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Understanding the Reproductive Experience and Pregnancy
Outcomes of Lesbian Women Undergoing Donor
Intrauterine Insemination
Taraneh Gharib Nazem, MD,
1,2
Sydney Chang, MD,
1,2
Joseph A. Lee,
1
Christine Briton-Jones,
1
Alan B. Copperman, MD,
1,2
and Beth McAvey, MD
1,3
Abstract
Purpose: The study purpose was to evaluate the reproductive experience, specifically cycle characteristics and
treatment outcomes, of lesbian women. In addition, we aimed to determine whether there are differences in preg-
nancy outcomes when comparing lesbian women undergoing ovulation induction (OI) versus natural cycles with
donor intrauterine insemination (IUI), as well as lesbian and heterosexual women undergoing the same assisted
reproductive technology treatment.
Methods: This was a retrospective cohort study including women who underwent an IUI with cryopreserved
sperm between 2006 and 2018. The primary outcome of interest was clinical pregnancy (CP) rate.
Results: A total of 216 lesbian women (451 natural cycles and 441 OI cycles) and 584 heterosexual women (1177
natural cycles and 1238 OI cycles) were included in the study. Thirty percent of lesbian women had a hysterosal-
pingogram as part of their initial workup. Approximately 40% of lesbian women who underwent OI/IUI had pre-
viously undergone at least one natural cycle/IUI. There was no significant difference in CP rate when comparing
lesbian women and heterosexual women undergoing natural or OI/IUI, or when comparing lesbian women who
underwent natural versus OI/IUI cycles. However, there was a significantly higher multiple gestation rate among
lesbian women undergoing OI compared with those undergoing natural cycles (11.8% vs. 0%, p=0.01).
Conclusion: This large study showed that while pregnancy outcomes were similar between groups, the multiple
gestation rate was higher in lesbian women undergoing OI compared with lesbian women undergoing natural cycles.
Keywords: intrauterine insemination, lesbian, ovulation induction, pregnancy
Introduction
Lesbian women have been building families through bi-
ological and nonbiological methods of parenting for
years. However, as the field of assisted reproductive technol-
ogy (ART) has advanced, additional family building options
have been developed, which have helped lesbian women
overcome the obstacles of reproduction. The reproductive
journey for lesbian couples is particularly unique, as lesbian
women have many available treatment options, but those
seeking treatment do not always have a diagnosis of infertil-
ity. However, there are limited data regarding ART treatment
outcomes in this presumably fertile population, and how the
reproductive experience of lesbian women differs from that
of heterosexual couples experiencing infertility.
Lesbian women encounter different reproductive obsta-
cles compared with heterosexual couples experiencing in-
fertility. Given their limited access to sperm or ‘‘absolute’’
male factor infertility, lesbian women must go through the
process of selecting a sperm donor, either known or anony-
mous, who is most compatible with their personal, medical,
and genetic background. Lesbian and heterosexual patients
seeking anonymous sperm donors may find this selection
process to be arduous due to the vast number of national
sperm donor registries available and the many historical
and medical components involved in their decision-making.
In addition, these women must manage the cost of shipping,
storing, and processing cryopreserved donor sperm samples.
Prices can rise substantially for women who undergo multi-
ple treatment cycles or for those who want extended storage
1
Reproductive Medicine Associates of New York, New York, New York.
2
Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York.
3
Department of Obstetrics and Gynecology, Icahn School of Medicine at Mount Sinai West, New York, New York.
LGBT Health
Volume 6, Number 2, 2019
ªMary Ann Liebert, Inc.
DOI: 10.1089/lgbt.2018.0151
62
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of multiple samples for future biological siblings for their
children.
1
Even though many lesbian women present for reproduc-
tive care without a diagnosis of infertility, they often undergo
a similar workup and treatment plan to heterosexual patients
with infertility. For example, a hysterosalpingogram (HSG)
is often part of this routine screening. And, while lesbian
women need access to donor sperm and often undergo an in-
trauterine insemination (IUI), there are many different meth-
ods of cycle preparation. During a natural cycle, patients may
monitor ovulation with home detection kits or by an ultra-
sound to confirm follicular maturity. In oligo-ovulatory patients
or hypothalamic patients, oral or injectable medications can be
used to induce ovulation. These medications can also be uti-
lized to achieve superovulation for patients with unexplained
infertility. A trigger shot with human chorionic gonadotropin
(hCG) is often employed to optimally time a donor IUI for
all types of cycles. Unlike heterosexual patients, lesbian cou-
ples sometimes have the unique opportunity to choose which
partner will carry the gestation as in many cases both partners
may have the reproductive ability to do so. Some couples opt to
undergo co-in vitro fertilization (co-IVF), also commonly
referred to as reception of oocytes from partner, in order
for both partners to share in the experience of biological
parenting.
2
Choosing the ideal treatment plan that minimizes cost and
time and optimizes the likelihood of achieving a healthy
baby can be challenging for lesbian patients as data regarding
ART outcomes in this population are limited and conflicting.
Although some studies have shown no difference in preg-
nancy rates when comparing lesbian women with heterosex-
ual women undergoing the same treatment with ovulation
induction (OI) and IUI,
3–5
others have shown improved preg-
nancy rates among lesbian women compared with heterosex-
ual women undergoing ART treatment.
6
This study aimed to characterize the typical reproductive
experience, specifically cycle characteristics and treatment
outcomes, of lesbian women. The study also sought to deter-
mine whether there are differences in pregnancy outcomes
when comparing lesbian women undergoing different types
of ART treatments as well as lesbian women and heterosex-
ual women undergoing the same type of treatment. The in-
tention of the study was to better define the reproductive
experience for lesbian couples seeking care at a fertility prac-
tice and determine the ideal mode of treatment for this
unique group of women.
Methods
This single-center, retrospective cohort analysis included
women 25–44 years of age, who underwent ART treatment
at an academic, private fertility practice between 2006 and
2018. Lesbian and heterosexual women who pursued natural
cycles or OI with IUI with a cryopreserved sperm source
were identified in an electronic medical record database
and included in the study. Patients undergoing OI for multi-
ple indications, including anovulatory disorders or polycys-
tic ovary syndrome (PCOS), unexplained infertility, and
male factor infertility, were included. PCOS was diagnosed
based on Rotterdam criteria.
7
Patients with an endometrial
thickness less than 6 mm at the time of IUI were excluded
from the analysis. Patients using injectable gonadotropins
for OI or with less than 5 million total motile sperm on
semen analysis (SA) at the time of IUI were also excluded.
During the study time frame, while several ART practices
have changed, natural cycle and clomiphene citrate (CC)
OI protocols have remained standardized. Letrozole was
more consistently used for OI starting in 2012. This study
was approved by the Icahn School of Medicine at Mount
Sinai Institutional Review Board with a waiver of patient
consent.
Patient selection
Lesbian and heterosexual women were included in the
study and identified through natural language processing of
electronic medical records. Women who self-identified as
‘‘lesbian’’ or in a ‘‘same-sex couple’’ relationship were in-
cluded in the ‘‘lesbian women’’ group. Women without
these identifiers and who had a known male partner in the da-
tabase were included in the ‘‘heterosexual women’’ group.
Women who identified as ‘‘single,’’ or as a ‘‘single mother
by choice,’’ or those who indicated a desire for ‘‘single par-
enting,’’ were excluded from the analysis.
Natural cycle
Patients undergoing natural cycle preparation for IUI were
monitored for the presence of a dominant follicle. Monitor-
ing was performed by transvaginal ultrasound starting be-
tween day 10 and 14, depending on cycle length, until a
dominant follicle (‡18 mm) was observed, at which point
ovulation was triggered with recombinant hCG (Ovidrel
;
EMD Serono, Inc., Rockland, MA). Endometrial thickness
was also recorded at this cycle time point. IUI was performed
36 hours after ovulation trigger was administered.
OI with oral medications
OI was performed with CC, a selective estrogen receptor
modulator, or letrozole, a third-generation aromatase inhibi-
tor. The choice of controlled ovarian stimulation protocol
was determined by the treating physician. Typically, women
with unexplained infertility were started on CC and those
with PCOS were placed on letrozole; however, variation in
medication choice was based on physician discretion. These
medications were administered starting on cycle day 3 until
cycle day 7. Initial doses of 100 mg of CC and 5 mg of letro-
zole were used until ovarian response was observed. Monitor-
ing by transvaginal ultrasound was performed starting on
cycle day 11 to 12 until a dominant follicle (‡18 mm) was
identified. If no response to oral medication was observed,
either the cycle was cancelled or additional medication
was administered in a stair-step manner, in which a higher
dose of the same medication was prescribed in step-wise in-
crements (e.g., CC 100 mg to 150 mg to 200 mg or letrozole
5 mg to 7.5 mg). Ovulation trigger and IUI were performed
as described in the natural cycle protocol.
Intrauterine insemination
Previously cryopreserved sperm samples were thawed in a
37-degree incubator for 15 minutes on the morning of the
scheduled IUI. Samples were then homogenized thoroughly
with a large volume pipette and the volume of the sample
and spermatozoa count was recorded. Sperm wash (Irvine
UNDERSTANDING THE LESBIAN REPRODUCTIVE EXPERIENCE 63
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Scientific, Santa Ana, CA) was then added to twice the vol-
ume of the sample and the sample was mixed. The sample
was then centrifuged at 300 times gravity, approximately
1500 revolutions per minute for 10 minutes. The supernatant
was then removed and the pellet was resuspended in 0.3 mL
of sperm wash media and mixed.
Outcome measures
Data were collected regarding the patient reproductive
journey, including diagnostic procedures and the number
and type of cycles each patient underwent. Patient demo-
graphics and baseline characteristics that were collected in-
cluded age, body mass index (BMI), gravidity, parity, and
markers of ovarian reserve (anti-Mu
¨llerian hormone [AMH]
level, day 3 follicle-stimulating hormone [FSH] level, and
basal antral follicle count [BAFC]). Several cycle characteris-
tics were also determined, including the number of mature fol-
licles and the endometrial thickness at the time of ovulatory
surge and SA parameters, specifically the total motile sperm
count (TMSC).
The primary outcome of interest was the clinical preg-
nancy (CP) rate, which was confirmed by the presence of a
gestational sac on transvaginal ultrasound. Secondary out-
comes included ongoing pregnancy/live birth (OP/LB) rate,
early pregnancy loss (EPL) rate, and clinical pregnancy
loss (CPL) rate. An OP was defined as a viable intrauterine
gestation at the time of discharge from the practice, which
occurred no earlier than 8 weeks of gestation. A LB was con-
sidered the delivery of a live born infant after 24 weeks of
gestation. EPL was defined as a loss following a positive
pregnancy test and before the detection of an intrauterine
gestational sac on ultrasound. CPL was defined as a loss fol-
lowing a positive pregnancy test and the detection of an in-
trauterine gestational sac on ultrasound. Multiple gestations
were defined by the presence of more than one gestational
sac on transvaginal ultrasound.
Statistical analyses
Demographic and cycle characteristics, as well as preg-
nancy outcomes were compared using a Student’s t-test,
Fisher’s exact test, and chi-squared test. A p-value of
<0.05 was considered significant. To assess differences in
clinical outcomes, a multivariate logistic regression was per-
formed for each outcome (CP, OP/LB, EPL, and CPL rate).
Models were adjusted for covariates, including age, markers
of ovarian reserve, number of mature follicles at the time of
surge, parity, and TMSC on SA. Likelihood of clinical out-
comes was presented as odds ratios (OR) with 95% confi-
dence intervals (CIs). All analyses were conducted using
SAS software (SAS Institute Inc., Cary, NC).
Results
A total of 216 lesbian women underwent 451 natural cy-
cles and 441 OI cycles. A total of 584 heterosexual women
underwent 1177 natural cycles and 1238 OI cycles. Of the
lesbian patients who underwent IUI cycles, 64 (30%) had
an HSG as part of their initial workup. The majority of les-
bian women who underwent a diagnostic HSG had a risk fac-
tor for tubal disease or had a hydrosalpinx identified on
ultrasound. Among heterosexual patients, 64% of patients
undergoing natural cycles and 81% of patients undergoing
OI cycles had an HSG as part of their diagnostic workup.
Of lesbian women who underwent OI, approximately 40%
Table 2. Lesbian and Heterosexual Women
Undergoing Ovulation Induction Cycles
Lesbian
women
(n=441)
Heterosexual
women
(n=1238)
pMean –SD Mean –SD
Age (years) 36.2 –4.0 38.4 –4.6 <0.0001
Body mass index
(kg/m
2
)
26.3 –5.7 26.1 –5.7 0.74
Day 3 follicle-
stimulating
hormone (ng/mL)
7.31 –2.9 8.3 –3.8 <0.0001
Anti-Mu
¨llerian
hormone (ng/dL)
4.1 –4.1 2.5 –2.8 <0.0001
Basal antral follicle
count
15.5 –7.3 13.7 –7.6 0.42
Number of mature
follicles at the
time of surge
1.6 –0.9 1.7 –0.9 0.03
Endometrial
thickness
at the time of
surge (mm)
8.7 –1.8 8.4 –1.6 0.0003
Gravidity 0.50 –0.7 0.75 –1.0 0.0001
Parity 0.16 –0.6 0.21 –0.5 0.30
Total motile sperm
count (millions
of sperm)
47.3 –13.1 48.6 –15.2 0.08
Clomid use (%, n) 62.6%
(276/441)
65.1%
(806/1238)
0.34
Table 1. Lesbian and Heterosexual Women
Undergoing Natural Cycles
Lesbian
women
(n=451)
Heterosexual
women
(n=1177)
pMean –SD Mean –SD
Age (years) 36.1 –3.8 39.3 –4.7 <0.0001
Body mass index
(kg/m
2
)
24.6 –5.7 25.7 –5.2 0.004
Day 3 follicle-
stimulating
hormone (ng/mL)
8.1 –4.8 8.0 –4.0 0.79
Anti-Mu
¨llerian
hormone (ng/dL)
4.0 –2.8 2.1 –1.7 0.002
Basal antral follicle
count
19 –3.6 14.6 –5.4 0.24
Number of mature
follicles at the
time of surge
0.96 –0.3 0.95 –0.4 0.66
Endometrial thickness
at the time of
surge (mm)
9.1 –1.7 8.9 –1.7 0.03
Gravidity 0.41 –0.8 0.73 –1.1 0.0006
Parity 0.11 –0.5 0.24 –0.5 0.0003
Total motile sperm
count (millions
of sperm)
46.8 –12.2 45.1 –14.1 0.02
64 NAZEM ET AL.
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had undergone at least one prior natural/IUI cycle (range
1–11 cycles).
Demographic and cycle characteristics of patients who un-
derwent natural and OI cycles are listed in Tables 1 and 2,
respectively. Lesbian women undergoing natural cycles were
younger (36.1 –3.8 vs. 39.3 –4.7 years, p<0.0001) and had a
lower BMI (24.6 –5.7 vs. 25.7 –5.2 kg/m
2
,p=0.004), higher
ovarian reserve (AMH 4.0 –2.8 vs. 2.1 –1.7, p=0.002), and
lower gravidity (0.41 –0.8 vs. 0.73 –1.1, p=0.0006) and parity
(0.11 –0.5 vs. 0.24 –0.5, p=0.0003) compared with heterosex-
ual women who underwent a natural cycles. Lesbian women
also had a thicker endometrial lining at the time of surge
(9.1 –1.7 vs. 8.9 –1.7 mm, p=0.03) and a higher TMSC on
SA (46.8 –12.2 vs. 45.1 –14.1, p=0.02) compared with het-
erosexual women. There were no significant differences in
day 3 FSH, BAFC, or the number of mature follicles at the
time of surge among groups undergoing natural cycles.
Among patients undergoing OI cycles, lesbian women
were younger (36.2 –4.0 vs. 38.4 –4.6 years, p<0.0001)
and had lower gravidity (0.50 –0.7 vs. 0.75 –1.0 p=0.0001),
higher ovarian reserve (AMH 4.1 –4.1 vs. 2.5 –2.8,
p<0.0001, lower day 3 FSH 7.31–2.9 vs. 8.3 –3.8 ng/mL,
p<0.0001), fewer mature follicles (1.6 –0.9 vs. 1.7 –0.9,
p=0.03), and thicker endometrium at surge (8.7–1.8 vs. 8.4 –
1.6 mm, p=0.0003), compared with heterosexual women. No
differences in BMI, BAFC, TMSC on SA, or parity were ob-
served among study cohorts.
A comparison of patient demographics and cycle charac-
teristics among lesbian women undergoing natural and OI
cycles is presented in Table 3. Lesbian women undergoing
OI cycles had a higher BMI (26.3 –5.7 vs. 24.6 –5.7 kg/m
2
,
p=0.003), lower day 3 FSH (7.31 –2.9 vs. 8.1 –4.8, p=0.04),
more mature follicles at the time of surge (1.6 –0.9 vs.
0.96 –0.3 follicles, p<0.0001), and thinner endometrial lin-
ings at the time of surge (8.7 –1.8 vs. 9.1 –1.7 mm, p=0.01)
compared with those undergoing natural cycles. Both groups
were similar in age, AMH, BAFC, gravidity, and parity and
had comparable SA parameters at the time of IUI.
There were no significant differences in CP, OP/LB, EPL,
CPL, or multiple gestation rate when comparing lesbian women
and heterosexual women undergoing natural (Table 4) and OI
cycles (Table 5). After adjusting for all observed confound-
ers, the likelihood of CP (natural cycle: OR 0.4 [95% CI
0.1–2.2], OI cycle: OR 1.4 [95% CI 0.4–4.6]), OP/LB (natural
cycle: OR 0.5 [95% CI 0.1–3.6], OI cycle: OR 3.2 [95% CI
0.4–29.1]), EPL (natural cycle: OR 1.7 [95% CI 0.1–31.4],
OI cycle: OR 0.7 [95% CI 0.1–8.1]), and CPL (natural
cycle: OR 0.1 [95% CI 0.002–4.2], OI cycle: 0.6 [95% CI
0.1–4.1]) were not significantly different between lesbian
women and heterosexual women.
When evaluating lesbian women who underwent natural
cycle/IUI compared with OI/IUI, no significant differences
in CP, OP/LB, EPL, and CPL rates, despite a higher average
number of mature follicles at the time of surge in the OI
group, were observed. However, for lesbian women, there
was a statistically higher multiple gestation rate among
those undergoing OI compared with those undergoing natu-
ral cycles (11.8% vs. 0%, p=0.01) (Table 6). Similarly, het-
erosexual women undergoing OI compared with those
undergoing natural cycles had a higher multiple gestation
rate (12.4% vs. 1.2%, p=0.0003).
Discussion
Lesbian women present for reproductive care often not
for a medical indication, but instead to gain access to repro-
ductive opportunities that are not otherwise available to
them. Although lesbian womenhaveaccesstomanytreat-
ment options, including the choice of shared motherhood
through co-IVF, these treatments come with a high burden
of cost and invasiveness that their heterosexual counterparts
do not always experience. In addition, several other ques-
tions regarding who will carry the gestation, the donor
sperm source, and the cost of using an anonymous rather
Table 3. Lesbian Women Undergoing Natural
and Ovulation Induction Cycles
Natural
cycles
(n=451)
Ovulation
induction
cycles
(n=441)
pMean –SD Mean –SD
Age (years) 36.1 –3.8 36.2 –4.0 0.79
Body mass
index (kg/m
2
)
24.6 –5.7 26.3 –5.7 0.003
Day 3 follicle-
stimulating
hormone (ng/mL)
8.1 –4.8 7.31 –2.9 0.04
Anti-Mu
¨llerian
hormone (ng/dL)
4.0 –2.8 4.1 –4.1 0.84
Basal antral follicle
count
19 –3.6 15.5 –7.3 0.86
Number of mature
follicles at the
time of surge
0.96 –0.3 1.6 –0.9 <0.0001
Endometrial thickness
at the time of
surge (mm)
9.1 –1.7 8.7 –1.8 0.01
Gravidity 0.41 –0.8 0.50 –0.7 0.34
Parity 0.11 –0.5 0.16 –0.6 0.27
Total motile sperm
count (millions
of sperm)
46.8 –12.2 47.3 –13.1 0.54
Table 4. Pregnancy Outcomes Among Lesbian
and Heterosexual Women Undergoing
Natural Cycles
Lesbian
women
(n=451)
Heterosexual
women
(n=1177)
p%(n)%(n)
Clinical
pregnancy rate
9.5% (43/451) 7.2% (85/1177) 0.12
Ongoing
pregnancy/live
birth rate
7.3% (33/451) 5.7% (67/1177) 0.22
Early pregnancy
loss rate
3.8% (17/451) 2.7% (32/1177) 0.27
Clinical
pregnancy
loss rate
23.3% (10/43) 21.2% (18/85) 0.79
Multiple gestation
rate
0% (0/43) 1.2% (1/85) 0.52
UNDERSTANDING THE LESBIAN REPRODUCTIVE EXPERIENCE 65
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than known sperm donor must be addressed with lesbian
women. Thus, the usual treatment paradigms used for a het-
erosexual couple experiencing infertility may need to be ad-
justed for lesbian patients.
Even though lesbian women have been using ART for
years, there is limited information regarding their experience
and likelihood of success with treatments. This lack of data
may be a result of incomplete societal and political accep-
tance of sexual minority individuals; however, with legaliza-
tion of same-sex marriage by the U.S. Supreme Court in
2015 and support from the American Society for Reproduc-
tive Medicine,
8
these barriers are breaking down. In the
United States alone, between 6 and 14 million children are
being raised by at least one gay or lesbian parent.
8
However,
as of 2014, only 60.2% of Society for Assisted Reproductive
Technology clinics reported treating lesbian couples.
9,10
As a
result, there is a paucity of data regarding utilization trends
and the reproductive experience of lesbian women seeking
fertility treatment.
In this large study, we found that approximately 30% of
lesbian women undergoing care at a reproductive practice
underwent an HSG as part of their initial evaluation, which
was warranted as most of these women had a risk factor
for tubal disease. This rate of HSG testing is lower compared
with the heterosexual population with infertility issues un-
dergoing treatment; however, this difference may be due to
the fact that lesbian women are presumptively fertile and
therefore, many may lack an indication for the test. Still, pro-
viders must employ clinical judgment when determining
whether a patient is an appropriate candidate for an HSG, es-
pecially given that lesbian women tend to have a higher rate
of gynecologic problems (i.e. chlamydia and salpingitis)
compared with heterosexual women.
3,11
Although lesbian women may not always have a medical
diagnosis of infertility, our findings demonstrate comparable
pregnancy rates between lesbian and infertile heterosexual
women undergoing both OI with oral medications and natu-
ral cycle IUI. This finding is in contrast to prior literature that
has suggested an improved pregnancy rate among lesbian
women compared with the general population
6,12
; however,
those studies have been limited by the inclusion of multiple
types of ART treatments and a lack of adjustment for possi-
ble confounders in the analysis. Although our findings are
consistent with several other studies that identified no signif-
icant difference in pregnancy outcomes between lesbian and
heterosexual women,
3,4,13
this is the first to evaluate preg-
nancy rates in women only taking oral OI medications, in-
cluding both CC and letrozole.
This study is also the first to assess pregnancy outcomes
among lesbian women pursuing different types of cycles before
IUI. A large proportion of lesbian women in the study began
their reproductive journey with a natural/IUI cycle before pro-
ceeding to ovarian stimulation with oral medications. Although
there was no difference in CP or OP/LB rates among lesbian
women who underwent a natural or OI cycle with IUI, a statis-
tically and clinically significantly higher multiple gestation rate
was observed among lesbian women who underwent OI com-
pared with those who underwent a natural cycle/IUI (11.8% vs.
0%, p=0.01). As singleton deliveries have become a priority
in the field of reproductive medicine, particularly following
ART treatment, this study suggests that prolonged treatment
with natural IUI cycles may be one method to minimize the
risk associated with multiple gestations.
Limitations
Some findings in this study warrant further discussion. In
particular, the observed CP and OP/LB rates for lesbian
women are lower than expected in a fertile population.
These findings may be explained by the utilization of cryo-
preserved sperm compared to fresh sperm, which has been
shown to result in lower cycle fecundity rates.
14
In addition,
these low success rates may suggest the limitations of ART
treatment for both lesbian and heterosexual patients. The
study may also be limited by a lack of information about cer-
tain diagnoses among lesbian patients, which could predis-
pose them to lower success rates (e.g., endometriosis or
PCOS). In fact, some previous literature has suggested a
higher prevalence of PCOS among lesbian women compared
to heterosexual women,
15
which could explain reproduc-
tive outcomes for this sexual minority group. In addition,
the retrospective design may introduce selection bias in our
Table 5. Pregnancy Outcomes Among Lesbian
and Heterosexual Women Undergoing Ovulation
Induction Cycles
Lesbian
women
(n=441)
Heterosexual
women
(n=1238)
p%(n)%(n)
Clinical
pregnancy rate
11.6% (51/441) 10.4% (129/1238) 0.51
Ongoing
pregnancy/live
birth rate
8.4% (37/441) 7.8% (97/1238) 0.71
Early pregnancy
loss rate
2.7% (12/441) 3.4% (42/1238) 0.49
Clinical
pregnancy
loss rate
27.5% (14/51) 24.8% (32/129) 0.69
Multiple
gestation rate
11.8% (6/51) 12.4% (16/129) 0.91
Table 6. Pregnancy Outcomes Among Lesbian
Women Undergoing Natural and Ovulation
Induction Cycles
Natural
cycles
(N=451)
Ovulation
induction
cycles
(n=441)
p%(n)%(n)
Clinical pregnancy
rate
9.5% (43/451) 11.6% (51/441) 0.32
Ongoing
pregnancy/live
birth rate
7.3% (33/451) 8.4% (37/441) 0.55
Early pregnancy
loss rate
3.8% (17/451) 2.7% (12/441) 0.38
Clinical pregnancy
loss rate
23.3% (10/43) 27.5% (14/51) 0.38
Multiple gestation
rate
0% (0/43) 11.8% (6/51) 0.01
66 NAZEM ET AL.
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results as patients were not randomized to groups, but rather
chosen based on whether they self-identified as lesbian or
heterosexual. However, both the univariate and multivariate
analyses, which were adjusted for possible confounders,
showed consistent findings.
Strengths
Strengths of the study include a large sample size and a
comparative analysis of cycle types among different popula-
tions. It is also one of the largest studies to characterize uti-
lization trends and ART outcomes in a lesbian population
seeking reproductive care. The study was also performed
in a single clinic with minimal practice variation and stan-
dardized sperm processing.
Summary
As access to care continues to improve, and more lesbian
couples engage in their reproductive journey, there will be an
increased need to identify methods to maximize treatment
success without minimizing the experience of family build-
ing. Personalized medicine is important for all patients, but
may be particularly necessary in the lesbian community as
these women do not always have a medical diagnosis of in-
fertility. Although pregnancy outcomes were similar among
lesbian and heterosexual women undergoing OI and IUI
with cryopreserved sperm, the study found a higher rate
of multiple gestations among lesbian women undergoing
OI compared to those undergoing natural cycle IUI with
no difference in pregnancy rates between these two groups.
Given the prioritization of achieving one healthy pregnancy
at a time in the field of reproductive medicine, this study
provides new insight regarding the optimal strategy to reach
this goal.
Conclusion
The reproductive experience of lesbian women differs
from that of heterosexual women with infertility. This
large study is the first to evaluate pregnancy outcomes
among lesbian and heterosexual women undergoing OI
with CC or letrozole and IUI with cryopreserved sperm, as
well as among lesbian patients undergoing different IUI
cycle types. Although pregnancy outcomes were similar be-
tween the groups, the multiple gestation rate was higher in
lesbian women undergoing OI compared with lesbian
women undergoing natural cycles. Given the importance of
singleton deliveries in the field of reproductive medicine,
natural cycle IUI may be a safer way for lesbian women to
achieve a successful pregnancy.
Acknowledgments
The authors acknowledge all the physicians and laboratory
staff at Reproductive Medicine Associates of New York for
their contribution to patient care, without which this study
would not be possible.
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Taraneh Gharib Nazem, MD
Reproductive Medicine Associates of New York
635 Madison Avenue, 10th Floor
New York, NY 10022
E-mail: tnazem@rmany.com
UNDERSTANDING THE LESBIAN REPRODUCTIVE EXPERIENCE 67
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