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How well are lesbians treated in UK fertility clinics? Helen Priddle To cite this article: Helen Priddle (2015) How well are lesbians treated in UK fertility clinics?, Human Fertility, 18:3, 194-199, DOI: 10.3109/14647273.2015.1043654 To link to this article: http://dx.doi.org/10.3109/14647273.2015.1043654
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Human Fertility, 2015; 18(3): 194–199 © 2015 The British Fertility Society ISSN 1464-7273 print/ISSN 1742-8149 online DOI: 10.3109/14647273.2015.1043654
SHORT REVIEW
How well are lesbians treated in UK fertility clinics? HELEN PRIDDLE
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Centre for Reproduction and Gynaecology Wales (CRGW), Rhodfa Marics, Ely Meadows, Llantrisant, CF72 8XL, UK
Abstract Legislation regulating fertility treatment in the United Kingdom originally discouraged treatment without a father, resulting in many clinics denying access to lesbian couples. Lesbians now enjoy rights to legal union, dual parenthood and protection against discrimination. Consequently, increasing numbers seek fertility treatment. This is a growing stakeholder group, but it is unknown whether UK licensed centres are serving them adequately. Data from the Human Fertilisation and Embryology Authority suggests live birth rates after in vitro fertilisation for lesbians is comparable to estimates for natural attempt at pregnancy for heterosexuals, whereas success rates with donor insemination are lower. Unsurprisingly, live birth rates for lesbians after in vitro fertilisation are higher compared with heterosexual couples (the latter attending with fertility issues). However, outcomes for lesbians after donor insemination are slightly lower, potentially due to increased female age. Rather than adopting a one-heterosexual-size-fits-all approach, lesbian couples may benefit from new treatment pathways. They also have a different experience of fertility treatment, some reporting a wish to be presumed fertile rather than medicalised, and others encountering heterosexism by fertility professionals. Additionally, some lesbians with known fertility issues have needed to resort to legal action to obtain the publicly funded treatment they are entitled to.
Keywords: lesbian, fertility, treatment, outcomes, experience, access.
Introduction
et al., 2002) and qualitative (Gabb, 2004; Golombok & Badger, 2010) studies find no cause for concern regarding the welfare of children raised by lesbian parents. However, some heterosexuals continue to have concern for the children of same-sex parents (Pennington & Knight, 2011). Homophobia in society, rather than the quality of the parenting received, seems to have an impact (Bos et al., 2008a), but less so in countries with minimal homophobia (Bos et al., 2008b). UK law began to protect the rights of lesbians in the form of equality legislation and a right to civil partnership (Civil Partnership Act, 2004; Equality Act, 2006). Commentators began questioning the child’s need for a father and whether fertility clinics should continue to discriminate against lesbians (Saffron, 2002). This ultimately led to amendment of the Human Fertilisation and Embryology Act and: (i) the child’s need for a father was replaced with the child’s need for ‘supportive parenting’; (ii) a woman is now described as being treated with a ‘man or woman’ (Human Fertilisation and Embryology Act, 2008a); and (iii) a female partner can also be a legal parent (Human Fertilisation and Embryology Act, 2008b).
The first in vitro fertilisation (IVF) birth (Steptoe & Edwards, 1978) led to a burgeoning of assisted reproductive technologies (ARTs) in the United Kingdom (UK). Public concern grew about ART ‘getting out of hand’, and the Warnock Committee was set up to consider limitations. The resulting Warnock Report (Warnock, 1984) recommended a framework of regulation for ART. The report made moral judgements of its time, including a view that heterosexual couples were best placed to raise children. The Human Fertilisation and Embryology Act (1990) was passed, including the creation of the Human Fertilisation and Embryology Authority (HFEA). This Act also determined that the welfare of resulting children must be considered, ‘including the need of that child for a father’. Consequently, many clinics have at some point denied treatment to single mothers and lesbian couples. Over the last fifty years opinions within society about homosexuality have shifted. It has been decriminalised (Sexual Offences Act, 1967) and declassified as a mental health condition (Suppe, 1984). Contrary to the views of the Warnock Committee, quantitative (Anderssen
Correspondence: Dr. Helen Priddle, BSc, PhD, Centre for Reproduction and Gynaecology Wales (CRGW), Rhodfa Marics, Ely Meadows, Llantrisant CF72 8XL, UK. Tel: ⫹ 01443 443999. Fax: ⫹ 01443 445 869. E-mail: [email protected] (Received 5 February 2014; accepted 23 December 2014)
194
Lesbian treatment options As a result of this change of attitudes and legislation, clinics are treating increasing numbers of lesbians each year (Figure 1). More than 9500 cycles of donor insemination (DI) or IVF (including intra-cytoplasmic sperm injection (ICSI)) were performed in the UK between 2007 and 2012 (HFEA, 2013b). However, it is interesting to consider how UK clinics advise lesbians of the best treatment option. The majority of heterosexual couples attending clinics are likely to be experiencing subfertility, whereas lesbian couples represent a full range of fertile and subfertile individuals. Estimates of subfertility in heterosexual couples vary. In Germany, 10.4% of couples failed to conceive after 12 months of timed intercourse at home (Gnoth et al., 2003), whereas a large UK study (based on reporting fertility problems to general practitioners) suggests the figure could be tenfold lower (Dhalwani et al., 2013). It would be naïve to extrapolate from these statistics and conclude that 1.1–10.4% of lesbians are subfertile. Not only will male factor subfertility account for a proportion of subfertile heterosexual couples, but also studies reveal pertinent differences in the lesbian population. Lesbians have an increased incidence of obesity (Boehmer & Bowen, 2009) and smoking (Balsam et al., 2012), and may (Agrawal et al., 2004) or may not (De Sutter et al., 2008) show an elevated incidence of polycystic ovary syndrome. Figures from HFEA (2014) indicate some difference in live birth rates for lesbian couples compared with women registered for treatment with a male partner (Figure 2). In IVF/ICSI treatment (for younger women or for all ages) lesbians have a statistically significant higher live birth rate than their counterparts (38.9% and 28.8%, respectively, for women under 35; 28.7% and 23.3%, respectively, for all ages). This may be expected, © 2015 The British Fertility Society
a)
900
Number of Treatment Cycles
The recent Equality Act (2010) made it illegal to discriminate on the grounds of a Protected Characteristic, including sexual orientation. This outlaws discrimination, including inequality in the provision of goods and services. The HFEA Code of Practice (HFEA, 2013a) now addresses the implications of the Equality Act. Guidance from the HFEA outlines a need to show respect for equality and diversity with auditing to ensure this objective is met. Centres should not refuse funding for treatment on the basis of a Protected Characteristic without checking with commissioning bodies. Managers should ensure that conscientious objectors are not discriminating against a Protected Characteristic. Additionally, if a donor withholds consent for the treatment of homosexual couples, this may result in illegally restricted donor provision to lesbian couples. Clinics that still include a check box for a donor to give or withhold consent for the use of their sperm for treatment of same-sex couples (or single women) are advised to reconsider this practice.
NHS
800
Private
700 600 500 400 300 200 100 0 2007
b) Number of Treatment Cycles
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Fertility treatment for lesbians in the United Kingdom 195
2008
2009
2010
2011
2012
2011
2012
Year 1600 1400
NHS
Private
1200 1000 800 600 400 200 0 2007
2008
2009
2010
Year Figure 1. The number of NHS funded (dark line) and privately funded (light line) treatment cycles performed each year (2007–2012) in HFEA licensed centres involving female patients registered with female partners. Panel (a) shows IVF/ICSI treatment cycles, and panel (b) shows cycles of DI. This information was obtained under a Freedom of Information Act 2000 request to the HFEA by the author, and the data is published with the permission of the HFEA (Human Fertilisation and Embryology Authority, 2013).
given that heterosexuals attending for IVF/ICSI have a known fertility problem, whereas some lesbians choosing this option may not. Lesbians sometimes select IVF/ICSI for its elevated live birth rates or its possibility for intra-partner egg donation, or in order to fund treatment through egg sharing. The live birth rate for lesbians under 35 years of age (38.9%) compares well with estimates of conception for heterosexual couples on their first attempt to conceive at home (38%, Gnoth et al., 2003). The comparison of lesbians and heterosexual couples choosing DI is likely a fairer one than those undertaking IVF/ICSI, as both groups receive treatment with donor sperm and there is no known female subfertility. There was a similar but significantly reduced live birth rate for lesbians compared with heterosexual couples (10.9% vs. 12.5%, respectively) with all ages combined, but no significant decrease for lesbian couples where the woman inseminated was under 35 years old (14.0% compared with 15.2%). The proportion of women inseminated who were under 35 years old was lower in the lesbian group compared with that in the control group (44.7%
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Figure 2. The percentage of live births for women registered for treatment in HFEA licensed centres with female partners (dark shading) or male partners (paler shading) was compared for pooled data from the years 2002–2011 (data shown in Table I). The data includes fresh IVF/ICSI treatment cycles and DI. The data is also broken down into either the under 35 age group or for all ages. Cycles where the woman treated was registered with a female (n ⫽ 2956 embryo transfers and 8833 DI cycles) versus no/male partner (n ⫽ 459746 embryo transfers and 32590 DI cycles) were compared statistically using chi-square analysis with Yates correction (data sets were too large for analysis with Fishers exact test). *p ⫽ 0.0592, **p ⬍ 0.0001. This information was obtained under a Freedom of Information Act 2000 request to the HFEA by the author, and the data is published with the permission of the HFEA (Human Fertilisation and Embryology Authority, 2014).
compared with 54.7%), suggesting that age could be a factor. It is also possible that lesbian couples were less well assessed for the appropriateness of DI, as either they or the healthcare professionals providing treatment may have assumed they had normal fertility. In contrast, heterosexual couples attending for DI are likely to have presented with a fertility issue and have been more thoroughly investigated. A recent Swedish study (Nordqvist et al., 2014) found that lesbian couples had a similar live birth rate compared with heterosexual couples when treated with donor sperm, irrespective of treatment (16.0% (70/438) and 12.8% (38/298), respectively, for DI; 26.2% (59/225) and 28.7% (66/230), respectively, for fresh and thawed IVF cycles with donor sperm). Live birth rates for lesbians undertaking IVF were not increased in this study; this is unsurprising, given that the heterosexual couples were also using donor sperm (thus excluding male factor subfertility), and fertile lesbians are less likely to undertake IVF in Sweden as public funding for DI is available to them. The fact that DI live birth rates were not statistically different in this study could reflect a difference in the population observed, or increased thoroughness of investigation of lesbian couples in Sweden. For both treatment types, it is important to note the smaller size of this study (1191 cycles compared with 504125 cycles in the HFEA data presented in this article), which would necessitate a
greater difference in outcomes before statistical significance could be demonstrated. The Swedish and UK live birth rates for DI (significantly less than 20%) seem low irrespective of sexuality when compared with the probability of conception in the first month of trying for heterosexuals (38%, Gnoth et al., 2003). This suggests that there may be room for methodological improvement. It is possible that cryopreservation has an impact on sperm viability (RibasMaynou et al., 2014) that is detrimental to sperm used for insemination (Thomson et al., 2011). It may be necessary to manage patient expectations of success with DI, especially if some lesbians assume they are fertile and should get pregnant immediately. The difference in success rates between DI and IVF should also be made clear, as should the difference in cost and invasiveness. Treating lesbians is a unique opportunity, with the availability of two sources of eggs and uteri, although each woman will have independent preferences and fertility. They will, however, need to source donor sperm. Lesbian couples are creating one family together even if the children have different mothers. In 2013, the HFEA (2013b) and their then Chair (Lisa Jardine, letter 29/11/13) confirmed that both women can use the same sperm donor and consider this one allocated family (not two) from the ten allowed for each donor under UK legislation. Costs for donor sperm could be reduced if clinics allow suitable known sperm donors to enter into a sperm sharing agreement. Where IVF is selected many options are possible, including participation in egg-sharing schemes. Intrapartner oocyte donation (first described by Woodward & Norton, 2006) allows both partners to contribute, one genetically and the other gestationally. This option may be chosen for social or clinical reasons, including the avoidance of impaired uterine receptivity following controlled ovarian stimulation (Shapiro et al., 2011). Marina et al., (2010) reported six pregnancies from thirteen embryo transfers using this method. There would also be an opportunity for couples with reduced chances of success to simultaneously maximise the chance of implantation and avoid multiple births by transferring embryos into both partners. This should only be undertaken with due consideration of the implications of both falling pregnant simultaneously. Lesbian experience of treatment Studies into the lesbian experience of fertility treatment can help UK licensed centres respect diversity and provide an improved service. Although the majority of lesbians may not have fertility issues, trying to conceive in a medicalised environment can take its emotional toll, not only from the rollercoaster of fertility treatment but also through the heterosexism of fertility professionals (Yager et al., 2010). Some lesbians feel they must justify their right to be parents during assessment for treatment by healthcare professionals, which seems discriminatory when this is not a prerequisite to conception for Human Fertility
Fertility treatment for lesbians in the United Kingdom 197 Table 1. Birth outcomes for women registered with female or male partners, treated by DI or IVF/ICSI. Registered with Female Partner
DI IVF/ICSI
Age
Live Birth
No Live Birth
⬍ 35 all ⬍ 35 all
552 964 403 847
3396 7869 634 2109
% Live Birth 14.0* 10.9** 38.9** 28.7**
Registered with Male Partner Live Birth
No Live Birth
2705 4074 56535 106906
15114 28516 139985 352840
% Live Birth 15.2* 12.5** 28.8** 23.3**
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*p ⫽ 0.0592, **p ⬍ 0.0001.
fertile heterosexuals (Nordqvist, 2012). Clinic staff may not appreciate that despite more tolerant attitudes in society, many lesbians still expect to be judged for their sexuality. Becoming parents necessitates a whole new layer of ‘coming out’. Couples must not only come out as lesbians to clinic staff, but reveal to society at large that they are choosing a form of parenting that many still see as unnatural (Almack, 2008). How can clinics help? Lesbian focus groups would like clinics to (i) provide clues that they are ‘gay friendlyʼ; (ii) offer them treatment options consistent with presumed fertility; (iii) have a straightforward process for known sperm donors; and (iv) provide support that is specific for lesbian needs (Ross et al., 2006). Clinics can also help non-biological lesbian mothers to feel more involved in the process. For example, one woman ‘pressed the plunger’ to deliver the sperm (Nordqvist, 2012). The matching of sperm to one or both partners’ physical characteristics can help increase a sense of relatedness (Nordqvist, 2010). Lesbians face difficulties accessing treatment. The National Health Service (NHS) treatment is not commonly utilised by lesbians, as they are either refused treatment or do not request it. Some assume themselves ineligible whilst others perceive the NHS as a homophobic environment (Nordqvist, 2011). The remaining options for lesbian couples are private treatment or self-insemination (SI) with a known donor. Some suggest that the lack of public funding drives women into unsafe SI, taking risks with sexually transmitted infections (Wykes, 2012). Whilst there is evidence infection does sometimes occur (Luce, 2010), lesbian decision making about the route of conception involves more complex considerations than finances and infections (Mamo, 2007; Donovan & Wilson, 2008; Luce, 2010; Nordqvist, 2011). In some cases, women begin with SI and move to a clinical setting when this does not work. Others begin clinically but have unsuccessful, expensive, discriminatory or dehumanising experiences and switch to SI. For some the clinical setting is seen as objectifying and medicalising, for others clinical procedures negate a need to handle undesirable bodily fluids. Clinics are seen as advantageous for those who wish to raise their child without interference from the donor, whereas others choose SI in order to allow a relationship between father and child. The National Institute for Health and Care Excellence (NICE) updated its fertility guidelines to © 2015 The British Fertility Society
recommend inter-uterine insemination (IUI) to treat same-sex couples (NICE, 2013). Although treatment of lesbians funded by NHS is on the increase (Figure 1), in 2012 only 61 lesbian couples received funded IVF (HFEA, 2013b). Even if we ignore NICE guidelines regarding IUI, lesbians experiencing subfertility are clearly entitled to funded IVF under equality legislation. The low uptake of NHS treatment may in part be due to lesbians’ perceptions and choices, but there is also evidence that legitimate requests are being denied. Legal actions have been brought by couples challenging inequality. In two cases decisions not to treat subfertile lesbians were legally challenged, resulting in a reversal of the decisions (IVF.net, 2009; BBC News, 2009). A third legal action has also commenced, but an outcome is yet to be reported (The Telegraph, 2013). Conclusion In the UK we have an evolved legal and regulatory framework, facilitating growing numbers of lesbians to seek fertility treatment. However, it is important to ensure that UK licensed centres match this with an evolved approach to treating lesbians. We need to take stock of how well we treat lesbians, in both senses of the word. It may not be surprising that lesbian couples have a subtly different live birth rate for donor insemination compared with all other DI cycles, given that the two groups may differ in the extent of fertility investigations, in age and in other demographic factors. However, it is a surprise that the average UK DI live birth rate is less than half the estimated chance of conception of a heterosexual couple’s first attempt at home. This raises questions about the methodology used and certainly raises an issue about managing patient expectations. Aspects of law and HFEA guidance have shifted an emphasis towards treating lesbians with respect for their diversity. Studies suggest that the experience of lesbians in fertility treatment is not ideal, although further feedback to clinics would be useful. Advice from the lesbian community could be collated and presented in workshops or presentations to fertility professionals. Such educational material would help to ensure that clinics are aware of the needs of lesbian couples and could also reiterate some of the finer details of the HFEA code of practice and equality legislation. Finally, access to funded treatment for infertile lesbian couples can be problematic judging by the ‘tip of
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the iceberg’ legal cases. Additionally, updated NICE guidelines recommend the funding of IUI for fertile lesbian couples but this practice is anything but commonplace. Clear information is required about what the regional entitlements are for lesbian couples so that they can challenge inappropriate decisions by their local service if necessary.
Acknowledgements
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The author would like to thank the Centre for Reproduction and Gynaecology Wales or CRGW for their support in the writing of this review, the two anonymous reviewers for their helpful suggestions and Ronne Randall for her editorial and proofreading contributions. Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
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Thomson, L.K., Zieschang, J.A., & Clark, A.M. (2011). Oxidative deoxyribonucleic acid damage in sperm has a negative impact on clinical pregnancy rate in intrauterine insemination but not intracytoplasmic sperm injection cycles. Fertility and Sterility, 96, 843–847. Warnock, M. (1984). Report of the Committee of Enquiry into Human Fertilisation and embryology. Available online at: http:// www.hfea.gov.uk/docs/Warnock_Report_of_the_Committee_ of_Inquiry_into_Human_Fertilisation_and_Embryology_ 1984.pdf. [Accessed 6/5/15]. Woodward, B.J. & Norton, W.J. (2006). Lesbian intra-partner oocyte donation: a possible shake-up in the Garden of Eden? Human Fertility, 9, 217–222. Wykes, K.A. (2012). Fertility services for same-sex couples: policy and practice. British Journal of Nursing, 21, 871–875. Yager, C., Brennan, D., Steele, L.S., Epstein, R., & Ross, L.E. (2010). Challenges and mental health experiences of lesbian and bisexual women who are trying to conceive. Health and Social Work, 35, 191–200.
ISSN: 1464-7273 (Print) 1742-8149 (Online) Journal homepage: http://www.tandfonline.com/loi/ihuf20
How well are lesbians treated in UK fertility clinics? Helen Priddle To cite this article: Helen Priddle (2015) How well are lesbians treated in UK fertility clinics?, Human Fertility, 18:3, 194-199, DOI: 10.3109/14647273.2015.1043654 To link to this article: http://dx.doi.org/10.3109/14647273.2015.1043654
Published online: 17 Jun 2015.
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Human Fertility, 2015; 18(3): 194–199 © 2015 The British Fertility Society ISSN 1464-7273 print/ISSN 1742-8149 online DOI: 10.3109/14647273.2015.1043654
SHORT REVIEW
How well are lesbians treated in UK fertility clinics? HELEN PRIDDLE
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Centre for Reproduction and Gynaecology Wales (CRGW), Rhodfa Marics, Ely Meadows, Llantrisant, CF72 8XL, UK
Abstract Legislation regulating fertility treatment in the United Kingdom originally discouraged treatment without a father, resulting in many clinics denying access to lesbian couples. Lesbians now enjoy rights to legal union, dual parenthood and protection against discrimination. Consequently, increasing numbers seek fertility treatment. This is a growing stakeholder group, but it is unknown whether UK licensed centres are serving them adequately. Data from the Human Fertilisation and Embryology Authority suggests live birth rates after in vitro fertilisation for lesbians is comparable to estimates for natural attempt at pregnancy for heterosexuals, whereas success rates with donor insemination are lower. Unsurprisingly, live birth rates for lesbians after in vitro fertilisation are higher compared with heterosexual couples (the latter attending with fertility issues). However, outcomes for lesbians after donor insemination are slightly lower, potentially due to increased female age. Rather than adopting a one-heterosexual-size-fits-all approach, lesbian couples may benefit from new treatment pathways. They also have a different experience of fertility treatment, some reporting a wish to be presumed fertile rather than medicalised, and others encountering heterosexism by fertility professionals. Additionally, some lesbians with known fertility issues have needed to resort to legal action to obtain the publicly funded treatment they are entitled to.
Keywords: lesbian, fertility, treatment, outcomes, experience, access.
Introduction
et al., 2002) and qualitative (Gabb, 2004; Golombok & Badger, 2010) studies find no cause for concern regarding the welfare of children raised by lesbian parents. However, some heterosexuals continue to have concern for the children of same-sex parents (Pennington & Knight, 2011). Homophobia in society, rather than the quality of the parenting received, seems to have an impact (Bos et al., 2008a), but less so in countries with minimal homophobia (Bos et al., 2008b). UK law began to protect the rights of lesbians in the form of equality legislation and a right to civil partnership (Civil Partnership Act, 2004; Equality Act, 2006). Commentators began questioning the child’s need for a father and whether fertility clinics should continue to discriminate against lesbians (Saffron, 2002). This ultimately led to amendment of the Human Fertilisation and Embryology Act and: (i) the child’s need for a father was replaced with the child’s need for ‘supportive parenting’; (ii) a woman is now described as being treated with a ‘man or woman’ (Human Fertilisation and Embryology Act, 2008a); and (iii) a female partner can also be a legal parent (Human Fertilisation and Embryology Act, 2008b).
The first in vitro fertilisation (IVF) birth (Steptoe & Edwards, 1978) led to a burgeoning of assisted reproductive technologies (ARTs) in the United Kingdom (UK). Public concern grew about ART ‘getting out of hand’, and the Warnock Committee was set up to consider limitations. The resulting Warnock Report (Warnock, 1984) recommended a framework of regulation for ART. The report made moral judgements of its time, including a view that heterosexual couples were best placed to raise children. The Human Fertilisation and Embryology Act (1990) was passed, including the creation of the Human Fertilisation and Embryology Authority (HFEA). This Act also determined that the welfare of resulting children must be considered, ‘including the need of that child for a father’. Consequently, many clinics have at some point denied treatment to single mothers and lesbian couples. Over the last fifty years opinions within society about homosexuality have shifted. It has been decriminalised (Sexual Offences Act, 1967) and declassified as a mental health condition (Suppe, 1984). Contrary to the views of the Warnock Committee, quantitative (Anderssen
Correspondence: Dr. Helen Priddle, BSc, PhD, Centre for Reproduction and Gynaecology Wales (CRGW), Rhodfa Marics, Ely Meadows, Llantrisant CF72 8XL, UK. Tel: ⫹ 01443 443999. Fax: ⫹ 01443 445 869. E-mail: [email protected] (Received 5 February 2014; accepted 23 December 2014)
194
Lesbian treatment options As a result of this change of attitudes and legislation, clinics are treating increasing numbers of lesbians each year (Figure 1). More than 9500 cycles of donor insemination (DI) or IVF (including intra-cytoplasmic sperm injection (ICSI)) were performed in the UK between 2007 and 2012 (HFEA, 2013b). However, it is interesting to consider how UK clinics advise lesbians of the best treatment option. The majority of heterosexual couples attending clinics are likely to be experiencing subfertility, whereas lesbian couples represent a full range of fertile and subfertile individuals. Estimates of subfertility in heterosexual couples vary. In Germany, 10.4% of couples failed to conceive after 12 months of timed intercourse at home (Gnoth et al., 2003), whereas a large UK study (based on reporting fertility problems to general practitioners) suggests the figure could be tenfold lower (Dhalwani et al., 2013). It would be naïve to extrapolate from these statistics and conclude that 1.1–10.4% of lesbians are subfertile. Not only will male factor subfertility account for a proportion of subfertile heterosexual couples, but also studies reveal pertinent differences in the lesbian population. Lesbians have an increased incidence of obesity (Boehmer & Bowen, 2009) and smoking (Balsam et al., 2012), and may (Agrawal et al., 2004) or may not (De Sutter et al., 2008) show an elevated incidence of polycystic ovary syndrome. Figures from HFEA (2014) indicate some difference in live birth rates for lesbian couples compared with women registered for treatment with a male partner (Figure 2). In IVF/ICSI treatment (for younger women or for all ages) lesbians have a statistically significant higher live birth rate than their counterparts (38.9% and 28.8%, respectively, for women under 35; 28.7% and 23.3%, respectively, for all ages). This may be expected, © 2015 The British Fertility Society
a)
900
Number of Treatment Cycles
The recent Equality Act (2010) made it illegal to discriminate on the grounds of a Protected Characteristic, including sexual orientation. This outlaws discrimination, including inequality in the provision of goods and services. The HFEA Code of Practice (HFEA, 2013a) now addresses the implications of the Equality Act. Guidance from the HFEA outlines a need to show respect for equality and diversity with auditing to ensure this objective is met. Centres should not refuse funding for treatment on the basis of a Protected Characteristic without checking with commissioning bodies. Managers should ensure that conscientious objectors are not discriminating against a Protected Characteristic. Additionally, if a donor withholds consent for the treatment of homosexual couples, this may result in illegally restricted donor provision to lesbian couples. Clinics that still include a check box for a donor to give or withhold consent for the use of their sperm for treatment of same-sex couples (or single women) are advised to reconsider this practice.
NHS
800
Private
700 600 500 400 300 200 100 0 2007
b) Number of Treatment Cycles
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Fertility treatment for lesbians in the United Kingdom 195
2008
2009
2010
2011
2012
2011
2012
Year 1600 1400
NHS
Private
1200 1000 800 600 400 200 0 2007
2008
2009
2010
Year Figure 1. The number of NHS funded (dark line) and privately funded (light line) treatment cycles performed each year (2007–2012) in HFEA licensed centres involving female patients registered with female partners. Panel (a) shows IVF/ICSI treatment cycles, and panel (b) shows cycles of DI. This information was obtained under a Freedom of Information Act 2000 request to the HFEA by the author, and the data is published with the permission of the HFEA (Human Fertilisation and Embryology Authority, 2013).
given that heterosexuals attending for IVF/ICSI have a known fertility problem, whereas some lesbians choosing this option may not. Lesbians sometimes select IVF/ICSI for its elevated live birth rates or its possibility for intra-partner egg donation, or in order to fund treatment through egg sharing. The live birth rate for lesbians under 35 years of age (38.9%) compares well with estimates of conception for heterosexual couples on their first attempt to conceive at home (38%, Gnoth et al., 2003). The comparison of lesbians and heterosexual couples choosing DI is likely a fairer one than those undertaking IVF/ICSI, as both groups receive treatment with donor sperm and there is no known female subfertility. There was a similar but significantly reduced live birth rate for lesbians compared with heterosexual couples (10.9% vs. 12.5%, respectively) with all ages combined, but no significant decrease for lesbian couples where the woman inseminated was under 35 years old (14.0% compared with 15.2%). The proportion of women inseminated who were under 35 years old was lower in the lesbian group compared with that in the control group (44.7%
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Figure 2. The percentage of live births for women registered for treatment in HFEA licensed centres with female partners (dark shading) or male partners (paler shading) was compared for pooled data from the years 2002–2011 (data shown in Table I). The data includes fresh IVF/ICSI treatment cycles and DI. The data is also broken down into either the under 35 age group or for all ages. Cycles where the woman treated was registered with a female (n ⫽ 2956 embryo transfers and 8833 DI cycles) versus no/male partner (n ⫽ 459746 embryo transfers and 32590 DI cycles) were compared statistically using chi-square analysis with Yates correction (data sets were too large for analysis with Fishers exact test). *p ⫽ 0.0592, **p ⬍ 0.0001. This information was obtained under a Freedom of Information Act 2000 request to the HFEA by the author, and the data is published with the permission of the HFEA (Human Fertilisation and Embryology Authority, 2014).
compared with 54.7%), suggesting that age could be a factor. It is also possible that lesbian couples were less well assessed for the appropriateness of DI, as either they or the healthcare professionals providing treatment may have assumed they had normal fertility. In contrast, heterosexual couples attending for DI are likely to have presented with a fertility issue and have been more thoroughly investigated. A recent Swedish study (Nordqvist et al., 2014) found that lesbian couples had a similar live birth rate compared with heterosexual couples when treated with donor sperm, irrespective of treatment (16.0% (70/438) and 12.8% (38/298), respectively, for DI; 26.2% (59/225) and 28.7% (66/230), respectively, for fresh and thawed IVF cycles with donor sperm). Live birth rates for lesbians undertaking IVF were not increased in this study; this is unsurprising, given that the heterosexual couples were also using donor sperm (thus excluding male factor subfertility), and fertile lesbians are less likely to undertake IVF in Sweden as public funding for DI is available to them. The fact that DI live birth rates were not statistically different in this study could reflect a difference in the population observed, or increased thoroughness of investigation of lesbian couples in Sweden. For both treatment types, it is important to note the smaller size of this study (1191 cycles compared with 504125 cycles in the HFEA data presented in this article), which would necessitate a
greater difference in outcomes before statistical significance could be demonstrated. The Swedish and UK live birth rates for DI (significantly less than 20%) seem low irrespective of sexuality when compared with the probability of conception in the first month of trying for heterosexuals (38%, Gnoth et al., 2003). This suggests that there may be room for methodological improvement. It is possible that cryopreservation has an impact on sperm viability (RibasMaynou et al., 2014) that is detrimental to sperm used for insemination (Thomson et al., 2011). It may be necessary to manage patient expectations of success with DI, especially if some lesbians assume they are fertile and should get pregnant immediately. The difference in success rates between DI and IVF should also be made clear, as should the difference in cost and invasiveness. Treating lesbians is a unique opportunity, with the availability of two sources of eggs and uteri, although each woman will have independent preferences and fertility. They will, however, need to source donor sperm. Lesbian couples are creating one family together even if the children have different mothers. In 2013, the HFEA (2013b) and their then Chair (Lisa Jardine, letter 29/11/13) confirmed that both women can use the same sperm donor and consider this one allocated family (not two) from the ten allowed for each donor under UK legislation. Costs for donor sperm could be reduced if clinics allow suitable known sperm donors to enter into a sperm sharing agreement. Where IVF is selected many options are possible, including participation in egg-sharing schemes. Intrapartner oocyte donation (first described by Woodward & Norton, 2006) allows both partners to contribute, one genetically and the other gestationally. This option may be chosen for social or clinical reasons, including the avoidance of impaired uterine receptivity following controlled ovarian stimulation (Shapiro et al., 2011). Marina et al., (2010) reported six pregnancies from thirteen embryo transfers using this method. There would also be an opportunity for couples with reduced chances of success to simultaneously maximise the chance of implantation and avoid multiple births by transferring embryos into both partners. This should only be undertaken with due consideration of the implications of both falling pregnant simultaneously. Lesbian experience of treatment Studies into the lesbian experience of fertility treatment can help UK licensed centres respect diversity and provide an improved service. Although the majority of lesbians may not have fertility issues, trying to conceive in a medicalised environment can take its emotional toll, not only from the rollercoaster of fertility treatment but also through the heterosexism of fertility professionals (Yager et al., 2010). Some lesbians feel they must justify their right to be parents during assessment for treatment by healthcare professionals, which seems discriminatory when this is not a prerequisite to conception for Human Fertility
Fertility treatment for lesbians in the United Kingdom 197 Table 1. Birth outcomes for women registered with female or male partners, treated by DI or IVF/ICSI. Registered with Female Partner
DI IVF/ICSI
Age
Live Birth
No Live Birth
⬍ 35 all ⬍ 35 all
552 964 403 847
3396 7869 634 2109
% Live Birth 14.0* 10.9** 38.9** 28.7**
Registered with Male Partner Live Birth
No Live Birth
2705 4074 56535 106906
15114 28516 139985 352840
% Live Birth 15.2* 12.5** 28.8** 23.3**
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*p ⫽ 0.0592, **p ⬍ 0.0001.
fertile heterosexuals (Nordqvist, 2012). Clinic staff may not appreciate that despite more tolerant attitudes in society, many lesbians still expect to be judged for their sexuality. Becoming parents necessitates a whole new layer of ‘coming out’. Couples must not only come out as lesbians to clinic staff, but reveal to society at large that they are choosing a form of parenting that many still see as unnatural (Almack, 2008). How can clinics help? Lesbian focus groups would like clinics to (i) provide clues that they are ‘gay friendlyʼ; (ii) offer them treatment options consistent with presumed fertility; (iii) have a straightforward process for known sperm donors; and (iv) provide support that is specific for lesbian needs (Ross et al., 2006). Clinics can also help non-biological lesbian mothers to feel more involved in the process. For example, one woman ‘pressed the plunger’ to deliver the sperm (Nordqvist, 2012). The matching of sperm to one or both partners’ physical characteristics can help increase a sense of relatedness (Nordqvist, 2010). Lesbians face difficulties accessing treatment. The National Health Service (NHS) treatment is not commonly utilised by lesbians, as they are either refused treatment or do not request it. Some assume themselves ineligible whilst others perceive the NHS as a homophobic environment (Nordqvist, 2011). The remaining options for lesbian couples are private treatment or self-insemination (SI) with a known donor. Some suggest that the lack of public funding drives women into unsafe SI, taking risks with sexually transmitted infections (Wykes, 2012). Whilst there is evidence infection does sometimes occur (Luce, 2010), lesbian decision making about the route of conception involves more complex considerations than finances and infections (Mamo, 2007; Donovan & Wilson, 2008; Luce, 2010; Nordqvist, 2011). In some cases, women begin with SI and move to a clinical setting when this does not work. Others begin clinically but have unsuccessful, expensive, discriminatory or dehumanising experiences and switch to SI. For some the clinical setting is seen as objectifying and medicalising, for others clinical procedures negate a need to handle undesirable bodily fluids. Clinics are seen as advantageous for those who wish to raise their child without interference from the donor, whereas others choose SI in order to allow a relationship between father and child. The National Institute for Health and Care Excellence (NICE) updated its fertility guidelines to © 2015 The British Fertility Society
recommend inter-uterine insemination (IUI) to treat same-sex couples (NICE, 2013). Although treatment of lesbians funded by NHS is on the increase (Figure 1), in 2012 only 61 lesbian couples received funded IVF (HFEA, 2013b). Even if we ignore NICE guidelines regarding IUI, lesbians experiencing subfertility are clearly entitled to funded IVF under equality legislation. The low uptake of NHS treatment may in part be due to lesbians’ perceptions and choices, but there is also evidence that legitimate requests are being denied. Legal actions have been brought by couples challenging inequality. In two cases decisions not to treat subfertile lesbians were legally challenged, resulting in a reversal of the decisions (IVF.net, 2009; BBC News, 2009). A third legal action has also commenced, but an outcome is yet to be reported (The Telegraph, 2013). Conclusion In the UK we have an evolved legal and regulatory framework, facilitating growing numbers of lesbians to seek fertility treatment. However, it is important to ensure that UK licensed centres match this with an evolved approach to treating lesbians. We need to take stock of how well we treat lesbians, in both senses of the word. It may not be surprising that lesbian couples have a subtly different live birth rate for donor insemination compared with all other DI cycles, given that the two groups may differ in the extent of fertility investigations, in age and in other demographic factors. However, it is a surprise that the average UK DI live birth rate is less than half the estimated chance of conception of a heterosexual couple’s first attempt at home. This raises questions about the methodology used and certainly raises an issue about managing patient expectations. Aspects of law and HFEA guidance have shifted an emphasis towards treating lesbians with respect for their diversity. Studies suggest that the experience of lesbians in fertility treatment is not ideal, although further feedback to clinics would be useful. Advice from the lesbian community could be collated and presented in workshops or presentations to fertility professionals. Such educational material would help to ensure that clinics are aware of the needs of lesbian couples and could also reiterate some of the finer details of the HFEA code of practice and equality legislation. Finally, access to funded treatment for infertile lesbian couples can be problematic judging by the ‘tip of
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the iceberg’ legal cases. Additionally, updated NICE guidelines recommend the funding of IUI for fertile lesbian couples but this practice is anything but commonplace. Clear information is required about what the regional entitlements are for lesbian couples so that they can challenge inappropriate decisions by their local service if necessary.
Acknowledgements
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The author would like to thank the Centre for Reproduction and Gynaecology Wales or CRGW for their support in the writing of this review, the two anonymous reviewers for their helpful suggestions and Ronne Randall for her editorial and proofreading contributions. Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
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