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should help couples or singles who are looking to conceive with donor sperm make the right choice for them.
There are also several considerations when opting to use donor sperm. Should the donor be recipient-recruited( known) or clinic-recruited( de-identified)? Both are options in NSW, other states may vary with availability of clinic recruited sperm, but women may travel interstate to access ART services if necessary.
De-identified donors must, by law, remain in contact with the clinic so that important biological information can be obtained if needed, and so that offspring conceived can access information about the donor once they turn 18.
In NSW, donors are allowed to donate to five families within that state and according to the Australian Reproductive Technology Accreditation Committee( RTAC,) donors should be limited in their donation to 10 families nationally.
Previously in NSW, two women in a lesbian relationship who both conceived using the same donor were regarded as“ two” of the families, which was discriminatory. The Assisted Reproductive Technology Act in NSW has recently been changed so that one family now encompasses two women in a relationship who conceive with the same donor. Other states vary in their legislation, for example in Queensland and Tasmania, clinics are allowed to set their own family limits for gamete donation. Many clinics have a selection of local and international donors available.
International donors must also comply with statewide laws regarding family / female limits and with life-long accessibility of donor information.
Sperm donors are required to attend a medical appointment, mandatory counselling and a semen analysis.
They undergo screening for blood-borne and sexually transmissible infections, and inherited diseases. Before release for use in ART cycles, donor sperm, whether clinicor recipient- recruited, enters a period of quarantine of no less than three months.
For women who are unable to conceive with their own, or a partner’ s oocytes, egg or embryo donation are valid alternatives.
Options for gender diverse people For trans and gender diverse people there are additional considerations around family planning as both medical and surgical approaches to transitioning may limit future fertility options.
The World Professional Association of Transgender Health( WPATH) in their
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Standards of Care( 2012) have stated:“ Because feminising / masculinising hormone therapy limits fertility … it is desirable for patients to make decisions concerning fertility before starting hormone therapy or undergoing surgery to remove / alter their reproductive organs”. 4
This can mean that adolescents( mid-teens onwards) who may be considering taking puberty blockers prior to starting gender affirming therapies are referred to fertility clinics to discuss preservation of gametes.
At present, only small numbers of adolescents are making the choice to preserve sperm or oocytes. 5 The reasons for this are varied, but include concerns around cost and having a physical reminder of a gender incongruent past in storage. 6
As well, transgender teens are often dealing with a myriad of biological, social and emotional challenges that take priority over future reproductive potential. Initial and ongoing costs are certainly major considerations for young people thinking about preserving oocytes or sperm.
While many trans teens are electing not to undertake fertility preservation at this time, it is important to increase awareness of its availability. 5
Once gender-affirming medical treatments start, options may disappear. Oestrogen therapy may be associated with irreversible atrophy of seminiferous tubules. However, ovaries that have been exposed to testosterone can still be induced to ovulate healthy oocytes after short-term cessation of testosterone and
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controlled ovarian stimulation.
For this reason, and with cost considerations, it is more common for young trans women to cryopreserve sperm than young trans men to undergo oocyte preservation procedures. 5
For older gender-diverse people who are looking to have children, decisions will depend on the availability of eggs and sperm and whether or not surrogacy is required. Many trans men elect not to have hysterectomy, oophorectomy and / or phalloplasty or metoidioplasty. 7
In this case a trans man can cease testosterone and undergo ovarian stimulation and IUI or IVF using donor or a partner’ s sperm. Testosterone is not an effective contraceptive and spontaneous pregnancies do occur. 8
If a trans-man is in a relationship with a biologically born female and wishes to conceive a genetic child of his own without carrying the pregnancy, controlled ovarian stimulation can be used to obtain oocytes from his ovaries after short-term cessation of testosterone.
These oocytes are then fertilised with donor sperm and resulting embryos are transferred to the female partner. Cryopreserved oocytes can also be used in this setting.
Another option is for the biologically born female partner to undergo IUI or IVF using her own oocytes and donor sperm. If a trans-man has a uterus and wishes to carry a pregnancy, then embryos created with his, his partner’ s or donor oocytes and donor or partner sperm can be transferred to his uterus and pregnancy achieved.
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Trans women may be able to use cryopreserved or fresh sperm and partner or donor oocytes with or without surrogacy depending on their relationship status and whether a partner is able to conceive.
For trans individuals or couples who require surrogacy and / or donor oocytes there are options available. Egg donation may occur through a known donor, ideally someone aged 21-31 who has had children. Most known donors are a family member or friend but some donors are found via the donor community online. International cryobanks also supply oocytes for donation. Donors undergo extensive screening for blood borne infections and inherited diseases and attend mandatory counselling. An oocyte donor may then undergo an IVF cycle and have oocytes collected and fertilized with donor, patient or partner sperm. Resultant embryos can be transferred to the patient or surrogate or cryopreserved for later use.
Options for gay and single men
For gay couples or single men, there are a number of possibilities for having a family.
Traditionally many gay couples have opted for surrogacy arrangements overseas. Recently, however, the laws regarding international surrogacy have become more stringent.
Australians attending overseas clinics for the purpose of surrogacy must comply with local state laws.
NSW, ACT and Queensland ban residents from travelling overseas to undertake
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commercial surrogacy and ART service providers in those states are unable to facilitate local patients seeking to travel internationally for the purposes of entering a commercial surrogacy arrangement.
In spite of this, some 400 Australian couples engage in surrogacy services overseas each year with most gay couples travelling to the US or Canada. 9 Australians are no longer able to undertake surrogacy in Nepal, Cambodia, India or Thailand.
The Commonwealth grants Australian citizenship, passports and government benefits to children born to Australian parents though international surrogacy. However, transfer of legal parentage to children born overseas in surrogacy arrangements may not be allowed under the Family Law Act.
Altruistic surrogacy is legal in most states and territories in Australia. Surrogates in this country are usually women known to the couple or individual, but some people seek an altruistic surrogate online and lasting close friendships often ensue.
Fertility clinics are forbidden by law from procuring surrogates for intended parents.
Surrogates should be healthy women, ideally multiparous( para 2-4), who have had uncomplicated pregnancies and births.
Extensive counselling is required and all parties must receive legal advice and have contracts signed before entering into an arrangement. Parentage orders differ between jurisdictions and intended parents need to be well informed of the rules
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that apply in their state or territory.
The surrogacy process is complex and may be costly as there are no Medicare rebates for investigations, medications or ART procedures with surrogacy. The intended parents are legally allowed to pay for the surrogate’ s out of pocket costs and obstetric care.
Most gay couples elect to use an oocyte donor and a surrogate and undertake“ gestational surrogacy”, which means the egg donor and the surrogate are two different people.
“ Traditional surrogacy” is where the surrogate’ s own oocytes are used. It is less commonly practised in Australia and many clinics will not support traditional surrogacy agreements. It is believed that rates of nonrelinquishment may be higher in cases of traditional surrogacy. 10
Options for intersex people Intersex individuals have a variety of phenotypes and combinations of chromosomal, gonadal and genital makeup. Some intersex people identify as gender diverse. Fertility options will depend upon relationship status and whether egg donation, sperm donation or both and / or surrogacy are required. An individualised approach to treatment is needed.
Other options Co-parenting Co-parenting involves an arrangement between couples or individuals to raise a child or children together despite not being in a relationship. One example of this might be a lesbian couple and a gay couple choosing to create and raise a family. Legal advice should be sought prior to entering a co-parenting arrangement as parenting rights and responsibilities can be restricted in the event of separation or otherwise.
Adoption As of February 2017, in all Australian states and the ACT, couples in same sex relationships are allowed to adopt. Same sex couples are not allowed to adopt in the NT. ●
Dr Devine is a gynaecologist and fertility specialist who practises in Sydney, NSW. She has special interests in donor and surrogacy programs, polycystic ovarian syndrome and periconceptional medicine. References on request.
The author would like to acknowledge the assistance of Stephen Page of Harrington Family Lawyers in Brisbane for his legal advice and Sam Everingham of Families Through Surrogacy.
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