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. SUBJECTS: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 2014-2020. EXPOSURE (FOR OBSERVATIONAL STUDIES):International versus US intended parents. MAIN OUTCOME MEASURES:Cycle characteristics, geographic distributions, and obstetrical outcomes. RESULTS:Of 40,177 embryo transfers to a gestational carrier from 2014-2020, 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 to 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 parentss were more commonly younger than 30 years (42.8% vs 29.1%) and identified as Hispanic race (28.6% vs 11.7%) compared to 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 pre-implantation genetic testing (79.0% vs 55.8%). Cycles with international and US intended parents had similar obstetrical outcomes, including live birth (adjusted risk ratio [aRR] 1.01, 95% confidence interval [CI] 1.00-1.03) and multiple pregnancy (aRR 1.00, 95% CI 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 due to 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.