Australian intended parents’ decision-making and characteristics and outcomes of surrogacy arrangements completed in Australia and overseas

Abstract

Markets for international surrogacy often arise in jurisdictions with limited regulations regarding assisted reproductive technologies. In some countries, like Australia, regulated domestic surrogacy services are often sidestepped for international providers. This study describes how Australian intended parents decide where to pursue surrogacy and compares the characteristics and outcomes of arrangements completed within and outside of Australia. The findings show that, although intended parents preferred undergoing surrogacy in Australia, perceiving the process as too long and complicated was a common reason to pursue an international arrangement. Multiple embryo transfer, anonymous gamete donation, and a lack of counselling were common in international surrogacy arrangements. When compared to surrogacy arrangements completed in Australia, where single embryo transfer is mandatory for surrogacy cycles, the rates of multiple birth, preterm birth and neonatal intensive care in international surrogacy were higher. These findings raise concerns about the health and welfare of international surrogacy participants, particularly the surrogates and children. In lieu of any international instrument regulating surrogacy, improving access to surrogacy at a domestic level would reduce the number of people engaging with international arrangements and in turn, reduce the potential for harm.

Keywords:

• Surrogacy
• reproductive decision making
• gamete donation
• embryo transfer
• multiple pregnancy
• cross-border reproductive care

Introduction

Surrogacy arrangements involve an individual (a surrogate) conceiving, carrying a pregnancy, and giving birth under the premise of relinquishing the child to the intended parents at or soon after birth. This process provides the opportunity of parenthood to those for whom pregnancy poses a health risk and those who are unable to carry a child, including some infertile women, single men, and same sex-male couples.

Whether there is a genetic relationship between the surrogate and the child born through surrogacy is dependent on the mode of conception used in the arrangement. In ‘traditional’ surrogacy, conception is achieved through insemination with sperm from an intended father or a donor and a resulting child will be genetically related to the surrogate. In ‘gestational’ surrogacy, an embryo is created from the intended parents’ and/or donor gametes and transferred to the surrogate, so any resulting child is not genetically related to the surrogate.

‘Cross-border’ or ‘international’ surrogacy describes the growing global phenomenon of people seeking surrogacy arrangements in jurisdictions outside of their own. International surrogacy may be utilised for various reasons. Surrogacy arrangements are forbidden by law in many nations (Salama et al., 2018), people of certain sexual orientations or relationship status may be restricted from becoming intended parents in some jurisdictions (Ethics Committee of the American Society for Reproductive Medicine, 2022), and the surrogacy laws in an international destination may be preferred to the ones at home (Everingham et al., 2014; Fenton-Glynn, 2022; Horsey, 2018; Horsey et al., 2015; Jadva et al., 2021). In some jurisdictions where surrogacy is permitted, such as Australia and the United Kingdom (UK), the majority of children born through surrogacy are born overseas (Department of Home Affairs, 2020; Jadva et al., 2021; Newman et al., 2021).

Health and safety concerns have been raised in relation to international surrogacy practices (Knoche, 2014) due to the varying standards of care for assisted reproductive technologies (ART) across the world (Ethics Committee of the American Society for Reproductive Medicine, 2022). Best practices, such as psychosocial counselling (psychological and social implications of the arrangement) and legal advice for surrogacy participants (Blyth et al., 2011), single embryo transfer (Human Fertilisation and Embryology Authority, 2021; International Federation of Fertility Societies Standards and Practice Committee, 2011; Shenfield et al., 2011) and identity-release or open gamete donation (Human Fertilisation and Embryology Authority, 2021; National Health and Medical Research Council, 2017), may not always be available, or required, in every jurisdiction.

It is difficult to obtain evidence on international surrogacy practices. There is no international framework regulating surrogacy (Fenton-Glynn, 2016; Trimmings & Beaumont, 2011), nor is there a global registry recording the details of arrangements (Deonandan, 2015; Salama et al., 2018). Destinations commonly utilised by intended parents also change over time. Many jurisdictions have been prompted to restrict surrogacy access to citizens only following concerns regarding surrogate and child welfare (Cohen, 2015; Parry & Ghoshal, 2018; Schurr & Militz, 2018). Following this, the international industry, which has been described as a ‘reproweb’ for its flexible nature, expands into new settings with poor or liberal surrogacy regulations (König & Jacobson, 2023; Whittaker et al., 2022).

In 2013, 259 Australians who were considering, were in the process of, or who had completed surrogacy were surveyed (Everingham et al., 2014; Hammarberg et al., 2015; Stafford-Bell et al., 2014). The major barrier to accessing surrogacy in Australia as reported by the study participants was a shortage of women willing to act as surrogates (Everingham et al., 2014). Of respondents that had completed surrogacy overseas, 45% reported their child was born prematurely (Stafford-Bell et al., 2014). In contrast, just 16% of babies born through ART in Australia during 2013 were preterm (Macaldowie et al., 2015). While the transfer of multiple embryos is the primary cause of multiple births and adverse perinatal outcomes in ART (Adamson & Norman, 2020), the study did not collect information regarding the use of single or multiple embryo transfer or the incidence of multiple birth.

The available evidence on the perinatal outcomes of surrogacy suggests that they are comparable to other forms of ART (Söderström-Anttila et al., 2016; Yau et al., 2021). However, this evidence stems from single site studies and fails to capture the differences in ART practices that may exist between jurisdictions. The aims of this study were to describe how intended parents in Australia decide where to pursue surrogacy and to compare the characteristics and outcomes of arrangements completed within and outside of Australia.

Materials and methods

Context

Australia is a federation of six states and two self-governing territories. There are no national laws governing surrogacy in Australia and arrangements are instead regulated at the state and territory level. There are some differences across the jurisdictions’ approaches to regulating surrogacy arrangements; however, the fundamental principles remain the same. These include: (1) the surrogate cannot receive financial payment from the intended parents beyond the reimbursement of expenses; (2) the surrogate is the legal mother of the child upon birth and parentage can only be transferred to the intended parent/s through a court order; and (3) the arrangement cannot be legally enforced, meaning the surrogate is under no legal obligation to relinquish the child at or soon after birth, but nor are the intended parents obliged to accept the child (Sifris & Page, 2021).

The various state and territory laws stipulate the requirements for parentage to be transferred and this is where the discrepancies are mostly seen between Australia’s jurisdictions, with some being more restrictive than others (Karpin & Millbank, 2020). Heterosexual couples, single women and same-sex female couples with a medical indication for surrogacy, single men and same-sex male couples are eligible to become parents through surrogacy in most states and territories. However, there are some exceptions. Gay male couples and single men are excluded from accessing surrogacy in Western Australia (Parliament of Western Australia, 2008) and single individuals are not eligible in the Australian Capital Territory (Australian Capital Territory Parliamentary Counsel, 2016).

It is also a requirement across all Australian jurisdictions that prior to treatment, the intended parents and surrogate must receive legal advice from a legal practitioner and psychosocial counselling by a qualified counsellor (Johnson, 2015). Egg donors must also receive psychosocial counselling prior to donation (Karpin & Millbank, 2020). However, in some states and territories, post-birth psychosocial counselling is also required for surrogacy participants (Allan, 2019).

Australian fertility clinics must comply with ethical guidelines governing the use of ART in clinical practice (National Health and Medical Research Council, 2017; Reproductive Technology Accreditation Committee, 2021). As part of these guidelines, clinics are only permitted to perform single embryo transfer in surrogacy arrangements. Furthermore, if a donor is required, the donor must consent to the release of their identifying information once the donor-conceived individual turns 18 years of age.

Ethical approval

The study was approved by the Monash University Human Research Ethics Committee (MUHREC 28359).

Participants and recruitment

Participants were recruited between August and November 2021. Representatives of two surrogacy not-for-profit organizations, Surrogacy Australia and Growing Families, disseminated information about the survey through their email list and social media accounts. An Australian family lawyer who specialises in surrogacy advertised the survey on their social media accounts and within the Australian Surrogacy Community closed Facebook group. Finally, personal contacts of the researchers were invited to participate through email. Australian citizens and permanent residents were eligible to participate if they had completed surrogacy, were in the process of completing surrogacy, or were planning on pursuing surrogacy in the future. Participants who were in a relationship were asked to complete only one survey per couple to avoid data from the same surrogacy arrangement being reported twice. Before participants were able to access the survey questions, they were provided with participant information and consent to participate in the study was implied if participants submitted their survey responses.

Survey development

An anonymous online survey with predominantly fixed-choice questions was hosted through Qualtrics. Questions were informed by the authors’ prior research (Everingham et al., 2014; Hammarberg et al., 2015; Kneebone et al., 2022; Stafford-Bell et al., 2014), similar published studies (Jadva et al., 2019, 2021; Lindheim et al., 2019), and one author’s (SE) experience of surrogacy and surrogacy advocacy. Survey questions were refined through an iterative process involving consultation with parents through surrogacy. The survey included 73 questions and was structured into three sections.

The first section assessed respondents’ motivations for surrogacy, information and support needs, and considerations for domestic and international arrangements. This section was available to all respondents (i.e. those who had completed surrogacy, those in the process of completing surrogacy and those who were planning on pursuing surrogacy). The second section asked questions about attempts at engaging with surrogates and the outcomes of these engagements. Section two was available to those who had completed surrogacy and those in the process of completing surrogacy. The final section assessed the characteristics and outcomes of completed surrogacy arrangements and was available to those who had completed surrogacy. If respondents had completed surrogacy more than once, they were asked to report on their most recent arrangement.

Statistical analysis

Data were imported from Qualtrics to SPSS and analyzed descriptively. Responses to the fixed choice questions are reported as percentages and number of respondents. Continuous data are reported as means when the data are symmetrically distributed and medians when they are skewed. ‘Gestational length’ is reported in categories defined by the International Glossary on Infertility and Fertility Care (Zegers-Hochschild et al., 2017). ‘Professional surrogacy providers’ include any individual or organization responsible for the recruitment and screening of surrogates, as well as the facilitation of the arrangement on behalf of intended parents (i.e. surrogacy agencies or fertility clinics). Respondents were not required to answer all survey questions. Where responses were missing, these are identified as ‘not reported’.

Results

Of the 334 respondents that began the survey, 320 met the eligibility criteria and completed the survey. One participant was excluded due to the ambiguity of their responses. Of the remaining participants, 43% had completed at least one surrogacy arrangement (n = 136), 28% were in the process of completing their first surrogacy arrangement (n = 90), and 29% were planning on pursuing surrogacy (n = 93). The mean age of respondents was 40 years (range 24–66). The gender, household income and relationship status are presented in Table 1. Respondents were asked to provide their gender and household income at the time of completing the survey, while relationship status was asked in relation to when they decided to pursue surrogacy. Over half of the respondents’ median annual income was greater than $182,000, double the median household income for Australians in 2019–2020 (Australian Bureau of Statistics, 2022). Most respondents were partnered, with only 11% pursuing surrogacy as a single person.

Table 1. Sociodemographic characteristics of the intended parents (n = 319).

Sociodemographic characteristic	% (N)
Gender
Man	55% (174)
Woman	44% (139)
Non-binary	0% (1)
Not reported	2% (5)
Household income
<$77,999	8% (25)
$78,000–$103,999	7% (23)
$104,000–$129,999	9% (28)
$130,000–$155,999	7% (23)
$156,000–$181,999	12% (39)
$182,000–$207,999	13% (40)
>$208,000	43% (137)
Not reported	1% (4)
Relationship status
Heterosexual couple	44% (140)
Same-sex male couple	41% (131)
Same-sex female couple	0% (1)
Single male	7% (22)
Single female	4% (14)
Not reported	3% (11)

Approximately two-thirds of respondents considered and/or attempted one or more alternative parenting options before deciding to pursue surrogacy (n = 215), with adoption (68%, n = 147), natural conception (43%, n = 92), and assisted conception (40%, n = 87) being the three most frequently contemplated/attempted options. Respondents who considered or attempted adoption ultimately decided to pursue surrogacy due to the perceived long wait times associated with adoption (71%, n = 105) and a desire to raise a genetically related child from birth (57%, n = 84). Respondents accessed information about surrogacy from multiple sources, most frequently online sources including closed Facebook surrogacy groups (66%, n = 209), the websites of non-profit surrogacy organizations (57%, n = 183), and the websites of overseas surrogacy agencies (54%, n = 172).

Australia versus overseas surrogacy

Respondents were asked whether they had completed, were completing or were planning to complete surrogacy in Australia and/or overseas. Almost half selected surrogacy overseas (46%, n = 147), while the remaining selected surrogacy in Australia (31%, n = 99), surrogacy in Australia and overseas (18%, n = 56), or that they had not decided yet (5%, n = 17).

Of the 203 respondents who selected ‘surrogacy overseas’ or ‘surrogacy in Australia and overseas’, only 8% reported that overseas was their preference (n = 17). Almost all respondents stated they would have rather pursued surrogacy in Australia had it been possible (92%, n = 186). Respondents who selected ‘surrogacy overseas’ or ‘surrogacy in Australia and overseas’ (n = 203) were asked to select the reasons for this from a list of eight fixed responses (Table 2). Perceiving surrogacy in Australia as a long and complicated process was the most common reason for pursuing surrogacy overseas (69%, n = 140). Respondents who selected ‘surrogacy in Australia’ or ‘surrogacy in Australia and overseas’ (n = 155) were asked to select the reasons for this from a list of seven fixed responses (Table 3). Desiring involvement with the pregnancy was the most frequently reported reason for pursuing surrogacy in Australia (50%, n = 77).

Table 2. Reasons for respondents (n = 203) choosing international surrogacy.

Reasons for choosing international surrogacy	% of respondents
	(n)
Surrogacy in Australia looked like too long/or complicated a process	69% (140)
I could not find a surrogate in Australia	56% (114)
I wanted a professional surrogacy provider to screen potential surrogates and facilitate my arrangement	46% (94)
In Australia, the surrogate has the right to keep the child if she changes her mind	43% (88)
I wanted to be able to compensate a surrogate for carrying my child	35% (71)
I was not eligible to pursue surrogacy in my State or Territory	15% (30)
I wanted greater choice of egg donors	14% (29)
I did not want any/much contact with my surrogate	11% (22)

Table 3. Reasons for respondents (n = 155) choosing surrogacy in Australia.

Reasons for choosing surrogacy in Australia	% of respondents
	(n)
Wanting to be involved in the pregnancy	50% (77)
Wanting an ongoing relationship with the surrogate	49% (76)
Australian woman offered to become my/our surrogate	47% (73)
Wanting child to know the surrogate	46% (71)
Difficulties in navigating another country’s legal and medical systems	43% (66)
More affordable	35% (54)
Concerns of surrogate treatment overseas	34% (52)

Characteristics of arrangements

Of the 136 respondents who had completed a surrogacy arrangement, 79% had completed their most recent arrangement overseas (n = 108). The characteristics of Australian and overseas surrogacy arrangements are presented in Table 4. All respondents who completed surrogacy in Australia obtained legal advice from an Australian lawyer and received counselling, while only 65% and 56% respectively did so in overseas surrogacy.

Table 4. Characteristics of Australian (n = 28) and overseas (n = 108) surrogacy arrangements.

Characteristics	Australian surrogacy	Overseas surrogacy
	(n = 28)	(n = 108)
Obtained legal advice	100% (28)	65% (70)
Obtained counselling	100% (28)	56% (60)
Mode of conception*
Insemination	14% (4)	8% (8)
Embryo transfer	86% (24)	92% (98)
Multiple embryo transfer	0% (0)	41% (40)
Donor oocytes	50% (12)	79% (77)
Anonymous donors	0% (0)	47% (36)

*Only 106 respondents who completed surrogacy overseas reported the mode of conception.

Most pregnancies were a result of an embryo transfer procedure (‘gestational’ surrogacy) and not insemination (‘traditional’ surrogacy). Of the transfers completed overseas, 41% involved multiple embryo transfer (n = 40). Most multiple embryo transfers were at the respondents’ request (35/40). Four reasons for electing to transfer multiple embryos were cited: a desire to have twins; to increase the chance of a successful transfer; following the advice of the doctor or surrogacy provider; and to avoid extra costs associated with a single embryo transfer. Of the donor oocytes used in overseas surrogacy, almost half were anonymously donated.

Outcomes of arrangements

The outcomes of surrogacy arrangements completed in Australia and overseas are presented in Table 5. There were 12 instances of twin births, all of which occurred in overseas arrangements. All but one twin birth arose from pregnancies resulting from a multiple embryo transfer. Rates of neonatal intensive care and preterm birth were higher in arrangements conducted overseas compared to in Australia. Most of the twin birth babies were preterm (75%, n = 9) and required neonatal intensive care (58%, n = 7).

Table 5. Outcomes of Australian (n = 28) and overseas (n = 108) surrogacy arrangements.

	% of respondents
	Australian surrogacy	Overseas surrogacy
Outcomes	(n = 28)	(n = 108)
Twin births	0% (0)	11% (12)
Neonatal intensive care	11% (3)	22% (24)
Gestational length*
28–36	11% (3)	20% (22)
37–42 weeks	89% (24)	79% (85)
>42 weeks	0% (0)	1% (1)

*One respondent who did surrogacy in Australia did not report the gestational length.

Almost all respondents indicated they had disclosed or planned to disclose to their child that they were born through surrogacy (98%, n = 133). Only one respondent reported they would not disclose the use of surrogacy, while two reported they were unsure. Of those that used donor oocytes (n = 89), the majority reported they had disclosed or planned to disclose to their child their genetic origins (98%, n = 87). Two respondents reported they will not or do not plan to disclose the use of donor oocytes to their child.

Surrogacy destinations

Twelve surrogacy destinations were used by respondents: the USA (34%, n = 37); Canada (17%, n = 18); Ukraine (n = 11%, 12); India (10%, n = 11); Georgia (9%, n = 10); Greece (6%, n = 7); Thailand (4%, n = 4); Mexico (3%, n = 3); Colombia (2%, n = 2); Cambodia (1%, n = 1); Brazil (1%, n = 1); and China (1%, n = 1). One respondent who completed overseas surrogacy did not report which country they completed the arrangement in.

The respondents were asked to select the considerations important to them when deciding which destination to pursue surrogacy in from a list of ten fixed responses (Table 6). A country with legal frameworks allowing the intended parents to be listed as the birth parents from birth was most frequently reported as an important consideration (86%, n = 93).

Table 6. Important considerations when deciding which overseas destination to engage in (n = 108).

Important considerations	% of respondents
	(n)
The ability to be the sole parent(s) on the birth certificate	86% (93)
Treatment and care of surrogates	84% (91)
Track-record of that country in managing surrogacy arrangements	76% (82)
A surrogacy provider which met all my needs	71% (77)
Affordability	63% (68)
Success rates of clinics	61% (66)
Ability to establish a relationship with my surrogate	53% (57)
Convenience e.g. I have family who live there or cultural ties to the country	12% (13)
Ability to choose the sex of my child	11% (12)
Ability to have little or no contact with the surrogate	8% (9)

Almost all had used a professional surrogacy provider to assist with surrogate recruitment, screening, matching and support (n = 105). These respondents were asked to select the considerations important to them when deciding which provider to use from five fixed responses (Table 7). Feeling like they could trust the provider was most frequently chosen (88%, n = 92).

Table 7. Important considerations when deciding which surrogacy provider to use (n = 105).

Important considerations	% of respondents
	(n)
Feeling like they could trust the provider	88% (92)
Recommendations from other intended parents	56% (59)
Affordability	56% (59)
Personalized programmes	29% (30)
Live birth guarantee	18% (19)

Discussion

This study made three important original findings. First, it observed that most Australian intended parents would prefer to pursue surrogacy in their home country if it were more accessible. Second, practices which aim to protect the wellbeing of surrogacy participants (e.g. counselling, single embryo transfer, known or identity-release gamete donation) are frequently absent in international surrogacy arrangements. Third, children born through surrogacy have less favourable outcomes when born overseas as compared to in Australia. These findings raise concerns about the health and welfare of all international surrogacy participants, but particularly for the women acting as surrogates and the children who are born as a result of such arrangements. They also suggest that reducing the barriers to surrogacy would encourage more people to complete arrangements domestically, which in turn would reduce the potential for harm associated with international surrogacy.

The ability to be involved with the pregnancy and to have an ongoing relationship with the surrogate were the most common reasons intended parents wanted to pursue surrogacy at home. This is possible in Australia because surrogacy is framed as an intimate relationship creating life-long friendships, and not simply as a form of conception (Jefford, 2020). While similar approaches to surrogacy exist in some international surrogacy destinations, for example Canada (Fantus, 2021) and the USA (Smietana, 2017), the high cost of surrogacy in such destinations may pose a barrier to some intended parents. In destinations where costs are lower, a relationship with the surrogate may be rare as arrangements can be perceived solely as a business-like exchange (Smietana et al., 2021). Contact between intended parents and surrogates during international arrangements can be further hindered by language barriers (Jadva et al., 2019) and can sometimes be prevented by surrogacy providers (Siegl, 2018). Very few respondents chose international surrogacy because they wanted little or no contact with their surrogate. This supports existing evidence of the significance for intended parents to have a relationship with their surrogate (Kneebone et al., 2022).

Completing surrogacy overseas can be a challenging journey for intended parents (Arvidsson et al., 2019; Gezinski et al., 2018). Stresses may arise from having to navigate a foreign country’s legal and medical systems, being separated from the pregnancy, and not having control over the process (Carone et al., 2017; Zandi et al., 2014; Ziv & Freund-Eschar, 2015). Australian legal advice and counselling help intended parents through their surrogacy journey but as this study shows, not all access these services and the reason for this is unclear. The non-profit organization Growing Families urges intended parents to seek legal advice and counselling (Growing Families, 2022). Australian Government information pages regarding international surrogacy also advise intended parents to obtain legal advice, although not counselling (Department of Home Affairs, 2023; Smarttraveller, 2022; Victorian Assisted Reproductive Treatment Authority, 2023). Barriers to accessing these services may be financial or stem from a lack of awareness of their benefits. Research into the attitudes and experiences of intended parents accessing such services in Australia could inform strategies to improve uptake.

While only a small proportion of respondents completed a surrogacy arrangement in Australia, the reported incidence of multiple (0%) and preterm (11%) births are consistent with the rates reported after ART in Australia (2.8% and 13.8% respectively) (Newman et al., 2022). Concerningly, the rates of multiple and preterm birth were much higher in international surrogacy arrangements. This raises concerns about the health impacts of the common practice of multiple embryo transfer in many international surrogacy destinations on surrogates and those born through surrogacy. Furthermore the health interventions required for babies born prematurely, for example neonatal intensive care, have financial implications for intended parents.

The proportion of preterm births in overseas arrangements observed in this study (20%) was lower than reported in a study conducted almost a decade ago (45%) (Stafford-Bell et al., 2014). This may indicate an increasing use of single embryo transfer, as is the trend for fertility treatments more generally (Adamson & Norman, 2020). However, a firm conclusion cannot be drawn as the earlier study did not collect data on single vs. multiple embryo transfer. It is also important to note that the rate of single embryo transfers can vary considerably between jurisdictions (Adamson & Norman, 2020). A limitation of this study is that, because of the large number of surrogacy destinations reported by respondents, the results were not differentiated by country.

The high use of multiple embryo transfer reported by respondents may seem somewhat contradictory considering that increased risk to surrogates and that ‘care of surrogates’ was reported as an important consideration in deciding which international surrogacy destination to pursue. There is even evidence to suggest that surrogates are more likely to receive multiple embryo transfers than other women undergoing non-surrogacy cycles (White, 2018). Contributing to this are the intended parents’ desires to complete their family, as reported in this and in other studies (Lindheim et al., 2019), and the surrogates’ desire to provide a greater ‘gift’ (Berend, 2010).

The Verona Principles, developed by the International Social Services, are a set of guiding principles for the protection of the rights of children born through surrogacy (International Social Services, 2021). The principles aim to protect the child’s identity and access to information about their genetic, gestational and social origins. While there is limited empirical evidence investigating the attitudes and experiences of those born through surrogacy, the available data supports the importance of these principles. In a recent focus group study conducted with children and young people with experience of surrogacy, most participants agreed that children born through surrogacy should know the identity of the surrogate and whether donor gametes were used in their conception (Wade et al., 2023). A longitudinal study investigating the psychological outcomes of people born through third-party reproduction found that young adults born through surrogacy, who in most cases were told about their conception before the age of 4 and were still in contact with their surrogate, felt positive or unconcerned about their method of conception (Jadva et al., 2023). These studies were conducted in the UK where ‘altruistic’ surrogacy is practised and had a small number of participants. The views of those born through ‘commercial’ surrogacy or through international surrogacy are unknown.

Whilst there was a high rate of disclosure or intention to disclose to children the way they were conceived in our study, there is still reason to be concerned about the psychosocial outcomes for those born through international surrogacy. This is because, as in this study, anonymous egg donation is common in international surrogacy. Furthermore, intended parents do not necessarily have contact with surrogates overseas and hence those born through surrogacy will likely face difficulties should they wish to find information regarding, or contact, the woman who gave birth to them. Research investigating the wellbeing of individuals born through international surrogacy, including the role of the donor, must be a priority.

The findings of this study support prior research conducted in Australia (Everingham et al., 2014; Riggs, 2015) and internationally (Fenton-Glynn, 2022; Horsey, 2018; Horsey et al., 2015; Jadva et al., 2021) on barriers to domestic surrogacy. International surrogacy, with its greater legal certainty, availability of surrogates and professional surrogacy providers, is often a more accessible option. A recent government inquiry into access to reproductive health care in Australia acknowledged the difficulties faced by intended parents attempting to access surrogacy domestically (Community Affairs References Committee, 2023). The report recommended that the exclusion of patients engaged in surrogacy arrangements from receiving public funding for ART services should be removed. However, it stopped short of recommending reforms that would remove other barriers to domestic surrogacy.

Reviews of current surrogacy legislation have recently been conducted in New Zealand, the Republic of Ireland, and the UK, with the aim of supporting residents to complete domestic surrogacy rather than go abroad (Department of Health, 2023; Kawharu et al., 2022; The Law Commission of England and Wales and the Scottish Law Commission, 2023). While the recommendations from these reviews do not include removing the prohibitions on surrogate payment or commercial providers, they include establishing non-profit regulated surrogacy organizations and a surrogacy registry, as well as more streamlined pathways for intended parents to be granted legal parenthood at birth (Horsey & Mahmoud, 2023). In the UK, however, the Law Commission of England and Wales and the Scottish Law Commission has made an exception for payments in relation to a modest recuperative holiday for the surrogate and her family (The Law Commission of England and Wales and the Scottish Law Commission, 2023). Similar reforms in other settings, including Australia, may allow more intended parents to complete surrogacy domestically which in turn may lead to better outcomes for children born from surrogacy.

Strengths of this study include its considerable sample size and the range of aspects of surrogacy covered in the survey. The respondents’ sociodemographic characteristics and motivations for surrogacy were similar to previously conducted studies, both within Australia (Everingham et al., 2014) and internationally (Fenton-Glynn, 2022; Horsey et al., 2023; Jadva et al., 2021). This suggests findings can be generalized to similar contexts where barriers restrict access to surrogacy.

Limitations must also be acknowledged. As this was an anonymous online survey a response rate cannot be calculated. Also, it is not known if those who completed the survey were representative of all intended parents in Australia. While fixed-choice questions allow for the collection of data from a large number of respondents, they fail to capture complexities of individual experience and the views and experiences not included in the response options provided. Moreover, we treated respondents as a single group but there may be differences between respondents, particularly regarding decision-making factors for heterosexual and same-sex male intended parents.

In conclusion, surrogacy is a legitimate path to parenthood and needs to be recognized and regulated as such by governments (Horsey & Mahmoud, 2023). Nations’ attempts to restrict access to surrogacy are ineffective considering the ability to enter international arrangements. This study’s findings raise concerns about the health and welfare of international surrogacy participants, particularly surrogates and children. In lieu of any international instrument regulating surrogacy, reducing the barriers to surrogacy at a domestic level would reduce the demand for international arrangements and in turn, reduce the potential for harm.

Author’s roles

All authors contributed to the conception and design of the study, interpreted the data, critically revised the article, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work. EK analyzed the data and drafted the article.

Acknowledgements

We thank the individuals and organizations who advertised the study and helped us recruit participants and those who completed the survey.

Disclosure statement

SE is the Global Director of Growing Families, a non-profit organization educating and advising on third-party reproduction. He is also a board member of a charity supporting Australian surrogacy participants. The remaining authors report there are no competing interests to declare.

Data availability statement

The data underlying this article cannot be shared publicly due to the confidentiality of the participants. The data will be shared on reasonable request to the corresponding author.

Additional information

Funding

EK receives a Research Training Program Scholarship awarded by the Australian Government Department of Education.