What assisted reproductive technology (ART) options and required medical, psychological, and legal evaluations are recommended for a same‑sex couple seeking to have children?

Same-Sex Family Planning: Assisted Reproductive Technology Options and Required Evaluations

Same-sex couples seeking to have children should undergo concurrent medical evaluation of both partners, comprehensive psychological counseling regarding reproductive options, and legal consultation regarding parental rights—with the specific ART pathway determined by which partner will carry the pregnancy and whether donor gametes are needed.

Reproductive Options for Same-Sex Female Couples

Primary ART Pathways

For same-sex female couples, donor insemination (DI) with fresh or frozen donor sperm should be the first-line approach for fertile women, as it is less invasive and costly than IVF. 1

• Intrauterine insemination (IUI) with donor sperm is appropriate when both partners have normal fertility assessments 2
• In vitro fertilization (IVF) with donor sperm should be reserved for couples with documented infertility factors (tubal disease, endometriosis, ovarian dysfunction) rather than offered as first-line to fertile women 1
• Reciprocal IVF (one partner provides eggs, the other carries the pregnancy) is an option that allows both partners biological/gestational participation, though it requires IVF technology 1

Critical Evaluation Before ART

Both partners should undergo fertility assessment concurrently, even though only one will carry the pregnancy, to determine the optimal carrier and identify any treatable conditions. 2, 3

For the partner who will carry:

• Reproductive history including menstrual regularity, prior pregnancies, pelvic inflammatory disease, and sexually transmitted infections 2, 3
• Physical examination including BMI calculation, thyroid assessment, breast examination, and pelvic examination to assess for anatomical abnormalities 2
• Ovarian reserve testing if age ≥35 years or history of gonadotoxic exposures 4
• Cervical cancer screening per guidelines 2
• Infectious disease screening (hepatitis B, hepatitis C, HIV, syphilis) before proceeding with ART 3

For the non-carrying partner (if considering egg donation):

• Same fertility assessment as above to determine egg quality and ovarian reserve 2
• Genetic screening if family history suggests hereditary conditions 2

Reproductive Options for Same-Sex Male Couples

Same-sex male couples require both donor eggs and a gestational carrier (surrogate), necessitating IVF with intracytoplasmic sperm injection (ICSI) as the only viable ART pathway. 2

Required Male Partner Evaluation

Both partners should undergo comprehensive fertility evaluation to determine which partner's sperm will be used, or whether both will contribute sperm for separate embryos. 2, 3

Essential components for each partner:

• Reproductive history documenting prior fertility, sexual function, testicular history (undescended testes, trauma, infections), systemic illnesses, medications (especially testosterone or anabolic steroids), and gonadotoxin exposures 2, 3
• Physical examination focusing on penile anatomy, testicular volume (normal >15 mL), vas deferens presence, epididymal consistency, varicocele detection, and secondary sexual characteristics 2, 3
• At least two semen analyses collected one month apart after 2-3 days abstinence, evaluating volume, concentration, total motile sperm count, progressive motility, and morphology 2, 3, 4
• Morning fasting total testosterone, FSH, and LH if oligozoospermia or azoospermia detected 3
• Karyotype and Y-chromosome microdeletion analysis if sperm concentration <5 million/mL 3
• Infectious disease screening (hepatitis B, hepatitis C, HIV, syphilis) 3

Sperm Retrieval Options

For partners with azoospermia or severe oligozoospermia, testicular sperm extraction (TESE) or testicular sperm aspiration (TESA) can retrieve viable sperm for ICSI. 2

Psychological Evaluation and Counseling Requirements

All same-sex couples pursuing ART must receive comprehensive psychological counseling addressing relationship dynamics, parenting roles, disclosure plans, and the emotional demands of ART procedures. 2, 5

Essential Counseling Components

• Clarification of each partner's reproductive life plan and priorities for family building 2, 5
• Discussion of which partner will carry (for female couples) or provide sperm (for male couples), recognizing that partners may have different priorities 5
• Exploration of genetic connection preferences—research shows men often prioritize genetic connection more highly than their female partners 5
• Realistic expectations about success rates: IVF yields approximately 37% live birth per cycle, with rates declining significantly after age 35 2
• Preparation for potential multiple cycles, financial costs, and the possibility of no suitable embryos for transfer 2
• Counseling about twin/multiple pregnancy risks (12.5% of IVF deliveries involve twins) 2
• Discussion of surplus embryo disposition and cryopreservation decisions 2

Relationship-Specific Considerations

Maintaining a close and satisfying relationship with one's partner is ranked as a high priority by majorities of both men and women pursuing fertility treatment, and should be explicitly addressed in counseling. 5

• Partners may not be aligned in prioritizing parenthood achievement versus other goals 5
• Women more frequently prioritize becoming a parent "one way or another" and achieving parenthood within a specific timeframe 5
• Men more frequently prioritize genetic connection, relationship maintenance, and avoiding treatment side effects 5

Legal Evaluation and Documentation

Same-sex couples must obtain legal counsel before initiating ART to establish parental rights for both partners, as legal parentage is not automatically conferred to the non-biological or non-gestational parent. 2

Critical Legal Considerations

• Pre-conception legal agreements establishing parental intent for both partners 2
• Second-parent adoption requirements vary by jurisdiction and should be clarified before conception 2
• Donor agreements clearly relinquishing parental rights if using known donors 2
• Gestational carrier contracts for male couples using surrogacy 2
• Estate planning and guardianship designations to protect parental rights 2

Genetic Counseling Indications

Genetic counseling is mandatory before ART if either partner has a family history of hereditary conditions, consanguinity, or belongs to an ethnic group with increased carrier frequency for specific disorders. 2, 6

When to Refer for Genetic Counseling

• Family history of hereditary cancer syndromes (BRCA1/2, Lynch syndrome)—couples may consider preimplantation genetic testing (PGT) to avoid transmitting pathogenic variants 2
• Carrier screening for autosomal recessive conditions based on ethnicity (cystic fibrosis, sickle cell disease, Tay-Sachs, thalassemias) 2, 6
• History of recurrent pregnancy loss or prior child with genetic condition 2
• Advanced paternal age (>40 years) increases de novo mutations, sperm aneuploidy, and offspring risk for autism, schizophrenia, and chondrodysplasia 2

Preimplantation genetic testing (PGT) requires IVF regardless of fertility status and involves testing embryos before transfer to select unaffected embryos, avoiding pregnancy termination decisions. 2

Lifestyle Optimization Before ART

Both partners should implement evidence-based lifestyle modifications at least 3 months before initiating ART to optimize gamete quality and pregnancy outcomes. 3, 4

• Complete smoking cessation for both partners 3, 4
• Eliminate alcohol and recreational drug use 3, 4
• Limit caffeine intake to fewer than five cups daily 3
• Optimize body weight targeting BMI 20-26 kg/m² 3
• Avoid occupational or environmental gonadotoxin exposures (heat, radiation, heavy metals, pesticides) 3, 4
• Folic acid supplementation for the partner who will carry pregnancy 3

Common Pitfalls to Avoid

Do not prescribe testosterone or anabolic steroids to male partners, as exogenous testosterone suppresses spermatogenesis through negative feedback on the hypothalamic-pituitary axis and causes infertility. 2, 3

Do not offer IVF as first-line treatment to fertile same-sex female couples when donor insemination is medically appropriate—this represents unnecessary medicalization with greater human and financial costs. 1

Do not evaluate only one partner in same-sex couples; both require assessment to determine optimal reproductive strategy and identify treatable conditions. 2, 3, 4

Do not delay evaluation if either partner is ≥35 years; begin assessment after only 6 months rather than 12 months due to age-related fertility decline. 4

Do not assume legal parentage is automatic for both partners; legal counsel is essential before conception to protect parental rights. 2

Do not recommend spermicides containing nonoxynol-9, as these increase genital lesions and may facilitate HIV transmission if applicable. 7

Referral Algorithm

Refer to reproductive endocrinology/fertility specialist when:

• Either partner has documented infertility factors (abnormal semen analysis, ovulatory dysfunction, tubal disease) 2, 3
• Female partner age ≥35 years (time-sensitive evaluation required) 4
• Male partner has azoospermia, severe oligozoospermia (<5 million/mL), or abnormal physical examination findings 3
• Couples desire reciprocal IVF or preimplantation genetic testing 2, 1
• Male couples requiring gestational carrier and donor eggs 2

Refer to genetic counselor when:

• Family history of hereditary conditions or prior affected child 2, 6
• Ethnic background with increased carrier frequency for recessive disorders 2, 6
• Advanced paternal age with concerns about offspring genetic risks 2

Refer to mental health professional specializing in reproductive medicine when:

• Significant relationship discord regarding family-building priorities 5
• History of depression, anxiety, or prior pregnancy loss requiring support 2
• Couples need assistance navigating complex decisions about genetic connection and parenting roles 5