Welcome to Fertility and Sterility On Air, the podcast where you can stay current on the latest global research in the field of reproductive medicine. This podcast brings you an overview of this month's journal, in-depth discussions with authors and other special features. FNS On Air is brought to you by the Fertility and Sterility family of journals, in conjunction with the American Society for Reproductive Medicine, and is hosted by Dr. Kurt Barnhart, Editor-in-Chief, Dr. Eve Feinberg, Editorial Editor, Dr. Micah Hill, Media Editor, Dr. Pietro Bortoletto, Interactive Associate-in-Chief, and Associate Editor, Dr. Kate Devine.
Hi everyone, and thanks for staying for the last session of the day. My name is Pietro Bortoletto, I'm one of the Interactive Associate-in-Chiefs for Fertility and Sterility. We have a cool topic that we're going to talk about, and we've invited fellows to help us talk about it.
Today's debate is going to be the use of gestational carriers in situations where there is not a medical indication for use. I know some in the room already do this, some in the room are resistant, and some in the room have pretty clear lines drawn in the sand that they won't do this. I want to quickly introduce our panel and set out the rules for how we're going to be talking about this topic.
I want to introduce first the pro side. On the pro side, we have three expert fellow physicians, Dr. Anthony Bui from Stanford, Dr. Bahar Yilmaz from UCSF, and Dr. Jensen Reckhow from RMA of New York. And on my con side, I have Dr. Howard Li from the NIH, Dr. Francesca Barrett from the RBA of New Jersey program, and Dr. Adriana Wong from USC.
I will be your moderator. My name is Pietro Bordaletto, and let's begin. We are going to have first the pro side start with a short under 60-second opening statement, and then we're going to bounce over to the con side.
And once everyone has had a chance to give an opening statement, it's a free-for-all. They're going to have an opportunity to poke at each other's arguments, and if the discussion gets stale, I have a couple of questions I'd like to ask them, and if I get stale, I have a couple of questions I'd like the audience to ask. Without further ado, Adriana, since you smiled and made eye contact with me, you're going to go first.
Good afternoon. The position against elective surrogacy without medical indication is grounded in the ethical principles that define our medical practice, particularly the obligation to minimize harm and protect all patients involved. The American Society of Reproductive Medicine explicitly supports the use of gestational carriers only in circumstances where a true medical condition precludes or significantly endangers a pregnancy, framing surrogacy as a treatment requiring clear clinical justification rather than a matter of personal preference.
Elective surrogacy introduces a unique ethical concern by transferring the inherent medical risks of pregnancy, including hypertensive disorders, operative delivery, and long-term morbidity to a third party without corresponding medical benefit to that individual. This extends beyond the scope of patient autonomy, which does not inherently justify the imposition of risk on another person in the absence of a medical necessity. Furthermore, physicians have a responsibility to exercise professional judgment in the allocation of limited resources and to remain attentive to the potential for financial coercion without surrogacy arrangements.
Given the scarcity of gestational carriers and the socioeconomic dynamics that often underlie participation, expanding access for elective indications may exacerbate inequalities and divert care from those with established medical need. In sum, our position is that maintaining a requirement for clear medical or well-defined psychosocial indications for surrogacy is essential to safeguarding gestational carriers, upholding our ethical standards, and preserving the integrity of reproductive medicine. Now you understand why we invite fellows to do this.
They are so prepared. Proside, your opening argument. This article explores an emerging ethical question in reproductive medicine, whether physicians should facilitate gestational carrier arrangements when the intended parents do not have a clear medical indication for using a gestational carrier.
While gestational carriers have traditionally been used for patients with medical contraindications to pregnancy or severe uterine factor infertility, increasing requests now arise for patients who fall outside of this narrow scope. The debate centers on two ethical priorities, reproductive autonomy and consistency in respecting gestational carrier choice versus physician responsibility to avoid exposing a healthy individual to a pregnancy risk without medical necessity. The central ethical question is not whether intended parents have a sufficiently compelling reason to avoid pregnancy because this makes no difference to the gestational carrier.
The risks of pregnancy do not differ depending on the rationale for using a gestational carrier. The question is really whether a fully informed gestational carrier can autonomously choose to help someone build a family within a regulated and safeguarded process. If we accept gestational carrier arrangements when safeguards are present, then selectively restricting them based on subjective judgments about the intended parents motives introduces inconsistency, bias, and unnecessary gatekeeping in reproductive medicine.
We got a debate on our hands. Quansai. Thank you, Jensen, for such a great argument.
I think the Quansai definitely agrees that there is this concern of gatekeeping and this risk of inconsistency and bias and gatekeeping when it comes to determining, you know, what is actually a medical indication, who deserves to have a gestational carrier. And I think we are all really sensitive to that. But I think it is really our role as physicians to still be the gatekeepers and establish professional norms amongst us about, you know, what are the indications that necessitate exposing a patient, a prospective gestational carrier to these risks.
That's a big part of like our role as physicians. We are often like counseling the risks and benefits of different procedures with our patients. And also we're also balancing what's the societal benefit of allowing these cycles to occur versus what's the societal cost.
All of us probably respect the risks and ethical complications that are inherent in a gestational carrier cycle, whether there's a medical indication or not. I think that it's probably most prudent for us to establish, even if it means expanding the definition of what constitutes a true medical indication, to be more responsible in embracing our roles as physicians in determining what are the cases where it's worth it to expose another individual to these risks. I have a question I'd like to pose to both sides of the panel, and I suspect one of you will want to answer, the other one won't.
Who's responsible for assessing medical necessity? Is it the REI who hasn't practiced obstetrics in many years? Is it the obstetrician who doesn't generally practice high-risk obstetrics? Who writes the doctor's note? I think it's the question is not who writes it. The question is what is a necessity? What is a medical indication? And what is elective? So what I'm hearing from our wonderful con side is that they're talking about a true medical indication. I want to ask you, what is a true medical indication for anything? And what's our goal here? The goal is not to normalize convenience, because that's not what we are supporting here, but it is to respect informed decisions that are made by capable intended parents and surrogates within a safe regulated system, because this is ultimately safer and more reliable when we are vetting these GCIP partnerships.
And who are we to be in this position when you actually look at it from a different perspective? The concept of elective in medicine is far less objective than we often assume. Many conditions we now consider and recognize as legitimate true medical indications, such as infertility itself, mental health conditions, gender dysphoria, were once dismissed as elective choices. So when we label gestational carrier use as elective, we may believe we are drawing a very clear medical boundary, but are we? In reality, we are often expressing our own interpretation of how compelling someone's circumstances are, and when one physician may view, for example, severe pregnancy anxiety or prior traumatic experience as a valid reason, and another may not.
So here the patient has not changed, but the interpretation has changed. So this introduces actually a deeper ethical concern of if the physicians become the arbiters of which reasons for avoiding pregnancy are legitimate enough, then access to these arrangements will be quite variable on individual physician values, personal empathy, and cultural perspectives. And there's a practical implication when you think about this, because when these are arranged within legitimate pathways with regulated medical systems, we are keeping both parties safe.
But when these are restricted, patients often do not abandon their dreams, but they seek care elsewhere. They may seek care in different states, in the post-op US, they may seek care through cross-border surrogacy arrangements, and they may be in less regulated systems. So in that sense, by restricting access within ethical frameworks may paradoxically increase the very risks we are trying to prevent.
So ultimately, the ethical focus here should remain where it belongs, ensuring that gestational carriers are protected, informed, and they are freely choosing to participate, and that intended parents pursue family building within transparent and responsible medical systems. Kansai, they've given you much to think about. Please respond.
Thank you so much for those things to think about. First off, I think we should all acknowledge that we know that pregnancy is not a health-neutral event. And in this case, when we're involving a gestational carrier, there are three patients involved.
There's the GC herself, the intended parent or parents, and the baby as well. And we know that there are screening processes in place, and we're trying to optimize and choose healthy women who've completed their childbearing and hopefully don't have poor obstetric histories. But there is data to suggest that there are still higher risks of pregnancy in GC pregnancies than for those who are carrying autologous pregnancies themselves.
Furthermore, one of the points that you brought up that I think we also have to acknowledge is that there's a supply and demand issue, that as of right now, not everyone that wants to be an intended parent has the opportunity to be an intended parent. There is a horrible asymmetric kind of matching for who is able to be a GC who's matched with that intended parent. And I think that it's also our duty when there's a limited scarce resource, just like in like the organ transplantation market.
These are not unregulated things where people were accepting people to sell their kidney on a black market. We really have a responsibility to these gestational carriers and these intended parents to match them appropriately, as well as to allow for patients that really do have a medical need at the first point to be able to have that intended parent, as opposed to someone who really is doing it completely electively. I think all of those are really valid and good arguments.
I do want to address your point, Adriana, about risk to the gestational carrier. I think this is why we emphasize how important it is for them to undergo medical screening, psychological evaluation, and independent legal representation so that we really are empowering them. Our argument is that we're trying to focus on their agency as opposed to the intended parents, such that they are going to make an informed decision in doing this voluntarily.
And I do want to kind of somewhat relate this to other examples within our broader specialty. The ARRIVE trial came out, and we used to regard elective inductions, and I guess to some degree still do, as having some degree of medical benefit. But to what Bahar was saying earlier, our understanding of the term elective evolves with time, and our understanding of what medical risk is and what constitutes medical risk changes with time.
In my training, I went from using the term elective induction of labor to risk-reducing induction of labor to, at the end, calling it induction of labor per patient request. And I do believe that we can apply a similar standard to intended parents who are seeking gestational carrier use and allowing it as long as the safeguards are in place to protect the gestational carriers. I would like to add to Anthony's point.
So I totally agree, Francesca. I think that it's important that people have access to care, and it's equitable. But I don't think we ever get more access or more equitable care because by restricting care.
I think that it's important to counsel both parties and perhaps have a prioritization system within that IPGC matching algorithm. And maybe that is one of the reasons why they may choose or not choose to use IP as well. But I totally agree with that.
But I don't think that restricting and classifying someone's very valid reason, not medical, is the answer to providing more equitable access. Prasad, I have a pointed question towards you now. So if elective surrogacy is ethically permissible, which is I think the central key argument, does restricting it to those who can afford it create potentially two-tiered system where there are haves and have-nots with regard to reproduction? I can answer this one.
So of course the goal is not to create an access issue that's rooted in financial abilities. But that's not the question here. And that flaw with the system remains no matter where we draw the line of what our access to gestational carrier use is.
And solving that problem should be a priority without this kind of distraction of thinking about our medical indications for care and the access our patients have. As physicians, we're taught to separate those things. And I don't think that means ignoring the financial issues.
But it does mean that when you're thinking about whether something is medically appropriate or not, the finances of it shouldn't be factoring in. I think the access to gestational carriers, the financial barriers to that are an issue already. And that's something that we need to address even if this debate weren't happening.
And those issues don't go away no matter where we draw the line. But are certainly of interest I think to everyone in this room as something that needs to be solved. I'd like to respond to the other side's comment about just the evolving role of what it means to have an indication being like an elective gestational carrier.
And I think that just empowering patient autonomy and promoting access to care doesn't mean abdicating our roles as physicians and stewards. I really appreciate the example from obstetrics that Anthony brought up at the ARRIVE trial. I think that in OB-GYN, there's so many examples of instances where we as physicians have not been able to step up in our role as stewards and gatekeepers.
Like all of us have trained in the era of external fetal monitoring. And this was a technology that evolved in response to logistical and market incentives and things that we didn't maybe adequately push up against. And now we are all managing pregnancies with this technology and still debating today whether or not it really helps or even if it potentially harms our patients.
I think we're highly aware of the strong demand for elective surrogacy, but I think this strong demand and this desire to empower our patients and support their reproductive autonomy is not a medical indication. And so much of our training involves our privileged roles as thoughtful stewards and gatekeepers. And we're entrusted by our patients and by the public to protect them from harm and potential exploitation.
I'd like to respond to your point, Howie, just by highlighting that the advent of gestational care, I think similarly to many interventions that have kind of come about throughout the course of history and been adopted for other indications. You know, when we think about how surrogacy came about, it was to address severe uterine factor or a very life or death kind of risk in terms of pregnancy. But again, I think in arguing your points, what we regard as risk changes over time as we have seen the power and the ways that gestational care use can really have a positive impact on the care, on the outcome, on kind of the trajectory of a couple's family building goals.
You just wonder whether it's something that is right to restrict. Every person has a different experience with pregnancy. It is for many people a very positive experience.
But for many people, not so much so. They may face a complication during pregnancy that, you know, might be dismissed by someone. They might be perfectly fit and capable of carrying pregnancy with no significantly increased risk to their life, as was the initial kind of indication for gestational carrier use as it had first come about.
But that's not to say that there isn't a benefit to its use. And so withholding this benefit, I think it's hard to make that argument. And it's hard to draw the line, especially when there's variability in different providers' judgments and values.
And so I guess to summarize what I'm trying to say in response to your argument is that it becomes kind of ethically difficult to withhold something that really can benefit so many in so many different circumstances. I'd love to respond to that. So I'm so appreciative how sensitive your guys' viewpoint is and how thoughtful you're being about some of the mistakes we've made in our longstanding medical history and how to be thoughtful moving forward.
I think that there is black and white and there's gray, and there's a big area of gray that I think that we would both agree that maybe you guys would consider as elective that we might consider as non-elective as a medical indication. So there's a lot of crossover, and there's a lot of new information that can come that sometimes our written standards that exist right now may not catch up. And so I do think that there is a role for individual clinics to have these ethics committees for these kind of harder, meatier points that maybe we might not agree on today, but with new information may be considered more of a medical, psychosocial reason for gestational carrier.
And that's a way to really have a living, breathing way of being able to assess risk and physician autonomy and some of these things in real time as opposed to hard and fast rules. But I do ultimately think that it's not the majority, but there are groups of people that can be reproductively coerced, that can have costs that really, you know, just because they happen to want it doesn't necessarily mean that that's really something that we as physicians have to do. Every day we have patients that come in and are like, I'd like snake oil for X. Our patients are desperate for care.
And so it is our job to guide them into things that are safe for them, safe for their families, and helpful moving forward. And it's our duty towards gestational carriers to also protect them. How does the indication from GCUs change the coercion of GC? I think the example is like gender dysphoria, right? Like 20 years ago, that might have not, like it was a DSM diagnosis.
And now it's something that we all are very supportive of. And so that's something where like, that's kind of a silly reason in some ways. But also, I think we'd all agree that that is a medical indication for a gestational carrier at this point.
And also just given the fact that we're not able to meet the demand for women who actually have medical needs for GCs, those women should have better access and be able to use GCs as opposed to those who have elective reasons for wanting to use one. In response to the coercion issue, again, I think that goes beyond the scope of what the indication for the GC is, because that's an issue regardless. And the risk that the GC is facing in that regard doesn't depend on what the IP's medical indication or lack thereof is, right? If someone's at risk of coercion, they're at risk of coercion.
And it's not about if the IP's reason for wanting a GC is like good enough medically for us. And so I think those are not to like brush that issue under the rug, because it is a really important consideration in this. But I think it's just, it's not quite what this issue is about.
This issue is like, do we trust ourselves to be able to say this is a medical indication and this isn't, and to feel comfortable wielding that power and that kind of paternalistic approach over patients today, knowing that in the past we haven't done a good job with it, with something as egregious as gender dysphoria, ever considering that that was not an indication is shameful. I think we can all agree. And so do we want to risk putting other things in that category? Because ultimately we do have to define elective.
If we're going to say that you can't do something electively, we need a definition for what that means. And we're saying that we're going to draw a line somewhere. And I think our main argument is just that we, you know, humbling for us, but maybe we're not great at drawing that line.
So on that, I mean, we as REIs are the experts. Like MFMs tell us when to deliver our patients. They say 37, you know, gestational diabetes, you know, preeclampsia, whatever it is.
And there is a line in the sand for what is an indication and not an indication. So I don't really, I actually don't agree with your point that we aren't the experts to be able to decide what is a medical indication to provide a service or what is actually a pregnancy for someone for nine months that puts them at a higher risk that is not a net neutral event. Like I just objectively disagree with that point.
So we've mentioned here the physician as the individual, kind of the center of this decision-making. But I think if we put our MFM hat for a second, there are societal guidelines that help guide some of that decision-making and counseling. There happen to be a few former ASRM presidents in the room.
What roles do the societies have or not have in coming up with formal indications or thresholds? Or do we think that's an overstep in gatekeeping for a society to stick their foot on the scales? So I think that the societal, the professional society example is so important. Like I think, I'm definitely feeling the humility that we all feel. Like who are we to decide who, what is a medical indication versus elective? And I don't think any one person here feels confident making that decision, but there's still a need for professional norms.
Like we say no to our patients all the time. There's a patient who's had failed multiple, who's failed several transfers and she wants five embryos transferred. You know, and that's why we have professional guidelines that ASRM has to empower us to make these decisions.
I think the whole purpose of meetings like this is for physicians in REI to come together, acknowledging that we alone don't have all the answers to help our patients and to adequately protect them. And there's a role for us as a profession to establish these norms rather than abdicating them out of a fear that we're going to make the wrong decision. I do want to ask though, we talk about protecting patients, protecting people, but I do want to clarify what we mean by that.
If a traditional carrier enters voluntarily, willingly into a contract and are fully understanding of the risks that they're taking on, not to like minimize these risks, these are real risks, risk to their life, risk to their their health, but their understanding of that and they have accepted the compensation on par with the risk that they're taking on, are we truly protecting them then in that scenario? Or are we doing them a disservice and our patients, our intended parent patients? Are we ultimately doing a disservice to all parties involved? So we talked about is there a role for societal involvement here? I think the pro side has brought recently brought up transplant medicine as a potential analog here of some of the pros of having this disseminated access to organs, but in the transplant world there are registries. Would the pro side advocate that we should registrify the gestational carrier access to better understand the problem, the indications, the risks? Or is that something that you guys would be wholesale against? I think we have to think about very carefully who will have access to that registry, what does that have, like what are the implications legally to involved parties, like the both the IEPs and the GC? Because once you have declared that you're in this, then there are so many different state laws, like who is responsible for what and in what states and even what restrictions will be there when you're trying to move in between different locations. So I am not personally very keen on who has access to these registries and those governments, governmental organizations will have access to these.
So I would say we need to be very careful in terms of what the implications would be. I think that there should be societal guidelines in terms of what is recommended and what is not recommended in terms of carrying a pregnancy versus using a gestational carrier to achieve that family goal. And those may tell us, this may be more beneficial for the intended parents and kind of justifies the risk that the GC is undertaking.
But I don't think that registers or being in race with each other or trying to get to the number one place will necessarily be the answer. And I think we need to be very careful what the implications legally would be of that. And does the same argument extend to the matching system that exists in organ transplant medicine, where there are prioritizations given for people at different extremes of their disease and their necessity for this life-saving intervention? Is there a world in which prioritizing gestational carriers to people with true medical indications might or might not make sense to the pro side? I think it's a little bit hard to say that a matching type or prioritization type system would be appropriate when, if you think about it, the pursuit of pregnancy in any circumstance is a quote-unquote elective act.
Undergoing IVF is an elective act just as is adopting a child. And so to assign some type of medical prioritization in what is fundamentally, and you know, this is, again, it's hard to use the word elective when it's such a nuanced and loaded term, but to assign some type of prioritization or matching process to what is really at its core an elective act, I would argue is hard to justify. I don't know if being pregnant is elective, right? It's our reproductive biological urge pushing us forward.
I feel like that's, it's something that sometimes people choose, sometimes they don't choose, right? Sometimes they get pregnant without meaning to, sometimes they would die to be pregnant and go through IVFs or an IUI, and sometimes they try and they don't get it. And so I think that's not quite, I think it's a simplified way of describing pregnancy. And I think that's why our society considers an infertility to be a medical condition and not treatment of it to be an elective procedure.
I think you're simply pointing out the fact that that definition is not something that holds its place or boundaries and it changes across time. I think that we agree with you. I don't, we agree that none of this is elective, but at the same time, it really depends on where you're looking at it from.
It depends on your perspective. So the same way from your view, because of this debate, because I know we would be on the other side if we were not sitting here, that you're seeing the use of GC elective in this case. From the same perspective, someone else can see pregnancy as elective as well.
Because I don't think that these are necessarily very different situations depending on the person's life experience, what they're going through. And I think that you're simply agreeing with us. I do appreciate the example of donor registries that was brought up by Dr. Bordoletto.
And I think having a matching system that we see in other organs does bring up an interesting example, because in that circumstance, it does kind of remove the ability to pay factor from that, which is something that kind of still feels a little strange and icky about what we might do. There are so many people who want to become pregnant and so many people who want to benefit from our services, and access to that still depends on the ability to pay. But I think for something as ethically complex as having a gestational carrier, this really does invite us to push back against, should access to having a gestational carrier be determined by ability to pay? And I think if we open ourselves up to allowing for elective gestational carrier cycles, we're going to see that disparity so much more viscerally, because we know that demand exists.
We know that there are plenty of patients who have the ability to pay who would want a gestational carrier out of convenience and preference. And if we don't accept that type of market in the kidney transplant market, I don't think that we should accept that in our own field as well. I think that's a really good point.
And I have reached my mental and spiritual limit of being able to defend this position. It should go without saying that they were randomly assigned to one side, not necessarily asked to pick a side that they agree with. Yeah, but I think that the financial aspect is the central argument of what makes this different from organ donation, in that both of those situations are seemingly elective.
It seems like you know what the risks are going into it, and it can end up being a life-threatening situation. And in a lot of parts of the world, this is something that's only accepted under altruistic circumstances. And I think it's telling that in this country, this is a commodified thing, and it's not an organ, it's your whole body.
And we've decided that, you know, we're okay with that in this situation and with this one group of people, surprisingly. But I think the reason it's so hard to compare to organ donation is because, first, our legal framework makes it so that this isn't something that can be nationally regulated. Like what Bahar was saying, we're just in a position where a lot of this has to happen in silos for the safety of the IPs, more for the safety of the gestational carriers.
But we aren't in a position in this country to be able to centrally regulate this without significantly limiting access to care. And I think, you know, you can address that from multiple directions. Obviously the low-hanging, well, what should be the low-hanging fruit but isn't, is addressing that legal framework that we're in, where patients don't have access to reproductive care, depending on where they live.
But it makes it hard to draw parallels between what should be similar situations of organ donation. Wonderful point. I'm going to start here.
If you could introduce your name and where you're from. One thing that I just want to say is that in our society as a species, we have very clearly made reproductive choice a priority, regardless of legislation, regardless of legality and safety. And so I think that one risk to our entire field, regardless of indication of using a gestational carrier, is that patients who want to use a gestational carrier are going to find one, right? And so what's happening right now, the U.S. is the gold standard for trying to do this as ethically and safely and thoughtfully as possible.
And what's happening is that we're basically doing low-cost surrogacy in other places, which probably should be called human trafficking. And so I think that we need to be really thoughtful about that. By limiting care for some patients, are we actually limiting care for all? Thank you.
Dr. Paulson. Brett Paulson from USC. I thought I was over on the elective side, and now I realize that actually you should have an indication for everything.
Now, you can argue as to who decides that that indication is adequate or not, but you have to have a thoughtful conversation with the patient. And I think this is where maybe the national guidelines or the societal guidelines would be able to help that. So, yeah, a patient can say, oh, I have really bad backache, and if I'm pregnant, I'm not going to be able to move.
So at least it's a reason, but there's lots of wrong reasons. Every week, at least, I see a patient who says, I think I should have a gestational surrogate because I've had two embryo transfers and they haven't implanted, so obviously I need a surrogate. In fact, the last doctor that I was at before you told me that I had adenomyosis, and that's an indication, and I should have gestational surrogacy.
And there's a spectrum, right? So we have unindicated use of baby aspirin, so that's useless, but if somebody wants to use it, that's not very harmful. And on the other end, I guess you have surrogacy, and in between you have interlipid infusions, PRP, all this other quackery that our field experiences on a regular basis. All of those things should be indicated.
We should have an indication. And so I think we need to have an indication for gestational surrogacy, and we should have education from the society that tells us what those reasons could be, but maybe we don't have to be absolute in saying, no, you can't have it because your reason is not good enough for me. Thank you.
We agree. If only there was another ASRM president. Dr. Adams.
I'll echo Rick's comments, I guess. Three major comments. One, I think almost all of us here in the room really believe strongly in reproductive autonomy, which is what this is about.
That said, Rick appropriately brought up the point there should be an indication. But to expand that thought a little bit more, there are societal norms. And in a society, if a group of people, such as reproductive endocrinologists, perform a service that maybe we perceive a benefit to one patient, but is widely opposed by many people in society, we lose support for everything we do.
For example, when we put too many embryos back and got octopus. And we've been around long enough to see some of these real problems that develop. So I think there's an ethical question about, do we help this one patient, recognizing that the outcome of this in society may represent less support, result in less support for many other patients who need care? So that was my first comment.
The second one is, some of you may know that last August, the UN rapporteur called for abolition of surrogacy globally and called for it to be reclassified as a form of prostitution because of the exploitation. And that bill was put before the World Health Assembly last October. So it's important to recognize that as we do this, we really want to be responsible because we are outliers here, especially in California, with respect to the rest of the world.
There's not a lot of support for this in many countries, and people are certainly at risk of going to jail. So if we do something here, the whole issue about informed consent for the risks of pregnancy are really critically important. The last comment I'll make is that the title is about gestational carrier.
And the International Committee for Assisted Reproductive Technology is going to come out with this new glossary in about two weeks in FNS and HR. And we actually took out the term gestational carrier. And I was around when we brought that term in because surrogacy was an old term, biblical, et cetera.
And gestational carrier sort of put the person who was pregnant in a place where she was really not the person, she was just a carrier for somebody else. This is seen in many views as impersonalization or depersonalization of the carrier, of diminishing the dignity of her role. And so we have removed that term and gone back to surrogacy in the new glossary because we need to recognize the potential for exploitation and the diminution of dignity in the person who is a, quote, carrier.
That's why the term's been changed. So just some thoughts around this very complex topic. And you guys have done a great job discussing it.
Thank you. Sounds like we've got two more weeks to use it. My name's Emily Danforth.
I'm a nurse practitioner at the University of Washington. I'm the third party lead for my clinic, so I have plenty of opinions on this topic. Thank you very much.
I appreciate also those comments that were just made. I think what I have to say is kind of echoing some of what Dr. Li was saying about the role of money as coercion because the arguing in favor side, one of the main tenants that you're using as your rationale is that it is not about the medical indication or lack thereof that forms a potential for economic coercion for the gestational carrier. However, a significant difference is that if we take away the need for a medical indication and make it a free-for-all for whoever just doesn't want to be pregnant, that means that we have many more parties entering the space that are demanding gestational carrier services, and we're upping the ante on what kind of economic compensation is going to be made available to surrogates.
And I think an excellent analogy to think about the kind of tipping point of coercion is actually thinking about taxation of tobacco. When tobacco is taxed at a low rate, more people will smoke more. And if you continue to increase the taxes on tobacco, you actually reach an eventual economic tipping point where people smoke less because they can no longer afford it.
And the inverse is going to be true for gestational carriers. And if you continue to increase the amount of compensation that is being offered, you're going to make the availability of gestational carriers less possible for those who have a medical indication in it and who do not have endless economic resources. You're also going to increase the proportion of people who learn to game the system and conceal their reproductive histories in order to be accepted as gestational carriers.
And you're going to get more and more people who say, I've had two babies, and here are my medical records for those two babies, and it's not going to be for their fourth delivery or their fifth delivery or their sixth delivery, and you're not going to know what their actual history is because they've learned what to hide, and you're going to end up with more poor outcomes. This is a comment, and if you want to respond, feel free to. Thank you.
This is a great conversation. Thank you. My name is Megan Raymond.
I'm an MFM genetics fellow at Hopkins, so I'm seeing everyone on the pre- and post-end of this conversation. I think I want to bring it back to the analogy of the organ donation as well. So, you know, in the U.S., we have, just like GCs are a limited resource, you know, organs are a limited resource, kidneys, livers especially, and those are unique, I think, organs as well compared to, you know, heart or lungs because you can have living donors as well, and so we always, you know, even though they are a limited resource, we do have this concept of altruistic donation, which I do struggle with this whole concept of even paying any GC at all, how we can justify that, and I hear the argument about, well, people will just go elsewhere, but we still don't allow the sale of kidneys or livers in the U.S. either, so I feel like that's not a fair argument in that way, and I struggle ethically with that, and then my other thought for you, and this is kind of more of a question, I guess one, do you have any ideas of how our societies can work together on this, MFM and REI, but the other piece of it is I'm thinking about the young woman in Georgia the past couple of years you might have heard about, who unfortunately, while she was pregnant, she suffered an accident where she was brain dead on life support, and her state did not allow her pregnancy to not be continued anymore.
She ended up delivering prematurely, and it was a bad outcome for both her and the neonate that was delivered, and I just wonder how do we stop a slippery slope from things like this, if we really even keep this structure of paying surrogates, having it be a commodity, somewhat the way it is in the U.S., and if you have thoughts on protecting the reproductive rights of GCs in general. Pro and con side, you can feel free to take off your pro or con hat and respond as an individual. Sorry, those are big questions.
So yeah, first thing that you brought up was amazing. I think sometimes patients come to us seeking a GC, and sometimes we'll kind of recommend that they meet with an MFM for preconception counseling, and you know, have your doctor send the note to us, and then we review the recommendations, but I think at most institutions in an ideal world, this would be a multidisciplinary decision where we could sit down and come up with the best plan for conception and pregnancy for those patients, and work together from the preconception stage that we're able to allocate these resources appropriately. And I'll put a plug for a talk tomorrow at 1 30 by my wife, who is an MFM, speaking on obstetric risks in ART to, I think, hash out this topic a little bit further.
All right, we have time for one more question. Oh, any thoughts on the reproductive rights thought? Just, I know it's a big thing, but it's something I struggle with myself. Is that something you think that we should be, like, legislating around? I don't know.
I was going to say, I think that that's a really important question. I don't have answers, certainly, but I appreciate you bringing it up, because I think we were almost too, you know, we already committed to this path of financial compensation, and so it's really hard to go back. But we are certainly in a position now where we're realizing the implications of that, and the potential for things to only get more scary and concerning, depending on, you know, where our patients are, and who is considered a person in the surrogacy relationship.
I think some of it stems from the, as I think people think of organ donation and surrogacy differently. Sorry, I'm adopting the term now, because that's what we're doing. Because, you know, organ donation is seen as this, like, definitive, final thing that's not, like, a natural process, whereas people become pregnant, you know, all the time.
And so the organ donation of a pregnancy is seen so differently as a different organ, but I don't have answers to your question. Hopefully somebody does. Can I just comment on this, because I've been looking into this.
We had a review last year. So I probably the better from the not supporters of surrogacy in the U.S. that's not altruistic. I think the comparison that's usually is made is to prostitution.
So it's commodification of female body and body and comparison of surrogacy to prostitution. But the difference between that is that in the U.S. it's still regulated. These surrogates are consented.
They consent to this. They know what they are doing. They are counseled.
They have psychological evaluation. They have legal support and legal contracts, and they can actually step out of it any time they want. So this is one of the biggest difference when they talk about the commodification of a female body, and that's what I, the way I understand.
I know Dr. Crockin is sitting here, and I'm talking legal things. That's wrong, but that's what my perspective as REI and justification for me feeling comfortable using the service with medical indication because we know that in the U.S. these surrogates or gestational carriers are protected, right? And we really try to go through their medical history and protect them medically as well, and that's our job in collaboration with MFMs. And we send as many patients with any concern to MFM to protect surrogates from being used by IPs that may not have very good indication.
Dr. Romansky, our final question before we close it out. Thank you, guys. I just wanted to, you know, say that was amazing.
I think all of you did so well debating this, you know, really complex topic over the last hour. I just wanted to pose one scenario for the con side. So you might have a patient, 40-year-old single female who just started a business a year ago, works, you know, six, seven days a week, has a team that completely relies on her.
The business relies on her. She's concerned about, you know, carrying a pregnancy. She wouldn't be able to take that much time off of work regarding recovery.
The business would collapse. All those that rely on her would lose their jobs. So she's interested in using a gestational carrier for this.
How do you reconcile that? What do you tell this patient? Sound familiar to anyone in the audience? I think it's a very complex situation. And while on the con argument side, I think ultimately there's a slippery slope for that exact explanation. I probably would say that it is not a medical or a psychosocial reason to provide a gestational carrier.
I think that there are a lot of people that have a lot of things going on in their lives that are very important. And to then say that that person's business employees, like that's clearly important. But that's then assigning a value, an economic value to that person that then allows them to have a gestational carrier.
So I would say that that's still, there are like certain like elite athletes or like, you know, psychological disorders or things like that, that I wouldn't say would be appropriate. But in that situation, it feels almost too elective. I want to provide a brief rebuttal to that.
You know, I think, not necessarily to equate the two, but I think if we're saying that this person doesn't qualify for or doesn't like rule in for a gestational carrier by whatever criteria we're using, then we're kind of making a judgment about their competency to be a parent and whether we should allow them to be a parent. And I think that is not a space that we as physicians should be getting into. Or at least like, not without like the help of like our ethics colleagues or it would have to be really well thought out.
But I'd be concerned that we're kind of equating, you know, whether we would allow a gestational carrier with like making a judgment whether they would be competent as a parent. Okay, so you tell her she can't have a biological child unless she's willing to give up her livelihood. So she goes home, she tells her family, her sister says, I would love to be a carrier.
So she comes back next week with her sister who wants to be a known carrier for her. Does that recommendation change or not? It sounds like you haven't written your assessment and plan on the note yet. You're looking for guidance.
And it's okay. You know, these are just like, obviously, these scenarios just get so complex. And there's always some other scenario that comes up.
This is where you should like bring it to your, like clinics, ethics committee, because it sounds like there's like an escalating interest that may not align with what your clinic can offer. And so being like a solo doctor versus having the weight of being able to say we discuss this in a room of experts and ultimately decided X, which is in accordance with our prior practices, would be like the next step, which I would imagine likely would probably say a similar thing that even in this situation, we still cannot offer a gestational carrier for these reasons. Yeah.
And I also agree with Francesca about how that economic and career indication alone may not be an adequate indication for an elective GC. But I think it also makes us realize that like the demand for elective GCs would dramatically decrease if we can kind of also put on our hats as advocates for women's health in general to make the conditions of pregnancy more tolerable in general. I think maybe instead of arguing the ethics of that, like that is also an opportunity to help reduce the demand for elective GCs and make it more favorable for women to carry pregnancies that they desire.
Thank you all. Thank you. Well, we went up to the buzzer.
I'm counting down at eight, seven, six, and five seconds left. We'll skip the closing arguments. I wanted to thank the panelists.
One more round of applause for our panelists. Fertility and Sterility recently launched a third podcast called FNS Roundtable. And this was one of the podcast episodes where they talked about medically indicated versus unindicated use of a gestational surrogate.
Thank you, Dr. Adamson. And you can listen to that wonderful podcast online wherever you get your other FNS podcasts. This concludes our episode of Fertility and Sterility On Air brought to you by Fertility and Sterility in conjunction with the American Society for Reproductive Medicine.
This podcast is produced by Dr. Molly Kornfield, Dr. Adriana Wong, Dr. Elena HogenEsch, Dr. Selina Park, Dr. Carissa Pekny, and Dr. Nicholas Raja.
