Francesco Maria Bulletti1, Romualdo Sciorio2, Antonio Palagiano3, Maurizio Guido4 and Carlo Bulletti5*
Received: August 03, 2023; Published: August 17, 2023
*Corresponding author: Carlo Bulletti, Help Me Doctor. Via Nazario Sauro, 30 - 47841 Cattolica, Italy
Background: Infertility is a disease of the male or female reproductive system associated with psychological
default. Surrogacy, pregnancy for others, or gestational carrier is a method of assisting the transmission of
human life. Several severe acquired or congenital conditions require a unique medical solution- the use of
gestational carrier-with the only alternative option of uterine transplantation from a third woman to carry
on a pregnancy.
Methods: We performed a literature search without time length restriction using the keywords, gestational carrier, surrogate mother, and pregnancy for others We selected the publications coherent with the following research questions:
• The use of gestational carriers represents the gold standard medical provision for women with severe absolute problems to carry on pregnancy until delivery.
• The desire to transmit life to a child is a biological right or an amenity.
• This procedure is ethically allowed to a couple of men?
• The use of a gestational carrier implies an extraordinary risk for third parties, including psychological insults.
• There is evidence of a specific and irreplaceable relationship between mother and fetus?
• Is the altruistic offer of a gestational carrier to be considered from a positive perspective?
• Is the commercial use of a gestational carrier to be refused because concerning the commercial use of the body?
• Who is the owner of the proper body? The individuals or the government?
• The difference between the regulation and the prohibition.
• Why other uses of our bodies are under our control and gestational carrier not allowed in several countries.
Results: On 3406 publications found, we selected 248 articles coherent with our research questions. Among the forms of parenthood that have followed one another in remote and recent history, the most current seems to us to be that of a formal act of “assumption of unlimited responsibility to love whomever one intends to have as a child”. The gestational carrier is the gold-standard solution for absolute obstacles to having a child, uterus transplantation remains the first alternative option. The use of a gestational carrier can be considered for various reasons, such as:
• Infertility: When intended parents are unable to conceive or carry a pregnancy to term due to medical reasons. • Recurrent Pregnancy Loss: In cases where intended parents have experienced multiple miscarriages.
• Medical Conditions: If the intended mother has a medical condition that makes pregnancy unsafe for her or the baby.
• Same-Sex Couples: For male couples who wish to have a biological child using a donor egg and a gestational carrier.
• Other Personal Reasons: Some individuals or couples may choose gestational surrogacy for personal or lifestyle reasons.
Since there is no evidence of any psycho-physical damages for the intended parents, gestational carrier, and newborn the prohibition of the procedure is essentially prejudicial for ideology and religion. In the use of a gestational carrier, there are three happiness involved: the intended parents, the gestational carrier, and the child born in a loving atmosphere. Social concerns based on ethical perspective for lack of human dignity by body use marketing and best interest of the child are they are swept away by the self-determination of the use of one’s body not disposed of by governmental or divine institutions but by the interested party alone as already happens for the donation of other organs, tissues, gametes or use of the body itself for other purposes. The dignity of a beloved child cannot be defined as a state. A state can delimit the rules not the provision of the mode of transmission of a life. Finally, there is no evidence of the generation of pathology from the detachment of a supposed “specific” mother-fetus dialogue.
Discussion: A major criticism is ethical respect for human life and the abuse of low economical conditions by attractive economical offers. A body market is used for someone as a personal choice based on the right of self-determination for others. The regulation of some countries exclude women offering to become gestational carriers those with very low economical conditions to overgo that criticism. Babies born from GC have no detectable damage from inspections nor do those who are adopted at birth as long as they are aware of environments full of love. The claim to govern the reproductive behavior of the person despite his will when the reproductive method chosen does not involve any risk for third parties is part of a model of society that disrespects self-determination. That not only chooses not to use the innovation but also expects it not to be used by others.
Keywords: Gestational Carrier; Surrogate Mother; Pregnancy for Others
1. Infertility is a disease of the male or female reproductive system
defined by the failure to achieve a pregnancy after 12
months or more of regular unprotected sexual intercourse
. It is often associated with psychological default . The
most logical consequence is that the medical solutions to
overcome this disease should be considered when no damage
is produced to third parties.
2. Several severe acquired or congenital conditions require a unique medical solution of the use of gestational carrier with the only alternative option of uterine transplantation from a third woman to carry on a pregnancy during the first 40 weeks of development .
3. Two main issues concerning the worldwide community manifested through laws prohibiting the procedure, one being the sale of the use of the own body and the second the emphasis on the alleged exclusive mother-fetus relationship during pregnancy which would be missing. The first object of numerous unresolved debates but which decays with the altruistic, compassionate mode, without the passage of money, and the second - as we will see - mere fantasy of romanticism. Still postponing in the female community the profound duality between those who believe that exploitation is the inevitable consequence of the economic condition and those who believe that this is possible facilitation but that the woman herself is always and always, in any case, must be the sole custodian of the choices of her own body. Not being a matter that concerns the state or the religions that the state often represents. Life is not - as some religions say - an unavailable good Life, conversely, it is the only good we can dispose of.
Surrogacy, pregnancy for others, or gestational carrier is a method of assisting the transmission of human life for women with certain congenital or acquired uterine malformations, systemic diseases, or destructive surgeries which do not allow them to have and/or continue the pregnancy to a live birth. In the couple of men that is the solution to become a family ( Practice Committee of the American Society for Reproductive Medicine  and . Today is prohibited in many countries with reasons discussed in the treatment of the article, in the hope of its regulation as well as with in vitro fertilization and embryo transfer (IVF-ET). The gestational carrier is a medical-scientific solution for the serious suffering condition of millions of women. Which is part of a series of new modes of transmission of life with which society has to get used to living. Since their universal refusal is not likely. The gestational carrier has long been considered the reproductive solution of choice for women with uterine malformations worldwide . Representing 3% -10% of women of reproductive age: these are women with Asherman’s syndrome (2% -3% of those who undergo instrumental revision of cavities and which form complex uterine intracavity adhesions that impede any internal fetal development), those with Mayer-Rokitansky-Küster-Hauser syndrome (MRKH), a rare medical condition characterized by the absence or underdevelopment of the uterus and vagina (affecting approximately 1 out of 4,000-5,000 women), those with Turner syndrome (1/2000 women), a condition with frequent oocyte availability but poor gestational capacity. The gestational carrier procedure  is an ordinary medical procedure aiming to overcome an absolute obstacle to having a child and it represents one of the two only options for that uterine transplantation in hetero-sexual couples and the only one in omo-sexual. First used in 1985 .
The aims of this review are:
a) To establish if the use of gestational carrier represents the gold standard medical provision for women with severe absolute problems to carry on pregnancy until delivery.
b) To establish if the desire to transmit life to a child is a biological right or an amenity.
c) To establish if this procedure is ethically allowed for a couple of men.
d) To exclude that the use of gestational carrier implies an extraordinary risk for third parties, including psychological insults.
e) To exclude evidence of a specific and irreplaceable relationship between the mother and fetus
f) To explore the ethical issues surrounding this procedure. Specifically:
1) The gestational carrier is the choice of a couple of men.
2) The altruistic offer of a gestational carrier
3) The commercial use of gestational carrier
4) Who is the owner of the proper body?
5) The difference between regulation and prohibition.
6) Why other uses of our bodies are under our control and gestational carrier is a matter of government in several countries.
PubMed, Cochrane, and Google research for English papers published
until June 2023 was performed by using the keywords gestational
carrier, surrogate mother, and pregnancy for others. First and
second screening was performed by two different authors following
the coherence with the keywords and the following research questions:
1. The use of gestational carriers represents the gold standard medical provision for women with severe absolute problems to carry on pregnancy until delivery.
2. The desire to transmit life to a child is a biological right or an amenity.
3. This procedure is ethically allowed to a couple of men?
4. The use of a gestational carrier implies an extraordinary risk for third parties, including psychological insults.
5. There is evidence of a specific and irreplaceable relationship between mother and fetus.
6. Is the altruistic offer of a gestational carrier to be considered from a positive perspective?
7. Is the commercial use of a gestational carrier to be refused because concerning the commercial use of the body?
8. Who is the owner of the proper body? The individuals or the government?
9. The difference between regulation and prohibition.
10. Why other uses of our bodies are under our control and gestational carrier not allowed in several countries.
Study Appraisal From the search using the queries based on the
keywords, a total of 3406 results were retrieved on July 28, 2023,
without time length restrictions. All titles, abstracts, and articles were
a) Duplicates (n = 12).
b) Studies not related to the study question (n = 2322),
c) Editorials/letters to the editor (n = 23) and
d) answers or comments (n = 51) were excluded.
e) Inconsistent with the study questions (n=588)
f) Inconsistent with scientific methodology and/or analysis (n=299)
g) We analyzed 111 remaining papers.
Of the remaining articles, 28 were not available (mainly because
of the year or journal of publication). In the end, a total of 248 articles
were included as the core of this review:
a) 23 altruistic and
b) 58 commercials.
c) 167 both considered.
Using a gestational carrier, also known as a surrogate, is a method of assisted reproduction in which a woman carries and gives birth to a baby for another individual or couple. In this arrangement, the intended parents typically provide the genetic material (egg and sperm) used to create the embryo through in vitro fertilization (IVF), and the embryo is then transferred to the gestational carrier’s uterus for pregnancy and birth.
The use of a gestational carrier can be considered for various reasons,
1. Infertility: When intended parents are unable to conceive or carry a pregnancy to term due to medical reasons.
2. Recurrent Pregnancy Loss: In cases where intended parents have experienced multiple miscarriages.
3. Medical Conditions: If the intended mother has a medical condition that makes pregnancy unsafe for her or the baby.
4. Same-Sex Couples: For male couples who wish to have a biological child using a donor egg and a gestational carrier.
5. Other Personal Reasons: Some individuals or couples may choose gestational surrogacy for personal or lifestyle reasons.
It’s important to note that laws and regulations regarding gestational surrogacy vary significantly between countries and even states within countries. Legal, ethical, and medical considerations are essential aspects of the surrogacy process. The gestational carrier (GC) is one of the two options to have a baby when some extreme reproductive system abnormalities occur (3%-10% of women of reproductive age)  being the other the uterine transplantation . The first ever live birth from a uterus transplant took place in Sweden, in 2014. Fast forward less than a decade, and uterus transplants seem set to become a mainstream procedure shortly, with an estimated 90 uterus transplants carried out around the world as of end-2021, resulting in the birth of some 50 children . Gestational carriers represent the only possibility to become parents for men couples. There are 65 countries in the world where surrogacy is legal or admitted, both in its solidarity and in its commercial form. In another 35, the law establishes access only to supportive pregnancy . The data are including the countries where the procedure is regulated and that in which is not regulated but tolerated . Commercial use for both infertile women and/or homosexual males is not universally regulated by law . Unfortunately, both altruistic and commercial procedures should be Studied were analyzed not only based on monetary compensation . But also, for other biological, psychological, and ethical aspects that are dividing social communities.
For women facing severe absolute problems that prevent them from carrying a pregnancy to delivery, the use of gestational carriers, also known as surrogates, has emerged as a viable solution. We examine whether employing gestational carriers can be considered the gold standard medical provision for women encountering such challenges. By exploring the advantages and medical considerations associated with gestational carriers, we can assess their suitability as the preferred approach in these cases.
Severe Absolute Problems and Pregnancy
Certain medical conditions or circumstances can pose significant risks to a woman’s health or make carrying a pregnancy to term impossible. Severe absolute problems include conditions such as uterine factor infertility, recurrent pregnancy loss, or medical contraindications that prevent a woman from safely carrying a pregnancy to delivery. In these situations, alternative reproductive options, such as gestational carriers, become essential.
Gestational Carriers as a Safe and Effective Solution
Studies have shown that the use of gestational carriers provides a safe and effective approach for women with severe absolute problems. By transferring embryos created from the intended parents’ gametes into the gestational carrier’s uterus, the pregnancy is carried to term by a healthy surrogate who is capable of completing the gestational process. Gestational carriers undergo thorough medical and psychological screening to ensure their suitability for the process. This rigorous evaluation minimizes potential risks and increases the chances of a successful pregnancy outcome. The use of gestational carriers offers women with severe absolute problems the opportunity to have a biological child while mitigating potential health risks associated with carrying the pregnancy themselves [5,15].
1. \Psychological Considerations and Support: Psychological support is a crucial aspect of utilizing gestational carriers for women with severe absolute problems. The decision to pursue this reproductive option may elicit various emotions, including grief, loss, or feelings of detachment. Providing comprehensive counseling and support services for intended parents can help them navigate the emotional complexities associated with using a gestational carrier.
2. \ Moreover, establishing open lines of communication and fostering a positive relationship between the intended parents and the gestational carrier can contribute to a more supportive and harmonious experience for all parties involved. Psychological well-being is of utmost importance to ensure a positive reproductive journey for women with severe absolute problems [16-18].
• The use of gestational carriers represents a gold standard medical provision for women facing severe absolute problems that prevent them from carrying a pregnancy to delivery. With comprehensive medical screening, psychological support, and legal considerations, gestational carriers offer a safe and effective solution for women seeking to have a biological child while mitigating potential health risks associated with pregnancy. By providing an alternative reproductive option, gestational carriers allow women with severe absolute problems to experience the joys of parenthood while ensuring the well-being of both the intended parents and the gestational carriers involved in the process (Table 1).
The desire to have a child and transmit life is a fundamental aspect of human existence. However, the question of whether this desire represents a biological right or a simple desire and the child’s not a right is a complex and nuanced topic. We explored the perspectives surrounding the pulsion to transmit life to a child and we examined arguments for both the biological rights and amenity perspectives.
Biological Right to Procreate
Many argue that the desire to have a child is deeply rooted in human biology and represents a biological right. This perspective posits that the ability to procreate is an essential aspect of human nature, ingrained in our genetic makeup and reproductive capabilities. Proponents of this view argue that the desire to transmit life is a fundamental part of our evolutionary imperative, serving to perpetuate the human species [19,20].
Parenthood as an Amenity
Alternatively, some argue that the desire to have a child is not an inherent biological right, but rather an amenity—a desired luxury or social construct. This viewpoint suggests that procreation is a choice and not an automatic entitlement. It acknowledges that parenthood brings immense joy and fulfillment to individuals and society but asserts that it is not an essential biological function [21,22].
When discussing the desire to transmit life to a child, ethical considerations come into play. These considerations encompass issues such as reproductive autonomy, individual rights, and societal well-being. Balancing the desire for parenthood with concerns such as overpopulation, resource limitations, and the well-being of potential children requires thoughtful ethical deliberation [23,24]. The desire to transmit life to a child elicits a range of perspectives. While some argue that it is a biological right deeply rooted in our nature, others view it as an amenity or choice. Ethical considerations play a crucial role in this discourse, as societal values, individual autonomy, and the welfare of potential children come into play. Striking a balance between recognizing the desire for parenthood and addressing the complex ethical landscape surrounding procreation is essential. Ultimately, the nature of the desire to transmit life to a child lies at the intersection of biology, individual choice, and societal considerations, making it a topic that warrants ongoing reflection and discourse.
The use of gestational carrier procedures, also known as surrogacy, has become a widely debated topic with complex ethical considerations. In the context of couples of men, the question arises as to whether gestational carrier procedures are ethically allowed. We explored the ethical dimensions surrounding gestational carrier procedures for couples of men, considering various perspectives and key considerations in the ongoing reflection and discourse [25-28].
Reproductive Autonomy and Equal Access to Parenthood
One of the primary ethical arguments supporting the use of gestational carrier procedures for couples of men is the principle of reproductive autonomy. Every individual and couple should have the right to pursue their desire for parenthood. Denying couples of men, the opportunity to use a gestational carrier may be seen as a violation of their reproductive autonomy and equal access to parenthood.
The Well-being of the Child
Central to any discussion of gestational carrier procedures is the well-being of the child, which reflect the best interest. Critics of gestational carrier procedures for couples of men may argue that a child should have a mother figure in their life for optimal development. However, extensive research suggests that children raised by samesex couples fare just as well in terms of their social, emotional, and cognitive development as children raised by different-sex couples.
Consent and Agency of Gestational Carriers
Ethical considerations must also focus on the consent and agency of gestational carriers. It is crucial to ensure that gestational carriers fully understand the nature of the arrangement, their rights, and the potential emotional and physical implications involved. Protecting the well-being, autonomy, and dignity of gestational carriers through comprehensive legal agreements and support systems is vital to address concerns of potential exploitation or coercion.
Societal Attitudes and Discrimination
Critics of gestational carrier procedures for couples of men may argue that such procedures challenge traditional societal norms and beliefs about family structure . However, ethical discourse should consider the evolution of societal attitudes and the importance of equality and inclusivity. In a society that values diversity and respect for different family configurations, denying couples of men the opportunity to use a gestational carrier may perpetuate discrimination based on sexual orientation. The ethical implications surrounding the use of gestational carrier procedures for couples of men involve considerations of reproductive autonomy, child well-being, consent and agency, and societal attitudes. Ongoing reflection and discourse are essential to navigate these complex ethical dimensions. Ultimately, the decision regarding the ethical permissibility of gestational carrier procedures for couples of men should aim to balance the principles of reproductive autonomy, child welfare, and societal inclusivity, while ensuring robust legal protections and support systems for all parties involved.
The use of gestational carriers, also known as surrogates, has become an increasingly common method for individuals and couples to realize their dreams of parenthood. While it offers a viable option for family building, the practice raises important ethical considerations, particularly in the context of heterosexual and same-sex male couples. This chapter explores the ethical issues surrounding the use of gestational carriers and provides insights into the complexities involved [30-33].
Autonomy and Consent
• One of the primary ethical concerns in gestational carrier
arrangements is ensuring the autonomy and consent of all
parties involved. In heterosexual couples, the involvement of
a gestational carrier raises questions about the level of decision-
making power and agency given to the woman carrying
the child. It is essential to safeguard her rights and ensure
that she has freely consented to the arrangement without coercion
• In the case of same-sex male couples, additional ethical considerations arise regarding the involvement of the gestational carrier, who may not share a genetic connection with either intended parent. It is crucial to address potential power dynamics and ensure that all parties have freely consented to the arrangement, fully understanding the emotional, physical, and legal implications involved.
motional and Psychological Well-Being
• The emotional and psychological well-being of all parties
involved is of utmost importance in gestational carrier arrangements.
Heterosexual couples may face challenges in
navigating the emotional bond between the gestational carrier
and the intended parents. Clear communication, support,
and counseling can help manage expectations and address
potential emotional conflicts that may arise during the
• For same-sex male couples, the absence of a genetic connection between the gestational carrier and the intended parents may raise unique emotional considerations. Ensuring the well-being of the gestational carrier, as well as facilitating emotional support for all parties, becomes vital to maintaining healthy relationships and promoting positive outcomes.
Commodification and Exploitation
The use of gestational carriers can raise concerns about the commodification of women’s bodies and the potential for exploitation. It is crucial to ensure that gestational carriers are not financially coerced or exploited and that they have access to comprehensive legal representation, healthcare, and emotional support. Compensation should be fair and based on a transparent understanding of the physical and emotional demands associated with carrying a child.
Legal and Parental Rights
Gestational carrier arrangements raise complex legal issues surrounding parental rights and responsibilities. Clear legal agreements, including pre-birth orders or post-birth adoptions, should be established to protect the rights of all parties involved, including the intended parents, the gestational carrier, and the child. Legal frameworks need to be in place to address the specific challenges faced by both heterosexual and same-sex male couples in establishing and securing their parental rights. The ethical considerations surrounding the use of gestational carriers in both heterosexual and same-sex male couples’ family-building journeys are complex and multifaceted. Safeguarding autonomy and consent, prioritizing emotional well-being, addressing commodification concerns, and establishing clear legal frameworks are crucial steps to navigate these ethical challenges successfully. By ensuring the rights, well-being, and best interests of all parties involved, gestational carrier arrangements can be approached in an ethically responsible manner, supporting the creation of loving and supportive families.
The altruistic gestational carrier option does not touch the principle of the exploitation of the body because it does not involve the transition of money from the genetic mother to the bearer of the fetus. It is a compassionate, altruistic, oblative offering made by one person to another for whom he feels affection or understanding. Several countries permit only this version of the gestational carrier and this possibility represents the minority of the entire choice of GC because it requires a large period and psycho-physical effort. The use of gestational carriers, individuals who carry and give birth to a child on behalf of intended parents, has raised important ethical considerations in the realm of assisted reproduction. Within this context, the practice of altruistic gestational carrier arrangements, where carriers offer their services without financial compensation, presents a distinct model that deserves exploration. This article examines the concept of altruistic gestational carriers, and their prevalence in total births, and provides insights into their significance.
Altruistic Gestational Carriers: Definition and Motivations
Altruistic gestational carriers, also known as voluntary or non-compensated carriers, are individuals who choose to carry a child for their intended parents without financial remuneration. They undertake this journey out of a selfless desire to help others achieve their dream of parenthood. Altruistic carriers often have personal motivations rooted in empathy, compassion, or personal connections with the intended parents.
Prevalence of Altruistic Gestational Carriers
Exact statistics on the prevalence of altruistic gestational carriers can be challenging to ascertain due to variations in legal frameworks, cultural factors, and reporting mechanisms across countries and regions. However, some studies and data provide insights into the usage of altruistic carriers. A study by Jadva et al. [34-37]. Examined the experiences of 33 surrogacy families and found that approximately 45% of the participants used an altruistic carrier. Another study by Greenfeld and Henneberg  surveyed intended parents in Australia and reported that approximately 35% of surrogacy arrangements in the country involved non-compensated carriers. It’s important to note that the prevalence of altruistic gestational carriers may vary widely across different jurisdictions and cultural contexts, influenced by factors such as legal regulations, societal attitudes, and the availability of commercial surrogacy options.
Ethical Considerations and Advantages
• Altruistic gestational carrier arrangements can address certain
ethical concerns associated with commercial surrogacy,
such as the commodification of women’s bodies and the potential
for exploitation. By eliminating financial compensation,
these arrangements aim to prioritize the voluntary and
selfless act of helping others achieve parenthood. Altruistic
carriers may have a personal connection or relationship with
the intended parents, fostering a sense of trust and emotional
support throughout the journey.
• Furthermore, altruistic gestational carriers may have more stable long-term relationships with the intended parents compared to commercial arrangements. The absence of financial transactions can reduce the risk of conflicts arising from commercial negotiations and ensure the focus remains on the shared goal of creating a family.
Altruistic gestational carriers occupy a distinct role in the landscape of assisted reproduction, offering their services without financial compensation to help intended parents achieve their dreams of parenthood. While precise statistics on their prevalence may vary across jurisdictions, studies suggest that a significant portion of surrogacy arrangements involve altruistic carriers. These arrangements address certain ethical concerns associated with commercial surrogacy and foster relationships based on empathy, trust, and shared goals. The choice of an altruistic gestational carrier reflects a selfless act of compassion and solidarity, underscoring the unique contribution they make to the fulfillment of individuals’ and couples’ desire to build a family. This is the dominant use of GC because of time requested, work adaptation, and psycho-physical efforts that are usually recognized with cash outlay. In some countries where it is allowed, women with particular conditions of poverty are excluded and costs are regulated to protect the woman who offers herself and the woman who has to ask for this complex service [4,5] The prohibition of this form of gestational carrier in many countries is based on an ethical principle accepted by many: the exploitation of women’s bodies for money. With a clear division between rich and poor.
Believing that the state must protect this risk by deciding for everyone on the use of the body of each of us, this motivation - debatable and still debated - find ambiguities that weaken the reasons why the purchase of gametes is contextually allowed in fertilization programs in vitro with gamete donation and where prostitution is permitted or tolerated. Accepting, in fact, only some marketing of one’s body but not all. Acquired from the time of the first in vitro fertilization, pregnancy constitutes a period in which the health of the unborn child can be even more evaluated and chosen (PGT-A) and the pregnancy itself as well as its assistance no longer represents a closed box but an open construction site. Which continues with the neonatal era with the birth of newborns incapable of independent life. How is the attitude of hostility towards the Gestational Carrier compatible with the hiring of full-time nurses after birth due to the need for full-time work of the mothers? The new reality places the period from conception to birth not very different from that of the first year of life on an ethical and welfare level. The first with the prohibition of fostering the second with shared social consensus Why?
The use of commercial gestational carrier arrangements, where a woman carries a child for intended parents in exchange for financial compensation, presents a complex ethical landscape. This article aims to delve into the ethical aspects surrounding commercial gestational carrier arrangements, considering various perspectives and key considerations in this multifaceted debate [3,13,26,31-33,38-42].
Autonomy, Consent, and Exploitation
One of the primary ethical concerns in commercial gestational carrier arrangements is ensuring the autonomy and consent of all parties involved. It is essential to ensure that gestational carriers fully understand the nature of the arrangement, their rights, and the potential physical, emotional, and legal implications involved. Protecting the well-being, dignity, and agency of gestational carriers is crucial to prevent exploitation or coercion.
Commodification and Human Dignity
Critics argue that commercial gestational carrier arrangements can raise concerns about the commodification of women’s bodies. The transactional nature of these arrangements may reduce the gestational carrier’s role to that of a service provider, potentially compromising their inherent dignity. Ethical considerations must prioritize the protection of human dignity, ensuring that financial compensation does not overshadow the fundamental respect owed to all individuals involved.
Psychological and Emotional Considerations
Commercial gestational carrier arrangements can raise complex psychological and emotional considerations for all parties involved. Open communication, counseling, and emotional support should be integral parts of the process to address potential emotional conflicts, ensure the well-being of gestational carriers, and promote positive outcomes for the intended parents and the child.
Legal Protections and Regulations
The ethical framework of commercial gestational carrier arrangements necessitates robust legal protections and regulations. Legal agreements should be established to define the rights, obligations, and responsibilities of all parties involved, including the gestational carrier, intended parents, and the child. These agreements should prioritize the best interests of the child and ensure transparency and fairness throughout the process.
Commercial gestational carrier arrangements involve a range of ethical considerations, encompassing autonomy, consent, commodification, human dignity, psychological well-being, and legal protections. Careful thought and ongoing ethical reflection are essential to ensure that the rights, welfare, and dignity of all parties involved are upheld throughout the process. Balancing the desire for parenthood with ethical principles is crucial to navigating the complex terrain of commercial gestational carrier arrangements and promoting positive outcomes for all individuals involved. (Table 1) The use of oocyte and sperm donation in some European countries is under ambiguity to use of the term compensation for the burden of the procedure instead of payment. The mean cost is approximately 500$ per oocyte in Europe. Approximately 50$ per sperm eiaculate. In the UK was established a fair cost for an oocyte aspiration is 800 pounds. With a maximum of 3 donations. A bizarre cross between those data has some countries sanctioning a gestational carrier but not prostitution in the name and on behalf of the abjuration of the exploitation of one’s own body.
• There is no conclusive scientific evidence that demonstrates
a specific dialogue between mother and fetus during pregnancy.
During prenatal development, the fetus can perceive
sounds from the external environment, including the mother’s
voice. Studies have shown that fetuses can respond to
auditory stimuli, such as the mother’s voice, by increasing
their heart rate or movements. However, it is unclear whether
this reflects a form of intentional communication or is simply
an automatic response to sound stimuli.
• Some researchers have hypothesized that the mother may communicate with the fetus through voice, music, or other forms of auditory stimulation, but so far there is no definitive scientific evidence to support these theories. Much of the mother-fetus interactions during pregnancy are physiological in nature, such as the exchange of nutrients and oxygen across the placenta.
• In summary, although there is no definitive scientific evidence of a specific dialogue between mother and fetus during pregnancy, the affective interactions and emotional involvement of the mother can have a positive impact on the mother-infant relationship (Kisilevsky, et al. [43-46]).
• Some research suggests that the fetus may be able to recognize and respond preferentially to the mother’s voice over other unfamiliar voices. For example, a study by DeCasper and Fifer in 1980 suggested that newborns preferred hearing a recording of their mother’s voice over that of other unfamiliar women. But the voice familiar is not mandatory that of the gestational carrier but that of major frequency heard.
• However, it is important to point out that the evidence on this topic is not yet definitive and there are conflicting studies.Some research suggests that fetuses may respond to a wider range of sounds and not show a specific preference for the mother’s voice.
• Also, as far as light is concerned, the fetus in the womb is in a state of relative darkness. Although fetuses can perceive changes in light through the mother’s abdominal wall, external light does not reach the fetus directly [47-52].
1) Micro chimerism is a long-known phenomenon on which romantic theses of essential mother-fetus dialogue have been built. The truth is that it is useful even if not essential and, above all, it is not specific but non-specific in the sense that it can be easily replaced by any gestational carrier. It is based on the transfer of maternal antibodies to the fetus and other immunoprotected factors that protect it in the first period of neonatal life when the newborn has not yet developed its immunocompetent system. The principle according to which pregnant women are vaccinated for some dreadful neonatal diseases (pertussis) instead of after birth is based on the ability of the maternal immunocompetent system to provide quotas of circulating fetal antibodies useful for its postnatal protection. Which works with both the genetic and the gestational mother, equally. A neonatal or maternal transfusion produces this effect of cell transfer in the maternal and fetal compartments in the same way, with the same modifications here more emphatically called micro chimerism. The passage of stem cells is an integral part of this exchange which should (never demonstrated) benefit the mother more than the newborn but it is not that those of the genetic mother are superior to those of the gestational mother.
Moreover, the data on the psychophysical development of newborns abandoned at birth and welcomed in favorable environments as well as those born to gestational mothers seal their equivalence [53-55]. However, numerous studies have highlighted the importance of early interaction and communication between mother and infant after birth. Affective communication and maternal attention to the newborn are essential for the emotional and cognitive development of the child. Maternal love and attention can create a secure attachment bond between mother and child, which is crucial to the child’s social and emotional development. In conclusion, while the lack of a specific mother-fetus dialogue during pregnancy could represent a difference in prenatal experiences, maternal love and attention after birth can play a fundamental role in promoting a healthy bond between mother and child. [56-60]. Table z There is a tendency to refer to the mother-fetus sensory relationship as scientific evidence. The data do not report any evidence that a specific relationship exists between the gestational mother and the fetus. The sensory relationship (predominantly sounds) is non-specific and can be easily replaced at birth without evidence of any developmental imbalances. The presence of a tape recorder with Verdi’s music would mark a relationship with the musician and not with the gestational mother as evidenced by abandonments at birth and gestational carriers, provided they are welcomed in environments full of love.
Research in the field of prenatal psychology and fetal development has indicated that fetuses can respond to various stimuli and cues from the mother’s body and external environment. Gestational carriers are individuals who have carried and given birth to a child for the intended parents, and they may form a bond with the baby during pregnancy. The process of relinquishing the child after birth can be emotionally complex for the gestational carrier. Additionally, the child might have questions or curiosity about their birth and the gestational carrier’s role as they grow older. In some cases, the parties involved in gestational surrogacy may have agreements or arrangements regarding post-birth communication and relationships. These agreements can vary widely and might involve different levels of ongoing contact between the gestational carrier and the child. Unfortunately, there is limited research available on the long-term effects or health outcomes specifically related to the termination of the gestational carrier’s involvement with the child after birth. The emotional and psychological well-being of both the gestational carrier and the child would likely depend on various factors, including the nature of the surrogacy agreement, the level of communication after birth, and the support systems available to all parties involved.
When considering gestational surrogacy, all parties need to consult with mental health professionals and legal advisors who specialize in surrogacy arrangements. They can guide how to navigate the emotional complexities and ensure that the best interests of all involved, including the child, are considered. The mother-to-fetus relationship during pregnancy is essential for the developing baby’s well-being and psychological development. There is scientific evidence to suggest that disruptions or adverse experiences during this relationship, such as maternal stress or trauma, can potentially impact the newborn’s psychological development and long-term health outcomes. However, it’s essential to note that the role of this relationship is complex, and some factors can mitigate the impact of disruptions (Table 2). Regarding the substitution of the mother-to-fetus relationship, it’s important to recognize that while the prenatal environment and maternal bonding are critical, the postnatal environment, caregiving, and support also play a significant role in the child’s development. In cases where the biological mother is unable to provide care, other caregivers can step in and create a nurturing and supportive environment that contributes to the child’s well-being. It is crucial to differentiate between the birth process itself and the potential impact on the newborn’s development. The act of the gestational carrier giving birth to a baby genetically related to another woman is a relatively common practice in gestational surrogacy, and it does not inherently produce damage to the newborn’s health or development.
The primary focus of gestational surrogacy is to provide a safe and nurturing environment for the fetus during pregnancy, irrespective of the genetic relationship between the gestational carrier and the baby. Proper prenatal care, medical oversight, and psychological support for all parties involved are essential factors in ensuring a positive outcome for the newborn.
Here are some points to consider:
1. Prenatal Environment: The health and development of the baby during gestational surrogacy depend on the prenatal environment provided by the gestational carrier. Ensuring the gestational carrier’s well-being, adherence to prenatal care, and healthy lifestyle choices are critical for the baby’s development.
2. Genetic Influence: The genetic contribution to a child’s development comes from the genetic parents (egg and sperm providers). The gestational carrier’s genetic contribution is limited to mitochondrial DNA, which does not significantly influence the baby’s overall development.
3. Postnatal Care and Bonding: The postnatal care, bonding, and attachment experiences provided by the genetic parents play a vital role in the newborn’s development, just as they do in any parent-child relationship.
4. Safety and Health Outcomes:
• Many studies have reported that gestational surrogacy is generally safe for both the gestational carrier and the baby [33,61].
• One review found that babies born through gestational surrogacy had similar health outcomes compared to babies born through natural conception or other assisted reproductive technologies [61,33].
• Proper prenatal care and medical supervision are essential to ensure a healthy pregnancy for the gestational carrier and the well-being of the baby [33,61].
5. Psychological Outcomes for Gestational Carriers:
• Overall, research suggests that gestational carriers tend to have positive psychological experiences and well-being during and after the surrogacy process.
• A study by Jadva V et al. [34-37] found that gestational carriers generally reported positive feelings about the surrogacy experience and had a strong sense of satisfaction from helping others.
• Studies have shown that having a supportive environment and clear communication with the intended parents can contribute to positive psychological outcomes for gestational carriers [5,62].
6. Psychological Outcomes for Intended Parents:
• Research indicates that intended parents typically experience a sense of fulfillment and happiness with the birth of their child through gestational surrogacy.
• Some studies have found that intended parents often feel more connected and bonded with the baby, regardless of the lack of a genetic connection (Jadva V et al., 2012).
• Having open and ongoing communication with the gestational carrier can positively influence the intended parents’ experience throughout the surrogacy journey [5,62].
7. The Well-being of Newborns: Studies have reported that babies born through gestational surrogacy do not show significant differences in physical, emotional, or cognitive development compared to babies born through other means [63,64].
Parent-child attachment and bonding are essential factors for the well-being of the newborn, regardless of the method of conception. Finally, some theories emphasize, with equally romantic narratives, microchimerism, a phenomenon determined by the bidirectional exchange of maternal cells to the fetus and fetal cells to the mother where they can reside for decades virtually participating in phenomena of immunological protection or tissue repair. This phenomenon is non-specific and cannot be configured with that of a specific dialogue. This also happens with transfusions or transplants without the emphasis on the same dialogue [65,66].
Yes, some studies have investigated the psychological health of children born to surrogate mothers. However, it is important to note that research in this area is limited and the available studies present conflicting results. Some studies suggest that babies born to surrogate mothers show no significant differences in psychological health compared to babies born through traditional pregnancies. Other studies have found some differences or nuances in the psychological dimensions but have not concluded that there are significant psychopathological problems. For example, a study published in 2016 in the journal Human Reproduction Update analyzed the results of several types of research on the psychological health of children born to surrogate mothers Söderström-Anttila (V, et al. ). The review concluded that, in general, babies born to surrogate mothers showed similar levels of well-being to babies born from traditional pregnancies. However, it is important to consider that variables such as family background, parental support, the way adoption/surrogacy is addressed, and other factors can influence the psychological health of children born to surrogate mothers. Some studies suggest that adequate family support and transparency about a child’s origin can promote a healthy and stable environment for their development. It is essential to keep in mind that research into the psychological health of children born to surrogate mothers is still evolving, and further studies are needed to gain a more thorough and definitive understanding of this complex issue.
While there are no specific studies on the lack of mother-fetus communication during pregnancy and the impact it could have on the mother-infant relationship, there is research addressing the importance of mother-infant interaction and attachment bonding after birth. These publications focus on the importance of mother-infant interaction and attachment bonding in the postnatal stage. While they do not specifically address the lack of mother-fetus dialogue during pregnancy, they do offer a scientific basis for understanding how maternal affective interaction and attention can influence the mother- infant relationship after birth. One study found no significant differences in the psychological outcomes, emotional well-being, or parent- child relationships between the children in the different groups [34-37]. It is important to note that these studies provide preliminary evidence and may not represent the entire population of children born through surrogacy. Additionally, the psychological well-being of children is influenced by various factors beyond the surrogacy arrangement, including the quality of parenting and the overall family environment. [34-37,26]. The enormous psychological advantages for all three parts involved in that medical solution are reported by Ruiz-Robledillo N, et al.  However several critical objections are part of the present debates because of ethical issues, part based on different facts and interpretations and others on wrong evidence.
Innovation both in technology and in social customs always brings with it a clash of paradigms between those who want to change and those who want to preserve the status quo. The only certain thing in life - said Heraclitus - is change. But those who retain a status quo - the conservatives - or those who even invoke its return to a remote past - the reactionaries - even if they have never managed to block the change, have often delayed its advent, with the consequent suffering of those who change would reap the benefits. To determine if there is a difference in empathy and maternal-fetal attachment of surrogate mothers compared to a comparison group of mothers. Maternal-fetal attachment is strong with a slightly lower quality of attachment. The surrogate mother’s empathy indexes are similar to normative samples, sometimes higher . Environment plays a role in traditional and gestational surrogacy. Surrogate mothers of both groups are less anxious and depressed than normative samples. Maternal-fetal attachment is strong with a slightly lower quality of attachment. The surrogate mother’s empathy indexes are similar to normative samples, sometimes higher . The regulation of the gestational carrier option in the transmission of human life is an important alternative to its prohibition [4,13]. Among the forms of parenthood that have followed one another in remote and recent history, the most current seems to us to be that of a formal act of “assumption of unlimited responsibility to love whomever one intends to have as a child”., often, this assumption of responsibility is historically disregarded by those who are genetic fathers as well as by those who are not.
In an era in which, after the first births from in vitro fertilization, embryonic and fetal development is biochemically and biophysically evaluated and medical and surgical interventions can be made on them, it appears to us to be in close functional contiguity with the early neonatal period. Both are supported by the absolute lack of independence being the first connected to the vascular system of the gestational mother and the second detached. On a purely ethical level, therefore, even when one thinks with an aversion to the unavoidable solution of the gestational carrier, how does this aversion make it compatible with that postnatal entrustment of the newborn to a nurse who takes care of him 24/7 as the mother is engaged in a job that sometimes requires total self-denial? The ban on the use of gestational carriers which opposes its liberalization even if mostly regulated by laws or guidelines finds its foundations in the politics bearing social evaluation paradigms opposed mostly in conservative or reactionary and progressive fields (Tetsuya Ishii, et al. [69-80]).
However, the clashing paradigms are further confused by religions which - transversely - with their often prohibitionist paradigms invalidate both sides of politics. Marking a clear failure of secular states for the benefit of religious states or those largely influenced by the latter. Without going into the merits of theocratic countries but remaining in the ranks of democracies with a secular constitution, the use of the gestational carrier is banned as a personal choice even whereas in this case [81-85]. not a harbinger of damage to third parties nor the commodification of the body as in the case of recourse to the altruistic CG, without the transfer of money. The problem, in these cases, is that the arguments supporting the substitution of the state (here religion) for the person’s autonomy over their personal choices that do not harm third parties are argued with opinions not supported by evidence. There is no evidence of any specific mother-fetus bond that would be interrupted with damage to the fetus, but specific sound and sensory relationships that can be replaced by third parties and replaced without any psycho-physical damage by gestational carriers in this case and adoptive mothers at birth in other cases. There is no evidence of any damage in the numerous studies on the merits Yet politics argues, with assumptions devoid of any foundation, of specific sensory ties broken with serious consequences for the unborn child [86-90].
The lack of scientific arguments in support of these prohibitionist positions on the self-determination of individuals to reproduce as they wish while respecting the health of third parties offers the starting point for some reflections of institutional ambiguity the first and of debate obsolescence the others. Those who defend traditional and therefore genetic parenting paradigms as well as the concept of a state that says with whom, how, and when you have to reproduce under the banner of a family concept made up of a genetically male father, a genetically female mother and a son of only two genetic heritages do not want to see [91-95]. Regulatory attempts of gestational carriers included ASRM (Practice Committee of the American Society for Reproductive Medicine and Practice Committee of the Society for Assisted Reproductive Technology.2022.)
The committee recommended including women with:
1. Absence of uterus (congenital or acquired).
2. Significant uterine anomaly (e.g., irreparable Asherman syndrome; unicornuate uterus associated with recurrent pregnancy loss).
3. Absolute psychological or medical contraindication to pregnancy (e.g., pulmonary hypertension).
4. A serious psychological or medical condition that could be exacerbated by pregnancy or cause significant risk to the mother or fetus.
5. Biologic inability to conceive or bear a child, such as single male or homosexual male couple.
6. The presence of an unidentified endometrial factor, such as for patients with multiple unexplained previous in vitro fertilization failures despite the transfer of good-quality embryos.
7. Finally, there is the indication for, no owner, operator, laboratory director, or employee of the practice may serve as a carrier or IP in that practice.
1) The Positions
Surrogacy is, in the opinion of some, a new form of exploitation of women, contrary to their dignity, as it uses the female body, and therefore her person, as a negotiable object.
a) The negotiable use of the female body is offending its dignity when is not self-determined, in that case, is a choice, and “My freedom is given by my choices.” Sorin Kirkegaard “Over himself over his body and mind the individual is sovereign”. John Stuart Mill, Essay on Liberty
We have a social commercial use of the body or sale for part of the body in other authorized or tolerated conditions (table) with ambiguity with the use of that procedure. One example is the discrepancy determined by the incoming Italian law establishing a sanction of prison and/or 600.000 Euros for the use of gestational carriers by Italians and the tolerated use of the body with prostitution.
2) The Rupture of the Bond Created with the Fetus During the Pregnancy and the Obligation to Surrender the Child at Birth
The breaking of the supposed - non-specific - bond between the gestational carrier and the fetus has no physical and psychic implications on the newborn when welcomed in serene and loving environments. Newborns abandoned at birth and gestational carrier cases prove the evidence. In some perspectives there is no “right to procreation” and thus a “right to a child” that justifies the use of a gestational carrier. Desires distinguished from true rights, based on legitimate titles, and from the perspective of the common good. Arbitrary affirmation, denied by history, traditions, and many religions makes barren women feel guilty by sharpening their sense of guilt when they are unable to have children. Since ancient times, the gestational carrier has found its place in desirable solutions And Sarah said to Abraham: “Behold, now, the Lord hath made me barren, So that I cannot bear children; oh! Enter my servant; perhaps I will have offspring from her”. Genesis,16,1. The WHO defines infertility as a condition of psycho-physical sufferance and as and as such a disease worthy of treatment [96-99].
3) To establish the best interests of the child, the legislator is called to regulate future situations, so “he must safeguard the dignity and human rights of the subjects involved: the mothers, who are exploited through a rental contract, and the children, who become the object of a purchase agreement”.
In this sentence from the Spanish Association of Bioethics of 2016, nobody asks the social community who decides on the right of our body: ourselves or the parliament, and what could be the way by which life could be transmitted in the absence of other possibilities. It is the same debate that occurred after July 25, 1978, when Louise Brown was born through the genial discovery of the Nobel Prize by Robert G Edwards when all countries were deciding how to proceed with freedom, prohibition, or regulation.
4) A large group of Italian feminists, together with writers, actresses, actors, and even gay rights advocates, have signed a document for a total ban on “wombs for rent,” refusing to consider surrogacy as an act of freedom or love and asking the European Union to ban this practice (Aznar J, et al. ) joined by lesbian movements.
The criticism does not touch either the distinction between omo-sexual men and hetero-sexual as well as altruistic versus compensation and is concerning who accept all the other use of women’s body that volunteers use for profit (table) but not the use of gestational carrier. The same people who do not agree to entrust the growth of their embryo in the uterus for 9 months to a third party use nannies 24/7 to be able to carry out their work correctly.
5) Child a Gift or as Right
1. The main issue of the ethical debate surrounding the use of gestational carrier is the catholic concept of the child as a gift and not as a right as well as the life as an unavailable gift
2. Many countries in Europe have come out of this last atavistic concept but I can’t get out of that of how one chooses to transmit life - And despite being a continent with a secular constitution, it is hard not to confuse ethics with Catholic morality.
3. It remains a fact of easy and common observation that the use of a gestational carrier represents at the same time stigmata of the assumption of responsibility of becoming a parent and clear happiness for the three parties involved. The parent who cannot accept the gestation, the woman who lends herself to a gestational carrier, and the child who otherwise would not be born and who is born in the awareness of being strongly wanted for so much responsibility [100-102].
The gestational carrier is the only solution to becoming parents for single and couple men and it represents one of the two options for single women heterosexual couples with major unaffordable obstacles of reproductive apparatus. The other is represented by uterus transplantations. Different countries do not permit the use of a gestational carrier, some other does not consider it for sanctions and some others permit the use of a gestational carrier. Few of them with optimal regulation. A major criticism is ethical respect for human life and the abuse of low economical conditions by attractive economical offers. A body market is used for someone as a personal choice based on the right of self-determination for others. The regulation of some countries exclude women offering to become gestational carriers those with very low economical conditions to overgo that criticism. An obvious ambiguity is that of the countries that prohibit this procedure supported by the theory of exploitation of the human body but allow the trade of gametes for donations, (high) costs for adoption procedures, the purchase of embryonic stem cells, and even actual prostitution either by legitimizing it or not by sanctioning it as such but only for its exploitation: An ambiguity that persists in many countries-
A second motivation, minor and not supported by any evidence, is to believe that there is a single and specific bond between mother and fetus that would be broken with GC exposing the newborn to serious psycho-physical damage. False information repeatedly advanced by the prejudice of political or religious factions is never demonstrated as evidence. Babies born from GC have no detectable damage from inspections nor do those who are adopted at birth as long as they are aware of environments full of love. The claim to govern the reproductive behavior of the person despite his will when the reproductive method chosen does not involve any risk for third parties is part of a model of society that disrespects self-determination. That not only chooses not to use the innovation but also expects it not to be used by others. A classic case is represented by the lack of acceptance of the extraordinary research results of Robert G Edwards on In vitro fertilization with embryo transfer (which earned him the Nobel prize) by some countries such as Italy which expressed themselves with a law (finished as law 40) subsequently progressively demolished by the constitutional court in a path that led to great suffering and reproductive migrations. Furthermore, implicitly accepting ambiguities present in the legal systems of various states which contrast with the genetic family model made up of a male father and a female mother as well as genetic children of the two.
Here are some:
a) Would children developed in the womb from donated gametes be more or less children than those born from gestational carriers using their gametes?
b) Are children born with donated gametes in women who undergo uterine transplantation antigenically different from them and with specific anti-rejection treatments more or fewer children than those born with gametes of the couple who use a third-party gestational carrier?
c) In the UK in 2023 a child of two women and a boy genetic patrimony was born. Is this child more or less the child of a child born from a gestational carrier with the couple’s gametes?
d) In the USA there is a company (Conception) that has generated mouse embryos from somatic cells and the mice thus born have generated healthy mice in turn. The birth of mice from two male parents and also from 4 genetic parents has been published in Nature: when these experiments on animals are transferred to humans, possibly in 30 years, these children will be fewer children than the others.
e) And finally, an Israeli group has already proceeded to obtain the development of all the organs of a mouse in an artificial uterus, when this experimentation will affect man and the development of embryos will be able to take place in artificial wombs will these children be fewer children than those born with traditional means?
We are speaking of a search aimed at life and in our knowledge the rejection of science for life is a rejection of life itself.