The world of fertility has grown and changed as the needs of families has changed. And now more than ever before, there are different populations seeking fertility care. Fertility Bridge helps fertility centers connect with their current and prospective patients in new and dynamic ways. In this episode of their podcast, Griffin talks to our very own Dr. Mark Leondires about the various paths of family-building and how fertility clinics can provide personalized care to those with differing goals and needs.
GRIFFIN JONES: Today my guest is the favorite guest that I've had on Inside Reproductive Health so far, because he's given me the skinniest bio to read so far. Dr. Mark Leondires is the founder, medical director, and partner at Reproductive Medicine Associates of Connecticut (RMACT) and Gay Parents to Be. He's a board-certified REI and he has come on today to talk to us about different family building paths. Dr. Leondires, Mark, Welcome to the show.
Dr. MARK LEONDIRES: Thank you Griffin for that introduction. And hello everybody out there!
Diverse LGBTQ Family Building Paths
JONES: When we prefaced this episode, one of your concerns was just us not being able to get to everything because we're going to talk about different family building paths for different populations of the patients that we serve and one of your concerns was, “There's just so much here. What do we even focus on?” And I think it's alright to just start from the beginning and help people unpack this, because I think there's a lot of people that haven't even begun to think about these different family building paths and certainly not to the degree that you've talked about. So, let's maybe build out just what those are. And when we say family building paths, we’re talking about those for heterosexual couples, maybe for single women, for same-sex couples, for transgendered couples. What is a family building path (if you want to bring it up to a higher level)? And who are some of the different populations that have very different family-building paths?
LEONDIRES: I think on a very basic level, everybody who's listening to here understands that you need sperm, an egg, and a uterus to have a successful birth of a child. And so if we break it down into people who walk through the door of my practice, I have opposite sex couples, so heterosexual couples that have access to those three items. I have single women who need a sperm source, but they have eggs and they have a uterus. I have single men--both gay and straight--who have sperm, but they don't have a uterus and they don't have eggs. And then I have same sex female couples (so lesbian couples would be another term for that), they have two uteruses and four ovaries, and they have to make decisions of whose biology they're going to use to carry the pregnancy, whose biology they're going to use for the egg source--and you also have the decision about whether they're going to both participate biologically. And then you have same-sex cis-male couples, so gay male couples, both born with testicles where they may both want to be genetic-intended fathers and use one egg source, and they're going to need access to a uterus. And then you have the trans population, which it's actually difficult to put that in one particular category because a trans-man, who was born with ovaries and a uterus, their family-building pathway would depend on who their partner is--whether it’s a cis-man, or a trans-woman, or another trans-man. So to unpack the family-building pathways, it just requires a kind of very process-oriented talk. And that's what I talk about on a daily basis and try to personalize everybody's care and I think that's the future of medicine: to personalize people's care to their unique needs and goals.
JONES: Part of the reason why this is becoming more urgent, and you mentioned a point to me before, is it there was a time where if you were a gay person in a relationship with a member of the same sex, essentially that meant that that person was relegating themselves to a future that did not involve children and that has changed dramatically. Can you just talk about that shift?
Positive Shifts in LGBTQ Families
LEONDIRES: Yes. Absolutely. So, it's really just in the past 50 years that same-sex couples have been able to have children outside of sexual intercourse. And the first same-sex couples that were able to move forward with this are lesbian couples who had access to sperm from a sperm bank or perhaps from a friend or colleague that provided sperm source, and they were completing insemination. And with the advent of in vitro fertilization in the 80s and 90s, then the door opened for same-sex cis-male couples to pursue reproduction using an egg source and a gestational carrier or surrogate. I can tell you it, kind of on my own personal story, one of my own struggles in coming out, was I had to struggle with the fact of, “I really want it to be a father and how was I going to do that as a gay man?” And I think we all have to remember as the 70s and the 80s to be part of the LGBTQ community was rather tough and there was something called the AIDS epidemic as well. So for men to be truly who they were, often meant that they had to give up their desires for family-building. Thankfully in the 21st century, that's no longer the case. The biggest hurdle in family-building for a cis-male, same-sex couples actually is the cost involved, but the technology and the biology and the arms of the reproductive services community, legal services, mental health community, are all open to help gay men conceive using an egg source and a gestational carrier. And certainly, over the past years, many members of the trans-community have also realized that they can work with the help of assisted reproductive technologies, either through insemination or through in vitro fertilization to also build a biological family that is unique to their personal desires.
JONES: Was assisted reproductive technology on your horizon, you were a board-certified REI by this point. But was ART on your horizon when you had this coming of age for yourself or did you also face the prospect of, “I might not be able to have children or my own family”?
What's it like to build your family through surrogacy...as a dad and a doctor?
LEONDIRES: ART was on the horizon. Obviously, I was reproductive endocrinologist and have been for over 20 years, but, you know, to take the hurdle of doing a non-traditional family-building pathway, requires understanding that your children are going to have a different entry into the world. For LGBTQ families--let's say same-sex male couple--their children do not have a mother, the egg donor is not the mother. For lesbian couples, their children do not have fathers. Right? For single people who choose to reproduce, it's either they have one mom or one dad. So, families are different. For myself, I came from a very traditional, Orthodox background, and it required me to pack that up and open my eyes up that to be a parent it’s about loving and wanting a child and intent. So I think it's very interesting to realize that 50% of pregnancies managed to states are unintended—they’re accidental pregnancies. But if you remember the queer community, you have to work really hard to have this child. And that intent that—
JONES: That number is effectively zero for the LGBTQ.
LEONDIRES: Yeah. That intent also means you want this child and you're going to work hard to be the best parent. And so I had to kind of get past the fact that my traditional family that I was raised in did a good job, and my family is going to be raised in a different way and it's okay. I'm privileged to have a family with the help of assisted reproductive technologies.
JONES: Is there a lag between the accessibility--or just simply the existence of the technology--and the narrative of the population that they have access to it or that it is going to be something that they use? In other words, IVF has been, and donor gametes, gestational carriers have been around for some time, but data that you've shared with me is that the millennial generation is far more, perhaps, predisposed or simply has in their plans, that they're going to use ART. You shared with me data that says 63% of LGBTQ Millennials, which is about 3.8 million people, are considering using ART to build their family. That’s definitely a generational shift, isn’t it?
LEONDIRES: It's a big change. Family Equality Council, so familyequalitycouncil.org, is a 501(c)3 corporation that's kind of dedicated to family building to support the LGBTQ+ community. And they recently completed a white paper which included more than a thousand participants from the straight population and the LGBTQ+ population and they looked at the differences of family-building. So historically LGBTQ+ people that had children, those children were conceived through intercourse from either a previous relationship or a different type of relationship from their partner. And but now if we look at Millennials--there's more than three million Millennials that are looking forward to having children, they don't see the barriers that the previous generation sees and they are aware that they have the option of assisted reproductive technology. So there should be a tremendous boon in family-building for LGBTQ persons. And I think part of that is that there's a feeling of safety with the passage of Marriage Equality, remember that only passed in 2015. And certainly, in a lot of parts of the United States, there's acceptance of LGBTQ+ families. So that being said, the Millennials that are coming out of the closet are secure in who they are, feel comfortable that they can be who they want to be, and don't see the barriers to having children. So this report, this white paper that came out earlier this year, it validates that the impression that Millennials are ready to have children, whether they're two women or two men or trans couples. And they're going to do that you with the help of assisted reproductive technologies, and it's really a call-to-action for assisted reproductive medicine groups to open their doors to the LGBTQ+ community and to improve their cultural competence on serving that community.
JONES: You live in Connecticut which instituted same-sex marriage long before The Supreme Court decision in 2015, but you also bring up that decision which the Defense of Marriage Act was stricken down. At that point--I don't have any data on it--but there's this sort of anecdotal conversation that there was an influx of spike in same-sex couples pursuing assisted reproductive technology. Did you see one at that time?
LEONDIRES: It's actually been quite an encouraging and amazing change in my practice in the past four years. Historically, I always saw same-sex male couples and the average age of people walking through the door was in their 40s and it was a long thought out conversation whether they were going to have children, if it was right for them and so on. And I would say regularly for the past two years, I see people who are 25 to 35, that same-sex relationship, that feel validated, they present to my office and they're married. And they're going to have children just like anybody else who gets married is going to have children. And they don't feel the same bias or the same concerns and they feel safe and they feel like their family’s going to be safe because they've been validated by Supreme Court. So yes, I think that there has been a change in attitude and acceptance and a feeling of freedom that they can also have families and their children are going to be safe.
JONES: Well, you talked about individualized care--personalized care, as a form of process, what are some process steps that you take to make sure that you can individualize for a different path to parenthood?
LEONDIRES: If we take it by portions of the community, if you have a same-sex cis-female couple where they were both born with ovaries, you have to personalize whether one of them desires to be pregnant. Not every woman desires to be pregnant, right? You have to personalize whether they both have a desire for genetic linkage or it doesn't matter to them. Right? You also have to understand their own biology. Women have a real biological clock, so if there's an age gap between the two partners, maybe one of them has lost their ability to use their own egg pool, while the other one has a good egg pool, but maybe doesn't want to be pregnant. You have to personalize how they want their family to look, and then you have to guide them. And I do this in line with our mental health professionals on how to pick a sperm donor. And one thing that is actually kind of amazing to conceive of is some cis-female couples use their brothers as a sperm source and they use the egg from the non-related partner and they are truly having a child that represents both family trees. And it's really quite beautiful and it's an act of giving within families and it's wonderful. So personalizing their care comes into understanding what options they have and how they want to build their family. If you take a same-sex cis-male couple, they're faced with the most decisions out of anybody in the LGBTQ+ community. It could be that in one of the partners, they have a family history that's concerning--let's say for cancer or mental illness--and they decide that they do not want to be a genetic sperm source, and then we're going to choose an egg donor that's more like their family tree. Or could be they both want to be sperm sources and they are going to try to find an egg donor that kind of runs the middle between their own ethnic groups. It could be a biethnic couple--so African-ancestry person and a Caucasian-ancestry person, and they might choose to use a Hispanic egg source, so they have basically a mix of races, so when they're walking down the street with their children, their children look a little bit like both of them. The other thing that comes into play for male couples is just appreciating that if one person has Hepatitis C positive or HIV positive, they can proceed into family-building, but they just have an extra step to do which includes, you know, particular sperm-washing techniques and forming the gestational carrier--the woman that's going to carry the baby of their particular situation. I like complex problems and working with the LGBTQ+ community presents complex situations, but thankfully they're all problems and hurdles that can be overcome as long as you take the time to peel the onion and make sure you have the pieces all taken apart. And you’re trying to meet each family-to-be’s goal.
JONES: You've brought some of that process up to the very front of the interaction between the provider or the clinic and the patient in the form of even how you answer the phone, how you do intake, how the office is set up. Talk a little bit about that.
LEONDIRES: I'm very proud to say, pun intended, that we were one of two freestanding fertility clinics in the country, of which there is about 450, that has received a healthcare equality stamp from the Human Rights Campaign, which basically means we've taken our practice through sensitivity training, looked at every form, made sure that everybody who answers the phone doesn't assume that somebody has an opposite sex partner. We’ve looked at our own benefits packages for employees and make sure that we are inclusive in regards to whether somebody has an opposite-sex partner or same-sex partner and being able to also serve inclusive for trans people that might exist within my practice. So to receive the HRC, the Human Rights Campaign Healthcare Equality Leader stamp, basically means you need to get a hundred on their tests. And we've achieved a hundred on their tests and we're moving into our third year, hopefully, coming up, of basically defining our practice as one that's inclusive and safe and has cultural competency to help anybody who walks through the door, regardless of their gender identity or sexuality.
JONES: I can just hear the progressives, especially at the Coastal practicing can mark up and jump on us. You’re ahead and at a good time, because we've talked about how this is going through the change in which far more Millennials will and are accessing ART than in previous generations. Another very interesting figure that you shared with me from the white paper is, if you think of it this way, 73% of LGBTQ families were formed from intercourse--current LGBTQ families--but only 37% are currently considering intercourse for their future family-building. And I imagine that this is a peek into where we start talking about costs. Now I think there are still more than a third of the LGBTQ population that is considering intercourse as a means of forming their families, my hypothesis--my assumption would be that that would be largely cost driven, is that correct? And are there other things to consider?
How to Be Your Own Advocate for LGBTQ Fertility Coverage
LEONDIRES: The opportunity to build a family how you want your family to be built, separate from intercourse, it represents a significant cost for anybody who needs the resources of a fertility clinic. You may be aware of something called the definition of infertility. So, you know, there's 12 states with fertility mandates across the country. There's many, many companies that cover infertility treatment and in vitro fertilization, but the single feature of many, many of these companies and all the state mandates, except for Delaware right now, is that you have to meet the medical definition of infertility, which means you have to have a year of unprotected intercourse of an opposite sex partner. So members of the LGBTQ+ community don't meet that definition. We have a different type of infertility. We have let's say biological infertility, or social infertility. We didn't choose to be who we are, but we need help. The way I kind of have worked through the years--I've done a lot of advocacy across the country with employers. And employers are starting to open their eyes to the fact that if they offer fertility benefit for their straight employees, they need to offer it for their gay employees.
The story I kind of tell with this is that if you're sitting next to your colleague at work and his wife or her husband has blocked tubes or a low sperm count, they can access a full suite of fertility services and access, sometimes multiple IVF cycles, but if you just happen to be a member of LGBTQ+ community, you can't. You're paying into the same insurance plan, you should have access to the same benefits. And what's happened over the past five years, some major employers Pepsi/Frito-Lay, Facebook, Google, and now there's more than a hundred greater-than-1,000-employee companies that have opened their eyes to the fact that people who have same-sex partners should be able to access their fertility benefits, because they have a different type of infertility. There's a significant barrier of cost for LGBTQ persons to conceive. So, intercourse is cheap, right? But if you're a lesbian couple and you need to pursue artificial insemination, just purchasing the sperm can run $500 to $1,500 per vial and just a fertility treatment insemination cycle that you do through a medical clinic, which is the safest way to do it and also allows you to protect your parentage rights in many states can run you $1,500 to another $1,500 to 3,000. So one attempt might cost a lesbian couple $2-3,000 dollars and most women don't achieve pregnancy one attempt. So they might spend $15-30,000 just to have one child, right? If you take a same-sex male couple, a cis-male couple, they need an in vitro fertilization cycle, which costs upwards of $15-20,000, plus they need to support their egg donors donating their eggs, which has a compensation stream of usually about $10,000. Plus, they need to have a surrogacy agency and help of a surrogate. So family-building for same-sex married couples approaches $120-150,000 for one child and that's a financial burden that the straight community often doesn't face barring, you know, significant fertility challenges for them. So the move right now, and the things that I personally work at with great support people, is to try to push this kind of snowball or boulder up the hill, just to be fair. We just want the same benefits that everybody else gets. We understand that it's going to be harder for us to conceive when we face the realities of our sexuality and our gender identity, but we just want to be treated fairly by our employers and the insurers.
JONES: You've also talked about that sometimes there's just sort of a notion that it's a same-sex male couple, double income, no kids--they're loaded. You talk about the school teachers, the blue-collar workers, that do not have access to the benefits that are brokered by being an executive of Pepsi or another Fortune 1000 company. I thought of your point there when I was watching the Netflix show called Jailbirds, if anyone has seen it, it's a real-life program about some women in Sacramento County Jail. And one of the inmates was talking about how her and her partner are going to conceive afterwards, which is essentially that her brother is going to have sex with her wife and that's how they're going to have their child, because they can't afford the $3,000 that you talked about. And I can just hear Melissa Brissman who was on the show a few months ago, or in any third-party reproduction attorney, just having a heart attack at this point. That's what they're facing and there's providers that need this education of the provide for these different family paths. There is also education necessary for the people going through these paths themselves. What resources are available to them?
Financial Resources for LGBTQ Parents
LEONDIRES: Obviously, Google is a tremendous resource and if you type in “gay male family-building,” “lesbian family-building,” there's a couple places for reliable information. Once again Family Equality Council, who recently merged with Path2Parenthood, has very reliable information. One of the things that I wanted to do, and I did with the support of my partners, my physician partners here, upwards of six years ago now, is we started a third-party web property called “Gay Parents to Be.” Gay Parents to Be provides information, you know for the entire LGBTQ+ community of where to start and there's some wonderful information on there and we've got some seminal contributors from the legal and mental health professional community. There's also an organization called Men Having Babies, MenHavingBabies.org, which seeks to educate the same-sex male community, as far as their family-building options. And actually guys that need to build families that do not have the six-digit incomes, they will provide grants. And the providers that participate with Men Having Babies after full vetting also will provide pro-bono care to help those men have families. And in regard to resources and collecting information, many of the people look towards the larger LGBTQ+ Community for family-building education and that sometimes you can find through HRC, as well as the LGBTQ task force and there are a lot of resources for education. I would encourage you to certainly educate yourself on what needs to be done. I often say that an LGBTQ person that wants to have a baby, whether they’re coupled or single, needs to assemble their team and their team needs to be their fertility clinic; a mental health professional to educate them on why they want to use a fully-screened donor, what interests they have in knowing their donor, and how they're going to talk to their children; a reproductive attorney who has experience in making sure their proper legal protections are in place so you can be on the birth certificate. If your partner, or your partner can complete a second parent adoption, but not genetically related to the child. And so you can travel freely within the United States and, perhaps, outside the country without your parentage being questioned. So you really need a medical clinic, a fertility doctor, a mental health professional, and a reproductive attorney to bring your child into the world safely with the protection of your parental rights moving forward and this is for the protection of your family, as well.
I think that for once you have a child you look at the world a little bit differently. For our family, when our second son was born, we didn't have a birth certificate from the state that he was born in for six months because of administrative issues. And it was anxiety-provoking to think of traveling outside of our liberal bubble of Connecticut to anywhere because there's a question about you know, “Is this actually your child?” So mental health professionals talk about how you're going to build your family how you going to talk to your children and reproductive attorneys to help you protect your family or are essential to the LGBTQ+ community to building their family. And I'm happy to say all those resources exist and I’m happy to say either contacting me through Gay Parents to Be or going through Family Equality Council, you can access those resources. So people shouldn't feel at a loss. They just do have to ask for education and assistance.
LGBTQ Legislation Changes
JONES: That was a question that I had, too is, how often do you pop in to check on the development of legislation of these different things to be updated on the laws, or maybe what's happening in New York with the surrogacy bill that's pending? Do you let the advocates and the attorneys do their thing with that? And you get updated you try to stay abreast of it as it's happening?
LEONDIRES: Yeah, I try to stay abreast of it as it’s happening. I get pulled in and popped in as I can as I can fit into my life and schedule. I mean the New York Parent-Child Security Act—I think tomorrow might be the last day that we're waiting for the assembly to pass it. In the state of Connecticut, I've just even yesterday spoke to an attorney at Yale where they're trying to make the infertility mandate inclusive for LGBTQ persons. Maryland has an inclusive state mandate and they're still trying to figure out how to build that inclusivity in to same-sex male couples.
As a doctor, it's hard for me to speak of the legal issues, so I morally often have a support role and I share my story that I actively kind of get engaged. The other thing is because I run a fertility practice and I'm a doctor, I have a different perspective and voice on it. So I get pulled in by lots of different places and I do what I can.
JONES: Mark. How would you conclude on the different paths to building a family and the different populations that are affected by those paths? For a provider may be a doctor or a practice owner that hasn't spent too much time on this where all of this sounds pretty--even if they've served same-sex patients which most of them have, but to the degree to which society is seeing so much more that this is still fairly new. How would you conclude on this topic?
LEONDIRES: I think that for the practices that are willing to serve this population, you need to look at every aspect of your practice and you should have, before you put the rainbow flag on your website or you the rainbow flag on your door, you need to do some sensitivity training for your front desk, for your financial advocates, for your medical assistance, for your doctors, for your nurses, for your people in the back. You need to look at your bathroom signage. You need to consider that in your production rooms there needs to be an option to watch gay porn versus straight porn. You really have to look at your practice from the top down. Actually, if you're already have some of those patients within your practice, ask them. They will very clearly tell you where you’re maybe falling short. I think that there's a lot of biases that were aware of and then there's biases that were unaware of. The only way you're going to find out about the way your practice looks to somebody from the LGBTQ+ community is to ask and you may be surprised to hear that i's great or that there are moments that a woman who's in a same-sex female relationship is asked about her husband, or is told to go home and have sex because she's going to ovulate soon. You know, these are things that drive home that care team that this woman is seeking care with just doesn't get her. The other thing that we've done in our practice that has been very helpful as we color code different types of patients. We have a color code for a single woman, a single man, a same-sex female couple, a same-sex male couple, and for a traditional straight couple, and for trans people and it leaps out at you in our EMR that there's something special about this person. We also have color coding for people who only speak Spanish. Also have color coding for any unique population within our community. Infertility has changed dramatically the past 20 years. I started off taking care of infertile couples, right? We now have women with cancer that are freezing eggs. We have young women who were protecting their fertility freezing eggs. We have single moms-to-be, single dads-to-be, lesbian moms-to-be, gay dads-to-be, trans-people who are trying to conceive with their partners and having to individualize that and it is a little bit of a Brave New World. It may be some of the new hurdles come up with some of the new technologies which include, you know, screening for adult diseases and screening for cancer. So people without infertility, they simply access fertility care because of this technology being so robust. I think it's important to remember that only about 30% of people who walk through the fertility clinic store actually need in vitro fertilization, but they all need help. Not everybody's infertile. So if you're going to serve the LGBTQ+ community, you also have to understand that we, because I'm a member of it, are going to need donors and we don't feel bad about it. And we want to meet our donors, and our we believe our children might want to meet our donors. We are going to need access to mental health services to help educate us on the process and we're going to need referrals to good reproductive attorneys. We want to be recognized for being a little bit different than your garden-variety patient that walks through the door. Not more, just want to be treated individually as the people that we are.
JONES: A topic that we could like we talked about for much longer and will likely have you back on the show for. Dr. Mark Leondires, thanks so much for coming on Inside Reproductive Health.
LEONDIRES: Thank you so much Griffin and good luck to everybody out there who is trying to have a baby!
You’ve been listening to the Inside Reproductive Health Podcast with Griffin Jones. If you're ready to take action to make sure that your practice drives beyond the revolutionary changes that are happening in our field and in society, visit fertiltybridge.com to begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to Inside Reproductive Health.
Previously posted on Fertility Bridge.