Karen Isaacs, 49, is surrounded by children all day, every day. The mother of two runs “Little Fingers Play School” at her home in Johannesburg. For the past 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’ cellphones. Phones are a distraction and not allowed. The children are the focus.

She reveals it is mostly children of domestic workers in the area who attend her school, while their mothers are on duty. On the wall of her office is a mural of a mermaid in blue and next to it hangs a cluster of medals. Isaacs is a runner. The feel of childhood is everywhere, from rainbow packs of stacked Post-It notes to small and colourful kids’ backpacks and lunch bags lying around.

Isaacs says it was 13 years ago when she gave birth to a little girl that was not hers.

Isaacs, 37 at the time, opted 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.

The most recent surrogacy came about after she heard that the mother of the twins had had 13 miscarriages. “I just thought I was going to give someone a life.”

“But,” cautions 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 her first surrogacy: “I was teaching another lady’s triplets. She had those 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. In the meanwhile, that has changed. You can now 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. Isaacs was paid a “substantial” amount of money.

“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, nowadays it is a criminal offence to be paid to be 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 of expense; so, if the surrogate mom buys an item of maternity wear, she must submit proof to the parents for reimbursement.

“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 to R500 for cellular airtime; about R1,000 for food,” explains Friedman. “For loss of income, there is provision made. Maternity leave is two months after birth. She’s allowed an allocation of vitamins or the parents can purchase vitamins on her behalf.”

Isaacs recalls her second experience as a 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 I was too old.”

But she went for tests and was told she was fit enough. “Both my kids were fine with it this time around.”

According to Friedman, age is a factor as 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 her two 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 Isaacs’ parents to come to terms with what she was doing. “Today it is more accepted in society. My parents were very supportive with the twins.”

Her own children were teenagers and gave her their blessing to proceed.

“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

The first set of surrogate parents bought the required eggs, whereas with the second surrogacy the eggs were from the twins’ mother.

“You are not allowed to use a surrogate’s eggs, so they (the first set of parents) bought eggs,” Isaacs explains.

The surrogate mother must decide “if you want to take two eggs to be used to create the embryo, because sometimes only one will take”.

“With my first pregnancy, I didn’t know I was pregnant until four months went by. With the second pregnancy I 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.”

Surrogacy laws have changed considerably.

“Back in the day, a surrogate had 62 days to give up the baby,” explains Isaacs. “The current law says parents of a baby born through a surrogacy arrangement have 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 at doctors’ visits. 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

The legal procedure was not seamless. “We had a phone conference with the twins’ parents. Then I had to sign three books – they were very heavy legal documents.”

In vitro fertilisation can only be done once all the legalities are in place. The minute the eggs are inserted, the embryonic baby becomes the property of the parents. Decisions concerning the pregnancy are up to the parents, through the signed agreement.

“It’s not for you to say, for example, 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 twins were a 100% okay.”

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 are done per year.”

Heylen notes that, from a medical point of view, “Surrogacy is rare because there are not many indications for it, but there are a lot of indications for egg donation. Most women 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.”

The South African Registry for Assisted Reproductive Technology 2015 report provides data from 16 assisted reproductive technology (ART) centres. ART refers to medical procedures that involve treatments such as in vitro fertilisation (IVF), intracytoplasmic sperm injection (ICSI) and oocyte (egg) donation.

The 2015 report shows that 5,681 “aspirations” were performed at ART centres in the preceding year. Aspirations refer to the removal of eggs from the ovary before they are sent for fertilisation in a 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 records 2,193 pregnancies from procedures involving IVF (conventional IVF and ICSI) and egg donation. There were 867 deliveries, live births or stillbirths.

The treatments

IVF and ICSI are the most common fertility treatments. With IVF, egg and sperm (of which there are many) are left in a petri dish to fertilise on their own. With ICSI, one sperm is directly injected into the egg. The latter is better in cases of sperm-related infertility.

According to Medfem Fertility Clinic, in egg donation, embryos are conceived using eggs obtained from a young egg donor (not the intended mom) and sperm from the intended dad (most commonly the husband of the mom). For a better success rate, 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 this process has grown over the years as more prospective parents learn how they can have a family and potential egg donors hear about the safe and rewarding process of donating eggs to a couple or single person in need.

Albertyn says there has been 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?

Costs vary from clinic to clinic, explains Albertyn.

“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.”

The 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.”

What are the options for those who can’t afford this amount?

In the public health sector, three centres offering less expensive fertility treatment operate from Steve Biko Academic Hospital in Pretoria and 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 medication dosages.

Laticia Pienaar, spokesperson at Tygerberg Hospital, says the hospital’s fertility clinic offers all forms of ART, including egg donation and surrogacy — at an average cost of about R12,000.

“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,” says Pienaar

Reproductive freedom

Reproductive health rights are often associated with access to abortion services and contraceptives. Surrogacy flips the coin to focusing on the choice of a person to procreate without sexual intercourse, through ART. This is important for people with limited biological options to have children themselves and who might choose to use another woman to carry a baby.

But surrogacy is still a contested issue.

When people ask Isaacs why she would take on such a huge responsibility, she doesn’t have a pat answer, but says 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. 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; the kids need to understand the difference before meeting me.”

Isaacs advises women who might want to be surrogate moms to 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 therapy when she was younger,” says Isaacs. “I think it would be nice to have a support system, before and during the process, for surrogates to talk to people who have been through it.” DM/MC

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 [email protected]).

In Johannesburg, the Steve Biko Academic Hospital’s Reproductive and Endocrine Unit is at [email protected] or [email protected] or 012-354-2540 / 5337.

This article was produced by Spotlight – health journalism in the public interest. Like what you have been reading? Sign up for a newsletter and stay informed.