Surrogacy
Surrogacy is an adoption arrangement, often supported by a legal agreement, whereby a woman agrees to childbirth on behalf of another person(s) who will become the child's parent(s) 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.
This article is about a type of pregnancy. For other uses of the word "surrogacy", see Surrogate.
While a surrogacy relationship or legal agreement contains the gestational carrier and the child's parent(s) after birth, the gestational carriers are usually being referred as surrogate mothers. Surrogate mothers are the woman who carries and gives birth to a baby for another person, in such process of surrogacy.[1] Surrogate mothers are usually introduced to parent(s) in need of surrogacy through third-party agencies, or other matching channels. They are usually required to participate in processes of insemination (no matter traditional or IVF), pregnancy, delivery, and newborn feeding early after birth.
In surrogacy arrangements, monetary compensation may or may not be involved. Receiving money for the arrangement is known as commercial surrogacy.[2]
[3] 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 surrogate.
Risks[edit]
Embryo[edit]
The embryo implanted in gestational surrogacy faces the same risks as anyone using IVF would. Preimplantation 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 implantation, and if multiple gestations occur, both the surrogate and the embryos face higher risks of complications.[10]
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 in gestational carriers often result in preterm labor and delivery, resulting in prematurity and physical and/or mental anomalies.[10]
Surrogate mothers[edit]
Gestational surrogates have a smaller chance of having hypertensive disorder during pregnancy compared to mothers pregnant by oocyte donation. This is possibly because gestational carriers tend to be healthier and more fertile than women who use oocyte donation. Gestational carriers also have low rates of placenta previa / placental abruptions (1.1–7.9%).[11]
In most countries, such as China, there exists a huge gap in the legal framework between the legislation and regulation for surrogacy. Due to insufficient authority supervision, surrogacy and the safety of surrogate mothers lack of professional support or reliable operation, the medical conditions cannot be achieved either. All these precarious factors increases the safety risks of artificial surgeries such as egg retrieval and insemination. Moreover, the underground contracts can inflict serious physiological harm on surrogate mothers. Surrogacy agencies ignore surrogate mothers' health risks and deaths: enforced fetal sex selection through forced abortions are very common,[12] and multiple implantations and fetal reduction procedures may also be repeated on the same surrogate mother, causing health hazards such as miscarriage, infertility, and even death.
Outcomes[edit]
Among gestational surrogacy arrangements, between 19–33% of gestational surrogates will successfully become pregnant from an embryo transfer. Of these cases, 30–70% will successfully allow the intended parent(s) to become parent(s) of the resulting child.[13]
For surrogate pregnancies where only one child is born, the preterm birth rate in surrogacy is marginally lower than babies born from standard IVF (11.5% vs 14%). Babies born from surrogacy also have similar average gestational age as infants born through in vitro fertilization and oocyte donation; approximately 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.[11]
Indications for surrogacy[edit]
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 (also known as Mayer–Rokitansky–Kuster–Hauser syndrome)[14] or post-hysterectomy.[15] 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.[15] 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.[16] The biological impossibility of single men and same-sex couples having a baby also may indicate surrogacy as an option.[16]
Gestational surrogacy[edit]
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 (IVF), using the eggs and sperm of the intended parents or donors, and is then transferred to the surrogate.[17]
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.[13]
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.[13]
The most commonly reported motivation given by gestational surrogates is an altruistic desire to help a childless couple.[13] Other less commonly given reasons include enjoying the experience of pregnancy, and financial compensation.[18]
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 since the ancient times. 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.[19][20]
Many developments in medicine, social customs, and legal proceedings around the world paved the way for modern surrogacy:[21]
Psychological concerns[edit]
Surrogate[edit]
Anthropological studies of surrogates have shown that surrogates engage in various distancing techniques throughout the surrogate pregnancy so as to ensure that they do not become emotionally attached to the baby.[26][27][28] Many surrogates intentionally try to foster the development of emotional attachment between the intended mother and the surrogate child.[29] Some surrogates describe feeling empowered by the experience.[27][30]
Although gestational surrogates generally report being satisfied with their experience as surrogates, there are cases in which they are not.[31] Unmet expectations are associated with dissatisfaction. Some women did not feel a certain level of closeness with the couple and others did not feel respected by the couple. Some gestational surrogates report emotional distress during the process of surrogacy. There may be a lack of access to therapy and emotional support through the surrogate process.
Gestational surrogates may struggle with postpartum depression and issues with relinquishing the child to their intended parents.[32] Immediate postpartum depression has been observed in gestational surrogates at a rate of 0-20%. Some surrogates report negative feelings with relinquishing rights to the child immediately after birth, but most negative feelings resolve after some time.[33]
Child and parents[edit]
A systematic review[32] of 55 studies examining the outcomes for surrogacy for gestational carriers and resulting families showed that there were no major psychological differences in children up to the age of 10 years old that were born from surrogacy compared to those children born from other assisted reproductive technology or those children conceived naturally.
Gay men who have become fathers using surrogacy have reported similar experiences to those of other couples who have used surrogacy, including their relationship with both their child and their surrogate.[34]
A study has followed a cohort of 32 surrogacy, 32 egg donation, and 54 natural conception families through to age seven, reporting the impact of surrogacy on the families and children at ages one,[35] two,[36] and seven.[37] At age one, parents through surrogacy showed greater psychological well-being and adaptation to parenthood than those who conceived naturally; there were no differences in infant temperament. At age two, parents through surrogacy showed more positive mother–child relationships and less parenting stress on the part of fathers than their natural conception counterparts; there were no differences in child development between these two groups. At age seven, the surrogacy and egg donation families showed less positive mother–child interaction than the natural conception families, but there were no differences in maternal positive or negative attitudes or child adjustment. The researchers concluded that the surrogacy families continued to function well.
Financial aspects[edit]
According to the Assisted Human Reproduction Act adopted in 2004, it is prohibited in Canada to compensate a female for acting as a surrogate mother or to advertise the payment of such compensation.[64] However, on October 1, 2016, Health Canada announced its intention to update and strengthen the Assisted Human Reproduction Act to regulate the financial aspects of contracts between intended parents and surrogate mothers.[64] According to research, surrogate mothers are mostly motivated by their low socioeconomic status or family debt;[12] they are more likely to be forced into surrogacy due to financial pressures. In 2020, Section 12 of the Assisted Human Reproduction Act provides for the reimbursement of expenses and monetary compensation to the surrogate mother to alleviate the financial burden associated with surrogacy.[64] According to this proposed regulation, the reimbursement of eligible expenses is not obligatory.[64] Aiming at emphasizing the voluntary nature of the gesture. The proposed regulation provides a non-exhaustive list of different categories of eligible expenses, such as parking fees, travel expenses, caregiver expenses, meals, psychological consultations, etc.[64] Additionally, the surrogate mother can be reimbursed for any lost wages during pregnancy if she obtains written confirmation from a qualified physician that the work posed a risk to the pregnancy.[64]