by Linda Hammer Burns


Infertility is an existential crisis of grand proportion and, as such, many individuals and couples go to great lengths to achieve parenthood pursuing medical treatments for years at great financial expense, emotional turmoil, even in the face of legal, religious, or cultural restrictions. The most complex form of assisted reproduction is Gestational Surrogacy [GS] in which the embryo (obtained from IVF) is implanted in the carrying woman’s uterus) while Traditional Surrogacy [TS] involves the surrogate not only carrying the pregnancy but donating her own oocytes to the pregnancy. Especially GS but also TS have become an increasingly popular means of achieving parenthood for both heterosexual and homosexual couples as well as single women and men. While originally in the 1980s GS was viewed as a medical godsend to young women who either were born without wombs or had lost their uterus to cancer or other conditions or for women who had medical conditions prohibiting pregnancy, overtime it has gained a broader more diverse and complex population of intended parents. One of the first reported cases of GS in 1992 a young Midwestern woman born with Rokitansky-Kuster-Hauser syndrome was married and 22 years old, when her 42 year old mother volunteered to carry her daughter’s pregnancy. She delivered healthy twins after an uneventful pregnancy. In was big news in the USA even prompting a TV movie ‘Labor of Love: The Arlette Schweitzer Story’. While Canadian author Margaret Atwood’s 1985 dystopian novel ‘The Handmaid’s Tale’ about the enslavement of fertile young women for reproductive purposes was considered science fiction, it now seems not so far from the reality of many Gestational Surrogates worldwide who view surrogacy as an economic means to better life and, as one (male) owner of a Chinese surrogacy agency told a heavily pregnant surrogate, ‘It’s better than prostitution, isn’t it?’ (

The world has changed a great deal over the past two decades and with it the changing faces of intended parents and gestational carriers. While all forms of surrogacy are specifically illegal in many countries, in most of the world there are a patchwork of areas in which surrogacy is legal in one form or another. Even in the United States, one of the top destinations for surrogacy, there is no national policy. The ‘legality’ of surrogacy is determined on a state by state basis with a lot of grey areas. It is between these grey areas within countries or states in the USA, the couples and individuals pursue surrogacy with varying degrees of successful outcomes. And the outcomes may not be simply a baby—there may be other factors influencing their choices.

One of the most common incentives is money. Where is the cheapest and/or most expeditious way to achieve parenthood via surrogacy? In Asia, commercial surrogacy has been legal in India and Thailand for years with both countries promoting it as a form of medical tourism. India offers high success rates at low prices because poor women are willing to be surrogates for a much lower rate than an American women. And because Indian women still experience more stigma in their own villages, they often spend their pregnancy living in dormitory style facilities where they are well cared for by medical staff offering reassurance to intended parents. So many Americans have traveled to India for surrogacy that the US government was forced to add additional staff to process passport paperwork for couples leaving India with their new baby or babies. However, in 2013 India introduced legislation (not yet passed) that would ban surrogacy to unmarried couples, single persons, and homosexuals. While this legislation lingers in debate commercial surrogacy continues at a price many find affordable $10,000 to $30,000.

In Thailand surrogates return to their villages during their pregnancy causing social turmoil. While the cost of surrogacy is about the same in Thailand as India, things may be changing due to two cases that have brought unwanted worldwide negative publicity to commercial surrogacy in Bangkok–much to the ire of the ruling military junta. During a police raid of a Bangkok clinic the case of a single Japanese man who hired at least a dozen surrogates who all gave birth around the same time to was discovered and is being investigated by Interpol. In the other case an Australian couple refused to take home one of their twins (a son, Gammy) with Down syndrome) causing consternation for the surrogate and Thailand authorities. In Australia the remarks made by the father, David John Farnell, during television interviews ‘I don’t think any parent wants a son with a disability’ caused alarmed and even more worrisome was the discovery that he had been convicted and imprisoned for 22 counts of child sexual abuse in the 1990s leading authorizes there to question his fitness for parenthood on any terms.

Many more couples (especially homosexual couples) go to the USA for surrogacy. They are not motivated by money, many will admit it has cost well over $100,000 but they achieved the family they wanted and consider it money well spent. The higher cost in the USA is based on two things: higher compensation to the surrogate ($30, 0000 versus $10,000 in Asia) and the additional legal fees. In some states the surrogate mother has to relinquish parental rights to the child while in others the intended parents name is put directly on the birth certificate. But the coordinating of these complex logistics has a price and this all contributes to the higher cost in the USA. Yet there is also more transparency in terms of available information on a fertility clinic’s IVF success rates, costs, and bribery is not only illegal, it’s not the social norm it is in other countries. But another motivation for going to the USA, particularly Chinese couples, is that the child’s birthplace is on American soil which makes the child an automatic US citizen. As such, parents may view this as a future opportunity for their child to attend university in the USA or for the family to immigrate at some point. However, this seems to be a goal of wealthy Chinese intended parents versus more middle class couples who pursue ‘underground’ surrogacy within China to thwart childlessness or bypass China’s one child policy that imposes fines and penalties for delivering more than one child in a marriage. Like India, China’s surrogates are typically impoverished women who leave their homes and families to avoid the stigma and shame of being a surrogate but are motivated by the payment which can be more than the woman would make in 18 years.

Commercial surrogacy flourishes despite professional guidelines and a wide array of legal regulation across countries and even within countries. One approach, taken by the United Kingdom, has been to allow only altruistic surrogacy but this has not been without problems either as described in a recent BBC 4 Radio Review: The Report-Surrogacy describes surrogacy arrangements as ‘all about trust’ but it is noteworthy that such arrangements are not legally enforceable in the UK so that both surrogates and intended parents are unprotected if things go awry. As such, the UK system, albeit perhaps a bit more ethically high-minded, is not without its pitfalls. And while there are legal provisions for advisory services available to provide support and education, the lack of legal protection is so discomfiting that many opt to use commercial surrogacy services elsewhere.

Sadly, the number of surrogacy agencies is flourishing worldwide, but with few regulations and/or oversight. This means there is plenty of room for corruption and exploitation of all parties. As one patient said, ‘They pop up on a Google search one day and are gone the next but then you find the same people under another name six months later.’ A simple Google search produce thousands of articles, agencies, advertisements, and contacts. Wikipedia has a site ‘Surrogacy Laws’ that lists 28 countries (and five states in the USA) as well as various lawsuits surrounding surrogacy. This is enough to overwhelm any consumer but is particularly troublesome for the vulnerable and desperate individual or couple who long for a child, typically after years of disappointment. One recent example is Rudy Rupak who ran Planet Hospital based in California and operating in India, Thailand, and Mexico offering an array of reproductive services especially surrogacy. He owned over 150 domain names on the Internet for his various surrogacy businesses targeting Christians or same-sex couples.   Mr. Rupak age 45 (also known as Rupak Acharya) had no medical training: he was a software developer of video games before founding Planet Hospital in 2002. He wasn’t interested in helping couples to have families. His motivation was money: Taking the money of intended parents while giving them little in return. Mr. Rupak is now bankrupt and under investigation by the FBI.

What then, is the role of the infertility counselor in all this? How does he/she help surrogates and their families as well as potential parents? Unfortunately, there is not nearly enough research to outline an ‘evidence based’ approach to the care of these special reproductive patients. But some things are clear:

  • In order to offer appropriate counseling either to surrogates and/or intended parents, the infertility must be informed. This means not only educating oneself about the laws, regulations, and standards of practice in the field but continuing updating their knowledge base because this is an ever-changing field.
  • All potential participants should consider not only how this arrangement will impact their lives today but how it will impact their lives in the future including their relationships with partners, their children and extended family.
  • Secrecy is not the answer. It may been the ‘standard of practice’ in the 20th century but it is not in the 21st century nor can anyone expect that it can or should be. Even with today’s technology few people can hope to keep much about themselves secret even in developing countries. ‘Privacy’ has a very different meaning today than it did even 30 years ago, what will it look like in another 30 or 50 years?
  • The most difficult challenge for the infertility counselor is getting both surrogates and intended parents to consider the ‘existential’ issues of this arrangement. Few potential parents willing desire to address the narcissistic and existential crises triggered by involuntary childlessness. Nor do can they easily look past the near future of having a child into the long-term future of that child’s life and circumstances. This is often the case of surrogates as well—particularly if they are economically vulnerable. The immediate gain too often outweighs consideration of long-term costs.
  • Infertility counselors should be prepared to find one or both parties back on their doorstep in the future even if their role has only been to assess, advice, or consult. Faced with life’s dilemmas the surrogate or parent may return for guidance because there is no one else who knows or understands the unique dynamics of this arrangement.


China Experiences a Booming Underground Market in Surrogate Motherhood By Ian Johnson and Cao Li. AUG. 2, 2014. New York Times.

Thailand’s Business in Paid Surrogates May Be Foundering in a Moral Quagmire. By Thomas Fuller. AUG. 16, 2014. New York Times.

Coming to U.S. for Baby, and Womb to Carry It: Foreign Couples Heading to America for Surrogate Pregnancies. By Tamar Lewin. July 5, 2014. New York Times.

Shadowy World for Chinese Surrogates. By Jonah M. Kessell. New York Times Video.

A Surrogacy Agency That Delivered Heartache.By Tamar Lewin. July, 27, 2014. New York Times.