Lessons from Uruguay's first gestational surrogacy case

For more than ten years, gestational surrogacy in Uruguay existed in a state of legal latency: provided for by law, carefully regulated as an exception, yet without a single birth to make it real.

That situation changed with the arrival of the first baby born under this framework – an event that activated, for the first time, the legal, clinical, and administrative structure designed to protect all parties. And, as often happens when a norm encounters its first concrete case, what emerged was a mix of institutional competence, professional creativity, and gaps that require urgent attention.

A brief overview of the case

The intended mother had Rokitansky syndrome, also known as Mayer-Rokitansky-Küster-Hausera (MRKH) syndrome, a congenital malformation that makes pregnancy impossible. Her only viable path was egg donation combined with gestational surrogacy. The surrogate was her sister, in line with legal requirements in Uruguay. Using the intended father's sperm and donor eggs, embryos were created, one of which was transferred after completing the full authorisation process.

The pregnancy progressed without complications, with the intended parents involved throughout, and ended in a scheduled caesarean section. At birth, the baby was handed to the intended mother, while her sister – the surrogate – received clinical and emotional support, including lactation suppression.

A precise and restrictive legal framework

Uruguay regulates surrogacy as an exceptional process under strict State oversight. It may only be used when there is an absolute medical impossibility to carry a pregnancy, and the following legal requirements are met:

1. The surrogate must be a second-degree relative by consanguinity.
2. At least one gamete must originate from the intended parent(s).
3. No economic compensation is permitted, except for strictly medical expenses.

A rigorous two-stage approval process complements these conditions. First, the Honorary Commission on Assisted Reproduction evaluates the medical indication, legal compliance, physical and psychological health of all parties, and the absence of coercion or vulnerability. Second, the National Resources Fund assesses medical pertinence, requires specific studies, and determines whether high-complexity techniques should be covered by the State.

Approval by the Honorary Commission is mandatory, and approval by the National Resources Fund is required when private coverage is absent. This model protects the surrogate, the child, and the intended parents. But it also establishes such a demanding threshold that in ten years, only three cases were initiated for approval – and baby V is the first to be born.

When there are no protocols: building practice on the move

The case exposed a critical point: although the law sets clear conditions, Uruguay has no national protocols or good-practice guidelines for gestational surrogacy. The clinical team had to design multiple ad hoc measures, many of which were decisive for emotional well-being and legal safety.

This included expanded interdisciplinary meetings, which involved neonatology, psychology, and social work, to plan roles, timelines, logistics, and the management of sensitive information, and a differentiated hospitalisation plan to ensure privacy, prevent emotional strain for the surrogate, and secure an immediate bonding environment for the intended mother. Further measures included designing a predefined documentation plan, specifying who would sign which forms, how the birth certificate would be issued, and how to avoid confusion in the delivery room. The team also offered continuous psychological support, essential for both parties, even though not required by regulation, and adapted their postpartum protocol to include lactation suppression and emotional and clinical follow-up for the surrogate.

These practices emerged from the expertise and ethical awareness of the professionals involved – not from the regulatory framework. The absence of official guidelines places excessive weight on individual judgment and generates avoidable risks.

Structural challenges and grey areas

Although surrogacy has been regulated since 2013, this is the first case to be approved and result in a birth. Other processes began but did not complete the circuit. The data reveal a system so restrictive that it operates, in practice, for an extremely limited group. For example, the current framework excludes male couples who cannot meet the familial requirement nor provide a uterus, and women without eligible relatives, even if they have a clear medical indication for seeking surrogacy. The prohibition of double donation also excludes those unable to provide gametes.

Furthermore, the absence of national guidelines may lead to potential disparities between clinical teams and regions, and there is a lack of definitions regarding leave, benefits, and labour protections for both the surrogate and the intended mother. There is also a lack of regulatory guidance as to the allocation of responsibility for maternity- and childbirth-related medical expenses, as well as for the provision of mandatory health insurance and life insurance coverage for the surrogate. The case shows that even a well-intentioned regulatory model requires revision to ensure access, transparency, and equity.

Conclusion: the need to systematise good practices

Uruguay's first birth through gestational surrogacy is more than a clinical milestone: it is a mirror. It reflects a strong institutional tradition, a secular framework committed to rights protection, and a system capable of acting with care. But it also underscores the need for national good-practice guidelines, clinical standards, and procedural frameworks that offer legal certainty, consistency, and comprehensive protection for all involved.

It also highlights the importance of sustained ethical and legal support to optimise assisted reproduction processes and to ensure institutionalised, durable standards for future cases.