A limited market: the recruitment of gay men as surrogacy clients by the infertility industry in the USA

Sexual and Reproductive Justice and Health Equity for LGBTQ+ Women

LGBTQ+ women have long been overlooked in sexual and reproductive health research. However, recent research has established that LGBTQ+ women have unique and specific needs that need to be addressed in order to improve effectiveness of sexual health education and practice with this historically and presently underserved population. Informed by a reproductive justice framework coupled with liberation psychology theory, this review discusses the current state of sexual and reproductive health and technologies among LGBTQ+ women. In particular, we focus on a range of HIV prevention and reproductive technologies and their use and promotion, including the internal condom, abortion, oral contraceptives, dapivirine ring, HIV pre-exposure prophylaxis, intrauterine device, and other less studied options, such as the contraceptive sponge. Grounded in an intersectional framing, this review acknowledges the intersecting systems of oppression that affect multiply marginalized women inequitably and disproportionately. A sociohistorical, critical lens is applied to acknowledge the well-documented racist origins of reproductive health technologies and ongoing coercive practices that have led to medical mistrust among marginalized and stigmatized communities, particularly racialized LGBTQ+ women, women with disabilities, and women who are poor or incarcerated. Moreover, we discuss the urgent need to center LGBTQ+ women in research and clinical care, community-engaged health promotion efforts, affirming non-heteronormative sexual health education, and health policies that prioritize autonomy and dismantle structural barriers for this population. We conclude with recommendations and future directions in this area to remedy entrenched disparities in health.

International gestational surrogacy in the United States, 2014-2020

OBJECTIVE

To describe characteristics, trends, and outcomes of international gestational surrogacy cycles in the United States (US).

DESIGN

Retrospective cohort study.

SETTING

All assisted reproductive technology cycles in the US reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting Systems that included an embryo transfer to a gestational carrier from 2014 to 2020.

PATIENTS

International vs. US intended parents.

MAIN OUTCOME MEASURES

Cycle characteristics, geographic distributions, and obstetrical outcomes.

RESULTS

Of 40,177 embryo transfers to a gestational carrier from 2014 to 2020, 32% were for international intended parents. The number and percent of international intended parents' gestational carrier cycles increased each year from 2014 (n = 2758, 22.0%) to 2019 (n = 4905, 39.8%) with a decrease in 2020 (n = 4713, 31.8%). Compared with cycles for US intended parents, there was a larger decrease in gestational carrier cycles between 2019 and 2020 for international intended parents (3.9% vs. 32.2%). International intended parents were more likely to be male sex (41.3% vs. 19.6%), older than 42 years (33.9% vs. 26.2%) and identify as Asian race (65.6% vs. 16.5%). International intended parents were largely from China (41.7%), followed by France (9.2%) and Spain (8.5%). Gestational carriers for international intended parents were more commonly younger than 30 years (42.8% vs. 29.1%) and identified as Hispanic race (28.6% vs. 11.7%) compared with gestational carriers for US intended parents. Cycles with international intended parents were more likely to use donor eggs (67.1% vs. 43.5%), intracytoplasmic sperm injection (72.8% vs. 55.4%), and preimplantation genetic testing (79.0% vs. 55.8%). Cycles with international and US intended parents had similar obstetrical outcomes, including live birth (adjusted risk ratio 1.01, 95% confidence interval 1.00-1.03) and multiple pregnancy (adjusted risk ratio 1.00, 95% confidence interval 0.94-1.06) rates.

CONCLUSION

An increasing number of international intended parents are utilizing gestational surrogacy in the US and more frequently using cost-enhancing specialized treatment techniques. This increase is potentially because of restrictive international commercial surrogacy laws and the increased availability of reproductive medical expertise. Given this growing demographic, continued examination of the volume of cross-border reproductive treatment, as well as the legal and ethical considerations, is warranted.

Main topics in assisted reproductive market: A scoping review

BACKGROUND

Infertility affects around 12% of couples, and this proportion has been gradually increasing. In this context, the global assisted reproductive technologies (ART) market shows significant expansion, hovering around USD 26 billion in 2019 and is expected to reach USD 45 billion by 2025.

OBJECTIVES

We realized a scoping review of the ART market from academic publications, market reports, and specialized media news, to identify the main terms and characterize them into the main topics in the area.

DESIGN

We apply an LDA topic modeling process to identify the main terms, and clustered them into semantic synonymous topics. We extracted the patterns and information to these topics and purposed a factor/consequence correlation to them.

RESULTS

We found 2,232 academic papers and selected 632 to include in the automatic term detection. We also included 34 market reports and seven notices produced by specialized enterprises. Were identified 121 most relevant cited terms covering 7,806 citations. These terms were manually aggregated into 10 topics based on semantic similarity: neutral terms (37.2%), economic aspects (17.6%), in vitro fertilization (IVF) commodities & cross-border reproductive care (CBRC) (10.6%), geographic distribution (9.5%), social aspects (7%), regulation (6%), trends & concerns (3.9%), accessibility (3.4%), internet influence (2.9%), and fertility preservation for non-medical reasons (2%).

DISCUSSION

The analysis indicates a market with expressive complexity. Most terms were associated with more than one topic, indicating the synergism of this market's behavior. Only seven terms related to economic aspects, surrogacy and donation represent around 50% of the citations. Except for the topic formed by generic terms, the topic of the economic aspects was the most represented, reflecting macro perspectives such as a-la-carte standard of treatments, many clinics operating on a small/medium scale, and the recent formation of conglomerates. The IVF commodities & CBRC topic brings an overview of gametes pricing and transnational surrogacy, and its regulation. The topic of geographic distribution indicates that that the Asia-Pacific (APAC) market has the most significant growth potential in all fields. Despite the increase in supply and demand for infertility treatments and technological advances in recent decades, the success rate of IVF cycles remains at around 30%. Terms referring to research and development or technical improvement were not identified in a significant way in this review.

CONCLUSIONS

The formation of topics by semantic similarity proved to be an initial path for the elaboration of in-depth studies on the dynamics between several factors, for this, we present the panel classifying main terms into factors (demand, pent-up demand, or distributive) or ART market consequences. Through this approach, it was possible to observe that most of the works addresses economic aspects, regulation and geographic aspects and that topics related to research and improvement have not been addressed. In this way, we highlight the need to deepen the analysis of market elements that may be related to increased efficiency of IVF in the technical field.

Shared Decision-Making Experiences of Couples with Inherited Cancer Risk Regarding Family Building

Patients with hereditary cancer predisposition syndromes have a high likelihood of passing germline mutations to future offspring. Patients at risk for inherited cancer may not have started and/or completed building their families; thus, they must decide about having children and consider the possibility of passing on their germline mutation. Utilizing the Shared Decision Making (SDM) Model, this study explores family building decision-making communication processes in opposite-sex couples with inherited cancer risk (ICR). Fifteen couples completed two recorded, analogue discussions and dyadic interviews at two time points. Participants were recruited through social media and snowball sampling. The constant comparison method was utilized to thematically analyze the data. When couples discussed family building options (FBOs), several themes were identified: FBO risks, FBO considerations, genetic-related FBO logistics, and life FBOs logistics. When deliberating family building decisions, couples shared easy conversational topics (e.g. FBO options and potential child's cancer risk due to a genetic variant) and difficult/conflict-inducing topics (e.g. preparing for possibilities, parenting, emotions, finances, and timing). Last, couples self-reported primary and secondary FBOs. The findings of this study capture couples' decision-making communication process while considering their experiences. Clinicians and practitioners can utilize these findings to support couples' family building decisions considering their ICR.

Commercial Surrogacy: An Overview

OBJECTIVE

 Surrogacy is the process in which a woman carries and delivers a baby to other person or couple, known as intended parents. When carriers are paid for surrogacy, this is known as commercial surrogacy. The objective of the present work is to review the legal, ethical, social, and cultural aspects of commercial surrogacy, as well as the current panorama worldwide.

METHODS

 This is a review of the literature published in the 21st century on commercial surrogacy.

RESULTS

 A total of 248 articles were included as the core of the present review. The demand for surrogate treatments by women without uterus or with important uterine disorders, single men and same-sex male couples is constantly increasing worldwide. This reproductive treatment has important ethical dilemmas. In addition, legislation defers widely worldwide and is in constant change. Therefore, patients look more and more for treatments abroad, which can lead to important legal problems between countries with different laws. Commercial surrogacy is practiced in several countries, in most of which there is no specific legislation. Some countries have taken restrictive measures against this technique because of reports of exploitation of carriers.

CONCLUSION

 Commercial surrogacy is a common practice, despite important ethical and legal dilemmas. As a consequence of diverse national legislations, patients frequently resort to international commercial surrogacy programs. As of today, there is no standard international legal context, and this practice remains largely unregulated.

Pathways to fatherhood: clinical experiences with assisted reproductive technology in single and coupled intended fathers

Objective

To explore the cycle characteristics and outcomes of single and coupled intended fathers (SCIFs) using assisted reproductive technology.

Design

Cross-sectional study.

Setting

Multicenter, fertility practices from 2016 to 2020.

Patients

In this study, cycles among SCIFs with access to fertility coverage from 2016 to 2020 were included.

Interventions

None.

Main Outcome Measures

Our primary outcome was live birth rate. The secondary outcomes included the number of embryos transferred, miscarriage rate, and incidence of multifetal birth.

Results

Five single and 39 coupled intended fathers completed an in vitro fertilization cycle with a majority using egg donation and an agency-based gestational carrier (69.7%, 83/119). In most couples, both partners wanted to serve as the sperm source (64.4%, 29/45). The vast majority (97.7%, 43/44) also used preimplantation genetic testing for aneuploidy. Among the embryo transfer (ET) cycles (n = 27), most consisted of a single euploid ET (74.07%, 20/27), whereas the remaining consisted of a double euploid ET (25.92%, 7/27). The SCIFs had high rates of success, with a live birth rate of 85.19% (23/27). A mean of 1.26 ± 0.44 embryos were transferred, with a majority resulting in singleton birth (70.37%, 19/27).

Conclusions

Our study of SCIFs using assisted reproductive technology in the United States demonstrates that this population shares similar preferences for sperm source and the use of preimplantation genetic testing. Clinical outcomes suggest that this population is successful at achieving a live birth when using egg donation and a gestational carrier.

The ART clock: Temporal limits to assisted reproduction

Conceptualizations of the 'biological clock' in popular imaginary in the USA centre on the temporal limits of fertility, with assisted reproductive technology (ART) an increasingly proposed answer to these constraints (at least in the public imaginary). In this study, I analyse how surrogates in the USA understand their own bioavailability for others' reproductive needs in the commercial ART market vis-à-vis their own reproductive trajectories. Based on interview data with gestational surrogates, I propose a new concept of the 'ART clock' to capture how time shapes the experiences of reproductive workers in the US fertility clinic. My findings point to four important ART time-related issues: (i) women desiring to extend their own 'biological clocks' via surrogacy; (ii) significant time being needed to achieve and sustain third-party pregnancy; (iii) women extending their total reproductive time via repeat surrogacy 'journeys'; and (iv) temporal constraints to surrogacy reproduction regarding time of year, the day-to-day time effort, the number of surrogacy journeys, the total number of pregnancies, and surrogates' age and the ages of their children. Each of these aspects point to important ways that reproductive desire and time shape the labour of reproductive workers, highlighting temporal constraints to assisted reproduction and limits to ART as a solution to delayed reproduction and the biological clock.

Reprowebs: a conceptual approach to elasticity and change in the global assisted reproduction industry

In the last few decades, assisted reproductive technologies (ARTs) have become increasingly transregional and transnational, often involving travel within or between countries or even continents. Until recently, the global ART industry was marked by so-called 'reprohubs'-places (such as southern California, Dubai, Anand, and Mumbai) specializing in the provision of reproductive services. While reprohubs continue to exist, in the last few years, many have splayed out, transforming into something more akin to webs that encompass, but go beyond these hubs. These webs show a unique dynamic capability to tighten, entangle, or extend in reaction to local and global changes, a characteristic which became particularly obvious during the global Covid-19 pandemic. In this paper, we propose conceptualizing this new dynamic capability as 'reprowebs'-an approach that adds a new dimension to the existing conceptualization of reproductive travel and helps us to better understand current developments in the global ART industry.

Cross-border reproductive care in the USA: Who comes, why do they come, what do they purchase?

This article explores the participation of non-US-resident patients/clients in the US reproductive market, garnering a picture of cross-border reproductive care (CBRC) into the USA by drawing on the existing literature, identifying the frequency of and motivations for such arrangements, the primary sending countries, and the reproductive services sought. I find that although the expense of US CBRC necessarily limits the patient/client pool, it is largely non-economic factors that drive CBRC into the USA. The US CBRC patient/client base, which is diverse in terms of national origin, race and sexual orientation, is recruited by the US fertility industry and drawn to the full range of assisted reproductive technology (ART) services, such as in-vitro fertilization, surrogacy, oocyte donation and preimplantation genetic screening/preimplantation genetic diagnosis, available in the US market which are often restricted or limited in their countries of origin. CBRC patients/clients enjoy the legal clarity for establishing parentage and citizenship for their children available in the USA, as well as what some view as a medically and ethically superior ART market.

HIV-, HBV-, and HCV-Related Information on U.S. Fertility Clinic Websites: A Content Analysis

Purpose: People living with human immunodeficiency virus, hepatitis B virus, or hepatitis C virus (PLHIV/HBV/HCV) face barriers to assisted reproductive technologies (ART), in part, due to laws and professional regulations mandating dedicated laboratory facilities and storage tanks for reproductive tissue to minimize theoretical risk of cross-contamination. These guidelines greatly increase the expense of providing equal care, however, fertility clinics are neither required to treat nor disclose whether they treat PLHIV/HBV/HCV. Clinics' websites are an important source of information regarding available services for prospective patients and referring providers. We assessed whether clinic websites disclose availability of ART for PLHIV/HBV/HCV.

Methods: Websites for Society for Assisted Reproductive Technology-accredited clinics in Northeast and South Atlantic United States were searched systematically for HIV-, HBV-, or HCV-specific content. Qualitative and thematic analysis was performed. Clinic characteristics (annual volume, practice setting) were collected.

Results: Of 136 websites, nine (6.6%) had information relevant to PLHIV seeking infertility treatment, and seven (5.1%) offered at least some treatments. Three clinics (2.2%) also mentioned treatment information relevant for PLHBV/HCV, one of which offered treatment. Information was often difficult to find or interpret. By contrast, 77/136 (56.6%) of clinics mentioned universally screening patients for HIV and 77/136 (56.6%) mentioned screening for HBV/HCV before ART.

Conclusion: Given economic disincentives to providing ART to PLHIV/HBV/HCV under current guidelines, the paucity of clinics openly offering treatment suggests a troubling lack of transparency or, possibly, a lack of available care. Further research should examine the impact of current guidelines and whether dedicated facilities and storage are medically indicated.

Societal pressures and procreative preferences for gay fathers successfully pursuing parenthood through IVF and gestational carriers

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.

Incidence of surrogacy in the USA and Israel and implications on women's health: a quantitative comparison

PURPOSE

Gestational surrogacy (GS) has been researched in multiple qualitative studies. In contrast, quantitative aspects of the practice are conspicuously understudied. The present article assesses and compares the incidence of GS in the USA and Israel, two industrialized countries that have maintained active commercial surrogacy practice, for over two decades.

METHOD

The article is a secondary analysis of GS figures published by the Israeli Parliament's Centre for Research and Information (2018) and by the USA's Centers for Disease Control (2016) and related professional publications. Each dataset is analyzed in reference to the respective country, so as to devise local incidence scores that are then juxtaposed in inter-country comparison.

RESULTS

The incidence of GS rises steeply in both countries. Though US surrogates are contracted by local and international, heterosexual and gay, and partnered and single intended parents, the relative incidence of GS is lower in the USA than in Israel, where only local heterosexual couples could contract a gestational surrogate. An exceptionally high rate of multiple births was observed in both settings, suggesting some overlooking of professional recommendations for elective single-embryo transfer.

CONCLUSION

GS incidence appears to resemble the ratio between the countries' respective fertility rates. The paper underscores two main risks facing gestational surrogates: the risk of not conceiving and not being paid and the risk of carrying a multiple pregnancy, which is extremely prevalent in GS pregnancies, and sustaining the short- and long-term health complications that are more prevalent in such pregnancies.

Procreative consciousness in a global market: gay men's paths to surrogacy in the USA

This article explores one of the contemporary contexts of reproductive decision-making: gay men's paths to surrogacy within the globalised USA fertility industry. The stories collected from qualitative interviews and ethnographic research with 37 gay men from several countries in Europe and the USA, who all had children through surrogacy in the USA, show that the men's understandings of their own reproductive aspirations and opportunities changed over time, as if recovering the fertility that was lost by coming out. This shift in the men's procreative consciousness - i.e. in their awareness of being subjects that could reproduce (or not) - disrupts the heteronormative idea that to be queer is not to contribute to the reproduction of the species, the family and the nation. Alongside this consciousness shift, however, reproductive decision-making of the gay men in this study was contingent on multiple factors: access to the fertility industry; economics, given how expensive and thus stratified surrogacy is; social support in the men's communities and extended families; their emotions and values. Therefore these gay men's reproductive decision-making could be characterized in terms of reproductive contingency and consciousness change, within which the globalised fertility industry was one relevant element among the choreography of multiple factors. These findings evidence that despite naturalization of reproduction as an obvious or 'natural' event in life, it is contingent, anything but obvious, and its perceptions are changeable. Reproduction is achieved not merely as a result of rational decision-making but rather in the interplay with an array of factors.