Podcast Review: SART Fertility Experts — Gestational carriers

'Gestational carriers' was not a term I had ever heard prior to being asked to review the latest podcast produced by ASRM Today and SART Fertility Experts. I think that this in itself exemplifies the differences between the UK and the US, which were very obvious throughout the podcast.

The podcast featured a discussion with Dr James Goldfarb on the topic of gestational carriers and surrogacy. As the doctor responsible for the world's first gestational carrier baby he is a leading expert on the subject, and he spoke knowledgeably on a topic that can be complex from both a biological and legal perspective.

Dr Goldfarb began by clarifying any unclear terminology. For those also unfamiliar with these terms, a gestational carrier refers to a woman carrying a baby that is not genetically related to her, whereas a surrogate is someone having a baby for somebody else using her own eggs. In the US, these two terms are an important differentiator; 'surrogate' might be used interchangeably in general parlance, but surrogacy itself is not something that is commonly carried out by clinics. In the UK, gestational carrier does not appear to be a term that is commonly used: a point that reflects the differing regulations between the two countries.

The rest of the podcast provided background as to when and why gestational carriers might be used in assisted reproduction, technical details as to how the process has improved over time, and the legal and medical procedures involved with finding a suitable gestational carrier. The background information provided in the podcast might be interesting to an international listener, but it is important to note that whilst commercial agencies exist in the US to pair gestational carriers with prospective parents, it is illegal to pay for surrogacy in the UK. Therefore, I felt that the legal and financial information would only be relevant to a US audience, or for those looking to pursue assisted reproduction in the US.

The US has seen a big increase in the prevalence of gestational carriers in recent years, from an average of 3200 births a year in the early 2000s to 4600 in 2017. As a proportion of births as a result of IVF, gestational carriers have also seen an increase, from 2.6 percent to 4.2 percent on an annual basis. According to Dr Goldfarb, this increase can be attributed to a number of different factors. Gestational carriers were originally an option pursued by women who did not have a uterus and were therefore unable to carry their own baby. Now, women who have an abnormal uterus or a medical condition that would be exacerbated by pregnancy might look for a gestational carrier, as might couples that have been through a number of miscarriages or failed rounds of IVF treatment. Dr Goldfarb also mentioned that an increase in the number of same sex male couples or single men pursuing fatherhood has resulted in an increased demand for gestational carriers. This data is better documented in the US than in the UK owing to the differing legal frameworks, but surrogacy in the UK also appears to have seen an increase, albeit on a smaller scale, over a similar timeframe.

The podcast moved on to discussing the process of finding a gestational carrier. As mentioned, in the US this might involve an agency, but Dr Goldfarb also emphasised that many gestational carriers are relatives or acquaintances of prospective parents. Regardless of the route through which they are found, all gestational carriers must undergo a rigorous screening process to ensure that no unforeseen problems arise during the process: a system that might involve the agency, a physician, a psychologist and lawyers. Both the parents and the gestational carrier must have independent legal advice. To reiterate, this is not the case in the UK, where such agencies do not exist and where independent surrogacy agreements are not law enforceable; the woman who gives birth to the baby is the child's legal mother, and a parental order must be issued by a court for legal parenthood to be transferred. Subsequent discussion around the financial cost and legal framework of using a gestational carrier are also irrelevant to the UK, but at a projected total of over $100,000, this is clearly not a cheap procedure to pursue.

Dr Goldfarb then summarised how the technology has improved since it was first developed, which I felt did have international relevance. If not using an egg donor, the first step is for the biological mother to undergo normal IVF preparation – something that was described as time-heavy rather than a complicated medical procedure. A major advance here is that the mother and the gestational carrier no longer need to be synced on coordinating hormonal cycles; more efficient technology means that embryos can be cryogenically preserved until the prospective carrier is ready to be implanted with the embryo. This also ensures that embryos are viable before gestational carriers start their own hormone treatments.

The episode ended by touching briefly on the ethical standpoint of using gestational carriers. Although they concluded that most gestational carriers are not motivated by money, and genuinely want to help individuals who would otherwise not have a child who was genetically related to them, there was no mention of exploitation of low-income women as a result of international paid surrogacy agreements.

As someone who was very unfamiliar with this topic before listening, I did learn a lot from this podcast. However, a great deal of information provided in this podcast is only relevant to the US. For a US listener who is interested in learning more or pursuing this route, the podcast would be a great place to start; for an international audience, other podcasts or websites that are more country-specific would probably be a better source of information.