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.

'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.

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 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.

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.

Wellbeing of gay fathers with children born through surrogacy: a comparison with lesbian-mother families and heterosexual IVF parent families.

STUDY QUESTION: Are there differences in levels of parental wellbeing (parental stress, psychological adjustment and partner relationship satisfaction) between gay-father families with infants born through surrogacy, lesbian-mother families with infants born through donor insemination, and heterosexual-parent families with infants born through IVF? SUMMARY ANSWER: There were no differences in parental wellbeing. WHAT IS KNOWN ALREADY: The only other study of parental wellbeing in gay-father families formed through surrogacy (mean age children: 4 years old) found no difference in couple relationship satisfaction between these families and lesbian-mother families formed through donor insemination and heterosexual-parent families formed without assisted reproductive technologies. STUDY DESIGN, SIZE, DURATION: This cross-sectional study is part of an international research project involving 38 gay-father families, 61 lesbian-mother families and 41 heterosexual-parent families with 4-month-olds. In each country (the UK, the Netherlands and France), participants were recruited through several sources, such as specialist lawyers with expertise in surrogacy (for the recruitment of gay fathers), lesbian and gay parenting support groups, fertility clinics (for the recruitment of lesbian and heterosexual parents), and/or online forums and magazines. PARTICIPANTS/MATERIALS, SETTING, METHODS: During a home visit when their infants were between 3.5 and 4.5 months old, participants completed standardized measures of parental stress, parental psychological adjustment (anxiety and depression) and partner relationship satisfaction. MAIN RESULTS AND THE ROLE OF CHANCE: All parents reported relatively low levels of parental stress, anxiety and depression, and were all relatively satisfied with their intimate relationships. After controlling for caregiver role (primary or secondary caregiver role), there were no significant family type differences in parental stress, P = 0.949, depression, P = 0.089, anxiety, P = 0.117, or relationship satisfaction, P = 0.354. LIMITATIONS, REASONS FOR CAUTION: The findings cannot be generalized to all first-time ART parents with infants because only families from relatively privileged backgrounds participated. WIDER IMPLICATIONS OF THE FINDINGS: Our findings may have implications for the development of policy and legislation in relation to these new family forms, as well as the regulation of surrogacy in the Netherlands and France. In addition, our findings might encourage professional organizations of obstetricians and gynecologists in these countries to recommend that requests for assisted reproduction should be considered regardless of the applicants' sexual orientation. STUDY FUNDING/COMPETING INTEREST(S): This research was supported, under the auspices of the Open Research Area (Application BO 3973/1-1; Principal Investigator, Michael E Lamb), by grants from the UK Economic and Social Research Council (ESRC; Grant ES/K006150/1; Principal Investigator, Michael E. Lamb), The Netherlands Organisation for Scientific Research (NWO; Grant NWO 464-11-001, Principal Investigator, Henny W.M. Bos) and the French Agence Nationale de Recherche (ANR; Grant ANR-12-ORAR-00005-01, Principal Investigator, Olivier Vecho) whose support is gratefully acknowledged. There were no competing interests.

Gay fathers' motivations for and feelings about surrogacy as a path to parenthood.

Study question: Why do gay men choose to start their families through surrogacy? Summary answer: Most fathers chose surrogacy because they considered adoption to be a less desirable and/or accessible path to parenthood. What is known already: Little is known of gay fathers' motivations to use surrogacy as a path to parenthood over and above other forms of family building, such as adoption, and no studies have examined fathers' satisfaction with the surrogacy process. Study design size, duration: This study used a cross-sectional design as part of a larger investigation of parent-child relationships and child adjustment in 40 gay father surrogacy families. Multiple strategies (e.g. surrogacy agencies, social events and snowballing) were used to recruit as diverse a sample as possible. Data were obtained from 74 fathers (in 6 families only 1 father was available for interview). Participants/materials, setting, method: Semi-structured interviews, lasting ~1 h, were conducted in the family home (65%) or over Skype (35%) with 74 gay fathers (35 genetic fathers, 32 non-genetic fathers and 7 fathers who did not know or did not disclose who the genetic father was), when the children were 3-9 years old. Main results and the role of chance: Genetic and non-genetic fathers were just as likely to want to become parents and had similar motivations for choosing surrogacy as a path to parenthood. Most fathers (N = 55, 74%) were satisfied with surrogacy and were satisfied (N = 31. 42%) or had neutral feelings (N = 21, 28%) about their choice of who would be the genetic father. Most fathers received supportive reactions to their decision to use surrogacy from both families of origin (e.g. parents, siblings) (N = 47, 64%) and from friends (N = 63, 85%). Limitations, reasons for caution: Although diverse recruitment strategies were used, data were obtained from a volunteer sample. Therefore, the possibility that fathers who had a positive surrogacy experience may have been more likely to participate in the study, and therefore introduce bias, cannot be ruled out. Due to the high average annual income of the fathers in the study, findings may not generalize to gay fathers with lower incomes. Wider implications of the findings: It is often assumed that parents' primary motivation for using ART is to have a genetic connection to the child. This study revealed that whilst genetic fatherhood was important for some gay fathers in surrogacy families, it was not important for all. This information will be of use to surrogacy agencies and organizations supporting men who are considering the different routes to parenthood. Study funding/competing interest(s): This work was funded by the Wellcome Trust [097857/Z/11/Z] and the Jacob's Foundation. None of the authors has any conflict of interest to declare. Trial registration number: N/A.

Children's thoughts and feelings about their donor and security of attachment to their solo mothers in middle childhood.

Study question: What is the relationship between children's thoughts and feelings about their donor and their security of attachment to their solo mothers in middle childhood? Summary answer: Children with higher levels of secure-autonomous attachment to their mothers were more likely to have positive perceptions of the donor, and those with higher levels of insecure-disorganized attachment to their mothers were more likely to perceive him negatively. What is known already: There is limited understanding of the factors that contribute to children's thoughts and feelings about their donor in solo mother families. In adolescence, an association was found between adolescents' curiosity about donor conception and their security of attachment to their mothers. Study design size, duration: 19 children were administered the Friends and Family Interview and Donor Conception Interview between December 2015 and March 2016 as part of the second phase of a longitudinal, multi-method, multi-informant study of solo mother families. Participants/materials setting methods: All children were aged between 7 and 13 years and had been conceived by donor insemination to solo mothers. Interviews were conducted in participants' homes. The Friends and Family Interview was rated according to a standardized coding scheme designed to measure security of attachment in terms of secure-autonomous, insecure-dismissing, insecure-preoccupied and insecure-disorganized attachment patterns. Quantitative analyses of the Donor Conception Interview yielded two factors: interest in the donor and perceptions of the donor. Qualitative analyses of the Donor Conception Interview were conducted using qualitative content analysis and thematic analysis. Main results and the role of chance: Statistically significant associations were found between the perception of the donor scale and the secure-autonomous and insecure-disorganized attachment ratings. Children with higher levels of secure-autonomous attachment to their mothers were more likely to have positive perceptions of the donor (r = 0.549, P = 0.015), and those with higher levels of insecure-disorganized attachment to their mothers were more likely to perceive him negatively (r = -0.632, P = 0.004). Children's narratives about the donor depicted him as a stranger (n = 8), a biological father (n = 4), a social parent (n = 3), or in ambivalent terms (n = 4). Limitations, reasons for caution: Findings are limited by the wide age range of children within a small overall sample size. Participants were those willing and able to take part in research on donor conception families. The statistical significance of correlation coefficients was not corrected for multiple comparisons. Wider implications of the findings: Findings highlight the importance of situating children's ideas about the donor within family contexts. It is recommended that those working with donor conception families consider this when advising parents about whether, what and how to tell children about donor conception. 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.

Absence or presence? Complexities in the donor narratives of single mothers using sperm donation.

STUDY QUESTION: How do single mothers who have conceived a child via anonymous or identity-release sperm donation represent the donor? SUMMARY ANSWER: While the majority of mothers described their anonymous and identity-release donors as symbolically significant to their families, others were more likely to emphasize that their lack of information limited their thoughts about him. WHAT IS KNOWN ALREADY: There is limited understanding of the factors that impact upon how single mothers represent the donor, and whether or not they are determined by specific donor programmes (anonymous or identity-release). STUDY DESIGN, SIZE, DURATION: Qualitative interviews were conducted with 46 women who had treatment at a UK licensed fertility clinic during the years 2003-2009. Twenty mothers (43%) had used an anonymous donor, and 26 (57%) had used an identity-release donor. PARTICIPANTS/MATERIALS, SETTING, METHODS: Among the 46 mothers interviewed, all had at least one child conceived via donor insemination who was between the ages of 4 and 9 years. Mothers were heterosexual and were currently without a live-in and/or long-term partner. Interview data were analysed qualitatively according to the principles of thematic analysis. MAIN RESULTS AND THE ROLE OF CHANCE: Findings indicated marked diversity in single mothers' representations of the donor. Most (n = 27) mothers talked about the donor as symbolically significant to family life and were likely to describe the donor as (i) a gift-giver, (ii) a gene-giver and (iii) a potential partner. Others (n = 16) talked about the donor as (i) unknown, (ii) part of a process and (iii) out of sight and out of mind. There were mothers with anonymous and identity-release donors in each group. Several mothers explained that their feelings about the donor had changed over time. LIMITATIONS, REASONS FOR CAUTION: All mothers conceived at a licensed fertility clinic in the UK. Findings are limited to individuals willing and able to take part in research on donor conception. WIDER IMPLICATIONS OF THE FINDINGS: The study offers greater insight into the factors influencing the donor narratives produced in single-mother families. It has implications for the counselling and treatment of single women seeking fertility treatment with donor gametes in both anonymous and identity-release programmes. Given that the number of clinics offering identity-release programmes worldwide seems to be increasing, the finding that single women may have varying preferences with regard to donor type, and varying interest levels with regard to donor information, is important. It is recommended that clinicians and other fertility clinic staff guard against making assumptions about such preferences and any thoughts and feelings about the donor or donor information on the basis of marital status. STUDY FUNDING/COMPETING INTERESTS: This study was funded by the Wellcome Trust [097857/Z/11/Z]. The authors have no conflicts of interest to declare.

'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.

Indian egg donors' characteristics, motivations and feelings towards the recipient and resultant child.

This is the first study to examine characteristics, motivations and experiences of Indian egg donors. In-depth interviews were conducted with 25 egg donors who had donated during the previous 8 months at a fertility clinic in Mumbai. The semi-structured interviews were conducted in Hindi and English. In addition to demographic information, data were collected on donors' motivations for donating, with whom they had discussed donation, and feelings towards the recipients. The response rate was 66%. All participants were literate and had attended school. Twenty (80%) egg donors had children and five (20%) did not. The most common motivation (19, 76%) for donating was financial need. Egg donors had discussed their donation with their husband or with close family/friends, with almost all mentioning that wider society would disapprove. The majority (20, 80%) had no information about the recipients and 11 (44%) preferred not to. The findings highlight the similarities and differences between egg donors from India and those from other countries and that egg donors are of a more varied demographic background than surrogates in India. Given that India has been a popular destination for fertility treatment, the findings have important implications for regulation and practice within India and internationally.

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.

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.

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.

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.

Donor insemination: a follow-up study of disclosure decisions, family relationships and child adjustment at adolescence.

The call for greater openness about gamete donation highlights the need to assess the long-term implications of telling donor-conceived children about their origins. This longitudinal study examined the consequences of secrecy versus openness about donor insemination (DI) for family relationships and child adjustment at adolescence. Thirty heterosexual families with an adolescent (aged 10-14 years) conceived by anonymous DI were assessed using standardized measures of parent-child and marital relationships, and parents' and adolescents' psychological wellbeing. Ten (33%) adolescents had been told about their donor conception. The only differences found between disclosed and non-disclosed families concerned parent-child relationships. In particular, whilst disclosure was associated with lower levels of conflict between mothers and sons, adolescents who were aware of their donor origins reported less warm father-child relationships than those who had not been told. This is of interest given that identity issues and a fuller understanding of donor conception are likely to arise at adolescence. However, differences between disclosing and non-disclosing families cannot be directly attributed to parents' disclosure decisions. Overall, these findings suggest that openness about DI does not create significant difficulties for family functioning or child adjustment and that a child's age and sex may be important in assessing the impact of secrecy and disclosure.

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.