In 1987 the CDF Instruction Donum Vitae condemned the practice of surrogate motherhood in its various forms.  The moral and ethical objections raised here were only the first hint of the legal and social confusion that surrogacy has produced:

The practice of surrogate motherhood has expanded into an international industry.  Poor women in India. China, and Europe are paid to bear children for wealthy infertile couples, same-sex-couples, single persons of either gender, and couples who  wish to have children without the inconvenience of pregnancy.  Numerous documentaries on the financial pressures that drive poor women to become surrogates have been produced.  The following article describes of these terrible realities, including the pressure that is brought to bear on surrogates who conceive twins or triplets, and who are subsequently required to “reduce” (abort) some of the children they carry. 

With an international network of surrogate mothers and egg and sperm donors, a new industry is emerging to produce children on the cheap and outside the reach of restrictive laws.

In a hospital room on the Greek island of Crete with views of a sapphire sea lapping at ancient fortress walls, a Bulgarian woman plans to deliver a baby whose biological mother is an anonymous European egg donor, whose father is Italian, and whose birth is being orchestrated from Los Angeles.

She won’t be keeping the child. The parents-to-be—an infertile Italian woman and her husband (who provided the sperm)—will take custody of the baby this summer, on the day of birth.

The birth mother is Katia Antonova, a surrogate. She emigrated to Greece from Bulgaria and is a waitress with a husband and three children of her own. She will use the money from her surrogacy to send at least one of her own children to university.

The man bringing together this disparate group is Rudy Rupak, chief executive of PlanetHospital.com LLC, a California company that searches the globe to find the components for its business line. The business, in this case, is creating babies.

Mr. Rupak is a pioneer in a controversial field at the crossroads of reproductive technology and international adoption. Prospective parents put off by the rigor of traditional adoptions are bypassing that system by producing babies of their own—often using an egg donor from one country, a sperm donor from another, and a surrogate who will deliver in a third country to make what some industry participants call “a world baby.”

They turn to PlanetHospital and a handful of other companies. “We take care of all aspects of the process, like a concierge service,” says Mr. Rupak, a 41-year-old Canadian.

For years couples have turned to sperm donors, egg donors or surrogate mothers to help them become parents. Now the process is being taken to a level that is stretching legal and ethical boundaries. WSJ’s Linda Blake reports from India.

Clients tend to be people who want children but can’t do it themselves: families suffering from infertility; gay male couples. They may also have trouble adopting because of age or other obstacles.

And they’re price sensitive. PlanetHospital’s services run from $32,000 to around $68,000, versus up to $200,000 for a U.S. surrogate.

Overseas surrogacy has other advantages. Surrogates in some poorer countries have little or no legal right to the baby. In Greece, a surrogate can be prosecuted for trying to keep a child. By contrast, some U.S. surrogates have tried to legally claim the children they’ve carried.

The process can bring profound dilemmas. In some cases, clinics end up creating more fetuses than a couple needs, forcing a decision over whether to abort one or more pregnancies. Babies carried to term occasionally find themselves temporarily unable to get a passport.

Mr. Rupak is learning to navigate the uncharted nature of his field—the stateless babies, the ethical complexities. His expansion to Greece, a European Union member nation, is specifically intended to lessen the likelihood of the passport problem for European parents-to-be.

Some of his own clients have faced the abortion decision, Mr. Rupak says. “Sometimes they find the money” to pay for more children than they expected, he says. After all, they went to such lengths. And if they decide otherwise, Mr. Rupak says, “We don’t judge.”

PlanetHospital’s most affordable package, the “India bundle,” buys an egg donor, four embryo transfers into four separate surrogate mothers, room and board for the surrogate, and a car and driver for the parents-to-be when they travel to India to pick up the baby.

Pricier packages add services like splitting eggs from the same donor to fertilize with different sperm, so children of gay couples can share a genetic mother. In Panama, twins cost an extra $5,000; for another $6,500 you can choose a child’s gender.

Nobody accurately tallies surrogate births abroad, but critics and industry insiders agree the numbers are growing. Since it started offering fertility services abroad in 2007, PlanetHospital has orchestrated 459 births, Mr. Rupak says. Last year, 280 clients hired the company for reproductive services, and that year 210 babies were born—168 of them twins. This year, 200 clients signed contracts, and 75 surrogates are currently pregnant.

“The ‘India bundle’ buys an egg donor, four embryo transfers into four separate surrogate mothers, room and board for the surrogate and a car and driver for the parents-to-be when they travel to India to pick up the baby.”

Critics say the business is strewn with pitfalls. “The potential for abuse on many levels is big,” says Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania in Philadelphia, discussing the industry in general terms. “You’re straddling all these [international] boundaries to buy the ingredients and the equipment.” Mr. Caplan calls it the “wild, wild west of medicine.”

Laws are vague and can conflict from country to country. In 2008, baby Manji was born to an Indian surrogate just weeks after the divorce of her Japanese parents-to-be. (The family wasn’t a PlanetHospital client.) According to a Duke University case study in legal ethics, it led to a tangle of Indian and Japanese law that first prevented the little girl from being issued a birth certificate, and later made it difficult for her father bring her home to Japan. Months went by. To fix the problem, Japan issued a special humanitarian visa.

“This area of law is very unsettled,” says Evgenia Terehova, PlanetHospital’s lawyer. “There can be all sorts of unforeseen circumstances.”

Ms. Terehova says PlanetHospital clients agree to settle disputes using arbitration under California law. The company says it hasn’t been sued and hasn’t been taken to arbitration.

Greek surrogacy is regulated by a 2005 law, but the business takes advantage of a legal loophole. Surrogate mothers are not supposed to act for profit. However, they can accept money for pregnancy-related expenses. Typically, the expenses are set at up to $50,000.

“The judge never asks” about the money, says Maria Kouloumprakis, a surrogacy lawyer in Greece. Ms. Kouloumprakis calls the situation “an emptiness in the law.”

Egg donors often come from the U.S. or Eastern European countries since white parents tend to prefer fair-skinned children. Those countries allow donor anonymity. Parents on tighter budgets might opt for a donor from India or Latin America. Sperm is often provided by the fathers-to-be, though it’s also available from a network of sperm banks in the U.S. and Europe.

Unlike traditional adoption, there is relatively little vetting of would-be parents either by agencies like PlanetHospital, regulators or clinics. There are also fewer restrictions, such as strict age limits, on who can participate.

Mr. Rupak says individual clinics use their own standards to make some of these decisions. He sometimes advises his clients to get a lawyer to be sure they’re in compliance with the laws of their home country.

“Our ethics are agnostic,” Mr. Rupak says. “How do you prevent a pedophile from having a baby? If they’re a pedophile then I will leave that to the U.S. government to decide, not me.”

Mr. Rupak says he has rejected clients. In one case, he suspected a woman wanted to use her own eggs and her son’s sperm. “Whatever the case was, these people weren’t honest. It worried us, so we said ‘no.’“

Mr. Rupak, a former screenwriter and movie producer (his credits include “Snowboard Academy,” starring Corey Haim and Brigitte Neilsen), ran a software business before opening PlanetHospital in 2002. Its first business, and still its biggest money-maker, is “medical tourism,” arranging travel to less expensive countries for knee surgeries, cosmetic dentistry and the like. Mr. Rupak says he got into the reproduction business after clients started asking about it.

Conversations between Mr. Rupak and his customers can be an odd mix of frank talk about sperm counts and menstrual cycles and good old-fashioned salesmanship. During one client meeting over tea in Chicago, Mr. Rupak first answers a question about the possibility of breast-feeding if you’re not the birth mother. Then, as the conversation wraps up, he says: “I have some good news for you. We’ll be offering you and your husband complimentary teeth-cleaning while you’re in Hyderabad.”

His client, Caroline Lu, smiles. “That’s great,” she says. Ms. Lu later says she and her husband passed on the teeth-cleaning.

Many factors drive surrogacy’s global spread. China and other big adoption destinations have toughened their rules in recent years. Some developed countries, including Japan, Spain, Germany, Italy and France, outlaw or severely restrict surrogacy at home. The United Kingdom prohibits surrogacy for pay, and in 2005 banned donor anonymity. Some U.S. states prohibit surrogacy for pay, and in recent years some have outlawed gay adoption.

PlanetHospital recently launched a website touting “surrogaycy” aimed at gay couples. “In some states you cannot marry, let alone adopt; but not a law in the land can take away a child that is biologically yours,” the site says.

“We are so excited, we are just gleaming,” says Marc Loeb, a 33-year-old sales director for a women’s apparel company in New York, whose baby girl, Eden, was born in India a few days ago.

Mr. Loeb and his spouse, Wolf Ehrblatt, (the two were legally married in Massachusetts two years ago) hired PlanetHospital in 2009. For a gay couple, domestic or international adoption is tough, says Mr. Loeb. And the expense of U.S. surrogacy made it feel like “that was for the gay elite,” he says.

The couple made a $10,000 down payment and decided to try for a child using a college-educated American egg donor and their own sperm.

PlanetHospital steered Mr. Loeb toward India. Mr. Loeb and Mr. Ehrblatt traveled to the Kiran Infertility Clinic in Hyderabad to deposit sperm. There they met some of the surrogate mothers, who live in apartments attached to the clinic—but not the woman who would carry their child.

Mr. Loeb says he didn’t want to ask. “It’s an emotional enough experience,” he said.

A few weeks later, Mr. Loeb says, Mr. Rupak called to say, “You’re pregnant, man.”

The couple made payments as the pregnancy progressed, with the final amount due at birth. Of the $35,000, PlanetHospital keeps around $3,600. Another $5,000 goes to the egg donor, plus another $3,000 or so for travel expenses. The surrogate gets $8,000. The rest, around $15,000, is paid to the clinic.

In the case of gay couples, the surrogate’s name appears on the birth certificate as the mother. In the case of heterosexual couples, the adoptive mother’s name appears.

Mr. Loeb and Mr. Ehrblatt learned of Eden’s birth on Dec. 3 while stuck in traffic in a rickshaw in Hyderabad. Sitting there, Mr. Loeb said, they received a text message from the doctor: “Congratulations, you had a baby girl!”

The couple will stay in India for a few more weeks while the U.S. embassy performs a DNA test. Once the test establishes that one of the men is the child’s biological father, the baby is eligible for U.S. citizenship.

Mr. Loeb says PlanetHospital arranged for them to live in a modern apartment in Hyderabad while waiting for their baby’s U.S. passport, and arranged for a nanny to help them. “Everything is running very smoothly,” he says.

Another gay couple, Jocelyn LaFleur and Denis Doyon of Montreal, are just getting started with PlanetHospital. Their home province of Quebec permits adoption by gay couples, the men say, but it can get drawn out and complicated.

This past Thursday, they received the news of a successful pregnancy of their surrogate, on a second attempt. If all goes well, they will travel back to India next September to collect their baby.

“Having our baby be born in India was not a choice, it’s just by chance, and we accept and are glad for that,” Mr. Doyon says.

No country has become a greater magnet for the business than India, which made surrogacy legal in 2002. It has an ample supply of inexpensive surrogates and egg donors. There is little regulation beyond guidelines that set age limits for surrogates and prohibit a woman from acting as a surrogate more than three times.

Suzanne and Thomas Lloyd of Richmond, Va., are on their third attempt at pregnancy with an Indian surrogate mother and donor. The first two implants failed to grow. Mr. Lloyd, who works for a credit-card company, says that having a child has been a “life-long dream” for his wife, a 42-year-old teacher.

They tried in vitro fertilization with no luck. They also looked into adoption but didn’t qualify in many countries because they were either too old or hadn’t been married long enough. The Lloyds are college sweethearts who split up after school, only to reunite and marry four years ago.

The couple paid $10,000 to PlanetHospital to try the surrogate route. Mr. Lloyd says there have been some aggravating lapses in communications: Their first contact at PlanetHospital was with a caseworker who would let weeks go by without responding to emails, they say. Since then, he said, Mr. Rupak became their primary contact and communications have improved.

Mr. Rupak acknowledges the communication problem and said he has learned from his mistakes. He recently hired someone in India whose job is to meet arriving clients and be available to them at all times by cellphone. “It’s a challenge to grow the business and still maintain a personal level of support and service,” he says.

Surrogacy’s complexity can give rise to extraordinarily difficult decisions, such as whether or not to abort. This can happen because clinics sometimes implant multiple embryos into multiple surrogates to improve the odds: If one miscarries, there are still viable pregnancies. However, if several implants successfully lead to pregnancy, clients face ending up with not just one or two children, but many.

Mike Aki and his husband, a Massachusetts couple, confronted this question. The couple planned on having two children. But their two surrogate mothers in India each became pregnant with twins.

At 12 weeks into the pregnancies, Mr. Aki and his husband decided to abort two of the fetuses, one from each woman. It was a very painful call to make, Mr. Aki says. “You start thinking to yourself, ‘Oh, my god, am I killing this child?’“

He didn’t think of his decision as an abortion, but as a “reduction,” he says. “You’re reducing the pregnancies to make sure you have a greater chance of healthy children,” Mr. Aki says. “If you’re going to bring a child into this world, you have an obligation to take care of that child to the best of your abilities.”

Today, Mr. Aki and his husband have two 21-month-old daughters. The girls share the same genetic mother. Each man is the genetic father of one of the girls. Next week, Mr. Aki and his husband will officially adopt each other’s genetic daughter.

Initially in 2008, Mr. Aki was a PlanetHospital client. But early in the process, following a dispute over money and communication, Mr. Aki decided to cut out the middleman and deal directly with the clinic.

The dispute arose because of poor communication and book-keeping at the clinic, Mr. Rupak says. He has since cut ties with that clinic. “We’ve improved upon all those things since.”

Mr. Rupak says he is vigilant about the risks inherent in a lightly regulated business. He says he stopped using egg donors from Georgia in Eastern Europe, for instance, because a black market for eggs has sprung up in the region. This fall, Greek authorities busted a group of Romanian and Bulgarian men for allegedly forcing poor immigrant women to undergo egg extractions. Now, Mr. Rupak contracts for eggs through donor banks rather than trying to recruit individuals himself.

And Mr. Rupak says he is looking to expand into Mexico and Ukraine, building on the success of the move into Greece.

On the island of Crete, the pregnancy of Mrs. Antonova, the Bulgarian woman carrying a child for the Italian couple, is proceeding according to plan. She lives at home with her husband and three children. She visits the clinic of Dr. Mattheos Fraidakis, Mr. Rupak’s partner on Crete, for regular checkups. She appeared in court this past fall and, in accordance with Greek law, promised to relinquish the baby to the Italian parents-to-be. She declines to detail her compensation.

“It’s good that I can help these people have a family, and it’s good for my family too,” says Mrs. Antonova, who is 40. “I will have this baby, and move on with my life.”

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