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Assisted Conception for Lesbian Women
Assisted Conception for Lesbian Women The creation of a family is considered a basic human right according to the United States Supreme Court deserving of protection under federal law prohibiting discrimination,1 yet persons identifying themselves as lesbian, gay, bisexual, transsexual, or transgender face specific challenges in regard to reproductive health care related to assistance with achieving pregnancy. According to the National Survey of Sexual Health and Behavior, 4.5% of females identify themselves as lesbian or bisexual.2 Specific challenges to fertility care among lesbian women are obvious because of physiology. Limited access to care may also result from providers not being knowledgeable about available options for achieving pregnancy and as a result may not be willing to discuss this important area of sexual health. Clinicians may believe it is unnatural or detrimental to offspring raised by same-sex parents despite research that does not support concern that children are harmed socially, physically, or psychologically.3 Women’s health professionals should be knowledgeable about options for lesbian women to achieve pregnancy using third-party reproductive services. Third-party reproduction refers to the use of eggs, sperm, or embryos that have been donated by a third person (donor) to enable the intended recipient to conceive.3 The woman planning to become pregnant, regardless of the treatment plan, needs standard preconception counseling and health assessment. Blood type, Rh factor, and complete blood count are obtained with screening for immunity to rubella and varicella. Vaccination, if indicated, is advised. Infectious disease screening includes hepatitis B (surface antigen and antibody); hepatitis C antibody; human immunodeficiency virus; syphilis (rapid plasma reagin); cytomegalovirus (immunoglobulin G and immunoglobulin M); and cultures for chlamydia, gonorrhea, mycoplasma, ureaplasma, and anaerobes. www.npjournal.org
Lesbian couples who are just beginning their attempt to achieve a pregnancy may choose to try on their own first. There are inhome insemination kits and donor sperm available on the Internet. These resources can be used by the couple in combination with an ovulation predictor kit to time insemination. Other approaches such as intrauterine insemination (IUI) or in vitro fertilization (IVF) using donor sperm require referral to a fertility specialist or reproductive endocrinologist.
QUALITY CARE FOR WOMEN’S HEALTH Ann Marie Collins, MS, WHNP-BS Age and health status of the partner carrying the pregnancy will be considered in determining the need to assess for underlying fertility issues before attempting assisted reproduction. For patients with comorbid conditions or over 35 years old, clearance from a primary care physician or cardiologist may be required. A preconception consultation with a maternalfetal medicine specialist may be advised. For patients with a body mass index greater than 40, weight loss is encouraged. Most fertility practices will not perform IVF in a patient whose body mass index is over 40. Ovarian reserve assessment includes serum hormone testing of follicle-stimulating hormone, antimüllerian hormone, estradiol on day 2 or 3 of the menstrual cycle, and transvaginal ultrasound (TVS) for antral follicle count. For patients having irregular cycles, random testing can be performed. Additional hormone testing would include thyroid-stimulating hormone and prolactin levels. Evaluation of the uterine The Journal for Nurse Practitioners - JNP
1
cavity and fallopian tubes is performed by hysterosalpingogram, an x-ray of the uterine cavity using radiopaque dye to rule out abnormalities within the cavity and ensure patency of the fallopian tubes. For patients undergoing IVF, a saline sonohysterogram can be performed rather than the hysterosalpingogram because the only concern is the uterine cavity.4 IUI can be done with a patient’s natural cycle or using medications to enhance the patient’s follicular development. Patients doing a natural or nonstimulated IUI cycle may use ovulation predictor kits, and when luteinizing hormone surge is noted, insemination is performed the following day. Many facilities require follicular monitoring with IUI cycles via TVS midcycle. The patient with mature follicle(s) is “triggered” with human chorionic gonadotropin to induce ovulation, and insemination is scheduled in 24 to 36 hours. In a stimulated cycle, the patient may be prescribed a follicle-stimulating medication on day 3 or 5 of the cycle for a period of 5 days. The patient returns midcycle for TVS, trigger, and IUI as described previously. Pregnancy rates with IUI depend on many factors, including the age of the recipient and the presence of other female fertility factors. The monthly chance of pregnancy ranges from 8% to 15%.3 IVF is another option for lesbian couples. IVF is used when the tubal factor or other infertility factors make IUI an impractical option. It is not uncommon for lesbian couples to have one partner donate eggs and the other partner carry the pregnancy so that each is part of the process. Evaluation of a patient undergoing IVF is similar to that of a patient planning IUI as outlined earlier. Although multiple medication protocols exist, the basic premise of stimulation is the same—using subcutaneous gonadotropin injections (folliclestimulating hormone and/or luteinizing hormone) to induce multiple follicles to grow
2
The Journal for Nurse Practitioners - JNP
to a mature size so eggs can be harvested by oocyte retrieval and inseminated with donor sperm to create embryos to later be transferred into the uterus of a patient or carrier. The sperm donor may be known or anonymous and must complete rigorous Food and Drug Administrationerequired testing for infectious disease and a semen analysis to rule out sperm issues. Anonymous sperm donors have a comprehensive genetic mutation screening performed. All sperm donors should have psychological evaluation and counseling by a mental health provider to rule out any psychological risks and evaluate for coercion. Donors should discuss feelings regarding disclosure of identity and plans for future contact.3 Psychological counseling may be required for all patients planning to conceive using a sperm donor to discuss issues related to third-party reproduction. With knowledge and sensitivity, primary care providers can assist lesbian women who wish to conceive through sharing information, initiating fertility testing with patients, or referring patients to a reproductive endocrinologist for care. References 1. Chandra A, Copen CE, Stephan EH. Infertility and impaired fecundity in the United States, 1982-2010: data from the National Survey of Family Growth. www.cdc.gov/nchs/data/nhsr/nhsr067.pdf. Accessed August 30, 2016. 2. National Survey of Sexual Health and Behavior, 2010. http://www .nationalsexstudy.indiana.edu/. Accessed August 30, 2016. 3. ASRM. Third-party reproduction: sperm, egg, embryo donation and surrogacy. 2012. www.ReproductiveFacts.org. Accessed August 31, 2016. 4. Practice Committee of the American Society of Reproductive Medicine. Diagnostic evaluation of the infertile female: a committee opinion. Fertil Steril. 2015;103:e44-e50.
Ann Marie Collins, MS, WHNP-BS is Nurse Practitioner and Third Party Reproduction Coordinator at Troche Fertility Centers in Glendale, AZ.
1555-4155/16/$ see front matter © 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2016.10.007
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Lesbian couples who are just beginning their attempt to achieve a pregnancy may choose to try on their own first. There are inhome insemination kits and donor sperm available on the Internet. These resources can be used by the couple in combination with an ovulation predictor kit to time insemination. Other approaches such as intrauterine insemination (IUI) or in vitro fertilization (IVF) using donor sperm require referral to a fertility specialist or reproductive endocrinologist.
QUALITY CARE FOR WOMEN’S HEALTH Ann Marie Collins, MS, WHNP-BS Age and health status of the partner carrying the pregnancy will be considered in determining the need to assess for underlying fertility issues before attempting assisted reproduction. For patients with comorbid conditions or over 35 years old, clearance from a primary care physician or cardiologist may be required. A preconception consultation with a maternalfetal medicine specialist may be advised. For patients with a body mass index greater than 40, weight loss is encouraged. Most fertility practices will not perform IVF in a patient whose body mass index is over 40. Ovarian reserve assessment includes serum hormone testing of follicle-stimulating hormone, antimüllerian hormone, estradiol on day 2 or 3 of the menstrual cycle, and transvaginal ultrasound (TVS) for antral follicle count. For patients having irregular cycles, random testing can be performed. Additional hormone testing would include thyroid-stimulating hormone and prolactin levels. Evaluation of the uterine The Journal for Nurse Practitioners - JNP
1
cavity and fallopian tubes is performed by hysterosalpingogram, an x-ray of the uterine cavity using radiopaque dye to rule out abnormalities within the cavity and ensure patency of the fallopian tubes. For patients undergoing IVF, a saline sonohysterogram can be performed rather than the hysterosalpingogram because the only concern is the uterine cavity.4 IUI can be done with a patient’s natural cycle or using medications to enhance the patient’s follicular development. Patients doing a natural or nonstimulated IUI cycle may use ovulation predictor kits, and when luteinizing hormone surge is noted, insemination is performed the following day. Many facilities require follicular monitoring with IUI cycles via TVS midcycle. The patient with mature follicle(s) is “triggered” with human chorionic gonadotropin to induce ovulation, and insemination is scheduled in 24 to 36 hours. In a stimulated cycle, the patient may be prescribed a follicle-stimulating medication on day 3 or 5 of the cycle for a period of 5 days. The patient returns midcycle for TVS, trigger, and IUI as described previously. Pregnancy rates with IUI depend on many factors, including the age of the recipient and the presence of other female fertility factors. The monthly chance of pregnancy ranges from 8% to 15%.3 IVF is another option for lesbian couples. IVF is used when the tubal factor or other infertility factors make IUI an impractical option. It is not uncommon for lesbian couples to have one partner donate eggs and the other partner carry the pregnancy so that each is part of the process. Evaluation of a patient undergoing IVF is similar to that of a patient planning IUI as outlined earlier. Although multiple medication protocols exist, the basic premise of stimulation is the same—using subcutaneous gonadotropin injections (folliclestimulating hormone and/or luteinizing hormone) to induce multiple follicles to grow
2
The Journal for Nurse Practitioners - JNP
to a mature size so eggs can be harvested by oocyte retrieval and inseminated with donor sperm to create embryos to later be transferred into the uterus of a patient or carrier. The sperm donor may be known or anonymous and must complete rigorous Food and Drug Administrationerequired testing for infectious disease and a semen analysis to rule out sperm issues. Anonymous sperm donors have a comprehensive genetic mutation screening performed. All sperm donors should have psychological evaluation and counseling by a mental health provider to rule out any psychological risks and evaluate for coercion. Donors should discuss feelings regarding disclosure of identity and plans for future contact.3 Psychological counseling may be required for all patients planning to conceive using a sperm donor to discuss issues related to third-party reproduction. With knowledge and sensitivity, primary care providers can assist lesbian women who wish to conceive through sharing information, initiating fertility testing with patients, or referring patients to a reproductive endocrinologist for care. References 1. Chandra A, Copen CE, Stephan EH. Infertility and impaired fecundity in the United States, 1982-2010: data from the National Survey of Family Growth. www.cdc.gov/nchs/data/nhsr/nhsr067.pdf. Accessed August 30, 2016. 2. National Survey of Sexual Health and Behavior, 2010. http://www .nationalsexstudy.indiana.edu/. Accessed August 30, 2016. 3. ASRM. Third-party reproduction: sperm, egg, embryo donation and surrogacy. 2012. www.ReproductiveFacts.org. Accessed August 31, 2016. 4. Practice Committee of the American Society of Reproductive Medicine. Diagnostic evaluation of the infertile female: a committee opinion. Fertil Steril. 2015;103:e44-e50.
Ann Marie Collins, MS, WHNP-BS is Nurse Practitioner and Third Party Reproduction Coordinator at Troche Fertility Centers in Glendale, AZ.
1555-4155/16/$ see front matter © 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2016.10.007
Volume
-,
Issue
-, -/-
2016