Clinical:Case Study: Mothers

Original materials created in May 2000 by Kate Paterson Neely, M.D.

History

DF is a 34 yo woman who comes in to discuss “having a baby.” She is accompanied by her 37 yo partner, KR. They have always wanted a child, but had assumed it was not an option for them as a lesbian couple. In the last few years they have noticed the increasing number of gay and lesbian families, and have reconsidered. DF has chosen to become pregnant, since KR relates that she feels her body and gender image would not be compatible with pregnancy. DF has never been pregnant. She reports sexual intercourse with a man in the distant past, always with contraception. Denies hx of sexual abuse, STI, or PID. Menstrual cycles are regular, occasionally with mittleschmirtz, and a clear midcycle libinal peak. She has had intermittent well-gyn care in the past, with all her paps normal.

Medications: DF has read the recent reports about folic acid, and is already taking a 400mcg supplement daily, as well as a multi-vitamin.

Past Medical/Surgical Hx: Chicken pox as a child, no surgeries.

Family Hx: No infertility, father has heart disease.

Social Hx: Neither smokes, both are social drinkers, and DF volunteers that she knows she will need to stop alcohol during the pregnancy. Together 9 years. DF is a lawyer, and KS a special service police officer. DF expresses excitement about pregnancy, but some concern about “getting fat”. She swims daily. They have no cats.

Exam: WD/WN slightly built woman without acne or hirsutism. Normal exam. Since DF had not had regular gynecologic care, and as a lesbian was at high risk for having had bad interactions with health care providers, I took the same approach I would to a first exam. She chose to have KS stay with her, and used a mirror to see for herself what I was doing.

Discussion

Family planning is an important, but often neglected, component of care for lesbian couples. While same-sex couples have always been parents, such families are becoming more visible and more prevalent, requiring physicians to have appropriate knowledge and attitudes to counsel and assist patients effectively. Family planning for lesbian couples does not require referral, and can be done in a simple office visit. Because family planning has traditionally been included in discussions about birth control, it is easily overlooked in same-sex couples. This may require extra thought by the provider, and re-arrangement of established history taking patterns. Discussion of fertility, nutrition, normal pregnancy, and issues of emotional, financial, and material preparation should be discussed. In addition, options for achievement of pregnancy and their relative risks and benefits must be presented.

This couple has no history suggestive of infertility, and infertility should not be assumed. In fact, the most common cause of infertility among lesbians is age, since the options for having children are not well-known, and the “gayby boom” is relatively new. This underscores the need for counseling any lesbian patient on the choice of raising a family, and availability of services. Among lesbians couples who chose to have a family, most opt for intra-vaginal insemination (IVI) from an unknown donor to achieve pregnancy; the other common option is insemination from a known-donor.

Anonymous donor sperm is obtained through a sperm bank. Most insurances do not cover donor insemination except as treatment for male factor infertility. Donors are chosen from a catalogue which lists information about race, religion, hair and eye color, education, employment, and in some cases, essays, pictures, and even video. Intravaginal insemination (IVI) can be taught and done at home, or intrauterine insemination (IUI) can be done in the office. Some studies indicate that with frozen sperm, IUI results in a higher fecundity rate, but these studies were done with women who have documented infertility. Many women choose to first attempt IVI at home, because of the more “normal” atmosphere and sense of control it allows. Pregnancy rates for frozen sperm are about half that of fresh sperm: 5- 11%, and 15-20%, respectively. Cumulative pregnancy rates with frozen sperm in women with normal fertility, range from 45-73% for a 1 year period. 86% of conceptions occur during the first 6 months, after which infertility work-up and possible ovulation induction may be warranted. Sperm banks require a physician’s signature to release sperm, and may prefer to ship to the physician office. Physicians unwilling to do this may suggest using known donors, but this has some additional important considerations.

Choosing a known donor may be appealing, especially if a relative of the partner is willing, or there is someone who will be in a long term relationship with the child. It raises, however, important infectious disease and legal issues. The donor will retain parental rights unless the sperm is given to a physician who then prescribes it to the patient. Parental rights cannot be relinquished except in court, and only after the birth of the baby. Because lesbian parenting rights are not yet protected by law, it is possible for the donor to end up with full custody. To ensure that donor semen is safe from an infectious disease stand point, the donor must be tested, and the semen frozen for 6 months. After six months, the donor must retested for HIV and other transmissible diseases. This service is available at some sperm banks and reproductive endocrinologists’, and the cost is similar to that of frozen anonymous donor sperm.

Plan

We began with the assumption that DF would easily become pregnant with donor insemination. We proceeded with routine preconception and prenatal care, with a few additions.

After explaining the hormonal cycle, we spent two months pinpointing DF’s ovulation using basal body temperature, cervical mucus, libido surge, and LH predictor kits. We identified DF‘s most fertile days. At our next meeting, we reviewed the timing and process of insemination: the egg is viable for 12-24 hours, and sperm likely lives for 48 hours. DF and KS had chosen a sperm bank and donor, and decided to proceed at home.

DF did LH surge tests in the morning beginning 2 days before ovulation was anticipated, and tested again in the evening if she had symptoms of ovulation. Insemination was done the evening of the positive test and again the following evening. Thawing the semen was performed according to the instructions from the bank, and using a candy thermometer to ensure the correct temperature. A TB syringe was used to draw up the semen, then the needle was removed and the same syringe used to deposit the sperm in the upper third of the vagina. While no evidence exists to require remaining supine afterwards, DF chose to stay in bed for 30 minutes after each insemination.

Follow-up

DF conceived during the third insemination cycle, and recently delivered a healthy 7#9oz baby boy. The baby was given a hyphenated version of both their last names, simplifying later issues of signing school and medical forms. They have applied for guardianship status for KS, and will soon begin the process of second parent adoption to further secure KS’s rights as a parent.

References

• Sciarra, John J., ed. Gynecology and Obstetrics, Vol 5. Philadelphia, Lippencott Williams & Wilkins, 1999.

• Trantham, Patricia, The Infertile Couple, American Family Physician, vol 54-3, Sept, 1996, pp 1001- 1010.

http://www.glpci.org/ is the web site for the Family Pride Coalition, a national group supporting gay and lesbian parenting, with useful references on legal support and other issues.

http://www.cryobank.com/ is the web site for California Cryobank, a sperm bank with stringent quality controls, and a willingness to work with lesbian clients. They will ship nationally and internationally directly to patient's homes.