Fertility Options for LGBTQ+ Families

In the ever-evolving fertility world, there are a lot of ways to make a baby, including a wide range of options for individuals and couples who identify as lesbian, gay, bisexual, trans, queer, questioning, two-spirited or other sexual orientations and gender identities.

It all starts with planning—from exploring your treatment options to optimizing your health for the journey ahead. To help you get set for your next steps, we break down the range of clinic-supported fertility treatments available to LGBTQ folks.

As part of your plan, you might be using an egg donor and gestational carrier/surrogate, or have a partner with eggs and a uterus.

For your strongest swimmers, it’s a good idea to start making healthy lifestyle choices three months before you start treatment. That’s roughly how long it takes sperm to mature, so it allows you to impact the quality of the sex cells. Start by eliminating high-saturated fats from your diet (think: processed and fatty meats, butter, palm oil) and getting a moderate amount of exercise. 

A word of caution though: If you’re heavy into your Peloton, stick to cycling less than five hours per week, because the seat causes the testicles to sit closer to the body and increases their temperature. Consistent overheating can lead to a significant reduction in sperm quality that can last a couple of months.

If you’re in a couple and using sperm from both partners, this prep applies to both, of course! Optimizing sperm quality is obviously great for embryo health, which translates to minimizing time to pregnancy. That means less time and money spent at the fertility clinic.

• And FYI! You can take an at-home sperm test to confirm that there is sperm in your semen, even before you set foot in a clinic. For some, this is an easy entry point into fertility investigation and intervention, and may get you to seek care faster than you would’ve otherwise.

For trans women on hormone therapy (like anti-androgens), it’s important to note that this will impact sperm quality, sometimes irreversibly. One option is to use the sperm or freeze some samples before starting gender-affirming hormone therapy. If you’ve paused hormone therapy, sperm quality may already be negatively affected. A study in 2020 looked at the sperm of trans women who hadn’t started or were on a break from gender-affirming hormone therapy and noted lower sperm quality from the start. If you’re on hormones, you will need to pause them for a few months to wash them out of the body to allow recovery of sperm production.

Your doctor will start with a general workup and sperm testing. If you’re using an egg donor and a gestational carrier (someone who carries a pregnancy they are not genetically linked to), you’ll likely go the IVF route. That’s when sperm and eggs are combined in a lab to make embryos, which are then transferred to the carrier. If you’re using a surrogate (where the egg donor and carrier is the same person), either IVF or IUI (a treatment where sperm is injected directly into the uterus) can be used.

Your journey might involve using a sperm donor (with or without a gestational carrier), or a partner with sperm.

You might have a different person carrying the pregnancy (it doesn’t have to be the same person who provided the egg). In that case, the carrier won’t need egg-quality support but can still benefit from nutrients ahead of time for endometrium (lining) quality to help implantation and pregnancy development, as well as during the pregnancy itself to support fetal development. (We recommend the Complete Prenatal Pack—everything you need to support fetal development and the health of the carrier.) Some patients who are intending to carry the pregnancy opt for acupuncture in the month leading up to the embryo transfer to increase blood flow to the uterus.

A 2019 study found that trans men who had taken testosterone had similar egg yields to cisgender female patients. That means that you don’t need to have your eggs frozen before doing hormone therapy, which was previously believed. In fact, it's common practice in fertility clinics to use testosterone "priming" in some patients (for those with low ovarian reserve, for example) to try to improve fertility outcomes. If you have a healthy uterus, you’ll be able to decide if you’d like to carry the pregnancy as well—though, if taking testosterone, you’d have to stop during the pregnancy as it can impact a developing fetus. In this scenario, sperm from a donor or partner can be placed in the uterus after ovulation in hopes of fertilization (IUI), or you can opt for IVF.

You’ll start off with testing to assess ovarian reserve (basically, your egg count) and overall well being, looking for things like anemia, thyroid function and glucose levels. It’s a good time to ensure your general health is optimized, like having immunizations and getting those Pap smears up to date. If you’re a couple with eggs, your doctor can help you decide whose egg and whose uterus to use based on biological, logistical and psychosocial factors.

You’ll also assess uterine function for the person planning to carry the pregnancy. Initial testing includes a pelvic ultrasound and sonohysterogram (where fluid is inserted in the uterus via the cervix so the doctor can get more information about the inside of the uterus and assess if the tubes are “open”) . Once all the screening is completed, you’ll have a consultation with your doctor to review options and then treatment starts. If you’re using someone else’s eggs, it will be fertilized in a lab with sperm and then transferred to your uterus (IVF). If it’s your own egg, you can either do IVF or IUI, where sperm is inserted past the cervix when you’re ovulating.