Hidden from view: Canadian gestational surrogacy practices and outcomes, 2001-2012

Surrogacy: An important pathway to parenthood. A call for international standardization

This comprehensive review examines the multifaceted landscape of surrogacy, a revolutionary treatment for infertility. The study examines historical origins, shifting trends, medical considerations, psychological implications, legal complexities, international variations, and ethical dilemmas surrounding surrogacy. With the advent of assisted reproductive technology, gestational surrogacy allows intended parents a genetic connection to their child. Medical facets encompass indications for gestational surrogacy, drawing attention to maternal health risks and infertility factors. Evidence indicates that medical outcomes are comparable to conventional pregnancies, suggesting a viable reproductive solution for intended parents. Due to the complex nature of surrogacy psychological and emotional vulnerability is inevitable; yet studies underscore positive psychological well-being and satisfaction among gestational carriers (GCs), intended parents (IPs) and children. Surrogacy also has many religious dimensions, as each religion has its own perspective on the distinctive process of creating life and its outcomes, such as, the determination of the child's mother according to their beliefs. Legal considerations emerge as a fundamental aspect, with differing regulations globally. The review emphasizes the significance of comprehensive agreements to safeguard the rights and responsibilities of surrogates and IPs. The unique surrogacy laws in Israel serve as a noteworthy example, reflecting a progressive approach that provides a promising template to establish crucial international guidelines on surrogacy. The absence of international consensus necessitates attention from the global community to address key concerns, including the well-being of GCs, legal recognition for IPs, and the child's best interests, with the goal of establishing a universal standard of care in the field.

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.

'Womb for work' experiences of Thai women and gestational surrogacy practice in Thailand

Risks to gestational surrogates became a concern for public health. In commercial gestational surrogacy arrangements, gestational surrogates are commonly recruited from low- to middle-income countries. Thailand is well known as a surrogacy hub in this regard. However, little is known concerning Thai surrogacy practice and the risks that Thai gestational surrogates experiences. The semi-structured interviews with fifteen Thai women who had been gestational surrogates were conducted over the telephone in Thai between March and May 2020 and lasted approximately 30 minutes. Thematic analysis was applied to analyse the translated interviews. The findings indicated that 'womb for work' was perceived as a surrogacy career among Thai women. 'Womb for work' was defined as a superordinate theme that consisted of three subthemes: (i) gestational surrogacy arrangements in Thailand; (ii) the business model of gestational surrogacy arrangements in Thailand; and (iii) risk experiences of gestational surrogates. Clear deficiencies in surrogacy practice and regulations were identified, which put gestational surrogates at risk, including those associated with embryo transfer, transnational gestational surrogacy, and unsupported pregnancies. This study shows the urgent need to introduce regulations to protect women's health transnationally in this domain more effectively.

The Social Experiences of Single Gay Fathers in Israel: An Intersectional Perspective

Through an intersectional lens, this study explores the experience of being a single gay father by choice in Israeli society, which continues to view the traditional heterosexual two-parent family as the ideal. Analysis of 15 in-depth, semi-structured interviews with single gay Israeli fathers suggests that their experiences are characterized by constant tension between their self-perceived social acceptance and sense of belonging on the one hand and their encounters with discrimination and bias on the other. The findings shed light on the ways in which the fathers' complex experiences are shaped by the intersection between their identity as parents and their two marginalized identities: single male parents and gay fathers. These identities were found to be highly contextual and affected by macro-level factors. As the fathers cope with their environment, they develop a sense of belonging alongside a deep sense of otherness, suggesting that the sense of belonging and the sense of otherness are not binary opposites, but rather two social categories that are continually constructed through the intersection between different identities and their interaction with macro-level factors, making single gay parenthood a multidimensional experience.

A reproductive health-care program for surrogate mothers: A mixed methods study

BACKGROUND

Surrogacy has become an alternative family formation option for women who are unable to carry a pregnancy. There is no comprehensive care program despite the different nature of this pregnancy. The present study aimed to develop a reproductive health-care program for surrogate mothers within the cultural and social context of Iran.

MATERIALS AND METHODS

In the present sequential exploratory mixed methods study, first through a qualitative approach surrogate mothers, care providers, and policy makers of reproductive health services were selected purposefully. Data were collected by using the in-depth semi-structured interviews and analyzed. A care program draft was designed by integrating results of the qualitative study and reviewing the literature and guidelines, then appropriateness of each proposed care was assessed by a two-Rounds Delphi technique (RAM), and the final reproductive health-care program for surrogate mothers was developed.

RESULTS

The surrogate mothers' reproductive health needs were summarized in four main categories: surrogate mothers' extra care, educational training, psychological support, and protecting against surrogacy's social and familial consequences. The reproductive health-care program for surrogate mothers were developed in four sections: prepregnancy health screenings and legal counseling; special care during embryo transfer until pregnancy confirmation; psychological support and prenatal care of surrogacy until delivery and follow-up postpartum care.

CONCLUSION

Women face many challenges in surrogacy and need special care such as legal counseling, reproductive health care, and psychological support. Implementation of this care program seems to help improve the reproductive health of these mothers.

The nexus between self-perception and behavioural responses of gestational surrogates' risk experiences

Despite associated risk and public concern, commercial surrogacy remains a thriving business, and opportunities for gestational surrogates continue to exist. Surrogacy arrangements have been found to place gestational surrogates at risk, with little support or guidance to help them understand or mitigate these risk factors. This study aims to investigate the self-perception of gestational surrogates through their reflection of their own risk-related behaviours throughout the surrogacy process. Data were retrieved through interviews with fifteen Thai women who had first-hand experience of commercial surrogacy, and thematic analysis was used to interpret the data. Findings showed that the perceptions of 'trust,' 'commitment to obligation,' and 'unacceptable actions' reflected their behaviours exposing risks to detrimental behaviours, disempowerment, and isolation. Understanding these perceptions would be advantageous for health planning programmes or policies in surrogacy practice to promote women's heath as a whole.

Pregnancy and birth outcomes of single versus multiple embryo transfer in gestational surrogacy arrangements: a systematic review and meta-analysis

Multiple embryo transfer (MET) is associated with both an increased risk of multiple pregnancy and of live birth. In recent years, MET has become standard practice for most surrogacy arrangements. There is limited review of the use of MET versus single embryo transfer (SET) in surrogacy practice. The present review systematically evaluated the pregnancy outcomes of surrogacy arrangements between MET versus SET among gestational carriers. A systematic search of five computerized databases without restriction to the English language or study type was conducted to evaluate the primary outcomes: (i) clinical pregnancy; (ii) live delivery; and (iii) multiple delivery rates. The search returned 97 articles, five of which met the inclusion criteria. The results showed that clinical pregnancy (RR = 1.21, 95% CI: 1.06-1.39, n  =  5, I² = 41%), live delivery (RR = 1.29, 95% CI: 1.10-1.51, n  =  4, I² = 35%) and multiple delivery rates (RR = 1.42, 95% CI: 6.58-69.73, n  =  4, I² = 54%) were statistically significantly different in MET compared to SET. Adverse events including miscarriage, preterm birth and low birthweight were found following MET. Our findings support the existing evidence that MET results in multiple pregnancy and subsequently more adverse outcomes compared to SET. From a public health perspective, SET should be advocated as the preferred treatment for gestational carriers.

Does body mass index impact assisted reproductive technology treatment outcomes in gestational carriers

BACKGROUND

The purpose of this study was to assess whether increased body mass index (BMI) negatively affects assisted reproductive technology (ART) outcomes among gestational carriers.

METHODS

A retrospective matched case-control cohort, including all gestational carrier (GC) cycles performed at CReATe Fertility Centre (Toronto, ON, Canada) between 2003 and 2016.

SETTING

A Canadian fertility clinic, with a large surrogacy program.

PATIENTS

All gestational carriers that had undergone a cycle completed to a transfer at our clinic, and had BMI and outcome data available, were matched by BMI to infertile patients treated at our clinic during the same years provided they had undergone a cycle completed to a transfer, and had outcomes data available.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Clinical pregnancies rates, miscarriage rates and live birth rates.

RESULTS

BMI was not a reliable prediction factor of any of the measured outcomes. Importantly, the gestational carrier population had better outcomes and a significantly lower overall incidence of maternal, fetal and neonatal complications when compared with infertile patients, treated at our clinic during the same years.

CONCLUSION

BMI is not a reliable predictor of outcomes among gestational carriers.

Surrogacy and Pregnancy

Importance

Surrogacy allows for parenthood when it is otherwise impossible or exceedingly difficult; however, the risks of surrogate pregnancy for the gestational surrogate and the fetus are not well defined.

Objective

The aim of this study was to review the literature to examine the prevalence and requirements of surrogate pregnancy and maternal and perinatal outcomes.

Evidence Acquisition

A CINAHL and 2 PubMed searches were undertaken using the terms "surrogate mothers" OR "(surrogate or surrogacy)" AND "(mothers OR pregnancy OR pregnant)." The second search used these terms and pregnancy outcomes. The search was limited to the English language, but the years searched were unlimited.

Results

The search identified 153 articles, 36 of which are the basis for this review. The number of surrogate pregnancies is increasing in the United States. Fetal risks associated with surrogacy include low birth weight, increased risk of multiple gestation, and preterm birth. Maternal complications associated with surrogate pregnancy include hypertensive disorders of pregnancy, postpartum hemorrhage, and gestational diabetes.

Conclusions and Relevance

Surrogacy is a route to parenting that is not without risk to the surrogate or the fetus, and surrogate pregnancy is increasing in frequency in the United States.

Analysis of gestational surrogates' birthing experiences and relationships with intended parents during pregnancy and post-birth

BACKGROUND

This study investigated the surrogates' birth experiences, their levels of emotional struggle at relinquishment, how often they thought about the surrogacy children, and the surrogate-parent relationship dynamics during pregnancy and post-birth.

METHODS

Data were collected from 06/2016 to 02/2017 using an anonymous questionnaire. Participants were Canadian gestational surrogates who had completed the process with or without a successful live birth, and who were at various stages of an ongoing surrogacy. For this paper, only a subgroup of cases with a successful live birth was selected for analysis.

RESULTS

The data set included 131 births involving 90 surrogates who delivered 157 babies (105 singletons and 26 sets of twins). Their mean age at the time of surrogacy was 31.7 ± 5 years (range: 21-47y). More than one-third (37.4%) of the cases were for intended parents who were same-sex male couples and single men. Surrogates assisting Canadian-resident intended parents had an overall better birthing experience compared with those assisting nonresidents. There was none or very little struggle with the relinquishment of the baby in 96.9% of cases. Continued contact with parents after the births was reported in 93.0% of cases. Surrogates were significantly more likely to have frequent post-birth contact with same-sex and single fathers compared with heterosexual parents and single mothers (76.6% vs 54.3%).

CONCLUSIONS

Same-sex male couples and single men can develop a long-lasting relationship with their surrogates even when no intended female partners are involved. The development of institutional practice guidelines in standardizing surrogacy birth practice is paramount in optimizing surrogates' care.

Reproductive and sexual Health of surrogate mothers, developing a care program: a protocol for mixed methods study

Background

Gestational surrogacy is one of the options for women whom pregnancy is contraindicated. Despite of increasing demand for gestational surrogacy, its various aspects are controversial. The unique nature of surrogacy causes surrogate mothers to face a variety of problems such as, ethical confusion, psychological disturbance and reproductive health matters. Therefore, it is necessary to develop a comprehensive care program for reproductive and sexual health providing specific care at prenatal and pregnancy as well as delivery and postpartum period in socio- cultural context of Iran.

Methods

This research is an exploratory study with the qualitative-quantitative sequencing design (mixed) that is consisted of three sequential phases. In the first phase, following a qualitative approach, the researcher will explain needs of reproductive and sexual health in surrogate mothers. In the second phase, a primary reproductive and sexual health care program is designed for surrogate mothers in which, in addition to using the qualitative study results, related papers and texts will be also used. In the third phase of the study, reproductive and sexual health care program will be evaluated by RAND method (RAM).

Discussion

The results of this mixed method study are expected to lead to the development of a reproductive and sexual health care program meeting the needs of surrogate mothers and are in accordance with the cultural conditions of the research community, ultimately leading to improvement in reproductive and sexual health of surrogate mothers.

"Not my child to give away": A qualitative analysis of gestational surrogates' experiences

PROBLEM/BACKGROUND

Limited empirical data are available on the experiences of women who have been a gestational surrogate.

QUESTION

What are the experiences of gestational surrogates along the surrogacy pathway?

METHODS

An anonymous study-specific cross-sectional survey was used to evaluate participants' experience of being a surrogate. A total of 184 Canadian women who were recruited from Canadian surrogacy agencies and the Internet completed the online survey; 9446 words were collected from 110 participants who entered comments to one or more questions. The qualitative data were analyzed through thematic analysis.

FINDINGS

Seven main themes, and eighteen interrelated sub-themes grouped under the pre-, during, and post-surrogacy stages were identified. Many surrogates viewed surrogacy as a positive experience and as something meaningful and impactful to other people's lives. Most surrogates had harmonious relationships with their intended parents and maintained on-going contact with the surrogacy family post birth.

DISCUSSION

Surrogacy involves deliberate efforts to establish a trustful surrogate-parent partnership through relationship building, boundary negotiation, and management of expectations. The compatibility between surrogate and intended parents, regarding aspects such as communication and pregnancy management styles, was an important contributing factor to a positive experience.

CONCLUSION

Our findings provide a deeper understanding of participants' reasons for and motivation to be a surrogate, the relationship dynamics with their intended parents and the gestated fetus during surrogacy, and their satisfaction on personal and relationship levels post surrogacy. The findings would be useful to mental health professionals in preparing new surrogates for the potential challenges along the surrogacy pathway.

"One for Sorrow, Two for Joy?": American embryo transfer guideline recommendations, practices, and outcomes for gestational surrogate patients

In January 2016, Melissa Cook, a California gestational surrogate experiencing a multiple-birth pregnancy following the in vitro fertilization (IVF) transfer of three embryos comprised of donor eggs and sperm provided by the intended father, went to the media when the intended father requested that she undergo a fetal reduction because twins were less expensive to raise than triplets. Much of the legal interest in this case to date has centered on the enforceability of surrogacy contracts. However, the Cook case also raises troubling issues about fertility treatment practices involving gestational surrogates, twin preference, and third-party reproduction medical decision-making. This paper focuses on multiple-embryo transfers in the context of US surrogacy arrangements. Offering an original analysis of data obtained from the US national-assisted reproduction registry, it examines single- and multiple-embryo transfer trends over a 12-year period (2003 to 2014). Findings reveal that recommended guidelines were followed in fewer than 42% of the cases in 2014. The paper argues that ensuring equitable medical treatment for all recipients of IVF requires the adoption of treatment guidelines tailored to, and offering protections for, specific patient groups, and that, once in place, guidelines must be robustly implemented.