louise johnson - victorian assisted reproductive treatment authority - issues associated with...
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Louise Johnson delivered this presentation at the 2014 Medical Tourism Summit. The Summit examines the implications of recent changes within the medical tourism industry and the impact on the Australian market. Find out more at http://bit.ly/1zgqUTXTRANSCRIPT
Physical and psychosocial risks
associated with surrogacy arrangements
in non-regulated settings Medical Tourism Summit
Louise Johnson, VARTA
Eric Blyth, University of Huddersfield
Karin Hammarberg, VARTA, Jean Hailes Research Unit.
Infertility is a public health issue – WHO
9% of couples at any given time experience infertility
Range of medical conditions – can’t conceive/ undertake pregnancy
↑ acceptance of diverse family formation including
single women and gay couples
Why surrogacy?
Accreditation of Australian clinics- quality assurance
Legislation in all states except NT
Counselling, legal advice for parties
Donors counselled - identifiable to children born
Single embryo transfer - the norm
Surrogate can make decisions about her pregnancy and birth
Processes for transfer of legal parentage from surrogate to commissioning parents
Cannot advertise for surrogate
Australian protective measures
Legal restrictions
Limited availability of treatment / donor eggs/sperm/embryos/surrogates in home country
Economic reasons
Search for quality services /ease of arrangements
Desire for privacy / cultural comfort in destination country
Drivers for overseas surrogacy
2013 Surrogacy Australia survey: 259 Australians considering or using surrogacy (1/2 heterosexual couples)
44% did not consider altruistic surrogacy
Reasons:
• Perceived risk of the surrogate keeping the child (75%)
• Too long & complicated process (68%)
• No one of the right age or life stage to ask (61%)
• Concern that carrying a child for no reward was an unfair exchange (46%)
Around half of the heterosexuals respondents had:
• Spent an average of more than 10 years trying to conceive naturally or through ART.
Everingham et al 2014
Australians travel for surrogacy
Only 19 babies born through surrogacy arrangements in Australia in 2012
Audit of 12 popular overseas surrogacy agencies by Surrogacy Australia:
• ↑ infants born to Australians via surrogacy
- 97 in 2009 → 269 in 2011
Practical & legal barriers in Australia ↑ traffic to India,
US & Thailand
Everingham at al 2014
New frontiers: Mexico & Nepal Media reports
Australians travel for surrogacy
Gestational surrogacy most common – IVF embryo used
Concerns internationally:
Exploitation of socio-economically disadvantaged surrogates and donors
Exploitation of commissioning parents with potential inability
- to secure legal parentage for child
- to obtain citizenship for child
- to return home with their child
Welfare of children born / existing children in commissioning parents or surrogates family
Concerns - overseas surrogacy
International Federation of Fertility Societies Surveillance 2010 report
No surrogacy-related regulation in most countries
Australians travel to countries where surrogacy is unregulated
IFFS
Surrogate and her family
Commissioning parents
Resultant and affected children
Donors providing eggs/sperm/embryos
Rights, health and well-being
Literacy variable : ~ ½ illiterate in some places – staff explain contracts
Meet with commissioning parents - when signing contracts
Some contracts not signed until 2nd trimester of pregnancy
Some may not have a copy of the contract
Motivated by:
• poverty/ unemployment
• desire to educate their own children
• desire to help a childless couple
Earnings used:
• to educate their children
• build a new house, set up business
Centre for Social Research 2012, Pande 2009; Stockey-Bridge 2012; Rudrappa 2012.
Research: Indian surrogates
Informed Consent? – level of literacy, lack of counselling
Lack of autonomy to make decisions when it impacts on their own health
• selective reduction, caesarian births – risks for future pregnancies, births?
• complications with multiple embryo implantation – up to 4 embryos in India
• lack of psychosocial support before, during and after pregnancy
• lack of follow up medical and social care
Paucity of research on short & long-term outcomes for surrogates
Surrogate - concerns
Australian commissioning parents express concerns about
Exploitation of surrogates and their well-being
Use of anonymous sperm or egg donors
Their preference for identity-release donors – in the best interests of their child
Attempts to avoid the risk of prosecution after entering into commercial arrangement by
• not seeking legal parentage
• moving interstate
Everingham et al 2014, Stockey-Bridge 2011, Stafford-Bell 2014
Research: Commissioning parents
Unregulated arrangements here or overseas :
• risk being ill-prepared
• no counselling, legal advice, or avenues for legal parentage
• risk of not being able to bring babies home
Risks of prosecution (NSW, QLD, ACT) by entering into commercial arrangement
High financial and psychosocial costs – agency exploitation of desperate desire to have children?
Impact on families short and long-term?
Commissioning parents - concerns
Respondents in Surrogacy Australia survey
• > ½ reported multiple pregnancy for surrogate
• Almost ½ respondents reported premature births
• Likelihood of anonymous donors Everingham et al 2014, Stafford-Bell 2014
4 UK research papers – in the short term the psychosocial outcomes for children appear benign
Cannot generalise these findings – none involved overseas arrangements
Jadva 2012
Research: Children
High risk of multiple pregnancies - selective reduction can jeopardise remaining foetus(es)
High proportion of premature births – • likelihood of low birth weight babies • ↑ risk of short-term and long-term adverse health
outcomes for child
No access to identifying information about the surrogate or donor • identity issues • health information about donor?
Health / lifestyle of donor & surrogate? • health of child into adulthood?
Impact on children of surrogate? – loss of contact for 9 months
Children - concerns
Informed consent - all parties
Access - adequate medical care
Access - psychological care - all parties
Adequate documentation
Avoidance - conflicts of interest
Involvement - ethics committees
Altruistic donation & surrogacy
Accessibility - donor & surrogate identity for offspring
National self-sufficiency – minimise inducements so people are less likely to go elsewhere
Blyth, Thorn & Wichman (2011)
Ethically grounded and evidence-based:
one approach
Best interests of the child - paramount
Restrictive laws do not stop people from using overseas surrogacy
Potential adverse long-term health outcomes for children, families of both commissioning parents and surrogates, surrogates and donors
Pragmatic approaches to minimise inducements to travel overseas?
• reconsider advertising? (as for sperm and egg donors)
• transfer of parentage arrangements review?
• empower Australian courts to make decisions based on the best interests of the child (as in UK)
• review level of compensation in an altruistic arrangement - varies - UK more generous.
International treaty desirable / feasible? (Permanent Bureau of the Hague)
Research /evidence to inform policy, guidelines and clinical practice.
Some conclusions
References
VARTA: www.varta.org.au
Johnson L, Blyth E & Hammarberg K, Barriers for domestic surrogacy and challenges of transnational surrogacy in the context of Australians undertaking surrogacy in India, (2014) JLM 22 136.
Boivin et al. International Estimates of Infertility Prevalence and Treatment-seeking: Potential Need and Demand for Infertility Medical Care (2007) 22 Hum Reprod 1506
Macaldowie et al 2013. Assisted Reproductive technology in Australia and New Zealand 2011 (National Perinatal Epidemiological and Statistics Unit, University of New South Wales.
Family Law Council, Report on Parentage and theFamily Law Act (Family Law Council, Dec 2013)
Shenfield F “We need a Code of Practice for Cross-Border Reproductive Care’’, BioNews (18 Oct 2010)
Everingham S, Stafford–Bell M, Hammarberg K, Australian’s use of surrogacy (2014) MJA 201 (5).
Stafford–Bell M, Everingham S, Hammarberg K, Outcomes of surrogacy undertaken by Australians overseas (2014) MJA 201 (6).
Blyth E, Thorn P and Wichman C, CBRC and Psychosocial Counselling: Assessing Needs and Developing an Ethical Framework for Practice (2011) 23 Reprod Biomed Online 642.