Commercialization, Altruism, Clinical Practice: What Explains Similarities and Differences in Californian and Canadian Gestational Surrogacy Outcomes?

Background: Surrogacy is growing world-wide. While recently some countries have sought to ban it, between 2010 and 2014 the number of babies born to gestational surrogates having IVF treatment in California doubled and in Canada, it grew by 35%. This paper seeks to fill identified knowledge gaps about the similarities and differences in the practices and outcomes of gestational surrogacy which in California operates on a commercial basis though in Canada, it is illegal to pay a surrogate. The paper focusses on the period 2010 to 2014 for which comparable American and Canadian national assisted reproduction technology information exist.

Study Design: A retrospective data analysis was performed using information on gestational surrogate multiple births obtained from Centres for Disease Control and Prevention National Assisted Reproductive Technology Surveillance System (NASS) and Canada’s Assisted Reproduction Registry-Better Outcomes Registry and Network (CARTR-BORN). Multiple birth rates and transfers of multiple embryos were compared using relative risk analysis. Adherence to voluntary ASRM-SART and CFAS embryo transfer guidelines was modelled.

Findings: Among gestational surrogates, when donor ova embryos obtained from women aged less than 35 were used, embryo transfer guideline adherence was 42% in California and 48% in Canada.

Conclusions: Regardless of where on the commercial/non-commercial boundary North American surrogates reside, they are more likely to receive more donor ova embryos per IVF transfer than other IVF patients. Altruistic desire to assist childless couples and individuals create families along with clinic practices appear to play major roles in treatment decisions privileging the transfer two or more embryos.

Lessons for Practice and Policy: Third-party reproductive decision-making is complex and nuanced. If recent trends hold, surrogacy in both California and Canada will experience sustained growth. Given this dynamic situation, it is extremely important that IVF practices and guidelines build in provisions for surrogate patients.