Family Building by Same-Sex Male Couples via Gestational Surrogacy

Abstract

Best estimates suggest that the number of households with same-sex male couples is increasing. One option for family building by same-sex male couples is gestational surrogacy. Embryos would be generated in vitro, using the biologic father's sperm with donor oocytes, and another woman (the gestational carrier) would undergo an embryo transfer to bear a child. Conceiving via gestational surrogacy requires advance planning, not only to coordinate the oocyte donor and gestational carrier but also to comply with regulations set forth by the Food and Drug Administration (FDA). The American Society for Reproductive Medicine (ASRM) has also published recommendations for practices using gestational carriers, which, in many cases, are more stringent than the FDA regulations. This article will review the FDA regulations and ASRM recommendations and their implications for same-sex male couples who plan to conceive via gestational surrogacy.

Keywords

gestational carrier - surrogacy - gay men - gay father - same-sex couples - third-party reproduction - assisted reproduction - sperm donor

Best estimates suggest that the number of households with same-sex male couples is increasing. In 2015, there were estimated 412,001 male same-sex couples in the United States, increased from 284,295 in 2011.[1] In 2015, 9.7% of same-sex male couples reported having children.[2] One option for family building by same-sex male couples is gestational surrogacy, a process in which one woman provides an egg and another woman (the gestational carrier) undergoes an embryo transfer to bear a child who is genetically unrelated to herself for another individual who intends to be the legal, rearing parent[3] [4] ([Fig. 1]). Gestational surrogacy differs from traditional surrogacy, in which one woman both supplies her eggs and gestates the pregnancy. Traditional surrogacy is discouraged by the American Society for Reproductive Medicine (ASRM) and is no longer offered by most programs[4] [5] due to the legal and ethical difficulties resulting from the genetic link between the surrogate and the child.

Fig. 1 Family building by same-sex male couples. Men will need both a source of oocytes and a gestational carrier. Sometimes, they may choose one of their female relatives as a directed oocyte donor so that both partners could have a genetic connection to the child. Alternatively, they may choose to split the oocytes obtained from one oocyte donor. With a young oocyte donor, recommendations would be to transfer one embryo into a gestational carrier. Any remaining embryos would be frozen for a future cycle. ASRM, American Society for Reproductive Medicine; FDA, Food and Drug Administration.

Through gestational surrogacy, patients who are unable to carry a pregnancy are able have genetic children. The American College of Obstetricians and Gynecologists (ACOG) recommends that gestational surrogacy be “restricted to situations in which carrying a pregnancy is biologically impossible or medically contraindicated for the intended parents.”[4] The Ethics Committee of the ASRM unequivocally states that programs should treat all requests for assisted reproduction equally, without regard to sexual orientation.[6] Based on ASRM recommendations, indications for gestational surrogacy include the presence of a serious medical condition that would be a contraindication to pregnancy, lack of a normal uterus (due to hysterectomy or uterine abnormality), or biologic inability to bear children, as would be the case with a single male or a same-sex male couple.[7]

Reasons that same-sex male couples would choose gestational surrogacy over other options, such as adoption, include more control over the process as well as having a genetic connection to the child.[8] A benefit of gestational surrogacy is that the gestational carrier will not have a genetic connection to the child. Typically, for gestational surrogacy, embryos are generated with gametes from the intended parents, but embryos may also be generated with gametes from a donor selected by the intended parent. In addition to a gestational carrier, men would need donor oocytes, either from a live donor or from an egg bank.

Gestational Surrogacy: Historical Perspective

Use of gestational carrier requires assisted reproduction with in vitro fertilization (IVF). In 1978, the birth of Louise Brown, the first human baby born after IVF, proved that viable embryos could be generated in the laboratory.[9] The ability to generate embryos outside the body allowed for third-party reproduction, using oocyte donors and gestational carriers. By synchronizing the uterine lining with the development of the embryo, embryos, generated with eggs from one woman, could be implanted in the uterus of another. The first pregnancy using donor oocyte was reported in 1984,[10] followed in the next year by the first pregnancy in a gestational carrier.[11]

The initial report of gestational surrogacy was for a woman who had required IVF for tubal disease. She had already conceived by IVF, but the pregnancy resulted in a hysterectomy at the time of caesarean delivery for a baby that did not survive. In a subsequent cycle, due to her history of hysterectomy, the generated embryos were successfully transferred into the uterus of a friend.[11] Now, as the use of gestational carriers is becoming more common and more widespread, there may be no indication for IVF other than the need for gestational carrier. The number of gestational carrier cycles reported to the Centers for Disease Control (CDC) increased from 727 cycles in 1999 to 3,432 cycles in 2013.[12] In 2014 (the most recent year for which there are data), there were 4,030 embryo transfers into a gestational carrier, representing approximately 3% of embryo transfers.[13] By 2014, 87% of the 458 clinics reporting to the CDC offered gestational carrier treatment,[13] increased from 45.1% of centers in 1999.[12]

Generally, gestational carrier cycles are very successful. Among U.S. clinics reporting to the CDC, between 2009 and 2013, gestational carrier cycles had higher rates of live birth (41.5%) than nongestational carrier IVF cycles (36.5%).[12] The same trend is seen in CDC data from 2014 with live birth rates being 4 to 7% higher for gestational carriers.[13] Similar results were found when examining data from Society for Assisted Reproductive Technology (SART). Between 2004 and 2013, a higher live birth rate (33.2%) was seen in gestational carrier cycles compared with all IVF cycles (31.2%).[14] The highest live birth rate (48.0%) was seen when multiple third-party IVF cycles were used[14]—as would be the case with same-sex male couples who would use donor oocytes along with a gestational carrier.

The number of IVF cycles performed for gay men is not easy to ascertain from CDC data. Between 2009 and 2013, in the United States, there were 648,457 cycles of assisted reproduction that resulted in embryo transfer, of which 14,682 (2.3%) used a gestational carrier.[12] “Other” was listed as the diagnosis for 6,842 (46.6%) of gestational carrier cycles, and of these, only 701 (10.3%) had diagnosis listed. Of these 701 cycles, 10.5% reported male same-sex couple or lack of female partner as indication for the cycle.[12] By this estimation, only 70 cycles would have been for gay men, but is likely an underestimation and highlights the need for improved data collection.

Despite increasing number of children born via gestational surrogacy, the procedure remains controversial due to ethical concerns regarding the appearance of “selling one's body” or “baby-selling” by the gestational carrier.[3] Because gestational surrogacy is illegal in some countries, an increasing number of international patients are seeking this service in the United States. In 2013, 18.5% of U.S. gestational carrier cycles were performed for non-U.S. residents.[12] Even within the United States, state laws regarding gestational surrogacy vary widely.[3] [4] In some states, paid surrogacy is prohibited, while in other states, laws are surrogacy friendly.[15] Some states have no legislation, which can lead to unpredictable outcomes when custody disputes arise.[16] Creative Family Connections, a surrogacy agency and law firm, maintains an interactive U.S. surrogacy law map, which provides a summary of laws as actually practiced in each state.[17]

Implications of FDA Regulations for Gay Men Using Gestational Carriers

To conceive with gestational carriers or oocyte donors, there are regulations from the Food and Drug Administration (FDA) that need to be followed. Reproductive tissues (eggs, sperm, embryos) are regulated by the FDA as human cells, tissues, and cellular and tissue-based products (HCT/Ps).[18] From the perspective of the FDA, the gestational carrier will be the recipient[19] of potentially infectious “products,” “egg and sperm,” and precautions are needed to prevent spread of communicable diseases. Section 361 of the Public Health Service Act authorizes the FDA to establish and enforce regulations “to prevent the introduction, transmission, and spread of communicable diseases.”[20] The regulations that address transfer of HCT/Ps are set forth in Code of Federal Regulations (CFR)[21] Title 21 Part 1271 and became effective on May 25, 2005.

The FDA regulations require “establishments to screen and test cell and tissue donors for risk factors for, and clinical evidence of, relevant communicable disease agents or diseases.”[22] Establishments that manufacture HCT/Ps are required to register with the FDA,[20] and, therefore, registration is required for all fertility clinics that screen and test gamete donors. After screening and testing of donors, a “donor-eligibility determination” is required before the tissue can be transferred into a recipient.[23] For embryos, donor-eligibility determination is required for both the oocyte and semen donor.[23] There are some instances when donor eligibility determination is not required, such as in the case of reproductive cells that will be transferred to a sexually intimate partner.[24] There are also situations in which tissues from “ineligible” donors may be used, which will be discussed later.

In the context of these FDA regulations, the terms “DONOR,” “SCREEN,” “TEST,” “RELEVANT COMMUNICABLE DISEASE AGENTS OR DISEASE,” and “ELIGIBLE” have specific meanings.[25] It is important to emphasize to patients that these terms may not reflect the colloquial uses. For example, the FDA defines “donor” as the person who is the source of cells or tissue.[25] For a man to use a gestational carrier, he will undergo screening and testing for communicable diseases as if he were a sperm donor to comply with the FDA regulations. For a man who will be the legal parent and will raise the child, it may be very disconcerting to be referred to as a “sperm donor” for the gestational carrier who will not have a relationship with the child. It should be explicit in the medical and legal documentation that he is a “sperm donor” only in the context of FDA regulations.

The FDA also defines “relevant communicable disease agents and diseases” for which screening and testing should be performed[25] as listed in [Table 1]. In addition to the diseases that are listed, the regulations also provide criteria that allow for addition of new diseases. The FDA specifically requires all human cell and tissue donors to be screened and tested for HIV-1, HIV-2, hepatitis B, hepatitis C, and Treponema pallidum. Because there is no laboratory test for human transmissible spongiform encephalopathy (e.g., Creutzfeldt–Jakob disease), only screening for risk factors is required. For donors of reproductive tissues, such as semen and oocytes, FDA also requires screening and testing for Chlamydia trachomatis and Neisseria gonorrhea. In addition, donors of leukocyte-rich products, such as semen, are screened and tested for HTLV-I and II. Although cytomegalovirus (CMV) is not a relevant communicable disease, FDA regulations also require testing for CMV disease in semen donors.[22] In addition to the diseases that are specifically listed, the FDA considers West Nile virus, sepsis, and Vaccinia virus to be relevant[19] and has issued new guidance documents as new diseases, such as Zika virus, emerge.[26]

Table 1 FDA requirements for donor-eligibility determination[19] [26]

	Screening	Testing
All tissue donors
Human immunodeficiency virus, types 1 and 2	Yes	Yes
Hepatitis B virus	Yes	Yes
Hepatitis C virus	Yes	Yes
Treponema pallidum	Yes	Yes
Human transmissible spongiform encephalopathy	Yes	X
West Nile virus	Yes	Yes
Sepsis	Yes	X
Vaccinia	Yes	X
Zika virus	Yes	X
Reproductive tissue donors
Chlamydia trachomatis	Yes	Yes
Neisseria gonorrhea	Yes	Yes
Semen donors
Human T-lymphotropic virus, types I and II	Yes	Yes
Cytomegalovirus	X	Yes

Abbreviations: ASRM, American Society for Reproductive Medicine; FDA, Food and Drug Administration.

Notes: Donor-eligibility determination is based on screening and testing for relevant communicable disease agents and diseases as defined by the FDA. Testing for the male intended parents (sperm donor by FDA designation) is performed within 7 days of sperm collection. Oocyte donors undergo testing up to 30 days before oocyte retrieval. The FDA does not consider the gestational carrier as a donor, but ASRM recommends that gestational carriers be treated similarly to oocyte donors with testing within 30 days before the embryo transfer.[19] [26]

For the FDA, the term “screen” refers to specific procedures. Donor screening involves assessment of risk factors and clinical evidence of the relevant communicable diseases. The FDA has provided specific guidance on conditions and behaviors (e.g., intravenous drug abuse, sex in exchange for money, nonsterile tattoos, and time in jail) that increase risk of relevant communicable disease.[19] To assess for risk factors, donor agencies and clinics will typically use a questionnaire, which will query medical history and social behaviors. For its members, the SART has developed a questionnaire for “use as a screening tool for reproductive tissue donors.” SART has also developed physical exam forms to assist with examining potential donors for clinical signs of relevant communicable disease or for signs suggestive of any risk factor for a relevant communicable disease. The FDA has also provided specific guidance regarding the physical evidence (e.g., unexplained jaundice, unexplained oral thrush, needle tracks, and recent tattoos) that should be assessed when screening a donor.[22]

For the FDA, the term “test” refers to laboratory studies, performed upon blood or urine. To comply with FDA regulations, there are very specific testing requirements for each particular disease. For example, testing for hepatitis C requires a test for anti-HCV and a nucleic acid test for HCV, whereas testing for hepatitis B requires a test for hepatitis B surface antigen and for total antibody to hepatitis B core antigen.[19] Additionally, testing must be performed by specific FDA-licensed, approved, or cleared tests. The current FDA-recommended tests are listed on the FDA Web site at the “Testing HCT/P Donors: Specific Requirements,” where it is noted that recommendations on specific tests may change in the future.[27]

The timing of the testing is also critical.[22] For oocytes, the specimen for testing may be collected up to 30 days before oocyte retrieval. For sperm, the specimen for testing (either blood or urine) may be collected up to 7 days before or after sperm collection. For anonymous semen donors, there is also requirement for repeat testing after 6 months. At least 6 months after the date of semen donation, a new specimen (blood and urine) must be obtained and undergo the required testing. Until the retesting is complete, the semen is quarantined and cannot be transferred.[19] The requirements are different for a directed donor, who intends to transfer his sperm into a known recipient, a person he knew before the donation. For directed semen donors, screening and initial testing must be performed, but there is no requirement to quarantine for 6 months or to retest.[22]

Based on the results of screening and testing, a donor-eligibility determination is made ([Table 1]).[22] A donor-eligibility determination is a conclusion that a donor is either “eligible” or “ineligible” to donate cells or tissues. With few exceptions, no tissue can be implanted until the donor has been determined to be eligible.[23] A potential HCT/P donor is determined to be “eligible” if donor screening indicates that the donor is free from risk factors for, and clinical evidence of, a relevant communicable disease and if the results of donor testing are negative or nonreactive for relevant communicable disease agents or diseases.[22] Donors who test positive or indicate a risk factor for a relevant communicable disease are “ineligible.” Generally, HCT/Ps from donors determined to be ineligible cannot be used, but directed reproductive donors represent a special situation. In the case of directed donors who are found to be ineligible, the use of their gametes is not prohibited.[28]

The ability to use sperm from ineligible donors is particularly important for gay men, as they will be “ineligible” as per the current FDA definitions. Due to concern for HIV and hepatitis B, “men who have had sex with another man in the preceding 5 years” is included in the “list of behaviors that increase the donor's relevant communicable disease risk” and would result in ineligibility.[19] Sperm from gay men would be labeled accordingly, with the statement “WARNING: Advise patient of communicable disease risks,” and it must be documented that the physician who will transfer the specimen was notified of the results of screening and testing.[19] For this reason, a gay man may only serve as a directed donor who knows and is known by the recipient before donation. Some men will use a friend or relative as a gestational carrier, but many will find a gestational carrier through an agency. In these situations, the intended male parents are introduced to the potential gestational carrier before planning donation.

Implications of ASRM Recommendations for Gay Men Using Gestational Carriers

The ASRM has published recommendations for practices using gestational carriers, which, in many cases, are more “stringent” than the FDA regulations.[7] For example, the FDA only requires that the physician (performing the embryo transfer) be notified of the results of screening and testing.[19] In contrast, the ASRM recommends that the gestational carrier should also be informed and counseled regarding the potential risks of undergoing transfer of embryos generated using gametes from ineligible sources.[7] Because gay men are considered to be “ineligible” for anonymous sperm donation, counseling gestational carriers about potential increased risk of infectious disease transmission would be recommended.

The ASRM also recommends that gestational carriers be offered a 180-day quarantine with release of embryos only after retesting of the genetic parents confirms negative results.[7] Neither retesting nor quarantine is required by the FDA for oocyte donors or for directed semen donors, but many centers follow the ASRM recommendations. The necessity of a 6-month quarantine period may come as a surprise for the intended parents, and they may be disappointed about the delay to parenthood.

The ASRM also provides recommendations that are unrelated to transmission of communicable disease. Recommendations are made for medical evaluation, genetic evaluation, and testing for Rh incompatibility. A strong recommendation is made for psychosocial education and counseling by a mental health professional to explore the “potential impact of the relationship between the intended parent and carrier.”[7] Legal counsel, independent of the gestational carrier, is also recommended.[7]

Implications of FDA Regulations and ASRM Recommendations for the Gestational Carrier

From the perspective of the FDA, the gestational carrier is the recipient of HCT/P and is not considered a donor. For this reason, the FDA does not require a donor-eligibility determination for the gestational carrier.[19] Nevertheless, there is risk of the gestational carrier transmitting communicable disease to the developing fetus, and screening and testing of the gestational carrier would be prudent. The recommendations published by the ASRM treat gestational carriers similarly to oocytes donors “to protect the health and interests of all parties involved.”[7] Similar to oocyte donors, the ASRM recommends testing within 30 days before embryo transfer.

Also, in an effort to limit the risk of multiple gestations for the carrier, ASRM recommendations state that “special consideration should be given to transferring a single embryo.”[7] Since the oocyte donor is likely to be young, transfer of a single embryo would be appropriate. In some cases, however, a male couple may choose to use one of their female relatives as a directed oocyte donor so that both partners could have a genetic connection to the child.[5] With an older source of oocytes, transfer of two embryos might be appropriate. Preimplantation genetic screening (PGS) may also be used to encourage the transfer of a single embryo.

In addition to the recommendations for practices using gestational carriers, the ASRM has also released opinions from their ethics committee regarding the ethical considerations of the gestational carrier,[3] including use of family members.[5] Potential carriers should be at least 21 years of age (ideally between 21 and 45 years), healthy, have a stable family environment, and have had at least one pregnancy (but ideally, not more than five vaginal deliveries or three cesarean sections) that resulted in a delivery of a child at term.[7] Potential carriers should be advised of medical and psychosocial risk associated with gestational surrogacy. There are risks with fertility treatment, such as self-administered exogenous hormones, and with pregnancy, such as bedrest or hospitalization.[15] Psychosocial risks may include impact on marriage, own children, or employment.[15]

ASRM recommends that gestational carriers undergo psychosocial evaluation and counseling and also obtain legal counsel.[7] It is emphasized that the gestational carrier should be free to choose her own lawyer.[3] Compensation for the gestational carrier should be agreed upon prior to treatment.[7] With legal counsel and assistance from mental health professionals, the gestational carrier and intended parents should determine that their expectations, particularly related to behaviors (caffeine, travel) during pregnancy, antenatal testing, pregnancy termination, multiple pregnancy, and selective reduction, are aligned[3] and outlined in the contract. Even with a contract, however, the carrier has the ultimate authority about any procedures on her body and cannot be compelled to submit to a procedure.[3]

To reduce costs and effort related to gestational surrogacy, intended parents may seek assistance from a family member. The ASRM finds use of adult family members as gestational surrogates to be ethically acceptable, but with unique challenges to assure that interests of all parties are protected.[5] Potential gestational carriers may be placed in an awkward situation if they have high-risk behaviors that would make them ineligible, but do not want to share this history with the intended parents or other family members. The ASRM finds it acceptable for clinicians to offer potential “gestational surrogates the option of being excluded as participants without other family members learning of their reluctance to participate.”[5]

Practical Considerations

It is important to manage the expectations of couples planning to use gestational carriers. Due to the expense and the need to coordinate several parties, while complying with FDA regulations and ASRM guidelines, advance planning is needed. It would not be surprising if 6 to 9 months were to elapse before embryo transfer is performed, particularly if a clinic requires 6-month quarantine of sperm. If there is no family member or friend who will serve as a gestational carrier, it may be necessary to find a gestational carrier from an agency, which may add months to the process. Even when a potential gestational carrier is identified, time is needed for psychosocial education and formulating the legal agreement. Due to the complex issues, it would be important to have a legal counsel from someone who is experienced with third-party reproduction.

Having a baby via gestational surrogacy may cost more than $100,000.[29] [30] Compensation to the gestational carrier for her time may range from $25,000 to $45,000, and there will be additional costs for her expenses (travel, lost wages, childcare, maternity clothing) as well as the costs of her psychological evaluation and legal fees. There will also be fees (approximately $20,000) paid to the agency to cover administrative costs. The intended parents will also have expenses related to their own psychological evaluation and legal fees, as well as for the screening and testing required for the FDA donor-eligibility determination. If the gestational carrier's health insurance will not cover the medical costs of a gestational carrier pregnancy, supplemental insurance will need to be purchased.

For same-sex male couples, the need for donor oocytes will add additional expense. Donor oocytes may be obtained from an egg bank or from a live donor. Until challenged by a class-action lawsuit,[31] the ASRM Ethics Committee's position was that “payments to donors in excess of $5,000 require justification and sums above $10,000 are not appropriate.[32] After settling the lawsuit in 2016, the compensation guidelines were removed from the new committee opinion.[33] It has been reported that oocyte donors with desired characteristics have been paid “in the six figures,” but typically, compensation to the oocyte donor is $5,000 to $10,000 with higher payments for donors whose eggs have led to births.[34] If using an oocyte donor, there will also be medical expenses, for her ovulation induction, monitoring, oocyte retrieval, and IVF, which may not be covered by insurance.

If both members of the couple are planning to have biologic children, they may choose to split the oocytes obtained from one donor cycle and inseminate donor oocytes with each of their sperm ([Fig. 1]). Splitting oocytes reduces costs, as the oocyte donor will undergo a single oocyte retrieval with one set of laboratory tests to determine donor eligibility. This will also ensure that their children will share a genetic connection in case their donor does not consent to future oocyte retrievals. Couples have asked about mixing sperm, but, in Illinois (where I practice), this is not possible. To ensure parental rights under the Illinois Gestational Surrogacy Act, one of the intended parents must be a genetic contributor and must be known so that the parent–child relationship can be established before birth, allowing the intended parent's name to be on the birth certificate. Since only one embryo will be transferred, remaining embryos are frozen for a future cycle.

Due to the high costs associated with gestational carriers and oocyte donors, it would be beneficial to identify potential problems before involving these third parties. For example, routine testing for infectious disease can be performed to minimize chance of positive FDA testing at the time of sperm collection. For men who have never tried to conceive, a semen analysis should be performed to confirm presence of sperm. A test sample may be frozen and then thawed to determine how well the sperm survives freezing. It may also be beneficial to confirm the availability of euploid embryos before contracting with a gestational carrier.

Gay men will be ineligible for anonymous donation and can only be directed sperm donors. This means the intended parent must know and be known by the recipient before plan is made for embryo transfer. Although FDA does not require quarantine and retesting for directed donors, some clinics may follow ASRM recommendations and require quarantine and retesting. Additionally, some gestational carriers may prefer to follow the regulations outlined for anonymous sperm donors.

Because some clinics and some gestational carriers may require 6-month quarantine for sperm, it may be beneficial to freeze sperm—even before obtaining donor oocytes or finding a gestational carrier. The screening (with questionnaire to obtain relevant medical history) and laboratory testing could be completed within the 7-day window, before or after semen collection. If sperm numbers are low, it should be possible to freeze two samples within this time period. It will be necessary to establish care at a clinic or sperm bank that will be able to freeze sperm and complete the appropriate screening and testing. Because the FDA requires very specific tests, it may not be possible for men to have these tests with their primary care physician. If it is not easy for the intended parent to travel for laboratory testing, there are companies, such as ViroMed, that provide shipping kits for reproductive donor testing so that laboratory samples can be obtained with a local physician.

Due to the expenses related to third-party reproduction, gestational surrogacy may not be an option for many couples. Even if friends or relatives volunteer, compliance with FDA testing is expensive, and some would argue that the requirements are overly burdensome. In fact, the FDA has been sued by a woman who was prohibited from using fresh sperm from a directed donor—because the donor had not undergone the mandated screening and testing.[35] Even for couples who have fertility benefits as part of their insurance coverage, lack of conception in a same-sex relationship may not meet the definition of infertility. As a result, same-sex couples will need to pay for the medical costs of IVF—in addition to the other costs related to gestational surrogacy. Finally, there is the need to establish parental rights for both fathers. As the legal processes are unique to each state, it will be necessary to pay for legal expertise.

Conclusion

These fathers' deep-seated desire for a family is evident by their considerable investment of time, emotion, and financial resources. The use of gestational carriers has been controversial due to concerns of commodification of the body or baby selling, but for many, gestational surrogacy is the only option for genetic parenthood. As outlined in this review, helping gay men become parents requires proficiency in navigating complex medical and legal regulations. Due to the expense and the need to coordinate several parties, advance planning is needed. When planning pregnancy with gestational carriers, the FDA regulations, as well as the recommendations from specialty societies, must be considered. Because laws vary throughout the United States, it is imperative that couples seeking to use gestational carriers seek guidance from a legal professional who is familiar with the laws of their state. As infertility specialists, we hold significant responsibilities in gay-men's journey to parenthood, but with this responsibility also comes the privilege of championing all types of families in our work.

No conflict of interest has been declared by the author(s).

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