Australian intended parents' decision-making and characteristics and outcomes of surrogacy arrangements completed in Australia and overseas.

Markets for international surrogacy often arise in jurisdictions with limited regulations regarding assisted reproductive technologies. In some countries, like Australia, regulated domestic surrogacy services are often sidestepped for international providers. This study describes how Australian intended parents decide where to pursue surrogacy and compares the characteristics and outcomes of arrangements completed within and outside of Australia. The findings show that, although intended parents preferred undergoing surrogacy in Australia, perceiving the process as too long and complicated was a common reason to pursue an international arrangement. Multiple embryo transfer, anonymous gamete donation, and a lack of counselling were common in international surrogacy arrangements. When compared to surrogacy arrangements completed in Australia, where single embryo transfer is mandatory for surrogacy cycles, the rates of multiple birth, preterm birth and neonatal intensive care in international surrogacy were higher. These findings raise concerns about the health and welfare of international surrogacy participants, particularly the surrogates and children. In lieu of any international instrument regulating surrogacy, improving access to surrogacy at a domestic level would reduce the number of people engaging with international arrangements and in turn, reduce the potential for harm.

The impact of Covid-19 on gamete shipping by Australian and New Zealand patients.

BACKGROUND: Cross-border surrogacy and egg donor arrangements are an increasingly common means to family building. Establishing patterns of use has always been difficult in relation to Australian patients. Accurate data is stymied by lack of documentation of international third-party reproductive care available to Australian authorities. When international travel bans came into effect, it is hypothesised that those planning to use cross-border reproductive care had to rely significantly more on local in vitro fertilisation (IVF) clinics for services such as sperm freezing, embryo creation and gamete release procedures. AIM: To quantify and characterise the impact of the Covid-19-related travel ban on international and interstate gamete shipping by Australian IVF clinics. MATERIALS AND METHODS: Thirty-one Australian and New Zealand IVF clinics were invited to provide de-identified data on interstate and international gamete export applications from two 12 month time periods pre- and during Covid-19-related international travel lockdowns. Seven IVF organisations provided data on: patient age; type of gametes exported; destination country/state; and date gamete release approved. RESULTS: Most gametes (78%) were shipped to another Australian IVF clinic and 22% internationally. Patient-initiated shipping domestically and internationally both showed significant increases when comparing pre- and post-Covid datasets. Of the 21 destination countries reported for international shipments, the US was the commonest (39%), followed by Ukraine (21%) and Canada (9%). CONCLUSIONS: The inability of involuntarily infertile patients to travel internationally, rather than halt cross-border reproductive care, has led to a significant increase in the uptake of gamete shipping. The high proportion of internationally shipped gametes going to the US and Ukraine is likely a reflection of the availability of surrogates and donors and more amenable legal frameworks.

For love or money? Australian attitudes to financially compensated (commercial) surrogacy.

BACKGROUND: Australian law allows for altruistic surrogacy but prohibits compensation of surrogates beyond their expenses, or the use of professional surrogacy agencies. These restrictions limit local access to surrogacy, driving Australians overseas where they can access commercial surrogacy. AIM: To assess the Australian public's views regarding the use of gestational surrogacy under various social and medical scenarios, together with their level of support for financial compensation of surrogates and the use of professional surrogacy agencies. MATERIALS AND METHODS: Online survey of 500 Australians of reproductive age (18-49 years) regarding views on surrogacy and acceptable levels of compensation, conducted during January 2016. RESULTS: The majority of respondents supported access to surrogacy for couples, irrespective of a couple's marital status or sexuality, with only 9% believing that surrogacy was unjustified under any circumstances. Of those who held a view on compensated surrogacy, over half (58%) believed the current ban was unjustified, with close to two-thirds (62%) also believing that Australians should be allowed to access commercial surrogacy overseas. In relation to compensation, most believed that payment should be determined by negotiation between the surrogate and commissioning parents, while also supporting additional payments for 'hardship' pregnancies. Half of the surveyed cohort supported the legalisation of professional surrogacy agencies, with only 17% being totally opposed. CONCLUSIONS: The majority of Australians support surrogacy, compensation for surrogates and professional surrogacy agencies. Therefore, the existing legal restrictions should be replaced with professional guidelines that protect the surrogate and commissioning parents, while also improving Australians' access to surrogacy.

Intended parents' motivations and information and support needs when seeking extraterritorial compensated surrogacy.

Cross-border reproductive care (CBRC) is becoming increasingly common. Little is known about the motivations and information and support needs of people who cross borders to access surrogacy. This study aimed to explore: how those considering or undertaking extraterritorial surrogacy reach their decision; what other avenues they have considered and tried to have children; their sources of information and support; and perceptions of how others view their decision. Members of two Australian parenting support forums completed an anonymous online survey. Of the 249 respondents, 51% were gay men, 43% heterosexual women and 7% heterosexual men. Most heterosexual respondents had tried to conceive spontaneously and with assisted reproductive technology before considering surrogacy. Most respondents felt supported in their decision to try extraterritorial surrogacy by close family and friends. Surrogacy-related information was mostly sourced online and from other parents through surrogacy. Few sought information from a local general practitioner or IVF clinic and those who did reported IVF clinic staff were significantly (P < 0.001) more likely than other groups to communicate negative reactions to their decision to seek surrogacy. The apparent negative attitudes to cross-border surrogacy among health professionals warrants further research into health professionals' knowledge, beliefs and attitudes relating to surrogacy.

Outcomes of surrogacy undertaken by Australians overseas.

OBJECTIVES: To describe the outcomes of surrogacy among Australian intended parents who engage in compensated surrogacy overseas. DESIGN, SETTING AND PARTICIPANTS: Members of two Australian parenting support forums who were considering surrogacy or were currently or previously in a surrogacy arrangement were invited to complete an anonymous online survey during July 2013. MAIN OUTCOME MEASURES: Destination countries; source of eggs; number of surrogates and embryo transfers; proportions who experienced pregnancy loss after 12 weeks' gestation, multiple pregnancy, prematurity, and live birth by destination country; and intentions regarding disclosure to children about the way they were conceived. RESULTS: Of 1135 potential participants 259 (23%) completed the survey. Of these, 112 (43%) had undertaken at least one surrogacy attempt overseas. India and the United States were the two most common destination countries. Most respondents (95/112; 85%) had used donor eggs; half (57/112; 51%) had used more than one surrogate; and the mean number of embryo transfer procedures was 2.9. As a result of surrogacy, 85% (95/112) had at least one child; 55% (62/112) reported that their surrogate had a multiple pregnancy; 10% (11/112) reported that a pregnancy had ended in a late miscarriage or perinatal death; and 45% of births (35/78) were premature. Most respondents (80/112; 71%) were most comfortable with using an identity-release donor, and 87% (97/112) believed that this would also be in their child's best interests. Almost universally, parents were planning to disclose the use of a surrogate and/or a donor to their child. CONCLUSIONS: Almost half of the intended parents via surrogacy who completed this survey had undertaken compensated surrogacy overseas; most of these used donor eggs, but few considered Australian donors. A high proportion of surrogates had multiple pregnancies and there was a high rate of premature birth. These adverse outcomes could be avoided if the surrogacy was undertaken in Australia. Removing some of the existing barriers to surrogacy in Australia may reduce the number of surrogacy arrangements carried out overseas.

Australians' use of surrogacy.

OBJECTIVES: To investigate the characteristics of parents and intended parents and their current and planned behaviour in relation to surrogacy arrangements. DESIGN, SETTING AND PARTICIPANTS: Members of two Australian parenting support forums who were considering surrogacy or were currently or previously in a surrogacy arrangement were invited to complete an online survey during July 2013. MAIN OUTCOME MEASURES: Sociodemographic characteristics; proportions engaging in domestic uncompensated and overseas compensated arrangements; countries used; costs incurred; and impact on behaviour of state laws criminalising compensated surrogacy. RESULTS: Of 1135 potential participants, 312 (27%) commenced the survey. Of these, 24 did not fulfil inclusion criteria and 29 did not complete the survey. Eighty-nine respondents were considering surrogacy and 170 had commenced or completed surrogacy. Many respondents (53%) considered both overseas and domestic surrogacy. Among those who only considered one option, overseas surrogacy was considered significantly more often than domestic surrogacy (92% v 8%; P < 0.05). Only 22 respondents (8%) commenced with a surrogate in Australia. The most common countries used for compensated surrogacy were India and the United States, and average total estimated costs were $69 212 for India and $172 347 for the US. Barriers discouraging domestic surrogacy included concern that the surrogate might keep the child (75%), belief that it was too long and complicated a process (68%) and having no one of the right age or life stage to ask (61%). Few intended parents (9%) were deterred by state laws criminalising compensated surrogacy. CONCLUSIONS: Most Australian intended parents via surrogacy consider or use overseas compensated arrangements. Laws banning compensated surrogacy do not appear to deter those seeking surrogacy arrangements.