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According to ART Bill 2014, Surrogacy is an arrangement in which a woman agrees to a pregnancy, achieved through assisted reproductive technology, in which neither of the gametes belongs to her or her husband; and it is done with the intention to carry and handover the resulting child to the commissioning couple, for whom she is acting as a surrogate.

It is to be noted that ESHRE does not state sexuality of the intended parents.

Types of surrogacy

1. Traditional surrogacy (Gestational or partial surrogacy) Artificial Insemination of the surrogate mother is done with intended father’s sperms, so she becomes a genetic parent.
2. Gestational surrogacy ( IVF/host/ full surrogacy) is one where the embryo from the intended parents or donated oocyte or sperm is transferred to the surrogate uterus.

Surrogacy is known as altruistic when the surrogate is a friend or relative and does not receive any monetary benefit apart from the medical costs of pregnancy and childbirth, which is borne by the commissioning couple. Contrast to this is commercial surrogacy where the surrogate can be a stranger and she is compensated monetarily, as well as the medical bills are paid for.

Indications for surrogacy

1. Congenital absence of a functioning uterus like the MRKH syndrome
2. Post hysterectomy
3. Structural abnormalities of the uterus or multiple fibroids
4. Severe adenomyosis
5. Persistently thin endometrium because of endometrial tuberculosis
6. Asherman’s syndrome
7. Repeated miscarriages and unexplained IVF failures despite good quality embryo
8. Repeated IVF failures due to non-receptive endometrium.
9. Life threatening medical conditions of mother which precludes pregnancy including cardiac and renal diseases.
10. Biological inability to conceive or bear child .Also applies to same sex couple or single men.

Steps involved in the surrogacy process.

1. Patient selection
2. Sourcing the surrogate from ART bank
3. Selection and screening of prospective surrogate
4. Counselling
5. Legal requirements, financial contracts and transparency of arrangements must be ensured.
6. Controlled ovarian stimulation and IVF of the prospective parents.
7. Preparing the surrogate
8. Synchronising cycle of genetic mother and surrogate
9. Window period for embryo transfer
10. Obstetric care of the surrogate

Risks associated with surrogacy.

One of the major risks is that of multiple pregnancy with its attended complications. In order to circumvent this risk, single embryo transfer (sET) has been recommended by ASRM and Association of Reproductive Managers. Other complications of pregnancy like pre-eclampsia, eclampsia, gestational diabetes, amniotic fluid embolism, PPH etc. can also occur, as in general population.

Emotional challenge - Surrogacy may cause emotional trauma to the surrogate mothers at the time of having to relinquish the newborn. But studies have revealed that after the initial emotional trauma, these feelings appear to lessen during the weeks following birth.

Various aspects and concerns involved in surrogacy.

1. Ethical aspects

Concerns of exploitation and commodification of surrogacy have often been expressed because women are paid to get pregnant and deliver. It is quite probable that the rich take advantage of the underprivileged.

2. Religious aspects and issues

Various religions take different stands. Catholic Christians and Islam consider surrogacy as gravely immoral. However, traditional surrogacy was the basis of this stand but with the current concept of Gestational surrogacy and IVF might have changed their stance. The Jews now accept full gestational surrogacy.

3. Psychological impact of surrogacy

Surrogacy weaves up strange associations, which may be emotionally taxing. Unlike in a donor egg programme, where relationships remain impersonal and anonymous, the commissioning couple in surrogacy, may often know about the surrogate. However, studies have shown that children of third-party reproduction do well psychologically and developmentally and are not adversely affected.

4. Identity and rights of the child

The child born to a surrogate is legitimate to the commissioning couple and retains the legal rights of parental support, inheritance, and all others that a child born to the couple through normal intercourse is entitled to.

After 18 years, the child can ask for information about the surrogate. The child born of donor gametes has no rights to know the identity of the genetic parents. The identity of donor or surrogate can be released only in cases of life-threatening medical conditions that require physical testing or samples of donors or parents or surrogate.

Legislation the international scenario

Surrogacy is not allowed in Austria, Bulgaria, Denmark, Finland, France, Germany, Italy, Malta, Norway, Portugal, Spain, Sweden, Japan, and Saudi Arabia. Altruistic surrogacy is allowed in Belgium, Greece, Netherlands, UK, Australia, Canada, New Zealand and in many states of USA. Poland and Czech Republic currently have no laws regulating surrogacy. Commercial surrogacy is legal in Georgia, Israel, Ukraine, Russia, and California.

In China, the Ministry of Health banned surrogacy in 2001. Stricter legislation has been suggested to curb the illegal surrogacy ‘black market.’ To check the nefarious activities, the Bulgarian government decided to sanction it. Instead of using the term surrogate, Bulgaria calls them ‘substitute mother.’

Surrogacy in India

Commercial surrogacy has been legalised since 2002. Till the 2015 ART bill, surrogacy was allowed for foreigners, persons of Indian origin (PIO) and overseas citizen of India(OCI). However, after many regulations by the regulatory authorities of India the surrogacy practice has ground to a halt.

For more details, look up the blog "Surrogacy in India - Procedural aspects"