Since the closure of unregulated surrogacy destinations, Ukraine, where commercial surrogacy is legal for heterosexual couples, emerged as a massive hub for both donor eggs and surrogacy. The Russian invasion has had flow-on effects for cross-border reproductive care globally.
At last month's annual ESHRE Conference in Milan, Italy, I spoke in an emergency session on the impact of the Russian invasion of Ukraine on cross-border reproductive care for foreigners. My co-presenter, Ukraine-based embryologist Dr Birol Adyin pointed out that by 2019, the nation was churning out 37,000 IVF cycles annually, a 57 percent increase compared to two years prior. At the time of the invasion, Ukraine had as many as 60 IVF clinics, 500 fertility specialists and 200 embryologists. When bombs starting falling, Ukraine's embryology labs housed well over 800,000 embryos and oocytes.
What factors fuelled such a massive build-up of gametes in one country? Ukraine's role as the European hub for third party reproduction was as much accidental as it was planned. When, between 2013-2015, countries in south-east Asia closed their (legally) unregulated programmes down one by one, the new mantra became certainty. This meant a focus on jurisdictions with legislative frameworks supporting foreigners engaging in surrogacy. These existed in very few countries: the USA, Ukraine, Georgia, Russia, Canada and Greece. Moreover, these last two jurisdictions operate under altruistic frameworks, meaning their capacity to recruit and properly screen surrogates is limited.
Ukraine's large population from which to draw surrogates and donors as well as low cost, high quality IVF, led many thousands of infertile couples to engage in accessing these in Kyiv, Kharkiv and Lviv for surrogacy arrangements. Ukraine also became a major source of frozen oocytes for some of the largest donor IVF programmes in countries such as Spain.
Infertile couples engaging in surrogacy in Ukraine or using Ukrainian oocytes in other countries come from across the globe, driven by poor or no access in their home countries. A recent Monash University study, presented at the Fertility Society of Australia and New Zealand Annual Conference, co-authored by Professor Andrea Whittaker and I showed that over half of intended parents accessing Ukraine surrogacy over the three years 2018-2020 were from China. As well, large numbers of Americans, priced out of surrogacy in their own country, were accessing surrogacy in Ukraine.
In the early days of the war, as Russian attacks became more intense, dozens of IVF professionals decided they had to act. Unlike Ukraine's other major exports – grains, iron and steel – oocytes are not reliant on access to its Black Sea ports. As long as transport times are not prolonged, they can instead be carried by road. The issue was – who would do this?
Within days, many embryologists decided to risk their lives to transport gametes from Kiev to more secure regions such as Lviv in their own vehicles. A small fraction (estimated at some 55,000 embryos) were re-housed in neighbouring countries such as Slovakia.
For some Ukraine clinics, their quick thinking has saved their donor oocyte business. However, for foreigners with Ukraine embryos they want shipped elsewhere, the options are few. The paperwork required to ship human embryos is complex. Many clinics, struggling for survival, have been reluctant to assist. As well, given anonymity is the default donor type in Ukraine, countries with bans on donor anonymity like Georgia, Australia, Ireland and the UK simply refuse to countenance accepting these gametes.
Russia closed down access to surrogacy for foreigners over a year prior to its invasion of Ukraine. This too has added to the hugely increased demand on surrogacy in the USA, Georgia, Canada, and Greece. This pressure along with flow-on effects of the COVID pandemic has led to huge blow-outs in surrogates 'match times'. Many agencies in the USA, Canada and Colombia are warning clients they will need to wait a year to be matched.
Such limitations are leading more singles and couples to engage in unregulated or emerging destinations where surrogates are more readily available. The former includes North Cyprus, Kenya, Albania and Mexico, while the latter includes Argentina. Already many Ukraine agencies and surrogates, both keen not to lose a significant income source, have arranged for their surrogates to undertake embryo transfers and births in other European jurisdictions offering such programmes.
When it comes to recruiting donors, countries with altruistic laws and large populations of women coming to family building later in life – countries such as Canada, the UK, Ireland and Australia – struggle. For going through an egg donor cycle is hard work. There are many clinic appointments, blood tests, monitoring, injections and ultimately a medicated and uncomfortable egg retrieval process. Local recruitment efforts are further hampered by the requirement for donors to access counselling and agree to keep their contact details on file should donor-recipient children want to contact them in later life.
As a result, egg banks have become a vital part of the IVF industry globally, fuelling a large demand for egg donors from countries which allow compensation such as the USA, Spain, Cyprus, South Africa, Czech Republic, Greece and Ukraine. The problem is, most of these countries also have laws guaranteeing donor anonymity.
Message educators, such as Growing Families, push about the importance to children of open identity has led to increased demand for identity release donors. However only a few countries – the USA, Ukraine and more recently Georgia – have been able to partially meet this need.
Hence, despite the war, and the likely difficulty in keeping track of donors, Ukraine's egg banks seem set to remain a key part of the global IVF market.
Just this week I met a young Ukrainian gamete courier here in Sydney, Australia, carrying eggs purchased by Australian IVF clinic patients. She and her egg bank team have been displaced to Bratislava in neighbouring Slovakia. With Russian troops building up on the Belarus front, she is worried that her home city of Lviv is now at real risk. Yet here she is, caring for a batch of Ukrainian eggs – a journey involving forty hours of travel by bus, airplane and taxi. There are couriers doing such trips every month. More surprisingly, this courier is returning to Europe with frozen embryos, bound for a Ukraine surrogate.
This is not the only instance of foreigners electing to access surrogacy and egg donors in Ukraine while the war continues. A number of Ukraine clinics and surrogates are willing to commence new arrangements. Handfuls of patients from the UK, Australia and elsewhere continue to pin their hopes on Ukraine. Some have engaged there before, bonded with their surrogate or the country. Others have embryos in-country which they cannot export and do not have budget to create more. Others still are hoping the war will end. Whatever the reasoning, foreign governments such as Australia and the UK are increasingly alarmed, reminding their citizens that they are on their own. Their governments cannot support them.
On Monday evening 12 September, Growing Families will run an evening webinar covering the latest trends in ever-changing cross-border surrogacy landscape – risks, likely longevity, track record and eligibility. It will also include a spotlight on donor and surrogacy trends in destinations that had once been discounted as off-limits.
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