Assisted reproduction at a clinic

There can be many questions and choices before an assisted reproduction at a clinic; if it should take place in Sweden or abroad, at a private or publically financed clinic, and – if you do it abroad – if you should be able to contact the donor or not. Many variables can play a part, for example waiting times to publically financed treatment in Sweden, the opportunity to finance treatment yourself at a private clinic in Sweden or abroad, or purely legal aspects.

Here you find information about what rules apply in assisted reproduction at a clinic and how insemination and IVF works in practice. If you instead want to read more about home insemination you will find information here. Information about how legal parenthood is determined after assisted reproduction at a clinic, you can read more about that here. The big difference, that concerns same sex (lesbian) couples, is, in short, that after treatment in Sweden the parenthood is determined through parental acknowledgement confirmation while related adoption is needed after treatment abroad.

• Who has access to assisted reproduction at a clinic?
• Fertility assessment
• Individual assessment
• How does the insemination and IVF work?
• Treatment at a public clinic in Sweden
• Treatment at a private clinic in Sweden
• Donation rules in Sweden and abroad
• Sibling treatment

Insemination at a clinic

An insemination at a clinic means that sperm is inserted into the uterus of a person who wants to get pregnant just before the person is ovulating. In order to place the sperm in the uterus the midwife or doctor uses a thin plastic catheter that is inserted into the uterus through the vagina and cervix. An insemination at a clinic generally doesn’t hurt.

IVF at a clinic

IVF treatment (In Vitro Fertilization) means that eggs are harvested from the ovaries (either from the person who wants to get pregnant or from a donor) and are fertilized by sperm outside of the body. Then the fertilized egg is placed in the uterus of the person who is to get pregnant.

In order to undergo a publically financed treatment at a clinic in Sweden you need a referral from a gynaecologist at a clinic within the county council. If you choose to have the treatment at a private clinic you don’t need a referral. At present only inseminations with donated sperm is offered at private clinics. IVF treatment with donated sperm is only carried out, at this point, at publically financed clinics, with one exception, the IVF clinic in Umeå. That is because that clinic is connected to a university hospital, which at this point is a prerequisite for a private clinic to be able to carry out IVF treatments with donated sperm.

Who can get help with assisted reproduction?

In Sweden same sex couples (lesbians) have been helped with assisted reproduction with donated sperm through public financing since 2005. After the demand of sterilization of transsexuals was removed in 2013, people who have changed their legal gender have also gained access to assisted reproduction through the county council in Sweden. As of April 1st 2016 it’s also possible for single people to get assisted reproduction in Sweden. It presupposes that you live as a single, i.e. that you’re not married, living with someone or have a registered partner. If you want to get pregnant and start a family with one or more people outside a relationship, you don’t have access to assisted reproduction at a clinic in Sweden at the present time.

In spite of these changes in the law, many LGBTQ people still travel to clinics in other countries to have assisted reproduction. The reasons can for example be long waiting times in the county council, age limitations for getting the treatment or the wish of an anonymous sperm donor.

Fertility assessment

Before attempts to get pregnant are started the person who is to get pregnant should undergo certain examinations, a so-called fertility assessment.

When is a fertility assessment carried out?

Before a publically financed assisted reproduction with donor sperm (insemination or IVF) at a clinic in Sweden a fertility assessment conducted by the gynaecologist that made the referral to the clinic is often mandatory. Normally it’s a standard gynaecological examination, where the uterus and the ovaries are thoroughly examined with an ultrasound. If insemination is to be done it can be important to know that the ovaries work (the examination is made with ultrasound and contrast fluid) and hormones are checked using blood tests. It’s also important to check your medical history and map possible medications. The fertility assessment aims at examining if there are any medical hindrances in order for you to get pregnant, and if there are, to make a plan for overcoming these obstacles. In some places in Sweden there is an assessment of both people in a couple, given that one can assume that both could become pregnant.

Even before assisted reproduction at a clinic abroad it’s good to find a gynaecologist in Sweden that can do the examination. Not all gynaecologists perform these examinations if you plan to have assisted reproduction abroad, so you might have to shop around.

In private fertility clinics you can have an assessment but then you might have to pay for the assessment yourself. In some county councils, for example Stockholm, they have introduced a “choice of care”. That means that you can contact a private fertility clinic and have a fertility assessment without having to pay more than ordinary county council tax for the appointments.

What’s included in a fertility assessment?

Generally there’s a gynaecological examination with vaginal ultra sound, measuring of height and weight, examination of the medical history and blood tests, which include among other things, hormone tests (taken on one or multiple occasions), STI tests (for example HIV, chlamydia, hepatitis B and C). In Sweden it’s routine to do this basic fertility assessment before a referral is sent to your nearest clinic that carries out assisted reproduction with donated sperm.

Yet another examination that’s often done before insemination at a clinic is Hystero-Salpingo-Sonography (HSS), sometimes called tubal flushing. This is to make sure that there’s free passage in the fallopian tubes so that the egg has free passage into the uterus. In HSS you insert a small amount of contrast fluid/cooking salt into the uterus through a plastic tube and see, with an ultrasound, that the fluid can pass through the fallopian tubes. Should the fallopian tubes be tight, IVF is recommended over insemination.

When the fertility examination is done you are referred to that nearest clinic that can perform assisted reproduction with donated sperm. There they, together with you, make a plan for suitable treatment. After that an individual assessment is made (link).

Individual assessment

Before a treatment (insemination or IVF) with donated germ cells (egg or sperm) at a clinic in Sweden, the person/couple undergoing the treatment gets to meet with a counsellor or other type of behaviourist. This is mandatory and forms part of a so-called individual assessment that is done before you start treatment with donated gem cells.

Why is an individual assessment done?

The aim of the individual assessment is to make sure that the future child/children will grow up in a good environment. The individual assessment also aims at securing that you understand the implications and regulations regarding donation of gem cells. The individual assessment is thus connected to the fact that you are to receive a donation of gem cells (egg or sperm), not to the fact that you are LGBTQ. Opposite sex couples that are to receive eggs or sperm also have to go through the individual assessment.

What questions are asked in the individual assessment?

Exactly what questions are asked varies, but the individual assessment and evaluation is based on the couple’s or the single parent’s possibility and ability to function as a parent/parents during the whole of the child’s upbringing. In the assessment the doctor and behaviourist looks at the couple’s mutual relationship (if you’re a couple) and the couple’s/the single person’s social network. An overall judgement connected to the couple’s/the single person’s age, health and possible disabilities, way of living and attitude towards revealing the child’s genetic origin to the child.

The assessment is based on a child’s perspective. The goal of the individual assessment is to make sure that the future child/children will grow up under good circumstances. The dialogue can also be a way of picking up if you need any additional information and/or extra support and to investigate how this can be provided.

What happens if I/we aren’t approved?

It is unusual to not be approved in the individual assessment, but it happens. Often it’s a due to serious flaws in the parenting ability, like serious mental illness, homelessness or similar. If you aren’t approved in the individual assessment you have the right to get information about why and what you need to change in your life before a new assessment. A new assessment can often be made after a certain time, depending on the reason for you not being approved. If you aren’t approved you have the possibility to appeal the decision at the National Board of Health and Welfare.

Where can I learn more about the individual assessment?

The National Board of Health and Welfare has produced a knowledge support for the individual assessment. It contains detailed information about the aim of the individual assessment and what is addressed in the assessments. The knowledge support can be downloaded at the National Board of Health and Welfare’s homepage.

What happens during an insemination at a clinic?

In some cases hormones that stimulate egg maturation/ovulation need to be administered in order to get the best result in an insemination. This can be in the form of pills or as injections. Other hormonal treatment can also be needed depending on what the fertility assessment has shown. In many cases it’s enough to inseminate during ovulation in a so-called natural cycle, i.e. without hormones. To assess when ovulation occurs during the menstrual cycle, an ovulation test is used. This will give a reading in connection with ovulation. It works in a similar way to a pregnancy test. You pee on a stick every morning a few days before expected ovulation, so that you don’t miss it. When the stick gives a reading (becomes positive) ovulation will occur within the next 24-36 hours. An insemination at a clinic is usually made the same day or the day after the person who is to get pregnant gets a positive ovulation test or has had an ovulation injection. This is to maximize the chance to target the day of ovulation when you do the insemination. If you’re doing an insemination at a clinic abroad you may need to travel to that country the same day, or the day after, you get a positive ovulation test in order be able to have an insemination within the time of ovulation. Most people need to undergo several insemination attempts, while some people get pregnant the first time. The chances of a pregnancy in an insemination are about 20% per insemination. If you do an insemination at a clinic you get help in following up what can be wrong if there is no pregnancy.

When is IVF done?

An IVF treatment can be done if several insemination attempts don’t result in pregnancy, or right away if there’s reason to believe that an insemination won’t work. It can be previously known medical factors or factors that have appeared in the fertility assessment that’s often done before assisted reproduction. Often it’s because the fallopian tubes are blocked or because of high age (when the chances of achieving pregnancy with insemination are lower).

How does an IVF treatment work?

In an IVF treatment you often do a hormone stimulation to get more eggs to mature in the fallopian tubes. There are different methods for this. At the clinic you will get help with what treatment is right for you. The goal with hormone stimulation is to get more eggs to mature, and when enough eggs have matured you take an ovulation injection. About 36 hours after the ovulation injection has been taken you harvest the eggs. The eggs are sucked out during an ultrasound via the vagina with a needle.

The good quality eggs are fertilized, the progression of the fertilized eggs are followed for a few days at the laboratory and after that the best embryo is selected and is inserted into the uterus of the person who is to get pregnant with the help of a thin plastic catheter. The insertion of a fertilized egg is called embryo transfer (ET). If there are more high quality embryos these can be frozen for future use.

At a clinic in Sweden ordinarily only one egg at a time is inserted into the uterus, even if there are exceptions. Abroad, for example in Denmark, it’s more common that two fertilized eggs are inserted at the same time, which increases the risk/chance of a twin pregnancy. When a frozen embryo is thawed and placed in the uterus it’s called FET (frozen embryo transfer). In Sweden the fertilized eggs can be kept frozen for five years according to the law, but you can apply for a prolonged freezing time at the National Board of Health and Welfare. According to your wishes the frozen embryos that you don’t want to use, or after the freezing time is up, can with your written consent be destroyed or donated for research. Abroad the rules about freezing of eggs differ between countries.

Public clinics in Sweden

If you have undergone a fertility assessment and have been referred to a publically financed fertility treatment, your referral will be sent to your nearest public clinic that does assisted reproduction with donated gem cells (eggs or sperm). To find contact information of all public fertility clinics in the country’s different university hospitals, see this map.

What are the waiting times?

The waiting times from a referral to when you get summoned to the clinic to start your treatment vary greatly between the different county councils. From 3-6 months up to several years. The most common waiting time is about 1,5 years. The waiting times are constantly changing because of access to donors and how many people are waiting at the time in the respective county council. For current waiting times, see the clinic’s home pages.

What do the waiting times depend on?

The long waiting times depend mainly on a lack of resources at the clinics. To some extent they can also, at some of the clinics, depend on a lack of donors. But the greatest reason for that there are waiting times now to get publically financed fertility treatment is that the resources at the clinics are limited and that they therefore can’t employ more staff and get bigger premises.

Doesn’t the healthcare guarantee apply?

No, the healthcare guarantee doesn’t apply when you need donated gem cells (eggs or sperm) to get pregnant. If you have your own eggs and sperm within the couple, the healthcare guarantee applies, i.e. you are summoned to the clinic within three months of the referral reaching the clinic.

Private clinics in Sweden

In Sweden there are many private fertility clinics that do insemination with donated sperm. Oftentimes the clinics have no or a relatively short waiting time. There’s often no need for a referral, you can contact the clinic directly and in most cases your fertility assessment is made there. For contact information of all fertility clinics in Sweden that carry out insemination with donated sperm, see this map. To contact a private clinic may mean that you pay for the treatment yourself. Lists of prices are on the clinics’ websites.

Can you do IVF with donated sperm at a private clinic?

No, IVF treatment with donated sperm is, currently, only done at public clinics, with one exception, the IVF clinic in Umeå. That is because the clinic is linked to a university hospital, which currently is a precondition for a private clinic to do IVF treatment with donated sperm.

What rules apply for sperm donation in Sweden?

Assisted reproduction with donated sperm has been legal for opposite sex couples since 1985, for same sex couples since 2005 and for single people since 2016. In Sweden there’s a law called the Genetic Integrity Act that among other things regulates that all sperm donors always should be reachable. That means that children that are conceived with the help of donated sperm in Sweden have the right to find out the donor’s identity, but not until they’ve reached a “mature age”. The children can then request information about the donor’s identity that is saved in a special journal at the clinic where the assisted reproduction took place. This also means that those who become pregnant by donated sperm in Sweden have to tell their children how they were conceived. When an assisted fertilization with donated sperm is done in Sweden, the clinic will inform you about this.

What rules apply abroad?

The rules regarding sperm donation is different in different countries. In Denmark for example it’s possible to choose between a donor that can be contacted and one that cannot. If the donor cannot be contacted you cannot find out their identity, neither you who are to get pregnant by sperm donation nor the children that are conceived through sperm donation. In many countries it’s also possible to get information about the donor. You can for example get information about the donor’s skin colour, eye colour, height and what they work with and what education they have. In some countries you can even get access to pictures of the donor. If you plan to do an assisted fertilization at a clinic abroad the clinic will inform you about what rules apply in the country in question.

Good to know before an assisted fertilization abroad

Most people who go abroad to another European country for assisted fertilization go to Finland, Denmark, Estonia or England. Before an assisted fertilization abroad a fertility assessment with preparatory examinations can be carried out by Swedish healthcare, but the treatments abroad are not covered by the Swedish high-cost protection for care and medication. To do an assisted fertilization abroad can cost a lot of money. Added to that there are often costs for medications, lodging and travels. The prices vary depending on if you’re doing an insemination or IVF with your own eggs and sperm, with donated eggs and sperm, with both donated eggs and sperm, or if there are already frozen embryos, etc. Clinics in different countries also have different demands on for example BMI (body mass index), age, and they have different waiting times and costs.

Egg donation

IVF treatment with donated eggs has been legal in Sweden since 2003. Because of a writ in the Genetic Integrity Act, egg donation is currently only accessible for opposite sex couples with their own sperm within the couple. Read more about this under embryo donation.

Freezing unfertilized eggs

Before 2013 it wasn’t possible for transsexuals to freeze and save gem cells before gender affirming treatment. In 2013 this was changed, and the possibility of freezing eggs and sperm to later try and become a genetic parent for people who are to undergo gender-affirming treatment now exists.

At the Karolinska University hospital in Stockholm a specific program for fertility preserving measures directed at young trans men is running. In that program they look at methods in order to make it possible to make eggs mature and harvest them but at the same time keeping the oestrogen levels low. If embryo donation becomes legal in Sweden those trans men that have saved eggs will be able to become genetic parents to a child carried by their partner.

Embryo donation

An embryo donation means that the fertilization happens outside the body with both donated eggs and donated sperm.

Embryo donation isn’t legal in Sweden which means a limitation for same sex couples that want to donate eggs to one another within the couple and for trans men who themselves don’t want to carry a child but has eggs or previously frozen eggs. It’s the Genetic Integrity Act that regulates this, and it states the following:

A fertilized egg can be placed in a woman’s body only if the woman is married or lives with a partner and the husband or partner has consented to this in writing. If the egg isn’t the woman’s, the egg should have been fertilized by the husband’s or partner’s sperm.

The background to the writ is a thought that the child should have a genetic connection with at least one of its parents, which would be the case if the donation of eggs was to happen within a couple. When this law was written assisted fertilization at a clinic wasn’t legal for same sex couples in Sweden, and therefore there was no consideration about making egg donation within a same sex couple possible.

Embryo donation and donation of eggs within a couple is legal in many European countries, so it is possible to travel to another country and have the treatment there, but it means financial costs and a more legally uncertain situation. If a woman in a same sex couple or a trans man donates an egg to their partner who carries it and gives birth to it, the person whose egg was used will be the genetic parent of the child, but they won’t necessarily be seen as a parent in Sweden. If the trans man is married to the woman that has carried the child he will (if he has a male social security number) be registered as the father to the child through fatherhood presumption. The woman in the same sex couple will, even if she’s married to the person who carried the child, need to apply for a related adoption.

Sibling treatment

In Sweden all fertility treatments aimed at having a sibling are self-funded. That’s because when you have a child (or two if it’s twins) you’re no longer involuntarily childless. In Sweden it’s only possible for involuntarily childless couples or singles to get publically financed fertility treatment.

What rules apply to sibling treatment?

At most clinics, both public and private, the starting point is that the first child should be at least one year old before efforts to have a sibling begin. If it’s the same person that’s to become pregnant a second time, possible breastfeeding of the first child must be finished before a sibling treatment starts. At the public clinics there’s often only the opportunity to try to have one sibling, and no possibility for a third child. Families that have had twins through previous insemination or IVF can be denied sibling treatment at the public clinics, but it varies between the clinics. At the private clinics there are no such limitations about the number of siblings.

Can we use the same donor?

Many who become parents through sperm donation have a wish to use the same donor in sibling treatment. It can be about wanting your child to be genetically connected through the donor. Others have a wish of changing donors in a sibling treatment. It can be about wanting that your child in the future should have an individual choice about whether they want to find out the donor’s identity or not. In a family with multiple siblings, having the same donor could lead to a conflict if one of the siblings wants to find out the donor’s identity and another sibling doesn’t want to. By changing donors before a sibling treatment this can be avoided. In a sibling treatment it’s good that you have thought about this issue.

At Swedish public clinics the starting point is always to use the same donor in a sibling treatment. Only in rare cases there’s a need to change donors, for example if the first child has a serious disability or if the donor is deceased. So if you would like to change donors in a sibling treatment it’s commonly not possible at a public clinic in Sweden. At the private clinics however it’s most often possible to change donors. At many clinics abroad it’s also possible, but it can vary from clinic to clinic and be different in different countries. Always check with your clinic to get information about their rules.

Can we switch carrier in a sibling treatment?

Yes, at Swedish clinics, both public and private, this is possible, with one exception. If the first child has been conceived through IVF and there are frozen fertilized eggs from the previous IVF treatment, it’s only the person the eggs come from that can try and get pregnant again with these. This is because it isn’t permitted in Sweden that both egg and sperm are donated, so called embryo donation. This applies even if the egg comes from a person that is to become a legal parent to the child. Abroad there are often similar rules.