surrogacy surrogacy surrogacy is an arrangement, often supported by a legal agreement, whereby a woman agrees to delivery/labour on behalf of another couple or person, who will become the child's parent(s) after birth. people may seek a surrogacy arrangement when a couple do not wish to carry a pregnancy themselves, when pregnancy is medically impossible, when pregnancy risks are dangerous for the intended mother, or when a single man or a male couple wish to have a child. intended parents attend the birth of their child by a gestational surrogate. in surrogacy arrangements, monetary compensation may or may not be involved. receiving money for the arrangement is known as commercial surrogacy. the legality and cost of surrogacy varies widely between jurisdictions, sometimes resulting in problematic international or interstate surrogacy arrangements. couples seeking a surrogacy arrangement in a country where it is banned sometimes travel to a jurisdiction that permits it. in some countries, surrogacy is legal only if money is not exchanged. where commercial surrogacy is legal, couples may use the help of third-party agencies to assist in the process of surrogacy by finding a surrogate and arranging a surrogacy contract with her. these agencies often screen surrogates' psychological and other medical tests to ensure the best chance of healthy gestation and delivery. they also usually facilitate all legal matters concerning the intended parents and the surrogate. methods surrogacy may be either traditional or gestational, which are differentiated by the genetic origin of the egg. gestational surrogacy tends to be more common than traditional surrogacy and is considered less legally complex. traditional surrogacy a traditional surrogacy (also known as partial, natural, or straight surrogacy) is one where the surrogate's egg is fertilised by the intended father's or a donor's sperm. insemination of the surrogate can be either through sex (natural insemination) or artificial insemination. using the sperm of a donor results in a child who is not genetically related to the intended parent(s). if the intended father's sperm is used in the insemination, the resulting child is genetically related to both the intended father and the surrogate. in some cases, insemination may be performed privately by the parties without the intervention of a doctor or physician. in some jurisdictions, the intended parents using donor sperm need to go through an adoption process to have legal parental rights of the resulting child. many fertility centres that provide for surrogacy assist the parties through the legal process. gestational surrogacy gestational surrogacy (also known as host or full surrogacy) was first achieved in april 1986. it takes place when an embryo created by in vitro fertilization (ivf) technology is implanted in a surrogate, sometimes called a gestational carrier. gestational surrogacy has several forms, and in each form, the resulting child is genetically unrelated to the surrogate: the embryo is created using the intended father's sperm and the intended mother's eggs; the embryo is created using the intended father's sperm and a donor egg; the embryo is created using the intended mother's egg and donor sperm; a donor embryo is transferred to a surrogate. such an embryo may be available when others undergoing ivf have embryos left over, which they donate to others. the resulting child is genetically unrelated to the intended parent(s). risks the embryo implanted in gestational surrogacy faces the same risks as anyone using ivf would. preimplantation risks of the embryo include unintentional epigenetic effects, influence of media which the embryo is cultured on, and undesirable consequences of invasive manipulation of the embryo. often, multiple embryos are transferred to increase the chance of implantation, and if multiple gestations occur, both the surrogate and the embryos face higher risks of complications. gestational surrogates have a smaller chance of having hypertensive disorder during pregnancy compared to mothers pregnant by oocyte donation. this is possibly because gestational carriers tend to be healthier and more fertile than women who use oocyte donation. gestational carriers also have low rates of placenta previa / placental abruptions (1.1-7.9%). children born through singleton ivf surrogacy have been shown to have no physical or mental abnormalities compared to those children born through natural conception. however, children born through multiple gestation in gestational carriers often result in preterm labor and delivery, resulting in prematurity and physical and/or mental anomalies. outcomes among gestational surrogacy arrangements, between 19–33% of gestational surrogates will successfully become pregnant from an embryo transfer. of these cases, 30–70% will successfully allow the intended parent(s) to become parent(s) of the resulting child. for surrogate pregnancies where only one child is born, the preterm birth rate in surrogacy is marginally lower than babies born from standard ivf (11.5% vs 14%). babies born from surrogacy also have similar average gestational age as infants born through in vitro fertilization and oocyte donation; approximately weeks. preterm birth rate was higher for surrogate twin pregnancies compared to single births. there are fewer babies with low birth weight when born through surrogacy compared to those born through in vitro fertilization but both methods have similar rates of birth defects. indications for surrogacy opting for surrogacy is often a choice made when women are unable to carry children on their own. this can be for a number of reasons, including an abnormal uterus or a complete absence of a uterus either congenitally (also known as mayer-rokitansky-kuster-hauser syndrome) or post-hysterectomy. women may have a hysterectomy due to complications in childbirth such as heavy bleeding or a ruptured uterus. medical diseases such as cervical cancer or endometrial cancer can also lead to surgical removal of the uterus. past implantation failures, history of multiple miscarriages, or concurrent severe heart or renal conditions that can make pregnancy harmful may also prompt women to consider surrogacy. the biological impossibility of single men and same-sex couples having a baby also may indicate surrogacy as an option. gestational surrogacy in gestational surrogacy, the child is not biologically related to the surrogate, who is often referred to as a gestational carrier. instead, the embryo is created via in vitro fertilization (ivf), using the eggs and sperm of the intended parents or donors, and is then transferred to the surrogate. according to recommendations made by the european society of human reproduction and embryology and american society for reproductive medicine, a gestational carrier is preferably between the ages of 21 and 45, has had one full-term, uncomplicated pregnancy where she successfully had at least one child, and has had no more than five deliveries or three caesarean sections. the international federation of gynaecology and obstetrics recommends that the surrogate's autonomy should be respected throughout the pregnancy even if her wishes conflict with what the intended parents want. the most commonly reported motivation given by gestational surrogates is an altruistic desire to help a childless couple. other less commonly given reasons include enjoying the experience of pregnancy, and financial compensation. history having another woman bear a child for a couple to raise, usually with the male half of the couple as the genetic father, has been referenced since the ancient times. babylonian law and custom allowed this practice, and a woman unable to give birth could use the practice to avoid a divorce, which would otherwise be inevitable. many developments in medicine, social customs, and legal proceedings around the world paved the way for modern surrogacy: 1936 – in the u.s., drug companies schering-kahlbaum and parke-davis started the pharmaceutical production of estrogen. 1944 – harvard medical school professor john rock became the first person to fertilize human ovum outside the uterus. 1953 – researchers successfully performed the first cryopreservation of sperm. 1976 – michigan lawyer noel keane wrote the first surrogacy contract in the united states. 1978 – louise brown, the first "test-tube baby", was born in england, the product of the first successful ivf procedure. 1985–1986 – a woman carried the first successful gestational surrogate pregnancy. 1986 – melissa stern, otherwise known as "baby m," was born in the u.s. the surrogate and biological mother, mary beth whitehead, refused to give up custody of melissa to the couple with whom she made the surrogacy agreement. the courts of new jersey found that whitehead was the child's legal mother and declared contracts for gestational carrierhood illegal and invalid. however, the court found it in the best interest of the infant to award custody of melissa to the child's biological father, william stern, and his wife elizabeth stern, rather than to whitehead, the gestational carrier. 1990 – in california, gestational carrier anna johnson refused to give up the baby to intended parents mark and crispina calvert. the couple sued her for custody (calvert v. johnson), and the court upheld their parental rights. in doing so, it legally defined the true mother as the woman who, according to the surrogacy agreement, intends to create and raise a child. 2009 – ukraine, one of the most requested countries in europe for this treatment, has its first surrogacy law approved. psychological concerns surrogate anthropological studies of surrogates have shown that surrogates engage in various distancing techniques throughout the surrogate pregnancy so as to ensure that they do not become emotionally attached to the baby. many surrogates intentionally try to foster the development of emotional attachment between the intended mother and the surrogate child. some surrogates describe feeling empowered by the experience. although gestational surrogates generally report being satisfied with their experience as surrogates, there are cases in which they are not. unmet expectations are associated with dissatisfaction. some women did not feel a certain level of closeness with the couple and others did not feel respected by the couple. some gestational surrogates report emotional distress during the process of surrogacy. there may be a lack of access to therapy and emotional support through the surrogate process. gestational surrogates may struggle with postpartum depression and issues with relinquishing the child to their intended parents. immediate postpartum depression has been observed in gestational surrogates at a rate of 0-20%. some surrogates report negative feelings with relinquishing rights to the child immediately after birth, but most negative feelings resolve after some time. child and parents a systematic review of 55 studies examining the outcomes for surrogacy for gestational carriers and resulting families showed that there were no major psychological differences in children up to the age of 10 years old that were born from surrogacy compared to those children born from other assisted reproductive technology or those children conceived naturally. gay men who have become fathers using surrogacy have reported similar experiences to those of other couples' who have used surrogacy, including their relationship with both their child and their surrogate. a study has followed a cohort of 32 surrogacy, 32 egg donation, and 54 natural conception families through to age seven, reporting the impact of surrogacy on the families and children at ages one, two, and seven. at age one, parents through surrogacy showed greater psychological well-being and adaptation to parenthood than those who conceived naturally; there were no differences in infant temperament. at age two, parents through surrogacy showed more positive mother–child relationships and less parenting stress on the part of fathers than their natural conception counterparts; there were no differences in child development between these two groups. at age seven, the surrogacy and egg donation families showed less positive mother–child interaction than the natural conception families, but there were no differences in maternal positive or negative attitudes or child adjustment. the researchers concluded that the surrogacy families continued to function well. legal issues main article: surrogacy laws by country the legality of surrogacy varies around the world. many countries do not have laws which specifically deal with surrogacy. some countries ban surrogacy outright, while others ban commercial surrogacy but allow altruistic surrogacy (in which the surrogate is not financially compensated). some countries allow commercial surrogacy, with few restrictions. some jurisdictions extend a ban on surrogacy to international surrogacy. in some jurisdictions rules applicable to adoptions apply while others do not regulate the practice. the us, ukraine, russia and georgia have the most liberal laws in the world, allowing commercial surrogacy, including for foreigners. several asian countries used to have liberal laws, but the practice has since been restricted. in 2013, thailand banned commercial surrogacy, and restricted altruistic surrogacy to thai couples. in 2016, cambodia also banned commercial surrogacy. nepal, mexico, and india have also recently banned foreign commercial surrogacy.