- Email: [email protected]
Lesbian Couples Seeking Pregnancy With Donor Insemination
Lesbian Couples Seeking Pregnancy With Donor Insemination Elisabeth ‘‘Boo’’ Markus, CNM, MS, Amanda Weingarten, CNM, MS, Yira Duplessi, CNM, MS, and Judith Jones, CNM, MS
S.S. is a healthy, 29-year-old nulligravida who comes to the clinic with her female partner, M.S., seeking advice on becoming pregnant through the use of donor sperm from a cryobank. S.S. has been charting her fertility signs for 3 months, and both she and her partner are very excited about the prospect of becoming parents. They have done some research into donor sperm, but have questions about the different types of donor sperm available, whether to pursue intracervical or intrauterine insemination, and if the insemination should be done at home or in the clinic. They report that they have been to an obstetrician-gynecologist seeking care. The physician was unfamiliar with donor insemination and referred them to a fertility clinic for preconception counseling. The physicians at the fertility clinic recommended that the couple pursue pregnancy using ultrasound to detect follicle growth, followed by a human chorionic gonadotropin trigger shot and then intrauterine insemination in the clinic 24 hours later. The couple felt that these interventions were unnecessary at this point, because they did not have a known fertility problem.
INTRODUCTION In the past, lesbians have most frequently conceived and raised children within the context of heterosexual marriage.1 Within the last 30 years, however, an increasing number of lesbians are choosing to become parents within the context of a partnered lesbian relationship.2 Lesbians may choose to become parents through former heterosexual relationships, foster care, adoption, step parenting, or donor insemination (DI). Many lesbian couples wishing to become parents choose DI because it allows for the creation of autonomous lesbian families.1 DI—also known as therapeutic DI, alternative insemination, artificial insemination, or artificial fertilization— is the act of using sperm obtained from a known or unknown donor to conceive a child.3 The term DI is used throughout this article because it is both specific and avoids the possible negative connotations associated with the terms ‘‘alternative’’ or ‘‘artificial’’; however, it is not a term that is used universally. Clinicians may wish to engage the couple in a conversation about what terminology they feel most comfortable using. This article focuses on the unique needs of the lesbian couple, including the role of the oftentimes invisible part-
Address correspondence to Elisabeth ‘‘Boo’’ Markus, CNM, MS, Columbia University, 3237 17th St., San Francisco, CA 94110. E-mail: em2202@ columbia.edu
124 Ó 2010 by the American College of Nurse-Midwives Issued by Elsevier Inc.
ner, during preconception and DI. Many of the principles of care for lesbian couples seeking pregnancy via DI also apply to single women, bisexual women, and transgender persons; however, each of these populations has its own unique needs. BACKGROUND DI was developed to serve heterosexual couples faced with male factor infertility or a previous vasectomy, and is still widely used by heterosexual couples for those same reasons today.4 In the past, lesbian couples have been denied access to DI based on the unfounded assumption that lesbian families may not provide an appropriate family environment for the child.5 Numerous studies have disproved these claims, and today in the United States, lesbians have complete access to a variety of cryobanks to obtain sperm for DI.6,7 It has also been deemed unethical—and in some cases, illegal—for providers to deny lesbians access to assisted reproduction on the basis of their marital status or sexual orientation.5,8 Whereas many heterosexual couples use DI because of infertility, lesbians are unique in that they choose to use DI solely because of the absence of a male partner.9 Therefore, they present for preconception counseling without a known history of infertility.4,10 Primary care clinicians, such as midwives, family practice physicians, and nurse practitioners, are qualified to supervise the process of DI for lesbians rather than referring them to a reproductive endocrinologist, unless a diagnosis of infertility is suspected.10 LESBIAN-SPECIFIC NEEDS Disclosing Sexual Orientation Despite estimates that lesbians comprise 2% to 12% of the female population, many clinicians are unaware of lesbian patients within their clinical practice because heterosexuality is often presumed.1 Therefore, lesbians wishing to become parents are faced with the decision about whether or not to disclose their sexual orientation, or ‘‘come out,’’ to the many health care providers who will care for them throughout preconception, pregnancy, birth, and the postpartum process.2 The majority of lesbians who chose to come out to their provider report that the care they received met their physical, emotional, and social needs.1,11,12 Volume 55, No. 2, March/April 2010 1526-9523/10/$36.00 doi:10.1016/j.jmwh.2009.09.014
Fewer, but still most, also felt that it also met their needs as lesbians.1,11,12 Conversely, lesbian couples may also experience homophobia after coming out, including provider detachment, inappropriate moral judgments, voyeurism, rough physical handling, outright refusal of care, or refusal to acknowledge or include partners.1,2,13 Therefore, lesbian couples may legitimately have worries that disclosure of their sexuality will result in lower-quality health care throughout preconception, pregnancy, and birth.2 Couples may choose to come out to their primary care provider only, selected providers whose reactions they believe will be positive, or to all providers they encounter. Some lesbians may choose to never disclose their sexual orientation.2 A woman who does choose to disclose her sexuality should be affirmed and her openness encouraged.14 Most importantly, the clinician must consciously avoid making assumptions or value judgments about the woman’s sexuality and work to create an atmosphere that is respectful of diversity.4,15 When a woman discloses her sexual orientation to a primary care provider, it is best to ask if she wants to have this information included in her medical record.16 Some lesbians may welcome this, because it prevents them from having to come out to each person involved in their care. Other lesbians may prefer to be selective about disclosing their sexual orientation. Partner Involvement Partner exclusion is a significant problem faced by many lesbian couples wishing to become parents.2,4 For couples who choose not to come out to their health care providers, the partner is rendered invisible.2 However, even couples who do choose to be open with their providers may encounter confusion and lack of understanding around the role of the partner.2 It is important for all providers caring for lesbian couples to acknowledge the couple as partners and co-parents.14 Even small signs of acceptance and support, such as making eye contact, have been shown to be quite meaningful to lesbian couples.2,15 The inclusion of all desired parties in the provision of maternity care will be appreciated by all women who choose to parent outside of the traditional heterosexual paradigm, including patients who are unmarried or uncoupled.4 The expectations of the role of the partner in the lesbian couple seeking to become parents can be quite varied,
Elisabeth ‘‘Boo’’ Markus, CNM, MS, is a graduate of Columbia University and a midwife in New York City. Amanda Weingarten, CNM, MS, is a graduate of Columbia University and a midwife at Wyckoff Heights Medical Center. Yira Duplessi, CNM, MS, is a graduate of Columbia University and a midwife at Jamaica Hospital Medical Center. Judith Jones, CNM, MS, is a graduate of Columbia University and a midwife at Jamaica Hospital Medical Center.
Journal of Midwifery & Women’s Health www.jmwh.org
ranging from the partner desiring recognition and involvement as a full parent to the partner seeing herself as a supportive secondary parent rather than a primary parent.3 In addition, there may be more people involved in the creation of a lesbian family than just the lesbian couple.4 Known donors (and their partners) may have an active role in preconception and parenting, and therefore questions that clarify who will be included in the pregnancy experience and to what extent they will be involved are important to learn as care is established.4 This, too, is information that the lesbian couple may want noted in the chart. There are many different terms that have been used to refer to the partner in a lesbian couple seeking to become parents.2 Each lesbian couple can be engaged in a discussion about the terminology that they prefer to use during preconception and pregnancy. Many couples find terminology such as ‘‘second mother,’’ ‘‘other mother,’’ ‘‘nonbiological mother,’’ or ‘‘nonpregnant partner’’ to have negative connotations and may prefer to use more positive terminology, such as ‘‘co-parent,’’ ‘‘co-mother,’’ or ‘‘social mother.’’16 Families may also choose to create their own terminology.16 Social mother is the terminology that is used in this case study. Adjustment of Children Health care providers may question or refuse to provide care for lesbians wishing to become parents out of concern for the well-being of the couple’s future children.5,8 Research has shown, however, that having lesbians as parents does not have adverse effects on child development or child psychosocial functioning.6,7 This is true both for children conceived within a previous heterosexual relationship and via DI within the context of a lesbian relationship.17 Children raised by lesbian parents do not differ statistically in emotional, social, or cognitive development from children raised by heterosexual parents.18 In addition, children conceived and raised within lesbian relationships are not more likely than other children to exhibit gender identity or role confusion or to grow up to be homosexual, although these are often fears voiced by opponents of lesbian parenting.18 Legal Considerations Lesbian couples wishing to conceive have several legal issues that they will need to address, and it can be helpful if the health care provider helps them identify these issues, including the legal relationship between the child and the social mother and the legal rights and obligations of the donor.2 Knowledge of state laws and a list of pregnancy resources for lesbian couples can be helpful for couples as they work through the legal aspects associated with becoming a parent.2 These can be the same resources 125
available for single mothers, adoptive families, and other nontraditional heterosexual families. In most instances, the social mother will have to adopt the child after his or her birth in order to be a legal parent. States and jurisdictions differ greatly in both the ease and permissibility of second-parent adoption in lesbian families.2 Even in states where gay marriage is legal (Connecticut, Massachusetts, Iowa, and Vermont at the time of this writing), second-parent adoption remains the safest way to ensure that the social mother is given full parenting rights. In states where second-parent adoption is not a legal option, it is possible to draw up legal documents that provide protection to the social mother.16 One of the greatest concerns in lesbian DI is the parental rights of a known donor.2 All couples wishing to use a known donor should be advised to seek legal counsel before beginning inseminations to establish a contract between the couple and their donor, regardless of what role they hope the donor will play in the future child’s life.11 Lesbian couples using a known donor may also wish to inseminate in the clinic rather than the home in order to ensure that insemination occurs in the presence of a medical professional, thereby providing support to the claim that the donor has relinquished his claim to that sperm and any future child that may result.3
PRECONCEPTION CARE Preconception Testing Lesbians coming for preconception care should receive typical preconception counseling and testing.10,19 In addition, lesbians planning DI with frozen sperm may wish to be screened for cytomegalovirus (CMV) immunoglobulin G (IgG) antibody. Transmission of CMV from a positive donor to a negative woman is possible from donor semen, although it is extremely rare.10 Infection with CMV during pregnancy is associated with an increased risk of fetal abnormalities. Therefore, women who are negative for CMV antibody may wish to choose sperm from a donor who has tested negative for CMV IgG.10 Nearly all cryobanks provide the donor’s CMV status in the initial donor profile. Lesbians who choose to inseminate with sperm from a known donor should ascertain the donor’s sexually transmitted infection (STI) status.10 They can do this by asking the donor to be tested for all STIs by his health care provider. HIV may take up to 6 months to be identified; therefore, a known donor who tests negative for HIV could test negative but actually be recently infected.10 Couples may choose to freeze the sperm from a known donor for 6 months, after which the donor is again tested for HIV. If the donor still tests negative, the couple can be assured that the quarantined sperm is negative for HIV.10 126
PREDICTING OVULATION There are a number of methods available to help a woman accurately predict ovulation and time insemination properly. While ultrasound may be the most precise way to predict ovulation, there are a number of other methods that when used together provide an accurate estimation of when ovulation will occur.20 These include monitoring cervical changes; cervical fluid monitoring; basal body temperature charting; and the use of saliva microscopes, ovulation predictor kits, and fertility monitors3,21,22 (Table 1). All findings should be recorded on a chart, so that the couple can become familiar with the changes that occur over the course of a menstrual cycle and begin to predict when ovulation will likely occur. It is best if charting is done for at least 3 months before insemination.3 Many couples also find that fertility monitoring and charting can be quite empowering, because they become the authority on their own fertility rather than relying on a health care provider to tell them when they are fertile.3
Cervical and Physical Changes That Signal Ovulation Lesbian couples seeking to become pregnant via DI can monitor cervical changes through touch and visual inspection using a speculum. While this may be accomplished by self-examination, the social mother may be the best person to examine her partner and chart the findings, because this shared process can promote intimacy and involvement.3 As ovulation approaches, the cervix becomes softer to the touch (from the texture of a nose to that of a lip), moves higher in the vagina (and less easy to reach with fingers during examination), and with the aid of a speculum, the os can be seen opening.3 Ovulation takes place when the cervix is soft, high in the vagina, and the external os is several millimeters open.3 The pattern of cervical mucus changes that take place during the phases of a woman’s cycle offers one of the best clues to the timing of ovulation.23 As ovulation approaches, cervical mucus increases in volume and becomes increasingly clear, slippery, and exhibits spinn barkeit (the ability to be stretched) in response to rising estrogen.24 Many women begin to notice this characteristic fertile cervical mucus 5 days before ovulation, which marks the beginning of a woman’s fertile window.24 The quantity and stretch of cervical mucus increases as ovulation approaches, until it is a consistency similar to egg white. After ovulation, cervical mucus becomes cloudy and decreases in quantity. Fertile cervical mucus is one of the most accurate means of predicting increasing fertility and ovulation.24 In many women, ovulation is accompanied by a unique set of physical and emotional changes, including an increase in sex drive, back pain, mittelschmerz (ovulation pain), or changes in appetite or mood.3 These symptoms Volume 55, No. 2, March/April 2010
Table 1. Methods to Predict Ovulation and Timing of Insemination Timing of Insemination3
Method of Predicting Ovulation Cervical position
Sign of Ovulation 3
Cervical consistency3
Visual examination of the os opening3
Cervical mucus3
Basal body temperature21,22
Saliva microscope to detect ferning21,22 Ovulation predictor kit (urine LH monitor)21,22
As ovulation approaches, the cervix moves higher in the vagina (less easy to reach with fingers) As ovulation approaches, the cervix become softer and then returns to firmer once ovulation has occurred As ovulation approaches, the cervix opens, which is visible by speculum examination As ovulation approaches, cervical mucus becomes clear, stretchy, and slippery, like an egg white (begins 5 days before ovulation and increases in quantity and stretch as ovulation approaches) Temperature may dip slightly before ovulation followed by a sustained temperature rise after ovulation
ICI Fresh and frozen sperm: When cervix is highest in the vagina
IUI When cervix is highest in the vagina
Fresh and frozen When cervix feels sperm: When softest or when cervix feels softest cervix just (like touching a lip) starts to become firmer Fresh and frozen sperm: When the os is wide open
When cervix is wide open or just beginning to close
Fresh sperm: On days On the last day of of fertile mucus fertile mucus to (1–3 days before 6 hrs after the ovulation) transition to Frozen sperm: On creamy cervical the last day of peak mucus mucus (18–36 hrs before ovulation)
Fresh sperm: 1–3 8–12 hrs before or 6 hrs after dip in days before dip in temperature temperature Frozen sperm: 18–36 hrs before dip in temperature When strong ferning Increased ferning Fresh and frozen patterns are occurs with rising sperm: When observed estrogen levels strong ferning patterns are observed During the LH surge, Fresh sperm: Up to 18–36 hours after a certain 36 hrs before first first positive concentration of positive and up to LH in the urine 24 hrs after first will cause the positive ovulation predictor Frozen sperm: Up to 12 hrs before first kit to read positive positive and up to (24–36 hrs before ovulation) 24 hrs after first positive
Cost ($)
Advantages
Disadvantages
None
Affordable; women May be uncomfortable gain knowledge for woman; about their bodies; changes in cervix may be performed may be difficult to by partner determine
None
Affordable; women May be uncomfortable gain knowledge for woman; about their bodies; changes in cervix may be performed may be difficult to by partner determine
Initial: 10–15 for speculum Monthly: None None
Affordable; women Speculum gain knowledge examination may about their bodies; be uncomfortable; may be performed may have difficulty by partner locating os Affordable; Changes in cervical prospectively mucus may be difficult to identifies complete fertile window; determine; may women gain have insufficient mucus production knowledge about their bodies
Initial: Affordable 10–15 for thermometer Monthly: None
Cannot be used to predict ovulation; changes in lifestyle and routine can alter results; may be inconvenient
Initial: 20–40 Monthly: None
Affordable
Results not reliable; eating, drinking, or oral hygiene may cause error
Initial: None Monthly: 20–75
Prospectively identifies up to 2 fertile days before ovulation; results easy to interpret (if using digital monitors)
Test sticks must be purchased every month; a positive result may not give a long enough window for multiple inseminations if using ICI (especially with fresh sperm)
(Continued)
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Table 1 (Cont’d). Methods to Predict Ovulation and Timing of Insemination Method of Predicting Ovulation
Timing of Insemination3 Sign of Ovulation
ICI
IUI
Cost ($)
Advantages
Disadvantages
18–36 hours after Initial: 100–200 Prospectively Expensive; test strips Rising levels of Fresh sperm: Up to first peak reading Monthly: identifies up to 6 must be purchased estrogen cause the 24 hrs before first 30–50 fertile days before each month; monitor to read peak reading and ovulation; results cannot be used by up to 36 hrs after ‘‘high’’ (3–6 days women with easy to interpret; before ovulation); first peak reading monitor adjusts irregular cycles the LH surge Frozen sperm: results to woman’s causes the monitor 12 hrs before to unique cycle; to read ‘‘peak’’ 24 hrs after peak monitors two (1–2 days before reading hormones ovulation) Saliva fertility monitor The levels of salivary Fresh sperm: 1–3 Up to 8 hrs before and Initial: Prospectively Expensive; conflicting (OvaCue)21,22 electrolytes change days before up to 8 hrs after 200–300 identifies up to 6 data concerning as ovulation ovulation (at ovulation (confirm Monthly: fertile days before accuracy 5–7 bars) ovulation with None ovulation; an approaches, which is recorded by the Frozen sperm: vaginal sensor) optional vaginal monitor, which 18–36 hrs before sensor can confirm displays an ovulation (at if ovulation 6–7 bars) occurred; memory increasing number of bars (up to 7) chip stores 4 mo of data as ovulation approaches; ovulation can be confirmed with the vaginal probe (sold separately)
Urine fertility monitor (ClearBlue)21,22
ICI = Intracervical insemination; IUI = intrauterine insemination; LH = luteinizing hormone. Sources: Stanford et al.,22 Brill,3 and Scolaro et al.21
can be charted and used to help identify the time of ovulation. Basal Body Temperature Basal body temperature is taken each morning at the same time before rising from bed, using a digital basal body thermometer. A daily log of the temperatures obtained each morning is kept to monitor the biphasic pattern of an ovulating woman. During the follicular phase, basal body temperature is lower (96 F–98 F).21 Just before ovulation, women may note a slight dip in temperature followed by a rise of 0.5 F to 1.6 F.21 After ovulation, the temperature remains elevated (97 F–99 F) until menstruation begins.21 A more precise thermometer that measures temperature from 96 F to 101 F (in 0.1 F increments) must be used to accurately monitor basal body temperature. Saliva Microscope As ovulation approaches, changes in salivary electrolyte concentration produce a crystallization or ‘‘ferning’’ pattern that may be observed in dried saliva with a microscope.22 Increasing ferning may indicate greater fertility and the approach of ovulation.25 Compact home saliva microscopes (about the size and shape of a lipstick 128
case) are available for purchase and are relatively inexpensive. Saliva should be monitored first thing in the morning before eating, drinking, or oral hygiene to ensure the most accurate results.25 Detecting ferning with a saliva microscope may indicate increasing fertility, but it has not been shown to be a reliable predictor of ovulation.25 Ovulation Predictor Kits Ovulation predictor kits measure the concentration of luteinizing hormone (LH) in the urine, and a positive reading is given during the LH surge when the concentration of LH in the urine exceeds a set control level.25 Ovulation occurs within 48 hours following the LH surge.22 Some test devices are more sensitive than others, although all accurately predict approaching ovulation.25 Many women enjoy using ovulation predictor kits because they are an objective and easy way to monitor fertility; however, ovulation predictor kits are expensive ($20–$75 per month), and waiting for a positive result may not allow time for multiple inseminations.3 Fertility Monitors There are two types of fertility monitors available today: those that monitor changes in the urine and those that Volume 55, No. 2, March/April 2010
monitor changes in saliva. Both types of monitor prospectively identify fertile days (5–6 days in advance of ovulation) and the results are easy to interpret.22 However, these monitors require a substantial initial investment ($100–$300) and are prohibitively expensive for many women.25 Urine fertility monitors, like the Clearblue Easy Fertility Monitor, measure the concentration of both LH and estrogen in the urine and become calibrated to the specific concentrations of hormones in the individual user. These monitors give a reading of ‘‘high’’ fertility in response to rising estrogen levels, and then ‘‘peak’’ fertility in response to the LH surge. Ovulation usually occurs within 2 days of the first peak reading.22 Urine fertility monitors are only accurate in women who have regular cycles with 21- to 42-day intervals.22 Saliva fertility monitors, like the OvaCue fertility monitor, use an oral probe to measure changes in salivary electrical resistance, which begin 6 to 7 days before ovulation.22 Fertility is depicted by one to seven bars that correspond to increasing fertility. A separate vaginal probe can also be purchased to test vaginal mucus to confirm that ovulation has occurred.22 There have been conflicting reports regarding the accuracy of saliva fertility monitoring for predicating ovulation.25
TIMING OF INSEMINATION All intracervical inseminations (ICIs) should be performed before ovulation; however, the timing of insemination depends on whether the couple is using fresh or frozen sperm and how many inseminations they would like to perform in each cycle. While fresh sperm may live for 2 to 3 days, frozen sperm only live for 18 to 24 hours.3,26 Because of their shortened lifespan, insemination with frozen sperm must take place much closer to the time of ovulation (12–24 hours before ovulation if using frozen sperm versus up to 3 days before ovulation if using fresh sperm). Many lesbian couples choose to inseminate more than once per cycle to try increasing the likelihood of conceiving.27 Multiple inseminations with fresh sperm are generally separated by at least 24 hours, while multiple inseminations with frozen sperm may be done more frequently (often 18 hours apart).3 It is important that all ICIs take place with peak fertile mucus, because fertile mucus both nourishes and transports the sperm from the vagina to the uterus.23 Sperm that has been prepared for IUI only lives in the uterus for 6 to 10 hours, and therefore insemination must occur very soon before (or after) ovulation occurs.26 It is possible for IUI to take place several hours after ovulation, because sperm are deposited directly in the uterus and do not require fertile mucus for transport.26 Planning overnight shipment of the donor sample(s) from the cryobank can be discussed with the cryobank Journal of Midwifery & Women’s Health www.jmwh.org
to ensure that the sperm arrives within the ovulation window. DONOR INSEMINATION OPTIONS There are three primary options for donor sperm: insemination with fresh sperm from a known donor, frozen sperm from a known donor, and frozen sperm from an unknown donor. Each option has advantages and disadvantages in terms of pregnancy rates, risk of infection, cost, and relationship with the donor (Table 2). Fresh Sperm From a Known Donor Using fresh sperm from a known donor (in most cases, a friend of the couple) greatly reduces the expense of insemination because the sperm is generally obtained for free or at low cost. In addition, using fresh sperm is associated with higher fecundity rates than frozen sperm.27 Lesbian couples may also choose to use a known donor if they wish for him to play a role in the child’s life.2 The major risk of inseminating with fresh sperm is the risk of acquiring an STI.10 Frozen Sperm From a Known or Unknown Donor The freezing and thawing of sperm is associated with decreased viability, motility, and functional ability.15 Clinicians may wish to inform couples planning on using frozen sperm from a known or unknown donor that it may take longer to achieve pregnancy.28 Sperm obtained from a cryobank generally costs between $200 and $600 per vial, and many women choose to inseminate more than once per cycle.10 Sperm obtained from a cryobank is classified as being from either an anonymous donor or from an open-identity donor. The identity of an anonymous donor cannot ever be revealed, whereas with an open-identity donor, the child will be able to contact or obtain information about the donor when they reach a certain age (usually 18 years).15 If the sperm is obtained from a cryobank, the donor (whether anonymous or openidentity) has no legal right or responsibility to any child that may result. This assurance of legal autonomy is one reason many lesbian couples choose to use frozen sperm. INSEMINATION OPTIONS Home Insemination DI may be performed either at home by the couple or at a health care facility with the assistance of a clinician. Performing the insemination at home has the added benefit of being free, except for the cost of sperm from a cryobank. Self-insemination, also called vaginal insemination, is the simplest method of insemination. The social mother uses a needleless syringe to insert the semen into the vagina of the partner who wishes to become pregnant. Home insemination can help facilitate the woman’s 129
Table 2. Risks and Benefits for Different Types of Donor Inseminations3,10 Fresh Sperm From Known Donor
Frozen Sperm From Known Donor
Cost
May be free or cost may be negotiated May be free or cost may be negotiated with donor with donor; additional cost of cryopreservation and storage Location Home (cannot be performed in most Home or health care facility clinics because of risk of HIV infection) Type of insemination Intravaginal insemination ICI or IUI (IUI sperm must be prepared before insemination) Risk of sexually transmitted infection Highest risk of all options Very safe after 6-month quarantine period to rule out HIV Risk of legal complications Possible—A legal agreement can be Possible—A legal agreement can be written between couple and donor written between couple and donor to prevent complications to prevent complications Possibility of relationship with donor
Yes
Yes
Frozen Sperm From Unknown Donor $200–$600 per vial; storage cost if vials purchased in advanced Home or health care facility Sperm available ‘‘ICI ready’’ or ‘‘IUI ready’’ Very safe Donor has no legal right or responsibility to any children that result from insemination with his sperm Only in cases of open-identity donation, usually after child turns 18 years
ICI = Intracervical insemination; IUI = intrauterine insemination.
confidence in her own fertility and allows the couple to be in a familiar environment that is comfortable and more intimate, making the experience seem like less of a medical procedure.3 Self-insemination at home also serves to support the importance of the partner in the process of conception, because she may be the person performing the insemination. Insemination in the Health Care Facility Vaginal insemination in the health care setting is commonly referred to as ICI and is a process during which sperm is injected into the vagina or into the cervical opening29 (Figure 1). Frozen sperm can be purchased either ‘‘ICI ready,’’ which means that they are only suitable for vaginal or cervical inseminations, or ‘‘intrauterine insemination (IUI) ready,’’ which means that they may be inserted directly into the uterus and do not require additional rewashing. All sperm that is not ‘‘IUI ready’’ must be washed before insertion in the uterus to eliminate exposure to seminal plasma, which may cause prostaglandininduced uterine contractions, uterine infection, or, rarely, anaphylaxis.27,30 An appropriate centrifuge is therefore needed to wash semen on site if it has not already been prepared. Clinicians who plan to perform IUI benefit from working with a nurse infertility specialist and cryobank for instructions and obtaining the suggested solution for preparing the semen for IUI. Clinicians may also perform IUI (Figure 1). To perform IUI, the patient lies in a lithotomy position on a standard gynecologic examination table with her feet in footrests. A speculum is placed into the vagina to visualize the cervix. A tenaculum may be used to help straighten the cervical canal for catheter insertion; however, some clinicians may wish to avoid using a tenaculum, because placement 130
may also release prostaglandins that may theoretically reduce fertility at the time of insemination.3 To perform an IUI, the washed sperm is aspirated into a 1.0-mL syringe. The plastic syringe is attached to a flexible polyethylene catheter (a standard IUI catheter).26 All air is removed from the syringe and the catheter is inserted through the endocervical canal and into the uterus. The clinician may offer the partner the opportunity to depress the syringe once the catheter has been inserted. Mild cramping may occur as the sperm are injected or after the insemination.27 After the injection, the catheter is slowly removed and the patient may wish to remain lying flat and still for 15 minutes.26 The woman may resume her normal activities upon leaving the office. Antibiotic prophylaxis is not required. IMPLICATIONS FOR PRACTICE The hallmarks of midwifery care as defined by the American College of Nurse-Midwives (ACNM) include cultural competence, advocacy on behalf of patients, and health education.31 These practices are guided by an ethical philosophy that is grounded in respecting the basic human rights and dignity of all individuals; partnering with women; and nondiscriminatory, private, and confidential care.32 Studies have shown that lesbians who received maternity care from midwives reported higher levels of support and satisfaction than did lesbians who used physicians.11 However, because providers hold a range of social, religious, and political beliefs, individual practice and care does not always conform to the midwifery model of care.1,11,12,33 All clinicians who care for women of reproductive age have the opportunity to develop their skills to meet the needs of lesbians and, in doing so, expand their circle of Volume 55, No. 2, March/April 2010
Figure 1. The placement of the catheter in intracervical and intrauterine insemination. Source: American Society for Reproductive Medicine.29
care to include more women.12 Even minor changes to existing services, to create an environment that acknowledges and respects diversity, may improve the satisfaction of lesbian patients.11,12 This includes being aware of treatment avenues and options for lesbians, being knowledgeable about appropriate referral and support services in their area, and showing respect to all families.4 The need for increased knowledge of lesbian health among providers has been recognized in academic research.25 In response, the Institute of Medicine developed eight specific recommendations to increase knowledge of lesbian health, including the recommendation that government, professional, and academic institutions develop and support mechanisms for educating providers, researchers, and the public about the unique health care needs of lesbians.34 To meet this goal and to help ensure that women seeking care do not encounter discrimination, professional organizations can develop a position statement that specifically addresses sexual orientation and patient care. Such statements have been developed by the American Medical Association and the Royal College of Midwives.14,35 ACNM has already approved a position statement on ethnic and cultural diversity, which addresses both the care of women with ethnic and cultural diversity and the value of such diversity in the membership.36 The development of a similar statement by ACNM regarding sexual orientation would serve as a guide for providers in the United States and acknowledge this often overlooked population. Journal of Midwifery & Women’s Health www.jmwh.org
The authors wish to thank Laura Zeidenstein, CNM, DrNP, for her guidance during the writing of this paper.
REFERENCES 1. Renaud MT. We are mothers too: Childbearing experiences of lesbian families. J Obstet Gynecol Neonatal Nurs 2007;36:190–9. 2. McManus AJ, Hunter LP, Renn H. Lesbian experiences and needs during childbirth: Guidance for health care providers. J Obstet Gynecol Neonatal Nurs 2006;35:13–23. 3. Brill S. The new essential guide to lesbian conception, pregnancy, and birth. New York: Alyson Publications, 2006. 4. Ross LE, Steele LS, Epstein R. Lesbian and bisexual women’s recommendations for improving the provision of assisted reproductive technology services. Fertil Steril 2006;86:735–8. 5. Ethics Committee of the American Society for Reproductive Medicine. Access to fertility treatment by gays, lesbians, and unmarried persons. Fertil Steril 2006;86:1333–5. 6. Maccallum F, Golombok S. Children raised in fatherless families from infancy: A follow-up of children of lesbian and single heterosexual mothers at early adolescence. J Child Psychol Psychiatry 2004;45:1407–19. 7. Anderssen N, Amlie C, Ytterøy EA. Outcomes for children with lesbian or gay parents. A review of studies from 1978 to 2000. Scand J Psychol 2002;43:335–51. 8. First amendment – California Supreme Court holds that free exercise of religion does not give fertility doctors right to deny treatment to lesbians. –North Coast Women’s Care Medical Group, Inc. v. San Diego County Superior Court, 189 P.3d 959 (Cal. 2008). Harv Law Rev 2008;122:787–94. 131
9. Baetens P, Brewaeys A. Lesbian couples requesting donor insemination: An update of the knowledge with regard to lesbian mother families. Hum Reprod Update 2001;7:512–9.
23. Zinaman MJ. Using cervical mucus and other easily observed biomarkers to identify ovulation in prospective pregnancy trials. Paediatr Perinat Epidemiol 2006;20:26–9.
10. Steele LS, Stratmann H. Counseling lesbian patients about getting pregnant. Can Fam Physician 2006;52:605–11.
24. Bigelow JL, Dunson DB, Stanford JB, Ecochard R, Gnoth C, Colombo B. Mucus observations in the fertile window: A better predictor of conception than timing of intercourse. Hum Reprod 2004; 19:889–92.
11. Ross LE, Steele LS, Epstein R. Service use and gaps in services for lesbian and bisexual women during donor insemination, pregnancy, and the postpartum period. J Obstet Gynaecol Can 2006;28:505–11. 12. Wilton T, Kaufmann T. Lesbian mothers’ experiences of maternity care in the UK. Midwifery 2001;17:203–11. 13. Spidsberg BD. Vulnerable and strong—Lesbian women encountering maternity care. J Adv Nurs 2007;60:478–86. 14. The Royal College of Midwives Web site. Position paper 22. Maternity care for lesbian mothers. London: The Royal College of Midwives; 2000. Available from: www.rcm.org.uk/college/standardsand-practice/position-papers/?locale=en [Accessed March 26, 2009].
25. Kelley L, Chou CL, Dibble SL, Robertson PA. A critical intervention in lesbian, gay, bisexual, and transgender health: Knowledge and attitude outcomes among second-year medical students. Teach Learn Med 2008;20:248–53. 26. Speroff L, Fritz M. Clinical gynecologic endocrinology and infertility, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2005:1156–60. 27. Carroll N, Palmer J. A comparison of intrauterine versus intracervical insemination in fertile single women. Fertil Steril 2001; 75:656–60.
15. Werner C, Westersta˚hl A. Donor insemination and parenting: Concerns and strategies of lesbian couples. A review of international studies. Acta Obstet Gynecol Scand 2008;87:697–701.
28. Allamaneni S, Bandaranayake I, Agarwall A. Use of semen quality scores to predict pregnancy rates in couples undergoing intrauterine insemination with donor sperm. Fertil Steril 2004;82:606–11.
16. Zeidenstein L. Health issues of lesbian and bisexual women. In: Varney H, Kriebs J, Gegor C, editors. Varney’s midwifery, 4th ed. Sudbury, MA: Jones and Bartlett, 2004:299–311.
29. American Society for Reproductive Medicine Web site. Third party reproduction (sperm, egg, and embryo donation and surrogacy). A guide for patients. Birmingham, AL: American Society for Reproductive Medicine, 2006. Available from: www.asrm.org/ Patients/patientbooklets/thirdparty.pdf [Accessed October 4, 2009].
17. Brewaeys A, Ponjaert I, Van Hall E, Golombok S. Donor insemination: Child development and family functioning in lesbian mother families. Hum Reprod 1997;12:1349–59. 18. Paige R. American Psychological Association policy statement: Sexual orientation, parents, and children. American Psychological Association, 2005. Available from: www.apa.org/pi/lgbc/ policy/parents.html [Accessed August 18, 2009]. 19. March of Dimes Web site. Before pregnancy: Preconception. Available from: www.marchofdimes.com/pnhec/173.asp [Accessed August 18, 2009]. 20. Lynch CD, Jackson LW, Buck Louis GM. Estimation of the day-specific probabilities of conception: Current state of the knowledge and the relevance for epidemiological research. Paediatr Perinat Epidemiol 2006;20(Suppl 1):3–12.
30. ESHRE Capri Workshop Group. Intrauterine insemination. Hum Reprod Update 2009;15:265–77. 31. American College of Nurse-Midwives. Basic competency section, Division of Education. Washington, DC: ACNM, 2007. 32. American College of Nurse-Midwives. Ad Hoc Committee on Code of Ethics. Washington, DC: ACNM, 2005. 33. Buchholz SE. Experiences of lesbian couples during childbirth. Nurs Outlook 2000;48:307–11. 34. Solarz A, editor. Lesbian health: Current assessment and directions for the future. Washington, DC: National Academy Press, 1999.
21. Scolaro KL, Lloyd KB, Helms KL. Devices for home evaluation of women’s health concerns. Am J Health Syst Pharm 2008; 65:299–314.
35. American Medical Association Web site. GLBT Advisory Committee. AMA policy regarding sexual orientation. Available from: www.ama-assn.org/ama/pub/about-ama/our-people/membergroups-sections/glbt-advisory-committee.shtml [Accessed August 18, 2009].
22. Stanford JB, White GL, Hatasaka H. Timing intercourse to achieve pregnancy: Current evidence. Obstet Gynecol 2002; 100:1333–41.
36. American College of Nurse-Midwives. Midwives of Color Committee. Position statement: Ethnic and cultural diversity. Available from: www.acnm.org/position.cfm [Accessed August 18, 2009].
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S.S. is a healthy, 29-year-old nulligravida who comes to the clinic with her female partner, M.S., seeking advice on becoming pregnant through the use of donor sperm from a cryobank. S.S. has been charting her fertility signs for 3 months, and both she and her partner are very excited about the prospect of becoming parents. They have done some research into donor sperm, but have questions about the different types of donor sperm available, whether to pursue intracervical or intrauterine insemination, and if the insemination should be done at home or in the clinic. They report that they have been to an obstetrician-gynecologist seeking care. The physician was unfamiliar with donor insemination and referred them to a fertility clinic for preconception counseling. The physicians at the fertility clinic recommended that the couple pursue pregnancy using ultrasound to detect follicle growth, followed by a human chorionic gonadotropin trigger shot and then intrauterine insemination in the clinic 24 hours later. The couple felt that these interventions were unnecessary at this point, because they did not have a known fertility problem.
INTRODUCTION In the past, lesbians have most frequently conceived and raised children within the context of heterosexual marriage.1 Within the last 30 years, however, an increasing number of lesbians are choosing to become parents within the context of a partnered lesbian relationship.2 Lesbians may choose to become parents through former heterosexual relationships, foster care, adoption, step parenting, or donor insemination (DI). Many lesbian couples wishing to become parents choose DI because it allows for the creation of autonomous lesbian families.1 DI—also known as therapeutic DI, alternative insemination, artificial insemination, or artificial fertilization— is the act of using sperm obtained from a known or unknown donor to conceive a child.3 The term DI is used throughout this article because it is both specific and avoids the possible negative connotations associated with the terms ‘‘alternative’’ or ‘‘artificial’’; however, it is not a term that is used universally. Clinicians may wish to engage the couple in a conversation about what terminology they feel most comfortable using. This article focuses on the unique needs of the lesbian couple, including the role of the oftentimes invisible part-
Address correspondence to Elisabeth ‘‘Boo’’ Markus, CNM, MS, Columbia University, 3237 17th St., San Francisco, CA 94110. E-mail: em2202@ columbia.edu
124 Ó 2010 by the American College of Nurse-Midwives Issued by Elsevier Inc.
ner, during preconception and DI. Many of the principles of care for lesbian couples seeking pregnancy via DI also apply to single women, bisexual women, and transgender persons; however, each of these populations has its own unique needs. BACKGROUND DI was developed to serve heterosexual couples faced with male factor infertility or a previous vasectomy, and is still widely used by heterosexual couples for those same reasons today.4 In the past, lesbian couples have been denied access to DI based on the unfounded assumption that lesbian families may not provide an appropriate family environment for the child.5 Numerous studies have disproved these claims, and today in the United States, lesbians have complete access to a variety of cryobanks to obtain sperm for DI.6,7 It has also been deemed unethical—and in some cases, illegal—for providers to deny lesbians access to assisted reproduction on the basis of their marital status or sexual orientation.5,8 Whereas many heterosexual couples use DI because of infertility, lesbians are unique in that they choose to use DI solely because of the absence of a male partner.9 Therefore, they present for preconception counseling without a known history of infertility.4,10 Primary care clinicians, such as midwives, family practice physicians, and nurse practitioners, are qualified to supervise the process of DI for lesbians rather than referring them to a reproductive endocrinologist, unless a diagnosis of infertility is suspected.10 LESBIAN-SPECIFIC NEEDS Disclosing Sexual Orientation Despite estimates that lesbians comprise 2% to 12% of the female population, many clinicians are unaware of lesbian patients within their clinical practice because heterosexuality is often presumed.1 Therefore, lesbians wishing to become parents are faced with the decision about whether or not to disclose their sexual orientation, or ‘‘come out,’’ to the many health care providers who will care for them throughout preconception, pregnancy, birth, and the postpartum process.2 The majority of lesbians who chose to come out to their provider report that the care they received met their physical, emotional, and social needs.1,11,12 Volume 55, No. 2, March/April 2010 1526-9523/10/$36.00 doi:10.1016/j.jmwh.2009.09.014
Fewer, but still most, also felt that it also met their needs as lesbians.1,11,12 Conversely, lesbian couples may also experience homophobia after coming out, including provider detachment, inappropriate moral judgments, voyeurism, rough physical handling, outright refusal of care, or refusal to acknowledge or include partners.1,2,13 Therefore, lesbian couples may legitimately have worries that disclosure of their sexuality will result in lower-quality health care throughout preconception, pregnancy, and birth.2 Couples may choose to come out to their primary care provider only, selected providers whose reactions they believe will be positive, or to all providers they encounter. Some lesbians may choose to never disclose their sexual orientation.2 A woman who does choose to disclose her sexuality should be affirmed and her openness encouraged.14 Most importantly, the clinician must consciously avoid making assumptions or value judgments about the woman’s sexuality and work to create an atmosphere that is respectful of diversity.4,15 When a woman discloses her sexual orientation to a primary care provider, it is best to ask if she wants to have this information included in her medical record.16 Some lesbians may welcome this, because it prevents them from having to come out to each person involved in their care. Other lesbians may prefer to be selective about disclosing their sexual orientation. Partner Involvement Partner exclusion is a significant problem faced by many lesbian couples wishing to become parents.2,4 For couples who choose not to come out to their health care providers, the partner is rendered invisible.2 However, even couples who do choose to be open with their providers may encounter confusion and lack of understanding around the role of the partner.2 It is important for all providers caring for lesbian couples to acknowledge the couple as partners and co-parents.14 Even small signs of acceptance and support, such as making eye contact, have been shown to be quite meaningful to lesbian couples.2,15 The inclusion of all desired parties in the provision of maternity care will be appreciated by all women who choose to parent outside of the traditional heterosexual paradigm, including patients who are unmarried or uncoupled.4 The expectations of the role of the partner in the lesbian couple seeking to become parents can be quite varied,
Elisabeth ‘‘Boo’’ Markus, CNM, MS, is a graduate of Columbia University and a midwife in New York City. Amanda Weingarten, CNM, MS, is a graduate of Columbia University and a midwife at Wyckoff Heights Medical Center. Yira Duplessi, CNM, MS, is a graduate of Columbia University and a midwife at Jamaica Hospital Medical Center. Judith Jones, CNM, MS, is a graduate of Columbia University and a midwife at Jamaica Hospital Medical Center.
Journal of Midwifery & Women’s Health www.jmwh.org
ranging from the partner desiring recognition and involvement as a full parent to the partner seeing herself as a supportive secondary parent rather than a primary parent.3 In addition, there may be more people involved in the creation of a lesbian family than just the lesbian couple.4 Known donors (and their partners) may have an active role in preconception and parenting, and therefore questions that clarify who will be included in the pregnancy experience and to what extent they will be involved are important to learn as care is established.4 This, too, is information that the lesbian couple may want noted in the chart. There are many different terms that have been used to refer to the partner in a lesbian couple seeking to become parents.2 Each lesbian couple can be engaged in a discussion about the terminology that they prefer to use during preconception and pregnancy. Many couples find terminology such as ‘‘second mother,’’ ‘‘other mother,’’ ‘‘nonbiological mother,’’ or ‘‘nonpregnant partner’’ to have negative connotations and may prefer to use more positive terminology, such as ‘‘co-parent,’’ ‘‘co-mother,’’ or ‘‘social mother.’’16 Families may also choose to create their own terminology.16 Social mother is the terminology that is used in this case study. Adjustment of Children Health care providers may question or refuse to provide care for lesbians wishing to become parents out of concern for the well-being of the couple’s future children.5,8 Research has shown, however, that having lesbians as parents does not have adverse effects on child development or child psychosocial functioning.6,7 This is true both for children conceived within a previous heterosexual relationship and via DI within the context of a lesbian relationship.17 Children raised by lesbian parents do not differ statistically in emotional, social, or cognitive development from children raised by heterosexual parents.18 In addition, children conceived and raised within lesbian relationships are not more likely than other children to exhibit gender identity or role confusion or to grow up to be homosexual, although these are often fears voiced by opponents of lesbian parenting.18 Legal Considerations Lesbian couples wishing to conceive have several legal issues that they will need to address, and it can be helpful if the health care provider helps them identify these issues, including the legal relationship between the child and the social mother and the legal rights and obligations of the donor.2 Knowledge of state laws and a list of pregnancy resources for lesbian couples can be helpful for couples as they work through the legal aspects associated with becoming a parent.2 These can be the same resources 125
available for single mothers, adoptive families, and other nontraditional heterosexual families. In most instances, the social mother will have to adopt the child after his or her birth in order to be a legal parent. States and jurisdictions differ greatly in both the ease and permissibility of second-parent adoption in lesbian families.2 Even in states where gay marriage is legal (Connecticut, Massachusetts, Iowa, and Vermont at the time of this writing), second-parent adoption remains the safest way to ensure that the social mother is given full parenting rights. In states where second-parent adoption is not a legal option, it is possible to draw up legal documents that provide protection to the social mother.16 One of the greatest concerns in lesbian DI is the parental rights of a known donor.2 All couples wishing to use a known donor should be advised to seek legal counsel before beginning inseminations to establish a contract between the couple and their donor, regardless of what role they hope the donor will play in the future child’s life.11 Lesbian couples using a known donor may also wish to inseminate in the clinic rather than the home in order to ensure that insemination occurs in the presence of a medical professional, thereby providing support to the claim that the donor has relinquished his claim to that sperm and any future child that may result.3
PRECONCEPTION CARE Preconception Testing Lesbians coming for preconception care should receive typical preconception counseling and testing.10,19 In addition, lesbians planning DI with frozen sperm may wish to be screened for cytomegalovirus (CMV) immunoglobulin G (IgG) antibody. Transmission of CMV from a positive donor to a negative woman is possible from donor semen, although it is extremely rare.10 Infection with CMV during pregnancy is associated with an increased risk of fetal abnormalities. Therefore, women who are negative for CMV antibody may wish to choose sperm from a donor who has tested negative for CMV IgG.10 Nearly all cryobanks provide the donor’s CMV status in the initial donor profile. Lesbians who choose to inseminate with sperm from a known donor should ascertain the donor’s sexually transmitted infection (STI) status.10 They can do this by asking the donor to be tested for all STIs by his health care provider. HIV may take up to 6 months to be identified; therefore, a known donor who tests negative for HIV could test negative but actually be recently infected.10 Couples may choose to freeze the sperm from a known donor for 6 months, after which the donor is again tested for HIV. If the donor still tests negative, the couple can be assured that the quarantined sperm is negative for HIV.10 126
PREDICTING OVULATION There are a number of methods available to help a woman accurately predict ovulation and time insemination properly. While ultrasound may be the most precise way to predict ovulation, there are a number of other methods that when used together provide an accurate estimation of when ovulation will occur.20 These include monitoring cervical changes; cervical fluid monitoring; basal body temperature charting; and the use of saliva microscopes, ovulation predictor kits, and fertility monitors3,21,22 (Table 1). All findings should be recorded on a chart, so that the couple can become familiar with the changes that occur over the course of a menstrual cycle and begin to predict when ovulation will likely occur. It is best if charting is done for at least 3 months before insemination.3 Many couples also find that fertility monitoring and charting can be quite empowering, because they become the authority on their own fertility rather than relying on a health care provider to tell them when they are fertile.3
Cervical and Physical Changes That Signal Ovulation Lesbian couples seeking to become pregnant via DI can monitor cervical changes through touch and visual inspection using a speculum. While this may be accomplished by self-examination, the social mother may be the best person to examine her partner and chart the findings, because this shared process can promote intimacy and involvement.3 As ovulation approaches, the cervix becomes softer to the touch (from the texture of a nose to that of a lip), moves higher in the vagina (and less easy to reach with fingers during examination), and with the aid of a speculum, the os can be seen opening.3 Ovulation takes place when the cervix is soft, high in the vagina, and the external os is several millimeters open.3 The pattern of cervical mucus changes that take place during the phases of a woman’s cycle offers one of the best clues to the timing of ovulation.23 As ovulation approaches, cervical mucus increases in volume and becomes increasingly clear, slippery, and exhibits spinn barkeit (the ability to be stretched) in response to rising estrogen.24 Many women begin to notice this characteristic fertile cervical mucus 5 days before ovulation, which marks the beginning of a woman’s fertile window.24 The quantity and stretch of cervical mucus increases as ovulation approaches, until it is a consistency similar to egg white. After ovulation, cervical mucus becomes cloudy and decreases in quantity. Fertile cervical mucus is one of the most accurate means of predicting increasing fertility and ovulation.24 In many women, ovulation is accompanied by a unique set of physical and emotional changes, including an increase in sex drive, back pain, mittelschmerz (ovulation pain), or changes in appetite or mood.3 These symptoms Volume 55, No. 2, March/April 2010
Table 1. Methods to Predict Ovulation and Timing of Insemination Timing of Insemination3
Method of Predicting Ovulation Cervical position
Sign of Ovulation 3
Cervical consistency3
Visual examination of the os opening3
Cervical mucus3
Basal body temperature21,22
Saliva microscope to detect ferning21,22 Ovulation predictor kit (urine LH monitor)21,22
As ovulation approaches, the cervix moves higher in the vagina (less easy to reach with fingers) As ovulation approaches, the cervix become softer and then returns to firmer once ovulation has occurred As ovulation approaches, the cervix opens, which is visible by speculum examination As ovulation approaches, cervical mucus becomes clear, stretchy, and slippery, like an egg white (begins 5 days before ovulation and increases in quantity and stretch as ovulation approaches) Temperature may dip slightly before ovulation followed by a sustained temperature rise after ovulation
ICI Fresh and frozen sperm: When cervix is highest in the vagina
IUI When cervix is highest in the vagina
Fresh and frozen When cervix feels sperm: When softest or when cervix feels softest cervix just (like touching a lip) starts to become firmer Fresh and frozen sperm: When the os is wide open
When cervix is wide open or just beginning to close
Fresh sperm: On days On the last day of of fertile mucus fertile mucus to (1–3 days before 6 hrs after the ovulation) transition to Frozen sperm: On creamy cervical the last day of peak mucus mucus (18–36 hrs before ovulation)
Fresh sperm: 1–3 8–12 hrs before or 6 hrs after dip in days before dip in temperature temperature Frozen sperm: 18–36 hrs before dip in temperature When strong ferning Increased ferning Fresh and frozen patterns are occurs with rising sperm: When observed estrogen levels strong ferning patterns are observed During the LH surge, Fresh sperm: Up to 18–36 hours after a certain 36 hrs before first first positive concentration of positive and up to LH in the urine 24 hrs after first will cause the positive ovulation predictor Frozen sperm: Up to 12 hrs before first kit to read positive positive and up to (24–36 hrs before ovulation) 24 hrs after first positive
Cost ($)
Advantages
Disadvantages
None
Affordable; women May be uncomfortable gain knowledge for woman; about their bodies; changes in cervix may be performed may be difficult to by partner determine
None
Affordable; women May be uncomfortable gain knowledge for woman; about their bodies; changes in cervix may be performed may be difficult to by partner determine
Initial: 10–15 for speculum Monthly: None None
Affordable; women Speculum gain knowledge examination may about their bodies; be uncomfortable; may be performed may have difficulty by partner locating os Affordable; Changes in cervical prospectively mucus may be difficult to identifies complete fertile window; determine; may women gain have insufficient mucus production knowledge about their bodies
Initial: Affordable 10–15 for thermometer Monthly: None
Cannot be used to predict ovulation; changes in lifestyle and routine can alter results; may be inconvenient
Initial: 20–40 Monthly: None
Affordable
Results not reliable; eating, drinking, or oral hygiene may cause error
Initial: None Monthly: 20–75
Prospectively identifies up to 2 fertile days before ovulation; results easy to interpret (if using digital monitors)
Test sticks must be purchased every month; a positive result may not give a long enough window for multiple inseminations if using ICI (especially with fresh sperm)
(Continued)
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Table 1 (Cont’d). Methods to Predict Ovulation and Timing of Insemination Method of Predicting Ovulation
Timing of Insemination3 Sign of Ovulation
ICI
IUI
Cost ($)
Advantages
Disadvantages
18–36 hours after Initial: 100–200 Prospectively Expensive; test strips Rising levels of Fresh sperm: Up to first peak reading Monthly: identifies up to 6 must be purchased estrogen cause the 24 hrs before first 30–50 fertile days before each month; monitor to read peak reading and ovulation; results cannot be used by up to 36 hrs after ‘‘high’’ (3–6 days women with easy to interpret; before ovulation); first peak reading monitor adjusts irregular cycles the LH surge Frozen sperm: results to woman’s causes the monitor 12 hrs before to unique cycle; to read ‘‘peak’’ 24 hrs after peak monitors two (1–2 days before reading hormones ovulation) Saliva fertility monitor The levels of salivary Fresh sperm: 1–3 Up to 8 hrs before and Initial: Prospectively Expensive; conflicting (OvaCue)21,22 electrolytes change days before up to 8 hrs after 200–300 identifies up to 6 data concerning as ovulation ovulation (at ovulation (confirm Monthly: fertile days before accuracy 5–7 bars) ovulation with None ovulation; an approaches, which is recorded by the Frozen sperm: vaginal sensor) optional vaginal monitor, which 18–36 hrs before sensor can confirm displays an ovulation (at if ovulation 6–7 bars) occurred; memory increasing number of bars (up to 7) chip stores 4 mo of data as ovulation approaches; ovulation can be confirmed with the vaginal probe (sold separately)
Urine fertility monitor (ClearBlue)21,22
ICI = Intracervical insemination; IUI = intrauterine insemination; LH = luteinizing hormone. Sources: Stanford et al.,22 Brill,3 and Scolaro et al.21
can be charted and used to help identify the time of ovulation. Basal Body Temperature Basal body temperature is taken each morning at the same time before rising from bed, using a digital basal body thermometer. A daily log of the temperatures obtained each morning is kept to monitor the biphasic pattern of an ovulating woman. During the follicular phase, basal body temperature is lower (96 F–98 F).21 Just before ovulation, women may note a slight dip in temperature followed by a rise of 0.5 F to 1.6 F.21 After ovulation, the temperature remains elevated (97 F–99 F) until menstruation begins.21 A more precise thermometer that measures temperature from 96 F to 101 F (in 0.1 F increments) must be used to accurately monitor basal body temperature. Saliva Microscope As ovulation approaches, changes in salivary electrolyte concentration produce a crystallization or ‘‘ferning’’ pattern that may be observed in dried saliva with a microscope.22 Increasing ferning may indicate greater fertility and the approach of ovulation.25 Compact home saliva microscopes (about the size and shape of a lipstick 128
case) are available for purchase and are relatively inexpensive. Saliva should be monitored first thing in the morning before eating, drinking, or oral hygiene to ensure the most accurate results.25 Detecting ferning with a saliva microscope may indicate increasing fertility, but it has not been shown to be a reliable predictor of ovulation.25 Ovulation Predictor Kits Ovulation predictor kits measure the concentration of luteinizing hormone (LH) in the urine, and a positive reading is given during the LH surge when the concentration of LH in the urine exceeds a set control level.25 Ovulation occurs within 48 hours following the LH surge.22 Some test devices are more sensitive than others, although all accurately predict approaching ovulation.25 Many women enjoy using ovulation predictor kits because they are an objective and easy way to monitor fertility; however, ovulation predictor kits are expensive ($20–$75 per month), and waiting for a positive result may not allow time for multiple inseminations.3 Fertility Monitors There are two types of fertility monitors available today: those that monitor changes in the urine and those that Volume 55, No. 2, March/April 2010
monitor changes in saliva. Both types of monitor prospectively identify fertile days (5–6 days in advance of ovulation) and the results are easy to interpret.22 However, these monitors require a substantial initial investment ($100–$300) and are prohibitively expensive for many women.25 Urine fertility monitors, like the Clearblue Easy Fertility Monitor, measure the concentration of both LH and estrogen in the urine and become calibrated to the specific concentrations of hormones in the individual user. These monitors give a reading of ‘‘high’’ fertility in response to rising estrogen levels, and then ‘‘peak’’ fertility in response to the LH surge. Ovulation usually occurs within 2 days of the first peak reading.22 Urine fertility monitors are only accurate in women who have regular cycles with 21- to 42-day intervals.22 Saliva fertility monitors, like the OvaCue fertility monitor, use an oral probe to measure changes in salivary electrical resistance, which begin 6 to 7 days before ovulation.22 Fertility is depicted by one to seven bars that correspond to increasing fertility. A separate vaginal probe can also be purchased to test vaginal mucus to confirm that ovulation has occurred.22 There have been conflicting reports regarding the accuracy of saliva fertility monitoring for predicating ovulation.25
TIMING OF INSEMINATION All intracervical inseminations (ICIs) should be performed before ovulation; however, the timing of insemination depends on whether the couple is using fresh or frozen sperm and how many inseminations they would like to perform in each cycle. While fresh sperm may live for 2 to 3 days, frozen sperm only live for 18 to 24 hours.3,26 Because of their shortened lifespan, insemination with frozen sperm must take place much closer to the time of ovulation (12–24 hours before ovulation if using frozen sperm versus up to 3 days before ovulation if using fresh sperm). Many lesbian couples choose to inseminate more than once per cycle to try increasing the likelihood of conceiving.27 Multiple inseminations with fresh sperm are generally separated by at least 24 hours, while multiple inseminations with frozen sperm may be done more frequently (often 18 hours apart).3 It is important that all ICIs take place with peak fertile mucus, because fertile mucus both nourishes and transports the sperm from the vagina to the uterus.23 Sperm that has been prepared for IUI only lives in the uterus for 6 to 10 hours, and therefore insemination must occur very soon before (or after) ovulation occurs.26 It is possible for IUI to take place several hours after ovulation, because sperm are deposited directly in the uterus and do not require fertile mucus for transport.26 Planning overnight shipment of the donor sample(s) from the cryobank can be discussed with the cryobank Journal of Midwifery & Women’s Health www.jmwh.org
to ensure that the sperm arrives within the ovulation window. DONOR INSEMINATION OPTIONS There are three primary options for donor sperm: insemination with fresh sperm from a known donor, frozen sperm from a known donor, and frozen sperm from an unknown donor. Each option has advantages and disadvantages in terms of pregnancy rates, risk of infection, cost, and relationship with the donor (Table 2). Fresh Sperm From a Known Donor Using fresh sperm from a known donor (in most cases, a friend of the couple) greatly reduces the expense of insemination because the sperm is generally obtained for free or at low cost. In addition, using fresh sperm is associated with higher fecundity rates than frozen sperm.27 Lesbian couples may also choose to use a known donor if they wish for him to play a role in the child’s life.2 The major risk of inseminating with fresh sperm is the risk of acquiring an STI.10 Frozen Sperm From a Known or Unknown Donor The freezing and thawing of sperm is associated with decreased viability, motility, and functional ability.15 Clinicians may wish to inform couples planning on using frozen sperm from a known or unknown donor that it may take longer to achieve pregnancy.28 Sperm obtained from a cryobank generally costs between $200 and $600 per vial, and many women choose to inseminate more than once per cycle.10 Sperm obtained from a cryobank is classified as being from either an anonymous donor or from an open-identity donor. The identity of an anonymous donor cannot ever be revealed, whereas with an open-identity donor, the child will be able to contact or obtain information about the donor when they reach a certain age (usually 18 years).15 If the sperm is obtained from a cryobank, the donor (whether anonymous or openidentity) has no legal right or responsibility to any child that may result. This assurance of legal autonomy is one reason many lesbian couples choose to use frozen sperm. INSEMINATION OPTIONS Home Insemination DI may be performed either at home by the couple or at a health care facility with the assistance of a clinician. Performing the insemination at home has the added benefit of being free, except for the cost of sperm from a cryobank. Self-insemination, also called vaginal insemination, is the simplest method of insemination. The social mother uses a needleless syringe to insert the semen into the vagina of the partner who wishes to become pregnant. Home insemination can help facilitate the woman’s 129
Table 2. Risks and Benefits for Different Types of Donor Inseminations3,10 Fresh Sperm From Known Donor
Frozen Sperm From Known Donor
Cost
May be free or cost may be negotiated May be free or cost may be negotiated with donor with donor; additional cost of cryopreservation and storage Location Home (cannot be performed in most Home or health care facility clinics because of risk of HIV infection) Type of insemination Intravaginal insemination ICI or IUI (IUI sperm must be prepared before insemination) Risk of sexually transmitted infection Highest risk of all options Very safe after 6-month quarantine period to rule out HIV Risk of legal complications Possible—A legal agreement can be Possible—A legal agreement can be written between couple and donor written between couple and donor to prevent complications to prevent complications Possibility of relationship with donor
Yes
Yes
Frozen Sperm From Unknown Donor $200–$600 per vial; storage cost if vials purchased in advanced Home or health care facility Sperm available ‘‘ICI ready’’ or ‘‘IUI ready’’ Very safe Donor has no legal right or responsibility to any children that result from insemination with his sperm Only in cases of open-identity donation, usually after child turns 18 years
ICI = Intracervical insemination; IUI = intrauterine insemination.
confidence in her own fertility and allows the couple to be in a familiar environment that is comfortable and more intimate, making the experience seem like less of a medical procedure.3 Self-insemination at home also serves to support the importance of the partner in the process of conception, because she may be the person performing the insemination. Insemination in the Health Care Facility Vaginal insemination in the health care setting is commonly referred to as ICI and is a process during which sperm is injected into the vagina or into the cervical opening29 (Figure 1). Frozen sperm can be purchased either ‘‘ICI ready,’’ which means that they are only suitable for vaginal or cervical inseminations, or ‘‘intrauterine insemination (IUI) ready,’’ which means that they may be inserted directly into the uterus and do not require additional rewashing. All sperm that is not ‘‘IUI ready’’ must be washed before insertion in the uterus to eliminate exposure to seminal plasma, which may cause prostaglandininduced uterine contractions, uterine infection, or, rarely, anaphylaxis.27,30 An appropriate centrifuge is therefore needed to wash semen on site if it has not already been prepared. Clinicians who plan to perform IUI benefit from working with a nurse infertility specialist and cryobank for instructions and obtaining the suggested solution for preparing the semen for IUI. Clinicians may also perform IUI (Figure 1). To perform IUI, the patient lies in a lithotomy position on a standard gynecologic examination table with her feet in footrests. A speculum is placed into the vagina to visualize the cervix. A tenaculum may be used to help straighten the cervical canal for catheter insertion; however, some clinicians may wish to avoid using a tenaculum, because placement 130
may also release prostaglandins that may theoretically reduce fertility at the time of insemination.3 To perform an IUI, the washed sperm is aspirated into a 1.0-mL syringe. The plastic syringe is attached to a flexible polyethylene catheter (a standard IUI catheter).26 All air is removed from the syringe and the catheter is inserted through the endocervical canal and into the uterus. The clinician may offer the partner the opportunity to depress the syringe once the catheter has been inserted. Mild cramping may occur as the sperm are injected or after the insemination.27 After the injection, the catheter is slowly removed and the patient may wish to remain lying flat and still for 15 minutes.26 The woman may resume her normal activities upon leaving the office. Antibiotic prophylaxis is not required. IMPLICATIONS FOR PRACTICE The hallmarks of midwifery care as defined by the American College of Nurse-Midwives (ACNM) include cultural competence, advocacy on behalf of patients, and health education.31 These practices are guided by an ethical philosophy that is grounded in respecting the basic human rights and dignity of all individuals; partnering with women; and nondiscriminatory, private, and confidential care.32 Studies have shown that lesbians who received maternity care from midwives reported higher levels of support and satisfaction than did lesbians who used physicians.11 However, because providers hold a range of social, religious, and political beliefs, individual practice and care does not always conform to the midwifery model of care.1,11,12,33 All clinicians who care for women of reproductive age have the opportunity to develop their skills to meet the needs of lesbians and, in doing so, expand their circle of Volume 55, No. 2, March/April 2010
Figure 1. The placement of the catheter in intracervical and intrauterine insemination. Source: American Society for Reproductive Medicine.29
care to include more women.12 Even minor changes to existing services, to create an environment that acknowledges and respects diversity, may improve the satisfaction of lesbian patients.11,12 This includes being aware of treatment avenues and options for lesbians, being knowledgeable about appropriate referral and support services in their area, and showing respect to all families.4 The need for increased knowledge of lesbian health among providers has been recognized in academic research.25 In response, the Institute of Medicine developed eight specific recommendations to increase knowledge of lesbian health, including the recommendation that government, professional, and academic institutions develop and support mechanisms for educating providers, researchers, and the public about the unique health care needs of lesbians.34 To meet this goal and to help ensure that women seeking care do not encounter discrimination, professional organizations can develop a position statement that specifically addresses sexual orientation and patient care. Such statements have been developed by the American Medical Association and the Royal College of Midwives.14,35 ACNM has already approved a position statement on ethnic and cultural diversity, which addresses both the care of women with ethnic and cultural diversity and the value of such diversity in the membership.36 The development of a similar statement by ACNM regarding sexual orientation would serve as a guide for providers in the United States and acknowledge this often overlooked population. Journal of Midwifery & Women’s Health www.jmwh.org
The authors wish to thank Laura Zeidenstein, CNM, DrNP, for her guidance during the writing of this paper.
REFERENCES 1. Renaud MT. We are mothers too: Childbearing experiences of lesbian families. J Obstet Gynecol Neonatal Nurs 2007;36:190–9. 2. McManus AJ, Hunter LP, Renn H. Lesbian experiences and needs during childbirth: Guidance for health care providers. J Obstet Gynecol Neonatal Nurs 2006;35:13–23. 3. Brill S. The new essential guide to lesbian conception, pregnancy, and birth. New York: Alyson Publications, 2006. 4. Ross LE, Steele LS, Epstein R. Lesbian and bisexual women’s recommendations for improving the provision of assisted reproductive technology services. Fertil Steril 2006;86:735–8. 5. Ethics Committee of the American Society for Reproductive Medicine. Access to fertility treatment by gays, lesbians, and unmarried persons. Fertil Steril 2006;86:1333–5. 6. Maccallum F, Golombok S. Children raised in fatherless families from infancy: A follow-up of children of lesbian and single heterosexual mothers at early adolescence. J Child Psychol Psychiatry 2004;45:1407–19. 7. Anderssen N, Amlie C, Ytterøy EA. Outcomes for children with lesbian or gay parents. A review of studies from 1978 to 2000. Scand J Psychol 2002;43:335–51. 8. First amendment – California Supreme Court holds that free exercise of religion does not give fertility doctors right to deny treatment to lesbians. –North Coast Women’s Care Medical Group, Inc. v. San Diego County Superior Court, 189 P.3d 959 (Cal. 2008). Harv Law Rev 2008;122:787–94. 131
9. Baetens P, Brewaeys A. Lesbian couples requesting donor insemination: An update of the knowledge with regard to lesbian mother families. Hum Reprod Update 2001;7:512–9.
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11. Ross LE, Steele LS, Epstein R. Service use and gaps in services for lesbian and bisexual women during donor insemination, pregnancy, and the postpartum period. J Obstet Gynaecol Can 2006;28:505–11. 12. Wilton T, Kaufmann T. Lesbian mothers’ experiences of maternity care in the UK. Midwifery 2001;17:203–11. 13. Spidsberg BD. Vulnerable and strong—Lesbian women encountering maternity care. J Adv Nurs 2007;60:478–86. 14. The Royal College of Midwives Web site. Position paper 22. Maternity care for lesbian mothers. London: The Royal College of Midwives; 2000. Available from: www.rcm.org.uk/college/standardsand-practice/position-papers/?locale=en [Accessed March 26, 2009].
25. Kelley L, Chou CL, Dibble SL, Robertson PA. A critical intervention in lesbian, gay, bisexual, and transgender health: Knowledge and attitude outcomes among second-year medical students. Teach Learn Med 2008;20:248–53. 26. Speroff L, Fritz M. Clinical gynecologic endocrinology and infertility, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2005:1156–60. 27. Carroll N, Palmer J. A comparison of intrauterine versus intracervical insemination in fertile single women. Fertil Steril 2001; 75:656–60.
15. Werner C, Westersta˚hl A. Donor insemination and parenting: Concerns and strategies of lesbian couples. A review of international studies. Acta Obstet Gynecol Scand 2008;87:697–701.
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29. American Society for Reproductive Medicine Web site. Third party reproduction (sperm, egg, and embryo donation and surrogacy). A guide for patients. Birmingham, AL: American Society for Reproductive Medicine, 2006. Available from: www.asrm.org/ Patients/patientbooklets/thirdparty.pdf [Accessed October 4, 2009].
17. Brewaeys A, Ponjaert I, Van Hall E, Golombok S. Donor insemination: Child development and family functioning in lesbian mother families. Hum Reprod 1997;12:1349–59. 18. Paige R. American Psychological Association policy statement: Sexual orientation, parents, and children. American Psychological Association, 2005. Available from: www.apa.org/pi/lgbc/ policy/parents.html [Accessed August 18, 2009]. 19. March of Dimes Web site. Before pregnancy: Preconception. Available from: www.marchofdimes.com/pnhec/173.asp [Accessed August 18, 2009]. 20. Lynch CD, Jackson LW, Buck Louis GM. Estimation of the day-specific probabilities of conception: Current state of the knowledge and the relevance for epidemiological research. Paediatr Perinat Epidemiol 2006;20(Suppl 1):3–12.
30. ESHRE Capri Workshop Group. Intrauterine insemination. Hum Reprod Update 2009;15:265–77. 31. American College of Nurse-Midwives. Basic competency section, Division of Education. Washington, DC: ACNM, 2007. 32. American College of Nurse-Midwives. Ad Hoc Committee on Code of Ethics. Washington, DC: ACNM, 2005. 33. Buchholz SE. Experiences of lesbian couples during childbirth. Nurs Outlook 2000;48:307–11. 34. Solarz A, editor. Lesbian health: Current assessment and directions for the future. Washington, DC: National Academy Press, 1999.
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35. American Medical Association Web site. GLBT Advisory Committee. AMA policy regarding sexual orientation. Available from: www.ama-assn.org/ama/pub/about-ama/our-people/membergroups-sections/glbt-advisory-committee.shtml [Accessed August 18, 2009].
22. Stanford JB, White GL, Hatasaka H. Timing intercourse to achieve pregnancy: Current evidence. Obstet Gynecol 2002; 100:1333–41.
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