I was recently invited to speak at a private meeting held on the campus of Harvard University.  I was asked to give some brief remarks on surrogacy and assisted reproductive technologies to frame the landscape and hopefully facilitate the group discussion that followed.  I’m sharing these remarks with you in hopes they will be helpful to you as you speak with others about the ethics of assisted reproduction!

Much of what I’m going to say applies to IVF in general, but to leave time for our discussion, I will focus mainly on what is referred to as third-party conception which requires the use of three separate individuals; women who provide their eggs, men who provide their sperm as well as women who provide their wombs as in contractual surrogacy. Who are the consumers of third-party conception? A growing demographic is gay men or single men “by choice” (another new demographic) will overwhelmingly use one woman for her eggs and another woman for her wombs – what is called “gestational surrogacy.”

Single women “by choice” or same-sex female couples may only require a sperm donor, while heterosexual couples may require a sperm donor if the man is sterile, or an egg donor if the woman in the couple is older or has ovarian insufficiency.  They may also need a surrogate womb if the intended mother has had difficulty carrying a pregnancy to term – there are many reasons why individuals or couples feel the need to access a third party to have a child.

We see the fertility market expanding now to offer “fertility preservation” to pre-and post-pubescent children and youth as part of their transition “gender affirmation” care since puberty blockers and cross-sex hormones render children sterile or at least can negatively impact their future fertility.

While sperm donation has been around for hundreds of years and is what I call “low tech”, think specimen cups and syringes, novel Assisted Reproductive Technologies like, IVF which often depends on women as egg donors and women as gestational carriers, is still relatively new “high tech” technology.

With the birth of Louise Brown, the first “test tube” baby, in the UK in 1978 fertility medicine really took off, but this was after years of trial and error using women as guinea pigs – as detailed in Gena Corea’s book: The Mother Machine. Reproductive Technologies from Artificial Insemination to Artificial Wombs.

Just five years after the birth of Louise Brown, we see documented in the medical literature the first IVF baby born in Australia using ‘donor eggs’. Dr. Alan Trounson authored this paper and it is curious that years later Trounson was recruited from Monash University to come to head the California Institute for Regenerative Medicine (CIRM) which was our state funded human cloning and embryonic stem cell initiative sold to voters as “Cures for California”.  Here you can see the intersection of reproductive medicine and scientific research – both dependent on the female reproductive body but both in need of a different type of woman.  The fertility clinics want smart, pretty, and talented women, where the bench scientist researcher just needs eggs.  In the science space, poor women will be heavily targeted for their eggs for much needed money.

Today’s global Landscape is a patchwork of laws, prohibitions, and regulations which serve to fuel a multi-billion dollar yearly reproductive tourism industry expected to reach $36 billion by 2026. The debate varies from country to country and in the U.S., state by state.  While surrogacy is illegal in Spain, women can be paid to sell their eggs.  In Italy, where surrogacy is illegal but women can donate their egg, but they can’t be paid. Prime Minister Meloni is considering making it illegal for Italians to travel abroad to employ surrogate mothers and has halted certifying birth certificates of children born via surrogacy through international arrangements.  The U.S. is a patchwork of 50 states with various laws regulating third party conception. My state, California, is the wild wild west with very permissive laws that protect the monied interests in contractual arrangements.

Decades of data in the U.S. still show that most IVF cycles fail. From the CDC’s most recent data of 2020 we see that 326,468 IVF cycles were done which resulted in 75,023 live born infants. A single IVF cycle, defined as ovarian stimulation, egg retrieval and embryo transfer, can conservatively cost from $15,000 to $30,000. The rich can buy but the poor have to sell.

Not only is IVF expensive and carries a high failure rate, but IVF is also harmful to women, new studies are exploring the dangerous effects on the children born through this technology. A 2021 study found that “children conceived by assisted reproductive technology (ART) had statistically significantly worse outcomes in left ventricular function and structure.” The article further stated that “children conceived by ART had increased blood pressure and unfavorable changes in left ventricular structure and function compared with children who were naturally conceived.” One study state that “The risks of heart defects, musculoskeletal and central nervous system malformations, preterm birth, and low birth weight are increased in children conceived by vitro fertilization (IVF). The risks seem to be based on maternal and paternal factors, but also on IVF itself.” Another study found “that children born via ART conception have a higher risk of any type of childhood cancer, as well as leukemia and hepatic tumors, compared with children born via either natural conception or parental subfertility.” 

Turning specifically to surrogacy, research shows that a gestational surrogate pregnancy has higher risks than a spontaneous or natural pregnancy even if the woman carries a single baby.  

In the journal Fertility and Sterility, research showed surrogate mothers had an increased risk of: maternal gestational diabetes, hypertension, and placenta previa when compared to spontaneous pregnancies. Surrogate pregnancies are also more likely to end in cesarean section rather than vaginal birth (which equates to more risks to both surrogate and baby). In addition to the increased risk of caesarian sections and longer hospital stays, the British Journal of Medicine warns “Multiple pregnancies are associated with maternal and perinatal complications such as gestational diabetes, fetal growth restriction, and pre-eclampsia as well as premature birth.” When compared to a natural pregnancy, surrogate pregnancies of a singleton or twin resulted in hospital charges 26 times higher and 173 times higher when triplets or more were born. A 2014 qualitative study on the experiences of eight surrogate mothers published in the Iranian Journal of Reproductive Medicine, revealed surrogate moms experience significant emotional attachment to the children they carry as well. Researchers concluded, “surrogacy pregnancy should be considered as a high-risk emotional experience because many surrogate mothers may face negative experiences.” 

Our own published research found that surrogate mothers were more likely to have a high-risk pregnancy and unfavorable outcomes during her surrogate pregnancy, including c-section delivery, high blood pressure, hemorrhage, pre-term labor and birth, placenta previa, postpartum depression, and postpartum high blood pressure when compared to her other, non-surrogate, pregnancies. These outcomes were consistent independent of her age or gravidity and confirmed that health disparities exist for women with surrogate pregnancies compared to non-surrogate pregnancies,

It is well understood that pregnancy is a full body experience, affecting the physical, social, mental, and emotional being of a woman. The fertility industry is littered with phrases like “renting a womb”, “just the babysitter”, “be an angel”, “give the gift of life”, and “my bun her oven” to try and minimize the whole-body experience of pregnancy and encourage the woman to dissociate from her body and the children their body helps to create via surrogacy or egg “donation”. 

So, how do we understand the tension between what federal laws makers want to protect, which is the “right to build a family” with no limits, and the rights and protections and best interests of women, children, and the family?  What does procreative liberty mean for maternal child health?  John Robertson’s book, “Children of Choice” supports no limitation to how one has children, believing that we have the right to have sex or not.  We have the right to have children or not.  And we have the right to have the kind of children that we want. But what is the best approach in shaping our thinking and supporting public policies – is it a risk: benefit calculus? Is it “my body my choice”? Is it regulation or is it abolition? These are the things for us to consider.

The New Yorker recently ran an article on “The Future of Fertility: A new crop of biotech startups want to revolutionize human reproduction”.  Will the future move to making all babies in the lab as Stanford Law Professor predicts in his book “The End of Sex?  Will men who want uterine transplants make “men having babies” a reality?  Will eggs and sperm be manufactured in the lab from skin cells and babies gestated in artificial wombs? Will children being offered fertility preservation schemes be left childless as they were offered risky and experimental hopes for their future? I’m not sure what the future holds but I am certain that women and children again will again be the guinea pigs for whatever the future of fertility holds. Women and children will not only be harmed but they will be wronged.

Author Profile

Jennifer Lahl, CBC Founder
Jennifer Lahl, CBC Founder
Jennifer Lahl, MA, BSN, RN, is founder and president of The Center for Bioethics and Culture Network. Lahl couples her 25 years of experience as a pediatric critical care nurse, a hospital administrator, and a senior-level nursing manager with a deep passion to speak for those who have no voice. Lahl’s writings have appeared in various publications including Cambridge University Press, the San Francisco Chronicle, the Dallas Morning News, and the American Journal of Bioethics. As a field expert, she is routinely interviewed on radio and television including ABC, CBS, PBS, and NPR. She is also called upon to speak alongside lawmakers and members of the scientific community, even being invited to speak to members of the European Parliament in Brussels to address issues of egg trafficking; she has three times addressed the United Nations during the Commission on the Status of Women on egg and womb trafficking.