LGBTQ+ Fertility and Preconception Counseling (Lopez 4/5/2022)

Many thanks to Dr. Julissa Lopez for her important Grand Rounds presentation on LGBQT+ Fertility and Preconception Counseling. Key take home message up front: primary care physicians SHOULD be helping LGBQT+ patients pursue the families they desire. It's definitely within our scope.

If you would like to watch, the presentation is available HERE. 

Dr. Lopez started with a reminder of the wide range of gender and gender identities that we may encounter. Refer to the Flying Gender Unicorn graphic below as often as you need to to remind you of the range of gender identity, gender expression, gender expression at birth, sexual identity, etc (and to help your patients and you better understand themselves). 

Dr. Lopez' 3-part framework for gender identity considerations

• Biology>>sex>>chromosomes and anatomy
• Psyche>>gender>> identity and expression
• Interpersonal>>sexuality, sexual orientation, attraction

Important reminder for all of us who care for childbearing age patients of all genders and gender identities: Do NOT assume that LGBQT+ do not desire pregnancy. 

In fact, since the early 2000s, there has been a "Gayby Boom"

• 2002: 41% of Lesbians and 52% of gay men expressed an interest in having children
• 2013: 51% of LGBT are parents or want to be
• 2017: 49% of lesbians and bisexual women have had a child (through previous relationship, reproductive technology, adoption, etc)

There is growing consensus that LGBTQ+ community have a right to pathways to parenthood. This includes an increasing number of state laws that protect fostering and adoptive parents. Information on state laws and protections are available HERE via the Movement Advancement Project, where maps like this live:

https://www.lgbtmap.org/equality-maps/foster_and_adoption_laws

The remainder of Dr. Lopez' presentation focused on ways in which primary care clinicians care for persons with ovaries not on gender affirming hormone therapy (GAHT) and persons with testicles not on GAHT achieve biologic parenthood.

1) Preconception care: this is similar to care for any patient who desires children. Goal is to plan for family building: optimize fertility and minimize pregnancy complications

• Risk assessment and counseling
• Cost: home insemination w/fresh semen (cheapest), genetic and STI testing can cost updwards of $3-4K, sperm is $700-$1500/vial
• Optimize health: routine screening, alcohol and substance use screening, prenatal vitamins, medical conditions (DM, BMI, stress)
• Social and legal considerations (depending on state of residence)
• Outcomes counseling: typically families achieve pregnancy with 3 cycles of IUI (this is much higher than other IUI populations because you are not dealing with someone with fertility challenges), increased rates when both (vs. one) partner attempt pregnancy

2) Deciding origin of sperm

• known vs. anonymous donor
• frozen vs. fresh (more effective)
• sperm banks provide STI and genetic testing (could be more desirable but more expensive)
• washed vs. unwashed (i.e. processed-- removing prostaglandins for IUI)
• West Cost sperm banks have online donor searches vs. direct contact
• differences in $$
• Local sperm banks: California Cryobank (LA), The Sperm Bank of California (Berkeley), California Sperm Bank (SF), Seattle Sperm Bank (Seattle, Tempe, San Diego)

3) Preparation for insemination: mapping out reproductive cycle (we definitely know how to do this)

• 28 day cycle: ovulation occurs 14 days before first day of menses
• educate on use of home ovulation kit: LH surge, cycles day 10-12
• frozen sperm has a short life span, so should be inserted 24 ours after LH surge (right before ovulation); there is no benefit to repeated insemination

4) Assisted Reproductive technology i.e. intrauterine insemination (IUI) in the office

IUI is more effective than transvaginal (home syringe method) and can (and should) be done by PCP in the office. Using the reproductive cycle above.

• 1cc syringe
• 18cm polyethylene catheter (available online)
• Speculum
• No other medications needed
• Patient lies down for 10-15 minutes after insemination

https://www.obgynofatlanta.com/iui

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In contrast with above, for persons contributing sperm (i.e. men), the needs are different and always require a fertility clinic/specialist (i.e. cannot be managed by PCP alone) because they must involve an ovum donor and a surrogate (or both in one)

Things to consider in discussions as you refer folks to fertility centers:

• intentional unknowing (mixing sperm to fertilize ovum)
• genetic fatherhood in turns
• genetic vs. gestational surrogacy (different ovum donor from who carries the pregnancy)

Local Fertility Centers: Southern California Reproductive Center, CCRM Fertility (SF and Orange County)