This is a transcript of Liz Purslow’s talk at the What’s wrong with surrogacy? webinar on 6 September 2020.

In this powerful talk, Liz looks at the health risks for women involved in surrogacy and the egg harvesting on which most surrogacy is predicated, along with the inevitable conflicts of interests and safeguarding issues that may arise. She asks, Should the NHS pay women to put themselves at risk of harm to breed babies for others?

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Hi. I’m Liz. It’s great to be here and I’m so glad so many of you have joined us. I was a midwife for twenty years, working in a variety of settings including tertiary referral and community. I now work as a nurse in a different area of the NHS.

I have always been opposed to surrogacy for the simple reason I have seen enough about the complications of pregnancy and childbirth, that I do not believe this is something anyone should ask another woman to do on their behalf. I am very concerned about the proposals from the Law Commission and what this means for the wellbeing of mothers and babies, as well as the potential impact on the NHS.

There are two types of surrogacy: traditional and gestational.

In traditional surrogacy, the surrogate mother (SM) uses her own egg to conceive the baby so she is both the gestational and genetic mother. At present in the UK about one third of surrogacy arrangements are traditional. I think mostly these are arrangements between friends or that have been sought out through social media, often as a cheaper, more affordable option, with a back of an envelope agreement and using home DIY insemination techniques. These carry the risk of infection and STDs as the sperm donor will not have been screened, and there’s no screening for common genetic disorders. The main risk is probably the legal risks that people expose themselves to by doing this if the arrangement breaks down.

Gestational surrogacy is an arrangement where the surrogate mother is not genetically related to the child. It involves the implantation of the surrogate mother with an embryo created from a donor egg or from the commissioning parent (CP) and this tends to be preferred these days, especially in jurisdictions where commercial surrogacy is legal as commissioning parents can have a baby which has genes from an egg donor chosen for specific genetic traits and this separates the surrogate mother from her connection to the baby and tightens the legal ownership claims of the CPs should there be a dispute.

The increase in gestational surrogacy means there’s an increasing demand for eggs. Egg donors may be chosen for favoured genetic traits and young women are targeted by advertising to sell their eggs. In the USA they may be offered $10,000 with tempting suggestions such as paying off their college fees. In the UK payment for egg donation is capped at £750 but women undergoing IVF may be offered the opportunity to “egg share” meaning any excess eggs after their treatment will be made available for another user and these women are offered a very substantial discount on the charges for their treatment.

In order to supply an egg, another woman, either the commissioning mother or an egg donor, is required and they undergo standard IVF treatment to stimulate the ovaries to produce more eggs than the normal one per month.

There are various risks, of which the commonest is Ovarian Hyper Stimulation Syndrome, which is an excessive response to the fertility drugs given to stimulate egg production. Fluid leaks into the abdomen from the large number of growing egg follicles and this is accompanied by bloating and nausea, mild symptoms are very common but about 1% of cases are graded severe and serious complications include severe pain, nausea and vomiting, blood clots, difficulty breathing, dehydration and other symptoms.

The ovaries increase in size: a normal ovary is about the size of a walnut but an overstimulated ovary can be the size of a grapefruit causing significant discomfort. In some cases, the pressure of the enlarged ovary pressing on the ureters draining into the bladder obstructs the drainage of urine from the kidneys, which is very serious.

Other complications can include ovarian torsion or twisting and rupture of a cyst which can cause serious bleeding. There is little research into the long-term risks, as women aren’t followed up but gradually women are coming forward with a range of complaints, including infertility and some women believe that ovarian and breast cancers they have developed may have been caused by repeated egg donation.

All pregnancies carry a degree of risk of harm and complications, which range from the so called minor complications of pregnancy, like morning sickness, backache, heartburn, haemorrhoids and varicose veins, through to more serious risks which can be life changing such as raised blood pressure, pre-eclampsia, gestational diabetes, thrombo-embolism, serious perineal tears, haemorrhage, and in some cases complications are fatal.

All maternal deaths in the UK are monitored. A body called MBRRACE – Mothers and babies, reducing risk through audits and confidential enquiries – monitor all maternal deaths in the UK and also comment on women who survived a significant event to make recommendations for clinical practice. This has contributed to substantial improvements in maternity care in the UK over the years.

Currently the maternal mortality rate in the UK is 9.2 women per 100,000 who have died during pregnancy and childbirth up to six weeks after childbirth. This is a risk that women undergoing surrogacy are taking in order to give their baby away to another person.

Donor oocyte pregnancy has been found to be an independent risk factor. This is thought to be related to immunological intolerance causing placental pathogenesis. In order to prevent rejection, daily injections of immunosuppressant drugs may be required for the first fourteen weeks.

It has been suggested that a gestational surrogate is at no more risk than a woman having IVF and using donor eggs. However, gestational surrogate mothers should be healthy women with a previously good obstetric history. They are now contracted to undergo medical procedures with attendant risks and are exposed to harm that wouldn’t be the case if they were having another spontaneously conceived baby. It is questionable whether these women are giving truly informed consent as they, not unreasonably, expect their surrogate pregnancy to be as uncomplicated as their own previous pregnancies.

A study in the USA which looked at 124 gestational surrogate mothers compared outcomes of their spontaneously conceived pregnancies with their surrogate pregnancies. It found the surrogate births had significantly higher obstetrical complications, including gestational diabetes, hypertension, placenta praevia and Caesarean section (LSCS). The babies had increased adverse perinatal outcomes, including preterm birth and low birth weight.

Multiple birth adds significantly to the risks for the mother and the babies, with higher rates of raised BP, pre-eclampsia, gestational diabetes, haemorrhage and LSCS and the need for premature delivery. The risk of death is also two and a half times higher. For the babies, prematurity can lead to long term health problems including respiratory problems, cerebral palsy and other physical and developmental problems.

Multiple births in IVF used to be very common due to multiple embryos being transferred to improve the chances of implantation. The Human Fertilisation and Embryology Authority (HFEA) introduced a “one at a time” campaign in keeping with NICE guidelines to encourage clinics to transfer single embryos only and this has reduced the multiple birth rate from 24% in 2008 to 10% in 2017.

However, in surrogacy twins are treated like an optional extra or even a “buy one, get one free” deal. In the USA mothers are typically paid around $5-10K more for a twin pregnancy, which in the context of an overall cost of over $100K represents value for money (so long as the babies are healthy).

The BBC programme “The Baby has Landed” featured a couple who decided to have two, so they could have one each! In a recent interview a celebrity couple said “We inserted one of my sperm and one of David’s sperm into two eggs with the hope that they would both take, just because we both wanted to be Dads biologically”.

A recent British case that was in the newspapers nearly ended in disaster – they were identical twins, so not planned for two, the implanted single embryo split, but the mother suffered a placental abruption which is when the placenta separates from the wall of the uterus. This is very dangerous for mother and babies and she suffered a serious haemorrhage, it was lucky that both she and the babies survived.

A new cohort of high-risk pregnancies will substantially impact the NHS, with demands on staff and knock-on effects for the service to all mothers and babies. Neonatal intensive care unit (NICU) cots are always in demand, and a shortage means babies are often transferred to distant units after birth.

A case from the MBRRACE reports illustrates the impact on the hospital (as well as the mother of course).

The woman had an LSCS, and haemorrhaged, she was taken back to theatre three times before the bleeding was finally stemmed. Multiple staff will have been involved, including anaesthetists, obstetricians, midwives, theatre staff, haematologists, the lab for blood supplies, ICU. This impacts the ongoing work of a busy labour ward, for instance women requiring an epidural for pain relief may have to wait until an anaesthetist is available.

Case reviews in MBRRACE reports sometimes flag up where problems were not recognised or treated promptly enough due to experienced staff being busy with another emergency.

The Law Commission do not plan to limit the number of surrogate pregnancies a woman can undertake. We have already seen evidence of some women treating surrogacy as a career. In the UK there are two women who have been in the news with respect to this.

One woman has had 13 surrogate babies for eight couples (as well as her own two daughters), including at least one set of twins and one set of triplets.

The other woman, a single legal secretary, had ten surrogate babies. Despite evidence of mental health problems and treatment for depression and a previous suicide attempt and serious complications following her eighth pregnancy she became pregnant again at the age of 47 with twins. Predictably this was problematic and she needed an emergency LSCS at 32 weeks, when she suffered a haemorrhage at home from placenta praevia – this could so easily have been fatal.

I find it profoundly shocking that a fertility clinic would give treatment to this woman, and it is also troubling that the commissioning parents would be so unconcerned about the health of a surrogate mother that they would choose to use a woman such as this, and that they would not understand the risks posed to the babies they claim to desire so badly.

The Law Commission propose to make counselling compulsory for both parties – but this is already a prerequisite of fertility clinics so it does not fill one with confidence for the quality of counselling that can be expected from agencies with a vested interest in surrogacy.

Incidentally, I have seen an American news article about this woman, with interviews with American obstetricians and surrogacy agencies, which have used this case as an example of BAD PRACTICE and to advertise their own high standards by comparison.

The Law Commission understands that pregnancy and childbirth involve pain and inconvenience, so they posed a question – what price should we pay to compensate women for these complications? What price should we put on the trauma of a serious haemorrhage and emergency hysterectomy for instance? These sort of events can cause a woman to suffer PTSD and serious mental health problems, quite apart from the physical problems. Or what price for a serious perineal tear extending to the anus which may cause problems with continence for life?

And how much should we compensate the family of a surrogate mother who dies as a result of her surrogate pregnancy.

Sometimes a surrogate pregnancy, like any pregnancy can be fatal.

These are some of the mothers who are known to have died as a result of surrogate pregnancy.

Brooke Lee Brown died in October 2015. She was reported to be on her third surrogacy, her second set of twins. She appears to have died of either a placental abruption or an amniotic fluid embolism. The twins also died. She left three young sons.

Crystal Wilhite died in February 2017 from complications of a preterm labour, followed by a fatal embolism. Due to a non-disclosure agreement (NDA) her death only came to light recently when another surrogate mother spoke out anonymously having been told by their surrogacy agency not to talk about her death. She leaves two young sons.

Michelle Reaves died in January this year. This was her second surrogate pregnancy and she appears to have had a haemorrhage, possibly related to an amniotic fluid embolism. She leaves a young son and daughter.

Natasha Caltabiano died on New Years Eve in 2004 in the UK. She had developed high blood pressure and suffered a ruptured aorta.

She was a surrogate mother to a couple who already had five children from previous relationships. She left two young children. The commissioning parents refused to pay the balance of the agreed £8,850 fee as they said they had huge legal bills.

Nine young children who lost their mothers through surrogacy.

There will be others not known about – the USA and other jurisdictions don’t keep records of maternal deaths in the way it is done in the UK, plus surrogate mother deaths may be hushed up or subject to an NDA. Even in the UK I’m not convinced that the MBRRACE report would look into the issue of surrogacy due to hospitals not keeping records for reasons of confidentiality. However, I feel confident news would leak out into the press as contracts in the UK are not binding and an NDA could not be enforced.

I am concerned that an increase in surrogacy will bring problems of safeguarding and conflicts of interests for medical professionals and the NHS to deal with.

For instance commissioning parents may assume ownership of the developing foetus and seek to influence medical decisions. They may demand induction or LSCS to fit in with their travel plans to collect the baby – demanding unwarranted medical interventions that the surrogate mother may not want and which are not medically justified.

Guidance from the Department of Health and Social Care is quite clear – the healthcare staff have a duty of care to the surrogate mother – but will they always be attuned to the needs of the surrogate mother in the face of noisy demands from commissioning parents?

Other demands might include for the commissioning parents to be accommodated in the hospital and helped to care for the baby. Depending on availability of single rooms and postnatal accommodation which varies from hospital to hospital this may be to the detriment of other postnatal mothers.

Commissioning parents aren’t subject to the same level of checks that apply in adoption and the Law Commissioners recommended a “light touch”.

I have looked at quite a few hospital policies and they vary. Some are alert to possible problems warning staff to raise concerns with appropriate safeguarding agencies and invoke child protection procedures. They note that in law at least one commissioning parent should be a genetic parent and warn of the potential difficulty that the identity of the intended father is taken on trust. Others hospitals appear not to have thought through the potential problems and give less than adequate guidance. The wellbeing of these babies depends on the alertness of staff.

The Law Commission report stated that NHS funding for surrogacy IVF is already available in Scotland and Wales. Surrogacy UK, who are key influencers collaborating with the Law Commission, have called for full NHS funding of surrogacy, including payment of the surrogate mother’s expenses.

This basically means the NHS will potentially be paying for women to put themselves at risk of harm to breed babies for commissioning parents. Employing a breeder class of women. Is this appropriate use of NHS resources?

Thank you so much for listening.