Churchill Fellowship Investigation

I was thrilled to be the recipient of a 2015 Churchill Fellowship to investigate the implications and risks to Australian families considering Cross Border Surrogacy. From December 2015, for 7 weeks, I travelled to the USA (Los Angeles, Chicago, Philadelphia and Boston), Russia (St Petersburg and Moscow), and India (New Delhi) to visit clinics and other services who assist Australians to undertake surrogacy arrangements. I met with fertility clinic staff, fertility counsellors, surrogacy lawyers, and surrogacy service brokers, to gain a better understanding of what the experience might be like for anyone considering travelling to these locations to seek surrogacy. I hope to use this information to provide counselling at home to families considering surrogacy, and assist them to make healthy, safe and informed decisions about their surrogacy treatment options.

On Friday 7th August 2015, I was very proud to stand alongside the other 20 Queensland recipients of the 50th Anniversary 2015 Churchill Fellowships. Our Fellowships were presented by His Excellency the Honourable Paul de Jersey AC, Governor of Queensland. If you would like more information about The Winston Churchill Memorial Trust, please visit https://www.churchilltrust.com.au

The following page contains the series of blog posts I wrote as I undertook my Investigation into Cross Border Surrogacy from December 2015 until February 2016. This was a once in a lifetime opportunity to travel the world and learn about a fertility treatment which is becoming far more common, but contains some real risks to those involved. I hope that what I learnt will not only help me in my counselling practice, but also help others who read what I discovered to decide whether surrogacy is for them, and whether or not they want to try and do this at home in Australia or abroad.

 

Los Angeles

The past few days held some incredible meetings with some amazing people. I feel so grateful to everyone who has shared their time and expertise with me already (and not just those I have met face to face, but also those who have already “met” me by Skype over the past few months).

I should start by making the observation that I am NOT encouraging any Australians to travel overseas to engage a donor or a surrogate. These services are available, legally, at home. From where I work and live in Queensland, if you travel overseas to engage these services you are breaking the law, and the offence is significant. Rather, I am reporting the information I have gleaned from people in the industry here. For anyone who chooses to travel overseas for treatment, please at least do it safely and knowledgeably!

So far I have been struck by the similarity in what I am hearing – whether I am speaking to a lawyer, a doctor, and counsellor or an agency service provider. And the message is this:

Firstly: Many, many Australians are coming to California each year to engage donors and/or surrogates. Each of the service providers I have spoken to indicate that a significant proportion of their work involves Australian clients (one person indicated that 40% of their business is coming from Australians). This number has decreased in the past couple of years (probably due to the significant costs, and the poorly performing Australian dollar, and the availability of other (Asian) clinics), but recent international developments (in surrogacy availability) mean that there is an expectation that the numbers will begin to climb again soon.

Secondly: The majority of Australians (seen by the professionals I spoke to) seek some form of ongoing relationship with their surrogates, and often also with their donors (if they use one). It was generally indicated that Australians are very open regarding ongoing contact and value the opportunity to let their child/ren grown up knowing the women (not so much the case with sperm donors, but this seems to be an interesting historical trend) who were involved in helping them to be born. This surprised me, as I think that there is a general assumption at home that anonymity is one of the key reasons Australians are travelling overseas for surrogacy/donor treatment (maybe those that want anonymous relationships are just choosing other destinations than California??).

So perhaps there is another question to answer there: why do they come to California? The simple answer is availability. It certainly seems to be the case that Australians who travel do NOT feel that they can find a suitable donor or surrogate at home.

Thirdly: There is an increasing number of medical practitioners who are advocating for fertility treatment which is much more like what you would expect to see in Australia. That is, (comparatively) lower intervention (such as only using treatments like PGD when it is really indicated) and encouraging single embryo transfers (with a real focus on reducing the risks associated with multiple pregnancies). I was really heartened to hear this, and I think it is incredibly important that anyone who chooses to travel thinks carefully about the medical advice they received at home from their local fertility specialists. If you would choose to undertake medical treatment one way at home, why would you suddenly make very different decisions overseas?

Fourthly: The system is incredibly confusing for someone accustomed to the Australian fertility system. Even with the advance knowledge that there was a very different system, I found figuring out “who’s who at the zoo” to be really very difficult. And there are a lot of interconnections (sometimes very nepotistic ones, and not in a good way!) You really need to spend time understanding which surrogacy and/or donor agencies will take good care of you, and they can help to guide you to legal, medical and counsellor services. But do your research here separately as well. It’s probably best if there is a level of independence between the services. And all of this is further complicated by the state by state differences, and a general lack of regulation. The primary constraints appear to relate to management of ESCROW funds (a type of trust fund that manages any monies paid to agencies in advance for services) and this has been regulated only very recently, and only in response to some really serious embezzlement of funds by some agency owners over the past few years – dodgy stuff!

Finally: I did learn about one surrogacy agency that provides what seems to be gold standard care to intending parents (IPs) and to surrogates. Unlike many agencies who focus on an initial assessment of the parties, then seem to drop the ball a bit with the ongoing support, this agency provides ongoing support for as long as 18 months – through the assessment phase, right through the pregnancy and then through the post partum. They provide regular check-ins to ensure all is ok, help with any ‘relationship management’ between the IPs and the surrogates and generally make sure everyone is doing ok. I love this model. It is totally congruent with my own belief that as long as everyone is communicating, and problems/concerns are being aired, then everything can be managed and will end up ok in the end. I would love this to be the standard at home as well, and will be following up on what we can do to make this a “normal” part of Australian surrogacy practice.

The key advice for those that choose to undertake donor/surrogacy treatment in California, is that if you are going to do it, do it “right”. Take care in choosing the agency that will provide you with support, and help you to find your donor/surrogate and choose a doctor with a good reputation. If you try to save money you are probably cutting some dangerous corners.

Particular thanks to Dr Michael Feinman, Hilary Hanafin, Andy Vorzimer, Andrea Bryman, Rich Vaughan and Robin Newman who all gave me a significant amount of their time and knowledge. Particular thanks to Robin for giving me advice on what NOT to do (see my next post) and to Andrea who gently tolerated a fair amount of my tears during our meeting – Andrea had the misfortune of meeting with me in the midst of a terrible attack of homesickness, and was very kind in taking good care of me at a tough moment.

Mexico

Well, tonight I am supposed to be half way through the Mexican leg of my trip. But I am in Chicago.

This was a REALLY tough decision. I have spent many hours with my clients, encouraging them to take (safe) risks: to step outside of the everyday and experience something new. To feel the fear and do it anyway. I had decided to travel to Mexico as part of the project, despite some real reservations about my safety. The recent very sad story of the 2 young Australian men who were murdered in their van while driving through Mexico had not helped me with my anxiety, but the advice from DFAT indicated that all was well and I had decided to leave the travel plans as they were set down.

But over the past couple of days I received 2 pieces of information that made me rapidly and VERY seriously rethink the decision that had been made to travel to Mexico as part of this project.

Firstly, on Monday I discovered that the situation in Mexico regarding availability of surrogacy has very recently changed. I had not learnt of this prior to my departure, probably because I was so busy getting ready for my trip, and also because (even now) I have been able to find very little in way of media reports. But on 15th December, The Guardian reported that:

“A Mexican state legislature has voted to close the door to foreign couples and gay men looking to have a child by surrogacy.

The Gulf coast state of Tabasco is currently the only Mexican state that allows surrogacy, supposedly on a non-commercial basis. It has attracted many foreign and gay couples looking to have children.

But the Tabasco state legislature voted 21-9 on Monday to restrict the option to Mexicans. It also says that couples looking for a child must include a mother aged 25 to 40 who can present proof that she is medically unable to bear a child. Mexico has become a low-cost alternative to the United States, where surrogacy can cost $150,000 or more.”

And with that, the door to surrogacy in Mexico for Australians slammed shut. The practitioners I have spoken to in California say they knew this was coming. The sense is that the pressure to stop surrogacy in Mexico has been building for about 18 months, but some very recent disastrous situations and a number of very unfavourable media reports about practices there seem to have been the final straw. I know that a few Australians had already commenced (and some had completed) their surrogacies in Mexico and I am aware that many more were contemplating this as an option. I understand that for those who have a pregnancy underway, they will be permitted to complete the process.

For anyone about to start, this is no longer an option, and I hope that money has not been lost (although dreams have undoubtably been shattered for some). So, from the point of view of the current project, there was minimal advantage to the Mexican leg, as Australians cannot any longer consider Mexico as a surrogacy option.

And the second piece of information: I had planned to visit the state of Tabasco anyway (to Villahermosa, where the surrogacies are completed), and my fabulous contact there, Carlos, had arranged meetings with many different people, including some of the surrogates themselves. But the advice from 2 of my California contacts was that this would be extremely unsafe. I did not have sufficient time to double and triple check (my flight was scheduled for less than 24 hours from when I received this advice) but I was assured that it would be very unwise for me to travel to that location.

So despite my initial intention to challenge myself and to “feel the fear”, I chose safety. I owe this to my family. Additionally, the Churchill Fellowship requires that I do not take any unnecessary risks. So while it would have been a fantastic experience to travel to Mexico, I cancelled my flights and re-routed early to Chicago.

I do still hope to obtain information about the surrogacy experience, and will be talking (by Skype) with a number of practitioners there. If you have had a personal experience of engaging a surrogate in Mexico, please contact me – I would love to hear how things went for you.

Chicago

A couple of days ago I watched (again) the 2010 remake of Alice In Wonderland. In the film, Alice is overwhelmed by everything she sees and experiences but reassures herself by telling herself, “It’s all just a dream and I’ll wake up soon”. She pinches herself on the arm many times to help herself return to reality.

As I walked through Chicago this morning, getting ready to head on to my next destination, I felt that same urge to pinch myself – that surely this is just a dream and soon I will wake up. I am so grateful to have the opportunity to do what I am doing. Two of the fabulous people I met with in the past few days made an identical observation – that this is truly “the trip of a lifetime”.

But I suppose I should talk about what I have been doing. After arriving earlier than expected in Chicago (an upside to cancelling the Mexico leg of my trip), I had a few spare days to check out the city (unfortunately, there was no chance to schedule extra meetings over the New Years long weekend). For someone with a very amateur interest in art and architecture, this city is incredible. I’ve had a chance to check out some of the amazing Art Deco era buildings, and took a tour around Oak Park – home to many buildings designed by Frank Lloyd Wright at the beginning of his career. I also got to spend a morning overwhelmed by the magnitude of the Chicago Institute of Art.

On Monday, I really got down to business, and started to meet with some of the practitioners working here in the area of IVF, donor conception and surrogacy. Illinois takes a very family friendly approach to third party reproduction, that is, the State is broadly supportive of whatever is necessary to assist people to have a family. They have had a pretty solid State Statute in place for the past 10 years, and this seems to provide general protections to all parties involved in surrogacy arrangements (i.e. Intending parents (IPs), surrogates, and kids born through surrogacy arrangements). I have been very impressed by the screening processes used by the agencies here (screening primarily relates to surrogates, but there is a less arduous process for IPs also), firstly by the agencies themselves, and then through their psychology evaluations. All parties also require legal representation and medical screening.

It’s taken me a little while to really get my head around the function of the agencies – when I left Australia, I really had not understood the role they play, and had wondered what they added to the process, to justify their fees. I think I have been fortunate to talk to agencies to do the job well (and this is a really important point, NOT everyone does it well, so it remains a “buyer beware” kind of environment ), because now that I have spent time and talked to the agency staff, and discussed their screening processes, I can see that they really can reduce the stress for IPs and surrogates. Surrogates are fully screened and approved long before meeting an IP, and long before an agreement gets drafted. This is quite different to the situation we have at home, where I have seen families recruit a potential surrogate, invest their emotional energy into that relationship, (and invest their financial resources into the background preparations), only to be disappointed that the surrogate is really not a suitable candidate.

Maybe that doesn’t seem like a big deal (“you will find someone else”), but potential surrogates really are tricky to find at home, and the restrictions on advertising mean that it’s a little like the blind man looking for the black hat in the darkened room. Also, if you’ve already had your heart broken by years of infertility and unsuccessful fertility treatment, surrogacy really is the last straw – your emotional, and financial resources are pretty depleted and there are often major strains beginning to show on relationships (within marriages/partnerships, but also with external social supports). Another false start has been the final straw for many people negotiating the fertility maze.

One of the agencies I spoke to here described how they have established a process where there is one clear contact for the IPs, and a different, separate contact for the surrogates. Each serve to assess, inform, educate, and very importantly, advocate, separately for their respective clients. When the time comes to make a match between IP and surrogate candidates, these 2 individuals then work together to decide who is well aligned in their expectations and wishes for the surrogacy arrangement. This just makes so much sense to me, and from what I was told, really helps to minimise problems later. (Once there is a baby on board, you really don’t want any more problems). But if problems do arise as the arrangement progresses, these 2 separate staff members are there to act as private sounding boards, and advocates and to assist in getting the communication happening again and repair the surrogacy relationship. At the end of the day, this seems to be in the best interests of the child, (which is the main focus for those of us working within the QLD legislative framework).

When I left Australia, I was really unsure of what I would think about the surrogacy process in the USA. I admit to having had some pre-conceived views of international surrogacy. I am pleased to say that already this trip is influencing my thinking and giving me an opportunity to open my eyes to how we can do things better in Australia. With the upcoming Federal Parliamentary Inquiry into surrogacy in mind, I think there is consensus that Australia needs to do surrogacy differently from the structure that has been established, but we really have a chance -RIGHT NOW- to learn from the mistakes, but also the successes of other jurisdictions, and get things right at home. After all, wanting to have a baby isn’t such a strange desire.

Many thanks to Nidhi Desai; Dr Kaplan and Dr Beltsos from Fertility Centres of Illinois; Mary-Ellen, Robyn and Antonia from Alternative Reproductive Resources; Nancy Block from Fertility SOURCE Companies; and Dr Angela Lawson, all of whom took time out of their busy schedules to meet with me and share their expertise about surrogacy and egg donation.

Boston

I have had the absolute pleasure of spending the weekend (and my birthday) in beautiful Boston. I have significantly increased my knowledge of American history and was fascinated to walk the Boston “Freedom Trail” that took me all the way from Boston Common to the USS Constitution. Today, I braved the rainy weather and made my way to explore the stunning Harvard University Campus – although I suspect this is far more welcoming in good weather, the trip did help me feel a little more inspired to head back to my hotel and put some work into compiling my Fellowship report. This is a beautiful and easy going city, and a weekend of wandering has been an absolute delight.

I also had the absolutely fabulous experience of spending an entire day with the team from Circle Surrogacy. Circle is amongst (if not) the largest surrogacy agency in the USA (in terms of staff with almost 50 employees, and in terms of the number of surrogacy arrangements they undertake), and certainly differs in structure from some of the other agencies I have seen so far. They function as a “full service” agency which has case management, ESCROW management, attorneys, and social work (and psychosocial and psychological assessment) services all provided in house.

A real strength of the model that this agency promotes (like some of the other agencies I have already met with) is their focus on the relationship between the IPs and their surrogate. I am told that the majority of surrogates really value having contact with their IPs, and Circle encourages IPs and surrogates to have weekly contact. In addition, and where it is possible, they also encourage the IPs to attend ultrasound appointments etc (if only by Skype). Circle acknowledges that there are other agencies (and of course private arrangements) which operate much more of a “business transaction” between the IP and the surrogate (i.e., the arrangement is established; there is minimal contact made between parties; monies are expended and the baby is collected at the end. There is no expectation of an ongoing relationship between the parties). Personally, I can’t imagine not having some kind of relationship with the woman you have entrusted to carry your baby for you for 9 months. And I really wonder how the surrogacy is explained to the children, when the relationship is fiscal, rather than personal.

I also had some lovely conversations about egg donor processes (with the Egg Donation Manager, and a previous egg donor). We discussed the relative merits of anonymous versus known donation, and I was delighted to learn that there is an increasing emphasis towards donors being known to the IPs. It seems that Australia’s very strong push towards known donation is a long ahead of where the USA currently stands, but there is certainly change afoot. And the Circle team were really interested in the processes that Australia takes regarding 3rd party reproduction (such as the establishment of donor registers, and recent changes such as retrospective removal of anonymity for donors in some states). The donor I spoke to had donated both anonymously and in the context of a known donation, and she had clearly preferred the experience of having contact with her donors. She even showed me photos of 2 of the beautiful kids that had been born as a result of her last egg donation, and she was clearly really proud of the family she had helped someone create.

Circle shared with me every aspect of what an IP or a surrogate might experience with the agency, and explained everything from the intake/assessment process, to the legal intricacies, and the complex web of medical insurance options and out of pocket fees. This was incredibly helpful to me, as I had really struggled to understand how some of these processes work. I really wonder how a potential IP can make sense of all of this, especially when they are in the midst of the already stressful experience of trying to have a family through fertility treatment.

I can certainly see the attraction for IPs in the “one stop shop” structure that Circle uses, particularly for clients travelling from overseas (international work accounts for over half of their work – with IPs coming from a number of destinations; and most commonly France, UK, China, Sweden and Norway. Australians accounted for around 4% of their clients last year). This model kind of simplifies all of the various tasks that are necessary in co-ordinating a surrogacy arrangement, and really helps to clarify the costs that are likely to be incurred.

I am consistently hearing that fees to undertake surrogacy in the USA are anywhere from USD$120,000- $160,000. When you account for our currently poorly performing dollar, that is around AUD$170,000 -$230,000. These fees include the (approximately) USD$25,000-30,000 plus expenses paid to the gestational surrogate. Of course, these figures make an assumption that treatment is successful reasonably quickly. Each embryo transfer to a surrogate, or each egg stimulation cycle (either to the IP or an egg donor) represents more expense. For an IP travelling from overseas, it is also important to add the costs of travel, accommodation and living expenses. Most IPs would expect to make between 2-4 trips to the US (to create the embryos, to meet the surrogate, maybe to check in/attend a significant scan during the pregnancy) and to collect their baby at the end). At delivery time, IPs need to plan to be in the USA for at least a week or two after the baby has been born, but depending on when parental rights are established (this will vary on a whole range of factors, such as medical insurance considerations, and the state that the surrogate lives (and gives birth) in), it may take more like 4 weeks. For same sex couples, some states are pretty surrogacy friendly, but for others, the establishment of parental rights gets a lot more complex. Like most things, complexity tend to equal extra time and/or expense.

Nobody goes to these lengths lightly. I have asked the agency staff (at each of the agencies I spoke to) if they saw a specific socio-economic group using their services, but I have consistently been told that there is an enormous range of backgrounds in their clients. While obviously there are many who could never, under any circumstances hope to find these sorts of amounts of money, and there are some for whom $200,000 is not overly significant (apparently these people do exist – I have been told!), the majority of clients seen by the agencies are on fairly average incomes, and have simply prioritised surrogacy over…. well… everything. Many have remortgaged their homes, or borrowed the money; some have had money gifted from parents/other family. I think that there is no doubt that for any person who is prepared to go through all of the emotional strain of surrogacy, and expend all of these financial resources, there really is a sense of desperation to be a parent.

This desperation to parent (that I have also seen in so many of my clients), is partly why I was motivated to undertake this Fellowship.

There is always a risk that someone who is so incredibly desperate to achieve a goal, might make poorly informed or rushed decisions. I believe it is critical that anyone who is considering this process (either domestic or international surrogacy), has a plethora of supports available to help provide guidance, information, and advocacy while they navigate their options. It is also critical that for anyone becoming a parent (including through surrogacy) that they have a range of supports they can access to help them through the tough times that they will inevitably encounter. In the midst of all of this work just to achiev a pregnancy, it is easy to forget that this is just the beginning – there will be a baby, who turns into a child, who turns into a teenager etc. Through each of these stages, parenthood is tough, and becoming a parent through surrogacy doesn’t guarantee you an easy run. Some who have become parents through fertility treatment (including donor conception and surrogacy) feel that they have no right to complain when the job of being a paren gets difficult (that “if they wanted it so badly, they should just be happy that they got what they wanted”). But these parents are equally susceptible to the normal anxieties and stresses of parenting, and to the bigger issues like perinatal depression. These families need access to support who understand what they have been through already and can help them negotiate the twists and turns.

A massive thank you to Circle Surrogacy, and the individual team members who gave up their day to help me understand surrogacy in Massachusetts: Emily, Sarah, Scott, Kelly, Gina-Marie, Frannie, Amanda and Jessica. Thank you also to Dr Alice Domar (for those in the know, one of the “go-to” people in fertility counselling and research) who took time out from her weekend to speak to me.

Philadelphia

Officially, my week in New York was to have been vacation only, (and New York is one of the few USA states were surrogacy is not permitted) but those who know me best know that I am not awfully good at sitting still.

In between checking out all of the usual tourist haunts (this is my first ever trip to the USA, so I have busied myself in each destination with taking in as much as I can of the local things to do and see) I had an opportunity too good to refuse, and diverted my stay for an overnight trip to Pennsylvania. I had the opportunity to spend some time talking to Dr Andrea Braverman; Clinical Assistant Professor, Department of Obstetrics and Gynecology, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey. Dr Braverman has published widely in the area of fertility counselling and presents an annual conference designed to train new counsellors to the area of fertility counselling

Dr Braverman was extremely generous with her time and expertise and I really enjoyed discussing our respective experiences of fertility counselling. I found her insight into surrogacy counselling really helpful, and the fact that she has previously visited Australia a number of times to speak at Fertility Society of Australia conferences, meant that she really understands the Australian experience of fertility treatment.

The visit to Philadelphia was not initially part of my itinerary, and I am particularly grateful to Dr Braverman for making her time (and hospitality) available to me at such short notice. I’d also like to plug the conference that she is involved in organising for fertility counsellors- 2016 will be the third time it has been held. This is the only conference I am aware of that is exclusively designed to train fertility counsellors in the ethical, legal, medical and emotional aspects of infertility and its treatment. I would have loved to have had the opportunity to attend something like this when I first entered the fertility counselling field, and I do hope I can find a reason to get back to Philadelphia in the next couple of years and attend a future iteration of this conference. When It Takes More Than Two To Make a Baby: Basic and Advanced Skills

Russia

I spent 9 days in Russia – St Petersburg and Moscow – and I feel incredibly fortunate to have had the chance to visit there as part of my Fellowship. This is a country I never expected to have a chance to visit, and it is pretty unlikely the opportunity to visit again is likely to come my way anytime soon.

Although surrogacy is relatively common in Russia (both domestically as well as for foreigners), finding services who were prepared to speak with me ended up feeling a little bit like I was hunting for unicorns. I found it extremely difficult to establish contact with service providers from the Russian Federation; the majority simply never answered my emails and calls. Those who did agree to meet me were friendly and very generous with their time and information, although some were somewhat reticent with the information they were prepared to provide (mostly due to some past negative media representations). Prior to departing Australia on my Fellowship, I was also able to make contact with providers from nearby countries this region. I spoke with clinics/agencies in Georgia and Ukraine, and they were helpful in providing me with information about the services they provide.

But why even visit Russia as part of this trip? Russia is a significant provider of surrogacy services, particularly for Northern Europeans, Chinese and Americans. The complex systems I had attempted to understand in the USA also exist here – but here I found it even trickier to clarify who does what and where, due to the language and cultural differences. There are around 150 IVF clinics in Russia and 3-4 surrogacy agencies (there are many more smaller agencies, but I am told they are actually subsidiary companies of the main 3-4). There were 855 documented surrogacy cycles undertaken in 2013, of which around 380 resulted in pregnancies (and around 480 babies – don’t question the maths, I will explain later). I am unsure of the exact numbers in Georgia and Ukraine, but these countries are also significant service providers to IPs from these locations, and Ukraine especially is emerging as a provider of services to Australian IPs. Due to the recent political issues in Ukraine, and safety requirements that sit around the Fellowship, travelling to the Ukraine was never really an option for me. Georgia is a comparatively small country, and although it is marketing itself very hard as a provider of surrogacy services to foreigners, the population is fairly small (therefore the number of women actually available to work as surrogates is reasonably limited). In deciding to travel to Russia, I was trying to determine not just who are the current providers of surrogacy to Australians (and other foreign nationals) but also predict which countries might be on the horizon. As has been very clear is the past couple of years, surrogacy service provision is fairly constantly dynamic and in order to understand what context cross border surrogacy exists within, we have to be thinking about not just who is, but also attempting to predict who will.

I had a chance to speak with a number of Russian service providers and learn about how surrogacy is conducted in a country that is largely hidden from Australian eyes. But travelling to Russia itself gave me far more than just information about specific treatments. It gave me a real insight into the culture of the country, and as I spent time there I realised how important that could be to a successful surrogacy. Not just logistically, in establishing the arrangement, but practically, in terms of the relative expectations for IPs, surrogates, and services providers. Visiting Russia, and going about normal daily activities told me much more than I could have ever learned just from having meetings by Skype, or exchanging information by email. There are some big differences between Russia and Australia (more than the obvious), and it made me think about some of the broader impacts of travelling to foreign locations in order to secure a surrogacy arrangement. The comments I make below are not only reflective of the risks associated with undertaking a surrogacy in Russia, but might be relevant in any location which is unfamiliar or less predictable. We all accept these risks when we travel abroad, but in the case of surrogacy it must be considered how these differences may impact on a pregnancy being carried by another person who you do not know, and probably will never meet.

In Russia, alcohol and nicotine is very cheap and accessible and the use of these substances is very common. I haven’t seen so many people smoking (across all age groups) for many, many years and I can’t recall the last time I side-stream smoked so many cigarettes!

There appear to be far fewer limits about where you can smoke in public. There do seem to be regulations against smoking on public transport, inside buildings etc), but many people smoke in the streets and one of my cab drivers even told me I was welcome to smoke in his taxi. I would think it very likely that even if a surrogate understood that she shouldn’t smoke during a pregnancy, that she would come into contact with smokers regularly in her life (if not her home).

I had been in St Petersburg for 2 days before I learned that the water is not really safe for drinking. It’s ok for teeth brushing but apparently there is Giardia in the water, as well as chemical contaminants resulting from old pipes and contaminated reservoirs. My hotel did not provide drinking water and there was no warning signage, so it never even occurred to me, in such a massive and developed city, that this may be an issue. I seem to be ok, but it was further food for thought about surrogate health and wellbeing. The impact of Giardia is similar to many other intestinal issues – diarrhoea, and the health issues associated with this, particularly if left untreated. From my research, there are no consistent recommendations for the treatment of pregnant patients because of the potential adverse effects of anti-Giardia agents on the fetus. If possible, treatment should be avoided during the first trimester. If the patient is left untreated, adequate nutrition and hydration maintenance are paramount.

There are other practicalities also. I visited in winter and the ground was covered in snow and ice. I fell numerous times while walking around (and not just because I am a little clumsy!) and there was quite a few times when I was crossing roads that I feared oncoming cars were not going to be able to stop. I lost count of the number of near-miss accidents I witnessed as cars lost control on the icy roads. I do realise that I am probably being a little paranoid in regards health and wellbeing, and the experience of dangerous roads and footpaths are common to many places, but I also recognise that IPs are usually really anxious about their surrogates staying safe and engaging in good health. Life in a climate like this is hard and I there are very different threats here than what we might experience in sunny Queensland. I also can’t imagine trying to manage a newborn in these conditions, and the reality is that post birth an IP would expect to remain in Russia for about a month until all of the legal and travel documentation were ready (perhaps less in other places, but it is unlikely that anyone leaves within a few weeks, as new parents await birth certificates and passports for their baby/babies).

I repeat that these comments are not intended to be criticisms of Russian life or culture, merely observations that the experiences we take for granted at home, may not apply when away. None of these differences would have ever occurred to me if I had not spent time walking the streets and noticing the differences in behaviour between Australians and Russians.

But perhaps it is time to describe the surrogacy experience more specifically. Russia, Ukraine and Georgia all have laws which are supportive of surrogacy, and in fact all 3 countries have national Legislation which regulates what the clinics and agencies are permitted to do (even Australia and USA don’t have these kinds of Federal legal boundaries). All three countries expressly forbid surrogacy for single male IPs or same sex couples, so any of these can only be considered if you are in a heterosexual relationship, or are a single woman. In reality, accessing a parentage order for a single person is also almost impossible, and I was told that single women and defacto couple are asked if they would consider getting married before the commence the process to ensure everything is managed smoothly. In addition to their surrogacy laws, Russian treatment also has oversight from an organisation which has a similar function to the Fertility Society of Australia: The Russian Association of Human Fertility (RAHF). I was told that around 60% of clinics comply with the guidelines proscribed by the RAHF and I was fortunate to visit one whose medical director is also the current President of the RAHF (Professor Korsak).

Costs for surrogacy in Russia are substantially less than one would expect to pay in a location such as the USA. Indications given by a Russian surrogacy agency suggest that fees would total around AUD $90,000 (presuming success within 1-2 IVF cycles). IVF clinics have medical specialists from both reproductive Endocrinology and Obstetrics and Gynaecology backgrounds, and the costs of additional IVF cycles in quite low compared to USA or Australia (less than $3000, including all medication). The IVF/surrogacy fee included costs such as travel to Russia and accommodation for the periods of time an IP would have to stay, fees to the surrogacy agency, IVF clinic and the surrogate herself.

Costs in Georgia seemed much lower again (around $50,000, although I don’t believe this included costs such as travel and accommodation, and there may be additional un-included costs). A Ukrainian agency quoted a “basic package” costing around AUD$8000 but this obviously excludes an entire range of costs. There is definitely difficulty in comparing services between countries (and even different agencies), and it is really tricky to figure out exactly what a quoted fee covers. Taking time to ensure one is comparing “apples with apples” is really hard, and it is pretty important to read the fine print. I would expect that many families get caught out by unexpected costs during these arrangements.

IPs are required to complete contracts with the surrogacy agency, the IVF clinic (the separation of services is similar to that of the USA structure) and with the surrogate herself. These contracts are primarily around enforcement of fee payments. In the instance that an IP eventually chooses not to accept a child, either as the pregnancy progresses or after delivery, the baby would simply be placed in an orphanage.

There is no “trust account” or ESCROW system such as exists in the USA. Instalment payments to the surrogate (more on this later) can be made either directly from the IP, or with the agency as an intermediary. Interestingly, the final payment made to the surrogate, immediately after the delivery and while she is still in hospital, is asked to be made in cash. This figure is around AUD $15,000-$22,000, and I would assume should be made in Russian Rubles (830,000-1,216,600 RUB). It was explained that the contracts signed by all parties are sufficient to ensure that all payments are properly made.

IPs can use their own embryos (created at the clinics, not brought from home), or egg and sperm donors are readily available. Considering that the majority of IPs are over 40 (one Russian agency indicated that 60% of patients are over 45), egg donors are particularly common. Sperm donors are generally accessed from a sperm bank and are ONLY anonymous. Egg donations are undertaken as fresh cycles, and donors can be selected by choosing from personal descriptions and photographs. Donations are always commercial and I was unable to ascertain what kind of implications counselling a donor might receive.

There does not appear to be any capacity for a donor to have their identity made known to a donor conceived child, and it appears that that majority of IPs are directly attempting to conceal from friends and family that a donor was required. Federal regulations are meant to limit the total number of donations (7 for egg donors) but it was unclear how many children could be born from the one sperm donor (in fact it didn’t seem to be viewed as terribly important). Egg donors can be aged 18-35 and must have had a minimum of one child already.

I was repeatedly told that while legally acceptable, there is still a strong tendency for donor treatment and surrogacy to be hidden. Domestic families who are using a surrogate commonly wear fake “bellies” and while IPs are encouraged to meet their surrogates at least once, this is still not common. I am aware that some psychologists work hard to provide counselling which allays the common fears about how a child might react to being born as a result of donation or surrogacy, but it sounds like there is a long way to go in this respect.

Donor cycles aim to stimulate around 12-14 eggs and genetic testing is not routinely recommended unless there is a known history of chromosomal issues (although it can be arranged if requested). (Pre-implantation genetic diagnosis would be recommended for an older IP hoping to use her own eggs). Sex selection is only permitted (by law) if there is known gender-related genetic issues. Following embryo transfer, surplus embryos can be cryopreserved, destroyed or on-donated. Egg cycle “splitting” is not an option.

I am told that in Russia, the success rate from embryo transfer to surrogates is just over 50%. Ukraine clinics give a success rate of around 35%. I am unclear of the commonly quoted pregnancy rate for Georgia.

Other than medical screening, there is really no intake/screening process for IPs, and medical screening can often be done in the country of origin by one’s own doctor. Screening effectively covers tests for the husband:

• screening for HIV, syphilis, hepatitis B and C,
• sperm count and wife:
• gynaecological examination with vaginal ultrasound,
• blood type and rhesus,
• screening for HIV, syphilis, hepatitis B and C,
• gram stain smear,
• clinical blood analysis (blood count).

There are generally no upper age limits for IPs – you could both be 60 when you commence parenthood. This is of great concern to me, as I do think we have a responsibility to consider the impact of significantly older parents on the child. IPs are not required to undertake any psychological intake process, and all of their specific wishes around how the surrogacy should be managed are managed within the surrogacy contracts that they complete, and there are enforced, rather then requested. Specific wishes are met through the matching process with a surrogate – a surrogate can’t be forced to agree to conditions she does not agree with, but if she wasn’t prepared to consent to a specific condition of the contract, she simply wouldn’t be selected for that couple.

I met with a psychologist from an IVF clinic who does try very hard to engage with IPs as they undertake the process, but she tells me that take-up of this support is low, and is probably reflective of generally low acceptance of psychological services within Russian culture. I did really admire her perseverance in attempting to change this treatment culture and her professionalism in keeping up with best international practice for what is currently considered to be in the best interests of the child in surrogacy treatment.

An IP would expect to visit Russia a minimum of twice: once to establish the cycle, and then again to collect the baby. It would be expected that the first trip would involve a stay of around 6 weeks, and the second, about 4 weeks.

The vetting/screening process for surrogates is rather different to what we are accustomed to at home. Obviously, medical screening remains rigorous, and is the focus. Apparently HIV and Hepatitis C are very common in young women, so medical screening of surrogates is critical.

I did wonder what happened to the young women who had previously been unaware of their positive HIV status, who the received a diagnosis as a result of medical screening and were rejected from the program.

Ukrainian clinics appear to be very proud in their assertions that there are no waiting periods for surrogates. My fear for this os how rigorous the screening process really is. In Russia, I was told only around 7% of applicants were considered suitable to become surrogates, but I note that the longer the waiting period, generally the better screened women have been. If you don’t need to wait, it is possible that corners are being cut.

There are also legal checks to ensure that the surrogate is suitable. A surrogate must be aged between 20 and 30 and must have already had a child of her own. She cannot be a surrogate if she has already had a caesarean section, and she should have had no more than 5 pregnancies (in total, including her own). She will be paid more for subsequent surrogacies, but becomes ineligible for subsequent arrangements if she requires a caesarean section.

Surrogate health is monitored regularly by the clinics and they have regular check-ins with the psychologists. My impression was that these checks are more about compliance and less to do with support. For example, surrogates are not permitted to consume alcohol during pregnancy and compliance with this is ensured by regular blood screening. If blood alcohol levels are detected during the pregnancy, the surrogate can be required to undergo a termination of pregnancy, the contract is voided and she is left without payment.

In Russia it is acceptable to transfer 2 or 3 embryos and around 30% of pregnancies are multiple (thereby giving the pregnancy numbers I quoted earlier – of 379 pregnancies, 279 were singleton, 88 were twins, and the rest were triplets or greater). Due to the high rate of multiple pregnancy, there is a high proportion of caesarean deliveries. Pregnancy reduction is permitted.

I am told there are never cases where the surrogate refuses to relinquish the baby, even though she is entitled to under the law. I am also told that if that did happen, there is legal precedent for the matter to be referred to a court and the IP would expect to be successful in being awarded custody of the child. If the surrogate does not content the birth, in Georgia and Russia, birth certificates are issued after the delivery of the baby, with the IPs listed as parents. In Ukraine, legislation considers the child to belong to the IP from the very moment of conception.

I was really pleased to see a treatment system which was managed within a legislative framework, but I was concerned that some of these rules seem to be fairly loosely enforced. My greatest concern was the focus on hiding identity of donors, and even surrogates. The model that we encourage at home is one of access to information for donor conceived children, or children who have been born through surrogates. To ensure that at any time in their lives, they have a chance to learn more about their donors and gestational carriers, and importantly, and donor-conceived “half-siblings”. Any system which does not really operate to limit the number of donations from a single donor, or aims to keep identifying information hidden from the donor conceived child is a problem, and absolutely does not comply with the expectations RTAC places on practice at home. Another big issue is the focus on multiple embryo transfers. The evidence surrounding risks associated with multiple pregnancies is indisputable, and a system which is comfortable with transferring 2-3 embryos means that rates of multiple pregnancy will always be higher. This will always place a burden on the surrogate and the health system as a whole. There is a responsibility on any potential IP to ensure they choose single embryo transfers, for the wellbeing of their surrogate, but also for the wellbeing of their babies.

Thankyou to Professor Vladislav Korsak, Director General of The International Centre of Reproductive Medicine (MCRM) and current President of the Russian Association of Human Reproduction (RARH) for permitting me to spend time at MCRM and speak with a range of staff about the experience of providing services to IPs and surrogates in St Petersburg. Thanks also to REPRIO for discussing how things work from the perspective of a Russian surrogacy agency. Many thanks also to New Life in Ukraine and Georgia for giving me time by Skype to discuss how surrogacy is managed there. I am also grateful to others who were able to speak to me about surrogacy in their various locations, but for various reasons are not able to be thanked personally.

India

My time in India ended up being a rather different-to-expected kind of adventure – I contracted a virus (probably on the flight from Russia, I suspect) and became quite ill with fevers, headaches and severe dehydration. Unfortunately, as I was travelling alone, managing these symptoms was more difficult that usual and after being in India for just 3 days I ended up in hospital, needing IV fluids. This experience gave me a very unwanted insight into medical treatment in India. The first hospital was of a very questionable standard and I was eventually transferred by land ambulance to a second facility. Although this was a significant improvement, the standard here still made me really appreciate the Australian healthcare system in a way I never could have otherwise. I was released after 3 days and decided that I needed to go home to Australia and finish my recuperation. This means that I had to cut short my journey but I did not feel physically or emotionally well enough to continue my Fellowship for another week. I lost around 5kg during this process and got an infection in my arm at the cannula site. My time in India also severely exacerbated my pre-existing asthma, and I can’t tell if that is due to the virus or the unbelievable pollution levels in Delhi (or a combination).

Before I became unwell, I did have a chance to speak to some local professionals who have been involved in the surrogacy industry, but my hospitalisation made me think again about some of the EXTRA risks of medical tourism (and in reality, surrogacy falls within that category). Although I am grateful to the nurses and doctors who took care of me, I don’t think the care compared to what I would have received at home. I am relieved that I had travelled with antibiotics in my suitcase as I ended up treating the cannula infection myself (and appear to have been fortunate that it was not an anti-biotic resistant strain of infection). Some of the conversations with treating staff were very difficult – just getting the cannula removed from my arm (when I knew there was something very wrong) took over 12 hours of insistent demands from me. My medical insurance company covered all costs (I believe) and eventually arranged to fly me home one I was medically cleared to fly, but I cannot understate how difficult it was to organise this. I am so fortunate to have had my husband in Brisbane who spent 3 days relentlessly ringing and emailing the insurance company, negotiating on my behalf, while I was too ill to do this for myself.

The thought of being in a situation such as that while trying to care for a newborn – or worse, that the baby became/was born ill, fills me with dread. You cannot be cleared to return to Australia until you are well, yet you do NOT want to stay in the facility until you cease to be ill. This is a really tricky catch22 and certainly a situation to avoid if possible- unfortunately we can’t always choose our health.

Fortunately, before my trip was curtailed, I did manage to meet with a few surrogacy providers and got some sense of what is happening in India currently. Most people would know that while the Indian Council for Medical Research has guidelines in place for fertility treatment, no specific regulatory framework exists. Surrogacy has become an enormous industry in the past few years, providing surrogacy services to domestic patients, as well as large numbers of foreigners. Australians have been significant users of Indian surrogacy services for some time, partly due to the relatively low cost of services, but also due to the relative proximity for travel. In recent years, there has been an increasing tide of negative media attention about Indian surrogacy, with great convener about the quality go services, and the potential for exploitation of the Indian surrogates. Despite this, the flow of Australians heading into India continued (and probably increased) until 2013 when the first draft of the Assisted Reproductive Technology Bill was released. This Bill restricted access to heterosexual couples and (if passed) prevented single people or same sex couples from accessing surrogacy services. As a result of the uncertainty created by this Bill, many clients sought services elsewhere, and demand was quickly catered for by Indian clinics establishing surrogacy services in Nepal.

The situation changed again in November 2015 (long after the itinerary for my trip had been cemented) and a further draft of the Bill was released, this time preventing any foreign couple (except for very specific conditions, and effectively excluding almost all Australians) from accessing surrogacy services in India. Again, it is important to reinforce that this Bill has not been passed – it is not law – but it has created a legal limbo in which it is too dangerous for any foreign couples to proceed with new surrogacy agreements. Surrogacy is still available, and arrangements continue to be set in motion for Indian nationals. For those foreign families who had already commenced the process in November (who had a pregnancy underway) there will also be no impact – they will be permitted to continue the surrogacy as normal, and birth certificates will be awarded without problem. The situation is very different however for anyone who had planned to commence an agreement after the redrafted Bill was released.

The situation is particularly difficult for families who have already created and cryopreserved embryos. There are currently hundreds of families (not all Australian) with embryos frozen and stored in Indian clinics. They are not able to use them in India, but neither are they able to have them shipped to their country of origin. Imagine the distress for a family who believes themselves to be at their last chance to have a child (or a sibling for their existing child). Perhaps the frozen embryos were created some time ago and the mother is now too old to create new viable embryos. But this is a real risk of undertaking surrogacy in a country where the legal situation is uncertain and things can change in a legal instant.

A very similar situation currently also exists in Nepal, where around 300 families have cryopreserved embryos that cannot be used. Nepal was a relatively recent entrant to the surrogacy industry, effectively providing services to families who were excluded by the first draft of the Indian Assisted Reproductive Technology Bill in 2013. Until August 2015 when the Nepalese government abruptly ceased all surrogacy arrangements. In that instance the impact was catastrophic for families, even for those with ongoing pregnancies, or with babies who had been recently delivered, as the Nepalese Government ceased issuing exit visas for the surrogate-born babies, and families were effectively unable to leave Nepal with their children. This situation was eventually rectified (although dozens of families were stuck there for around 3 months) but no further surrogacy agreements can be commenced, and the already created embryos are in limbo.

So why the extraordinary response from these Governments to an industry which was bringing literally millions of dollars of foreign money into these countries? From my conversations with those within the Indian industry, I can see there is deep division in regards how surrogacy is perceived.

On one hand, there is a belief that surrogacy services to exploit Indian surrogates, that these women are simply being used to achieve the child creation wishes of wealthy white westerners. I suspect, at least in some clinics, there is absolute evidence of unethical practice and exploitation of Indian women. Did I have an opportunity to witness this firsthand – of course not! Unfortunately, none of the clinics I have visited during my trip gave access to the surrogates themselves, to discuss their experiences. And really, if there had been a chance to speak with a surrogate directly, I suspect that the clinics would not have introduced me to someone who had had a negative experience. However, there are just too many reports of exploitation and questionable practices (such as surrogates houses, high rates of caesarean sections etc) to ignore it all.

However, I was also offered a very different perspective: that some surrogates are achieving an improvement in their social standing as a result of their surrogacy experience. I was told that for some women, the opportunity to be a surrogate (and to earn in 9 months what would normally take them 10 years) has increased their value as a wife and as a woman. Some of these women earn far more than their husbands could hope to, and this provides them the opportunity to educate their children, buy property or learn new skills and start a small business for themselves. The clinic I spoke to insisted that their surrogates be married, have at least one child of their own and have completed their own family. They were only permitted to act as surrogates on one occasion, and they were encouraged to deliver vaginally. These are excellent conditions for surrogacy, but does that apply at all clinics?

So which of these versions of surrogacy are true? I suspect probably both, and the reality is completely dependent upon the ethics of the clinic and individual treatment of women.

However, there are still other issues with Indian surrogacy practice. Transfer of multiple embryos is routine, and the risks of multiple pregnancy have already been discussed in earlier blogs. There have been multiple instances reported where IPs discover they are “DNA negative” to their children. DNA Negative is an innocuous euphemism which means “oops, sorry, we transferred somebody else’s embryo into your surrogate”, and there have been many reported instances of this in India, Thailand and Mexico in recent years (and elsewhere, I would assume).

What happens to the baby? Good question!

Where did the IP’s actual embryo go? Another excellent question!

Scary stuff.

For any person seeking surrogacy overseas, there is a personal responsibility to choose a country which has established legislation that restricts the way in which a clinic can do business. When the state itself imposes the boundaries, the individual practices will inevitably improve. And sometimes we need to choose treatments which are better than a regulation permits. If we know it is in a surrogate’s best interest to have only 1 embryo transferred, and we can predictably enhance the health of our baby by only attempting for a singleton, then this is the choice that must be made (even if we are permitted to transfer 3 embryos). Of course a surrogate will agree to more embryos being transferred – she is paid extra if she does, and she receives a bonus for a multiple birth. Yes, she has consented, but can an uneducated rural girl really consent to the risks associated with this – and should we ever ask her to? As parents, we also have a responsibility to make decisions which protect our children – deliberately choosing a multiple pregnancy and the associated risks of this, is NOT making a decision which is protective.

It is also critical that IPs consent to good treatment decisions for themselves. In many of the clinic/services I met (not just India, but also USA and Russia) I had conversations with clinicians who mentioned the poor preparation for parenthood that some IPs exhibit. Unfortunately, surrogacy at a distance can create an “unreality” in becoming a parent. The added complexity of undertaking a treatment which is not permitted at home, means that for many IPs there is a cloak of secrecy around the upcoming birth and a lack of engagement with the usual parent preparation services. I heard reports of IPs who were overwhelmed by a crying baby, and had no idea of settling techniques. IPs who thought that you should feed the baby EVERY time she/he was unsettled (instead of just cuddling the baby, changing a nappy, or perhaps accepting that sometimes babies cry). Becoming a parent is always tricky, but doing this in a hotel in a foreign country? With not one, but 2, or even 3 babies? What if one of them is sick or premature? What if you have no real experience of babies and no social supports nearby to assist?

It is expected that India will enact the ART Bill soon and a firm set of practice regulations will come into existence. What impact will this have for those foreigners who were hoping to undertake surrogacy in India? It’s really anyone’s guess at this stage but theories range from India reopening the industry, to Indian clinics establishing themselves elsewhere (perhaps Sri Lanka – the precedent for offshore satellite clinics was set when Indian clinics opened up in Nepal, but this puts in place the potential to repeat the hazards experienced there). Some wonder if the Indian Government will permit families who already have cryopreserved embryos in India to commence a surrogacy arrangement, or to ship them elsewhere – we will have to wait and see.

Many thanks to Sonia Arora from New Life India and also to Poonam Jain from International Star Assistance for their time and insights. Poonam Jain was incredibly helpful, as she has experience in surrogacy not only in India, but also in Nepal and Thailand and really does have an incredible knowledge of the region’s processes.

Cambodia

Unfortunately, fate (or at least a virus and dehydration) intervened and prevented me from making my final stop in Cambodia. This is a real disappointment to me, as Cambodia is the newest player in the international surrogacy industry, really only appearing in late 2014, and in a direct response to legislative changes in Thailand. As you are no doubt aware, surrogacy in Thailand was abruptly banned in February 2015, in the wake of the “Baby Gammy” case and another incident where a Japanese businessman concurrently fathered 16 children through different Thai surrogates. Ongoing investigations of this latter incident are considering whether this matter in fact involves a child-trafficking ring.

But Thai clinics didn’t close, they simply moved across the border to Cambodia, and although Cambodia commenced surrogacy treatment only a year ago, there are now at least 16 different clinics operating there. In November 2015, it was known that at last 20 Australian families had contracted to undertake surrogacy in Cambodia, and I assume that number has increased in the intervening 3 months. A surrogacy arrangement in Cambodia costs around $AUD40,000 (rather less than the USA!) and in terms of travel proximity it is a very near option for Australians.

But is it a good idea to undertake surrogacy in Cambodia?

There are so many issues around this. The legal situation in Cambodia is very very unclear. The Australian Government released this statement last year on their website https://smartraveller.gov.au/bulletins/surrogacy

Cambodia

In November 2014, Cambodian authorities advised the Australian Government that the act of commercial surrogacy, or commissioning commercial surrogacy, was illegal in Cambodia with penalties including imprisonment and fines. Australians are advised not to visit Cambodia for the purpose of engaging in commercial surrogacy arrangements. Those considering commercial surrogacy in Cambodia should seek independent legal advice. While in Cambodia, Australians are subject to the local laws of Cambodia and should not rely on assurances from commercial clinics or other agencies suggesting there are ways to circumvent or influence local laws.

I understand that no laws have actually been enacted yet in Cambodia, but there is certainly an expectation that legislation will be drafted by the Cambodian government any time, and that the crackdown on surrogacy will be severe.

The clinics operating in Cambodia are inexperienced (even IVF is a new technology in this country) and the ethics and safeguards of many of the Thai clinics that had been operating before the Thai government changed it’s laws were highly questionable. “DNA Negativity” (remember that cute little euphemism) was not uncommon. Surrogate houses, high rates of multiple pregnancy and caesarean section deliveries were normal practice. I was not able to visit the Cambodian clinics to check if these practices continued across the border, but I would have been surprised to find otherwise.

Before I left Australia, many were asking about the quality of the labs – the ones that create and how the embryos, and those that do the health checks on the surrogates.

Unfortunately, I didn’t have a chance to speak to the labs about their standards, but I have seen these statistics, which very clearly demonstrate the importance of good labs, not just for pregnancy rates, but also for the health of surrogates and babies. If we just consider HIV infection rates, UNAids.org quotes 2014 prevalence rate In Cambodia for adults with HIV/AIDS to be 0.6% [0.4% – 1.3%], and the number of women aged 15 and up living with HIV to be 36,000 [23,000 – 70,000].

This compares to only around 27,000 Australians IN TOTAL currently living with HIV/AIDS. (The current total population of Cambodia is slightly less than 16 million, which is around 6 million fewer than Australia).

I am not certain how surrogates are being recruited. I had heard that there is a preference for single women to work as surrogates in Cambodia. When the primary motivation to become a surrogate is financial, I have to assume that these young women tend to be more vulnerable than most; to have less options available to them. In my experience, poor vulnerable poor have exposure to far greater health threats than wealthier, empowered individuals. In terms of selecting a healthy surrogate, that, to me, is the sound of escalating risk.

I had intended to meet with some clinics based in Cambodia, some of which have been advertising their services very visibly. However, in the weeks leading up to my scheduled arrival, I noted that continuing contact with these clinics became increasingly difficult. Some (like the one below) simply ceased correspondence, after being very positive about meeting me (for example, this email on 3/9/15)

I would feel extremely fearful about engaging in a surrogacy contract with clinic who are determined to be so opaque in their practice. My visit as a Churchill Fellow has been welcomed in other locations – the clinics who met with me elsewhere were clear that I was no threat to their service, and I have become increasingly suspicious of any agency or clinic that feels they have something to hide, even from another professional working within the fertility industry (such as myself).

I genuinely expect that the surrogacy industry in Cambodia will have short-lived access to foreigners. I also genuinely fear that we will see another disaster (like the Baby Gammy case) before legislation is enacted. I do hope I am wrong.

Australia

I am now back on home soil (5 days sooner than expected). I counted down the 48 sleeps since I left my family at Brisbane airport, and I can’t begin to describe how much missed them and how delighted I am to be back with them. I flew over 63,000 km (that is equal to circumnavigating the globe 1.5 times) and I walked over 350km (yes really, on my own 2 legs. I wore a Fitbit while I travelled to see how far my legs would take me). I spent 3 days in Indian hospitals, and my trip was cut short due to the virus I contracted while away. I am mostly recovered, but lost over 5 kg and am feeling pretty weak and tired as a result of how my trip ended.

I have spoken to incredible people, learned amazing things that will be of incalculable help with my work. I have also had the incredible opportunity to visit places that I would never have otherwise had a chance to see, and my brain has been filled with these wonderful sights and experiences. I have realised that I never hated history and geography lessons when I was at school and university, I just hated learning from books for the purpose of assessment. Learning from the world suits me far better and I feel that the past 7 weeks have afforded me a far better understanding not just of surrogacy, but also of the world as it is today, and also the events that have led us to where we are. I am humbled by what I have been given the chance to do.

I would like to repeat my thanks to The Winston Churchill Trust and the Queensland Selection Committee for giving me this chance. I also wish to repeat my thanks to all of those who assisted in the preparation of my application, then the organisation of the trip. Thank you gain to Stephen Page, Steven Fleming and Kate Bourne for acting as my referees and to Dr Fiona Hawthorne for providing me with assistance and support in preparing my application.

I particularly need to thank my beautiful husband and family for letting me go for so long – and for coping so well without me. Special thanks to all of the friends who made sure they were well fed while I was gone!

Much, much, much gratitude to all of the individuals who shared their time and knowledge about surrogacy with me. As I have already mentioned, there was SO MUCH MORE gained by meeting people face to face, than by emails or phone/skype meetings. I actually can’t believe what a difference it made to the learnings that I acquired. There was no reason for any of these people to take time out of their busy schedules to make time to speak with me, but they did it anyway. Building these collegial connections has ended up being an enormous aspect of the Fellowship – a far greater aspect of the trip than I had anticipated.

I also need to thank a few individuals who gave up their time to speak with me by Skype, even prior to my departure. Richard Vaughan (Attorney in California) was extremely helpful in assisting me to understand the California legal structure that surrounds surrogacy. My discussion with Rich really helped me to form a structure around the subsequent conversations that I had once I hit the ground in the USA. He also helped me make a number of connections with people I met with during my Fellowship trip.

I also spoke with a number of surrogacy agencies in Ukraine, Georgia and Mexico. I particularly want to acknowledge Carlos Herrera, the Director of Mexico Surrogacy Foundation, who had arranged to assist me during my (eventually cancelled) visit to Villahermosa. Carlos gave me a significant amount of time over Skype to explain surrogacy in that region.

Thank you to my very patient clients at home who were understanding of me taking a break from clinical practice to undertake this project. I am very happy to report that some much much-wanted pregnancies were confirmed, and some long awaited babies were born during my absence. Congratulations to these happy new parents, and parents to be. Thank you also to the colleagues who “held the fort” while I was away.

And thank you for reading my little blog posts, it has been lovely to share my experiences while I have travelled. This process has really helped me to assemble my thoughts and will make it easier to finalise the report that I am required to prepared for the purposes of the Fellowship (and will eventually be uploaded to the Trust’s website).

I am looking forward to applying everything that I have learned and sharing my knowledge with my colleagues. I am excited by the potential to maintain the collegial relationships that were established in this trip, and do hope that some of the people I met with will one day be able to travel to Australia in a reciprocal fashion. My first task of the Fellowship has been to prepare a submission to the Australian Federal Inquiry into surrogacy. I have been writing my submission during my trip as the closing date for submissions is actually the date of my return to Australia. I genuinely believe that the Fellowship has provided me with a unique contribution to the Inquiry and I eagerly anticipate the findings when they are released later in the year.

The landscape of surrogacy treatment, both domestically and internationally, has changed enormously in the past few years and I do believe that further significant changes are just around the corner, both in Australia and overseas. I am hopeful that the future will make it easier for people to access services which allow them to create their families in a medically, legally and emotionally safe environment; one which is protective of the children who will be born from surrogates; and one which ensures that the women who choose to act as surrogates are protected. Maybe the endorphins from the trip are still rushing through my veins, but I have a good feeling.