Surrogacy

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.

The orientation of a decellularized uterine scaffold determines the tissue topology and architecture of the regenerated uterus in rats†

A decellularized uterine scaffold (DUS) prepared from rats permits recellularization and regeneration of uterine tissues when placed onto a partially excised uterus and supports pregnancy in a fashion comparable to the intact uterus. The underlying extracellular matrix (ECM) together with an acellular, perfusable vascular architecture preserved in DUS is thought to be responsible for appropriate regeneration of the uterus. To investigate this concept, we examined the effect of the orientation of the DUS-preserving ECM and the vascular architecture on uterine regeneration through placement of a DUS onto a partially defective uterine area in the reversed orientation such that the luminal face of the DUS was outside and the serosal face was inside. We characterized the tissue structure and function of the regenerated uterus, comparing the outcome to that when the DUS was placed in the correct orientation. Histological analysis revealed that aberrant structures including ectopic location of glands and an abnormal lining of smooth muscle layers were observed significantly more frequently in the reversed group than in the correct group (70% vs. 30%, P < 0.05). Despite the changes in tissue topology, the uteri regenerated with an incorrectly oriented DUS could achieve pregnancy in a way similar to uteri regenerated with a correctly oriented DUS. These results suggest that DUS-driven ECM orientation determines the regenerated uterus structure. Using DUS in the correct orientation is preferable when clinically applied. The disoriented DUS may deteriorate the tissue topology leading to structural disease of the uterus even though the fertility potential is not immediately affected.

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.

Description and evaluation of experimental models for uterine transplantation in pigs

Objective

To evaluate the technique of uterine transplantation and the use of drugs used in the process of immunosuppression.

Methods

We included 12 sows, and immunosuppression was performed with minimal doses of cyclosporine, and cross-match was done to exclude the possibility of blood incompatibility. Hysterectomy was performed in the donor under general anesthesia, with the removal of the aorta and inferior vena cava in monobloc, and anastomosis of these vessels was made in the recipient.

Results

Six experiments were performed, and on the immediate postoperative period, five animals had good reperfusion. However, on the seventh postoperative day, histological analysis showed rejection in five animals.

Conclusion

The experimental model of uterine transplantation is feasible, but monitoring doses of immunosuppressants is pivotal to prevent rejection episodes.

Surrogacy in modern obstetric practice

Surrogacy is rising in profile and prevalence, which means that perinatal care providers face an increasing likelihood of encountering a case in their clinical practice. Rapidly expanding scientific knowledge (for example, fetal programming) and technological advances (for example, prenatal screening and diagnosis) pose challenges in the management of the surrogate mother; in particular, they could exacerbate conflict between the interests of the baby, the surrogate mother, and the intending parent(s). Navigating these often-tranquil-but-sometimes-stormy waters is facilitated if perinatal care providers are aware of the relevant ethical, legal, and service delivery issues. This paper describes the ethical and legal context of surrogacy, and outlines key clinical practice issues in management of the surrogate mother.

Experimental uterus transplantation

Today, most causes of infertility are successfully treated. Yet there is still a subgroup of female infertility affecting around 4%, which so far is untreatable because of an absolute uterine factor. To acquire motherhood, these women are today referred to either adoption or surrogacy. Research in the field of uterus transplantation has been evaluated in different animal models for decades and has presently reached a human clinical application as a possible treatment for absolute uterine factor infertility. Organ transplantation is no longer reserved to those with a life-threatening disease and neither is organ transplantation together with concurrent immunosuppression prohibiting pregnancy. Uterus transplantation involves four parties - recipient, donor, partner of recipient and future child - and is a subject of ethical controversies.

Partial regeneration and reconstruction of the rat uterus through recellularization of a decellularized uterine matrix

Despite dramatic progress in infertility treatments and assisted reproduction, no effective therapies exist for complete loss of uterine structure and/or function. For such patients, genetic motherhood is possible only through gestational surrogacy or uterine transplantation. However, many ethical, social, technical and safety challenges accompany such approaches. A theoretical alternative is to generate a bioartificial uterus, which requires engineering of uterine architecture and appropriate cellular constituents. Here, rat uteri decellularization by aortic perfusion with detergents produced an underlying extracellular matrix together with an acellular, perfusable vascular architecture. Uterine-like tissues were then regenerated and maintained in vitro for up to 10 d through decellularized uterine matrix (DUM) reseeding with adult and neonatal rat uterine cells and rat mesenchymal stem cells followed by aortic perfusion in a bioreactor. Furthermore, DUM placement onto a partially excised uterus yielded recellularization and regeneration of uterine tissues and achievement of pregnancy nearly comparable to the intact uterus. These results suggest that DUM could be used for uterine regeneration, and provides insights into treatments for uterine factor infertility.

Commercial surrogacy: how provisions of monetary remuneration and powers of international law can prevent exploitation of gestational surrogates

Increasing globalisation and advances in artificial reproductive techniques have opened up a whole new range of possibilities for infertile couples across the globe. Inter-country gestational surrogacy with monetary remuneration is one of the products of medical tourism meeting in vitro fertilisation embryo transfer. Filled with potential, it has also been a hot topic of discussion in legal and bioethics spheres. Fears of exploitation and breach of autonomy have sprung from the current situation, where there is no international regulation of surrogacy agreements--only a web of conflicting national laws that generates loopholes and removes safeguards for both the surrogate and commissioning couple. This article argues the need for evidence-based international laws and regulations as the only way to resolve both the ethical and legal issues around commercial surrogacy. In addition, a Hague Convention on inter-country surrogacy agreements is proposed to resolve the muddled state of affairs and enable commercial surrogacy to demonstrate its full potential.

An overview of surrogacy around the world: trends, questions and ethical issues

Although the birth of a child is typically considered a very happy time for parents, surrogacy is often unchartered territory that can become very stressful for all parties involved. Part of the stress stems from the fact that different states and countries have varying laws and regulations overseeing surrogacy. This article provides insight regarding surrogacy around the world, including professional, societal and ethical issues.

A new surgical technique of uterine auto-transplantation in cynomolgus monkey: preliminary report about two cases

OBJECTIVE

Uterine transplantation experiments have been performed in various animal species for future clinical applications of uterine transplantation for permanent uterine factor infertility in humans. The aim of this study was to confirm the feasibility of uterine auto-transplantation in cynomolgus monkeys by developing new surgical techniques.

METHODS

Two female cynomolgus monkeys underwent surgery under general anesthesia. The uterus with vascular grafts and the vaginal wall was removed, and back-table preparation was performed using heparinized saline. The uterus with vascular grafts and the vaginal wall was anastomosed with the vaginal stump and blood vessels in the pelvis, respectively. The auto-transplant uterine function was evaluated by confirming engraftment of the uterus by laparotomy, endometrial proliferation by transabdominal ultrasonography and periodical menstruation.

RESULTS

The first animal died due to acute renal failure 2 days after the operation. Second-look laparotomy in the second animal at 40 days after the operation indicated there was no congestion in the uterus, and the uterus showed the typical red color of a normal uterus. Thereafter, endometrial proliferation was observed by transabdominal ultrasonography and periodical menstruation was confirmed, indicating re-established uterine function.

CONCLUSION

This is the preliminary report of uterine auto-transplantation in cynomolgus monkeys. This study demonstrates the feasibility of uterine auto-transplantation by using new surgical technique in cynomolgus monkeys. Accumulation of basic experimental data in non-human primates is required prior to performing the procedure in humans.

Experimental uterus transplantation

BACKGROUND

Uterus transplantation (UTx) is developed in animal models as a future method to treat uterine factor infertility.

METHODS

All published studies in the area of UTx research were identified. Aspects relating to surgery, cold-ischemia/reperfusion, rejection, immunosuppression, pregnancy, ethics and institutional requirements were examined.

RESULTS

Uterus retrieval surgery has been solved in animals, including primates. Studies on cold-ischemia/reperfusion indicate an ischemic tolerance of >24 h. The transplantation procedure, with vascular anastomosis, has not been fully developed in animal models, indicated by frequent thrombosis formation. Pregnancies have only been reported in syngenic/auto-UTx animal models. Several ethical issues in relation to UTx, and requirements for a team that would be suitable to undertake human UTx, exist.

CONCLUSION

Much research on UTx has been performed in appropriate animal models. Several aspects of the procedure have been optimized but some remain to be solved. It is predicted that the research will soon reach a stage that could merit introduction of human UTx as an experimental procedure.

The attitudes and knowledge of medical students towards surrogacy

We aimed to evaluate the attitudes and knowledge of medical students' towards surrogacy as a means of assisted reproduction. An online survey was sent to medical students from UK universities, 185 anonymous replies were received. A total of 72.2% agreed with surrogacy as a means of assisted reproduction; 43.9% thought the intended mother was the legal mother at birth; 28.7% correctly identified the surrogate mother as the legal mother; 76.0%felt that the intended mother should be the legal mother at birth; 15.2% thought surrogacy arrangements were enforceable by law; 29.2% correctly knew they were not. There was no difference in knowledge of surrogacy among students who had studied obstetrics and gynaecology compared with those who had not. Medical students were generally tolerant in their attitudes to surrogacy. There were discrepancies between the position of UK law governing surrogacy and the personal views of medical students.