Infertility Treatment for Non-Traditional Families

by William Buckett, MB ChB, MD, MRCOG.
Spring 2007

During this festive season, many thoughts turn to recognized cultural and religious traditions which dominate the written and broadcast media at this time of year. These traditions are also often associated with family – which traditionally consists of a man, married to a woman, and their children. The father is the provider and the mother stays at home to raise their normally conceived biological children.

 

Although this idealized concept may once have been common, it has never been fully realized, and has certainly changed in the past three decades with increasing numbers of women continuing to work, high divorce rates, out-of-wedlock birth rates, adoption, assisted reproduction, the use of donor eggs and sperm, the gay-rights movement, and other social and economic factors^1,2.

 

While most children born in Canada are conceived by sexual intercourse to heterosexual couples, there is an increase in those born following assisted reproductive techniques – nearly 3000 children were born following IVF treatments in 2004, out of 340,000 children born throughout Canada over the same period^3,4. Furthermore, many children may also be conceived using either donor sperm or donor eggs. Data concerning the numbers of children born with these modalities are unavailable in Canada. However, data concerning children born from donor sperm is available in the United Kingdom where 825 children were born following donor insemination treatment (compared with 10,242 following IVF) in the same time period⁵.

 

The number of children born to single women and lesbian couples has also increased, although reliable data is scarce. The 1996 census data shows that about 10% of Canadian children are brought up in lone-parent families⁶. A more informative picture should be available when the 2006 census data is published later on in 2007. Estimates from the United States suggest that between 6 and 14 million children are being brought up by at least one gay or lesbian parent⁷ – usually as the result of a heterosexual coital relationship, although increasingly gay and lesbian couples are turning towards some form of assisted reproduction⁸.

 

Therefore, already in Canada children are born into and are being brought up by many variations of non-traditional families.

 

The Canadian Charter of Rights and Freedoms states that every individual has equal right to protection and benefit without discrimination – including sexual discrimination – and, in effect, all provinces and territories have included the term ‘sexual orientation’ in their human rights legislation.

 

Given that same-sex couples share equal rights with heterosexual couples, providers of infertility treatments are in a position to respond to their unique needs. Because same-sex couples are unable to conceive by coitus, there is a need for donor sperm, donor eggs, or gestational surrogacy. This is often referred to as third-party reproduction.

 

Most lesbian couples seek treatment with donor sperm insemination. This involves monitoring of a normal menstrual cycle or minimal ovarian stimulation, and injection of prepared donor sperm into the uterine cavity at the time of ovulation. In Canada, all donor sperm is subject to stringent processing and screening for infective and inherited disease in order to minimize any risk to the woman undergoing treatment and her eventual offspring. All centers are inspected annually by Health Canada. Although pregnancy rates are dependent on many factors, rates are typically around 15-20%.

 

There have been some concerns regarding availability of donor sperm. In Canada, there is no payment for sperm donation and over the past few years there has been a decline in the number of sperm donors and many programmes have closed⁹. Furthermore, many countries - such as Sweden, Australia, and the Netherlands¹⁰ – have removed donor anonymity, and others – such as the United Kingdom – are evaluating the possibility¹¹. This gives the child the right to know the identity of his or her genetic father. Most children born to lesbian couples with donor insemination will know their origins and the right to further information is unlikely to be a threat to the family. However, international experience has shown the loss of donor anonymity further reduces the number of men willing to altruistically donate sperm¹².

 

More recently, some authors have considered the possibility where within a lesbian relationship, one partner would donate her eggs, which would be then fertilized with donor sperm, and subsequently implanted in the uterus of the second lesbian partner. This would allow both partners to have a biological link to their child¹³. At present, in Canada, treatment as such would need ethical approval.

 

For single-sex male couples, the treatment options are more complex. They need an egg donor and also a gestational carrier, where either partner would ‘donate’ the sperm. In Canada, gestational surrogacy is uncommon and each case requires ethical approval. Furthermore, it is illegal to pay a gestational surrogate. There have been cases where gay couples from many parts of the world have had this type of treatment in the United States.

 

In Canada, at present, the most realistic option for homosexual men to raise children is either through a heterosexual conception, or by adoption or fostering.

 

Counselling, as is mandatory for all third party reproduction in Canada, needs to cover such issues as the psychological adjustment of the child, disclosure, homophobia, parenting roles, family structures, and possible discrimination.      

 

 

 

Research on same-sex couples (usually lesbian couples) and their children began in the 1970s. Initial concerns centered on the social isolation of the child, the development of atypical gender roles, and sexual-orientation problems^14,15. However, the evidence to date does not support such fears – in fact children raised in lesbian families are as well adjusted as those raised in heterosexual families^{16,17,18,19,20}.

 

The American Psychological Association policy quotes that social science research has failed confirm the fears about children of gay and lesbian parents. Sexual identities (including gender identity, gender-role behaviour, and sexual orientation) develop in much the same ways among children of lesbian mothers as they do among children of heterosexual parents. Studies of other aspects of personal development (including personality, self-concept, and conduct) similarly reveal few differences between children of lesbian mothers and children of heterosexual parents. Evidence also suggests that children of lesbian and gay parents have normal social relationships with peers and adults. Overall results of research suggest that the development, adjustment, and well-being of children with lesbian and gay parents do not differ markedly from that of children with heterosexual parents.

 

There are fewer studies concerning the outcomes children of male homosexual parents, although what evidence there is also shows no negative effect^21,22 and that, not unsurprisingly, both parents were more alert to the children’s needs and provided more care than heterosexual fathers (who may see themselves primarily as the provider of financial security).

 

The biological reproductive needs of single women are de facto the same as for lesbian couples – i.e. the need for donor sperm (see above). Treatment is by donor insemination, or occasionally IVF with donor sperm, and these treatments should be preceded by the mandatory counselling. 

 

Early research on the psychological well-being of children from fatherless families found that these children were at increased risk for cognitive, social and emotional problems^23,24. However, these were situations where the father had left following separation or divorce, exposing the child to a discordant parental relationship as well as the loss of a once-present parent¹⁸. Furthermore, single parenthood following divorce or separation may also be associated with financial hardship, low socio-economic status, and a lack of social support.

 

The confounding issue appears to be the experience of parental separation. Children whose parents have divorced or separated have more behavioural and adolescent problems than those whose fathers have died^25,26.

 

However, data from families where the father has been absent from birth or early infancy has been reassuring¹⁸. The children’s social and emotional development is not negatively affected by the absence of a father, when compared with father-present families. Not unsurprisingly, children from father absent families experienced more interaction with their mothers than children from father-present families, although the mothers reported more severe disputes than their counterparts.

 

There will always be difficulties associated with single motherhood, particularly poverty and social status. Financial hardship, parental conflict, and maternal depression do put children at risk – but the absence of a father does not appear to necessarily result in psychological disadvantages for the children.

 

There is little evidence available concerning the treatment of couples, one or both of whom is or are transsexual. This may be because transsexualism is not as socially accepted and also because it is often treated as a psychiatric disorder.

 

Data concerning children from male-to-female transsexuals has not been reassuring²⁷. Follow-up research shows that these women, even after gender re-assignment surgery, continue to exhibit multiple psychopathological and adjustment problems, including a high suicide rate. At present, therefore, in the absence of further research it would appear prudent to avoid infertility treatment²⁸.

 

Non-traditional families are part of the fabric of Canadian society. Same-sex couples and single women may also wish to become parents. All the evidence so far shows that children born into and brought up within these families have no psychological disadvantages when compared with children brought up in traditional families.

 

Same-sex couples and single women need treatment with third-party reproductive techniques. This often involves treatment at fertility centers across the country. In the absence of any data suggesting a harmful effect, it is appropriate to help these people and to treat them with the sensitivity they deserve.