Surrogacy


Surrogacy is an arrangement whereby a woman gets pregnant and gives birth on behalf of another person or couple who will become the child's legal parents after birth. People pursue surrogacy for a variety of reasons such as infertility, dangers or undesirable factors of pregnancy, or when pregnancy is a medical impossibility. Surrogacy is highly controversial, with many countries legally regulating or banning its practice.
A surrogacy relationship or legal agreement contains the person who carries the pregnancy and gives birth and the person or persons who take custody of the child after birth. The person giving birth is the gestational carrier, sometimes referred to as the birth mother, surrogate mother or surrogate. Those taking custody are called the commissioning or intended parents. The biological mother may be the surrogate or the intended parent or neither. Gestational carriers are usually introduced to intended parents through third-party agencies, or other matching channels. They are usually required to participate in processes of insemination, pregnancy, and delivery.
In surrogacy arrangements, monetary compensation may or may not be involved. Receiving money for the arrangement is known as commercial surrogacy. The legality and cost of surrogacy varies widely between jurisdictions, contributing to fertility tourism, and sometimes resulting in problematic international or interstate surrogacy arrangements. For example, those living in a country where surrogacy is banned travel to a jurisdiction that permits it. In some countries, surrogacy is legal if there is no financial gain.
Where commercial surrogacy is legal, third-party agencies may assist by finding a surrogate and arranging a surrogacy contract with her. These agencies often obtain medical tests to ensure healthy gestation and delivery. They also usually facilitate legal matters concerning the intended parents and the gestational carrier.

Methods

Surrogacy refers to an arrangement where a woman carries a child for intended parents. In some cases, it's specified as traditional surrogacy, where the gestational carrier's own egg is used. More commonly, surrogacy is when the egg comes from someone other than the gestational carrier, making the legal and emotional boundaries clearer.

Surrogacy

Surrogacy was first achieved in April 1986. It takes place when an embryo created by in vitro fertilization technology is transferred to a gestational carrier. Surrogacy has several forms, and in each form, the resulting child is genetically unrelated to the surrogate:
  • The embryo is created using the intended father's sperm and the intended mother's eggs;
  • The embryo is created using the intended father's sperm and a donor egg;
  • The embryo is created using the intended mother's egg and donor sperm;
  • A donor embryo is transferred to a gestational carrier. Such an embryo may be available when others undergoing IVF have embryos left over, which they donate to others. The resulting child is genetically unrelated to the gestational carrier and the intended parents.

    Traditional surrogacy

A traditional surrogacy is one where the gestational carrier's egg is fertilised by the intended father's or a donor's sperm.
Insemination of the gestational carrier can be either through sex or artificial insemination. Using the sperm of a donor results in a child who is not genetically related to the intended parents. If the intended father's sperm is used in the insemination, the resulting child is genetically related to both him and the gestational carrier.
Some choose to inseminate privately without the intervention of a doctor or physician. In some jurisdictions, the intended parents using donor sperm need to go through an adoption process to have legal parental rights of the resulting child. Many fertility centres that provide for surrogacy assist the parties through the legal process.

Risks

Embryo

The embryo transferred to the gestational carrier faces the same risks as any embryo transferred through IVF. Pre-transfer risks of the embryo include unintentional epigenetic effects, influence of media which the embryo is cultured on, and undesirable consequences of invasive manipulation of the embryo. Often, multiple embryos are transferred to increase the chance of success, and if multiple gestations occur, both the gestational carrier and the embryos face higher risks of complications.
Children born through singleton IVF surrogacy have been shown to have no physical or mental abnormalities compared to those children born through natural conception. However, children born through multiple gestation by gestational carriers often result in preterm labor and delivery, resulting in prematurity and physical or mental anomalies.

Gestational carriers

Overall, the medical risks for the gestational carrier, such as pre-eclampsia, are higher than if she were carrying her own genetically related baby. Research showing that gestational carriers have a smaller chance of medical complications such as hypertensive disorder during pregnancy compared to mothers pregnant by oocyte donation are usually comparing younger, healthier, fertile gestational carriers against older, less healthy, infertile women using assisted reproductive technology.
About 5% of surrogate pregnancies develop placenta previa or placental abruptions, which can cause dangerous complications for both the gestational carrier and the baby.
In some countries, such as China, there exists a gap in the legal framework between the legislation and regulation for surrogacy. There can be an increase in the safety risks of artificial surgeries such as egg retrieval and insemination. Moreover, any underground contracts can inflict serious psychological harm on gestational carriers. Surrogacy agencies have ignored gestational carriers health risks which has led to death and have enforced foetal sex selection through abortions. Multiple embryo transfers and foetal reduction procedures may also be repeated on the same gestational carrier, causing health hazards such as miscarriage, infertility, and even death.

Outcomes

Among gestational surrogacy arrangements, between 19–33% of gestational carriers will successfully become pregnant from an embryo transfer. Of these cases, 30–70% will result in live birth.
For surrogate pregnancies where only one child is born, the preterm birth rate in surrogacy is marginally lower than babies born from standard IVF. Both of these rates are higher than the global average. Babies born from surrogacy also have similar average gestational age as infants born through in vitro fertilization and oocyte donation, at approximately 37 weeks. Preterm birth rate was higher for surrogate twin pregnancies compared to single births. There are fewer babies with low birth weight when born through surrogacy compared to those born through in vitro fertilization but both methods have similar rates of birth defects.

Indications for surrogacy

Opting for surrogacy is a choice for single men desiring to raise a child from infancy, same sex couples unable or unwilling for pregnancy, or women unable or unwilling to carry children on their own. Surrogacy is chosen by women for a number of medical reasons, such as abnormal or absent uterus, either congenitally or post-hysterectomy. Women may have a hysterectomy due to complications in childbirth such as heavy bleeding or a ruptured uterus. Medical diseases such as cervical cancer or endometrial cancer can also lead to surgical removal of the uterus. Past implantation failures, history of multiple miscarriages, or concurrent severe heart or renal conditions that can make pregnancy harmful may also prompt women to consider surrogacy.

Gestational surrogacy

In gestational surrogacy, the child is not biologically related to the surrogate, who is often referred to as a gestational carrier. Instead, the embryo is created via in vitro fertilization, using the eggs and sperm of the intended parents or donors, and is then transferred to the surrogate. Because gestational surrogacy includes at least one round of IVF, it is always more expensive than a round of IVF alone.
According to recommendations made by the European Society of Human Reproduction and Embryology and American Society for Reproductive Medicine, a gestational carrier is preferably between the ages of 21 and 45, has had one full-term, uncomplicated pregnancy where she successfully had at least one child, and has had no more than five deliveries or three Caesarean sections.
The International Federation of Gynaecology and Obstetrics recommends that the surrogate's autonomy should be respected throughout the pregnancy even if her wishes conflict with what the intended parents want.
The most commonly reported motivation given by gestational surrogates is an altruistic desire to help a childless couple. Other less commonly given reasons include enjoying the experience of pregnancy, and financial compensation.

History

Having another woman bear a child for a couple to raise, usually with the male half of the couple as the genetic father, has been referenced a couple of times in historical text, but does not seem to ever have been a common practice. Babylonian law and custom allowed this practice, and a woman unable to give birth could use the practice to avoid a divorce, which would otherwise be inevitable.
Many developments in medicine, social customs, and legal proceedings around the world paved the way for modern surrogacy:
  • 1936 In the U.S., drug companies Schering-Kahlbaum and Parke-Davis started the pharmaceutical production of estrogen.
  • 1944 Harvard Medical School professor John Rock became the first person to fertilize human ovum outside the uterus.
  • 1953 Researchers successfully performed the first cryopreservation of sperm.
  • 1976 Michigan lawyer Noel Keane wrote the first surrogacy contract in the United States.
  • 1978 Louise Brown, the first "test-tube baby", was born in England, the product of the first successful IVF procedure.
  • 1985–1986 A woman carried the first successful gestational surrogate pregnancy.
  • 1986 Melissa Stern, otherwise known as "Baby M," was born in the U.S. The surrogate and biological mother, Mary Beth Whitehead, refused to give up custody of Melissa to the couple with whom she made the surrogacy agreement. The courts of New Jersey found that Whitehead was the child's legal mother and declared contracts for gestational carrierhood illegal and invalid. However, the court found it in the best interest of the infant to award custody of Melissa to the child's biological father, William Stern, and his wife Elizabeth Stern, rather than to Whitehead, the gestational carrier.
  • 1990 In California, gestational carrier Anna Johnson refused to give up the baby to intended parents Mark and Crispina Calvert. The couple sued her for custody, and the court upheld their parental rights. In doing so, it defined the legal mother as the woman who, according to the surrogacy agreement, intends to create and raise a child.
  • 2009 Ukraine, one of the most requested countries in Europe for this treatment, has its first Surrogacy Law approved.
  • 2015 India prohibits commercial surrogacy for foreigners over concerns the country has become a hub for reproductive tourism.
  • 2016 A Swedish government inquiry recommends banning all surrogacy in Sweden and taking steps to prevent its citizens from doing it abroad.
  • 2021 The Supreme Court of Mexico ruled that every individual, regardless of sexual orientation, marital status, or nationality, has the right to access assisted reproductive technology to form a family, and that the Civil Code of the state of Tabasco that restricts surrogacy to Mexican married couples is unconstitutional. It also ruled that legal parentage should be based on the presence of procreational will, not genetic or gestational relationship.
  • 2024 Italy bans surrogacy both at home and abroad, making it illegal for Italian citizens to travel abroad for surrogacy.
  • 2025 Slovakia passes a constitutional amendment that bans surrogacy.