Love (and Science) Make a Family

We often hear the phrase, “Love makes a family,” and while it's true that love is the most important ingredient in creating family, for many of our LGBTQ+ kids and beloveds, love also needs to be accompanied by access to reproductive medical support. So today, we’re diving into what it really means to create family—from science to love to justice. Sara sits down with reproductive endocrinologist Dr. Jacqueline Gutmann to discuss the avenues available for creating family in queer partnerships.

Special Guest: Dr. Jacqueline N. Gutmann

Dr. Jacqueline N. Gutmann (she/her) is a Reproductive Endocrinologist at RMA of Philadelphia and has devoted her career to helping people create their families of choice. She has published numerous articles and has lectured extensively on topics including LGBT family building, third party reproduction, fertility preservation including egg freezing, and the use of complementary and alternative medicine in fertility treatment. She has held numerous leadership positions in local and national professional organizations and is on the medical advisory boards of several patient advocacy groups. She is the recipient of many awards, though the one she values most is the Joyce M. Vargyas, M.D. Visionary Award from Path2Parenthood, for her impact in the fields of fertility, reproductive health, and family building within the LGBTQ+ community. Dr. Gutmann completed her medical education, residency and fellowship at Yale University. She also serves as a Clinical Associate professor of Obstetrics and Gynecology at Thomas Jefferson University.

Links from the Show:

• More about Dr. Gutmann:  https://rmanetwork.com/staff/jacqueline-n-gutmann/ 
• Jefferson OB/GYN: https://www.jeffersonhealth.org/locations/obgyn-center-city 
• Join Mama Dragons here: www.mamadragons.org 

In the Den is made possible by generous donors like you. Help us continue to deliver quality content by becoming a donor today at www.mamadragons.org. 

Transcript

SARA: Hi everyone. Welcome to In the Den with Mama Dragons. A podcast and community to support, educate, and empower parents on the journey of raising happy and healthy LGBTQ+ humans. I’m your host, Sara LaWall. I’m a Mama Dragon myself and an advocate for our queer community. And I’m so glad to be part of this wild and wonderful parenting journey with all of you. Thanks for joining us. We’re so glad you’re here.

In the fight for marriage equality, we’ve often heard the phrase, “Love makes a family.” And it’s true. Love is one of the most important ingredients in creating family. But for many of our LGBTQ+ kids and beloveds, love also needs to be accompanied by access to reproductive medical support. So, today, we are honored to welcome Dr. Jacqueline Gutmann, a nationally recognized expert in reproductive endocrinology and infertility who has devoted her career to helping people create their families of choice.

Doctor Gutmann has published numerous articles and lectured extensively on topics including LGBTQ+ family building, third party reproduction, fertility preservation including egg freezing, and the use of complementary and alternative medicine in fertility treatment. She has held numerous leadership positions in local and national professional organizations and is on the medical advisory boards of several patient advocacy groups. She is also the recipient of many awards, though the one she values most is the Joyce M. Vargyas, M.D. Visionary Award from Path2Parenthood, given for her impact in the fields of fertility, reproductive health, and family building within the LGBTQ+ community.

Dr.Gutmann completed her medical education, residency and fellowship at Yale University. And she also serves as a Clinical Associate professor of Obstetrics and Gynecology at Thomas Jefferson University. In her practice with Reproductive Medicine Associates of Philadelphia, RMA as they’re known, she has been a pioneer in LGBTQ+ fertility care since they opened their doors in 1999 and they, as a practice, are recognized by the Human Rights Campaign for their commitment to providing expert, compassionate care in a safe, affirming environment.

So today, we are diving into what it takes to create family in our LGBTQ+ communities from science, to love, to justice. It’s going to be such an interesting and important conversation. We’re so glad you’re with us. Dr. Gutmann, we’re so happy to have you In the Den. Welcome.

DR. GUTMANN: Thank you so much. I’m truly honored to be here.

SARA: And your bio is so impressive. I’m really excited to have this conversation which I don’t think we’ve had in quite this way before with a medical professional on the podcast. So this is wonderful. You know, fertility and family-building – particularly when medical intervention and support is needed – are often really personal and private topics. We don’t talk about that a lot in our society, particularly in our queer and trans communities. And I’m curious why you think that is, and what do you wish more people understood about LGBTQ+ people’s desires and options for creating family?

DR. GUTMANN: So I think that ultimately education is power. Knowledge is power. And having that information, being able to talk about that information actually really improves the care for all of our patients that come to us. And so in all honesty, it would be ideal if people feel comfortable talking about their fertility journeys, as people call it. Because in all honesty, I think that they’d be pretty surprised to find out who else is going through it, and again receiving additional support and education which can do nothing other than empower people.

SARA: And I think for many queer and trans folks, the idea of growing a family can perhaps feel out of reach for them. So for some maybe even out of the question without that knowledge and without the medical support. What are some of the unique fertility needs or considerations for trans folks and nonbinary people that some providers and patients might want to be aware of?

DR. GUTMANN: If you’re okay with it, I’m going to answer that question in two pieces. First is, there is unfortunately ample data to support exactly what you said which is oftentimes people don’t really recognize what would be available to them. And that is a responsibility, I think, of their care providers –  family doc and whoever is taking care of them – to recognize that there are options for them. If you look at literature that’s been published, there’s ample literature that supports that. And that, for better or worse – and I think there’s both better and worse – that people, particularly younger people, are getting a lot of their information from social media. And some of it’s true and great, and, again, opening the dialogue. What we’re doing now is so super important but there needs to be some factual stuff behind it as well so that there really is a better understanding and recognizing what really is within reach. So that’s sort of addressing the first part of the question.

And then the second part, if I’m not mistaken, what is available to them. And I would answer that, at least start with a, “What’s not available?” And so when we think about building families, there’s some very, very basic ingredients that are required. As I give lectures in 2025 and I talk to patients in 2025 as I’m talking to you, we still need eggs, we still need sperm, and we still need some place to have that embryo go. Fallopian tubes may not be a bad option to have as well, but they are not required. Maybe in five or ten years from now when you’re having this conversation with somebody else younger than me, we won’t need eggs and sperm, and maybe we can use skin cells and everything else. But for today, you need eggs, you need sperm, and you need a uterus. And so, ultimately, the question is from where do these parts come? Where do we get the egg? Where do we get the sperm? Who’s carrying the pregnancy? And so those answers will be very, very different depending on the clinical scenario that we’re encountering.

SARA: So can you share with us some scenarios particularly for trans and nonbinary folks about choices they may have in front of them in terms of how to have some of their own biological children or their own biology in creating their family?

DR. GUTMANN: Absolutely. So part of it, the first question is, is that individual partnered or not partnered? Are they coming with just what they have or is there somebody else or two somebody else’s with whom they are building their family? And that matters because so far there’s not one individual who has all three ingredients in the same place, right? So it does depend on whether they are partnered or not. So that’s the first question. The second question is, “What parts are they bringing either by themselves or in a relationship?” And so, for example again, so many different combinations, permutations that we can go through. But let’s say that we have a trans man who had gender affirming surgery prior to freezing eggs. And they are partnered with a cis female who we have no reason to presume doesn’t have eggs and a uterus. She may not, right, but presume that she does for purposes of this conversation. So the trans man had gender affirming surgery before freezing eggs, for example, and clearly is not coming with sperm. So in that unit, we would potentially be able to do donor insemination on the cis female partner using the eggs that the cisfemale partner comes with and they would carry the pregnancy as well. So all parts are then there, and again it becomes a question of where do we pull it? Let’s think about that same scenario, trans man, but he froze eggs before undergoing transition? Now we have eggs, biologic relationship. We have a uterus. We’re still missing sperm. There’s not sperm in this relationship. So, again, they will still need a sperm donor. And ultimately, that cis female partner can use her eggs to carry the pregnancy or alternatively the trans man’s eggs that have been previously frozen. Make embryos in a laboratory, she would carry the pregnancy. So, again, we can spin ourselves in a lot of different circles. It’s just a matter of thinking, “What parts do we have? What parts do we need? And how can we put all of this together?”

SARA: Yes. So there’s lots of different combinations. And it’s just really helpful to hear you talk through a few of them for us. Because as I’ve been in this work, I think there is a misconception that when someone transitions, particularly female to male, that that comes with this sense of they don’t want to have children. And yet, I am aware of many transmen in my world and my life who are really working with their own providers to protect and preserve the ability to carry a child or offer up their biology in some other way to create their family, freeze eggs. And I think there’s probably are some misconceptions. And I’m wondering if you can help us sort through how hormone therapy for trans folks impacts fertility and what are the considerations that folks and families need to think about as they’re moving through their transition and their medical care?

DR. GUTMANN: Absolutely. So first thing, let’s think about preserving fertility. And sometimes an individual plans to preserve their fertility. They freeze eggs. They freeze sperm. And they never come to use it. But the door is always left open, right. It keeps that opportunity for that biologic link available. In the ideal world, it would be nice if we could do that prior to the initiation of gender-affirming hormones. That’s particularly true for people who have sperm initially, male assigned at birth. So two separate parts, right. So sex assigned male at birth, ideally you freeze sperm before starting medication. Sometimes that’s possible. Sometimes it’s not depending on when the individual, obviously, presents to us.

SARA: Then, would it be possible for someone who maybe started on the younger side, gets further into their 20s or 30s, has had some medication, hormone blockers, cross-sex hormones, but then to decide, “Oh, I think I want to see if I can try this?” Is that possible?

DR. GUTMANN: Yes. Absolutely. So there is data that tells us that transwomen, even without taking hormones, without taking gender-affirming hormones, may have lower sperm counts and sperm motility than their nontrans, age-matched, counterparts, interestingly.

SARA: Very interesting.

DR. GUTMANN: In those individuals who have already taken hormones, those numbers drop even more so. There is data that tells us that for most individuals, the sperm can come back to some degree or another. It is typically not going to be normal. But we don’t need a lot of sperm to be able to achieve a pregnancy with IVF, with in vitro fertilization. And I’m sure later in our discussion we’ll get to “What does IVF mean? How does that work?” Nobody should say, “Gee. I’ve been on hormones for three months, six months, three years, six years.” And simply shut a door on themselves if they are interested in using their genetic material. And they may or may not be. Everybody’s really different. There’s no reason not to look. There’s no reason not to try.

SARA: I love hearing you say that, in part because as the parent of a trans young adult moving through with doctors and this conversation around preserving fertility and my kiddo made a choice for themselves early on. But it sounded a little dire. Some of our medical professionals made it sound like this is your opportunity to choose and then the door closes. So I’m really encouraged. I just want to lift that up for our families who are listening that it is possible to explore with medical professionals to change your mind and to enter the conversation and see what’s possible.

DR. GUTMANN: So I think, had they cushioned it with, this is the best opportunity to freeze sperm. Sure. That’s true. But it doesn’t mean that it can’t be done later. And, again, it goes back to the concept of knowledge is power. Let’s see what’s there and then use that information to decide on what the appropriate next steps might be.

SARA: But the door is open. So don’t think that this door is closed and that it’s a final thing. And I think that’s really encouraging for people to hear.

DR. GUTMANN: Correct. Absolutely and without a doubt.

SARA: So I did have a question, and because you mentioned it, I wonder if you’ll talk us through some of the particular paths to parenthood, the medical interventions, IUI, IVF, sperm or egg donation, surrogacy. There’s lots of different options for folks. Can you break it down for us? Can you give us a little bit on what the most common options might be?

DR. GUTMANN: So before we even get there, just to go back to the concept of freezing sperm, collecting sperm. Again, ideally prior to the initiation of hormone therapy, but not necessarily required. And then, depending on how much sperm is available will help decide what the best way to use this is as well as where those other pieces are coming from. Was the egg coming from a partner? Is the egg coming from an egg donor agency? Again, you have to find where those other pieces are coming from. Sometimes it makes your head spin a little bit. So what are the options for people to get pregnant? Lots of different options. And, again, it depends on what’s in the relationship, if there is a relationship and then what’s in the relationship. But to break it down without specifics, let’s walk through some of the different treatment options. So honestly, one of the treatment options is – oh my god – Sex.

SARA: Let’s go back to basics.

DR. GUTMANN: Let’s go back to basics. You have a trans woman who still has some sperm, who’s partnered with a cis female who has a vagina, uterus, eggs. There is sex. And there definitely are individuals who have achieved their pregnancy having sex. And I’m going to take half a step back if that’s okay. I know we’re talking about family building here. But I think it’s also really important to think about what the opposite of family building is. And so then, if you have a transwoman, even taking estrogen, and they are having penetrative sex with somebody who has eggs and a uterus, if they do not want to be pregnant, they need to think about that. They cannot automatically assume that being on hormones is “Not pregnant.”

SARA: Meaning, they need to think about contraception if they want to prevent pregnancy?

DR. GUTMANN: Exactly right. And I know that’s not really what I’m here to talk about. But it’s so, so important to recognize that that needs to be taken into consideration.

SARA: Thank you for naming that. Yes. I think we often skip over that part.

DR. GUTMANN: Right. But, again, you need to know. So other than sex, the two other options are insemination and in vitro fertilization. So what is insemination? So sometimes the short hand is IUI, intrauterine insemination. We take sperm from wherever it might have come, and we put it into the uterus of somebody attempting pregnancy at the time that we anticipate an egg being there at the time of ovulation. Where does that sperm come from? It depends, right? It could’ve come from somebody who froze their sperm previously. It could be coming from somebody who still has sperm. It could be coming from a sperm bank. So lots of options in order to do insemination. The recipient kind of needs to have a uterus, at least one patent fallopian tube, at least one open fallopian tube, and eggs. So that’s insemination. It’s a little catheter that gets slid right into the uterus. People may feel a twinge when it happens. They may feel absolutely nothing at all. The likelihood of success depends on the age of the egg more than anything else –assuming there’s an adequate amount of sperm there – it depends on the age of the egg. The younger the egg, which typically means the younger the individual having the eggs in them, the greater the likelihood of success, the older the egg, the lower the likelihood of success. So that’s what insemination looks like.

The other is in vitro fertilization. In vitro fertilization is an involved process that requires many steps. In vitro fertilization ultimately is what would be used if somebody is freezing their eggs after they’ve transitioned as long as it’s not surgical, just medical. It would be used in somebody who’s having difficulty achieving a pregnancy. It could be used in a situation where there’s a very, very small amount of sperm available, so so many different paths to get there. For the person having their eggs removed, they used injectable medication. So normally what happens is our brain makes hormones, FSH and LH, that act on our ovaries to mature eggs. Typically, the single cycle per person matures one egg. Not as efficient as we’d like it to be. So what we do is we use medication to increase the number of eggs that get matured. That medication is FSH and LH, same stuff that the brain is making but in concentrations far greater. So typically it’s daily injections of this medication, on average about ten days worth. Some people will use less than ten days. Some people will use more than ten days. It is not good or bad if somebody uses less or more. It just is. And then we monitor the response to the medication frequently – this is a labor intensive process – with blood work and ultrasound. So typically we see people after three days of medication, blood work and ultrasound. Two more days later, maybe bloodwork and ultrasound. And then, again depending on how they’re responding, could be every day for four, five, six, seven days, could be every couple of days. But it is labor intensive. The ovaries will get big. Not as big as the hands that you’re not seeing. The ovaries will get enlarged. And then as a result, the person being stimulated may feel some pressure. They may feel some fullness. They may feel absolutely nothing at all. Everybody’s very different.

SARA: Okay.

DR. GUTMANN: Now, this is what’s super duper important. If you have somebody going through this process, a transman, somebody that’s nonbinary, they may not feel so comfortable having a vaginal ultrasound for example. We typically monitor the response to medication with vaginal ultrasound. It is extremely important as we’re engaging with our patients to meet them where they are. So there’s certain things that have to get done. They need monitoring. But are you comfortable with a vaginal ultrasound? Would you prefer doing an abdominal ultrasound? We see a little less well with an abdominal ultrasound, but we should be able to do that if you’re not comfortable with a vaginal scan. Taking into consideration the person that’s in front of you and how this very private, invasive process is going to impact them, and really working through that at the beginning.

SARA: That’s beautiful. That sounds very affirming. And just to hear you say the words, I imagine for trans and nonbinary folks, feels like they are being welcomed in and a place being created that is as safe as possible and affirming as possible for who they are rather than them having to kind of go into the system, the medical system that treats us in a very particular, binary way oftentimes.

DR. GUTMANN: Correct. And so going back to your point about how the system treats us in a binary way, we, like other medical practices, have forms that need to be completed. You need a name. You need a birthday. And the forms are electronic. And so what will happen is whatever they check – they’re smart forms. I don’t know what you really call them – but they ask for gender. And then based on gender and based on sex assigned at birth, another question, they will get different questions posed to that so that somebody sex assigned at birth female, transman let’s say, will get a different set of questions than a cis male because it’s really important that we ask them the right questions for them. The other thing is, I think it sends a signal that we get it, that we want to make this as comfortable a place as possible.

SARA: Absolutely. As I’ve talked to the trans folks in my world, there is a lot of fear around entering into the medical system, particularly in this moment, particularly in certain places in this country. And so it’s beautiful to hear you say those words as a way to remind people that there are very affirming, safe, friendly medical providers and practices out there who really want to welcome them in.

DR. GUTMANN: Absolutely. There is not a soul that walks into a doctor’s office without some element of trepidation. You don’t go to the doctor because everything is great. Maybe you do. Most of the time you don’t. And so that’s already a challenge. And then, obviously, for the LGBTQ+ community, there are greater challenges, right, misnamed, mis-pronouned, all of those things. Can I say that nobody in our office has ever made a mistake? I wish I could. I really wish I could say that somebody in the office didn’t use the wrong pronoun. But everyone is trained in advance about how do you make a patient fill comfortable whoever that patient is. And in this case, it’s using the right name. So our forms ask for pronouns. Our forms ask for, “What do you want to be called?” I’m going to be honest. My given name is Jacqueline. I go by Jackie. I know that when I go into a doctors office and they go, “Jacqueline.” They don’t have a clue who I am and that’s fine. I don’t really care. So we ask those questions in advance, again, to try and make everybody feel as comfortable as possible, recognizing again it’s a doctor’s office. Nobody wants to be there. So eggs are ready, the eggs are ripe and so we do the egg retrieval. IV sedation, needle goes through the wall of the vagina into the ovary. So here we really do have to go vaginally and we discuss that, again, ahead of time, right. Everything is open and transparent because it’s much safer and easier to get the eggs typically through the vagina. And given that they are sleeping, there’s not that same kind of anxiety. But they need to know, again, in advance. No surprises. The procedure usually takes 15, 20 minutes. We do want people to go home and rest that day. And then, ultimately, by the next day, they should feel a little bit better. Their ovaries will get a little bit big again and then a few days later they should feel perfectly and completely fine. And we will have taken their eggs whether we are freezing them for later use, fertility preservation, or whether we’re using them to try and get pregnant. The other thing is all our staff is trained. So our anesthesia group is trained, again, to try and make sure that we do and say the right things.

SARA: You talk about preserving fertility, ideally, prior to starting treatment. But that is not prohibitive. Some folks can choose to try and start at any time with the help of qualified medical professionals. For folks who are freezing sperm, freezing eggs, preserving the fertility at any stage, how long does that last?

DR. GUTMANN: Probably forever, but nobody’s going to ever be able to prove me wrong. So there are kids born from frozen sperm after forty years. There are babies born from frozen embryos, I think, from 27 and 24 years if you donated embryos. But, again, in absence of an incredible act of God, the place storing them explodes or something like that, the likelihood is really forever. Again, hard to prove me wrong. And surely impossible to prove that I’m right. So they absolutely can hang around forever. Previously we talked about collecting a semen sample and how using estrogen may negatively impact the sperm. Interestingly, testosterone does not seem to have a negative impact on eggs. And there is a whole body of literature that has looked at that and found that to be the case. Typically we do stop the testosterone, the T, before starting the egg retrieval cycle. But there’s even some data, very small studies looking at just continuing the T during the egg retrieval cycle in somebody who’s trying to freeze their eggs. So estrogen, not so great for sperm, T probably not bad for eggs.

SARA: So potentially folks on testosterone just adding in those fertility hormones that increase the egg production.

DR. GUTMANN: Exactly right. Exactly.

SARA: That’s fascinating. And then, in this moment right now, do patients need to stop their hormone treatments if they’re already on cross-sex hormones in order to engage in the process of their family building if they want to use their own biology?

DR. GUTMANN: One of my favorite answers, it depends. You can look at the semen sample and see if they have sperm there or not. And if there are not, or there are very few, yes, you have to stop the hormones, repeat it in three months, see what happens. For the T, again, there’s very little data looking at continuing on the T while you’re freezing your eggs. But it seems like it’s okay. You certainly don’t need to stop for any long period of time. You can stop and then simply get started, at least based on the data that’s available now. And I do think, in the future, I think we will probably be continuing the T because who wants to come off their hormones. Nobody wants to come off their hormones. And sometimes, particularly if you’re on T, you crash. T makes all of us feel good. T is an energy hormone in addition to being gender affirming. And so when you’re off and bottom out, that can be hard. And it’s really important for us to, again, as we’re counseling patients, make sure that they’re aware of, “This is what’s going to happen. It will not be that way forever. But I want you to be prepared for it.” Again, it’s much easier to manage somebody's expectations rather than, “Oh my god. I feel so terrible. What am I going to do.”

SARA: Yeah. That’s really helpful. And is there a typical length of time that folks would need to stop taking estrogen?

DR. GUTMANN: So the sperm that gets ejaculated today was made 72 to 90 days ago. So if you were to collect a sample now, and it wasn’t so good, I’d look at another sample short interval. But then I would say three months stop the estrogen and then look three months later.

SARA: So it sounds like the investigation can be done, kind of, on a three month evaluated period to figure out what’s next.

DR. GUTMANN: Correct. And then some people may not be okay. Some people may say, “You know what? I’m not going to keep checking – potentially you could do a biopsy of the testicle and see if there’s sperm there -- “but it’s so harming for me to be off my hormones that I’m going to go back on them.” We’re not just going to keep looking [inaudible].  

SARA: And I’m curious also about the interaction for queer folks because I know mental health concerns are very much a part of this journey. But they are, for so many straight folks as well and cis folks as well, and particularly folks who struggling with infertility. How do mental health meds, anti-anxiety meds and antidepressants and such interact with your work?

DR. GUTMANN: Not at all.

SARA: Okay. That’s great to hear.

DR. GUTMANN: The only time it’s really an issue is if somebody is on medication, for example lithium, that shouldn’t be taken when they are pregnant. So the issue is exposure during pregnancy. And for most mental health meds, it’s a risk versus benefit as is true for anything. And typically, most individuals are able to stay on their medication during pregnancy as well.

SARA: Oh, that’s very good news. That’s great. I would love to hear, if you would share with us, a little bit about egg banks and how people access eggs, freeze eggs, etcetera.

DR. GUTMANN: So if an individual or group trying to build their family doesn’t have eggs, either they had a gender-affirming surgery, ovaries out, or it’s somebody who never came with eggs, most eggs are gotten at this point from egg banks . So what happens is that women will get stimulated for IVF. They’ll have their eggs retrieved. And then they get frozen, typically in groups of six. And then you can literally go online and type in some stuff – and the same thing is true for sperm and sperm banks – type in some stuff in terms of what’s important to you in a donor with respect to certain characteristics and interests and all sorts of stuff. And then, those eggs will get warmed up and put with sperm. And, again, the sperm can come from a sperm bank, or from prior frozen sperm, it can come from the testicles here and now in an ejaculate to be able to make embryos.

SARA: That’s really helpful. I think we’ve covered a lot. I’m curious, Dr. Gutmann, are you with your patients all the way through pregnancy and labor? And if so, you talked a little bit about some of the stories of transmen carrying their children in their own uterus. And if you have some insight based on your experience with those patients about what that was like for them culturally, societally?

DR. GUTMANN: Absolutely. The answer with respect to the first part of your questions is, do I see them through the whole pregnancy, the answer is absolutely not. I help to get them pregnant. We watch them during the early parts of pregnancy. We smile really big and we wave goodbye and send them off to their OBGYN usually somewhere around 8 to 10 weeks of pregnancy. So certainly in the first trimester. Your question brings me back to the first trans man that I worked with who elected to carry a pregnancy. And this was 12, 15. It was a long time ago. And so I met with the OB people. The plan was for them to deliver at a certain hospital. The OB team did training of people in the clinic. The OB did training of people on labor and delivery to try and make this as comfortable a process as possible. It was a while ago and so this was the first man that they had that was having a baby. And unfortunately, our patient was going along, going along, going along, and ultimately made a decision to use a lay-midwife and deliver at home. Now, I’m going to be honest, I like granola as much as the next person. I really do. It’s a delicious breakfast food. I don’t think people should be having their babies at home. I recognize that there are issues with respect to having babies in the hospital, and there’s a greater risk of intervention and everything else. But home is not my favorite place for somebody to deliver anyway. Unfortunately, he ran into complications, had very long labor, started to have a fever, and the lay midwives felt that they could no longer provide appropriate care and they called 911. And the ambulance came and the ambulance took him to the nearest hospital which was not the hospital that was trained to try and provide the best gender-affirming care. And it was a horribly, horribly traumatic experience. Ultimately, they did well. Dad and baby, great, terrific, did well. But it was very, very difficult for him. And so I think we have made progress with that there are more men that are having babies and that the education has been more broadly disseminated. But that patient and their experience certainly stays in my mind.

SARA: Thanks for sharing that story. That’s really, really helpful. And I imagine that those stories are common among trans men in the experience and just thinking about my own experience and how much you got this mama language there is in the delivery experience.

DR. GUTMANN: Right. And again, no malice, good people.

SARA: Please, I would love it if you would share with us a little bit about younger trans and nonbinary folks coming in, with parents maybe, as they are beginning their transition and medical care and that conversation is unfolding about family planning. And I can speak for my own experience, it was a hard conversation because many young people, their initial reaction is, “No. I don’t want kids. I don’t want to do that. I don’t want to freeze sperm. I don’t want to freeze eggs.” And you’ve shared their parents might have some different thoughts. Talk with us a little bit about how that plays out and how you engage in that conversation?

DR. GUTMANN: Absolutely. So I think we start with the premise that the parent, most of the time, thinks they know best. And I think sometimes they do. You know, life experience and everything else. And maybe not all of the time. But oftentimes the parent is thinking both short and long-term. And I think that – and I don’t mean to be unkind or unfair – but I think that older adolescents are thinking more in the short term, perhaps, than in the long term. And so oftentimes, kids don’t want to delay their gender-affirming care. They don’t want to delay their treatment and they just want to start their meds, and “I don’t want kids. I mean, who wants kids. I don’t want kids.” And so sometimes there is really a dissynchrony between the parents and the kids. And the parents typically are actually trying to be supportive of the kid. This is something you should consider. And I will talk to these kids by themselves and make sure the parents leaves the room. A lot of times, it’s done via telehealth. But kick the parent out and talk to the kids. And it’s not that uncommon for the kids to say, “I only agreed to get on this call because my mom told me I had to.” And there’s not a lot you can do other than, educate and explain what the process would entail and let them know that there may be possibly, again particularly with estrogen, some impact of the hormones on sperm production. But that, again going back to our early conversations about the doors closing and that the door hasn’t closed and that they should keep top of mind or keep in mind if they’re not interested now. And, again, despite the fact that my whole career is built on helping people build their families. There are people that don’t want to build their families. And certainly, we need to recognize that as well.

SARA: This is why I’ve so appreciated the conversation because you have helped us to understand that the door does not necessarily close forever when you start hormone therapy. But also, in the conversation, you have shared with us all kinds of ways people can create their family, with or without their own biology or the support of others and dear friends. And so it just opens up the world of possibilities that can exist for folks wherever they are in their life path and their transition and their medical care.

DR. GUTMANN: Absolutely. A family does not imply biology and biology does not necessarily imply family.

SARA: And that we all feel very acutely sometimes. I’m really curious to hear a little bit of your story. How did you come to find this path and end up in this specialty and field?

DR. GUTMANN: Alright. So how did I get here? So, I wound up being exposed to reproductive endocrinology and infertility – as you can see from my hair color – a very, very long time ago. Way, way back when. And ultimately joined a practice and one of the docs in the practice was well-known in the primarily, honestly, lesbian community. This was a long time ago. And so if you had two same-sex females trying to have a baby, again, there’s a piece missing. So maybe there are plenty of eggs and there are plenty of uteruses or at least two of them. But you’re missing sperm, typically donor insemination. And so I joined a practice where she was seeing a bunch of patients. And so, in a group practice, you wind up taking care of other people’s patients. I’m the doctor that was there for the insemination, or whatever. And so totally people are able to find that community whatever that community happens to be. In this case the LLGBTQ+ community, but find their community. And so the vast majority of patients actually come to us by word of mouth. “Our friend came here. They felt good about the care that they got.” whatever it happens to be. Suddenly I think we are one of the go-to practices and I honestly think that there are a number of reasons for it. Certainly success rates, and we’re good at what we do. I don’t want to sound, but we really are good at what we do from a scientific standpoint. And we’re good at taking care of people and recognizing the best ways to do that, the best practices.

SARA: And you fell into it.

DR. GUTMANN: I fell into it.

SARA: And so I know that in your bio and some of the reading I did, you have helped provide care for some more well-known folks like trans influencer Trystan Reese and his husband. I watched several of their videos. Can you share a story that has stayed with you about the joy and power of this work in queer family building?

DR. GUTMANN: And so, in all honesty, I did not take care of Trystan. We became friends after he had a baby. And he carried the pregnancy all by himself and they got pregnant, oh my god, by sex. He would share that very openly. I mean, I’ve heard him share it very openly. So we got to know each other afterwards and he’s a tremendous – for anybody who’s listening who doesn’t know who Trystan Reese is, he is a tremendous, tremendous asset – I turn to him when I’ve had questions and he really is just terrific. Probably the most striking case that I ever had. And it’s not striking because it was magic. But we had a couple, a trans man, a trans woman. Each of them still had the parts with which they were born, right? So the trans woman still had the testicles, penis, trans man uterus and ovaries. Both had been on hormones for a period of time. And they had gone to another practice that shall not be named in our community. And they felt unwelcome. They pursued treatment there because they didn’t know where else to go. But they felt extraordinarily unwelcome and somebody ultimately recommended that they come and see us. And they subsequently wound up needing IVF because there wasn’t a lot of sperm available. But there was some. And this was years after starting estrogen. And so we did IVF and our trans man carried the pregnancy. It was an uncomplicated pregnancy. And really the part that stays with me more than anything else is that they felt that they had to leave another reputable practice because they weren’t being cared for. They really felt uncomfortable in that practice. And I don’t think anybody had any intention of malice. They just didn’t get it. They didn’t get what was involved in actually taking care of the people as well as putting the parts together.

SARA: That’s a beautiful story and a great success story, too. So that’s also encouraging to hear all those amazing success stories. I’m curious if you’ll share a little bit about – since you’ve been in the work for such a long time – what big changes you’ve seen from then to now.

DR. GUTMANN: So over the course of years, we’ve just gotten better at what we do in the laboratory. Our science has gotten better. Technology has continued to improve. There’s some things that haven’t changed. As I sort of started out by saying you still need eggs, sperm, and a uterus. But what we can do in our IVF laboratory has definitely dramatically changed. That’s the biggest thing. The other thing, relative to this specific conversation is – I started out by talking about these lesbian moms-to-be. We didn’t see trans people 30 years ago. It’s not that there weren’t trans people out there. But they did not present for care. And so really what is wonderful is that more people are recognizing that there are options for them. And so the door, hopefully, feels much more open. Probably not for everybody. But the door feels much more open and allows people to step through that door and decide what the right information is for them. If you look at society guidelines – not the society the regular society that’s out there – but the professional society guidelines, other professional society guidelines, everybody who’s thinking about transitioning as we talk about trans individuals are supposed to be counseled regarding family building, fertility preservation, and family building. If you look at the data, and there was a study that I had read a few years ago where people at a trans conference were questioned about it, “Do you bring up family building, fertility preservation: Always, Sometimes, Something in the middle, Whatever, Rarely, Never?” It should have been 100%,  “Yes, I bring this up.” It was very far from that. But I do think that we are making progress. The other thing is that if you look at the number of publications regarding the trans population and family building year after year, last years there has been a spike, which again, to me, suggests that people recognize the importance of it. They have to come to me from somewhere, that they’re recognizing the importance and discussing it. Not everyone wants to build a family, but if they elect that they know  that there are opportunities out there.

SARA: I’m really glad to hear you share all of that because I worry a lot in this political climate, particularly now where there’s so many attacks on our trans and nonbinary community, and attacks on science and funding. So to hear you reiterate the value of the science coming so far and being able to offer so much more success than there even was 30 years ago, and more providers, is just really lovely to hear. And lovely for our community to hear, I think, when there’s been a bit of a chilling effect in this moment and folks are getting a little quieter, I think, about these kinds of conversations.

DR. GUTMANN: Unfortunately, I think that’s right.

SARA: One of the things that I wanted to ask a little bit about – it sounds like you see patients from all over the  country, I know that fertility care for anyone is really expensive and isn’t always equitable. And I’m wondering if you have any experience or advice you can share on what queer families can do to navigate insurance, financial assistance, and other means of being able to access care like this?

DR. GUTMANN: Sure. So there are a couple of things regarding insurance. So the vast majority of insurance companies actually, fortunately, do not make a distinction between LGBTQ+ family building and cis/heterosexual [inaudible]. They typically do not make a distinction, which is great. And depending on what state you’re in will impact coverage. So it is a reasonably local issue rather than a national issue. So we in Philadelphia do not have mandated coverage. Again, heterosexual, cis, no. California has mandated coverage. So it really does depend on, unfortunately, where somebody is. And your point is extraordinarily well taken, which is, it is an expensive proposition. Buying sperm from a sperm bank is not cheap. It may be as much as almost $2,000 a vial of sperm, a single attempt. And that’s typically not covered by almost every insurance company. There is one or two probably that do. IVF is not cheap. So a lot of technology involved, there’s a lot of specialized skill involved, and it is not cheap either. But, again, the good news is the vast majority of insurances do not discriminate against same sex family building, LGBTQ+, other trans family building as well.

SARA: That’s good. I appreciate that. I know that’s always a barrier, can be a barrier for all kinds of folks just thinking about family building and how they can afford it.

DR. GUTMANN: I mean, let’s be very honest here. Nobody should have to be able to afford building a family. It’s going to be expensive to raise a kid. So that’s an element to take into consideration. But in terms of actually making it happen, that’s a right. That is a right that everybody is entitled to have. And that we are in this situation – and this is not new, this is not with an administration thing that we are in this situation – where people who have more money, better insurance, have access that others don’t. That’s ridiculous.

SARA: It feels really unequal. And we’ve been in that world for a long time when it comes to medical care and insurance in this country. And it’s always something that I think we’re all hoping can change, or we hope can make a little better and maybe close that gap a little bit.

DR. GUTMANN: Yeah. Absolutely. Without a doubt.

SARA: For folks who are just starting to think about family planning, LGBTQ+ folks particularly, maybe just even in the dreaming stage, what advice would you have for them?

DR. GUTMANN: Make an appointment to see a reproductive endocrinologist. Honestly. Clearly this is not a plug for me. God only knows where everybody is. But make an appointment to get counseling. Again, knowledge is power. Learn what your options are. You can decide what you want to do, right? Do you want to freeze sperm? Do you want to freeze eggs? You can decide all of those things. That’s you. But at least this way you will have the information. And I think that we, as a field, are the best people to be able to provide that information in a meaningful fashion.

SARA: What gives you hope when it comes to the future of inclusive reproductive health care?

DR. GUTMANN: My hope is that we get to a point in the society where it is inclusive society, it is an equitable society. I think most people are really good people and don’t necessarily have an understanding of how somebody else lives. They don’t walk in somebody else’s shoes. They don’t know what the experiences are.  That’s not to say that they are not some mean, evil people in this country or in this world. But I think most people want to do right. And it’s complicated. What’s right to me is not necessarily right to somebody else. But, again to me, we’re created equal. And if we’re created equal, we should have equal access to everything. And that’s not where we are.

SARA: I think the hope for equal access is beautiful, that we can work towards that as a society. And the through line in this conversation has been beautiful about how knowledge is power. And sometimes when we don’t know or don’t understand or haven’t had a lived experience or know someone who has, we can make all kinds of assumptions and judgements and that is part of what complicates the waters in this conversation. But in all of my reading and prep for this interview, it’s joyful to read success stories of trans, nonbinary, queer families who have had children and who are just the most delighted by their family. And in many ways, I think queer or not, for those folks who have had to struggle to create their family, there is deep intention and commitment and love because it has taken so much for them to be able to bring a child into their life.

DR. GUTMANN: Absolutely and without a doubt. There is no question about that. And though, I recognize this isn’t about me, one of my favorite things is Pride in Philadelphia. So there’s a parade and then there’s sort of a little festival. And we have a booth there. And our patients know that we have a booth there. There’s a listing of all the different booths. And you have people coming up to you, their kids again – I’ve already acknowledged that I’m old – their kids are off to college, whatever it happens to be. People come by with little babies. People come by with medium size kids, elementary school, whatever it happens to be. Again, it’s not about me, but can I tell you the joy that it brings to me to be able to help people complete their families.

SARA: Oh, what a joy. What a joy to be able to see the children that you’ve helped bring into this world and that your patients are excited to come to you and say, “Look at what you helped us do. And we’re so happy.” That’s such a joyful moment.

DR. GUTMANN: It truly is the best. And, again this shouldn’t be about me, but it is in that one little instance. And it does obviously bring our patients joy as well.

SARA: Oh, yeah.

DR. GUTMANN: Other things that we’ve not talked about. And again, I don’t know what exactly you want to ask. So we talked about egg freezing, making the eggs. There’s the back of IVF as well where we either make embryos right away if somebody’s trying to get pregnant if we have sperm. Or, alternatively, they’ve frozen their eggs and they’ve come back to use them. So we put the eggs and the sperm together. It’s important, unfortunately, to recognize that not every egg has the capacity to make a baby. But we watch them in our laboratory. We watch them grow. And then ultimately plan to put back a single embryo. And the reason that we only want to put back one embryo is because that offers the greatest likelihood of having a healthy baby. Two embryos, slightly higher likelihood of success in the short run, not in the long run but in the short run. But a greater risk in terms of premature labor, premature delivery, those kinds of things. It  gets a little complicated when you’re looking at an individual or a couple that needs a surrogate. There’s no uterus in the mix. And so they need a surrogate. So they need somebody, either that they know or somebody that they’ve identified with the help of an agency. And if they’re using an agency, and even if not – there are certain things in an agency – it is an extraordinarily expensive, unfortunately. And often prohibitively expensive proposition. And so I’m certain, and there's a data to support this, that people would like to put back two embryos, kind of knock their family out in one try. But because of the risks, we typically will only put back a single embryo.

SARA: That’s interesting. I didn’t realize that. I think we hear the stories of multiple embryos resulting in multiple children.

DR. GUTMANN: Our goal regardless of whether it’s the LGBTQ+ community or not, is a single healthy baby.

SARA: That’s great. This has been an extraordinary conversation. I have learned so much. And I feel so encouraged. And I’m encouraged for our community and for our parents who are our podcast listeners for all of the detail you’ve shared with us, but the hope and the possibility for all the ways that our queer beloveds and queer kids can create families if they so choose. So Thank you so much. I do have some final questions. We, on the podcast, like to ask all our guests the same two questions at the end of every episode. And the first question has to do with the Mama Dragons name which came about out of a sense of fierceness and fierce protection for our kids. And so I like to ask my guests, what is it you are fierce about?

DR. GUTMANN: Dragon boating. We’re talking about dragons.

SARA: Yes, dragon boating. Tell us more about that.

DR. GUTMANN: So dragon boating is an old Chinese sport where you race in boats and they have a little dragon head and a dragon tail. And it’s just super fun to be able to do. You’re part of a community. And, look, it’s always great to be part of a community and have support and everything else which is part of the reason why it’s important that people share their experiences, recognizing that they are not alone. Again, listening to the podcast, connecting with different people, all of those kinds of things. But, truly, from a very serious standpoint, I think most importantly is everybody deserves care. Everybody deserves equal access. And fertility treatment should not be reserved for the few. It should be available for the many. Having a family, building your family, is not something that is a luxury. It is absolutely and without a doubt a right. And I feel quite strongly about it. Recently, Resolve, which is a national fertility organization, we had an advocacy day where we speak with our congresspeople and senators to, again, go through that this really is a right and, in all honesty, that the government should help making people responsible for making that happen.

SARA: Yes. That’s great. Thank you for that. And our final question is, what is bringing you joy right now? We like to name, particularly in these times, it’s so important to cultivate and find joy. So what’s bringing you joy?

DR. GUTMANN: So what’s bringing me joy? So, again, we can go back to the dragon boating. I love to win. Who doesn’t? So what’s bringing me joy? So I told this story before about being at Pride and having people come up to me. And so there is joy in knowing that I can help people reach their goals. I can help people build their families despite many of the challenges that they will encounter.

SARA: That’s beautiful. Thank you. Thank you so much for your time and for your work.

DR. GUTMANN: And thank you so much for having me.

SARA: You bet. Thank you so much for joining us here In The Den. Did you know that Mama Dragons offers an eLearning program called Parachute? This is an interactive learning platform where you can learn more about how to affirm, support, and celebrate the LGBTQ+ people in your life. Learn more at Mamadragons.org/parachute. Or find the link in the episode show notes under links.

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