Abstract
This study compares embryo transfer and pregnancy outcomes among US same-sex female couples undergoing reciprocal and autologous oocyte in vitro fertilization (IVF) cycles.
Reciprocal in vitro fertilization (IVF) allows both partners in a same-sex female couple to have a biological role in family building; one partner serves as the oocyte donor while the other partner carries the pregnancy. Reciprocal IVF has gained clinical and social relevance with the growing accessibility of IVF and evolving acceptance in the queer community.
Prior studies indicate that reciprocal IVF is an effective option for same-sex female couples, with outcomes largely similar to or better than autologous IVF,1,2,3 which is when the patient who undergoes oocyte retrieval also carries the pregnancy. The largest study to date was a multicenter cohort study that included 660 reciprocal IVF cycles over a 10-year period,4 but the other studies were small, including less than 100 reciprocal IVF cycles.5,6 This study aims to compare embryo transfer and pregnancy outcomes among same-sex female couples undergoing reciprocal and autologous oocyte IVF cycles in the US.
Methods
This retrospective cohort study used data from the Society of Assisted Reproduction and Technology (SART) Clinical Outcome Reporting System from 2022, the first year that partner sex was collected. Embryo transfer cycles for female patients with female partners were included (eFigure in Supplement 1). Female was defined as female sex. The dataset variable for gender was missing for most patients. Reciprocal IVF cycles were identified either as embryo transfer cycles in which the gestational carrier was the partner or cycles in which the oocyte donor was the partner. Female-female couples undergoing autologous oocyte IVF were the reference group. Demographic, reproductive, and clinical characteristics and pregnancy outcomes were compared between couples who underwent reciprocal vs autologous IVF. Multivariable log-binomial regression models with generalized estimating equations were used to evaluate the association between the reciprocal IVF and embryo transfer cycle outcomes adjusting for oocyte and recipient age, infertility diagnosis of diminished ovarian reserve, endometriosis, tubal factor, and use of preimplantation genetic testing.
This study was determined to be exempt by the Emory University Institutional Review Board. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline was followed.
Results
There were 866 embryo transfer cycles from 700 couples using reciprocal IVF and 2835 embryo transfer cycles from 2122 couples using autologous oocyte IVF. Both partners within the couples pursuing reciprocal IVF were, on average, younger than those pursuing autologous oocyte IVF (Table 1). Among those undergoing reciprocal IVF, the age of the partner undergoing oocyte retrieval was moderately correlated with the age of the partner undergoing embryo transfer (Spearman correlation = 0.59). Compared with couples using reciprocal IVF, the prevalence of diminished ovarian reserve, endometriosis, tubal factor, and unexplained infertility was higher among couples using autologous IVF, and the prevalence of infertility not in one of these categories and patients without infertility was lower among couples using autologous IVF.
Table 1. Characteristics of Same-Sex Female Couples at First Embryo Transfer and Cycles Using Autologous or Reciprocal IVF, 2022.
| Characteristics | No. (%) | |
|---|---|---|
| Autologous IVF | Reciprocal IVF | |
| Couple characteristics | n = 2122 | n = 700 |
| Oocyte age, y | ||
| <35 | 1067 (50) | 384 (55) |
| 35-37 | 528 (25) | 182 (26) |
| 38-40 | 353 (17) | 85 (12) |
| ≥41 | 174 (8) | 36 (5) |
| Missing data | 0 | 13 (2) |
| Partner age, y | ||
| <35 | 856 (40) | 399 (57) |
| 35-37 | 502 (24) | 135 (19) |
| 38-40 | 313 (15) | 101 (14) |
| ≥41 | 399 (19) | 65 (9) |
| Missing data | 52 (2) | 0 |
| Infertility diagnosisa | ||
| Diminished ovarian reserve | 307 (14) | 55 (8) |
| Endometriosis | 106 (5) | 15 (2) |
| Male factor | 421 (20) | 81 (12) |
| Ovulatory dysfunction | 25 (1) | 0 |
| Tubal factor | 151 (7) | 13 (2) |
| Uterine factor | 96 (5) | 26 (4) |
| Unexplained | 261 (12) | 26 (4) |
| Other | 1101 (52) | 570 (81) |
| Mandated IVF coverage for same-sex couples in state of residenceb | ||
| Yes | 411 (19) | 124 (18) |
| Possibly | 313 (15) | 30 (4) |
| No | 1390 (66) | 532 (76) |
| Missing data on state of residence | 8 (<1) | 14 (2) |
| Embryo transfer cycle characteristics | n = 2835 | n = 866 |
| Preimplantation genetic testingc | ||
| Yes | 1453 (51) | 503 (58) |
| No | 1374 (49) | 357 (41) |
| Intracytoplasmic sperm injectionc | ||
| Yes | 2270 (80) | 747 (87) |
| No | 557 (20) | 113 (13) |
| Blastocyst transfer | ||
| Yes | 2428 (86) | 820 (95) |
| No | 407 (14) | 46 (5) |
| Type of embryo transfer | ||
| Fresh embryo | 617 (22) | 114 (13) |
| Thawed frozen embryo | 2218 (78) | 752 (87) |
Abbreviation: IVF, in vitro fertilization.
Couples could have more than 1 infertility diagnosis; categories are not mutually exclusive. For reciprocal IVF, infertility diagnosis was reported for 620 patients donating oocytes and 80 patients receiving donor embryos.
In 2022, 13 states mandated IVF coverage; 4 (Illinois, Maryland, New Jersey, and New York) covered same-sex female couples, 5 (Arkansas, Connecticut, Hawaii, Rhode Island, and Utah) did not cover same-sex female couples, and 4 (Colorado, Delaware, Massachusetts, and New Hampshire) had language in the law that may or may not result in coverage for same-sex female couples depending on how employers interpreted the language.
Fourteen cycles were missing information on use of intracytoplasmic sperm injection and preimplantation genetic testing.
Compared with autologous oocyte IVF transfers, transferred embryos for reciprocal IVF were more likely to be frozen (87% vs 78%), use preimplantation genetic testing (58% vs 51%), and have a blastocyst embryo (95% vs 86%). Among reciprocal vs autologous oocyte embryo transfer cycles, respectively, there were no differences in probability of clinical pregnancy (64% vs 57%; adjusted risk ratio, 1.06; 95% CI, 1.00-1.13) and live birth (52% vs 48%; adjusted risk ratio, 1.04; 95% CI, 0.96-1.12) after multivariable adjustment (Table 2). The rate of singleton preterm birth was slightly elevated among reciprocal vs autologous oocyte IVF cycles (15% vs 11%; adjusted risk ratio, 1.31; 95% CI, 0.99-1.74).
Table 2. Cycle and Pregnancy Outcomes for Embryo Transfer Cycles Among Same-Sex Female Couples Using Autologous or Reciprocal IVF, 2022.
| Outcomes | No./total No. (%) | Risk ratio (95% CI)a | ||
|---|---|---|---|---|
| Autologous IVF (n = 2835) | Reciprocal IVF (n = 866) | Unadjusted | Adjustedb | |
| Clinical pregnancy | 1618 (57.1) | 550 (63.5) | 1.11 (1.05-1.18) | 1.06 (1.00-1.13) |
| Live birth | 1352 (47.7) | 451 (52.1) | 1.09 (1.01-1.18) | 1.04 (0.96-1.12) |
| Miscarriage | 246/1618 (15.2) | 89/550 (16.2) | 1.06 (0.85-1.33) | 1.06 (0.85-1.33) |
| Multiple birth | 65/1352 (4.8) | 22/451 (4.9) | 1.01 (0.63-1.63) | 1.03 (0.63-1.66) |
| Singleton preterm birthc | 145/1283 (11.3) | 62/427 (14.5) | 1.28 (0.97-1.69) | 1.31 (0.99-1.74) |
| Singleton low birth weightd | 87/1210 (7.2) | 32/410 (7.8) | 1.08 (0.74-1.60) | 1.05 (0.70-1.57) |
Abbreviation: IVF, in vitro fertilization.
All risk ratios were calculated using autologous IVF as the reference.
Models were adjusted for oocyte and recipient age; infertility diagnosis of diminished ovarian reserve, endometriosis, or tubal factor; and use of preimplantation genetic testing.
For analyses of preterm birth, 6 singleton births (4 autologous IVF and 2 reciprocal IVF) were excluded due to missing or erroneous data on gestational age.
For analyses of low birth weight, 96 singleton births (77 autologous IVF and 19 reciprocal IVF) were excluded due to missing birth weight data.
Discussion
Reciprocal IVF is an effective option for same-sex female couples, with outcomes comparable with traditional autologous IVF. This study represents the largest analysis, to our knowledge, comparing reciprocal vs autologous IVF cycle outcomes among same-sex female couples. A study limitation is that the relatively recent inclusion of partner sex in SART may have resulted in cycles that were not captured in this analysis.
eFigure. Study flow diagram
Data Sharing Statement
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eFigure. Study flow diagram
Data Sharing Statement
