This retrospective study surveyed decision-making and challenges among 78 gay cisgender male couples utilizing in-vitro fertilization (IVF) and a gestational carrier. While most couples (67.1%) found the decision to actively pursue fertility treatment ‘not difficult’, 32.9% felt that it was ‘somewhat difficult’ or ‘very or extremely difficult’. Almost 30% of couples had not undertaken financial planning for treatment, which introduced delays of >2 years for 25.3% of participants. Conceiving twins was ‘important to very important’ in 52.3% of couples, and 84.2% of couples chose to transfer two embryos to ‘increase the odds’ or reach an ideal family size in a single attempt despite increased complications with multiple pregnancies. Paternal leave was granted for one partner in 47.3% of couples, and for both partners in 43.2% of couples. One-third of couples reported experiencing discrimination, prompting a partner to seek employment, and 38% changed jobs or careers. For 80.3% of couples, the estimated cost exceeded US$100,000. Couples where one partner was aged >50 years were significantly more likely to find the decision to actively pursue fertility treatment ‘very or extremely difficult’ (28.6%), and less likely to agree on becoming parents (64.3%). Gay male couples undergoing assisted reproduction face challenges regarding decision-making, lack of infertility benefits and discrimination, which appear to be influenced by age and country of residence. Policy and educational changes are needed, including broader fertility benefits, more egalitarian parental leave, and greater awareness of risks inherent to multiple gestation.
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