ASRM Today: Reciprocal IVF

In this episode of ASRM Today, host Jeffrey Hayes and co-host Dr. Lowell Ku continue their season-long exploration of LGBTQ+ issues in reproductive medicine with a thoughtful conversation on reciprocal IVF. They are joined by Dr. Samantha Estevez, Assistant Professor at the University of Pittsburgh School of Medicine and attending REI physician at UPMC, whose work focuses on comprehensive, compassionate fertility care and expanding access for all. Together, they unpack what reciprocal IVF is and how it differs from traditional IVF, exploring the emotional and medical dimensions unique to shared biological parenthood. The discussion also addresses the motivations behind choosing reciprocal IVF as well as the legal, financial and insurance-related challenges many LGBTQ+ couples face. Dr. Estevez offers insight into inclusive, affirming clinical practices, potential health considerations, and emotional realities of the process, along with practical advice to help intended parents prepare for their family-building journey. 

Welcome to ASRM Today, a podcast that takes a deeper dive into the current topics in reproductive medicine. I'm Jeffrey Hayes and today on the show we continue our season-long discussion of LGBTQ plus issues in reproductive medicine by diving into reciprocal IVF. Joining me for this discussion is my co-host, Dr. Lowell Kuh.

How are you today, good sir? Doing great, guys. Thanks for being here. Wonderful to have everybody here today.

And our guest today is Dr. Samantha Estevez, who is an assistant professor at the University of Pittsburgh School of Medicine and attending REI physician at UPMC. She completed her fellowship at Mount Sinai in RMA of New York. Board certified by the American Board of Obstetrics and Gynecology, Dr. Estevez focuses on comprehensive reproductive health and fertility care and is known for clear, compassionate communication.

Her clinical interests include LGBTQIA plus health, as well as increasing access to care for all people seeking to grow their families. Welcome to ASRM Today, Samantha. Thanks so much for having me.

Very happy to be here and speaking with you both. Wonderful. I know, Dr. Kuh, you're chomping at the bit to get into these questions, so I'm going to let you go ahead and lead.

Awesome, awesome. Thank you so much, Jeff. And thank you, Dr. Estevez, for being with us today.

It's just so awesome to have you here. And so first, I know everybody is interested about reciprocal IVF. And so our audience is not only physicians, but also non-physicians as well.

So if it's okay, if you could tell us what exactly is reciprocal IVF? How does it differ medically from traditional IVF for same-sex couples? Sure. So reciprocal IVF is a really unique way that we could use IVF to get basically all parties involved in reproduction. If you're in the position of having two egg-producing partners and two partners with uteruses, or potentially one or both in swapping.

So basically, when one partner acts in the most basic sort of way of saying it's the egg donor, they provide the eggs, they go through the IVF stimulation, embryos are created. And then the other partner then carries that pregnancy. So both people are contributing in a way to that pregnancy and building their family.

And there's many iterations of it, like I hinted at before, it could be both swapping, one carrying, one making embryos or both. So it's really an interesting and unique way to take advantage of some of the different positions that our patient populations come to us with. Yeah, I've always been so excited when patients come in and they're interested in reciprocal IVF, because both partners can be part of the process.

And I think that is beautiful and awesome. So thank you. Thank you.

And so, what are the most common motivations for couples choosing reciprocal IVF instead of other family building options? I think what you hinted at and what I spoke about are really one of the biggest things, or is really one of the biggest things, just both wanting to be involved in this really unique and special part of their family building and their life. Because they're in a place where they do have the fortune of both being able to be involved, right? So they come in and they say, well, I may not care so much about being the person whose egg this is, but I really want to carry a baby. And I want to be the person experiencing pregnancy and giving birth.

And their other partner might say, I have no interest in that, but I do want to like be genetically involved or biologically involved. So it's just a unique way to do that. And really, at the end of the day, it kind of balances out for the most part in regards to what's involved.

Both partners then also experience what it is to be evaluated, what it is to prepare for these cycles. So that teamwork goes beyond just a partner by your side helping, which is big enough in and of itself, but both of you experiencing really unique aspects of fertility care as well. Well, let me ask you this then.

What are some barriers that these couples most often face when pursuing reciprocal IVF? Is it just medical, legal, financial, the whole trio there? Yeah. You always hit on those main things for anything, I think, when it comes to fertility care as a big challenge. Now, obviously financial, there's always the cost of things.

With reciprocal IVF, most of these patients don't have a sperm producing partner in that sort of situation. So you have that additional cost of donor sperm that's inherent to it, which adds quite a bit onto things. And then again, like I said, both partners are involved in evaluation.

So versus one partner doing everything, that adds on to the additional cost for both people to be evaluated and prepared for their respective portions of this. But as you mentioned, there's also legal concerns as well, too. And this would be in any sort of situation when you have LGBTQIA plus families or nontraditional families ensuring that parentage is appropriately acknowledged in the state they're in or beyond that.

So getting kind of a legal element in there as well, because you can be the person birthing a child, but what are the specific laws in your state? Does that child have to be genetically related to you? Will you be acknowledged as a parent or will your partner be acknowledged as a parent? So having to take that all into account is important as well. And additionally, there's always the surprises, right? Many of these couples have never tried to conceive or been with a sperm producing partner, and they come to see us for an evaluation and presuming that things will all be fine and look easy and straightforward. But people are people.

There's going to be fertility challenges for anybody. And so I've had patients doing reciprocal IVF where they come in and we see lower values for their ovarian reserve, or we don't get the outcomes we were hoping for when making embryos or doing transfers. So they face all the same inherent challenges that any fertility patient might face as well.

Even if, like I said, on the surface, it just seems like, oh, we're coming in here in that ideal situation of two uteruses, two sets of ovaries and everything like that. But many patients still have some challenges that there's no way you could see on the surface until they come into the office. Absolutely right.

I know. I agree that every couple is different and they are faced with different challenges each different time. So and even with different, even with the subsequent pregnancy, there are different challenges as well.

So are there specific health considerations or risks that are unique to reciprocal IVF that couples should be aware of? Generally, I would say overall, it's a very safe process. It's just, you know, you might be with your partner and somebody that you're with, but it's still, like I said, is in a way acting as a donor and a carrier if you're looking at it most objectively. So the risks that the person carrying a pregnancy would be experiencing would be the same thing as long as everything else, I should say, medically looks fine for them would be the same thing that a gestational carrier might be experiencing.

But generally, those are very healthy pregnancies. There's not many changes or anything else we do differently. And you take away this not actually being a gestational carrier, it's a parent carrying this pregnancy.

So you don't have many, like I said, as many involved processes in that side of things. So overall, it's a very straightforward process. And it goes very smoothly.

And like I mentioned before, you know, and you did as well, Dr. Koo, every experience is a little different, every pregnancy transfer patient journey is a little bit different. So there is some ups and downs for everybody. But overall, I think it's a generally a very smooth process for these patients and parents.

Yeah, totally. I agree. You know, when I've been so fortunate to care for patients who decided they'd like to do the reciprocal IVF, yeah, it's it is usually very straightforward, just making sure we check everything properly, and then move forward.

And yeah, it's a beautiful process. Are there emotional challenges that normally come up that couples might experience during this process? Do you usually recommend a specific type of support system? Or how do you walk them through that? Yeah, so for me, with these patients, again, most often they're going to be using donor sperm. So they already have some counseling, you know, based on recommendations from ASRM and most practices to meet with a counselor or psychologist or somebody who specializes in this to prepare what these different and unique elements of family building might be.

Reciprocal IVF, of course, takes it to another level. But I think emotionally, when I've seen patients most challenged are during those situations where things aren't going as smoothly as they expect, which at the core of it, the same challenges that any of our fertility patients might experience. So again, say somebody didn't respond well to IVF, or they had a loss or didn't get pregnant after a transfer.

These can be challenges to anyone. But the unique situation in reciprocal IVF is that we also have the ability to potentially pivot. So potentially that patient who is the partner who's going to be, you know, providing eggs to make the embryos, if something doesn't go well with their stimulation, that other partner, if they're willing, has the opportunity to step in and change spots.

Or same thing with a transfer. You know, if something else isn't going well, or something with them medically changes, or their choices change, they do have this extra level of flexibility that I think may not be the plan they originally had. But when I've had some of my patients have to shift what their original plan was, for them, it really is something they appreciate and a very freeing sort of position to be in.

So yes, they have those challenges emotionally of not building the family in the way they envisioned it to. But in the other sense, they also have this really amazing benefit of other ways of building a family that many of our patients just don't even have as an option. Absolutely right.

Yeah, I've had couples where one had diminished ovarian reserve. She was the partner that wanted to donate eggs. But then we pivoted because the other partner did have a good ovarian reserve.

So we harvested her eggs. So very, very, very nice to have that opportunity. And so how can intended parents prepare themselves financially, physically, or even emotionally for this journey of reciprocal IVF? Yeah, I think the biggest thing is just to start off with the conversation.

How do each partner's envision themselves being involved? Because we see plenty of queer couples who come in that one partner is totally fine not being involved. And there's no judgment from us as the physicians. Like, you just build your family the way that it works.

And we're here to support you. But really delineating what that perfect scenario would be. Who do you want playing what roles? You know, for whatever reasons, we don't judge in any way what that might be.

But also, you know, taking into account if we need to shift positions, like we've discussed a couple of times, are we willing to do that? Who's willing to do what? And do we want both of us involved? Are we going to switch spots? Things like that. Really preparing what their mental map is so they can come to our offices and really lay out what they think. Because that gives us really the information to then best advise of who we're going to evaluate, how we're going to do things for this whole process.

Like you mentioned, you know, the finances are a huge part. I, for my patients, I usually will classify them as, you know, male factor in fertility. It's pretty absolute.

There's no sperm there. But, you know, in the most classic sense of fertility and trying to conceive, many of these patients don't meet that definition. ASRM has, you know, fortunately updated what their definition for that is to be much more inclusive.

But insurances and state laws are different and behind the times. And that can produce financial barriers for patients most definitely. So whether you're a cis hetero couple or a queer couple or a single parent, any patient that I see, you know, it's important to counsel them about the cost of things and what the specific locality and coverages and laws are so they can prepare.

Because sometimes I'll see patients will have that initial conversation. They need to take a step back to save up time and money and everything else needed to go through this entire process. And they might even do it piecemeal and that's okay.

But beyond that, it's really just a lot of preparation. And then again, as I've said before, if there's not a sperm source that adds this unique element to it. And I think most patients are excited and recognize the challenge of it, but don't realize how challenging it is to find that perfect donor.

So I always use my own experience with my wife in this situation. And it really helps patients understand that it can take quite some time to figure out and find that right person. And no one really realizes the additional cost of it.

They just think, okay, I'll get some donor sperm. And the thought of how much do we need? How much will that cost? And, you know, the donor sperm, whether there was a quote unquote insurance approved indication for infertility or not is generally not covered either. So that's always going to be an out of pocket cost.

So many of my patients will tackle that first once they've figured out what their game plan is ideally before they potentially proceed with cycling or transferring or anything like that. Well, Samantha, thank you so much for taking time out to come on the show today to talk about reciprocal IVF. I know that our listeners will greatly appreciate this conversation.

I know I do. I always like learning things, learning new things, keeping my mind open to these sorts of things. But again, thank you so much for being here.

My pleasure, really. And I think this is a wonderful topic to be going over. It's a really unique and important part of our field.

Like I said, from personal experience, I've done it with my wife too. It's a really beautiful thing and a beautiful opportunity for us to build families with so many different peoples and couples that this used to be impossible for them before. So I think it's a really unique part of our field and an honor for us to be working with as physicians.

Thank you so much, Dr. Espinosa. We appreciate you being here. Thank you so much as always for the wise words.

Thank you. If you have questions about this show or any of our shows, feel free to email us, asrm at asrm.org. And until next time, I'm Jeffrey Hayes. And I'm Lowell Coo.

This is ASRM Today. This concludes this episode of ASRM Today. For show notes, author information and discussions, go to asrmtoday.org. This material is copyrighted by the American Society for Reproductive Medicine and may not be reproduced or used without express consent from ASRM.

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