Single fathers' experiences of using egg donation and surrogacy to start a family.

STUDY QUESTION: What are the experiences of single men using egg donation and surrogacy as a route to parenthood? SUMMARY ANSWER: The fathers mainly had a positive relationship with the surrogate and simultaneously exercised agency, and experienced challenges, during the process of surrogacy. WHAT IS KNOWN ALREADY: Little is known about single men's experiences of egg donation and surrogacy arrangements. Studies have focused on single men's decision-making processes about the use of surrogacy and family functioning once these families are formed. Questions remain about how fathers experience and navigate the process of surrogacy as a single man. STUDY DESIGN, SIZE, DURATION: The study is an international, in-depth qualitative study of fathers who chose to begin a family and parent alone. Data were collected between 2018 and 2021 as part of a larger study of solo fathers with different routes to parenthood. The present study reports on 21 fathers who used surrogacy and egg donation to begin their family. The average age of the fathers was 44 years, the fathers had young children aged 6 years or younger, and lived in countries across Australia, Europe, and North America. PARTICIPANTS/MATERIALS, SETTING, METHODS: Purposive sampling was used to recruit participants. In-depth semi-structured interviews were conducted. Interview topics included fathers' experiences of the process of using egg donation and surrogacy, and navigating the relationship with the surrogate. The audio-recorded interviews lasted around 2 hours and were subsequently transcribed verbatim. MAIN RESULTS AND THE ROLE OF CHANCE: Data were analysed using reflexive thematic analysis and qualitative content analysis. Most of the fathers chose an identifiable egg donor. Regarding the relationship with the surrogate, many fathers had remained in contact with her, but to differing degrees, and they generally reported positive relationships. Thematic analysis led to the identification of three themes relating to the fathers' experiences of choosing surrogacy as a single man: the ability to make choices; challenges and constraints; and special relationship. LIMITATIONS, REASONS FOR CAUTION: Due to the variation between different countries regarding laws on surrogacy, contextual factors may have impacted on the experiences of single fathers, and the sample size was small. However, the research provides new insights into an area with little academic literature. WIDER IMPLICATIONS OF THE FINDINGS: Given the growing trend of single men having children through surrogacy, the findings suggest that this new path to parenthood can be both rewarding and challenging. Single men may benefit from tailored support and counselling to help them navigate the surrogacy journey. STUDY FUNDING/COMPETING INTEREST(S): This study was funded by the Wellcome Trust (grant number 208013/Z/17/Z). The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: n/a.

'I know it's not normal but it's normal to me, and that's all that matters': experiences of young adults conceived through egg donation, sperm donation, and surrogacy.

STUDY QUESTION: What are thoughts and feelings of young adults born following egg donation, sperm donation, and surrogacy? SUMMARY ANSWER: Young adults felt either unconcerned or positive about the method of their conception. WHAT IS KNOWN ALREADY: Much of what we know about adults born to heterosexual couples following anonymous donation has come from samples of donor conceived people who had found out about their origins during adulthood. There have been no studies of how young adults born through surrogacy feel about their conception and towards their surrogate. STUDY DESIGN, SIZE, DURATION: Thirty-five young adults were interviewed as part of the seventh phase of a larger multi-method, multi-informant longitudinal study of assisted conception families in the UK. Adults were conceived using either egg donation, sperm donation, gestational surrogacy, or genetic surrogacy and were raised in households headed by heterosexual couples. PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants had a mean age of 20 years and were born following traditional surrogacy (n = 10), gestational surrogacy (n = 5), egg donation (n = 11), or sperm donation (n = 9). All young adults born following sperm donation and most (n = 10) born from egg donation had an anonymous donor. In all surrogacy arrangements, the parents had met the surrogate prior to treatment. The majority of young adults were told about their conception by the age of 4 years. Participants were interviewed over the internet using a semi-structured interview. Interviews were transcribed verbatim and analysed using qualitative content analysis to understand young adults' thoughts and experiences related to their conception and whether they were interested in meeting their donor or surrogate. MAIN RESULTS AND THE ROLE OF CHANCE: Fourteen (40%) young adults felt their conception made them feel special or unique, with the remainder feeling either neutral or unconcerned (n = 21, 60%). A higher proportion of young adults conceived using egg donation (n = 8, 73%) felt unique/special compared to young adults born following sperm donation and surrogacy. For 10 of the young adults, their feelings about their conception had changed over time, with most becoming more positive (n = 9, 26%). For most young adults (n = 22, 63%), conception was rarely or infrequently discussed with others. However, when it was, these conversations were largely conducted with ease. Most (n = 25, 71%) did not know other individuals born through the same method of conception as themselves, and the vast majority (n = 34, 97%) were not members of any support groups. For the 25 young adults not in contact with their donor or surrogate, 11 wished to meet them, 8 did not want to have contact, and 6 were unsure. Young adults in contact with their donor or surrogate had varying levels of closeness to them. Only one young adult had searched for the identity of their donor. LIMITATIONS, REASONS FOR CAUTION: Of the 47 young adults invited to participate in the present study, 35 agreed to take part resulting in a response rate of 74%. It is therefore not known how those who did not take part felt about their conception. Given that the families reported here had been taking part in this longitudinal study from when the target child was aged 1 year, they may have been more likely to discuss the child's conception than other families. The study also utilized self-report measures, which may have been prone to social desirability, with donor conceived young adults wanting to present their experiences in a positive light. WIDER IMPLICATIONS OF THE FINDINGS: The findings suggest that young adults born through surrogacy and donor conception do not feel negatively about their birth and this may be a consequence of the young age at which they found out about their conception. Although some young adults said they wished to meet their donor, this did not necessarily mean they were actively searching for them. STUDY FUNDING/COMPETING INTEREST(S): The study was funded by the Wellcome Trust [grant number 208013/Z/17/Z]. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

Predictors of self-harm and suicide in LGBT youth: The role of gender, socio-economic status, bullying and school experience.

BACKGROUND: Lesbian, gay and bisexual (LGB) young people's increased risk of self-harm, suicidal attempts and suicide compared with heterosexual youth is well established. The current study sought to examine whether these findings also apply to the trans (T) population and which factors act as additional risk or protective factors. METHODS: In a national cross-sectional survey, 3713 LGBT adolescents, aged 11-19 years, reported on their own history of self-harm, suicidal ideation and suicide attempts, as well as their experiences of school and homophobic, biphobic and transphobic bullying. Logistic regressions tested the association between risk and protective factors on self-harm, suicidal ideation and suicide attempts. RESULTS: A high proportion of the sample reported self-harm (65.3%), suicidal ideation (73.8%) and suicide attempts (25.7%). Demographic risk factors included identifying as female, non-binary or trans and being from a low-income background. Bullying and online bullying were associated with an increased risk for each outcome, and positive school experience was associated with a reduced risk for each outcome. CONCLUSIONS: Consistent with minority stress theory, the study found high rates of mental health problems within LGBT youth. Interventions focused on improving young people's experiences in schools appear useful targets to help improve mental health outcomes.

'I'm the only mum she knows': parents' understanding of, and feelings about, identity-release egg donation.

STUDY QUESTION: How do parents understand and feel about identity-release egg donation? SUMMARY ANSWER: Almost one-third of mothers and fathers did not understand the identifiable nature of their egg donation; mothers expressed complex and sometimes difficult feelings about the prospect of future donor-child contact. WHAT IS KNOWN ALREADY: Identity-release egg donation has been the only treatment option available to patients wishing to pursue this route to parenthood in the UK since 2005. However, little is known about how well parents understand this legislation, and how they feel about potential donor-child contact. STUDY DESIGN, SIZE, DURATION: This qualitative interview study included 61 mothers and 51 fathers whose 5-year-old children were conceived via identity-release egg donation. Interviews were conducted between April 2018 and December 2019. PARTICIPANTS/MATERIALS, SETTING, METHODS: Data are reported from phase two of a longitudinal study of families created using open-identity egg donation. In-depth, semi-structured interviews were conducted with mothers and fathers. The interviews contained a section on what parents understood about the identifiable nature of the donor. These data were analysed using qualitative content analysis. Mothers who understood the identifiable nature of their egg donation (n = 44) were then asked about their thoughts and feelings regarding the prospect of future donor-child contact. Mothers' narratives were analysed using thematic analysis. MAIN RESULTS AND THE ROLE OF CHANCE: Almost one-third of parents (28% of mothers, n = 17; 31% of fathers, n = 16) did not understand the identifiable nature of their egg donation. Mothers' and fathers' misunderstandings about identity-release egg donation fell into two categories: (i) Unclear about identity-release and (ii) Belief that the donor is anonymous. Reflexive thematic analysis revealed that egg donation mothers' feelings about identity-release donation could be understood via three organizing themes: (i) identity-release as a threat, (ii) acceptance: it is what it is and (iii) embracing identity-release. The findings indicated that egg donation mothers utilized various strategies to manage their feelings about identity-release egg donation in day-to-day life, and each theme was associated with at least one coping strategy. LIMITATIONS, REASONS FOR CAUTION: Participants were predominantly from White, middle-class backgrounds. Further research with a more diverse sample is needed to improve generalizability. WIDER IMPLICATIONS OF THE FINDINGS: These findings indicate that parents would benefit from more comprehensive provision of information, both at time of treatment and following conception, to ensure they have fully understood the nature of the donation. Parents may also benefit from follow-up care to help manage any complex or difficult feelings about donor-child contact. STUDY FUNDING/COMPETING INTEREST(S): This research was supported by a Wellcome Trust Collaborative Award [208013/Z/17/Z]. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

Parent-child relationship quality and child psychological adjustment in families created using egg donation: children's perspectives at age 5 years.

STUDY QUESTION: What are children's perspectives of the quality of their relationships with their parents and their own psychological well-being in families created using egg donation? SUMMARY ANSWER: Children's scores indicated good parent-child relationship quality and high levels of psychological well-being, with children in families created using egg donation rating their relationships with their mothers as higher in warmth/enjoyment than children in a comparison group of families created using IVF. WHAT IS KNOWN ALREADY: Little is known about how children in families created through egg donation view their family relationships and their own psychological well-being. Research with 7-and-10-year-olds in anonymous egg donation families has indicated good parent-child relationship quality from children's perspectives, but studies have not involved younger children or those conceived following identity-release egg donation. STUDY DESIGN, SIZE, DURATION: This study included 50 children who had been born through egg donation and a comparison group of 43 children conceived through IVF with the parents' own gametes. Data were collected between April 2018 and December 2019. The sample forms part of a larger longitudinal study examining family functioning in families created through fertility treatment. PARTICIPANTS/MATERIALS, SETTING, METHODS: Children were aged 5 years old and had been born into families with different-sex couple parents. All families were visited at home. Children were administered the Berkeley Puppet Interview, a standardized assessment of parent-child relationship quality and psychological well-being. MAIN RESULTS AND THE ROLE OF CHANCE: Children in egg donation families rated their relationships with their mothers as higher in warmth and enjoyment than did children in IVF families. No differences were found between the two family types in children's ratings of the father-child relationship, or in children's ratings of their own psychological well-being. LIMITATIONS, REASONS FOR CAUTION: It is possible that children who did not consent to take part in the research had less positive perceptions of their family and themselves than children who participated. WIDER IMPLICATIONS OF THE FINDINGS: The findings are relevant to UK clinics offering identity-release egg donation, to parents who have used egg donation to create their family and to individuals and couples considering their fertility treatment options. That children in egg donation families were more similar than different to children in IVF families in their self-concept and perception of their family relationships should prove reassuring. STUDY FUNDING/COMPETING INTEREST(S): This research was supported by a Wellcome Trust Collaborative Award [208013/Z/17]. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

A comparison of the characteristics, motivations, preferences and expectations of men donating sperm online or through a sperm bank.

STUDY QUESTION: How do the demographic characteristics, motivations, experiences and expectations of unregulated sperm donors (men donating sperm online through a connection website) compare to sperm donors in the regulated sector (men donating through a registered UK sperm bank)? SUMMARY ANSWER: Online donors were more likely to be older, married and have children of their own than sperm bank donors, were more varied in their preferences and expectations of sperm donation, and had more concerns about being a sperm donor. WHAT IS KNOWN ALREADY: While studies have examined motivations and experiences of both regulated sperm bank, and unregulated online sperm donors, no study has directly compared these two groups of donors. STUDY DESIGN, SIZE, DURATION: An email was sent to the 576 men who were registered sperm donors at the London Sperm Bank, the UK's largest sperm bank regulated by the Human Fertilisation and Embryology Authority (HFEA), who had commenced donation between January 2010 and December 2016, and had consented to be contacted for research. The online survey, which contained multiple choice and open-ended questions, was completed by 168 men over a 7-week period. The responses were compared to those of sperm donors registered on Pride Angel, a large UK-based connection website for donors and recipients of sperm: our research team had already collected these data. In total, 5299 sperm donors were on Pride Angel at time of data capture and 400 men had completed a similar survey. The responses of 70 actual online sperm donors (i.e. those whose sperm had been used to conceive at least one child) were used for comparison with the sperm bank donors. PARTICIPANTS/MATERIALS, SETTING, METHODS: The survey obtained data on the sperm donors' demographic characteristics, motivations, experiences and expectations of sperm donation. Data from sperm bank donors were compared to online donors to examine differences between the two groups. The study compared online and clinic donors who had all been accepted as sperm donors: online donors who had been 'vetted' by recipients and sperm bank donors who had passed the rigorous screening criteria set by the clinic. MAIN RESULTS AND THE ROLE OF CHANCE: A response rate of 29% was obtained from the sperm bank donors. Online donors were significantly older than sperm bank donors (mean ± SD: 38.7 ± 8.4 versus 32.9 ± 6.8 years, respectively) and were more likely to have their own children (p < 0.001 for both characteristics). Both groups rated the motivation 'I want to help others' as very important. Online donors rated 'I don't want to have children myself', 'to have children/procreate' and 'to enable others to enjoy parenting as I have myself' as more important than sperm bank donors, whereas sperm bank donors rated financial payment as more important than online donors, as well as confirmation of own fertility. Most (93.9%) online donors had donated their sperm elsewhere, through other connection sites, fertility clinics, sperm banks or friends and family, compared to only 2.4% of sperm bank donors (p < 0.001). There was a significant difference in how donors viewed their relationship to the child, with online donors much less likely than sperm bank donors to see their relationship as a 'genetic relationship only'. Online donors had more concerns about being a donor (p < 0.001), for example, being concerned about 'legal uncertainty and child financial support' and 'future contact and uncertainty about relationship with donor-conceived child'. LIMITATIONS, REASONS FOR CAUTION: Findings may not be representative of all sperm donors as only one online connection site and one HFEA registered sperm bank were used for recruitment. WIDER IMPLICATIONS OF THE FINDINGS: Despite concern regarding shortages of sperm donors in licensed clinics and unease regarding the growing popularity of unregulated connection websites, this is the first study to directly compare online and sperm bank donors. It highlights the importance of considering ways to incorporate unregulated online sperm donors into the regulated sector. With many online donors well aware of the legal risks they undertake when donating in the unregulated online market, this would both increase the number of sperm donors available at clinics but also provide legal protection and support for donors. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by the Wellcome Trust Grants 104 385/Z/14/Z and 097857/Z/11/Z. The authors have no conflicts of interest.

Psychological well-being of identity-release egg donation parents with infants.

STUDY QUESTION: What are the psychological health, relationship quality and perceived social support outcomes of heterosexual couples who have conceived an infant through identity-release egg donation? SUMMARY ANSWER: Parents' scores on all measures were within the normal range. Egg donation mothers had poorer perceived social support, and egg donation fathers had less optimal psychological health than a comparison group of IVF parents, although these differences were associated with the older age of egg donation parents, rather than being an effect of family type. WHAT IS KNOWN ALREADY: There is limited understanding of the psychological health and couple relationship quality of egg donation parents, and no empirical data on parents' social support, during the first year of parenthood. No studies have included families who have used an identity-release egg donor. The study offers the first examination of the psychological well-being of identity-release egg donation parents. STUDY DESIGN, SIZE, DURATION: This study included 57 families created through identity-release egg donation, and a comparison group of 56 families who had used IVF with their own gametes, recruited through UK fertility clinics. Families were visited at home between October 2013 and June 2015. The sample forms part of a larger study examining family functioning in families created following fertility treatment. PARTICIPANTS/MATERIALS, SETTING, METHOD: All families were heterosexual two-parent families with an infant aged 6-18 months. Mothers and fathers were administered standardised questionnaires assessing psychological health (Edinburgh Postnatal Depression Scale, Trait Anxiety Inventory and Parenting Stress Index-short form), couple relationship quality (Golombok Rust Inventory of Marital State) and perceived social support (Multidimensional Scale of Perceived Social Support). MAIN RESULTS AND THE ROLE OF CHANCE: Scores from the egg donation and IVF parents were within the normal range on all measures. Significant differences were found between the groups indicating less optimal social support in egg donation mothers compared to IVF mothers, and poorer psychological health in egg donation fathers compared to IVF fathers. These differences appeared to be related to the older age of egg donation parents or to twin parenthood, rather than to egg donation per se. No differences were found between the groups in the parents' relationship quality. LIMITATIONS, REASONS FOR CAUTION: It is possible that families who were managing the transition to parenthood less well may have been less likely to participate in research. Fewer IVF than egg donation fathers participated in the study, so the statistical power was lower for comparisons between fathers. WIDER IMPLICATIONS OF THE FINDINGS: The findings are of relevance to UK clinics offering identity-release egg donation. That scores of egg donation parents on measures of psychological well-being were more similar than different to those of IVF parents should prove reassuring to individuals considering this treatment type. As less optimal outcomes were found for egg donation parents on several measures, and these were associated with parental age rather than conception type, it is recommended that clinics discuss with older patients how they may establish a social support network and signpost patients to appropriate post-natal support. STUDY FUNDING, COMPETING INTERESTS: This research was supported by a Wellcome Trust Senior Investigator Award [097857/Z/11/Z] and a CHESS-ESRC studentship. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

The psychological well-being and prenatal bonding of gestational surrogates.

STUDY QUESTION: How does the psychological well-being and prenatal bonding of Indian surrogates differ from a comparison group of mothers? SUMMARY ANSWER: Surrogates had higher levels of depression during pregnancy and post-birth, displayed lower emotional connection with the unborn baby, and greater care towards the healthy growth of the foetus, than the comparison group of mothers. WHAT IS ALREADY KNOWN: Studies in the West have found that surrogates do not suffer long-term psychological harm. One study has shown that surrogates bond less with the foetus than expectant mothers. STUDY, DESIGN, SIZE, DURATION: This study uses a prospective, longitudinal and cross-sectional design. Surrogates and a matched group of expectant mothers were seen twice, during 4-9 months of pregnancy and 4-6 months after the birth. PARTICIPANTS/MATERIALS, SETTING, METHODS: Semi-structured interviews and standardized questionnaires were administered to 50 surrogates and 69 expectant mothers during pregnancy and 45 surrogates and 49 expectant mothers post-birth. All gestational surrogates were hosting pregnancies for international intended parents. MAIN RESULTS AND THE ROLE OF CHANCE: Surrogates had higher levels of depression compared to the comparison group of mothers, during pregnancy and post-birth (P < 0.02). Low social support during pregnancy, hiding surrogacy and criticism from others were found to be predictive of higher depression in surrogates post-birth (P < 0.05). Regarding prenatal bonding, surrogates interacted less with and thought less about the foetus but adopted better eating habits and were more likely to avoid unhealthy practices during pregnancy, than expectant mothers (P < 0.05). No associations were found between greater prenatal bonding and greater psychological distress during pregnancy or after relinquishment. LIMITATIONS, REASONS FOR CAUTION: All surrogates were recruited from one clinic in Mumbai, and thus the representativeness of this sample is not known. Also, the possibility of socially desirable responding from surrogates cannot be ruled out. WIDER IMPLICATIONS OF THE FINDINGS: As this is the first study of the psychological well-being of surrogates in low-income countries, the findings have important policy implications. Providing support and counselling to surrogates, especially during pregnancy, may alleviate some of the psychological problems faced by surrogates. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by the Wellcome Trust [097857/Z/11/Z] and Nehru Trust, Cambridge. K.K. is the Medical Director of Corion Fertility Clinic. All other authors have no conflict of interest to declare.

The perspectives of adolescents conceived using surrogacy, egg or sperm donation.

STUDY QUESTION: What are the perspectives of adolescents conceived using surrogacy, egg or sperm donation regarding their conception and the third party involved? SUMMARY ANSWER: The majority of adolescents described feeling indifferent about their conception, and yet simultaneously reported an interest in the third party involved, or were in contact with them. WHAT IS KNOWN ALREADY: There is an assumption that children conceived through reproductive donation will feel negatively about their origins in adolescence. However, little is known about the views of adolescents who have been conceived through different types of reproductive donation. STUDY DESIGN, SIZE, DURATION: Forty-four adolescents, all of whom had been told about their conception in childhood, participated in a semi-structured interview as part of the sixth phase of a longitudinal, multi-method, multi-informant study of assisted reproduction families in the UK. PARTICIPANTS/MATERIALS, SETTING, METHODS: All adolescents were aged 14 years, had been conceived using surrogacy (n = 22), egg donation (n = 13) or sperm donation (n = 9) to heterosexual couples, and varied in terms of their information about, and contact with, the third party involved in their conception. Semi-structured interviews were conducted in participants' homes. Interviews were analysed qualitatively to determine adolescents' perceptions of their conception, and their thoughts and feelings about the surrogate or donor involved. MAIN RESULTS AND THE ROLE OF CHANCE: Adolescents were found to feel positive (n = 7), indifferent (n = 32) or ambivalent (n = 5) about their conception. Amongst adolescents not in contact with the surrogate or donor, most were interested (n = 16) in the surrogate or donor, and others were ambivalent (n = 4), or not interested (n = 6) in them. Adolescents in contact with the surrogate or donor expressed positive (n = 14), ambivalent (n = 1) or negative (n = 1) feelings about them. LIMITATIONS, REASONS FOR CAUTION: Of 56 adolescents invited to take part in the study, 47 consented to take part, giving a response rate of 84%. It was not possible to obtain information from adolescents who do not know about their conception. WIDER IMPLICATIONS OF THE FINDINGS: The findings contradict the assumption that children conceived through reproductive donation will feel negatively about their origins in adolescence and suggest that it may be helpful to draw a distinction between adolescents' feelings about their conception in general, and their feelings about the surrogate or donor in particular. STUDY FUNDING/COMPETING INTEREST(S): This study was funded by the Wellcome Trust [097857/Z/11/Z]. The authors have no conflicts of interest to declare.

Online sperm donation: a survey of the demographic characteristics, motivations, preferences and experiences of sperm donors on a connection website.

STUDY QUESTION: What are the demographic characteristics, motivations, preferences and experiences of heterosexual, gay and bisexual sperm donors on a connection website (i.e. a website that facilitates direct contact between donors and recipients of gametes)? SUMMARY ANSWER: This demographically diverse group of men was donating for altruistic reasons and perceived the website as providing greater choice over donation arrangements: approximately one third favoured anonymous donation, most of whom were heterosexual, whilst gay and bisexual donors were more likely to be in contact with children conceived with their sperm. WHAT IS KNOWN ALREADY: Despite substantially more sperm donors being registered on connection websites than with clinics, there has been very little research on this population. Current understanding of the impact of sexual orientation on donors' attitudes is also limited. STUDY DESIGN, SIZE, DURATION: An online survey was conducted over 7 weeks with 383 men registered as sperm donors with Pride Angel, a large UK-based connection website for donors and recipients of sperm. PARTICIPANTS/MATERIALS, SETTING, METHODS: The survey obtained data on participants' demographic characteristics and their motivations, preferences and experiences regarding online sperm donation, including attitudes towards contact with offspring. Differences according to participants' sexual orientation were examined. MAIN RESULTS AND THE ROLE OF CHANCE: Most participants (80.4%, 308) were heterosexual, 10.5% (40) were gay and 9.1% (35) were bisexual; ages ranged from 18 to 69 years (median = 36, mean = 37.3, SD = 9.7). A greater proportion of gay and bisexual men desired open-identity donation (P < 0.005) and contact with offspring (P <0.005) than heterosexual men. Approximately one third (28.7%, 110) had donated sperm; 18.3% (70) had conceived at least one child, of whom a minority (25.7%, 18) were currently in contact with the child, comprising significantly more gay and bisexual than heterosexual men (P = 0.001). Heterosexual men were most likely to state a preference for natural insemination, although the large majority (94.3%, 66) of donors who had conceived children had used artificial insemination. LIMITATIONS, REASONS FOR CAUTION: Findings may not be representative of all sperm donors using connection websites because members of only one website participated and participants were, by necessity, a self-selected sample. WIDER IMPLICATIONS OF THE FINDINGS: This is the first comprehensive study of donors who connect with recipients via the internet, including a substantial number who have donated and conceived children. The findings indicate that sexual orientation may influence men's donation preferences and raise policy issues concerning donor recruitment and the incorporation of online sperm donation into clinical practice. STUDY FUNDING/COMPETING INTERESTS: This study was supported by the Wellcome Trust (097857/Z/11/Z). E.T. is the co-founder of Pride Angel; the remaining authors have no conflicts of interest.

Surrogate mothers 10 years on: a longitudinal study of psychological well-being and relationships with the parents and child.

STUDY QUESTION: How do the psychological health and experiences of surrogate mothers change from 1 year to 10 years following the birth of the surrogacy child? SUMMARY ANSWER: The psychological well-being of surrogate mothers did not change 10 years following the birth, with all remaining positive about the surrogacy arrangement and the majority continuing to report good mental health. WHAT IS KNOWN ALREADY: Studies have found that surrogates may find the weeks following the birth difficult, but do not experience psychological problems 6 months or 1 year later. Research has also shown that surrogates can form close relationships with the intended parents during the pregnancy which may continue after the birth. STUDY DESIGN, SIZE, DURATION: This study used a prospective longitudinal design, in which 20 surrogates were seen at two time points: 1 year following the birth of the surrogacy child and 10 years later. PARTICIPANTS/MATERIALS, SETTING, METHODS: The 20 surrogates (representing 59% of the original sample) participated in a semi-structured interview and completed self-report questionnaires. Eleven surrogates were gestational carriers and nine surrogates had used their own oocyte (genetic surrogacy). Four were previously known to the intended parents and 16 were previously not known. MAIN RESULTS AND THE ROLE OF CHANCE: Ten years following the birth of the surrogacy child, surrogate mothers scored within the normal range for self-esteem and did not show signs of depression as measured by the Beck Depression Inventory. Marital quality remained positive over time. All surrogates reported that their expectations of their relationship with the intended parents had been either met or exceeded and most reported positive feelings towards the child. In terms of expectations for the future, most surrogates reported that they would like to maintain contact or would be available to the child if the child wished to contact them. None expressed regrets about their involvement in surrogacy. LIMITATIONS, REASONS FOR CAUTION: The sample size of this study was small and the women may not be representative of all surrogates. Therefore the extent to which these findings can be generalized is not known. WIDER IMPLICATIONS OF THE FINDINGS: Contrary to concerns about the potentially negative long-term effect of surrogacy, the findings suggest that surrogacy can be a positive experience for some women at least. These findings are important for policy and practice of surrogacy around the world.

'Friendly allies in raising a child': a survey of men and women seeking elective co-parenting arrangements via an online connection website.

STUDY QUESTION: What are the characteristics, motivations and expectations of men and women who search for a co-parent online? SUMMARY ANSWER: Male and female prospective co-parents differed in terms of their motivations, choice of co-parent and expectations of co-parenting, while differences according to sexual orientation were less marked. WHAT IS KNOWN ALREADY: Very few studies have addressed the experiences of elective co-parents, i.e. men and women who are not in a relationship with each other creating and raising a child together. No study has examined the motivations and experiences of those who seek co-parents online. STUDY DESIGN, SIZE AND DURATION: An online survey was completed by 102 participants (61 men, 41 women) who were members of Pride Angel, an online connection website that facilitates contact between people looking for someone with whom to have a child. The survey was live for 7 weeks. PARTICIPANTS/MATERIALS, SETTING, METHODS: Details of the survey were emailed to all members of Pride Angel. The survey obtained data on participants' demographic characteristics, motivations, choice of co-parent and expectations of co-parenting. Data were analysed to examine differences by gender and by sexual orientation within each gender. MAIN RESULTS AND THE ROLE OF CHANCE: Approximately one-third of men and one half of women seeking co-parenting arrangements were heterosexual. The majority (69, 68%) of participants were single, although significantly more gay and bisexual men (15, 36%) and lesbian and bisexual women (11, 55%) had a partner compared with heterosexual men (4, 20%) and heterosexual women (2, 12%), respectively. Overall, the most important motivation for seeking co-parenting arrangements was in order for both biological parents to be involved in the child's upbringing. Co-parents were looking for someone with a good medical history. Most female co-parents expected the child to live with them, whereas male co-parents either wished the child to reside with the mother or to live equally in both households. A higher proportion of gay and bisexual men than heterosexual men wanted daily contact with the child. LIMITATIONS, REASONS FOR CAUTION: Although this study presents data from the largest sample of elective co-parents to date, the main limitations were the low response rate and that only members of one website were approached. The findings may not be representative of all potential elective co-parents. WIDER IMPLICATIONS OF THE FINDINGS: This study provides important insights into the new phenomenon of elective co-parenting. With the increasing use of assisted reproductive technologies and the diversification of family forms, a growing number of people are seeking co-parenting arrangements to have children. While up until now, elective co-parenting has been principally associated with the gay and lesbian community, this study shows that, with the rise of co-parenting websites, increasing numbers of heterosexual men and women are seeking these types of parenting arrangements. This study generates the first findings on the expectations and motivations of those who seek co-parents online and examines whether these differ according to gender and sexual orientation. Future studies are needed to assess the impact of this new form of parenting on all involved, particularly the children. STUDY FUNDING/COMPETING INTERESTS: This study was supported by the Wellcome Trust (097857/Z/11/Z). Erika Tranfield is the co-founder of the website Pride Angel, the remaining authors have no conflicts of interest to declare.

Children of surrogate mothers: psychological well-being, family relationships and experiences of surrogacy.

STUDY QUESTION: What impact does surrogacy have on the surrogates' own children? SUMMARY ANSWER: The children of surrogate mothers do not experience any negative consequences as a result of their mother's decision to be a surrogate, irrespective of whether or not the surrogate uses her own egg. STUDY DESIGN, SIZE AND DURATION: Participants were recruited as part of a study of the long-term effects of surrogacy for surrogates and their family members. Data were collected from 36 children of surrogates at a single time point. PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants whose mother had been a surrogate 5-15 years prior to interview and who were aged over 12 years were eligible to take part. Thirty-six participants (14 male and 22 female) aged 12-25 years were interviewed (response rate = 52%). Questionnaires assessing psychological health and family functioning were administered. MAIN RESULTS AND THE ROLE OF CHANCE: Forty-four per cent (15) of participants' mothers had undergone gestational surrogacy, 39% (14) had used their own egg (genetic surrogacy) and 19% (7) had completed both types of surrogacy. Most surrogates' children (86%, 31) had a positive view of their mother's surrogacy. Forty-seven per cent (17) of children were in contact with the surrogacy child and all reported good relationships with him/her. Forty per cent (14) of children referred to the child as a sibling or half-sibling and this did not differ between genetic and gestational surrogacy. Most children (89%, 32), reported a positive view of family life, with all enjoying spending time with their mother. Mean scores on the questionnaire assessments of psychological health and self-esteem were within the normal range and did not differ by surrogacy type. LIMITATIONS, REASONS FOR CAUTION: The sample size for this study was relatively small and not all children chose to take part, therefore their views cannot be known. Nevertheless, this is the first study to assess the experiences of surrogacy from the perspective of the surrogates' own children. There may be some bias from the inclusion of siblings from the same family. WIDER IMPLICATIONS OF THE FINDINGS: Findings of this study show that family relationships within the surrogate's own family are good and that the children are not negatively affected as a result of their mother's decision to be a surrogate. These results are of importance to counsellors and support groups offering advice to surrogates and intended parents. STUDY FUNDING, COMPETING INTERESTS: This work was supported by the Economic and Social Research Council (grant number ES/I009221/1). None of the authors has any conflict of interest to declare.

Parent psychological adjustment, donor conception and disclosure: a follow-up over 10 years.

STUDY QUESTION: What is the relationship between parent psychological adjustment, type of gamete donation (donor insemination, egg donation) and parents' disclosure of their use of donated gametes to their children. SUMMARY ANSWER: Disclosure of donor origins to the child was not always associated with optimal levels of psychological adjustment, especially for fathers in donor insemination families. WHAT IS KNOWN ALREADY: Cross-sectional analyses have found mothers and fathers who conceived a child using donated sperm or eggs to be psychologically well-adjusted, with few differences emerging between parents in gamete donation families and parents in families in which parents conceived naturally. The relationship between mothers' and fathers' psychological well-being, type of gamete donation (donor insemination, egg donation) and parents' disclosure decisions has not yet been examined. STUDY DESIGN, SIZE, DURATION: In this follow-up study, data were obtained from mothers and fathers in donor insemination and egg donation families at 5 time points; when the children in the families were aged 1, 2, 3, 7 and 10. In the first phase of the study, 50 donor insemination families and 51 egg donation families with a 1-year-old child participated. By age 10, the study included 34 families with a child conceived by donor insemination and 30 families with a child conceived by egg donation, representing 68 and 58% of the original sample, respectively. PARTICIPANTS/MATERIALS, SETTING, METHODS: Families were recruited through nine fertility clinics in the UK. Standardized questionnaires assessing depression, stress and anxiety were administered to mothers and fathers in donor insemination and egg donation families. MAIN RESULTS AND THE ROLE OF CHANCE: Mothers and fathers in both donor insemination and egg donation families were found to be psychologically well-adjusted; for the vast majority of parents' levels of depression, anxiety and parenting stress were found to be within the normal range at all 5 time points. Disclosure of the child's donor origins to the child was not always associated with optimal levels of parental psychological adjustment. For example, disclosure was associated with lower levels of psychological well-being for certain groups in particular (such as fathers in donor insemination families), at certain times (when children are in middle childhood and have a more sophisticated understanding of their donor origins). LIMITATIONS, REASONS FOR CAUTION: Owing to small sample sizes, the value of this study lies not in its generalizability, but in its potential to point future research in new directions. WIDER IMPLICATIONS OF THE FINDINGS: Donor insemination and egg donation families are a heterogeneous group, and future research should endeavour to obtain data from fathers as well as mothers. Support and guidance in terms of disclosure and family functioning might be most beneficial for parents (and especially fathers) in donor insemination families, particularly as the child grows older. The more that is known about the process of disclosure over time, from the perspective of the different members of the family, the better supported parents and their children can be. STUDY FUNDING COMPETING INTERESTS: The project described was supported by grant number RO1HD051621 from the National Institute of Child Health and Human Development. The content is solely the responsibility of the authors and does not represent the official views of the National Institute of Child Health and Human Development or the National Institutes of Health. The authors have no conflict of interest to declare.

Surrogacy families 10 years on: relationship with the surrogate, decisions over disclosure and children's understanding of their surrogacy origins.

BACKGROUND: This study aimed to prospectively examine families created using surrogacy over a 10-year period in the UK with respect to intending parents' and children's relationship with the surrogate mother, parents' decisions over disclosure and children's understanding of the nature of their conception. METHODS: Semi-structured interviews were administered by trained researchers to intending mothers, intending fathers and children on four occasions over a 10-year period. Forty-two families (19 with a genetic surrogate mother) participated when the child was 1-year old and by age 10 years, 33 families remained in the study. Data were collected on the frequency of contact with the surrogate mother, relationship with the surrogate, disclosure of surrogacy to the child and the child's understanding of their surrogacy birth. RESULTS: Frequency of contact between surrogacy families and their surrogate mother decreased over time, particularly for families whose surrogate was a previously unknown genetic carrier (P < 0.001) (i.e. where they had met through a third party and the surrogate mother's egg was used to conceive the child). Most families reported harmonious relationships with their surrogate mother. At age 10 years, 19 (90%) children who had been informed of the nature of their conception had a good understanding of this and 13 of the 14 children who were in contact with their surrogate reported that they liked her. CONCLUSIONS: Surrogacy families maintained good relationships with the surrogate mother over time. Children felt positive about their surrogate mother and their surrogacy birth. The sample size of this study was small and further, larger investigations are needed before firm conclusions can be drawn.

Marital stability and quality in families created by assisted reproduction techniques: a follow-up study.

An increasing number of children are being born with the use of assisted reproduction techniques such as donor insemination, egg donation and surrogacy. There have been concerns that the use of these third-party reproduction techniques may have a negative effect on the quality of the relationship between the mother and father. Marital stability and quality was examined in a UK sample of donor insemination, egg donation and surrogacy families and families in which children were naturally conceived. Interview and questionnaire assessments of marital stability and quality were collected from mothers and fathers over five time points, when the children in the families were aged 1, 2, 3, 7 and 10. Of those families who participated when children were 10years old, a minority of couples in each family type had divorced/separated and few differences emerged between the different family types in terms of mothers' or fathers' marital quality. Despite concerns, couples in families created by donor insemination, egg donation and surrogacy were found to be functioning well.

Sperm and oocyte donors' experiences of anonymous donation and subsequent contact with their donor offspring.

BACKGROUND: This study examined the motivations and experiences of anonymous donors who decide to make themselves open to contact with their donor offspring. METHODS: Online questionnaires were completed by 63 sperm donors and 11 oocyte donors recruited via the Donor Sibling Registry (http://www.donorsiblingregistry.com/), a US-based international registry that facilitates contact between donor-conceived offspring and their donors. RESULTS: Donors' main reasons for donating were financial payment and wanting to help others. Sperm donors had donated between 1 and 950 times (median = 100) and oocyte donors had donated between 1 and 5 times (median = 2). The majority of sperm donors and more than one-third of oocyte donors expressed concerns about having donated. These concerns were mainly about the well-being of any children conceived using their gametes and not being able to make contact with them. Most sperm and oocyte donors felt that it was important to know how many offspring had been born using their donation, and 51% of sperm donors and 46% of oocyte donors wanted identifying information. All of the donors who had contact with their donor offspring reported positive experiences and the majority continued to have regular contact. CONCLUSIONS: Although the sample may not be representative of all anonymous donors, this study highlights the importance of donors having access to information about their donor offspring and the positive consequences that may arise when contact is made.

A longitudinal study of recipients' views and experiences of intra-family egg donation.

BACKGROUND: For the past 10 years, we have been carrying out a longitudinal investigation of egg donation families in the UK; a subsample of recipients in these families had a child by egg donation from a sister or sister-in-law. In response to the current debate over the practice of intra-family donation, together with the general lack of available data on the consequences of donation between family members, we examined recipients' experiences of donation between sisters and sisters-in-law. METHODS: We analysed data from a subsample of recipient mothers who were taking part in a larger investigation of gamete donation families. Mothers were visited at home and interviewed when their child was aged 1, 3, 7 and 10 years. Data from nine recipient mothers whose egg donor was either their sister or sister-in-law were examined to assess the nature of mothers', fathers' and the child's relationship with the donor, and whether mothers had disclosed the nature of their child's conception to others, including the child. RESULTS: The majority of recipient mothers reported positive relationships between the donor and members of their family (themselves, their partner and their children). Most mothers were happy with the donor's level of involvement with the child and reported that they and the donor maintained their social roles within the family, i.e. as mother and aunt, respectively. By age 10, two children had been told that they had been conceived using egg donation, both of whom had been told the identity of the donor. CONCLUSIONS: Although the sample was small, this study provides the first longitudinal data on the experiences of families created using donated gametes from a family member. Intra-family donation between sisters or sisters-in-law can be a positive experience for recipients during the first 10 years following the child's birth. Studies that are specifically designed to look at donation between family members are needed to better evaluate the practice.

'Daddy ran out of tadpoles': how parents tell their children that they are donor conceived, and what their 7-year-olds understand.

BACKGROUND: The present study explored the process of disclosure in gamete donation families in the UK. METHODS: Interviews were conducted with 23 mothers and 15 fathers who had told their 7-year-old child about the nature of their conception. Twelve children were interviewed about what they understood and how they felt about their donor conception (DC). RESULTS: The majority of families had disclosed by the age of four and mothers were found to be the main disclosers. Although some parents expressed concerns about the disclosure, the majority did not experience difficulties. No child responded to disclosure in a negative way. Seven-year-old children showed little understanding of their DC, despite parents starting the process of disclosure before the age of four. CONCLUSIONS: In spite of mothers' concerns about disclosing DC to their children, children responded to disclosure in a neutral way and most parents did not find disclosure to be problematic.

Gamete donation: parents' experiences of searching for their child's donor siblings and donor.

BACKGROUND: This study investigates the new phenomenon of parents of donor offspring searching for and contacting their child's 'donor siblings' (i.e. donor offspring conceived by the same donor) and donor. METHODS: Online questionnaires were completed by 791 parents (39% lone-mother, 35% lesbian-couple, 21% heterosexual-couple, 5% non-specified) recruited via the Donor Sibling Registry; a US-based international registry that facilitates contact between donor conception families who share the same donor. Data were collected on parents' reasons for searching for their child's donor siblings and/or donor, the outcome of these searches and parents' and their child's experiences of any resulting contact. RESULTS: Parents' principal motivation for searching for their child's donor siblings was curiosity and for their donor, enhancing their child's sense of identity. Some parents had discovered large numbers of donor siblings (maximum = 55). Most parents reported positive experiences of contacting and meeting their child's donor siblings and donor. CONCLUSIONS: This study highlights that having access to information about a child's donor origins is important for some parents and has potentially positive consequences. These findings have wider implications because the removal of donor anonymity in the UK and elsewhere means that increasing numbers of donor offspring are likely to seek contact with their donor relations in the future.