Deficiencies in reporting results of lesbians and gays after donor intrauterine insemination and assisted reproductive technology treatments: a review of the first emerging studies

Differences in medically assisted reproduction use by sexual identity and partnership: a prospective cohort of cisgender women

STUDY QUESTION

Does medically assisted reproduction (MAR) use among cisgender women differ among those with same-sex partners or lesbian/bisexual identities compared to peers with different-sex partners or heterosexual identities?

SUMMARY ANSWER

Women with same-sex partners or lesbian/bisexual identities are more likely to utilize any MAR but are no more likely to use ART (i.e. IVF, reciprocal IVF, embryo transfer, unspecified ART, ICSI, and gamete or zygote intrafallopian transfer) compared to non-ART MAR (i.e. IUI, ovulation induction, and intravaginal or intracervical insemination) than their different-sex partnered and completely heterosexual peers.

WHAT IS KNOWN ALREADY

Sexual minority women (SMW) form families in myriad ways, including through fostering, adoption, genetic, and/or biological routes. Emerging evidence suggests this population increasingly wants to form genetic and/or biological families, yet little is known about their family formation processes and conception needs.

STUDY DESIGN, SIZE, DURATION

The Growing Up Today Study is a US-based prospective cohort (n = 27 805). Participants were 9-17 years of age at enrollment (1996 and 2004). Biennial follow-up is ongoing, with data collected through 2021.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Cisgender women who met the following criteria were included in this sample: endorsed ever being pregnant; attempted a pregnancy in 2019 or 2021; and endorsed either a male- or female-sex partner OR responded to questions regarding their sexual identity during their conception window. The main outcome was any MAR use including ART (i.e. procedures involving micromanipulation of gametes) and non-ART MAR (i.e. nonmanipulation of gametes). Secondary outcomes included specific MAR procedures, time to conception, and trends across time. We assessed differences in any MAR use using weighted modified Poisson generalized estimating equations.

MAIN RESULTS AND THE ROLE OF CHANCE

Among 3519 participants, there were 6935 pregnancies/pregnancy attempts and 19.4% involved MAR. A total of 47 pregnancies or pregnancy attempts were among the same-sex partnered participants, while 91 were among bisexual participants and 37 among lesbian participants. Participants with same-sex, compared to different-sex partners were almost five times as likely to use MAR (risk ratio [95% CI]: 4.78 [4.06, 5.61]). Compared to completely heterosexual participants, there was greater MAR use among lesbian (4.00 [3.10, 5.16]) and bisexual (2.22 [1.60, 3.07]) participants compared to no MAR use; mostly heterosexual participants were also more likely to use ART (1.42 [1.11, 1.82]) compared to non-ART MAR. Among first pregnancies conceived using MAR, conception pathways differed by partnership and sexual identity groups; differences were largest for IUI, intravaginal insemination, and timed intercourse with ovulation induction. From 2002 to 2021, MAR use increased proportionally to total pregnancies/pregnancy attempts; ART use was increasingly common in later years among same-sex partnered and lesbian participants.

LIMITATIONS, REASONS FOR CAUTION

Our results are limited by the small number of SMW, the homogenous sample of mostly White, educated participants, the potential misclassification of MAR use when creating conception pathways unique to SMW, and the questionnaire's skip logic, which excluded certain participants from receiving MAR questions.

WIDER IMPLICATIONS OF THE FINDINGS

Previous studies on SMW family formation have primarily focused on clinical outcomes from ART procedures and perinatal outcomes by conception method, and have been almost exclusively limited to European, clinical samples that relied on partnership data only. Despite the small sample of SMW within a nonrepresentative study, this is the first study to our knowledge to use a nonclinical sample of cisgender women from across the USA to elucidate family formation pathways by partnership as well as sexual identity, including pathways that may be unique to SMW. This was made possible by our innovative approach to MAR categorization within a large, prospective dataset that collected detailed sexual orientation data. Specifically, lesbian, bisexual, and same-sex partnered participants used both ART and non-ART MAR at similar frequencies compared to heterosexual and different-sex partnered participants. This may signal differential access to conception pathways owing to structural barriers, emerging conception trends as family formation among SMW has increased, and a need for conception support beyond specialized providers and fertility clinics.

STUDY FUNDING/COMPETING INTEREST(S)

The research reported in this publication was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health (NIH), under award number R01MD015256. Additionally, KRSS is supported by NCI grant T32CA009001, AKH by the NCI T32CA057711, PC by the NHLBI T32HL098048, BM by the Stanford Maternal Child Health Research Institute Clinical Trainee Support Grant and the Diversity Fellowship from the American Society for Reproductive Medicine Research Institute, BGE by NICHD R01HD091405, and SM by the Thomas O. Pyle Fellowship through the Harvard Pilgrim Health Care Foundation and Harvard University, NHLBI T32HL098048, NIMH R01MH112384, and the William T. Grant Foundation grant number 187958. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The first author recently had a leadership role in the not-for-profit program, The Lesbian Health Fund, a research fund focused on improving the health and wellbeing of LGBTQ+ women and girls. The fund did not have any role in this study and the author's relationship with the fund did not bias the findings of this manuscript.

TRIAL REGISTRATION NUMBER

N/A.

Assisted Reproductive Technology Results Using Donor or Partner Sperm: A Danish Nationwide Register-Based Cohort Study

This was a nationwide cohort study based on Danish health registers focusing on assisted reproductive technology (ART) treatments in women using donor or partner sperm from 2007 to 2017. Women using donor sperm were subdivided into groups based on relationship status: women with male partners, single women, or women with female partners. The live birth adjusted odds ratios (aORs) after the IUI treatments in women using donor sperm compared with women using partner sperm were 1.48 (95% CI: 1.38–1.59) in women with male partners using donor sperm, 1.20 (95% CI: 1.13–1.28) in single women, and 1.46 (95% CI: 1.32–1.62) in women with female partners. The live birth aORs after IVF treatments in women using donor sperm compared with women using partner sperm were 1.16 (95% CI: 1.02–1.32) in women with male partners using donor sperm, 0.88 (95% CI: 0.80–0.96) in single women, and 1.20 (95% CI: 1.00–1.44), in women with female partners. The use of donor sperm was associated with a higher chance of a live birth after the IUI treatments, but there was no difference after the IVF treatments. Our study invites healthcare professionals to increase their attention toward the different needs and fertility issues of all women attending fertility clinics.

Donor sperm recipients: fertility treatments, trends, and pregnancy outcomes

Purpose

To report fertility treatment use and outcomes among patients who use donor sperm for intrauterine insemination (IUI), in vitro fertilization (IVF), and reciprocal IVF (co-IVF).

Methods

This is a retrospective review of patients who used donor sperm at an urban, southeastern academic reproductive center between 2014 and 2020.

Results

Among the 374 patients presenting for care, 88 (23.5%) were single, 188 (50.3%) were in a same-sex female partnership, and 98 (26.2%) had a male partner with a diagnosis of male factor infertility. Most patients did not have infertility (73.2%). A total of 1106 cycles were completed, of which there were 931 IUI cycles, 146 traditional IVF cycles, and 31 co-IVF cycles. Live birth rates per cycle were 11% in IUI, 42% in IVF, and 61% in co-IVF. Of all resulting pregnancies, hypertensive disorders were most commonly experienced (18.0%), followed by preterm delivery (15.3%), neonatal complications (9.5%), gestational diabetes (4.8%), and fetal growth restriction (4.8%). Of the 198 infants born, fifteen (8.3%) required admission to the neonatal intensive care unit and three (1.7%) demised. Pregnancy and neonatal complications were more likely to occur in older patients and patients with elevated body mass index.

Conclusion

The use of donor sperm for fertility treatment is increasing. These data show reassuring live birth rates; however, they also highlight the risks of subsequent pregnancy complications. With the expansion of fertility treatment options for patients, these data assist provider counseling of patients regarding anticipated cycle success rates and possible pregnancy complications.

Pathways to fatherhood: clinical experiences with assisted reproductive technology in single and coupled intended fathers

Objective

To explore the cycle characteristics and outcomes of single and coupled intended fathers (SCIFs) using assisted reproductive technology.

Design

Cross-sectional study.

Setting

Multicenter, fertility practices from 2016 to 2020.

Patients

In this study, cycles among SCIFs with access to fertility coverage from 2016 to 2020 were included.

Interventions

None.

Main Outcome Measures

Our primary outcome was live birth rate. The secondary outcomes included the number of embryos transferred, miscarriage rate, and incidence of multifetal birth.

Results

Five single and 39 coupled intended fathers completed an in vitro fertilization cycle with a majority using egg donation and an agency-based gestational carrier (69.7%, 83/119). In most couples, both partners wanted to serve as the sperm source (64.4%, 29/45). The vast majority (97.7%, 43/44) also used preimplantation genetic testing for aneuploidy. Among the embryo transfer (ET) cycles (n = 27), most consisted of a single euploid ET (74.07%, 20/27), whereas the remaining consisted of a double euploid ET (25.92%, 7/27). The SCIFs had high rates of success, with a live birth rate of 85.19% (23/27). A mean of 1.26 ± 0.44 embryos were transferred, with a majority resulting in singleton birth (70.37%, 19/27).

Conclusions

Our study of SCIFs using assisted reproductive technology in the United States demonstrates that this population shares similar preferences for sperm source and the use of preimplantation genetic testing. Clinical outcomes suggest that this population is successful at achieving a live birth when using egg donation and a gestational carrier.

Live birth, cumulative live birth and perinatal outcome following assisted reproductive treatments using donor sperm in single women vs. women in lesbian couples: a prospective controlled cohort study

Purpose

Assisted reproductive technology (ART) treatments with donor sperm have been allowed for women in lesbian relationships (WLR) since 2005 in Sweden, but for single women (SW), these became approved only recently in 2016. This study was conducted to compare the outcomes of ART treatments in SW vs. WLR.

Methods

This is a prospective controlled cohort study of 251 women undergoing intrauterine insemination (D-IUI) or in vitro fertilization (D-IVF) using donor sperm between 2017 and 2019 at the department of Reproductive Medicine, Karolinska University Hospital. The cohort comprised 139 SW and 112 WLR. The main outcomes included differences in live birth rate (LBR) and cumulative live birth rate (cLBR) between the groups. The SW underwent 66 D-IUI and 193 D-IVF treatments and WLR underwent 255 D-IUI and 69 D-IVF treatments. Data on clinical characteristics, treatment protocols and clinical outcomes were extracted from the clinic’s electronic database. The outcomes of D-IUI and D-IVF were separately assessed.

Results

The cohort of SW was significantly older than WLR (37.6 vs. 32.4 years, P < 0.001), and more commonly underwent IVF at first treatment (83% vs. 29%, P < 0.000). Conversely, WLR underwent more frequently D-IUI as a first treatment (71% vs. 17% of SW, P < 0.001) and more often in the natural cycle (89.9% vs. 70.8%, P = 0.019), respectively. There was no statistically significant difference in the main outcome LBR between the two groups, or between the two different types of treatment, when adjusted for age. Perinatal outcomes and cLBR were also similar among the groups.

Conclusions

SW were, on average, older than WLR undergoing treatment with donor sperm. No significant differences were seen in the LBR and cLBR when adjusted for age between the two groups and between the two types of treatment (D-IVF vs. D-IUI).

Trial registration

ClinicalTrials.gov NTC04602962.

Putting reproductive rights into practice. The profile of the demand in a publicly sponsored ART program for single or female partner women in Catalonia

PURPOSE

To evaluate the size and characteristics of the demand for a newly established, publicly sponsored, program of assisted reproduction for single women (SW) and women with a female partner (FP) in a European country.

MATERIALS AND METHODS

We analysed the application forms received during the first two years and structured interviews with 300 successive non selected applicants.

RESULTS

The mean sustained size of the demand was of 52.6 applications per month (sd 14) and corresponded to 0.06 % of the target population. Data from 237 applicants was evaluable. 119 (50.2 %) were SW and 118 (49.8 %) were FP. The median age was 36 years, 36.5 years for SW and 34 years for FP (p < 0.001, Mann-Whitney). Clinically 18.6 % of women presented irregular cycles, and 17.8 % of women had undergone hysterosalpingography (HSG), with a 14.3% prevalence of tubal dysfunction.

CONCLUSIONS

A publicly sponsored program for Assisted Reproduction for SWFP should establish clear inclusion criteria, especially as regards to age, ovarian reserve, techniques offered, and the number of cycles to obtain the maximal efficiency. Further research specific for this group is required to ensure that they receive adequate care and ultimately to fulfil their reproductive rights.

Lesbian Women Undergoing Assisted Reproduction: Diverse, But Not Different

The use of assisted reproduction among women in relationships with other women has increased in the United States over the past decade as a result of increased legal access and social acceptance. Despite this shift, limited studies currently exist to guide optimal fertility care for this growing patient population of women seeking assisted reproduction. In this Commentary, assisted reproduction will be meant to include ovulation induction, intrauterine insemination (IUI), and in vitro fertilization (IVF). Conflicting studies suggest that self-identified lesbian women may demonstrate an increased prevalence of polycystic ovarian syndrome. Most available studies find that a woman's sexual orientation does not affect the outcome of fertility treatment. Self-identified lesbian women undergoing donor sperm IUI and IVF have similar pregnancy and live-birth rates as heterosexual women. Better evidence regarding patient demographics and comorbidities, underlying etiologies of subfertility, and assisted reproductive outcomes among women building families with other women is needed to optimize care.

Donor IUI is equally effective for heterosexual couples, single women and lesbians, but autologous IUI does worse

STUDY QUESTION

Are there differences in the clinical outcomes of IUI among different populational groups (heterosexual couples, single women and lesbian couples)?

SUMMARY ANSWER

The outcome of donor IUI (D-IUI) is similar in all populational groups and better than that seen with autologous insemination.

WHAT IS KNOWN ALREADY

A vast body of literature on clinical outcome is available for counselling heterosexual couples regarding decisions related to ART. The reproductive potential of single women, lesbian couples and heterosexual couples who need donor semen is assumed to be better, but there is a scarcity of data on their ART performance to actually confirm it.

STUDY DESIGN, SIZE, DURATION

In this retrospective multicentric cohort study, a total of 7228 IUI treatment cycles performed in 3807 patients between January 2013 and December 2016 in 13 private clinics belonging to the same reproductive medicine group in Spain were included. Patients with previous IUI attempts were excluded from the study. Only 1.9% of cycles were lost to follow-up.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 5318 D-IUI cycles were performed in three different populational groups: heterosexual couples (D-HC, 1167 cycles), single women (SW, 2839 cycles) and lesbian couples (LC, 1312), while a total of 1910 autologous IUI cycles were performed in heterosexual couples (A-HC). This last one was considered the control group and was composed of cycles performed in couples with a male partner with sperm parameters equivalent to those requested from donors. In order to identify factors with an impact on clinical outcome, a multivariate logistic regression analysis was performed. Regarding live birth rate (LBR), mixed effect models were employed to control for the fact that different patients were submitted to different numbers of treatments.

MAIN RESULTS AND THE ROLE OF CHANCE

Parameters that were significant to the primary outcome (LBR) according to the multivariate analysis were the populational group (D-HC, SW, LC and A-HC) to which the patient belonged, female age and a diagnosis of low ovarian reserve. At the age range of good prognosis (≤37 years), LBR was similar in all groups that underwent D-IUI (18.8% for D-HC, 16.5% for SW and 17.6% for LC) but was significantly lower in the autologous IUI (A-HC) group (11%). For all these significant findings, the strength of the association was confirmed by P values <0.001. From 38 years of age on, no significant differences were observed among the populational groups studied, and for all of them, LBR was below 7% from 40 years of age on.

LIMITATIONS, REASONS FOR CAUTION

To the best of our knowledge, a smoking habit was the only known factor with a potential effect on ART outcome that could not be controlled for, due to the unavailability of this information in a significant percentage of the clinical files studied. Our study was not capable of precisely quantifying the impact of a diagnosis of low ovarian reserve on the LBR of both IUI and D-IUI, due to the number of cycles performed in patients with such diagnosis (n = 231, 3.2% of the total).

WIDER IMPLICATIONS OF THE FINDINGS

For the first time, a comparison among D-HC, SW, LC and A-HC was performed in a study with a robust sample size and controlling for potential sources of bias. There is now sound evidence that equivalent clinical outcome is seen in the three groups treated with donor semen (D-HC, SW and LC). Specifically, regarding the comparison between SW and LC, our findings rule out differences in LBR proposed by previous publications, with very similar clinical outcomes within the same age ranges. At age ranges of good prognosis (≤37 years), reproductive performance of D-IUI is significantly better than that seen in heterosexual couples undergoing autologous IUI, even when only cases of optimal sperm quality are considered in this last group. This finding is in agreement with the concept that, as a group, A-HC are more prone to have female factor infertility, even when their infertility assessment finds no contraindication to IUI. Age affects all these groups equally, with none of them reaching a 7% LBR after the age of 40 years. Our findings will be useful for the counselling of patients from the different populations studied here about ART strategies.

STUDY FUNDING/COMPETING INTEREST(S)

None.

Double intrauterine insemination (IUI) of no benefit over single IUI among lesbian and single women seeking to conceive

PURPOSE

To explore clinical benefit of performing two intrauterine inseminations (IUI) 24 h apart-a double IUI vs. a single IUI among lesbian and single women.

METHODS

Retrospective cohort study using electronic medical record review during a 17-year period (11/1999-3/2017). A total of 11,396 patients at a single academic-affiliated private practice were included in this study. All cycles with a single or double IUI were included. A sub-analysis of first cycles only (n = 10,413) was also performed. Canceled IVF cycles converted to IUI were excluded. T tests and Wilcoxon rank-sum tests were used for continuous data, and chi-square for categorical data. Multivariable logistic regression controlled for patient age, day 3 follicle-stimulating hormone (D3 FSH), body mass index (BMI), peak estradiol (E2), and post-wash total motile sperm counts to model the association between IUI number and ongoing pregnancy rate (OPR) according to sperm source (autologous vs. donor). Generalized estimating equations and mixed effect models accounted for multiple cycles from the same woman. Adjusted odds ratio (AOR) with 95% CI was determined. Sub-analyses of sexual orientation and partner status were performed to compare heterosexual couples with proven infertility to women with lesbian and single women.

RESULTS

During the study period, 22,452 cycles met inclusion criteria (single IUI 1283 vs. double IUI 21,169). Mean patient age and BMI were similar between groups. For couples using autologous sperm, OPR was significantly higher with double IUI (12.0% vs. 14.1%; p = 0.0380). A similar increase was observed for donor sperm OPR among heterosexual couples (14.4% vs. 16.2%), though this did not reach statistical significance (p = 0.395). A sub-analysis restricted to donor sperm demonstrates a clinical benefit of second IUI in heterosexual couples, 8.5% vs. 17.6% OPR (AOR 2.94; CI 1.00-10.99; p = 0.0496). When lesbian and single patients were evaluated, there was no difference (17.2% vs. 15.2%; AOR 0.99; CI 0.59-1.70; p = 0.0958).

CONCLUSIONS

Double IUI is associated with a significantly higher OPR for heterosexual couples using an autologous or donor sperm source. The benefit of a second IUI is less clear in patients with undocumented fertility status using donor sperm, such as single and lesbian women.

Assisted reproductive technology with donor sperm: national trends and perinatal outcomes

BACKGROUND

Information regarding the use of donor sperm in assisted reproductive technology, as well as subsequent treatment and perinatal outcomes, remains limited. Outcome data would aid patient counseling and clinical decision making.

OBJECTIVES

The objectives of the study were to report national trends in donor sperm utilization and live birth rates of donor sperm-assisted reproductive technology cycles in the United States and to compare assisted reproductive technology treatment and perinatal outcomes between cycles using donor and nondonor sperm. We hypothesize these outcomes to be comparable between donor and nondonor sperm cycles.

STUDY DESIGN

This was a retrospective cohort study using data from all US fertility centers reporting to the Centers for Disease Control and Prevention's National Assisted Reproductive Technology Surveillance System, accounting for ∼98% of assisted reproductive technology cycles (definition excludes intrauterine insemination). The number and percentage of assisted reproductive technology cycles using donor sperm and rates of pregnancy, live birth, preterm birth (<37 weeks), and low birthweight (<2500 g) were the primary outcomes measured. Treatments assessed include use of donor vs nondonor sperm. The trends analysis included all banking and fresh assisted reproductive technology cycles using donor and autologous oocytes performed between 1996 and 2014 (n = 1,710,034). The outcomes analysis was restricted to include only fresh autologous cycles performed between 2010 and 2014 (n = 437,569) to focus on cycles with a potential outcome and cycles reflective of current practice, thereby improving the clinical relevance. Cycles canceled prior to retrieval were excluded. Statistical analysis included linear regression to explore polynomial trends and log-binomial regression to estimate relative risk for outcomes among cycles using donor and nondonor sperm.

RESULTS

Of all banking and fresh donor and autologous oocyte assisted reproductive technology cycles performed between 1996 and 2014, 74,892 (4.4%) used donor sperm. In 2014, 7351 assisted reproductive technology cycles using donor sperm were performed, as compared with 1763 in 1996 (6.2% vs 3.8% of all cycles). Among all autologous oocyte cycles performed between 2010 and 2014, the live birth rate was lower for donor sperm (27.9%) than nondonor sperm cycles (32.5%); however, after adjustment for maternal age, donor sperm use was associated with an increased likelihood of live birth (adjusted relative risk, 1.06, 95% confidence interval, 1.01-1.10). Per transfer, there was no significant difference in live birth rates for donor vs nondonor sperm (31.9% vs 36.8%; adjusted relative risk, 1.04, 95% confidence interval, 0.998-1.09). Per singleton live birth, there was no significant difference in preterm birth (11.5% vs 11.8%; adjusted relative risk, 0.98, 95% confidence interval, 0.90-1.06); however, low birthweight delivery was slightly lower in donor sperm cycles (8.8% vs 9.4%; adjusted relative risk, 0.91, 95% confidence interval, 0.83-0.99).

CONCLUSION

Donor sperm use in assisted reproductive technology has increased in the United States, accounting for approximately 6% of all assisted reproductive technology cycles in 2014. Assisted reproductive technology treatment and perinatal outcomes were clinically similar in donor and nondonor sperm cycles.

Threat of biographical disruption: the gendered construction and experience of infertility following cancer for women and men

BACKGROUND

Infertility is a major concern for people with cancer and their partners. There have been calls for further research on the gendered nature of psychosocial, emotional and identity concomitants of fertility post-cancer across women and men.

METHOD

The gendered construction and experience of infertility following cancer was examined through a survey of 693 women and 185 men, and in-depth one-to-one interviews with a subsample of survey respondents, 61 women and 17 men, purposively selected across cancer types and age groups. Thematic decomposition was used to examine the open ended survey responses and interviews. The chi square test for independence was used to test for group differences between women and men on closed survey items.

RESULTS

In the thematic decomposition, infertility was identified as providing a 'Threat of Biographical Disruption' which impacted on life course and identity, for both women and men. Subthemes identified were: 'Parenthood as central to adulthood'; 'Infertility as a threat to gender identity'; ' Unknown fertility status and delayed parenthood'; 'Feelings of loss and grief'; 'Absence of understanding and support'; 'Benefit finding and renegotiation of identity'. In the closed survey items, the majority of women and men agreed that they had always 'wanted to be a parent' and that 'parenthood was a more important life goal than a satisfying career'. 'It is hard to feel like a true adult until you have a child' and impact upon 'my feelings about myself as a man or a woman' was reported by both women and men, with significantly more women reporting 'I feel empty because of fertility issues'. Many participants agreed they 'could visualise a happy life without a child' and there is 'freedom without children'. Significantly more men than women reported that they had not discussed fertility with a health care professional.

CONCLUSION

The fear of infertility following cancer, or knowledge of compromised fertility, can have negative effects on identity and psychological wellbeing for both women and men, serving to create biographical disruption. Support from family, partners and health care professionals can facilitate renegotiation of identity and coping.

Lesbian and bisexual women's likelihood of becoming pregnant: a systematic review and meta-analysis

BACKGROUND

Few data exist regarding pregnancy in lesbian and bisexual (LB) women.

OBJECTIVES

To determine the likelihood of LB women becoming pregnant, naturally or assisted, in comparison with heterosexual women SEARCH STRATEGY: Systematic review of papers published 1 January 2000 to 23 June 2015.

SELECTION CRITERIA

Studies contained details of pregnancy rates among LB women compared with heterosexual women. No restriction on study design.

DATA COLLECTION AND ANALYSIS

Inclusion decisions, data extraction and quality assessment were conducted in duplicate. Meta-analyses were carried out, with subgroups as appropriate.

MAIN RESULTS

Of 6859 papers identified, 104 full-text articles were requested, 30 papers (28 studies) were included. The odds ratio (OR) of ever being pregnant was 0.19 (95% CI 0.18-0.21) in lesbian women and 1.22 (95% CI 1.15-1.29) in bisexual women compared with heterosexual women. In the general population, the odds ratio for pregnancy was nine-fold lower among lesbian women and over two-fold lower among bisexual women (0.12 [95% CI 0.12-0.13] and 0.50 [95% CI 0.45-0.55], respectively). Odds ratios for pregnancy were higher for both LB adolescents (1.37 [95% CI 1.18-1.59] and 1.98 [95% CI 1.85, 2.13], respectively). There were inconsistent results regarding abortion rates. Lower rates of previous pregnancies were found in lesbian women undergoing artificial insemination (OR 0.17 [95% CI 0.11-0.26]) but there were higher assisted reproduction success rates compared with heterosexual women (OR 1.56 [95% CI 1.24-1.96]).

CONCLUSIONS

Heterosexuality must not be assumed in adolescents, as LB adolescents are at greater risk of unwanted pregnancies and terminations. Clinicians should provide appropriate information to all women, without assumptions about LB patients' desire for, or rejection of, fertility and childbearing.

TWEETABLE ABSTRACT

Review of likelihood of LB women becoming pregnant: LB teenagers at greater risk of unwanted pregnancies.