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9/3/2019 1 SURROGACY: Gestational Carriers and Intended Parents Our Focus Understanding the process Care of the surrogacy family Issues surrounding surrogacy Total Agreement? What is your definition of a family? A group consisting of parents and children living together or not living together. Traditional Families. The traditional make up of a family consists of a mother and father with biological or adopted children. Blended Families: a family that includes children of a previous marriage of one spouse or both Extended Families: a family that extends beyond the nuclear family, including grandparents, aunts, uncles, and other relatives, who all live nearby or in one household.

Transcript of surrogacy - j.b5z.net · surrogacy contracts, agreements, or arrangements “void and unenforceable...

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SURROGACY:Gestational Carriers and Intended Parents

Our Focus

� Understanding the process

�Care of the surrogacy family

� Issues surrounding surrogacy

Total Agreement?

� What is your definition of a family?

A group consisting of parents and children living together or not living together.

� Traditional Families. The traditional make up of a family consists of a mother and father with biological or adopted children.

� Blended Families: a family that includes children of a previous marriage of one spouse or both

� Extended Families: a family that extends beyond the nuclear family, including grandparents, aunts, uncles, and other relatives, who all live nearby or in one household.

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FAMILY

Respect for differing opinions

Definitions

� Surrogacy

A woman carries a pregnancy for another couple or person. She may have no biological relationship and eventually relinquishes the child to the other party.

� Commercial Surrogacy

Surrogacy that involves financial remuneration for the surrogate.

� Altruistic Surrogacy

Surrogacy that does not involve financial remuneration.

� Gestational Carrier/Surrogate

A term for the woman who carries a pregnancy for another person.

A Traditional surrogate is a woman who is genetically related to the child.

� Intended parent/Commissioning parents

The parents of the child who will be born by the surrogate. The parent may or may not be biologically related to the child.

Aznar, J., Martinez Peris, M. (2019). Gestational surrogacy: Current view.

The Linacre Quarterly, 86(1), 56-67. doi:10.1177/0024363919830840

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Surrogacy Laws by Countryhttps://en.wikipedia.org/wiki/Surrogacy_laws_by_country

Both gainful and

altruistic forms are

legal

No legal regulation

Only altruistic is legal

Allowed between

relatives up to

second degree of

consanguinity

Banned

Unregulated/uncerta

in situation

Surrogacy Laws By Country

Commercial Surrogacy

US (Some states)

Georgia

Ukraine

Russia

India (Married couples with medical justification)

Thailand (Sister only)

Nigeria (Baby factories)

Mexico (Mexican only)

Altruistic

SurrogacyBelgiumGreece (Heterosexual couples)HollandUKPortugal (Women without a womb)Australia

CanadaDenmarkUruguay Israel (Heterosexual couples)

ProhibitedSpainAustriaFinlandFrance

GermanyItalyMaltaNorwaySwedenNepal

https://en.wikipedia.org/wiki/Surrogacy_laws_by_country

European Parliament

� 2011 Prohibited surrogacy and said that it was exploitation of women and a human rights issues. It undermines human dignity. Upheld in 2015

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Surrogacy: Ethical and Legal Issues

� No global legal consensus regarding surrogacy whether for payment or altruistic.

� Cross border concerns with citizenship, nationality, parentage, and rights of the child.

� Women and babies are treated as commodities

� Agencies profiting and exploiting poor vulnerable women (India and Nigeria)

� Sometimes even called “human trafficking”

Saxena, P., Mishra, A., and Malik, S. (2012). Surrogacy: Ethical

and Legal Issues. Indian Journal of Community Medicine, 4, 211-213. doi:10.4103/0970-0218.103466

Surrogacy Laws of the US

� https://www.creativefamilyconnections.com/us-surrogacy-law-map/

� Green California: permitted by statue

� Green MN: permitted because no statue prohibits it.

� Yellow Arizona surrogacy contracts are prohibited by statute. Arizona Revised Statute § 25-218 states that no person may enter into or assist in creating a surrogacy contract. Although the contracts are unenforceable, Gestational Surrogacy continues to be practiced in Arizona.

� Red The Michigan Surrogate Parenting Act MCL Section 722.851 makes all surrogacy contracts, agreements, or arrangements “void and unenforceable as contrary to public policy.” In addition, surrogacy

contracts for compensation are subject to criminal penalties.

Other Concerns Surrounding Surrogacy

� Impact on the surrogateProvision of mental health care and support.

� Parents do not want a baby that has problems (termination)

Baby Gammy in Thailand. Linacre Quarterly.

https://www.youtube.com/watch?v=jcM0rX7w9Yg

� Multiples and fetal reduction

� Long term relationships of surrogate and parents

� Cross border surrogacy issues

� Financial AspectsCost to parents….California $70-120,000 (Aznar 2019)

Twin Cities $120,000 (Quote from surrogacy agency 2019)Payment to Surrogate… California and Twin Cities $30,000

� Reimbursement for services

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Reasons People Choose Surrogacy

� Infertility of medical conditions

� Single mothers

� Single fathers

� Same-sex parents

Our Service

� Health care providers

� Process

� Documentation

Providers

�Perinatal Nurse Navigator

Connection and preparation with all family members

�Social Worker

Legal process, paperwork, and agency connections

�Obstetrician

�Perinatologist

�Staff

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Our Process

� Initial contact

�Welcome letter

� Birth planning ( give some responses and concerns)

Email or face to face

Tour (include NICU)

20 weeks scan

Newborn classes

Welcome book

�Coordinating care during hospital stay

� Follow up

Welcome Letter

Birth (Gestational Carrier)

Significant history

Comfort measures and pain relief

People in the OR

Legal guardian and Medical decision makers

Baby will be banded to whom?

Care of baby

Who will baby be given to after birth?

Will you do skin to skin?

Formula:

Breast milk from donor or from surrogate:

Pacifier:

Medications:

Vitamin KErythromycin OintmentVaccinations: Hepatitis B

Circumcision if baby is a boy?

Birth PlanRoom for parents and baby.

A room will be provided, free of charge, for the parents and the newborn. This room will be separate from the gestational carrier. A nurse will be assigned to care for baby and help with any cares or teaching needed. Meals are not provided, but are available in the cafeteria.

Siblings, family, and friends of intended parents

and surrogate who may be present

Names of family and friends

How and when would you like them involved?

Medical care of baby (Intended Parents)

A pediatric hospitalist will care for the baby and transfer all hospital records to your pediatrician.

Pediatrician of baby: Address:Phone:Fax number for medical records:

Plans for discharge

A car seat for the baby upon dischargeTypical stay for baby is 48 hours

A

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Documentation and Communication

� Initial contact and throughout care

� Birth plan in electronic and hard chart

� Legal documents and directions in hard chart

� Communication in Care Rounds

Interviews with Families

Intended Parent Responses

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Tell us about your journey to parenthood and why you chose surrogacy.

� As a same-sex couple our options were limited. The process took years but it was worth the wait.

� I decided to take the plunge at 36 and become a single parent. After 3 years of failed IVF I gave up on my body and was lucky enough to have

the financial resources to move on to surrogacy.

� My uterus ruptured with the birth of our first daughter and I had a

hysterectomy at that time. This was our only option for a second biological child.

Is there a reason why you chose to do surrogacy in the U.S.?

� Altruistic surrogacy is legal in the UK, but agreements aren’t enforceable and there is more uncertainty for both parties.

� The U.S. was more expensive than other countries, but we wanted a good legal system and good IVF practices.

� Surrogacy is legal in Israel but not for gay couples.

What are the challenges of the

surrogacy process?

� You need to be patient.

� The IVF journey is outside your control

� It is a very intimate process and both parties need to be respectful of each other.

� Living abroad we did not get to meet our surrogate beforehand.

� The cost. It is prohibitively expensive for most people.

� Waiting. Most people have been waiting for a child for years before they even begin the surrogacy journey.

� Deciding when to come to MN was difficult. I did not want to miss the birth, but ended up waiting for two weeks.

� Being Europeans, the US insurance system was mind boggling.

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What are the joys of the surrogacy

process?

� We grew very close to our surrogate and she is now part of our family. She is coming to the UK to visit us next week.

� We are eternally grateful to our amazing surrogate for what she has done for our family. We still Skype once per week.

� The joys are our amazing twins!

� Receiving the most wonderful, beautiful gift a woman can give. My awe for Traci is immeasurable.

What was important to you as you prepared for your baby’s birth and the

hospital experience?

� It is important to discuss the birth plan with your surrogate beforehand.

� Expect the unexpected. Our twins arrived 3 weeks early.

� Come to the U.S. 4 weeks before the due date, we were so happy we could be at their birth.

� Intended parents should go to the 20 week scan if possible. It was amazing!

� Visiting in advance was a huge help. Everyone at the hospital made it super easy, although I was a newbie, you had surrogacy down to a science.

Did you have any issues getting your child registered as citizens of your country?

� The process is complicated but many parents are doing it.

� Typically court hearings are around the 1st birthday.

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What would you want HCP’s to know or

understand? Did you feel welcome?

� Yes, they treated us like any other parents.

� It was helpful to take a newborn class. I was comforted to know that I knew no less than anyone else the first time around.

� I felt very taken care of.

� The HIPPA process and Skyping into the clinic visits was very challenging. They wouldn’t speak with me, even though I was the mom. It was hurtful.

� There is nothing about our experience that I would change, except the weather!

� We never felt judged.

� We were treated with kindness and felt very welcomed.

� This place has been so welcoming!

Surrogate/Gestational Carrier Responses

Why do you do this?

To help families. It’s a gift. I love kids and want others to have the same joy that I have and wouldn’t be able to. I have easy pregnancies and enjoy being pregnant.

Imagine your life without your kids. I can’t give a ton of money, so I can do this. It’s life changing.

My partner did not want more children and I am young and do pregnancy well. I wanted to be able to give someone a baby.

I loved begin pregnant and had easy pregnancies. I love helping people. The look on the parents face when they hold the baby is amazing. They are so grateful.

We struggled for years with infertility and after 5 IVF cycles had our son. I knew that paying it forward was something I wanted to do. Infertility is such a long and lonely road and I couldn’t imagine not giving back after how blessed we have been. My main goal in life is to teach my children kindness. To always look for opportunities to help someone.

We struggled for 2 years to have a baby and we know how it feels to want something so precious. We truly wanted to give gack to a family who wanted the same end goal.

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How do you feel after the baby is born?

Is this a difficult time?I never felt like I was intruding and always felt invited in. The first family wasn’t here so

there were no issues. Hormonally you feel different. You have done your job. It’s never

been your baby. The parents had been more concerned with me until around 12 weeks, then their focus shifted to the baby.

People ask that question all the time. These were never my babies. I talked to the dads throughout the pregnancy and met them at the time of transfer and again at the 20 week ultrasound. We communicated weekly about their babies. It felt completely natural to hand them to their fathers.

I do not want more kids. Knowing that the babies were not mine the whole pregnancy helps and I like my sleep!

This is an easy question for me to answer. There was not one ounce of me that was sad about “letting him go”. He was never mine. I formed a relationship with his parents long before he was even created. My bond was with his parents and my desire was to help them. Nothing made me more happy than to see them hold him and be his parents. Nothing sad about it!

It has been a reward to be able to grow this perfect, beautiful person. Separating from the baby will not be hard because he isn’t mine. I hope to watch him grow!

It’s unknown. It feels like a foreign thing. It can feel like you are an incubator.

I had wonderful care.

The most helpful thing they can do is address the baby’s parents during appointments and during the birth. Treat the carrier as just that but include the

parents in any decisions regarding the baby. The most important thing would be for the providers to be very careful with labels and what they call us during appointments. I was referred to as “mom” or they would say “your baby” to me and that can be very hurtful to the intended mother.

The healthcare providers know we are a package deal. They address each of us comfortably and are extremely supportive.

What would you like HCPs to know?

What are the challenges of surrogacy?

Husband needs to be supportive. It is a lot of time away from family. Travel and responsibilities when gone. Very time consuming. All the pre-pregnancy stuff. I had

a miscarriage the first time around and that was awful to have to call the parents.

Loss of control. All the medications. You put life on hold. No travel during a certain time of the pregnancy. Dates of transfer determine life. Telling hard news.

Had to tell a family that they had a 10 week miscarriage. Negotiating with the family. What works for everyone. Culture. Life is very different.

Starting this journey was overwhelming. Multiple steps to complete. It took several cycles for my body to respond. There was a lot or re-arranging schedules, but I wanted to do this more than anything. I feel like in life there is always going to be a challenge but that defines you as a person,.

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What are the joys of surrogacy

Seeing their faces along the way. Little milestones. Seeing their happiness and getting updates on baby’s room.

Handing them their babies and watching them together.

Gaining a connection to wonderful families and knowing that they would not have

a child if not for you.

Being a gestational carrier is one of the best things I have ever done and I would do it many times again if I was able. The biggest joy for me was seeing his parent’s joy and seeing his big sister love on him. I love getting videos, pictures, and updates from them.

You not only help create a family, but you build an amazing relationship with some wonderful people. You become part of their family. I hope to forever be part of their lives and can’t wait to do it again!!

What would you tell other women

contemplating surrogacy?

I would just say that normal pregnancy changes are the biggest challenge. Also, my first transfer didn’t work so we had to do it again and that was disappointing.

One of he challenges I had was dealing with the different clinics and how they did

things differently. My first clinic was fast and efficient, my second clinic was slower and I had to do things twice. This cost the parents more money and I didn’t like that. Another challenge could be if we had to terminate.

It can be overwhelming to go through the IVF cycles, for someone who has never given themselves shots, and had tons of appointments. The most challenging part for me was the waiting. I was so ready and excited to get to the transfer day, but there are lots of steps before that. A lot of hurry up and wait.

Surrogacy Literature

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Children of Artificial Reproductive Technology

� No differences were found for maternal negativity, maternal positivity or child adjustment, although the surrogacy and egg donation families

showed less positive mother-child interaction than the natural conception

families. The findings also suggest that both surrogacy and egg donation families function well in the early school years.

Golombok, S., Readings, J., Blake, L., Casey, P., Marks, A., and Jadva, V. (2011)Families created through surrogacy: Mother-child relationships and children’s psychological adjustment at age 7. Developmental Psycholology, 47(6), 1579–1588. doi:10.1037/a0025292

Children of Artificial Reproductive Technology

� Although several studies show that parents in NRT families are more

emotionally involved in their parenting than are parents in naturally

conceived families no empirical evidence was found that the

psychological adjustment of children in NRT families differs from that of their

counterparts in natural-conception families.

Bos, H., van Balen, F.,(2010) Children of the new reproductive technologies: Social and genetic parenthood. Patient Education and

Counseling 81. 429-435. doi:10.1016/j-pec.2010.09.012

Parent Relationships with their Surrogate

� The specific country where couples conducted their surrogacy

arrangement (US, UK, or Thailand/India) was associated with how involved

they were in the pregnancy and their contact with the surrogate over time.

Parents who had surrogacy in the UK or US felt very involved in the

pregnancy compared to those who had surrogacy in Asia. They also

described positive relationships with their surrogate. Couples whose

surrogacy was completed in Asia were less likely to want contact with their

surrogate after the birth. Gay couples intended to tell their child about

surrogacy more than heterosexual couples.

Jadva, V., Gamble, N., Prosser, H., Imrie, S. (2019) Parents relationship with their surrogate in cross-border and domestic surrogacy arrangements: Comparisons by sexual orientation and location. Fertility and Sterility,

111(3), 562–570. https://doi.org/10.1016/j.fertnstert.2018.11.029Accessed July 19, 2019.

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Parent Relationships with their Surrogate

� Heterosexual and gay parents reported low levels of parenting stress and

generally experienced positive or neutral reactions to their parenthood in

contacts with healthcare providers, in preschool, and in recreational

activities. Almost all parents were open about the child’s mode of

conception. A majority of parents described being treated positively or as

any other parent.

Sydsjo, G., Skoog, S., Svanber, A., and Lampic, C. (2019) Cross-border

surrogacy: Experiences of heterosexual and gay parents in Sweden. Acta

Obstetricia et Gynecologica Scandinavica, 98(1). 68-76.

Experiences of Surrogate Mothers

� The importance of a genetic link differed significantly. There was lack of substantial

differences between quality of life between these two types of surrogates. In

general, the experience of surrogacy was important and very positive for most

surrogates, though some negative experiences were also reported.

van den Akker, O. (2003). Genetic and gestational surrogate mothers’ experience of surrogacy. Journal of Reproductive and Infant Psychology, 21(2),145 – 161.

Experiences of Surrogate Mothers

� Ten years following the birth of the surrogacy child, surrogate mothers

scored within the normal range for self-esteem and did not show signs of

depression. Marital quality remained positive. All surrogates reported that

their expectations of their relationship with the intended parents had been

met or exceeded and most reported positive feelings towards the child.

Jadva, V., Imrie, S., and Golombok, S. (2015.) Surrogate mothers 10 years on: a longitudinal study of psychological well-being and relationships with the parents and child. Human

Reproduction, 30(2), 373-379. soi:10.1093/humrep/deu339.

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Experiences of Surrogate Mothers

� Environment plays a role for traditional and gestational surrogacy.

Surrogate mothers of both groups are less anxious and depressed than

normative samples. Maternal–foetal attachment is strong with a slightly

lower quality of attachment. Surrogate mother’s empathy indexes are

similar to normative samples, sometimes higher.

Lorenceau, E., Mazzucca, L., Tisseron, S., Pizitz, T. (2015). A cross-cultural study on surrogate mother’s empathy and maternal–foetal attachment. Women and Birth 28, 154–159.

Experiences of Surrogate Mothers

� Surrogate mothers (traditional and gestational) generally report being quite satisfied with their experiences as surrogates. Pre- and post-birth experiences, relationship with the parents, and whether expectations about surrogacy are met are important influences on the surrogate mothers’ level of satisfaction.

� It is often implied that surrogacy could exploit poor, young, or ethnic women, yet the data do not support this. Most surrogate mothers are in their twenties or thirties, White, married, and have children of their own. Surrogacy agencies screening procedures are designed to circumvent this concern.

� Only one study out of 16 found that 25% of surrogates had significant emotional distress in giving up the child.

Ciccarelli, J. and Beckman L. (2005) Navigating rough waters: An overview of psychological aspects of surrogacy. Journal of Social Issues, 61(1) 21-43

Experiences of Surrogate Mothers

� Surrogacy pregnancy should be considered a high-risk emotional

experience because many surrogate mothers may face negative

experiences. Surrogates should receive professional counseling prior to,

during, and following pregnancy.

Tehran, H., et al. (2014) Emotional experiences in surrogate mothers: A qualitative study. Iran Journal of Reproductive Medicine. 12(7). 471-480.

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Surrogate’s Own Biological Children

� Scores revealed profiles that were within normal limits with all the children

falling into the low-risk category for developing emotional disorders,

behavioral disorders, or hyperactivity/ concentration problems. According

to the surrogates, the majority of children (61%) had a positive response to

their mother’s surrogate pregnancy with only 1 child being identified as

having had a negative

Riddle, M. (2017). An investigation into the psychological well-being of the biological children of surrogates. Cogent Psychology, 4: 1305035 h https://doi.org/10.1080/23311908.2017.1305035

Recommendations For Practice

� Practice Committee of the American Society for Reproductive Medicine and Practice Committee for the society of Assisted Reproductive

Technology. (2017) Recommendation for practices utilizing gestational carriers: a committee opinion. Fertility and Sterility, 107(7): e3-10. doi.org/10.1016/j.fertnstert.2016.11.007

� Family building through gestational surrogacy. Committee Opinion No. 660. American College of Obstetricians and Gynecologists. (2016). Obstetrics

and Gynecology 127:e97–103. Reaffirmed 2019. https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Ethics/Family-Building-Through-Gestational-Surrogacy?IsMobileSet=false. Accessed July 19, 2019.

Practice Recommendations:Responsibilities of the Obstetrician to potential Gestational Carriers

�OB history

� Risk of multiples

� Assess for potential stress and grief after the birth

� Honest assessment of general fitness of the surrogate if asked by agency

ACOG Committee Opinion

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Practice Recommendations:Responsibilities of the Obstetrician to pregnant Gestational Carriers

� Communicate clearly her right to autonomous decision making related to her health. The obstetrician should not look for input from the parents with medical decision making.

� Continuation of pregnancy with maternal health issues. Surrogate’s health takes priority of the fetus and desires of the parents.

� Clear understanding of how medical details will be communicated with the parents. (Example of surrogate’s illness that may impact baby)

� Clear understanding of legal and medical decision-making of newborn.

ACOG Committee Opinion 2019

Practice Recommendations:Responsibilities of the Obstetrician to Intended Parents

� Presentation of ethical, medical, and legal complexities

� Facilitation of appropriate attorneys and counselors.

ACOG Committee Opinion

Stories

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Philosophy of Care

What makes the difference between a good health care provider and a great provider?

Compassion

� Gandi

Compassion is a muscle that gets stronger with use.

� Tao

See others as yourself. See families as your family. See towns as your town. See countries as your country. See worlds as your world.

� Nelson Mandela

There can be no greater gift than that of giving one’s time and energy to help others without expecting anything in return.

There is a secret place, a radiant sanctuary.Constructed of the purest elements. Overflowing with

beautiful forests, rivers, and fountains bubbling beneatha canopy of stars……. This magnificent refuge is inside ofyou. Enter, shatter the darkness that shrouds the doorway.Believe the incredible truth that the Beloved has chosenfor his dwelling place the core of your own being, the single

most beautiful place in all of creation.

Teresa of Avila