School of Health Sciences, The Medical School, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
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Abstract |
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Key words: psychosocial assessment/selection/surrogacy arrangements
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Introduction |
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Within the UK, two agencies deal with partial surrogacy, a straightforward process requiring artificial insemination (AI). Many AI procedures are carried out within the couples' homes, and do not require medical intervention (van den Akker, 1998b). Both agencies have demonstrated high success rates. A large number of clinics hold an Human Fertilisation and Embryology Authority (HFEA) licence; however, only six have experience of in-vitro fertilizationsurrogacy (IVFS) (Balen, 1998
; van den Akker, 1998a
). IVFS can only be achieved through medical intervention, and requires a considerable amount of testing and treatment accompanied by discomfort. Virtually all British clinics offering IVFS rely on the two agencies to help their infertile couples find a suitable surrogate. Unlike partial surrogacy, IVFS is a comparatively new practice. Since the UK does not have any enforceable legislation regarding surrogacy, the practice is largely unmonitored and unregulated, and relies entirely on the guidelines laid out by individual clinics and agencies (van den Akker, 1998a
).
The 1985 Surrogacy Arrangements Act legalized surrogacy, provided it is non-commercial, although a subsequent act rendered any arrangements and contracts unenforceable in law (HFEA Act, 1990). Nevertheless, those using IVFS have the protection of the HFEA's licence, which, according to Blyth (1994), provides them with more support than those undergoing straight surrogacy. However, no act or legislation has drawn on psychosocial aspects of surrogacy. Ideally, evidence-based criteria for good outcome should be part of the surrogacy process, particularly since IVF poses its own stress (Freeman et al, 1987). Furthermore, when controversial cases are brought before the courts, professionals are asked to provide expert opinions. It is therefore essential that expertise is based on the same evidence used to select cases for good outcome (Taub, 1992
).
Although numerous women are treated relatively easily with IVFS, (Ben-Rafael et al, 1998; Brinsden, 1998), the success rates of IVF surrogacy tend to be more limited than IVF in the biological mother (Brinsden, 1998). Consequently, psychological distress of failure of IVFS is likely to be more common in IVFS than is reported for other IVF (Braverman and Corson, 1992
; Domar et al., 1992
). Since this practice is increasing, it is necessary to evaluate the mechanisms used to assess prospective commissioning and surrogate women's psychological status, in an attempt to avoid post-treatment psychological ill health. In the USA selection procedures are stringent, probably because their practice is more regulated and commercial. The companies play a major role in negotiating between the parties and acting as advocates and go-betweens (Ragone, 1994
). Ince (1984) describes her account as an applicant to the `surrogate industry', where rigid application processes take place. The company controlled both parties, but the surrogate in particular was contracted and therefore under full control of the company.
Unlike the USA, the UK organizations do not screen for parental fitness in surrogacy. This may be because we do not have the socio-cultural experience of this unorthodox route to parenting (McGee, 1997; Johnson, 1997
; Sureau, 1997
); we do not posses the language to accommodate these reproductive liberties; and we know too little about the psychological importance of the `genetic link'. Consequently, at present, arrangements are often based on trust between people who are complete strangers. Because there has been no official requirement for monitoring the parties' well-being, the emphasis is on the couples to support each other. However, since money is exchanged and contracts are drawn up, we are not simply dealing with `donations' or altruistic carriers, but with a `market' for surrogacy (Johnson, 1997
). The present paper therefore investigated the assessment and selection procedures employed in surrogate motherhood.
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Materials and methods |
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Sample
All organizations known to have experience (n >2 in last year) of surrogacy were approached individually. Many clinics are known to hold HFEA licences for IVFS, but only a fraction have completed more than two cases in the last year (Balen, 1998). Since the majority of clinics had no successful IVFS cases yet, or only one, they were not deemed experienced. The six most successful clinics in terms of numbers of completed surrogacy cases per year were accepted as experienced. Ten organizations took part in the survey, six were clinics, the rest surrogacy agencies (n = 2) or voluntary organizations/helplines (n = 2). The clinics dealt virtually exclusively with full surrogacy, the agencies with full and partial surrogacy. All those interviewed and completing the questionnaires were: directors for agencies and helplines; medical directors (n = 2), consultants (n = 1), and a senior sonographer/egg donation and surrogacy coordinator (n = 1) for clinics.
Procedure
After initial telephone contacts, letters were sent out, and the organization's co-operation was obtained. The questionnaire was sent, followed by the semi-structured telephone (n = 1) or face to face (n = 7) interview. The survey was conducted approximately between November 1997 and March 1998.
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Results |
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All organizations sought medical, legal, psychiatric and ethical committee advice when necessary. Despite the overwhelming reports of serious enquiries by commissioning couples, significantly fewer commissioning and surrogate couples were ever involved in actual arrangements. The mean numbers and ranges of actual arrangements started for clinics and agencies are shown separately in Table I. The difference in numbers between commissioning and surrogate mothers is due to the fact that many more commissioning couples' attempts fail, whereas surrogates are known to offer themselves more than once for different couples, whether previous attempts failed or not. Numbers of successful pregnancies resulting in relinquishments by surrogates and adoptions by commissioning mothers range from 2210. Only one agency reported a 4.5% refusal to relinquish rate, which is surprising considering the assessment procedures reported. No commissioning couple has been known to refuse to adopt a baby following the arrangement.
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Discussion |
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Screening was carried out by nearly all organizations, however undefined this was. This lack of uniform screening does not necessarily constitute bad practice, because few non relinquishments of babies were documented. However, with an inevitable increase in this practice, in line with the predicted growth in infertility figures, we may need to err on the side of caution by using some form of consistent selection criteria. There is no reason why one individual, whether commissioning or surrogate, rejected by one organization, should not try another. Discussions with the organizations reveal this is already taking place.
Furthermore, although the experience of the organization's appointed selector is important, it also opens the system to individual bias and preferences. These are not always based on good or fair judgement, and should play no part in the selection of people into such an important arrangement. Only one clinic used the same counsellor, who had extensive experience of the surrogacy process, and who considered the outcome phase as equally important within a professional assessment format, for all its clients. Interestingly, the purported age criteria for selection into the arrangements were not always adhered to. It is possible that this is a direct result of the lack of evidence indicating age to be a major detrimental factor to motherhood in modern family units (van den Akker, 1994). Alternatively, the organizations follow HFEA guidelines, which do not stipulate a limit (Dimond, 1995
). The organizations also confirmed that the wider family concerns were addressed to some extent. The manner of address varied, however, from simply enquiring about relatives' opinions of surrogate children, to interviewing close family members. Golombok et al.'s (1990) research has shown that the wider local network can also have damaging effects on those involved in surrogacy, suggesting this area should also be explored further.
The lack of standardized psychological assessment precludes this practice from the benefits of predicting emotional response during and post-agreement, as was found by Newton et al. (1990) in infertile couples going for IVF. Thus from a psychosocial point of view, related research suggests it could be beneficial to implement a standard protocol of assessment for both parties in the surrogacy agreement, although this needs to be carried out with caution (Parker, 1982). Media reports tend to broadcast impossible people in impossible surrogacy situations, yet in practice, the successes far exceed the disasters. Apart from anxiety and depression, personality factors could also be part of the assessment protocol. According to Appleton (1993) it is unlikely that commissioning couples are in a real position to exploit the surrogate, and certainly his own work suggests this may be a rare occurrence. Similarly, from the surrogate's point of view, altruism is seen as commendable, but even if they embark on an agreement for financial reasons (Blythe, 1994), this is unlikely to damage the infertile couple emotionally. Although these cases are extremely rare, they could be avoided with increased assessment.
Similarly, issues of bonding are either not assessed or not considered fully and systematically in current practice with surrogacy. These issues need to be addressed in the assessment process, because as Smith (1998) points out, it is the unprepared midwifery practitioners who deal with the unpredictable reactions of the surrogate and commissioning mothers. Following clinical care, it becomes a problem for the wider family network, including that of existing children.
Faith in others is unlikely to be a sufficient criteria of success for the future of surrogate motherhood. Since both parties knowledge of infertility, and particularly surrogacy, was perceived as less than adequate by many organizations, an arrangement based on faith in the unknown may be unacceptable. It is, on the other hand, equally debatable whether we want the American approach (Ragone, 1994). Appleton (1993) advocates we aim for `an independent body to provide a proper level of support, counselling, and follow up monitoring within surrogacy'. This body could also regulate assessment and selection of those involved in surrogacy, with the specific aim of evaluating suitability of both parties in the surrogacy arrangement, for their immediate and long-term benefit.
In conclusion, this study investigated the assessment and selection procedures currently employed in British organizations dealing with surrogacy. The results of related research and the information obtained from the organizations taking part in this study demonstrates areas of selection and assessment for psychological health which are not addressed systematically. It is expected that standardized screening will direct areas where counselling may be indicated. Nevertheless, it is worthy to note that `the social consequences of a relatively new biomedical technique cannot be predicted in great detail or with total accuracy' (Walters, 1983).
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Acknowledgments |
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Notes |
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1 Present address: Division of Primary Care, Public and Occupational Health, The Medical School, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
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References |
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Submitted on July 30, 1998; accepted on October 8, 1998.