There are several types of fertility care options available for queer people, including same-sex couples, transgender individuals, and other LGBTQ+ families looking to carry a pregnancy.
Types of LGBTQ fertility treatments
In this article, we’ll cover many of the different LGBTQ fertility options you have to build a family through carrying a pregnancy: IVF, RIVF, IUI, ICI, and IVI. We’ll also touch upon the different stages in fertility testing and treatment like ovarian stimulation and sperm analysis.
We want to outline exactly what happens during each procedure, so you have the knowledge to choose an option best fit for your LGBT family-building journey. We’ll review each fertility treatment option from the fewest medical interventions to the most. It’s important to remember that there isn’t one right pathway and what option is right for you will depend on your health, medical history, age, and comfort level. Read on to learn more about reproductive medicine from a queer lens.
Intravaginal insemination (IVI) and Intracervical insemination (ICI)
Intravaginal insemination (IVI) is a process in which sperm is placed inside the vagina with a syringe or other transport device. This method can be done with fresh sperm or frozen sperm that has then been thawed. IVI is attractive to many parents-to-be, because it:
- can be done at home;
- doesn’t require a medical instrument or a healthcare provider/fertility specialist; and
- is much less expensive than other conception methods.
Intracervical insemination (ICI) encapsulates the process in which a medical provider places sperm—either from a sperm donor or a partner—into the cervix via a small tube known as a catheter. During IVI, the sperm is placed into the back of the vaginal canal near the cervix using a syringe, whereas during ICI the sperm is placed directly into the cervix. This means that ICI has a higher success rate than IVI, given that the sperm is directed closer to.
Intrauterine insemination (IUI)
Intrauterine insemination (IUI) is a process that involves a medical professional putting “washed'' sperm into the uterus through a very small catheter through the cervix. Washing the sperm removes any lower-quality sperm or bacteria from the ejaculate so that the remaining sperm is a highly concentrated sample of healthy sperm.
IUI has a higher success rate than IVI or ICI. IUI can either be done with donor sperm or with the sperm of a partner if penis-in-vagina penetrative intercourse hasn’t resulted in pregnancy or for any other reasons. After the sperm has been washed, your ovulation will be monitored and may be stimulated, if necessary. Based on the signs of impending ovulation, your healthcare professional will perform the procedure. The IUI procedure usually requires no medications or pain relievers.
Ovarian stimulation (or ovulation induction, as mentioned above) is the process through which the ovaries are stimulated via medications to produce as many mature eggs as possible. Before this process, you'll need to undergo fertility testing including blood and urine tests to check hormone levels, a pap smear to check the health of your cervix, ultrasound, and imaging to make sure fallopian tubes are open or to look for fibroids or uterine abnormalities. This will help your healthcare provider create a plan properly suited to the needs of your body.
If you’re non-binary or transgender person on testosterone hormone therapy, it’s generally recommended to stop taking your testosterone three or so months before ovarian stimulation to give you the best chance of success. However, depending on your age and other factors, you may not need to stop testosterone prior to stimulation. If you plan to carry a pregnancy in your body, it is necessary to stop testosterone prior.
There are various medications to stimulate egg production. There are oral medications that help enhance and time ovulation. In addition, some people use a “trigger shot” of human chorionic gonadotropin (hCG) to stimulate ovulation and time conception.
There are also injectable medications specifically used as part of IVF egg retrieval. Two injectable medications are derived from two key hormones, FSH (Follicle Stimulating Hormone) and Luteinizing Hormone (LH); they can be used for about 2 weeks and help ovaries produce multiple mature eggs.
A semen analysis or sperm analysis looks at the quality of the sperm of a known donor, which can be a family member. A semen analysis will evaluate many aspects of the sperm in order to assess the potential for successful fertilization. This will require you, your partner, or your donor to provide a semen sample via masturbation. Since sperm count varies from day to day, more than one sample may need to be provided. The factors that are evaluated in a semen analysis can include:
- Semen volume: the amount of semen (in millimeters)
- Sperm concentration: number of sperm per millimeter of semen
- Sperm morphology: size and shape of the sperm
- Sperm motility: the ability of the sperm to swim toward an egg
- Vitality: percent of live sperm in the sample
- pH level: whether semen is too acidic, which can affect sperm health
- White blood cells: a sign of infection or inflammation
A sperm analysis may also be useful for transgender or nonbinary people on estrogen hormone replacement therapy (HRT) to get a good idea of their current level of fertility.
In vitro-fertilization (IVF)
You have probably heard of the acronym IVF before. In vitro-fertilization is a medical procedure whereby an egg is removed from an ovary and fertilized by a sperm to create an embryo, in a laboratory outside of the body. IVF treatment can be done with a couple’s own eggs and sperm, or with the sperm or eggs from a partner and/or a known or anonymous donor. The embryo that is created is eventually implanted in a uterus and the pregnancy continues.
People may carry their own pregnancy if they have a uterus, or it can be carried by a gestational carrier (someone who agrees to have the embryo implanted in their uterus–usually with a legal contract and financial compensation) via gestational surrogacy. IVF is the most effective form of assisted reproductive technology, but often the most time consuming, expensive, and medically invasive, which is why it’s rarely the first step someone takes on their fertility journey. Additionally, IVF includes several steps which are outlined in detail below.
If a person is trying to use their own eggs, the start of a single IVF cycle usually begins by stimulating the ovaries to produce multiple eggs—rather than the one egg that typically develops each month during ovulation. The eggs are stimulated using synthetic hormones both in the form of oral and injectable medications. You will typically need a week or two of ovulation induction before your eggs are ready for retrieval. To determine the correct timing you might have a vaginal/internal ultrasound to monitor the development of follicles and/or blood tests to measure your response to the medications.
When the follicles are mature and eggs are ready to harvest, you or your partner will go through a procedure to remove eggs that can then be used to create an embryo outside the body. The procedure to retrieve eggs can be uncomfortable and feel invasive for many people, which is why anesthesia is used to help with anxiety, discomfort, or pain. In a healthcare setting or fertility center, a thin needle is passed through the vagina using an ultrasound guide to get to the ovary and the follicles. This is what is called a transvaginal ultrasound aspiration. The eggs are then removed from the follicles through the needle via a suction device. The procedure usually takes about 10 to 20 minutes. The mature eggs are then placed in liquid and incubated under carefully controlled environmental conditions.
Sperm Retrieval (if applicable)
If you use a partner or known donor’s sperm, this person will provide a semen sample the morning of the egg retrieval, either through masturbation or testicular aspiration. If you are using a sperm donor, the vial of sperm you purchased will be used. Either way, sperm are separated from the semen in the lab and will be mixed with the healthy and mature-appearing eggs in an attempt to allow fertilization and eventually the creation of embryos.
Fertilization and Development
Fertilization can happen in one of two ways. The sperm and eggs are either mixed in the lab (in-vitro) about four hours after the retrieval and incubated overnight, or individual healthy sperm is injected into the mature eggs via Intracytoplasmic sperm injection (ICSI). More on that procedure below.
The eggs will be monitored carefully and routinely checked for evidence of fertilization. After about two to five days, embryos that have developed will either be transferred into the uterus, or cryopreserved for later use. A mild sedative is given for this process, because although it should be relatively painless, you may experience anxiety and cramping. The medical professional will insert a small flexible tube or catheter into your vagina, through the cervix, and into your uterus. The embryo or multiple embryos will then be transferred to your uterus through the catheter into the uterine cavity. If successful, the embryo(s) will implant and continue to develop. Between 12 days to two weeks after egg retrieval, you will have blood tests to measure HCG (the pregnancy hormone) levels and determine if you are pregnant.
Reciprocal in vitro fertilization (RIVF)
Reciprocal in vitro fertilization (RIVF), also known as partner-assisted reproduction, partner IVF, or co-IVF, is a process where one genetic parent provides the egg to the birth parent, who carries the child. This allows lesbian couples or trans men and non-binary partners in a couple to both participate biologically in a pregnancy.
Similar to IVF, the process for reciprocal IVF consists of the ovulation stimulation of one partner, followed by egg retrieval and fertilization to create embryos that can then be transferred back into their partner’s uterus. Essentially, one partner acts as an egg donor for the other. This allows for one partner to be genetically connected to the child, while the other partner is connected to the child through the pregnancy, birth, and/or breastfeeding/chestfeeding process.
Fresh embryo transfer vs. Frozen embryo transfer
If you and your partner undergo IVF and embryo transfer, deciding which partner would act as the donor and which partner would carry the child is up to every couple or family. You will also have to decide whether a fresh embryo transfer or a frozen embryo transfer may better suit your needs. A frozen embryo transfer is when embryos from a previous IVF procedure are thawed and transferred into the uterus.
A fresh embryo transfer as part of the reciprocal IVF process will require that both partners’ cycles are synced prior to the transfer to ensure that the uterine lining of the carrying partner is at the proper stage of development when the embryo is transferred. Birth control pills can synchronize both partners’ cycles before the process begins. One fresh embryo transfer will usually be less expensive than a frozen embryo transfer, as it doesn’t require the process of cryopreservation (otherwise known as egg or embryo freezing).
Technology and science continue to evolve with fertility preservation. At present, experts so far conclude that while there are no major differences in pregnancy success, there are pros and cons to each type of embryo transfer. That decision is personal and best discussed with your fertility medical provider.
Intracytoplasmic sperm injection (ICSI)
Intracytoplasmic sperm injection (ICSI) can be an additional step in IVF. During ICSI, a single sperm is injected directly into the egg's cytoplasm to help fertilize it. In traditional IVF, the sperm will be placed next to the egg in a laboratory dish during the fertilization process. Fertilization occurs when one of the sperm enters the egg. During ICSI, a tiny needle called a micropipette is used to inject a single sperm into the center of the egg. This is usually performed for a number of reasons, such as if previously frozen eggs are being used or if eggs have not been fertilized by either P-in-V intercourse or traditional IVF.
While this can be a lot of information to take in, there isn’t any rush to making such an important decision. You’re in right place seeking out relevant information. (We also recommend you read a similar FOLX article: What the Definition of Infertility Means for LGBTQ+ People.) There isn’t one right way to get pregnant, and the fertility process for many people is rarely linear. Once you’ve got an idea of the fertility basics, the next step is to schedule an appointment with your healthcare provider, a FOLX clinician, or a fertility specialist for an initial consultation to help you figure out what path is right for you and your family.