Reproductive Attorney, Law Office of Brian Esser
Family Planning Coordinator, The L.G.B.T. Community Center
Medical Director, Saint Barnabas Medical Center
Given the expense associated with building a family as a gay, or single, father, many are eager to have two children from a single cycle. For those who want to have multiple children in their family, having twins could save hundreds of thousands of dollars in a future surrogacy process. The option is especially popular for gay fathers because transferring multiple embryos may allow each partner to simultaneously become a biological father in the process.
To execute this, a reproductive endocrinologist will transfer multiple embryos to the surrogate. This dramatically cuts down on the risk that there won’t be a single live birth from the process, and raises the odds of a multiple pregnancy from the low single digits to the 30 – 40% range.
But, delivering twins carries a meaningfully higher risk to both the carrier and to the offspring. Twins typically are born at 36 weeks, instead of the 40 weeks needed to gestate, and in some circumstances come much earlier.
Reproductive endocrinologists are often conflicted about the concept of multiple embryo transfer in these cases. On the one hand, they want their customers to walk away with a baby, and they want their clinic’s publicly-available data to reflect their competency. On the other hand, they know transferring multiple high-quality embryos into a healthy uterus may come into conflict with the principle of “do no harm.”
While many clinics will claim they are a “single embryo clinic,” and the average number of embryos transferred from donor cycles has fallen precipitously (below), most clinics will still allow multiple embryo transfers. Today, the average number of embryos transferred during a donor egg cycle is still comfortably above 1.0, and the percentage of single-embryo donor cycles is still below half.
For gay couples, who will face substantially higher costs to have a family, many reproductive endocrinologists will break their own self-imposed rules and allow the transfer of multiple embryos. Some REs will come right out and declare they are amenable, and others may not broach their willingness until the second visit. All the same, this is something you want to discuss, and you may receive mixed signals as the RE seems to mull it over themselves. Given the real risks, this is something future parents, the surrogate, and the clinician need to weigh carefully.
Just as the medical risks rise with twins, so too do the average hospital costs. Often, whoever is paying for the medical bills will want to see a single embryo transfer take place. In some circumstances, where employers pay for a health plan that covers the cost of treatment, they will steer you towards a clinic known to do more single embryo transfers. For instance, Google will pay for up to three cycles of fertility treatment at a clinic where the company gets a discount and where single embryo transfers are regularly done.
At the same time, about one in three Americans is enrolled in a high-deductible health plan, which typically means those patients are responsible for a higher percentage of the overall hospital bills. In that case, you may care a great deal about the downstream costs from a multiple-birth pregnancy.
A major question gay couples struggle with, especially in the context of a single-embryo transfer, is whose sperm to use. This can be an incredibly sensitive subject, as some couples may not have the means to have another child, and both partners want to feel like they are equally “fathers.”
One solution is to fertilize the donor eggs with both men’s sperm. Thereafter, if the couple decides to do PGS genetic testing, they can decide which embryo to transfer based upon the health or gender of the embryo.
One question to consider is whether it makes sense to do ICSI and PGS during a gay surrogacy. ICSI is the process of injecting a single sperm into the egg to overcome issues of male factor infertility. While male factor infertility typically exists in 30 - 50% of infertility cases (and 3 – 10% of the male population at large), ICSI is used today in over 70% of cases. ICSI clearly shows benefit in delivering higher pregnancy rates, and live birth rates, in the setting of male factor infertility. In circumstances where there is no male factor infertility, ICSI has not been shown to increase live birth rates. ICSI typically costs $1,000 - $2,500, and while the risks associated seem slight, they are still understudied.
As for PGS, or Preimplantation Genetic Screening, that’s harder to answer. PGS is used as tool to help clinicians determine which embryo to transfer by ruling out embryos that are chromosomally abnormal. When a PGS-tested embryo is revealed to be chromosomally normal, in 67% of the cases, it will lead to a live-birth. The implications are that with PGS, you have a better chance of selecting a "good" embryo to transfer.
PGS skeptics, in this circumstance, might argue PGS is not necessary, because embryos created using eggs from younger, healthier egg donors, are far more likely to be chromosomally normal. Thus they’ll argue the benefit of using PGS is diminished compared to the utility of using it for a an older female patient, who has a higher percentage of worse embryos. At the same time, PGS biopsy itself is an additional procedure on the embryo, and one that costs upwards of $5,000, thus tacking on cost to an already expensive process.
PGS proponents take a different view: they cite research showing that 30 – 50% of embryos created from young egg donors are still abnormal and will lead to miscarriage, thus screening out those embryos is critical. And if you use an older donor, say your 35-year-old sister, the need to use PGS becomes more immediate. While PGS costs are substantial, they represent single-digit percentages of the total cost of this process, and if it can ensure an expensive, emotional, and time-consuming process does not end in a failed transfer or miscarriage, then it may be worth it. If transferring PGS-tested embryos allows you to utilize your surrogate in the window in which you paid for her, that is invaluable. If you lose your surrogate after multiple failed attempts, that can be devastating as you’ll be back to square one.
In the circumstances where everyone has decided on using a single embryo transfer, PGS-testing is often used to take advantage of this one-shot opportunity. What’s more, PGS testing will reveal the gender of each embryo. To the extent this is a useful data point to intended parents, according to our data, 45% of US fertility clinics will reveal the gender of each embryo to their clients.