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FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health - ethical guidelines


Committee Statement to be used when publishing Ethical Guidelines

Introduction

The FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health considers the ethical aspects of issues that impact the discipline of Obstetrics, Gynecology and Women’s Health. The following documents represent the result of that carefully researched and considered discussion. This material is intended to provide material for consideration and debate about these ethical aspects of our discipline for member organizations and their constituent membership.

Surrogacy

Background and recommendations

Background
  1. Surrogacy describes a reproductive model where a woman carries a pregnancy and delivers a child on behalf of a couple where the woman is unable to do so, because of a congenital or acquired uterine abnormality, or because of a serious medical contra indication to pregnancy


  2. In all cases, the intention is that the surrogate will relinquish the born child to the commissioning couple


  3. Some societies have strong reservations about the practice of surrogacy, and make it illegal. In other countries the process is supported by specific legislation, enabling the commissioning couple to become the legal parents


  4. In practice, surrogacy may involve a woman with no genetic link to the future child, where the embryo is conceived with the gametes of the commissioning parents by IVF(or full surrogacy), or a woman who also provides her oocytes (or partial surrogacy), or is related to one of the parents . Other possibilities include the addition of gametes donation in either case


  5. Surrogates undergo risks during pregnancy, similar to any other pregnant woman (miscarriage, ectopic pregnancy, common pregnancy complications), which may be increased by the risk of multiple pregnancy when IVF is used to create the embryo(s). Psychological reactions may complicate this further with depression with surrendering the child, grief, and even refusal to release the child.


  6. The commissioning parents are suffering from intractable infertility, and generally consider this is their last chance at achieving parenting with genetic link of one or both parents to the offspring


  7. There is only short follow up and psychological study of children born by surrogacy, and of the families involved, including the impact on natural child(ren) the surrogate may have. Potential harms for the offspring include the sequelae and complications of multiple pregnancy on surviving children as well as the issues of gametes donation (anonymity and openness) on the psychological well being of the child. Clarification of the legal standing of the surrogate mother also known as gestational mother, as well as the commissioning parents should be addressed carefully and prior to any gamete or embryo transfer. In particular, abandonment of the child by the commissioning parents and /or gestational carrier, in case of unexpected complications or birth defects, must be addressed before conception.


  8. In general, compensation for expenses directly related to the pregnancy, and loss of income due to the pregnancy, is accepted. Disproportionate payment given to surrogate women risks undue inducement of vulnerable women, and has the potential to lead to commercial exploitation, in particular recruitment of women of underprivileged background. There is also the issue of familial coercion: separate counseling of the surrogate mother and commissioning parents is essential.


  9. Contracts are often drawn between commissioning parents and the surrogate, engaging all parties responsibilities: the surrogate to behave responsibly during pregnancy in order to minimize the risks for the future child, with regard to usual nutritional advice and antenatal screening for instance; and the future parents to undertake their parental responsibility to that child whatever the circumstances and health, in case of congenital abnormality for instance.


  10. Ultimately, the surrogate who delivers the baby may have the right to keep the child in some jurisdictions even when parental rights are legally transferred to the commissioning parents. Furthermore, she also has legal rights during her pregnancy where her bodily integrity is paramount. Appropriate counseling of all parties is again essential to ensure all parties are aware of their responsibilities as well as their rights in this contract they undertake with also the welfare of the future child in the equation.


  11. Openness about the mode of conception in all methods of ART has become more common since their inception, with no evidence of detriment, and the advantage of avoiding the revelation of secrets in moments of stress or distress , and the added possible interest of the child to be aware of his/her genetic background. The added complexity of partial surrogacy compared to full surrogacy where the commissioning parents are also the genetic parents means that full surrogacy is the preferable option.


  12. It is generally accepted where surrogacy is legal, in order to avoid conflicts of interest that might create undue pressure or coercion, that different medical teams should look after the commissioning parents undergoing IVF, and the pregnant surrogate.

Recommendations
  1. Surrogacy is a method of ART reserved solely for medical indications. It is unacceptable for social reasons


  2. Because of the possibility of psychological attachment of the surrogate to her pregnancy on behalf of others, only full surrogacy is acceptable. Furthermore, all efforts must be undertaken to reduce the chance of multiple pregnancy with the ensuing risk to the surrogate and future babies


  3. The autonomy of the surrogate mother should be respected at all stages, including any decision about her pregnancy which may conflict with the commissioning couple’s interest


  4. Surrogate arrangement should not be commercial, and are best arranged by non profit making agencies. Special consideration must be given to trans-border reproductive agreements, where there is increased risk of undue inducement of resource poor women from resource rich countries citizens


  5. The commissioning couple and surrogate potential must have full and separate counseling independently prior to their agreement, and be encouraged to address the question of eventual disclosure to the child before entering into the intended procedure. Counseling must include the risks and benefits of the technique to be used, and of pregnancy, including prenatal diagnosis. Such counseling should be factual, respectful of the woman’s view, and non-coercive


  6. Where there is no national legislation, prospective parents and the surrogate should be encouraged to seek independent legal advice. They should be encouraged to enter into a consent agreement that outlines the critical issues involved and delineates the rights and responsibilities of all parties. The disposition of all unused embryo should be agreed upon.


  7. Surrogacy, if conducted by individual physicians should be approved by an ethical committee and should be practiced strictly under medical supervision.


  8. When the practice is performed it should take full regard of the laws of the country concerned and participants should be fully informed of the legal position.


  9. Research about coercion and harm to collateral Individuals such as existing children of the surrogate must be conducted to understand the harm or benefits of this reproductive model.

Lyon, June 2007