Transnational Gestational Surrogacy During Covid-19 pandemics and War in Ukraine. A qualitative, interdisciplinary study of Danish infertile couples' experiences in a world of change

Abstract Study question How do permanently infertile couples experience surrogacy in cross border reproductive care (CBRC) and which considerations do they have in relation to this? Summary answer The couples find surrogacy treatment in CBRC satisfying but feel forced to use CBRC, and estranged from own country, missing reproductive body, and home What is known already Permanently infertile couples in Denmark must go abroad if they want a genetically related child, as health care professionals are not allowed to assist in a surrogacy process. Divergent legislation on surrogacy worldwide often creates a demography of permanently infertile couples, moving around depending on which country permits gestational surrogacy. Only few academic studies have described how external circumstances as Covid-19 pandemics and the current war in Ukraine affect the world of surrogacy and even fewer studies have focused on the infertile couples’ situation. Study design, size, duration Semi-structured qualitative interviews, including a total of fourteen couples, were conducted with permanently infertile couples across Denmark from May 2022 to September 2022. The couples chose place, time and if they preferred to be interviewed individually or together. Eleven couples chose their own home, two preferred online interviews and one interview was held in another place. Each interview lasted for an average of 93 minutes. Participants/materials, setting, methods Fourteen infertile couples (N = 23 participants), majority heterosexual, in different stages from planning to use a gestational carrier to having two children through surrogacy were interviewed. Interview themes included “history of infertility”, “experiences with surrogacy”, “openness about one’s own situation”, and “considerations about surrogacy”. The majority used/had used Ukraine as destination of surrogacy. The interviews were recorded, anonymized, and transcribed. Data were analysed using Malterud’s method of systematic text condensation. Main results and the role of chance Most couples had a relative in Denmark who offered to be a gestational carrier, but all except one couple declined this offer as they felt very unsecure about the legal situation not only for them, but also for the carrier, and a potential child. Instead, they decided to go abroad, mainly to Ukraine, to have an enforceable transparent contract, professionals to advise and the possibility of using the intended mother’s eggs. They didn’t feel it as a “choice” but more as the only option to have the longed-for child. Many felt that Danish authorities on purpose tried to obstruct their way home with the new born which contributed to this sentiment of estrangement. According to Danish legislation if the gestational carrier was reimbursed, the intended mother cannot be granted legal motherhood at any time. This lack of acknowledgement of motherhood was not only a practical issue for the couple, but deeply affected the intended mothers of not being “worthy mothers”. The empirical realities of these couples within the context of a pandemic, a war, and borders that open and close are a confrontation and clear illustration of the different legislations on surrogacy in Denmark and worldwide. Limitations, reasons for caution The study participants had all chosen to be part of this study after advertisement in targeted internet forums. Hence, the results may not be directly transferred to all permanently infertile couples regarding attitudes towards being infertile and using surrogacy. Wider implications of the findings This study contributes to the understanding of being permanently infertile and the implications of the Danish and international legislation on surrogacy. Findings from our study will be useful to form the academic basis of a near-future revision of the existing surrogacy legislation. Trial registration number Institutional Review Board at Aarhus University, Denmark (HE 2022-001)