“ Her bun in my oven ” : Motivations and experiences of two-mother families who have used reciprocal IVF

Objectives: What motivates same-gender female couples to choose reciprocal in vitro fertilization (IVF)? Do their experiences of becoming and being a mother via reciprocal IVF match their pre-parenthood expectations? Background: Reciprocal IVF is a treatment route available to cis, same-gender female couples, and other couples in which both partners have a uterus and egg stores. One partner ’ s egg is retrieved, fertilized in vitro with donor sperm, then carried by the other partner. Existing debate has considered the ethical implications of this treatment route. To date, no empirical research has explored the experiences of families who have used reciprocal IVF. Method: Semistructured interviews were conducted with genetic and gestational mothers in 14 families headed by cis, same gender female couples who had conceived by reciprocal IVF in the United Kingdom ( N = 28 mothers). Data were analyzed according to the principles of reflexive thematic analysis. Results: Four themes were constructed: (a) becoming mums together; (b) legitimacy: “ who ’ s the real mum ” ; (c) choices and constraints; and (d) biological connections strengthen family connections. Conclusion: Families had multiple and nuanced motivations for choosing


INTRODUCTION
An increasing number of LGBTQ+ individuals are pursuing parenthood (Family Equality, 2019) and cis, same-gender female couples make up the largest proportion of this group (S.Goldberg & Conron, 2018).Same-gender female couples may become parents through various routes, and although rates of adoptive parenthood are higher within LGBTQ+ communities than non-LGBTQ+ communities (S.Goldberg & Conron, 2018), many LGBTQ+ individuals desire biologically related children (Richards, 2014).This is typically achieved using assisted reproductive technologies (ARTs).Due to technological advancements and changes in societal attitudes and legislation, there has been rapid growth in the range of ARTs available to same-gender female couples (Inhorn & Birenbaum-Carmeli, 2008).
One novel ART that is growing in visibility and popularity is that of reciprocal in vitro fertilization (IVF), which is also known as shared biological motherhood (Golombok et al., 2022), or ROPA (reception of oocytes from partner; Marina et al., 2010).Through this novel procedure, couples in which both parents have a uterus and egg stores (such as cis women, trans men and non-binary people assigned female at birth) are able to "share" biological parenthood: One partner's egg is retrieved, fertilized in vitro with donor sperm, then carried by the other partner.One parent has a gestational connection to their child, and the other has a genetic connection, providing many couples with the first opportunity to both be biologically connected to their child.
Although current legislation permits access to ARTs for same-gender female couples in 18 European countries (Calhaz-Jorge et al., 2020), there is a lack of information on whether reciprocal IVF, specifically, is permitted.Bodri et al. (2018) noted that most European cases of reciprocal IVF come from the United Kingdom and Spain, and in their clinical study of 121 couples, it was found that around 40% of mothers accessed reciprocal IVF for medical reasons, including low egg count in the birth mother, advanced maternal age, and a history of other unsuccessful treatment routes, such as intrauterine insemination or nonreciprocal IVF (Bodri et al., 2018).In clinical studies, reciprocal IVF has been shown to be a viable route to parenthood for these couples (Bodri et al., 2018;Marina et al., 2010).
Although there is clear justification for the use of reciprocal IVF for medical reasons, ethicists have questioned the use of reciprocal IVF for nonmedical reasons because it requires clinical intervention for both prospective parents without medical justification (Dondorp et al., 2010;Zeiler & Malmquist, 2014).Reviews of the clinical literature have shown less positive pregnancy outcomes in IVF with donor eggs compared to own-gamete IVF (Keukens et al., 2022), and this has raised ethical concerns regarding reciprocal IVF as a treatment route of choice, rather than medical necessity.Given that over half of same-gender female couples have been found to choose reciprocal IVF for nonmedical reasons (Bodri et al., 2018), it is important to understand what these reasons are.
Suggested nonmedical reasons include within-couple equality, the achievement of "shared motherhood," and the avoidance of jealousy between mothers in the family unit (Bodri et al., 2018;Marina et al., 2010;Pennings, 2016;Yeshua et al., 2015).However, there has been no research on the experiences of couples who have used reciprocal IVF, meaning that such suggestions are not empirically grounded.This article draws upon data collected in the first study of two-mother families who have become parents via reciprocal IVF, offering a timely insight into the motivations and experiences of mothers who have chosen this treatment method.It asks two important questions: What motivates same-gender female couples to choose reciprocal IVF?And do their experiences of becoming and being a mother via reciprocal IVF match their pre-parenthood expectations?
Motherhood within the U.K. public sphere In the United Kingdom, the current legal definition of motherhood refers to the "biological process of conception, pregnancy and birth" (McConnell and YY v. Registrar General, 2020).As such, it is not legally possibly for a child to have two mothers, nor is it possible for a trans man who gives birth to be legally identified as a father.Within twomother families, the non-birth mother must instead be registered as their child's "parent" (Green, 2019).U.K. legislation around motherhood can therefore be seen as both heteronormative and cisnormative, as these definitions are not inclusive of any family where conception, pregnancy, and birth are separated, such as in two-mother families who have conceived using reciprocal IVF (Christiansen, 2015).
Legislation can be particularly exclusionary for non-birth mothers.For example, in surrogacy law, the person who gestates the pregnancy receives the legal status of mother regardless of whether they are genetically connected to the child (Richards, 2014).This situation has been described as a "biologisation" of motherhood, and it means that non-birth mothers must navigate this narrow definition of motherhood when forming their own identities.Relatedly, the terms used to describe these mothers, such as non-birth, nonbiological, and other mothers, tend to define these parental roles by what they are not, rather than what they are, highlighting the linguistic hierarchy of m/otherhood (Brown & Perlesz, 2007).As such, it is argued that it is necessary to de-essentialize motherhood and to expand legal definitions of what motherhood means, in order to include the mothering experiences of LGBTQ+ families (Averett, 2021;Frieder, 2021).
LGBTQ+ families' decision making about parenthood LGBTQ+ parents will go to considerable lengths and utilize complex, invasive, and costly technologies to have a genetic child (Richards, 2014).In the context of the lack of inclusivity in legislation for LGBTQ+ parents, it is not surprising that parents often choose to have a genetic child as opposed to an adopted or foster child, in part due to fears of discrimination within the adoption process.Genetic relationships are seen as incontestable in their capacity to convey parenthood, and it has been suggested that ARTs that offer parents a genetic connection to their child may be used as a safety strategy in the face of discrimination (Blake et al., 2017;Bower-Brown & Zadeh, 2021).Similarly, research with lesbian mothers who have used nonreciprocal IVF has found that mothers consider potential discrimination from their extended family when making decisions about who will carry their child, reporting concerns that nongenetically related grandparents will not see the child as their own (Nordqvist, 2015).Reciprocal IVF may appeal to two-mother families as the option that is most likely to help avoid issues of discrimination.
In addition to fear of discrimination, many parents find there are practical constraints to consider when making decisions regarding their route to parenthood.For example, although it is known that LGBTQ+ people have similar desires to become parents irrespective of their income, those with higher incomes have greater choice regarding how they may become parents (Family Equality, 2019;Jennings et al., 2014).This is particularly the case for reciprocal IVF, which is only available in private fertility clinics and is more expensive than nonreciprocal IVF.Beyond economic constraints, some parents find their choices are constrained by national legislation that prohibits LGBTQ+ people from accessing some, or all, ARTs.It is estimated that around 10% of families who have accessed reciprocal IVF in the United Kingdom are crossborder patients (Bodri et al., 2018).
LGBTQ+ parents must balance many complex factors when deciding on their route to parenthood (McInerney et al., 2021).After opting for ART, same-gender female couples must decide which mother will carry the child and how they will divide parental leave.For those considering reciprocal IVF, decisions become increasingly complicated as both members of a couple become medical patients and the number of medical procedures increases (Pennings, 2016).
Two-mother families: The "other" mother and biological inequality Research with two-mother families has found that non-birth mothers are often not seen as a legitimate parent by others and they report feeling anxious and insecure about their absence of a biological connection to their child (Abelsohn et al., 2013;McInerney et al., 2021;Padavic & Butterfield, 2011).In some cases, such feelings of disconnection have been prompted by mothers' lack of physical resemblance to their child (McInerney et al., 2021), which has been shown to be challenging for nonbiologically related parents (Becker et al., 2005).In some cases, grandparents have been found to not recognize their nonbiological grandchild as part of their family (Costa et al., 2020;Nordqvist, 2015).
Donor matching (where physical characteristics of the sperm donor are matched with those of the nonbiological mother) is a strategy that can be used to attempt to overcome lack of resemblance and establish a "figurative bio genetic tie" between mother and child (Jones, 2005, p. 225).The desire for nonbiological mothers to donor match suggests that there is a motivation for non-birth mothers to feel physically connected to their child, although for some two-mother families, nonbiological mothers have reported that they do not want to be pregnant (Malmquist & Nieminen, 2021).Reciprocal IVF may therefore offer non-birth mothers an opportunity to be genetically related to their child without having to undergo pregnancy.
When a same-gender female couple conceives via nonreciprocal IVF or intrauterine insemination (IUI), the egg from one mother is fertilized by donor sperm, and the same mother carries the pregnancy, meaning the other has no biological involvement.Previous research has found that this "biological inequality" raises concerns for some two-mother families, because it contradicts the equality they strive for in their relationship (Malmquist, 2015).For example, A. E. Goldberg and Perry-Jenkins (2007) found housework was shared equally in same-gender female couples, but parenting tasks were still predominantly undertaken by the birth mother.Similarly, Keegan et al. (2021) found that, because of pregnancy and birth, biological mothers felt like they had a unique bond and instinctual physical and emotional connection to their child.However, they also experienced a larger burden to be a stereotypical mother and primary caregiver than their partner.
The time spent and bond forged through breastfeeding has been proposed as one of the reasons for unequal division of parenting between biological and nonbiological mothers.Breastfeeding has been found to be important for lesbian birth mothers in forming their identity as a mother, whereas non-birth mothers have been found to feel excluded as breastfeeding offered their partner more availability and opportunity to comfort their child (Rippey & Falconi, 2017).To address the inequality that arises due to their biological roles, birth mothers have reported that they deliberately created opportunities for the non-birth mother to bond with the child (A.E. Goldberg & Perry-Jenkins, 2007) Reciprocal IVF provides the non-birth mother with a genetic tie, but it is unknown whether this tie will offer protection against the feelings of inequality described by same-gender female couples who conceive via routes that do not involve both mothers biologically.

Current study
The literature on LGBTQ+ parenthood suggests that reciprocal IVF offers couples the opportunity to overcome practical and medical limitations and become parents in line with their preferences.It may also appeal as a strategy to avoid discrimination by providing both mothers with a biological relationship to the child.Given the feelings of insecurity reported by non-birth mothers and the emphasis placed on equality within many two-mother families, it has also been suggested that reciprocal IVF may enhance equality within the couple (McInerney et al., 2021).It is currently unknown whether these motivations do indeed drive couples to choose this route to parenthood.Additionally, it is not known whether couples' reasons for choosing reciprocal IVF are reflected in the reality of becoming and being a mother via this route.Thus, the current study asks two key questions: What motivates same-gender female couples to choose reciprocal IVF?And do their experiences of becoming and being a mother via reciprocal IVF match their pre-parenthood expectations?

Recruitment and sampling
This article focuses on 28 parents from 14 families who took part in a larger study of motherchild relationships in families created through reciprocal IVF (Golombok et al., 2022).Participants were recruited through the London Women's Clinic, an independent fertility clinic in the United Kingdom.Email contact was made with all parents with a child aged between 0-8 years who had consented to being contacted for research purposes at the time of their reciprocal IVF treatment.To allow for in-depth analysis of a rich data set, this article focuses on a subsample of couples with children aged 0-3 years.These parents had chosen reciprocal IVF and undergone treatment more recently, which lead to detailed discussions about their motivations and experiences during the interview.
The current sample includes all families who had a child aged 0-3, responded to the recruitment email, had accessed reciprocal IVF in the United Kingdom between 2017-2020, and were still cohabiting at the time of interview.Children were aged between 6 and 33 months (M = 20.50,SD = 8.77), gestational mothers were aged between 29 and 43 years (M = 37.86, SD = 4.13), and genetic mothers were aged between 31 and 44 years (M = 36.93,SD = 4.29).Of the 14 families included in this article, six had more than one child at home: Two families had an older child living with them part-time from a previous heterosexual relationship, and four couples had another child conceived through nonreciprocal IVF, or via reciprocal IVF with the biological roles reversed.The sample had a high socioeconomic status, with 90% of parents (n = 25) in either professional or managerial occupations.Five parents in three families (10%) reported that their family was experiencing some financial difficulties at the time of interview.Of the 22 parents who provided demographic information about ethnicity and nationality, 90% of mothers (n = 20) described their ethnicity as White-British or White-Other.In terms of nationality, 17 parents (77%) identified as British or Northern Irish.Further demographic information is not provided to protect participant anonymity within this sample.

Interviews
Written, informed consent to take part in the study was obtained from all participants.Verbal consent to ask questions relating to each topic was obtained at the start of each interview section.The study received ethical approval from the University of Cambridge Psychology Research Ethics Committee.Each family received a £30 voucher for taking part in the research.
Both genetic and gestational mothers from the 14 families were interviewed separately by one of two trained researchers (KS & AM).Participants were asked about their experiences of the treatment journey, including their motivations for choosing reciprocal IVF, and their experiences of parenting.Questions sought to explore how participants thought and felt regarding the biological relationships in their families.Participants were also asked about their experiences as a same-gender family within wider society, including questions relating to disclosure about their method of conception.The content of the interview was influenced by previous qualitative research that explored LGBTQ+ parents' experiences (Bower- Brown & Zadeh, 2021) and the experiences of families formed through other assisted reproductive technologies (Imrie et al., 2020).
Interviews lasted between 45 minutes and 2 hours, and they were conducted either in person at the participants' home or via a video call.The interviews were audio recorded, transcribed, and anonymized.Transcripts were checked for accuracy against the original audio recording during data familiarization.Below, the data are presented verbatim, although pseudonyms are used to protect participants' identities, ellipses have been used to indicate that material has been omitted, square brackets have been used to indicate modifications to the data, and certain repeated words and filler words (e.g., like, you know) have been tidied up to aid legibility.

Analysis
We analyzed the data according to the principles of reflexive thematic analysis (Braun & Clarke, 2021), which aims to identify and understand patterns of meaning across a data set.This analysis took a critical realist approach, a position which is based upon both ontological realism (i.e., there is a reality independent of the way we construct it) and epistemological relativism (i.e., our understandings of the world are socially constructed; Willig, 2016).Within this perspective, reflexive thematic analysis aims to explore the subjective, interpreted realities of participants and pays particular attention to the way in which social structures shape individuals' experiences of meaning making (Braun & Clarke, 2021;Sims-Schouten et al., 2007).
Given the limited qualitative literature relevant to the study's research questions, an inductive approach was taken to analysis.The primary authors engaged in collaborative coding and this was a joint, reflexive process of discussing ideas and assumptions and developing codes, preliminary themes, and thematic maps together (Braun & Clarke, 2021).We undertook lineby-line open coding of all 28 transcripts using ATLAS.ti,and then grouped together codes relating to motivations for choosing reciprocal IVF and experiences of having a child this way.We identified four candidate themes that were salient across the data set (relating to sharing/ togetherness, legitimacy, practical considerations, and bonding as a family).The themes were developed and revised upon reengagement with the data.
Discussion between authors was central at all stages of research, as we aimed to engage fully with how our own experiences, assumptions, and positions shaped both data collection and analysis (Braun & Clarke, 2021;McCorkel & Myers, 2003).The two researchers undertaking data collection (KS & AM) and the researchers involved in data analysis and writing (KS & SBB) are all queer, nonparents.Thus, the researchers may be seen as both insiders (with regards to being LGBTQ+) and outsiders (with regards to not being parents; Hayfield & Huxley, 2015).

RESULTS
The results centered around four key themes, and all themes addressed both research questions.
Theme 1 (Becoming mums together) describes how reciprocal IVF appealed to prospective parents because it offered the opportunity for both mothers to be involved in the process of creating their child.Shared involvement from the start was important because (a) it made parents feel they were "in this together," (b) it allowed them to set a tone of equality within the couple and in their parenting roles, and (c) it felt meaningful and special to them as a couple.After their children were born, the realities of parenting meant that couple equality was difficult to maintain, although the specialness of becoming mothers together remained important.
Theme 2 (Legitimacy: "We're both real mums") explains how parents were motivated to use reciprocal IVF so that they would (a) be seen as a "real" mum by others, and (b) feel like a "real" mum themselves.In general, participants reported that their genetic/gestational relationship to their child was useful in ensuring that others saw them as a legitimate parent, although many still faced questions about their legitimacy.Participants' biological relationship with their child promoted feelings of legitimacy and security within the couple, although for many mothers the importance of biological connections declined over time.
Theme 3 (Choices and constraints) describes the medical reasons why couples had accessed reciprocal IVF, highlights the practical considerations that went beyond the medical remit, and explores the experiences of families whose treatment choices were shaped by practical constraints, such as cost.
Theme 4 (Biological connections strengthen family connections) explores participants' choice of reciprocal IVF as a means of promoting parent-child bonding.Many gestational mothers described instantaneous bonding with their child, whereas the experiences of genetic mothers were more varied.Joint biological connections with the child were described as important in strengthening both the couple's relationship and relationships between siblings within a family.However, many mothers reported that despite their biological connection, the absence of a genetic or gestational connection could sometimes lead to difficult feelings.

Sharing experiences
The opportunity for couples to become mums together was a key motivator for choosing reciprocal IVF over other fertility treatments available to same-gender female couples: "We talked about IUI, where you basically squirt it in … but then we considered actually that way, we don't get to share the experience of it" (Abby, gestational mother).
Some couples described how reciprocal IVF enabled them to share the clinical experience of the IVF process: We both had to do injections, we both had to do scans, it was very much like we were in this together and it felt like we were making a baby.'Cos obviously you wish every day that you could just go upstairs, have sex and fall pregnant, but it's really not that fun at all.So that was the advantage of it … we were in it together.(Marsha, gestational mother) Beyond opting for reciprocal IVF, decisions made during the treatment process were also driven by a desire to share experiences.For example, five couples chose to have their eggs collected at the same time because "we thought it was going to be a nice process of both of us going through the IVF and the egg collection so we both have a very similar experience" (Penny, genetic mother).
One couple shared their experiences particularly closely by choosing to be pregnant at the same time, carrying embryos created from each other's eggs: It was nice having someone with experience at home saying "Okay, this is how it all works, the drugs and everything," because [partner] had literally done it a few weeks before … I think that definitely helped, and it helped through pregnancy as well, just both of us having very similar experiences.(Deb, genetic parent to Child 1, gestational parent to Child 2) Striving for equality.
Same-gender female couples value within-couple equality particularly highly (Malmquist, 2015; A. E. Goldberg & Perry-Jenkins, 2007).This was evident when participants discussed their motivations for choosing reciprocal IVF, with one parent stating that "it was really important to us that we made a family as equally as we could … it was about being equal" (Sienna, genetic mother).In addition, by sharing the process of making their family, parents hoped it would set the tone of equality within their parenting roles: I would say our relationship is very equal … that's kind of what our relationship is founded on … [reciprocal IVF] gave us the chance to both be involved in the process so it didn't feel like "oh this is [partner] having a baby or this is me having a baby."(Meryl, gestational mother) For some parents, being equally involved in the clinical process did provide feelings of equality after their child was born: It's a shared journey anyway, but [reciprocal IVF] is a much closer shared journey, and I think particularly if you did have feelings about involvement or whatever, then I guess this is a good way to get around some of those thoughts.(Kayleigh, genetic mother) However, in practice, Meryl (gestational mother) found that the practicalities of parenting meant that the equality she had hoped for when choosing reciprocal IVF was not necessarily achieved: When we thought about having a baby, I always pictured us doing shared parental leave and maybe having more of a shared experience … but if I'm really honest you still face the same role differences that you do when it's a straight relationship.
In other cases, genetic mothers described how they had to strive for equality in their parenting role by being quite proactive … if you were someone less engaged, I can see how easy it would be to take a step back and let [partner] take the bulk of the work … I had to take supportive partners' leave, and that doesn't really describe it.(Florence, genetic mother) Meaningful as a couple.
The opportunity to create a child who felt part of them both made reciprocal IVF attractive and unique to couples.Some parents described it as a "magical thing" (Penny, genetic mother) because it allowed them to share in a way that wasn't previously available to same-sex couples: "I've been out gay since I was fifteen.I remember never thinking it was possible to ever do that, and then hearing about being able to do that suddenly felt like 'wow, this is exciting'" (Sharon, genetic mother).
Other parents felt that it was especially meaningful to be able to carry their partner's baby because it connected them as a couple: As a straight couple, probably the idea of bringing together your two genetic histories and creating a new being is one of the big motivations for having children and I didn't really feel like we could ever have that, until we discovered that you could do this and all of a sudden, that whole idea of being able to become parents where we were both involved … that was really important.(Abby, gestational mother) Research on different-gender couples has shown the rise in popularity of ARTs that enable parents to conceive in a way that meets the social expectation that children will be biologically related to both parents (Pennings, 2016;Richards, 2014).Mirroring this finding, some participants in the current study felt that sharing the process of creating their child felt particularly meaningful because it offered an experience that had "some parity with heterosexual couples" (Kitty, gestational mother): "We just felt that it was the most similar to a natural way of getting pregnant.So just that we were both involved in the process and we were both needed to make him" (Esther, gestational mother).
Theme 2: Legitimacy: "Who's the real mum?" Being legitimate in the eyes of others A number of parents described being motivated to use reciprocal IVF so that others would accept that "we're both mummies" (Esther, gestational mother): "We are parents because I gave birth, and it's [partner's] DNA.So, no one in the world can doubt that we are both parents" (Chloe, gestational mother).
This legitimacy as a parent was deemed necessary due to pervasive societal ideas about "real" motherhood: They're like, "Oh.So, who is the mummy?" "We're both the mummies.""Yeah, but who, you know, who is the-" They don't want to say the real mummy … And we're like, "Well I'm the biological mother, and [partner's] the birth mother."And they're like, "Oh!So, you're both mummies."(Penny, genetic mother) This hierarchy of motherhood was also present within legislation, with Steph (genetic mother) reporting that gestational motherhood was prioritized when registering her child's birth: "You don't get a choice, whoever gives birth to a child, they have to be mother, parent one … and then I was parent two.But at least these days you're … not 'other' or 'father.'"This highlights the view that legal definitions of motherhood prioritize gestational connections (Richards, 2014), and demonstrates that such legislation does not work for families with two mothers.For some participants, reciprocal IVF offered protection against heterosexist legislation in other countries: I told [my lawyer friend], "I'm a little bit afraid 'cos [my home country] doesn't recognise me as the mother."… And he looked at everything and said, "Well, at the end of the day, you're also the biological mother 'cos it is your egg." (Penny, genetic mother) Notions of maternal legitimacy were also present on the journey to parenthood, with some genetic mothers reporting exclusion, such as clinical staff asking "Should I put you down as the father?"(Florence, genetic mother).The presence of a genetic connection was often not sufficient in overcoming heteronormative assumptions due to the invisibility of genetic connections.In response, some mothers described being very open about their route to parenthood to reinstate the genetic mother's legitimacy: It's like "her bun in my oven" [laughs], so we have been very open about it … it's important for people to know that the other person has had a role to play in creating the baby and actually in some ways a bigger role than the person who visibly looks pregnant.(Meryl, gestational mother) Sometimes genetic motherhood was perceived as more important than gestational motherhood, and some gestational mothers reported feelings of resentment: I felt like I'd been duped.You know what I mean?I felt like I'd been a bit like, I'm a fucking mug, 'scuse my French.I'm a mug, I've gone through all of this and now I've got all these bloody people telling me that she's not mine.(Marsha, gestational mother) Some couples also considered their wider family in their treatment decisions and chose reciprocal IVF so that "both our parents would feel that he was part of their family because he was part of us as individuals" (Esther, gestational parent).In some cases, reciprocal IVF did promote acceptance by couples' extended families: "One of [partner's] relatives … was just asking about the pregnancy and I remember saying about it being [partner's] egg and she was like 'oh that's good so he is my family'" (Esther, gestational mother).
However, in a number of cases, these biological links were still insufficient for acceptance by extended family.As Penny, a genetic mother, reported, "at the beginning, [my mother] didn't even recognise my child as my child because [partner] gave birth."Unsurprisingly, extended families questioning parents' legitimacy was found to be very difficult: "When [child] was first born, my mum said to me 'well I hope that you're gonna have your own baby.'And that crushed me" (Marsha, gestational parent).Camilla managed this through telling her family that "an egg from me and an egg from [partner] was inserted in me, so we don't actually [know] … it's a 50-50." Other parents reported that once their family got to know their child, the biological connections between their children and family were not essential in the long run: We were always wondering … [partner's] side of the family, do they have as much of a connection to [sibling], as they do to [child]?And all the rest of it.And I can honestly say, it's made absolutely no difference … In fact, it's quite surprising how much they all love both the babies completely.(Rio, gestational mother)

Feeling like a legitimate parent
Participants expected that their legitimacy as a parent would be questioned by others, and reciprocal IVF was chosen over nonreciprocal IVF because "in that instance, I wouldn't have any kind of claim, if you like, that I had been there at the start, at the very beginning" (Audrey, genetic mother).Having a claim to their child was particularly important for genetic mothers, due to genetic relationships being invisible to others during pregnancy and birth (see above): "When you're in the hospital room, and they're like, 'Where's mum?' And it's obviously the one who's just given birth.It's [partner]" (Deb, genetic parent).
While at the hospital, Deb also described reassuring herself that "it is my biological baby," which demonstrates that genetic connections can allow nongestational mothers to feel legitimate in the face of exclusion.
Participants also expected that the biological bond to both mothers achieved via reciprocal IVF would offer protection from their children questioning their legitimacy in the future, were they to ask "who's my real mum?" (Florence, genetic mother): We always used to joke where there shouldn't ever be a time where he or any of our children would say "oh you're not my Mum" because "well I am your Mum because I carried you for 9 months" and that shit and that's [partner's] response and my response would be "well I am because you're part of my biology."(Sienna, genetic mother) Once the participants' children had been born, biological relatedness continued to help some genetic parents with "feeling confident" (Jill, gestational mother) as legitimate parents, particularly within the context of some genetic mothers feeling like a "second parent" (Audrey, genetic mother): "I think it gives me security especially in light of the fact that she is actually closer to [partner] … I slightly feel she's part of my clan" (Bea, genetic mother).
Although genetic relatedness did help some mothers feel legitimate beyond the birth of the child, generally, thoughts about biological relatedness offering legitimacy became less relevant as their child grew up: "I was like 'I wanna be biologically … I want it to be mine' … and when she came along it didn't make a single difference really.I don't ever look at her and think she's not mine biologically" (Norma, birth mother).
Other parents noted that "doing" parenting reduced the importance of "theoretical" (Deb, genetic mother) concerns about biological relatedness, with a number of mothers commenting that they thought about their biological relationship to their child less and less: Once they turn two, they become their own individual.And then it really does all go out the window massively.It was something that I would think about maybe every second day and now I haven't thought about it literally for the last six months.(Toni, genetic mother) Theme 3: Choices and constraints

Clinical choices and constraints
Some participants chose to use reciprocal IVF because they wanted to maximize the chance of IVF success by using the "healthier eggs" (Penny, genetic mother) or "best materials" (Bridget, gestational mother) available in their couple, rather than using the eggs of the mother who planned to be pregnant: We were trying to get the best chance, so we went for the egg that had the highest probability of success.That seemed to be mine.On reflection, that was probably a good idea, because [partner] suffers from endometriosis, which was later discovered, and would have made conceiving through IUI almost impossible.And I guess there wasn't a need to use a donor egg because my egg was good enough.(Robyn, genetic mother) Some participants used reciprocal IVF to maximize success, so as to avoid their treatment becoming a "long and drawn-out process" (Jill, gestational parent), whereas for others it was due to a desire to minimize the costs associated with multiple rounds of IVF: "When we were having to pay that amount of money, we wanted the most success" (Fi, gestational mother).
Regardless of their initial reason for choosing reciprocal IVF, many participants stated that the choice of who would fulfill which biological role was shaped by age and/or medical-related considerations: "My age meant that I would be more likely to provide more eggs, and her womb was in a better condition than mine.So it kind of dictated which way round we did it" (Audrey, genetic mother).
For some couples, reciprocal IVF offered a solution to fertility issues.Four families had experienced unsuccessful treatment via other methods, such as nonreciprocal IVF or IUI.In these families, parents explained how using reciprocal IVF "wasn't like a planned thing, it was the doctors who suggested it" (Margot, genetic mother): Using [partner's] egg wasn't our first choice.I tried to get pregnant using my eggs first, as I said I would like to give my body the chance to do what I felt like it was meant to do … that was how we chose the intra-partner thing because it didn't work the other way first.(Jill, gestational mother) Other mothers noted that when they found out about reciprocal IVF, after other unsuccessful treatments, there was "no other way that we wanted to do it" (Marsha, gestational mother): "We made it into this whole 'oh we've always wanted to this' … it's this really nice way of having a biological connection to your child when you didn't give birth to them" (Penny, genetic mother).
Although existing research has tended to categorize parents' motivations for choosing this treatment route as either medical or nonmedical (e.g., Bodri et al., 2018), these responses highlight that parents' motivations are often interconnected and can change over time.

Nonclinical choices and constraints
Decisions about who would provide the egg and who would carry the pregnancy were often mediated by practical considerations.In around half of the families, the genetic parent had no interest in being pregnant: "It was always a no-brainer … she's just never wanted to carry" (Marsha, gestational mother).Some genetic mothers, therefore, were grateful that reciprocal IVF allowed them to be biologically involved in conception, without having to carry a child: I was like, "I never wanna have kids."And then we found out it was a nice way… 'cos she wanted the process of being pregnant, and breastfeeding, and everything, which I never thought about … so it just seemed like a practical way.(Sadie, genetic mother) When both mothers were open to the idea of pregnancy, some decided who would carry the pregnancy based on who was best placed to take parental leave: "[Partner] didn't like her job and because I earn more … financially it made sense for me to stay at work" (Kayleigh, genetic mother).
A number of participants mentioned the cost of reciprocal IVF, with many reflecting that they were "privileged and very lucky to be in a financial position to be able to afford it" (Kitty, gestational mother).However, the choices of several couples were constrained by cost: We had a dream at first that we would both go through the egg retrieval and fertilise, and then that I would carry [partner's] and [partner] would carry mine … but then as we dug into it, it cost a fortune and it would have been crippling costs.(Jill, gestational mother) For other families, the financial necessity of donating eggs to egg sharing schemes to "help with the payment of our treatment" (Kayleigh, genetic parent) motivated their decision regarding whose egg would be used for the pregnancy: It was my egg, but we were planning on doing it the other way around.But we were looking at the egg donation 'cos we couldn't afford it without, and [partner's] hormone level was just outside the cut off to be an egg donor … So that kind of made the decision for us.(Steph, genetic mother) Toni (genetic mother) reflected that financially was definitely the motivation for the sharing of the egg thing.But then at the same time … we felt like it was the right thing to do.We've had to have help having a kid, so why not help someone else.
Theme 4: Biological connections strengthen family connections

Promoting bonding with baby
Parents hoped that the biological connections resulting from reciprocal IVF would help both parents develop a strong relationship with their child.Meryl (gestational mother) described reciprocal IVF as "a great way to create your family and I think that it can create strong bonds." Across the sample, the relationship between gestational mothers and their child was often seen as a "magic bond" (Penny, gestational mother), with Marsha (gestational mother) reporting that "definitely carrying a child gives you that maternal instinct."A number of participants stated that their gestational relationship with their child enabled quicker bonding: "If I hadn't carried him I can imagine I would still love him so much but I feel like that bond might have taken a bit longer" (Meryl, gestational mother).The role of gestation in bonding was reflected on further by mothers who had reversed the biological roles when conceiving another child by reciprocal IVF: "It took me longer to bond with [genetic child], I'd say probably like six, seven months even.Whereas with [gestational child] it was instantaneous … Even though I knew that he's mine genetically, I didn't have that same feeling" (Abby).
For some parents, the gestational connection continued to impact their relationship with the child as they grew older: [When my child] got terribly cold in the sea I held her and sang to her, and it was almost like kind of bringing her back inside of me to warm her up and that was something that I did instinctively from having kind of carried her and breastfed.(Jill, gestational mother) This biologistic approach to understanding bonding, which draws upon the existence of key biological differences between gestational and nongestational motherhood, has also been identified in research with two-mother families who had conceived using nonreciprocal IVF (Malmquist, 2015).
Given the closeness of the gestational bond, some genetic mothers reported that they felt less close to their child than their partner: "I think at the start with all the feeding and stuff, they get that really strong relationship, so yeah I think he's definitely more closer to her than me" (Margot, genetic mother).
Bridget (genetic parent) described her relationship with her genetic child as "very unsatisfactory … all you're doing is holding a crying baby that you can't make feel better … the cooing and the little smiles are so infrequent when you are the second parent." However, other genetic mothers felt that their biological connection did promote bonding with their child.Sienna, a genetic mother, said, it "help[ed] you feel closer to him because you are biologically connected."For others, it was not considered to be so important for their parent-child bond: "He definitely feels safe in both our arms, so I don't think he's got any clue about DNA and who's who" (Robyn, genetic mother).
Biological connectedness was often described as being "important to me even though I don't think it's necessary" (Kitty, gestational mother), with many mothers noting that they would have "fallen in love with them anyway" (Irene, gestational mother) because "whatever child you have, you're still a parent and you'll still have that bond and relationship" (Steph, genetic mother).Relatedly, many participants said that their biological connection to their child was "maybe originally more important … than I think it is now" (Kayleigh, genetic mother) and described how "the more time that passes, the more nine months diminishes in its time frame and meaning" (Deb, genetic mother).Similarly, the majority of parents reflected that the strongest bonds were formed through the doing of parenting, rather than the biological connection: "I think we developed the biggest connections just by looking after her and being responsible for her and watching her develop and I don't think I would love her more or less because of a biological or pregnancy reason" (Gloria, gestational mother).

Avoiding jealousy in the couple relationship
Reciprocal IVF appealed to couples because it could "[make] sure that everyone was really bonded" (Meryl, gestational mother).More specifically, many genetic mothers described choosing reciprocal IVF because they were "afraid of being jealous" (Sadie, genetic mother) of their partner's relationship with the child: If you had your own genetic baby there could be room to feel jealous or some sort of partition in your family like that and I think having each other's eggs completely negates that because, because he's part of her.(Sharon, genetic mother) However, some genetic parents did report difficult feelings within the couple after their child was born because, as described in the subtheme "promoting bonding with baby," the gestational relationship offered "more opportunities" (Florence, genetic mother) for bonding: As far as I'm concerned, the gestational relationship, the breastfeeding, the maternity leave, that's what creates the attachment and the strong bond.… I think if I hadn't contributed to the egg, I'd have perhaps felt even more isolated still.(Audrey, genetic mother) In response, some genetic mothers deliberately created opportunities for bonding with their child, echoing prior research on non-birth mothers in families formed through donor insemination (A.E. Goldberg & Perry-Jenkins, 2007): I remember in the very early days when [partner] had just had [child], I remember just wanting to be as involved as I possibly could, like waking up every two hours … I didn't really need to for the feeding, but I would do the changing … there was a need to be involved.(Deb, genetic mother) Other mothers managed their difficult feelings by looking forward to carrying the pregnancy for their next child: "Knowing that we're hoping that I'll carry next really helps, because I feel like I'm not missing out on stuff, I feel like I'm just waiting my turn" (Florence, genetic mother).
However, gestational mothers also experienced difficult feelings about their lack of genetic connection: I might say "oh she's just done that, she doesn't get that from me."Or "she does get that from me."And [partner] it gives, it's like a little sting each time because [partner] doesn't have that ability to kind of say "oh she gets that from me or not."(Audrey, genetic mother) The difficulties of "resemblance talk" are well documented with other nonbiological parents (Becker et al., 2005) and can be understood as stemming from a societal discourse that prioritizes genetic relatedness.Reflecting on the pain of going through pregnancy and birth for a child she wasn't genetically related to, Marsha (gestational mother) said, I suppose I was jealous of her because she got to not be pregnant, she got to not do the whole birthing thing, and she got to be genetically associated … the cat that ate the cream, do you know what I mean?DISCUSSION Two-mother families often have multiple, nuanced, and varied motivations for choosing reciprocal IVF.Participants chose reciprocal IVF so that they would both have a biological link to their child, in the hope that this would allow each parent to be seen as and feel legitimate, to share the journey of motherhood with each other, and to build strong connections with their child and family.A small number of participants had accessed reciprocal IVF due to medical necessity, but these parents reported that there were also nonmedical, social implications to their chosen route to parenthood.Participants' experiences partially confirm prior suggestions of why reciprocal IVF may appeal to same-gender couples, including overcoming medical or age-related issues, increasing couple equality, avoiding jealousy, and achieving shared motherhood (Bodri et al., 2018;Marina et al., 2010;Pennings, 2016;Yeshua et al., 2015).As expected, decision making was found to be complex, in part due to the additional decisions regarding who will carry, and whose egg will be used, that are specific to reciprocal IVF (McInerney et al., 2021).
The findings highlight that parents' feelings about their route to parenthood, and their experiences of biological connection within their family, can change over time.Mothers' preparenthood expectations regarding reciprocal IVF did not always match the realities of becoming and being a mother this way.Some mothers experienced disappointment that the biological connections made possible through reciprocal IVF proved insufficient for them to be seen as equally legitimate parents within heteronormative society.Genetic mothers had diverse experiences as to whether they felt that their genetic connection helped promote bonding and/or avoid jealousy in their families.Most parents found that the significance of their treatment route diminished, as doing parenting became the primary focus as their children grew up.

One mother, and one mother only
The findings of this study demonstrated that socio-legal notions of "real" motherhood are impactful for parents when they consider their treatment route, and after they have children.As has been found in previous research on LGBTQ+ parents (Blake et al., 2017;Bower-Brown & Zadeh, 2021), participants chose reciprocal IVF due to the uncontested nature of biological relationships.For genetic parents, specifically, their biological bond did help them feel secure in their role as a mother.Reciprocal IVF sometimes allowed both mothers to be seen as "real mums," but in other cases these relationships were contested.Participants reported facing the normative assumptions in legislation, documentation, and interactions with others that are similar to the documented experiences of two-mother families who have conceived by donor insemination (Abelsohn et al., 2013;McInerney et al., 2021).
During pregnancy, birth, and the first few months of the baby's life, the gestational mother was prioritized by clinical staff, and sometimes by participants' extended families, leading many genetic mothers to feel excluded.Feelings of exclusion during pregnancy and birth have been reported in research on the experiences of cis fathers (Hodgson et al., 2021), demonstrating the commonality of this experience among non-birth parents.However, research with trans and cis nongestational mothers has found that it may be particularly difficult to be a nongestational mother (rather than a father) during the perinatal period, in part due to societal understandings of birth and pregnancy as "essential" to motherhood (Bower-Brown, 2022;McInerney et al., 2021).Therefore, it is necessary for clinicians to be aware of the unique needs of non-birth mothers during the perinatal period.
As children grew older, some participants felt a reversal in these unbalanced feelings of legitimacy as parents.For example, gestational mothers reported feelings of jealousy as instances of resemblance talk (Becker et al., 2005) increased when children started to show more similarities to the genetic parent.The current sample was restricted to families with children in infancy and early childhood, so further research exploring the experiences of genetic and gestational mothers with older children is needed.

Biological equality and parenting equality
The study's findings corroborated the suggestion that reciprocal IVF is attractive to samegender female couples because it offers the chance to overcome the biological inequality that occurs when only one parent has a biological connection to their child (McInerney et al., 2021).It was expected that by sharing involvement in the treatment process, reciprocal IVF would facilitate equality in their parenting roles (Pennings, 2016;Yeshua et al., 2015).However, these suggestions were only found to be sometimes supported.Although some mothers found that their genetic or gestational relationship protected against feelings of jealousy, other mothers found that their parenting experiences after birth did not align with their pre-parenthood expectations.Gestational relationships were perceived to be particularly close and special, as gestational mothers had more opportunities to bond through breastfeeding and parental leave.
In some cases this unique closeness was maintained as the child grew older, as has been found for two-mother donor insemination families (Malmquist, 2015).Mothers reported comparing their own relationship with their child to that of their partner (McInerney et al., 2021;Padavic & Butterfield, 2011), and the closeness of the gestational bond was found to be difficult for genetic mothers, some of whom reported feelings of jealousy.Additionally, some gestational mothers reported feelings of jealousy due to their lack of physical resemblance of the child.Such findings echo prior research on two-mother families conceived via nonreciprocal IVF (McInerney et al., 2021) and highlight that, even though each mother had a biological connection to their child, biological equality was not necessarily achieved.

Reciprocal IVF: Reproducing or rupturing normative family ideals
In some ways, reciprocal IVF enables same-gender female couples to reproduce normative family ideals as it allows them to have a child to whom they are both biologically connected.The findings from this study show that such couples are willing to go through invasive and costly procedures in order to create a family in which both mothers have biological ties (Richards, 2014).In social and legislative contexts, priority is given to biological parenthood (Frieder, 2021;Green, 2019).It is therefore understandable that parents had a desire to be biologically related to their children, making reciprocal IVF, the only route that can provide this, particularly attractive.In this way, reciprocal IVF can be seen as contributing to the essentialization of motherhood (Averett, 2021): Participants were more accepted because of their biological relationship to their child.A number of participants reported that part of the appeal of reciprocal IVF was that it was "as close as they can get" to replicating conception via unassisted, heterosexual reproduction.
However, in other ways, reciprocal IVF ruptures traditional notions of who can be involved in creating a child by allowing two cis women intending to parent together to both be biologically involved in conception.This route to parenthood creates a new type of motherhood where genetic and gestational connections are distinct and separated.Importantly, reciprocal IVF potentially offers a viable route to parenthood for trans men and non-binary people with a cis female partner who wish to have genetic children while avoiding pregnancy, particularly given that male/non-binary pregnancy has been found to be an isolating and difficult experience (Charter et al., 2018).
In addition, reciprocal IVF allowed some participants to overcome medical issues to enable them to conceive.It also enabled mothers who did not wish to be pregnant to have a genetically related child, and many participants described feeling grateful for this opportunity.Throughout the interviews, mothers described ambivalent feelings about their desire for biologically related children.Although they were grateful to have been able to access reciprocal IVF, they made it clear that they did not believe biological relationships were necessary to be a real mother.There existed a juxtaposition whereby parents wanted biological relationships for themselves but did not wish to reproduce discrimination against families that do not share biological connections.

Strengths and limitations
The qualitative approach taken in this article offers a novel insight into the motivations and experiences of two-mother families who have conceived children via reciprocal IVF.The strengths of this study lie in the inclusion of both the genetic and gestational mothers' perspectives from each family, and in the relatively large sample size for an analysis of this depth.The study may be limited by selection bias, with families who had a positive experience of reciprocal IVF being more likely to respond to the call for participation, although the diversity observed in the narratives in the sample suggests otherwise.This study focused only on the experiences of two-mother families who were cohabiting at the time of interview.Parents who have separated after conceiving via reciprocal IVF may have different experiences, and future research should include the perspectives of these families.Homogeneity in the socioeconomic status of the sample also limits the generalizability of the findings, but given the costs involved in this treatment route, the sample is likely to be representative of couples who have accessed this treatment in the United Kingdom.

Conclusions and implications
Legal and social definitions of motherhood center around there being one real mother who is biologically related to their child in all possible ways (Frieder, 2021;Green, 2019).Clearly, existing definitions and legislation are not appropriate for two-mother families in general, and particularly not for those who conceive via reciprocal IVF.Promoting the inclusion of all parents in legislation, birth services, and wider society, irrespective of whether they have a biological connection to the child, will be beneficial to families of any nontraditional structure.
Ethical debate has considered whether allowing reciprocal IVF for nonmedical reasons is acceptable (Dondorp et al., 2010;Zeiler & Malmquist, 2014), but such debates have not been informed by empirical evidence.This study demonstrated that same-gender female couples have multiple, interconnected reasons for choosing reciprocal IVF, such as the desire to share the journey of motherhood with their partner, to be perceived as legitimate parents, to overcome practical barriers, and to build strong family relationships.Clear information about the variety of treatment options should be available to prospective parents to allow them to choose the route that meets their reproductive needs and feels right for them as a family.For participants in the current study, undergoing reciprocal IVF together was often very special and meaningful, and participants reported feeling grateful that they had been able to access this novel route to parenthood.It is noted that promoting reciprocal IVF within clinical practice has the potential to lean in to dominant notions that legitimate parenthood means biological parenthood.However, increasing the social acceptability of nonbiological parenthood is not a burden that must be undertaken by LGBTQ+ individuals themselves and the findings of this study suggest that greater availability of reciprocal IVF would be beneficial in allowing more parents the opportunity to access this route to parenthood, described by one of the participants in this study, as a "magical thing" (Penny, genetic mother).