Donor conception and surrogacy — structured oral station (12 minutes)

Opening prompt — "Tell me how you would set up donor-oocyte IVF for the Turner-syndrome patient, and what you would cover before any treatment."

Model response — say it in this order: ^[1][2]

• "Before any technique, three gates: implications counselling, valid informed consent covering the identity status of the donor and what the donor-conceived person can access, and a welfare-of-the-child assessment. These are mandatory under the NHMRC ethical guidelines, not optional."
• "The donor-oocyte cycle has two arms. The donor is stimulated under a GnRH-antagonist protocol, triggered and retrieved; the oocytes are fertilised by ICSI. The recipient's endometrium is synchronised — oestradiol to proliferate, then luteal progesterone to open the transfer window — and a single embryo is transferred."
• "I would plan single-embryo transfer, because multiple pregnancy magnifies the obstetric risk that already attaches to oocyte-donation recipient pregnancies."^[1][21]

Examiner is listening for: the gates first, then the two arms and synchronisation, then single-embryo transfer. ^[1]

Probe 1 — "What obstetric risk should she know about, and where is the evidence?"

• "Oocyte-donation recipient pregnancies carry increased risk of pregnancy-induced hypertension and preeclampsia compared with autologous conceptions. The DONOR IPD meta-analysis in Human Reproduction Update found this excess risk persists independent of maternal age, parity and number of embryos transferred — so it is not simply because the recipient is older. I would plan heightened hypertension surveillance in pregnancy."^[21]
• "I would not over-state it as higher risk of everything: a US cohort found gestational surrogacy, carried by younger proven women, actually had lower odds of several adverse perinatal outcomes. The recipient risk and the carrier picture are different, and I would keep them distinct."^[17]

Probe 2 — "What about the donor? What must you tell her?"

• "The donor is a volunteer but not a zero-risk one. In the 4052-cycle series, retrieval complications occurred in about 0.42 percent — intra-abdominal bleeding, severe pain, ovarian torsion — and about 0.35 percent were hospitalised. Moderate or severe OHSS occurred in about 0.87 percent, all with HCG triggering."^[16]
• "I would counsel that rare fatal OHSS has been reported, and that long-term safety — breast cancer, earlier menopause — remains incompletely characterised. She gives informed consent for the procedure and for the number of donations she may undergo."^[16][1]

Probe 3 — "Now the gay couple. They want surrogacy in Australia. Counsel them on what is and is not possible."

• "In Australia, only altruistic gestational surrogacy is available — the carrier is reimbursed reasonable expenses but is not paid. Commercial surrogacy is a criminal offence in every Australian state and territory, and in several states that prohibition applies overseas too. The international commercial route exists but carries real legal exposure, which I must flag."^[7][20]
• "Supply is the constraint — altruistic carriers are scarce, so the wait can be long. I would counsel patience and the alternatives, and I would not minimise the legal risk of going abroad."^[7]

Probe 4 — "They ask whether, once pregnant, they become the parents at birth."

• "No. The surrogacy agreement is generally not legally binding in Australia, and parentage does not pass automatically at birth. The carrier is the legal mother at delivery."
• "After birth the intended parents apply for a parentage order — the mechanics vary by state under the relevant surrogacy act. In New Zealand, under the HART Act 2004, the intended parents must apply to the Family Court to adopt the child, with the carrier's consent. I would plan that pathway, with independent legal advice for both sides, before any embryo transfer."^[7][9]

Probe 5 — "The Turner-syndrome patient asks: should we tell the child?"

This is a scored communication and clinical-knowledge domain — demonstrate it out loud: ^[2]

• "Current guidance favours telling the child, early and in an age-appropriate way. The ASRM Ethics Committee opinion favours informing offspring of their conception by gamete donation, and the longitudinal evidence shows young adults who learned before age 7 had less negative mother-child relationships."
• "I would also explain the identity-release direction: Victoria gave donor-conceived adults the right to identifying information, and Aotearoa New Zealand has mandated identifiable donors since 2005. Lifelong secrecy is against the direction of policy. I would support them toward open disclosure, not dictate it."^[2]

Communication domain: use her name, check her understanding, invite questions, avoid jargon, and do not moralise.^[2]