Inside the technology that’s allowing gay HIV-positive men to start a family

In Toronto’s Barbara Hall Park, behind The 519 community centre, there is an AIDS memorial comprised of columns arranged in a semi-circle. On each column is a list of the names of people in the community who died during a particular year of AIDS-related illnesses. There are a few names for each year in the 1980s, and then suddenly, a proliferation, as fatalities peak in the 1990s before beginning to wane. You can visually track the point at which the disease changed from a certain death sentence to a manageable chronic health condition. After more than a decade of fatal inaction—paltry funding for medical research, expensive and inaccessible drugs, policies that ensured people with HIV remained socially isolated—effective antiretroviral treatment became accessible to Canada’s gay and bisexual communities in the late 1990s, leading to a sharp curtailing of the death count. Now there is only one plaque added each year, with just a few names on it. There are so few deaths that it looks like the original memorial design—a full circle of columns—will, hopefully, never be complete.

Blake, who owns a condo almost directly above the memorial with his husband, Ali, is a marketing executive and among the more than 10,000 people in the city living with HIV. Blake will never be a name on the memorial. When I meet him in person in early April, he seems the epitome of good health: compact and fit, with boyishly handsome features that make him look much younger than his 38 years. Since he was diagnosed in 2010, Blake has taken a daily cocktail of antiretroviral medication that keeps the level of virus in his blood undetectable and prevents him from infecting Ali, a well-built, attractive 37-year-old who has always tested negative. Their health is especially important because for the past year and a half, the couple have been trying to have a baby with Victoria, a 34-year-old mother of two from Sault Ste. Marie, as their surrogate.

Ali, Blake and Victoria are all fake names; while they are open with some of their close friends and immediate family about both Blake’s HIV status and their plans for surrogacy, the public is a different story. For one, despite increasing awareness about how HIV is no longer a death sentence, people living with the virus face ongoing stigma. Canada has the third-largest number of recorded prosecutions for HIV non-disclosure worldwide. It’s a pattern that experts on the virus say is scientifically out-of-date and unnecessarily stigmatizing. People living with the virus who are marginalized in additional ways—Indigenous people, Black people, immigrants and low-income people—also make up a disproportionate number of new infections. (According to 2016 estimates, Indigenous people made up 4.9 percent of Canada’s population but 11.3 percent of new infections.) At Toronto’s Casey House, the country’s first and only standalone hospital for those with HIV/AIDS, communications officer Lisa Macdonald tells me that clients have been turned away from dental offices and, despite policies preventing discrimination, report disadvantages in finding housing and work if they are “out” as HIV+.

A less discussed symptom of stigma: the limited resources for HIV+ parenting. Even among the HIV+ and surrogacy communities, there is little knowledge about how seropositive men can safely father children without transmitting the virus. Statistics on fertility clinics are difficult to find—there is no central agency that gathers data on assisted reproduction in Canada—but a 2010 study found that in Canada, clinics in only five provinces offered fertility treatments to people living with HIV. The same study found that just 26 percent provided sperm washing, a necessary part of the in vitro fertilization (IVF) process for men living with HIV. In 2014, 20 Canadian fertility clinics participated in a survey that found that while 95 percent accepted HIV+ patients for consultation, only half were equipped to provide them with a full range of assisted reproduction technologies. This falls short of the interest HIV+ people have shown in becoming parents. One UK study of 25 gay and bisexual men living with HIV found that roughly half wanted to become fathers, but during medical consultations, their reproductive options were discussed only “rarely.”

This doesn’t surprise Blake, who had always wanted to be a dad but wasn’t sure at first how his status would affect his prospects to conceive a child. “You’re too scared to even ask,” he recalls. “Where do I even go to talk about it? Who do I even ask?” But he says being diagnosed with a disease that had been almost inevitably fatal just 15 years ago has made him more eager to experience parenthood. “HIV really gives you a reality check on how life is worth living.” He wanted nothing more than to share his life with Ali and a child—maybe two. They just needed to figure out how.

Ali and Blake had their first date in 2015, at a tea shop in Toronto’s gay village. Their immediate chemistry came as a surprise to Blake, who had just ended a six-year relationship and wasn’t looking for anything serious. But there was something familiar and admirable about Ali. Like Blake, he was ambitious and optimistic, and Ali’s background—the only son of a tightly knit Lebanese family—wasn’t dissimilar from his own, growing up in a close family of farmers in southwestern Ontario. And unlike too many other men Blake had met, Ali was intellectually minded and compassionate.

“I told him I was HIV+ immediately,” Blake recalls, “and he didn’t even flinch. Ali was the first man I’d dated who was educated about the disease.”

“In the early 2000s, there wasn’t any information about options for having kids when you were in a gay male couple”

As the son of a doctor, Ali had always been proactive about his health; he was one of the first men he knew to start taking pre-exposure prophylaxis (PrEP), when few healthcare providers were recommending it, and many in the gay community were sceptical. (The term #truvadawhore was trending among conservative gay men, based on the misconception that PrEP users were, in the words of one Huffington Post contributor, “irresponsible” barebackers.) Ali’s knowledge of gay men’s health issues again came in handy when, a year or so after he started dating Blake, the two began discussing the possibility of having children.

“When I understood that I was gay, the idea of having children was not really a possibility,” Ali tells me. “In the early 2000s, there wasn’t any information about options for having kids when you were in a gay male couple.” “I remember seeing protesters on TV saying, ‘Two men can’t raise a child!’” Blake adds.

But as same-sex parenting became more commonplace and accepted, Ali and Blake wanted to explore parenthood. With his previous partner, Blake had researched adoption and decided against it. While many couples in Ontario, including same-sex couples, adopt successfully out of the foster care system (same-sex fostering and adoption has been approved by the Children’s Aid Society since 1995), it was still a difficult process that could take years. Other common adoption avenues were restricted: many international adoption agencies, for example, will only consider straight married applicants, and long-term health conditions, including HIV, can exclude applicants. So they started discussing surrogacy.

Ali called up a male couple he knew in Israel who had had two children via surrogacy and donor eggs. “They’d done it in India,” he explains. However, by 2017, surrogacy in India for international parents was becoming increasingly difficult, and, later that year, the country outlawed their international surrogacy business, a blow to the over $300-million revenue India generated from the industry each year.

In Canada, surrogacy and egg and sperm donation are restricted by the 2004 Assisted Human Reproduction Act (AHRA), which criminalizes paying surrogates, egg donors, and sperm donors. However, the Act allows intended parents to seek altruistic surrogacy, where the carrier agrees to undertake a pregnancy without payment (aside from expenses related to the pregnancy and related procedures). There are drawbacks to this system: as few women are willing to undertake an arduous pregnancy without compensation, surrogates are in short supply. It can also be difficult to navigate the Canadian system, as the AHRA prohibits third parties from advertising or arranging surrogacy; that means no agencies facilitate the lengthy and complicated process. While there are a number of legal consultancies that advertise matching intended parents with surrogates for a fee, they can’t promise to arrange the surrogacy itself. Still, there are advantages to the Canadian system: the ban on payment, combined with government-funded health care for surrogates’ pregnancies and births, makes it immensely cheaper than the commercial surrogacy arrangements available in parts of the US, where a single surrogacy can cost up to $150,000. “The cheapest, best option is for you to do it in Canada and that’s it,” Ali’s friend told him. “Don’t look elsewhere.”

Within weeks, the couple were talking to Sara Cohen, a reproductive lawyer in Toronto, who helped them put together a game plan. A friend of theirs had already agreed to provide eggs—as with surrogates, egg donors in Canada are only reimbursed for costs relating to their donation—but a lot of work still lay ahead. Ali and Blake needed to find a fertility clinic that could create embryos with their donor’s eggs and both men’s sperm (as is common among many male couples, they wanted to fertilize half the donor’s eggs with each partner’s sperm). They also needed to match with a surrogate. And, importantly, they needed to make sure all parties were knowledgeable about doing a surrogacy with a gay couple of whom one was living with HIV.

“Don’t even worry about it,” Cohen told them. While their options were limited compared to intended parents without HIV diagnoses, a number of her clients were living with HIV and all had easily located surrogates and clinics who were not only willing to work with them, but did so with understanding and sensitivity.

Blake had anticipated difficulty because of his HIV status, but he and Ali actually found it was more of a struggle to navigate the confusing world of Canadian surrogacy itself. They chatted with representatives from a few consultancies, but found their credibility difficult to gauge. Then, just as things got frustrating, they wound up in a Facebook group for intended parents looking to skip the middlemen and match with surrogates themselves—what’s known as an “indie journey” in surrogacy parlance. Almost immediately, they began chatting with a young woman named Victoria who quickly put them at ease. She had been a surrogate for two couples before, including a gay male couple, and was proud of the three babies she had helped create.

“It’s not an easy thing to start chatting with someone like, ‘OK, you’re having our baby!’” Blake tells me. “But right away we felt very comfortable with her. She was very knowledgeable. The fact that she had two kids of her own and three surrogacies was really important for us.”

Blake and Ali flew to Sault Ste. Marie to meet Victoria for the first time in person in October 2017. Victoria remembers it well: a few weeks before, she had given a speech at an AIDS vigil, drawing on her experience as a surrogate and her personal connections to Sault Ste. Marie’s LGBTQ2 communities to discuss how men living with HIV could use surrogacy to safely father children. The trio had lunch at a restaurant and were chatting amicably when Blake’s expression suddenly changed.

“He fumbled around, then paused and studied my face and said, ‘I have HIV,’’” she recalls. “Just a few weeks ago I was talking about how wonderful this option was, and now I could be a part of it.” She had initially been drawn to surrogacy because her own parents had experienced years of infertility before adopting her as an infant; she had always liked the idea of helping build families. This surrogacy would allow her to help in a new way. Not only would she be creating a new family, she would contribute to a type of family that couldn’t exist only 15 years before.

The couple went home, nervous but excited. There was no baby on the way yet, but both went into “nesting mode”: Blake spent weekends at the couple’s new property up north, restoring it into the perfect summer cottage for a family with small children; Ali, already fit, became more serious about his diet and exercise. “Fresh air, being outdoors, a healthy lifestyle,” he says. “I want to be ahead of the game as a dad.”

In recent years, HIV experts have embraced findings that with HIV, “Undetectable = Untransmittable,” a phenomenon summarized as “U=U” in public outreach. As with much progress around HIV, the U=U awareness campaign started as a grassroots movement among people living with HIV and allies. While HIV researchers had found as early as 2008 that people living with HIV whose viral load had been suppressed to undetectable levels by antiretroviral therapy could not transmit the virus to others, HIV policy and public discussion still reflected the idea that anyone with HIV, no matter their viral load, was an infection risk.

After years of advocacy and pressure by community groups across Europe and North America, HIV clinicians, researchers and policymakers officially established U=U as a standard of care. At the 9th International AIDS Society Conference in 2017, scientists from around the globe declared that an undetectable viral load made transmission impossible. At home, the Canadian AIDS Society issued a statement confirming U=U in 2016, and the Canadian government declared its support of U=U on World AIDS Day in Toronto in 2017.

If U=U applied to intercourse, it also applied to reproduction: alongside the transformation in HIV care came new possibilities to help people of all genders living with HIV conceive and parent children. A consensus emerged that it was safe for seropositive individuals to conceive biological children provided they follow certain protocol and careful planning. Straight couples can conceive via condomless sex, as long as the HIV+ partner has had an undetectable viral load for more than six months and they limit unprotected sex to the woman’s ovulation period; similar guidelines apply to single women and lesbians. But because gay and bisexual men who want to conceive typically do so through gestational surrogacy, which requires IVF, their process is more complicated and costly. IVF requires isolating sperm cells from seminal fluid, which is done through sperm washing.

“If U=U applied to intercourse, it also applied to reproduction: alongside the transformation in HIV care came new possibilities to help people of all genders living with HIV conceive and parent children”

Sperm washing is a relatively inexpensive treatment—somewhere between $300 and $850 a pop—that has been standard in fertility clinics since the 1980s. A basic sperm wash involves diluting a fresh semen sample with a solution containing antibiotics and protein supplements, after which a technician runs the sample through a centrifuge that separates out the sperm out the surrounding seminal fluid. In men who have issues with sperm number or quality, washing concentrates sperm, and thus provides a greater chance of insemination per sample. In an infectious sample, sperm washing removes the virus, by separating the white blood cells in semen (which can contain the virus) from the sperm cells (which do not). And in a sample from a person with low viral load, there is no virus to remove (though sperm will be washed anyway as part of the IVF process).

All of this should make working with HIV+ semen samples relatively straightforward. But Canadian Standards Association guidelines require that laboratories store semen samples from HIV+ men in specially reinforced containers, which are costly and require additional laboratory space. Anti-discrimination legislation does not apply to businesses where accommodating HIV+ clients would burden them with excessive costs or hardship. As such, only a small number of clinics across the country can work with patients like Blake.

ReproMed Clinic in Toronto is one of them. In the early spring of 2017, Blake’s washed sperm was used to fertilize half of the eggs they retrieved from their friend; Ali’s were used to fertilize the rest. They produced seven embryos, which were frozen and stored at the clinic, while the pair went through the lengthy and expensive process of contracting Victoria as a surrogate. Both parties drew up a contract with lawyers and received counselling, and Victoria had a number of tests to ensure that she was medically fit for another pregnancy. Over the next few months, Victoria flew to Toronto to review her medical history with a reproductive endocrinologist, had bloodwork done to check her hormone levels and thyroid function, and underwent a sonohysterogram, a type of enhanced ultrasound where her uterus and fallopian tubes were filled with saline and examined for abnormalities. Once everything was clear, the trio were given the go-ahead to proceed with frozen embryo transfers, a process that required Victoria to take estrogen and progesterone to prevent her from ovulating and maximize her uterine lining.

Over the course of a year, their doctor at ReproMed transferred the embryos, one by one, to Victoria’s uterus, a process that cost more than $1,000 per attempt. (Victoria had limited coverage under the province’s fertility funding, but they still had to pay for her medication, as well as costs associated with her travel to and from Toronto.) Each time, the embryos failed to implant. Not even a faint line on the home pregnancy tests Victoria bought in bulk. It was an eye-opening experience for Victoria, who, unlike the infertile and gay parents she had helped, had never faced challenges trying to conceive. Conceiving her own daughters and the children she had carried as a surrogate had been so easy. “Negative test after negative test for no reason… I’d never felt that out of control,” she says. In between transfers, Victoria tried tweaking her diet and exercise—she even did a cleanse—thinking maybe the small changes would help. Nothing. “It was only a glimpse into what couples go through while battling infertility, but not an enjoyable one,” she says.

Blake and Ali felt even more helpless. “I was trying not to be emotional,” Blake says. “But it was a whirlwind of emotions.” A sense of dejection set in. “At first, I talked to everyone about [the surrogacy] a lot—I was telling everyone I knew, so everyone was really excited for us, and asking about it. And then over time, they stopped asking.”

In November 2018, with two embryos left, the trio decided to switch clinics to Toronto’s Create Fertility, which works with a significant number of patients living with HIV. Maybe the embryos were failing to implant because there was an issue with the transfer protocol at the clinic, or maybe there was a medical problem on Victoria’s end. They had their embryos transferred from one lab to the other, and the new clinic had Victoria undergo a hysteroscopy—a procedure where a tiny camera is inserted into the uterus to check for fertility-impairing fibroids or other abnormalities. The tests came back normal. They prepared for another embryo transfer. “This is it,” Blake thought. “This has to work.”

It didn’t.

Surrogacy wasn’t working for Ali and Blake, but still, they knew they were lucky. They had the resources to even try it. Canada—and Toronto in particular—has become a hub for gay men worldwide, including those living with HIV, to have children via surrogacy, which is unregulated or banned outright in most parts of the world. Canada does not gather statistics on surrogacy, but experts I spoke with concurred that, despite the often complicated and time-consuming nature of our altruistic surrogacy system, hundreds of gay couples and single men seek out surrogacy arrangements here each year. Canada is one of a handful of countries, along with Greece, Ukraine, Georgia and some parts of the US, that allows foreign intended parents to make surrogacy arrangements; however, only Canada and surrogacy-friendly US states include same-sex couples in this legislation. Ontario’s straightforward parentage process is also attractive. The All Families are Equal Act, passed in the province in 2016, allows both parents of a child born of surrogacy and/or donor gametes to establish parentage shortly after birth; prior to this, same sex couples had to go through the legal adoption process.

Add HIV to the mix, though, and the picture gets more complicated. Some fertility clinics in Europe have been helping men and women with HIV conceive children since the 1980s; several European countries have national programs to help people with HIV plan pregnancies. However, all are countries where surrogacy is illegal, which by default excludes single men and men in same-sex relationships. In parts of the US and in Canada, where surrogacy is legal, patients with HIV are often unaware of their reproductive options; neither country has a national program to standardize and ensure pregnancy planning for people living with HIV.

Dr. Clifford Librach, director of Create Fertility, says while the demand for services is there, knowledge often isn’t. “Not uncommonly, I’ll see a same- sex couple and I’ll say, ‘OK, so we’re making embryos with both of your sperm?’ and they’ll say, ‘We can do that?’ They just didn’t know that you can safely use sperm from an HIV+ man in IVF,” he says. Michelle Pine is a board member of Men Having Babies, a US non-profit that provides education, advocacy and financial assistance to gay men pursuing surrogacy; she’s also a surrogate herself, and carried a baby for a mixed-status male couple (one had HIV, the other did not). She tells me that a general lack of HIV education can deter both men and surrogates from pursuing conception. Compared with the 1990s, at the height of HIV panic, she says that “our education about HIV has decreased. Most people who are the age to be surrogates don’t know the advances that have been made in the past 20 or so years.”

A 2016 metastudy of more than 4,000 intrauterine insemination (IUI) and IVF treatments in which sperm from a man with HIV was used found that there were zero transmissions of the virus to either the pregnant person or child. However, many men living with HIV, as well as surrogates, are unaware of this. “Once I read the statistics about undetectable status, I had no fears at all about carrying for my IFs [intended fathers],” Pine says. But when she reached out to other surrogates as part of her education research, she found that only about half were willing to carry a baby created from HIV+ semen.

The knowledge gap about reproduction on the side of both patients and surrogates is compounded by a service gap in the fertility world, even in countries where surrogacy is legal. A 2005 study of US fertility clinics found that fewer than three percent were able to provide full services to patients living with HIV. To address these inequalities, Dr. Mona Loutfy, a world leader in HIV+ conception and pregnancy and founder of the Women and HIV Research Program at Women’s College Hospital, and her colleagues sought to bring Canada’s fertility industry up to date with HIV research. In 2012, she led the development of the first guidelines for HIV+ pregnancy planning that were sent to clinicians across Canada. (They were updated in 2018.) Key recommendations included counselling on reproductive options for all HIV+ people upon diagnosis, an emphasis on education for HIV care providers and fertility specialists about special needs of HIV+ patients (which can include Hepatitis C testing and proper use of antiretroviral medication during treatment) and help for patients who may be dealing with stigma as they try to conceive and parent.

“‘U=U has been in play since 2015,’ says Logan Kennedy. ‘But in the fertility community, they don’t even know what that is’”

Two years later, Loutfy’s team surveyed 34 fertility clinics across Canada to gauge progress. Twenty responded. Of those, only 20 percent had implemented the 2012 guidelines. Compared to 2007, more clinics had improved services to patients living with HIV, but a significant gap in services remained. Barriers to reproduction were numerous and interlinked: treatments like sperm washing and surrogacy can cost tens of thousands of dollars and are not covered by provincial health care. Many people living with HIV are in remote areas and can’t access fertility clinics at all. And, despite the impossibility of a man with an undetectable viral load transmitting HIV through insemination or IVF, legal sanctions around transmission have left many people nervous about attempting pregnancy with an HIV-negative partner or gestational carrier. Even in cases where pregnancy occurs, intended parents living with HIV may still face stigma from others who aren’t aware that such pregnancies are safe for the pregnant person and child.

A big reason for this is that the fertility industry has yet to catch up with the U=U campaign. “U=U has been in play since 2015,” says Logan Kennedy, research program manager with the Women and HIV Research Program in Toronto. “It’s been fully embraced by the HIV+ community, but in the fertility community, they don’t even know what that is.”

In Canada, there’s the unnecessary requirement that semen from HIV+ men with undetectable viral loads be stored separately, for one. And among clinics that specialize in patients living with HIV, there is a lack of consistency in how the findings of U=U are applied. For example, in Bedford, Massachusetts, the Special Program for Assisted Reproduction (SPAR), which has helped deliver hundreds of babies worldwide to men living with HIV and is recommended by many US surrogacy agencies serving the gay male community, pre-tests semen for HIV before washing sperm. They do so under the assumption that the sample size of HIV+ IVF cycles is currently too small to conclude that transmission of the virus to pregnant person or child is impossible, and Pine tells me that many surrogates appreciate this extra safety step. But several experts I spoke with in Canada said that this step contradicts the current science on transmission and is superfluous.

All of this—the paucity of services offered to patients living with HIV, the gap between science and practice, the lack of consistency across clinics—is as reflective of the ongoing stigma against people living with HIV as it is of the often glacial nature of progress in the assisted reproduction world. As the researchers of the 2012 HIV+ pregnancy planning guidelines conclude, clinics fail to meet the needs of patients living with HIV partly due to a perceived lack of demand, and partly “out of concern that serving HIV-positive people could deter HIV-negative individuals from accessing services.”

After the fifth embryo transfer to Victoria failed, Blake and Ali felt like they were at a dead end. They’d lost one embryo in the thawing process, and now had only one left; the chance of it turning into a baby were slim. Transferring the last embryo would be an expensive gamble. “We were doing the same thing over and over again, with the same results every time,” Blake explains. “It was really frustrating.”

Another IVF cycle with another egg donor would cost over $10,000 more, and who knows how many additional embryo transfers they’d have to pay for. “The idea of us going through this again was putting such a burden on me,” Ali says. He and Blake considered calling the whole thing off and going forward as a family of two.

Meanwhile, Victoria had been researching. As an adoptee, she’d thought a lot about family and DNA, and had come to a place where she saw genetic connections as secondary to the bond of commitment. Could she be Blake and Ali’s egg donor, in addition to carrying the baby? The more she considered it, the more secure she felt about Blake and Ali raising a child to whom she was genetically connected. “There’s value in a genetic connection,” she tells me. “But anyone who thinks that’s at the forefront of what makes up a family is missing the big picture. I’m not genetically related to my parents.” Meanwhile, Victoria had come to see Blake and Ali as her chosen brothers. Donating her egg to them felt like a natural extension of their existing bond. “There will always be that genetic connection [to the child], who may have questions for me to answer as they grow up, but that’s okay,” she says. “I can be their surrogate mother and a genetic contributor without being their parent.”

With Victoria’s eggs in play, the couple could bypass IVF, and the thousands of dollars it cost, altogether. She knew that straight couples where the man was HIV+, and had an undetectable viral load, could conceive without the risk of transmitting the virus to the woman or baby. She and the intended fathers could do the same thing, only using the “turkey baster” method of home insemination, rather than intercourse. She received the go-ahead from Dr. Loutfy to use Blake’s sperm, as long as she could ensure his viral load had been undetectable for more than six months. She put the idea to Blake and Ali, who were intrigued, but a bit wary: in Canada, traditional surrogacy—where the surrogate uses her own egg and one of the parents’ sperm—has long been disfavoured. Clinics and lawyers largely advise against it, under the impression that surrogates were more likely to become attached to babies they carried with whom they shared DNA. The couple phoned Sara Cohen again for legal advice, and were happy to hear that the scepticism professionals have around traditional surrogacy is largely unwarranted: with the right counselling and forethought, traditional surrogacies go as smoothly as gestational surrogacies. As with gestational surrogacy, both dads would go on the baby’s birth certificate shortly after birth, making them full legal parents. “When I realized [legal complications were] a non-issue, for me, everything seemed kosher,” Ali says. “And the more I thought about it, the more I realized, why didn’t we do this in the first place?”

“There’s less stress on everyone, just being out of the clinical setting,” Blake says. At the same time, the couple is trying to be realistic about their chances, and make conceiving “not the only focus.”

“If Blake had a baby, it would almost be a reversal of the isolation, stigma and loneliness with which too many men living with HIV continue to struggle”

In the spring of 2019, the trio—nervous, excited and, given their history, cautious—started planning their new surrogacy journey. Traditional surrogacy meant they didn’t have to submit to the schedules and instructions of fertility clinics and doctors. With home inseminations, they were at the mercy of Victoria’s menstrual cycle, which she tracked with home ovulation predictor kits. This introduced a new set of challenges: there was a short window during which Victoria could conceive, which meant one of the men would have to show up at her home on short notice to provide the semen sample. Blake and Ali had imagined having two kids, one with sperm from each of them, but they had no preference about who went first. They decided that sperm would be provided by whichever of them could most easily make it out to Sault Ste. Marie for each cycle.

In late-June, Victoria saw a dark line on her ovulation predictor kit and phoned Ali and Blake to let them know. Blake was stuck in Toronto for work, but Ali, an airline worker, could fit a Sault Ste. Marie stopover in between flights for his job. A year and a half after they first connected, Ali flew to the Soo and, after some laughing at the awkwardness, provided Victoria with his semen sample.

I arrived a few hours later and met Ali for the first time. Over lunch, he and Victoria chatted about the pregnancy—what names the couple had picked; where she wanted to give birth; whether the baby might think of Victoria’s own daughters as sisters or cousins or who knows. It was a friendly, familial conversation; it was easy to forget just how much the two of them, along with Blake, had been through to get to that point. Blake had also talked about how, if he had a baby, it would almost be a reversal of the isolation, stigma and loneliness with which too many men living with HIV continue to struggle. “If we can be dads, it will be a complete 180 of what I felt was possible when I was diagnosed,” he says.

There are two weeks between the insemination and Victoria’s pregnancy test, and during that time, Blake and Ali wait. Over the past year and half, waiting is something they’ve become good at. When they were doing embryo transfers at fertility clinics, Blake says, it was easy for him to get caught up in obsessing over the results, and he had been neglecting other areas of his life. “Now, I’m just trying to take things in stride,” he says, when I call him after I return to Toronto. He still talks to Victoria often, but they chat less about the surrogacy and more about everyday stuff. When Victoria’s pregnancy test comes back negative, he and Ali are disappointed, but not crushed.

“It’s only one try, and only our first attempt doing [a traditional surrogacy], so it wasn’t that difficult,” Blake tells me. “I know there are straight couples who have to try for months and months.”

“It’s a learning curve for the three of us,” Ali adds. “I wasn’t expecting a positive test on the first try. We’re just really lucky that we have someone who is willing to stick with us until something works.” The couple filled their schedule with other plans: their cottage was nearing the end of renovations, and they were planning a trip there for the end of the summer. Blake was also helping out on his parents’ farm, preparing produce for local farmers’ markets. “Any energy we use to worry can be used to accomplish other things,” he says.

It’s a commitment to his own mental health and happiness that Blake has cultivated over the years, and one he’s eager to teach his kids. “I think I’ll be a more open parent with my kids than I would have before,” he says. “And also I think I can help them be more accepting of difficulties that might come their way. It’s not about what’s happened to you, it’s how you deal with it that matters.”

In the middle of August, Victoria saw the happy face on her ovulation predictor kit again, and again made a call to Toronto. This time, it was Blake who had an opening in his schedule. Months before, he had confided in his boss that he and Ali were trying to get pregnant with a surrogate located out of town, and that August day, he was grinning when he approached her to ask for time off. “Get out of here,” she told him. “And don’t worry about coming in tomorrow either.” I ask Blake if he was nervous about his first home insemination. He wasn’t. “I mean, it’s literally a miracle in the first place,” he says. “We’re really fortunate to be this far along in the process at all, to even have a surrogate, and to be in Canada where we can do this.” Maybe there was a reason for all the struggle, he thought; maybe it was meant to work out this way. Sometimes the universe gives you signs, and your job is to follow them.

Blake got to the airport just in time to catch the outbound flight to Sault Ste. Marie. There was only one seat left on the plane, and he took it.