Surrogacy
One of the significant causes of infertility is the inability of the mother (the wife) to carry and nurture a fetus in the womb. Uterine replacement becomes necessary when a couple possesses all the factors involved in the formation of the embryo but is deprived of the possibility of having children due to the absence of a uterus or a healthy uterus. In Vitro Fertilization (IVF/ICSI) technology has made it possible for the couple's embryo, resulting from the fertilization of the mother's egg and the father's sperm, to be transferred to the uterus of a third party at the appropriate time in the embryology laboratory.
The surrogacy treatment method is a complex procedure from medical, legal, and psychosocial perspectives, requiring precise and specialized medical examinations, health assessments, and psychological evaluations of the genetic parents and the surrogate woman, as well as legal follow-ups to achieve maximum success.
A surrogate mother is a woman who undergoes the stages of fertility and carries the embryo of another couple in her uterus (i.e., the pregnancy stages) until, after completion of the pregnancy and childbirth, she delivers the baby to the gamete-owning couple (the genetic parents).
What follows is a specialized guideline and a set of recommendations established as the minimum essential indicators for the selection, evaluation, acceptance, or rejection of couples seeking surrogacy treatment and the surrogate woman. This collection incorporates the recommendations of specialists in the fields of obstetrics and gynecology, embryology, andrology and urology, social medicine, internal medicine, infectious diseases, endocrinology, genetics, psychiatry, psychology, and law. In its preparation, in addition to the knowledge and experience of specialists at the Hazrat-e Maryam Infertility Center and the valuable achievements of infertility treatments obtained in recent years, the latest guidelines from countries such as the USA, Australia, the Netherlands, and Canada, as well as the World Health Organization (WHO), have been used.
It is evident that in situations where, in addition to surrogacy treatment, the need for receiving donated eggs for the couple seeking treatment is established by the relevant specialists, the guideline for health assessment in egg donation must also be implemented. In this regard, considering the country's legal and social regime, it seems that selecting one individual for simultaneous surrogacy and egg donation to a single recipient should be avoided.
Given the aforementioned points and the potential for misuse of surrogacy treatment, attention to the therapeutic necessities of using this method and adherence to the present guideline are required.
1. Evaluation of Couples Seeking Surrogacy Treatment
1-1 Reasons Necessitating Surrogacy Treatment
Treatment via surrogacy may be considered if one of the following reasons exists:
Absence of the uterus, either congenital (e.g., Rokitansky syndrome) or acquired (e.g., hysterectomy due to various reasons such as uterine malignancies).
Presence of a uterus with abnormal structure, congenital or acquired (e.g., very large and numerous fibroids in the uterus and Asherman's syndrome).
Cases of recurrent miscarriage with unknown cause.
Cases of repeated failure in ART treatment despite the availability of suitable embryos and adequate endometrial growth.
Underlying maternal diseases where pregnancy would endanger her life or exacerbate the disease; such as advanced heart failure, kidney failure, certain malignancies, autoimmune diseases like lupus erythematosus, and diabetes with severe organic complications.
1-2 Preliminary Counseling and Evaluation of Couples Seeking Surrogacy
Couples seeking surrogacy must be evaluated in various aspects before using this method and should be guided regarding the treatment stages and conditions, laws, and legal, social, and psychological dimensions. The duration and frequency of this counseling, preferably provided by a specialist in social medicine, will vary according to the couple's needs. During this counseling, an initial acquaintance with the couple takes place, and while providing necessary information, the couple is prepared for treatment. For this purpose, the following should be considered in the preliminary counseling and evaluation:
The couple's cultural and economic status.
The nature of the couple's relationship with each other and examination of factors such as uncertainty about the stability of the family foundation, history of consanguineous marriage, and divorce.
Having children or adopted children.
Significant criminal history.
Additionally, in this session, the applicants will be informed about:
The different stages and aspects of the health assessment and its necessity.
The approximate time required for treatment.
The stages of ovulation induction and IVF procedure and its potential short-term and long-term complications.
The possibility of treatment discontinuation at any stage based on the medical team's discretion.
The limitations of infectious and genetic evaluations and the need to inform the couple about the possibility of genetic, congenital, infectious, internal, and acquired abnormalities in the resulting baby, within the limits of the general population.
Conditions that the surrogate woman must meet.
How the surrogate woman is introduced.
The stages and criteria for evaluating the surrogate woman and their necessity.
The amount and method of payment for the health screening costs for both parties.
The amount and method of payment for treatment costs and the financial commitments of the intending couple.
The treatment success rate.
The possibility of multiple pregnancies and fetal abnormalities.
Drafting, concluding, and registering the necessary contracts between the genetic parents and the surrogate woman (and her spouse, if married) under the supervision of the infertility treatment center.
How to obtain birth certificates and identification documents.
Emphasis on the personal nature of Sharia and jurisprudential issues related to surrogacy and emphasis on the non-responsibility of infertility treatment centers in this regard.
1-3 Legal Counseling, Explanation of Contract Terms, and Informed Consent
Legal principles, obligations, and responsibilities of the couple seeking surrogacy treatment, the effects and outcomes of the treatment, and the contents of the informed consent must be fully explained by expert jurists in counseling sessions, and the couple's legal questions must be answered.
The terms of the contract between the genetic parents and the surrogate woman must be precisely presented and considered. Drafting, signing this contract, and completing the consent forms must occur in a session with all contracting parties present (the genetic parents, the surrogate woman, and her spouse).
Some topics that need to be addressed in the contract include: agreed-upon costs, the surrogate's readiness for embryo transfer and pregnancy, her complete care of the said fetus during pregnancy and childbirth, multiple pregnancies, the potential need for fetal reduction, possible fetal defects, therapeutic abortion, spontaneous abortion, the necessity of fetal evaluation during pregnancy, rest, nutrition, etc. (The mentioned items are based on the contract terms and the mutual agreement of the parties).
1-4 Evaluation of the Reproductive Health of the Couple Seeking Surrogacy
1-4-1 Gynecological Evaluation:
The wife must be examined by a gynecologist. A complete medical history, clinical examinations, especially specific and complete examinations of the genitalia and pelvic region, should be performed, and structural and physiological reproductive abnormalities should be diagnosed and recorded.
Hormonal evaluation on the second or third day of menstruation and ultrasound of the uterus and ovaries are necessary to assess ovulation, determine the need for donated eggs, and establish the necessity of surrogacy treatment. Hysterosalpingography, laparoscopy, hysteroscopy, and other appropriate diagnostic procedures should be performed if necessary.
1-4-2 Andrological and Urological Evaluation:
The husband must be examined by an andrologist or urologist. A complete medical history and clinical examinations, especially a specific and complete examination of the genitalia, must be performed and recorded. Semen analysis and spermiogram must be conducted in the andrology laboratory of the same treatment center, and the male hormonal evaluation should include tests for PRL, FSH, LH, and Testosterone.
1-5 General Health Evaluation of the Couple Seeking Surrogacy
Couples seeking surrogacy must be evaluated in various aspects before starting treatment, and necessary diagnostic measures and consultations to confirm their health should be performed.
1-5-1 General and Paraclinical Counseling and Evaluation:
Taking a complete personal and family medical history, social, sexual, and reproductive history, and performing physical examinations are necessary for all couples. Laboratory evaluations conducted to assess health should be comprehensive, cost-effective, and appropriate.
1-5-2 Internal Medicine Counseling and Evaluation:
In addition to the general evaluations, clinical examinations such as heart and lung auscultation and blood pressure assessment in the couple, especially the woman, are particularly important. If approved by a cardiology consultant, therapeutic procedures for the couple will commence.
1-5-3 Hematology Counseling and Evaluation:
The surrogate woman is examined by a hematology specialist to be thoroughly evaluated hematologically. The process continues upon approval from the relevant physician.
1-5-4 Mental Health Counseling and Evaluation:
The health, psychological balance, and ability of the couple to adapt to the upcoming conditions require precise evaluation. In the psychiatric counseling session, various aspects of this treatment method, including the couple's attitude towards it, short-term and long-term issues the couple may face during treatment, the possibility of multiple births, the importance of finding a suitable woman for embryo transfer, and considering the conditions and problems of the surrogate, must be communicated to the couple.
1-5-5 Genetic Counseling and Evaluation:
In the family history and background of the couple seeking surrogacy, attention to hereditary diseases and genetic abnormalities is important. In cases where there is a history of genetic problems in the couple's family history, the decision regarding the possibility of continuing treatment and the best possible treatment will be made based on the genetic specialist's opinion.
2. Evaluations of the Surrogate Woman
2-1 Preliminary Counseling and Evaluation of the Surrogate Woman
The purpose of counseling with the surrogate woman is to inform and make her aware of the treatment process and its short-term and long-term challenges. During counseling, it is necessary to explain the ethical, medical, legal, psychological, and social issues, as well as the potential risks and complications of this method for the surrogate woman and, if married, for her spouse.
Mentioning the following in the preliminary counseling and evaluation of the surrogate woman is essential:
The different stages and aspects of the surrogate's health assessment and its necessity.
The treatment process and potential problems during treatment, pregnancy, and childbirth.
The stages of medication for synchronizing the cycles of the intending wife and the surrogate, preparing the surrogate's uterus for embryo transfer, and its potential short-term and long-term complications.
The approximate time required for health assessment and treatment.
Unconditional presence at the treatment center upon notification by the medical team or the occurrence of any problem or complication.
Unconditional acceptance and implementation of the recommendations and instructions of the treatment center.
The possibility of treatment discontinuation at any stage, based on the discretion of the treatment center.
The amount and method of payment to the surrogate woman.
The treatment success rate.
The possibility of multiple pregnancies and fetal abnormalities.
The limitations of infectious and genetic evaluations and the need to inform the surrogate woman and her spouse about the possibility of genetic, congenital, infectious, internal, and acquired abnormalities in the resulting baby, within the limits of the general population.
Emphasis on the necessity of honesty in statements and explanation of the negative consequences of non-compliance on the physical and mental health of the resulting children of the involved couple.
The potential reaction of family members and friends towards the surrogate woman's acceptance of this treatment method.
Drafting and concluding the necessary contracts between the genetic parents and the surrogate woman (and her spouse, if married) under the supervision of the infertility treatment center and their registration at this center.
Emphasis on the personal nature of Sharia and jurisprudential issues related to surrogacy and the non-responsibility of infertility treatment centers in this regard.
2-2 Legal Counseling, Contract Explanation, and Informed Consent:
Conducted in accordance with Section 1-3.
2-3 Evaluation of the Reproductive Health of the Surrogate Woman
2-3-1 Gynecological Evaluation:
A complete medical history and clinical examination, especially a complete genital examination, are necessary for the surrogate woman. A history of having at least one child, age under 35, and being married are preferred in selecting a surrogate. The surrogate woman cannot be over 40 years old, and at least two years must have passed since her last pregnancy ended.
History of infertility treatments, recurrent miscarriage, menstrual regularity, problems during previous pregnancies and childbirths such as bleeding, preeclampsia, eclampsia, diabetes, and preterm delivery, medication use, and illnesses should be inquired about. Uterine health should be assessed with a baseline ultrasound or hysterosalpingography.
2-4 General Health Evaluation of the Surrogate Woman
Normal physical and mental health, absence of addiction to narcotics and psychotropic substances, absence of incurable diseases, absence of factors causing high-risk pregnancy, and the physical readiness of the surrogate woman must be examined and verified by the medical team. Taking a complete personal and family medical history, social, sexual, and reproductive history, performing physical examinations, and routine tests are essential for the surrogate woman. Generally, the surrogate woman must be considered normally healthy and have no history of addiction to narcotics, psychotropic substances, alcohol, or diseases that could pose a risk to herself and the fetus during pregnancy and childbirth.
2-4-1 Paraclinical Counseling:
Laboratory evaluations should also be performed to prove the general health of the surrogate woman. The tests requested for this purpose, while assessing various systems such as cardiovascular, renal and urinary tract, and liver, should be cost-effective and appropriate.
2-4-2 Internal Medicine Counseling and Evaluation:
In addition to the general evaluations, clinical examinations such as heart and lung auscultation and blood pressure assessment in the surrogate woman are particularly important. If approved by a cardiology consultant, therapeutic procedures for the surrogate woman will commence. The examination for internal diseases in the surrogate woman is important not only for assessing her health but also for identifying those diseases that are risky for the health of the pregnant woman and the fetus during pregnancy and childbirth, such as diabetes, lupus, high blood pressure, and epilepsy.
2-4-3 Hematology Counseling and Evaluation:
The surrogate woman is examined by a hematology specialist to be thoroughly evaluated hematologically, and the process continues upon approval from the relevant physician.
2-4-4 Mental Health Counseling and Evaluation:
Evaluating the mental health of the surrogate woman is of particular importance. Assessment of the individual's personality, their motivation for participating in the treatment process, ensuring their awareness of the treatment process and potential problems, common life stresses and coping mechanisms, history of mental disorders, history of dependence or abuse of narcotics, stimulants, psychotropic substances, alcoholic beverages, or any drug without medical purposes are among the items that must be considered in the mental health assessment.
The presence of any of the following in the surrogate woman (or her spouse) may lead to her rejection as a surrogacy candidate:
Instability in marital life.
Instability in decision-making.
Lack of consent from her spouse for the treatment.
Lack of awareness of the surrogate woman's child/children, if they have sufficient understanding of the subject.
Dependence or abuse of narcotics, stimulants, psychotropic substances, or alcoholic beverages.
Any personality disorder.
Intellectual disability.
Significant criminal history.
History of attempted suicide, self-harm, or homicide.
Suffering from a significant psychiatric illness.
Risky sexual behavior.
Multiple sexual partners.