All parents-to-be face a huge mountain of questions. From pregnancy to naming to parenting, many feel overwhelmed. Lesbian couples also ask themselves these questions. On top of that, it is not that easy for them to get pregnant at all. Although marriage for same-sex couples has finally been introduced almost everywhere, the road to baby bliss is still quite bumpy.

This little guide is intended to answer a few basic questions about artificial insemination, sperm donation, legal basics and treatment abroad. It should be a small guide to what you need to look for and give you some initial orientation.

Counselling

Basically, every wish to have a child through artificial insemination begins in the consulting room of your gynaecologist. She will carry out an initial examination with you. This includes a blood test and an ultrasound scan as standard. Your blood will mainly be tested for various diseases. These include hepatitis, syphilis, HIV and rubella. Your hormone balance is also examined. The thyroid hormones TSH, T4 and T3 and the hormone prolactin are particularly important. Of course, all hormones that have to do with follicle maturation and pregnancy are also examined. These include FSH, LH, AMH and progesterone.

During the ultrasound examination, we look to see if any malformations or diseases, such as fibroids, could affect your chances of getting pregnant.

The different methods of fertility treatment

In vitro fertilisation (IVF) is often used as a kind of synonym for all possible treatment strategies. However, it is actually only one of many methods. Here I would like to give you an overview of the different treatments.

IUI (insemination)

Intrauterine insemination, or IUI for short, is the most common method of treatment for lesbian infertility patients. This is mainly because it is quite uncomplicated. Ultimately, the sperm are introduced directly into the uterus. Before this, ovulation can be stimulated with medication in order to find the optimal time. However, the method can also be used without hormone therapy. IUI is one of the most favourable options with a success rate of about 10%-15% per attempt.

IVF

IVF stands for in vitro fertilisation and corresponds to the classic test tube fertilisation. As a rule, hormone therapy is administered beforehand in order to have enough mature eggs available. Shortly before ovulation takes place, the eggs are removed by ultrasound. The sperm are then added in a test tube. Nowadays, the ICSI method is more commonly used, where the sperm are injected directly into the egg. The success rates depend on the age of the woman from whom the eggs originate. Furthermore, the success rates vary depending on the clinic, between 20% and 50% per attempt.

ROPA (shared motherhood)

In a heterosexual relationship, each parent contributes something to the pregnancy in some way, so that the child ends up with half of the genes from the mother and half from the father. In a lesbian relationship, this is not a given in that sense. However, a similar situation is possible in the context of a "Reception of oocytes from partner" (ROPA). In this case, one partner donates her egg, which is fertilised in IVF. The embryo is then transferred to the other partner. In principle, one woman would carry the child of the other. The child therefore has a genetic and a biological mother. The characteristics of the gestating mother are not passed on, but this can also be an advantage. If, for example, one partner desperately wants to carry the child, but she runs the risk of passing on genetic diseases to the child, the other partner can donate an egg.

The sperm donor

Even though your child will certainly get along great with two mothers, it needs a biological father. Here you have to decide whether you want a sperm donor from a sperm bank or whether the donor should be someone you know.

Anonymous or open sperm donation from the sperm bank

Generally, a distinction is made between open and anonymous donation. The open donor can be contacted, the anonymous donor cannot. All donors accepted by the sperm bank must meet the following requirements:

• A higher than average quantity of high quality sperm must be delivered.
• The donor must not have any transmissible diseases (HIV, hepatitis, chlamydia, jaundice, gonorrhoea, cytomegalovirus or syphilis).
• There must also be no hereditary diseases in the immediate family. These include, for example, cleft palate, metabolic disorders, diabetes, rheumatism or allergies.
• The donor must have a healthy lifestyle.
• There must be no known psychological illnesses in the donor or the donor's family.
• The donor must be between 20 and 50 years old.
• The donor must be of at least average intelligence.

When you apply, you must first fill out a questionnaire about yourself. You can then indicate which characteristics best suit your future family. The sperm bank will then make suggestions from which you can choose a suitable donor. Often, voice samples, handwriting samples and pictures are also available. When choosing a sperm bank, it is best to ask your gynaecologist for a suitable one in your area. There are also international and European sperm banks.

Anonymous donation is a good decision, especially if you do not want to have a father in your family. Your child will never know him. This is a fundamental decision and is up to you.

The advantage of the sperm bank is that you can assume that the sperm are of very high quality without much effort. In addition, the anonymous donor will certainly never interfere in the upbringing of the child.

A known person as donor

The other possible donor is someone you know, for example a friend of yours. In this case, the person must also undergo an examination beforehand. The same things are tested as at the sperm banks. After all, diseases should be avoided. The advantage here is that you can see for yourself how the person lives. Perhaps you would like the child to have a male partner later on. In that case, the biological father can also be involved in the upbringing to some extent. However, if the father does not give up all rights to raise the child, your partner cannot adopt the child. You can find more on this topic in the chapter "Legal situation". Whether it is a good idea to use a known person as a donor depends very much on your individual situation.

At this point, you and your partner must decide what is best for your little family. It is not possible to make a general recommendation.

Egg donation / embryo donation

Just as with heterosexual couples, it is possible that neither of you is fertile enough to have a child. If adoption is not an option for you, you can also resort to egg donation. However, this is only allowed in certain European countries, but not in Switzerland or Germany. In some cases, even the surplus embryos can be adopted by other women. The ROPA method is therefore only allowed in countries where egg donation is also permitted. One of these would be Spain and Northern Cyprus, for example.

Finding the right offer

The country

Where you can have the treatment depends on the method you choose. Depending on the country, you may have to wait, especially if you are going abroad for treatment. Countries usually give preference to their own nationals.

In general, the following countries in Europe offer fertility treatment for lesbian couples:

Austria, Belgium, Bulgaria, Denmark, Germany (some regions but only sperm donation), Finland, France, Iceland, Ireland, Latvia, Netherlands, Northern Cyprus, Portugal, Spain, Switzerland since 2021 but only sperm donation and Sweden.

Within these countries, the regulations for open and anonymous sperm donation, egg donation, shared motherhood (ROPA), genetic testing and so on are different. So if you have your sights set on a particular country, you need to get more detailed advice. Here you will only get an overview.

The following countries offer the possibility of open sperm and egg donation:

Denmark, Finland, Great Britain, Ireland, the Netherlands, Austria, Northern Cyprus (must be delivered in) and Sweden.

Anonymous sperm and egg donation is available in these countries:

Belgium, Denmark, France, Northern Cyprus and Spain.

Preimplantation genetic diagnosis is allowed in these countries:

Belgium, Greece, Netherlands, Northern Cyprus, Sweden and Spain.

Compared to other countries, Spain and the UK are considered very expensive, even attracting local women to go abroad for treatment. Northern Cyprus is very popular because it does not require a registered partnership, the age limit is 56 years and the gender of the future baby can be chosen. As a non-European country, South Africa is also an option. Treatments may be carried out here up to the age of 55. South Africa is therefore also a popular place to go for late child wishes.

The clinic

Since you may have to travel a long way for the treatment, many clinics offer an initial consultation via video chat. However, this varies from clinic to clinic, so you first have to contact them by email. Based on the answer, you can make a preliminary decision. If you don't get an answer or the staff doesn't speak your language or at least English, you can cross the clinic off your list. Communication is of elementary importance for the treatment, but of course you cannot assume that German is spoken in Spanish hospitals. After the first conversation, you can tell a lot about whether you feel comfortable with the staff and the clinic. If you don't, you shouldn't choose the clinic.

Costs of treatment

Depending on your home country, you may be able to get help from your health insurance company, for example. Since you will receive little to no support from your health insurance for artificial insemination, depending on the country, it is important to start saving in good time.

Here are a few examples:

• IUI without hormone therapy 200 € per treatment (Germany).
• IVF about 1,600 € per treatment (Germany)
• One sperm sample 600 € (+ shipping costs 100 - 150 € Example sperm bank Erlangen, Bavaria)
• IVF with egg donation 4.000 - 9.000 €.

Please note that you will probably need several treatments including sperm donation to finally get pregnant. Costs also vary from country to country.

Other

You should bear in mind that you will have to travel to the clinic for the treatment. This means that you will also have to pay for flights and accommodation.

Legal situation

By far the most complicated part of the whole process is getting an overview of the legal situation. The laws vary from country to country and sometimes depend on the federal state. In some places, there are no regulations at all for lesbian couples.

Germany

Artificial insemination:

The Embryo Protection Act is mainly intended to regulate IVF in Germany. If you violate this law, you can be imprisoned for up to five years. The prohibitions relevant to you here are the misuse of artificial insemination methods, the misuse of embryos, choosing a sperm based on gender during fertilisation and genetic testing of the embryo before it is placed in the womb.

Whether lesbian couples are approved for artificial insemination is regulated differently in the federal states. Often they are simply not mentioned at all, so that admission is at the discretion of the clinic.

Custody:

The biological mother automatically receives custody of the child at birth, but the wife does not. The wife must adopt the child.

Adoption:

In adoption, both parents are equal, provided they are married. However, the process of adopting a child is very time-consuming and can take several years. In addition, relatively few children are usually given up for adoption in Germany. However, it is also possible to adopt a child from abroad, for example from Mexico, Brazil or Portugal.

Austria

Artificial insemination:

In Austria, lesbian couples have a variety of methods at their disposal, for which they are also officially approved. There is also a choice between open and anonymous sperm donation. To be able to use the offer, the couple does not have to be married.

Custody:

If the couple is married when the child is born, then custody, as it were, lies with both mothers. In the case of unmarried couples, only the biological mother has custody for the time being. In this case, custody of the other mother can be applied for by making a joint declaration at the competent registry office.

Adoption:

In general, marriage is not a prerequisite for adoption in Austria; single persons are also eligible. The child of the wife only has to be adopted if it was not conceived by artificial insemination or if both parents are not Austrian citizens. If, for example, a stepchild is adopted, the spouse receives the same custody rights as the biological mother.

Switzerland

In Switzerland, marriage for all was approved in 2021. Until now, medical procreation was prohibited for same-sex couples, but this ban will now be lifted as part of the amendment to the law.

Stepchild adoption has been permitted up to now. The prerequisite for this is a registered civil partnership or a cohabitation. The child must also have lived with the family for at least two years before the application for adoption can be filed. During this time, custody lies exclusively with the biological mother. Lesbian couples are still excluded from other forms of adoption, but this will also change with the new law.

Conclusion

Many countries still have some catching up to do when it comes to equal rights for lesbian couples in fertility treatment. However, if you choose the right clinic, many things are already possible today and the costs can also be made more affordable. With this guidebook you have a first orientation on the way to a desired child - start NOW!