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Using a Surrogate Mother: What You Need to Know

There's still some controversy about using a surrogate mother to have a baby. The legal process is also tricky because it varies from state to state. Even so, whether it's because of fertility problems or other reasons, surrogacy is an option for you and your partner. Find out how it works and see if it's right for you.

What Is a Surrogate Mother?

There are two kinds:

Traditional surrogate. It's a woman who gets artificially inseminated with the father's sperm . They then carry the baby and deliver it for you and your partner to raise.

A traditional surrogate is the baby's biological mother. That's because it was their egg that was fertilized by the father's sperm. Donor sperm can also be used.

Gestational surrogates. A technique called " in vitro fertilization " (IVF) now makes it possible to gather eggs from the mother (or an egg donor), fertilize them with sperm from the father (or a sperm donor), and place the embryo into the uterus of a gestational surrogate.

The surrogate then carries the baby until birth. They don't have any genetic ties to the child because it wasn't their egg that was used.

A gestational surrogate is called the "birth mother." The biological mother, though, is still the woman whose egg was fertilized.

In the U.S., gestational surrogacy is less complex legally. That's because both intended parents have genetic ties to the baby. As a result, gestational surrogacy has become more common than a traditional surrogate. About 750 babies are born each year using gestational surrogacy.

Who Uses Surrogates?

If you're a woman, you may consider a surrogate for several reasons:

• Medical problems with your uterus
• You had a hysterectomy that removed your uterus
• Conditions that make pregnancy impossible or risky for you, such as severe heart disease

You may want to think about surrogacy if you tried but couldn't get pregnant with a variety of assisted-reproduction techniques, such as IVF.

Surrogates have also made parenthood an option for people who might not be able to adopt a child, perhaps because of their age or marital status.

If gay men decide to use a traditional surrogate, one of them uses their sperm to fertilize the surrogate's egg through artificial insemination. The surrogate then carries the baby and gives birth.

A gay couple might also choose an egg donor, fertilize that donated egg, and then have the embryo implanted in a gestational surrogate to carry until birth.

Finding a Surrogate

There are several ways you can find a surrogate mother:

Friends or family. Sometimes you can ask a friend or relative to be a surrogate for you. It's somewhat controversial. But because of the high cost of surrogacy and the complex legal issues it raises about parental rights, a tried-and-tested family relationship can be simpler to manage.

The American Society for Reproductive Medicine accepts certain family ties as acceptable for surrogates. It generally discourages surrogacy, though, if the child would carry the same genes as a child born of incest between close relatives.

A surrogacy agency. Most people  arrange a gestational surrogate through an agency that acts as a go-between. The agency helps you find a surrogate and make arrangements. It also collects any fees that get passed between you and the surrogate, such as paying for their medical expenses.

How to Choose a Surrogate

Right now there aren't any regulations about who can be a surrogate mother. But experts agree on a few points about how to select one.

You should choose surrogates who:

• Are at least 21 years old
• Have already given birth to at least one healthy baby so they understand firsthand the medical risks of pregnancy and childbirth and the emotional issues of bonding with a newborn
• Have passed a psychological screening by a mental health professional to uncover any issues with giving up the baby after birth
• Sign a contract about their role and responsibilities in the pregnancy, such as prenatal care and agreeing to give you the baby after birth

Using a Surrogate

The American Society for Reproductive Medicine says surrogates should get a medical exam to check that they are likely to have a healthy, full-term pregnancy. The organization suggests they get tests that check for infectious diseases such as syphilis , gonorrhea , chlamydia , HIV , cytomegalovirus, and hepatitis B and C.

Surrogates should get tests to make sure they have immunity to measles , rubella ( German measles ), and chickenpox. Also, you may want to ask that they get a medical procedure to visually "map" the uterus, which can help the doctor check their potential to carry a pregnancy. Surrogate mothers should have their own doctor during pregnancy rather than use yours.

The cost of surrogacy can range from $80,000 to $120,000. A lot of different things go into the price, such as whether the surrogates have their own medical insurance or whether you need to buy a surrogacy-pregnancy policy for them.

Legal Issues With Surrogates

Parental rights aren't guaranteed after a surrogate pregnancy. The law continues to change as reproductive technology and the very definition of a "parent" changes.

There isn't a federal law on surrogacy and state laws vary. After a surrogate pregnancy in some states, you may still have to pass adoption proceedings to gain legal custody of the child. In other states, a "declaration of parentage" before birth lets you avoid having to "adopt" the baby.

To protect your rights as parents-to-be -- and the rights of the child you're hoping to have -- hire an attorney who specializes in reproductive law in your state. They can write a surrogacy contract that clearly spells out what everyone needs to do.

A contract like that may help if legal issues come up after birth. It can also outline agreements about a variety of possible scenarios with the pregnancy, such as what happens if there are twins or triplets.

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What Is Surrogacy And How Does It Work?

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Table of Contents

What is surrogacy, why would someone choose surrogacy, how much does surrogacy cost, how does someone become a surrogate, legal issues around surrogacy.

Surrogacy is becoming an increasingly common family-building option that offers a beacon of hope for people who are unable to carry a pregnancy on their own.

But how does surrogacy work, and how is a gestational carrier different from a traditional surrogate? Continue reading to explore what surrogacy is, reasons people may choose this route of family-building and important details to know before considering surrogacy as an option.

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At its most basic, surrogacy is when a person carries and delivers a child with the intention that another individual or couple will be the intended parent(s).

More specifically, the most common type of surrogacy in the U.S. occurs when an embryo is created with the egg of an intended mother (or a donor) and sperm of an intended father (or a donor) and then inserted into the uterus of a gestational carrier, says Shiva Landry, founder and executive director of Shared Conception, a surrogacy agency in Houston, Texas.

While surrogacy means another person carries a pregnancy, the intended parent(s) will have full custody of the child, adds Rashmi Kudesia, M.D., a triple board-certified physician in obstetrics and gynecology, reproductive endocrinology and infertility and lifestyle medicine, who is affiliated with Memorial Hermann Health System in Houston, Texas.

Gestational Carrier vs Traditional Surrogate

While surrogacy is often used as a catch-all phrase to describe the process of an individual carrying a child for another person or couple, there are actually two distinct types of surrogacy: A traditional surrogate and a gestational carrier. The difference between the two has to do with the genetic relationship between the person carrying the pregnancy and the resulting child.

• A traditional surrogate , also known as a genetic surrogate, is a person who is biologically related to the resulting child because their egg is used to create the embryo.
• A gestational carrier —or person who carries someone else’s pregnancy from an egg that is not their own—has no genetic relation to the resulting child.

Traditional surrogacy is a rare and legally risky option in the U.S. “After a series of cases where the surrogate found it difficult to surrender the child to the custody of the intended parents, it became the norm to identify one individual as the egg donor and another as gestational carrier,” explains Dr. Kudesia.

For gestational carrier surrogacy, in vitro fertilization (IVF) is used to retrieve eggs and sperm—either from the intended parent(s) or donors, or a combination of both—and then create an embryo to transfer to the carrier.

There are several sperm and egg fertilization combinations in surrogacy.

Traditional surrogacy:

• Intended father sperm + surrogate egg
• Donor sperm + surrogate egg

Gestational carrier surrogacy:

• Intended father sperm + intended mother egg
• Donor sperm + intended mother egg
• Intended father sperm + donor egg
• Donor sperm + donor egg or donated embryo

Note: Some gestational carrier cycles may involve more than one embryo, which increases the chance for multiple births.

There are many reasons, medical and otherwise, intended parent(s) opt for surrogacy.

People may choose surrogacy when there is a medical reason that would make it unsafe for them to carry a pregnancy, says Dr. Kudesia. For instance, they may take medications deemed unsafe for pregnancy or have a condition that would make pregnancy life-threatening, she says.

Additional medical reasons that might cause someone to consider using a surrogate according to Iris Insogna, M.D., a board-certified physician in obstetrics and gynecology and a reproductive endocrinology and infertility specialist at Columbia University Fertility Center in New York, include:

• The absence of a uterus (either an absence since birth or the removal of a uterus)
• Scarring of the uterus
• Recurrent embryo implantation failure
• Recurrent pregnancy loss

Single men, men in same-sex couples and transgender individuals or couples may also build their families with the help of donor eggs (and sometimes donor sperm) and a surrogate.

Surrogacy can be very expensive compared to other family-building options. Expenses can include:

• Medical expenses
• Surrogacy agency fees
• Compensation for the gestational carrier or surrogate
• Additional costs

Landry says that while costs are difficult to predict since each journey is unique, gestational carrier surrogacy typically runs between $125,000 to $200,000.

Part of the high cost of modern surrogacy comes down to the inclusion of IVF. “All of the IVF treatment is included, plus the additional cost for the gestational carrier [or surrogate] to carry the pregnancy,” says Dr. Kudesia.

These costs can be much lower in the case of altruistic surrogacy, which is when a carrier does not receive compensation beyond coverage for costs associated with the pregnancy.

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Does Health Insurance Cover Surrogacy?

Insurance typically does not cover the total cost of surrogacy. Some plans may cover some or all of the intended parents’ IVF expenses and the carrier’s maternity expenses, while others may not. Some intended parents use their own insurance when it covers a carrier’s maternity expenses, while others may opt to have the carrier use their own insurance when their policy has a surrogacy exclusion clause, meaning the insurance company will not cover a pregnancy carried by someone else.

Additionally, certain insurance agencies offer special packages designed to cover surrogate pregnancies. But while these tailored plans can be the most comprehensive option, they can also be expensive.

While it’s a good idea to ask an attorney or health insurance professional to review your health care benefit options before proceeding, it’s important to know that insurance plans can change over the course of a pregnancy (such as when an employer changes plans or the carrier leaves a job).

“The financial burden imposed on patients requiring the use of a gestational carrier represents a significant reproductive health care disparity,” says Dr. Insogna. “Improving access to care by expanding insurance coverage for this population is critical to protecting all patients’ fundamental right to reproduce.”

A person who would like to become a surrogate must undergo screening required by the Food and Drug Administration (FDA) and recommended by the American Society for Reproductive Medicine (ASRM), says Dr. Insogna.

According to both Dr. Insogna and Dr. Kudesia, screening includes:

• A medical and obstetric history evaluation
• A physical exam
• An extensive questionnaire
• A psychological evaluation
• Clearance from an obstetrics provider (ideally a maternal-fetal medicine specialist)
• Blood work, including infectious disease screening
• An ultrasound (to assess the prospective carrier’s status regarding the ability to carry a pregnancy)

Intended parents are also screened to ensure they are physically, mentally, legally and financially able to begin the surrogacy process.

Surrogates may already know the intended parent(s) before entering a surrogacy contract, but a prior relationship is not a requirement. Beyond clearance of the above screening steps, an ideal candidate is 21 years of age or older, has been pregnant previously and delivered a baby to full-term without complication, has a stable social environment and is cleared by references, according to the American Society for Reproductive Medicine.

If you’d like to learn more about becoming a surrogate, Landry recommends researching and then reaching out to a reputable, experienced surrogacy agency for more information.

Surrogacy laws vary widely across the globe with some countries banning any type of surrogacy. In the U.S., surrogacy is legal but not federally regulated. “Each state has its own laws regarding the use of gestational carriers,” says Dr. Insogna. For that reason, intended parents and surrogates are encouraged by the American College of Obstetrics and Gynecologists to seek legal counsel before entering into a gestational surrogacy contract.

Individual states regulate surrogacy based on some or all of the following grounds:

• The intended parent(s)’ marital status
• The intended parent(s)’ sexual orientation
• The source of the egg and sperm (some states require a genetic relationship between intended parents and resulting children)
• Compensation (some states only allow compensation for pregnancy-related costs)
• Pre- and post-birth parentage orders (meaning who is recognized as a legal parent with legal decision-making rights)

If surrogacy is banned in your state, Landry says you can seek out an agency in a surrogate-friendly state.

One way to do that, says Dr. Kudesia, is to speak with a local fertility specialist who can connect you with a reputable specialist in another state where surrogacy is allowed. “Or you can seek out consultation on your own with a specialist in a state where an identified gestational carrier may be or perhaps a state that would be convenient for you to travel to if you have family in the area,” she says.

While cross-border reproductive care can open doors to people looking to grow their family, Dr. Insogna says using a gestational carrier out of state may be more logistically challenging in terms of travel before and during pregnancy, and during and after delivery.

Surrogacy is often not an easy decision and tends to be a lengthy process both medically and legally, but it can also be an extremely rewarding experience for both the intended parents and the surrogate. If you or someone you know is interested in surrogacy, don’t be afraid to start the conversation with your doctor or with a reputable agency.

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• ART and Gestational Carriers. Centers for Disease Control and Prevention. Accessed 08/29/2022.
• Joseph RA, Rafanello AM, Morris CJ, Fleming KF. Surrogacy: Pathway to Parenthood. Neonatal Network. 2018;37(1):19-23.
• What's the Difference Between a Surrogate and a Gestational Carrier?. Adoption & Surrogacy Choices of Oklahoma. Accessed 08/29/2022.
• Surrogacy Facts and Myths: How Much Do You Know?. PBS. Accessed 08/29/2022.
• Traditional Surrogacy. Academy of Adoption & Assisted Reproduction Attorneys. Accessed 08/29/2022.
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• Rasheed A. Confronting Problematic Legal Fictions in Gestational Surrogacy. Journal of Health Care Law and Policy. 2022;24(2).
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• The Cost of Surrogacy vs. Adoption. Worldwide Surrogacy Specialists LLC. Accessed 08/29/2022.
• The Ethics Committee of the American Society for Reproductive Medicine. Disparities in access to effective treatment for infertility in the United States: an Ethics Committee opinion. Fertility and Sterility. 2021;116(1)0015-0282.
• Commercial Surrogacy vs. Altruistic Surrogacy. Worldwide Surrogacy Specialists LLC. Accessed 08/29/2022.
• Compensation & Benefits. Worldwide Surrogacy Specialists LLC. Accessed 08/29/2022.
• Fertility & IVF costs. Aurora Health Care. Accessed 08/29/2022.
• Coverage and Use of Fertility Services in the U.S.. Kaiser Family Foundation. Accessed 08/29/2022.
• Surrogacy & Medical Insurance. Worldwide Surrogacy Specialists LLC. Accessed 08/29/2022.
• What Is In Vitro Fertilization (IVF)?. Worldwide Surrogacy Specialists LLC. Accessed 08/29/2022.
• Health Insurance. Academy of Adoption & Assisted Reproduction Attorneys. Accessed 08/29/2022.
• Surrogacy Laws By State. Legal Professional Group: The American Society for Reproductive Medicine. Accessed 08/29/2022.
• Sadeghi MR. Surrogacy, an Excellent Opportunity for Women with More Threats. J Reprod Infertil. 2019;20(2):63.
• Parentage Proceedings. Academy of Adoption & Assisted Reproduction Attorneys. Accessed 08/29/2022.
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Article Contents

Introduction, supplementary data, authors' roles, conflict of interest, acknowledgements.

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Surrogacy: outcomes for surrogate mothers, children and the resulting families—a systematic review

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Viveca Söderström-Anttila, Ulla-Britt Wennerholm, Anne Loft, Anja Pinborg, Kristiina Aittomäki, Liv Bente Romundstad, Christina Bergh, Surrogacy: outcomes for surrogate mothers, children and the resulting families—a systematic review, Human Reproduction Update , Volume 22, Issue 2, March/April 2016, Pages 260–276, https://doi.org/10.1093/humupd/dmv046

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Surrogacy is a highly debated method mainly used for treating women with infertility caused by uterine factors. This systematic review summarizes current levels of knowledge of the obstetric, medical and psychological outcomes for the surrogate mothers, the intended parents and children born as a result of surrogacy.

PubMed, Cochrane and Embase databases up to February 2015 were searched. Cohort studies and case series were included. Original studies published in English and the Scandinavian languages were included. In case of double publications, the latest study was included. Abstracts only and case reports were excluded. Studies with a control group and case series (more than three cases) were included. Cohort studies, but not case series, were assessed for methodological quality, in terms of risk of bias. We examined a variety of main outcomes for the surrogate mothers, children and intended mothers, including obstetric outcome, relationship between surrogate mother and intended couple, surrogate's experiences after relinquishing the child, preterm birth, low birthweight, birth defects, perinatal mortality, child psychological development, parent–child relationship, and disclosure to the child.

The search returned 1795 articles of which 55 met the inclusion criteria. The medical outcome for the children was satisfactory and comparable to previous results for children conceived after fresh IVF and oocyte donation. The rate of multiple pregnancies was 2.6–75.0%. Preterm birth rate in singletons varied between 0 and 11.5% and low birthweight occurred in between 0 and 11.1% of cases. At the age of 10 years there were no major psychological differences between children born after surrogacy and children born after other types of assisted reproductive technology (ART) or after natural conception. The obstetric outcomes for the surrogate mothers were mainly reported from case series. Hypertensive disorders in pregnancy were reported in between 3.2 and 10% of cases and placenta praevia/placental abruption in 4.9%. Cases with hysterectomies have also been reported. Most surrogate mothers scored within the normal range on personality tests. Most psychosocial variables were satisfactory, although difficulties related to handing over the child did occur. The psychological well-being of children whose mother had been a surrogate mother between 5 and 15 years earlier was found to be good. No major differences in psychological state were found between intended mothers, mothers who conceived after other types of ART and mothers whose pregnancies were the result of natural conception.

Most studies reporting on surrogacy have serious methodological limitations. According to these studies, most surrogacy arrangements are successfully implemented and most surrogate mothers are well-motivated and have little difficulty separating from the children born as a result of the arrangement. The perinatal outcome of the children is comparable to standard IVF and oocyte donation and there is no evidence of harm to the children born as a result of surrogacy. However, these conclusions should be interpreted with caution. To date, there are no studies on children born after cross-border surrogacy or growing up with gay fathers.

Definitions

Surrogacy implies that a woman becomes pregnant and gives birth to a child with the intention of giving away this child to another person or couple, commonly referred to as the ‘intended’ or ‘commissioning’ parents ( Shenfield et al. , 2005 ). A surrogate mother is the woman who carries and gives birth to the child and the intended parent is the person who intends to raise the child. The definition from the European Society for Human Reproduction and Embryology (ESHRE) ( Shenfield et al. , 2005 ) does not state the sexuality of the intended parents. There are two main types of surrogacy, traditional and gestational. The first traditional surrogacy arrangement is believed to have happened about 2000 years before the birth of Christ and was mentioned in the Old Testament of the Bible. Sarah and Abraham were unable to conceive and Sarah hired her maiden Hagar to carry a child for her husband. Subsequently Hagar gave birth to a son, Ishmael, for Sarah and Abraham. Nowadays traditional (also called genetic or partial) surrogacy is the result of artificial insemination of the surrogate mother with the intended father's sperm. This means that the surrogate mother's eggs are used, making her a genetic parent along with the intended father. Gestational or IVF surrogacy (also called host or full surrogacy) is defined as an arrangement in which an embryo from the intended parents, or from a donated oocyte or sperm, is transferred to the surrogate's uterus. In gestational surrogacy, the woman who carries the child (the gestational carrier) has no genetic connection to the child ( Zegers-Hochschild et al. , 2009 ). The first successful IVF surrogate pregnancy was reported by Utian et al. in 1985 ( Utian et al. , 1985 ). In this review, we have decided to use the terms ‘traditional surrogacy’ and ‘gestational surrogacy’ for the two different types of surrogacy treatment.

Surrogacy may be commercial or altruistic, depending upon whether the surrogate receives financial reward for her pregnancy. In commercial surrogacy the surrogate is usually recruited through an agency, reimbursed for medical costs and paid for her gestational services. With altruistic surrogacy, the surrogate is found through friends, acquaintances or advertisement. She may be reimbursed for medical costs directly related to the pregnancy and for loss of income due to the pregnancy ( FIGO, Committee for Ethical Aspects of Human Reproduction and Women's Health, 2008 ; Dempsey, 2013 ).

Indications for surrogacy treatment

The main indication for surrogacy treatment is congenital or acquired absence of a functioning uterus. Müllerian aplasia, including congenital absence of the uterus such as Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome, is relatively rare with an incidence of one per 4000–5000 newborn girls ( Lindenman et al. , 1997 ; Aittomaki et al. , 2001 ). Young fertile women with normally functioning ovaries might lose their uterus in connection with serious obstetric complications, such as intra- or post-partum heavy bleeding or rupture of the uterus. Such obstetric complications will often lead to the death of the baby as well. Medical diseases of the uterus, for example cervical cancer, will also lead to hysterectomy and uterine infertility. Significant structural abnormalities, an inoperably scarred uterus or repeated miscarriages are other indications for considering using a surrogate mother. Severe medical conditions (e.g. heart and renal diseases), which might be life-threatening for a woman during pregnancy, are also indications that a surrogacy may be considered, provided that the intended mother is healthy enough to take care of a child after birth and that her life expectancy is reasonable ( Brinsden, 2003 ). A further indication is the biological inability to conceive or bear a child, which applies to same-sex male couples or single men ( Dempsey, 2013 ). In some countries gestational carriers may be considered when an unidentified endometrial factor exists, such as for couples with repeated unexplained IVF failures despite retrieval of good-quality embryos ( Practice Committee of American Society for Reproductive Medicine; ASRM, 2015 ).

Choice of a surrogate mother

The choice of a surrogate mother is of the highest importance for the successful outcome of the treatment. She might be a member of the family, such as a sister or a mother, or an anonymous or known unrelated person. According to recommendations from ESHRE and the American Society for Reproductive Medicine (ASRM), a gestational carrier should preferably be between the ages of 21 and 45 years and she should have at least one child. Her previous pregnancies should have been full-term and uncomplicated ( Shenfield et al. , 2005 ; ASRM, 2015 ). Ideally, the carrier should not have had more than a total of five previous deliveries and three deliveries via Caesarean section ( ASRM, 2015 ). General requirements as to the screening and testing of gestational carriers and the latest recommendations related to psychosocial consultations have been summarized by the expert groups from ESHRE and ASRM ( Shenfield et al. , 2005 ; ASRM, 2015 ). According to an International Federation of Gynecology & Obstetrics (FIGO) committee report only gestational surrogacy is nowadays acceptable. It was also decided that the autonomy of the surrogate mother should be respected at all stages, including any decision about her pregnancy, which may conflict with the commissioning couple's interest. Surrogacy arrangements should not be commercial ( FIGO Committee for Ethical Aspects of Human Reproduction and Women's Health, 2008 ).

Pregnancy and delivery rates after surrogacy treatment

In gestational surrogacy programmes, the clinical pregnancy rate per embryo transfer has been reported as being between 19 and 33%, with between 30 and 70% of the couples succeeding in becoming parents as a result of the arrangement ( Meniru and Craft, 1997 ; Corson et al. , 1998 ; Parkinson et al. , 1998 ; Wood et al. , 1999 ; Beski et al. , 2000 ; Brinsden et al. , 2000 ; Goldfarb et al. , 2000 ; Soderstrom-Anttila et al., 2002 ; Raziel et al. , 2005 ; Dar et al. , 2015 ).

In the recent, and thus far largest, report including 333 consecutive surrogacy treatments in Canada, the pregnancy, miscarriage and delivery rates did not differ between patient groups with different indications for surrogacy treatment ( Dar et al. , 2015 ).

Legislation in different countries

In Europe, surrogacy is not officially allowed in Austria, Bulgaria, Denmark, Finland, France, Germany, Italy, Malta, Norway, Portugal, Spain and Sweden. Altruistic, but not commercial, surrogacy is allowed in Belgium, Greece, the Netherlands and the UK. Some European countries, such as Poland and the Czech Republic, currently have no laws regulating surrogacy ( Brunet et al. , 2013 ; Deomampo, 2015 ). Commercial surrogacy is legal in Georgia, Israel, Ukraine, Russia, India and California, USA, while in many states of the USA only altruistic surrogacy is allowed. Altruistic surrogacy is also allowed in Australia, Canada and New Zealand.

Cross-border surrogacy

As surrogacy treatment is illegal in the majority of Western countries, infertile couples are seeking commercial surrogacy arrangements elsewhere, for example in Russia, Ukraine and India, where the treatment is available. It has been estimated that more than 25 000 children have been born or are to be born to surrogates in India, of which 50% are from the West ( Shetty, 2012 ). Cross-border gestational surrogacy is an activity that challenges legal and ethical norms in many countries. It puts both intended parents and gestational surrogates at risk and can leave the offspring of these arrangements vulnerable in a variety of ways ( Pande, 2011 ; Crockin, 2013 ). There is uncertainty about the status of the parent and child, as well as legal issues regarding immigration and citizenship ( Crockin, 2013 ; Deomampo, 2015 ; Schover, 2014 ). By legalizing surrogacy, potential harm to the health and well-being of all parties involved in unregulated cross-border surrogacy arrangements can be avoided ( Ekberg, 2014 ). Another way of reducing the legal uncertainties is to regulate the legal implications of surrogacy (i.e. legal parenthood) without making surrogacy itself legal. This has been suggested by the Hague Convention on Private International Law. In Austria and Germany, the best interest of the child has been decided to outweigh the reservations of the national legislation concerning surrogacy ( http://www.hcch.net/index ).

Concern about surrogacy arrangements

In many Western countries surrogacy practice has been made illegal because of concern for the surrogate mother, the welfare of the child and the family created by the birth of the new baby. There have been worries about the possibility of exploitation or coercion of women to act as gestational carriers ( Tieu, 2009 ; Pande, 2011 ; Deonandan et al. , 2012 ). A surrogate undergoes risks during pregnancy similar to any other pregnant woman. She is exposed to the possibility of miscarriage, ectopic pregnancy and common obstetric complications, which are increased by the risk of multiple pregnancies. There has also been concern that psychological reactions may occur post-partum in relation to surrendering the child, as the carrier may develop emotional attachments to the child she has carried ( FIGO Committee for Ethical Aspects of Human Reproduction and Women's Health, 2008 ). Furthermore, there have been fears that the baby might be abandoned by the intended parents and/or the surrogate mother in the case of unexpected complications or birth defects. Potential harm to the health of the offspring includes the negative effects of multiple pregnancies, as well as the possible effects of gamete donation on the well-being of the child ( FIGO Committee for Ethical Aspects of Human Reproduction and Women's Health, 2008 ).

During recent years there have been discussions in many European countries, and all Nordic countries, about whether surrogacy should be allowed in the future. This has led to an urgent need to summarize what we currently know about surrogacy in a systematic way. This systematic review summarizes current levels of knowledge of the obstetric, medical and psychological outcomes for surrogate mothers, the intended parents and the children born as a result of surrogacy.

We searched the PubMed, Cochrane and Embase databases up to February 2015. The main outcomes we examined were as follows.

For the surrogate mothers: obstetric outcome, psychological characteristics, personality, motivation, relationship with intended couple, contact with the couple and child, experiences after relinquishing child, openness, psychological well-being, satisfaction with surrogacy.

For the children: preterm birth, low birthweight, birth defects, perinatal mortality, child psychological development, child psychological adjustment.

For the intended mothers: quality of life, parent psychological status, parent–child relationship, quality of parenting, marital quality and stability, relationship with surrogate mother, motivation, experience of surrogacy, disclosure to the child.

Systematic search for evidence

The terms used in the searches were (‘Surrogate Mothers’[Mesh]) OR (ivf-surroga*[tiab] OR surrogate mother*[tiab] OR surrogate parent*[tiab] OR surrogacy*[tiab] OR gestational carrier*[tiab] OR surrogate pregnanc*[tiab])) NOT (Editorial[ptyp] OR Letter[ptyp] OR Comment[ptyp]).

OR ((animals[mh]) NOT (animals[mh] AND humans[mh])) NOT (‘News’[Publication Type] OR ‘Newspaper Article’[Publication Type]).

We also manually searched reference lists of identified articles for additional references. Guidelines for meta-analysis and systematic reviews of observational studies were followed ( Stroup et al. , 2000 ).

Literature searches and abstract screening were performed by three researchers (CB, UBW and VSA) and one librarian. Differences of opinion in the team were solved by discussion and consensus.

Inclusion and exclusion of studies

Original studies published in English and the Scandinavian languages were included. In the case of double publication the latest study was included. Studies published only as abstracts and case reports were excluded. Studies with a control group and case series (more than three cases) were included.

Appraisal of quality of evidence

The methodological quality of the studies, in terms of risk bias, was assessed by two reviewers (CB and UBW). They used the tools developed by Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) for assessing original articles, which grade articles as of low, moderate and high quality. Only cohort studies, not case series, were assessed for methodological quality. For quality of evidence we used the GRADE system ( Guyatt et al. , 2008 ).

The GRADE system evaluates the following variables for all studies, both combined and per outcome: Design, study limitations, consistency, directness, precision, publication bias, magnitude of effect, relative effect and absolute effect. Quality levels are divided into high, moderate, low and very low quality. Quality levels are based on our confidence in the effect estimate, which in turn is based on the number of studies, design of studies, consistency of associations between studies, study limitations, directness, precision, publication bias, effect size, and relative and absolute effect.

The quality levels are; very confident = high quality, moderately confident = moderate quality, limited confidence = low quality and very little confidence = very low quality. If conclusions are based on RCTs, GRADE starts at high quality level (level 4) but can be downgraded, while if conclusions are based on observational studies GRADE starts at low quality level (level 2) but might be upgraded (or downgraded). If conclusions were based on case series, no assessment of GRADE was performed.

The search strategy identified a total of 1795 abstracts, of which 55 were selected for inclusion in the systematic review (Fig.  1 ).

Selection process of publications for a systematic review of surrogacy.

Thirty studies were cohort studies, 22 were case series and three were qualitative studies ( Supplementary Table SI ). Excluded studies are presented in Supplementary Table SII .

Quality assessment of included cohort studies is presented in Supplementary Table SIII . Of the cohort studies one article was of high quality, 16 were of moderate quality and 13 of low quality.

Obstetric outcome in surrogate mothers

Five studies were identified that reported on pregnancy complications, one cohort study with historical controls and four case series. Three were from the USA, one was from Canada and one from Finland (Table  I ). The studies included between 8 and 133 deliveries after surrogacy, out of a total of 284 deliveries. Hypertensive disorders in pregnancy (HDP) were reported in between 3.2 and 10% of subjects and placenta praevia/placental abruption in between 1.1 and 7.9% of singleton surrogate pregnancies. The cohort study and one of the case series also reported on pregnancy complications in twin pregnancies. HDP occurred in between 2.9 and 7.4%, and placenta previa/placental abruption in 1.1 and 3.7% in twin pregnancies ( Parkinson et al. , 1998 ; Dar et al. , 2015 ). Three cases of hysterectomies were reported. The reasons for hysterectomy were uterine atony, placenta accreta and uterine rupture. Two of these three complications occurred in multiple pregnancies.

Obstetric complications in surrogate pregnancies.

GC, gestational carrier; NA, not available.

*IVF pregnancies from Brinsden and Rizk (1992) .

Conclusion: Rates of HDP and placental complications in surrogate pregnancies were similar to those for IVF. Rates of HDP were lower than reported in OD pregnancies. Peripartum hysterectomies were reported as severe complications. Since most data was derived from case series, no GRADE assessment was performed.

The outcome for children

Gestational age.

Two cohort studies and five case series reported on the gestational age of children born after surrogate pregnancies (Table  II ). Most studies come from the USA. The cohort studies included in total 1308 children, while the case series included a total of 271 children born after surrogacy. The preterm birth rate (PTB) in surrogate singletons varied between 0 and 11.5% as compared with 14% for IVF singletons. In the largest cohort study ( Gibbons et al. , 2011 ) including 1180 surrogacy singletons the mean gestational age was 37.2 weeks as compared with 37.7 weeks for IVF singletons and 37.4 weeks for singletons from OD. The rate of multiple pregnancies was 2.6–75.0% (Table  II ). The cohort study with historical controls and the case series also reported on gestational age in twin pregnancies ( n = 1–38 twin pregnancies). PTB occurred in 20.4–100% of surrogate twin pregnancies. In the cohort study, mean gestational age was 36.2 (SD 0.4) weeks in surrogate twins and 36.0 (SD 2) weeks in IVF twins ( Parkinson et al. , 1998 ).

Gestational age and plurality in deliveries after surrogacy.

GA gestational age; OD, oocyte donation; PTB, preterm birth.

*IVF children from Brinsden and Rizk (1992) .

Conclusion: Similar rates of PTB (<37 weeks) were reported after surrogacy and in pregnancies which were the result of fresh IVF. Low quality of evidence (GRADE⊕○○○).

Birthweight

Birthweights were recorded in three cohort studies, including a total of 1775 children, and in five case series, including a total of 252 children (Table  III ). Studies came mainly from the USA, Canada and Brazil. Mean birthweight for surrogate singletons varied between 3309 and 3536 g, compared with 3100–3240 g for IVF singletons and 3226 g for OD singletons (OD comparison in only one study). In two small case series from Europe ( Soderstrom-Anttila et al., 2002 ; Dermout et al. , 2010 ) the mean birthweights of surrogate singletons were 3536 and 3498 g, respectively. Low birthweight (LBW; <2500 g) occurred in between 0 and 11.1% for surrogate singletons, in 13.6–14.0% for IVF singletons and in 14.0% for OD singletons.

Birthweight in children born after surrogacy.

LBW, low birthweight; SC, spontaneous conception; SGA, small for gestational age; VLBW, very low birthweight.

Two cohort studies (exact numbers of twins not available) and five case series ( n = 2–76 twins) reported on birthweight in surrogate twins. In surrogate twins, LBW occurred in 29.6–50%. In the largest cohort study, LBW occurred in 50 versus 56% in fresh IVF twins and 53.6% in fresh OD twins ( Schieve et al. , 2002 ). The other cohort study also reported on mean birthweight in surrogate twins, which was 2.7 (SD 0.06) kg as compared with 2.4 (SD 0.04) kg in IVF twins ( Parkinson et al. , 1998 ).

Conclusion: Numerically similar or lower rates of LBW were reported after surrogacy and in pregnancies resulting from fresh IVF. Low quality of evidence (GRADE⊕⊕○○).

Birth defects

Birth defects were reported in eight cohort studies, of which seven were annual reports from Society for Assisted Reproductive Technologies (SART), and in three case series (Table  IV ). In total, data from 1238 children born after surrogacy were identified. Birth defects were reported in 0 to 6.5% of the surrogacy children, as compared to 1.1 to 2.9% for IVF children and 0.6 to 2.1% for children born after OD.

Birth defects* in children born after surrogacy.

SART, Society for assisted reproductive technology.

*Birth defects as defined by authors.

**IVF children from Brinsden and Rizk (1992) .

Conclusion: Similar rates of birth defects in singletons were reported after surrogacy and after fresh IVF and oocyte donation. Low quality of evidence (GRADE⊕⊕○○).

Psychological follow-up

Eight studies, made up of six cohort studies and two case series, were identified as dealing with the psychological outcome for children born after surrogacy (Table  V ). Six of these papers were published by Golombok and co-workers ( Golombok et al. , 2004 , 2006a , b , 2011 , 2013 ; Jadva et al. , 2012 ). The authors followed 42 children from 1 to 10 years of age. No major differences in psychological development were found between children born after surrogacy, children born after OD and children born after natural conception. However, at the age of 7 years children born after surrogacy showed higher levels of adjustment problems than children born after gamete donation. At the age of 10 years this difference had disappeared. In another study from the UK ( Shelton et al. , 2009 ) 21 children born after surrogacy were compared with children born after different kinds of assisted reproduction (IVF, OD, insemination and embryo donation) and followed up for between 4 and 10 years. No differences in psychological adjustment between the groups were detected. Jadva et al. (2012) investigated children's views of surrogacy at the ages of 7 and 10 years. A majority of the children had some knowledge of modes of conception. Fourteen out of 42 children had met their surrogate mothers in the past year and all were either positive or indifferent to surrogacy births. Lastly, a large case series of 110 surrogate children was reported from Brazil ( Serafini, 2001 ). Outcomes included speech delay, as well as growth and motor development. A low rate of slow physical growth was also reported. Speech delay declined with age and was 3.8% at 2 years of age. No motor delays were reported.

Development and psychological follow-up of children born after surrogacy.

ADHD, attention deficit hyperactivity disorder; DI, donor insemination.

*Mix of traditional and gestational carrier surrogacy.

Conclusion: Up to the age of 10 years there were no major psychological differences between children born after surrogacy and children born after other types of ART, or after natural conception. Low quality of evidence (GRADE⊕⊕○○).

Psychological outcome for surrogate mothers

Sixteen studies, eight cohort studies, six case series and two qualitative studies including between 8 and 61 surrogate mothers, examined psychological outcome ( Supplementary Table SIV ). No serious psychopathology among the surrogate mothers was noted. The motives for surrogacy were mostly altruistic but financial reasons were also noted. The rate of immediate post-partum depression was between 0 and 20% ( Parkinson et al. , 1998 ; Soderstrom-Anttila et al., 2002 ; Jadva et al. , 2003 ; van den Akker, 2007 , Imrie and Jadva, 2014 ). Six studies assessed relinquishing issues. In one study from the UK ( Jadva et al. , 2003 ) including 34 surrogate mothers, 35% initially had some/moderate difficulties handing over the child. One year on, 6% still reported some negative feelings related to relinquishment. The majority of the surrogates in this study were traditional surrogates. In two other studies relinquishing the child was a problem in 1/33 and 1/15, respectively ( Blyth, 1994 ; Pashmi et al. , 2010 ).

In studies which assessed contact between the surrogate mother and the intended mother/family, in the vast majority of cases contact was harmonious and regular, both during pregnancy and after birth ( Jadva et al. , 2003 ; Imrie and Jadva, 2014 ). The frequency of contacts decreased over time while the quality of the relationship seemed to continue to a similar degree, also after 10 years ( Jadva et al. , 2012 , 2015 ). One study assessed the psychological well-being, family relationships and experiences of the surrogates’ own children, born prior to the surrogacy arrangements ( Jadva and Imrie, 2014 ). The children whose mother had been a surrogate between 5 and 15 years earlier did not experience any negative consequences as a result of their mother's decision to be a surrogate, irrespective of whether the surrogate mother had used her own oocytes or not ( Jadva and Imrie, 2014 ).

Conclusion: Most surrogate mothers are within the normal range on personality tests. Most psychosocial variables were satisfactory, although relinquishing problems sometimes occurred. Very low quality of evidence (GRADE⊕○○○).

Psychological outcome for intended parents

We identified 16 studies, 11 cohort studies, four case series and one qualitative study that reported on outcomes for the intended mothers and their families ( Supplementary Table SV ). Most studies were from the UK, seven from Golombok and co-workers ( Golombok et al. , 2004 , 2006a , b , 2011 , 2013 ; Blake et al. , 2012 ; Jadva et al. , 2012 ). No major differences in the parents’ psychological states or mother-child interactions were observed in groups made up of commissioning mothers, mothers who had received OD and mothers who had conceived naturally. The mothers’ and fathers’ marital quality was compared at five time points between different family types when the children were between 1 and 10 years of age ( Blake et al. , 2012 ). The mothers and fathers of children born through surrogacy had similar marital satisfaction as parents in gamete donation families. When the children were 2 years old the mothers in natural conception families had higher levels of marital satisfaction than their counterparts in ART families. This difference had disappeared when the children were 3, 7 and 10 years ( Blake et al. , 2012 ). In families with a 2-year-old child born through surrogacy fathers reported lower levels of parenting stress than their natural conception counterparts ( Golombok et al. , 2006a ).

Four studies were reported by another UK group ( van den Akker, 2000 , 2005a , b , 2007 ). Genetic links were found to be more important to mothers whose children were the result of gestational surrogacy than those who had children after traditional surrogacy. These differences were observed both during pregnancy and after birth. In a study from the Netherlands ( Dermout et al. , 2010 ) more than 500 couples enquired about surrogacy by telephone or e-mail, but only 35 couples actually entered the IVF programme. After this extensive screening, no negative or harmful consequences were detected among the parties involved. This meant that there were no problems in accepting even a disabled child. Disclosure of surrogacy to the children was recorded in one study. In 29 out of 33 families, disclosure to the child had been made by the age of 7 years ( Readings et al. , 2011 ). In three other studies, 97–100% of parents aimed to tell the child about the surrogacy ( Blyth, 1995 ; van den Akker, 2000 ; MacCallum et al. , 2003 ).

Conclusion: There were no major differences in the psychological states of mothers of children who were the product of surrogacies, mothers of children conceived after other types of ART and mothers of children who were conceived naturally. Low quality of evidence (GRADE⊕⊕○○).

This systematic review summarizes the published literature on surrogacy, including both medical and psychological outcomes for surrogate mothers, intended parents and the children born after surrogate arrangements. Although these arrangements, including gestational carrier programmes, have been carried out since the late 1980s, research on outcomes for the parties involved is very limited. Most studies have significant methodological limitations, such as small sample size. Also, for the studies on psychological follow-up in particular, a low response rate is noted, introducing a risk of selection bias. The research literature on surrogacy is sparse for many reasons. It is believed that financial support for such controversial research is difficult to secure and that it is difficult to track the number of children born, especially those born as a result of traditional surrogacy. Furthermore, given the social stigma associated with surrogacy arrangements, it is thought that intended parents are perhaps unwilling to sacrifice their privacy to participate in research in the field ( Ciccarelli and Beckman, 2005 ).

One objection to allowing surrogacy is that the woman carrying the child will be exposed to unexpected health risks related to the pregnancy and delivery. Only five studies have looked into the risks of pregnancy complications; four of these involved gestational and one traditional surrogacy. The incidence of HDP was between 4.3 and 10% in singleton gestational carrier pregnancies compared to between 16 and 40% usually reported in OD pregnancies ( Parkinson et al. , 1998 ; Dar et al. , 2015 ; van der Hoorn et al., 2010 ). The high frequency of HDP noted in OD pregnancies has been associated with the fact that the oocyte recipient is immunologically unrelated to the donor ( van der Hoorn et al., 2010 ). In theory, the same situation occurs in gestational surrogacy, as in such cases the entire fetal genome is allogeneic to the carrier. Based on the few reports on GC outcome available, there has been speculation that a healthy carrier with a normal reproductive background might somehow compensate for atypical immunological reactions related to a foreign embryo, and that the surrogates might have a more hospitable uterine environment than infertile oocyte recipients ( Gibbons et al. , 2011 ). Although the number of cases studied is small, the lower HDP rate in surrogate mothers, most of whom have already experienced normal pregnancies and deliveries, supports the view of a connection between nulliparity and HDP ( Parkinson et al. , 1998 ).

The duration of singleton surrogacy pregnancies was similar to or shorter than that of singleton standard IVF pregnancies, and the incidence of preterm birth (<37 weeks) was, in general, numerically lower than in standard IVF singletons. The shorter mean gestational age seen in one study is interesting as the rate of obstetric complications in general was low and, according to selection criteria for surrogate mothers, they should previously have experienced uncomplicated pregnancies ( Gibbons et al. , 2011 ). The articles give no information on the rate of induction of labour or the rate of Caesarean section performed for non-medical reasons. The surrogate mother might also have had one of a number of risk factors, as reported in the early paper by Reame and Parker (1990) in which the profiles of 66% of the traditional surrogate mothers had risk factors, including smoking or having had no previous deliveries. These factors may have had implications for pregnancy length.

There were three reports of hysterectomies related to delivery, two of which occurred in multiple pregnancies, in a twin and a triplet pregnancy. The third hysterectomy occurred in a singleton pregnancy after uterine rupture in a gestational carrier with three previous, full-term, normal vaginal deliveries, indicating that there are always potential maternal risks, even if the carrier has no obstetric risk factors in her case history.

One of the cornerstones in surrogacy arrangements is the importance of choosing the surrogate mother with extreme caution. To minimize the medical risks to the surrogate mother recommendations drawn up by expert groups in ESHRE, ASRM and FIGO should be followed. Gestational carrier candidates, who have had previous adverse obstetric outcomes should not be accepted. The pregnancy history of the surrogate candidate might be more predictive of obstetric complications than her age ( Duffy et al. , 2005 ). Furthermore, the risk of almost all maternal complications is increased by multiple pregnancies (HDP, haemorrhage during pregnancy and delivery, preterm labour and delivery, operative delivery). To avoid unnecessary endangerment of the health of the surrogate and the future child it is strongly recommended that only one embryo at a time is transferred to the surrogate ( Shenfield et al. , 2005 ).

The most important concern related to surrogacy treatment is anxiety about possible harmful medical and psychological consequences for the child. For infants born after surrogacy, perinatal outcome has been satisfactory. The mean birthweight of gestational carrier singleton children was higher than average and the incidence of LBW was low (Table  III ). This positive outcome is probably because in surrogacy pregnancies the pregnant women have better reproductive health than infertile women with a history of reproductive illness. As in standard IVF and OD treatments, the rate of PTB and LBW in multiple births in gestational carriers was high, at between 30 and 100%. This underlines the importance of avoiding multiple pregnancies in surrogacy arrangements.

Two papers give the incidence of birth defects as 6% ( SART 1994 ; Dermout et al. , 2010 ). However, all SART reports from 1995 onwards, and including much higher numbers of children, showed a lower rate of birth defects, at between 0 and 2.9%, which was comparable to SART data for standard IVF and OD treatments. Another Dutch study by Dermout included only 13 deliveries out of which one twin baby had severe malformations ( Dermout et al. , 2010 ). Published studies show that the risk of birth defects in infants born after surrogate pregnancies is similar to risks after IVF and OD treatment.

Follow-ups of the psychological development of older children belonging to the surrogate group are very limited and almost all studies come from the UK. An initial group of 42 surrogacy children was followed up for 10 years from the age of 1 year. Of the children, 71% were still participating in the study at the age of 10 years. Through the years the children's psychological adjustment was normal and comparable to that of OD and naturally conceived children. The higher levels of adjustment problems noted in surrogacy children at 7 years of age proved to be temporary and had disappeared 3 years later. Good psychological adjustment in surrogacy children was also reported by Shelton and associates ( Shelton et al. , 2009 ). It is possible that families and children taking part in these studies are not representative of the outcome in general, but the studies from the UK following these families for up to 10 years are the largest and most representative samples so far collected.

The research literature on psychological implications for surrogate mothers and intended parents is sparse and the heterogeneity of the groups of surrogate mothers included in published studies makes it impossible to drawn any firm conclusions about this group. Some of the studies examine commercial and others altruistic non-paid surrogates. Other studies include both gestational and traditional arrangements where the surrogate might be unknown, or known, to the intended couple.

An interesting question relates to the characteristics which make women willing to act as surrogates. Do these women have some special traits which set them apart? Again, non-representative samples, a lack of control groups and ambiguous comparisons with test norms make it difficult to reach firm conclusions ( Ciccarelli and Beckman, 2005 ). A cautious summary of published research indicates that the psychological profiles and characteristics of most surrogate mothers are in the normal range of personality tests ( Pizitz et al ., 2013 ). However, it has been suggested that some characteristics of surrogate mothers make them more flexible regarding moral and ethical principles to do with traditional family values and the meaning of motherhood ( Kleinpeter and Hohman, 2000 ; Ciccarelli and Beckman, 2005 ).

The primary motivation reported by surrogate mothers is altruistic concern for infertile couples. Money was named as a prime motive by only a small number of the women. However, financial interests are probably also present in many cases where the main motivation is reported to be empathy for childless couples ( Braverman and Corson, 1992 ; Blyth, 1994 ; Kleinpeter and Hohman, 2000 ; Hohman and Hagan, 2001 ; Baslington, 2002 ; Jadva et al. , 2003 ; van den Akker, 2003 ; Pashmi et al. , 2010 ).

Surrogate mothers generally report being satisfied with their experiences ( Jadva et al. , 2003 ). The frequency of post-partum depression seems to be low. Important factors that determine the surrogate mother's satisfaction after the birth of the baby have been related to the quality of the relationship with the intended couple, especially the intended mother, and circumstances to do with the relinquishment of the child ( Blyth, 1994 ; Hohman and Hagan, 2001 ; MacCallum et al. , 2003 ). One reason for regarding surrogacy as problematic and controversial is the risk of dispute between the surrogacy mother and the intended parents as to custody of the child. What if the surrogate mother decides to keep the child or the intended parents are not willing to welcome a disabled child? There have been reports highlighted in the media about situations when problems arise, such as the Baby M case and more recently the case of Baby Gammy ( Peterson, 1987 ; BBC News Asia, 2014 ; Schover, 2014 ; Topping and Foster, 2014 ). Baby M was born in 1986 as a result of traditional surrogacy and after the birth the surrogate mother decided to keep the child. In court, the genetic father was awarded legal custody, with the surrogate mother having visiting rights.

Follow-up studies show that generally there were no significant difficulties for the surrogate mothers to hand over the children to the intended parents ( Fischer and Gillman, 1991 ; Blyth, 1994 ; Baslington, 2002 ; Jadva et al. , 2003 ; van den Akker, 2003 ; Pashmi et al. , 2010 ). It has been suggested that surrogate mothers may not view the child they are carrying as theirs, thereby facilitating relinquishment ( Jadva et al. , 2003 ; van den Akker, 2003 ; Ahmari Tehran et al ., 2014; , Lorenceau et al ., 2015 ). However, in a minority of cases the woman experienced some difficulties in giving up the child. The reasons for these problems have not been reported, but it might have to do with insufficient screening of the surrogate mothers or, for example, lack of emotional support. Furthermore, it was not always clear whether the child was the result of traditional or gestational surrogacy. There is evidence to suggest that where the surrogate mother has a genetic link to the child the potential for disputes between the parties is increased ( Trowse, 2011 ).

Recently, the case of Baby Gammy has made international news. The intended Australian parents of twins born to a Thai surrogate mother did not accept baby Gammy, who had Down syndrome. They took baby Gammy's healthy sister back to Australia leaving the critically ill baby Gammy with the surrogate mother. Fortunately, such cases are rare events. In Western countries, the risk that the intended parents involved in gestational surrogacy would not want to welcome their own child must be estimated as small ( Brinsden, 2003 ). Those couples, who after screening and counselling are committed to going further with this time-consuming and complicated treatment, are in general highly motivated to become parents. However, pretreatment counselling is extremely important and requires high attention. It should include descriptions of all the risks and benefits of gestational surrogacy as well as information on the rights and responsibilities of all parties.

In general, at least in countries where surrogacy is legal, a large majority of the intended parents plan to inform their child about the method of conception ( van den Akker, 2000 ; MacCallum et al. , 2003 ; Readings et al., 2011 ). In this respect the surrogacy families are more open with their children than families created through other forms of ART, for example OD and donor insemination ( Söderström-Anttila et al. , 2010 ; Readings et al. , 2011 ; Sälevaara et al. , 2013 ). Genetically related surrogate mothers have been shown to be more likely than genetically unrelated surrogate mothers to wish the child to be told about the surrogacy arrangement ( Jadva et al. , 2003 ). Continuation of contact between the family and the surrogate mother will depend on whether the child has been informed or not. The type of surrogacy has been shown to be associated with the frequency of contact with the child's parents, with the parties involved in traditional surrogacy arrangements maintaining less frequent contact than those involved in gestational surrogacy ( Jadva et al. , 2012 ; Imrie and Jadva, 2014 ). Most families created by surrogacy have reported a harmonious relationship with the surrogate mother ( Kleinpeter, 2002 ; Imrie and Jadva, 2014 ). Again, this refers to countries that have regulated surrogacy. In cross-country surrogacy, there are no studies on the relationship between the intended parents and the surrogate mother, who might even be unknown to the commissioning couple.

Surrogacy arrangements have been used by same-sex men to become fathers, as it allows one of the couple's spermatozoa to provide a genetic link to the child and an opportunity to raise the child from birth ( Norton et al. , 2013 ). However, there is very limited research on gay men and surrogacy. A few studies have addressed questions of counselling, decision-making and the significance of biogenetic paternity to gay male couples becoming parents through surrogacy ( Greenfeld and Seli, 2011 ; Dempsey, 2013 ; Norton et al. , 2013 ). Outcomes for the children and the families have not been reported.

It is obvious that surrogacy involves deep ethical considerations. Normally the person who wants the child takes the medical risks of the pregnancy. In surrogacy arrangements the carrier takes the risks. Relationships between the parties may change during the procedure and disagreements between the intended parents and the carrier may occur over issues related to the pregnancy and the relinquishment of the child. However, in Western countries, many of these risks can be minimized by careful counselling and psychological support. This should be offered to all parties, not only before and during the treatment, but also after the child has been born. Emotional and legal support can best be offered in the home country of the partners involved. The risks of conflicts between the intended parents and the surrogate mother will probably rise in line with increasing cross-border ‘reproductive tourism’ and the lack of regulations in countries with commercial surrogacy. Ethical issues specific to the engaging of surrogate mothers from low and middle income countries include questions about custody rights, limits of surrogacy care, remuneration, multiple embryo transfer, medical advocacy and the exploitation of poor women ( Deonandan et al. , 2012 ). In commercial cross-border surrogacy, it might be argued that children are transformed into something one can buy. If wealthy couples go to poor countries to find a surrogate mother, that woman might be put under pressure to live under certain conditions while she is being paid. The woman might also agree to enter into a surrogacy arrangement simply because of her poor financial situation. These are strong arguments against commercial surrogacy and these are situations which do not arise in altruistic surrogacy.

It seems clear there is a growing practice of surrogacy treatments worldwide and that many of these arrangements cross national borders. During the last years, prohibition of surrogacy treatment has led to critical discussion in several European countries. It is an ethical dilemma that couples have to turn to the commercial surrogacy industry abroad to receive help for their infertility problem. In Iceland the Government has, at time of writing, prepared a law proposing legalization of altruistic gestational surrogacy. Recently, the National Advisory Board on Social Welfare and Health Care Ethics in Finland (ETENE, www.etene.fi ) and Swedish Medical Advisory Board in Ethics (SMER; www.smer.se ) have suggested that surrogacy treatments should be allowed in restricted medical situations. Details of the current legal regime of surrogacy in European Union (EU) member states, as well as reports on solutions of legal implications of cross-border surrogacy, can be found in papers published by the EU and Hague Convention on Private International Law ( Brunet et al. , 2013 ; http://www.hcch.net/index ).

Strength and limitations

The major strength of this review is the comprehensive appraisal of the literature regarding outcome for the children as well as outcomes for the surrogate and intended mothers, and including both medical and psychological variables. Limitations are the lack of high quality studies. Most studies have significant methodological limitations such as small sample size, lack of controls and a low response rate. Gestational and traditional surrogacy was not always separated in the studies. To date there are no studies on children growing up with gay fathers. There are no follow-up studies on families created via commercial cross-border surrogacy in countries such as India, Russia and Ukraine, where surrogacy seems to be increasing.

Conclusions

Most studies reporting on surrogacy have serious methodological limitations. According to these studies most surrogacy arrangements are successfully implemented, and most surrogate mothers are well motivated and have little difficulty separating from children born as a result of the arrangement. The perinatal outcome of the children is comparable to standard IVF and OD and there is no evidence of harm to the children born as a result of surrogacy. However, these conclusions should be interpreted with caution. We have not found any publications on outcome for families and surrogate mothers involved in commercial cross-country surrogacy in less well developed countries where surrogacy is a growing industry. Furthermore, there are no studies on children growing up with gay fathers. Long-term follow-up studies on surrogacy children and families will be needed in the future.

Supplementary data are available at http://humupd.oxfordjournals.org/ .

All authors contributed substantially to conception and design of the study. C.B., U.-B.W. and V.S.-A. selected and appraised the articles. V.S.-A., C.B. and U.-B.W. wrote the article. All authors revised the article critically and approved the final version.

The Nordic Expert group's research work was unconditionally supported by MSD in Finland, Norway and Denmark and by an agreement concerning research and the education of doctors (ALFGBG-70 940).

The authors confirm that they have no conflict of interest in relation to this work.

The authors wish to thank librarian Therese Svanberg for searching of literature and Gwyneth Olofsson for correction of the English language.

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How to Use a Surrogate Mother

What is surrogacy, who uses surrogate mothers, how do you find a surrogate mother, read this next, 1. surrogacy agencies, 2. a friend or family member, what happens once you find a surrogate mother, what is the process of surrogacy, how much does hiring a surrogate mother cost, does insurance cover surrogacy, what are the possible risks of using a surrogate mother, what are the legal implications of using a surrogate mother, can a surrogate mother change her mind and keep the baby.

Despite its cost and legal obstacles, surrogacy is an option to consider for hopeful parents who aren’t able to carry a pregnancy themselves.

What to Expect Before You're Expecting , 2nd edition, Heidi Murkoff. What to Expect When You’re Expecting , 5th edition, Heidi Murkoff. WhatToExpect.com,  In Vitro Fertilization , April 2020. WhatToExpect.com, How the Artificial Insemination Process Works , March 2019. WhatToExpect.com, Infertility , 2020. WhatToExpect.com, Why Can’t I Get Pregnant? , September 2020. American Academy of Obstetricians and Gynecologists, Family Building Through Gestational Surrogacy , March 2016. American Society for Reproductive Medicine,  Consideration of the Gestational Carrier: an Ethics Committee Opinion , November 2018. American Society for Reproductive Medicine, Gestational Carrier (Surrogate) , 2012. Society For Assisted Reproductive Technology,  Prerequisite Testing , 2020. Mayo Clinic, Intrauterine Insemination (IUI) , July 2019. Resolve, Legal Aspects of Domestic Gestational Carrier Agreements , 2020. Resolve, Surrogacy Myths and Facts , 2020. Columbia University, Surrogacy Law and Policy in the U.S.: A National Conversation Informed by Global Lawmaking , May 2016. Family Equality, What’s a Second Parent Adoption? , May 2019.

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• Internet Encyclopedia of Philosophy - Surrogate Parenting
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• Surrogate mother - Student Encyclopedia (Ages 11 and up)

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surrogate motherhood , practice in which a woman (the surrogate mother) bears a child for a couple unable to produce children in the usual way, usually because the wife is infertile or otherwise unable to undergo pregnancy . In so-called traditional surrogacy, the surrogate mother is impregnated through artificial insemination with the sperm of the husband. In gestational surrogacy, the wife’s ova and the husband’s sperm are subjected to in vitro fertilization , and the resulting embryo is implanted in the surrogate mother. Normally, in either procedure, the surrogate gives up all parental rights, but this has been subject to legal challenge.

The practice of surrogate motherhood, though not unknown in previous times, came to international attention in the mid-1970s when a reduction in the number of children available for adoption and the increasing specialization of techniques in human embryology made such methods a viable alternative to lengthy and uncertain adoption procedures or childlessness. Surrogate motherhood has raised a number of issues—such as the matter of payment for services (which, taken to the extreme, has implications of making children a commodity) and the rights of all of the individuals involved should any aspect of the procedure go awry.

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The Life of a Surrogate Mother: What Is It Really Like?

Table of Contents

The Life of a Surrogate

The life of a surrogate is marked by a unique blend of altruism and the profound impact of assisting others in their journey to parenthood. From the initial decision to explore surrogacy, surrogates embark on a comprehensive process that involves thorough screenings, interviews, and matching with Intended Parents. Once matched, the surrogate undergoes medical evaluations and legal processes to ensure a clear and comprehensive agreement, setting the foundation for a collaborative and well-supported surrogacy journey. The life of a surrogate is often a transformative and emotionally rich journey, driven by the noble desire to help others build the families they dream of. Many surrogates also find that surrogacy helps them achieve personal or financial goals, in addition to the altruistic rewards.

Making the Decision to Explore Surrogacy:

Many women decide to become surrogates out of a desire to help others experience parenthood. This decision often arises from a combination of empathy, compassion, and a willingness to contribute to the joy of starting a family .

Surrogates must do their own research prior to getting too far ahead of themselves to understand the basic medical and legal requirements . Any prospective surrogates will eventually be cleared by medical and legal professionals.

Matching with Intended Parents:

Either via an agency, friends groups, or self-matching via a site like SurrogacyPlace.com , a surrogate will interview prospective Intended Parents in hopes of matching. This process involves mutual selection, where both parties get to know each other through interviews and sharing information about their reasons for pursuing surrogacy, medical history, and details about their families. It’s crucial for both the surrogate and Intended Parents to feel comfortable with the match.

Medical Clearance:

Once a match is made, the surrogate undergoes medical and psychological evaluations. These assessments ensure that she is physically and emotionally prepared for the surrogacy journey. The Intended Parents may also undergo similar screenings.

The medical and psychological screenings for surrogates play a crucial role in ensuring the well-being of the surrogate throughout the surrogacy journey. The medical evaluation involves a comprehensive assessment of the surrogate’s health and reproductive history. This includes a detailed examination of her reproductive organs, hormone levels, and overall physical health. Surrogates typically undergo fertility treatments to synchronize their menstrual cycles with the intended mother or egg donor, preparing their bodies for embryo transfer . The medical screenings aim to identify any potential health concerns, ensuring that the surrogate is physically capable of carrying a pregnancy to term.

In addition to medical evaluations, psychological screenings are a vital component of the surrogacy process . Surrogates undergo psychological assessments conducted by mental health professionals experienced in reproductive issues. These assessments explore the surrogate’s mental and emotional well-being, ensuring she is prepared for the emotional challenges that may arise during the surrogacy journey. Psychologists may assess the surrogate’s understanding of the emotional aspects of surrogacy, her support system, and her ability to cope with potential stressors. This ensures that the surrogate is mentally resilient and prepared to navigate the complexities of carrying a child for another family.

The combination of medical and psychological screenings serves to create a comprehensive profile of the surrogate, addressing both her physical and emotional suitability for surrogacy. These screenings not only benefit the surrogate, but also contribute to the overall success and well-being of the Intended Parents and any unborn child. The thorough evaluation process helps establish a foundation of trust between the surrogate and Intended Parents, fostering a supportive and collaborative environment for the entire surrogacy journey.

Legal Contracts:

The legal phase of a surrogacy journey is a critical aspect that ensures the rights , responsibilities, and expectations of all parties involved, including the surrogate. Once a suitable match is made and medical clearances are obtained, the legal process begins with the drafting, reviewing, and finalization of legal contracts . Surrogates have their own legal representation (paid for by Intended Parents) to ensure their interests are protected throughout the journey.

Legal contracts in surrogacy cover a wide range of topics, including compensation , medical decisions, potential risks , and the Intended Parents’ rights and responsibilities. The contracts also outline the surrogate’s obligations and commitments during the pregnancy. The goal is to create a clear and comprehensive agreement that protects all parties and minimizes the potential for legal disputes.

During the legal phase, surrogates may work closely with their attorneys to fully understand the terms of the contract and to address any concerns or questions they may have. This phase ensures that the surrogate is fully aware of her rights and responsibilities, providing a legal framework that supports a smooth and well-defined surrogacy journey. Legal professionals play a crucial role in facilitating open communication between the surrogate and Intended Parents, fostering a relationship built on trust and mutual understanding.

After the birth of a child, additional legal steps may be required to establish parentage. Depending on jurisdiction, surrogates may need to play a part in the legal processes designed to ensure the Intended Parents are legally recognized as the child’s legal parents .  

Overall, the legal phase of a surrogacy journey is designed to protect the rights of all parties involved.

Medical Procedures:

The medical process that surrogates undergo is a carefully orchestrated series of procedures designed to optimize the chances of a successful pregnancy.  The surrogate is prescribed hormonal medications to prepare her uterus for implantation. The embryo transfer then takes place with the hopes that implantation will occur.

Throughout the medical process, surrogates receive close monitoring and support from fertility specialists and healthcare professionals. Regular check-ups, ultrasounds, and hormonal assessments are conducted to track the progress of the pregnancy. The goal is to ensure the surrogate’s health and the well-being of the developing fetus. The medical process is a collaborative effort involving the surrogate, Intended Parents, and medical professionals, working together to achieve a successful and healthy pregnancy.

Pregnancy and Prenatal Care:

Once the embryo is successfully implanted, marking that the surrogate is pregnant, she enters a phase of comprehensive prenatal care. Regular check-ups, conducted by her obstetrician-gynecologist (OB-GYN) , become a crucial aspect of ensuring the surrogate’s health and monitoring the progress of the pregnancy. These appointments include ultrasounds, hormonal assessments, and other routine prenatal tests to track the development of the fetus and address any potential health concerns. The surrogate’s physical and emotional well-being are prioritized throughout this period, with the medical team providing the necessary guidance and support to optimize the chances of a healthy and successful pregnancy.

The involvement of the Intended Parents during the prenatal care phase varies based on mutual preferences. Many Intended Parents choose to actively participate in medical appointments, allowing them to witness the milestones of the pregnancy and stay informed about the well-being of their future child. This collaborative approach fosters a sense of shared responsibility and connection between the surrogate and the Intended Parents, creating a supportive environment for the duration of the surrogacy journey. Open communication and shared experiences during prenatal care contribute to the overall positive and fulfilling nature of the surrogacy process.

Birth and Post-Birth Process:

The culmination of the surrogacy journey is marked by the surrogate giving birth, a momentous event that is often attended by the Intended Parents. The presence of the Intended Parents during the delivery allows them to be actively involved in the birthing experience and witness the joyous arrival of their child. This shared moment becomes a significant bonding experience, reinforcing the collaborative nature of the surrogacy journey. The surrogate’s contribution is acknowledged and celebrated, creating a meaningful connection between the surrogate and the Intended Parents.

Post-birth , the nature of the relationship between the surrogate and the Intended Parents varies widely. Some parties choose to maintain a close connection, continuing to share updates, photos, and milestones of the child’s life. This ongoing relationship is often built on mutual respect and appreciation for the surrogate’s role in helping the Intended Parents achieve parenthood. On the other hand, some surrogates and Intended Parents may prefer a more distant relationship, with communication limited to essential updates. Regardless of the level of connection, open communication is essential to navigate post-surrogacy dynamics successfully. Clear expectations, boundaries, and mutual understanding contribute to a positive post-surrogacy relationship, allowing all parties to reflect on the journey with gratitude and satisfaction.

FAQ: The Surrogacy Journey

Why do women decide to become surrogates.

Many women decide to become surrogates out of a desire to help others experience parenthood. This altruistic decision often stems from a combination of empathy, compassion, and a genuine willingness to contribute to the joy of starting a family.

What is the surrogacy matching process like?

Surrogates can be matched with intended parents through agencies, friends groups, or self-matching platforms like SurrogacyPlace.com. The matching process involves interviews, sharing information about medical history and reasons for pursuing surrogacy, ensuring both parties feel comfortable with the match.

What medical and psychological screenings do surrogates undergo?

Surrogates undergo comprehensive medical evaluations, including assessments of reproductive health and fertility treatments to prepare for embryo transfer. Psychological screenings ensure surrogates are emotionally prepared for the journey, assessing their understanding of surrogacy’s emotional aspects and support systems.

What legal steps are involved in surrogacy?

The legal phase includes drafting, reviewing, and finalizing contracts that cover compensation, medical decisions, and the rights and responsibilities of all parties. Surrogates have their own legal representation to protect their interests. Post-birth, legal processes may be required to establish parentage, ensuring the intended parents are legally recognized.

  What is the medical process like for surrogates?

The medical process involves synchronization of menstrual cycles, fertility treatments, embryo transfer, and careful monitoring of the surrogate’s health through regular check-ups, ultrasounds, and hormonal assessments. The goal is to optimize the chances of a successful and healthy pregnancy.

  How are Intended Parents involved during prenatal care?

During prenatal care, Intended Parents may actively participate in medical appointments, fostering a shared responsibility and connection with the surrogate. Open communication and shared experiences contribute to a positive and fulfilling surrogacy journey.

What happens during and after birth?

The surrogate gives birth, often attended by the Intended Parents. Post-birth, the relationship between the surrogate and Intended Parents varies. Some maintain a close connection, sharing updates and milestones, while others prefer a more distant relationship. Open communication is key to navigating post-surrogacy dynamics successfully.

Bridget Myers

Bridget Myers grew up in small town in Maryland. She started her career as a substitute teacher before meeting the love of her life and moving to the suburbs of Chicago. She has a passion for dogs and painting. Bridget got involved in Surrogacy Place after researching surrogacy for her best friend. Since joining the team at Surrogacy Place, she has developed a passion for advocating on behalf of Intended Parents and surrogates and doing her part for meaningful reform in the industry.

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Ethical Argument for Surrogate Motherhood Essay

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Family is a very important unit of human race. Motherhood and family are two interrelated terms, as through family motherhood is able to fulfill the roles ascribed the society (Teman 2008). In that sense, family is the only continuation of our existence. Without a family, the entire human race is threatened with extinction. Families that cannot have children are at high risk of becoming extinct when the two partners die off. From an evolutionary point of view, motherhood can be seen as a very important unit in the society.

According to the theory of Natural Selection by Charles Darwin, in an environment where there is a competition for limited resources, only the fittest individuals survive, where individuals with suitable characteristics are selected against those who are not able to adapt. This law has been quite often referred to as survival for the fittest. According to this theory, couples who are unable of bearing children are at risk of becoming extinct in their generation, as they lack the ability to pass their genetic material. Therefore, surrogate motherhood in this case can be of use as a vital process that can facilitate the transfer of genes to another generation.

Accordingly, this process provides the means through which couples that are not able to bear children to compete with other capable couples. In this case, surrogate motherhood can be viewed as a fair and ethical practice that enables such people to make families (Vasanti Jadva et al. 2003). From a genetic point of view, surrogate motherhood is an arrangement that enables the transfer of genes in families that are incapable of doing so. In that sense, Surrogate motherhood is an important process that brings variability in the human race instead of letting genes disappear simply because the inability of the couple to reproduce. Variability in the genetic combination of the child is a very unique phenomenon, in a sense that it can bring about the occurrence of desirable traits which were not present in parents. Such desirable genes are present in the surrogate mother and they can be admired by other parents, where the desirable traits can be different in terms of physical attributes such as height, skin color, IQ and many others (Teman 2008).

In psychology, according to Maslow’s hierarchy of needs, there comes a time in life when achieving self actualization and satisfaction implies the need for children. The lack of satisfaction of such needs can lead to undesirable behavior. Children in that sense can become an essential factor in achieving self satisfaction in couples. Childless couples have higher risk of separation than those who formed a family with children.

If couples do not consider themselves in a position that allows them to bear children themselves, a surrogate arrangement can be the only way of creating a full family. Accordingly, having children they can achieve the aforementioned satisfaction in their life. Thus, surrogate motherhood becomes a marriage savior for families threatened with separation and divorce because of the inability of one of the partners to bear children. For the purpose of protecting the institution of family and marriage, surrogate motherhood is a very vital human arrangement.

Research studies have continued to indicate that infertility is a common course of disintegration in most marriages. The pressure to bear children can be originated from different angles, as it is quite inevitable to avoid these pressures because we all live in a society that affect our beliefs and values. The society acknowledges that a family without children cannot stand and compete among the others. Based on such acknowledgements and systems of belief, it becomes very difficult for affected couples to find a purpose if they cannot reproduce. Surrogacy therefore, becomes a very essential alternative for such partners to fulfill their marital responsibilities (MacCallum, Fiona et al. 2003).

According to the Holy Bible, Christians believe that it is the will of God for the people to propagate in the world. Therefore, by marrying, forming a family, and giving birth to children people are fulfilling the will of God. For those who are unable of fulfilling this will in a “traditional” way, surrogacy as a mean for parenting is an acceptable way of fulfilling God’s will.

From a Christian perspective, there is no commandment that is disobeyed by engaging in surrogate motherhood, as it does not contradict the teachings of the Bible. Without this alternative the affected people might think that they have been denied the opportunity to bear children and fulfill the will of God, and the dream of some people to have children would be completely shattered (MacCallum, Fiona et al. 2003).

Nevertheless, there are some isolated cases in surrogacy where exploitation manifested itself in both parties. Without proper legal framework, the arrangement of surrogate motherhood can be abused by some people. For instance, surrogate mothers can take advantage of childless couples by exploiting them financially after giving birth to their children. Such incident would not occur when surrogate motherhood is practiced within a proper legal framework.

There were also issues regarding the exploitation of the surrogate mother, where cases of inadequate compensations for conceiving and giving birth after the children were taken from their surrogate mothers (Rae et al 1993).

Additionally, there are also some genetic shortcomings that have been associated with surrogacy. This concerns some undesirable behaviors in children who are products of surrogacy. Some couples can express disappointments especially with traits such as criminal tendencies in children sired by surrogate mothers, where such incidents can be major challenges in the practice of surrogate motherhood.

Despite these isolated incidences, couples that have infertility related problems can still find solace in surrogate motherhood instead of going for other alternatives like polygamy or divorce that are characterized with deceit and lack of true love. As recognition of the fact that infertility is an unfortunate incidence in people’s life, surrogate motherhood should be left as an alternative that will enable these couples to make families. (Teman 2008) Such practice is an alternative that addresses the needs of those who might be disadvantaged in one way or another caused by their inability to bear children. From the stand point of protecting the interests of people who are disadvantaged reproductively, surrogate motherhood should be supported by all who care about the continuity of mankind and the future generations.

• Rae, Scott B. “Brave New Families?: The Ethics of the New Reproductive Technologies.” Christian Research Journal , 1993, pp. 8.
• Teman, Elly. 2008. “The Social Construction of Surrogacy Research: An Anthropological Critique of the Psychosocial Scholarship on Surrogate Motherhood,” Social Science & Medicine. Volume 67, Issue 7, Pages 1104-1112.
• MacCallum, Fiona et al. 2003. Surrogacy: The experience of commissioning couples Human Reproduction, Vol. 18, No. 6, 1334-1342.
• Vasanti Jadva et al. 2003. Surrogacy: the experiences of surrogate mothers. Human Reproduction, Vol. 18, No. 10, 2196-2204.
• Ethics and Reproduction Health: Surrogacy, Multiple Pregnancies, Abortion
• Sperm Donation and Surrogacy in Islam and Christianity
• Ethical Issues of Surrogacy in Panama
• Effects of Augmentin Maternal Income on Child Development
• The Global Impact of Divorce on Children
• Grandparenting Roles in Child's Upbringing
• Sexual Educatuion in Modern World
• Psychology and Sociology in Families
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IvyPanda. (2021, November 18). Ethical Argument for Surrogate Motherhood. https://ivypanda.com/essays/ethical-argument-for-surrogate-motherhood/

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Bibliography

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Ethical and Philosophical Issues Arising From Surrogate Motherhood

In Fundamental and Legal Problems of Surrogate Motherhood. Global Perspective, P. Mostowik (ed.), Warsaw 2019, p. 23-75

53 Pages Posted: 15 Oct 2019

Marta Soniewicka

Jagiellonian University

Date Written: October 4, 2019

In this paper, I presented the most important philosophical and moral issues concerned with the idea of contract pregnancy. Terminological disputes over the concept of surrogacy, which I presented, are rooted in different axiological backgrounds, which can be defended on various philosophical grounds. The most important moral and legal dilemmas, which were revealed in the landmark cases, can be also elucidated with the reference to the major philosophical doctrines, which I presented in this paper with reference to the problem of surrogacy. Most of the proponents of surrogacy contracts invoke the concept of reproductive autonomy and the principle of privacy (including the right to use one’s own body and reproductive capacities). Yet, this concept just as our relationship with the body may be differently interpreted depending on the philosophical stance we take. Most of the arguments in favor of surrogacy are formulated from either libertarian or utilitarian perspective. The strongest arguments against the practice of surrogacy are provided within a deontological and neo-Aristotelian approach.

Keywords: surrogate motherhood, reproductive technologies, biomedical ethics, bioethics

Suggested Citation: Suggested Citation

Marta Soniewicka (Contact Author)

Jagiellonian university ( email ).

Krakow Poland

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Surrogacy: Ethical and Legal Issues

Pikee saxena.

Department of Obstetrics and Gynecology, Lady Hardinge Medical College and Shrimati Sucheta Kriplani Hospital, New Delhi, India

Archana Mishra

Sonia malik.

1 Department of Obstetrics and Gynecology, Infertility and IVF, South End Fertility and IVF Centre, Holy Angels Hospital, Basant Lok, Vasant Vihar, New Delhi, India

Surrogacy refers to a contract in which a woman carries a pregnancy “for” another couple. Number of infertile couples from all over the World approach India where commercial surrogacy is legal. Although this arrangement appears to be beneficial for all parties concerned,there are certain delicate issues which need to be addressed through carefully framed laws in order to protect the rights of the surrogate mother and the intended parents.

The ever-rising prevalence of infertility world over has lead to advancement of assisted reproductive techniques (ART). Herein, surrogacy comes as an alternative when the infertile woman or couple is not able to reproduce. Surrogacy is an arrangement where a surrogate mother bears and delivers a child for another couple or person. In gestational surrogacy, an embryo, which is fertilized by in vitro fertilization, is implanted into the uterus of the surrogate mother who carries and delivers the baby. In traditional surrogacy, the surrogate mother is impregnated with the sperms of the intended father artificially, thus making her both genetic and gestational mother. Surrogacy may be commercial or altruistic, depending upon whether the surrogate receives financial reward for her pregnancy.

Commercial surrogacy is legal in India,( 1 ) Ukraine, and California while it is illegal in England, many states of United States, and in Australia, which recognize only altruistic surrogacy. In contrast, countries like Germany, Sweden, Norway, and Italy do not recognize any surrogacy agreements. India has become a favorite destination of fertility tourism. Each year, couples from abroad are attracted to India by so-called surrogacy agencies because cost of the whole procedure in India is as less as one third of what it is in United States and United Kingdom (10-20 lakhs).

Is Surrogacy Profitable for All?

At a glance, surrogacy seems like an attractive alternative as a poor surrogate mother gets very much needed money, an infertile couple gets their long-desired biologically related baby and the country earns foreign currency, but the real picture reveals the bitter truth. Due to lack of proper legislation, both surrogate mothers and intended parents are somehow exploited and the profit is earned by middlemen and commercial agencies. There is no transparency in the whole system, and the chance of getting involved in legal problems is there due to unpredictable regulations governing surrogacy in India.

Although in 2005, ICMR issued guidelines for accreditation, supervision, and regulation of ART clinics in India, these guidelines are repeatedly violated.( 2 ) Frustration of cross border childless couples is easily understandable who not only have to cope up with language barrier, but sometimes have to fight a long legal battle to get their child. Even if everything goes well, they have to stay in India for 2-3 months for completion of formalities after the birth of baby. The cross border surrogacy leads to problems in citizenship, nationality, motherhood, parentage, and rights of a child. There are occasions where children are denied nationality of the country of intended parents and this results in either a long legal battle like in case of the German couple with twin surrogate children or the Israeli gay couple who had to undergo DNA testing to establish parentage or have a bleak future in orphanage for the child. There are incidences where the child given to couple after surrogacy is not genetically related to them and in turn, is disowned by the intended parent and has to spend his life in an orphanage.( 3 )

If we look upon the problem of surrogate mothers, things are even worse and unethical. The poor, illiterate women of rural background are often persuaded in such deals by their spouse or middlemen for earning easy money. These women have no right on decision regarding their own body and life. In India, there is no provision of psychological screening or legal counseling, which is mandatory in USA. After recruitment by commercial agencies, these women are shifted into hostels for the whole duration of pregnancy on the pretext of taking antenatal care. The real motive is to guard them and to avoid any social stigma of being outcast by their community. These women spend the whole tenure of pregnancy worrying about their household and children. They are allowed to go out only for antenatal visits and are allowed to meet their family only on Sundays. The worst part is that in case of unfavorable outcome of pregnancy, they are unlikely to be paid, and there is no provision of insurance or post-pregnancy medical and psychiatric support for them. Rich career women who do not want to take the trouble of carrying their own pregnancy are resorting to hiring surrogate mothers. There are a number of moral and ethical issues regarding surrogacy, which has become more of a commercial racket, and there is an urgent need for framing and implementation of laws for the parents and the surrogate mother.( 4 )

Assisted reproductive technology legislation

The Indian government has drafted a legislation, earlier floated in 2008, finally framed as ART Regulation draft bill 2010. The bill is still pending with Government and has not been presented in the Parliament. The proposed law has taken consideration of various aspects including interests of intended parents and surrogate mothers. The proposed draft needs to be properly discussed, and its ethical and moral aspect should be widely debated by social, legal, medical personal, and the society before any law is framed.

The bill acknowledges surrogacy agreements and their legal enforceability.( 5 ) The surrogacy agreements are treated at par with other contracts under the Indian Contract Act 1872 and other laws applicable to these kinds of agreements. Both the couple/single parent and surrogate mother need to enter into a surrogacy agreement covering all issues, which would be legally enforceable. Some of the features of proposed bill are that an authority at national and state level should be constituted to register and regulate the I.V.F. clinics and A.R.T centers, and a forum should be created to file complaints for grievances against clinics and ART centers. The age of the surrogate mother should be 21-35 years, and she should not have delivered more than 5 times including her own children. Surrogate mother would not be allowed to undergo embryo transfer more than 3 times for the same couple. If the surrogate is a married woman, the consent of her spouse would be required before she may act as surrogate to prevent any legal or marital dispute. A surrogate should be screened for STD, communicable diseases and should not have received blood transfusion in last 6 month as these may have an adverse bearing on the pregnancy outcome. All the expenses including insurance of surrogate medical bill and other reasonable expenses related to pregnancy and childbirth should be borne by intended parents. A surrogacy contract should include life insurance cover for surrogate mother. The surrogate mother may also receive monetary compensation from the couple or individual as the case may be for agreeing to act as such surrogate. It is felt that to save poor surrogate mothers from exploitation, banks should directly deal with surrogate mother, and minimal remuneration to be paid to the surrogate mother should be fixed by law.

The surrogacy arrangement should also provide for financial support for the surrogate child in case the commissioning couple dies before delivery of the child, or divorce between the intended parents and subsequent willingness of none to take delivery of the child so as to avoid injustice to the child. A surrogate mother should not have any parental rights over the child, and the birth certificate of the baby should bear the names of intended parents as parents in order to avoid any legal complications. Guidelines dealing with legitimacy of the child born through ART state that the child shall be presumed to be the legitimate child of the married/unmarried couple/single parent with all the attendant rights of parentage, support, and inheritance.

The ART clinics should not be allowed to advertise for surrogacy for its clients, and couples should directly seek facilities of ART Bank. The intended parents should be legally bound to accept the custody of the child/children irrespective of any abnormality in the child/children. Confidentially should always be maintained, and the right to privacy of the donor as well as surrogate mother should be protected. If a foreigner or NRI is seeking surrogacy, they should enter an agreement with written guarantee of citizenship for the child from their government, and they should also appoint a local guardian who would be legally responsible for taking care of the surrogate during and after the pregnancy till the child is delivered to the foreigner couple or reaches their country. Sex-selective surrogacy should be prohibited, and abortions should be governed by the Medical Termination of Pregnancy Act 1971.( 6 )

It seems ironical that people are engaging in the practice of surrogacy when nearly 12 million Indian children are orphans. Adoption of a child in India is a complicated and a lengthy procedure for those childless couples who want to give a home to these children. Even 60 years of Independence have not given a comprehensive adoption law applicable to all its citizens, irrespective of the religion or the country they live in as Non-Resident Indians (NRIs), Persons of Indian Origin (PIOs) or Overseas Citizens of India (OCIs). As a result, they resort to the options of IVF or surrogacy. The Guardian and Wards Act, 1890 permits Guardianship and not adoption. The Hindu Adoption and Maintenance Act, 1956 does not permit non-Hindus to adopt a Hindu child, and requirements of immigration after adoption have further hurdles.( 7 )

There is a strong need to modify and make the adoption procedure simple for all. This will bring down the rates of surrogacy. Altruistic and not commercial surrogacy should be promoted. Laws should be framed and implemented to cover the grey areas and to protect the rights of women and children.

Source of Support: Nil,

Conflict of Interest: None declared

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• > An Essay on Surrogacy and Feminist Thought

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An essay on surrogacy and feminist thought.

Published online by Cambridge University Press:  28 April 2021

Surrogacy is not an easy issue for feminists. On one hand, it raises concerns about exploitation; one is faced with images of poor women being enlisted to produce babies for wealthy men and their wives, either because of fertility problems or because pregnancy is simply too inconvenient for those women who can afford to hire someone to do it for them. On the other hand, there is the specter of the state passing laws, once again, that tell women what they can and cannot do with their bodies. If we believe, as many of us do, that the state has no right to prohibit a woman from selling the sexual use of her body, doesn't the also have the right to sell the reproductive use? And if many of us, doctors, lawyers, law professors, have been willing to employ other women, less privileged women, to take care of our children after they are born, what is so different in moving the date back a bit and hiring them to carry our children before birth as well?

Assuming that surrogacy is not legally prohibited, does that mean that surrogacy contracts must be enforced? If we find something abhorrent in the idea of babies being taken from their mothers arms because, after all, a contract is a contract, we might argue that the contracts can be legal but unenforceable.

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• DOI: https://doi.org/10.1111/j.1748-720X.1988.tb01054.x

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The surrogacy debate

Although surrogacy has been illegal in France since 1994, it remains a topical and emotive issue among researchers from various disciplines: anthropology, philosophy, sociology, psychology, law, and psychoanalysis. Surrogacy involves a woman developing an embryo and then a fetus in her uterus, which grows into a baby that will be handed over to the “intended parent(s)” after birth. The French ban on surrogacy leads many heterosexual and homosexual couples to seek a surrogate abroad.

In Volume 1, Issue 3, May 2017

Presentation

1 Although surrogacy has been illegal in France since 1994, it remains a topical and emotive issue among researchers from various disciplines: anthropology, philosophy, sociology, psychology, law, and psychoanalysis. Surrogacy involves a woman developing an embryo and then a fetus in her uterus, which grows into a baby that will be handed over to the “intended parent(s)” after birth. In most cases, the embryo is created by in vitro fertilization, using sperm from either the intended father or from a donor, although in some cases the surrogate mother’s egg is fertilized by insemination. The surrogate mother may or may not receive monetary compensation for her services.  The French ban on surrogacy leads many heterosexual and homosexual couples to seek a surrogate abroad. French specialist literature, which has developed over the past twelve years or so, continues to oscillate between nuanced approval of and radical—to a certain extent—opposition to surrogacy.

2 Included in this issue:

3 Jérôme Courduriès, Laura Lange, and Claudine Veuillet-Combier

4 And also: Muriel Fabre-Magnan, Catherine Dolto, Geneviève Delaisi de Parseval, Chantal Collard, and Françoise Zonabend

5 Carte blanche given to Elly Teman

• Anthropologists’ Testimonies

6 The first anthropological work carried out on surrogacy was by the American Heléna Ragoné, who began researching the subject in the late 1980s. Other works followed, notably that of Israeli Elly Teman (see the interview with her below). In France, one of the most recent studies is that of Jérôme Courduriès. In the Journal des Anthropologues , Courduriès reports on interviews he conducted with sixteen French “families”: “In ten cases, these were families made up of a male couple, in five cases the parental couple was heterosexual, and in the final case the surrogacy was initiated by a gay, single man.” Before discussing these cases, Courduriès refers to several historical and anthropological works which show that the practice of “leasing a uterus” (Lévi-Strauss) goes back a long way, and can be found in many so-called primitive societies.

7 The most striking lesson to be drawn from the various cases studied by Courduriès coincides with the conclusions of other anthropologists: in most cases, the Western (usually North American) surrogate mother has a generally positive pregnancy experience, and the “intended parents” view her with respect, tending to value her alongside the child. To a male couple she can even be “a kind of mother.”  The intended mother in a heterosexual couple does not view the surrogate as a mother, but in fact readily views her as a friend. A reciprocal friendship can indeed form, to such an extent that Elly Teman reports the case of a woman who, after having carried a child for a homosexual couple, chose to carry a second pregnancy of twins for the same couple, without asking for financial compensation. When she is not a friend, the surrogate is often considered by a homosexual couple as a “nanny.” But Courduriès also refers to the case of a homosexual man who lived alone who, having had a child in this way, refused to consider the relationship with the surrogate as anything other than strictly contractual. But even he did not intend to hide anything from his daughter, saying that “when she is grown up” she will be able to meet the woman who gave birth to her.

8 The surrogate relationship is of course a completely different matter for Indian women who rent their uterus to strangers through a relevant institution. The relationship is in this case purely financial. Indian surrogates interviewed by anthropologists appear happy with their lot, since one pregnancy can earn them the equivalent of five years of household income.

10 Jérôme Courduriès is a researcher at the Institut d’anthropologie clinique (Institute of Clinical Anthropology) in Toulouse. He co-edited Homosexualité et parenté , Armand Colin 2014, with Agnès Fine.

Read this article

• What Surrogacy Produces
• Jérôme Courduriès
• In Journal des anthropologues Volume 144-145, Issue 1, 2016
• Translated from the French by Cadenza Academic Translations

• Carte Blanche Given to...

13 Elly Teman

• “The French Position is Unreasonable”

14 The Israeli law restricts surrogate motherhood to heterosexual couples. Is this a wise position?

15 The Israeli Surrogacy Law was passed in March 1996, and surrogacy is regulated in Israel by a state-appointed committee that must approve each and every contract before the surrogate and intended parents can begin the medical preparation for the embryo transfer. This law protects the surrogate, the intended parents, and the baby, because it ensures the baby will be an Israeli citizen, that the contract will be legal and valid and the intended parents will be able to be recognized as the baby’s parents, and that there are provisions for the baby if something happens to the intended parents during the surrogacy process.  The screening process also protects the surrogate, as only a woman whom the state committee believes to be psychologically prepared and in good medical health can become a surrogate, and her fee is set aside by an attorney trustee so that she will receive reimbursement for all possible expenses. She forms a relationship with the intended parents, which humanizes this process that could otherwise be an opening for exploitation and objectification.

16 As a result of the law not allowing same-sex couples or single persons to contract a surrogate within Israel, many same-sex couples and single persons have had to go abroad in order to contract surrogates. Instead of developing a relationship with their surrogate, they are often unable to even meet her. Surrogates are put in unethical situations in which they may be put at risk medically, psychologically, or without the rights a legal contract in a regulated framework can provide. Moreover, Israeli intended parents have found themselves stuck in limbo for months, or even years, in countries where they traveled for surrogacy such as India, Nepal, Thailand, and Mexico. There have been cases where babies have ended up being born stateless, and the intended parents have not been allowed to take them home.  I therefore believe it is a very unwise position of the state to restrict surrogacy to heterosexual couples. It is time for the law, after twenty successful years, to include same-sex couples and single persons.

18 France forbids any surrogate motherhood. Is this a wise position?

19 I feel this is a very unwise position. French citizens who want to have children through surrogacy have been traveling abroad for many years because they cannot enter into the surrogacy process in their home country. Cases such as that of the Mennesson family, who established the C.L.A.R.A association, show the heartache that intended parents and their children born from surrogacy abroad must face in light of the current French legislation. The current research by French anthropologist Jérôme Courduriès on French citizens who travel abroad for surrogacy shows the difficulties these citizens still face.

20 I believe that France must acknowledge that surrogacy is here to stay, and that people will go to great lengths and great expense to enter into these agreements. Banning the practice within France and making it difficult for intended parents to bring their children back into France and establish parental rights hurts the children born through these arrangements, who we all want to protect the most. Legalizing and regulating surrogacy, for instance through the court system, could protect the babies—by ensuring their citizenship and legal parentage—, and the surrogate’s rights through contract. It could also prevent the harmful situation that is created for all parties involved when surrogacy is pursued in uneven regulatory frameworks. There will always be the potential for exploitation, commodification, and ethical harm in the concept of surrogacy, but regulating it and enabling a contract, protection, and especially the formation of a supportive relationship between the surrogate and intended parents can “warm up” the process and make it one that can even be empowering for the surrogate, as my ethnographic research and that of fellow ethnographers, such as Zsuzsa Berend, shows.

22 Many French law and psychology specialists say surrogate motherhood gives priority to the desire for children and neglects the true interests of the children. As an anthropologist, how do you feel about this?

23 Debates about surrogacy are often filled with cultural assumptions that are based on social and cultural norms rather than on evidence from the “field.” My work as an anthropologist is to leave these assumptions aside and to really listen what surrogates and intended parents are saying. Psychologists and the public at large may assume that the surrogate and baby form emotional bonds in utero, and that the children will eventually want to meet the “mother” who carried them, as we often hear in the case of adoption.

24 However, my research shows that none of the surrogates I interviewed bonded with the baby. The children of surrogacy who I have watched grow up in Israel, some now eighteen years old, do not see the surrogate as their mother. Most of them have met her, some see her as part of the extended family or someone who gave their mother a very important gift, but they do not wonder “why she gave them up.” They know that she “babysat” them in her home and her body, cared for them and fed them, and then “returned” them to their “real parents.”

25 I have not done systematic research on the children of surrogacy, but there are important long-term follow-up (ten-year) psychological studies on the children of surrogacy conducted by Susan Golombok’s research group at Cambridge University that show that the children of surrogacy in the UK are “normal,” very loved, not traumatized, and that they have usually met the surrogate, do not see her as their mother, and are grateful to her for helping their parents. At a surrogacy debate at Dexeus University Hospital that I participated in last week, teenage twin boys born through surrogacy were asked, “Do you feel different because of being born this way?” One of the twin boys, smiling at the audience said, “Yes, I am the only one of my friends with a US passport.”

26 Elly Teman is senior lecturer at the Ruppin Academic Center in Israel. She is the author of Birthing a Mother: The Surrogate Body and the Pregnant Self , University of California Press, 2010.

• The Neoliberal Discourse

27 In an article published in the Christian-inspired journal Études , the young philosopher Laura Lange examines “neoliberal discourse,” which is also in favor of surrogacy. This view is based on the value of individual autonomy as defined by John Stuart Mill: of developing one’s character by making a choice, and of choosing “[one’s] plan of life” ( On Liberty ). In The Birth of Biopolitics , Michel Foucault thus emphasizes the “generalization of the ‘enterprise’ form” regarding an individual’s relation to himself and his family, which Foucault believed was what characterized American society. Philosopher Laura Lange makes the following observation in an issue of Dialogue (March 2013): “parenthood increasingly tends toward being an individual ‘business.’”

28 She describes the “mutual benefits” at play in surrogacy: for the intended parents, the surrogate, but also very often those for the associations or surrogate mother agencies in the US.

29 Lange expresses a certain skepticism regarding the argument often made in favor of surrogacy that “physical action can be dissociated from the mind.” She cites Plotinus: “The Soul using the body as an instrument, it does not follow that the Soul must share the body’s experiences.” She also cites psychoanalyst Geneviève Delaisi de Parseval, who believes surrogate mothers’ pregnancies are “less charged on a psychological level because they do not involve a commitment to future parenting.”  According to Lange, “in a situation in which neoliberalism creates the conditions of economic existence, every woman invents her own notion of her body. In this sense, surrogacy presents itself as an instance of economic freedom.”

30 She also cites jurist Marcela Iacub, for whom the “the body, its parts and its organs, must be no more than an instrument of the will.” For anthropologist David Le Breton, the body is designed “as an accessory of the person.” For philosopher Michela Marzano, “there exists today a genuine effort to construct and manipulate the body and to remake it in the image of the market.”

31 Lange bases her line of inquiry on the disappearance of or disregard for meaningful debate concerning the “right to regret.” Élisabeth Badinter, among others, has suggested that the surrogate should have a three-day period after the birth to retract the contract to give the child away, thus becoming the legal mother. In practice, only British law leaves this possibility open, because “the surrogate mother is considered the child's mother [and] this continues until she gives up her parental rights.”

32 Whatever the case, the principle of surrogacy is that of a “rational project” in which the “body is reduced purely to its function.” Laura Lange emphasizes the “risk of an approach that bases motherhood on an act of abandonment—not of a child, as is sadly familiar, but of the body.”

34 Laura Lange wrote her thesis in philosophy on surrogacy. She now organizes philosophy conferences for managers. 

• What Representations of the Body and Will Are There?
• Laura Lange
• In Études Issue 2, 2014

• What Does It Mean for the Child?

37 All children want to know where they come from. From this perspective, we ought to compare surrogacy with adoption, where the civil status of the birth parents is erased. In the journal Dialogue , clinical psychologist Claudine Veuillet-Combier concludes that surrogacy’s distinctive feature is related to the fact that its starting point (which until recently was always the act of sexual intercourse between the parents) can be broken down into three “scenes”: “the scene of parental desire, the scene of conception-fertilization, and the scene of pregnancy (followed by childbirth).” Yet in surrogacy, the “participants in each of these scenes are different, and they therefore construct a story of origins from multiple viewpoints.” Veuillet-Combier, who has been influenced by psychoanalysis, believes that “it is essential that each of these scenes be part of the parental discourse used to respond to the child's questions.”

38 She is critical in this regard of France’s legal position, which refuses to recognize children born to surrogate parents abroad. She points out that France was condemned by the European Court of Human Rights in 2014 (and again in 2016 and 2017) because of this. She examines the situation of the status of adopted children to judge that in France “the law often chooses erasure to manage situations that appear too complex because they break with traditional models.”

39 She also draws on original personal experiences, such as that of a nine-year-old boy born through surrogacy who traveled to his surrogate mother’s country to meet her children, and experienced emotional distress, asking “but why did she not keep me?”

41 Claudine Veuillet-Combier is a clinical psychologist and lecturer at the University of Angers, France.

• Surrogate Motherhood, the Story of Origins, and the Triple Scene
• Claudine Veuillet-Combier
• In Dialogue Volume 215, Issue 1, 2017

• Further Reading on Cairn.info...
• Opposition from the Legal Camp

44 In her 2016 book Introduction au Droit  ( in French on Cairn.info )  Muriel Fabre-Magnan , professor of law at Paris I University (Panthéon-Sorbonne), develops legal and practical arguments that she believes justify the prohibition of surrogacy. In an interview published by the French magazine Books  ( in French on Cairn.info ) she explains how she has aligned her position with that of the Court of Cassation (1991), which rules that surrogacy “violates the principle of inalienability of the human body and the principle of inalienability of individual status.” Firstly, the “human body cannot be rented out or sold.” Secondly, “we do not have the right to do as we please with children that we have brought into the world.”

45 On a practical level, she talks about “inevitable consequences,” such as “lodging complaints because the product is defective.” On the subject of children born in India: “What happens if no one wants the child any more, for example because he or she has a disability?” The “surrogate mother” incurs health risks. And “who should make the decision if, when it comes to the birth, we have to choose between the life of the mother and that of the child?”  She opposes what she sees as a regression of the rights of the child: “After so much effort and struggle for babies to be considered as people in their own right, we would thus be conceding that they are in this case the object of a “right to”—in other words, a product made on demand.”

• Opposition from the Medical Camp

46 Following the example of Jean-Pierre Winter, who published a book on the subject, many French psychoanalysts are decidedly hostile to surrogacy. Daughter and spiritual heir to the famous psychoanalyst Françoise Dolto, Catherine Dolto is not a psychoanalyst herself but a doctor and “haptotherapist,” which means she specializes in the psychological accompaniment of the mother throughout pregnancy, and of the mother and child during the latter’s first year and even beyond, up to adolescence.

47 She has published several books on children’s health. In an article published in Le Débat ( in French on Cairn.info ), she says that the “pain of not having a child” does not justify the claim of a “right to a child,” which is today “brandished as an undeniable truth, like the ‘right to health,’ a house or a car, and those to whom society ‘refuses’ a child are labeled victims.” Catherine Dolto refers to many studies showing the long-term impact of the quality of mother-child relationships in utero: “Upbringing begins well before birth.”

• ... and Elsewhere
• Geneviève Delaisi de Parseval and Chantal Collard, “La gestation pour autrui, un bricolage des représentations de la paternité et de la maternité euro-américaines,” in L’Homme 2007.
• Chantal Collard and Françoise Zonabend, “Parenté sans sexualité, le paradigme occidental en question,” in L’Homme 2013.

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Massachusetts Bill Would Make Surrogacy Easier to Help Same-Sex Couples Raising Children

Bill Would Also Jettison Terms Like ‘Father,’ ‘Mother’ and ‘Paternity’

A bill designed to make same-sex parenting easier and remove assumptions about traditional families is moving through the Massachusetts Legislature.

The Massachusetts Parentage Equality Act, as the measure is known, is meant to ensure that each member of a same-sex couple has automatic parenting rights concerning a child they begin raising together.

"In the LGBTQ community, by definition, always one of the parents is a non-bio parent,” said Arline Isaacson, according to State House News Service , which covers state government in Massachusetts.

“So we’ve got to fix these laws to protect our families because, right now, the state of affairs is so messed up we actually have to adopt our own children, which takes money, and it takes time, even if you have a bio parent in the relationship, which is a crazy system,” said Isaacson, a lawyer, activist and co-chairwoman of the Massachusetts GLBTQ Political Caucus.

The bill also proposes language changes in state law to remove references to sex-specific roles in a family and any presumption that a family consists of: a married father and mother and their children.

Some examples: “Mother” becomes “person who gave birth”; “father” becomes “other parent”; “man and woman” becomes “persons”; “paternity” becomes “parentage”; “child born out of wedlock” becomes “nonmarital child”; “his” becomes “their” when referring to a single person; “her” becomes “their” when referring to a single person; and “himself” becomes “themselves” when referring to a single person.

The Massachusetts House of Representatives passed the bill 156-0 on June 12. The Massachusetts Senate has not scheduled a vote on the bill.

The bill also would loosen current regulations on surrogacy in the state, allowing mothers to sign a surrogacy agreement after a baby is conceived and even if the child wasn’t conceived with the help of a fertility clinic.

Surrogacy plays a major role for same-sex couples seeking to raise children, as same-sex couples aren’t able to conceive a child together and so often turn to surrogacy to have a child that is genetically linked to at least one of the pair.

The 41-page bill before the state Legislature mentions “surrogacy” or a word with the same root 160 times.

Surrogacy nowadays typically involves in vitro fertilization, in which an embryo is conceived in a petri dish by bringing together sperm from a man and an egg from a woman. It’s the most common form of what is known as “assisted reproductive technology”: conceiving a baby outside of sexual intercourse.

About 2.3% of all babies born in the United States in 2021 were conceived through assisted reproductive technology, according to the U.S. Centers for Disease Control and Pre vention . That’s about 86,000 of the approximately 3.68 million babies born that year.

Massachusetts has the highest percentage in the country, about 5.4% that year, or 3,717 babies of the 69,137 born.

Baby-Selling?

Patience Griswold, writing in The Federalist earlier last month, pinpointed two passages from the parentage bill that she says would break new ground in surrogacy.

One passage (Section 28N(b)), she says, would allow “if all parties agree” what the bills call “a genetic surrogacy agreement” after a child has been conceived but before the child is born, a scenario she describes as “baby-selling.”

Another passage (Section 28M(d)), she says, would allow payment for “a child born to a genetic surrogate … alleged not to have been conceived by assisted reproduction” meaning conceived through sexual intercourse.

“That’s to say, this bill could allow a woman to accept money in exchange for sex as long as she conceives and then relinquishes her parental rights so the father could raise the child, thus combining both prostitution and child trafficking in one terrible clause,” writes Griswold, the engagement coordinator of Them Before Us , a children’s rights organization.

Katy Faust, founder and president of Them Before Us, told the Register the Massachusetts bill could allow making money from legally transferring a baby conceived through sexual intercourse to a third party.

“So, really, what this is, is prostitution, unless the prostitution results in a baby, in which case it’s no longer prostitution but helping somebody build a family,” Faust said. “You can shack up, conceive and sell the baby.”

Faust opposes all kinds of surrogacy, which she says divides the traditional roles of a mother into at least two, and possibly, three separate persons — egg donor, gestational carrier and caregiver — to the detriment of the child.

“It’s all child loss. But what makes this bill different is that it’s blurring the very thin lines that the industry has set for itself,” Faust told the Register by telephone. “It’s indistinguishable from child trafficking at this point.”

Massachusetts state Rep. Hannah Kane, R-Shrewsbury, one of the principal sponsors of the bill, told the Register such criticisms aren’t warranted.

Kane, who spoke on the floor of the House before the vote June 12 about how she hopes her lesbian daughter can use similar provisions to have her own family some day in the future, told the Register that the bill will help families, not hurt them.

“While it is understandable for people to have questions about this legislation, we need not look far to see what is being alleged hasn’t happened in other states with these basic protections. This bill creates clear guidelines for establishing legal parentage for children born through surrogacy and will protect people acting as surrogates. It ensures that Massachusetts law has best-practice provisions to ensure the protection of children, parents, and people acting as surrogates,” Kane told the Register by email.

What Does the Church Say?

The Catechism of the Catholic Church condemns both in vitro fertilization and surrogacy as immoral. Techniques used to conceive a baby outside the womb “dissociate the sexual act from the procreative act,” the Catechism states (2376), adding that “the act which brings the child into existence is no longer an act by which two persons give themselves to one another.”

In January 2024, Pope Francis condemned surrogacy during a speech to foreign ambassadors and called on the international community “to prohibit this practice universally.”

“The path to peace calls for respect for life, for every human life, starting with the life of the unborn child in the mother’s womb, which cannot be suppressed or turned into an object of trafficking. In this regard, I deem deplorable the practice of so-called surrogate motherhood, which represents a grave violation of the dignity of the woman and the child, based on the exploitation of situations of the mother’s material needs,” Pope Francis said . “A child is always a gift and never the basis of a commercial contract.”

• catholics in massachusetts
• church teaching on surrogacy
• in vitro fertilization

Matthew McDonald Matthew McDonald is a staff reporter for The National Catholic Register and the editor of New Boston Post. He lives in Massachusetts.

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Taylor Swift’s ‘good role model’ status questioned because she’s ‘childless’ and ‘unmarried’

Gareth Cattermole / Getty

By Christina Marfice July 2, 2024

Taylor Swift is everywhere right now. Thanks to the success of her chart-topping latest album, “The Tortured Poets Society,” and her record-breaking “Eras” tour, it’s safe to say she’s solidly on top. Her tour is big enough to impact entire economies in some of the cities and countries it visits, which has prompted the creation of the term “ Swiftonomics .” She particularly resonates with young girls, teens, and women—arguably because of her ability to set everyday thoughts and feelings to a solid bop everyone can relate to. And dance to, too.

As Tim Sommer wrote of her impact on young women last year , “Taylor Swift has the ability to hold a mirror to the hearts and minds of her listeners; and they see her in that mirror, mouthing the words they are thinking but can’t articulate, the notes and texts they so desperately wish they could write. Seriously, if you want to conjure Taylor Swift, imagine a girl in 9th or 10th grade looking into the mirror but seeing Taylor Swift’s lips moving, expressing their thoughts and feelings.”

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But that much success certainly doesn’t come without criticism, and John Mac Ghlionn, who penned an editorial for “Newsweek” entitled “ Taylor Swift Is Not a Good Role Model, ” is leading the charge this week. His essay centers around one main point: That women and girls should think twice about looking up to Swift because, at 34 years old, she’s unmarried and childless.

“I suggest, it’s crucial to consider what kind of example this sets for young girls. A role model, by definition, is someone worthy of imitation. While Swift’s musical talent and business acumen are certainly admirable, even laudable, we must ask if her personal life choices are ones we want our sisters and daughters to emulate. This might sound like pearl-clutching preaching, but it’s a concern rooted in sound reasoning,” Ghlionn writes.

It’s worth asking what, exactly, is there to fear about a 34-year-old unmarried, childless woman? A woman who has chosen her own path in life? A woman who has pursued a career and amassed power? Is that truly concerning? And if so, why?

Ghlionn goes on to rehash another exhaustive point of discussion surrounding the pop star: Swift’s dating history. He points out that her beaus have been “a source of prime tabloid fodder for years,” as if that’s her fault.

“This revolving door of relationships may reflect the normal dating experiences of many young women in today’s world, but it also raises questions about stability, commitment, and even love itself,” he continues. “Should we encourage young girls to see the ‘Swift standard’ as the norm, something to aspire to? Or should we be promoting something a little more, shall we say, wholesome? Would any loving parent reading this want their daughter to date 12 different men in the span of just a few years? This is not an attack on Swift; it’s a valid question that is worth asking.”

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One of the most striking statements Ghlionn makes is this: “Although breakups can hurt both males and females, it’s the latter group that tends to feel more emotional pain.”

While many feel his entire op-ed is deeply rooted in sexism, many people who rebut it will focus on Ghlionn’s misogyny toward Swift—which is valid.

But this statement, minimizing the emotions of men, is just as sexist, is it not? It also perpetuates the kind of toxic masculinity that feeds the patriarchy itself. Study after study shows that women are absolutely not more emotional than men , nor do they feel more emotions. Rather, society pressures men into suppressing the emotions they feel , telling them that feeling or displaying natural human emotion isn’t manly, and thus, they shouldn’t. This attitude only harms men , increasing their instances of loneliness, substance abuse, and mental health issues like anxiety and depression.

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They put aside millions for surrogates. Now the money has vanished, sparking an FBI inquiry

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They scrimped, and they saved. Some asked family and friends to pitch in. Others took out loans for tens of thousands of dollars.

Their goal was twofold: To raise the small fortune necessary to pay for a surrogate. And to realize a dream previously impossible — having a child of their own.

Hundreds of people across California, the U.S. and around the globe put their money, sometimes $50,000 or more, into the hands of a Texas-based escrow company so the funds could be held in trust and doled out to a surrogate for healthcare costs, insurance and compensation.

But this month, expectant parents and their surrogates learned the money they had set aside at Houston-based Surrogacy Escrow Account Management, or SEAM, is inaccessible and likely gone.

“We want answers,” said Chris Kettmann of Fair Oaks, Calif., a suburb of Sacramento. “Is there recourse to get the money back? If not, what can we do?”

Kettmann, 33, said he and his wife had about $45,000 in their escrow account, money owed to their surrogate, who is pregnant with their baby boy and due in October. “We don’t know enough to say what happened,” he said. “We just know there’s something crazy going on.”

Police in Houston have opened a wide-reaching investigation. Christina Garza, a spokeswoman for the FBI’s Houston field office, confirmed last week that the agency also is investigating SEAM. The FBI has developed a public portal for SEAM clients to report their account information and how much money they believe they are owed. Garza, however, cautioned that the inquiry was in its early stages and said, “We’re trying to compile as much information as possible.”

A married same-sex couple in Washington, D.C., says they are out $55,000. A Los Feliz couple said they demanded their $40,111 be returned and believe it is gone. Arielle Mitton, an L.A. native who recently moved to Bellingham, Wash., can recite the amount that she and her husband are missing down to the cent: $37,721.44.

“I assumed naively that an escrow account was a safe thing,” said Mitton, whose surrogate in Indiana is pregnant with their daughter and is due to deliver on Christmas Eve.

Mitton has joined hundreds of affected parents and surrogates in a private Facebook group that has become a forum for venting, grieving, exchanging information and trying to answer the overriding questions: What happened here? And where did all their money go?

Scrutiny has centered on the sole owner of SEAM, Dominique Side, who has told customers that she had once been a surrogate. The 44-year-old billed herself as an entrepreneur of multimillion dollar businesses in the Houston area, including a vegan grocery store, a nonprofit school, a vegan music studio, and the surrogacy escrow outfit. She walked the red carpet in L.A. for vegan fashion events and ran a concierge service for those seeking a more eco-friendly lifestyle.

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Lilly Frost continued her business even as several failures made clear that her plan was too good to be true. The collapse of her enterprise and its trail of heartbreak provide a look at what can go wrong in the largely unregulated surrogacy industry.

July 10, 2022

“One common thread runs through all my businesses: each is based firmly on a foundation of compassion — for others, for myself and for the planet,” she told a Houston publication in 2022.

Side did not respond to calls or written questions. Emails to Side triggered an auto-response that doubled as a press statement. Citing the “active investigation by federal authorities,” Side wrote in the email, “Under the advice of counsel, I am not permitted to respond to any inquiries regarding the investigation.”

On Thursday, Side and SEAM were hit by a lawsuit from a merchant cash-advance lender, the third such lawsuit this year. Merchant cash advance lenders provide small businesses with quick infusions of money at high fees akin to interest rates of 50% to 100%.

A judge in Texas also froze all of the company’s accounts along with Side’s other businesses after a SEAM client, Marieke Slik, sued over her “vanished” $28,000.

Calling herself a “victim of a scam,” Slik alleged that Side and her company had lured her and others “into a fiduciary relationship in order to steal their escrow funds,” according to her lawsuit, which was filed in Texas. “The Defendants have left hundreds of surrogates throughout the country — who are pregnant with a child that does not belong to them — with no way to pay for necessary prenatal care.”

Sides’ actions, according to the lawsuit, “are nothing short of evil.”

Struggling parents

Many surrogacies often involve LGBTQ+ couples who want children, or older couples for whom childbearing is no longer a viable possibility.

For others, the road to surrogacy is one of heartbreak and tragedy.

The married woman in Los Feliz said she had had multiple miscarriages. She was recently pregnant but gave birth in the second trimester. The newborn died at Cedars-Sinai in his parents’ arms.

The couple turned to surrogacy after exhausting all other options. They selected a surrogate, completed the necessary contract — which often requires using an escrow firm — and put more than $40,000 into the account, a portion of the overall cost. But their embryo had yet to be transferred into the surrogate.

“Nothing is clear,” she said, explaining that she and her husband demanded their funds weeks ago. “Obviously that fell on deaf ears — we didn’t get our money back,” she said, speaking on the condition of anonymity because their extended family remains unaware of their attempt at using a surrogate.

“I’d love to carry this child,” she said, and “not spend any money on a surrogate. There’s a level of that, where you feel so terribly sad. You feel sad about the money, but you feel sad about the situation.”

‘Something really bad has happened’

For intended parents and surrogates, trouble emerged around late May, when surrogates did not receive their usual payments.

In early June, Tena Doan — a 42-year-old surrogate mother in Indiana — said she noticed her bank account balance was lower than expected and realized her monthly payment and allowance had not come through. Her surrogacy agency told her that banking issues at SEAM had delayed the arrival of the money.

“I said, ‘No problem, they’ll get it fixed,’” Doan recalled, figuring that banking issues happen. When she logged into SEAM’s portal, she saw that the money listed as due her was still there.

Then came a June 12 email from Side claiming that fraudulent charges had prompted Capitol One to freeze SEAM’s account.

“Some payments were able to go through before the accounts were frozen,” Side wrote in the email. She stated that new bank accounts were established and promised service would be restored.

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Two days later, however, Side sent another email indicating that “all operations have been placed on hold” due to legal action.

Doan said that the email stopped her in her tracks.

“That’s when we were like, ‘Oh s—, this is not good. Something really bad has happened,’” Doan recalled. “From there, it’s been a whirlwind.”

Mitton — the mother of the child that Doan is carrying — was at home more than 2,000 miles west.

“The first few days, I barely slept, I was nauseous from all the emotional aspects and had vertigo,” Mitton remembered.

She contacted the FBI, Houston police, the Texas attorney general. Mitton even emailed the CEO of Capital One, questioning how the money could apparently vanish.

Both Doan and Mitton joined the Facebook group and realized they were part of a club they never wanted membership in: those affected by SEAM’s financial collapse.

An informal poll among members suggested that about $10 million was unaccounted for. Parents and surrogates from across the country and around the world have traded information in the Facebook group about current police investigations and become sleuths themselves.

They’ve pored over Side’s various businesses — the Vgn Bae Music Studio, and Nikki Green, a luxury vegan fashion line. They’ve also mined her social media accounts.

A recent post on Side’s Instagram page VgnBaeDom, which has since been deleted, recounted her birthday week in June: Side said she flew to L.A., enjoyed a vegan dinner at the upscale Culver City vegan restaurant Shojin, dined at Crossroads Kitchen and Craig’s — both frequent celebrity hotspots — enjoyed a “full day of spa and cabana” at the Four Seasons, before doing fittings at Celine, the luxury French fashion house.

“The week this was going down was also her birthday week,” said Mitton, who recalled thinking, “She’s probably spending our escrow money there.”

Signs of financial difficulty SEAM was first registered in Texas in 2014. Testimonials from 2017 onward show glowing reviews, and one parent told The Times he had used SEAM for their first child without issue.

Lawsuits from cash advance lenders filed against SEAM and Side in New York this year indicate mounting financial trouble in recent months.

So-called merchant cash-advance lenders send sums of money to distressed businesses, often with a rapid turnaround, and, in exchange, a business lets the lender withdraw a portion of future receipts directly from the business’ bank account to pay off the debt. Cash-advance lenders often insist they aren’t lenders and that cash advances against future revenue aren’t technically loans — but New York’s former attorney general had lambasted the industry for predatory debt-collection practices.

In January, Side received an unspecified sum from Pearl Delta Funding and agreed to pay back $69,500. But she defaulted the next month, prompting the lender to sue her in New York in March. (Pearl Delta’s attorney did not respond to an email seeking comment.)

On May 6, Side secured $650,000 from Dynasty Capital and agreed to pay $975,000, or 150% of the amount borrowed, according to court records.

Under the agreement, the lender was allowed to debit $12,500 per day from SEAM’s account until the full amount was paid back. On May 31, Dynasty Capital said in court papers, SEAM “breached the agreement” and either failed to put revenue into the business account or diverted it elsewhere, leaving Dynasty unable to recoup its money.

Dynasty Capital sued Side, SEAM and her various businesses on June 18. Dynasty’s lawyer declined to comment.

On May 29, Side obtained $100,000 from Arsenal Funding and agreed to allow Arsenal to deduct 1.25% of SEAM’s daily revenue from its business bank account until $149,000 was paid off.

Arsenal sued Side and SEAM last week after Side stopped making payments on June 21 and defaulted, according to the lawsuit filed in New York, which demands about $190,000 to cover the outstanding debt and fees.

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To secure the loan from Arsenal, Side had to disclose her largest revenue sources. She listed three companies, all in Southern California: US Harvest Babies Surrogacy in the City of Industry; Mle & Mlang International Surrogacy in L.A.; and a Shady Grove Fertility office in Solana Beach.

But there is reason to doubt the accuracy of what Side told the lender. In a statement, Shady Grove said it had no financial relationship with Side or SEAM and did not refer patients to the company, explaining that “some patients may have independently engaged with SEAM.”

Further, the name that Side had listed as her contact has never been an employee of Shady Grove, according to a person familiar with the company’s operations. And the address she listed for Shady Grove is a small branch in the San Diego area that’s been open for only a few months; Shady Grove is headquartered in Maryland and has 49 locations nationwide.

Neither Harvest Babies or Mlan responded to requests for comment.

Side told Arsenal that she was the 100% owner of SEAM and projected an average monthly revenue of $2.78 million, according to a copy of the financial agreement that Arsenal included with its lawsuit.

Lori Hood, a Houston-based attorney who is representing Slik — the client who sued Side this month in Texas — said she was confounded by SEAM’s financial practices. She said the lawsuit from Dynasty Capital indicated that escrow money was used to secure the $650,000 cash payment.

“How do you put up escrow funds as collateral?” said Hood. “That’s my first indication that something’s desperately wrong. You don’t recognize escrow funds as revenue.”

Second, Hood said, SEAM’s tax records that she’s reviewed also showed revenue of “millions of dollars.”

“Did her company make millions of dollars, or is she putting into the tax returns that the escrow money was her revenue?” Hood asked.

To press their client’s lawsuit against SEAM, Hood and her law partner, Marianne Robak, petitioned a judge to freeze all of SEAM’s accounts at Capital One along with other accounts owned or controlled by Side.

“The evidence shows that SEAM’s escrow account with Capital One ... has no funds available,” notes the request for a restraining order to freeze all accounts. “SEAM is insolvent.”

In the filing, Hood also accused SEAM of diverting money into accounts in the name of Life Escrow LLC, a company registered last year to Side’s business partner, Anthony Hall, who is also a defendant in the suit filed by Slik.

Side’s “actions appear to be to avoid having to face the clients she defrauded. It appears she had absconded,” states the restraining order, which a Harris County, Texas, judge signed off on June 21.

Reached by phone on Thursday, Hall said he “had no connection with SEAM,” adding, “I wish I had answers.” Hall said he was a business partner of Side in the vegan music studio, Vgn Bae Studios, adding, “Everything was great until it wasn’t.”

Hall said he did not know if Side had an attorney and said that he was speaking only for himself.

“She’s not gonna respond,” he said of Side. “I’m defending myself. I don’t know what they have going on.”

Pregnancies don’t wait

For Hood and hundreds of surrogate mothers and parents, questions mount.

“I won’t cast blame on any of the parents. They did everything they were supposed to do,” Hood said.

Time is short, however, for ongoing pregnancies and those couples who hope to have a surrogate receive an embryo soon.

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Kettmann, from the Sacramento area, said their surrogate is 22 weeks pregnant. Of the $57,000 they put into SEAM, he said, $45,000 is missing. The rest had already been distributed to the surrogate.

“It’s a scramble,” he said. He and his wife had some money saved for additional expenses, which they’ve used to cover the June payment that never arrived from SEAM. He’s now fundraising from family and friends.

“We told her we’ll do everything we can to keep her up to date on payments,” he said, “but [we’re] asking her to be patient.”

Mitton and her surrogate, Doan, have started collecting donations through GoFundMe and plan to extend the payment terms two years, rather than having all the money sent to Doan shortly after delivery.

“I’m growing a healthy baby girl for them,” Doan said, “and that’s all that matters.”

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Matt Hamilton is a reporter for the Los Angeles Times. He won the 2019 Pulitzer Prize for investigative reporting with colleagues Harriet Ryan and Paul Pringle and was part of the team of reporters that won a Pulitzer Prize for its coverage of the San Bernardino terrorist attack. A graduate of Boston College and the University of Southern California, he joined The Times in 2013.

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Meet Cristiano Ronaldo's six lookalike children and their mothers

Portuguese footballer cristiano ronaldo is father to six children.

Cristiano Ronaldo's partner Georgina Rodríguez,  30,   delighted football fans on Monday, when she took several of Ronaldo's children to watch the superstar sportsman take to the pitch in a match against Slovenia.

While all eyes were on Ronaldo during the game, onlookers noticed that the footballer's adorable children were sitting with his partner, offering a glimpse into their family life.

While Georgina is not the biological mother to all of Ronaldo's children, she considers herself their mother, with her Instagram bio reading: "Mama to six blessings."

 Read on to meet Ronaldo's six children...

Portuguese footballer Ronaldo is father to six children, three of whom he had through surrogacy, before meeting Georgina, who is the biological mother to three of his children.

Ronaldo's oldest son Cristiano Jr

Ronaldo's first child, Cristiano Jr., was born in 2010 via a surrogate. Now 14 years old, his dad refers to him as his 'partner in crime,' with the teen following his dad's famous footsteps as a talented footballer.

Cristiano Jr and his siblings

The identity of Cristiano's mother is not known, and the footballer has full custody of his firstborn.

Georgina loves Cristiano Jr as one of her own, celebrating his 14th birthday by writing on Instagram: "Happy Birthday to my big boy, I love you to the moon and back."

She has been in his life since he was six, and they share a close bond.

Eva Maria and Mateo Ronaldo

Ronaldo began dating Georgina in 2016, and in June 2017, the sports icon welcomed twins Eva and Mateo through a surrogate.

The identity of the seven-year-old twins' biological mother also remains private, but Georgina is mother to the two little ones

Alana Ronaldo

Five months after Eva Maria and Mateo were born, Georgina gave birth to her first biological child, Alana, in November 2017, making her less than half a year younger than her twin siblings.

Bella Esmerelda and Baby Ángel Ronaldo

In October 2021, Georgina and Ronaldo shared they were expecting twins, due in April 2022, however, they suffered the devastating loss of their baby boy on the day he and his sister were born.

Ronaldo's baby daughter and her older sister

In a heartbreaking statement, Ronaldo wrote: "It is with our deepest sadness we have to announce that our baby boy has passed away.

"It is the greatest pain that any parent can feel. Only the birth of our baby girl can give us the strength to live this moment with some hope and happiness," he added, revealing that their other baby was born safe and sound.

He continued: "We would like to thank the doctors and nurses for all their expert care and support.

Bella Esmerelda with her siblings

"We are all devastated at this loss and we kindly ask for privacy at this very difficult time. Our baby boy, you are our angel. We will always love you."

One month later they shared that their baby son's twin sister was named Bella Esmerelda.

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Elon Musk's 12 Children: All About His Kids and Their Mothers

Elon Musk is the father of 12 children, including a pair of twins and a set of triplets with his ex-wife Justine Wilson and two boys and a girl with ex-girlfriend Grimes

Elon Musk 's family keeps on growing.

Within two decades, the Tesla founder has become a father of 12 children with three women. His first child was born in 2002 and his most recent arrived in 2024.

The first six children he shares with his ex-wife, Canadian author Justine Wilson . After first meeting as students at Queen's University in Ontario, Canada, the SpaceX CEO wed Wilson in 2000 — but after seven years of marriage and five kids, the couple officially divorced in 2008.

"Custody of our five children is split evenly," Musk said in a 2010 Business Insider op-ed. "Almost all of my non-work waking hours are spent with my boys, and they are the love of my life."

The entrepreneur went on to marry and divorce actress Talulah Riley twice — the first lasting from 2010 to 2012, and the second from 2013 to 2016. They never had children together.

In 2018, Musk and singer-songwriter Grimes (whose real name is Claire Boucher) were linked — and had their first child together in 2020.

Despite splitting up in September 2021 after three years, Grimes revealed in a March 2022 Vanity Fair interview that the couple had reconciled and welcomed another child via surrogate in December 2021. At the time, she also revealed that the couple wants more babies — telling the outlet, "we've always wanted at least three or four" — but the day the article was released, she tweeted that they had broken up again.

A few weeks prior to the arrival of their second child together, the CEO secretly fathered twins with Shivon Zilis in November 2021, according to court documents published by Insider . The twins were born in Austin, Texas.

In September 2023, a biography about Musk revealed that he and Grimes had secretly welcomed a third child. They named their second son Techno Mechanicus , who also goes by “Tau."

Musk became a dad again in early 2024. He welcomed baby No. 12 — whose name has yet to be disclosed — with Zilis.

During an interview with The Wall Street Journal ’s CEO Council, Musk spoke about his children's futures. He shared that he has no plans to "automatically" give his children shares of his companies "if they have no interest or inclination or ability to manage" his empire.

Learn more about Musk's family, below.

Nevada Alexander

Musk had his first son, Nevada Alexander, with his first wife, Justine Wilson in 2002. Sadly, at 10 weeks old, he passed away from sudden infant death syndrome (SIDS).

"Nevada went down for a nap, placed on his back as always, and stopped breathing," Wilson wrote in a 2010 essay for Marie Claire . "By the time the paramedics resuscitated him, he had been deprived of oxygen for so long that he was brain-dead."

She continued, "He spent three days on life support in a hospital in Orange County before we made the decision to take him off it. I held him in my arms when he died."

Vivian Jenna Wilson and Griffin

In her Marie Claire essay, Wilson details their journey to expanding their family further.

"I buried my feelings ... coping with Nevada's death by making my first visit to an IVF clinic less than two months later. Elon and I planned to get pregnant again as swiftly as possible. Within the next five years, I gave birth to twins, then triplets," she wrote .

One of Musk's now 18-year-old twins has filed to legally change her name and gender and said she no longer wishes to be related to her father, according to court documents obtained by PEOPLE.

The April 18 petition seeks the legal change of her name to Vivian Jenna Wilson (the maiden name of her mother, Justine Wilson); recognition of her gender as female; and the issuance of a new birth certificate to reflect the changes.

"Gender Identity and the fact that I no longer live with or wish to be related to my biological father in any way, shape or form," Vivian wrote in the petition explaining her request for the changes.

In an October 2022 interview with Financial Times , Musk said he believes Vivian doesn't want to be associated with him because of the supposed takeover of elite schools and universities by neo-Marxists. "It's full-on communism . . . and a general sentiment that if you're rich, you're evil," said the Tesla CEO. "It [the relationship] may change, but I have very good relationships with all the others [children]. Can't win them all."

Kai, Saxon and Damian

Wilson gave birth to triplets named Kai, Saxon, and Damian in 2006, two years after having twins. She revealed in a 2017 TedTalk that they were also conceived via IVF, but she and Musk have not discussed the children themselves publicly.

Musk does not often discuss his own family, but he does have strong opinions on increasing the birth rate — stating that there are "not enough people" in the world at Wall Street Journal 's annual CEO Council in December 2021.

"I think one of the biggest risks to civilization is the low birth rate and the rapidly declining birthrate," he said. "Please look at the numbers – if people don't have more children, civilization is going to crumble, mark my words."

In a 2023 biography on the tech mogul, titled  Elon Musk ,  author Walter Isaacson wrote about Damian , who became a vegetarian at age 8 to "decrease my carbon footprint."

Isaacson also mentioned that Damian became a classical music prodigy who excelled in math and physics. Musk's mom, Maye, even once told her son, "I think Damian is brighter than you."

For more on Elon Musk, listen below to our daily podcast on PEOPLE Every Day.

Grimes and Musk welcomed their first child on May 4, 2020 after the singer announced her pregnancy with a picture of her baby bump back in January 2020. Their son X Æ A-12, whose name was later changed to X Æ A-Xii , was in part named after the CIA's Lockheed A-12 reconnaissance plane.

Though nicknamed "X," Grimes broke down his pronunciation in her Instagram comment section. "It's just X, like the letter X," she wrote. "Then A.I.," she added. "Like how you said the letter A then I."

But Musk explained the pronunciation differently, saying on The Joe Rogan Experience podcast that "X" is spoken "like the letter" while "the 'Æ' is pronounced like 'ash.'"

While proudly stating that "A-12 was [his] contribution," he said it was Grimes who " mostly came up with the name ." She even gave a thorough description of the meaning behind it on her Twitter .

The boy later made headlines when he joined his dad for a tense meeting at Twitter at the age of 2.

According to The Washington Post , Musk brought X Æ A-Xii to Twitter's offices while meeting with Trust and Safety Office Yoel Roth in October 2022. The child was reportedly running around the building as Musk discussed Twitter's future. X Æ A-Xii also made himself comfortable in the conference room, which the newspaper reported "was strewn with toys."

In April 2023, X Æ A-Xii tagged along with his dad to the MMA Global Possible Conference in Miami. The little boy was seen playing with Musk on stage, which the audience found heartwarming.

Four months later, Grimes opened up about her son's love of spacecraft . "X knows a lot about rockets. It's crazy," she explained. "He knows more about rockets than me."

She even admitted that she was worried about his "obsession with space" after SpaceX's Starship rocket exploded after takeoff in April.

"When X saw Starship blow up, he had, like, a three-day PTSD meltdown," the mom of two said. "Every hour, he was waking up and going, 'Starship ...' and I had to rub his back."

Strider and Azure

Walter Isaacson/Twitter

Musk secretly welcomed twins, son Strider and daughter Azure, with Shivon Zilis in November 2021, according to court documents published by Insider on July 6 . The twins were born in Austin, Texas — just weeks before he and Grimes welcomed a baby girl via a surrogate.

The papers reveal that in April, Musk and Zilis — who is the project director at his Neuralink company — asked a Texan county court to change their babies' names so they would "have their father's last name and contain their mother's last name as part of their middle name."

The parents revealed the babies' names and sexes in September 2023, when they were 16 months old.

Exa Dark Sideræl

Grimes revealed a year later in a Vanity Fair interview that she welcomed a baby girl via surrogate in December 2021, three months after the couple's public breakup. Named Exa Dark Sideræl, the singer-songwriter explained that her name has double meaning.

Exa refers to a supercomputing term, exaFLOPS, while Dark represents "the unknown." She explained to the outlet, "People fear it but truly it's the absence of photons. Dark matter is the beautiful mystery of our universe."

The third part of Y's full name, Sideræl, is pronounced "sigh-deer-ee-el," according to Vanity Fair. Grimes described the word as "a more elven" spelling of sidereal, which she defined as "the true time of the universe, star time, deep space time, not our relative earth time."

The second meaning of Sideræl is a nod to Grimes' favorite Lord of the Rings character, Galadriel, who "chooses to abdicate the ring."

In March 2023, Grimes shared a rare photo of her daughter on Twitter — and revealed that the little girl is going by a new name.

"Normally we [don't] post her for her privacy, but she's fairly unrecognizable here since shes channeling Goku," the mom-of-two wrote in the comments, referring to a Dragon Ball character. The photo showed Musk's youngest in a red onesie with super blonde spiked hair.

In a separate comment, Grimes said: "She's Y now, or "Why?" or just "?" (But the government won't recognize that). curiosity, the eternal question, .. and such."

In August, Grimes described her younger child as "a little engineer," and said, "she likes industrial shipping. She's very strange."

Techno Mechanicus

Journalist Walter Isaacson's biography about Musk revealed the birth of the Tesla founder's third child with Grimes. The couple secretly welcomed a second son, Techno Mechanicus , who also goes by “Tau."

Elon Musk's Baby No. 12

In June 2024, Musk confirmed the arrival of his 12th child (and third with Neuralink Corp.'s director of special projects, Shivon Zilis). The baby's name and birth date have yet to be released.

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Who Is Shivon Zilis? Meet the Mother of 3 of Elon Musk's 12 Children

Elon musk has confirmed he and shivon zilis welcomed their third baby via surrogate, his 12th child overall. but who is the the tech exec working for musk's neuralink.

Elon Musk has said people should have as many children as they feasibly can for the good of the planet.

Hence the SpaceX founder becoming the poster billionaire for his own cause.

The 52-year-old quietly welcomed his 12th child and third with 38-year-old  Shivon Zilis  earlier this year, confirming as much to Page Six on June 23.

"People are going to have to revive the idea of having children as a kind of social duty," Musk said in a 2014 interview, per biographer Walter Isaacson . "Otherwise civilization will just die."

That brand of charm may not be for everybody, but the thrice-married  (twice to the same woman) Tesla CEO has enjoyed a robust romantic life  in the course of becoming a prolific procreator—though one circumstance hasn't necessarily been required to lead to the other. 

"He really wants smart people to have kids, so he encouraged me to," Zilis told Isaacson for his 2023 book on the man frequently atop  Forbes ' real-time richest-person-alive list . "If the choice is between an anonymous sperm donor or doing it with the person you admire most in the world, for me that was a pretty f--king easy decision. I couldn't possibly think of genes I would prefer for my children."

Not least, she added, "It seemed like something that would make him very happy."

But what else makes Zilis tick, you ask? Here's more to know about the tech executive who's had three babies with Musk:

Who is Shivon Zilis?

Zilis was born Feb. 8, 1986, in Markham, Ontario, to mom Sharda , who's originally from India, and dad Richard  of Canada.

Speaking of her heritage, Zilis told  USA Today   in 2015 that she "pretty much turned out white," but attributed her big eyes to her Punjabi side. 

She played ice hockey at Yale before graduating in 2008 with degrees in economics and philosophy.

Zilis credited being a goalie for helping her develop some of the skills she later utilized in the fast-paced tech world, so much of which runs on being able to predict what consumers are going to want years down the road.

"The goalie gets to watch the play unfold from a bit of a distance so you get a unique macro level versus always being in the thick of it," she told the Financial Post   in 2015. "The real art of goaltending is being able to get a good read on the players and predict what he/she is going to do." 

What does Shivon Zilis do?

She kicked off her career working for IBM in New York, focusing on micro-finance initiatives in developing countries—and furthering her interest in artificial intelligence.

In 2012 she cofounded San Francisco-based Bloomberg Beta, a $75 million venture capital fund investing in early-stage startups that focused on machine intelligence, which Zilis correctly envisioned  would eventually affect countless industries.

"I always knew that stuff was going to happen before it happened," she told  USA Today . Still, she called herself an "unsexy investor," more inclined to support an agricultural-tech endeavor than a buzzier company like Snapchat. 

Forbes included her in its "30 Under 30: Top Young Investors of Venture Capital" list in 2015—which Zilis called  "a pretty delightful surprise."

Musk cofounded OpenAI in 2015 and reportedly met Zilis when she did consulting work for the ChatGPT creator.

In 2017, Zilis joined Tesla—where Musk was an early investor and has been CEO since 2008—as a project director for its Autopilot product and chip design team.

Musk left OpenAI in 2018, while Zilis remained on the board  until March 2023 . She is currently director of operations and special projects at Neuralink, which Musk started in 2016.

What is Shivon Zilis' relationship with Elon Musk?

Zilis has acknowledged that the owner of the company she works for has his issues, but she's gone to bat for Musk as a humanitarian and visionary.

"No one's perfect but I've never met anyone who goes through more personal pain to fight for an inspiring future for humanity— and has done so tirelessly for decades," Zilis tweeted about Musk in May 2020 (two years before he bought Twitter and turned it into X). "Everyone's entitled to their opinion but mine is that there's no one I respect and admire more."

Zilis told Musk biographer Isaacson that she "learned more unique lessons from Elon per minute than any other human I've met. It would be dumb to not spend some of your life with such a person."

Hence her decision to relocate from Silicon Valley to Austin, Texas, as Musk did and then have children with him, conceived via IVF. (Zilis acknowledged having "the motherhood bug super hard" but wasn't interested in getting married.)

They welcomed twins Strider Sekhar Sirius and Azure Astra Alice in November 2021—the expansion of Musk's family not known until the following July, when they filed paperwork in Texas to legally change the kids' last name from hers to his.

Zilis said that the name change was spurred by Musk's estrangement from his daughter  Vivian Jenna ,   one of his five surviving children with ex-wife Justine Wilson . (Son Nevada Alexander died of SIDS when he was 10 weeks old.)

"When Jenna deleted 'Musk' from her name," Zilis explained, "he was just really sad. And he asked me, 'Hey, would you be open to our twins taking my name?'"

Zilis didn't expect Musk to play a traditional father role in the raising of the twins—"because the dude's got a lot going on," she told Isaacson—but he would stay at her house at least once a week and was surprisingly doting.

"There's just some stuff he can't do because he's emotionally hardwired a bit differently," she explained. "But when he comes in, they light up and have eyes only for him, which lights him up as well."

Is Shivon Zilis friends with Elon Musk's ex Grimes?

Once Zilis moved to Austin, she was part of a social circle that included Musk and his now-ex-partner  Grimes , with whom he also shares  sons  X Æ A-Xii   (X for short), 4, and Techno "Tau" Mechanicus , 2, and daughter  Exa Dark Sideræl  (also known as Y), 2.

According to Isaacson, the singer considered Zilis a friend and occasionally tried to matchmake for her. 

Musk's twins with Zilis arrived a few weeks before Exa was born through a surrogate in December 2021, three months after Musk and Grimes " semi-separated ," as he put it in a tweet.

"It's mostly that my work at SpaceX and Tesla requires me to be primarily in Texas or traveling overseas and her work is primarily in LA," Musk wrote. "She's staying with me now and Baby X is in the adjacent room."

As for Grimes' decision to have a second child with Musk (via surrogate following her tough first pregnancy), she told Isaacson, "I really wanted him to have a daughter so bad." 

Grimes and Musk reunited but had  broken up again by March 2022  while their third child was on the way. Tau was born via surrogacy in June 2022.

Meanwhile, Grimes didn't know that Musk was the father of Zilis' babies until the rest of the world found out from the published court filing in July 2022 and, according to Isaacson, was "outraged."

Musk acknowledged the eyebrow-raising news that he had children with someone who worked at his companies by tweeting , "Doing my best to help the underpopulation crisis. A collapsing birth rate is the biggest danger civilization faces by far."

Where is Shivon Zilis now?

Zilis lives in Austin with the twins and her months-old third child with Musk, whose name and sex have not been publicly shared.

"All our friends and family know," he told Page Six June 23. "Failure to issue a press release, which would be bizarre, does not mean 'secret.'"

And Zilis remains onboard with his myriad visions.

"It's been one of the most meaningful friendships of my life, by far," Zilis told Isaacson of her kids' father. "Soon after I met him I said, 'I hope we're friends for life."

As Musk quipped during a dinner with several NASA directors in February 2022, barely two months removed from the birth of his twins with Zilis and then his daughter with Grimes, "Among my friends, the average number of kids is one. Some have zero. I try to set a good example." 

For a full breakdown of Musk's family, relationships and the 12 children that followed, read on…

Maye Musk (Mom)

Maye was born in Saskatchewan, Canada and emigrated with her parents to Pretoria, South Africa in 1950, when she was 7. She and Elon's father,  Errol Musk , split in 1979. After Elon moved to Canada at age 17, Maye obtained Canadian citizenship by birthright and moved there too. There, she established a dietician practice and became President of the Consulting Dieticians of Canada. She also worked as a model. In 2019, after Elon sold his company Zip2 for more than $300 million, he bought his mom an apartment in New York City, where she lived for 13 years and continued her modeling career after being signed to the IMG Models agency. "I brought my children up like my parents brought us up when we were young: to be independent, kind, honest, considerate and polite," Maye wrote in an essay  for CNBC. "I taught them the importance of working hard and doing good things."

Errol Musk (Dad)

Elon's father is an engineer and like Elon, was born in South Africa. Though Errol said in a 2015 Forbes interview that he used to often take his kids on trips overseas — "Their mother and I split up when they were quite young and the kids stayed with me. I took them all over the world."—his relationship with Elon isn't picture perfect. In an emotional 2017 Rolling Stone interview, Elon criticized his father and talked about his upbringing, saying that after his parents split, he moved in with his dad, which, he said, "was not a good idea." However, Errol told  Rolling Stone , "I love my children and would readily do whatever for them." Following his divorce from Maye, Errol married Heide , whose daughter  Jana Bezuidenhout was 4 years old at the time. Errol and Heide went on to have two daughters together before they, too, broke up.  Years later, Jana reached out to Errol following a breakup of her own. "We were lonely, lost people," Errol explained  in a 2018 interview with The Sunday Times . "One thing led to another—you can call it God's plan or nature's plan." Either way, the duo became romantic and welcomed son Elliott in 2017 and then a baby girl in 2019. As Errol put it to The Sun , "The only thing we are on Earth for is to reproduce. If I could have another child I would. I can't see any reason not to."

Kimbal Musk & Tosca Musk (Siblings)

Kimbal, born in 1972, is a restauranteur and the founder of The Kitchen, a collective of five restaurants that source directly from local farmers. He also runs a non-profit, Big-Green, that has built 200 learning gardens in schools across the U.S., the outlet said. Tosca, born in 1974, is a filmmaker. In 2017, she founded Passionflix, a female-focused streaming service that targets the billion-dollar romance novel industry. 

Justine Wilson (Ex-Wife)

Elon and Canadian-born Justine, his college sweetheart from Queen's University in Ontario , married in 2000. In a 2010 article she penned for  Marie Claire , titled I Was a Starter Wife: Inside America's Messiest Divorce , Justine said that while dancing at their wedding reception, Elon told her, "I am the alpha in this marriage." "I shrugged it off," Wilson wrote, "just as I would later shrug off signing the postnuptial agreement, but as time went on, I learned that he was serious." The two faced an unthinkable tragedy when their baby boy Nevada Alexander died at 10 weeks from Sudden Infant Death Syndrome (SIDS). "Nevada went down for a nap, placed on his back as always, and stopped breathing," Justine wrote in her article. The couple pursued IVF to conceive again and went on to welcome five more kids: Twins Vivian  and Griffin and triplets Kai , Saxon and Damian .  In 2008, Elon filed for divorce.

Vivian Wilson; Griffin, Kai, Damian & Saxon Musk (Kids)

In a July 2022 snap, Elon revealed he took his oldest sons to meet Pope Francis . While he was honored to meet the head of the Catholic church, Elon added of his 'fit, "My suit is tragic."  That same year, Elon's daughter Vivian filed a petition to change her full name in accordance with her new gender identity, writing, "I no longer live with or wish to be related to my biological father in any way, shape or form."

Talulah Riley (Ex-Wife)

Elon and Talulah—who starred on HBO's Westworld— married in 2010. "It all happened very fast," she told CBS News . "We were engaged after, I think, two weeks of knowing each other." The two divorced in 2012, then remarried a year later before divorcing again in 2016. In June 2024, she wed Love Actually  alum Thomas Brodie-Sangster .

Amber Heard (Ex-Girlfriend)

Elon and Amber went public with their romance in early 2017, a year after she filed for divorce from Johnny Depp and Elon ended his (second) marriage to Talulah. Though their relationship didn't last long .

"I just broke up with my girlfriend," Elon told Rolling Stone   at the time. " I was really in love , and it hurt bad...Well, she broke up with me more than I broke up with her, I think."

Grimes (Ex-Girlfriend)

Elon and the singer dated on-and-off for four years, starting in 2018. In September 2021, Elon told Page Six that he and Grimes "are, I'd say, probably semi-separated," adding, "It's mostly that my work at SpaceX and Tesla requires me to be primarily in Texas or traveling overseas and her work is primarily in LA. She's staying with me now and Baby X is in the adjacent room." However, in March 2022, she told Vanity Fair that they "live in separate houses" and are "best friends." She later tweeted, "Me and E have broken up *again* since the writing of this article haha, but he's my best friend and the love of my life, and my life and art are forever dedicated to The Mission now."  When news broke in September 2023 that the couple share three children together, the "Crystal Ball" singer confirmed that, yes, their most recent addition Techno Mechanicus had joined son  X Æ A-12 , 3, and daughter  Exa Dark Sideræl .

X Æ A-Xii Musk (Son)

In 2020, Elon and Grimes welcomed their first child together, a son. They soon modified the spelling of his name in order to meet California's legal guidelines, which only permit letters from the English alphabet. Switching over to roman numerals, the parents agreed to spell his name, X Æ A-Xii. "X, the unknown variable," Grimes explained on Twitter . "Æ, my elven spelling of Ai (love &/or Artificial intelligence) A-12 = precursor to SR-17 (our favorite aircraft). No weapons, no defenses, just speed. Great in battle, but non-violent."  Grimes continued, "A=Archangel, my favorite song" adding a rat and sword emoji. "Metal rat."

Exa Dark Sideræl & Techno Mechanicus Musk (Kids)

In her 2022  Vanity Fair interview, Grimes revealed she and Elon privately welcomed a baby girl via surrogacy. "Exa is a reference to the supercomputing term exaFLOPS (the ability to perform 1 quintillion floating-point operations per second)," she said. "Dark, meanwhile, is the unknown. People fear it but truly it's the absence of photons. Dark matter is the beautiful mystery of our universe.'" Sideræl—pronounced "sigh-deer-ee-el"—is, according to mom, "the true time of the universe, star time, deep space time, not our relative earth time," and a nod to her favorite Lord of the Rings character, Galadriel, who "chooses to abdicate the ring." A year later, the  New York Times ' review of Walter Isaacson 's biography Elon Musk confirmed that Elon and Grimes share three children. The on-again, off-again couple at one point welcomed a child named  Techno Mechanicus , nicknamed  Tau , a report Grimes  confirmed soon after . "I wish I could show u how cute little Techno is," she  wrote on X , "but my priority rn is keeping my babies out of the public eye, Plz respect that at this time."

Strider & Azure Musk (Kids)

In 2022,  Business Insider published court documents that stated Elon welcomed twins in November 2021 with Neuralink executive Shivon Zilis . The babies were born in Austin, Texas, where he lives.

He also seemingly weighed in on the report on X , writing, "Doing my best to help the underpopulation crisis. A collapsing birth rate is the biggest danger civilization faces by far."

"Mark my words," he added, "they are sadly true."

In September 2023, a TIME magazine cover story revealed that their twins were named Strider and Azure .

Baby No. 12

In 2024, Elon and Zilis welcomed their third baby together. The billionaire confirmed the news in June 2024, telling  Page Six , "All our friends and family know," adding, "Failure to issue a press release, which would be bizarre, does not mean 'secret.'"