SART Fertility Experts - Fertility and LGBTQ

In this episode, Dr. Daniel Grow interviews Dr. Mark Leondires, the founder and medical director of both the Reproductive Medicine Associates of Connecticut and of Gay Parents To Be. Dr. Leondires is board certified in Reproductive Endocrinology and serves as Chair of the ASRM’s LGBTQ Special Interest Group. He has worked with thousands of LGBTQ couples over the last 20+ years, and takes pride in leading his program to deliver compassionate and high quality care to all members of this community. His insights inspire REI physicians to treat all patients with respect and to highlight pathways to care for patients. This may be through therapeutic donor insemination or through IVF. He highlights the journey through counseling, egg or sperm selection choices, and treatment.

The information and opinions expressed in this podcast do not necessarily reflect those of ASRM and SART. These podcasts are provided as a source of general information and are not a substitute for consultation with a physician. Welcome to SART Fertility Experts, a podcast that brings you discussions on important topics for people trying to build a family.

Our experts are members of SART, the Society for Assistive Reproductive Technology, an organization dedicated to ensuring you receive quality fertility care. Well, Dr. Leondires, I want to sincerely thank you for joining us today. Dr. Leondiresis the founder and director of the Reproductive Endocrinology Practice, a very big and successful practice in Connecticut known as RMA Connecticut.

He's also founder and director of Gay Parents to Be, which he founded and is leading. He's board certified in both obstetrics and gynecology, reproductive endocrinology, and perhaps most importantly, and I think we're really lucky to have him as chair, of the ASRM LGBTQ special interest group. Not a minor distinction, he's also currently a member of the Resolve Physician Council, and we all appreciate Resolve for their support of all kinds of infertility patients in addition to LGBTQ patients and parents to be.

So, Mark, thank you very much for being with us today. Thank you, Dr. Grow, for having me, and thank you for everybody who's listening out there. Now, I see in my office, and I know you see many more than I do, you know, wonderful members of the LGBT community who would make loving and compassionate parents, would be really great parents, and they're looking for some guidance, perhaps even from this podcast, on what their next steps may be on this journey for them, and I'm helping to fill in some of those, you know, some of those gaps for them.

I wonder, Dr. Leondires, if you could start and tell us how you got so interested in this area. Sure, happy to. I mean, for myself as a of the LGBTQ community, as well as a reproductive endocrinologist, back in 2007, I wanted to have children, and here I am, have been helping people have their babies for 15 years at that point in time, and realized how complicated it was for a same-sex male couple, cisgender male couple, to go ahead and find a surrogacy agency, find a donor, work with an IVF laboratory, decide whose sperm you're going to use, whose embryo you're going to transfer, whether you're going to transfer one or two, and become the patient.

You know, after we went through our own fertility journey, I prefer really the term roller coaster, I thought there needed to be more for people in the community, and remember, back in 2009, you know, gay marriage wasn't legal, there was still a lot of open discrimination, it wasn't legal in as many states as it is now, and it was sometimes hard to even get a birth certificate. You know, the good news is through the efforts of many people, you know, a lot of those things have changed, but you know, I'm personally passionate about helping people who really want to be parents. I think it's important to remember that 50% of pregnancies are unplanned, but in the LGBTQ community, 100% of pregnancies are planned, because there's not really a lot of accidents, right? Even in the, even in a trans couple where they are, you know, they have the ability to come, you know, maybe a trans woman with a trans man, they could potentially reproduce, but they often need help, need advice.

That being said, there's no accidental pregnancies, and I feel like as a member of the community, we need to work with Resolve, work with the insurance companies to bring to light another kind of infertility, you know, biological infertility. We talk about infertility as defined as a disease process where two opposite sex partners, you know, cannot conceive within a year or within six months, depending on age, but for people who, you know, didn't ask to be LGBTQ, they are, you know, they can't conceive as well. They have biological infertility, and that needs to be acknowledged, and the great news is in 2020, there's, you know, a couple hundred companies that I'm aware of now, really large ones that actually offer benefits for LGBTQ employees, and, you know, the next hurdle really is to work with the state mandates, the states that have a mandate to offer benefits.

You know, when we were emailing back and forth a little bit preparing for this, something that you said really struck me in response to a pretty basic question that I phrased, and I'm going to ask it to you now. What are most of your patients looking for? As an LGBTQ person, when you walk into a doctor's office, sadly, you're expecting not to be accepted. You're actually looking for subtle clues to show that it's okay, and those clues give you a sense of safety to actually be your true self, so they're looking for, you know, a well-trained staff that's able to acknowledge that they have a same-sex partner.

They're looking for people who are not, who can help process their insurance issues, and they're understanding that they probably don't have any benefits. When they look at somebody's website, they want to see that there's, you know, not only a rainbow flag, but maybe, you know, pages of content on how to build a family as a member of the LGBTQ community. I think really importantly, they want to be acknowledged as a human, and they want to feel safe, and they want, you know, empathy to their different struggle with infertility.

You know, infertility patients, cisgender infertility patients, you know, there's a lot of grief in trying to get pregnant, and it's very much acknowledged, and it's really, really tough for them. For an LGBTQ person, we can't even get started, and we need your help, and we want to know that that hand is out there for us. You know, that's really helpful, and I want to thank you for saying that so clearly.

You know, clearly there's much that we can do in our own offices, which is perhaps beyond the scope of this session, but infertility patients in general have tremendous anxiety about attempting pregnancy, and it's just magnified and accentuated for the LGBTQ community, so thank you for sharing that, and, you know, and for the practitioners listening to this, I think it's a real lesson, which hopefully most of us have learned and know, so thank you. We hope you're finding this episode of SART Fertility Experts helpful. Remember, for more information on this and related topics, visit www.sart.org, and click on the tab labeled Patients.

And now, back to SART Fertility Experts. You know, let's get started here. What's the most common scenario you see coming into your practice in terms of couples seeking help? So, you know, it depends on the couple, right? So, for a cisgender female couple, and just to explain that phrase, that means two people that were born with, you know, ovaries and a uterus, they've often done a lot of internet homework, and they perhaps have friends that are lesbian or queer that have had children, but they are armed with a lot of information, sometimes misinformation, and they want to know where to start, and they, these appointments, when you have two cisgender women arriving for your appointment, can be complicated, because whose eggs are we going to use? Whose uterus are we going to use? Do we want to keep it real simple and try just timed insemination, or do we want to think about what we call, you know, shared in vitro fertilization, where we use one person's egg, one woman's egg, one, let's say it differently, one person's eggs and another person's uterus, right? So, for cisgender female couples, there's actually a lot of options and to figure out how they want to build their family and how their future family wants to, they want it to look as important.

The other thing is we, as a practitioner, you also have to go back to the basics, right? Are they ovulatory? Do they have open fallopian tubes? What's their ovarian reserve? And you may or may not be aware that in the LGBTQ community, for lots of different reasons, there tends to be maybe a little bit more, you know, use of tobacco, alcohol, marijuana, maybe some more mental health issues because of everything that those folks have gone up, so you want to address those lifestyle choices. So, the most common scenario in our practice are cisgender women who come in and they want to be a parent and they need advice on how to get started and how to navigate the monopoly of choices they have because they have, you know, four ovaries, two uteri, and two different sets of menstrual cycles, right? So, lesbian women or queer women who come to the practice as a couple do not think they have any infertility problems, but they may underneath have infertility problems. So, you know, when you see a lesbian couple, you need to make sure that not only you appreciate all the choices that they have, but also complete a standard fertility evaluation to help guide you on maybe whose eggs you should use or whose uterus you should use and what's the best pathway for them.

I think that many practitioners think it's pretty straightforward. Oh, well, we have double the options, but it's often a lot more complicated than that, and you also have people's individual desires to maybe not be pregnant or just to be the genetic parent. So, I think that caring for your LGBTQ plus people requires an appreciation by the practitioner that it's not simply, oh, they just need a donor.

It's actually a lot more that's involved and really taking the time to drill down on that. An initial consultation with a same-sex female couple often takes longer because you have to collect two histories, and you have to peel that onion on how they want to build their family. Yeah.

So, thank you for that. You know, let's assume that you have a couple, a cisgender female couple in your office who's really interested in getting pregnant soon, and they decide that they want to use donor sperm and therapeutic donor insemination or donor insemination. What would be the next practical steps for them getting started? So, in our practice, we follow the guidelines from the mental health professional group through the American Society for Reproductive Medicine.

So, I guide them to reputable sperm donor banks, which includes, in 2020, hopefully, full mental health screening, as well as screening for recessive genes that cause disease, and then we have them book a appointment with one of our social workers. And I know there's some different opinions on this, but let me ask you, Dan, how has anyone ever been prepared to make the decision of who's going to be the genetic component for your future child? Nobody's ever faced that decision tree. So, everybody needs some education, not just what he looks like, not just the medicine, as far as mental health and social work, but what about future contacts? How are you going to speak to your child? How do you and your partner differ in what you think is important? And so, that 45-minute to an hour individual consultation with a mental health professional is meant to be supportive.

We're not screening these women on, can they be a parent? We are educating them on the complexities of picking a donor, which is a lifelong decision for your child, that you're going to look into the eyes of your child someday when they're 12 and explain to them why they made that decision. So, I think the first step is to guide them to sperm banks and then have them talk to a mental health professional, obviously complete your workup, and then decide their pathway, which there's basically many options. Finding a trustworthy source for fertility information can be overwhelming.

Reproductivefacts.org, a patient website developed by the American Society for Reproductive Medicine, has the medical information you need for your family building journey. At Reproductivefacts.org, you'll find up-to-date videos, fact sheets, and answers to frequently asked questions, all developed by medical experts based on scientific evidence without commercial bias. For your fertility questions, turn to a source you can trust, Reproductivefacts.org. So, let's assume, because I want to get this out for the audience, because I know we have a lot of patients in this boat, let's assume the evaluation is normal, they have healthy perspectives on proceeding, they've chosen a donor at the advice of the counselor, help taking into consideration both of their perspectives on what's important in donor selection, and they want to proceed with donor insemination.

If you don't mind, could we walk through some of the practical steps involved? Sure. The mom-to-be who's going to carry the pregnancy needs an evaluation of her uterine cavity and to make sure her fallopian tubes are open. And then, if she has regular cycles, she is obviatory.

And then the discussion needs to be had, and this also sometimes involves finances, about if they have good ovarian reserve, ovulatory cycles, do they want to try to conceive basically naturally, without the help of any fertility medicines, but with the assistance of delivering sperm high up into the female reproductive tract into the uterine cavity. Or, maybe there's diminished ovarian reserve, maybe there's a limited insurance benefit which they have coverage for, and do they want to take advantage of, underlying the word gentle, supraovulation to bring up maybe two or three follicles in a particular month to hopefully shorten their interval to pregnancy. Because if you're a female couple and you need to pay out-of-pocket for donor sperm and insemination, plus maybe one monitoring appointment, that can add up pretty fast.

I want to take a sidebar for a minute as well. It's something that's very relevant and important, especially considering all that's in the news lately. We as LGBTQ parents have to fiercely protect our parental rights.

And I think a lot of cisgender female couples are not maybe fully advised on the need for a reproductive attorney, proactively, to make sure the non-genetic mom has full parental rights. So, I encourage all my moms to be to, at the start of the process, work with a reproductive attorney to make sure their intent is captured in a contract, so when that child's born, that both moms are on the birth certificate. Or, if there is something that needs to be addressed later in regards to five, six, seven years later in regards to relationship, that it's very clear that both moms intended to parent.

Because you never want a child stuck in the middle. And historically, genetics has been king or queen. Historically, genetics has been queen, meaning defining the linkage to the child.

But in the case of a same-sex female couple, if they both wanted to be parents and they were both counseled together, they decided who was going to be genetically linked to the child. But we want to make sure the non-bio mom has full rights. So, having access and education from her reproductive attorney, which does add cost to them, is essential in protecting their parental rights in the present and in the future.

So, I think that was an important sidebar. Sorry about that. No, I think that's really important advice.

And for the patients listening, I want to perhaps emphasize that centers, sophisticated centers like yours, with counselors and with educated physicians, often will make it relatively easy for patients to find their pathway to parenthood, even though there are a lot of inputs and testing of going to get there. But our job to facilitate this for our patients and make it easier for them is really important. So, in summary, you indicated that some of our patients will go through natural cycles or slightly stimulated cycles, and then we use some timing to help them identify the day of ovulation with blood testing or urine testing, and then do a minor, very minor, procedure in the office.

It takes typically five minutes to do an insemination, placing the sperm high in the reproductive tract. And hopefully, patients will get pregnant relatively quickly. You know, if a cisgender female couple, a lesbian couple, you know, says, you know, maybe I would like to use my eggs, but my partner would like to carry the pregnancy.

Can you highlight for us how that works? Absolutely. So, that is called different things. It's called a shared IVF cycle or a reciprocal IVF cycle, meaning that the one of the moms-to-be is going to go through a standard in vitro fertilization protocol, which means she is going to be, her ovaries are going to be evaluated for the quality of the response to medication.

She's going to be trained to give herself injections, or perhaps her partner's going to give herself injections of human hormones to make the ovary that typically releases one egg per month, hopefully release more than 10 eggs in a particular month. It's a period of about seven to 12 days of not only injections, but visits to the office, you know, perhaps every two to three days and culminating with even every one day. And then there's a procedure called an egg retrieval, where that mom-to-be gets some form of anesthesia, and we go into the ovary and retrieve eggs.

Those eggs go into the IVF laboratory, are combined with the sperm that they have previously chosen, and embryos are allowed to grow. And then it will be up to how they want it to proceed. Perhaps their partner has on a parallel track been prepared for embryo transfer, or perhaps they've chosen to cryopreserve the embryos and come back for embryo transfer at a future time.

Then the non-egg donor, I'm sorry, the non-genetic mom-to-be is going to carry the pregnancy. So it's essential that her uterine cavity be assessed for polyps or fibroids or any structural abnormalities. And then, you know, in preparation for transfer, she would go on estrogen preparation or perhaps use her natural cycle.

And then an embryo would be warmed and transferred into her uterine cavity, which is very similar to an intrauterine insemination that we discussed before, just a little bit higher stakes because you're dealing with a, you know, a single embryo and you want to place that embryo in there very delicately. So it has the best chance for a sustained implantation. Thank you very much.

All right. Thank you for listening to SART Fertility Experts, your resource for information on IVF. If you found this podcast useful, please like us on your favorite social media platform and tell your friends about us.

For more family building resources, visit www.sart.org slash patient dash information or www.reproductivefacts.org