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This article focuses on Israeli single gay fathers' reproductive choices. Thematic analysis of 13 in-depth semi-structured interviews with Israeli single gay fathers yielded two themes related to their reproductive choice. The first theme pertains to their decision to become single fathers. Three dimensions were prominent in the participants' decision to pursue lone parenthood: the choice to fulfill parenthood as gay men; the choice to separate parenthood from couplehood; and the view of single parenthood as empowerment. The second theme pertained to the fathers' decision to use surrogacy, which was influenced by three key factors: the desire to parent a biological child, the desire for exclusive fatherhood, and the perceived advantages of surrogacy for single fathers. The findings indicate that the fathers narrated their reproductive experiences in terms of choice and autonomy, while negotiating with dominant concepts of parenthood as a two-parent, heteronormative and biogenetic phenomenon. These men referred to the challenge they posed to some of these concepts and the social barriers they encountered as factors that facilitated their coping skills in lone parenthood, thereby enhancing their agency. These findings highlight the contextual, multidimensional and relational nature of the reproductive choices of men from minority groups like single gay fathers.

Study Question: How do surrogates think, feel, and reflect on their experiences of being a surrogate over time?, Summary Answer: Despite continuing to require physical, emotional, and interpersonal labour, surrogates in this study reflected positively on their experiences of being a surrogate decades later., What Is Known Already: Research on families created through surrogacy shows that it can be a positive experience for both the intended parents and the surrogate. No existing research has examined the experiences of surrogacy for surrogates beyond 10 years post-birth., Study Design, Size, Duration: Semi-structured, qualitative interviews were conducted with 21 women who had completed a total of 71 surrogacy arrangements. Participants had given birth to their first surrogate child on average 20 years previously., Participants/materials, Settings Methods: Data were collected about (i) surrogates' relationships with the families they had helped, (ii) how important being a surrogate was to their own identity, and (iii) how they felt surrogacy was perceived by the public. Data were analysed according to the principles of reflexive thematic analysis., Main Results and the Role of Chance: Surrogates' reflections on their experiences were constructed into two themes: (i) hard work but worth it and (ii) part of who I am. Surrogacy had taken a physical toll on some participants, and for most, being a surrogate continued to involve emotional labour and effort to maintain relationships with the families. Making friends through the process and feeling proud of what they had done to help someone meant that overall, surrogates reflected positively on surrogacy and had incorporated their experiences as surrogates into a stable aspect of their identity., Limitations, Reasons for Caution: There is a risk of selection bias, with surrogates who had a more positive experience being more likely to continue to participate in the research. All surrogacies occurred within the UK. While the sample is relatively diverse in terms of surrogates' ages, current employment status, and relationship status, the sample lacks ethnic diversity. Most participants had been surrogates for heterosexual couples, and thus long-term relationships involving gay couples or single men may differ., Wider Implications of the Findings: The findings from this study show the importance of understanding surrogacy as a 'relational' process and suggest to prospective surrogates and intended parents what they may expect from their relationship over time. Given the findings that even as the children grow up, being a surrogate continues to require emotional labour, support should be made available to surrogates over the longer term if required., Study Funding/competing Interest(s): This project was funded by the Wellcome Trust [grant number 208013/Z/17/Z] and the University of Cambridge Returning Carers Scheme. The authors have no competing interests to declare., Trial Registration Number: N/A., (© The Author(s) 2024. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology.)

This paper offers a comprehensive review of the gestational surrogacy process in the US, as well as internationally, focusing on the legal and ethical challenges that gestational carriers, intended parents, fertility providers, and OB/GYNs may face. The objective of this review article is to serve as an overview and provide information on legal, cultural, and ethical aspects of the decisions to pursue gestational surrogacy both for intended parents and gestational carriers in the US and globally. By understanding the surrogacy landscape and the obstacles, the surrogacy agencies and other involved parties can improve the surrogacy process to better serve all parties involved., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Research Question: What is the profile of women in the USA who become surrogates, and what is their power of decision and motivations?, Design: This quantitative study was performed with 231 participants in the USA, given the country's long history of surrogacy, to help clarify the profile of women who become surrogates, their power of decision and motivations., Results: Descriptive and multivariate cluster analyses showed that women who become surrogates earn above the average income for their state of residency, have a high level of education, have health insurance, are employed, and decide to become a surrogate for prosocial/altruistic reasons., Conclusions: In contrast to the premise of both radical feminism and ultra-conservative Catholicism, this study found that altruism and empathy are the primary motivations for participating in surrogacy processes, and that a woman's decision to become a surrogate is not motivated by social conditioning relating to poverty or social status., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objective: The present study aimed at investigating whether gay fathers' coherence of mind within the Adult Attachment Interview (AAI) moderated the influence of parental disclosure on children's exploration of their surrogacy origins during middle childhood and early adolescence., Background: Once children of gay fathers are disclosed to about their surrogacy conception, they may start exploring the meanings and implications of their conception. Very little is known about the factors that may enhance such exploration in gay father families., Method: A home-visit study was conducted with 60 White, cisgender, gay fathers and their 30 children born through gestational surrogacy, all residing in Italy and with medium to high socioeconomic status. At time 1, when children were aged 6-12 years ( M  = 8.31, SD = 1.68), fathers were rated for AAI coherence of mind and interviewed about their disclosure of the surrogacy origins to their child. At time 2, approximately 18 months later ( M  = 9.87, SD = 1.69), children were interviewed about their exploration of their surrogacy origins., Results: In the context of more information disclosed about the child conception, only children whose fathers showed greater AAI coherence of mind explored their surrogacy origins in more depth., Conclusion: Gay fathers' ability to show an internally consistent, but not emotionally overwrought, state of mind regarding their own attachment experiences impacted the extent to which their children felt safe and legitimated in sharing their curiosity about their conception.

The present study investigated child behavior problems, parenting styles, coparenting, and couple relationship satisfaction in 67 European gay father families via surrogacy and 67 European heterosexual parent families via unassisted conception, all with children aged 1.5-10 years (M = 3.57 years, SD = 2.09). The two family groups were matched for child age and gender. In the gay father group only, the associations between family anti-gay microaggressions, family/friend support, and other main variables also were explored. Children of gay fathers had fewer externalizing and internalizing problems compared to children of heterosexual parents. Also, gay fathers reported more effective parenting styles, greater coparenting quality, and higher couple relationship satisfaction compared to heterosexual parents. Overall, child externalizing problems (i.e., aggression, rule-breaking) and internalizing problems (i.e., anxiety, depression) were more strongly associated with being raised in a heterosexual parent family, more authoritarian parenting, and lower positive coparenting. Specific to the gay father sample, anti-gay microaggressions experienced by family members were associated with more child internalizing problems, lower positive coparenting, and lower social support from family and friends. These results refute concerns about possible detrimental effects on child development of surrogacy conception or of being raised by gay fathers. The results further suggest that family therapists treating child behavior problems should focus mainly on improving the coparenting relationship, reducing authoritarian/punitive parenting styles, and (for gay father families specifically) coping with anti-gay microaggressions and lack of social support outside the nuclear family., (© 2023 The Authors. Family Process published by Wiley Periodicals LLC on behalf of Family Process Institute.)

Building on existing scholarship examining how audiences interpret reproductive experiences on film and television, we investigate how viewers make meaning of representations of motherhood, abortion, adoption, and surrogacy on the Hulu television miniseries Little Fires Everywhere . We recruited twenty-one participants to watch the series and conducted three virtual focus groups of seven women each. Based on the racial identities of the main characters in the series, we segmented these groups by race: one group each of white women, Black women, and Chinese American women. Focus groups were facilitated by moderators who matched the racial and ethnic backgrounds of each group. We asked participants about their overall reactions to the series, their impressions of various characters, and each reproductive health plotline. Participants expressed both tender and critical reactions to characters who endured motherhood, surrogacy and adoption, yet most participants were overtly critical of Lexie, the character who obtained an abortion. We argue that this is likely because the character of Lexie is written as largely unsympathetic, leaving audiences with little opportunity to form a parasocial relationship with her. We discuss the implications of this for cultural conversations and understandings of abortion more broadly.

Comprehensive access to medically assisted reproduction procedures and techniques in Argentina has been assured by National Law No. 26,862 since 2013. This Law does not include surrogacy procedures, and the lack of specific regulation shifts practices to a paralegal setting. In this context, planned parenthood by male couples through surrogacy is performed through actions that convey demands for access rights and active State policies. For these couples, the argument is that surrogacy is the only option to have a child with a genetic bond with at least one of the two parents and recognize both filiatory bonds. This work results from field work in progress with parents from the Province of Buenos Aires running this practice in Argentina. Based on in-depth interviews, we attempted to rebuild personal experiences and analyze the meanings that the narratives construct regarding their parenting, the biological connections in establishing or defining family relationships, and the importance of genetics in constructing and maintaining affiliations.

This case explores the legal and ethical considerations for pediatricians surrounding gestational carrier pregnancies in the United States. Because of high success rates for assisted reproduction, state laws supporting same-sex adoption and surrogacy, and established legal precedents, gestational carrier pregnancies are increasingly common. The case presented involves a gestational carrier in preterm labor at 30 weeks' gestation with malpositioned twins who declines a cesarean delivery. Three commentaries are presented. The first highlights the importance of understanding the ethical implications of gestational carrier pregnancies in prenatal counseling. The second commentary emphasizes the pregnant person's right to autonomy and bodily integrity, and discusses considerations in surrogacy pregnancies, including the authority to authorize a cesarean delivery, valid informed consent, and decision-making for neonates. The third commentary discusses autonomy, emphasizing the importance of contracts in surrogacy pregnancies, and suggests that, in the case of a conflict between the gestational carrier and the intended parent(s), the gestational carrier's preference should be decisive regarding medical care during pregnancy. These discussions highlight key concepts for ethically informed and family-centered care in gestational carrier pregnancies and deliveries., (Copyright © 2024 by the American Academy of Pediatrics.)

Surrogacy (GS) has been established as a means of access to male homoparenting and, despite not being regulated in Argentina, it is negotiated in a "paralegal" scenario. For some time now, LGBT organizations have proposed regulation based on the argument that GS represents the only option available for a male homosexual couple to have a child with a genetic link, albeit with only one of them, and consecutively acknowledge the family ties of both. By means of ethnographic work carried out within the scope of a postgraduate research project, our objective is to ascertain the experiences of male homosexual couples who seek the legitimacy of GS processes and equal access to the healthcare system. With this in mind, we seek a reflection that articulates the construction of public health policies and the claims of sectors of the LGBT movement, focusing on the meanings of the collective experience, on the ways in which these actors organize their family demands, and on the conceptions and practices that articulate these claims with the production of public policies.

Objectives: The aim of the study was to find out what proportion of women with MRKHS have decided to become mothers and have children or would like to have children and consider various options for motherhood. Additionally, the survey aimed at identifying factors that might influence the women's decisions and opinions regarding adoption, gestational surrogacy (GS) and uterus transplantation (UTx)., Material and Methods: The study group consisted of 100 adult women with MRKHS who filled out questionnaires consisting of 56 questions. The survey was self-administered and anonymous., Results: Most of the study participants were under 30, lived in large cities ( > 150 000 inhabitants) and declared to be heterosexuals in a steady relationship (p < 0.05). While 11 participants had children, 66 out of 89 childless women (74%) expressed a desire for motherhood, but as many as 80 surveyed women have felt pressured to have children. The number of participants for whom a biological relationship with offspring was significant and insignificant respectively equaled (p = 1.000). The majority of the study participants supported the process of legalizing GS in Poland (95 vs 4) yet would opt for commercial rather than altruistic GS (64 vs 31) (p < 0.05). Most respondents stated that UTx is consistent with their faith and conscience (91 vs 4) and found UTx ethical (88 vs 4) (p < 0.0001)., Conclusions: The majority of Polish women with MRKHS express the need to become a mother, but only one in ten has a child. The women's interest in biological motherhood is significant.

Purpose: To examine surrogates' mental health, social support, and relationship with intended parents (IPs) during the COVID-19 pandemic from March 2020 to February 2022., Methods: Data were collected between April 29, 2022 and July 31, 2022, at an academic IVF center in Canada using an 85-item online anonymous cross-sectional survey that included three standardized scales measuring mental health (PHQ-4), loneliness, and social support. Eligible surrogates actively involved in surrogacy during the study period received email invitations., Results: The response rate was 50.3% (338/672); 320 submitted surveys were analyzed. Two-thirds (65%) of respondents experienced mental health concerns during the pandemic and were significantly less comfortable about seeking mental health support than those without concerns. Nonetheless, 64% were highly satisfied with their surrogacy experience; 80% received a high level of support from their IPs, and 90% reported a good relationship with them. The final hierarchical regression model identified five significant predictors, explaining 39.4% of the variance in PHQ-4 scores: a prior mental health history, COVID-19 impact on personal life, surrogacy satisfaction, loneliness, and social support., Conclusions: COVID-19 created an unprecedented challenge to surrogacy care, increasing surrogates' risk of experiencing mental health symptoms. Our data show that IP support and the surrogate-IP relationship were fundamentals to surrogacy satisfaction. The findings are relevant to fertility and mental health practitioners in identifying surrogates who are more susceptible to mental health challenges. Fertility clinics should ensure adequate psychological screening of surrogate candidates and proactively offer mental health support services., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Perinatal distress affects approximately 10% of fathers, but little is known about how gay fathers experience the challenges surrounding childbirth and early parenting of a child. This study explored gay fathers' experiences of having a baby via transnational surrogacy, raising that baby as a gay parent, and the context of the COVID-19 pandemic. In-depth qualitative interviews were conducted with 15 Israeli men to understand their experiences of surrogacy and early parenthood, focusing on the impact on their mental health and the relational factors involved. Secondary narrative analysis revealed that fathers constructed surrogacy as a perilous quest that required strong intentionality to undertake. The first year of parenthood was conceptualised alternately as a joyful experience and/or one that challenged fathers' identities and mental health. A relational framework was applied to better conceptualise the fathers' narratives, revealing that actual connections-and the potentials for links-considerably shaped experiences of surrogacy, perinatal distress and recovery. Implications for research and policy are discussed., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Kelly et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

This study aimed to explore the psychological welfare, as indicated by postnatal depressive symptomatology, life satisfaction, and posttraumatic growth (growth after contending with stressful birth events), of Israeli gay fathers through surrogacy in comparison to heterosexual fathers. For that purpose, a sample of 167 Israeli fathers ( M = 35.6, SD = 4.4) was recruited (68 identified as gay fathers through surrogacy and 99 as heterosexual fathers). Participants completed questionnaires assessing their postnatal depressive symptomatology, life satisfaction, and sense of posttraumatic growth after becoming fathers. Results indicated that gay fathers through surrogacy reported higher levels of life satisfaction and posttraumatic growth than heterosexual fathers. Yet, gay fathers also reported higher levels of postnatal depressive symptomatology than heterosexual fathers when life satisfaction or posttraumatic growth values were low or medium. The findings were interpreted in light of the hardships associated with cross-border surrogacy and the psychological outcomes associated with succeeding to become fathers after contending with them. The study contributes to the limited literature on postnatal depressive symptomatology and posttraumatic growth among gay fathers through surrogacy and provides clinicians and policymakers with relevant information on the psychological strengths and potential difficulties associated with cross-border surrogacy among gay fathers.

Objective: To examine the psychological impact of gestational surrogacy on surrogates' families., Background: ASRM practice committee guidelines recommend that psychological counseling prior to surrogacy include consideration of a surrogate's own family, but there has been little research to help guide mental health professionals (MHPs) providing implications counseling., Methods: Fifty-nine family members from 16 surrogate families were recruited and data were collected on family relationships, child psychological well-being, and family experiences of surrogacy. Family members filled out a series of questionnaires based on their age and role in the family system., Results: Participants included 16 surrogates (28 surrogate pregnancies) with an average time since first surrogate pregnancy = 2.93 years (range = 0-8 years). Overall, families of surrogates are functioning well across a number of psychological domains. There were some differences between surrogates and spouses regarding their perceptions of their children's experience. A small number of children reported negative emotions about surrogacy and more research is needed to identify which children may be at risk. Children reported surrogacy having a positive impact on their lives and endorsed both pride and excitement about their mother being a surrogate., Conclusions: There has been limited data to inform MHPs tasked with implications counseling prior to surrogacy in offering guidance to surrogates' family members to help prepare them for the experience. This data can be used by MHPs providing implications counseling to help facilitate discussions about the potential impact of surrogacy tohelp ensure positive psychological outcomes for surrogates and their family members.

Gestational surrogacy in the United States has quadrupled since 1999, but to date, only a few states explicitly permit compensated gestational surrogacy. Current legal prohibitions are often influenced by outdated and stereotyped understandings of surrogacy. It is increasingly important to understand the current literature about the medical and mental health impacts of surrogacy and how state legislatures have addressed compensated gestational surrogacy in recent years. Based on this review, we found no evidence of substantial adverse medical or psychological outcomes among women who are gestational carriers or among the children they give birth to. The literature suggests that gestational surrogacy is a safe and increasingly popular option for families as long as rigorous screening and medical, psychological, and social supports are equitably provided. As states move to responsibly legalize and regulate gestational surrogacy, there is a continued need for further longitudinal studies on the health and psychological outcomes of gestational surrogacy., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Reproductive losses experienced by gestational surrogates, who do not share a genetic connection to the child they are carrying, may not be acknowledged or treated as compassionately as women who lose their "own" pregnancies. In-depth, semi-structured interviews were conducted with 17 gestational surrogates from diverse religious backgrounds. Grounded theory analysis of data included line-by-line coding, and emergent themes were identified. The results suggest that understanding and utilizing the religious/spiritual beliefs of a gestational surrogate may be one way for health professionals to provide implications counseling prior to surrogacy and also as a means to help process and grieve losses that may occur within surrogacy.

Background: Commercial surrogacy is a highly controversial issue that leads to heated debates in the feminist literature, especially when surrogacy takes place in developing countries and when it is performed by local women for wealthy international individuals. The objective of this article is to confront common assumptions with the narratives and experiences described by Indian surrogates themselves., Methods: This qualitative study included 33 surrogates interviewed in India (Mumbai, Chennai and New Delhi) who were at different stages of the surrogacy process. They were recruited through five clinics and agencies. This 2-year field study was conducted before the 2018 surrogacy law., Results: Surrogates met the criteria fixed by the national guidelines in terms of age and marital and family situation. The commitment to surrogacy had generally been decided with the husband. Its aim was above all to improve the socioeconomic condition of the family. Women described surrogacy as offering better conditions than their previous paid activity. They had clear views on the child and their work. However, they declared that they faced difficulties and social condemnation as surrogacy is associated with extra-marital relationships. They also described a medical process in which they had no autonomy although they did not express complaints. Overall, surrogates did not portray themselves as vulnerable women and victims, but rather as mothers and spouses taking control of their destiny., Conclusions: The reality of surrogacy in India embraces antagonistic features that we analyze in this paper as "paradoxes". First, while women have become surrogates in response to gender constraints as mothers and wives, yet in so doing they have gone against gender norms. Secondly, while surrogacy was socially perceived as dirty work undertaken in order to survive, surrogates used surrogacy as a means to upward mobility for themselves and their children. Finally, while surrogacy was organized to counteract accusations of exploitation, surrogates were under constant domination by the medical system and had no decision-making power in the surrogacy process. This echoes their daily life as women. Although the Indian legal framework has changed, surrogacy still challenges gender norms, particularly in other developing countries where the practice is emerging.

Identifying the process of making the decision to use a surrogate mother can create a broad knowledge of this concept. In this grounded theory study, participants were selected through snowball sampling method and obtaining an informed consent, in-depth interviews were conducted face to face and recorded. Then, all the interviews, field notes, and memos were analyzed using Strauss-Corbin 1998 method. Analysis of the statements of the participants boiled down to 487 initial codes, 311 codes, 14 subcategories, and six categories. In the conceptual model of this process, "the hope to have a child" was an influential concept that interacted with other concepts.

The goals of a gestational surrogacy relationship are to have a healthy baby for the intended parents while maintaining the medical and psychological well-being of the gestational carrier. A successful gestational surrogacy relationship will result also in good psychosocial outcomes for the gestational carrier, intended parents, and child. Finding a gestational carrier who will achieve these goals would be the ideal. This article focuses on key medical, reproductive, and ethical considerations to optimize clinical outcomes in gestational carrier cycles. Recommendations from available clinical guidelines regarding gestational surrogacy are reviewed, along with updates from current literature., (Copyright © 2020 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

The role of a mental health professional (MHP) in the psychological assessment of gestational carrier (GC) candidates has evolved over time, with clinical practices well established in the United States. Current ASRM guidelines recommend that all GC candidates undergo a psychosocial consultation and psychological testing (where deemed appropriate). Practice standards are relatively consistent among mental health disciplines, with assessments typically involving a clinical interview and the administration of a single, objective, self-report personality inventory. Although recent studies have established normative data for GCs, there has been little research into which assessment protocols are best suited to answer the referral questions of interest. Current challenges for MHPs placed in a gate-keeping role include providing a thorough screening using measures that typically yield defensive profiles that make them difficult to interpret. Research is emerging that suggests that using a multimethod approach in the psychological assessment of GCs may yield a more comprehensive psychological profile of GC candidates. This could allow MHPs to determine psychological appropriateness with more confidence and contribute additional data to be used in pre-surrogacy counseling. Assessing the psychological appropriateness of a woman to serve as a GC is a complex process, and there are a multitude of factors that must be considered, not the least of which are the psychological well-being of a potential GC, her partner, and her children throughout the process and beyond., (Copyright © 2020 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Gestational surrogacy can provide an effective family-building method for women whose uterus is absent or dysfunctional and with contraindications to pregnancy, single men, and same-sex male couples. Over the past 30 years, gestational surrogacy cases have represented a growing percentage of third-party reproduction cases, both in the United States and internationally. The following series of articles provides a summary of current topics in optimizing GS arrangements. They focus on medical and psychological screening; psychosocial adjustment of carriers, children, and their families; legal considerations with precedent-setting cases that every clinician should know; and an international overview of cross-border surrogacy., (Copyright © 2020 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Based on a critical interpretative review of existing qualitative research investigating accounts of 'lived experience' of surrogates and intended parents from a relational perspective, this article proposes a typology of surrogacy arrangements. The review is based on the analysis of 39 articles, which belong to a range of different disciplines (mostly sociology, social psychology, anthropology, ethnology, and gender studies). The number of interviews in each study range from as few as seven to over one hundred. Countries covered include Australia, Canada, Greece, India, Iran, Israel, Italy, Mexico, Norway, Russia, Sweden, UK, Ukraine, and the USA. Most studies focus only on surrogacy practices in one country (although often with intended parents from other countries), and some include several countries (e.g. interviewees from several countries or fieldwork in different field-sites). The proposed typology goes beyond the division between altruistic versus commercial, and traditional versus gestational surrogacy, in order to inform further research and to contribute to bioethical and policy debates on surrogacy in a transnational context. Four types of relations are identifiable: open, restricted, structured, and enmeshed. The criteria which influence these relationships are: the frequency and character of contact pre- and post-birth; expectations of both parties; the type of exchange involved in surrogacy arrangements; and cultural, legal, and economic contexts. The theoretical contribution of the article is to further the development of a relational justice approach to surrogacy.

Problem/background: Limited empirical data are available on the experiences of women who have been a gestational surrogate., Question: What are the experiences of gestational surrogates along the surrogacy pathway?, Methods: An anonymous study-specific cross-sectional survey was used to evaluate participants' experience of being a surrogate. A total of 184 Canadian women who were recruited from Canadian surrogacy agencies and the Internet completed the online survey; 9446 words were collected from 110 participants who entered comments to one or more questions. The qualitative data were analyzed through thematic analysis., Findings: Seven main themes, and eighteen interrelated sub-themes grouped under the pre-, during, and post-surrogacy stages were identified. Many surrogates viewed surrogacy as a positive experience and as something meaningful and impactful to other people's lives. Most surrogates had harmonious relationships with their intended parents and maintained on-going contact with the surrogacy family post birth., Discussion: Surrogacy involves deliberate efforts to establish a trustful surrogate-parent partnership through relationship building, boundary negotiation, and management of expectations. The compatibility between surrogate and intended parents, regarding aspects such as communication and pregnancy management styles, was an important contributing factor to a positive experience., Conclusion: Our findings provide a deeper understanding of participants' reasons for and motivation to be a surrogate, the relationship dynamics with their intended parents and the gestated fetus during surrogacy, and their satisfaction on personal and relationship levels post surrogacy. The findings would be useful to mental health professionals in preparing new surrogates for the potential challenges along the surrogacy pathway., (Copyright © 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Surrogacy raises a number of concerns about the psychological adjustment of the surrogate, the parents, and the child. Despite surrogacy becoming more common, research into the postdelivery psychological adjustment of the individuals involved has lagged far behind. This review examines research on the psychological adjustment of surrogates and their children. It then presents findings from studies assessing parents' psychological health and parent-child relationships, and children's adjustment within families formed through surrogacy. Finally, it examines how children born through surrogacy feel about their birth and toward their surrogate. Overall, studies have shown good psychological outcomes for surrogates, parents, and children, but research is still very limited, particularly in relation to the geographical location of the research, the ages of the children studied, and the lack of longitudinal projects. Different forms of surrogacy now exist under the umbrella term of "surrogacy." There is now greater diversity in terms of who is using surrogacy, their motivations for using it, whose gametes are used for the pregnancy, and how a surrogacy arrangement is managed. There is therefore a need for future studies to examine the consequences of these different forms of surrogacy on the postdelivery psychological health of surrogates, surrogacy parents, and their children., (Copyright © 2020 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

As gestational surrogacy (a process by which intended parents contract with a woman to carry a fetus that the intended parents will raise) increases across the United States, it is imperative that obstetrician/gynecologists understand the unique nuances of caring for patients who are gestational surrogates. Gestational surrogacy offers a route to parenthood for individuals and families who may otherwise have limited options. Understanding surrogacy requires multiple ethical considerations about the potential medical and psychosocial effects on gestational surrogates as well as the families built through surrogacy. There is a dearth of research on the subject, particularly in the United States and other countries that practice compensated surrogacy. Here we seek to review the process of gestational surrogacy in the United States, including the legal landscape, current trends in gestational surrogacy use, and what is known about the medical and social effects of this process on all participants. We also aim to highlight the limitations of available data and to identify topics for future research to provide optimal evidence-based and just care for these patients., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To characterize the sociodemographic and psychological profiles of participant groups involved in altruistic surrogacy in Australia., Design: Cross-sectional study., Setting: Single psychological practice in Sydney, Australia., Patient(s): Six hundred and two individuals involved in 160 altruistic surrogacy arrangements: 143 intended mothers, 175 intended fathers (including 17 same-sex intended father couples), 160 surrogates, and 124 surrogate partners., Intervention(s): None., Main Outcome Measure(s): Responses to a presurrogacy sociodemographic assessment counseling protocol and the Personality Assessment Inventory (PAI)., Result(s): The surrogates were primarily sisters, sisters-in-law, mothers (48.6%), or other extended family or friends (46.3%) of the intended parents. Most participants resided in residential postcode areas within the highest socioeconomic status quintile; however, intended mothers were more likely than surrogates to live in the most advantaged residential areas, to be younger and be more educated, and to be employed in professional occupations. Most participant psychological profiles were normal. A statistically significantly elevated PAI Somatic Complaints-Health Concerns subscale for intended mothers was observed compared with other participant groups. The higher PAI Warmth scale scores of intended mothers and surrogates were statistically significantly different from their respective partners, although not different from each other., Conclusion(s): Sociodemographic and some psychological differences between participant groups were observed that warrant exploration in pretreatment surrogacy counseling. Importantly, the higher scores on the PAI Warmth scale exhibited by intended mothers and surrogates in the context of close family and friendship relationships are likely to serve as protective mechanisms for the altruistic surrogacy outcome., (Copyright © 2019 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: In gestational surrogacy, a woman incubates an embryo to which she is not genetically related. Genetic distance from both her and the commissioning parents is increased further when donor gametes are employed. Ethical implications vary depending on the extent to which the parents and surrogates share genetic material with the produced child., Purpose: This paper seeks to address two primary questions: What do selected ethical frameworks tell us of (1) the relationship between genetic motherhood, gestational motherhood, social motherhood, and marital fidelity? And (2) the effects of gestational surrogacy and gamete donation on our understanding of lineage and heritability?, Methods: Current literature and thought on these questions were considered through the classical ethics lenses of religion, the adoption standard, and Western liberalism., Results: A genetic link between the parents and the child serves to simplify the adoption process (if one is required) and supports a family's desire to resemble as much as possible a traditional biological family, thus providing a minimum set of challenges to religious or conservative hesitations., Conclusion: Inasmuch as gestational surrogacy, with or without donor gametes, is tolerated in a variety of ethical contexts; the basis of its acceptance may be the Western liberal celebration of contractual agreement.

Background: This study investigated the surrogates' birth experiences, their levels of emotional struggle at relinquishment, how often they thought about the surrogacy children, and the surrogate-parent relationship dynamics during pregnancy and post-birth., Methods: Data were collected from 06/2016 to 02/2017 using an anonymous questionnaire. Participants were Canadian gestational surrogates who had completed the process with or without a successful live birth, and who were at various stages of an ongoing surrogacy. For this paper, only a subgroup of cases with a successful live birth was selected for analysis., Results: The data set included 131 births involving 90 surrogates who delivered 157 babies (105 singletons and 26 sets of twins). Their mean age at the time of surrogacy was 31.7 ± 5 years (range: 21-47y). More than one-third (37.4%) of the cases were for intended parents who were same-sex male couples and single men. Surrogates assisting Canadian-resident intended parents had an overall better birthing experience compared with those assisting nonresidents. There was none or very little struggle with the relinquishment of the baby in 96.9% of cases. Continued contact with parents after the births was reported in 93.0% of cases. Surrogates were significantly more likely to have frequent post-birth contact with same-sex and single fathers compared with heterosexual parents and single mothers (76.6% vs 54.3%)., Conclusions: Same-sex male couples and single men can develop a long-lasting relationship with their surrogates even when no intended female partners are involved. The development of institutional practice guidelines in standardizing surrogacy birth practice is paramount in optimizing surrogates' care., (© 2019 Wiley Periodicals, Inc.)

The rise of surrogacy in India over the last decade has helped individuals across the world to realize their parenting aspirations. In the macro-context of poverty in India and the hierarchical and patriarchal family set-up, concerns are expressed about coercion of women to participate in surrogacy. While the ethical issues engulfing surrogacy are widely discussed, not much is known about the role women play in the decision-making to participate in surrogacy. The paper aims to addresses this gap and is based on a part of a larger ethnographic study conducted at a surrogacy clinic in Anand, Gujarat, India. We explored experiences of forty-one surrogate mothers using in-depth interviews and analysed the narratives to identify women's own perceived role in the decision-making to participate in surrogacy. Narratives describing the decision-making process were identified and treated as a preliminary unit of analysis. We examined the use of singular and plural pronouns like "I," "me," and "mine" versus "we," "us," and "our," along with the use of active and passive voice to determine whether women assumed responsibility for the decision to participate in surrogacy or they attributed the decision to others. Findings unravelled the complexities of the decision-making process and indicated that eighty-five percent of the women played an active role in the decision-making to participate in surrogacy, albeit with new avenues of exploitation in the commercial market space and raised serious bioethical concerns.

This study aimed to evaluate the attitudes of male and female members of the public toward uterus transplantation (UTx), surrogacy, and adoption in Japan via a web-based survey. One thousand six hundred participants were recruited with equal segregation of age (20s, 30s, 40s, and 50s) and gender. We assessed the association between ethical view and gender, age, infertility, and the knowledge level of UTx, using a questionnaire. The findings were as follows. First, 36.5% and 31.0% of respondents agreed that UTx and gestational surrogacy should be approved, respectively. Second, the respondents would potentially choose to receive UTx (34.4%), gestational surrogacy (31.9%), and adoption (40.3%), if they or their partners experienced absolute uterine factor infertility. Third, 10.1%, 5.8%, and 14.3% of the respondents chose UTx, gestational surrogacy, and adoption as the most favorable option, respectively. Fourth, if their daughters suffered from absolute uterine factor infertility, 32.3% of female respondents might want to be donors, and 36.7% of male respondents might ask their wives to be donors. These data were affected by age, gender, infertility, or the knowledge level of UTx. UTx was a more acceptable option than gestational surrogacy and adoption. The effects of gender, age, infertility, and the level of knowledge of UTx are important in understanding the attitude toward UTx. On the other hand, there were concerns about the safety of UTx for recipients, donors, and babies. It is important to continue to understand public attitudes to inform the development and safety of UTx, which will enhance the discussion on the ethical consensus on UTx., Competing Interests: The authors have declared that no competing interests exist.

Research Question: The study undertook an evaluation of the retrospective experiences of gestational surrogates within a Canadian context., Design: Data were collected using an anonymous online survey from June 2016 to February 2017 with participants recruited from the Canadian surrogacy community and the internet. The characteristics of surrogacy arrangements carried out by the participants, factors influencing their surrogacy satisfaction, the impact of surrogacy on their family functioning, and their attitudes towards carrying a pregnancy for different types of intended parents were analysed., Results: A total of 184 gestational surrogates (mean age at surrogacy 32 years, range 21-48 years) who were involved in 287 arrangements completed a study-specific survey. More than three-quarters of these cases involved an agency (225 cases, 78.4%). Most of the intended parents were heterosexual couples (158, 55.1%), followed by same-sex male couples (113, 39.4%). More than one-third of these cases were for non-residents from 15 different countries (n = 108, 37.6%). The two main determinants of surrogates' satisfaction were being a surrogate for domestic intended parents (P < 0.05) and having a viable pregnancy outcome (P < 0.005). Nine out of ten participants were comfortable with carrying a pregnancy for same-sex male couples (93.4%) and cancer survivors (89.6%), yet less than one-third (30.7%) were comfortable with being a surrogate for heterosexual couples at advanced ages of over 50 years., Conclusions: The findings suggest that many intended parents, including same-sex male couples and non-residents, used Canadian surrogacy services to build their families. A better understanding of the fundamentals contributing to positive experiences would help clinicians develop better practice models to care for the well-being of surrogates., (Copyright © 2019 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: To study heterosexual and gay couples' relationship with their surrogate and their disclosure decisions when the surrogacy arrangement was completed domestically compared with internationally., Design: Cross-sectional study., Setting: Not applicable., Patient(s): Participants were 40 gay couples and 76 heterosexual couples who had domestic surrogacy in the United Kingdom (UK) (n = 38) or international surrogacy in the United States (n = 58) or Asia (20). Most (75%) of the children were aged <4 years., Intervention(s): Online surveys containing open-ended and multiple-choice questions., Main Outcome Measure(s): Experiences of finding a surrogate, relationship with the surrogate, and disclosure to the child were examined among UK parents who had undergone surrogacy in the UK, United States, or India/Thailand., Result(s): Parents who had surrogacy in the UK and United States felt very involved in the pregnancy compared with those who had surrogacy in Asia. Couples whose surrogacy was completed in Asia were less likely to want contact with their surrogate after the birth and were also less likely to have any current contact with the surrogate. Parents who had surrogacy in the UK and United States described positive relationships with their surrogate. Gay couples intended to tell their child about surrogacy more than heterosexual couples., Conclusion(s): The specific country where couples conducted their surrogacy arrangement (i.e. United States, UK, or Thailand/India) was associated with how involved they were in the pregnancy and their contact with the surrogate over time. Limitations of the study include use of survey methodology and that the representativeness of the sample is not known., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Drawing on a comparison of two ethnographic research projects on surrogacy in the United States and Israel, this paper explores surrogates' views about motherhood and parenthood, relationships and relatedness. The paper challenges three myths of surrogacy: that surrogates bond with the babies they carry for intended parents, that it is immoral not to acknowledge the surrogates' maternity, and that surrogacy upsets the moral order of society by dehumanizing and commodifying reproduction. Contrasting the similarities and differences in the voices of surrogates from these studies, the authors argue that surrogates draw on ideas about technology, genetics and intent in order to explain that they do not bond with the child because they are not its mother. This is followed by an exploration of surrogates' definitions of what constitutes parenthood, suggesting that in both contexts, surrogates draw clear boundaries between their own family and that of the intended parents. Finally, it is suggested that surrogates expect a relationship, or a bond, to develop with the intended parents and view their contribution as exceptional moral work which involves nurturing, caring, friendship and solidarity. The paper concludes that for surrogates in the USA and in Israel, maternity, bonding and kin-ties are not automatic outcomes of pregnancy, but a choice. Surrogates in both contexts hold that bonding with other people's children as if they were one's own is wrong while bonding with their couple and creating 'fictive kin' ties with them is the logical outcome of the intense and intimate process of collaborative baby-making.

The purpose of this qualitative study was to explore the experiences of commissioning parents (CPs) who travel abroad for surrogacy, paying attention to motivations, processes, and sources of social support. The authors recruited 10 CPs and used semistructured, in-depth interviews to illicit storytelling. Data analysis revealed primary themes around CPs' experiences pre-surrogacy, during surrogacy, and post-surrogacy. International surrogacy was described as a long and arduous journey only undertaken after multiple failed attempts at "natural" conception. Prior to traveling abroad, CPs engaged in trade-off decision making, weighing their reproductive assistance options. CPs were primarily motivated to undertake international surrogacy by health complications and legal restrictions in their home country. CPs emphasized strenuous relationships in both the destination country and at home, and they worried about disclosure to family, friends, and children. The mental health and social needs of CPs were neglected throughout and should be incorporated in future interventions to address stigmatization.

This article explores the way that surrogacy and normal pregnancy share cultural assumptions about pregnancy. Through a juxtaposition of our ethnographic studies of two groups of Jewish-Israeli women-women who have undergone "normal," low-risk pregnancies and women who have given birth as gestational surrogates-we argue that surrogacy and pregnancy emerge as potent metaphors for one another. Both pregnant women and surrogates divided their bodies into two separate realms: fetus and maternal pregnant body. Both trivialized the effect of gestational influence on fetal health, making the fetus seem detached from gestational capacities of the mother. We argue for closer scrutiny of the way local cultural priorities and experiences of pregnancy shape surrogacy and for bringing the scholarship on pregnancy and on surrogacy into deeper conversation., (© 2017 by the American Anthropological Association.)

Study Question: What are the perspectives of adolescents conceived using surrogacy, egg or sperm donation regarding their conception and the third party involved?, Summary Answer: The majority of adolescents described feeling indifferent about their conception, and yet simultaneously reported an interest in the third party involved, or were in contact with them., What Is Known Already: There is an assumption that children conceived through reproductive donation will feel negatively about their origins in adolescence. However, little is known about the views of adolescents who have been conceived through different types of reproductive donation., Study Design, Size, Duration: Forty-four adolescents, all of whom had been told about their conception in childhood, participated in a semi-structured interview as part of the sixth phase of a longitudinal, multi-method, multi-informant study of assisted reproduction families in the UK., Participants/materials, Setting, Methods: All adolescents were aged 14 years, had been conceived using surrogacy (n = 22), egg donation (n = 13) or sperm donation (n = 9) to heterosexual couples, and varied in terms of their information about, and contact with, the third party involved in their conception. Semi-structured interviews were conducted in participants' homes. Interviews were analysed qualitatively to determine adolescents' perceptions of their conception, and their thoughts and feelings about the surrogate or donor involved., Main Results and the Role of Chance: Adolescents were found to feel positive (n = 7), indifferent (n = 32) or ambivalent (n = 5) about their conception. Amongst adolescents not in contact with the surrogate or donor, most were interested (n = 16) in the surrogate or donor, and others were ambivalent (n = 4), or not interested (n = 6) in them. Adolescents in contact with the surrogate or donor expressed positive (n = 14), ambivalent (n = 1) or negative (n = 1) feelings about them., Limitations, Reasons for Caution: Of 56 adolescents invited to take part in the study, 47 consented to take part, giving a response rate of 84%. It was not possible to obtain information from adolescents who do not know about their conception., Wider Implications of the Findings: The findings contradict the assumption that children conceived through reproductive donation will feel negatively about their origins in adolescence and suggest that it may be helpful to draw a distinction between adolescents' feelings about their conception in general, and their feelings about the surrogate or donor in particular., Study Funding/competing Interest(s): This study was funded by the Wellcome Trust [097857/Z/11/Z]. The authors have no conflicts of interest to declare.

Spain's plummeting fertility since the late twentieth century may seem to reflect a waning desire for children. Nevertheless, reproductive disappointments resulting from gender inequalities cause many Spanish women to postpone motherhood and experience age-related fertility problems. For them, creating a family often becomes possible only through the reproductive labor of other women. Our analysis of transnational adoption, egg donation, and surrogacy in Spain shows how anonymity and altruism play out in these three strategies, with implications for the valuation of women's reproductive work and relationships among reproductive providers, intermediaries, recipients, and the resulting children.

Study Question: How do gay father families experience surrogacy in terms of their relationships with surrogates and egg donors, fathers' disclosure decisions and children's views on their surrogacy origins?, Summary Answer: More families had a relationship with the surrogate than the egg donor, and almost all had started to disclose to their children, the majority of whom expressed limited interest in their surrogacy conception., What Is Known Already: Gay fathers tend to report greater contact with the surrogate than the egg donor and to disclose only the use of a surrogate (omitting discussion of the egg donor and the respective fathers' genetic relatedness). Children's views on their surrogacy conception to gay fathers are not known., Study Design, Size, Duration: Thirty-one children and 80 fathers were interviewed as part of a larger in-depth investigation of 40 Italian gay father surrogacy families. Multiple strategies were used to recruit participants., Participants/materials, Setting, Methods: Children were aged 6-12 years and had been born to gay fathers through gestational surrogacy. Semi-structured interviews were conducted in participants' homes with each family member, separately. Fathers' interviews were presented from the perspective of the father who identified as being most involved with the child on a day-to-day basis. Qualitative content analysis was performed and quotations illustrating the findings were reported. Where appropriate, comparisons were conducted using χ2 or Fisher's exact tests., Main Results and the Role of Chance: A total of 31 children in 24 families were interviewed. Most families reported a harmonious relationship with the surrogate (n = 20, 57.1%) and a distant relationship with the donor (n = 10, 66.7%) (χ2(1) = 23.33, P < 0.001). Before the child was aged 4 years, almost all families (n = 34, 85%) had started to disclose their use of a surrogate, with 16 families (n = 16, 40%) also disclosing their use of a donated egg, and only 4 (10%) disclosing which father's sperm had been used. Of the 31 children interviewed, most (n = 17, 54.8%) showed a clear understanding of their conception. About 19 (61.3%) expressed limited interest in their conception, 11 (35.5%) felt positive and 1 child (3.2%) was unsure how he felt. Children differed in their feelings towards their surrogate and egg donor (Fisher's exact test, P = 0.002). Of the 31 children who were aware of the surrogate, the majority felt grateful towards her (n = 22, 71%), while of the 25 children who were also aware of the egg donation, 11 (44%) showed limited interest in their donor., Limitations, Reasons for Caution: The sample's convenience nature and the gay father families' high income limited the representativeness of the findings. Further, some children belonged to the same family, and this could have biased the results, as these children may have had similar experiences., Wider Implications of the Findings: Prior to this study, the voice of children conceived by gay fathers through surrogacy had not been heard. Future research on factors influencing children's desired contact with-or interest in-the surrogate and/or egg donor and their feelings when contact is not possible will be important in preparing families for such events., Study Funding/competing Interest(s): Support was obtained from a Sapienza Starting Grant for Research to the first author (grant number AR11715C77EB56B2). None of the authors has any conflict of interest., (© The Author 2017. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com)

Aim: Little knowledge is available about the experiences of the commissioning mothers during the process of surrogacy; thus, the present study was conducted in order to explore and analyze this process., Methods: This study was conducted in a referral institute in Tehran with a qualitative approach and using grounded theory methodology. The data were collected through 39 unstructured, in-depth interviews that were conducted with 15 gestational commissioning mothers, two of their husbands, four surrogates, and five of the personnel at centers for assisted reproduction (some participants were interviewed more than once). Sampling started purposively and then continued theoretically., Results: The analysis revealed the main concern of these mothers to be the feeling of "insecurity about becoming a mother" and their predominant strategy for dealing with it to be "seeking security about becoming a mother," which emerged as a core concept. The consequences of the mothers' adopted strategies and the effects of the intervening factors included "reaching a state of relative peace," "a continuing threat to one's identity," and "mental and physical exhaustion.", Conclusion: Identifying the demands of this group of mothers can help medical personnel, particularly nurses, adopt better plans for the future and to optimize the care they provide to these patients., (© 2017 Japan Academy of Nursing Science.)

Assistive reproductive technology has progressed significantly over the past few decades. In spite of the advances, people may still resort to a surrogate for bearing and birthing a baby. Surrogacy, though an altruistic act, has been commercialized in the past few years, leading to emergence of several ethico-legal concerns. Nurses care for the surrogates, the infants, and the intended parents through their journey with sensitivity, advocacy, compassion, and confidentiality. This article intends to explore the implications of surrogacy to individuals, families, nations, and health care.

Ethical and bioethical problems, which are typical of the practice of surrogate motherhood, refer to its protagonists: the couple that orders it, due to its demand to satisfy the desire of paternity and maternity and the promptness of having a female body to fulfill its aspirations; the expectant mother, and the physical and psychic repercussions coming from the role performed in the surrogacy contract, as well as the risks of manipulation and exploitation, related to her position; the baby and his right to grow counting on the certainty of his parental relationships and on the preservation of his emotional balance. The human and anthropological importance of these issues, along with the growing development of this practice in the world, has questioned our moral conscience. In this context, the expectant mother, the weakest and the most affected part among the parts involved in the surrogacy contract, demands a particular attention. In this sense, the aim of this work is to lead a phenomenological analysis of the different steps of the practice of surrogacy, from the first stage of collection and classification of the information referring to the candidates, to the stage of the insemination and of its consequences about to the private life of the expectant. On the other hand, this work tries to justify the existence of a parallelism, as for the exploitation of the female body, between the practice of surrogate motherhood and prostitution. Finally, the issue relating to the effective social emancipation of the surrogate women in poor countries, the real autonomy and the freedom of their decision, as well as the typical features of the desire of paternity of the ordering couple are dealt with. The carried out study has allowed to conclude that this practice always implies a degree of physical, psychic and moral exploitation of the expectant mother, which suggests its prohibition at global level.

The new reproductive technologies have significantly impacted definitions of motherhood. Historically, mothers were defined through the act of giving birth, but egg donation, embryo donation, and surrogacy disrupt this. Now multiple women can potentially claim maternity through gestational, genetic, legal, and social ties. Although there is some legal precedent for designating parentage, there is no simple solution to identify the 'true' mother. I address maternal claims-making in third party reproduction via a content analysis of US patient literature for infertile women. Major tensions arise over which link to privilege, especially regarding genetic versus gestational ties in egg donation versus surrogacy; however, adding embryo donation to the analysis illuminates another crucial dimension previously overlooked - that heterosexual women's maternal claims are supported by their partner's paternity claims. Ultimately, I argue that although reproductive organisational discourse carefully constructs credible options for maternal claims-making, contemporary reproductive medicine does not define maternity through assisted reproduction as a truly autonomous connection. Rather, maternity is highly contingent and thus potentially discreditable., (© 2017 Foundation for the Sociology of Health & Illness.)

The purpose of this research study was to conduct a content analysis of commercial surrogacy websites to explore how surrogacy is marketed to intended parents. The researchers developed a template to code website data, and a total of 345 website pages were reviewed. Websites depicted surrogacy as a solution to a problem, privileged genetic parenthood, ignored the potential for exploitation, dismissed surrogates' capacity to bond with the fetuses they carry, emphasized that surrogacy arrangements are mutually beneficial, ignored structural inequalities, and depicted surrogates as conforming to strict gender roles. These framings introduce vulnerabilities to both intended parents and surrogate mothers.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.