and is for all of these reasons a real patient.
Patients who are not perceived to be considered “real” patients and/or do not receive the appropriate attention they feel they deserve as patients, therefore, may be best off by looking for an alternative clinic.
READING LIST
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