Shared motherhood IVF: high delivery rates in a large study of treatments for lesbian couples using partner-donated eggs

Over recent decades, changes in attitudes towards lesbian couples (as well as unmarried single people and gay couples) have meant that assisted reproduction technique treatment has become increasingly accessible to them. In the UK, the right to civil partnership for same-sex couples was recognized in 2004, and same-sex marriage was introduced in 2014. In 2008, amendments were made to the Human Fertilisation and Embryology Act removing previous requirements for ‘a child's need for a father’ and allowing female partners to become legal parents. Subsequent equality legislation outlawed discrimination based on Protected Characteristics and prohibited refusal of fertility treatment based on sexual orientation (). In Europe and the USA, some professional bodies have issued concordant guidelines recognizing the right to access fertility treaments for singles, lesbian and gay couples as well as transgender people (, ).

Shared motherhood IVF treatment was first described in 2010 () and has generated extensive ethical debate. Whereas donor insemination or IVF with donor sperm (if a medical indication is present) was deemed acceptable for lesbian patients, for some practitioners and clinics, intra-couple egg donation for non-medical reasons was considered to be non-justifiable, risky and not cost-effective. According to a number of leading ethicists, however, this reasoning is weak and does not justify undermining autonomy by refusing to treat lesbian patients who wish to share their biological parenthood and accept undergoing a more complex procedure (, ). Currently, shared motherhood IVF treatment can only be practised without restriction in a few European countries, including Spain, from where the first published series has originated. Extensive ethical debate has led to it becoming gradually accepted in others, such as Belgium and Sweden; however, in many, such as France, Germany and Italy, shared motherhood IVF is either prohibited or discouraged (Table 1).

The current terminology describing shared motherhood IVF treatment is relatively heterogeneous, reflecting its unique clinical context. Although the term ‘intra-couple or intra-partner egg donation’ correctly describes the medical procedure itself, it might be perceived as too medical for lesbian couples who are not donating or receiving their own eggs for the same reasons as participants of altruistic egg-donation programmes (). Similarly, the uniquely Spanish acronym ROPA/REPA, established by the Barcelona group, which was the first to publish its experience, also underlines the medical aspect of ‘receiving eggs/embryos from the partner’ () and might be difficult to adopt in the English-language medical literature. The original term of ‘Co-IVF’ (or the similar sounding ‘Reciprocal IVF’) was coined by a US group emphasizing an equal contribution to the IVF process (). These authors have also insisted on abandoning the classical nomenclature of ‘donor’ and ‘recipient’ that simply focus on the providing and accepting female gametes. Similarly, some encourage the more sensitive utilization of ‘egg provider/giving partner’ and ‘receiving/gestating partner’ for prospective shared motherhood IVF couples. In our study, we have preferred to use the already existing term ‘shared motherhood IVF’ treatment to emphasize that, for lesbian couples, the main reason to undergo the complex IVF procedure is mostly non-medical, motivated by a strong wish to achieve shared parenthood as well as a more positive relationship between the parents.

In recent years, shared motherhood IVF treatment has become increasingly accepted among practitioners and patients; however, its overall efficiency and outcomes have been subject to little study and are poorly understood. Therefore, the aim of our retrospective review was to present our 6-year experience with shared motherhood IVF treatment from a single centre, that, over the past 2 decades, has been a leading provider of fertility care for same-sex couples in the UK.

As far we we are aware, this retrospective study reports the largest number of cases of women in a same-sex relationship who wish to share biological motherhood, and shows that intra-partner egg donation is an acceptable, successful and safe treatment option offering good obstetrical and perinatal outcomes.

The patients in our study derive from a country in which assisted reproduction techniques for lesbians (including shared motherhood IVF treatment) has been widely accepted for several years. In other European countries, eligibility criteria for lesbians to undergo fertility treatment are subject to great variation according to country-specific assisted reproduction technique legislation and other soft regulation (professional guidelines and generally accepted clinical practice) (). Moreover, relevant aspects of family law (marriage, registered partnership, legal parentship, adoption rules) also differ significantly and could limit the reproductive autonomy of lesbian couples wishing to conceive. A Europe-wide comparison shows that, whereas in recent years same-sex marriage has become fully legalized in Northern and Western countries (as well as Malta, Spain and Portugal), in several Southern-, Central- and some Eastern-European countries, only (limited) registered partnership is allowed, and in a number of other Eastern-European countries, neither is permitted. A similar pattern (North and West versus South and East Europe) arises when examining the eligibility of lesbians to undergo fertility treatment either as couples (involving both partners with joint parenthood allowed legally, mainly in Northern-Western Europe, Spain and Portugal); only when declaring as a ‘single’ woman (for some Southern and Eastern-European countries); or no access to assisted reproduction technique at all (in some Eastern-European contries but also France and Italy) (). Less information is available on the possibility of undergoing shared mothethood IVF treatment, which, apart from assisted reproduction technique eligibility rules, is also affected by whether or not oocyte donation is legally authorized in a particular country. At present, only a few countries (including Belgium, Finland, Ireland, the Netherlands, Spain, Portugal and the UK) allow this treatment option without any restriction. In these countries, the following generally apply: same-sex marriage is allowed, lesbians are eligible for all forms of assisted reproduction techniques, and ‘known’ egg donation (when the donor is known by the recipient) is not restricted. So far, however, far most reported cases of shared parenthood have emerged from just two European countries (Spain and UK), although this might change with increasing patient demand and the gradually accumulating experience of IVF centres in different countries. This European ‘legal patchwork’ also opens the possibility of cross-border reproductive care for lesbian couples who want to share motherhood; in fact, in our series 12 couples (10%) were cross-border reproductive care patients.

In the present study, non-medical indications were predominant (about 60%), reflecting that, for many lesbian couples, experiencing shared motherhood was the primary objective of choosing this treatment option. In contrast, medical reasons (previous failed IUI or IVF treatment, diminished ovarian reserve markers or advanced female age) were present in about 40% of receiving partners. These indications, however, were often not exclusive and usually co-existed with the wish to share motherhood. Currently, studies on the motivations of prospective same-sex couples choosing shared motherhood treatment and how they choose their reproductive (egg-provider or gestating) roles are lacking.

Different approaches can be used for shared motherhood IVF treatment. Apart from the already described synchronized and non-synchronized treatment options, another less conventional scenario during a synchronized treatment might involve the simultaneous fresh embryo transfer in both partners with the possibility of concordant success and simultaneous (even multiple) pregnancies and deliveries. Understandably, this option puts higher physical and psychological strain on the couple, and therefore it is only rarely chosen. Same-sex couples also have the unique possibility of switching their reproductive roles after a successful treatment (and delivery) or in the case of unsuccessful treatment (usually if cycle outcome was suboptimal with suspected egg quality issues). Compared with heterosexual couples undergoing IVF, same-sex couples undergoing shared motherhood IVF treatment inherently have an increased reproductive potential. If for any medical reason (related to egg/embryo quality or uterine conditions) a treatment cycle is unsuccessful, by switching provider or recipient roles the lesbian couple could compensate for a previous failed attempt. Similarly, for those couples in whom intra-couple egg donation would be indicated for a purely medical reason (ovarian or uterine indications), resorting to shared motherhood IVF treatment would reduce the need for anonymous egg donation or surrogacy treatment (often conducted abroad).

In our study, most sharers were stimulated using co-treatment with a GnRH antagonist protocol and GnRH agonist triggering, resulting in the absence of any significant moderate to severe OHSS cases. This approach is consistent with the now well-established policy routinely used for anonymous oocyte donors that has been proven to be much safer and as efficient (compared with GnRH agonist-based protocols) both in large published series and a meta-analysis (, ). Similarly, from the receiving partner's point of view, single embryo transfer at the blastocyst-stage was the preferred option which contributed to maintaining a high success rate while reducing the number of multiple conceptions close to the level recommended by the HFEA (). Although basic perinatal outcomes were significantly better for singletons, no severe prematurity has occurred, and perinatal outcome was favourable even for twins. The caesarean section rate in singletons, however, was well above the UK national level (42 versus 26.2% in 2013–2014), which clearly needs further attention ().

The findings of our study are concordant with previous smaller studies reporting on the outcome of couples undergoing intra-couple egg donation treatment. The first published European study reported the pioneering experience of a Spanish group from Barcelona () on 14 same-sex couples who achieved 4 (29%) ongoing pregnancies. Although this study was small, it has successfully focused attention on this new treatment option and generated an extensive ethical debate that has influenced awareness among clinicians throughout Europe (, ). A more recent study reported a similarly encouraging experience from a single centre in New York between 2002 and 2014 (). This study involved 21 same-sex couples undergoing ‘Co-IVF’ treatments who achieved 13 (62%) ongoing pregnancies, a similar overall outcome to ours. Sixty-two per cent of the couples had some medical indication, mainly previously failed IUI and IVF treatments or diminished ovarian reserves. Although no obstetrical outcome data were presented, the proportion of multiple deliveries was 33% (including a triplet pregnancy), suggesting that the average number of transferred embryos was much higher (2.4 compared with 1.4) than in our study.

Limitations of our study are related to its retrospective nature. It included all consecutive couples undergoing shared motherhood IVF treatment at our centre, however, thus reducing the risk of selection bias. As its strength, it represents the largest published series so far, giving insight into patient characteristics and overall outcomes that were not available until now.

In conclusion, shared motherhood IVF is an increasingly requested form of assisted reproduction technique treatment among many lesbian couples. Increasingly, the autonomy of lesbian patients is being respected even though complex IVF treatment is carried out for (mostly) non-medical indications. To this end, OHSS-free ovarian stimulation with single-blastocyst-transfer provides a uniquely safe and highly efficient treatment modality. As shared motherhood IVF is taken up more widely worldwide, studies on mother–child relationships will become paramount to understand the psychological wellbeing of children born through this emerging medical procedure.

The authors greatly appreciate the present manuscript's thorough review and suggestions made by Dr Zeynep Gurtin and Professor Susan Golombok.