It was like something out of a movie: blindfolded, her cellphone confiscated, Miranda was being driven in a van carrying only other women. When she attempted to strike up a conversation with the passenger next to her, the driver made her move to another seat.

The silence stretched for 45 minutes before the blindfolds were removed and the vehicle pulled up at what appeared to be a resort-style compound.

“I only knew the site lay on the city’s outskirts, nothing more,” said Miranda, who declined to give her full name. “They did not want me to learn the precise location. That was standard procedure every single time I was taken there.”The facility was a surrogacy house in Wuhan, capital of central China’s Hubei province and Miranda’s hometown.

Chinese law says assisted reproductive technologies can only be performed by permitted medical institutions for married couples dealing with infertility, and only for medical purposes. Those using such technologies for surrogacy can be fined or face criminal charges.

“I knew it was illegal, of course, but surrogacy was a forced choice for me, and it was my last hope of having my own baby,” Miranda said. She opted for it following two second-trimester miscarriages caused by moderate intrauterine adhesions, which complicate pregnancy by damaging the uterine lining and shrinking the space required for a fertilised egg to develop. About five years ago, she learned about the Wuhan surrogacy agency from a friend in Shenzhen.

Her first impression was that the facility was clean and well-equipped. She described the agency as “professional”, while noting the irony of applying that term to an illegal operation.

“The doctors they arranged came from top local hospitals,” Miranda said. “For egg retrieval, a doctor and anaesthetist would come to the house, and nurses would make home visits for the ovulation-induction injections. But for key examinations, they would drive me to hospitals.”Two years later, her son was born in a Wuhan hospital. The baby’s birth certificate listed the names of her husband and the surrogate mother. After obtaining her son’s household registration document, Miranda asked the surrogate mother to sign a contract waiving her parental rights.

She paid more than 600,000 yuan (US$89,454) to the Wuhan facility, with roughly a third going to the surrogate mother.

Miranda said the agency told her that most of its clients turned to surrogacy for the same reason: their uteruses were no longer medically viable to carry a pregnancy. Others were seeking to avoid exhausting rounds of hospital treatment.

China’s restrictive stance on surrogacy is consistent with concerns expressed by many policymakers and ethicistsOlivia Ngan, University of Hong Kong alysis released in March by Frost & Sullivan, a consultancy firm, said the number of infertile couples in China had risen from 54.8 million in 2020 to 60.6 million last year, and was projected to climb to 74.4 million by 2035.

While surrogacy may appear to be the solution for women like Miranda, Chinese policymakers consider it a practice carrying far more risks than benefits, and the authorities are adamant that surrogacy activities – in any form – are prohibited.

In 2021, when deputies to the National People’s Congress – the country’s top legislature – suggested allowing legal surrogacy to prevent repeated illegal operations, the National Health Commission replied that “surrogacy severely harms women’s health rights and interests”.

The practice “objectifies women and gives rise to a string of grave social problems, including human trafficking, and can cause ethical crises within the family and society”, it said. The authorities renewed a clampdown on underground surrogacy networks last month.

Two laboratories, one in Wuhan and the other in Changsha, the capital of neighbouring Hunan province, were shut down for offering surrogacy services. Wuhan’s municipal health commission said eight people had been detained, police were investigating and “any illegal activities” would be severely punished.

This month, the health commission in Taicang, part of Suzhou bordering Shanghai, said it had carried out inspections together with police at an alleged surrogacy facility following online tip‑offs. It has yet to release its findings. They were not the first crackdowns by national and local regulators targeting surrogacy operators.

In the second half of 2023, a 14-department task force headed by the National Health Commission rolled out a targeted nationwide campaign. It sought to root out crimes stemming from the unauthorised use of assisted reproductive technology, including commercial surrogacy and illegal egg harvesting.

“China’s restrictive stance on surrogacy is consistent with concerns expressed by many policymakers and ethicists,” said Olivia Ngan, research assistant professor at the University of Hong Kong’s school of clinical medicine. “The central ethical concern is that commercial surrogacy may lead to the commodification of women, reproduction and children.”She said critics argued that “when pregnancy becomes a paid service, there is a risk that economically vulnerable women may be pressured into acting as surrogates, raising concerns about exploitation, coercion and unequal power relationships”.

“Demand for surrogacy does not arise in a vacuum,” Ngan said, noting that those who had experienced infertility, recurrent pregnancy loss or related medical conditions could have a profound desire for genetically related children.

Propelled by such desires, China’s underground surrogacy industry now provided “one-stop service”, said Karen, a Shanghai resident who also declined to give her full name.

She married late and struggled with infertility for over five years. By the time she turned 45, her diminished egg quality meant scant prospects for wholly natural conception.

That was when Karen began exploring alternative options outside hospital care and was surprised to discover that the underground industry offered everything she needed. She opted for the same agency used by Miranda.

“The eggs I bought were relatively affordable,” she said. “I paid around 10,000 yuan because the donor – a woman in her twenties – did not have a top-tier educational background.

“The surrogate mothers were typically in their thirties. The agency told me that all of them had previously given birth, and it only recruited women from southwestern China’s Yunnan or Guizhou provinces because they tended to come from relatively low-income backgrounds.”After the eggs were successfully fertilised with her husband’s sperm, the agency matched Karen with a surrogate mother.

Industry insiders said Wuhan and Guangzhou, the capital of southern China’s Guangdong province, were the two major Chinese hubs for surrogacy agencies, drawn by convenient transport links and relatively lower living costs, which helped keep overall expenses down.

China recorded a crude birth rate of 5.63 per thousand people last year, less than half the 12.95 per thousand in 2016, according to the National Bureau of Statistics.

Ngan said that as China’s population aged and fertility rates remained low, “reproductive aspirations and reproductive health needs may become even more prominent social issues”.

To address infertility, China provides assisted reproductive technology services, with more than 600 medical institutions having been approved to deliver them or serve as human sperm banks by June last year.

At a news conference in June this year, the National Health Commission said the success rates for assisted reproductive technology services in China had reached internationally advanced levels. “Following comprehensive interventions, 80 per cent to 90 per cent of couples experiencing fertility difficulties are able to conceive naturally,” a commission official said.

However, that means multiple fertility treatments fail for 10 per cent to 20 per cent of women who are unable to carry a pregnancy.

Professor Kirsty Horsey, from the school of social sciences and humanities at Loughborough University in the United Kingdom, said: “Prohibition [of surrogacy] tends to make people seek alternatives, like going overseas or entering into more dangerous clandestine and potentially unethical arrangements. It is not unknown for trafficking and surrogacy to be connected, but ‘feeding’ this market by prohibitions really does not help.”Chinese media have reported that because legal surrogacy services were unavailable, some people had sought them out overseas, with the US serving as one of the top destinations. Several high-profile Chinese actresses have been caught up in overseas surrogacy controversies in recent years, leading to some of them being effectively banned from the entertainment industry.

Beyond the United States, the UK, Canada and New Zealand also permit altruistic surrogacy, while banning the commercial arrangements allowed in America. Australia is conducting a review of its laws related to surrogacy.

Ngan said many countries that permitted surrogacy only allowed altruistic arrangements, where surrogates were reimbursed for expenses but received no payment for carrying a pregnancy. “This approach seeks to reduce commercial incentives and the risk of exploitation,” she said.

Horsey said overseas experience in jurisdictions with regulated surrogacy showed that “having a regulated and safe form of surrogacy available to infertile couples – with involvement of legitimate clinics, counsellors, lawyers, et cetera to give their respective advice and guidance – would legitimise a particular form of or route through surrogacy, meaning people would not have to resort to dangerous underground arrangements which are also likely to be less ethical”.

Miranda said that without surrogacy, “women like me” who were basically incapable of conceiving babies, even with modern medical help, “might never have children”.

“So I don’t believe this government-led clampdown will fully stamp out the business,” she said.