What evidence is already out there?

Q6. Are perinatal outcomes different for LGBTQIA+ people, and are they affected by how someone attempted pregnancy or became pregnant?

By perinatal outcomes we mean live birth rates, stillbirths and miscarriages; pregnancy, labour and birth complications; interventions to start labour or during labour; mode of birth; gestational parent/surrogate mortality rates; birth trauma; mental health; infant feeding, health, developmental and mortality outcomes

Although many papers are included here, the question is not considered answered because only a subset of outcomes and sections of the LGBTQIA+ community are covered

Mental and physical health:

Mamrath et al, 2024: Higher anxiety in sexual minority women postnatally during the pandemic lockdown https://doi.org/10.1371/journal.pone.0297454. Open Access 

Summary: 381 postnatal women (including 20 sexual minority women) completed an online survey during the first UK lockdown, including completing a psychometric test. Sexual minority women were more likely to score highly on an anxiety scale than their heterosexual counterparts. Lesbian, gay, bisexual, and pansexual participants scored highly in the ‘psychosocial adjustment to motherhood’ category.

Shenkman et al, 2023: Better mental health of lesbian mothers compared to heterosexual mothers

https://doi.org/10.1007/s13178-023-00800-8 Paywall

Summary:  Seventy-two lesbian mothers by donor insemination (from 36 families) were compared with 72 heterosexual parents by assisted reproduction (without donated gametes; from 36 families) on positivity, life satisfaction, and depressive symptoms. All parents were cisgender and had at least one child born through assisted reproduction, aged 3–10 years. Lesbian mothers reported greater positivity, greater life satisfaction and less depressive symptoms

Carone, Rothblum et al, 2021: Good mental and physical health outcomes for transgender parents compared to cisgender parents https://doi.org/10.1037/fam0000776 Paywall

Summary:  The study compared the quality of life and several mental health (psychological distress, life satisfaction, happiness, social wellbeing) and health (physical health, alcohol and drug use) dimensions by gender identity and parenthood status in a sample of 1,436 transgender and cisgender respondents to the U.S. Transgender Population Health Survey (TransPop study). An estimated 18.8% of transgender respondents were parents, with the majority (52.5%) being transgender women. After controlling for age, education, and relationship status, there were no significant differences between trans- and cisgender parents and their nonparent counterparts on any mental health or health dimensions.

Van Rijn-van Geldern et al, 2018: No difference in mental health and wellbeing of gay fathers through surrogacy compared to lesbian mothers and heterosexual parents using IVF https://doi.org/10.1093/humrep/dex339 Open Access

Summary:  This cross-sectional study is part of an international research project involving 38 gay-father families, 61 lesbian-mother families and 41 heterosexual-parent families with 4-month-olds in the UK, the Netherlands and France. There were no differences in levels of parental wellbeing (parental stress, psychological adjustment and partner relationship satisfaction) between gay-father families with infants born through surrogacy, lesbian-mother families with infants born through donor insemination, and heterosexual-parent families with infants born through IVF.

Goldberg, Gartrell & Gates, 2014: Transition to parenthood for LGB people was similar to heterosexual people (report) https://escholarship.org/uc/item/7gr4970w. Open Access 

Summary: This report addresses the research on LGB parenting, including functioning and experiences of LGB parents and their children. Relevant summary points are that, similar to heterosexual parents, LGB parents’ mental health and relationship quality decline across the transition to parenthood, although support from friends, family, and the workplace buffered all parents from the challenges of new parenthood. Studies comparing LGB and heterosexual parents in regard to mental health, parenting stress, and parenting competence have found few differences based on family structure. Conditions linked to poorer wellbeing for LGB parents include living in less supportive legal contexts, perceiving less support from family or supervisors, having higher levels of internalized homophobia, and encountering more child behaviour problems. Compared to heterosexual parents, LGB parents have not been found to differ on average, in parental warmth, emotional involvement, and quality of relationships with their children.

Borneskog et al, 2014: Higher relationship satisfaction of lesbian couples compared to heterosexual couples https://doi.org/10.1186/s12905-014-0154-1 Open Access

Summary: Three-year follow up assessment of lesbian and heterosexual couples after assisted reproduction. Participants requesting assisted reproduction at all fertility clinics performing gamete donation in Sweden were recruited consecutively 2005–2008. A total of 114 lesbian couples (57 treated women and 57 partners) and 126 heterosexual couples (63 women and 63 men) participated. Lesbian couples reported higher relationship satisfaction than heterosexual couples, however the heterosexual couples’ satisfaction with relationship quality was not low. At a follow-up after assisted reproduction with donated sperm, lesbian couples reported stable relationships and a high satisfaction with their relationships, even when treatment was unsuccessful.

General pregnancy-related:

Leonard et al, 2022: Comparison of mother-father, mother-mother and father-father birth outcomes

https://www.sciencedirect.com/science/article/abs/pii/S0002937822001727. Paywall

Summary: A population-based cohort study of all live births in hospital 2016-2019 in California. Likely sexual and/or gender minority parents were identified by a birthing parent identifying as a father (n = 498), or both parents identifying as a mother (n = 2572). The comparison group were those where the birthing parent identified as a mother and the other parent identified as a father (n = 1,483,119). Compared with mother-father partnerships, birthing parents in mother-mother partnerships were significantly more likely to have a multiple pregnancy (adjusted risk ratio, 3.9; 95% confidence interval, 3.4–4.4), induction of labour (adjusted risk ratio, 1.2; 95% confidence interval, 1.1–1.3), excessive bleeding after birth (adjusted risk ratio, 1.4; 95% confidence interval, 1.3–1.6) and severe illness/morbidity (adjusted risk ratio, 1.4; 95% confidence interval, 1.2–1.8). There was no difference in gestational diabetes, pregnancy related hypertension, caesarean birth, premature birth or low birthweight. No outcomes significantly differed between father birthing parents and birthing parents in mother-father partnerships.

Hodson, Meads and Bewley, 2017: Systematic review of likelihood of pregnancy for lesbian and bisexual women https://doi.org/10.1111/1471-0528.14449 Open Access
Summary: 30 papers (28 studies) were included.  In the general population, the odds of pregnancy were nine-fold lower among lesbian women and over two-fold lower among bisexual women compared to heterosexual women (the odds ratios were 0.12 [95% CI 0.12–0.13] and 0.50 [95% CI 0.45–0.55], respectively). The odds of adolescent pregnancy were higher for lesbian adolescents and particularly for bisexual adolescentscompared to heterosexual adolescents (odds ratios of 1.37 [95% CI 1.18–1.59] and 1.98 [95% CI 1.85, 2.13]). There were inconsistent results regarding abortion rates. The odds of pregnancy after assisted reproduction were higher for lesbian women compared with heterosexual women (the odds ratio was 1.56, 95% CI 1.24–1.96). This analysis included eight papers, most of which were designed to look at outcomes other than pregnancy/birth rate. The single paper designed to look at the question of birth rate after assisted reproduction with donor sperm showed no differences between lesbian and heterosexual couples (this specific study is https://doi.org/10.1093/humrep/det445, Open Access).

Own egg versus partner egg (reciprocal IVF):

Matorras et al, 2023: Comparing the outcomes of in-vitro fertilisation in lesbians using their partner’s egg IVF versus artificial insemination https://doi.org/10.1093/humrep/dead035 Open Access

Summary: Single pregnancies after shared motherhood IVF compared to own-egg artificial insemination had similar outcomes, except for a non-significant increase in the rate of preeclampsia/hypertension after shared motherhood IVF (age-adjusted odds ratio = 1.9, 95% CI = 0.7–5.2). Twin pregnancies after shared motherhood IVF had a much higher frequency of preeclampsia/hypertension (age-adjusted odds ratio = 21.7, 95% CI = 2.8–289.4; p = 0.01).

Wrande et al, 2022: Comparing the outcomes of own egg IVF versus artificial insemination

https://pmc.ncbi.nlm.nih.gov/articles/PMC8995219/ Open Access
Summary: This is a prospective cohort study of 251 women undergoing intrauterine insemination (IUI) or in vitro fertilization, all with donor sperm, between 2017 and 2019 at one department in Sweden. This was 112 lesbian women in a relationship and 139 single women. The single women were older and more often had IVF at first treatment. There was no statistically significant difference in live birth rate after IUI between the two groups, when adjusted for age. Live birth per insemination was 19% for lesbians in a relationship compared to 14% for single people. In those using IVF, there was a higher pregnancy rate for lesbian women in relationships compared to single women (even after adjustment for age). Pregnancy per embryo transfer was 67% compared to 40% (p = 0.005, after adjustment for age) and birth per embryo transfer was 45% compared to 24% (p = 0.08 after adjustment for age). 

Diego et al, 2022: Similar outcomes of in-vitro fertilisation in lesbians using their partner’s egg versus their own egg https://pmc.ncbi.nlm.nih.gov/articles/PMC9464617/ Open Access

Summary:  This is a retrospective review of patients who used donor sperm at an urban, southeastern USA centre 2014-2020. Among the 374 patients, 88 (24%) were single, 188 (50%) were in a same-sex female partnership, and 98 (26%) had a male partner with a diagnosis of male factor infertility. Most patients did not have infertility (73.2%). Live birth rates per cycle were 11% in intrauterine insemination (IUI), 42% in in-vitro fertilisation (IVF), and 61% in co-IVF (where one partner’s egg is used and the other partner carries the pregnancy).  Same sex partners were no less likely than opposite sex partners to have a live birth (adjusted odds ratio was 1.48, 95% confidence interval 0.92 to 2.36). Same sex partners were no more likely than opposite sex partners to have pregnancy complications (adjusted odds ratio was 0.49, 95% confidence interval 0.19 to 1.25, p = 0.1) or miscarriage (adjusted odds ratio was 0.69, 95% confidence interval 0.32 to 1.49, p = 0.3).

Brandao et al, 2022: Similar outcomes of in-vitro fertilisation in lesbians using their partner’s egg versus their own egg https://pmc.ncbi.nlm.nih.gov/articles/PMC9474973/ Open Access

Summary:  Retrospective multicentre cohort study 2011-2020 in 18 fertility clinics in Spain. A total of 99 partner-egg cycles (73 couples) and 2929 own-egg cycles (2334 couples or single patients) of women younger than 38 years old with no known fertility disorder were included. Couples using partner egg were younger than those using own egg. A greater number of eggs and embryos were obtained for couples using partner egg than own egg. No differences were found between groups in outcomes, with or without adjustment for age. The total clinical pregnancy rates per embryo transfer were 57% and 50% and the live-birth rates were 46% and 41%. There was no difference in premature birth (8% vs. 12%) or birthweight (2.8 kg vs. 3.1 kg).

Nunez et al, 2021: Better outcomes of in-vitro fertilisation in lesbians using their partner’s egg versus their own egg https://pubmed.ncbi.nlm.nih.gov/34061679/ Paywall

Summary: This was a retrospective matched cohort study of couples performing a first cycle of either partner-egg (n = 60) or own-egg in-vitro fertilisation or intra-cytoplasmic sperm injection (IVF/ICSI; n = 120) 2012-2018. Pregnancy and birth rates were better with partner-egg embryo transfers: biochemical pregnancy 70% versus 48% (p = 0.004), clinical pregnancy 60% versus 40% (p = 0.01), ongoing pregnancy 60% versus 37% (p = 0.003), and live birth 57% versus 30% (p = 0.001). After adjusting for age, body mass index, and number of mature oocytes, there was still a significant improvement across all outcomes in partner egg cycles (live birth rate odds ratio 3, 95% confidence interval 1.4-6.6). Cumulative live birth rates were higher with partner eggs (66% vs. 43% [p = 0.005]).

Surrogacy:

Fuchs et al, 2018: Perinatal outcomes for surrogacy if the surrogate uses their own egg versus a donated egg https://pmc.ncbi.nlm.nih.gov/articles/PMC5962328/ Open Access
Summary: 222 women living in the United States completed a brief online survey between November 2015 and February 2016. There were 204 gestational carriers (using donated egg) and 18 traditional surrogates (using own egg). Overall, obstetric outcomes were similar. Traditional surrogates were younger, more likely to be Hispanic, more likely to be a full-time student, more likely to be on Medicaid, less likely to be a first-time carrier and more likely to have a high Depression Scale score (38% vs. 4%)

Woo et al, 2017: Perinatal outcomes for own egg pregnancy vs a donated egg surrogacy

https://www.fertstert.org/article/S0015-0282(17)31941-6/fulltext. Open Access
Summary: We identified 124 gestational surrogates who achieved a total of 494 pregnancies (312 their own spontaneous pregnancies and 182 surrogate pregnancies with donated egg). Surrogate pregnancies more likely to result in twin pregnancies than own egg pregnancies (33% compared to 1%, p<0.01). Miscarriage and ectopic rates were similar. Surrogate births had higher rates of preterm birth (10.7% vs. 3.1%), and higher rates of low birth weight (7.8% vs. 2.4%, 105 g lower birthweight on average). Surrogate births had significantly higher obstetrical complications, including gestational diabetes, hypertension, use of amniocentesis, placenta previa, antibiotic requirement during labour, and caesarean section.

Pavlovic et al, 2010: Perinatal outcomes for own egg pregnancy vs a donated egg surrogacy

https://pmc.ncbi.nlm.nih.gov/articles/PMC7183021/ Open Access

Summary: 78 donated-egg surrogacy pregnancies (with single baby) were compared to 71 own-egg pregnancies that the surrogate had previously been through for their own family building. Surrogacy cycles had worse perinatal outcomes than own pregnancies (a combination of preterm delivery, postpartum haemorrhage, preeclampsia, gestational hypertension, gestational diabetes, in utero growth restriction, oligohydramnios, abnormal placentation, placental abruption, and NICU admission; 25.6% vs. 9.9%; p = 0.02). There were no significant differences in the incidence of vaginal or caesarean birth.

Söderström-Anttila et al., 2016: Systematic review of surrogacy health outcomes for surrogate, child and family https://doi.org/10.1093/humupd/dmv046 Open Access

Summary:  Most studies reporting on surrogacy have serious methodological limitations. According to these studies, most surrogacy arrangements are successfully implemented and most surrogate mothers are well-motivated and have little difficulty separating from the children born as a result of the arrangement. The perinatal outcome of the children is comparable to standard in-vitro fertilisation and egg donation and there is no evidence of harm to the children born as a result of surrogacy. There were no studies on children born after cross-border surrogacy.