Pathways to Pregnancy for Sexual Minority Women in Same-sex Marriages

Objective In August 2018, the American Congress of Obstetricians and Gynecologists reaffirmed its support for marriage equality for all adults and its intent to “understand, recognize, and address the challenges the [lesbian, gay, bisexual, transgender, intersex, queer/questioning, asexual and many other terms (such as nonbinary and pansexual)] and gender nonconforming communities experience in accessing reproductive health care, including family building.”1 There are more than 280,000 women in same-sex marriages in the United States,2 yet little is known about how they build families. Specifically, no research we are aware of has documented the prevalence of fertility treatments and technologies used by this population. Prior work found sexual minority women have worse pregnancy outcomes compared with heterosexual women.3 While more work is needed to confirm and better understand this finding, it is important to identify and consider how sexual minority women conceive their pregnancies. Our objective was to describe fertility technologies and treatments used by women with live births in same-sex marriages. Study Design We estimated the prevalence of types of fertility treatments for women in same-sex and different-sex marriages using birth certificate data from Massachusetts for all live births from 2012 to 2016. Our unit of analysis was pregnancies with live births, which included all births per mother in a given pregnancy (n = 234,597 pregnancies). Use of fertility services and technologies was identified from the hospital data and the birth certificate worksheet completed by the parents. Pregnancies were identified as resulting from 1 or more of the following: any infertility treatment, fertility-enhancing drugs, assisted reproductive technology, intrauterine insemination, intracervical insemination, and anonymous donor sperm. These data could have been underreported or misreported, yet it is unclear whether accuracy of reports differed between pregnancies of same- and different-sex couples. Results Compared with pregnancies of women in different-sex couples (n = 233,158), the proportion of pregnancies to women in same-sex couples (n = 1439) was 12 times higher for use of any type of fertility treatments, 9 times higher for fertility-enhancing drugs and assisted reproductive technology (in vitro fertilization), 33 times higher for intrauterine insemination, and 44 times higher for intracervical insemination (Table). Among all pregnancies using anonymous donor sperm, 4 in 5 were to women in same-sex couples (854 of 1081)