Written by Cremieux Recueil.
TL;DR: Cremieux Recueil reviews the scientific literature on surrogacy. He concludes that there is little evidence of physical or psychological harm to the surrogate mother, the surrogate child or the intended parents. However, the possible exploitation of surrogate mothers is something that has to be kept in mind.
Surrogate mothers are women who become pregnant and give birth to a child that is intended for someone else. They are the subject of immense controversy and derision – from both the religious right and the progressive left. Detractors on the right view surrogacy as immoral, emphasizing the need for parental bonding with infants, and thus opposing the separation of kids from their biological parents. Detractors on the left view the practice as exploitative and sometimes even as tantamount to eugenics.
But political narratives aren’t satisfying. If any side is right, it won’t be in virtue of their stories and opinions alone. Knowing more about surrogacy may help to correct these narratives, so let’s review the facts. To start things off, just how common is it?
Prevalence
Surrogate births are uncommon. The Centers for Disease Control and Prevention (CDC) reported that, between 1999 and 2013, 2% of U.S. pregnancies using assisted reproductive technology (ART) involved surrogates. That 2% corresponds to a total of 30,927 instances of surrogacy over a fifteen-year period and an increase from about 1% of ART pregnancies to around 2.5%. The result in terms of births was considerably smaller: over that period, there were 13,380 deliveries of 18,400 infants (with 53.4% of surrogate deliveries involving twins, triplets, or beyond). For comparison, the CDC reported a total of 3.93 million births in the U.S. in 2013 alone. In other words, fifteen years of surrogate births amounted to less than half a percent of the births in a single year of that monitoring period.
The discussion about surrogacy has become more heated precisely because use of the practice has undergone rapid and recent growth. Global Market Insights projected that the market for surrogacy would grow by more than an order of magnitude between 2018 and 2032. For a market worth $14 billion in 2022, that amounts to a sizable $129 billion by 2032.
But the size of the market doesn’t directly inform us about the number of surrogate births. The CDC’s most recent numbers come from their 2020 report on ARTs.
Between 2013 and 2019, the proportion of ART pregnancies with embryo transfers that involved a surrogate increased from 2.6 to 5.4% before dipping to 4.7% in 2020, presumably due to the COVID pandemic. The report itself does not indicate how many surrogate births took place, only how many ART pregnancies involved surrogates. Using the numbers for the period 1999-2013, there were 30,927 ART pregnancies that involved surrogates, so only 43.26% resulted in a birth. That’s a high success rate. To put that figure into perspective, compare it to the percentage of ART uses that result in live births in general.
Between 2013 and 2020, there was an 11% increase in the percentage of assisted births that resulted in a live birth. From the numbers provided in the report, it’s not clear why this happened, but there are two main possibilities – both of which may be true to some extent. First, technology may have improved, so if the people who used ARTs in 2013 teleported to 2022, they would be more successful. For example, the transition from the slow freezing of eggs to vitrification substantially improved the use of egg freezing services. Another source of improvement is the increasing use of donor eggs, which is a major reason why gains have been greater at older ages.
Second, there may have been a compositional shift whereby, as ARTs became more widely used, the population changed in ways that led to higher success rates. For example, as in vitro fertilization (IVF) became more common, the people who use it may have become those who have fewer or more marginal fertility problems compared to earlier cohorts of users. Regardless of the reasons, surrogates are more likely to successfully deliver a child than typical users of ARTs, perhaps because they tend to be younger, perhaps because they tend to be healthier, or likely some combination of the two.
To bound the number of surrogate pregnancies, let’s assume that success rates vary between the average for all ART users in 2019 and 100% success even though we know the success rate is higher than it is for typical ART users. The report’s description for Figure 8 reads “the number of embryo transfer cycles that used a gestational carrier increased, from 2,841 in 2011 to 9,195 in 2019, with a decrease in 2020 (7,786)” (p. 21). With 37.2% success, that’s 3,421 infants born via surrogacy.
Consider three facts. First, surrogacy is expensive. Second, most people prefer not to use surrogates, and even many infertile women have negative opinions towards surrogacy. And third, many wealthy countries have banned or severely restricted surrogacy. The result is that globally, surrogacy is responsible for a small fraction of the births in the U.S. alone. In other words, it is very rare.
Why do people seek surrogacy in the first place?
Indications for Surrogacy
While precise and current numbers aren’t available, the most common reason people seek out surrogates has been and remains fertility problems. Women suffering from Müllerian aplasia, Mayer-Rokitansky-Küster-Hauser syndrome, polycystic ovary syndrome, and other fertility-limiting conditions are still the primary users of surrogacy services. The simple fact is that obstetric conditions often affect the people most likely to want kids: young women. These women then look for other means of having kids, despite conditions like ovarian cancer, structural abnormalities, repeated miscarriages or demises, hormonal problems aplenty, endometrial issues, etc.
Another, fast-growing group of surrogacy seekers is homosexuals. Since the legalization of gay marriage, many gay couples have gotten married and decided it’s their time to have kids. As such, they’ve been greatly increasing the demand for surrogates. This is primarily a male thing. Lesbian couples tend to seek out sperm donors (though they still seek surrogacy arrangements at greater rates than heterosexual couples).
Homosexual parents were relatively rare until quite recently, and many have expressed concerns over their ability to raise children. A review of the papers on this topic was inconclusive about whether having homosexual parents affects kids’ outcomes. The only outcome noticeably affected by having homosexual parents seems to be kids’ own sexuality – perhaps because homosexual parents are more accepting of non-heterosexual sexual orientations among their own children. Because the research on this topic is of unusually low-quality, due to issues of low power and unrepresentative comparisons, it’s probably not informative. Yet insofar as behavior genetic studies tend to show near-zero family influence on most of the traits people find important, unless homosexual families offer a substantially different environment, it’s unlikely that they affect child development.
Can the women who have fertility issues even afford surrogacy? How well compensated are the surrogates?
What’s the Price?
If you search for estimates of surrogacy prices, the results will end up fairly similar: $110,000 to $170,000, $110,000 to $225,000, as little as $15,000, an average of $100,000, and up to $250,000, around $80,000 to upwards of $200,000, $125,000 to $175,000, as little as $13,000 to $220,000 – you get the picture. Surrogacy in the U.S. is a costly endeavor, with average costs per child running over $100,000 total. If IVF is involved, expect to pay about $20,000 on top of that. That’s the price people are willing to pay to have a child.
Of course, not all that money is handed over to the surrogate mother. A sizable chunk of it goes towards agency and legal fees, fertility treatments, donor egg and sperm costs, etc. Many of these costs are situation-dependent, but if you’re spending $100,000, expect to pay roughly 60% of that to the surrogate herself. If they’re an experienced surrogate, and thus the risk of a miscarriage or other mishap is lower, then expect to pay closer to $80,000.
With all these costs, it’s obvious that surrogacy is inaccessible to most people. Although people struggling with fertility tend to be older, and therefore tend to have higher earnings, wage trajectories aren’t so steep that lots of older people can afford to pay $100,000 for something that’s also very time-consuming.
But there’s a simple way to drastically reduce the costs: use an international surrogate. The U.S. has the world’s highest wages for a major nation. Hiring a surrogate elsewhere means the costs will be scaled relative to that nation’s wages, which will almost certainly be lower than they are in the U.S. For example, one estimate for the cost of surrogacy without IVF in the U.S. was $120,000, but in the same table, the cost for hiring a surrogate in Ukraine was a much more reasonable $45,000, and that’s all-inclusive.
The fact that surrogate wages are so modest, despite the length of time and the emotional toll involved, has led many people to describe the transaction as exploitative. When the transaction extends across borders, where the economic gap between surrogate and intended parents is much larger and the law is much murkier, the case for considering surrogacy to be an economically exploitative act is greatly strengthened. The logic is simple: few can resist several years’ worth of wages.
I mentioned international surrogacy is an area where the law is murky. This is especially true when the people seeking an international surrogate come from a country where surrogacy is illegal. For example, Germans going to India for surrogate services will have to subject their surrogates to legal travails related to the child’s immigration status. But perhaps most damaging of all is the possibility that they abandon the surrogate entirely, leaving her without any recourse and saddling her with a child, abortion, miscarriage, ectopic pregnancy or worse.
The price
