Reopen surrogacy debate, IVF expert says

Malta should reopen the debate on legalising surrogacy and amend legislation to allow lesbian couples to use the same sperm donor, according to a leading medical expert.

IVF consultant Christine Schembri Deguara, medical director at HOPE Fertility Clinic, both reforms are needed to close gaps in Malta’s reproductive rights framework.

She believes surrogacy should be introduced under a tightly regulated legal framework for women who cannot carry a pregnancy and for male same-sex couples. Additionally, existing donor sperm rules should be amended to link donors to families rather than individual parents. This will allow lesbian couples to have biologically-related children.

The Labour Party has proposed amending IVF legislation in its first 100 days but has stopped short of outlining what the changes will be.

Surrogacy had been part of the wide-ranging legislative changes proposed by the Labour government in 2018 but the matter was dropped from the final bill, pledging instead to put forward the proposal separately. Nothing ever came of that promise.

Reopen the surrogacy debate

Schembri Deguara argues Malta already has a “very robust regulatory system” and that introducing surrogacy within a controlled framework could protect both intended parents and surrogates.

“I would really love to get the discussion of surrogacy going, both from a medical side and also from an equal rights side,” she says, adding ethical concerns could be addressed through proper regulation and safeguards.

Schembri Deguara says surrogacy should not be viewed only through the lens of LGBTQ+ rights, pointing out some women face serious medical barriers to carrying a pregnancy. “Some women are born without uteruses, some women are born with small uteruses, some women have had chemotherapy or radiotherapy to their uterus,” she points out.

Schembri Deguara argues that medical surrogacy can provide an alternative for patients who have no possibility of carrying a child. She insists that banning surrogacy does not prevent people from seeking it aboard, potentially exposing vulnerable patients to less regulated systems.

“If something is not legislated, it doesn’t mean people don’t go abroad to countries with less regulation, and go through the turmoil of insecurity,” she says. “If you offer something, you offer it to patients to also secure the rights of the patient and the surrogate, because if it’s done properly, that’s the way things are done.”

Changes to sperm donation regulations

Schembri Deguara also calls for changes to Malta’s sperm donor regulation to better reflect the country’s recognition of same-sex families. She argues that current rules are based on an outdated definition of parenthood.

While praising Malta’s progress on LGBTQ+ rights, Schembri Deguara says current IVF legislation still contains provisions that were written around the traditional model of a family made up a man and a woman. “Compared to most of Europe, we’ve done advancements in recognising single-sex marriages,” she says, but adds some aspects of fertility law have not caught up with these changes.

She explains that under the current system, a sperm donor is linked to an individual rather than a family, which creates difficulties for female same-sex couples who wish to have children using the same donor.

“If two women are regarded as a family, then the sperm donor can actually be used by both women,” Schembri Deguara says. Changing the wording of the law could allow female couples to access the same donor while maintaining safeguards around donor limits and family links. This, she says, would also allow the possibility of half-siblings through the same donor within a recognised family structure.

Embryo testing

Schembri Deguara welcomes the 2022 changes to introduce preimplantation genetic testing for monogenic disorders (PGT-M). She says the procedure has already delivered successful outcomes in Malta.

“PGTM is being done. We’ve had successful cases here; we’ve had the first successful births in the country,” she says.

However, she argues that broadening the list of conditions for which doctors could test will allow more couples carrying serious inherited diseases to have healthy children. “Increasing the number of diseases, we can test for via PGT-M benefits the patient,” she says. “It enables more people with different diseases to have children born free of disease.”

However, she notes that under the current framework, patients are not entirely excluded if their condition does not appear on the approved list. Currently, fertility specialists can apply to the Embryo Protection Authority on a case-by-case basis to seek approval for testing in exceptional circumstances. “If there is a known genetic condition that is incompatible with human life or results in very severe defects... we can still apply to the Embryo Protection Authority… however, a broader list of approved conditions would be a nice thing.”

Turing to Pre-implantation Genetic Testing for Aneuploidy (PGT-A), Schembri Deguara is cautious. She is not against its introduction but stresses that it is a “tool” rather than a universal solution.

She says that no major fertility organisation recommends it as a standard practice because it carries risks and does not increase the overall likelihood of taking home a baby.

She explains that PGT-A involves removing cells from an embryo for genetic testing before it is frozen, a process that can weaken the embryo or even result in its loss. She warns that the test is not always accurate, with the possibility of false positive and false negative results. “It is not risk-free to the embryo, and in reality, doesn’t guarantee you a baby.”

Schembri Deguara also says that some clinic fails to highlight the number of embryos that do not survive the testing process.

However, she says PGT-A should be considered where there is a strong medical justification, such as recurrent miscarriages linked to suspected genetic abnormalities or older patients with a higher risk of chromosomal disorders. “I would happily see a change in that, but I would be very cautious about blanket policies,” she adds. “It should be a case-by-case basis where there is a solid medical foundation to do it.”

Egg fertilisations

There have been calls to increase the number of eggs that can be fertilised. A woman aged under 39 can have up to five fertilised eggs and if the patient is between 39 and 45 it is eight. Schembri Deguara does not find this regulation limits doctors. She says the current system does not reduce success rates when supported by careful egg selection and effective freezing techniques.

She points to HOPE, which she says has an embryologist, who assesses the quality of eggs before fertilisation occurs. “Our data has shown no difference in success rates compared to cases abroad.”

She adds that the clinic collects as many eggs as needed, fertilises them in batches and freezes the remainder without disadvantaging patients. She says this approach also helps avoid the ethical and legal dilemmas associated with creating surplus embryos that may never be used. Rather than fertilising all available eggs, patients are counselled on how many children they hope to have before treatment begins, with additional eggs kept frozen if needed.

Schembri Deguara warns patients to look beyond headline IVF success rates, arguing that statistics can sometimes be influenced by the number of embryos created.

She says clinics that create large numbers of embryos may report higher success rates because they measure outcomes per embryo transfer, but this does not necessarily translate into a higher overall chance of having a child.

“Creating 20 embryos gives them a higher chance of succeeding with the first transfer,” she says, adding that patients may achieve the same outcome through multiple transfers while avoiding the creation of excess embryos.

“What you’re interested in is creating a family, not creating embryos… I would rather transfer twice... making people comfortable that they don’t have surplus embryos rather than creating 15-20 embryos which I know I’m not going to use.”

Over 1,000 babies

Figures tabled in parliament by Health Minister Ian Borg show that in 2013, just 100 prospective parents accessed IVF services and government’s annual budget then stood at €75,000. More than a decade later, IVF has become a significantly larger public service, with government funding rising to €6.7 million and thousands of prospective parents benefiting from treatment.

Borg was replying to a series of parliamentary questions put to him by Labour MP Romilda Zarb.

The number of people turning to IVF to start a family has also shot up. A total of 4,757 prospective parents benefited from the service between 2013 and 2025, with annual numbers rising from 100 users in 2013 to 774 in 2025.

Since the last amendments to the IVF law in 2022, the government has offered up to five free IVF cycles to prospective parents regardless of sexual orientation or gender.

The increase in access has coincided with a steady rise in IVF births, with data showing that 998 babies were born through IVF procedures between 2013 and 2026, while another 111 births are expected from ongoing treatment cycles.

A further 50 babies were born through intrauterine insemination (IUI), bringing the total number of babies born through assisted reproduction procedures to 1,109 over the period. Borg told parliament the take-home baby rate has also improved, increasing from 18% in 2013 to 45% in 2025.