What Fertility Options Are Available for Same-Sex Couples in the United States?
A complete guide to IVF, IUI, reciprocal IVF, gestational surrogacy, and adoption pathways.
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SCRC Editorial Team
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7 min read
Same-sex couples in the United States now have access to a wider range of fertility options than at any point in history. Donor sperm, donor eggs, gestational surrogacy, and adoption are all available. Medical technology works. The legal framework, while still uneven across states, has improved substantially since the Supreme Court affirmed marriage equality in 2015.
What’s often missing is clear, direct information. This guide covers the primary family-building pathways available to female couples, male couples, and nonbinary or transgender individuals, along with the medical procedures each involves, the legal considerations every couple should know about, and the questions worth asking a specialist before you begin.
OPTIONS FOR FEMALE COUPLES
Pathways most often used by female same-sex couples
Female couples typically have three main options: IUI with donor sperm, conventional IVF with donor sperm, or reciprocal IVF. Which makes sense depends on age, ovarian reserve, whether there are any fertility diagnoses, and how much each partner wants to be medically involved in the pregnancy.
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IUI with donor sperm
Intrauterine insemination places prepared donor sperm directly into the uterus around the time of ovulation. It is the least invasive and least expensive starting point, and it can be done with or without ovarian stimulation medications. Success rates per cycle are modest (typically 10–20% depending on age and whether fertility medications are used) so multiple cycles are common. IUI is a reasonable first step for couples with no identified fertility issues where at least one partner is under 35.
Ask your doctor: Am I a candidate for IUI, or does my age or ovarian reserve make IVF a better first step?
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IVF with donor sperm
In vitro fertilization with donor sperm is used when IUI has not succeeded, when there is a known fertility diagnosis (such as diminished ovarian reserve, endometriosis, or tubal factor), or when a couple wants to do preimplantation genetic testing (PGT-A) to identify chromosomally normal embryos before transfer. One partner undergoes ovarian stimulation and egg retrieval; her eggs are fertilized with donor sperm in the lab; resulting embryos are cultured to the blastocyst stage and either transferred fresh or frozen for later use.
Ask your doctor: What is my ovarian reserve, and how does it affect the number of eggs I’m likely to retrieve?
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Reciprocal IVF (co-IVF)
Reciprocal IVF allows both partners to have a direct biological role in the pregnancy. One partner (the “genetic mother”) undergoes egg retrieval. Her eggs are fertilized with donor sperm in the lab. The resulting embryo is then transferred into the other partner, who carries the pregnancy and gives birth. Both women are biologically connected to the child: one genetically, one gestationally. Reciprocal IVF follows the same medical protocol as conventional IVF, with the addition of uterine preparation for the carrying partner. It has become increasingly popular among female couples who want both partners meaningfully involved.
Ask your doctor: Are there any uterine or hormonal factors that would affect which of us should carry?
OPTIONS FOR MALE COUPLES
Pathways most often used by male same-sex couples
Male couples cannot carry a pregnancy without a gestational carrier, so their primary path to biological parenthood involves gestational surrogacy, a legal and medical arrangement in which a woman carries a pregnancy created with donor eggs and one or both partners’ sperm. Adoption is also a well-established option, as discussed below.
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Gestational surrogacy with donor eggs
Gestational surrogacy is the most common path to biological parenthood for male same-sex couples. The process involves four parties: the intended fathers, an egg donor (anonymous or known), a gestational carrier (who has no genetic relationship to the child), and a reproductive attorney who handles the legal agreement and establishes parental rights before birth. Medically, the egg donor undergoes stimulation and retrieval. Eggs are fertilized in the lab with one or both partners’ sperm, which can be mixed, or assigned to individual embryos. The gestational carrier’s uterus is prepared hormonally, and an embryo is transferred. She carries the pregnancy and the intended fathers are named on the birth certificate.
Ask your doctor: Which of our sperm samples would you recommend testing first, and what would the results tell us about how to proceed?
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Using one or both partners’ sperm
Male couples can choose to fertilize some eggs with one partner’s sperm and some with the other’s, resulting in embryos that are each genetically related to one partner. PGT-A can be done on all resulting embryos, and the couple can decide which to transfer. This allows both partners to potentially have a biological child, either during the same cycle or in future cycles. Some couples prefer to use one partner’s sperm for a first child and the other’s for a second. There is no medical reason one approach is superior, it is a personal decision.
Ask your doctor: What does each of our semen analyses show, and how does that affect our planning?
ADDITIONAL CONSIDERATIONS
Transgender and nonbinary individuals
Transgender and nonbinary individuals may wish to preserve fertility before beginning hormone therapy or gender-affirming surgery, or to build families using their own genetic material. Options depend on anatomy and where someone is in their transition.
Transgender women (MTF) who have not had gender-affirming surgery can preserve sperm before beginning estrogen therapy, which suppresses sperm production. Preserved sperm can later be used with a partner’s eggs or a donor egg via IVF and gestational surrogacy.
Transgender men (FTM) who retain ovarian function may be able to pause testosterone therapy temporarily to pursue egg retrieval and embryo banking. These eggs can later be used in a gestational surrogacy arrangement or transferred to a partner’s uterus.
Fertility preservation options are most effective before gender-affirming hormone treatment begins, but are sometimes still possible afterward. A reproductive endocrinologist familiar with transgender care can evaluate individual circumstances.
NON-BIOLOGICAL PATHWAYS
Adoption and foster-to-adopt
Adoption is a legal family-building option for same-sex couples in all 50 states. The Obergefell v. Hodges ruling in 2015 affirmed that same-sex married couples have equal adoption rights, though the landscape for unmarried same-sex couples can vary by state and agency. Adoption pathways include domestic infant adoption (through agencies or attorneys), foster-to-adopt (working through the public child welfare system), and international adoption (which has become more limited, as many countries restrict adoption by same-sex couples).
Foster-to-adopt is the most accessible option from a cost standpoint. Domestic infant adoption typically involves a significant waiting period. Same-sex couples considering adoption are encouraged to research agency policies carefully, as some faith-based agencies in certain states have successfully claimed religious exemptions from anti-discrimination rules.
LEGAL LANDSCAPE
What same-sex couples need to know about the law
Reproductive law for same-sex couples is federal in some respects but still substantially state-governed. A few principles apply broadly:
- Marriage equality is federal law under Obergefell (2015) and reinforced by the Respect for Marriage Act (2022), which provides additional statutory protection.
- Parental rights for non-gestational or non-genetic parents are not automatic in all states. A second-parent adoption, pre-birth order, or stepparent adoption may be required to legally establish both parents on the birth certificate.
- Donor agreements for sperm or eggs should be reviewed by a reproductive attorney regardless of whether the donor is anonymous or known. Anonymous donor sperm from a licensed sperm bank generally comes with established legal protections.
- Surrogacy laws vary sharply. States like California have robust statutory frameworks. Others have no laws at all, creating legal ambiguity. A pre-birth order in a surrogacy-friendly jurisdiction is the most protective approach for intended parents.
- Insurance coverage for fertility treatments varies by state mandate and employer plan. Some states require coverage for same-sex couples explicitly; others have no mandate at all.
COMMON QUESTIONS
Frequently asked questions
For sperm obtained through a licensed sperm bank under a formal donor agreement, the donor has no legal parental rights or obligations. This is well-established in U.S. law. If sperm is obtained through a known or informal arrangement (a friend, for example), the legal situation is more complex and varies by state. A reproductive attorney should be involved before any known-donor arrangement proceeds.
Yes, through reciprocal IVF. One partner provides the eggs, the other carries the pregnancy. Both are biologically connected, one genetically, one gestationally. This is a medically straightforward variation of standard IVF and is widely available.
Not to the same child. However, in a multi-embryo IVF cycle, some embryos can be fertilized with one partner’s sperm and others with the other’s. Each child would then be genetically related to one father. If a couple wants two children, they can plan one with each partner’s sperm. PGT-A can be performed on all embryos regardless of which partner’s sperm was used.
No. Surrogacy laws vary significantly by state. California, Nevada, Washington, and Connecticut have clear, permissive frameworks. Some states have restrictive laws or no statutory guidance. Working with a reproductive attorney who practices in the state where the gestational carrier resides is essential to establishing parental rights before the birth.
Total costs for gestational surrogacy in the U.S. generally range from $100,000 to $200,000 or more, depending on the state, agency fees, carrier compensation, legal fees, egg donor fees (if applicable), and IVF costs. It is among the more expensive family-building options. Some employer benefits and fertility financing programs now include surrogacy support.
For family building involving donor sperm, eggs, or a gestational carrier, a reproductive endocrinologist (RE) is the appropriate starting point. REs specialize in the medical procedures involved (ovarian stimulation, egg retrieval, embryo culture, transfer protocols) and are familiar with the third-party logistics. A general OB takes over once a pregnancy is established.
Medically, egg quality and quantity are the primary considerations. Age is the biggest factor in egg quality, so if there is a meaningful age difference between partners, using eggs from the younger partner may result in better outcomes. Ovarian reserve testing (AMH and antral follicle count) gives a more complete picture. Beyond the medical factors, which partner provides eggs and which carries is ultimately a personal decision.
Medical disclaimer: This article is for informational purposes only and does not constitute medical or legal advice. Laws governing surrogacy, donor conception, and parental rights vary by state and change over time. Consult a board-certified Reproductive Endocrinologist and a reproductive attorney for personalized guidance.
