Welcome to Fertility and Sterility Roundtable. This podcast will delve into sections of the journal previously unexplored in the Fertility and Sterility podcast family. Articles that we would consider some of the most timely, cutting edge, thought provoking, and dare I say controversial.
We will be joined by a couple of the authors each month to explore the themes, debate the pros and cons, and generally expand our knowledge in a conversational format. I'm your host and FNS Interactive Associate, Dr. Emily Barnard. And I'm your co-host and producer, Dr. Ben Peipert.
We will be covering articles in the fertile battle and views and reviews portions of Fertility and Sterility. This podcast is brought to you by the Fertility and Sterility family of journals in conjunction with the American Society for Reproductive Medicine. Welcome everyone to Fertility and Sterility Roundtable.
I'm your host, Dr. Emily Barnard, and I'm joined by my producer and co-host, Dr. Ben Peipert. Today, we will be discussing the fertile battle from the April 2026 edition of Fertility and Sterility, which is entitled Is Concurrent Gestational Surrogacy an Ethical Practice? Now, for those of our listeners who aren't familiar with what concurrent gestational surrogacy is, this is where there are two gestational carriers or more engaged simultaneously where their pregnancies overlap to allow a single intended parent or couple to have children born without the typical spacing that usually occurs between births. And we're going to get into all the ethical considerations of that today.
We are joined by three of the esteemed authors of this publication to discuss the issue. And we're really excited to dig in with everyone today. So I'm going to start by introducing our guests.
First, we have Dr. Michelle Bayefsky, who is a second year reproductive endocrinology and infertility fellow at the Icahn School of Medicine at Mount Sinai. She has written a book and more than 30 peer reviewed papers on issues related to reproductive ethics and fertility preservation. She's currently a member of the ASRM Ethics Committee.
And for the purposes of this discussion, Dr. Bayefsky authored the pro side of the argument that concurrent gestational surrogacy is an ethical practice. Thank you so much for joining us, Michelle. Thank you so much for having me today.
We are also joined today by Dr. Caroline Violette. She is a second year reproductive endocrinology and infertility fellow at Brown University. Prior to fellowship, Dr. Violette obtained her medical degree from Emory University School of Medicine, and she completed her residency in obstetrics and gynecology at the University of Southern California.
Her research interests include oncofertility and addressing healthcare disparities related to access to fertility treatment in the United States. For the purposes of this discussion, Dr. Violette authored the con side of the argument that concurrent surrogacy arrangements are unethical. We are also joined by Dr. Arthur Kaplan.
He is a professor and the founding head of the Division of Medical Ethics at NYU School of Medicine in New York City. Dr. Kaplan served on a number of national and international committees, including chairing the Advisory Committee to the United Nations on Human Cloning. He's also a member of the Advisory Committee to the International Olympic Committee on Genetics and Gene Therapy and the co-director of the Joint Council of Europe and United Nations Study on Trafficking in Organ and Body Parts.
He's the author or editor of 35 books and over 890 papers in peer-reviewed journals. Dr. Kaplan was also one of the authors on the pro side of the argument. Thank you so much for joining us, Dr. Kaplan.
As a disclaimer, the authors for Fertile Battle, Infertility, and Sterility are chosen to represent the full breadth of opinions. And while these individual authors may be espousing one side of the debate, that does not necessarily mean they agree with all the viewpoints expressed today. So to kind of jump right into things today, I would love to have each side, you know, kind of summarize briefly your main points, and then we can kind of delve into things a little bit more.
So maybe between Dr. Bayofsky and Dr. Kaplan, we could talk a little bit about the pro side of the argument for concurrent gestational surrogacy. Yeah, Michelle, you want to start? Sure. So our basic argument was that although there have been several disturbing cases of concurrent surrogacy in the news in the last couple of years, making some big headlines, the issue, we said, was not the concurrency itself, but some other underlying factors.
So, for example, there was a case of somebody who was orchestrating multiple surrogacies from prison. So the issue there being more his inability to personally provide care for those children, or the relationship that he was maybe not envisioning having with those children, rather than the concurrency itself. And I would just jump in and say a couple of other ethics points.
One, we do give a lot of discretion to individuals to create families. And there are a lot of families created in ways that might not be the mainstream way. You can certainly build a family quickly by putting in a lot of embryos into an individual recipient.
So you might make multiple births and more than someone might expect. I remember the days when we used to talk about the amazing production of instant families, seven or eight babies all at once. There were certainly issues around that, but the number in itself isn't necessarily the moral hang up.
And the fact that something can be abused is probably not an argument in of itself against permitting it. It may be that we have plenty of practices that exist where somebody can abuse them and people do abuse them, but it doesn't mean that we're going to take away the liberty, the freedom, the opportunity from the majority because there's a minority who do abuse a practice. Those are really good points.
Thank you so much. And we'll of course get into that a little bit more. Dr. Violette, would you like to share a little bit, some of the key highlights of your points from the con side of the argument? Absolutely.
So the core of our argument is that concurrent gestational surrogacy we feel is shifting ART away from a therapeutic intervention towards more of a commodity. One that is designed to optimize the composition of one's family as opposed to addressing a medical need. And while we have the deepest respect for reproductive autonomy, we feel that this practice is exposing two or more carriers simultaneously to compounding medical and psychological risk.
It raises concerns about how their roles and their contributions are valued and concentrates access of an already very limited resource among those with the greatest financial means. And ultimately we feel that the same family building goal almost always can be achieved through sequential pregnancies without any of these additional ethical concerns. And are there certain groups of people or certain types of patients that are more interested in concurrent gestational surrogacy? We've found just anecdotally that sometimes it's same-sex male couples who want to each be able to contribute genetically to the birth of one child and they just want to have two kids and knock out their family building at the same time.
So in our view that was not inherently unethical and there's no particular reason to think that babies born into those families wouldn't be loved and cared for and adequately nurtured just because they were born at the same time. Michelle, we saw another instance I think, you correct me if I'm wrong, but just some people who are getting older and wanted to create a family more quickly than they otherwise might have. They had concerns ranging from aging gametes all the way out to aging bodies and would they be able to parent adequately? But I think that's another motivator.
I think the counterpoint to that is in thinking about valuing children and I certainly would give each intended parent the benefit of the doubt that no one intends to go into having a child to value them any less. But I think you know the comparison to twins for example is that twins are most often spontaneous right? It's not an intentional decision to have two children born at the same time and I think when we're talking about concurrent surrogacy it's a very intentional structural decision to have two children born at the same time that feels in some ways more like family design as opposed to family building. And I think that that can be a slippery slope and you know certainly the examples that you've brought up are extremely sympathetic and as REIs we all want to help our patients achieve their family building goals.
But I think we have to be extremely careful with how we allocate the resources that we have. I mean I think the resource allocation issue is one you mentioned a couple of times now and I would be taking that seriously except there are so many barriers in the whole field that are based upon you know lack of resources to access. I'm not sure you know just picking out the fact that not everybody can go retain a number of surrogates at the same time that's true but you know it hasn't stopped us from making other things where people can't easily afford them available in the infertility field at all.
So I'm not sure I'm not persuaded quite yet that you know picking out access based on ability to come up with the payment for that is going to be persuasive just on this practice. The other is people tend to forget it and I'll concede that it doesn't happen very often but there are altruistic instances of this. Years ago I did have a case where two sisters did it you know for the third sister and nobody was getting paid and I'm not saying that's an altruistic concurrent surrogacy doesn't have a big future I don't think but you know we again you're in an area where sometimes you got to really look at the individual case.
I actually do think that the justice and the resource allocation argument has some merit because I think that gestational surrogacy is really out of reach for many many people because of its cost and so if people are able to afford multiple gestational carrier arrangements at the same time they may also be the people that are able to pay more and you know people who can't afford it are going to have a harder time accessing gestational carrier arrangements so I do think that that is an important issue which is why in our article we actually do recommend capping concurrent surrogacy usually at two maybe there might be certain circumstances in which more than two could be appropriate in a very limited sense but I do think that's an important argument. Although I'll turn our own argument on its head I'll stand in for you Carolyn now going to fight with my co-author. It isn't so much the concurrency as it was the paid surrogacy right that's what got us nervous so if surrogacy was cheap or you know the government subsidized it or something I don't think we'd use that just as the you know that wouldn't solve some of the opposition I suspect is where I'm headed to the idea.
Michelle's right that is why we decided one of the reasons that maybe a cap of some number made some sense. I think one thing I would add is we know that financial disparities already are existent within the field of ART I think that's absolutely true and so I think to look at it in a different way perhaps that's a reason that we should be even more judicious and cautious with how we allocate certain resources and be aware and thoughtful about practices that could further widen the gap that already exists and I think you if we're viewing gestational carriers as a therapeutic intervention for a medical need those resources should be allocated fairly and not distributed just to those who have the extraordinary wealth that it would require to hire to work with multiple gestational carriers. I find this idea of a cap to be really interesting because it kind of concedes on the pro side that there may be some problems to having multiple concurrent gestational carriers at least at a point.
From your perspective what ethical arguments beyond a justice-based argument would you use to say that there's a difference between two and three concurrent surrogates for example? That's a really good point and I think that to some extent it's hard to be non-arbitrary. I think what we find in practice is that people who are wanting to do more and more and more at the same time tend to have some other problematic circumstances you know like the cases that have come out in the news and what we really really want to prevent is children being treated as a means to an end. So these cases where people say I want to have many children because I think my my genetics are incredible and I want to spread them in the world or I want to you know people have said explicitly I want to have you know many children so that they can run my business later or that I can marry them off to important families in my community you know that's that's pretty disturbing stuff because you're treating that child as a means to an end and I don't know that the difference is between two and three or two and four or even two and five but I do think that once you get higher and higher and in the numbers of concurrent surrogacies that are being attempted at the same time that it it's kind of just raising a red flag so I should say it's more of a marker of some of the other things that are deeply problematic and less of a very clear justifiable line in the sand.
So just to add a little amendment there I think one of the things we're thinking about is yes reproductive autonomy very important but it's not the be all and end all and those in the field have some duty to look out for the best interests of kids that are created in unusual different or medically assisted ways. I mean it's access to the technology in a sense that we're arguing about if someone wanted to go out and have affairs or make arrangements with people and make multiple kids you know just by sexual means if they weren't infertile we we haven't banned that we haven't said you can't do that sort of thing there are polyamory situations there are definitely groups that have multiple spouses for someone and could easily create pregnancies at the same time so I think part of the issue Ben is what can we say about our kind of feel or hunch about best interest is it good to have a parent or parents all of a sudden have five kids to care for all at the same time pretty tough difficult challenging may not be in the kids best interest on the other hand if they're super rich and they have help all the time and you know somebody could spin a scenario for me where I'd have to say well yeah I guess maybe they could handle that I was laughing because my next door neighbor just had a conversation with him outside he got divorced he's been living in the house across from us rattling around in it with two little girls 10 and 7 well anyway he met somebody in town in my town here in Connecticut and it looks like they're going to get married move in together and she's got three girls so they're going pretty quickly to a five all-girl family and you know we were joking and all of us think Brady Bunch and other cultural memes about this situation but I'm not worried that they can't handle it and I'm certainly not something I would say oh well you can't build a family overnight that way and go from two to five so I have something of that reaction I think Michelle does too about you know it's hard to say when there are too many kids all at once too much but it's like 30 yeah and two no I think you know one thought I have about these extreme cases that we're kind of alluding to that have been you know high profile in the news over the last couple of years and I think what makes some of these cases feel uncomfortable at least for me is that they're amplifying some concerns that I suspect are already present just on a smaller scale right we're talking about things like commodification power balances things that we've already touched on and I think it's easier for all of us to say okay working with two gestational carriers feels more or less permissible but 10 feels egregious but that distinction feels more like it's based on intuition as opposed to some data-driven clear ethical boundary and so I would argue that this is more of a spectrum and as we kind of progress along that spectrum Michelle as you were saying like it becomes more and more visible that there are ethical concerns and sort of red flags that underlie the motives so I think at least in my view it's less about where we're drawing a hard line and more about evaluating the practice kind of at its root and minimizing harm where we can and I think you know on the autonomy spectrum I agree there's many situations in real life sort of outside of our office that transpire that people build families in all kinds of ways but I would argue at least within the realm of what we are able to control and the services that we provide as REI physicians autonomy isn't infinite and you know I think we have a role not to facilitate every request that we receive and it's our obligation to self-regulate and try to practice within boundaries where we can. I totally agree with that I think it's really important you know to have boundaries and not just to always say yes because we do care so much about reproductive autonomy and we know that reproductive autonomy is not necessarily being respected everywhere and so we empathize with that with our patients deeply but there is a but which is that you know sometimes we have to think about what's in the best interest of the and how what we feel comfortable with as medical providers.
On the other hand we just have to make sure that we're doing that in a really non-arbitrary way because it's really easy to imagine a scenario in which a particular provider might just get kind of a negative feeling about a particular person or couple and maybe that's based on a bias because we're all you know human and have biases and it's not necessarily based on anything more objective so I think as the ASRM guideline on child rearing ability and the provision of fertility services talks about it's just important to have policies laid out in advance that you discuss as a group as a practice for example or as a society at large in order to make sure that we're not making arbitrary decisions on a case-by-case basis. Who do all of you think is best to sort of get to the root of some of the motives you know I think ASRM does recommend a social work consultation psychological evaluation that kind of thing but is that something we as clinicians just say okay we're going to put that on this person to decide or is that something that we need to be deciding yeah I'm curious your thoughts on that. That's a hard question to answer I think psychiatric evaluation or psychological evaluation is very important in all third-party cases you know ASRM recommends that I'm sure most practices do that whether they employ someone themselves or they have someone that they work with who does that for them.
I think most of the burden probably will be borne by that person but not necessarily alone I mean they can say I have a feeling that and then it becomes a group discussion maybe with you know multiple physicians in the practice I know many practices would have like a an MD meeting or a division meeting or something like that to discuss and it makes sense to have recourse whether that's like a second psychological evaluation or something like that because it is it is a lot to ask one person to do but I think I think it's reasonable for them to be the ones that are kind of raising the red flags if they are seeing them. I totally agree I think it's challenging I think the trouble with having the psyche about which I think is an important component to these cases as you mentioned is that most intended parents I would presume are going to have you know good motivations and most likely are not going to raise major major red flags as we see in these sort of fringe cases and so I think that's where it becomes really difficult how do you parse apart you know what is ethically sound and what is not I think I fear that it can become arbitrary when there isn't more clear guidance and I agree it's a lot to rest that upon one psychologist for the practice. Yeah it's interesting I think when I think evaluation I think competency are they able to make a decision can they you know make a true choice and understand the consequences and so on that tends to be what my psychology psychiatric friends say they do in evaluations if you said to them evaluate motives evaluate why someone's undertaking this some of them are going to say we don't do that that isn't part of what we evaluate we'll we'll decide if they have abilities and skill sets but we don't get into their motives so I don't know I'm not sure about whether you could really ask for a specialty consult to determine the morality of what's being undertaken I think the provider does have to probe a bit for motive or rationale because I think most of the people who come in here want to do all this and they get this far they're pretty competent they're not going to flunk that that side of the street but I did want to flag something else which is you know we also have to be worrying about is the surrogate or surrogates are they adequately empowered and protected I mean one of the problems of surrogacy you know that you encounter again and again is no lawyer for the surrogate they may not have a great educational background maybe poverty maybe abuse maybe someone's coercing them I think in some ways evaluation of the would-be surrogate or surrogates would be better than trying to probe motive on the commission what I'll call the commissioning person or couple I'll just say that they already do that so that this part of the psych eval it's it's for the parents but definitely the motivations of the gestational carriers are also evaluated specifically the motivations because the the idea is that hopefully there would be some altruistic motivation in addition to wanting the compensation that comes with commercial surrogacy so we do already ask our you know our psychiatrists or psychologists or social workers to evaluate motivations on the side of the gestational carriers so I don't think it's you know where we've got multiple poor women in a sort of sketchy environment and some are overseas some are here I don't think anybody's bringing them a lawyer but if we said you ought to have adequate representation you ought to have a clear contract you ought to know what your rights are that sort of angle my sense is that I mean I I think those cases may be the ones that are hard to track but as a as a minimum requirement for signing a gestational carrier agreement that's going to be valid or we're going to be respected or upheld in any way they do need to each have their own representation yeah yeah so I I think that that really is this the standard in the United States I do worry you know about how things may work in some other more lower income countries but I I'm I'm hopeful that that that doesn't really happen in the U.S. too much.
Carolyn if we said we're going to make sure that the people seeking the services really are in need of infertility help we're gonna have some sort of probing of motive of the person who's trying to do concurrent surrogacy we're going to make sure as best we can about defending the rights and best interests of the surrogates does that package does that go far enough to then let us tolerate the practice? I still think that there are ethical concerns despite even if you package it in all of those you know doing the best that you can and being diligent in all of the ways that we can control I think that there are still several underlying ethical concerns that we can't control for one example that comes to mind is a power dynamic that is going to exist and I would concede that there is a power dynamic even in a single intended parent couple or individual with a single gestational carrier and that you know is something that would have to be handled with care and has nuance but I think when you introduce multiple gestational carriers you've now not only amplified that right but you've now introduced this new relationship between each gestational carrier and I feel that there's some sort of implicit competition you know does a gestational carrier want to be perceived as the more flexible one doesn't you know feels pressure to comply with the same agreements and expectations as the other perhaps that would make her less likely to advocate for herself or to feel less empowered to do so and so I think you know to Professor Kaplan's point even if you try to arrange every detail in the best way that you can I still worry that there are underlying tensions that can't be overcome. I think that those are all really valid hypothetical concerns but I think that in practice so I have an ongoing research study so I haven't published this yet but it involves interviewing reproductive lawyers who work on gestational carrier agreements around the U.S. essentially and from what I can tell it seems like actually the power is lying increasingly in the hands of the gestational carriers and they are learning more and more it sounds like to advocate for themselves which most people I think generally thinks of as a as a positive development well I definitely see that concern and to situations that Dr. Kaplan alluded to that maybe are maybe aren't the types of situations that I was speaking to people about because they wouldn't have had those kinds of lawyers you know I can't say for sure that they don't exist where there is that unfortunate dynamic where the gestational carrier feels unduly pressured I think for the most part actually gestational carriers are able to advocate for themselves or at least to a greater extent than prior and you know I think that's overall good news and you can imagine that if you're a family that's trying to balance multiple gestational carriers all of whom are hopefully able to advocate for themselves that actually might lead to the opposite kind of power imbalance which again is hypothetical I think it might be different on a case-by-case basis but that's just to say I don't think that necessarily has to be the case. Building off that I think one of the arguments that was brought up very well in the fertile battle was this issue of transparency with the gestational carriers I kind of have a compound question so the first is how often is it explicitly communicated to the gestational carriers if they're part of a concurrent surrogacy arrangement and if we feel like there's a lack of transparency there is there an ethical obligation to make sure that all the gestational carriers are aware of the concurrent activities of the intended parents? So one thing that I actually learned by speaking with these lawyers not to give away too many of my findings so there's an organization called Quad A which is the Academy of Adoption and Assisted Reproductive Attorneys that many reproductive attorneys belong to and Quad A comes out with guidelines ethical guidelines and one of them that they came out with pertains to the need to inform gestational carriers if they are part of a family's concurrent journey so I do think that even if ASRM hasn't necessarily actually that's not true ASRM also has said that you need to be transparent on this particular question so I think the lawyers and the doctors are aligned that it's important for the gestational carriers to know about it.
I would echo you know Michelle's points and I appreciate the sneak peek into your into your research I'm excited to to read more but I would say you know I think we can all agree that transparency is paramount you know you can't have informed consent that is valid if the gestational carrier is not informed about all parts of the situation that's at hand but I think transparency is an issue because we are assuming and hoping that the patients who come into the office are being transparent and we know that that may not always be the case and we don't have right we talked about a registry I think and you're part of the piece and I think there would be challenges associated with that but because that doesn't exist we're reliant upon the transparency of the patients that come into our office. It is difficult to know what's happening and I think that's a big concern especially in these sort of bad actor type cases when we're relying on the trust that people have with their doctors that they're open with what they're doing we're relying on agencies which are you know regulated to a greater or lesser extent depending on the state really and the lawyers as well and we're just hoping that everyone is is doing the right thing and is is speaking up when there's something that needs to be mentioned but it's it is entirely possible that somebody can be working with multiple carriers in different states with different agencies and different fertility clinics and we just wouldn't know. You know one other thing that comes up with respect to transparency is if you call for it and it isn't manifest does the field and the practitioners in it and the emphasis of whoever do a good job calling it out or condemning it or criticizing it I mean some of these hyper notorious cases I'm going to try and have children from prison you get some negative comments but I'm not sure you know if we're going to rely on the field to police part of self regulation or let's call it field regulation is you got to be willing to speak up and say when something isn't being done optimally.
You bring up a good argument Dr. Kaplan that if if we as a field don't start policing ourselves with some of these bad actors and some of these very egregious motivations to pursue concurrent surrogacy I think we risk inviting additional regulation in ways that we may not be happy with. These situations represent I think a call to action in our field to start thinking critically about how do we want to invite some stronger guidelines and stronger rules so that we can maintain control over the types of care that we're able to provide our patients. I think that's really important but I also worry that preemptively creating rules that we don't fully agree with or can't fully justify is just going to set us up for people not following those rules because ASRM guidelines are guidelines and they're you know strong recommendations and most places do abide by them or do their best to most of the time but not all of the time and so that's just the nature of self-regulation where we are a group of people that represent a bigger group of people and to some extent if you tell all those people to do something that they don't want to do it's just not going to you know it's not going to work anyway so we have to be we have to be cognizant of that as well.
Yeah one way to perhaps move in less than hard rules or bans or sort of blacks and whites is points to consider. There are regulatory areas say releasing information on genetic testing before it's been validated but it's still raising concerns about disease risk. A lot of geneticists are struggling you know when is it time to tell a patient that they may have a high risk factor for something even though the data isn't totally in and they're not sure they kind of do it with what I'll call the points to think about this think about that think about this and some of that type of education may be useful and it may be useful dealing with the media a lot of these things are going to get adjudicated in the court of public opinion basically it's not like anybody's going to come and arrest anybody at the end of all this but you get a bad reputation or people feel you know I can't do that again it's going to hurt my image in the community kind of stuff.
To that point I think you know the ASRM Ethics Committee opinion while is somewhat ambiguous about this topic they're not necessarily neutral you know I think that they have put very explicit statements in their ethics committee opinion about this situation you know they say specifically that engaging multiple carriers could be a reason that an intended parent and a gestational carrier are misaligned in the practice committee under reasons or criteria why an IP might be rejected it's listed that you is interested in engaging multiple gestational carriers and so I think you know Michelle is right they're just strong recommendations right there isn't necessarily any repercussions behind not following these but I think that we would benefit from having more explicit clear guidance if for nothing else then how do we evaluate these cases if we're expected to evaluate it on a case-by-case basis and use our best judgment is there a better framework by which we can do this so that there's less variability between providers and I think that would be at least a good starting point. Let me give a quick example of what I'm talking about with respect to self-regulation some years ago I was at I got invited to go to Cold Spring Harbor and meet with people who are interested in germline engineering they're all working animals not people but there was a guy there from China who kept saying I'm going to try this in humans and asking people their opinion about human embryo genetic engineering for various disease elimination or prevention reasons and it was being discussed at lunch and being discussed informally but nobody did anything and the next time we heard about that guy was when he announced that he had tried it at a meeting in Hong Kong and he's still rattling around promising to do it but my point is I'm not sure that field or any field or the emphasis or whoever you really have to stress that if you have concerns writing about them talking about them in the abstract writing an op-ed these are good it's the way you sort of till the moral field a little bit without necessarily having a court standoff and people screaming for bans and that sort of thing no you write about them in fertile battles or write about them in fertile battles one other case that came up just to make it fully complicated about motive this was years ago I admit and may not be as necessary today but there was a situation where concurrency was being used in to generate a bone marrow donor so there was a kid they were looking for a donor and they were looking for a donor fast that's that's a really hard case especially when it comes to the means to an end argument but then maybe they're not mere means maybe they're you know you probe and you say you're gonna love your even if they're not a match and there's like sure of course you know no one's gonna say nah they're just a tool and a vehicle to get bone marrow but they wouldn't come into existence unless that need was there it was pretty clear you know they weren't planning to have more kids they were doing it for a reason to help an existing kid I struggle when we get into the realm of the non-identity problem and the you know they wouldn't have existed otherwise type arguments because I think that it just sets the bar too low you know existing or existing with a pretty bad life it's not a good thing even if it's maybe slightly better than not existing so I do think the non-identity problem kind of rears its head in these in these conversations about when it's reasonable and justified to bring a kid you know into existence the problem here is it slides down a slope and pretty soon you wind up in that position that some church groups advocate for which is you've always got a maximum you know you've got to be very fruitful constantly creating lives you can't stop and you should genetically engineer all of them so that they live the best lives yes so as a clinician if an individual or couple is coming to us and they're contemplating their options they're considering concurrent surrogacy they have the means to do that how do you think is a good way for us to counsel them on the potential considerations the things we want to think about the pregnancy complications perhaps for the carriers the the social things we've been talking about how how would you as clinicians talk to patients about that kind of weighing the pros and cons and someone who's considering this I think it's a lot to cover right I think you know certainly when we consider the options between concurrent surrogacy and potentially you know multiple embryos and risky twins we eliminate the obstetric risk associated with the transfer of multiple embryos but I do think that a lot of the psychosocial challenges and practical challenges of having two children born at the same time remain and I think it's very difficult to counsel a patient or for anyone to fully grasp or understand what that might look like until it's happening and there's a lot of hypothetical scenarios that would be difficult what if one gestational carrier has pregnancy complications delivers prematurely in another state and the other is full term and is in a different state I mean logistically how does that work and how do you plan for all of these different hypotheticals I do think an important counseling piece is to share the data that demonstrates increased rates of parental stress strain on financial resources and postpartum depression things like that that impact parents of closely spaced children and so I think that is very important information that we share with these patients as they're considering this option another option from the clinician's perspective I think is to stagger the pregnancies a little bit so they can still be maybe concurrent but at several months apart so that you or the embryo transfers would be several months apart so that you would make sure or at least you know you can't fully make sure but at least to minimize those kinds of situations coming up because it you know that would be very stressful for a family and you do want to make sure that every gestational carrier and every newborn is getting the kind of adequate care that they deserve but it's it's fairly unlikely to begin with given that these are people who've had tested healthy pregnancies in the past and if you stagger it a little bit that would make it even less likely one thing I like in those situations is to begin maybe with showing people some videos educational materials about what's involved and what does it mean to be a surrogate and what does it mean in terms of economic impact psychological impact maybe some voices of people who've done it who liked it who didn't like it who mixed feelings about it sometimes I think in our counseling we don't use all of the sort of low-tech video opportunities that are available to us to let people take things home and think about it you know you may want to have them go talk to their religious leaders if they talk to any of their family members about it why why not you know what's the reaction going to be from them if they go through this and so on so I like beginning counseling with some broad paintbrush swaths about what's involved here and who might be touched and impacted if you go ahead and do this yeah I completely agree Professor Kaplan I really think that sometimes we miss out on the opportunity to lean into narrative ethics and think about the potential paths that one could end up on while pursuing something like concurrent surrogacy I think that with some of the populations that we think more of you know we jumped to thinking about a same-sex male couple pursuing concurrent surrogacy as being one of the more common examples and I think that every couple who's engaging with this thinks about this going beautifully and amazingly well and they think about this ideal version of the family that they're going to be able to have with raising these two beautiful children at the same time but the reality is that even in the best of scenarios we're looking at a 60 percent live birth rate with a gestational carrier and a high quality embryo and so that idealized narrative may not become a reality for a significant portion of patients who are pursuing this option and I think that that is a really important part of the counseling if you're going to even consider inappropriately spaced concurrent pregnancies when you're talking to your patients about that option one of the things that Michelle has been working on and I think is very important she's doing a job and I hope it gets emulated is to go out and survey and ask and study so there is a lot of empirical information we can gather again it's not always definitive just because you know a poll shows that a lot of people don't like civil rights doesn't mean that they're bad it's just it's nice to know where you're starting from so I think that kind of work in this area concurrent surrogacy but you know across the board in many of our more thorny ethical issues in reproductive matters that's to be encouraged so if you're listening and you get the urge to get involved in some of these arguments I think plenty of empirical both qualitative quantitative work to be done I could not agree more I think there's there are a lot of things that we are worried about that we're afraid of and they're important they're interesting ethical issues are important ethical issues but they might not even be the right things all the time to really be focused on or to really be worrying about and so I think it's really important to learn more about what's actually happening and we hear a lot about you know these bad cases in the news and we really should work hard to avoid those kinds of cases occurring and you know do better and try to try to limit that for the sake of the children that are coming into the world but there's a whole lot more going on most of which is is positive and it's helping people have families that you know would otherwise not be able to so I think I think we just need to keep that perspective in mind we want to say thank you to our three guests today Professor Kaplan, Dr. Bayefsky, Dr. Violette I would encourage everybody after listening to this podcast if you're interested please go read The Fertile Battle April 2026 that's where you can get more information on this and I think as gestational carrier pregnancies become more and more common a lot of us are going to be dealing with this in clinical practice so it's really important to think of all these ethical considerations as we take care of patients and help grow families so thank you to our guests thank you to our listeners and we'll see you next month thank you thank you Fertility and Sterility Roundtable was developed by Fertility and Sterility and ASRM as an educational resource and service to its members other practicing clinicians and members of the public the opinions expressed are those of the discussants and do not reflect the views of Fertility and Sterility or ASRM
