Evelyn and Will Clark met after college through mutual friends. Their shared sense of humor sparked a friendship that blossomed, and "it just felt meant to be, with no question that it was right and the timing was perfect for both of us," Evelyn recalled.
The Clarks were involved at their church, and they dreamed of raising a family together in the town where Will grew up and where they met. Everything was falling into place: After dating for less than a year, they got engaged, and four months later they were married. They found a home in a safe neighborhood with great schools, close to relatives.
Unbeknownst to the Clarks, the road to expanding their family would be a long and grueling one—a roller coaster of heartbreak, hope, and medical intervention. Realizing their dream would require the help of a series of specialists, plus a woman who started out as a perfect stranger.
Around four years into marriage, frustrated by her inability to conceive, Evelyn submitted to a battery of invasive and uncomfortable fertility tests. Sometimes it is relatively simple to treat fertility issues. But when it is not, the results of these tests can crush patients. Unfortunately, Evelyn's diagnosis revealed an issue impossible to fix. A brusque radiologist delivered the news that she had a congenital abnormality—a unicornuate, or partial, uterus.
Would she ever be able to have children, she wondered? It's possible, he replied, but perhaps "half" as many as your friends do. Then he laughed.
The sting of the doctor's joke remains fixed in her memory years later. In a follow-up conversation with her reproductive endocrinologist, the news got worse: Her uterine abnormality meant not only that becoming pregnant would be difficult, but that any given pregnancy had just a 28 percent likelihood of ending with a live baby. She was at higher risk of miscarriage and stillbirth, but also of ectopic pregnancy—a potentially lethal condition where an embryo implants outside of the uterus.
This unnerving possibility would stop many women from trying to conceive altogether. Yet even with the deck stacked against her, Evelyn was committed to finding a way. Although fertility treatment could not resolve the risks attendant to a partial uterus, it could increase Evelyn's chances of conceiving. "I'm not brave by nature," Evelyn ventures. But she was determined.
IVF Under the Microscope
A couple years ago, fertility treatments weren't on the public policy radar. The use and existence of reproductive technologies were largely taken for granted. That changed after the Supreme Court's Dobbs v. Jackson Women's Health Organization decision kicked off a wave of stricter abortion laws at the state level. The Supreme Court of Alabama ruled that embryos created through in vitro fertilization (IVF) were legally children, halting fertility treatment for some women in the state and catapulting the topic into the national spotlight.
Although Alabama's Legislature hurriedly passed legislation granting patients and medical providers immunity from prosecution, IVF became a live policy issue overnight. Pro-life commentators and research analysts quickly began to wade into the debate.
IVF joins human eggs and sperm in a lab and transfers the resulting embryo back to the patient in hopes of a successful pregnancy. It is the most effective way for patients to overcome a varied list of male and female fertility issues, from damaged fallopian tubes to low sperm motility, and it produces about 97,000 U.S. births annually.
Despite these benefits, critics have laid out an expansive list of concerns. These range from anxieties about separating procreation from the marital act to exaggerated worries about medical risks. But for pro-lifers, the leading fear is that doctors are discarding or indefinitely freezing unborn children. As then-Rep. Matt Rosendale (R–Mont.) put it, "If you believe that life begins at conception…there is no difference between an abortion and the destruction of an IVF embryo."
It is true that IVF sometimes creates extra embryos that are not transferred back to the patient. At the outset, patients and doctors don't know how many embryos will develop successfully (two-thirds of embryos' development arrests) or how many embryo transfers will be required to produce a live birth for an individual patient. Beginning the process with more embryos increases the likelihood of success.
Such critics downplay how much the creation of human life is an inefficient process, whether it happens inside or outside the body. Conventional conception results in significant embryo loss, and the body regularly and naturally discards embryos in the process of trying to create life. Research suggests around 70 percent of conventional human conceptions do not survive to live birth, which makes IVF more like conventional reproduction than IVF critics care to admit.
President Donald Trump says he does not subscribe to his right flank's more extreme views on this topic. Indeed, he promised during the campaign that the "government will pay" or "your insurance company will be required to pay" for all IVF treatment costs—proposals that pose their own problems, including high costs and unintended incentives for would-be parents to delay childbearing.
Yet despite Trump's embrace of reproductive technology, fertility treatment feels fraught today in a way that it didn't one year ago. IVF is a fresh target for activists emboldened by a major win on abortion. Since states will continue to set new abortion policy in the coming years, there will be many natural openings for policies that limit fertility treatments.
But when Evelyn began pursuing treatment several years ago, the political outlook was simpler. So instead of worrying about political complexities, she steadied herself and then launched headlong into a series of treatments with increasing levels of invasiveness, cost, and corresponding likelihood of success.
Fertility doctors often initially run patients through a course of intrauterine insemination, or IUIs, which have a low success rate of 5 percent to 15 percent. The thinking is that sometimes these procedures work, and the invasiveness of the process is so much lower than IVF that if it does work, patients have saved themselves some pain, time, and money.
But IUIs often don't work. If patients grow tired of disappointment after several rounds of treatment over multiple months, the next step is IVF, which has higher odds of success—25 percent to 50 percent per cycle for women 40 and under. After several failed rounds of IUI, Evelyn's doctor recommended IVF.
IVF is a complex, absorbing, and time-sensitive process, and it's taxing for the patient: daily injections and medications, regular appointments, reading consent forms, making decisions, and generally staying informed about a complex regimen.
Evelyn's years of fertility treatment were rewarded with two healthy babies—an incredible success. But that success wasn't without grave risk to her personally or to the babies themselves. Both pregnancies were high-risk, and in each pregnancy she developed gestational diabetes and hypertension. The latter can lead to a variety of complications, including preterm birth, poor fetal growth, and stillbirth.
With Evelyn's second pregnancy, the fetus's movement slowed so much in the third trimester that it required constant monitoring. At delivery, the baby's umbilical cord was triple wrapped around its neck; the girl was lucky to be alive.
Evelyn's doctor told her that, in light of her history, it was not safe for her to get pregnant and carry a baby again. Although she'd gambled twice, the odds were never in her favor and now looked much worse.
But the feeling that her family wasn't complete continued to nag at Evelyn. Being a mother, she felt, was her calling and purpose. After careful consideration, research, and discussion, Evelyn felt called to move forward with gestational surrogacy, by far the most common form of surrogacy today.
Surrogacy in the Courtroom
Surrogacy initially burst into the popular consciousness with the Baby M custody dispute of the late '80s. In that case, the genetic surrogate, Mary Beth Whitehead, initially relinquished her rights to the baby but then sensationally threatened the intended parents and kidnapped Baby M for nearly three months.
Following trial and appeal, the courts gave Baby M's intended parents custody, with Whitehead awarded visitation rights. In the end, the grown-up child legally terminated Whitehead's parental rights, stating that she loved and was happy with the intended parents who raised her.
Since then, reproductive technology has improved so much that modern-day surrogacy is categorically different from the technology at the center of the Baby M case. While Baby M was genetically related to the surrogate who carried her, gestational surrogacy, where the gestational carrier is not related to the child, is today's norm. In this type of surrogacy, IVF is used to produce embryos, usually using the intended parents' genetic material. This gives couples an opportunity to have genetically related children while bypassing obstacles that make it difficult or impossible to conceive.
Despite its value to these parents, gestational surrogacy has its own cadre of detractors. For critics on the political right, all the usual objections to IVF apply, with additional concerns besides. An article by Carmel Richardson in Compact hints that commercial surrogacy constitutes "baby selling," and characterizes the American approach to surrogacy as irresponsibly laissez faire. In First Things, Catholic University of America professor Michael Hanby criticized surrogacy as one component of "the conception machine" that must be resisted in a dystopian "brave new world."
Meanwhile, the conservative Heritage Foundation alleges that surrogacy harms women and children. Internationally, Pope Francis describes the practice as "deplorable" and "based on exploitation." Conservative critics have also implied that surrogate pregnancies are frequently terminated, referencing sensational reporting and defying all logic.
Although the political left has recently been more restrained on the topic, "exploitation" is a common refrain from liberal critics as well. Some critics argue that surrogacy "extend[s] the oppressive logic of the market to its farthest and final frontier." Prominent feminists such as Gloria Steinem vocally oppose commercial surrogacy on grounds that it is coercive for low-income women and poses serious risks, and feminist icon Margaret Atwood's popular book The Handmaid's Tale (and associated TV drama) depicts surrogacy as a nonconsensual nightmare.
Yet American surrogacy is nothing like the Brave New World of the right or The Handmaid's Tale of the left, and current research does not support critics' views. Instead, surrogacy is voluntary, gestational carriers are well-compensated to the tune of $30,000 to $60,000 personally, and the vast majority of carriers have their own legal representation during the process. Gestational carriers also report undergoing medical and psychological screenings, during which they are informed of the possible risks.
Gestational carriers typically have positive long-term psychological outcomes—and although pregnancy and fertility treatment are not risk-free, medical outcomes for gestational carriers resemble outcomes for the general population of women using IVF. Children resulting from surrogacy generally do well from a psychological and medical perspective.
If surrogates feel exploited by the process, the research doesn't show that. Instead, gestational carriers often experience a sense of self-worth and achievement following the process; there is little evidence of postsurrogacy regret, and many surrogates would consider carrying again. A long-term study that followed gestational and genetic surrogates in the U.K. found that no surrogates expressed regret about their involvement in surrogacy 10 years after the birth of a child. A separate survey showed 83 percent of gestational carriers in California said they would consider becoming a gestational carrier again.
The Clarks' own experience with surrogacy is a far cry from the cynically transactional picture painted by critics. Following the completion of another IVF cycle, Evelyn's clinic matched her with the person she calls her "angel on earth," Sarah Schneider. (All the names of the families are pseudonyms.) In a phone call, Evelyn's nurse noted Sarah's "pure intentions"—interviews, research, and nonscientific surveys find that gestational carriers are commonly motivated by altruism—and the nurse provided Evelyn with Sarah's email address so she could reach out for an initial conversation.
Following an introductory call where the women shared their histories and hopes for the future, and following a dinner date that included Evelyn, Will, Sarah, and Sarah's husband, the Clarks and Schneiders decided it made sense to move forward. "We felt like old friends and honestly everything just felt right," Sarah says. That's when the start of the many legal, medical, psychological, and insurance hurdles began.
While gestational surrogacy can be miraculous, it is by no means easy. IVF is complex, and gestational surrogacy increases the complexity by leaps and bounds, as it adds an entirely new set of legal, financial, medical, and psychological requirements for both intended parents and gestational carrier.
If IVF feels like a part-time job, navigating gestational surrogacy is like a full-time one. The requirements for the Clarks and Schneiders included individual psychological assessments, as well as group counseling, where they ran through every possible scenario, including how they would feel if Sarah lost the baby during pregnancy or delivery.
The legal process was similarly structured to cover every possible contingency. The Clarks paid for the Schneiders to have their own counsel, which is common. Then, together and separately, the couples considered potentially thorny hypotheticals, including how many embryos Sarah was willing to transfer and under what circumstance all parties would be unwilling or willing to terminate the pregnancy. (For such meticulously planned and desperately hoped-for pregnancies, this scenario is vanishingly rare.)
Alongside these sensitive questions, the Clarks and Schneiders worked through financial questions about compensation in case of bed rest, compensation for house cleaning, and even compensation for major medical issues, should these needs result from pregnancy or delivery. Intended parents also typically cover the cost of agency fees, legal fees, IVF, health insurance, and other miscellaneous expenses related to the pregnancy (clothing, travel, lodging, and more), and it is these costs that lead to the eye-popping "all-in" cost for intended parents of $100,000 to $225,000.
Despite the enormous financial cost, and although the Clarks covered what economists call the "opportunity cost" of Sarah's time and the risks she was voluntarily taking, they knew that what Sarah gave them was a gift. And although money would change hands in the process, it would not change the moral case for their joint project. As Evelyn put it, "You know, the compensation was such a small part of it. After we signed the contracts, we never spoke of it again."
Baby Bobbie
Although compensation was not a central focal point for the Clarks and Schneiders, compensation is a major sticking point for critics of surrogacy in the U.S. and elsewhere. Various countries—including the United Kingdom, Canada, Australia, and New Zealand—have made compensated surrogacy illegal while allowing uncompensated surrogacy.
In the U.S., most surrogacy is compensated, and gestational carriers and intended parents are both made better off under voluntary compensated surrogacy arrangements. In a curious paradox, critics characterize surrogacy as "exploitative" but are eager to outlaw the payments that cover gestational surrogates' time, efforts, and voluntarily taken risks, even though outlawing payment would make gestational carriers objectively worse off.
Outspoken antisurrogacy advocates, such as Jennifer Lahl, think compensating surrogates is harmful and should be illegal in the U.S. and around the world. Lahl founded The Center for Bioethics and Culture Network and is part of an international campaign to ban commercial surrogacy, though she maintains that ultimately all types of surrogacy—compensated or not—are unethical.
Lahl sees parallels between surrogacy and organ donation, where policy prohibits compensation for organ donors, and she believes organ donation policy provides useful insights for third-party reproduction. She has written that "organ donation should be motivated by the desire to freely give a gift—not by the lure of financial incentives," and she feels it would be best if gestational surrogacy followed suit.
If compensation were forbidden, surrogacy would endure the same fate as kidney transplants, where shortages and delays abound. This may be what Lahl wants, but it is hard to imagine a worse model: Because of existing laws prohibiting compensation, 100,000 Americans languish on kidney transplant waiting lists, and 4,000 Americans die annually as they wait for a kidney, despite nearly everyone having a kidney they could donate.
Prohibiting compensated surrogacy would be similarly tragic, forcing intended parents to endure agonizing and futile waits, pushing intended parents to look for surrogacy services in riskier contexts, and leaving many couples ultimately unsuccessful at expanding their families. Thousands fewer babies would be born in the U.S. annually.
Compensation helps efficiently allocate resources, provides incentives for participation, effectively signals a need, and ensures participants are treated fairly. These benefits are most important when human life is on the line.
Fortunately, the Clarks were not living under Lahl and other critics' policy prescriptions. Evelyn had two embryos left for transfer—the Clarks' last hope. They agreed to transfer both at once, and one took.
As the pregnancy progressed, Sarah messaged Evelyn several times daily to ease her nerves by letting her know that the baby was moving and wiggly. The "gratitude overrode the anxiety because I was so grateful for every month and every milestone," says Evelyn. Evelyn had full trust in Sarah, and Evelyn, Will, Sarah, and Sarah's husband attended each of the many fertility and prenatal appointments together—two grown men and two women huddled close in each small exam room.
The families lived three hours apart, so attending all those appointments together was a logistical feat. Toward the end of the pregnancy, the Schneiders began driving to doctor's appointments in the city where the Clarks lived and she would deliver. Sarah moved in with her sister for the last 10 days of the pregnancy to be closer to the hospital.
Last August,Baby Bobbie arrived perfect and healthy at 38.5 weeks and 7 pounds, 8 ounces. Before delivery, Sarah told Evelyn she couldn't wait to see her face the first time Evelyn held him. As Evelyn described it, when Bobbie arrived, the two women looked at each other as though to say, "We did it. He's here."
"The delivery itself couldn't have been more perfect," Sarah says. "He came pretty fast and it was so surreal and special and spiritual and just honestly so beautiful."
It's been a decade since the Clarks first set out to expand their family, and today they have three rosy-cheeked children to show for it. "I spent 10 years trying to get my babies here," Evelyn recalls, tucked into a recliner with her baby snuggled close in her living room. "But I felt led and supported by God the entire way. And Sarah felt supported by God the same as I did."
It is hard to imagine anyone taking issue with the family that Evelyn and Will created with the help of a generous stranger. It might be an unusual story for two families to be knit together this way, but that doesn't make it less heartfelt.
The Schneiders have returned to their former lives, but the two families stay connected through calls, texts, and pictures. In September, they joined the Clarks for Bobbie's baby blessing, a special religious rite of passage held in the Clarks' backyard. The happy family of five was surrounded by the people closest and most important to them—a group that now includes Sarah and her family.
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