Direct-to-consumer (DTC) DNA testing has had a major impact on people affected by donor conception, including donor-conceived people, their parents, and donors. It has enabled people to discover their conception status and to identify the donor. Donors who were assured of anonymity and their extended families are being contacted by their donor offspring and recipient parents. Consequently, it is now impossible to assure donors they will be anonymous, and parents can no longer consider that nondisclosure of donor treatment to their children is a viable option. Fertility counselors need to prepare their clients for the implications of DTC DNA testing, be fully informed of the repercussions faced by donor-conceived adults, especially those finding out their conception status past childhood, and also to have donor-linking skills as part of their counseling tool kit.

Counseling patients through their journey to conceive can be challenging. When a therapist becomes pregnant, the therapeutic alliance alters.This chapter explores the unique dynamics between the pregnant fertility counselor and reproductive clients. Questions around the “who, what, where, when, why and how” of pregnancy disclosure are used as a tool to help think about the various elements to the therapeutic alliance. Intense feelings can be triggered for a patient who is struggling with infertility or pregnancy loss, but can also trigger emotional reactions for the fertility counselor. The transference and countertransference that arises with the self-disclosure of a pregnancy is likely to unfold complicated dynamics and emotions. The positive and negative implications that a pregnancy disclosure can have from the patient’s point of view, as well as that of the therapist, are addressed. Additionally, the postpartum experience and the return back to work after parental leave are also discussed. While this chapter focuses on the pregnant therapist, the issues raised pertain to all pregnant reproductive medical staff treating infertility patients.

Gestational surrogacy arrangements have been documented throughout history, but more recent technological advances in assisted reproductive technologies (ART) have made it possible for a woman, referred to as a gestational carrier (GC), to gestate and give birth to a child that is not genetically related to her on behalf of the intended parents (IPs) who are to be the legal, rearing parents. This chapter considers the multifaceted role of the fertility counselor, as well as both the complexity of these arrangements and issues of competence in fertility counseling. It moves beyond a “how to” guide and addresses the delicate balance of a multitude of psychological and ethical factors that the fertility counselor must consider for all parties involved. The assessment process, facilitated by the fertility counselor, aids in helping all participants in these arrangements make sound decisions. Fertility counselors provide accurate information to all parties, facilitate relationships between parties, and create a basis for informed consent. Thus, how these arrangements and relationships are facilitated become crucial in their success. Due to the number of participants in these arrangements and the competing vulnerabilities and needs of each, there is a vital role for the fertility counselor in surrogacy screenings.