By Marsha Darling
The act of women birthing children for other women is a very old social behavior dating to biblical times. Commercial gestational surrogacy is recent and of compelling importance because it invokes sharp ethical dilemmas regarding the use of invasive and risky protocols on women's bodies, and the well-being of children born into arrangements where the genetic, gestational, nurturing and even institutional (as in when birthed surrogate infants are placed in orphanages staffed by women) mothers of infants may not be the same woman. Commercial surrogacy also portends challenges for our advocacy as stakeholders, who in the United States participate in a democratic social order that promotes reproductive freedom "choice," and at the same time social justice.

Exactly what does "choice" mean in the context of participation in surrogacy arrangements when one lives below the poverty line in the United States or especially in a "low resource" country like India or Thailand? This question bears on us now as present day gestational surrogacy has become a transnational commercial enterprise, linking multiple individuals and their interests in an interconnected global web: mostly poor women's labor, gametes, infants, medical services, surrogate hostels, legal contracts, state and national policy makers, sometimes human traffickers, international trade institutions (WTO), and of course, lots of money. This article identifies some of the challenges associated with women's work in the commercial gestational surrogacy industry, and argues that we should move beyond 'just wait and see what happens' to the complex work of legislating responsible governance of the new biotechnologies that reach so very deeply into our bodies.

Few people might have imagined the exponential expansion of gestational surrogacy taking place within and across national borders in recent decades. Used primarily to intervene in infertility, contract gestational surrogacy is the centerpiece of a fertility production complex with a set of contractual arrangements that mark: a) the convergence of women's reproductive labor (whether paid or uncompensated), b) female and male gametes (purchased or donated), c) written contracts or just verbal agreements offered by commissioning individuals or couples, d) fertility brokers and doctors and medical staff often working in private hospitals specializing in fertility services in "low resource" countries, e) fertility hostels as places where contract surrogate mothers-to-be are often housed especially in "low resource" countries, f) some regulatory policy makers often intent upon allowing citizens some measure of autonomy in utilizing surrogacy in response to infertility, and g) other policy makers who are intent on taking a place in the global economy by offering medical and reproductive services and encouraging citizen participation, especially in "low resource" countries.1

In vitro reproductive interventions are ushering forth an era where for an increasing number of persons, mostly in western societies, reproduction is shifting from conception as a possible outcome of coital sex to laboratory managed medical intervention and control of conception. Social identity rights based movements and the sexual revolution begun in the 1970s have altered definitions of "family" in much of the global North, creating new alternatives to traditional familial relationships. Fertility interventions enable greater agency on behalf of reproductive freedom, especially for heterosexual couples challenged by infertility, genetically transmitted disorders, or just wanting to opt out of the inconvenience of childbearing. However, persons who are disabled or differently able who seek to reproduce, same sex couples, single persons, and at some point transgender persons who seek to enable their reproductive choices, often encounter a refusal of fertility and surrogacy services.

The revolution in reproductive biotechnologies has made parenthood possible for thousands of people around the world for whom this would otherwise have been impossible, and their use is steadily growing. The number of babies born to gestational surrogates in the United States grew 89% percent from 2004-2008.2 The commercial fertility industry which is nearly entirely unregulated in much of the world is a multi-billion dollar annual business, generating enormous profits for fertility specialists, clinics, and brokers. While in the main these powerful stakeholders seek to minimize health and economic risks, they rigorously fight regulation. In many countries, including the United States, the industry self-reports, and as such sometimes covers over errors of judgment or adverse outcomes-preferring to focus on successes. Recognizing multiple dangers and ethical issues, policy makers in a number of countries have banned or severely limited fertility and surrogacy practices, turning countries with no regulation into "free market" zones. Many are concerned about negative impacts on women's health and infants in the fertility industry.3

The challenges to protecting surrogate women's health and well-being everywhere deepen, as women who labor as surrogates are almost always economically vulnerable and are lured by the promised payment that is a desperately needed income supplement. In "low resource" countries like India, where a large segment of poor women workers are illiterate, they are vulnerable in a system of intermediaries, all of whom have more power and authority than impoverished women. Needless to say exploitation and fraud of women fertility workers are very real issues. At many clinics in India, surrogates recruited from among the poor are warehoused assembly-line style in long rows of beds where they are confined for the duration of their pregnancy. In the United States, it is estimated that nearly 50% of gestational surrogates are "military wives," a much sought after group for agencies and brokers. Many "military wives" are low income ($16,000 to $28,000 USD in annual income), and tend to marry and have their children at young ages, so the prospect of doubling their income by serving as a surrogate can be irresistibly attractive. These women have few legal or regulatory protections, however, making them ripe for exploitation and fraud.4

Egg donors are a significant factor in the commercialized reproduction business. Egg suppliers, largely young college women struggling to finance their educations, are drawn by ubiquitous ads in campus newspapers and social media. One typical ad running in campus newspapers in the United States offers "$25,000 for a donor who is 100% Jewish with high SAT scores, attractive, at healthy body weight and free of genetic diseases." Many of the young, child bearing age women who enter ova selling networks, or the "embryo trade" as it is quickly becoming known, enter the industry to donate or sell their ova for the infertility industry. More recently, much of the quest to further stem cell research initiatives rests on recruiting young women to undergo ovarian stimulation so as to produce multiple embryos for research. This industry is also expanding rapidly. Much of the discourse about the arrangements undergirding these practices reduces them to "market arrangements."  Yet, the well-being and health of many of the young women is at risk as they enter ova trade networks.5

The potential for serious health risks from these practices is very real. Synthetic hormones and other drugs utilized in IVF can have harmful short and long-term health consequences for the women who work as egg suppliers and surrogates, as well as for the women undergoing these procedures to conceive and give birth to a child of their own. Short-term health risks associated with these procedures include ovarian hyper stimulation syndrome (OHS), which ranges from mild to life-threatening. Nausea, vomiting and abdominal swelling are common; more serious complications may include kidney and other organ failure, strokes, and even death. Long-term risks include increased rates of uterine, breast and other cancers and infertility.6 Despite the seriousness of these potential health risks for women working in the fertility industry, insufficient attention has been given to gathering empirical data and crafting responsible regulation of women's work that generates not a material "something" but a "someone." There is a resounding need for open debate, international collaboration and tighter regulation of this global marketplace.

The global commercial fertility industry has created a market for virtually every aspect of human reproduction: sperm ($275 a vial), eggs (up to $50,000 apiece), nine months use of a womb ($20,000), and the creation of an embryo ($12,000 per cycle). The fertility-industrial complex is a stunning array of businesses. It includes the manufacturing of fertility hormones, harvesting of renewable natural resources (sperm and egg collection), international trade (foreign adoptions), expert services (IVF and other high-tech medicines), long-term storage (embryo banks), and even rental property (surrogate mothers).7 As the industry continues to grow and affect more and more people's lives all over the world, awareness and understanding of its far reaching implications for social justice should accompany the development of the technologies (IVF, Preimplantation Genetic Diagnosis-PGD, etc.) and practices of this global phenomenon. As all of the arrangements noted above amount to purchasing and securing the production of a child, a concern for the infants born within the surrogacy industry should also be on our radar screen.

Who looks after the interests of the children who are born through the gestational surrogacy industry? Do they have a right to know information about their biological parent(s) in cases where the egg and/or sperm donor is/are not the commissioning parents? What if they seek information about the surrogate mother or egg supplier? What rights do children have to information regarding any siblings they may have who are the offspring of the donor parents? In a more frightful scenario, who will look after the interests of the infants rejected or abandoned because of multiple births, or a serious disability deemed unacceptable by commissioning individuals, or infants unclaimed or abandoned or in the event of the death of a commissioning parent-to-be? Equally dire, what if a commissioning individual's home country will not accept the newborn infant or upon its birth the infant is placed in an orphanage in the country of physical birth? All of the above questions bear immediately on the well-being of children born within the fertility industry.

Lastly, addressing the issue of averting potential and real harm at a time when the fertility industry is bustling will be a challenge for Americans because advertising has cleverly linked increasing personal individual choices connected with parenting with letting the marketplace rule without regulation. As for women's interests, how do we defend abortion rights but also disentangle that issue from advocacy towards regulating risky technologies? While we have outlawed the market for selling organs in the United States, where are our heads about allowing young women's wombs, their ova with its all so very valuable totipotent embryonic stem cells, even their DNA and genetic sequences to be thrown into a marketplace, patented and sold as a manufacturing "part" or "process"? Can we be under the illusion that our reproductive freedom will increase by allowing elites to patent or privatize the genetic sequences and processes embedded in women's reproductive biology? A really tough question is what are the moral and ethical consequences of transforming a normal biological function of a woman's body into a commercial production process with its attendant input costs, organized under a legally binding contract? Exactly how will that play out without our exerting a mitigating influence on the development of biotechnologies that reach deep within our bodies?

Marsha Darling, PhD, is Professor of History and Interdisciplinary Studies and Director of the African American & Ethnic Studies Program at Adelphi University.




1. See Amrita Pande, "Commercial Surrogacy in India: Manufacturing a Perfect Mother-Worker," Signs, Vol. 35, No. 4, 969-992, 2010, and Lisa C. Ikemoto, "Reproductive Tourism: Equality Concerns in the Global Market for Fertility Services," 2009.

2. ART self-reporting data in the United States: Victoria Clay Wright, et. al. Division of Reproductive Health, CDC, "Assisted Reproductive Technology Surveillance, United States, 2003," in Surveillance Summaries, May 22, 2006; for Canada and the United States: Edward G. Hughes, et. al. "Cross-Border Fertility Services in North America: A Survey of Canadian and American Providers,"; and for Europe: F. Shenfield, et. al "Cross Border Reproductive Care in Six European Countries,"Human Reproduction, Vol. 25, no. 6, 1361-1368, 2010.

3. Legal status of ARTs: Liberal regulations in Spain, Belgium, Cyprus, Czech Republic, India; Jordan, Israel, South Africa; no regulations in US, Ukraine; strict regulations in Germany, France, the UK, Italy, Queensland and Victoria in Australia, Iceland, Sweden, Austria, Norway, Turkey; pending regulation in Thailand.

4. See Magdalina Gugucheva, Surrogacy in America. Cambridge, MA: Council for Responsible Genetics, 2010.

5. Re allegations of price-fixing: Marimer Matos, Human Egg Donor Files Antitrust Class Action, Courthouse News Service, April 14, 2011.

6. See especially the longstanding commitment of feminist organizations to protecting women's health, well-being, and reproductive rights of FINRRAGE in Australia and Bangladesh, SAMA in India, ISHA L'ISHA in Israel and Boston, USA based OurBodies/OurSelves.

7. Author is grateful to Kathy Sloan for her assistance in providing important data for this article.

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