Ethics, Medicine and Public Health 27 (2023) 100880

Available online at

ScienceDirect
www.sciencedirect.com

REVIEW

A comparative study of surrogacy rights in

Iran and European countries, a review
article
F. Ghodrati ∗

Department of Islamic Jurisprudence and Law, Hazrat-e-Masoumeh University, Qom, Iran

Received 14 October 2022; accepted 27 February 2023

Available online 22 March 2023

KEYWORDS Summary
Comparative law; Background. — Surrogacy is a type of medically assisted reproduction (MAP) and is a solution to
European Countries; help infertile couples that requires legislation and detailed legal discussions. To comparatively
Infertility; investigate the surrogacy rights in Iran and European countries in a review article.
Iran; Methodology. — This review article was conducted from April to August 2021 to compara-
Surrogacy; tively investigate the rights of surrogacy in Iran and European countries. Studies published by
Surrogate Mother researchers between 1970-2021 were searched for in PubMed, Science Direct, Google scholar,
Magiran, SID, Iranmedex and other jurisprudential texts using the key words of ‘‘surrogacy, Iran,
European countries, and infertility’’.
Results. — This article analyzed the legal perspective and types of legislation in thirteen
European countries, twelve in the European Union (France, Germany, Italy, Spain, Greece,
Netherlands, Belgium, Denmark, Lithuania, Czech Republic and Portugal) and three out of it
(Britain, Ukraine and Russia). Among Islamic countries, pregnancy and commercial surrogacy
are carried out in Iran with the permission of Shia authorities, while no legal mechanism is
passed in the civil law.
Conclusion. — It is possible to support surrogate mothers when there are comprehensive laws
approved by the legislators and jurists. Also, the conditions and effects of these agreements
are clearly defined to guarantee women’s dignity and destiny and children’s rights and health
after birth.
© 2023 Elsevier Masson SAS. All rights reserved.

∗ Correspondence. Al-Ghadir Boulevard - in front of Yadegar Imam Stadium - Hazrat—e-Masoumeh University, Qom, Iran.
E-mail address: fatimaarta22@chmail.ir

https://doi.org/10.1016/j.jemep.2023.100880
2352-5525/© 2023 Elsevier Masson SAS. All rights reserved.
 F. Ghodrati
Introduction
Infertility as an individual and social problem affects the
couple’s life and family functioning, leading to mental
stress and various mental disorders in couples. Infertility
can affect work relationships and sexual skills of couples,
and as a serious medical problem, it can have devastating
effects on quality of life. Evidence shows that infertility is a
painful experience and causes anger, poor economic status,
divorce and general isolation, loss of social status, priva-
tion, despair, and violence [1—3]. According to the reports
of the World Health Organization, the highest rate of infer-
tility is in some regions of Central Africa, where it may reach
50%, while it is 20% in the Eastern Mediterranean region and
11% in developed countries [4]. Since the birth of a baby in
Iran has a great social, cultural and religious importance,
infertility seems to be a bigger problem and it raises the
need for more investigations in different provinces of the
country [5]. A meta-analysis study on the causes of infertil-
ity among patients referred to different infertility clinics in
Iran showed that 34% of infertility problems are caused by
male factors, 43.5% by female factors, 17% by both female
and male causes, and 1.8% has no specific cause [6]. Medi-
cally assisted reproduction (MAP) is deeply rooted in modern
society and is constantly growing. A wide range of methods
are available to help infertile couples, including in vitro fer-
tilization (IVF), assisted reproductive technology (ART), and
embryo transfer (ET) [7,8]. Surrogate uterus is one of the
new methods of fertility assistance and its use is an optional
solution to have a child, which has attracted the interest of
many infertile couples.
The contract revolves around three axes, the surrogate
mother carrying the pregnancy and the owner of the womb,
the infertile couple (Commissioning couple, legal parents)
and the Surrogate contract. It can be done in several differ-
ent ways.
• Host or full gestational surrogacy: the embryo of an
infertile couple is fertilized using in vitro fertilization
(IVF) and then transferred to a surrogate mother. In this
situation, there is no genetic and developmental depen-
dence through the egg or the surrogate mother (the egg
and sperm are taken from a registered couple).
• Partial gestational surrogacy: in this method, the sperm
belongs to the infertile couple, but the egg belongs to the
surrogate mother, and after fertilization in the laboratory,
the produced embryo is transferred to the womb of the
surrogate mother. In this situation, the surrogate mother
is called the biological/genetic mother. Gestational surro-
gacy can have several modes. The embryo is created using
the father’s sperm and the mother’s egg, or the father’s
sperm and a donor’s egg, or the mother’s egg and a donor’s
sperm. Sometimes a donor embryo is transferred to a sur-
rogate mother. Such embryos may be available when other
women are undergoing IVF and have leftover embryos to
donate to others. The born child is not genetically related
to the intended parents [9,10].
• Traditional surrogacy (also known as partial, natural or
direct surrogacy) is where the surrogate’s egg is fertilized
by the father’s or donor’s sperm. Alternative fertilization
can be through sexual intercourse (natural insemination)
or artificial insemination. Using donor sperm results in
a child that is not genetically related to the intended
2
parents. If the intended father’s sperm is used in insem-
ination, the resulting child is genetically related to the
intended father and the surrogate [11]. According to
jurisprudence, artificial insemination is either homol-
ogous or heterologous. Regarding the jurisprudential
examination of homologous artificial insemination (the
husband’s sperm is inseminated into his wife using assisted
reproduction techniques), some Shia jurists did not con-
sider this practice permissible [12], but the majority of
jurists consider it permissible. The reason for the per-
missibility of this type of fertilization is that the zygote
is made of the couple’s sperm and egg, only an unusual
method of fertilization [13—15]. Jurisprudential exam-
ination of heterologous artificial insemination (enough
sperm of another man is obtained through a permissi-
ble method and transferred to the woman’s uterus after
washing and discarding the excess) suggested that the use
of this method has few supporters (Ayatollah Khamenei
and Seyyed Mohammad Mousavi Bojnordi) [16] and many
opposers [17—20]. Traditional surrogate has a very long
history, it was done around 2000 years before Christ,
which is mentioned in the Holy Quran of Muslims and
the holy book of Christians where Sarah was the wife of
prophet Abraham and was sterile and unable to have chil-
dren. Hajar was a servant of Sarah who wanted to bear a
child for Abraham [21].
The types of surrogacies include commercial surrogacy
(or compensation contracts for agreed amounts of money),
humanitarian or altruistic (mostly friends and relatives), or
an unpaid contract. Surrogate pregnancy is currently the
subject of many disputes and even in some European coun-
tries its use has some legal prohibitions [22]. Many issues
regarding surrogacy remain unresolved, with considerable
disagreement within the medical profession, the medical
ethics community, state legislatures, courts, and the general
public. There are those who believe that surrogacy should
be allowed because it benefits all parties; that its prohi-
bition limits the independence of infertile couples. On the
other hand, there are those who instead believe that its
risks outweigh the benefits [23]. The supporters of surrogacy
mostly argue based on the freedom of contracts, protection
of children’s rights, and diversity of sexual freedom. The
opposers want to stop the exploitation of women and the
violation of the dignity of women and children. Supporters
of women’s rights criticize this method and consider it a
form of exploitation of women. Commercial surrogacy has
become a highly controversial issue that has led to heated
debates in the feminist literature, especially when surro-
gacy is performed in developing countries and when it is
performed by local women for wealthy international indi-
viduals. Statistics show that most women willing to do so
are in financial need (there are few cases where this is
done based on humanitarian motives) [24,25]. In Islamic
jurisprudence, there are also differences between Shia and
Sunni Islamic scholars in this field. The famous contem-
porary jurists of Imamiya, including Ayatollah Khamenei,
Ayatollah Makarem Shirazi, and Ayatollah Khoei, issued sim-
ilar rulings on the performance of surrogacy contracts and
they do not differ much. Only a few jurists, including Aya-
tollah Tabrizi and Ayatollah Fazel Lankarani, have ruled
against it. According to Sunni jurists, renting the uterus
 Ethics, Medicine and Public Health 27 (2023) 100880
of another woman is one of the western innovations and
is against moral standards. The Ahl al-Sunna Islamic Fiqh
Council has made it haram or prohibited [26]. According to
Sunni scholars, the Islamic Jurisprudence Assembly of the
Organization of the Islamic Cooperation in its sixth meet-
ing in 1410 AH, as well as the Assembly of International
Islamic Fiqh Academy in Mecca in 1404 AH, prohibited all
methods of artificial insemination with the intervention of a
third person, including surrogacy (without marriage with the
man). Therefore, Iranian Sunni scholars also do not consider
this method permissible [27]. Examining the current legal
situation regarding surrogacy, there is no codified legal reg-
ulation in many advanced democracies, which puts the rights
of future children and parents at risk. This study examined
the laws that currently exist in fourteen European coun-
tries in the EU (France, Germany, Italy, Spain, Greece, the
Netherlands, Belgium, Denmark, Lithuania, the Republic of
Czech Republic and Portugal) and out of it (UK, Ukraine and
Russia), and compared their legal frameworks with that of
Iran.
Method
This review article was conducted from April to August 1401
to investigate the comparative law of surrogacy in Iran and
European countries. In this review article, the studies pub-
lished by researchers from 1970 to 2021 in the databases
of Scopus, PubMed, Science Direct, Google scholar, Magi-
ran, SID, and Iranmedex, as well as other jurisprudential
texts were searched using the key words of ‘‘surrogacy,
Iran, and European countries’’. This review study examined
31 articles extracted from 49 articles about infertility and
surrogacy in Iran and European countries (Fig. 1). For data
collection, at first the articles that had one of the above
keywords alone or in combination in the title or text were
selected. Based on the inclusion criteria, abstracts of the
articles published in Persian and English were studied. After
excluding articles that did not meet the inclusion criteria,
the full text of all eligible articles was studied. Then, their
results were extracted according to the investigated factor
and provided to another researcher to review and correct.
Overall, out of 46 articles, 31 articles were selected and
reviewed.
Findings
It is obvious that surrogacy has made a lot of progress com-
pared to before the end of the 20th century and today it
is progressing rapidly with a combination of different meth-
ods. The various types of surrogacies available also help to
complete the family and parents who intend to have chil-
dren. More codified laws are being developed for surrogate
women who change the lives of others forever. The legality
of surrogacy varies around the world. Many countries do not
have laws that specifically address surrogacy. Some coun-
tries ban surrogacy entirely, while others ban commercial
surrogacy but allow reproductive surrogacy (where the sur-
rogate is not financially compensated). Some countries allow
commercial surrogacy with few restrictions. Some jurisdic-
tions have extended the ban on surrogacy to international
surrogacy.
3
The first group: legality of surrogacy in all its
forms (gestational, commercial and
international surrogacies) according to the
conditions of each country
The countries in this group are Russia, Ukraine, Greece, UK
and Iran.
Russia
The first surrogacy program in Russia was successfully
implemented in 1995 in one of the country’s IVF centers.
Gestational and commercial surrogacy are legal in Russia
and available to all adults who wish to become parents and
have medical problems or repeated IVF failure despite high-
quality embryos [28]. Even on August 5, 2009, a court in St.
Petersburg registered a single mother as the mother of her
surrogate son. Also, on August 4, 2010, the Moscow court
allowed a single man who applied for surrogacy (using a
donated egg) to be registered as the only parent of his son,
the name of the surrogate mother was not mentioned in
the birth certificate. The father was listed as the only par-
ent [29]. On March 19, 2021, a draft law was presented that
would restrict the surrogacy industry with a special emphasis
on outlawing their use by foreigners and same-sex couples.
Due to relatively low cost of surrogacy procedure, Russian
surrogacy is in high demand worldwide. According to the
Economist, ‘‘nine months of pregnancy plus delivery can be
bought for about $20,000’’ [30]. Liberal laws make the coun-
try attractive to ‘‘reproductive tourists’’ who seek surrogacy
techniques not available in their home countries. Of course,
there is always the concern that the surrogate may keep the
baby, but there are some countries (e.g. Armenia, Belarus,
Kazakhstan, Kyrgyzstan, Ukraine, and Russia) in which there
is no such problem anymore, because surrogate’s consent is
not necessary to register the parents in the baby’s file. If
the birth takes place in a surrogacy program in Russia, the
ordering parents will receive a Russian birth certificate with
both parents’ names, as if the intended mother had given
birth herself. The surrogate mother’s name is never men-
tioned. The genetic relationship to the child (if donated)
is not important, there is no requirement that the child be
genetically related to at least one of the ordering parents.
No adoption required. To transfer a child to their country,
the intended parents need to know whether their country
has signed the Hague Convention of October 5, 1961 or not.
Therefore, it is necessary to consult with a lawyer special-
izing in reproductive and family law so that parents do not
have any problems in obtaining national documents for their
children at the consulate [31].
Ukraine
Surrogacy in Ukraine is legal in all its forms. Surrogacy is
officially regulated by Article 123 of the Law. The order
of the Ministry of Health of Ukraine regarding ‘‘Request
for Assisted Reproductive Technologies in Ukraine’’ was
approved on September 9, 2013 with number 787 [32].
Ukraine is fast becoming a ‘‘promised land’’ of commercial
surrogacy, while other countries have banned or severely
restricted the practice. Ukrainian law allows the intended
parents to carry out the surrogacy program and their names
 F. Ghodrati
Figure 1. Process of literature review Surrogate uterus.
are registered on the birth certificate from the very begin-
ning. The child is considered legally ‘‘belonging’’ to the
future parents from the moment of conception. The sur-
rogate’s name is never mentioned in the birth certificate,
and the surrogate cannot keep the child after the birth,
even if there is a donation program and no biological rela-
tionship between the child and the intended mother, their
name will be in the birth certificate (paragraph 3, Article
123 of the Family Law of Ukraine). Ukraine has the freest
law in Europe and many foreigners turn to Ukraine to use
surrogacy because of prohibitions in their domestic laws,
but subsequently some face legal problems when crossing
the border with the baby. In addition, there are several dif-
ficulties in obtaining citizenship for a child in the country
of his parents, and it may lead to the initiation of crimi-
nal proceedings in Ukraine and other countries. Therefore,
the existing legal basis in Ukraine is not sufficient in this
regard, and mainly due to the lack of unified rules on inter-
national legal relations, it may create problems for genetic
parents.
4
The optimal way is for all countries to accept that ART
technology is a treatment method. European countries, in
cases where surrogate mother is prohibited, should freely
recognize the rights of the parents of people who use the
surrogate mother method in other countries and the rights
of their babies to obtain the citizenship of their parents [33].
Republic of Greece
Surrogacy was legalized in the Hellenic Republic in 2002
and is regulated by the Greek Civil Code and the Assisted
Reproductive Law. Under Law 3305-2005 (‘‘Medical assisted
reproduction’’), surrogacy is legal in Greece, and it is one
of the few countries in the world that provides legal pro-
tection to the intended parents. In 2014, foreigners also
gained the right to use surrogacy in Athens and other Greek
cities. There is a law for heterosexual or unmarried parents
who must prove their inability to get pregnant medically
and not be more than 50 years old. The surrogate mother
must also be tested for medical and psychological fitness.
 Ethics, Medicine and Public Health 27 (2023) 100880
Greek laws have created conditions for using a surrogate:
(i) Relatives and friends of genetic parents cannot donate
eggs/sperm; (ii) Parents do not have the opportunity to
choose the sex of the embryo; (iii) The law prohibits discard-
ing unused embryos. They are stored for a certain period,
after which they are used for research purposes or trans-
ferred to patients who need them; (iv) Also, for the legal
surrogacy, permission from the court is required, confirm-
ing that the person or the couple requesting can have the
child. On the contrary, in UK, the permission of the court
is required to provide the conditions before the operation
of surrogacy, and the agreement of the parties is impor-
tant, and the delivery of the baby to the applicant after
birth is with the permission of the court [34]. Greece intro-
duced laws 3089/2002 and 3305/2005 within just two years
and regulated the issues related to medically assisted repro-
duction. The first law, 3089/2002, resolved the fundamental
questions about ‘‘medically assisted procreation’’ and reg-
ulated the resulting consequences for the institutions of
kinship and inheritance. The second law 3305/2005 pro-
vided solutions for the issues related to the preconditions for
the use of medical assisted reproductive methods, insurance
coverage, and the establishment and operation of medically
assisted fertility clinics and cryopreservation banks. Finally,
Law 3305/2005 not only provides for the establishment of an
independent national administrative authority with jurisdic-
tion over biological law, but also provides for criminal and
administrative penalties in case of violation of its provisions
[35,36].
United Kingdom
The foundation of the current surrogacy law in the UK was
laid in 1985, then completed and implemented by the Fer-
tility and Embryology Act 1990 and 2008 [23,37]. In October
2019, the Law Commission of England and Wales and the
Law Commission of Scotland set up an independent body to
review the surrogacy and pregnancy laws. Then, discussed
the final review report and their proposals in a bill to be con-
sidered in the parliament in 2021 [38]. Altruistic surrogacy is
legal in the UK. However, commercial surrogacy (according
to Article 2 of the 1985 law) has been banned. But with the
amendment of the law in 2008, non-profit and private cen-
ters were allowed to advertise surrogacy at a reasonable
cost. Carrying out surrogate operation with the mother’s
or carrier’s or non-parent’s egg is completely allowed, and
health regulations must be followed before the operation,
and a court order is required to transfer the baby to the
applicant parents. Individual applicants, subject to condi-
tions, including genetic relationship with the child, singles
and most homosexuals seeking parenthood, provided they
are resident in the UK, can also use it [38]. The surrogate
mother cannot receive any fees other than compensation for
expenses incurred during pregnancy. According to Article 1A
of the 1990 Law, ‘‘the surrogacy agreement is not valid for or
against any of the parties. This means that if the surrogate
mother does not deliver the baby to the couple according
to the agreement or the couple does not pay the agreed
fee, none can seek legal action in this regard. Surrogate
pregnancy is performed under the above conditions, while
commercial surrogacy is prohibited. The law allows surro-
gates to provide services on a non-profit basis. The child’s
5
biological parents only pay the ongoing expenses of the sur-
rogate mother, which is estimated at approximately $50,000
including prescriptions. There are no restrictions for UK citi-
zens. Couples in any family status including legal marriage or
partnership can participate in the fertility program using a
surrogate. The only strict requirement is British citizenship.
Foreigners cannot benefit from private surrogacy in the UK
[37,39]. A surrogate mother has the legal right to keep the
child for herself after birth, even if they are not genetically
related. Unless a parental order or an adoption order has
been issued to the parents, otherwise the surrogate mother
remains the legal mother of the child [40]. This is because
under section 33 of the Human Fertilization and Embryology
Act 2008 (HFEA 2008), a ‘mother’ refers to a woman who
has carried a child. Furthermore, if the surrogate is married,
under section 42 of the HFEA 2008, their partner becomes
the other legal parent, unless it is proven that he did not
consent to the insemination of his wife’s surrogate [41].
Iran
Surrogacy (pregnancy, commercial, and altruistic) is legal
and common in Iran, and the agreed money that the
surrogate mother receives has been allowed by religious
authorities, and many couples from the Middle East use sur-
rogacy in Iran because of legal ease [42,43].
Of course, there is no specific law regarding surrogacy
in Iran, but in 2003, a law regarding embryo donation was
approved in the Islamic Council of Iran, and it was confirmed
by the Guardian Council in 2003 which can be used for sur-
rogacy, too. Regarding surrogacy contracts, they are made
based on Articles 10 and 512 of the Civil Code, in the form of
a lease contract or otherwise stipulating that private con-
tracts for those who have concluded them, in case of no
explicit opposition to the law, are viable and enforceable.
Currently, there are about 70 infertility clinics across the
country that perform surrogacy. Meanwhile, two infertility
research and treatment centers in Tehran are among the
centers that, in addition to IVF embryo implantation of cou-
ples to surrogate mothers, provide other services including
legal advice and medical and psychological screening for
surrogates. Out of every 100 applicants introduced to the
center, 10 to 15 people are rejected after the examination.
Annually, about 2000 babies are born in Tehran alone through
surrogacy. The only treatment method that is not used in this
center is sperm donation, which has special conditions. In
addition, this center has an international department, which
does not prohibit providing infertility services to foreign
couples. Iranian nationals abroad can also have surrogacy
contracts in this country [43].
)There is a difference of opinion among religious scholars
regarding the use of donated sperm. Some (e.g. Ayatollah
Khamenei) consider it permissible to use sperm donated
by a man other than a woman’s husband for fertility, but
most scholars do not consider it permissible. It is obvious
that in jurisprudence the woman’s husband will not be the
father of the baby. According to Islamic jurisprudence, the
legal father of the child (sperm donor) is responsible for
all father’s duties such as providing expenses, caring, edu-
cation, and love for the child and should not fail to fulfill
these duties. Therefore, people should act according to the
fatwa of their Marja’(.
 F. Ghodrati
The second group: the legality of altruistic
surrogacy, but ban of commercial and
international surrogacy (taking into account
the conditions in each country)
Countries such as the Netherlands, Belgium, Denmark, Czech
Republic are in this group.
Netherlands
Altruistic surrogacy is legal in this country, while commer-
cial surrogacy is prohibited. However, few hospitals provide
related services. Services in the country are carried out with
strict rules and couples travel abroad to seek surrogacy [44].
Belgium
No official law explicitly prohibits altruistic surrogacy,
although it is also hard to access it. Commercial surrogacy
is illegal. There is currently no targeted law [45].
Denmark
In 2007, the ‘‘New Artificial Insemination Law’’ was passed,
allowing funding of IVF programs for everyone, regardless
of orientation and marital status. Despite the liberaliza-
tion of laws in the field of reproductive technologies, the
commercial format of surrogacy is prohibited in Denmark. A
surrogate mother is only allowed if the surrogate mother is
willing to give her child to a childless couple without finan-
cial compensation. Only a few people can decide to take
this step. Because of this, it is almost impossible to find a
surrogate mother in Denmark, so Danes often go to the US,
Mexico or Ukraine in search of a surrogate mother. When
altruistic surrogacy is performed and assisted reproductive
techniques are not used, the surrogate mother must use her
eggs (traditional surrogacy) [46,47].
Czech Republic
Currently, there is no law. Surrogacy in its altruistic form
is considered legal. Commercial surrogacy is considered
a crime. But the practice is reported to be on the rise,
although legal experts warn that any contract or agreement
in this regard is unenforceable [48].
The third group: includes countries where any
surrogacy practices that are commercial or
altruistic are illegal
It includes countries such as France, Germany, Spain, Italy,
Portugal, Lithuania and Ireland.
France
The first decision on surrogacy is the famous Alma Mater
ruling on December 13, 1989, which invalidated potential
surrogate mothers, as well as the process of surrogacy. Sur-
rogacy was banned again by the Bioethics Act of 1994. By
adding Article 7-16 to the Civil Law (Law No. 653-94), ends
the surrogate mother problem and confirms the existing
judicial procedure [49]. ‘‘Any agreement related to repro-
duction or pregnancy on behalf of another person is null and
6
void’’. The surrogacy raises many ethical questions, espe-
cially regarding the commodification of the human body.
Since 1994, any commercial or altruistic surrogacy practices
have been illegal. Agreements related to reproduction or
pregnancy by third parties are a criminal offense (accord-
ing to Article 227-12) [50]. Articles 227-12 and 227-13 of the
Penal Code punish various types of surrogacies with penalties
ranging from 6 months in prison and a fine of 7,500 Euros to
6 years in prison and a fine of 45,000 Euros. However, these
provisions do not apply when surrogacy is performed abroad
in a country that allows this procedure [51].
Due to the legal prohibition in France, the majority of
French children born from surrogacy are the result of cross-
border practices. Currently, the most important problem is
protecting children born to French parents abroad through
surrogacy after the family returns to their own country [52].
Germany
All surrogacy practices (both commercial and altruistic)
are illegal. In 1991, the Fetus Protection Act was passed,
severely restricting reproductive medicine in Germany. This
law prohibits any medical procedures on German soil that
involve illegal actions with the life of newborn human
beings. According to German civil law, the legal mother is
always the woman who gave birth to the child. IVF is allowed
in Germany, but only with the applicant’s own eggs. Such
restrictions in the field of reproductive medicine force Ger-
mans to turn to neighboring countries to solve infertility
problems, where surrogacy and egg donation are allowed
[53,54].
Spain
According to the law approved on May 26, 2006, all sur-
rogacy contracts are void and illegal. Strong debates have
been raised about the ethical and legal aspects of surrogacy.
There is a common concern about the risks of exploita-
tion of women in relation to commercial surrogacy. At the
same time, it is possible for people who are unable to con-
ceive to have permission for altruistic surrogacy to become
fathers/mothers. To defend this proposal, they drew an
analogy between altruistic organ donation and altruistic
surrogacy in a way that a couple can gain the ability to con-
ceive. Other authors commented that, first, there is no real
analogy between organ donation and altruistic surrogacy.
Second, if we think seriously about possible regulations for
altruistic surrogacy, we will find many problems with difficult
or impossible solutions [55].
Italy
Thirteen years after the adoption of Law No. 40, on February
19, 2004, several judgments were issued by the European
Court of Human Rights (ECHR), the Italian Constitutional
Court, as well as by local courts. Any sale of gametes or
embryos, as well as surrogacy, is prohibited, and in case of
action, it is accompanied by a prison sentence of between
three months and two years. This ban has been confirmed
by the ruling of the Italian Constitutional Court (No. 272
of 2017), which states that ‘‘the practice of surrogacy
unbearably violates the dignity of women and profoundly
undermines human relations’’. However, surrogacy is still
 Ethics, Medicine and Public Health 27 (2023) 100880
illegal in France, Spain, and Germany [56,57]. Even in Italy,
Law n. 40 has imposed several restrictions that are stricter
than other European countries [58]. Besides, Zaami et al.
(2022) stated that when residents of countries where sur-
rogacy is prohibited travel abroad and hire a surrogate,
significant legal barriers may also arise. Because some coun-
tries recognize the surrogate as the legal parent, others
attribute the parentage to the ordering parent. This contra-
diction can lead to ‘‘conflict of laws’’ and probably family
and citizenship problems will occur for children [59]. On the
other hand, in Italy, homosexual couples travel abroad to
access surrogacy, in order to have a child. Due to the lack
of genetic connection with the children, the joint sessions
of the Italian Supreme Court have ruled that such children
cannot be legally registered in Italy, because the birth cer-
tificate issued abroad does not show any genetic connection
between the children and homosexual couples [60].
Portugal
Since 2006 (Law No. 32/2006), surrogacy, in any of its forms,
has been prohibited in Portuguese law and even criminalized
in some cases. However, as of August 22, 2016, surrogacy was
allowed under certain restrictive conditions, provided that
several regulations were met prior to surrogacy. Finally, on
August 1, 2017, the regulations entered into force. The Por-
tuguese law on surrogacy does not provide any regulation on
the content of the surrogacy contract. However, the clauses
in the surrogacy contract are subject to judicial review to
prevent abuse, and the law is still required to establish some
basic rules and restrictions for the parties to comply with.
Otherwise, it is likely that one side will end up dominat-
ing the other [61,62]. Currently, the authors believe that
the interpretation of this law of surrogacy is very uncer-
tain. Although the legal agreement represents an important
attempt to exercise the right of families who could not have
children on their own [63].
Lithuania
Surrogacy is illegal in Lithuania and any agreement will be
unenforceable. The Republic of Lithuania (September 14,
2016, No. XII-2608) declared all surrogacy contracts null and
void. In addition, the Lithuanian Parliament (Simas) recently
issued a resolution condemning surrogacy [64].
Ireland
Surrogacy is relatively new and largely illegal in Ireland
[65]. However, on March 10, 2022, he published an impor-
tant bill on human health and assisted reproduction. In
this bill, important measures are proposed in surrogacy.
Among them, 1. Create a specific legal framework for
the provision of Assisted Human Reproduction (AHR) treat-
ment and related research; 2. Authorize the establishment
of the Assisted Human Reproduction Regulatory Authority
(AHRRA); 3. Establish criteria for the provision of AHR treat-
ments including assisted human reproduction after Death
and genetic diagnosis before implantation; 4. Conditions for
allowing surrogacy in Ireland; 5. Any child born through sur-
rogacy must be genetically related to at least one parent;
6. According to this bill, any surrogacy contract It must also
be non-commercial (altruistic) and pre-approved by AHRRA
7
[66]. Gracias believes Irish surrogacy exists in a legal vacuum
and is governed by weak statutory regulations. However, Ire-
land is free to draft laws in line with modern societal views
on reproduction. Altruistic arrangements can be a boon to
Irish society if mothers and children are supported by pub-
lic education and appropriate legal frameworks [65]. On the
other hand, although the Medical Council of Ireland does
not approve surrogacy in its current practice guidelines, and
there is currently no specific law regarding surrogacy in Ire-
land. But a contract-based model for surrogacy has been
developed to adjudicate any potential disputes arising from
surrogacy arrangements [67].
Discussion
Surrogacy creates a complex and extensive reproductive
unit - the ‘‘surrogacy triad’’ consisting of the surrogate
mother, the child, and the intended parents. These compo-
nents are linked by reliable mutual obligations. Among the
countries under review, Ukraine, Russia, and Greece have
the most liberal laws in the world, which legally allowed
commercial, altruistic surrogacy, including for foreigners.
Some jurisdictions specifically prohibit only commercial, not
altruistic, surrogacy. If a surrogacy contract is prohibited or
invalid in a country, in cases that one of the parties to the
contract changes their mind, there will be no recourse. That
is, if the surrogate changes her mind and decides to keep the
child, the intended mother has no claim to the child, even
if it is her genetic child. Also, the couple cannot get back
any money they may have paid to the surrogate. If the par-
ents change their mind and ultimately do not want the child,
the surrogate cannot receive money to compensate for the
expenses or the promise of payment, and the legal custody
of the child is given to the surrogate’s mother. Although both
types of surrogacy arrangements are currently carried out
in the UK, there is also this notion, that because genetic
surrogacy has the potential to be more psychologically com-
plex, it appears that genetic surrogates are more likely to
change their minds about giving up the baby to the intended
parents [68,69]. However, surrogates have been reported in
Britain mainly tend to help childless couples with altruistic
motivations [70,71].
In Iran, commercial surrogacy is done according to the
permission of legal and religious authorities, but due to
the lack of codified law and lack of adequate and accurate
monitoring and supervision of the performance of medical
centers, it has caused problems and many lawsuits have
been filed in recent years. The surrogate mother in Iran
only has the role of growing and developing the fetus, and
after giving birth, all the rights and custody of the child are
of the applying parents. This issue has been happening in
Iranian law for more than a decade and is generally done
under the supervision of specialized infertility clinics, by
concluding a contract between the applicant or candidate
for surrogacy and the couples who want a child. Unfortu-
nately, this fertility method in Iran has problems such as the
uncertain financial cost of the surrogate mother, which is
due to the lack of accurate and efficient monitoring. After
the birth of the baby, the relationship between the parties
ends and the surrogate mother does not have the right to
take care of the baby. No claim will be heard after the birth
 F. Ghodrati
of the child. The noteworthy point is that this contract is one
of the permissible contracts and none of the parties have
the right to cancel or not fulfill their obligations. Accord-
ing to the jurisprudence rule in Iran, a formal contract is
necessary because any claim for the fetus by the surro-
gate mother will be rejected. Also, Iranian Civil Registration
Office will issue the birth certificate of the baby if the offi-
cial contract of surrogacy has already been registered that
office.
One of the advantages of surrogacy is that it helps a cou-
ple to solve the problem of not having children and have a
better quality of life. However, most of the countries that
have a legal prohibition consider drawbacks for this method,
including the fact that medical ethics and commercial meth-
ods are considered contrary to the surrogate mother’s rights,
because in addition to her body, her emotions and feelings
may be involved in the pregnancy, willingly or unwillingly.
they consider that these conditions cannot be traded with
money and it is an instrumental use of women, and they
reject the commercial model of surrogacy [72]. However,
cases of psycho-emotional problems have been observed,
especially immediately after the delivery of the baby to the
applicant couple, although in most cases these problems
were not acute, it is important to pay attention to them
[70,73]. Some researchers believe that surrogate women are
exposed to high risk if surrogacy is done for money, espe-
cially if the financial and educational levels of the parties
are at different levels [74]. The issue may even go further,
some women do not give in to pregnancy due to busy work or
fear of pregnancy complications, and the sanctity of preg-
nancy is reduced and the child is commodified [75]. In case
of appropriate raise of social awareness by planners with the
motive of helping a couple, who cannot have children, sur-
rogacy like other charitable actions (organ donation) will be
a valuable and humane action, moving from a commercial
to an altruistic practice [76].
Conclusion
From a social point of view, the complete ban on commer-
cial surrogacy is not a good solution, and it usually backfires
and worsens the situation. In this sense, it is necessary that
the consequences of banning commercial and international
surrogacy be re-examined by legislators and jurists. Espe-
cially in many countries and Iran, the lack of law causes an
increase in chaos and underground actions, and the occur-
rence of disputes causes the parties’ claims to be referred
to judicial centers. Ethics committees should also make
sure that the payment fee is not more than the health
and treatment and disability expenses of surrogate women,
and with these conditions, the communication between the
parties will move towards humanitarian communication.
Therefore, the final goal, which is guaranteeing dignity and
honesty, determining the fate of women at every stage
of the surrogacy process, and the rights and health of
children afterward, is better provided. Although even the
researchers stated that if surrogacy is done for altruistic
reasons and feeling of value, many psychological and social
challenges must be considered and it needs more investiga-
tions and studies in different societies.
8
Human and animal rights
The authors declare that the work described has not involved
experimentation on humans or animals.
Informed consent and patient details
The authors declare that the work described does not involve
patients or volunteers.
Funding
This work did not receive any grant from funding agencies
in the public, commercial, or not-for-profit sectors.
Author contributions
All authors attest that they meet the current International
Committee of Medical Journal Editors (ICMJE) criteria for
Authorship.
Acknowledgement
I would like to thank Dr. Zahra Yazdanpanahi who specializes
in reproductive health in Iran, for her guidance in writing
the article. Likewise, from all the authors who published
articles, a comparison platform was provided for the author.
Disclosure of interest
The author declares that she has no competing interest.
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