Putting a Pause on the Practice of Surrogacy

Conor here: Perhaps I’m missing something, but this issue has always seemed relatively straightforward: the fact that this practice involves the exchange of money means power dynamics are in play.

Even if we accept the author’s assertion that, “The desire for a child is primal, one of the most natural urges in the world” (evidence suggests that’s a myth), must we act on all such natural urges? Does a poor woman or poor couple have the same ability to act on that urge as a wealthy one? What about the desire not be exploited—yes, even if “it’s all there in the contract”?

As Ihor Pechonoha of the Swiss-based BioTexCom, which runs baby factories in Ukraine, says, “We are looking for women in the former Soviet republics because, logically, [the women] have to be from poorer places than our clients.”

By Ferrukh Faruqui, an Ottawa- based family physician, writer, and essayist who focuses on medical ethics. She was a 2025 Fellow at the University of Toronto’s Dalla Lana Fellowship in Journalism and Health Impact. Originally published at Undark. 

In 2000, a Canadian woman named Sally Rhoads-Heinrich carried and delivered a set of twins for a Maryland couple. It was her first experience as a surrogate, she told me, and she found it so rewarding that, a year later, she established the agency Surrogacy in Canada Online, which helps connect intended parents with potential surrogates. Between 2002 and 2008, she recalls that she underwent eight more IVF cycles to help other infertile couples become parents. Instead, she ended up miscarrying four times. None of these subsequent attempts produced a baby.

Her final attempt at surrogacy left her with a life-threatening twin ectopic pregnancy that landed her in the hospital, Rhoads-Heinrich said. She survived emergency surgery but lost her left fallopian tube in the process.

As an agency owner, Rhoads-Heinrich has also witnessed the dangers other surrogates face. She described negative outcomes such as hemorrhages at birth and numerous placental abnormalities. She explained, however, that some complications have decreased over time, as fertility specialists have switched from the practice of multiple embryo transfers, which often result in twins or triplets, to single-embryo transfer protocols that aim for one baby.

Rhoads-Heinrich told me that she understood the medical risks of carrying genetically unrelated babies for commissioning parents, and so do the surrogates she works with. “It’s all there in the contract,” she said, adding that the contract specifies “all the different things that can happen and all the pregnancy risks.”

With her remaining fallopian tube intact, Rhoads-Heinrich was able to have two more children of her own. She calls surrogacy “an absolutely beautiful way to create families.”

With infertility affecting nearly one in six adults around the world, Global Market Insights reports that the worldwide surrogacy business is currently worth more than $22 billion. It’s projected to grow nearly 10 times that amount by 2034. But the health risks faced by surrogates bring up thorny ethical issues. Earlier this month in Geneva, the United Nations Special Rapporteur on Violence Against Women and Girls presented her report on surrogacy to the UN General Assembly, concluding that the practice is harmful and exploits women and girls. She recommends that UN member states take steps to abolish all forms of surrogacy — both traditional surrogacy (in which the surrogate’s own egg is used) and gestational (in which an unrelated embryo is implanted).

The desire for a child is primal, one of the most natural urges in the world. So why, surrogacy advocates ask, shouldn’t a woman create a baby for someone who wants one? This plea sidesteps the real question: How ethical is it to prioritize someone’s wish for parenthood over the well-being of a woman at risk of suffering harm while she produces that child? On the surface, surrogacy seems like a nearly perfect solution to both biological and social infertility (which affects single people without partners and same-sex couples who desire children). But at its core, even with regulation, I believe that surrogacy exploits women’s bodies for the benefit of others.

Surrogacy practice differs around the world. It’s banned outright in many European countries including France, Spain, and Italy. Australia and Canada permit altruistic surrogacy, which means surrogates can only be paid for pregnancy-related expenses. Some U.S. states, including California and New York, have legalized surrogacy for hire.

“Women are conditioned to be ‘nice’ and to sacrifice ourselves for others,” wrote activist Julie Bindel in a commentary for Al Jazeera that questioned why having a biological child is considered a “right” when surrogacy is needed. “Pregnancy is a major endeavour, and surrogacy can cause complications and carries health risks,” wrote Bindel.

To prepare her body for pregnancy, a gestational surrogate typically takes estrogen for two to three weeks to thicken the lining of her womb. She also takes progesterone. This hormone enhances endometrial blood flow and primes it to embrace a lab-conceived embryo that is genetically unrelated to her. Doctors then transplant the five-day-old embryo into the surrogate’s womb, where it implants and grows into a baby.

Research findings published last year by McGill University reproductive endocrinologist Maria Velez confirm that gestational carriers (an industry term some critics call “dehumanizing”) experience higher rates of maternal complications than women with spontaneous pregnancies or those carrying their own embryos created via in vitro fertilization.

Velez’s widely circulated paper examined maternal complications among all singleton pregnancies past 20 weeks gestation in Ontario, Canada, from 2012 to 2021. She found that severe maternal morbidity, including hemorrhagic shock and uterine rupture, occurred 3.3 times more frequently among gestational carriers than in spontaneous pregnancies. Her results also showed increased rates of preterm births under 37 weeks gestation among surrogates.

Norbert Gleicher, medical director at The Center for Human Reproduction in New York, wrote in The Reproductive Times last year that doctors already know anecdotally why gestational surrogates face a higher risk of obstetrical complications: They’re carrying an embryo that is completely unrelated to them genetically. (Gleicher is the founder and editor-in-chief of The Reproductive Times.)

In 2017, Irene Woo and colleagues studied perinatal outcomes among 124 California surrogates who had also had their own spontaneous pregnancies. They found that surrogate babies had higher rates of premature birth and low birth weight, and the surrogates themselves suffered increased rates of pregnancy-induced hypertension and diabetes. These researchers concluded that assisted reproduction techniques such as IVF, without which surrogacy is impossible, could increase maternal and neonatal risk.

Surrogacy critic Kallie Fell, a perinatal nurse who is executive director of the conservative-leaning California-based Center for Bioethics and Culture Network, told me she battles what she calls “Big Fertility” — a vast conglomerate of pharmaceutical companies, physicians, and surrogacy agencies — that preys on vulnerable, often impoverished women reduced to their useful body parts. (Fell spoke on the topic at a Make America Healthy Again Institute event in July.)

When we spoke last October, she recounted the story of Kelly Martinez, a three-time South Dakota surrogate who has said she nearly died of liver failure while carrying twins for a couple from Spain. In 2017, Martinez told her story before the United Nations, saying the couple was unhappy with receiving two boys instead of the boy-and-girl set for which they had paid extra fees to the surrogacy agency. According to Martinez, the couple took the babies, who were born prematurely, and left her with unpaid medical bills, a crumbling marriage, and the feeling of being used and discarded.

U.S.-trained Toronto fertility specialist Prati Sharma juggles surrogacy risks every day when matching surrogates with interested couples. In Canada, where only one surrogate is available for every 100 couples who want babies, it can take 18 months to make a match. In those U.S. states where surrogates are paid, matching carriers to couples can take only three to six months.

Sharma described to me how tough it is to balance maternal risk against approving surrogates. Sometimes, she said, Canadian fertility clinics can be more flexible with accepting surrogates who “maybe are less than ideal.” She acknowledged that the risk of complications can be higher, depending on how strictly the clinics adhere to medical criteria, which include limiting the number of a surrogate’s previous cesarian sections and premature births, as well as choosing surrogates who don’t exceed a healthy weight.

Sharma’s admission is worrying. If the pressure to produce babies for prospective parents trumps the well-being of women who take on the risks, what does that say about our priorities?

The surrogacy debate, complicated by the mounting evidence of health risks, underscores what old-school feminists, worried about a shiny new world where anyone can get whatever they please, never mind the fallout, have been saying all along.

Ghislaine Gendron, the Canadian co-coordinator of Women’s Declaration International, is alarmed by Velez’s findings, and said in an interview that surrogates sign contracts without fully grasping the risks. Gendron called surrogacy the “opposite” of freedom: a commercial transaction for delivery of what she apologetically calls a “product” — which in this case is a child. According to Gendron, the woman generating that product, no matter how fervently she believes she’s exercising her reproductive rights, is reduced to a human incubator.

Others say this blanket perspective on surrogacy is paternalistic. Melbourne fertility lawyer and former surrogate Sarah Jefford, who told me she used her own egg to conceive a baby girl for a grateful male couple, also told me some aspects of global surrogacy are exploitative and require better regulation. But she added the caveat that that’s not universally the case, especially in places like Australia where women have agency. Jefford doesn’t believe in infantilizing grown women who have the right to control their own bodies. In Australia, expert panels review each medical file and reject candidates deemed too risky, she said. They’re not after babies at any cost but want surrogates to remain “alive and well at the end.”

Gleicher’s takeaway isn’t that surrogacy itself should be interrogated. Instead, he urges doctors to be clear about the health risks with intended parents and their carriers and to tighten their screening of carriers to ensure only the healthiest qualify for surrogacy. Velez also says she hopes her study findings promote regulation of this industry.

Creating new life is a wondrous act. But not every advance is a step forward. Even with regulation, the risk of surrogacy seems too great. We need to hit pause, to listen to what the evidence is saying. Otherwise, we’re failing the very women who sacrifice their own health to gift strangers the joy of parenthood.