Impact of the war in Ukraine and the COVID-19 pandemic on transnational surrogacy - a qualitative study of Danish infertile couples' experiences of being in 'exile'.

RESEARCH QUESTION: How did Danish permanently infertile couples experience surrogacy when going abroad and what impact did the war in Ukraine and the COVID-19 pandemic have on this? DESIGN: A qualitative study was performed between May and September 2022. The in-depth semi-structured interviews were conducted with 14 permanently infertile couples across Denmark who were in different stages of using surrogacy. The interviews were transcribed and analysed using systematic text condensation. RESULTS: All except one couple went abroad, mainly to Ukraine, to have an enforceable transparent contract, professionals to advise them and the possibility of using the eggs of the intended mother. They did not feel that this was a 'choice' but rather the only option they had to have the longed-for child. According to current Danish legislation, the intended mother could not obtain legal motherhood over the child, not even through stepchild adoption, and this increased the feeling of not being a 'worthy mother'. This study expanded on the term 'reproductive exile' by identifying four different forms of exile: the exiled Danish couple, the gestational carrier in exile, exile at home and, finally, the reproductive body in exile. CONCLUSIONS: Understanding infertile couples' experiences when crossing borders is important for several reasons. It may, among others, assist politicians and authorities in developing a sound Danish legal policy on surrogacy to address the current issues of legal parenthood and avoid missing reproductive opportunities for permanently infertile couples.

Experiences of surrogates and intended parents of surrogacy arrangements: a systematic review.

This review reports on the experiences of surrogates and intended parents of surrogacy arrangements. The findings from 47 studies, conducted across 12 countries and investigating predominately gestational surrogacy in a commercial setting, were analysed thematically, and are reported in a narrative summary. The findings reveal that the experiences of both parties of surrogacy arrangements are largely satisfactory and frequently involve positive relationships forming between one another, which they hope to maintain after birth. Some surrogacy participants experience challenges, particularly when the surrogate and intended parents reside in different countries. Intended parents face legal hurdles when returning home after an international arrangement. Concerningly, multiple reports of clinical practices in India have been published, in which commercial surrogacy was accessed by foreign intended parents, which infringed on surrogates' autonomy during the pregnancy. Intended parents turn to these international destinations when they face barriers to accessing surrogacy in their home country, such as the prohibition of commercial surrogacy. Looking beyond the altruistic and commercial dichotomy may alleviate some of the barriers to domestic surrogacy. Collaboration between professional fertility organizations to develop best practice guidelines can support clinics in providing international surrogacy services that minimize the risk of harm to those accessing care.

Cross-border reproductive healthcare attitudes and behaviours among women living in Florence, Italy.

BACKGROUND: The number of women living in Italy and seeking cross-border reproductive care (CBRC), especially for medically assisted reproduction (MAR), has increased. The purpose of this study was to explore CBRC attitudes and behaviours among a cohort of reproductive-aged women who have never engaged in CBRC to gauge social and cultural perceptions and gain a deeper understanding of family planning discourse. METHODS: In-depth interviews were conducted during May - June 2018 with 30 women aged 18-50 living in or around Florence, Italy and enrolled in the Italian healthcare system. Interviews offered in-depth insight into CBRC attitudes, behaviours, and experiences among a cohort of women living in Italy who had never engaged in CBRC. Researchers used an expanded grounded theory through open and axial coding. Emergent themes were identified via a constant comparison approach. RESULTS: Three themes and two subthemes emerged from the data. Participants discussed how limitations in Italy's access to MAR can lead women to seek reproductive healthcare in other countries. Women had mixed feelings about the effect of religion on legislation and reproductive healthcare access, with many views tied to religious and spiritual norms impacting MAR treatment-seeking in-country and across borders. Participants perceived infertility and CBRC-seeking as socially isolating, as the motherhood identity was highly revered. The financial cost of traveling for CBRC limited access and exacerbated emotional impacts. CONCLUSIONS: Findings offered insight into CBRC perceptions and intentions, presenting a deeper understanding of the existing family planning discourse among reproductive-aged women. This may allow policymakers and practitioners to address social and cultural perceptions, increase access to safe and effective local care, and empower women in their family planning decisions.

Never too late? Quadruplets at the age of 65 years.

BACKGROUND: We discuss the challenges of multiple pregnancy at very advanced reproductive age. CASE PRESENTATION: We present the case of a quadruplet pregnancy at the maternal age of 65 following in-vitro fertilization (IVF) with donor eggs and sperm, involving cross-border reproductive care. All children born were at 25 weeks' gestation and survived; however, poor neurodevelopmental outcome remains a major concern in one child. CONCLUSIONS: The use of reproductive technology to achieve a multiple pregnancy at such an advanced post-menopausal age generated a debate on ethical, psychosocial and medical questions. We share this debate and highlight the need to reconsider international guidelines for women of advanced reproductive age.

Cross border reproductive care (CBRC): a growing global phenomenon with multidimensional implications (a systematic and critical review).

PURPOSE: Many people travel abroad to access fertility treatments. This growing phenomenon is known as cross border reproductive care (CBRC) or fertility tourism. Due to its complex nature and implications worldwide, CBRC has become an emerging dilemma deserving more attention on the global healthcare agenda. METHODS: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review of the literature was performed for all relevant full-text articles published in PubMed in English during the past 18 years to explore CBRC phenomenon in the new millennium. RESULTS: Little is known about the accurate magnitude and scope of CBRC around the globe. In this systematic and critical review, we identify three major dimensions of CBRC: legal, economic, and ethical. We analyze each of these dimensions from clinical and practical perspectives. CONCLUSION: CBRC is a growing reality worldwide with potential benefits and risks. Therefore, it is very crucial to regulate the global market of CBRC on legal, economic, and ethical bases in order to increase harmonization and reduce any forms of exploitation. Establishment of accurate international statistics and a global registry will help diminish the current information gap surrounding the CBRC phenomenon.

Quality of life, anxiety and depression of German, Italian and French couples undergoing cross-border oocyte donation in Spain.

STUDY QUESTION: What is the quality of life (QoL) and mental health of infertile heterosexual couples from different nations (Italy, Germany and France) undergoing cross-border oocyte donation (OD) in Spain? SUMMARY ANSWER: Women have lower QoL and more anxiety than their male partners; overall French couples have lower QoL than their Italian and German counterparts. WHAT IS KNOWN ALREADY: In Europe, thousands of couples move across national borders annually to seek ARTs, primarily OD, driven mainly by legal restrictions in their countries of origin. Most research shows that infertility and ARTs affect patients' mental health and QoL. The decision to undergo reproductive care abroad might add further emotional and practical complexity. Reliable information on how this experience affects the mental health and QoL of cross-border reproductive care (CBRC) patients is lacking. Moreover, most research has focused on women, and further research on male partners and intercultural differences is needed. STUDY DESIGN, SIZE, DURATION: Cross-sectional study including 548 heterosexual individuals (347 women, 201 men) from Italy, Germany and France seeking IVF with donated oocytes in Barcelona, Spain between March and November 2013. PARTICIPANTS/MATERIALS, SETTING, METHODS: A total of 432 couples were invited to participate and handed a questionnaire set. Questionnaires were answered separately and anonymously by each member of the couple on the day of embryo transfer. The questionnaire set included the Fertility Quality of Life (FertiQoL) instrument, the generic Hospital Anxiety and Depression Scale (HADS) instrument and three close-ended questions assessing perceived usefulness, desire, and use of psychological support. The overall response rate was 63.4%. MAIN RESULTS AND THE ROLE OF CHANCE: Men reported significantly higher scores than women in the emotional (+13.74; P < 0.001), mind-body (+13.39; P < 0.001) and social (+4.11; P < 0.01) FertiQoL domains, at multilevel analysis controlled for confounder factors. Intercultural differences in QoL of couples were seen. French individuals had significantly lower emotional (-6.44; P < 0.01), mind-body (-7.41; P < 0.001) and relational scores (-6.41; P < 0.001) compared to Italians. Germans showed higher social scores (+6.41; P < 0.001) but lower relational scores (-8.94; P < 0.002) than Italians. Men reported significantly lower anxiety scores for the HADS than their partners (-1.38; P < 0.001), and German couples reported lower anxiety (-1.70; P = 0.003) and depression than their Italian counterparts (-1.56; P < 0.001). French patients were more likely to have required support by a mental health professional due to fertility problems in the past (+0.19; P < 0.001). LIMITATIONS, REASONS FOR CAUTION: The scope of this study is limited to heterosexual couples undergoing cross-border OD. Caution on the interpretation of the results in men is advised, mainly because only three men for every five women completed the questionnaire. WIDER IMPLICATIONS OF THE FINDINGS: These findings call for further work to identify the true nature of the differences in QoL and mental health observed. STUDY FUNDING/COMPETING INTEREST(S): None.

The contribution of multiple pregnancies from overseas fertility treatment to obstetric services in a Western Australian tertiary obstetric hospital.

BACKGROUND: Increasingly couples are travelling overseas to access assisted reproductive technology, known as cross border reproductive care, although the incidence, pregnancy outcomes and healthcare costs are unknown. AIMS: To determine obstetric and neonatal outcomes for multiple pregnancies conceived through fertility treatment overseas, and estimate cost of these pregnancies to the health system. MATERIALS AND METHODS: Retrospective study of women receiving care for a multiple gestation between July 2013 and June 2015 at Western Australia's sole tertiary obstetric hospital, where conception was by overseas fertility treatment. Obstetric and neonatal outcomes were recorded and cost estimates calculated. RESULTS: Of 11 710 births, 422 were multiple pregnancies. Thirty-seven pregnancies were conceived with fertility treatment, with 11 (29.7%) conceived overseas. Median antenatal clinic attendances, ultrasound examinations, and fetal assessments for the overseas fertility cases were six, 10, and nine, respectively. The gestational age at delivery ranged from 30 to 38 weeks (median 34 + 1). Median neonatal admission duration was 18 days (range 0-47). Cost for obstetric care was estimated between $170 000 and $216 000, and cost of neonatal care was estimated as $810 000, giving a combined total cost of between $980 000 and $1 026 000. CONCLUSION: At the sole tertiary obstetric centre in WA, approximately one-third of all multiple pregnancies conceived with fertility treatment resulted from treatment overseas. The Australian healthcare cost for these 11 women and their infants exceeded $1 000 000. This study suggests that overseas fertility treatment has a significant health-related cost to the mother and infant, and the local healthcare system.

Learning from Cross-Border Reproduction.

Drawing upon the preliminary findings of an Australian empirical project on cross-border reproduction (CBR), this article argues that regulators and policymakers could learn from the experiences of those who travel overseas in order to access fertility treatment and surrogacy. It makes four principal observations. First, the distinction between so-called 'altruistic' and 'commercial' gamete donation and surrogacy is increasingly unsustainable and is not experienced as meaningful by many participants in CBR. Secondly, the status of the law in CBR is profoundly equivocal; for participants it is often there and not there at the same time. Thirdly, self-sourced information, from the internet and more specifically social media such as Facebook, is now the principal source of information and peer support for reproductive travellers. Fourthly, and relatedly, domestic reproductive services providers are often sidestepped. If one of the goals of regulation is to minimise the risk of harm to participants, it is not clear that it is currently achieving this aim, and this article argues that any reforms will only work if they are more responsive to the reality of CBR.

Intended parents' motivations and information and support needs when seeking extraterritorial compensated surrogacy.

Cross-border reproductive care (CBRC) is becoming increasingly common. Little is known about the motivations and information and support needs of people who cross borders to access surrogacy. This study aimed to explore: how those considering or undertaking extraterritorial surrogacy reach their decision; what other avenues they have considered and tried to have children; their sources of information and support; and perceptions of how others view their decision. Members of two Australian parenting support forums completed an anonymous online survey. Of the 249 respondents, 51% were gay men, 43% heterosexual women and 7% heterosexual men. Most heterosexual respondents had tried to conceive spontaneously and with assisted reproductive technology before considering surrogacy. Most respondents felt supported in their decision to try extraterritorial surrogacy by close family and friends. Surrogacy-related information was mostly sourced online and from other parents through surrogacy. Few sought information from a local general practitioner or IVF clinic and those who did reported IVF clinic staff were significantly (P < 0.001) more likely than other groups to communicate negative reactions to their decision to seek surrogacy. The apparent negative attitudes to cross-border surrogacy among health professionals warrants further research into health professionals' knowledge, beliefs and attitudes relating to surrogacy.

Patient pressure: is the tide of cross-border reproductive care beginning to turn?

Two important explanations exist for cross-border reproductive care: restrictive legislation at home and limited access to affordable treatment. Both have recently been subject to patient pressure, favouring domestic and not cross-border services. The oppressive effect of regulation has been best illustrated in Italy, where legislation introduced as Law 40 in 2004 imposed restrictions on embryo freezing and embryo selection. After a decade of legal challenges by patients, the components of Law 40 have now been deemed unconstitutional in Italy. Similarly, a paucity of donor gametes in the UK has left many patients with few options but to seek donors and treatments overseas. Yet new techniques of donor recruitment and a revised allowance of compensation now means that some UK clinics can meet all requirements for donor gametes and patient matching from their own resources.

A survey of UK fertility clinics' approach to surrogacy arrangements.

This paper draws on the findings of the first survey of surrogacy arrangements in Human Fertilisation and Embryology Authority (HFEA) licensed fertility clinics since 1998. Given the complex social, ethical and legal issues involved, surrogacy continues to raise debate worldwide and fuel calls for increased domestic provision in developed countries. However, little is known about how recent changes have affected HFEA licensed clinics. A 24-item online survey was undertaken between August and October 2013, designed to improve understanding of recent trends and current practices associated with UK-based surrogacy, and consider the implications for future policy and practice in UK and cross-border surrogacy arrangements. The response rate was 51.4%, comprising 54 clinics. Quantitative data were analysed using descriptive statistics, and open-ended qualitative responses analysed for extending understanding. Of the participating clinics, 42.6% offered surrogacy (mostly gestational surrogacy). Heterosexual couples using gestational surrogacy were the largest group currently using services followed by male same-sex couples. Most clinics reported having encountered problems with surrogacy treatments, suggesting barriers still exist to expanding the UK provision of surrogacy arrangements. It is important that professionals are well informed about the legal implications of surrogacy and that clinics have consistent and appropriate operational protocols for surrogacy arrangements.

Evolving minimum standards in responsible international sperm donor offspring quota.

An international working group was established with the aim of making recommendations on the number of offspring for a sperm donor that should be allowable in cases of international use of his sperm. Considerations from genetic, psychosocial, operational and ethical points of view were debated. For these considerations, it was assumed that current developments in genetic testing and Internet possibilities mean that, now, all donors are potentially identifiable by their offspring, so no distinction was made between anonymous and non-anonymous donation. Genetic considerations did not lead to restrictive limits (indicating that up to 200 offspring or more per donor may be acceptable except in isolated social-minority situations). Psychosocial considerations on the other hand led to proposals of rather restrictive limits (10 families per donor or less). Operational and ethical considerations did not lead to more or less concrete limits per donor, but seemed to lie in-between those resulting from the aforementioned ways of viewing the issue. In the end, no unifying agreed figure could be reached; however the consensus was that the number should never exceed 100 families. The conclusions of the group are summarized in three recommendations.

Reiterative changes in the Italian regulation on IVF: the effect on PGD patients' reproductive decisions.

National legislations represent one of the main factors influencing access to assisted reproduction treatment. The Italian situation in the last decade is an example of how the treatment of patients for preimplantation genetic diagnosis (PGD) was more dependent on regulators than on medical choices. This report analysed how the changes in Italian regulation affected the number of PGD referrals to this study centre, as well as their decision to opt for cross-border reproductive care (CBRC). The analysis showed that during the period in which PGD was actually not performed because of the restriction imposed by the Italian law on IVF (from 24 February 2004 to 7 May 2009) there was a significant decrease in the number of referrals asking for PGD (2.5% of total referrals) compared with the previous years (3.3%; P < 0.025) and following years when PGD was legalized (5.1%; P < 0.001). The number of couples opting for CBRC had an opposite trend, reaching a maximum when PGD was banned from Italian centres (55 couples), whereas after the readmission of PGD, only eight couples went abroad for treatment. Concomitantly, since May 2009, the proportion of couples performing a PGD cycle in this centre has constantly increased.

International gestational surrogacy in the United States, 2014-2020.

OBJECTIVE: To describe characteristics, trends, and outcomes of international gestational surrogacy cycles in the United States (US). DESIGN: Retrospective cohort study. SETTING: All assisted reproductive technology cycles in the US reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting Systems that included an embryo transfer to a gestational carrier from 2014 to 2020. PATIENTS: International vs. US intended parents. MAIN OUTCOME MEASURES: Cycle characteristics, geographic distributions, and obstetrical outcomes. RESULTS: Of 40,177 embryo transfers to a gestational carrier from 2014 to 2020, 32% were for international intended parents. The number and percent of international intended parents' gestational carrier cycles increased each year from 2014 (n = 2758, 22.0%) to 2019 (n = 4905, 39.8%) with a decrease in 2020 (n = 4713, 31.8%). Compared with cycles for US intended parents, there was a larger decrease in gestational carrier cycles between 2019 and 2020 for international intended parents (3.9% vs. 32.2%). International intended parents were more likely to be male sex (41.3% vs. 19.6%), older than 42 years (33.9% vs. 26.2%) and identify as Asian race (65.6% vs. 16.5%). International intended parents were largely from China (41.7%), followed by France (9.2%) and Spain (8.5%). Gestational carriers for international intended parents were more commonly younger than 30 years (42.8% vs. 29.1%) and identified as Hispanic race (28.6% vs. 11.7%) compared with gestational carriers for US intended parents. Cycles with international intended parents were more likely to use donor eggs (67.1% vs. 43.5%), intracytoplasmic sperm injection (72.8% vs. 55.4%), and preimplantation genetic testing (79.0% vs. 55.8%). Cycles with international and US intended parents had similar obstetrical outcomes, including live birth (adjusted risk ratio 1.01, 95% confidence interval 1.00-1.03) and multiple pregnancy (adjusted risk ratio 1.00, 95% confidence interval 0.94-1.06) rates. CONCLUSION: An increasing number of international intended parents are utilizing gestational surrogacy in the US and more frequently using cost-enhancing specialized treatment techniques. This increase is potentially because of restrictive international commercial surrogacy laws and the increased availability of reproductive medical expertise. Given this growing demographic, continued examination of the volume of cross-border reproductive treatment, as well as the legal and ethical considerations, is warranted.

Cross-border reproductive care among French patients: experiences in Greece, Spain and Belgium.

STUDY QUESTION: What are the characteristics, motivation and experience of French patients seeking cross-border reproductive care (CBRC)? SUMMARY ANSWER: French patients seeking CBRC are same-sex couples, single women who are not eligible for assisted reproduction technologies (ARTs) in France and heterosexual couples seeking oocyte donation due to extremely limited access to this technique in France, while their choice of Greece as a destination is influenced by financial issues. WHAT IS KNOWN ALREADY: CBRC is a new, increasing, complex and poorly understood phenomenon. A few studies have investigated UK, German or Italian CBRC patients, but none have specifically investigated French patients although France is one of the top four countries of origin of CBRC patients in Europe. STUDY DESIGN, SIZE, DURATION: A cross-sectional study was carried out in 2010-2012 in three ART centres in Greece, Belgium and Spain in order to investigate French patients treated in these centres. Recruitment was prospective in Greece and Belgium and retrospective in Spain. The overall response rate was 68%, with 128 French patients participating. PARTICIPANTS/MATERIALS, SETTING, METHODS: French patients filled in a questionnaire. Information was collected on their socio-economic characteristics and their search for ART treatment in France and in other countries. MAIN RESULTS AND THE ROLE OF CHANCE: In the Belgian centre, 89% of French patients used sperm donation whereas oocyte donation was used by 100% of patients in the Greek centre and 74% of patients in the Spanish centre. The majority (94%) of French patients using sperm donation in Belgium were not legally eligible for access to ART in France as they were same-sex couples or single women, and the main criterion of choice of centre was its geographical proximity (71%). Most of the French patients using oocyte donation in Greece and Spain fulfilled criteria for fully reimbursed oocyte donation treatment in France as they were heterosexual couples (99%) with the woman aged <43 years (65%). For these couples, CBRC was motivated by the extremely limited access to oocyte donation in France. Half of French CBRC patients using oocyte donation in Spain had a low/intermediate occupational level (such as primary school teachers, nurses, administrative officers or sales agents, workers and employees) and this proportion was much higher in Greece (82%, P < 0.01). LIMITATIONS, REASONS FOR CAUTION: Larger and more wide-ranging studies are needed as this study included only 128 patients who may not be representative of all French CBRC patients, especially because the study was carried out only in three ART centres and these too may not be representative. WIDER IMPLICATIONS OF THE FINDINGS: CBRC among French patients had been thought to reflect mainly law evasion. This study showed that the reality is much more complex and that CBRC among French patients reflects both law evasion and limited access to oocyte donation in France. It also brings new insight into the characteristics of the patients by suggesting a certain degree of 'democratization' in access to such care. However, the choice of centre seemed related to socio-economic characteristics, in that the Greek centre treated a less advantaged population than the Spanish centre. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by French public research funds, the Institute Emilie du Châtelet from the Ile-de-France Region, the Biomedicine Agency and the Research Institute of Public Health (IReSP). There are no conflicts of interest. TRIAL REGISTRATION NUMBER: Not applicable.

'The bloke can be a bit hazy about what's going on': men and cross-border reproductive treatment.

While social science research has begun to demonstrate the significant impact of infertility and involuntary childlessness for men, far fewer studies have specifically explored the male experience of, or men's involvement in, infertility treatment-seeking and there are few published studies which specifically describe men's experiences with cross-border reproduction. This paper presents data from the first UK study of transnational treatment-seeking and specifically explores men's involvement in this process. Data from interviews with 10 men and 34 women who were seeking treatment abroad are organized according to three themes: 'going along with it'; 'being a rock'; and 'doing their bit'. The paper argues that gender is an important aspect of the cross-border treatment experience and that both traditional and emergent gender identities are expressed in the process of treatment-seeking. Healthcare providers need to actively explore men's perspectives of the treatment process in all locations, to improve quality of care by reducing men's feelings of marginalization and enhancing their experience of treatment, especially but not exclusively, around the issue of semen collection.

Growing families in a shrinking world: legal and ethical challenges in cross-border surrogacy.

Crossing national borders to have children is a rapidly growing phenomenon, fuelled by restrictions on access and technologies in some countries and for some patients, by high costs in others, and all generating a burgeoning multibillion dollar international industry. Cross-border gestational surrogacy is one form of family building that challenges legal, policy and ethical norms between countries and puts both intended parents and gestational surrogates at risk, and can leave the offspring of these arrangements vulnerable in a variety of ways, including parent-child, immigration and citizenship status. The widely varying political, religious and legal views amongst countries make line drawing and rule making challenging. This article reviews recent court decisions about and explores the legal dimensions of cross-border surrogacy.

Comparison of embryo transfer strategies and assisted reproduction outcome in Slovenian and cross-border patients.

A reduction in the number of embryos transferred is the most important step in decreasing multiple gestation rates after medically assisted reproduction. Slovenia has implemented insurance company regulations that regulate single-embryo transfer in selected good-prognosis couples. The aim of the present study was to evaluate its effects on the Slovenian population compared with cross-border patients, who are not affected by the insurance company policy. Ultimately, 2403 couples undergoing IVF or intracytoplasmic sperm injection were included in the retrospective analysis. Patients were classified according to their origin. The decision about the number of embryos transferred and the treatment success were evaluated. The implementation of the policy favouring single-embryo transfer resulted in a significant decrease in the twin birth rate in Slovenian patients (24.4% before policy versus 6.7% after policy implementation, P<0.001). Although in cross-border patients twin birth rates have declined through the study period, they remained significantly higher compared with Slovenian patients (23.1% versus 6.7%, P<0.001). The data demonstrate that insurance company policies favouring single-embryo transfer are an effective tool in decreasing multiple gestation rates. Similar mechanisms should be implemented in the cross-border patient population.

Reproductive Entanglements in Times of War: Transnational Gestational Surrogacy in Ukraine and Beyond.

Until early 2022, within the global fertility industry, Ukraine was one of the most important destinations for reproductive travel worldwide, particularly specializing in gestational surrogacy for international intended parents. Already weakened by the COVID-19 pandemic and related restrictions, the surrogacy market, and here especially surrogates and intended parents, was strongly affected by the Russian invasion in February 2022. In this article, I discuss and analyze the reproductive entanglements of surrogates, intended parents, and the children born through such transnational surrogacy arrangements in Ukraine and how this extreme crisis of war exposed and exacerbated existing vulnerabilities.

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

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