IVF and ROPA for lesbian couples

Carmen Avilés Salas, MD, PhD
Medical Director

Same Sex Couples

#IVFWEBINARS about IVF for Lesbian Couples in Spain - ROPA Method explained by Dr Salas - Medical Director at Phi Fertility
From this video you will find out:
  • What options are available for couples who want to start a family through assisted reproduction techniques?
  • What are the reasons why couples may opt for the ROPA technique?

IVF for lesbian couples in Spain - ROPA method explained

What options do lesbian couples have while building a family? It turns out that there are several techniques in Assisted Reproduction which not only make the dream of becoming parents possible but also allow both partners to become physically involved in the conception and actively share the maternity process.

One of such methods is the ROPA in which one woman contributes with her oocytes and the other woman contributes with her uterus to achieve a full-term pregnancy and a healthy baby at home. How does it work? During this webinar Dr. Carmen Avilés Salas from Phi Fertility Center presents the topic and answers attendees questions afterwards.

What the law says about Lesbian Couples treatment in Spain

ROPA stands for Reception of Oocytes from the Partner. The ROPA method is a variant of in vitro fertilisation treatment. This technique, known as shared biological motherhood, allows a couple formed by two women to share the process of in vitro fertilisation in an active way. One of the women will be the genetic mother who provides the eggs and the other one will be the biological mother who carries the pregnancy.

According to the Spanish law, a woman should be able to benefit from reproductive techniques regardless of her sexual orientation.

Dr. Carmen Avilés Salas reminds us that a lesbian couple have to be married to start the ROPA procedure. It is highly important as both egg and sperm donation in Spain is anonymous. The only exception that is possible is when we talk about married couples. In case of heterosexual couples, a husband can donate sperm to his wife. In case of lesbian couples, one woman can donate her eggs to the other one – without anonymity.

Lesbian shared biological motherhood has been legally recognised in Spain since 2007. Consequently, babies that are born through the ROPA technique within the lesbian married couple have two legal mothers.

Reasons and requirements for lesbian couples

Apart from the legal status of the relationship, another requirement is the positive medical analysis of the couple. Doctors need to know the ovarian reserve, the quality of the eggs and the state of the uterus of both of the women to advise which one of them would be the best donor and which one – the best recipient. Dr. Avilés Salas admits that they usually prefer a younger woman to be the donor. Both women need to perform a blood test in order to be sure that they don’t have any infectious diseases, as well as a karyotype test.

The reasons for deciding on ROPA technique may be different and they do differ from couple to couple. Of course, the main motivation is the possibility for homosexual partners to become active participants in the reproduction process. However, there are also some medical reasons, such as alterations in oocyte quality one of the women suffers from, absence of own oocytes or severe disfunction of own ovarian reserve. Other cases may include a risk of hereditary transmission of any disease, chromosomal or genetic abnormalities and – last but not least – failure of previous fertility treatments.

What ROPA involves

During the ROPA method, one woman undergoes an ovarian stimulation and the other one receives the embryo and carries the pregnancy. Apart from the women involved in the process, there is also a sperm donor needed. Dr. Avilés Salas says that because of donor anonymity enforced in Spain, the women and the donor will not be able to know or meet one another at any point of their life. The sperm donor is selected on the basis of the physical characteristics to ensure maximum similarity with the recipient. The sperm donors should have a normal karyotype and a negative serology. On the couple’s demand, the donor’s semen is checked for recessive diseases (like e.g. cystic fibrosis).

In order for the ROPA technique to work, both women have to be ‘synchronized’. Whilst one of them is being stimulated, the other’s endometrium is being prepared for the reception of the embryo. The woman who provides her eggs undergoes an ovarian stimulation in order to produce follicles in an attempt to obtain an optimal number of oocytes. Such a stimulation involves hormonal injections and takes about 10-12 days. Once the follicles have achieved an adequate size (16-18 millimetres), the egg collection is performed.

The hormonal treatment is also needed to prepare the endometrium of the recipient woman. According to Dr. Avilés Salas, there are various protocols used to achieve this goal, but at Phi Fertility Center they use the one with an increasing dosage of estrogens. When the eggs have been fertilised (with the use of ICSI technique), the recipient starts with progesterone to complete the endometrium preparation.

The embryo transfer day depends on the number of embryos and their development. If there are only two or three embryos, doctors usually perform the embryo transfer on day 3 as the uterus is the best incubator that they have. However, if there are three, four or even more embryos, they will be left to achieve the blastocyst stage and transferred on day 5. 12 days after the embryo transfer, the recipient has a pregnancy blood test performed. If it is positive, 2 weeks later the woman undergoes the first ultrasound scan to make sure the pregnancy is going on.

At this point it is important to mention other possibilities that the ROPA method allows. Dr Avilés Salas talks a little bit about the reciprocal IVF cycle which is, in other words, a simultaneous stimulation. During such a technique, both women are stimulated hormonally at the same time. After the eggs are collected from both women, they are fertilised with the sperm of the same sperm donor. The embryos are cultured and afterwards, the embryos from woman A are transferred to the uterus of woman B and the embryos from woman B are transferred to the uterus of woman A. In that way, both women can be pregnant at the same time. If everything goes according to the plan, both of them will be genetical and biological mothers to their babies.

Probability of pregnancy

Dr. Avilés Salas admits that the probability of pregnancy depends mainly on the egg donor’s age. It is generally known that a woman starts to lose her reproductive capacity in a natural and an irreversible process that tends to intensify from the age of 35 . So if the donor is less than 35 years old, after the first attempt the probability of a pregnancy is about 65% and after all the attempts of the same cycle – about 70%. In comparison, in case of a 40-year old woman, the success rate after the first attempt is only 15% – after all the attempts it is increased slightly to 20%.

- Questions and Answers

How long should a couple stay in Spain for the whole procedure?

As we have to perform an IVF cycle, we need a couple to stay in Spain for about 15 days. This is because of the ovarian stimulation. If you start with the stimulation, the first or the second ultrasound scan can be performed in your country but the ultrasound scan previous to the egg collection should be done in Spain. And between the ultrasound and the egg ‘pick-up’, 2 or 3 days will probably pass. And from the ‘pick up’ to the embryo transfer – around 5 days. So you need to stay in Spain for more or less 8-10 days, depending on how long the ovarian stimulation takes.

Is there an age limit for the partner (egg donor)?

There is no an age limit but in Spain we usually don’t perform IVF treatment in women older than 50 years old. So this can be the limit for this kind of treatment. But it’s going to depend mainly on the ovarian reserve and the quality of the eggs from the donor. The recipient cannot be older than 50 years old.

I don’t know if it’s possible for you to answer but it’s bothering me. We live in the country where our relationship has no legal status, so we’re not married. Is relationship status important and does it need to be confirmed somehow in the clinic in Spain?

Yes, it’s really important. As I explained earlier, egg donation in Spain is anonymous and the only unique situation where the anonymity is not needed, is in in the context of a married couple. So we need you to be married to be able to perform the treatment. Because if you’re not married, the treatment would not be legal. It doesn’t matter which country a couple is married in – but they should be married.

We’re a couple from abroad (UK). What is the possible time frame for us from contacting the clinic to starting the treatment? What about all the process afterwards: synchronisation, stimulation, etc.? Do you have a clinic or doctor to recommend in UK? How long does it take to choose the sperm donor?

I will send you our mail address to contact us before starting the treatment. We only need to have your test results: serology and karyotypes, general blood test and blood group. Once we have the results, we can start the treatment. If a couple does not have a karyotype test done, it should take about 20-25 days to get a result, depending on a laboratory. The patients can bring the results from their home country as well. The synchronisation and the stimulation is something that’s not too long. As we need to synchronise the periods of both a donor and a recipient, we need to start with the period of one of them – usually it is the donor’s. We will give you contraceptive pills – their number depends on when the period starts. It usually takes about a month to synchronise both periods. When we start with the ovarian stimulation, we start with the endometrium preparation, too. So about 10-12 days will pass from the start of the ovarian stimulation until the egg collection. And then comes the day of the transfer. So there is generally about a month and a half between the start of the period synchronisation and the embryo transfer. I don’t know if I have any doctor in UK to recommend but I can ask about that. Choosing the sperm donor is something really quick because we only need to know your physical characteristics. When sperm samples are frozen and they are in a sperm bank, the only thing that we need to do is to look for a donor with the same physical characteristics as the recipient. We can have the sperm donor selected in 1 or 2 days. This is the fastest part of the whole procedure.

I’ve already had a 9th round of IVF. We’re struggling a lot as a couple but we keep on fighting. But more often I have thoughts that I should say STOP. I heard lately that hundreds of hormones I was taking would lead to cancer… Is it possible?

It’s true that you have used high doses of hormones. And it’s also true that prolonged treatment with hormones can increase the risk of a breast cancer. But it’s the age that is the most important factor increasing the risk of a cancer. The hormonal treatment can accelerate the process – but it’s not going to induce the breast cancer. I think 12 treatments is enough. You should start thinking what’s happening or change the type of treatment. Obviously something is not working correctly here.

Can our sperm donor be our friend from a gay male couple? Is it allowed by the law?

No, it isn’t because donation in Spain is anonymous. You and your donor cannot know each other.

How should we decide about our “roles”. Who should provide eggs and who should carry the pregnancy? We have similar test results.

If you have similar test results, I think the age is the most important thing. In such case, I would advise the younger of you to be the donor and the older – the recipient. But it depends. If both of you want to be pregnant and the results are similar, I’d advise to stimulate the older first to get better embryos. In two years’ time, the results won’t probably be similar. And then we will stimulate the younger of you to make the other one pregnant. If you are the same age and none of you has a problem with her uterus, you should choose for a pregnancy the one that has a lighter job and has enough time, etc. If there are no differences in the age or test results, there is no medical reason to select one or the other.

Does it happen often that transfers are cancelled because there are no eggs retrieved or embryos to transfer (in egg donation) or because donor and recipient cycles are not synchronised?

This is not usual when we stimulate a young woman with good ovarian reserve. It depends on the donor’s reserve. If ovarian reserve is good, then usually we have good embryos. It’s unusual not to get any embryos to transfer. If the donor is older and the reserve is not adequate, sometimes there is the possibility that we won’t have embryos to transfer. It depends on the number and the quality of the eggs. For example, if we have a 33-year old donor with 15-20 follicles, it’s really difficult not to get any embryos to transfer. But if we have a 40-year old donor with 3 or 4 follicles when we start the stimulation, in that case it is possible not to have any embryos to transfer. And it is not usual for us to cancel the cycles because of the synchronisation. We usually start the recipient’s protocol a little bit earlier to be sure that we would have enough time to prepare the endometrium.

Do you guarantee the number of eggs and embryos in the ROPA method program?

In the ROPA program, it depends on the age of the donor and her ovarian reserve. This is what makes the most difference. If we have a young donor with good reserve, we can guarantee 2 or 3 blastocysts. But if the woman is not young enough or the reserve is not adequate, or we have problems like endometriosis, we cannot guarantee any particular number of eggs or embryos. It’s simply not possible.

What test we need to (or can do) in advance and deliver to the clinic to speed up the treatment to the maximum?

We need a serology test from both of the women. We would also need the ultrasound scan with an antral follicle count (AFC) for the donor as well as the ultrasound scan to evaluate the uterus and the uterine cavity of the recipient. We would also need a karyotype and AMH test from the donor and a blood group test from both of women. And I think that’s all.

I am curious and want to be sure. Is ROPA the same as reciprocal IVF? When doing some research, I found this term and now I’m not quite sure if it is the same thing and just a language thing? Thank you for explaining!

It can be the same. The reciprocal IVF cycle is when we stimulate both women at the same time, we produce embryos from both of them. Then we transfer the embryos from the woman A to the woman B and the embryos from the woman B to the woman A. ROPA stands only for the general method. It means that we stimulate one woman, we get the eggs, we fertilise them and the embryos that we obtain are transferred to the other woman. So reciprocal IVF would be like a double ROPA.

Do these two programs differ in price: reciprocal IVF cycle and the ROPA program? We have 2 stimulations in the reciprocal IVF cycle, is it more expensive then?

Yes, it is a little bit more expensive. We have 2 stimulations and we have to perform 2 ICSI’s. And we also have to culture more embryos. I cannot tell you how much it will cost. It won’t of course be like two ROPA’s, but it will probably be more expensive.
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Carmen Avilés Salas, MD, PhD

Carmen Avilés Salas, MD, PhD

Dr. Carmen Avilés Salas is a specialist in reproductive medicine and genetics with over 15 years of experience graduated from Miguel Hernández University (Alicante, Spain). Currently, from 2018 she’s a Medical Director at PHI. She’s a Member of the SEGO (Spanish Society of Gynaecology and Obstetrics) and SEF (Spanish Fertility Society).
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