title: Surrogacy: outcomes for surrogate mothers, children and the resulting families-a systematic review.
abstract: BACKGROUND
  Surrogacy is a highly debated method mainly used for treating women with infertility caused by uterine factors. This systematic review summarizes current levels of knowledge of the obstetric, medical and psychological outcomes for the surrogate mothers, the intended parents and children born as a result of surrogacy.
  
  
  METHODS
  PubMed, Cochrane and Embase databases up to February 2015 were searched. Cohort studies and case series were included. Original studies published in English and the Scandinavian languages were included. In case of double publications, the latest study was included. Abstracts only and case reports were excluded. Studies with a control group and case series (more than three cases) were included. Cohort studies, but not case series, were assessed for methodological quality, in terms of risk of bias. We examined a variety of main outcomes for the surrogate mothers, children and intended mothers, including obstetric outcome, relationship between surrogate mother and intended couple, surrogate's experiences after relinquishing the child, preterm birth, low birthweight, birth defects, perinatal mortality, child psychological development, parent-child relationship, and disclosure to the child.
  
  
  RESULTS
  The search returned 1795 articles of which 55 met the inclusion criteria. The medical outcome for the children was satisfactory and comparable to previous results for children conceived after fresh IVF and oocyte donation. The rate of multiple pregnancies was 2.6-75.0%. Preterm birth rate in singletons varied between 0 and 11.5% and low birthweight occurred in between 0 and 11.1% of cases. At the age of 10 years there were no major psychological differences between children born after surrogacy and children born after other types of assisted reproductive technology (ART) or after natural conception. The obstetric outcomes for the surrogate mothers were mainly reported from case series. Hypertensive disorders in pregnancy were reported in between 3.2 and 10% of cases and placenta praevia/placental abruption in 4.9%. Cases with hysterectomies have also been reported. Most surrogate mothers scored within the normal range on personality tests. Most psychosocial variables were satisfactory, although difficulties related to handing over the child did occur. The psychological well-being of children whose mother had been a surrogate mother between 5 and 15 years earlier was found to be good. No major differences in psychological state were found between intended mothers, mothers who conceived after other types of ART and mothers whose pregnancies were the result of natural conception.
  
  
  CONCLUSIONS
  Most studies reporting on surrogacy have serious methodological limitations. According to these studies, most surrogacy arrangements are successfully implemented and most surrogate mothers are well-motivated and have little difficulty separating from the children born as a result of the arrangement. The perinatal outcome of the children is comparable to standard IVF and oocyte donation and there is no evidence of harm to the children born as a result of surrogacy. However, these conclusions should be interpreted with caution. To date, there are no studies on children born after cross-border surrogacy or growing up with gay fathers.
authors.affiliation: Väestöliitto Clinics, Fertility Clinic, Helsinki, Olavinkatu 1b, 00100 Helsinki, Finland viveca.soderstrom-anttila@vaestoliitto.fi.
authors.forename: Viveca
authors.initials: V
authors.lastname: Söderström-Anttila
authors.affiliation: Department of Obstetrics and Gynaecology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Sahlgrenska University Hospital, Östra (East) SE-416 85 Gothenburg, Sweden.
authors.forename: Ulla-Britt
authors.initials: UB
authors.lastname: Wennerholm
authors.affiliation: Fertility Clinic, Section 4071, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
authors.forename: Anne
authors.initials: A
authors.lastname: Loft
authors.affiliation: Department of Obstetrics and Gynecology, Hvidovre Hospital, Institute of Clinical Medicine, Copenhagen University Hospital, Copenhagen, Denmark.
authors.forename: Anja
authors.initials: A
authors.lastname: Pinborg
authors.affiliation: Department of Medical Genetics, Helsinki University Central Hospital (HUCH), 00029 HUS, Helsinki, Finland
authors.forename: Kristiina
authors.initials: K
authors.lastname: Aittomäki
authors.affiliation: Spiren Fertility Clinic, Trondheim NO-7010, Norway and Department of Public Health, Norwegian University of Science and Technology, Trondheim, Norway.
authors.forename: Liv Bente
authors.initials: LB
authors.lastname: Romundstad
authors.affiliation: Department of Obstetrics and Gynaecology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Reproductive Medicine, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden.
authors.forename: Christina
authors.initials: C
authors.lastname: Bergh
mesh_terms: D002648:Child; D015331:Cohort Studies; D005190:Family / Q000523:psychology; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D007246:Infertility / Q000453:epidemiology / Q000523:psychology / Q000628:therapy; D018587:Oocyte Donation / Q000523:psychology / Q000706:statistics & numerical data; D010287:Parent-Child Relations; D011247:Pregnancy; D011256:Pregnancy Outcome / Q000453:epidemiology* / Q000523:psychology; D011272:Pregnancy, Multiple / Q000523:psychology / Q000706:statistics & numerical data; D027724:Reproductive Techniques, Assisted / Q000523:psychology / Q000706:statistics & numerical data; D013533:Gestational Carriers / Q000523:psychology / Q000706:statistics & numerical data*
keywords: altruistic; assisted reproduction; birthweight; child development; gestational; intended parent; obstetric complication; prematurity; relinquish; surrogacy