Best Practice Guide
A practice guide for healthcare professionals caring for and
interacting with people going through assisted conception
Created by Ash Bainbridge (they/he)
Student Nursing Times Awards’ 2024 Student Midwife of the Year, LGBTQ+ inclusion facilitator, academic writer and poet
Overview
Assisted conception is any type of assisted reproduction that may or may not involve the use of medications, gametes provided by an individuals or individuals who are not the child’s intended parent/s, and a pregnancy being carried by an individual who is not the child’s intended parent. Examples of assisted conception sometimes available on the NHS are intrauterine insemination (IUI) and in vitro fertilization (IVF). Another example is surrogacy, which is currently unavailable on the NHS.
Assisted conception is a childbearing option that may be considered by anyone regardless of sexual orientation, gender identity, relationship status, or family structure. All people building a family via assisted conception should receive holistic personalised care that centres safety, informed choice, and positive experiences.
Trust guidelines and policies outlining assisted conception care recommendations should be co-produced with service users who have lived experience. They should also be up to date, consider the entire childbearing continuum, and cover all pregnancy outcomes, including reproductive loss.
Language guide
Assisted conception is a complex and consistently evolving area of reproductive health. This language guide includes the most common current terms and should not be considered exhaustive.
Parties
Co-Parents: individuals raising a child together who are not in a romantic or sexual relationship.
Egg Donor: a person who donates eggs to assist conception. This person may or may not be an Intended Parent.
Gestational Carrier: see Surrogate.
Gestational Parent: the parent who carries the pregnancy and births the child.
Intended Parent: a person who intends to have full parental rights and responsibilities for a child conceived through assisted conception. This person may or may not have a genetic connection to the child.
Non-gestational Parent: the parent who does not carry the pregnancy or birth the child.
Sperm Donor: a person who donates sperm to assist conception. This person may or may not be an Intended Parent.
Known Donor (or Open Identity Donor): A person known to the Intended Parent/s who provides eggs or sperm to assist conception. This person may be a friend, community member, or someone met on the internet.
Unknown Donor (or Anonymous Donor): A person who donates eggs or sperm to a bank that can be accessed by Intended Parent/s who require them to assist conception. The Donor’s identity is not shared with the Intended Parent/s
Surrogacy Agency: A professional organisation that matches Intended Parents with a Surrogate. The Surrogacy Agency may co-ordinate parts of the assisted conception process.
Surrogate: A person who carries a pregnancy for the Intended Parent/s. The Surrogate’s eggs may be used for conception, or eggs may be provided by the Intended Parent or an Egg Donor. In the UK, a Surrogate will be the child’s legal parent at birth. If a Surrogate is married or in a civil partnership, their spouse or civil partner will be the child’s legal second parent at birth unless they do not give their permission. Legal parenthood is then transferred to the Intended Parent(s) after the child is born. While surrogacy is legal in the UK, surrogacy agreements are unenforceable by law. See also: Gestational Carrier.
Types of assisted conception
Altruistic Surrogacy: when a Surrogate carries a pregnancy for the Intended Parent/s and is only financially compensated for reasonable expenses (for example, medical bills, travel expenses, compensation for time off work). Altruistic Surrogacy is the only legal way to family build via surrogacy in the UK.
Assisted Reproductive Technologies (ART): methods to assist conception where eggs or embryos are handled.
Compensated Surrogacy (or Commercial Surrogacy): when a Surrogate carries a pregnancy for the Intended Parent/s and is financially compensated for doing so. Compensated Surrogacy is illegal in the UK.
Embryo Transfer (or Frozen Embryo Transfer): transferring an embryo(s) into the uterus of a gestational parent or surrogate.
Full Surrogacy (or Gestational Surrogacy, Host Surrogacy): when a Surrogate carries a pregnancy and eggs from an Intended Parent or Egg Donor are used. In Full Surrogacy, the Surrogate does not have a genetic connection to the child.
Home Insemination (or At Home Insemination): when outside a clinic setting donated sperm is introduced into the vagina of the person intending to carry the pregnancy.
Intracervical Insemination (ICI): when sperm is inserted into the cervix of the person intending to carry the pregnancy.
Intrauterine Insemination (IUI): when sperm is inserted into the uterus of the person intending to carry the pregnancy.
In Vitro Fertilization (IVF): when conception occurs outside the body of the person intending to carry the pregnancy. IVF involves the stimulation and retrieval of eggs before they are fertilized with sperm in a laboratory. If fertilization is successful, the resulting embryos develop for between two to six days. The strongest embryo/s are selected and transferred to the uterus of the person intending to carry the pregnancy.
Matching Process: the process where a Surrogate and/or Egg Donor and/or Sperm Donor are matched with the Intended Parent/s.
Partial Surrogacy (or Straight Surrogacy, Traditional Surrogacy): when a Surrogate carries a pregnancy and the Surrogate’s eggs are used for conception. In Partial Surrogacy, the Surrogate has a genetic connection to the child.
Self-Insemination: when the person intending to carry the pregnancy inserts sperm into their own vagina. May also refer to Home Insemination, At Home Insemination.
Other relevant language
Double Embryo Transfer (DET): when two embryos are transferred to the uterus of the person intending to carry the pregnancy. This may occur if the person wishes for a twin pregnancy or the embryos to be transferred are considered low quality.
Egg Retrieval: when eggs are obtained from the ovary for donation or as part of the IVF process.
Gender Affirming Hormone Therapy (GAHT): medical treatment when trans, non-binary and gender diverse people receive the hormones associated with their identified gender. Prior to commencing GAHT, an individual may have banked their eggs or sperm owing to both known and unknown effects on fertility of hormonal therapies and the extent of their reversibility.
Hysterosalpingography: a radiographic procedure where the uterine cavity and fallopian tubes are filled with dye and inspected via X-ray.
Hysteroscopy: a medical procedure where the uterine cavity is inspected via endoscopy through the cervix.
Intracytoplasmic Sperm Injection (ICSI): a method where a singular sperm is inserted into an egg.
Mock Cycle (or Trial Cycle): where a Surrogate or person undergoing IVF first follows the medical protocol required for embryo transfer without transferring an embryo. This allows healthcare providers to assess how the individual’s body responds to the medical protocol.
Preimplantation Genetic Diagnosis (PGD): where cells from embryos created outside the body by IVF are tested for genetic disorders that the embryos are known to be at risk of inheriting.
Saline Infusion Sonography (SIS): a procedure where the uterine cavity is filled with saline solution to enable endometrium inspection via ultrasound.
Single Embryo Transfer (SET): when one embryo is transferred to the uterus of the person intending to carry the pregnancy.
How to better support those involved
Policies, guidelines, and care and referral pathways
All policies, guidelines, and pathways regarding assisted conception should be up-to-date and based on the best available evidence. Separate policies should exist for (1) ICI, IUI, and IVF; and (2) surrogacy. If these documents do not exist, they need to be written and made readily accessible to clinical and administrative staff, healthcare students, and service users. Important information for policy includes planning where care is to be provided and by whom, appropriate referral pathways should additional needs arise, and guidance on appropriate language use.
Language
Language use should reflect each individual and their role in the assisted conception process. This language can be learned by asking open and sensitive questions; for example, “How would you like me to refer to you?”; “Who have you brought with you today?” The answers provided should be listened to and respected, and then an offer made to document this information on care records to save unnecessary repeated conversations.
As a starting point for best practice, if a pregnant person is a surrogate, do not use the term “surrogate mother”; a surrogate is not a mother to the child, and the phrase can harm the intended parents. Language use, however, should always be tailored to individual circumstances; if a surrogate requests to be referred to as “Mother” or a similar term associated with parenting, her wishes should be respected.
Staff
Where possible, care should be provided by healthcare professionals with relevant knowledge and experience. Regarding midwifery care provision, Continuity of Carer (see Sandall, 2017) has the potential to improve experiences and outcomes for family building via assisted conception owing to the opportunities provided for consistent relationship building based on mutual trust.
Assisted conception should be seen as part – not the whole – of an individual’s reproductive care needs. Specialist input may be required in order to address additional care needs (e.g. smoking cessation, diabetes management), and involve collaborating with members of the multidisciplinary and interagency teams. In some Trusts, the midwife responsible for co-ordinating perinatal care for surrogates is the Specialist Midwife for Vulnerable Pregnant People. In this instance, the midwife’s specialty may need to be discussed sensitively with the surrogate and intended parent/s owing to the connotations of ‘vulnerable’.
Consent should be gained from the surrogate and intended parent/s for the community midwife, GP, and Health Visitor to be informed about the surrogacy arrangement.
Documentation
Documentation should be clear, accessible, and evolving with relevant details regarding assisted conception easily visible to healthcare staff when required.
Care planning
Following assisted conception via ICI, IUI, or IVF, the needs of the gestational parent form the basis of care planning. With the pregnant person’s consent, healthcare professionals can actively encourage involvement from non-gestational parents and partners.
A birth plan should include both intrapartum and postnatal wishes, and be documented as per Trust policy. Time should be allocated for in-depth conversations about who is present at the time of birth, skin-to-skin contact, cord cutting, etc. Extra appointments could be offered to revisit these discussions throughout pregnancy. Appropriate members of the multidisciplinary and interagency teams, including specialist midwives and ward managers, should be informed of relevant arrangements.
In assisted conception where egg donation is involved, antenatal care should include a conversation with the pregnant person around the association between egg donation, and the increased risk of hypertension and pre-eclampsia. Additional blood pressure monitoring can be offered, and referral to a specialist midwife and the hypertension in pregnancy clinic where available.
For families growing via surrogacy, birth plans should be completed with the surrogate and intended parent/s. These plans should include choices in the event of a pregnancy ending in miscarriage, a termination for medical reasons, or stillbirth. Support for this part of care planning may be required from specialist bereavement midwives who should be informed of any arrangements made so requests can be facilitated in the event of reproductive loss. Healthcare professionals should be aware that on UK baby loss certificates, parents can self-determine their relationship to the baby (unlike on birth certificates) and the process is inclusive of surrogates.
Every effort should be made to fulfil infant feeding requests. Midwives and breast/chestfeeding support workers should be aware that a surrogate may not wish to breast/chestfeed. Repeated questions about infant feeding choices may be insensitive. If a surrogate chooses not to breast/chestfeed, they should be informed that medication can be offered to suppress breast/chest milk production. If a surrogate chooses to breast/chestfeed, this choice should be supported, and any conversations around infant bonding led by the surrogate and intended parents. Introducing the option of colostrum harvesting and hand expression, and the benefits of human milk for both the surrogate’s and neonate’s health, can be included in antenatal conversations.
Locations
Families growing via assisted conception should see themselves represented in the services they access. Posters, leaflets, and websites should use language and contain imagery that reflects these families.
Parents need to be able to access appropriate areas to care for their child. For example, a two-father family who have welcomed a child via a surrogacy arrangement should be able to access areas where neonatal care is being provided. A plan for where neonatal and postnatal care is to take place must be made antenatally, and a side room offered for this time to the surrogate and intended parents. This may mean non-clinical, family-facing staff such as ward clerks need to be made aware of any surrogacy arrangements.
A newborn may be discharged separately from a surrogate. Consent should be gained from the surrogate for this to occur, and this consent documented in both postnatal and neonatal records. In this circumstance, the community midwife and Health Visitor should be aware that postnatal and neonatal care will be provided in different locations.
Safeguarding
A person carrying a pregnancy – whether a gestational parent or a surrogate – should be seen alone where the Domestic Abuse Routine Enquiry can be asked.
Healthcare providers should have a clear knowledge of the legal regulations surrounding surrogacy to recognise signs of illegality – including signs of commercial arrangements – should they arise. If there are concerns, they should be escalated promptly and appropriately, and the specialist midwife for safeguarding pregnant people and children contacted.
Signposts for further support
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British Fertility Society: a society for fertility professionals that promotes knowledge sharing, furthering education, and raising standards of practice. Their web-site includes evidence-based, peer-reviewed, and practical guidance.
https://www.britishfertilitysociety.org.uk
ConnecteDNA: a collaborative research project across UK-based universities exploring how people involved in donor conception use and are impacted by online DNA testing. The web-site provides information leaflets to support egg and sperm donors and their families when living with the possibility of contact by someone conceived as a result of their donation.
https://sites.manchester.ac.uk/connecte-d-n-a/prep-for-contact/
Donor Conceived UK: a peer-led charity that represents donors, donor conceived people, and those affected by donor conception practices in the UK.
https://donorconceiveduk.org.uk
Donor Conception Network: a charity network providing information and support for parents with children conceived with donated sperm, eggs or embryos; those who are considering or currently undergoing donor conception procedures; and donor conceived people.
European Society of Human Reproduction and Embryology: a society that aims to increase understanding in reproduction and medicine. Their website contains guidelines, consensus documents, and practice recommendations to support best practice in reproductive healthcare.
Human Fertilisation and Embryology Authority: the UK government’s fertility regulator that exists to provide partial, accurate information about IVF, clinics, and fertility treatments.
LGBT Mummies: an organisation that educates, supports, and advocates for LGBTQ+ people on their journey to parenthood, including via assisted conception. The organisation’s founders have lived experience after welcoming four children via IUI and IVF.
Sources and further reading
Bergman, Kim (2019) Your future family: the essential guide to assisted reproduction (Conari Press)
Department of Health and Social Care (2024) Care in surrogacy: guidance for the care of surrogates and intended parents in surrogate births in England and Wales. Available at: https://www.gov.uk/government/publications/having-a-child-through-surrogacy/care-in-surrogacy-guidance-for-the-care-of-surrogates-and-intended-parents-in-surrogate-births-in-england-and-wales
Department of Health and Social Care (2024) Having a child through surrogacy. Available at: https://www.gov.uk/government/publications/having-a-child-through-surrogacy
Golombok, Susan (2020) We are family: what really matters for parents and children (Scribe Press)
Gov.uk (ND) Request a baby loss certificate. Available at: https://www.gov.uk/request-baby-loss-certificate
Gov.uk (ND) Surrogacy: legal rights of parents and surrogates. Available at: https://www.gov.uk/legal-rights-when-using-surrogates-and-donors
Kali, Kristin L. (2022) Queer conception: the complete fertility guide for queer and trans parents-to-be (Sasquatch Books)
NHS (2023) Ways to become a parent if you’re LGBT+. Available at: https://www.nhs.uk/pregnancy/having-a-baby-if-you-are-lgbt-plus/ways-to-become-a-parent-if-you-are-lgbt-plus/
Nuffield Council on Bioethics (2023) Surrogacy law in the UK: ethical considerations. Available at: https://www.nuffieldbioethics.org/assets/pdfs/Surrogacy-law-in-the-UK-ethical-considerations-1.pdf
Rachlin, Ray and Goodman, Marea (2023) Baby making for everybody: family building and fertility for LGBTQ+ and solo parents (Balance)
Sandall, Jane (2017) The contribution of continuity of midwifery care to high quality maternity care. Royal College of Midwives. Available at: https://www.rcm.org.uk/media/2265/continuity-of-care.pdf
Silver, AJ (2022) Supporting queer birth: a book for birth professionals and parents (Jessica Kingsley Publishers)
Surrogacy UK (2023) Care in surrogacy: practice, ethics and regulations. Available at: https://surrogacyuk.org/wp-content/uploads/2023/05/IJBPE-Care-in-Surrogacy-Guide-April-2023.pdf
World Professional Association for Transgender Health, Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, International Journal of Transgender Health. Available at: https://www.tandfonline.com/doi/pdf/10.1080/26895269.2022.2100644