General

In surrogacy, money held in a bonded trust or escrow account ensures security by a neutral third party (not the agency), preventing misuse and guaranteeing funds for the surrogate’s expenses and compensation per contract, with legal requirements in many states mandating this structure for ethical and legal protection, offering transparency and preventing conflicts of interest. 

Why It’s Required & How It Works

1. Legal Mandate: States like California (Family Code § 7961) require funds to be held in a secured account not held by the surrogacy agency.
2. Neutral Third Party: An independent escrow company or attorney holds funds, distributing payments as the contract dictates (for medical bills, compensation, etc.).
3. Protection: This protects intended parents by ensuring funds are available and protects surrogates by guaranteeing payment, preventing agencies from mismanaging large sums.

Key Benefits

• Security: Funds are safe from mismanagement or agency failure.
• Transparency: Clear, contract-based disbursements.
• Reduced Conflict: A neutral manager removes financial stress between IPs and surrogates. 

What to Look For

• Independent Provider: Choose an escrow service or attorney not owned by the agency.
• Strong Bonding/Insurance: Verify the coverage amount.

The California Court of Appeal, in Hoang Long Ngoc Pham v. Superior Court of Orange County (Cal. Ct. App., Dec. 16, 2025), addressed a dispute over the disposition of two frozen embryos created through IVF by a married couple who were divorcing. Pham (husband) sought to have the embryos discarded, asserting a right not to procreate, while Kon (wife) sought to use them to attempt pregnancy.

The parties signed a written IVF consent agreement specifying what would happen to embryos upon certain “adverse events,” including divorce. For divorce, they selected and initialed the option that embryos would be “[m]ade available to the partner if he/she wishes.” After separation, Kon requested the embryos; Pham opposed.

The Court of Appeal affirmed the trial court’s interpretation and enforcement of the IVF agreement. The Court ruled: Where parties have a valid, clear agreement specifying embryo disposition upon divorce, that contract controls. The phrase “made available to the partner if he/she wishes” was unambiguous and meant Kon could use the embryos to attempt pregnancy.

The Court stated: “We conclude that where, as here, the parties have entered into a valid contract specifying how the frozen embryos shall be treated in the event of divorce or legal separation, the contractual approach governs. The contractual approach “ ‘minimize[s] misunderstandings and maximize[s] procreative liberty by reserving to the progenitors the authority to make what is in the first instance a quintessentially personal, private decision.’ ” (Rooks, supra, 429 P.3d at p. 592.) There are also “significant benefits to making this decision in advance, rather than at the moment of disposition. Preexisting agreements ‘promote serious discussions between the parties prior to participating in in vitro fertilization’; [citation]; and manifest choices ‘made before disputes erupt ’ [Citation.] This ‘minimize[s] misunderstandings’ that might arise in the future, provides certainty for progenitors and fertility clinics, and decreases the likelihood of litigation.” (Bilbao, supra, 217 A.3d at p. 986.)”

This is a helpful case because it advises couples to put their intentions in writing, which will be honored by the law. Discussing these issues with various professionals prior to building your family is highly advised.

Public health crises—whether pandemics, natural disasters, or widespread infectious disease outbreaks—pose significant challenges to health systems worldwide. Among the services most affected are reproductive health and fertility care. Because reproductive services encompass a broad spectrum of care—from contraception and prenatal care to assisted reproductive technologies (ART) and fertility preservation—their disruption during crises can have profound and long-lasting individual and societal consequences.

This overview examines how reproductive and infertility care are disrupted during public health crises, the mechanisms behind these disruptions, their impacts, and strategies to mitigate negative outcomes.

1. Defining Reproductive and Infertility Care

Reproductive health care includes a wide range of services related to sexual health, family planning, maternal health, pregnancy, and childbirth. It also includes access to contraception, safe abortion where legal, prevention and treatment of sexually transmitted infections (STIs), and reproductive education.

Infertility care comprises evaluation and treatment for individuals and couples who experience difficulty conceiving, including diagnostic services and fertility treatments such as in vitro fertilization (IVF), intrauterine insemination (IUI), and fertility preservation techniques.

Both reproductive and infertility services are essential components of comprehensive health care.

2. Types of Public Health Crises and Their General Impacts

Public health crises vary widely:

• Pandemics (e.g., COVID-19)
• Infectious disease outbreaks (e.g., Zika, Ebola)
• Natural disasters (e.g., hurricanes, earthquakes)
• Technological or environmental emergencies (e.g., chemical spills)

While diverse, these crises share common impacts on health systems: resource diversion, facility closures, staffing shortages, and heightened fear of infection. These disruptions strain healthcare delivery and often disproportionately harm services not deemed immediately “life-saving,” including reproductive and fertility care.

3. Mechanisms of Disruption in Reproductive and Infertility Services

a. Health System Reallocation and Prioritization

In crises, resources (staff, facilities, funding) are often diverted toward emergency response. During the COVID-19 pandemic, many hospitals and clinics postponed elective procedures, including fertility treatments like IVF or IUI, citing infection risk and resource scarcity. Similarly, reproductive health clinics may be repurposed for COVID-19 testing or vaccination, reducing service availability.

b. Policy and Regulatory Responses

Public health directives that restrict movement or deem certain medical procedures “non-essential” can block access to care. During COVID-19 lockdowns, several regions categorized fertility services as non-urgent, leading to widespread suspension of treatments.

c. Supply Chain Interruptions

Crises often disrupt supply chains, affecting availability of essential medicines, reproductive health supplies (e.g., contraceptives), and laboratory materials critical to infertility treatments.

d. Workforce Shortages and Provider Burden

Health workers may be reassigned, fall ill, or face burnout, limiting the workforce available for reproductive care. Specialist providers (e.g., reproductive endocrinologists, gynecologists) may be particularly affected.

e. Patient Behavior and Fear

Fear of infection or misinformation may deter people from seeking in-person care. Patients may delay routine checkups, fertility evaluations, or prenatal care, risking adverse outcomes.

4. Impacts on Reproductive Health Services

a. Contraceptive Access and Unintended Pregnancies

Disruptions in supply and clinic access can lead to contraceptive shortages and reduced family planning services. This increases the risk of unintended pregnancies. During COVID-19, many individuals reported difficulties accessing contraception due to clinic closures or reduced hours.

b. Maternal and Perinatal Care

Routine prenatal visits, ultrasounds, and screening tests sometimes shifted to telehealth or were delayed. While telemedicine provided continuity of care, it could not fully replace hands-on evaluations, particularly for high-risk pregnancies.

In some outbreaks (e.g., Zika), the disease itself posed direct risks to pregnancy outcomes, including congenital anomalies, prompting increased demand for prenatal counseling and testing—often unmet during crises.

c. Safe Abortion Services

In many settings, abortion services were restricted as part of broader limitations on non-emergency care. This had implications for reproductive autonomy and forced delays or travel for care where legal.

d. STI Prevention and Treatment

Public health crises often interrupt screening programs for STIs, including HIV. Deprioritization means delayed diagnoses and treatment, undermining long-term sexual health.

5. Impacts on Infertility Care

a. Suspension of Assisted Reproductive Technologies

Infertility treatments were among the first services paused in many areas during COVID-19 because they were considered elective. This had significant clinical and emotional repercussions for patients, particularly those with age-related fertility decline or diminished ovarian reserve.

b. Delayed Diagnosis and Evaluation

Clinic closures and reduced services delayed fertility evaluations (e.g., hormone testing, semen analysis). Delay in diagnosis can impact treatment timelines and success rates, especially for time-sensitive conditions.

c. Emotional and Psychological Toll

Infertility is already associated with psychological stress. When care is disrupted, uncertainty and anxiety increase, sometimes exacerbating existing mental health conditions.

d. Financial Consequences

Fertility treatments are often costly and may not be covered by insurance. Delays can increase financial strain, especially when treatments must be repeated due to postponed cycles.

6. Disproportionate Effects on Vulnerable Populations

Crises magnify existing inequities in healthcare access:

a. Socioeconomic Disparities

Individuals with lower socioeconomic status often have less access to private care or telehealth, making them more vulnerable to service disruptions. They may lack transportation or face financial barriers that worsen during economic downturns triggered by crises.

b. Racial and Ethnic Inequities

Healthcare disparities rooted in systemic racism are exacerbated during crises. Minority populations often experience higher rates of infection and mortality and face greater challenges accessing reproductive and infertility care.

c. Geographic Barriers

Rural and underserved areas with fewer healthcare providers are disproportionately affected. Clinic closures force patients to travel longer distances if services remain at all.

d. Adolescents and Young Adults

Younger populations may lack knowledge, resources, or autonomy to navigate disrupted services, especially for confidential reproductive care.

7. Innovations and Mitigation Strategies

Despite challenges, public health crises have catalyzed adaptations that can strengthen care delivery.

a. Telehealth Expansion

Telemedicine emerged as a key tool during COVID-19. Virtual consultations allowed continued access to contraceptive counseling, prenatal check-ins, medication refills, and some aspects of fertility care counseling. Telehealth expands access, especially for those in remote regions.

Strengths: Maintains continuity, reduces infection risk, improves convenience.
Limitations: Limited for procedures requiring physical interaction (e.g., ultrasounds, egg retrievals), and dependent on technology access.

b. Task Shifting and Community Health Workers

In resource-constrained settings, training community health workers to provide basic reproductive health services, distribute contraceptives, and support prenatal care can maintain service coverage when clinicians are diverted to crisis response.

c. Flexible Policy and Regulation

Some regions introduced policy changes during crises—for example, allowing multi-month contraceptive prescriptions or expanding the scope of practice for midwives and nurse practitioners to increase service access.

These regulatory adaptations can permanently improve access beyond crises.

d. Prioritization Frameworks

To prevent blanket cancellations of fertility treatments, some professional organizations developed triage systems prioritizing patients based on urgency (e.g., age, ovarian reserve) to minimize negative outcomes. Guidelines for safe continuation, infection control, and patient support were also developed.

e. Mental Health Support Integration

Recognizing the psychological toll, many clinics and public health programs incorporated mental health services into reproductive and fertility care during crises, using virtual support groups, counseling, and stress-management resources.

8. Case Studies from Recent Crises

COVID-19 Pandemic

The COVID-19 pandemic offers the most extensive contemporary example of reproductive and infertility care disruption:

• Fertility Clinic Closures: Many jurisdictions classified fertility treatments as non-essential, halting IVF and related procedures for weeks to months.
• Reproductive Health Access: Contraceptive services experienced intermittent closures; however, telehealth helped sustain counseling and prescriptions.
• Prenatal Care Shifts: Many prenatal visits moved to hybrid models, with in-person visits limited to essential checks.
• Policy Innovations: Expanded telehealth reimbursement, regulatory flexibility for medication dispensing, and prioritization protocols for fertility care mitigated some impacts.

These shifts underscore the need for resilient systems that can adapt services during emergencies while maintaining essential reproductive care.

Zika Virus Outbreak

During the Zika outbreak (2015–2016), reproductive care faced unique challenges:

• Risk Communication: Women of reproductive age required accurate information about infection risks during pregnancy and sexual transmission.
• Family Planning Demand: Calls for access to contraception and safe abortion increased in affected regions, but stigma and legal barriers impeded care.
• Infertility Impact: Fertility clinics navigated risk of infection and adapted protocols to protect patients and staff.

This crisis highlighted the interplay between infectious disease threats and reproductive decision-making.

9. Long-Term Consequences and Recovery

The effects of disrupted reproductive and infertility care extend beyond the immediate crisis.

a. Delayed Family Planning and Increased Unintended Pregnancies

Disruptions can lead to spikes in unintended pregnancies, with implications for maternal and child health, economic stability, and social services.

b. Fertility Outcomes and Age-Related Decline

For individuals seeking fertility treatment, delays may reduce success rates due to age‐related factors, particularly among women with diminished ovarian reserve.

c. Health System Resilience and Preparedness

Recovery periods offer opportunities to strengthen infrastructure, integrate telehealth sustainably, and build policies that protect essential reproductive services during future crises.

10. Policy and System Recommendations

To safeguard reproductive and infertility care during public health emergencies, stakeholders should consider the following:

a. Designate Reproductive Care as Essential Health Services

Ensuring that reproductive and fertility services are protected and prioritized in emergency planning can prevent blanket shutdowns.

b. Strengthen Telehealth Infrastructure and Access

Investing in technology, broadband access, and training can expand care delivery options, especially for underserved populations.

c. Develop Clear Clinical Guidelines

Professional bodies should create evidence-based guidelines for care continuity during crises, including infection control and triage systems.

d. Address Equity and Social Determinants of Health

Policies must specifically address disparities in access, with targeted strategies for vulnerable groups.

e. Emergency Stockpiles and Supply Chain Planning

Anticipating supply chain disruptions by maintaining essential reproductive health inventories (e.g., contraceptives, hormones) can prevent shortages.

11. Conclusion

Public health crises expose vulnerabilities in health systems, often severely disrupting reproductive and infertility care. These disruptions can have immediate and long-lasting effects on individual lives and broader population health. Lessons from recent emergencies like the COVID-19 pandemic emphasize the importance of system resilience, policy foresight, and adaptability.

Maintaining reproductive and fertility services during crises requires intentional planning, flexible delivery models, and a commitment to equity. By learning from past challenges and building robust frameworks for continuity of care, health systems can better protect reproductive health as an essential component of comprehensive healthcare—no matter the crisis.

Modern Fertility Law has made this content available to the general public for informational purposes only. The information on this site is not intended to convey legal opinions or legal advice.

Working with family members as gamete donors or gestational carriers has become an increasingly discussed topic within assisted reproductive technologies (ART). While the practice remains a minority choice in IVF treatment plans, it holds distinct personal, cultural, and logistical appeal. At the same time, it raises complex ethical, legal, emotional, and privacy-related questions. Because fertility medicine intersects deeply with family dynamics, decisions involving relatives can amplify both benefits and risks.

I. Motivations and Personal Benefits

1. Genetic Connection Within the Family Line

One of the most cited reasons intended parents choose a family member as a donor is the desire to maintain a biological connection within the family. For example, an intended mother who cannot produce viable eggs might ask her sister to donate oocytes, preserving genetic similarity in ways that anonymous donation cannot. Similarly, gay male couples may use sperm from one partner and an egg from a sister of the other partner, creating genetic links to both intended parents’ families.

2. Trust, Familiarity, and Emotional Comfort

Family relationships often bring pre-existing trust and intimacy. Intended parents may feel more at ease knowing that the donor or gestational carrier is someone they know well, rather than an anonymous or agency-matched individual. Loved ones may also feel honored to participate in helping a family member grow their family.

3. Reduced Costs and Logistical Convenience

In some cases, family donors volunteer without compensation (beyond legal reimbursement for medical and pregnancy-related expenses), significantly reducing financial burdens associated with IVF and surrogacy. A known donor or surrogate can also simplify scheduling because they live nearby and are motivated to cooperate closely with the process.

4. Cultural and Familial Expectations

In some cultures, family-based donation or surrogacy is viewed not only as acceptable but as morally favored, because it keeps reproductive roles within the kinship circle. In certain communities, this can reduce social stigma associated with infertility or surrogacy.

Despite these advantages, the overlapping layers of intimacy, obligation, genetics, and reciprocity can complicate personal relationships. Thus, the apparent benefits must be weighed against the complexities addressed below.

II. Confidentiality and Privacy Concerns

1. Confidentiality in Clinical Settings

When a family member is a donor or gestational carrier, the usual boundaries between patient confidentiality and family transparency may blur. Clinics have distinct patients in these arrangements: the donor or carrier is a patient, and the intended parents are patients or clients. HIPAA and local privacy laws require clinics to treat each as a separate individual with independent rights to privacy.

This can lead to challenges. For example:

• A donor may receive sensitive medical results (e.g., genetic carrier screening) that they do not want to disclose to the intended parents.
• A gestational carrier may develop a pregnancy complication or test result that legally cannot be shared without explicit authorization—even if the intended parents feel personally entitled to the information.

Clinics must ensure that all parties understand these boundaries before treatment begins. Written consent forms must specify what information can or cannot be shared and when.

2. Privacy Within the Family System

Even if clinical confidentiality is addressed, privacy within the family can become strained. For example:

• A sister who donates eggs may worry about relatives later commenting on physical similarities or attributing traits of the child to her.
• A cousin who acts as a gestational carrier may feel obligated to share personal health updates or lifestyle choices during pregnancy.

Family-based arrangements often heighten expectations of access, transparency, and involvement. Without explicit communication and boundaries, privacy erosion can strain relationships long after the child is born.

3. Child Privacy and Future Disclosure

Because family donors are known, the child will be born into a social environment where their genetic or gestational background may be widely known. Decisions about disclosure become collective: if an aunt donated eggs, can she tell extended relatives? Are grandparents allowed to mention it casually?

Intended parents must consider:

• how they want their child to learn their conception story
• how much information they want shared
• which relatives they trust to maintain discretion

Family participation can make confidentiality more fragile, making structured agreements critical.

III. Legal Implications

1. Parentage Law and Intra-Family Donation

Legal frameworks vary widely by state and country, but intra-family donation and surrogacy often require additional scrutiny because judges, clinics, and attorneys want to ensure the absence of coercion, exploitation, or undue influence.

Key legal implications include:

a. The Need for Independent Legal Counsel

All parties—donor, surrogate, and intended parents—must have separate attorneys to ensure voluntariness. Courts may treat family arrangements as inherently higher-risk for coercion.

b. Enforceability of Agreements

Surrogacy contracts, parentage declarations, and donor agreements must satisfy local law. Some jurisdictions impose special rules on familial surrogacy, such as requiring psychological evaluations or court pre-approval.

c. Genetic and Custodial Risks

Even if everyone has good intentions, family donors may create legal ambiguity if:

• a donor later claims parental rights
• relatives pressure the donor for involvement
• laws treat certain types of known donation as presumptively parental

Modern contracts typically require explicit renunciation of parental claims, but enforceability depends on jurisdiction.

2. Incest and Consanguinity Concerns

While intra-family donation is legal in many areas, some combinations may raise legal or ethical scrutiny. For example:

• A brother donating sperm to his sister to create a pregnancy would usually be prohibited due to consanguinity rules.
• Egg donation or surrogacy from a mother to her daughter or from a daughter to her mother may be legally permissible but triggers additional evaluations.

Some states require psychological counseling specifically to explore relational power dynamics.

3. Compensation Rules

Many jurisdictions regulate payments to donors or surrogates. Within families, compensation often becomes symbolic or limited to expenses, but legal clarity is still essential. Failure to handle compensation properly can jeopardize contract enforceability.

4. Immigration and Citizenship Implications

If family members cross borders to act as donors or carriers, international law may complicate:

• genetic and gestational parentage rules
• citizenship of the child
• import/export of gametes

Family ties do not simplify these issues; in fact, they can heighten jurisdictional concerns because informal agreements are more common.

IV. Ethical and Relational Considerations

1. Coercion and Power Dynamics

Family pressure—subtle or overt—can influence a person’s decision to donate or carry a pregnancy. A relative may feel they cannot say no without damaging family harmony. Conversely, intended parents may feel indebted or obligated to maintain a closeness they would not otherwise choose.

Factors that elevate coercion risk include:

• parental expectations of adult children
• financial dependence
• cultural norms emphasizing family responsibility
• relatives with unequal power, such as older siblings

A major ethical challenge is ensuring the donor or surrogate is acting freely, without guilt or pressure.

2. Boundary Setting

Questions likely to arise include:

• Who attends medical appointments?
• How much contact will the donor or surrogate have with the child, and will this change over time?
• How will holidays, birthdays, and family gatherings be managed?

Without boundaries, role confusion can occur. For instance, an aunt who donates eggs may be viewed—by others or herself—as more than an aunt.

3. Emotional Aftermath

Even when relationships remain positive, emotional complications may arise:

• A donor may struggle watching a child genetically linked to them grow up under someone else’s parentage.
• A gestational carrier may feel postpartum sadness, grief, or attachment.
• Relatives may disagree about how much the donor or carrier should be acknowledged.

Family therapists often recommend structured communication plans and psychological evaluations before proceeding.

V. Medical and Screening Considerations

1. Medical Risks

All gamete donors and gestational carriers must undergo screening, regardless of kinship. Working with a relative does not reduce clinical risk:

• Egg donation carries risks such as ovarian hyperstimulation syndrome (OHSS).
• Gestational carriers face standard pregnancy risks that may be more serious if the carrier is older or has had prior complications.

Family members often volunteer out of love, which can cause them to minimize or overlook risks the clinic must treat seriously.

2. Carrier Screening and Unexpected Information

Genetic carrier screening can have sensitive outcomes:

• The donor may learn they carry recessive conditions.
• These results may reveal information with implications for other relatives.

Decisions about what to disclose can have family-wide consequences, especially when genetic risk affects siblings or cousins.

VI. Practical Strategies for Families Considering Donation or Surrogacy

1. Structured Communication

It is essential to organize:

• pre-agreement conversations facilitated by a counselor
• clear expectations about roles, disclosure, boundaries, and communication
• ongoing check-ins during pregnancy and after birth

2. Independent Psychological Evaluation

Most best-practice guidelines recommend separate psychological evaluations for all parties, including partners of donors and surrogates. These assessments explore:

• motivations
• expectations
• potential emotional risks
• relational dynamics

3. Independent Legal Representation

Each party must have separate counsel. Even highly cooperative families need legal structure because:

• memories and relationships may change
• oral agreements are unreliable
• courts want documented voluntariness

4. Written Agreements that Address Post-Birth Relationships

Agreements should clarify:

• visitation expectations (if any)
• privacy and communication rules
• child disclosure plans
• boundaries at family gatherings
• dispute-resolution procedures

5. Clinic-Led Confidentiality Plans

Clinics should help establish what information can be shared among the parties and what remains private, and should require written consent for any shared medical information.

VII. Balancing Benefits and Risks

Family-based donation and surrogacy can be profoundly meaningful, allowing relatives to support one another in ways that reflect deep love, generosity, and solidarity. Many families describe positive outcomes characterized by closeness, gratitude, and shared joy. However, the same intimacy that creates these benefits also increases the risk of misunderstandings, boundary crossing, coercion, or long-term relational stress.

Thus, the decision requires more preparation—not less—than arrangements with anonymous or agency-matched donors or surrogates. Legal, psychological, and medical safeguards are essential, and honest communication is indispensable.

Conclusion

Working with family members as gamete donors or gestational carriers occupies a complex space at the intersection of biology, law, ethics, privacy, and personal relationships. The potential benefits—genetic continuity, trust, reduced cost, and emotional closeness—are significant. Yet these advantages are counterbalanced by confidentiality challenges, legal intricacies, risks of coercion, and long-term relational implications. Successful outcomes depend on transparency, independent counseling, comprehensive legal agreements, and an unwavering commitment to respecting boundaries.

Ultimately, when family members help one another build families through assisted reproduction, the process can reinforce bonds and create narratives of love and mutual support. But the best outcomes arise when the arrangement is grounded in clear consent, robust planning, and respect for the autonomy and privacy of every individual involved.

Modern Fertility Law has made this content available to the general public for informational purposes only. The information on this site is not intended to convey legal opinions or legal advice.

Life insurance is important for gestational carriers (surrogates) because it provides financial protection for their families in the event of a worst-case scenario. 

Although serious complications are rare, pregnancy and childbirth do carry medical risks, and surrogates take on those risks on behalf of intended parents.

Surrogates often have children or dependents of their own. If a life-threatening complication occurred, the policy ensures their family wouldn’t face financial hardship.

Most ethical agencies or legal agreements require a policy:

• usually at least $250,000 to $500,000
• paid for by the intended parents
  This safeguards everyone in the arrangement.

Knowing coverage is in place allows the surrogate and her family to feel secure throughout the process.

Modern Fertility Law has made this content available to the general public for informational purposes only. The information on this site is not intended to convey legal opinions or legal advice.