#Whatsitlike: The fascinating world of Surrogacy in South Africa

Karen Isaacs (49) is surrounded by children all day, every day. The mother of two runs a pre-school “Little Fingers Play School” in Johannesburg from her home. For the last 20 years she has also taught children how to swim. When Spotlight sat down with Isaacs at her school with the sounds of children playing a ball game outside, she first had to collect all the teachers’ cell phones. Phones are a distraction and not allowed. The children are the focus. She tells Spotlight it is mostly children of domestic workers working in the area that attends her school while their mothers are at work.

On the wall of her office is a mural of a mermaid in blue and next to it hangs a thick row of medals clumped together. Isaacs is a runner. The feel of childhood is imprinted everywhere from rainbow packs of stacked Post-It notes to small and colourful kid backpacks and lunch bags laying around.

Isaacs says it was thirteen years ago when she gave birth to a little girl that was not hers. Isaacs who was 37 at the time decided to be a surrogate for a couple who could not have children. More recently, in September last year she helped another couple through surrogacy. This time she gave birth to twins.

“I just decided that it was one of those things I could do to help these young ladies to have a family. My own pregnancies were very easy, so it was only my pleasure to help,” she explains. Isaacs says with her recent surrogacy experience, it touched her heart when she heard that the mother of the twins had thirteen miscarriages before she opted for surrogacy. “I just thought I was going to give someone a life.”
“But,” says Isaacs, “it is very important to make sure you know what you are doing. Don’t promise someone a baby and then you can’t give up the child. It’s different once you’re pregnant and you have to give it up,” she explains. “It was fine for me because I went into it knowing what I was doing – those babies were not mine.”

Her first time

Isaacs recalls how her first time as a surrogate mom came about 13 years ago. “I was teaching another lady’s triplets. She had her babies through surrogacy and asked me if I would be interested in it because legally I was a good candidate. I was a single mother then,” Isaac notes. “In the meanwhile, that has changed, you can do surrogacy as a married woman, you just need to get your spouse’s permission.” At the time her daughter was three and her son six years old.

Isaac says back then she was given a “substantial” amount of money to do it. “But 13 years ago the laws were very different and the couple paid me a deposit before I fell pregnant, then I got a monthly salary while I was pregnant and then I got a gift amount once the baby was born. It was legally done with different laws then.”

According to surrogacy lawyer Robynne Friedman, it is a criminal offence to be paid as a surrogate mother. “Our law only recognises altruistic surrogacy. Only small amounts are permitted to be reimbursed to the surrogate for expenses directly relating to the surrogacy journey and pregnancy.”

Friedman explains that the surrogate has to provide proof so, if she (the surrogate mom) purchases an item of maternity-wear, proof has to be submitted to the parents. “Normally what I do is I allocate a certain amount, a maximum amount per month in the surrogate motherhood agreement for maternity wear, no more than say R1 000 per month, no more than R300 – R500 for cellular airtime, about R1 000 for food. For loss of income, there is provisions made for that, maternity leave is two months after birth. She’s allowed an allocation of vitamins or the parents can purchase vitamins on her behalf.”

Meanwhile Isaacs recalls her second time as surrogate. She was approached four years ago. “One of my swimming moms asked me. She heard I’d done it before. I was already 47 years old when she asked me, and to be honest I felt that I was too old to do it.” Isaacs says she nevertheless went for the tests and was told she is fit enough. “Both my kids were fine with it this time around.”

According to Friedman age is a factor since the risks of pregnancy related health issues increase with age. “We try and utilise the assistance of surrogates between 23 and 42 years. If they are older the medical practitioners will need to perform thorough health checks such as referral to a specialist physician.”

Family matters

Isaacs says that the two surrogacy experiences were different. “With the first surrogacy, my daughter had to go for play therapy after the birth of the baby. She thought I would give her away too. She was young the first time.”

Back then it was also hard for Isaac’s parents to come to terms with it. “Today (surrogacy) is more accepted in society. My parents were very supportive with the twins.”

Her children are teenagers now and they gave their blessing. “With the twins’ pregnancy, both my children were old enough to understand. My daughter was old enough to hold me down, she held my hand when I was sick. Both came with me to doctor visits – they were amazing.”

Different pregnancies

According to Isaacs, the first surrogate parents bought the eggs, but with the second surrogacy the eggs were from the mother of the twins. “You are not allowed to use the surrogate’s eggs, so they (the first surrogate) bought eggs,” Isaacs explains.
She notes as a surrogate mom, you decide beforehand “if you want to take two eggs to be used to create the embryo because sometimes only one would take”.

“With my first pregnancy, I didn’t know I was pregnant until four months went by. With the second pregnancy I only realised I was pregnant at around three months. With the twins I was sick from the day they put the eggs into me. All my births were caesareans.”

Isaacs recalls the first ultrasound of the twins and their mother’s reaction. “Her reaction was amazing, she was very excited. She said ‘OMG they are there!’ Every single ultrasound was exciting for her (the mother).”

Isaacs says laws around surrogacy have changed. “Back in the day with the past laws, a surrogate had 62 days to give up the baby. The current law says parents of a baby born through a surrogacy arrangement, has the right to say what will happen to the baby the day the egg is inserted into the surrogate mom. “I agree with the current law. The baby was theirs from the beginning.”

During her pregnancy, she only saw the parents of the babies born through a surrogacy arrangement, at doctors’ visits, or if she needed something she would send them a WhatsApp message. “I contacted them once to ask for a pregnancy cushion because I had trouble sleeping. Within a few hours after I messaged them, the cushion arrived.”

The legal process

According to Isaacs, the legal process was not seamless. “We did a phone conference (with the twins’ parents), but I had to sign three books – it was very heavy legal documents.” She says with the first surrogacy, she went to see a lawyer, because the laws were different then.
Isaacs explains the legal process is done before the in vitro fertilisation (IVF) is done. “The legal process of the twins was different – the minute they inserted the eggs into the surrogate, the baby is not yours. Decisions made around the pregnancy is not up to you, it’s up to the parents of the babies through a surrogacy arrangement,” she explains.
“Whether or not you’re okay with that, you have to sign for it . So, it’s not for you to say the baby is deformed I want to give it up. It’s for the maternal parents to decide what they want to do. Thankfully the babies (twins) were hundred percent okay.”

On whether a possible miscarriage is also discussed, Isaacs says: “The doctor gives it to you on how many times he is going to allow you to try. I agreed to try three times. Everything is in the contract – if there’s a miscarriage – it’s all in the contract.”

Friedman explains after a surrogate volunteers her assistance she will undergo thorough medical and psychological and criminal screening checks. “The intended parents also undergo the same evaluations to confirm their suitability as parents or a parent.
“Once this is complete there is an in-depth legal process which must be followed. An application is brought to the High Court to confirm their surrogate motherhood agreement and supporting documents are provided to the court as evidence of full compliance with the Children’s Act. Only once the High Court confirms the agreement and a High Court order is issued, may the fertility specialists transfer the embryos into the uterus of the surrogate mother.”

On whether surrogates can donate their own egg, Friedman says they can, but it’s preferred they not do this. “Mainly we use donor eggs because there’s less risk. I don’t use a surrogate mother’s own eggs since she can change her mind and keep the baby.”

Medical view

A specialist in reproductive surgery and President of the Southern African Society of Reproductive Medicine and Gynaecological Endoscopy Dr Sulaiman Heylen, says there are no specific statistics on surrogacy because it is not common. “I would guess less than a 100 is done per year.”
Heylen notes from a medical point of view, “surrogacy is rare because there is not many indications for it but there is a lot of indications for egg donation”. “Most women,” he says “have a normal uterus, so they are healthy enough to carry a baby. You can make use of an egg donor or you can get any other form of help. It is rarely necessary to do surrogacy. We suggest surrogacy if there is a severe abnormality of the uterus,” Heylen explains.

The report South African Registry for Assisted Reproductive Technology 2015 provides a collection of data from 16 Assisted Reproductive Technology (ART) centres. ART is when medical procedures are performed which involve treatments like In Vitro Fertilisation (IVF), Intracytoplasmic sperm injection (ICSI) and Oocyte (egg) donation.

The 2015 report shows that a total of 5 681 aspirations were performed at the ART centres in the preceding year. Aspirations refer to the removal of eggs from the ovary before it is sent for fertilisation in the laboratory. From these aspirations, there were 4 255 fresh embryo transfers and 2 269 frozen embryo transfers. Embryo transfer is the last step of assisted reproduction, where embryos are placed into the uterus of a female with the intent to create a pregnancy.

The report also show that there were 2 193 pregnancies from the total procedures done involving the treatments IVF (Conventional IVF & ICSI) and Oocyte (egg) donation. There were 867 deliveries from the total treatments involving IVF (Conventional IVF & ICSI) and Oocyte (egg) donation. Deliveries refer to women giving birth, irrespective of whether they are live births or stillbirths.

The different treatments

In Vitro Fertilisation (IVF) and Intracytoplasmic Sperm Injection (ICSI) are the two most common fertility treatments.
For IVF and ICSI, the difference is how the sperm fertilises the egg. According to USC Fertility, in IVF, the egg and sperm (of which there are multiple) are left in a petri dish to fertilise on their own. In ICSI, one sperm is directly injected into the egg. ICSI will likely be better for you if you are affected by sperm-related infertility.

According to Medfem Fertility Clinic, in Oocyte (egg) donation, embryos are conceived using eggs obtained from a young egg donor (not the intended mom’s) and sperm from the intended dad’s (which is most commonly husband of the mom) genetic contribution. For a better success rate of fertility, the donor undergoes ovarian stimulation with injectable medications and multiple eggs are produced. Simultaneously, the intended mother’s uterus is prepared for implantation.

Getting eggs

In many surrogacies donor eggs are used. Tertia Albertyn, strategic director of Nurture, an egg donation agency, says egg donation has grown over the years as more prospective parents realise that this is a wonderful, successful way of having a family, and potential egg donors get to hear about the safe and very rewarding process of donating eggs to a couple or single (person) in need.
Albertyn says they have seen an increase in international fertility patients coming to South Africa for egg donation treatment. “South Africa has world class medical facilities, some of the best fertility specialists in the world, and a very favourable exchange rate.”

What does it cost?

According to Albertyn, costs vary from clinic to clinic. “In general, Cape Town is cheaper than Gauteng, and Pretoria is cheaper than Sandton. Total cost of an egg donor IVF is between R65 000 and R110 000. Total cost of using frozen donor eggs is between R67 000 and R90 000.”
She explains this treatment is not covered by medical aid. “Medical aids do pay for some diagnostic tests, but not for the IVF. Egg donor agencies don’t have payment plans unfortunately.”

So, what are the options for those who can’t afford the costs? In the public health sector three centres offering affordable fertility treatment operate from the Steve Biko Academic Hospital in Pretoria and the Tygerberg and Groote Schuur hospitals in Cape Town. According to TimesLive, these centres have managed to cut the costs of assisted reproductive treatment in South Africa by changing some of the treatment processes and in some cases lowering the doses of medication.

Laticia Pienaar, spokesperson at Tygerberg Hospital, said at the hospital’s fertility clinic they do offer all forms of assisted reproductive technologies (ART), including egg donation and surrogacy. According to Pienaar, Tygerberg Hospital’s Fertility Clinic provides fertility services for infertile individuals with an appropriate indication – confirmed cause – for their infertility.

“The clinic also offers all forms of assisted reproductive technologies (ART) such as IVF (In vitro fertilisation) and ICSI (Intracytoplasmic Sperm Injection). The average cost of IVF or ICSI at the clinic is approximately R12 000,” Pienaar says. “The patients buy their own hormonal stimulation medication, egg retrieval needles, the embryos culture and transfer media, and catheters. Our services are fundamentally developed to serve the state patients who have limited resources. Medical aids do not pay for fertility treatments in general.”

Reproductive freedom

Reproductive health rights are often associated with access to abortion services and contraceptives which are both means, as some studies show, by which to avoid procreation. Surrogacy flips this coin and places the focus on the other side of reproductive freedom – the choice of a person to procreate without sexual intercourse through the vast and growing forms of assistive reproductive technology. This is especially important for people with limited biological options to have children themselves and who choose to use another woman to carry their baby.

But surrogacy is still a curious and contested issue for many.

When people ask Isaacs why she would take on such a huge responsibility, she often tells people she doesn’t really know the answer but it feels right to do something if you’re in a position to help another.  “I tell them I don’t know what the answer is, I did it because I could do it. I was comfortable doing it but I don’t think every woman can do it,” she says. “I would do it again but not when I’m 50. I’m turning 50 this year. From an age perspective I wouldn’t want to do it again.”
And the children?
“The children are welcome to meet me, if they want in the future,” Isaacs says. “But they have to know that this was not an adoption, it was a surrogacy. I told the parents to make the kids understand this – that there’s a difference. They were always yours, they (the kids) need to understand the difference before meeting me.”
Isaacs advises that people who want to be surrogate moms should talk to someone who has been through it. “A lady approached me recently. I could tell her about my experience especially about my daughter who had to go for play therapy when she was younger,” says Isaacs. “I think it would be nice to have a support system, before and during the process for the surrogates to talk to people who have been through it.”

For more information:
If you are interested in fertility treatments you can make a booking at Tygerberg Hospital’s Fertility Clinic 021 938 5487 or alternatively send an email (preferably) to tygerberg.fc@gmail.com.
If you are in Johannesburg, you can contact the Steve Biko Academic Hospital’s Reproductive and Endocrine Unit at Zozo.Nene@up.ac.za or Krushmee.Singh@gauteng.gov.za or 012 354 2540/ 5337.