Surrogacy 101: Get the Facts

From selecting a gestational carrier to having the baby

Mother and father holding an ultrasonography of their baby
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Surrogacy may be used to help build a family when a woman cannot carry a pregnancy herself. A gestational carrier carries a pregnancy with the original intention of giving the baby to the parent or parents who commissioned the gestational carrier. Ideally, the intended parents will be listed on the birth certificate.

There are two main kinds of surrogacy, traditional surrogacy and gestational surrogacy. In traditional surrogacy, the gestational carrier's own eggs are used. In gestational surrogacy, the gestational carrier is not genetically related to the baby.

In gestational surrogacy, the intended parents may be the genetic parents of the baby, or an egg donor or sperm donor may be used in combination with one of the intended parent's gametes. Another possibility is an egg donor and sperm donor will be chosen by the intended parents, or embryo donation may be used.

Due to legal complications that can occur with traditional surrogacy, gestational surrogacy is the preferred method of surrogacy. 

Did You Know?

The word surrogate is frequently misused. Surrogate is correct only when a gestational carrier is also the egg donor. Because this is legally and psychologically complex, traditional surrogates are almost never used. Gestational carrier is the proper term for the vast majority of surrogacy arrangements.

When Is Surrogacy Used?

Surrogacy is usually used when a woman cannot medically carry a pregnancy herself. Reasons may include:

  • no uterus, due to a congenital defect known as müllerian agenesis
  • prior hysterectomy
  • uterine malformations that prevent embryo implantation or cause repeated miscarriage
  • untreatable Asherman's syndrome, or uterine adhesions
  • unexplained repeated miscarriages, not resolved by other treatment
  • repeated embryo implantation failures during IVF treatment
  • medical conditions that would make pregnancy life-threatening to the mother or baby, including severe heart disease, lupus, history of breast cancer, severe kidney disease, cystic fibrous, severe diabetes, or a history of severe pre-eclampsia with HELLP syndrome

Surrogacy may also be used to help a gay male couple become parents. Not quite (but almost) surrogacy, sometimes a lesbian couple will do what's known as reciprocal IVF. This is when the eggs are taken from one female partner, fertilized with donor sperm in the lab, and then the resulting embryo is transferred to the other female partner's uterus.

There is a myth that surrogacy is often used by women trying to protect themselves from the physical burdens and aftereffects of pregnancy. This is not true. Surrogacy involves intense financial and emotional investment, and it is not something used to avoid a few stretch marks.

How Do You Find and Choose a Gestational Carrier

Gestational carriers may be someone you know, like a friend or family member, or a stranger, usually found through an agency.

There are advantages and disadvantages of using someone you know for a surrogacy arrangement. One possible advantage is the gestational carrier can easily maintain an ongoing relationship with the child, if that is important to you as the parent. One potential disadvantage is arguments regarding parental decisions may arise, especially if future roles are not completely understood, agreed to, or kept.

If you decide to use an agency to find a gestational gestational carrier, you should speak to your fertility clinic or local RESOLVE support group contact. They should be able to recommend agencies they have had positive experiences with in the past.

It's essential that you get references for any agency you consider, do loads of research, and feel comfortable with your decision before moving forward. If anything feels not right, listen to your gut, even if you received positive reviews of an agency from others.

Surrogacy is complicated, full of legal and emotional challenges. It's important that every member of your family building team is right for you and is the best available for your situation.

Some people consider "going independent" — that is, looking for a gestational carrier (that is not known to you) without the help of an agency. While finding a gestational carrier independently may be less expensive, you're better off going through an agency for such a complex arrangement. It will be less stressful for you and the gestational carrier.

There are some people out there looking to take advantage of couples desperate to have a baby. If you're looking on your own, be aware of fertility frauds and scams.

Something else to keep in mind, seeking a gestational carrier without the help of an agency is not a legal option in some countries.

What Is the Surrogacy Process?

As mentioned above, in gestational surrogacy, there are four potential options for conception of the child:

  • Using egg and sperm from the intended parents. In this situation, both intended parents would be genetically related to the child.
  • Using either egg or sperm from one intended parent, in combination with donor egg or sperm. In this situation, one intended parent would be genetically connected to the baby.
  • Using both donor egg and donor sperm. In this situation, the intended parents would not be genetically related to the child. (This can lead to legal complications in some places.)
  • Using donor embryo. This also would not lead to genetic relation to the baby, which can create legal issues in some places.

To somewhat simplify what is already a complicated process, this explanation will assume the intended parents are providing the egg and sperm for conception.

First, the intended parents will have decided with the help of their doctor that surrogacy is a possible option for them to have a child, and that the intended mother and father have eggs and sperm healthy enough to conceive a child. The intended parents will need to have a psychological screening or evaluation, to help them fully understand the risks and possible complications of an IVF surrogacy, as well as help them think through and understand other options, including adoption or pursuing a childfree life. This may occur before or after the intended parents find an agency.

Then, the intended parents will need to find a surrogacy agency that fits their needs. Getting referrals from their fertility doctor or clinic, their local RESOLVE chapter, or the psychologist who counseled them are possibilities to consider.

Before choosing an agency, the intended parents should get references, speak with former clients of the agency (both gestational carriers and parents), research the agency, and have a meeting with an agency representative.

Once an agency is chosen, and a fee schedule for the agency is discussed and agreed upon, the intended parents will be shown surrogacy profiles that they agency feels may fit them best. When a gestational carrier is found that feels right for the parents, the gestational carrier may "meet" the parents via phone conference. If that goes well, an in-person meeting may take place next. (This is not always required, but highly suggested, even if travel is necessary.)

If the intended parents and gestational carrier feel they are a match, then the gestational carrier will go through medical and psychological screening (this may be repeated even if a previous screening had occurred). If she passes the screening, then the intended parents and gestational carrier will negotiate a contract, with the help of experienced surrogacy lawyers. The agency may suggest a lawyer, or you may choose one yourself.

Most important, it's not a good idea for you and the gestational carrier to share one lawyer. It may seem to save money, but it's not worth the risk that your (or your gestational carrier's) best interests are not fully represented.

Once contracts are signed, fees are negotiated (part of the contract process), and all surrogacy payments have been put in an escrow account, you'll give all this information and paper work to your fertility clinic. Now, the surrogacy procedure itself can begin.

The gestational carrier and the intended mother will have their cycles put in sync with birth control pills and then hormonal injections. Once the treatment cycle begins, the intended mother will go through the beginnings of IVF treatment, which involves injections to stimulate the ovaries and monitoring through ultrasound and blood work.

In the meantime, the gestational carrier will take hormones to help prepare her uterus for embryo transfer.

On the day of the egg retrieval, the intended father will provide a semen sample to the clinic. The retrieved eggs will be combined with the sperm of the intended father. Any resulting embryos will be watched for a few days, to determine their viability.

Then, three to five days after the retrieval, a carefully chosen number of embryos will be transferred to the gestational carrier's uterus. She may need to take hormonal supplements in the form of injections or suppositories to help support the pregnancy.

If the cycle is successful, once a heartbeat has been detected, the gestational carrier will be cared for by her regular OB/GYN. There may be communication between the intended parents and gestational carrier, either directly or through a mediator, throughout the pregnancy. The level and kind of communication should have been agreed to before the surrogacy arrangement, so the parents do not feel left out and the gestational carrier does not feel micro-managed or overwhelmed.

As the time of birth arrives, the gestational carrier may need to relocate temporarily to another state or country, where surrogacy arrangements are legally recognized. This may not be needed if the gestational carrier already lives in a surrogacy friendly state or country, and ideally, it's best to choose a gestational carrier in a surrogacy friendly place.

All this should have been arranged and agreed upon during the contract process, with the help of the lawyers.

When the gestational carrier is verified to be in labor, she will contact the intended parents. The hospital should have been told about the surrogacy arrangement beforehand, so proper communication and access can be provided for all involved.

Whether the intended parents will be with the gestational carrier during or after the birth will depend on agreements between them, hopefully decided upon earlier. Some gestational carrier will be happy to have the parents present, while others may request privacy for all or parts of the labor.

Assuming a happy and healthy birth occurs, the parents should get to hold the baby soon after the birth. In some surrogacy arrangements, the gestational carrier may agree to provide pumped breast milk for the baby for a certain period of time.

The attorney should have arranged the parental rights or pre-birth order paperwork before birth, and it should be available at the time of the baby or babies' birth. This will help get the intended parents' names on the birth certificate, instead of the gestational carrier's name.

In some states and countries, there is a required delay of days or weeks before the gestational carrier can confirm the intended parents as the true parents.

While we always hope for success, it's possible that the IVF cycle will not be successful and several cycles will be attempted. It's also possible for the IVF cycle to be canceled midway for medical reasons, for no embryos to be viable, for the gestational carrier not become pregnant even with viable embryos, or for the gestational carrier may miscarry.

Other potential complications to the surrogacy include a high-order multiple pregnancy, which may lead to a selective fetal reduction (something that should have been discussed prior to signing the surrogacy agreement); detection of a birth defect, which may lead to questions of terminating the pregnancy; or any number of pregnancy complications with the gestational carrier or baby.

All of these situations should be discussed prior to the contracts being signed, to be sure the gestational carrier and intended parents agree on how to handle the situations.

How Much Does Surrogacy Cost?

Surrogacy cost will depend on a number of factors, including whether or not the gestational carrier is known, if the surrogacy is compensated surrogacy (meaning the gestational carrier will receive compensation for her services, almost always the case in the United States), and if gamete or embryo donation is involved. The experience level of the gestational carrier will also affect price, with experienced gestational carriers costing more.

That said, the range is anywhere between $50,000 to $100,000, which includes legal fees, agency fees, IVF fees, and payments to the gestational carrier.

The gestational carrier herself, in compensated surrogacy, is usually paid between $20,000 to $35,000. The payments are provided in parts, starting with confirmation of a heartbeat and given out every few months, via an escrow account that should be set up prior to the IVF process.

Insurance usually does not cover surrogacy arrangements, but may in some cases, cover certain procedures, such as the IVF treatment. The gestational carrier's prenatal and birth may be covered by some insurance carriers, but others include a surrogacy exclusion clause. (When choosing a gestational carrier, finding someone who does have insurance coverage is ideal.)

However, because coverage for the entire surrogacy arrangement is rare and never completely covered, you should plan to pay for the entire process.

A Word From Verywell

Surrogacy can enable individuals and couples who would not otherwise be able to have a child have a baby. As you consider whether surrogacy is right for your family, you'll need to consider the emotional, legal, and financial aspects of the process. Some may struggle with ethical or religious concerns as well. Talk to your fertility doctor, as well as a lawyer familiar with reproductive family law, and counselor before you make a decision or sign any contracts.

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