Decision making of male same-sex couples pursuing pregnancy via assisted reproductive technology: a qualitative study

Abstract

Objective

To explore the decision-making of male same-sex couples when selecting sperm, donor eggs, and embryo(s) to transfer when using assisted reproductive technology (ART).

Design

Qualitative.

Subjects

Twenty participants: 8 successfully achieved pregnancy via ART, and 12 were actively pursuing pregnancy. Most participants were gay, White, cisgender men.

Exposure

Not applicable.

Main Outcome Measures

Reflexive thematic analysis of interview transcripts.

Results

Four themes related to the decision-making processes of male same-sex couples using ART were conceptualized from the data and included desire for actual or perceived genetic relatedness, actual or perceived risk mitigation, desire for control, and financial cost. Many couples preferred using ART because both partners wanted to contribute sperm to fertilize donor eggs. Couples often preferred using the same egg donor if they wanted more than one child, and many couples wanted to achieve a blended family by using an egg donor who looked like one or both partners. Many couples made decisions, such as genetically testing embryos or transferring a single embryo into a gestational carrier, on the basis of increasing the chances of a healthy pregnancy. Some couples wanted more control during the process; thus, they made decisions regarding sex selection because they had the option to. The high financial cost of ART was the largest barrier for many couples, causing many to make sacrifices to mitigate cost.

Conclusion

Decision-making of male same-sex couples pursuing ART is complex and unique to each couple. There are many stages throughout the process that require complicated decision-making; however, decisions are often shaped by the desire for genetic relatedness, risk reduction, control, and financial costs. Male same-sex couples often must make decisions without evidence-based medicine; thus, better clinical guidance is needed to allow reproductive experts to facilitate these delicate conversations and improve the experience of intended parents. The high cost makes the process more difficult for many couples, requiring many to make sacrifices and leaving many unable to pursue ART to build their families. Better insurance coverage needs to be made available to improve care for this marginalized patient population.

The percentage of adults who openly identify as lesbian, gay, bisexual, transgender, and/or queer (LGBTQ+) has doubled from 3.6% to 7.6% in the last decade (1). In 2022, there were approximately 35,000 male same-sex couples with children in the United States, and that number is expected to increase as societal attitudes regarding LGBTQ+ family building change and access to assisted reproductive technology (ART) involving donor-derived oocytes (donor eggs) and gestational carriers (GCs) increases (2, 3, 4, 5). From 2016 to 2020, the percentage of ART cycles with an embryo transfer to a GC involving male same-sex couples or single men increased from 16.7% to 30.7% (6). Despite this increased utilization, reproductive medicine has traditionally focused on cisgender, infertile, heterosexual couples, and there has been little research regarding ART for male same-sex couples.

Male same-sex couples often have a broader range of ART options than most heterosexual and female same-sex couples, including several options unique to their family building. Couples navigate decisions regarding sperm source, donor eggs, GCs, and embryo transfer, each involving unique considerations that may differ from one couple to the next (7).

Early in their family building journey, couples decide whose sperm to use to fertilize eggs, and these decisions may take many different factors into consideration (e.g., desire for genetic relatedness, medical history, and history of prior children) (4, 7, 8). Some studies suggest that many couples split the total number of donor eggs, with each partner fertilizing half, whereas others suggest that some couples choose 1 partner to fertilize eggs (2, 4, 5, 7, 8, 9).

Couples may consider many different factors when selecting an egg donor (e.g., medical/family history, contact preferences, and physical attributes) (5, 9). Many prefer an egg donor of a similar ethnic background; however, research has shown significant racial disparities among egg banks, with many racial groups being underrepresented (10, 11). Prior research regarding egg donor selection has primarily focused on heterosexual couples, and little is known about the decision-making of male same-sex couples given these potential racial disparities.

Previous studies suggest that there are likely limited benefits to performing preimplantation genetic testing for aneuploidy (PGT-A) when using a young egg donor because there is no significant difference regarding rates of implantation, clinical pregnancy, miscarriage, and live delivery for ART cycles involving PGT-A compared with those without (12). Despite this, many male same-sex couples do PGT-A, although their rationale is unclear (e.g., physician recommendation, selection on the basis of sex chromosomes, preference of surrogacy agency, and to help avoid termination) (7, 9).

Couples may use test results to choose which embryo(s) to transfer into a GC; however, many clinics lack specific guidelines regarding embryo transfer, so that choice may be deferred to embryologists who prioritize embryo quality. Depending on clinic guidelines, couples may choose single-embryo transfer (SET) or double-embryo transfer (DET). For couples who choose SET, they may discuss transfer order and take different factors into consideration (e.g., sex selection, embryo quality, and desire for parenthood) (5). Other couples may prefer DET for a variety of reasons (e.g., perceived increased chance of success, desire for twins, and reduced overall cost associated with a single ART cycle compared with multiple) (7, 13, 14). Double-embryo transfer is not consistent with current American Society for Reproductive Medicine (ASRM) guidelines for the general population due to increased risks of obstetric complications (e.g., preterm labor, cesarean deliveries, and postpartum hemorrhage) and adverse clinical outcomes (e.g., preterm delivery, low birth weight, and perinatal mortality); thus, many clinics have general guidelines that favor SET (7, 13, 14, 15). Although guidelines would likely not differ for male same-sex couples, specific recommendations regarding DET are not currently available, and a more nuanced approach may be needed for this population with special considerations (e.g., high financial cost).

Prior research on male same-sex couples using ART has largely addressed relationships with GCs (16) and, to a lesser extent, clinical outcomes (8, 17) and experiences of intended parents (10). The aim of this study was to build on prior qualitative work and explore the decision-making processes of male same-sex couples using ART, specifically when selecting sperm, donor eggs, and embryos to transfer. The objective was to better understand clinical decisions for intended parents and to provide insight into how providers can better address the medical and psychosocial aspects of having a child via ART for this population.

Materials and methods

Design

This qualitative study consisted of a demographic survey and semistructured interviews. Members of male same-sex couples were asked about their experiences and decision-making with ART. Interviews were analyzed, and themes were generated using reflexive thematic analysis, a qualitative research method for analyzing and conceptualizing themes within data (18, 19, 20, 21, 22). This research was approved by the Stanford University Institutional Review Board (IRB-71642).

Participants

Eligible participants spoke English, were ≥18 years old, were part of a male same-sex couple, and were using or had previously used ART in the United States. He/him pronouns are used throughout because this study represents a cohort of cisgender men.

Recruitment involved targeted and snowball sampling. Flyers were posted to Facebook and Reddit groups focused on male same-sex family building. One investigator has an established relationship with Men Having Babies, an international nonprofit that provides surrogacy support for male same-sex couples. This partnership has been a trusted method of participant recruitment in the past and was used to promote community engagement during recruitment.

Data collection and analysis occurred concurrently. Recruitment ended once the data were determined to be high quality and variable enough to access new knowledge (22).

Data sources and collection

Demographic information (Supplemental Materials 1, available online) was collected via an online Qualtrics survey to determine interview eligibility. Interview questions were based on a literature review and were refined throughout the interview process (Supplemental Materials 2v). The Health Belief Model, a theoretical approach used to show how individuals make decisions regarding health services, was used to inform creation of the interview guide, with emphasis on perceived benefits and barriers when using ART (23). The first investigator (S.D.) organized interviews via email and conducted them using the Zoom video conferencing platform. Audio- and video-recorded interviews occurred between January and May 2024. Recordings were transcribed verbatim using a third-party transcription service, deidentified, and checked for accuracy by S.D. Each participant received a $25 Amazon gift card for his participation.

Analysis

S.D. coded interview data using Dedoose, a research tool used to organize and code qualitative data. Data were analyzed following the 6 phases of reflexive thematic analysis: data familiarization; initial coding; generating initial themes; reviewing themes; defining, naming, and refining themes; and writing up results (17). Initial themes were coconceptualized with the research team. Throughout data analysis, S.D. reviewed and refined themes with his coinvestigators.

Results

Twenty-nine individuals completed the survey. Four participants were ineligible, and 5 did not respond to outreach. Twenty interviews were conducted. One interview was excluded from analysis after it was determined that the participant did not meet inclusion criteria. Of the 19 interviews that were coded, 18 were performed with 1 partner and 1 was performed with both partners, for a total of 20 participants. Eight individuals successfully achieved pregnancy, and 12 were actively pursuing pregnancy. Interviews lasted on average 34 minutes (range, 21–61 minutes). The mean age of participants was 37 years. Most participants were gay, White, cisgender men. Full demographic information can be found in Table 1.

Table 1.

Participant demographics (N = 20).

Characteristic	Values
Age
20–30 y	2
31–40 y	13
41–50 y	5
Location of residence
United States
California	6
Indiana	1
Ohio	1
Missouri	2
New Jersey	1
New York	3
Pennsylvania	1
South Carolina	1
Washington	2
International
Sweden	2
Race/ethnicity (select all that apply)
Asian	3
Black, African American, or African	2
Hispanic, Latino, or Spanish	2
White	16
Sex assigned at birth
Male	20
Current sexual orientation
Bisexual	2
Gay	18
Current gender
Cisgender man	20
Highest level of education
Some college or secondary	2
Associate’s degree	1
Bachelor’s degree	2
Graduate school and/or professional degree	15
ART stage
Successfully achieved pregnancy via ART	8
Actively pursuing pregnancy	12

Note: ART = assisted reproductive technology.

Themes

Four themes were conceptualized from the data. Theme 1, desire for actual or perceived genetic relatedness, describes how having a genetic connection influenced decisions. Theme 2, actual or perceived risk mitigation, details decisions to minimize risk and achieve a healthy pregnancy. Theme 3, control using ART, describes how a desire for control influenced decision making. Theme 4, decisions based on financial cost, details how ART decision-making is influenced by financial cost. Additional quotes can be found in Supplemental Table 1 (available online).

Desire for actual or perceived genetic relatedness

Preference for ART over other family building methods

Many couples have conversations about other family building options (e.g., adoption and fostering) before pursuing ART. Several participants described that having a genetic connection to their children was a main factor when deciding to have children via ART over other options.

“We thought about adoption. … We decided to lean towards surrogacy because we wanted the genetic connection to our children.” (Interview 1)

Couples select sperm on the basis of genetic connection preferences

Many couples split donor eggs, with each partner fertilizing half, because both partners wanted a genetic connection. For couples where only one partner contributed sperm, several factors influenced that decision (e.g., physical/mental health history, prior genetically related children, and using a genetically related egg donor to one of the intended parents).

“We both wanted to be sperm sources because it was important for us to at least have one child from each of us.” (Interview 9)

Some participants described increased anxiety and tension when one partner had fewer viable embryos after a split cycle, resulting in fewer opportunities to have a genetic connection. One participant shared that they would have preferred separate cycles, one for each partner, if they were to repeat the process.

“Our first cycle, we did a split cycle. For my partner, it was unsuccessful. For another cycle, we decided to just do my partner because he didn’t have any [embryos]. It brought a lot of fear in my life because I would’ve liked to have one more embryo. … If we could have reversed time, it would probably have been better for just me to do the full eggs for fertilization, rather than splitting it in half. It brought up a lot of tension between me and my partner.” (Interview 12)

Couples prioritize a genetic connection between children

Some couples had preferences on using the same egg donor to have multiple children, allowing for their children to have a genetic connection with each other.

“The plan is for us to want more kids, definitely two, and we want them to be half siblings and want one of each of ours.” (Interview 16)

Couples aim for a blended family

Many couples wanted to achieve a blended family by using an egg donor who looked similar to one or both partners; however, some couples also preferred a donor from a similar cultural background.

“One thing we really wanted was someone who was mixed race because my husband is mixed race. We wanted our daughter to not be obvious whose biological daughter she is.” (Interview 3)

One White couple described not looking at particular donors out of fear of racial discrimination. They described discrimination that they already faced related to their sexuality, and they did not want their children to face additional discrimination.

“There were different races and ethnicities that we didn't go through. … We get harassed in our town for being gay, and we've had minority friends that get harassed in our town for being minorities. I'm like, ‘Let’s not combine those two.’” (Interview 14)

Actual or perceived risk mitigation

Adoption was riskier than ART

Although many couples describe the genetic connection to their children as an important factor when pursuing ART, other couples pursued ART because they believed that adoption was riskier.

“The timeline for adoption seems unpredictable. People seemed like they were at it for years with close calls and heartbreaks.” (Interview 7)

Couples make decisions that are perceived to increase the chance of a healthy pregnancy

Couples frequently made decisions, including pursuing PGT-A, with the goal of increasing the chance of a successful embryo transfer.

“It helped us feel confident that our embryos are going to be the healthiest that we could have.” (Interview 14)

Following PGT-A, some couples chose to transfer the most viable embryo, rather than choosing on the basis of sex chromosomes.

“We wouldn't pick based on if it was genetically male or female. It would be the highest grade.” (Interview 8)

Couples often had conversations about how many embryos to transfer into a GC; however, ultimately, many chose SET because it was less risky. Others mentioned that their clinic did not perform DET.

“As a physician, I know that a twin pregnancy is riskier for both the carrier and babies. … That's what pushed the scales ultimately towards doing singleton journeys.” (Interview 16)

Control using ART

ART gives couples more control

Many couples pursued ART because they wanted more control over decisions and who was involved, whereas others wanted greater legal protections.

“The whole adoption process is challenging. Doing what we did felt like we had more control over the process, more involvement.” (Interview 17)

Couples may select embryos on the basis of sex chromosomes if given the option

Some couples made choices regarding sex selection because they wanted more control.

“Not making a choice felt like giving up something. Someone is going to choose. It's going to be you or the doctor, so why not choose if we have the opportunity to?” (Interview 18)

For couples with a sex preference, many chose to transfer embryos with XY chromosomes because they had the lived experience of growing up male. Others did not choose embryos on the basis of predicted sex because they wanted their pregnancy to feel more like a typical pregnancy.

“We wanted a boy. … We both have been boys and know what that experience is like and can empathize and relate to that. Having a girl… we'll need more folks outside of our immediate couple to help raise her in the best way possible.” (Interview 2)

ART decisions based on financial cost

Financial considerations are often the most difficult

Couples frequently noted that their decision-making was influenced by financial factors, with some describing the cost of ART as the most difficult part of the process.

“Getting an egg and surrogate has been really challenging. That's been the hardest emotional part, that extra cost that we had because neither of us had a uterus.” (Interview 14)

Financial costs influence egg donor selection

Some couples preferred using an identified donor because they wanted to form a relationship with the donor. Others chose a nonidentified (anonymous) donor because it was less expensive.

“With the egg donor, it’s an unidentified agreement. The deciding factor for that was financial. … We were trying to find ways to save money throughout the process.” (Interview 9)

Affordability was a deciding factor when pursuing genetic testing

Cost was a deciding factor for some couples when choosing to do PGT-A, with many deciding to do testing only if they could financially afford it. Other couples made the decision not to do PGT-A to reduce costs:

“Doing pre-implantation genetic testing, you increase your yield rate, you increase your chance that it's going to be a successful transfer. And financially we were able to do it.” (Interview 7)

Financial factors shape decisions regarding SET and DET

Some couples chose SET as a way to reduce risk and maximize the chances of a successful pregnancy. Others chose DET because they wanted multiple children and could only afford 1 ART cycle:

“Our surrogate gave us a breakdown of what she was expecting. … $80,000 after all is said and done with a singleton versus $110,000 for twins. … It's more of a financial decision than necessarily wanting twins.” (Interview 10)

Discussion

Male same-sex family building involves numerous steps that require complex decision-making. We identified four key themes that influence this decision-making: desire for actual or perceived genetic relatedness, actual or perceived risk mitigation, desire for control, and financial cost. Couples prioritize these factors differently, leading to diverse family building journeys. For example, couples may choose DET to ensure that each partner has a genetic connection to their children, because they believe that it will increase the chance of a successful transfer, because the option is available, or because they want to reduce the need for multiple ART cycles and reduce ART-related costs. Given limitations in accessibility to ART for male same-sex couples, many couples make sacrifices in one area to prioritize another. These decisions are complex and unique to each couple; thus, it is critical for clinicians to better understand these considerations to help guide couples on their family building journeys.

When both partners contribute sperm, our study agrees with prior findings that show that many couples perform a split cycle (4, 5, 7). Our study suggests that couples agree early on and may not consider or know about other options. Participants expressed more negative experiences when more than one split cycle was performed, particularly when the number of viable embryos after the first round was low and resulted in one partner having fewer viable embryos. Some shared that they would have preferred two separate cycles if they were to repeat the process. Desire for genetic relatedness caused feelings of anxiety, and couples described more tension between each other and with providers when one partner had fewer opportunities to have that genetic connection. This suggests that couples may benefit from more detailed conversations with providers regarding fertilization options. It is unclear whether clinical outcomes are negatively impacted by split cycles compared with separate cycles, warranting further exploration.

Some couples expressed difficulty deciding which embryo(s) to transfer. For heterosexual couples with one sperm source and genetically tested embryos, there are typically two options: best quality embryo or best quality embryo of a particular sex (24). For male same-sex couples with two sperm sources and genetically tested embryos, there are four: best quality embryo (blinded genetic linkage), best embryo from one sperm source, best embryo of a particular sex (blinded genetic linkage), and best embryo of a particular sex from one sperm source. Not all clinics allow sex selection of embryos; however, for clinics that do, sex selection for nonmedical reasons may be performed for family balancing, where the selected embryo is predicted to be a different sex than previous children, or for personal preference (24). Our results suggest that many couples prefer to transfer embryos that are predicted to be male because they have the lived experience of growing up male. Some studies suggest that nonmedical sex selection raises ethical concerns, such as creating a bias against female embryos; however, our results suggest that with male same-sex couples, couples often select the sex of embryos that they feel they can raise in the best way possible (25). Couples transferring a single embryo into a GC described a variety of factors that influenced their decision (e.g., partner’s desire for genetic relatedness, age, number of viable embryos, and presence of the next generation in the family). It is not currently known how the numerous possibilities when transferring embryos impact clinical outcomes.

Our results align with previous findings that suggest that couples take many factors into consideration when choosing an egg donor (e.g., physical appearance, racial background, personal/family history, age, personality, intelligence, and anonymous donor status) (5, 9, 10). Our study highlights that many couples choose an egg donor to create the most blended family possible, with many attempting to avoid having children who look too much like one specific partner. For some interracial/multiethnic couples, having an egg donor of a similar cultural background may be just as important as physical appearance. Given racial disparities among egg donors, it may be difficult for many couples to find egg donors of a desired background, resulting in a more negative experience (11).

Many couples take financial considerations into account when pursuing ART, and there is a higher incidence of twin births for male same-sex couples than for other ART users (7, 26). This may be because some couples choose DET to reduce the need for multiple ART cycles and associated ART-related costs, even though pregnancies with multiples have higher overall healthcare costs due to increased obstetric complications compared with singleton pregnancies (27, 28). Some couples were willing to take on additional risks, even though DET does not follow current ASRM guidelines (15). Due to these guidelines, some clinics only offer SET; thus, couples seeking a twin pregnancy may have difficulty finding a clinic that allows for DET, leading to a lengthier ART experience with perceived higher cost. The specific prevalence of multiples carried by GCs for male same-sex intended couples or the cost-effectiveness of DET in this setting is unknown, and further research is warranted given the potential risks and ethical concerns of multiples for both the GC and intended parents (7, 17).

Participants frequently noted that navigating the financial aspects of ART was the most difficult part of the process. Insurance companies often provide coverage on the basis of a heterosexual and cisgender definition of medical infertility; thus, many male same-sex couples have limited or no insurance coverage (29). It has yet to be determined whether the new ASRM definition of “infertility” will impact coverage (30). Our results show that the cost of ART often limits ART-related decision-making, leading to decisions that can negatively impact the child, intended parents, and GC (e.g., anonymous egg donor and DET). Given these financial strains and the effect that they may have on decision-making and clinical outcomes, it is important to advocate for more inclusive insurance coverage so that couples are not limited to making decisions on the basis of cost. There is also no available guidance for providers regarding split or multiple separate cycles when both parents contribute sperm or for order of embryo transfer; thus, specific guidelines are needed for reproductive experts to help facilitate these conversations with couples. As societal attitudes regarding LGBTQ+ family building continue to evolve, ensuring that ART is accessible and individualized will be essential for supporting diverse paths to parenthood.

Limitations

Our study’s participants are predominantly White, well-educated, wealthy, gay men; thus, conclusions may not be generalizable to other racial, socioeconomic, sexual (e.g., bisexual), or gender (e.g., nonbinary) groups in male same-sex couples. Couples working with Men Having Babies actively sought out clinics that they perceived to be less heteronormative. Participants who were recruited through other strategies, or who experienced more prejudice/bias, may not be able to go through this process or may have different experiences. We did not discuss decision-making with other involved parties (e.g., GC agency, physician, and benefit providers).

Future directions

Our study focused on male same-sex couples and excluded single men because they are a distinct patient population with unique considerations that warrant separate study. Further research is needed to better understand clinical outcomes (e.g., number of viable embryos, frequency of successful embryo transfer, and number of live births) of male same-sex couples using ART, particularly in relation to split vs. separate cycles, transfer order, and SET vs. DET. Further research is needed involving couples recruited from other sources (e.g., fertility clinics) or those not affiliated with Men Having Babies because their experiences may differ from those of our participants. Additionally, our study was performed with couples using ART in the United States; thus, male same-sex couples in other countries may have other factors impacting their decisions.

Conclusion

Our study showed that couples often make decisions on the basis of a desire for genetic relatedness, risk mitigation, control, and financial cost. For many couples, the cost of ART is the largest barrier. Our study provides additional insight on clinical decision-making for male same-sex couples particularly because it relates to use of DET and add-on (i.e., PGT-A) services. Additional research is needed to determine whether these decisions perceived to decrease overall cost and/or increase success are supported by evidence-based medicine. Specific clinical guidelines are needed for male same-sex couples for providers to proactively navigate conversations regarding the unique aspects of third-party reproduction for this population.

Declaration of Interests

S.D. reports that this study was funded by the Stanford University Genetics Department as part of S.D.’s thesis. M.C. has nothing to disclose. K.Z. has nothing to disclose. B.M. reports funding from National Institutes of Health (K12 HD103084) for the submitted work.