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Surrogate Pregnancy After Prenatal Diagnosis of Spina Bifida Lynnette J Surrogate Pregnancy After Prenatal Diagnosis of Spina Bifida Lynnette J. Mazur, MD, MPH, a Mary Kay Kisthardt, JD, LLM, b Helen H. Kim, MD, c Laura M. Rosas, BBA,a John D. Lantos, MDd Some pregnancies today involve infertile individuals or couples who abstract contract with a fertile woman to carry a pregnancy for them. The woman who carries the pregnancy is referred to as a “gestational carrier.” The use of such arrangements is increasing. Most of the time, these arrangements play out as planned; sometimes, however, problems arise. This article discusses a case in which a fetal diagnosis of spina bifida led the infertile couple to request that the gestational carrier terminate the pregnancy, and the gestational carrier did not wish to do so. Experts in the medical and legal issues surrounding surrogacy discuss the considerations that should go into resolving such a conflict. The number of births that follow consultation at 21 3/7 weeks’ surrogacy arrangements involving gestation. The pregnancy was the a gestational carrier is at an all-time result of in vitro fertilization (IVF); high in the United States. 1 Typically, the patient was a surrogate. The a in these cases, an infertile individual University of Texas Health Sciences Center, Houston, Texas; intended parents lived in Europe. bUniversity of Missouri–Kansas City School of Law, Kansas or couple makes an arrangement with Because surrogacy was illegal in City, Missouri; cDepartment of Obstetrics and Gynecology, d a woman who is capable of carrying their country, an American lawyer University of Chicago, Chicago, Illinois; and Children’s Mercy Kansas City, Kansas City, Missouri a pregnancy to bear a child and then initiated the contract between the turn that child over at birth to the couple and the surrogate. After a few All authors contributed to the design of the article, the drafting of the manuscript, and the review infertile individual or couple. In some months of legal, psychological, and cases, the egg and sperm come from of the manuscript. All authors approved the fi nal medical preparations, an egg from version. the contracting couple. In other cases, an anonymous donor was fertilized the egg comes from an oocyte donor DOI: 10.1542/peds.2016-2619 with the father’s sperm, and the or, less often, from the gestational Accepted for publication Aug 8, 2016 resultant embryo was implanted in carrier (an arrangement called Address correspondence to John D. Lantos, MD, the surrogate. The agreement was for traditional surrogacy). The parties Children’s Mercy Kansas City, 2401 Gillham Rd, the intended parents to take the child to such arrangements sign legal Kansas City, MO 64108. E-mail: [email protected] contracts. Sometimes, money changes back to their country; the surrogate PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, hands; in other cases, the surrogacy would have no future rights or contact 1098-4275). is altruistic. All such arrangements with the child. Copyright © 2017 by the American Academy of are fraught with potential conflicts. Pediatrics When such contracts arise, the courts An ultrasound showed a male fetus FINANCIAL DISCLOSURE: The authors have may be called upon to resolve them. In with SB at the second sacral level. No indicated they have no fi nancial relationships relevant to this article to disclose. this Ethics Rounds, we present a case hydrocephalus or other anomalies of surrogacy in which the fetus was were noted. Shortly after the doctor FUNDING: No external funding. diagnosed with spina bifida (SB) and introduced herself to the pregnant POTENTIAL CONFLICT OF INTEREST: The authors analyze the conflicts that followed. woman, she said that she was not have indicated they have no potential confl icts of interest to disclose. the mother. She called herself "the toaster.” She suggested calling the THE CASE intended parents to discuss SB. The To cite: Mazur LJ, Kisthardt MK, Kim HH, et al. A 32-year-old G3P2 female patient father spoke some English; his wife Surrogate Pregnancy After Prenatal Diagnosis of Spina Bifi da. Pediatrics. 2017;139(2):e20162619 presented for a prenatal pediatric did not. Over the course of 45 minutes, Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 139 , number 2 , February 2017 :e 20162619 ETHICS ROUNDS the doctor explained the expected can be traditional or gestational. the principle of autonomy, it is challenges that their son may In traditional surrogacy (natural, impossible either to prevent her or develop. partial, or straight surrogacy), the to force her to have an abortion. 5 She surrogate is impregnated naturally or retains the right to confidentiality In general, the disabilities depend artificially with the intended father’s and the right to determine what on the level of the lesion; the higher sperm, and the child is genetically information about the pregnancy the the defect, the more adverse the related to both the surrogate and health care providers can share with outcomes. Neurologically, most the father. In a gestational surrogacy the commissioner(s). children with SB have an IQ in the (full, host, or IVF surrogacy), the normal range but many having In view of the fetus’ birth defect, embryo, resulting from the intended learning difficulties. In this case, both parties questioned the father’s sperm and an egg donor, because of the low level and the agreement. Each wanted to do is implanted in the surrogate and absence of hydrocephalus, the need what was in their best interest, the is biologically unrelated to her. for a ventriculoperitoneal shunt principle of ethical egoism. The Either form can be commercial (the was considered unlikely. However, surrogate wanted to continue the surrogate is compensated by the because sacral nerves are needed pregnancy, and the couple did not commissioners) or altruistic (the for bladder and bowel function, the want a child with SB. However, surrogate has reasons other than infant would be at risk for recurrent given their conflicting desires, financial gain). Our patient was a urinary tract infections and declining who should make the decision? commercial surrogate. renal function. Daily intermittent A termination may adversely affect bladder catheterizations and Surrogacy is especially complex the surrogate’s health, her ability medications to prevent leaking might because the interests of the intended to care for her current children, or be needed. Sensory deficits in the parents, the surrogate, her spouse her future pregnancies. It may be genital area may require medications (if she has one), and the future child, against her beliefs or it may be too for future erectile dysfunction. In may differ. Cases with international late in the pregnancy to perform. addition, constipation is a common contracts have unique complexities. Accordingly, adoption would be an problem and can lead to leaking When unexpected fetal defects are option; the surrogate could follow of stool, recurrent urinary tract encountered, both parties may her conscience, and the couple would infections, pressure ulcers, and shunt face ethical, legal, medical, moral, not have to raise the child. Payments malfunction. Orthopedically, the and practical dilemmas. Given the and/or reimbursements for both muscles innervated by the nerves time limitations on a postviability the surrogate’s and the infant’s below the defect will be weak. termination or a late-term abortion medical expenses would need to be Children with sacral defects usually (after 20 weeks’ gestation) and determined. walk without assistive devices, but for fetal surgery (before 26 weeks’ Other important questions remain. orthotic devices for ankle stability gestation), a timely legal settlement For the surrogate’s family, what and protection of the feet will likely may not be possible. be needed. Sensory deficits place are the psychological consequences him at risk for pressure ulcers and How do the involved parties address for the surrogate’s family of fractures. 2 these issues? By the nature of the relinquishing their child/sibling? agreement, both parties voluntarily Our patient stated that her own After explaining these challenges, accepted some restrictions on their children were confused about her the couple stated that they did not autonomy. It follows that neither pregnancy. One afternoon her want to raise a defective child. They party should unilaterally change their daughter’s kindergarten teacher preferred an abortion but would mind after the start of the pregnancy. asked for clarification of her consider in utero correction. The In addition, because the surrogate daughter’s statement “My mommy surrogate objected to a termination freely entered into the contract, she is pregnant but he is not our and because of the low level of accepted other restrictions to her brother.” What are the consequences the lesion, she was not a surgical autonomy. She is expected to follow if the surrogate keeps in contact candidate. 3, 4 a healthy lifestyle and attend regular with the resulting family? For the physician visits. Although she has commissioning parents, what are the Lynnette J. Mazur/Laura M. Rosas a prima facie obligation to accept legal consequences of breaking the Comments the advice of the obstetrician that contract? What is the risk of rejection The first successful surrogate will ensure the best outcome for or risk of the child being the object of pregnancy (ie, the carrying of a herself and the child, she cannot be conflict between the parties? What pregnancy for other intended forced to accept a cesarean delivery information is shared with the child parents) occurred in 1985. Surrogacy (CD) for a child with SB. Also, given as he matures? For the egg donor, Downloaded from www.aappublications.org/news by guest on September 28, 2021 2 MAZUR et al is there a duty or a responsibility to require a gestational surrogate of the discussion because they help to find and inform her about her to abort a fetus at the request of to inform the decision.
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