The Road to Fatherhood Using Assisted Reproductive Technology: Decision Making Processes and Experiences Among Gay Male Intended Parents and Gestational Surrogates

Ilana B. Ressler, Danielle Bessett, Julie M. Sroga, Sarah Rompola, Rachael M. Fer rari, Michael A. Thomas, Steven R. Lindheim

New York Fertility Services,16 E. 40th St., 2nd Fl, New York, NY 10016, USAUnited States
Department of Sociology, University of Cincinnati, Cincinnati, OH, USAUnited States
Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cin-cinnati, OH, USAUnited States
Department of Obstetrics and Gynecology, Boonshoft School of Medicine, Wright State Uni-versity, Dayton, OH, USAUnited States
Department of Obstetrics and Gynecology, Boonshoft School of Medicine, Wright State Uni-versity, Dayton, OH, USA; Miami Valley Hospital, 128 Apple Street, Suite 3800 Weber CHE, Dayton, OH, USAUnited States

DOI: https://doi.org/10.17140/goroj-1-104 · Published 2014-12-01 · Licence: https://creativecommons.org/licenses/by/4.0 · © 2014 The Author(s)

Also available as PDF (figures and tables appear in the PDF).

Keywords: Gay men; Fatherhood; Gestational surrogacy; Assisted reproductive technology

Introduction

The family, traditionally understood as a husband, wife and their biological children, is undergoing a transformation. The number of children living with 2 parents has fallen from 88% in 1960 to 68% in 2012.1 Additionally, there has been an increase in the number of non traditional families, which may consist of a single parent, unmarried heterosexual couples, heterosexual couples with non-biological children, gay or lesbian couple. No national registry provides exact numbers of gay and lesbian parents, but recent reports estimate up to 6 million children in the United States are parented by gay or lesbian families.2 The American Community Survey suggests that 26.5% of female-female unmarried couple and 13.9% of male-male unmarried couple households contain children.3

Simultaneous with this transformation is a progression of the gay rights movement, including increased legalization of same sex marriage and parenting options through joint adoption and ART. In 2009, the American Society for Reproductive Medicine (ASRM) Ethics Committee published a report entitled, “Access to fertility treatment by gays, lesbians and unmarried persons,” supporting access to ART regardless of marital status or sexual orientation.4 Furthermore, this report and several others find no data suggesting that children are harmed or disadvantaged based on non traditional family compositions. Since the early 1980s when donor insemination became more readily available, there has been an increase in the number of babies born to lesbian couples. There are several studies that have evaluated this social trend including issues related to the prospective les- 11-12 13,14 bian mothers, the use of donor insemination and IVF and 15-17 the outcomes of their children. An increasing number of gay men are also seeking biological parenthood through gestational surrogacy. There is a paucity of literature, however, examining gay male couples, and to our knowledge, there is no published data regarding their gestational surrogates (GS). The purpose of our study was to report the decision making processes and experiences for gay male couples using ART and their GS in order to identify potential needs for programmatic improvement.

Materials And Methods

This was an institutional review board approved retrospective qualitative survey. Questionnaires were distributed by the University of Cincinnati Center for Reproductive Health and The Surrogacy Center in Madison, Wisconsin. All potential candidates for the study were identified through a database maintained at the Surrogacy Center. Questionnaires were sent to gay men (n=102) and GS for gay men (n=51) who had completed or were currently undergoing ART in the United States. All participants reviewed and signed informed consent documents. Questionnaires were self-administered.

The questionnaire was designed to assess the respondent’s background, ART experience (including medical, psychological, legal and financial) and insights gained from the experience. Questionnaires included both closed and open-ended questions that allowed for comments. Questions regarding the level of “support” felt at various times during the process utilized a likert scale (1=extremely supportive, 5=not at all). Questionnaires included parallel themes on: sexuality, ART, the legal process, the pregnancy, postpartum and plans for the future. Questionnaires for men also included: family support, the decision to become a father, selection criteria of the egg donor, the selection of the GS and psychological evaluation. GS questionnaires also inquired about: motivation and compensation. The questionnaires were completed by gay male who were in a committed relationship with a total of 22 responses (22%) and 11 (22%) from GS.

Preparation for the cycle, including explanation of the medical, legal and psychological aspects, were reviewed at the initial consult with the ART team and surrogacy center. In addition, an information packet with internet resources and ASRM links were provided. Members of the ART team were also available throughout the cycle to answer any questions or concerns that presented at a later time. The Surrogacy Center has a specific checklist for GS and Intended Parents (IPs) that is comprehensively reviewed. This process is complex, therefore it may require further explanation and support throughout the process. 5,6,7-10

Data were entered into an SPSS database (version 18.0, SPSS Inc., Chicago, IL) and comments were paired as themes only after group agreement by the authors. Statistical analysis including descriptive and Kappa correlations was performed.

Results

Same sex male intended parents

The average age of respondents was 41.3 years (range 30-55 years). Ninety five percent were Caucasian and 5% Asian. Countries of residence included the U.S. (64%), France (27%) and the Netherlands (9%). All of the gay men were in a committed relationship, with a mean length of 14 years (range 7-33 years). With respect to their ART outcomes, 10 of the couples had their GS successfully deliver at least once, resulting in 7 sets of twins and 4 singletons, whose mean age was 3.6 years (range 1 month to 10 years).

When asked how supportive their immediate families were when the men disclosed their sexual orientation, only 41% of men reported family support. When couples announced their intentions of becoming fathers, all reported having discussed the use of ART and gestational surrogacy with family and friends with 77% reporting family support. Ninety one percent had clear plans to disclose the nature of conception to their children, with many emphasizing age appropriate conversations.

With respect to family planning, 32% reported that the

desire to have children was an important characteristic in selecting a partner. Half reported that they desired to have children equally, while the other half reported that one partner desired fatherhood more. Thirty six percent reported difficulties within their relationships surrounding the decision to become fathers. Other difficulties regarding the ART process included costs, failed cycles and concerns about potential discrimination against offspring. Some descriptions of the difficulties experienced included, “I worried about how it would be for children having gay parents, I was afraid for them,” “I worried about societal issues that could harm our child, how to handle it,” and “the difficulties only arose after many failed attempts and high costs of continuing; it was a 5+ year journey.”

When considering ART treatment options, only 14% of respondents considered traditional surrogacy, while nearly all (91%) considered adoption. All French men reported that adoption was not possible for gay men due to French laws. American men also cited hurdles to adoption for gay men in the U.S. Sixty four percent of men were familiar the ART process and with domestic and international laws (including adoption, parentage agreements and donor oocytes) prior to the visit with their reproductive endocrinologist and ART program. Half of the men found legal counsel by referral from a surrogacy center.

Subjects were asked to describe their priorities when selecting both an egg donor and GS (open response question). Priorities for selecting an egg donor included medical history (73%), ethnicity or appearance (41%) and intelligence (32%) (Figure 1A), which is very similar to heterosexual couples.18 When selecting a GS, priorities included a prior successful pregnancy (32%), medical history (27%) and working with someone who was gay-friendly (27%) (Figure 1B). Subjects were also asked to rate how well supported they felt from several professionals involved in the ART process. Ninety one percent of men found the reproductive endocrinology medical and paramedical staff supportive, and an equal number found their attorney to be supportive. One third, however, found their obstetrician and pediatrician less supportive.

In 77% of men, both partners’ banked sperm, with nearly all subjects mentioning a strong desire for each to be a biological father. With respect to the embryo transfer, 20 of 22 were counselled about transferring the best quality embryos regardless of paternity. Ultimately, 55% had at least 1 embryo from each partner transferred.

The antepartum and intrapartum concerns of greatest importance for the men focused on the health of the baby and GS. Only 1 of the 22 men raised concerns regarding legal issues. During the postpartum period, concerns shifted to geographic logistics (living in different cities or countries), execution and legitimacy of legal contracts related to parentage rights and anxiety about being a new father.

Egg donors were recruited by local advertising and word of mouth. A donor was presented to the male and his partner by the ART team based on IPs preferences ascertained by questionnaire. All egg donors remain anonymous, unless arrangements for direct donation by a known donor are made by the IPs and donor. When asked about plans for maintaining contact with their egg donor, with only 1 exception, it was not expected or desired to maintain a relationship. There was agreement between partners on this point (K=0.62, p=0.03). In contrast, 55% did desire to keep in touch with the GS, however the partners did not always agree on this point (K=0.42, p=NS). If planning a future pregnancy, all men expressed a desire to use the same egg donor, yet only 38% of respondents would use the same GS.

Gestational surrogates

The average age of respondents was 37.4 years (range 34-48 years). Eighty two percent were Caucasian and 18% Hispanic. All respondents resided in the U.S. Ninety one percent of the women were heterosexual, 82% married, and all had at least one child of their own. At the time of questionnaire completion, 55% of the women had delivered a baby as a GS once, 36% twice and 9% three times. Seventy three percent reported employment outside the home. The mean number of embryos transferred was 1.9 (range 1-3), with 82% of the women successfully delivered and 18% still expecting. This resulted in 9 singletons and 5 sets of twins. Ninety two percent delivered full term and half delivered by cesarean section.

Altruistic motives were cited as the most common reason for becoming a GS (73%), and 18% stated finances as primary motivation (Figure 2). Compensation for services averaged $26,600 (range $5,200-45,000) and 82% received additional gifts, including books, jewelry, electronics, food, clothes and perfume. None had any reservations regarding carrying for a gay couple, and 27% reported a preference to carry for a gay couple (“Less neurotic than the heterosexual couples”). Eighteen percent knew the IP prior to becoming their GS. All GS disclosed the IPs’ sexual orientation to friends and 91% to their extended families. All of the GS’s significant others were supportive

of their decision to be a GS regardless of the IP’s sexual orientation, while 18% of family members were not supportive of the decision.

Despite guidance by a surrogacy agency and ART program, women disclosed that they did not fully understand the legal issues as the process unfolded. Ninety one percent found their legal counsel by referral from a surrogacy center, and 18% found the attorney’s support inadequate. When asked about the support they received throughout the process, 36% reported a lack of support from the IVF program and 18% from the obstetrician. Top antepartum concerns for the GS were the babies’ health and maintaining their own support systems from family and friends.

The number of visits by the IPs prior to delivery ranged from 0 to “countless.” Despite considerable ante- and postpartum support from family and IPs, and all denying difficulty with separating from the infant(s), 22% of those delivered reported postpartum depressive symptoms, (either diagnosed by a physician or self-assessment). Seventy three percent have maintained contact with their IPs, ranging from weekly to once every few years. Sixty four percent reported they would agree to be a GS for the same couple again. Reasons for not wanting to be a GS again included pregnancy-related complications, age and a desire to expand their own families.

Discussion

Our study describes the ART process from the perspective of gay males and their GS. Some common themes can be extrapolated from these data. All of the gay males were in stable, long-term committed relationships. They chose biological fatherhood after a great deal of consideration and contemplated several options. Options were often limited, however, due to their sexual orientation and legal limitations. They had all discussed the nature of conception with their friends and families and had not only considered, but had clear plans of having that

discussion with their children in the future. Their families were much more supportive of them when announcing the decision to become fathers than when they initially disclosed their sexuality. This is possibly due to the wider acceptance of welcoming a child into the family than of an alternate lifestyle. In addition, the gay males and GS did not report universal support from the IVF programs, attorneys, obstetricians and pediatricians, indicating a need for improvement.

An increasing number of gay men view fatherhood as an expected part of their life.19A study of young gay men reported that while one third of the males anticipated getting married, 86% expected to become fathers in the future.20 A lack of social acceptance of gay men as fathers remains. Common prejudices contributing to this include concerns that the children will be stigmatized, that the children are more likely to become homosexual and that gay males are more likely to molest their own 21 22-27 children. Despite several studies discrediting these ideas, universal access to fertility treatment does not exist.

From a medical perspective, an ART cycle for a gay male couple is not unique. It is the additional legal, psychological and logistical components that make it more involved than traditional ART cycles. There are several important programmatic considerations when implementing care for this type of cycle. This starts with patient access to ART and then involves medical and psychological evaluation, selection of an egg donor, GS selection, legal contracts and checklist requirements, including those mandated by the U.S. Food and Drug Administration (FDA).28 Careful coordination with effective communication between all involved parties is imperative. One must also be mindful that while each professional may only see the patient at one step during the process, the process is ongoing from attempted conception, to antepartum, through the postpartum period.

For gay male couples seeking fatherhood, potential options include adoption, traditional surrogacy and IVF with an egg donor and GS. In certain scenarios, there are legal limitations placed on one or more of these options (i.e. depending on state or national laws). There are also substantial financial costs to these options. A recently published ASRM ethics committee document28 states that “reasonable economic compensation to the gestational surrogate is ethical.” Specific costs may vary with use of donor egg or surrogacy agencies, geographic region and egg donor or GS desirability. Costs for such a cycle may range from $80,000-160,000. There is a great amount of financial pressure on the IPs, as a failed cycle means even higher costs. There is additional pressure felt by the GS, as the majority of her compensation is based on a successful pregnancy. These financial pressures felt by each party may create an underlying tension in the IP/GS relationship.

There are a number of legal issues entrenched in this ART process, including those surrounding oocyte donation,

gestational surrogacy, adoption and parentage agreements. Selecting legal counsel familiar with these issues and educating themselves are important steps in this process. Many relied on a surrogacy center’s referral for retaining counsel. Additionally, IVF programs must be familiar with the laws of the state in which they practice as well as the FDA regulations.

The gay men in this study formed close relationships with their GS, most with continued communication postpartum. Interestingly, only approximately one third gay males would use the same GS for a future pregnancy, while two thirds of the GS were willing to carry for the same couple again. Specific reasons for this discrepancy were not elicited and further research is needed in this area. Furthermore, IVF programs and surrogacy agencies should be sensitive to the potentially-divergent needs of IPs and GS. All of the men, however, were interested in using the same egg donor if planning a future pregnancy. Perhaps the preference for the same egg donor and not the GS was to maintain genetic similarity, which would not be surprising in a sample that chose biologic fatherhood over adoption (where legal) and specifically mentioned a strong desire for each partner to be a biological father when banking sperm. Additionally, more than half of the males transferred at least 1 embryo from each partner, suggesting a priority of perpetuating their own genetics over the recommended elective single embryo transfer and reducing the risk of twins.

Consistent with existing literature, altruism was the most common reason cited for becoming a GS. All were not only comfortable carrying for gay couples, but some preferred it. The percent of GS reporting postpartum depressive symptoms was higher than the estimated prevalence of 13 to 19% in the general population. The current description does not indicate why this population of GS may feel more postpartum depression. Reasons behind this may be feelings of loss of identity, separation not only from the baby, but also the IPs, and pain and recovery of pregnancy with no baby in hand. Our sample size is small and our definition of postpartum symptoms/depression is broad; larger more specific studies are needed to assess this. While evaluation by a mental health professional is routine prior to entering into a treatment cycle as a GS or IP, it is not routinely provided during the cycle or postpartum. It is critical that adequate psychological support be provided to these women in the postpartum period.

This study is one of very few in the literature that investigates gay male couples and ART as well as their GS, two understudied populations with an increasing presence in third party reproduction. Our sample size is small, which limits the generalizability of our findings. The limited number of responses may be due to the length of the questionnaire and to the personal nature of the questions. That said, our study does suggest areas for needed improvement in the ART process for both gay men and GS, including the need for increased sensitivity and support from those providing care/services to the IPs and GS. Further

study is needed to expand upon these results and to elicit specifics regarding how increased support may be provided.

In conclusion, while gay men and their GS reflect many of the experiences and concerns that characterize ART generally, they also bring specific needs to the process. These unique concerns can be addressed by those sensitive to the issues. Attention not only to medical, but also to emotional and legal needs of both the IPs and GS is necessary. The continuum of care from pre- to post-ART treatment must be considered at the local, national and international levels. There is a lack of a standardized process, which requires attention first at a national level. Finally, further education is needed to raise awareness to professionals including specialists in this area and beyond. The medical practice must evolve to meet the needs of increasingly diverse families in today’s society.

Study Funding/Competing Interest

This study was supported by the Patty Brisben Foundation. The authors declare that there is no conflict of interest associated with this manuscript.

Acknowledgements

The authors thank the Surrogacy Center in Madison, WI for assistance with data collection.

29,30 REFERENCES

1. US Bureau of the Census. Table CH-1: living arrangements of children under 18 years of age: 1960 to present. Website: http:// www.census.gov/hhes/families/files/graphics/CH-1.pdf. 2012; Accessed 2013.

2. Gates GJ. LGBT Parenting in the United States. Website: http://williamsinstitute.law.ucla.edu/wp-content/uploads/LG- BT-Parenting.pdf. 2013; Accessed 2014.

3. Krivickas KM, Lofquist D. Demographics of same-sex couple households with children. U.S. Census Bureau. Website: http:// www.census.gov/hhes/samesex/files/Krivickas-Lofquist%20 PAA%202011.pdf. 2011; Accessed 2013.

4. Ethics Committee of the American Society for Reproductive Medicine. Access to fertility treatment by gays, lesbians, and unmarried persons. Fertil Steril. 2009; 92: 1190-1193. doi: http:// dx.doi.org/10.1016/j.fertnstert.2006.08.085

5. Stacey J, Biblarz T. (How) does the sexual orientation of parents matter? American Sociological Review. 2001; 66: 159- 183.

6. Bigner JJ, Bozett FW. Parenting by gay fathers. Marriage Fam Rev. 1989; 14: 155-175.

7. Bigner JJ. Raising our sons: gay men as fathers. J Gay Lesbian Soc Serv. 1999; 10: 61-68. doi: 10.1300J041v10n01_04

8. Anderssen N, Amlie C, Ytterov EA. Outcomes for children with lesbian or gay parents. A review of studies from 1978 to 2000. Scand J Psychol. 2002; 43: 335-351. doi: 10.1111/1467- 9450.00302

9. Maccallum F, Golombok S. Children raised in fatherless families from infancy: a follow-up of children of lesbian and single heterosexual mothers at early adolescence. J Child Psychol Psychiatry. 2004; 45: 1407-1419. doi: 10.1111/j.1469-7610- .2004.00324.x

10. American Psychological Association. Sexual Orientation, Parents & Children. Website: http://www.apa.org/about/governance/council/policy/parenting.aspx. 2004; Accessed 2012.

11. Gartrell N, Hamilton J, Banks A, et al. The national lesbian family study: 1. Interviews with prospective mothers. Am J Orthopsychiatry. 1996; 66: 272-281. doi: 10.1037/h0080178

12. Baetens P, Brewaeys A. Lesbian couples requesting donor insemination: an update of the knowledge with regard to lesbian mother families. J Hum Reprod. 2001; 7: 512-519. doi: 10.1093/ humupd/7.5.512

13. Werner C, Westerståhl A. Donor insemination and parenting: Concerns and strategies of lesbian couples. A review of international studies. Acta Obstet Gynecol Scand. 2008; 87: 697-701. doi: 10.1080/00016340802011603

14. Marina S, Marina D, Marina F, Fosas N, Galiana N, Jové I. Sharing motherhood: biological lesbian co-mothers, a new IVF indication. Hum Reprod. 2010; 25: 938-941. doi: 10.1093/humrep/deq008

15. Braeways A, Ponjaert I, Van Hall E, Golombok S. Donor insemination: child and family development in lesbian-mother families with children of 4 to 8 years old. Hum Reprod. 1997; 12: 1349-1359. doi: 10.1093/humrep/12.6.1349

16. Chan R, Raboy B, Patterson CJ. Psychosocial adjustment among children conceived via donor insemination by lesbian and heterosexual mothers. Child Dev. 1998; 69: 443-457. doi: 10.1111/j.1467-8624.1998.tb06201.x

17. Golombok S, Tasker F, Murray C. Children raised in fatherless families from infancy: family relationships and the socioemotional development of children of lesbian and heterosexual mothers. J Child Psychol Psychiatry. 1997; 38: 783-791. doi: 10.1111/j.1469-7610.2004.00324.x

18. Lindheim SR, Kavic S, Sauer MV. Understanding differ-

ences in the perception of anonymous parties: A comparison between gamete donors and their recipients. J Assis Reprod Genet. 2000; 17: 127-130.

19. Rabun C, Oswald RF. Upholding and expanding the normal family: Future fatherhood through the eyes of gay male emerging adults. Fathering. 2009; 7: 269-285. doi: 10.3149/fth.0703.269

20. D’Augelli AR, Rendina HJ, Sinclair KO. Lesbian and gay youths’aspirations for marriage and raising children. Journal of LGBT Issues in Counseling. 2008; 1: 77-98. doi: 10.1300/ J462v01n04_06

21. Mallon GP. Gay men choosing parenthood. New York: Columbia University Press. 2004.

22. Harris MD, Turner PH. Gay and lesbian parents. J Homosex. 1985; 12: 101-13.

23. Bozett FW. Children of gay fathers. In: Bozett FW, ed. Gay and lesbian parents. New York: Praeger, 1987: 39-57.

24. Bozett FW. Gay fathers: a review of the literature. In: Bozett FW, ed. Homosexuality and the family. New York: Harrington Park. 1989:137-162.

25. Miller B. Gay fathers and their children. Fam Coord. 1979; 28: 544-552.

26. Barrett H, Tasker F. Growing up with a gay parent: views of 101 gay fathers on their sons’ and daughters’ experiences. Educ Child Psychol. 2001; 18: 62-77.

27. Jenny C, Roesler TA, Poyer KL. Are children at risk for sexual abuse by homosexuals? Pediatrics. 1994; 94: 41-46.

28. Ethics Committee of the American Society for Reproductive Medicine. Consideration of the gestational carrier: a committee opinion. Fertil Steril. 2013; 99: 1838-1841. doi: 10.1016/j. fertnstert.2013.02.042

29. Van den Akker O. Genetic and gestational surrogate mothers’ experience of surrogacy. Journal of Reproductive and Infant Psychology. 2003; 21: 145-161. doi: 10.1080/0264683031000124091

30. Ciccarelli JC, Beckman LJ. Navigating rough waters: An overview of psychological aspects of surrogacy. Journal of Social Issues. 2005; 61: 21-43. doi: 10.1111/j.0022-4537- .2005.00392.x

31. O’Hara MW, McCabe JE. Postpartum depression: current status and future directions. Annu Rev Clin Psychol. 2013; 9: 6.1-6.30. doi: 10.1146/annurev-clinpsy-050212-185612