Stop 6: 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, particaulry 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-implanation 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 caesarian 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 cesarian section.

Surrogate health is monitored regularly by the clinics and they have regular checkins 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 caesarian 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.

The following image is an unapologetic holiday snap to prove I did indeed visit the amazing city of St Petersburg. A lovely German tourist did me the favour of taking this photo of me standing beside the statue The Bronze Horseman in St Petersburg.  Yes, it was very, very cold (about -15C deg that day).

Artworks representing parenthood are Old Masters works on display in the Hermitage Museum in St Petersburg.

I was going to apologise for the unambiguously maternal or heterosexual representations of parenthood in the works that I have been using, as I had failed to encounter any work (in the museums and galleries that I have visited during the trip) that specifically represents fatherhood outside of a heterosexual relationship, (particularly single parent or same sex fatherhood).  I am delighted that I found this statue (that I have chosen to interpret as a father proudly holding his child) in the Metro Station just off Red Square, Moscow – ironically in a country where surrogacy is not available to single men or men in same sex relationships.