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The ART clock: temporal limits to assisted reproduction

Open AccessPublished:November 24, 2021DOI:https://doi.org/10.1016/j.rbms.2021.10.004

      Abstract

      Conceptualizations of the ‘biological clock’ in popular imaginary in the USA centre on the temporal limits of fertility, with assisted reproductive technology (ART) an increasingly proposed answer to these constraints (at least in the public imaginary). In this study, I analyse how surrogates in the USA understand their own bioavailability for others’ reproductive needs in the commercial ART market vis-à-vis their own reproductive trajectories. Based on interview data with gestational surrogates, I propose a new concept of the ‘ART clock’ to capture how time shapes the experiences of reproductive workers in the US fertility clinic. My findings point to four important ART time-related issues: (i) women desiring to extend their own ‘biological clocks’ via surrogacy; (ii) significant time being needed to achieve and sustain third-party pregnancy; (iii) women extending their total reproductive time via repeat surrogacy ‘journeys’; and (iv) temporal constraints to surrogacy reproduction regarding time of year, the day-to-day time effort, the number of surrogacy journeys, the total number of pregnancies, and surrogates’ age and the ages of their children. Each of these aspects point to important ways that reproductive desire and time shape the labour of reproductive workers, highlighting temporal constraints to assisted reproduction and limits to ART as a solution to delayed reproduction and the biological clock.

      Keywords

      Introduction

      Recent media reports of a ‘pandemic baby bust’ reinforce decades-long concerns about increasing numbers of people postponing parenthood, and what that might mean both for individuals and for the wider society (

      Broster, Alice. 2021. ‘Coronavirus Hasn't Lead to the Baby Boom that was Anticipated, According to a New Study.’ Forbes.

      ,
      • Dockterman E.
      ‘Women Are Deciding not to have Babies because of the Pandemic.
      ). These concerns coalesce in the concept of the ‘biological clock’, which first emerged in the US popular imaginary in the 1970s during a time of significant changes in family formation, access to contraception and legalized abortion, decreasing wages and job stability, and women’s increased participation in paid work and higher education (
      • Bratti M.
      • Cavalli L.
      Delayed first birth and new mothers’ labor market outcomes: Evidence from biological fertility shocks.
      ,
      • Daniluk J.C.
      • Koert E.
      • Cheung A.
      Childless women’s knowledge of fertility and assisted human reproduction: identifying the gaps.
      ,
      • Friese C.
      • Becker G.
      • Nachtigall R.D.
      Rethinking the biological clock: eleventh-hour moms, miracle moms and meanings of age-related infertility.
      ). A corresponding rising age of first birth and decreasing national birth rate resulted in heightened concerns about fertility (
      • Casper L.M.
      • Bianchi S.M.
      Continuity and change in the American family.
      ,
      • Li N.P.
      • Patel L.
      • Balliet D.
      • Tov W.
      • Scollon C.N.
      The incompatibility of materialism and the desire for children: Psychological insights into the fertility discrepancy among modern countries.
      ,
      • Wyndham Nichole
      • Figueira Paula Gabriela Marin
      • Patrizio Pasquale
      A persistent misperception: assisted reproductive technology can reverse the ‘aged biological clock’.
      ). These demographic shifts have only expanded in the last 50 years (sharply, it appears, during the pandemic), and have been problematized by different actors for a variety of individual, social and political reasons (
      • Bratti M.
      • Cavalli L.
      Delayed first birth and new mothers’ labor market outcomes: Evidence from biological fertility shocks.
      ,
      • Gallagher J.
      Fertility rate: 'Jaw-dropping' global crash in children being born.
      ,
      • Kearney M.S.
      • Monday P.L.
      ‘Half a Million Fewer Children?.
      ,
      • Li N.P.
      • Patel L.
      • Balliet D.
      • Tov W.
      • Scollon C.N.
      The incompatibility of materialism and the desire for children: Psychological insights into the fertility discrepancy among modern countries.
      ,
      • Waldby Catherine
      • Cooper Melinda
      The biopolitics of reproduction: Post-Fordist biotechnology and women's clinical labour.
      ). The ‘ticking of the biological clock’ has been a sieve for these concerns, laid at the feet of women seen to be voluntarily deferring pregnancy (or giving it up altogether) (
      • Briggs L.
      How all politics became reproductive politics: From welfare reform to foreclosure to Trump.
      ,
      • Damaske S.
      For the family?: How class and gender shape women's work.
      ,
      • Harwood K.
      The infertility treadmill: feminist ethics, personal choice, and the use of reproductive technologies.
      ,
      • Roberts D.E.
      Killing the black body: Race, reproduction, and the meaning of liberty.
      ).
      One proposed solution to delayed reproduction and the biological clock, which seems to be increasingly popular (in the public imagination, if not in reality) is assisted reproductive technology (ART) (
      • Daniluk J.C.
      • Koert E.
      • Cheung A.
      Childless women’s knowledge of fertility and assisted human reproduction: identifying the gaps.
      ,
      • Friese C.
      • Becker G.
      • Nachtigall R.D.
      Rethinking the biological clock: eleventh-hour moms, miracle moms and meanings of age-related infertility.
      ,
      • Sandelowski M.
      Compelled to try: the never-enough quality of conceptive technology.
      ,
      • Thompson C.
      Making Parents: The Ontological Choreography of Reproductive Technologies.
      ,
      • Waldby Catherine
      • Cooper Melinda
      The biopolitics of reproduction: Post-Fordist biotechnology and women's clinical labour.
      ,
      • Wyndham Nichole
      • Figueira Paula Gabriela Marin
      • Patrizio Pasquale
      A persistent misperception: assisted reproductive technology can reverse the ‘aged biological clock’.
      ). The ‘ART solution’ has entered the public consciousness as an individualized strategy to deal with postponed parenthood, but ART is not individually enacted. It is highly dependent on others: not only clinicians, but also those who donate their oocytes, sperm and gestational/birthing abilities – and their time. Through their own bodily and time investments, reproductive workers
      I join others, such as

      Anderson, Elizabeth S. 1990. ‘Is women's labor a commodity?’ Philosophy & public affairs:71-92.

      ,
      • Pande A.
      Not an ‘angel’, not a ‘whore’ surrogates as ‘dirty’ workers in India.
      ,
      • Vora Kalindi
      ‘Medicine, markets and the pregnant body: Indian commercial surrogacy and reproductive labor in a transnational frame’. Scholar and Feminist.
      ,
      • Boris E.
      • Parreñas R.S.
      Intimate Labors: Cultures, Technologies, and the Politics of Care.
      ,
      • Rudrappa S.
      Discounted life: The price of global surrogacy in.
      ,
      • Smietana M.
      • Rudrappa S.
      • Weis C.
      Moral frameworks of commercial surrogacy within the US, India and Russia.
      ,
      • Waldby Catherine
      • Cooper Melinda
      The biopolitics of reproduction: Post-Fordist biotechnology and women's clinical labour.
      , and
      • Cooper M.
      • Waldby C.
      Clinical Labor: Tissue Donors and Research Subjects in the Global Bioeconomy.
      , in considering the labour of conception, gestation and birth as a form of work, and those who engage in this labour in the commodified surrogacy industry as reproductive workers.
      – the gamete donors and surrogates – enable the delayed or medically challenged attempts at childbearing of others ‘running out of time’ on their biological clocks.
      There are other reasons why patient/clients use ART, such as not having a partner with oocytes, a uterus or sperm as is the case for gay, lesbian and/or single intended parents. As I argue in this paper, however, temporal constraints face all ART-intended parents.
      In the present paper, I analyse how one specific group of reproductive workers – US commercial surrogates – understand their own availability for others’ reproduction. I ask, how does surrogacy fit into surrogates’ own reproductive trajectories? Do ideas about reproductive timing and reproductive desire (the twin bedrocks of the biological clock) shape their surrogacy work? How do surrogates think about and experience the temporal constraints of reproduction and how can that inform our understandings about ART as a solution to the biological clock? Based on in-depth interviews with US surrogates, I propose that in shifting reproductive experiences to commercial surrogacy, women working as gestational surrogates in the USA are bound by a new ‘clock’, which I call the ‘ART clock’.
      The ART clock is a concept meant to capture issues of time and desire specific to assisted reproduction. Although the ART clock and the biological clock both centre on reproductive timing, the ART clock has unique characteristics that are particularly evident when viewed via the experiences of reproductive workers who are ‘donating’ their reproductive matter or abilities for others’ pregnancy attempts. In this paper, I provide empirical evidence of the experiences of US gestational surrogates to explore the dynamics of the ART clock specific to US surrogacy. I posit the ART clock as a concept that can contribute to understandings of reproductive timing and reproductive labour.

      US surrogacy and reproductive timing

      Gestational surrogacy in the USA is embedded in a robust ART market that has grown, even as understandings of age-related fertility, the challenges of fertility treatment, its cost and limited accessibility, and specific ART procedures are not well understood by the general public (
      • Daniluk J.C.
      • Koert E.
      • Cheung A.
      Childless women’s knowledge of fertility and assisted human reproduction: identifying the gaps.
      ,
      • Jensen R.E.
      • Martins N.
      • Parks M.M.
      Public perception of female fertility: initial fertility, peak fertility, and age-related infertility among US adults.
      ,
      • Kudesia R.
      • Chernyak E.
      • McAvey B.
      Low fertility awareness in United States reproductive-aged women and medical trainees: creation and validation of the Fertility & Infertility Treatment Knowledge Score (FIT-KS).
      ,
      • Law C.
      Biologically infallible? Men’s views on male age-related fertility decline and sperm freezing.
      ). Author comparisons of data published by the Centers of Disease Control and Prevention (CDC) in their annual national summary reports (

      CDC. 2019. 2017 Assisted Reproductive Technology National Summary Report. In Atlanta, GA: CDC.

      ) point to increased utilization of ART despite <35% of all intended ART retrievals currently ending in a live birth. Not only are there low overall success rates, which vary considerably by the age of the oocytes used, but the more complicated ART procedures, such as in-vitro fertilization (IVF) and embryo cryopreservation, used in gestational surrogacy (which are often exactly those proposed as possible solutions to future infertility) are not often covered by health insurance and are prohibitively expensive for many in the USA, making them a privilege afforded to a niche, relatively wealthy, clientele (
      • Bell A.V.
      Misconception: Social class and infertility in America.
      ,
      • Briggs L.
      How all politics became reproductive politics: From welfare reform to foreclosure to Trump.
      ,
      • Conrad P.
      • Leiter V.
      Medicalization, markets and consumers.
      ,
      • Greil A.
      • McQuillan J.
      • Slauson-Blevins K.
      The social construction of infertility.
      ,

      Jacobson, Heather. 2020. ‘Cross-border reproductive care in the USA: who comes, why do they come, what do they purchase?’ Reproductive Biomedicine & Society Online.

      ,
      • Seifer D.B.
      • Wantman E.
      • Sparks A.E.
      • Luke B.
      • Doody K.J.
      • Toner J.P.
      • van Voorhis B.J.
      • Lin P.C.
      • Reindollar R.H.
      National survey of the Society for Assisted Reproductive Technology membership regarding insurance coverage for assisted reproductive technologies.
      ).
      Although comprehensive national longitudinal data on US surrogacy do not exist, limited CDC data indicate increased rates of ART cycles utilizing surrogates in the USA (
      • Birenbaum-Carmeli D.
      • Montebruno P.
      Incidence of surrogacy in the USA and Israel and implications on women’s health: a quantitative comparison.
      ,
      • Jacobson H.
      A limited market: the recruitment of gay men as surrogacy clients by the infertility industry in the USA.
      ). This finding is confirmed by ethnographic research, according to which surrogacy is frequently framed as a miracle and a ‘precious gift’ by intended parents who experience success in using it to welcome a child into their lives (
      • Berend Z.
      The Online World of Surrogacy.
      ,
      • Deomampo D.
      ,
      • Majumdar A.
      Transnational commercial surrogacy and the (un) making of kin in.
      ,
      • Jacobson H.
      Labor of Love: Gestational Surrogacy and the Work of Making Babies.
      ,
      • Pande A.
      Transnational commercial surrogacy in India: gifts for global sisters?.
      ,
      • Ragone H.
      Surrogate Motherhood: Conception in the Heart.
      ,
      • Rudrappa S.
      Discounted life: The price of global surrogacy in.
      ,
      • Teman E.
      Birthing a Mother: The Surrogate Body and the Pregnant Self.
      ). Although some fertility clinics will work with patient-clients for social reasons, such as being afraid of pregnancy or not wanting to ‘ruin’ one’s figure, intended parents typically utilize US surrogacy for three reasons: medical conditions precluding pregnancy; repeat IVF failure; and ‘biologic inability to conceive or bear a child’ (
      • Lewin T.
      Coming to US for Baby, and Womb to Carry It.
      ; Practice Committee of the American Society for Reproductive and Practice Committee of the Society for Assisted Reproductive, 2017;

      Richards, Sarah Elizabeth. 2014. ‘Should a Woman Be Allowed to Hire a Surrogate because She Fears Pregnancy Will Hurt Her Career?’ Elle. https://www.elle.com/life-love/a14424/birth-rights.

      ).
      Surrogacy, particularly for coupled heterosexual intended parents, often comes at the end of a significant time investment in fertility treatment (
      • Berend Z.
      The Online World of Surrogacy.
      ,
      • Jacobson H.
      Labor of Love: Gestational Surrogacy and the Work of Making Babies.
      ,
      • Teman E.
      Birthing a Mother: The Surrogate Body and the Pregnant Self.
      ). Therefore, in addition to ‘ovarian reserve issues’ (if the intended mother’s oocytes are being used), the ‘clock’ that is running out for surrogacy clients is often one related to the ability – financially, emotionally and psychologically – to sustain additional treatment on the ‘infertility treadmill’; to persist and remain hopeful that a baby awaits at the end of the next procedure (
      • Harwood K.
      The infertility treadmill: feminist ethics, personal choice, and the use of reproductive technologies.
      ,
      • Spar D.L.
      The baby business: elite eggs, designer genes, and the thriving commerce of conception.
      ). As Gay
      • Becker G.
      The Elusive Embryo: How Women and Men Approach New Reproductive Technologies.
      thoughtfully demonstrated in her classic work on ART, hope and persistence are hallmarks of the fertility treatment experience, and are embedded in the organization and advertising strategies of the US fertility industry. ART patients, Becker shows, come to ‘equate new reproductive technologies with hope’ and display high levels of persistence, even despite repeat failure (
      • Becker G.
      The Elusive Embryo: How Women and Men Approach New Reproductive Technologies.
      ). A hallmark of this persistent hope is the investment not only of money, but of time.
      The ethnographic literature on ART has detailed the experiences of patient-clients, their desire for children, and their challenges achieving parenthood due to infertility and cost (
      • Becker G.
      The Elusive Embryo: How Women and Men Approach New Reproductive Technologies.
      ,
      • Inhorn M.C.
      Cosmopolitan conceptions: IVF sojourns in global.
      ,
      • Spar D.L.
      The baby business: elite eggs, designer genes, and the thriving commerce of conception.
      ,
      • Thompson C.
      Making Parents: The Ontological Choreography of Reproductive Technologies.
      ). This research has highlighted the intense time investments that many patient-clients expend in their attempts to achieve pregnancy and birth (
      • Becker G.
      The Elusive Embryo: How Women and Men Approach New Reproductive Technologies.
      ,
      • Friese C.
      • Becker G.
      • Nachtigall R.D.
      Rethinking the biological clock: eleventh-hour moms, miracle moms and meanings of age-related infertility.
      ,
      • Hertz R.
      Single by chance, mothers by choice: How women are choosing parenthood without marriage and creating the new American family.
      ,
      • Speier A.
      Fertility Holidays: IVF Tourism and the Reproduction of Whiteness.
      ). As Amy
      • Speier A.
      Fertility Holidays: IVF Tourism and the Reproduction of Whiteness.
      notes, ‘when couples confront infertility, they often respond by embracing ideological notions of hard work in pursuing IVF’. This ‘hard work’ is time-intensive and is part and parcel of the contemporary biomedical model, as

      Clarke, Adele E., Janet K. Shim, Laura Mamo, Jennifer Ruth Fosket, and Jennifer R. Fishman. 2003. ‘Biomedicalization: Technoscientific transformations of health, illness, and US biomedicine.’ American sociological review:161-194.

      articulate, in which ‘health becomes something to work toward’, a moral project, as Peter
      • Conrad P.
      Medicalization and social control.
      has discussed, in and of itself. In a particularly painful way, given the important temporal factor of age and fertility, time works against the hard work of pursuing ART as more time in treatment is correlated with diminishing possibilities of success and more complex time-heavy procedures (
      • Harwood K.
      The infertility treadmill: feminist ethics, personal choice, and the use of reproductive technologies.
      ,
      • Spar D.L.
      The baby business: elite eggs, designer genes, and the thriving commerce of conception.
      ,
      • Thompson C.
      Making Parents: The Ontological Choreography of Reproductive Technologies.
      ).
      The time investment that intended parents give to reproduction and to surrogacy is easily culturally discernable to others in countries with strong pronatalist tendencies such as the USA and Israel (
      • McQuillan J.
      • Greil A.L.
      • Shreffler K.M.
      • Tichenor V.
      The importance of motherhood among women in the contemporary United States.
      ,
      • Teman E.
      Birthing a Mother: The Surrogate Body and the Pregnant Self.
      ). For those assisting them – the women gestating and bearing their children – the motivation to engage in this arrangement and their investment of time and effort is often less clear to the general public and has been a major touchstone of concern.
      Over the course of the last 40 years, there has been a lot of speculation in the public sphere about the motivations of women to engage in paid gestation and birth for others. Often, women are assumed to be either willingly or coercively participating in an exploitative process: one seeking to dupe them, or allow them to dupe others, in order to profit off their wombs (
      • Deomampo D.
      Transnational surrogacy in India: Interrogating power and women's agency.
      ,
      • Markens S.
      The global reproductive health market: US media framings and public discourses about transnational surrogacy.
      ,
      • Teman E.
      Birthing a Mother: The Surrogate Body and the Pregnant Self.
      ). The commodification of reproduction and the separation of gestation from social/legal mothering have been significant concerns for various groups from the beginning of organized surrogacy in the USA (
      • Corea G.
      The Mother Machine.
      ,
      • Markens S.
      Surrogate motherhood and the politics of reproduction.
      ,
      • Rothman B.K.
      Recreating Motherhood.
      ,
      • Weiss Gregory L.
      Public attitudes about surrogate motherhood.
      ). Surrogacy has been particularly controversial due to racial/ethnic and economic disparities evident in the organization of the global surrogacy industry (
      • Deomampo D.
      ,
      • Hovav A.
      Producing moral palatability in the Mexican surrogacy market.
      ,
      • Majumdar A.
      Transnational commercial surrogacy and the (un) making of kin in.
      ,
      • Riggs D.W.
      • Due C.
      A critical approach to surrogacy: Reproductive desires and demands.
      ,
      • Rudrappa S.
      • Collins C.
      Altruistic agencies and compassionate consumers: Moral framing of transnational surrogacy.
      ,
      • Whittaker Andrea
      International surrogacy as disruptive industry in Southeast Asia.
      ). Controversial US domestic cases of surrogacy gone awry, such as Baby M or Johnson v. Calvert, have also captured attention, bringing sharp critique (
      • Markens S.
      The global reproductive health market: US media framings and public discourses about transnational surrogacy.
      ,
      • Teman E.
      The power of the single story: surrogacy and social media in Israel.
      ). A growing body of empirical research on surrogacy, however, posits that the situation is more complex, especially in the US surrogacy market (
      • Berend Z.
      The Online World of Surrogacy.
      ,
      • Jacobson H.
      Labor of Love: Gestational Surrogacy and the Work of Making Babies.
      ,
      • Jacobson H.
      Commercial Surrogacy in the Age of Intensive Mothering.
      ,
      • Riggs D.W.
      • Due C.
      A critical approach to surrogacy: Reproductive desires and demands.
      ,
      • Rudrappa S.
      Discounted life: The price of global surrogacy in.
      ,
      • Teman E.
      The power of the single story: surrogacy and social media in Israel.
      ,
      • Ziff Elizabeth
      ‘The mommy deployment’: Military spouses and surrogacy in the United States.
      ).
      The small but growing body of ethnographic research on surrogacy in the USA addresses this question of motivation to participate in third-party pregnancy and potentials for exploitation. Researchers have established that US surrogates are most often white, married and lower/middle class mothers who have some financial stability. The majority are monetarily compensated (with an average of $25,000–30,000 for a successful ‘journey’ ending in a live birth) and report enjoying pregnancy and satisfaction with their surrogacy experiences (
      • Berend Z.
      The Online World of Surrogacy.
      ,
      • Jacobson H.
      Labor of Love: Gestational Surrogacy and the Work of Making Babies.
      ,
      • Jacobson H.
      Commercial Surrogacy in the Age of Intensive Mothering.
      ,
      • Ragone H.
      Surrogate Motherhood: Conception in the Heart.
      ,
      • Ziff Elizabeth
      ‘The mommy deployment’: Military spouses and surrogacy in the United States.
      ,
      • Ziff Elizabeth
      ‘Honey, I Want to Be a Surrogate’: How Military Spouses Negotiate and Navigate Surrogacy With Their Service Member Husbands.
      ). In this paper, I am particularly interested in how US surrogates themselves strategize the timing of third-party pregnancy, and how they understand their surrogacy time investments. In other words, how is reproductive timing understood and experienced when reproductive efforts are invested in the gestation and birthing of someone else’s child rather than one’s own?

      From the biological clock to the ART clock

      The issues of reproductive desire and time are central to concerns about contemporary reproduction and the common articulation of the biological clock. Visible in the discourse surrounding the biological clock, for example, are strong gendered expectations prevalent in the USA since the 19th century of an innate ‘visceral physical and emotional desire’ for children – a ‘baby fever’ – that women are thought to hold (
      • Brase G.L.
      • Brase S.L.
      Emotional regulation of fertility decision making: What is the nature and structure of ‘baby fever’?.
      ,
      • McQuillan J.
      • Greil A.L.
      • Shreffler K.M.
      • Tichenor V.
      The importance of motherhood among women in the contemporary United States.
      ,
      • Zelizer Viviana A.
      Pricing the priceless child: The changing social value of children.
      ). These expectations reflect and result in pressure for US women – especially white, middle-class women – to desire children and to reproduce (
      • Roberts D.E.
      Killing the black body: Race, reproduction, and the meaning of liberty.
      ; Van Balen, 2002). This pressure remains strong even as the age of first birth continues to climb, the number of total births decreases, and a new cultural acceptance of voluntary childlessness has emerged (
      • Koropeckyj-Cox T.
      • Pendell G.
      Attitudes about childlessness in the United States: Correlates of positive, neutral, and negative responses.
      ).
      Time is also central to the notion of the biological clock; namely, the idea that birth has a proper time, one that aligns with age and placement in the life course (
      • Earle S.
      • Letherby G.
      Conceiving time? Women who do or do not conceive.
      ). The inability to conceive, gestate and bear children is only considered a problem for those of reproductive age who have reached a culturally-understood appropriate time for childbearing and for whom reproduction itself is viewed as ‘appropriate’ (
      • Bell A.V.
      The margins of medicalization: Diversity and context through the case of infertility.
      ). This problem of childlessness was once primarily a social issue; it is now also a medical issue via the medicalization of ‘infertility’ (
      • Friese C.
      • Becker G.
      • Nachtigall R.D.
      Rethinking the biological clock: eleventh-hour moms, miracle moms and meanings of age-related infertility.
      ,
      • Greil A.
      • McQuillan J.
      • Slauson-Blevins K.
      The social construction of infertility.
      ,
      • Majumdar A.
      ARTs and the problematic conceptualisation of declining reproduction.
      ). As Peter
      • Conrad P.
      Medicalization and social control.
      articulated in one of his classic works on the concept, ‘medicalization consists of defining a problem in medical terms, using medical language to describe a problem, adopting a medical framework to understand a problem, or using a medical intervention to “treat” it’. The inability to conceive and/or carry a pregnancy to live birth became a medical problem once there were medical options available for treatment – and once these medical options developed, markets followed (
      • Conrad P.
      • Leiter V.
      Medicalization, markets and consumers.
      ,
      • Greil A.L.
      • McQuillan J.
      ‘Trying’ times: Medicalization, intent, and ambiguity in the definition of infertility.
      ,
      • Spar D.L.
      The baby business: elite eggs, designer genes, and the thriving commerce of conception.
      ).
      The clinical diagnosis of infertility – the failure to conceive after 12 months of unprotected sex – has time at its core (
      • Greil A.
      • McQuillan J.
      • Slauson-Blevins K.
      The social construction of infertility.
      ). Current fertility treatment also privileges time. While the ‘biological clock’ previously centred on menopause as the anxious deadline to reproduce, with advances in reproductive medicine, treatment now focuses on the aging of oocytes and ‘diminished ovarian reserve’ which comes, typically, at a younger age (
      • Friese C.
      • Becker G.
      • Nachtigall R.D.
      Rethinking the biological clock: eleventh-hour moms, miracle moms and meanings of age-related infertility.
      ,
      • Greil A.
      • McQuillan J.
      • Slauson-Blevins K.
      The social construction of infertility.
      ,
      • Sharara F.I.
      • Scott Jr R.T.
      • Seifer D.B.
      The detection of diminished ovarian reserve in infertile women.
      ,
      • Thompson C.
      Making Parents: The Ontological Choreography of Reproductive Technologies.
      ).
      • Friese C.
      • Becker G.
      • Nachtigall R.D.
      Rethinking the biological clock: eleventh-hour moms, miracle moms and meanings of age-related infertility.
      : 1552) note that this shift is ‘significant because it ruptures the longstanding historical connections between menstruation and female reproductive capacity by specifically focusing on women’s eggs’. This focus on the age and quality of eggs, in turn, increases reliance on medical expertise to determine fertility and on medical technologies to ‘treat’ infertility. Advanced maternal age, a widely accepted and used medical term, is now considered to begin at 35 years (
      • Attali E.
      • Yogev Y.
      The impact of advanced maternal age on pregnancy outcome.
      ), so while the desire for children is understood to remain strong for many women in the USA, the ‘correct’ window of time for ‘healthy’ reproduction is increasingly – and often anxiously – framed as winnowing.
      This winnowing is reflected in the practices and rhetoric surrounding new ART programmes such as elective oocyte freezing (often called ‘fertility preservation’ by the ART industry) geared at young women’s potential future infertility (
      • Martin L.J.
      Anticipating infertility: Egg freezing, genetic preservation, and risk.
      ; Van de Wiel, 2015;
      • Inhorn M.C.
      • Ruoxi Y.u.
      • Patrizio P.
      Upholding Success: Asian Americans, Egg Freezing, and the Fertility Paradox.
      ). It can also be seen in the uptick of third-party reproduction and the ART market promoting it, especially for ‘older’ patient-clients relying on the oocytes of younger women and the uteruses of others. These programmes are a good example of what reproductive scholars have been pointing out for the last several decades: with the development of ART, the medicalization of infertility – and the proliferation of the ART market – has intensified (
      • Bell A.V.
      The margins of medicalization: Diversity and context through the case of infertility.
      ,
      • Friese C.
      • Becker G.
      • Nachtigall R.D.
      Rethinking the biological clock: eleventh-hour moms, miracle moms and meanings of age-related infertility.
      ,
      • Greil A.L.
      • McQuillan J.
      ‘Trying’ times: Medicalization, intent, and ambiguity in the definition of infertility.
      ,
      • Martin L.J.
      Anticipating infertility: Egg freezing, genetic preservation, and risk.
      ,
      • Sandelowski M.
      Compelled to try: the never-enough quality of conceptive technology.
      ). In these ways, the ART market is responding to – but also defining and profiting from – biological clock constraints and ‘failures’. As the market expands, so too seemingly do the temporal dimensions of reproduction, with these new programmes created around both extended fertility (people able to have children born later in life) and what Lauren Jade
      • Martin L.J.
      Anticipating infertility: Egg freezing, genetic preservation, and risk.
      has coined ‘anticipated infertility’ (people able to ‘pre-treat’ possible infertility younger in life). Reproductive time and timing shift in the fertility clinic, so much so that I propose a new ‘clock’ conceptualization: the ART clock. This concept captures important dimensions of assisted reproduction that mirror the biological clock – namely, reproductive desire and temporal constraints.
      The ART clock elucidates how timing constraints in ART vary considerably from non-ART reproduction. On the one hand, this is directly related to ART reproduction occurring within the world of organization medicine. As Charis
      • Thompson C.
      Making Parents: The Ontological Choreography of Reproductive Technologies.
      discusses in her ethnography of ART:
      in an infertility clinic, time is organized around the working day and
      progresses linearly, like most other bureaucratic office places. Calendars
      and other scheduling devices are calibrated to make incremental passages
      of time. For the patients, visits to the clinic must be fitted into working
      days and coordinated with their own working schedules.
      The ART clock acknowledges those daily time constraints – so distinct from reproduction outside of the fertility clinic – which shape the experiences not only of patient-clients but of reproductive workers as they engage in the various activities related to ART treatment. The ART clock also captures larger temporal dimensions of fertility treatment.
      Just as the concept of the biological clock is meant to conceptualize the temporal limits of reproduction and is used especially in contexts of those attempting pregnancy facing winnowing opportunities, the ART clock articulates similar temporal constraints and winnowing opportunities in the fertility clinic. The ART clock can be seen, for example, in the battles that intended parents face in terms of the emotional, psychological, physical and financial limits common to those who spend extended time in US fertility treatment (
      • Becker G.
      The Elusive Embryo: How Women and Men Approach New Reproductive Technologies.
      ,
      • Friese C.
      • Becker G.
      • Nachtigall R.D.
      Rethinking the biological clock: eleventh-hour moms, miracle moms and meanings of age-related infertility.
      ,
      • Speier A.
      Fertility Holidays: IVF Tourism and the Reproduction of Whiteness.
      ,
      • Thompson C.
      Making Parents: The Ontological Choreography of Reproductive Technologies.
      ). The ART clock forces acknowledgement that assisted reproduction has temporal limits – even as ART is proposed and marketed in the public sphere as a seemingly endlessly possible route to parenthood for those experiencing infertility or contemplating future reproductive challenges (
      • Friese C.
      • Becker G.
      • Nachtigall R.D.
      Rethinking the biological clock: eleventh-hour moms, miracle moms and meanings of age-related infertility.
      ,
      • Sandelowski M.
      Compelled to try: the never-enough quality of conceptive technology.
      ,
      • Wyndham Nichole
      • Figueira Paula Gabriela Marin
      • Patrizio Pasquale
      A persistent misperception: assisted reproductive technology can reverse the ‘aged biological clock’.
      ). In this paper, the temporal dimensions of the ART clock from the perspective of US gestational surrogates are explicated.

      Methods

      This study is based on 32 in-depth interviews with US gestational surrogates collected during two phases. The majority of data were collected over a 4-year period, from 2009 to 2013, during which 31 US surrogates were interviewed for a larger study on gestational surrogacy in the USA. The second phase of data collection began in 2016 and is an ongoing part of a larger study on the US ART industry. In the second phase, one additional surrogate was interviewed and several surrogates from the early phase were recontacted for updates.
      To be eligible for participation, women had to have worked (or be working) as paid gestational surrogates in the USA. Recruitment during the first phase was limited geographically to Texas and California, two surrogacy-friendly states; the second phase was opened to any state. Participants were recruited for the larger studies using both purposive and snowball sampling techniques via the connected web of US surrogates, surrogacy agencies and other surrogacy professionals (reproductive endocrinologists, attorneys specializing in reproductive law, and counsellors).
      At the time of the first interview, the 32 surrogates in this study were aged 25–45 years. Most (84%) were in heterosexual marriages, self-identified as white (93%), worked outside of the home in paid employment (62.5%) largely in female-dominated occupations (nursing, teaching, retail, social work), and had attended some college (34%) or had a college degree (43%). They were all mothers to children they had birthed themselves; although this was not a requirement for recruitment into this study, it was a condition of the surrogacy agencies and fertility clinics with whom these women worked, as was having ‘completed their own families’ (i.e. not wanting more children). The majority of participants (75%) had either two or three children of their own. All but one study participant reported that at the time of their first surrogacy journey, they emphatically did not want to/could not bring another child into their family.
      After receiving informed consent, five interviews occurred by telephone; the remaining 27 interviews were in-person and completed primarily in surrogates’ homes. Any follow-up contact occurred by telephone or via e-mail. The interviews averaged 2.5 h in length (range 45 min to 4.5 h) and all were recorded digitally and transcribed verbatim. Participants provided additional demographic, family and reproductive history information via a ‘face sheet’.
      The interviews with surrogates during both phases centred on how they themselves understood and discussed their own experiences working as gestational surrogates: their motivations; the procedures and processes involved; and their relationships with intended parents, professionals, their own families and others in the surrogacy community. In the second phase, questions about the impact of the coronavirus disease 2019 pandemic on surrogacy experiences were also included. A standardized interview guide was used in both phases.
      Data analysis was in the qualitative tradition of an iterative process of reading the transcripts, writing summary and analytical memos, and generating codes (Gerson and Damaske, 2020). The qualitative software program Atlas.ti was used to manage the data and facilitate memo-writing and coding, which allowed data to be isolated by code for continued analysis. This paper centres specifically on reproductive desire and reproductive timing. Two codes relevant to those concepts – surrogacy time and love of pregnancy – emerged during data analysis. Elsewhere (
      • Jacobson H.
      Labor of Love: Gestational Surrogacy and the Work of Making Babies.
      ), I have explored the larger cultural scripts regarding US surrogates’ motivations, their facilitation by the US ART industry, and the role that they play in making surrogacy palatable and profitable for a US consumer-base. My focus differs in the present paper; here, I examine a narrower thread in surrogates’ narratives of their work. I look specifically at surrogates’ expectations and behaviours associated with time and the timing of surrogacy pregnancies and their reproductive desires. I centred the data analysis for this paper on the specific data within my interviews from which the concept of the ART clock grew. The analysis contained in this paper is, therefore, a thin slice of the surrogacy experience for US gestational surrogates, and does not capture the full complexity or nuances of their motivations or experiences.

      Findings: extending reproductive time

      In my interviews with US gestational surrogates, the issue of reproductive time and timing arose in several important ways. The first was a desire that women expressed to extend their time in reproduction. Having birthed their final child (of their own) and closed the reproductive chapter of their lives, participants in this study described a sadness that overcame them when they realized they would not experience pregnancy or birth again. April Palmer (all names are pseudonyms), a 35-year-old mother of two and two-time surrogate, pregnant on her third surrogacy journey, summed this up:After I had my younger daughter, we knew that we were done having children. [My daughters] were born very close in age, which was unexpected. And we knew we didn’t want the risk of that occurring again. So I went ahead and had my tubes tied. But I knew that I wanted to… I loved pregnancy and I really couldn’t imagine not having that experience again.
      Similar bittersweet feelings at having completed their reproductive lives – and a desire to extend those experiences – were reported by all of the women in this study. Participants stated that they enjoyed the embodied experience of pregnancy, particularly the feelings of fetal movement and the effects of pregnancy hormones on their mood. All of the women in this study also shared that pregnancy and birth were ‘easy’ for them. This can be seen in the comments of Molly Hughes, a 29-year-old mother of two and two-time surrogate:
      I love being pregnant itself. I had super easy pregnancies. No sickness, nothing. And I had my issues with birth. Not every birth is perfect but, I don’t know, being pregnant and feeling the baby and then giving birth, it just wasn’t this horrible, awful thing that people make it sound like in the movies and stuff. So, easy deliveries and heartbroken. I knew we didn’t want any more [children]. We had our boy and our girl. We were good to go, but heartbroken that I was never going to be pregnant again. So I started looking into surrogacy.
      Like Molly and April, the other surrogates with whom I spoke saw themselves as skilled at pregnancy and birth, they enjoyed it and were ‘heartbroken’ that they were ‘never going to be pregnant again’.
      All of the women in this study told me that although they did not want more children, they were ‘not done’ with pregnancy and were ‘delighted’ to have found an arrangement allowing them to experience it again – while being monetarily compensated for doing so – without having to assume responsibility for another child. I have found this to be a popular framing of surrogacy in the USA as have others (
      • Berend Z.
      The Online World of Surrogacy.
      ,
      • Jacobson H.
      Labor of Love: Gestational Surrogacy and the Work of Making Babies.
      ,
      • Ragone H.
      Surrogate Motherhood: Conception in the Heart.
      ,
      • Ziff Elizabeth
      ‘The mommy deployment’: Military spouses and surrogacy in the United States.
      ). Part of this framing rests on the feelings of accomplishment and importance that women derive from their involvement in surrogacy (
      • Jacobson H.
      Commercial Surrogacy in the Age of Intensive Mothering.
      ,
      • Teman E.
      Birthing a Mother: The Surrogate Body and the Pregnant Self.
      ). By extending their reproductive time via third-party pregnancy, these women provide a service that is understood by intended parents, many of whom have struggled to have a child, as life-changing and is deeply appreciated, which is sometimes demonstrated through compliments, attention and gifts in addition to monetary compensation. Research has explored how the US surrogacy industry itself encourages these particular framings of surrogates’ motivations and skills while downplaying the commodification of reproduction and compensation that surrogates receive (
      • Jacobson H.
      Labor of Love: Gestational Surrogacy and the Work of Making Babies.
      ,
      • Markens S.
      The global reproductive health market: US media framings and public discourses about transnational surrogacy.
      ,
      • Smietana M.
      • Rudrappa S.
      • Weis C.
      Moral frameworks of commercial surrogacy within the US, India and Russia.
      ). In addition to wanting to extend their time in reproduction via surrogacy, examining the time that women spend as surrogates highlights several other temporal dimensions specific to the ART clock.

      Time as a surrogate

      A second important temporal dimension to surrogacy that arose during my interviews with gestational surrogates was the length of time required to achieve pregnancy within assisted reproduction. Outside of two new surrogates, the women in this study had been participating in surrogacy for at least 1 year, most had been involved for several years, and a couple of women had spent nearly a decade in third-party reproduction. At the time of the interviews, 30 women in the study had successfully completed one (n=16) or more (n=14) surrogacy arrangements, resulting in the birth of 71 children (including 20 sets of multiples). The two women who had yet to give birth to a ‘surro-baby’ were en route. Some surrogacy journeys took approximately 12 months from start to finish; others were significantly longer due to the complications of assisted reproduction.
      The shift from non-assisted personal reproduction to commodified ART third-party pregnancy results in an intense time commitment (
      • Jacobson H.
      Labor of Love: Gestational Surrogacy and the Work of Making Babies.
      ). Gestational surrogacy, which involves IVF, requires a regime of medications for multiple people, a battery of tests, multiple doctors visits with specialists, and medical monitoring – all of which were new to the women in this study at the time of their first surrogacy journey. Only one surrogate had experienced difficulty achieving pregancy (with her own children), and none of the surrogates had previous experience with advanced ART or IVF prior to their work as a surrogate. Their role as a surrogate was, therefore, their first personal foray into the world of assisted reproduction which commonly involves delays, failures and extended time commitments (
      • Becker G.
      The Elusive Embryo: How Women and Men Approach New Reproductive Technologies.
      ,
      • Thompson C.
      Making Parents: The Ontological Choreography of Reproductive Technologies.
      ).
      Time spent in third-party pregnancy differed in several important ways from time spent in previous reproductive experiences for US surrogates. Most obviously, ‘surro-pregnancies’ are facilitating the parenting of other people, not oneself – and they are monetarily compensated within an ART industry. In the USA, surrogacy is largely structured as a type of cooperative venture between surrogates and intended parents who work together towards the shared goal of live birth and, in doing so, get to know each other, rather than one popular in other reprohubs (e.g. India) where interactions are limited and sometimes the identities of the parties are closed to each other (
      • Rudrappa S.
      Working India’s reproduction assembly line: surrogacy and reproductive rights.
      ). As I have detailed elsewhere (
      • Jacobson H.
      Labor of Love: Gestational Surrogacy and the Work of Making Babies.
      ), this often results in a significant time investment by US surrogates in the interactions they have and the relationships they form with the intended parents with whom they are matched. Those interactions and relationships are formed in the context of time-intensive infertility treatment, which is a new milieu for first-time surrogates. As one of the women in this study, Deanna Meer, a mother of two and two-time surrogate, emphasized, ‘when you join surrogacy, you join the land of infertility’ which, in the USA, is full of time delays. These delays came as a surprise to new surrogates, who, like Ashley Padilla, a mother of five and two-time surrogate on her third journey, prior to surrogacy had ‘never seen a negative pregnancy test before’.
      The time period for surrogates between signing on with a surrogacy agency or fertility clinic and pregnancy involves multiple steps with various agency staff, healthcare providers and other professionals (such as attorneys and counsellors). Medical testing, counselling, matching between surrogates and intended parents, contract negotiation, mock embryo transfers, egg and sperm retrieval, embryo creation and testing, the medical protocal to prepare the body to accept an embryo, embryo transfer and the ‘2-week wait’ between embryo transfer and official clinic pregnancy test all need to occur before a pregnancy announcement. This extended time period can be frustrating for new surrogates as they are eager to become pregnant. As Deidre Richards, a two-time surrogate and mother of two, explained:
      when I first started [surrogacy] I had no idea really what to expect early on. And there’s a lot involved early on. And a lot of waiting. And I think when a surrogate is ready to carry for somebody, they’re like, ‘Okay. Get me signed up! Make my appointment next week and we’ll transfer some embryos!’ And it doesn’t happen that fast.
      Not only did pregnancy via surrogacy take more time than these women were used to, but the time spent in attempting a surrogacy pregnancy was mentally and physically taxing in new ways due to the number of required steps, doctor’s appointments, medications, and the intensity of these processes which commonly involved pregnancy failure. The demanding nature of surrogacy work aligns with descriptions of women’s experiences navigating and managing fertility treatment for themselves (
      • Becker G.
      The Elusive Embryo: How Women and Men Approach New Reproductive Technologies.
      ,
      • Harwood K.
      The infertility treadmill: feminist ethics, personal choice, and the use of reproductive technologies.
      ,
      • Speier A.
      Fertility Holidays: IVF Tourism and the Reproduction of Whiteness.
      ,
      • Thompson C.
      Making Parents: The Ontological Choreography of Reproductive Technologies.
      ). An important distinction of the labour in which surrogates are involved, of course, is that surrogates are not experiencing infertility themselves; their bodily work is not being performed on behalf of their own health, fertility or parenting. This intense reproductive work is of them, but not for them. This idea is captured well by Catherine Waldby and Melinda Cooper (2008: 59) in their concept of ‘clinical labour’, with which they examine how reproductive workers’ very bodies become the site of third-party reproduction via clinical ‘access to the productivity of their in vivo biology, the biological labour of living tissues and reproductive processes’.
      Given the intensity of surrogacy work and surrogates’ investment in success, it is not surprising that some women shared with me that they had a difficult time not thinking about themselves as infertile. This was especially common when women were on their initial journeys and experiencing surrogacy for the first time. Rosalyn Wheelan, for example, a new surrogate and mother of one, told me:
      sometimes I do have to remind myself, ‘I’m not infertile’. Because I forget. Because it’s really easy to lose yourself because you do have to really understand and try to really listen and be there for [intended parents]. So sometimes it’s hard to remind yourself, ‘OK, I’m not doing IVF for myself. I’m not infertile, I’m just helping someone who is’.
      As Roslyn and others articulated, ‘losing yourself’ in the intensity of surrogacy work, in the time and effort of fertility treatment, in the clinical labour, sometimes translates to fully taking on infertility as part of one’s identity, which was an uncomfortable and largely untenable position for surrogates. This idea of the blurring of identities and body boundaries and the strategies that surrogates and intended mothers employ in the process to establish ‘correct’ positions is detailed beautifully by Elly
      • Teman E.
      Birthing a Mother: The Surrogate Body and the Pregnant Self.
      in her ethnography on surrogacy in Israel.
      Time spent as a gestational surrogate in the USA involves more than just pregnancy. It encompasses a host of activities, medical procedures and social necessities – including the accompanying medical protocal and procedures (hysteroscopy, vaginal ultrasound, embryo transfer, bedrest, possible fetal reduction and/or caesarean section). These aspects of gestational surrogacy were not articulated by the women in this study as aspects of reproductive work that drew them to surrogacy; rather, they consistently and emphatically shared with me that they wanted to extend their reproductive experiences via surrogacy pregnancy which would enable them to be pregnant but not have another child for whom to care. The time necessary to achieve third-party pregnancy, however, came as a surprise to many. In ‘Labor of Love’ (
      • Jacobson H.
      Labor of Love: Gestational Surrogacy and the Work of Making Babies.
      ), I argue that the work of surrogacy, which is time-intensive and not without physical and emotional risks, and the idea of surrogacy as paid labour are deliberately obscured by all stakeholders (including surrogates) in order to make surrogacy culturally palatable to a US audience, acceptable to surrogates and their families, and profitable to the industry. Interestingly, however, for surrogates, despite these new experiences in fertility treatment, time delays, an uncomfortable medical protocol which comes with risk, and the increased time commitment and labour involved, the women in this study reported that they came to enjoy their surrogacy journeys – so much so that many wanted to extend their time in third-party reproduction.

      Extending time in third-party reproduction

      Based on positive surrogacy experiences, after having completed one successful journey, most of the women in this study (93%) told me they wanted to do another. For many, engaging in multiple surrogacies was not their original intent; most thought they would do just one journey, only to find themselves back again, wanting to do more. The experience of Andrea Tyson, a 31-year-old three-time surrogate and mother of one, was typical. She told me, ‘I thought I would only do it once. ‘I’ll just do this one time. I’m young. I’m not having any more kids of my own right now. No big deal’. But ‘once’ turned into another time and another time. And on from there!’ Like Andrea, having completed one journey, the women in the study found themselves wanting to extend their time in surrogacy.
      Experienced surrogates are welcomed by the US surrogacy industry as they are seen to be reliable and to possess important knowledge about third-party reproduction that helps to smooth the process for intended parents. As such, women who have successfully birthed a live infant for whom the intended parents assumed legal custody without issue (on the part of the surrogate), generally receive more compensation and are actively recruited by surrogacy agencies and clinics (
      • Berend Z.
      The Online World of Surrogacy.
      ,
      • Jacobson H.
      Labor of Love: Gestational Surrogacy and the Work of Making Babies.
      ). Surrogates reported engaging in multiple journeys not only because surrogacy allowed them to experience pregnancy again, but out of the joy that the surrogacy process itself brought to them. As I have discussed elsewhere (
      • Jacobson H.
      Labor of Love: Gestational Surrogacy and the Work of Making Babies.
      ,
      • Jacobson H.
      Commercial Surrogacy in the Age of Intensive Mothering.
      ), US surrogates’ motivation narratives centre on these aspects of enjoyment rather than compensation, although I have argued that compensation is nevertheless an essential feature of their participation in the US surrogacy market.
      Surrogates reported that they ‘fell in love’ with surrogacy, which became an important part of their identity, shaping their social networks and leisure time, as Zsuzsa
      • Berend Z.
      The Online World of Surrogacy.
      found in her ethnographic work on US surrogacy. Similar to their experiences following the births of their own last child, many participants shared feelings of letdown or sadness once their journeys concluded. These feelings of what might be called ‘post-surrogacy blues’ (different from – but perhaps also related to – ‘baby blues’ or postpartum depression) were mitigated for some by beginning the process over again; so while a desire to extend their reproductive lives brought many of the women in this study to surrogacy, it was the surrogacy process itself – despite the extended time commitments – that got them ‘hooked’ on surrogacy.
      Many women had told me, in a joking kind of way, that they had actually become ‘addicted’ to surrogacy and wanted to extend their reproductive experiences within the world of third-party pregnancy (
      • Jacobson H.
      Labor of Love: Gestational Surrogacy and the Work of Making Babies.
      ). Tina Vargas, a mother of four and two-time surrogate, shared, ‘I’m addicted to being pregnant!’ Tina found herself feeling ‘mopey’ at the thought she would ‘never get to experience [pregnancy] again’. And when she saw other women pregnant, she would think, ‘Why does she get to be pregnant and I don’t?’ These urges to experience a surrogacy pregnancy again propelled Tina and the other women in this study to complete multiple surrogacy journeys. The ‘surrogacy addiction’ that women reported was also shaped by the compensation they received; positive experiences with intended parents; and feelings of importance, joy and satisfaction they felt in the instrumental role they played in ‘fulfilling someone’s dream’ of becoming a mother or father. These tangible benefits to surrogacy for surrogates are common findings in the ethnographic surrogacy literature in the USA and Israel (
      • Berend Z.
      The Online World of Surrogacy.
      ,
      • Jacobson H.
      Labor of Love: Gestational Surrogacy and the Work of Making Babies.
      ,
      • Jacobson H.
      Commercial Surrogacy in the Age of Intensive Mothering.
      ,
      • Ragone H.
      Surrogate Motherhood: Conception in the Heart.
      ,
      • Smietana M.
      • Rudrappa S.
      • Weis C.
      Moral frameworks of commercial surrogacy within the US, India and Russia.
      ,
      • Teman E.
      Birthing a Mother: The Surrogate Body and the Pregnant Self.
      ,
      • Ziff Elizabeth
      ‘The mommy deployment’: Military spouses and surrogacy in the United States.
      ,
      • Ziff Elizabeth
      ‘Honey, I Want to Be a Surrogate’: How Military Spouses Negotiate and Navigate Surrogacy With Their Service Member Husbands.
      ).
      The women in this study articulated strong empathy for the infertility struggles of intended parents. This further cemented their interest in engaging in surrogacy multiple times. As Ann Beltran, a mother of four and two-time surrogate, commented, ‘I think when you get in that [mode] of helping people, you wish you could help everybody’. Ann went on to note this was especially the case as surrogates have ‘gotten all the messages and stories from [intended parents] and what they’ve had to go through’. This desire to help as many people as possible was repeated frequently by the women in this study. As Ann put it, the other surrogates she knew ‘all feel the same way. They would help everybody if they could. And it’s not possible!’ As Ann indicates, although surrogates may want to do surrogacy ‘again and again and again’ to experience that accomplishment ‘high’, most cannot – for several important reasons that place time constraints on their surrogacy work.

      Surrogacy time constraints

      Despite the fact that US surrogates report enjoying their surrogacy experiences and want to extend them, surrogacy work – and all ART – is not without temporal boundaries. This was another important surrogacy time aspect that emerged during interviews: participation in surrogacy does have various time limits; it is not interminable. The first temporal boundary is implemented by agencies/clinics over concerns about the total amount of time that surrogates spend in reproduction and the physical impact of the total number of births (irrespective of process) on pregnancy success. I found agencies relying on physicians’ assessments, which vary by practitioner but which, nonetheless, place limits on the number of surrogacies with which women can engage (often based on the number of previous pregnancies).
      Some agencies/clinics also have concerns about the total amount of time in reproductive work. They were troubled by surrogates wanting to engage in multiple journeys, which they feared indicated dubious money-driven motivations, and they therefore capped surrogacy to a certain number (in my experience, often three) to mitigate against this. As I discuss elsewhere (
      • Jacobson H.
      Labor of Love: Gestational Surrogacy and the Work of Making Babies.
      ), the US surrogacy industry is organized in such a way to try and avoid critique, including images of reproductive exploitation and a ‘baby factory’ system. Limiting surrogates’ number of involved surrogacies is one way to accomplish this. While these externally-imposed limits shaped the numbers of surrogacies enacted, the women in this study spoke most readily of self-imposed time limits.
      Surrogates’ self-imposed temporal limits to third-party reproduction were related to surrogacy timing and family constraints. Coherent with the rule held by agencies/clinics, the women in this study shared that it was best to become a surrogate once ‘your own family was complete’. Their reasoning, however, was less about any confusion about emotional connections to ‘surro-babies’ and more about the potential for negative health outcomes from multiple pregnancies. Surrogates emphasized the possibilities they understood to exist in any pregnancy for unforeseen problems to arise that would result in serious injury or death, and the inability to carry subsequent pregnancies or to care for their existing children. Gillian Dorsey, a mother of three and one-time surrogate on her second journey, for example, asks potential surrogates to contemplate, ‘What if you lose your uterus? What if you die?’ Having been pregnant and experienced US maternity care previously, the women in my sample were cognizant of serious pregnancy and birth-related complications and did not want to place themselves in dangerous positions; this included engaging in surrogacy ‘too many times’ or at the ‘wrong time’.
      Calculating the ‘wrong time’ for surrogacy involved considerations of the time commitment needed to engage in surrogacy and the resulting impact on family life. My interviews with both surrogates and surrogacy professionals revealed that if everything goes smoothly with a surrogacy journey, the process takes around 1 year. Most surrogates, however, invest more time into their journeys as delays are typical. Many indicated that more than one embryo transfer was needed, for example, to achieve pregnancy – with each transfer requiring a new ramp-up of medication to prepare the uterus and multiple doctor’s appointments. Sometimes changes were made in medical protocols, which took time to finalize. Sometimes new embryos needed to be created, often requiring new egg retrievals or the procurement of donated eggs. This all takes time. Among the 32 women in my sample, rare was the surrogate who had experienced no delay in any journey. With this time investment in mind, surrogates thought seriously about the timing of beginning a new journey and their families’ schedules.
      Similar to there being a ‘correct time’ for reproduction on the biological clock, many women also told me they wanted to find a good time for surrogacy reproduction on the ART clock. For many women, the ‘best time’ to be a surrogate was one that aligned with their families’ lives, when there was ‘nothing major’ going on, which would allow them to dedicate themselves to often-delayed surrogacy journeys. They also considered the time of year in which the third trimester and birth would occur, noting the avoidance of summer, when it would be hot and their school-aged children would be home all day on summer break.
      Women also considered the time impact of surrogacy on day-to-day family needs in ways similar to the negotiations that women make in ‘balancing’ paid employment with family (
      • Jacobson H.
      Commercial Surrogacy in the Age of Intensive Mothering.
      ). As the women in this study were caring for their young children during their surrogacy pregnancies, they thought about their children’s ages and the hands-on care required when deciding when to time surrogacy. Vanessa Moreno, for example, a mother of three and first-time surrogate, explained:
      so after I had my third son and I knew my family was complete and I didn’t want any more kids, I had my tubes tied. I’m like, ‘We’re done’. I waited for [my third son] to get a little bit older and I told my husband, ‘I keep thinking about [surrogacy] and I think it’s time.
      According to Vanessa, a big part of it being ‘time’ was the fact that all three of her children were now in school and she would, therefore, have more time to dedicate to surrogacy. Like Vanessa, the women in this study wanted their children to be a bit older – no longer toddlers – and for them to be school-aged when they began surrogacy. Third-party reproduction was particularly challenging for women who had children not yet in school, not only because their children required more day-to-day hands-on care, but they had to make childcare arrangements when they went to medical appointments and surrogacy-related meetings. Having children in school for a good part of the day helped with this dilemma – but not entirely, as some appointments/meetings required travel or occurred during the summer or weekends, when children are not in school.
      Women also considered their own age when contemplating surrogacy. Some expressed concerns about the wear and tear that third-party pregnancy imposes on their own bodies, and they did not want to wait too long to become surrogates. For example, Amber Castillo, a mother of two and one-time surrogate contemplating her second journey, shared:
      I would rather do [another journey] sooner than later for a lot of different reasons. One of them mainly being physical. I think my body would recover physically and from the pain; I’m worried about my figure! And also, I think pain-wise and all that good stuff, I think I would recover better being younger.
      Amber had given birth three times, each by caesarean section, and although she told me she recovered well and was able to return to work quickly, she was worried that another pregnancy would become more difficult the longer she waited. Amber’s concerns about the impact on her body and her ability to recover were mirrored in my interviews with other women. Deidre Richards, for example, who was 34 years old at the time of her first surrogacy, let me know that she felt she was too old to pursue a second journey. She wanted to do so, telling me, ‘I would do it five more times if I could! I wish I was younger and could do it more!’ She felt like she could not do so, however, because of the stress on her body. Although physically, women can continue to be gestational surrogates well past menopause (as the uterus does not age to the same extent as oocytes), most of the surrogates in this study, like Deidre, saw there being a finite and a best time for them to engage in third-party pregnancy.

      Discussion

      Interviews with US surrogates offer a unique window into decision making about pregnancy and the positioning of ART as a solution to infertility, postponed motherhood and the biological clock. Similar to the way that time shapes, constrains and problematizes reproduction for those dealing with infertility or delayed childbearing, coalescing in the concept of the biological clock, interviews with US gestational surrogates indicate that time plays an important role in third-party reproduction. My findings point to four important ART time-related issues: (i) women desiring to extend their own biological clocks via surrogacy; (ii) significant time being needed to achieve and sustain third-party pregnancy; (iii) women extending their total reproductive time via repeat surrogacy journeys; and (iv) temporal constraints to surrogacy reproduction regarding time of year, the day-to-day time effort, the number of surrogacy journeys, the total number of pregnancies, and surrogates’ age and the ages of their children. Each of these aspects point to important ways that reproductive desire and temporal extensions and constraints shape the labour of reproductive workers under the ART clock.
      As ART becomes part of surrogates’ reproductive trajectories, important distinctions from previous reproductive events emerge. Although the women in this study report that a desire to extend their reproductive lives motivated them to engage in surrogacy, the move to third-party pregnancy was not a simple extension of their biological clocks. By entering surrogacy arrangements, the women in this study joined an industry centred on providing reproductive services to others. In doing so, surrogacy work represents a significant shift, not a simple jumpstart to their reproductive lives. These women enter a new physical, social and economic arrangement, one no longer dictated by their needs and their own biological clocks, but by the biological clocks and reproductive needs of others, operating within a commodified industry of networked professionals (clinicians, agencies and attorneys) with industry rules and best practices.
      By joining the ART industry, as I posit in ‘Labor of Love’ (
      • Jacobson H.
      Labor of Love: Gestational Surrogacy and the Work of Making Babies.
      ), these women become reproductive workers with their labour mirroring aspects of other forms of paid employment such as recruitment, monitoring and time investment. Although the national and local context varies, Sharmila
      • Rudrappa S.
      Discounted life: The price of global surrogacy in.
      found Indian surrogates being recruited out of garment industry work and into surrogacy labour, which they preferred as they found it ‘afford[ing] them greater control over their emotional, financial, and sexual lives’. None of the women in this study suspended paid employment for surrogacy. In fact, concerns were expressed by experienced surrogates and agency directors about women who thought such a move to full-time, long-term reproductive labour was possible. This highlights another temporal constraint of ART: third-party pregnancy is not work that can be sustained in the long term. Commercial surrogates, whether in the USA or in India (or elsewhere), are paid for a finite amount of time for gestating and bearing children for others; as such, they are both literally and figuratively ‘on’ an ‘ART clock’ that is ticking down.
      The ‘ticking’ of the ART clock results, in part, from surrogates’ own and clinic rules regarding age and parity limits. The toll of pregnancy on the body and the time investment in third-party pregnancy were serious considerations for women adding third-party pregnancy to their reproductive trajectories. Although surrogates are not preparing for the arrival of a newborn in their home or anticipating the intense hands-on care needed for one – and they are being paid for their reproductive efforts – they can still find it challenging to incorporate pregnancy into their lives. They consider their abilities to attend medical appointments and travel given the care needs of their children. They often try and time surrogacy, especially the third trimester and birth, to occur during the school year to alleviate some of their care burdens and allow them to enjoy their journeys. They also noted concerns about the impact of pregnancy on their own bodies, given their age and the number of pregnancies they had experienced. The limits that surrogates self-impose – despite their expressed desire to engage in surrogacy ‘again and again’ – highlight the challenges that many women in the USA face when contemplating pregnancy, including how to balance the demands of the second shift, work, education and the intense physicality of pregnancy (Bulanda and Lippmann ,2012;
      • Martin L.J.
      Delaying, debating and declining motherhood.
      ).
      The temporal constraints experienced by surrogates are tightly interwoven with those of the intended parents with whom they work; as patient-clients run out of time on the ART clock, so too do surrogates (at least on that particular journey, with those particular intended parents). Surrogates’ reproductive work is performed on behalf of – and is therefore dependent upon – the ability (financially, emotionally, physically) of ART patient-clients to remain in the fertility clinic. Reproductive workers and ART patient-clients both face an intertwined ART clock that constrains their time and shapes their experiences with assisted reproduction.

      Conclusion

      Recent attention to the pandemic ‘baby bust’ illustrates how reproductive decision making and the timing of reproductive events in the USA, including delays in motherhood, involve not only ‘calculations about one’s ability and desire to conceive, gestate, birth and raise a child’ but strategies to ‘maximize social, economic and human capital’ in response to perceived barriers to parenthood, such as decreasing job security, high educational debt and a lack of universal childcare (
      • Damaske S.
      For the family?: How class and gender shape women's work.
      ,
      • Martin L.J.
      Pushing for the perfect time: Social and biological fertility.
      ,
      • Martin L.J.
      Delaying, debating and declining motherhood.
      ,
      • Waldby Catherine
      • Cooper Melinda
      The biopolitics of reproduction: Post-Fordist biotechnology and women's clinical labour.
      ). The pandemic has exacerbated these issues, highlighting how paid work, childcare, K-12 schooling and higher education are organized in ways constraining or even antithetical to reproduction and the caring of young children (
      • Briggs L.
      How all politics became reproductive politics: From welfare reform to foreclosure to Trump.
      ,

      Broster, Alice. 2021. ‘Coronavirus Hasn't Lead to the Baby Boom that was Anticipated, According to a New Study.’ Forbes.

      ,
      • McQuillan J.
      • Greil A.L.
      • Shreffler K.M.
      • Tichenor V.
      The importance of motherhood among women in the contemporary United States.
      ).
      It will be interesting to see in the months and years ahead how the pandemic baby bust will be framed and any ‘solutions’ proposed. Since the 1970s, the ‘problem’ of the biological clock and delayed motherhood has been understood largely as one of individualized reproductive control, pitting women’s reproductive practices against the ‘natural’ (and therefore, immutable) reality of their own body’s biological limitations (
      • Blair-Loy M.
      Competing devotions: Career and family among women executives.
      ,
      • McQuillan J.
      • Greil A.L.
      • Shreffler K.M.
      • Tichenor V.
      The importance of motherhood among women in the contemporary United States.
      ,
      • Russo N.F.
      Overview: Sex roles, fertility and the motherhood mandate.
      ,
      • Spain D.
      • Bianchi S.
      Balancing act: Motherhood, marriage, and employment among American women.
      ). This false notion of reproductive control, this individualized framing of the ‘problem’ of the biological clock, can be seen in the push (in the public imagination, if not in reality) for the ART solution to delayed motherhood (
      • Sandelowski M.
      Compelled to try: the never-enough quality of conceptive technology.
      ,
      • Waldby Catherine
      • Cooper Melinda
      The biopolitics of reproduction: Post-Fordist biotechnology and women's clinical labour.
      ). ART is increasingly framed as an individualized solution to the ‘dilemma’ of the biological clock and ‘delayed motherhood’ for those able to afford these services (
      • Daniluk J.C.
      • Koert E.
      • Cheung A.
      Childless women’s knowledge of fertility and assisted human reproduction: identifying the gaps.
      ,
      • Wyndham Nichole
      • Figueira Paula Gabriela Marin
      • Patrizio Pasquale
      A persistent misperception: assisted reproductive technology can reverse the ‘aged biological clock’.
      ); perhaps this trend will continue post-pandemic and the rates of third-party reproduction will remain on the rise. If so, as the public enters into new dialogues spurred on by the pandemic about delayed reproduction and inequalities in parenting, the reproductive experiences not only of ART patient-clients, but those of reproductive workers must be part of the larger calculations. In those larger discussions, the concept of the ART clock – including surrogates’ own reproductive desires and temporal constraints to participation in third-party pregnancy – may be helpful to contemplate the temporal limits not only of biology but of the ART ‘solution’.
      Although ART has the potential to extend the temporal dimension of reproduction for patient-clients, allowing for the creation of their children beyond previously understood (and experienced) age limits for parentage, the ART industry is dependent upon the participation of reproductive workers, which has temporal limits. Based on the experiences of US gestational surrogates, the concept of the ART clock proposed in this paper captures that unique temporal landscape of ART reproduction. As shown, the experiences of surrogates demonstrate important limits to ART.
      Assisted reproduction in the USA is embedded in the fertility clinic, which has temporal demands in its operation. ART procedures occur within medical clinics and are, therefore, time-bound to office scheduling and medical/bureaucratic calendars (
      • Thompson C.
      Making Parents: The Ontological Choreography of Reproductive Technologies.
      ); in addition, surrogacy work needs to be completed at a particular time of life, for a particular time period, with preferred times of the year and at preferred family stages. The race against the ART clock, therefore, is not only one that attempts to meet the reproductive desires of patient-clients and their winnowing biological clocks (often within the confines of dwindling economic and emotional reserves), but one that captures reproductive process desires of surrogates and the finite time available for women to engage in surrogacy. The ART clock captures a reality that ART is not an endlessly available option for reproduction as it is dependent upon reproductive workers whose work comes with temporal limits.

      Uncited references

      • Bulanda R.E.
      • Lippmann S.
      The timing of childbirth and family-to-work conflict.
      ,
      • Gerson K.
      and Sarah Damaske.
      ,

      Practice Committee of the American Society for Reproductive, Medicine, and Technology Practice Committee of the Society for Assisted Reproductive. 2017. ‘Recommendations for practices utilizing gestational carriers: a committee opinion.’ Fertility and Sterility 107 (2):e3-e10.

      ,

      Van Balen, F. and Inhorn, M. 2002. ‘Interpreting infertility: A view from the social sciences In: Van Balen, F and Inhorn, M eds.’ Infertility around the globe; New thinking on childlessness, gender, and reproductive technologies:3-32.

      ,

      Van de Wiel, Lucy. 2015. ‘Frozen in anticipation: Eggs for later.’ Women's Studies International Forum 53:119-128.

      .

      Acknowledgements

      The authors would like to thank Anindita Majumdar for the invitation to participate in this special issue on the biological clock, and for her feedback and support. This work was generously supported by the Research Enhancement Program, Faculty Development Leave Program, and the College of Liberal Arts Endowment for Faculty Research Award at The University of Texas at Arlington.

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      Biography

      Heather Jacobson is Professor of Sociology at the University of Texas at Arlington (USA) where she directs the Master’s in Sociology programme. Her research centres primarily on various routes to family formation in the contemporary USA. She is the author of Labor of Love: Gestational Surrogacy and the Work of Making Babies (Rutgers University Press) and Culture Keeping: White Mothers, International Adoption, and the Negotiation of Family Difference (Vanderbilt University Press).