Journal of Health Service Psychology

https://doi.org/10.1007/s42843-020-00004-3

Psychological Evaluations for Assisted Reproductive Intervention:

Guidelines for Clinical Practice
Sara Rosenquist

# National Register of Health Service Psychologists 2020

Abstract
Psychological factors present significant concerns when assisted reproductive technologies (ART) are needed, whether for the
treatment of infertility or for nontraditional family building. Psychological evaluation of all parties involved is recommended
when treatment involves gamete donation or the services of a gestational carrier. The American Society for Reproductive
Medicine (ASRM) has offered guidelines for the psychological evaluation of involved individuals. These ASRM guidelines
appear long and complex, but a careful reading suggests they are fairly similar to a routine in-depth psychological evaluation.
This article reviews the process of doing an assisted reproductive psychological evaluation, the most critical psychosocial topics
to explore, and assessment of the psychological capacity to successfully participate in an assisted reproductive procedure. Report
preparation is also covered.

Maria and Jo, both 39, have been married for seven years
and have been trying to conceive for the last four. After a
year of trying they consulted with their first specialist,
who found no gross abnormalities. Further visits led to a
series of three intrauterine insemination (IUI) attempts.
Each emotionally painful experience raised expectations
and dashed hopes. In vitro fertilization (IVF) attempts
came next, along with hormones and injections. The ex-
perience was draining. They experienced three pregnan-
cies and three miscarriages. They suffered alone, not tell-
ing their extended families of their failed attempts.
Finally, the doctors confirmed a rare, difficult-to-
diagnose genetic anomaly in Maria, which meant that do-
nor eggs and a gestational carrier was their only option.
Psychological evaluation of all parties to the process is a
requirement for going forward, which is why they have
come to you. What are the professional expectations for
such an evaluation? Do you also need to do psychological
evaluations of the donor and carrier? What are the essen-
tial issues to evaluate and explore?
Clinical Challenge
Incidence and Prevalence
Infertility is defined as difficulty conceiving or carrying a
pregnancy to term (American Society for Reproductive
Medicine, 2019). The operational definition of “difficulty
conceiving” that is used to trigger evaluation and intervention
is one year of regular, unprotected intercourse. Roughly one
third of these cases turn out to be due to a problem with the
woman’s fertility, known as “female factor infertility.”
Another one third are due to a problem with the man’s fertility,
known as “male factor infertility.” The final one third are
either due to a combination of factors or remain a mystery
(American Society for Reproductive Medicine, 2019;
Cammack et al., 2018; Galst, 2018; Kim & Hicks, 2015).
Roughly 10–13% of couples in the US have difficulty con-
ceiving and completing a pregnancy. This percentage translat-
ed to 385,000–500,000 US couples out of 3,850,000 births in
2017 (Centers for Disease Control and Prevention, 2019). The
year earlier, the CDC reported 263,577 total assisted repro-
duction cycles performed, resulting in 65,996 pregnancies and
76,930 live infants (Sunderam et al., 2019).
The vast majority of assisted reproductive pregnancies in-
volve the biological mother carrying her own pregnancy, most
typically with her own eggs and sperm from her partner. A
smaller percent involve the mother carrying her own pregnan-
cy with donated sperm or eggs. Only about 1.7% of those
needing assisted reproductive support utilize a gestational car-
rier, with about 750 babies born to gestational carriers each
year (Murugappan et al., 2018; Perkins et al., 2016). In addi-
tion to fulfilling the dreams of family building for
heteronormative couples struggling with infertility, assisted
reproduction has opened the door to family building for non-
traditional couples, transgendered persons who previously
might have had to choose between reproduction and gender

reassignment, and anyone wishing or needing to delay family
building while also preserving fertility.
Reproductive Health Care
The first live birth in the US of a child conceived by in vitro
fertilization was Elizabeth Carr in 1981 in Norfolk, Virginia.
Eleven years later, Congress defined assisted reproductive
technology in the Fertility Clinic Success Rate and
Certification Act (1992), 42 U.S.C. § 263a-7 as “all treat-
ments or procedures which include the handling of human
oocytes or embryos.” The medical specialty that is dedicated
to treating fertility challenges has come to be known as re-
productive medicine.
Because these medical procedures involve the handling
and transfer of human fluids and tissues, the use of human
sperm and eggs in reproductive medicine are regulated by
the U.S. Food & Drug Administration. Reproductive technol-
ogies have evolved quickly, along with an unanticipated num-
ber of complex legal challenges. In the absence of compre-
hensive federal regulation, states have struggled to apply and
adapt existing legal theory (such as contract law, tort, or prop-
erty law) and precedent to the emerging complexities (Casolo
et al., 2019). Thus, psychologists practicing in the area of
reproductive health psychology occupy an intersectional
space between medicine and the law that is in constant flux
and continuing to evolve.
The American Bar Association drafted a Model Act
Governing Assisted Reproductive Technology in hopes of
inspiring more uniform regulation of the field, but no states
have adopted the Model Act and a plethora of judicial prece-
dents abound and vary by state (American Bar Association
Model Act Governing Assisted Reproductive Technology,
2008). Varying kinds of discrimination against nonmarried
and/or nonheterosexual couples and gender nonconforming
persons remain in many states and jurisdictions. For example,
Louisiana only allows gestational carrier arrangements that
involve a heterosexual married couple where both will be
biologically related to the resulting child, the mother’s health
is at risk in carrying a pregnancy, and the carrier is only
reimbursed for costs related to pregnancy (Casolo et al.,
2019). The Georgetown Journal of Gender and the Law has
published an extensive review of the current state of assisted
reproductive technologies and the law and is a highly recom-
mended read for any psychologist wishing to enter this field
(Casolo et al., 2019).
In the absence of consistent federal regulation, the
American Society of Reproductive Medicine (ASRM) sets
“best practices” guidelines to help physicians interpret and
comply with state and FDA regulations and self-regulate the
industry. The ASRM was established in 1944 and has since
become an international and multidisciplinary society that
J Health Serv Psychol
includes obstetricians/gynecologists, reproductive endocrinol-
ogists, urologists, embryologists, internists, psychologists,
nurses, social workers, laboratory technicians, pediatricians,
research scientists, and others (American Society for
Reproductive Medicine, 2019).
ASRM Practice Guidelines
The ASRM guidelines are meant to help those who practice in
this area adhere to the highest standards of care (ASRM,
2008). They are similar to the American Psychological
Association (APA) Practice Guidelines and are entirely volun-
tary. ASRM multidisciplinary practice committees meet, re-
view evidence, and draft these practical guidelines, which are
not laws or regulations. The ASRM guidelines are first and
foremost concerned with physical/medical safety of
patients—and secondarily concerned with the legal and ethi-
cal ramifications of work that redraws relationships and cre-
ates new ones. The ASRM guidelines acknowledge that with
each participant role in the assisted reproductive process there
are implicit expectations that need to be articulated and liabil-
ities that need to be defined.
The ASRM guidelines (2008) specify that any evaluation
of a potential gamete donor, gestational carrier, or recipient
couple must contain certain elements—including psychologi-
cal evaluations. The guidelines spell out relative and absolute
exclusion criteria for the proposed donor, carrier, or recipient.
Embryos created from the gametes of a sexually intimate cou-
ple and created for use by that couple are exempt from the
requirements of donor screening and testing.
A reading of the guidelines suggests that the purpose of
these documented evaluations and consultations is fully
informed consent and risk management. Assessment is
mandated in certain cases, but formal psychological testing
remains optional. Even so, routine evaluation practices
evolve. Increasingly, the use of psychological testing, par-
ticularly the MMPI or PAI, is regarded as a reasonable tool
to complement a clinical interview in the evaluation of
gamete donors and gestational carriers. Although the
MMPI and the PAI might not be the instruments best suit-
ed to the task in these evaluations, they are revered by the
physicians ordering and using the evaluations and have
come to be regarded as part of a “gold standard” in the
industry. Many workshops and conference papers support
their use in practice.
Although the ASRM guidelines have been in place for over
a decade, a simple internet search reveals that many sperm
banks are more lax about providing psychological evaluation
for sperm donors. Some began requiring criminal background
checks in 2013 and psychological testing in 2017. This ap-
pears to be a function of pressure from the marketplace rather
than action by any regulatory body.
J Health Serv Psychol
Consideration of Psychological Factors in Assisted
Reproduction
A consideration of the psychosocial factors involved in
assisted reproduction emerged over time and continues
to evolve. Views about the potential role of psychosocial
factors and marital quality in the etiology of infertility
have also evolved over several decades (Boivin &
Gameiro, 2015). Psychosocial factors are not considered
causative. The role of stress and the psychosocial supports
that ameliorate stress are viewed as important in reducing
the burden of biological challenge, not as relevant to ei-
ther the etiology or resolution of infertility problems
(Boivin, 2003; Boivin et al., 2012; Boivin & Gameiro,
2015; Gourounti et al., 2012).
The ASRM guidelines use permissive language suggesting
that the physician “may provide counseling” as part of quality
care. “The physician should offer psychological counseling by
a qualified mental health professional to all couples and
should require psychological consultation for couples in
whom there appear to be factors that warrant further evalua-
tion” (ASRM, 2008). The “counseling” provided is generally
defined in terms of documented conversations covering vari-
ous hypothetical eventualities.
Most such psychological evaluations are conducted
“in-house”—meaning that the psychologist (or other qual-
ified mental health professional) works as an employee or
contracted consultant to the medical practice. As part of
the evaluation process, the psychologist is expected to go
over all the medical procedures with the involved parties
to help the participants imagine their emotional response
at various points and to help prepare for them. This is part
of the process for assessment of each participant’s ability
to cope over time with the process and outcome of
assisted reproduction. Because these conversations are
both delicate and detailed, a psychologist wishing to enter
into this field is well advised to obtain supervision before
doing so for the first time.
Any psychological evaluation is done for the reproduc-
tive medicine specialty clinic, not for the couple who are
paying for the evaluation. This is different than typical
school psychology or mental health setting testing con-
texts. The physician or clinic, not the intended parents,
owns the final work product. Given that couples undergo-
ing infertility treatment are paying a great deal of money
for these professional services, they often feel that the
psychologist or mental health professional is working for
them and ought to be facilitating their reproductive goals.
Thus, clarifying the relationship at the outset, as part of
the informed consent process, is very important. A sample
informed consent document for psychological evaluation
for participation in the assisted reproductive process is
attached in Appendix A.
Understanding the ASRM Guidelines
in Context
The ASRM guidelines appear long, complex, and redundant.
The typical psychologist, unfamiliar with doing an ART eval-
uation, may feel intimated by the guidelines. They may feel
unsure of where or how to begin, and they may lack a sense of
what the ASRM guidelines consider essential to such an as-
sessment report. The “answer” to what type of evaluation is
needed is closer to a typical psychological evaluation than one
might expect. It involves a comprehensive life and family
history, a psychological assessment, and in-depth discussions
of the procedural and common psychological experiences in
reproductive health cases.
There are two basic aspects to the psychological evalua-
tion. The first part of the assessment is to determine whether
any parties to the assisted reproductive process (in whatever
role) are not appropriate for involvement in the process. The
second part of the assessment is to determine whether or not
all parties are likely to be able to successfully participate in the
assisted reproductive process and the 9–12 month collabora-
tive interpersonal process. This requires the consideration of
habits and biases, control issues, problem-solving skills, and
so forth.
Table 1 presents an overview of the social history and psy-
chological assessment of each intended parent, the gestational
carrier and the donor. As noted earlier, this is a fairly standard
set of subjects to explore in any psychological evaluation.
Attention to drug and alcohol history, abuse history, legal in-
volvement, and medical history might receive slightly more
attention than in a routine evaluation. Table 2 presents the
absolute and relative rejection criteria from the ASRM guide-
lines in relation to each role in the reproductive process.
Informed consent is critical for all parties involved in the
assisted reproductive process. A comprehensive psychologi-
cal consultation regarding the process of surrogate pregnancy
(and areas of potential conflict) is part of such an informed
consent process. Table 3 lists some of the essential topics to
cover during such consultation. Since the overall informed
consent form is long, detailed, and educative, the psychologist
should generally go over the form on a paragraph-by-
paragraph basis to insure the participant is fully aware of all
aspects and details.
Meeting the Infertile Couple in Various Settings
The private practice psychologist is likely to see a client with a
history of infertility at any point in their reproductive journey:
before they begin the process, in the early or middle stages,
and (in a few cases) for a formal psychological evaluation. In
some cases a couple may present with martial issues or de-
pression, without mentioning their long struggle with infertil-
ity. Not infrequently, sexual problems exist and the marriage

Table 1 Social History and Psychological Assessment
Intended Parents
This psychosocial history and psychological assessment should include:
• A family history of each intended parent, including educational and
occupational history
• Assessment of emotional stability, maturity, personality style,
and coping skills
• Sexual history, including negative experiences and abuse
• Psychological history, including hospitalizations, psychotherapy,
and medications
• Legal history
• History of infertility and methods of coping
• Assessment of psychological issues that could compromise successful
collaboration with the gestational carrier
Gestational Carrier
The psychosocial history should include:
• Family of origin history
• Educational background
• Occupational and financial history
• Assessment of stability, including personality style, coping skills, and
capacity for empathy
• Maturity, judgment, assertiveness, and decision-making skills
• Current major life stressors or anticipated changes within
the next two years
• Social network and interpersonal relationships
• Sexual history, including sexual abuse
• History of abuse and/or neglect
• Reproductive history, including difficult or traumatic reproductive events
• History of postpartum disorders and other unresolved negative reproductive
events
• Psychiatric history including prior hospitalizations, suicide attempts,
medication, and counseling
• History of substance use and/or abuse, including history of smoking
• Legal history
• Religious beliefs that may influence behavior
Additional dimensions to explore:
• Motivation to become a gestational carrier
• Previous gestational carrier experience (or application to other facilities)
• Negative medical history as it relates to the psychosocial adjustment
of being a gestational carrier (e.g., bed rest, gestational
diabetes, preeclampsia)
• Support of significant other for being a gestational carrier
• Desire for more children of her own
• Anticipated impact of gestational experience upon her children and
significant other
• Anticipated type and duration of relationship with intended parents
• Ability to separate from and relinquish the child
• Anticipated feelings toward the child
• Feelings about multiple pregnancy, bed rest, hospitalization, and pregnancy
loss
• Feelings about possible sexual abstinence
• Feelings and decisions about termination of pregnancy, multifetal
pregnancy reduction, amniocentesis, chorionic villus sampling, and other
prenatal diagnostic testing
• Reactions to the possibility of becoming infertile as a result of the process
• Agreement with the financial compensation arrangement
Donor
A psychosocial history and assessment should include:
• Family history
• Educational background
• Assessment of stability
• Motivation to donate
• Current life stressors and coping skills
• Interpersonal relationships
• Sexual history
• Difficult or traumatic reproductive history
• History of major psychiatric and personality disorders
• Substance abuse in donor or first-degree relatives
• Legal history
• History of abuse or neglect
• Travel history
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Table 2 Criteria for rejection
Intended Parents
Criteria for rejection of intended parents:
• Absolute criteria for rejection include:
• Inability to maintain respectful and caring relationship
with gestational carrier
• Abnormal psychological evaluation as determined by the qualified
mental health professional
• Unresolved or untreated addiction, child abuse, sexual or physical
abuse, depression, eating disorder
• Unresolved or untreated major depression, bipolar disorder, psychosis,
or significant anxiety disorder or personality disorder
• Current marital or relationship instability
• Intended parent(s)' failure to agree with gestational carrier's decision on
number of embryos transferred
•Relative criteria for rejection include:
• Ongoing legal disputes
Gestational Carrier
Criteria for rejection of a gestational carrier
• Absolute rejection criteria include:
• Cognitive or emotional inability to comply or consent
• Evidence of financial or emotional coercion
• Abnormal psychological evaluation/testing as determined by the qual-
ified mental health professional
• Unresolved or untreated addiction, child abuse, sexual abuse, physical
abuse, depression, eating disorders, or traumatic pregnancy, labor
and/or delivery
• History of major depression, bipolar disorder, psychosis, or a significant
anxiety disorder
• Current marital or relationship instability
• Chaotic lifestyle, current major life stressor(s)
• Inability to maintain respectful and caring relationship with intended
parent(s)
• Evidence of emotional inability to separate from/surrender
the child at birth
•Relative rejection criteria include:
• Failure to exhibit altruistic commitment to become a gestational carrier
• Problematic personality disorder
• Insufficient emotional support from partner/spouse or support system
• Excessively stressful family demands
• History of conflict with authority
• Inability to perceive and understand the perspective of others
• Motivation to use compensation to solve own infertility
• Unresolved issues with a negative reproductive event
Donor
Relative exclusion criteria for a gamete donor include:
• Presence of significant psychopathology
• Positive family history of heritable psychiatric disorders
• Substance abuse
• Two or more first-degree relatives with substance abuse
• Current use of psychoactive medications
• History of sexual or physical abuse with no professional treatment
• Excessive stress
• Marital instability
• Impaired cognitive functioning
• Mental incompetence
• High-risk sexual practices
needs repair (Luk & Loke, 2015). Awareness of infertility and/
or pregnancy desire/avoidance should be one intake question
in the initial assessment of any couple aged 18–38 regardless
of their presenting complaint.
For couples coming to psychotherapy for help, support, and
understanding of the emotional side of infertility, it is common
J Health Serv Psychol
Table 3 Surrogacy psychosocial consultation and informed consent
The ASRM guidelines are geared toward providing both intended parents and
gestational carriers with a comprehensive understanding of the surrogacy
process and the relationship and interactions between the parties in order to
provide a full and complete informed consent decision process. This
procedure has both counseling aspects and evaluation aspects.
Psychosocial surrogacy consultation with the intended parent includes:
• Informing intended parent(s) of potential psychological issues and risks
associated with the gestational carrier process
• Discussion of the medical protocol, scheduling demands, risks of
canceled cycles or unsuccessful cycles
• Determination of the number of embryos transferred and number of
cycles planned by the gestational carrier and the physician
• Requirement of intended parent(s)' agreement with the gestational
carrier regarding all medical issues
• Informing the gestational carrier of source of gametes before
legal consent
• Management during pregnancy of expectations and relationship with
the gestational carrier and her family
• Gestational carrier's behavior during pregnancy and methods for
resolving conflicts (e.g., eating habits, prescription drugs, alcohol)
• Meeting the emotional and physical needs of the gestational carrier and
her family
• Understanding the gestational carrier's right to make choices for her
body over the rights of the intended parents
• Rights of the gestational carrier to refuse or to accept medical
interventions or prenatal diagnostic testing
• Multiple pregnancy and associated risks
• Multifetal pregnancy reduction and discussion of psychological risks
and concerns
• Possibility of abortion in the event of an abnormal fetus
• Disclosure to offspring
•Psychosocial surrogacy consultation for gestational carriers includes:
• Informing the potential gestational carrier and her partner regarding the
potential psychological issues and risks associated with the process
• Impact on gestational carrier's marriage or partnership
• Impact on gestational carrier's employment
• Disclosure to family members and friends about the
surrogacy pregnancy
• Risks of attachment to the child and risk to the gestational
carrier's children
• Coping appropriately with the pregnancy
• Matching of gestational carrier and intended parent(s)
• Need for separate legal consultation and a written contract
• Discussion of the medical protocol, including scheduling demands,
risks of canceled cycle and unsuccessful cycle, multiple pregnancy,
multifetal pregnancy reduction, prenatal diagnostic testing,
and elective termination
• Disposition of extra embryos
• Potential guilt reaction of gestational carrier associated with failed
attempts or problems that may arise
• Relationship issues, expectations, and impact of failed cycle
• Discussion of requirement of intended parent(s)' agreement with
gestational carrier regarding all medical issues
• The balance between the gestational carrier's right to privacy and the
intended parent(s)' right to information
• Management of the relationship between the intended parent(s) and the
gestational carrier: past, present, and future
• Expectations of relationship between gestational carrier, intended
parent(s), and children after birth
• Need for gestational carrier and her children to interact with
baby after birth
that they have experienced a long period of frustration and, in
some cases, of hope alternating with disappointment (Schmidt
et al., 2003). The assisted reproductive treatments themselves
are intrusive, aversive, and emotionally charged (Greil et al.,
2010; Hasanpoor-Azghdy et al., 2014). Complex patterns of
self-blame, other blame, shame, frustration, and anger may ex-
ist, undercutting the martial relationship and bond. Such cases
may be characterized as a “shared medical trauma” (Moura-
Ramos et al., 2015), particularly in cases with repeated success-
ful pregnancies followed by miscarriages.
Evaluation Process
Psychological evaluations for assessing intended parents, ges-
tational carriers, and gamete donors are all quite similar and
standardized according to ASRM guidelines. The evaluation
proceeds along three stages: comprehensive diagnostic inter-
view of both the couple (when indicated) and the other indi-
viduals concerned, psychological testing, and consultation
about the surrogate process.
Intended Parents
Couples who are going through IVF using their own gam-
etes and intending for the woman to carry her own preg-
nancy do not need to be evaluated. Couples who will be
using donor gametes (donor sperm or donor eggs) and/or
who will be using the services of a gestational carrier do,
however, require evaluation and counseling by a qualified
mental health professional.
The evaluation proceeds through three steps: interviews
of the couple (and of each intended parent, separately),
psychological testing using the MMPI or PAI (or other
justifiable and relevant psychological test), and counsel-
ing. The mental health professional is tasked with ascer-
taining the emotional health of each intended parent and of
the relationship itself. The report must document these
areas and the assessment of them.
The ASRM provides clear rejection criteria (see
Table 2), and if the intended parents meet rejection criteria,
they will be denied further ART services. This can be
heartbreaking and lead to many recriminations if the pro-
cess and the nature of the professional relationship are not
properly understood from the beginning.
The final report should document not only the assessment
process and testing results but also that various topics were
discussed in “counseling” the intended parents. These topics
are found in Table 3. They consist of speculative conversa-
tions about various possible eventualities and how the couple
might handle each of these. The intent is to get the couple to
think about any potential problem areas and have some idea of
how they would approach problem-solving together should
difficulties arise in the future.

Gestational Carrier
When assisted reproductive technology was in its infancy, the
term used for a woman who would bear a child for an infertile
couple was “surrogate.” In a “surrogate” arrangement, a wom-
an undergoes artificial insemination using her own eggs in
order to produce a child to be adopted by others. But the legal
and psychological risks with surrogacy are much greater than
with a gestational carrier because the surrogate might poten-
tially change her mind, decide to keep the child, and sue for
child support. As technology advanced and egg donation be-
came easy and commonplace, the gestational carrier role
supplanted surrogacy.
In a gestational carrier arrangement, one woman donates
her eggs and another carries the pregnancy—each contribut-
ing to an infertile couple’s goal of creating a family but neither
retaining any legal claim to the resulting child. The ASRM
recommends that gestational carriers be in a long-term, stable
partnership and have successfully carried at least one pregnan-
cy to term without complications. This means that most ges-
tational carriers are married or in long-term relationships and
have children at home. The mental health professional is
tasked with ascertaining the emotional health of the potential
gestational carrier and the quality of her support system
(Practice Committee of the American Society for
Reproductive Medicine and Practice Committee of the
Society for Assisted Reproductive Technology, 2017). The
items to be covered in the interviews are found in Table 1.
Many cases of gestational carriers refusing to relinquish a
child or attempting to refuse to terminate a pregnancy have
appeared in the news. This has garnered a great deal of nega-
tive attention for reproductive medicine. Thus, one aspect of
the psychologist’s evaluation is to ascertain the carrier’s emo-
tional capacity to compartmentalize her own attachment to-
ward the developing fetus as well as other dimensions of men-
tal and relational health. It is important to interview the carrier
with her partner (as well as interview the partner alone) in
order to have as complete a picture as possible of the strengths
and weaknesses of her primary relationship.
Gestational carriers are paid considerable sums for as-
suming the physical and emotional risks of pregnancy. It is
incumbent on the psychological examiner to make every
effort to ferret out the many factors motivating this choice.
The ASRM has developed absolute and relative criteria for
rejection of a gestational carrier (see Table 2). The absolute
criteria for rejection are, as the name suggests, absolute and
non-negotiable. The relative rejection criteria, such as the
presence of a personality disorder, are subject to a judg-
ment call on the part of the evaluator. The report should
state that these rejection criteria have been assessed. If a
gestational carrier is approved despite the presence of at
least one relative rejection criterion, a clear rationale for
not rejecting should be provided.
J Health Serv Psychol
The final stage of the evaluation process for gestational
carriers includes counseling, which consists of a carefully
documented psychosocial consultation with the carrier and
her partner about the potential physical and emotional risks
associated with carrying a third-party pregnancy. The terms of
the legal contract that this arrangement entails also should be
covered. The topics to be covered are found in Table 3.
It is very important that both the gestational carrier and her
partner understand what they are agreeing to and that, in mak-
ing this agreement, they are relinquishing agency over many
ordinary health decisions that can impact the pregnancy. It is
also important that expectations about any future relationship
with the intended parents and the resulting child be thoroughly
explored and contingency plans made. An example plan for
immediately after birth might allow the gestational carrier and
her family to meet and say “goodbye” to the newborn.
Some agencies provide a standardized group therapy expe-
rience for gestational carriers with the presumption that post-
partum depression is a function of the drop in reproductive
hormones that occurs with birth. However, it is perhaps im-
portant to note that evidence for this hypothesis is scant, while
evidence is accumulating that shows postpartum depression to
be a psychosocial phenomenon that affects adoptive mothers
and adoptive fathers at the same rates as birthmothers and
birthfathers (Edward et al., 2015; Gentile & Fusco, 2017;
Paulson & Bazemore, 2010; Payne et al., 2010; Senecky
et al., 2009; Swedsen & Mazure, 2000).
Gamete Donors
Historically, egg donors have been scrutinized more carefully
and evaluated more thoroughly and consistently than sperm
donors. As stories begin to appear in the popular press about
sperm donors who lied about their backgrounds or who passed
on genetic defects to offspring (Cha, 2019), the requirements
for assessment of sperm donors are beginning to catch up to
those of egg donors.
The requirements for psychosocial interviews of gamete
donors are significantly less rigorous than for intended
parents or for gestational carriers as can be seen in
Table 1. Moreover, not all agencies require psychological
testing as part of the evaluation process for sperm donors,
although many do for egg donors. The rejection criteria,
found in Table 2, are also much less comprehensive and
mostly involve psychological or behavioral factors that are
believed to be genetically heritable. The ASRM does not
require further psychosocial consultation with egg and
sperm donors beyond an assessment of the motivation to
donate. Nonetheless, it is prudent to consider the possible
impact of being located by offspring as the popularity of
genetic testing and websites such as Ancestry.com and
23andMe.com proliferate and grow in popularity.
J Health Serv Psychol
Tips to Remember in Gestational Carrier
Psychological Evaluations
Infertility treatment is a stressful experience. Assisted repro-
ductive technology can be a nerve-racking process, with high
hopes alternating with deep disappointments. It can also be
legally intricate. The use of a gestational carrier in the preg-
nancy and birthing process is a somewhat rare final attempt at
having a child. The gestational carrier arrangement is com-
plex, involving many individuals and often involving multiple
family systems. Attempting to predict successful gestational
carrier arrangements and helping to support all parties during
the process is a valuable clinical effort.
The purpose of psychological evaluations of all parties to a
gestational carrier pregnancy is to predict and support a suc-
cessful pregnancy and positive interpersonal experience for all
involved. The ultimate goal is to produce a healthy infant for an
infertile couple, one that is handed over to intended parents with
minimal emotional drama and no legal ambiguities. The pur-
pose of the psychological evaluation of all parties in this unusu-
al arrangement is to (a) ascertain, as far as is humanly possible,
each party’s appropriateness to participate and ability to suc-
cessfully navigate the almost yearlong, layered, interpersonal
process, and (b) ensure that all parties understand and give
informed consent to the special conditions and experiences that
this unconventional arrangement is likely to produce.
& The treatment of infertility can be very stressful and pro-
duce lasting effects on a couple’s relationship and subse-
quent sexual functioning.
& The psychological evaluation of gamete donors, gestation-
al carriers, and intended parents exists for the purpose of
allowing the clinic to comply with the ASRM guidelines
and thus belongs to the physician and/or clinic and not to
the infertile couple seeking ART services even though the
couple may be paying for the evaluation.
& ASRM guidelines provide relative and absolute psycho-
logical and behavioral rejection criteria for gamete donors,
gestational carriers, and intended parents.
& In order to comply with ASRM guidelines, any psycho-
logical evaluation of gamete donors, gestational carriers,
or intended parents must document conversations as
outlined in Tables 1 and 2 and must mention that absolute
and relative rejection criteria have been considered.
APPENDEX A
CONTRACT FOR PSYCHOLOGICAL EVALUATION
This is a consent for psychological evaluation, which is being
conducted at the request of a physician as part of the process
required for your participation as a(an) [egg donor/gestational
surrogate/intended parent] in an Assisted Reproductive
Technologies (ART) procedure. It is therefore somewhat dif-
ferent than other psychological services. It is important for
you to understand how a psychological evaluation for ART
differs from more traditional psychological evaluations. While
the results of this evaluation may or may not be helpful to you
personally, the goal of this evaluation is to provide informa-
tion to the physician requesting the evaluation about how you
are functioning psychologically. In agreeing to this evaluation,
you agree to hold me harmless should your application for
ART services be denied based on the findings documented
in my report.
The psychological evaluation includes the administration
of standardized, empirically validated psychological tests and
an in-person, structured interview. I will ask you questions
about your psychosocial history and will assess your psycho-
logical functioning and your ability to provide informed con-
sent for the medical procedures in which you are seeking to
participate. I will then submit a report to the egg donor agency,
egg bank, reproductive attorney, and/or fertility practice.
Your participation in this evaluation is entirely voluntary. I
will not conduct the evaluation without assurance that you are
acting of your own free will as evidenced by your signature on
this document. You have the right to stop the evaluation at any
time. If, at any time, you have a question about any aspect of
the evaluation or these procedures, pleased feel free to ask me.
In addition, if at any time you need a break from the evalua-
tion, please let me know and we will stop. Once the evaluation
is completed, the evaluation will be sent to the physician/clinic
and will become part of the intended parents’ permanent med-
ical record.
I have read and agree to the above: ____________________
Date signed: __________________________________
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Publisher's Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
Sara Rosenquist, PhD, ABPP, is a licensed practicing psychologist and
diplomate in health psychology with offices in Cary, NC, and
Georgetown in Washington, DC. She has specialized in sexual and repro-
ductive health concerns in private practice since 1993, is a certified sex
therapist (AASECT), and is an approved consultant in hypnosis (ASCH).