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LGBTQ+ Couples Face Barriers to Accessing Fertility Treatments

Contributors: Martin N. Kathrins, MD; Alex S. Keuroghlian, MD; Andrew Shin
7 minute read
Two young  white men look adoringly at the baby that one of the men holds.

Starting a family is a complex and highly personal decision. For LGBTQ+ couples who want to have biological children, fertility preservation treatments are often the answer. These treatments allow people to have their eggs or sperm collected and stored for future use. But does everyone have equal access to these treatments?

Andrew Shin, a student at Harvard Medical School, was interested in how laws and regulations affect the diverse populations that might use these services. In the United States, the Food and Drug Administration (FDA) regulates the use of eggs and sperm in fertility preservation treatments.

With his co-authors Martin Kathrins, MD, a Mass General Brigham urologist who cares for patients at Brigham and Women’s Hospital, and Alex S. Keuroghlian, MD, a Mass General Brigham psychiatrist who cares for patients at Massachusetts General Hospital, Shin decided to study how policies affect sperm banking and sperm storage.

They published a recent article in LGBT Health detailing their findings. They found that the FDA regulations have created systematic barriers for sexually and gender diverse patients. The regulations make it more difficult and often more expensive for them to access sperm banking and storage.

“Our paper highlights that, historically, this has been a very oppressed population. This is a service that affects multiple facets of the LGBTQ+ community: transgender women, gay men, and intersex individuals,” Shin explains. “The regulations result in discrimination based on sexual orientation and gender identity, because cisgender heterosexual couples do not have these issues at all.”

Fertility preservation treatments

Fertility preservation methods include:

People who can benefit from fertility preservation include anyone who wants to delay starting a family, or patients with cancer or other chronic conditions that can affect fertility.

For same-sex or gender non-binary couples, fertility preservation allows them to use eggs or sperm from a member of the couple. The samples are then paired with donor eggs or sperm to create an embryo. For couples whose partners both produce sperm, a surrogate would then carry the embryo on behalf of the couple.

Fertility preservation regulations

Gay men, transgender women, and intersex individuals may have difficulty accessing sperm preservation treatments.

Under FDA policy, donors of reproductive tissues fall under three categories. Each category has different regulations for screening and testing for infectious diseases like HIV and syphilis.

  1. Donors to sexually intimate partners: For heterosexual couples, this would be a male donating sperm to their female partner. Because both partners are assumed to have the same sexually transmitted infection (STI) status, the FDA doesn’t require any additional screening or testing

  2. Directed donors: A friend, relative, or previously selected donor known to the intended parents. These donations require additional screening and testing for HIV, hepatitis, syphilis, chlamydia, and gonorrhea.

  3. Anonymous donors: A donor of eggs or sperm unknown to the intended parents. In addition to the screening and testing for directed donors, anonymous donors must also repeat the testing procedures after 6 months. Their donated samples are quarantined before they can be donated.

Not all hospital-based or non-profit fertility centers accept directed or anonymous donors. There are increased costs for the additional testing and storage of sperm during quarantine. People in this situation may have to use a private clinic, which is often more expensive, especially if their insurance coverage doesn’t apply.

“Individual facilities may not have the capacity to carry out these types of donations. This puts an increased testing burden on these diverse populations. It makes the process of fertility preservation much more difficult to access for them,” says Shin.

“I’ve seen patients get angry and frustrated when facing these issues. I’d like to see future patients avoid the frustration of being turned away for fertility preservation,” adds Dr. Kathrins.

An example of the impact of regulations

To illustrate their findings in the article, Shin and Drs. Kathrins and Keuroghlian developed a theoretical example. Cal is a 31-year-old cisgender gay man who is married to his cisgender husband. Cisgender refers to people whose gender identity is the one they were assigned at birth, or not transgender.

Cal was diagnosed with colorectal cancer and advised that chemotherapy could affect his fertility. He and his husband decide to preserve Cal’s sperm in case they want to start a family in the future. The couple would then find an egg donor and a gestational surrogate to carry the pregnancy.

Because Cal’s husband is a man who can’t become pregnant, the recipient of his sperm sample is technically not his sexually intimate partner. The couple also haven’t identified an egg donor or gestational surrogate yet. Under FDA policy, Cal’s sperm sample is classified as an anonymous donation, even though it’s intended to be used by a committed, married couple to start a family.

Unfortunately, the hospital treating Cal does not process anonymous sperm donations. He and his husband wind up having to seek care through a private fertility clinic, which costs substantially more.

Cal and his husband are a hypothetical example, but their experience is based on reality. “This is a very plausible scenario that could happen under the current guidelines. We’ve seen elements of this situation in real life. It was very upsetting for the patients,” says Shin.

“The policy is rigged against an already minoritized population,” notes Dr. Keuroghlian.

Potential solutions to ensure equity in fertility preservation treatments

In the article, Shin, Dr. Kathrins, and Dr. Keuroghlian recommend policy changes to increase access for sperm-producing people whose partners also produce sperm. They recommend the following:

  • The FDA should mandate that all fertility practices provide equal access to treatment, regardless of donor status.

  • The FDA should allow more nuance in testing requirements for fertility samples. Patient medical history, including relationship status, should be considered.

  • The FDA should adjust the categories of donors to recognize the sexually and gender diverse people that may be using these methods.

It may be a while before the affected populations see any policy changes. “Federal agencies do not change very easily. Blood donation guidelines for gay men have only recently changed after several decades of advocacy and a large social movement behind the issue,” Shin says.

In the meantime, the authors hope their study raises awareness about this issue. Ideally, patients won’t be blindsided when seeking fertility preservation treatments.

“Many providers may not be aware of these policies or how they affect their patients. We wanted to kickstart this conversation from an equity perspective. Hopefully as more people become aware of this issue, there will be more support for a policy change in the future,” says Dr. Kathrins.

Martin N. Kathrins, MD


Alex S. Keuroghlian, MD


Andrew Shin


Andrew Shin
Medical Student