Physical and psychosocial risks

associated with surrogacy arrangements

in non-regulated settings Medical Tourism Summit

Louise Johnson, VARTA

Eric Blyth, University of Huddersfield

Karin Hammarberg, VARTA, Jean Hailes Research Unit.

Infertility is a public health issue – WHO

9% of couples at any given time experience infertility

Range of medical conditions – can’t conceive/ undertake pregnancy

↑ acceptance of diverse family formation including

single women and gay couples

Why surrogacy?

Accreditation of Australian clinics- quality assurance

Legislation in all states except NT

Counselling, legal advice for parties

Donors counselled - identifiable to children born

Single embryo transfer - the norm

Surrogate can make decisions about her pregnancy and birth

Processes for transfer of legal parentage from surrogate to commissioning parents

Cannot advertise for surrogate

Australian protective measures

Legal restrictions

Limited availability of treatment / donor eggs/sperm/embryos/surrogates in home country

Economic reasons

Search for quality services /ease of arrangements

Desire for privacy / cultural comfort in destination country

Drivers for overseas surrogacy

2013 Surrogacy Australia survey: 259 Australians considering or using surrogacy (1/2 heterosexual couples)

44% did not consider altruistic surrogacy

Reasons:

• Perceived risk of the surrogate keeping the child (75%)

• Too long & complicated process (68%)

• No one of the right age or life stage to ask (61%)

• Concern that carrying a child for no reward was an unfair exchange (46%)

Around half of the heterosexuals respondents had:

• Spent an average of more than 10 years trying to conceive naturally or through ART.

Everingham et al 2014

Australians travel for surrogacy

Only 19 babies born through surrogacy arrangements in Australia in 2012

Audit of 12 popular overseas surrogacy agencies by Surrogacy Australia:

• ↑ infants born to Australians via surrogacy

- 97 in 2009 → 269 in 2011

Practical & legal barriers in Australia ↑ traffic to India,

US & Thailand

Everingham at al 2014

New frontiers: Mexico & Nepal Media reports

Australians travel for surrogacy

Gestational surrogacy most common – IVF embryo used

Concerns internationally:

Exploitation of socio-economically disadvantaged surrogates and donors

Exploitation of commissioning parents with potential inability

- to secure legal parentage for child

- to obtain citizenship for child

- to return home with their child

Welfare of children born / existing children in commissioning parents or surrogates family

Concerns - overseas surrogacy

International Federation of Fertility Societies Surveillance 2010 report

No surrogacy-related regulation in most countries

Australians travel to countries where surrogacy is unregulated

IFFS

Surrogate and her family

Commissioning parents

Resultant and affected children

Donors providing eggs/sperm/embryos

Rights, health and well-being

Literacy variable : ~ ½ illiterate in some places – staff explain contracts

Meet with commissioning parents - when signing contracts

Some contracts not signed until 2nd trimester of pregnancy

Some may not have a copy of the contract

Motivated by:

• poverty/ unemployment

• desire to educate their own children

• desire to help a childless couple

Earnings used:

• to educate their children

• build a new house, set up business

Centre for Social Research 2012, Pande 2009; Stockey-Bridge 2012; Rudrappa 2012.

Research: Indian surrogates

Informed Consent? – level of literacy, lack of counselling

Lack of autonomy to make decisions when it impacts on their own health

• selective reduction, caesarian births – risks for future pregnancies, births?

• complications with multiple embryo implantation – up to 4 embryos in India

• lack of psychosocial support before, during and after pregnancy

• lack of follow up medical and social care

Paucity of research on short & long-term outcomes for surrogates

Surrogate - concerns

Australian commissioning parents express concerns about

Exploitation of surrogates and their well-being

Use of anonymous sperm or egg donors

Their preference for identity-release donors – in the best interests of their child

Attempts to avoid the risk of prosecution after entering into commercial arrangement by

• not seeking legal parentage

• moving interstate

Everingham et al 2014, Stockey-Bridge 2011, Stafford-Bell 2014

Research: Commissioning parents

Unregulated arrangements here or overseas :

• risk being ill-prepared

• no counselling, legal advice, or avenues for legal parentage

• risk of not being able to bring babies home

Risks of prosecution (NSW, QLD, ACT) by entering into commercial arrangement

High financial and psychosocial costs – agency exploitation of desperate desire to have children?

Impact on families short and long-term?

Commissioning parents - concerns

Respondents in Surrogacy Australia survey

• > ½ reported multiple pregnancy for surrogate

• Almost ½ respondents reported premature births

• Likelihood of anonymous donors Everingham et al 2014, Stafford-Bell 2014

4 UK research papers – in the short term the psychosocial outcomes for children appear benign

Cannot generalise these findings – none involved overseas arrangements

Jadva 2012

Research: Children

High risk of multiple pregnancies - selective reduction can jeopardise remaining foetus(es)

High proportion of premature births – • likelihood of low birth weight babies • ↑ risk of short-term and long-term adverse health

outcomes for child

No access to identifying information about the surrogate or donor • identity issues • health information about donor?

Health / lifestyle of donor & surrogate? • health of child into adulthood?

Impact on children of surrogate? – loss of contact for 9 months

Children - concerns

Informed consent - all parties

Access - adequate medical care

Access - psychological care - all parties

Adequate documentation

Avoidance - conflicts of interest

Involvement - ethics committees

Altruistic donation & surrogacy

Accessibility - donor & surrogate identity for offspring

National self-sufficiency – minimise inducements so people are less likely to go elsewhere

Blyth, Thorn & Wichman (2011)

Ethically grounded and evidence-based:

one approach

Best interests of the child - paramount

Restrictive laws do not stop people from using overseas surrogacy

Potential adverse long-term health outcomes for children, families of both commissioning parents and surrogates, surrogates and donors

Pragmatic approaches to minimise inducements to travel overseas?

• reconsider advertising? (as for sperm and egg donors)

• transfer of parentage arrangements review?

• empower Australian courts to make decisions based on the best interests of the child (as in UK)

• review level of compensation in an altruistic arrangement - varies - UK more generous.

International treaty desirable / feasible? (Permanent Bureau of the Hague)

Research /evidence to inform policy, guidelines and clinical practice.

Some conclusions

References

VARTA: www.varta.org.au

Johnson L, Blyth E & Hammarberg K, Barriers for domestic surrogacy and challenges of transnational surrogacy in the context of Australians undertaking surrogacy in India, (2014) JLM 22 136.

Boivin et al. International Estimates of Infertility Prevalence and Treatment-seeking: Potential Need and Demand for Infertility Medical Care (2007) 22 Hum Reprod 1506

Macaldowie et al 2013. Assisted Reproductive technology in Australia and New Zealand 2011 (National Perinatal Epidemiological and Statistics Unit, University of New South Wales.

Family Law Council, Report on Parentage and theFamily Law Act (Family Law Council, Dec 2013)

Shenfield F “We need a Code of Practice for Cross-Border Reproductive Care’’, BioNews (18 Oct 2010)

Everingham S, Stafford–Bell M, Hammarberg K, Australian’s use of surrogacy (2014) MJA 201 (5).

Stafford–Bell M, Everingham S, Hammarberg K, Outcomes of surrogacy undertaken by Australians overseas (2014) MJA 201 (6).

Blyth E, Thorn P and Wichman C, CBRC and Psychosocial Counselling: Assessing Needs and Developing an Ethical Framework for Practice (2011) 23 Reprod Biomed Online 642.