INFERTILITY TREATMENT FOR NON-TRADITIONAL FAMILIES by William Buckett, MD, MRCOG (Fall 2011)

INFERTILITY TREATMENT FOR NON-TRADITIONAL FAMILIES
by William Buckett, MD, MRCOG

The traditional family – consisting of a married, biological mother and father, and their 2 or 3 children (with assorted pets) all living in harmony in a single home – is increasingly less common. In Canada, published data from the most recent census continues to show the proportion of family defined as traditional continues to fall (currently less than 70% of families are comprised of traditional married parents – and within the province of Quebec less than 55% of families meet these criteria). Although many non-traditional families comprise a heterosexual, but unmarried, couple living together with their biological children, there continues to be an increase in the proportion of families with a single parent and families with same-sex parents 1.

Although the idealized concept of a traditional family may once have been common, it has never been fully realized, and it has certainly changed in the past three decades. Reasons for this are complex and are associated with the increasing number of women continuing to work, high divorce rates, out-of-wedlock birth rates, adoption, assisted reproduction, the use of donor eggs and sperm, the use of surrogacy, the gay rights movement, and other social and economic factors2, 3.

While most children born in Canada are conceived by sexual intercourse of heterosexual couples, there is an increase in those born following assisted reproductive techniques – over 3,500 children were born following IVF treatments in 2009, out of 380,000 children born throughout Canada over the same period 4, 5. Furthermore, many children may also be conceived using donor sperm, donor eggs, or gestational surrogacy. Complete data concerning the numbers of children born with these modalities are unavailable in Canada, although over 250 children were born following 500 cycles with oocyte donation performed in Canada in 2009, and there were 270 treatment cycles involving gestational surrogacy4. No reliable data is available concerning the number of babies conceived as a result of donor sperm in Canada; however, such data 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 period6.

The number of children born to single women and lesbian couples has also increased, although reliable data in scarce. The 2006 census data shows that about 15% of Canadian children are brought up in lone-parent families1. A more informative picture should be available when the 2011 census data is published. 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 relationship, although increasingly gay and lesbian couples are turning towards some form of assisted reproduction8.

Therefore, in 2011 in Canada many thousands of children are already born into, and are being brought up by many variations of non-traditional families.

Reproductive needs of same-sex couples
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, 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 centres are inspected annually by Health Canada. Although pregnancy rates are dependent on many factors, they are typically around 15-20%.

There have been some concerns regarding availability of donor sperm as there is no payment for sperm donation in Canada, 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, the Netherlands, and the United Kingdom10, 11 have removed donor anonymity, and others – including Canada – 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. Currently many clinics advise purchase of sperm from companies which import donated sperm from the United States which have met the Health Canada criteria.

More recently some couples have considered the possibility where, within a lesbian relationship, one partner would donate her eggs, which would then be fertilized with donor sperm, and subsequently implanted in the uterus of the second lesbian partner. At present, it is unknown how many lesbian couples undergoing treatment choose this option. Obviously, the medical risks of ovarian stimulation and IVF are higher than the risks of insemination and appropriate counseling is required.

For male couples, the treatment options are more complex. They need an egg donor and a gestational carrier, with either partner ‘donating’ 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.

At present in Canada the most realistic option for homosexual men is to raise children either through a heterosexual conception, or by adopting or fostering.

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

Effects on the child
Research on same-sex couples (usually lesbian couples, although increasingly gay couples too) 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 problems14, 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 families16, 17, 18, 19, 20.

The American Psychological Association policy quotes that social science research has failed to 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 way 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 for children of male homosexual parents, although what evidence there is also shows no negative effect21, 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 providers of financial security).

Single women
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 therefore by donor insemination, or, when indicated, by IVF with donor sperm. Again, these treatments should be preceded by mandatory counseling.

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 problems23, 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 died25, 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.

The increasing availability and use of donor insemination in single women using donor sperm has allowed some research on the well-being of the children born to ‘single mothers by choice’. Although reassuring, the data is still early, and confounding variables such as the mother’s age and health – generally single mothers by choice are older and have a higher disease burden than mothers within a relationship (both homo- or heterosexual) – as well as multiple pregnancy need to be considered27, 28.

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

Transgender parents
There is little evidence available concerning the treatment of couples, one or both of whom is/are transsexual. This may be because transsexuals are not as socially accepted and also because being a transsexual is often treated as a psychiatric disorder. Treatments often would involve use of donor gametes and possibly surrogacy depending on the nature of the transgender shift.

Many transgender people already have children, though these children were usually born prior to their parents' shift in gender identity. The psychological well-being of these children is, however, not well studied.

Although preliminary data from transgender parents as a whole has not shown any obvious detrimental effect on children, data concerning children from male-to-female transsexuals has not been reassuring29. 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 treatment in these couples30.

Summary
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 centres across the country. In the absence of data suggesting any harmful effect, it is appropriate to help and treat all people with the sensitivity they deserve.

All references are listed on the IAAC website at iaac.ca/content/library.

About the author
Dr. William Buckett is Attending Physician and Sub Specialist in Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, at the Royal Victoria Hospital, McGill University Health Centre, in Montreal, Quebec, Canada. He is also Assistant Professor in the Department of Obstetrics and Gynaecology, McGill University, Montreal.