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An Alternative Approach To Infertility Management: Adoption And Surrogate Motherhood And Related Issues
Date Posted: 20/Aug/2019
Infertility has serious consequences especially in Africa where a high premium is placed on child bearing. The very concept to procreate and have babies has been thought to be a basic Maslow need (Oladokun, et al. 2010), and has got immense social, psychological, cultural, economic and biological relevance. Human is after all an organism and every organism by the virtue of being a member of species has got the need, instinct and right to produce more of its own kind. Infertility as a pathological entity robs the organism of the right which is due to it. Moreover procreation and survival of the species has been seen in the light of the ultimate aim for life. Humans in their reproductive age group are fretted with a wide spectrum of pathologies, both organic and inorganic, many of which culminate into infertility. 
The ever-rising prevalence of infertility in the world over has led to diverse alternative approaches in its management including adoption and surrogacy. The subject of child adoption and surrogate motherhood evokes mixed reactions from different persons and cultures. To some, it is a wholesome practice and socially accepted. To others, it is an aberration and culturally abominable. 
As cited in Omeire, Iheriohanma, Osita-Njoku & Omeire (2015), Leavy & Weinberg (1979) points out that, child adoption inaugurates the relationship of parent and child between persons not related by nature. When the process of child adoption is perfected through the issuance of adoption order by a court of competent jurisdiction, the adoptee becomes a full member of the adoptive family. The adoption order transfers the legal responsibilities of parenthood from the natural parents to the adoptive parents. It also gives the adopted child all the rights of a biological child. Once the adoption order has been issued, both the adoptee and the adoptive parents are stopped from denying each other what is due (Omeire, Iheriohanma, Osita-Njoku & Omeire, 2015).Child adoption in Nigeria is regulated by local state laws, with the process usually managed by the social welfare departments in each state’s ministry of women affairs.
Conversely, Rao & Khan (2017) reiterates that intended parents may seek a surrogacy arrangement when either pregnancy is medically impossible, pregnancy risks present an unacceptable danger to the mother's health or is a same sex couple's preferred method of having children. Monetary compensation may or may not be involved in these arrangements. The legality and costs of surrogacy vary widely between jurisdictions, sometimes resulting in interstate or international surrogacy arrangements. 
There are laws in some countries which restrict and regulate surrogacy and the consequences of surrogacy. Some couples or individuals wanting a child in this manner but who live in a jurisdiction which does not permit surrogacy in the circumstance in which they find themselves may travel to another jurisdiction which permits it. Nigeria is yet to acknowledge legally, and thus, provide policy guidelines and legislation to formalize and regulate surrogacy in the country. It means also there are no laws prescribing or proscribing surrogacy in the country. To the best of our knowledge and belief, the topic has not come up for detailed discussion in any legislative chambers in Nigeria. This has created a void, which is being and can be exploited further by illegal commercial operators with news of baby factories, baby sale, baby swap rife in the country (Makinde, et al., 2017).
Objectives of this paper are:
explain the concept of infertility management.
explain the concept of adoption as an alternative approach to infertility management.
explain the concept of surrogate motherhood as an alternative approach to infertility management.
discuss the psychological issues related to adoption and surrogate motherhood.
discuss the socio-cultural issues related to adoption and surrogate motherhood.
discuss the religious issues related to adoption and surrogate motherhood.
discuss the economic issues related to adoption and surrogate motherhood.
discuss the ethico-legal issues related to adoption and surrogate motherhood.
discuss the issues associated with adopted children.
highlight the implications of adoption and surrogacy to nursing practice.
The concept of infertility management
Infertility management cannot be discussed without first understanding the meaning of infertility.
The World Health Organization (WHO, 2019) defines Infertility clinically as follows. A disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.The inability of a sexually active, non-contracepting couple to achieve pregnancy in one year.
WHO’s Demographic Definitions of Infertility are as follows.
An inability of those of reproductive age (15-49 years) to become or remain pregnant within five years of exposure to pregnancy.An inability to become pregnant with a live birth, within five years of exposure based upon a consistent union status, lack of contraceptive use, non-lactating and maintaining a desire for a child.Demographic definitions of infertility are appropriate when making population-based estimates of infertility using household surveys (Mascarenhas, et al., 2012).
The WHO’s epidemiological definition refers to a population of women of reproductive age (15–49 years) at risk of becoming pregnant (not pregnant, sexually active, not using contraception and not lactating) who report trying unsuccessfully for a pregnancy for two years or more.The WHO’s epidemiologic Definition is more closely aligned with clinical practice than demographic definitions are, and may be measured using survey data. However, few household surveys determine whether a couple is trying to become pregnant, and the majority do not collect information on past pregnancies, only on previous live births. This infertility definition can also be used to monitor infertility; however, it is not appropriate when making population-based estimates of infertility using household surveys (Mascarenhas, et al., 2012).
Classifications of infertility
Infertility can be classified into Primary and Secondary Infertility. When a woman is unable to ever bear a child, either due to the inability to become pregnant or the inability to carry a pregnancy to a live birth, she would be classified as having primary infertility. Thus, women whose pregnancy spontaneously miscarries, or whose pregnancy results in a still born child, without ever having had a live birth, would present with Secondary infertility.
Many more couples, however, experience involuntary childlessness for at least one year: estimates range from 12% to 28%. 20-30% of infertility cases are due to male infertility, 20-35% are due to female infertility, and 25-40% are due to combined problems in both parts. In 10-20% of cases, no cause is found. Men are most likely to be infertile, if they had sperm counts below 13.5 million, less than 32% sperm motility, fewer than 9% of sperm had a normal appearance. The causes of infertility in female were ovulation problems (20-25%), tubal problems (15-25%), endometriosis (4-8%), cervical mucus hostility (1-2%), uterine problems (2.5%).Unexplained infertility was seen in 10-15% of couples. Other causes might be marital problems, psychological factors, sexual factors, lack of education and knowledge.
About 15% of couples had more than one cause for their infertility. It is therefore, important to make complete investigations from the outset rather than focusing treatment on the first cause identified.
Infertility management
Abnormal fertility can be seen in some women of reproductive age and as such they need infertility management to enhance their chances of conception. These infertility managements includes the use of fertility enhancing drugs, assisted reproductive technologies and surgery. Treatment options are usually dependent on the underlying etiology of infertility. For female causes, options include surgical management of tubal occlusion, surgical treatment of endometriosis, ovarian "drilling" for treatment of polycystic ovary syndrome(PCOS), use of ovulation-induction agents including oral (clomiphene citrate or letrozole) and injected drugs (gonadotropins), artificial insemination with either partner or donor sperm (depending on partner fertility status), and ART, which includes both IVF and intra-cytoplasmic sperm injection (ICSI).( Practice Committee of American Society for Reproductive Medicine,2012).  Couples who have not succeeded in conception through the means of these infertility managements may opt for an alternative to infertility management of which adoption and surrogate motherhood is available for these intending couples.
Concept of adoption 
Adoption is defined as the process through which an adopted child is permanently separated from his biological parents and becomes the legitimate child of his adoptive parents with all rights, privileges and responsibilities that are attached to the relationship (Avidime, et al., 2013). Adoption is considered the most desirable situation for any child who has no other home of which he or she is a part. The easy availability of newborn infants to be adopted no longer exists. Many more childless couples wish to adopt than can be accommodated. Ancient adoption practices differed markedly from the modern practices of adoption. Foremost, they were legal tools to strengthen political ties between wealthy families and they provided male heirs to manage the estates of other notables. Adoption was inherently an act that fostered the interests of adults and placed less emphasis on the interests of those adopted. The use of adoption along these lines by the aristocracy is well documented; many of Rome’s emperors were adopted sons. Moreover, evidence suggests that although legal, infant adoption for the purpose of building a family was rare. The abandoned were often rounded up for slavery rather than for adoption purposes (Omosun & Kofoworola, 2011). 
Adoption is a major life-changing event in which a new member to the family is welcomed. While the financial and legal responsibilities of parenthood end when the child reaches the age of maturity (typically 18), adoption is a lifetime commitment.
Types of adoption 
- Adopting Through an Agency: Adoption agencies are public or private agencies regulated by the state and licensed to place children with adoptive parents. Public adoption agencies typically handle children who are wards of the state, often because they have been abandoned, orphaned or abused. Private adoption agencies are often run by charities and social service organizations and typically place children who have been brought to the agency by parents or expectant parents seeking to give their child up for adoption.
- Adopting Independently: One of the other types of adoption involves a direct arrangement between birth parents and adoptive parents, sometimes using a go-between such as a doctor or member of the clergy. Because of the delicate nature of an independent adoption, it is probably a good idea for the adoptive parents to hire an attorney to handle the paperwork. Not all states allow independent adoptions, and many states regulate them extensively. One variety of independent adoption is often referred to as an "open adoption," where the biological parents maintain some form of limited contact even after adoption.
- Adopting Internationally: Adopting internationally is the most complicated of all the different types of adoption. To adopt a child who is a citizen of a foreign country, you must satisfy both the laws of the state you live in as well as the laws of the host country. Parents must also obtain an immigrant visa for the child through the Citizenship and Immigration Services. If approved, the child will be granted citizenship automatically upon entering the foreign country. 
- Adopt as Step Parents: A stepparent adoption occurs when a parent's new spouse adopts the parent's child from a different partner. The process is simple compared to traditional adoption if the birth parents both consent. If one of the parents does not consent or cannot be found, however, then an attorney will need to be involved and there is a significant amount of time and paper work involved.
- Relative Adoptions: Relative, or kinship adoptions as they are known in some states, occur when a child's relative steps forward to adopt the child. Typical candidates for this type of adoption are grandparents, aunts and uncles, and the typical situations for relative adoptions involve the death or incapacitation of the birth parents. The law favors relatives raising children, and accordingly the process is significantly easier than other types of adoption.
- Adult Adoptions: Adult adoptions are rare, but most states provide for them. Typically, there must be at least a ten year difference between the age of the parent and that of the adult being adopted, and the parties must show why it is in the best interest of the parties to allow the adoption. The primary reason why people undergo an adult adoption is to secure inheritance rights for people they have grown fond, especially when they do not have children of their own.
Most countries prohibit adult adoptions when caregivers are involved, in order to prevent caregivers from taking advantage of their elderly patients. However, In Nigeria, there are three types of adoption, namely local (within the country), international (outside the country) and relative adoption within a family. Another common type is a ‘stepparent adoption’, where the new partner of a parent may legally adopt a child from the parent’s previous relationship. Intra-family adoption can also occur through surrender, as a result of parental death, or when the child cannot otherwise be cared for and a family member agrees to assume responsibility (Omosun & Kofoworola, 2011).
Illegal adoption: Emergence of baby factory
In recent times, a trend has emerged in Nigeria whereby unmarried pregnant teenagers are quarantined in a particular location until they give birth. Upon delivery, the teenage mothers are paid token amounts and discharged while their babies are taken from them and sold at exorbitant prices by the proprietors who engage them. The phenomenon is now referred to as “Baby Factory” business (Mba, 2013). The baby factory business has become a social menace in Nigeria, particularly in Igbo land where they predominate. It is also proliferating at an alarming rate.(Uzor, 2014) indicates that about 2,500 teenagers were rescued by the police from baby factories within one year in the South Eastern states of Nigeria.
Baby factories are usually buildings or institutions such as hospitals or orphanages that have been converted to shelters for young pregnant girls and women for the purpose of delivery and selling off their offspring (Makinde, et al., 2017). Heinous crimes are noted to occur in these baby factories that include baby breeding, forced impregnations, sale of babies, illegal adoptions, and even human trafficking. It is not uncommon in baby factories for women to be forcefully impregnated by one of their kidnappers or an associate for the sake of birthing another offspring to be trafficked after a completed cycle. The emergence of baby factories in Nigeria and the high patronage it enjoys challenges or impacts negatively on child adoption in three fundamental ways.
First, genuine orphanages no longer have enough babies for adoption. This is mainly because most of the teenagers with unwanted pregnancies now prefer to make gain out of their mistake by selling their babies to operators of baby factories rather than placing them in orphanage homes or even dumping them where they would be located and taken to motherless babies’ homes.
Second, those women who fake pregnancies will prefer to purchase babies from baby factories and claim such as their biological babies rather than formally adopting children from orphanages. The reasons for this fraudulent practice are to create the impression that the woman is capable of becoming pregnant, and that she is not barren after all. 
The Third reason is to secure for the new baby cultural acceptability, and remove from the child the stigma associated with adopted children. This is based on the general notion that child adoption is not fully embraced by Nigerians because it is not autochthonous but a product of colonialism and globalization (Nwaoga, 2013). Nigerians are known for their penchant to adapt to, and adopt, novel cultural patterns (Omeire, Iheriohanma, Osita-Njoku & Omeire, 2015). In some cases, they prefer the new cultures to the neglect of their own way of life. This is evidenced in Igbo land by the dominance of the English Language, instead of the Igbo language, as the mother tongue of most Igbo families (Ugo-Ochulo, 2014). Also most Nigerians tend to prefer foreign attire to their traditional wears. It is therefore paradoxical that the Nigerians that have certain xenocentricist tendencies are having reservation in fully embracing child adoption. This irony is more perplexing considering that the culture places optimal value in children.
Reasons couples and individuals adopt children
The reasons for child adoption vary with individuals and cultural settings. For some, the reasons include the following:
intense love for children, 
couple desiring gender balance in children, 
couple with only one child, 
avoidance of discomfort and pain of pregnancy and labour, and 
infertility (Omosun & Kofoworola, 2011).
In a country such as Nigeria that has no social security provision for the elderly and the unemployed, the following are the reasons.
Child adoption serves as an insurance policy for old age for the adoptive parents. 
It also gives the adoptive parents a sense of fulfillment, joy and pride, especially if they are infertile. 
The adoption of sons by infertile couples provides a means to perpetuate their family names which is very important to the Igbo in particular, and Africans in general (Omeire, Iheriohanma, Osita-Njoku & Omeire, 2015).
In Igbo land, those who engage in child adoption do so primarily for socio-economic and psychological reasons. In some parts of Igbo land, certain traditional titles are the exclusive preserve of wealthy men who have children, especially sons. An affluent man who desires such title but has no biological son may be constrained to adopt a son in order to qualify for such a title (Nwaoga, 2013).  Other factors that account for child adoption in Igbo land include:
Desire to stabilize a childless marriage,
Legitimize an illegitimate child.
Rescue a child in an irreversible situation of abandonment or relieve parents who are unable to take care of their children (Eke, et al., 2014).
American Adoptions (2019) gives the following reasons for adopting a child.
Some women are facing medical conditions like Diabetes and Hypertension that make it dangerous to carry a pregnancy.
They do not want to pass down genetic disorders or diseases. 
They are a single parent and want to start a family.
They are a same-sex couple and want to become parents.
They want to give a child in need a loving home.
They want to help pregnant women considering adoption to continue to pursue their life goals.
They want to help a friend or family member who is not in a position to raise a child.
They want to help one of the thousands of children living without permanent families.
They want to raise an older child rather than an infant.
They want to choose the gender of their child.
The adoption process has more potential for success than infertility treatments.
They feel called to adopt, for religious, emotional or other reasons.
They just decide personally.
They just “want to “Here, adoption seems natural for them to do.
Concept of surrogate motherhood
Surrogacy comes from the Latin word “subrogare” meaning to substitute. Surrogacy is a method or agreement whereby a woman agrees to carry a pregnancy for another person or persons, who will become the newborn child's parent(s) after birth. Intended parents may seek a surrogacy arrangement when either pregnancy is medically impossible, pregnancy risks present an unacceptable danger to the mother's health or is a same sex couple's preferred method of having children. Monetary compensation may or may not be involved in these arrangements. If the surrogate receives money for the surrogacy the arrangement is considered commercial surrogacy, if she receives no compensation beyond reimbursement of medical and other reasonable expenses it is referred to as altruistic (Rao & Khan, 2017). The legality and costs of surrogacy vary widely between jurisdictions, sometimes resulting in interstate or international surrogacy arrangements. 
There are laws in some countries which restrict and regulate surrogacy and the consequences of surrogacy. Some couples or individuals wanting a child in this manner but who live in a jurisdiction which does not permit surrogacy in the circumstance in which they find themselves may travel to another jurisdiction which permits it. 

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