Surrogacy 101: Get the Facts

From selecting a gestational carrier to having a baby

Mother and father holding an ultrasonography of their baby
Kohei Hara/Getty Images

Surrogacy (sometimes called third-party reproduction) is one way you can start a family if you or your partner is unable to carry a pregnancy. A gestational carrier is a person who is commissioned by a person or couple to carry a pregnancy. When the baby is born, the intended parents may be listed on the birth certificate.

Surrogate vs. Gestational Carrier

The word surrogate is frequently misused. Surrogate is the correct term only when a gestational carrier is also the egg donor.

A gestational carrier correctly describes most surrogacy arrangements. The legal and psychological complexity of traditional surrogacy means that it is rarely used.

Surrogacy can be traditional or gestational. With traditional surrogacy, a gestational carrier's own eggs are inseminated with the sperm of an intended parent or donor. The surrogate is therefore genetically related to the baby.

With gestational surrogacy, an egg from an intended parent that has been fertilized with a partner's sperm (or donor sperm) is used. In these cases, the gestational carrier is not genetically related to the baby.

In gestational surrogacy, the intended parents are often the genetic parents of the baby. However, it's also possible to use an egg donor or sperm donor with one of the intended parent's gametes (reproductive cells). Intended parents might choose both an egg and a sperm donor, or even choose embryo donation.

When Is Surrogacy Used?

The most common reason people choose surrogacy is when a pregnancy is not possible. There are several reasons why a person might not be able to become pregnant, including:

Surrogacy is one way that LGBTQ+ can become parents. For example, lesbian couples can use reciprocal IVF. During this procedure, eggs are taken from one partner and are fertilized with donor sperm in a lab. The resulting embryo is then transferred to the other partner's uterus.

How To Find and Choose a Gestational Carrier

Gestational carriers can be someone you know (such as a friend or family member) or a stranger that you've connected with through an agency. Each option has pros and cons.

If it's important to you that the gestational carrier maintains a relationship with your child, this will be easier if someone you know is part of the arrangement. However, a possible downside to this arrangement is that disagreements about raising the child could come up.

Disagreements about parental decisions are more likely to occur if roles and expectations are not made clear early in the surrogacy arrangement process.

If you decide to use an agency to find a gestational carrier, start by reaching out to your fertility clinic or local RESOLVE support group. They can recommend agencies that they have had positive experiences with.

Get references for any agency that you are considering and do your research. If anything feels not wrong to you, listen to your gut—even if you received positive reviews of an agency from others.

Surrogacy is complicated and comes with legal and emotional challenges. You want to feel comfortable with your decision and supported by every member of your team.

You might wonder if you can find a gestational carrier independently. In some cases, private surrogacy might be an option.

While searching for a gestational carrier on your own might cost less money, both you and the person you choose will have more support if you have the help of an agency.

You'll also need to look at the laws where you live. In some countries, it is not legal to form a surrogacy arrangement independently. In the United States, there is no federal law that governs surrogacy, which means each state has its own laws.

Avoiding Scams

If you're on your own, you're also more vulnerable to fertility frauds and scams.

The Surrogacy Process

To try to simplify a complicated process, this explanation of the surrogacy process assumes that the intended parents are providing the egg and sperm for conception.

Choosing Surrogacy

When an individual or couple tells their provider they are seriously considering surrogacy, there are few steps that can be taken to support them through the decision-making process.

First, the intended parents will have psychological counseling. This is to make sure that they fully understand and accept the risks and potential complications of using surrogacy.

These discussions also give an individual or couple the opportunity to thoroughly consider the other options, such as becoming a foster parent, adoption, or pursuing a childfree life.

Finding an Agency

When intended parents have decided to pursue surrogacy, the next step will be to find an agency that suits their needs. They might get referrals from their fertility clinic, a local RESOLVE chapter, or the psychologist who provided counseling.

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.

Choosing a Surrogate or Gestational Carrier

Once an agency has been selected and a fee schedule is discussed and agreed upon, the intended parents will be shown profiles of potential gestational carriers.

When the intended parents select a gestational carrier, the first meeting with them might take place over the phone or through video chat. If the initial meeting goes well, an in-person meeting might be scheduled.

An in-person meeting with a gestational carrier is not necessarily required but is often suggested—even if travel is necessary.

If the intended parents and a gestational carrier feel that they are a match, then the gestational carrier will go through medical and psychological screening (a process that might be repeated even if the carrier was screened for a previous potential arrangement).

If the gestational carrier passes the screening, the next step is for everyone to negotiate a contract. This is generally done with the help of experienced surrogacy lawyers. The agency might suggest a lawyer, or you might select one yourself.

You and the gestational carrier should not share the same lawyer. It might seem like a way to save money, but it's not worth the risk that your (or your gestational carrier's) best interests are not fully represented.

Signing Contracts

Once the contracts have been created, the fees have been negotiated (part of the contract process), and all surrogacy payments have been put in an escrow account, the contracts will be finalized and signed. Your fertility clinic will get copies of all the signed paperwork.

Conception

Once the paperwork is in order, it's time to move on to the process of making a baby. The first step in gestational surrogacy is for a gestational carrier and the intended parent who will contribute eggs to have their cycles synced with birth control pills and, later, hormonal injections.

Once the treatment cycle begins, the intended parent will go through the initial stages of IVF treatment, which typically involves injections to stimulate the ovaries, ultrasound monitoring, and blood work. The gestational carrier will take hormones to help prepare the uterus for embryo transfer.

If you're using gestational surrogacy, there are four possible ways to conceive:

  • Using an egg and sperm from the intended parents. In this situation, both intended parents would be genetically related to the child.
  • Using the egg or sperm from one intended parent with a donor egg or sperm. In this situation, one intended parent would be genetically related to the baby.
  • Using both a donor egg and donor sperm. In this situation, the intended parents would not be genetically related to the child (which can have legal ramifications in some cases).
  • Using a donor embryo. Again, the intended parents are not genetically related to the child in this situation. Depending on where you live, this can have legal complications.

On the day of the egg retrieval, the intended partner providing sperm will give a sample at the clinic. The retrieved eggs will be combined with the sperm. Any embryos that result will be watched for a few days to determine their viability.

Three to five days after the retrieval, a carefully chosen number of embryos will be transferred to the gestational carrier's uterus. The carrier might need to take hormonal supplements (injections or suppositories) to support the pregnancy.

Pregnancy

Once a heartbeat has been detected, the cycle will be considered successful. The gestational carrier will then be cared for by their regular OB/GYN. Throughout the pregnancy, there might be direct or indirect communication between the intended parents and the gestational carrier. A mediator might be used if the communication is indirect.

The level and kind of communication will have been decided before the surrogacy arrangement. This helps ensure that the intended parents do not feel left out and the gestational carrier does not feel "micromanaged" or overwhelmed.

Labor and Delivery

As the time of birth gets closer, the gestational carrier might need to temporarily relocate to another state or country where surrogacy arrangements are legally recognized. If the gestational carrier already lives in a state or country where surrogacy is recognized, relocation might not be necessary.

Laws about surrogacy in the gestational carrier's location should be reviewed during the selection and contract negotiation process.

The hospital where the gestational carrier will deliver should be notified of the surrogacy arrangement in advance and have clear instructions for communication. When the gestational carrier goes into labor, the intended parents will be notified.

The intended parents and gestational carrier will have discussed plans for labor and delivery during the contract formation process. Together, they will decide who will be present during labor and delivery.

Some gestational carriers are fine having the intended parents present through labor and delivery, while others might prefer privacy until after the baby is born.

After Delivery

If all goes well, the intended parents will be able to meet and hold their baby soon after birth. For the first few days, weeks, or even months, the gestational carrier might continue to play a role in the baby's life. For example, depending on the surrogacy agreement, some gestational carriers agree to provide pumped breast milk for the baby for a certain amount of time.

All parental rights and pre-birth order paperwork should be completed and readily available at the hospital by the time the baby arrives. This will help ensure that the intended parents' names are listed on the birth certificate instead of the gestational carrier's name.

Possible Complications

IVF cycles are not always successful, and several cycles might need to be attempted. It's also possible for an IVF cycle to be canceled midway because:

  • No embryos are viable
  • The gestational carrier does not become pregnant even with viable embryos
  • The gestational carrier miscarries
  • There are medical complications

High-order multiple pregnancies can also occur and can lead to selective fetal reduction—a possible outcome that should be discussed prior to signing the surrogacy agreement.

The intended parents and gestational carrier may need to discuss termination if there is a problem with the fetus or the pregnancy.

How Much Does Surrogacy Cost?

Depending on where you live, it may or may not be legal for a gestational carrier to receive financial compensation. If you live in the United States, you need to know that compensated surrogacy arrangements are not legal in every state.

In some countries, such as the United Kingdom, it is illegal for the gestational carrier to be paid. The only option in these countries is "compassionate surrogacy" (also called "altruistic surrogacy").

In compassionate surrogacy arrangements, the intended parents cover all the costs and the gestational carrier does not receive any form of compensation. Most often, these arrangements involve a person the intended parents know.

If you choose to pursue a compensated surrogacy agreement, there are several factors that will affect the overall cost:

  • The experience level of the gestational carrier (experienced gestational carriers generally cost more)
  • Whether the gestational carrier is known or unknown to the intended parents
  • Whether gamete or embryo donation is involved

In compensated surrogacy, the gestational carrier is usually paid between $20,000 to $35,000. The payments are divided, with the first being paid at confirmation of a heartbeat, then the rest is given every few months via an escrow account that is set up prior to starting IVF.

Surrogacy costs can reach upwards of $100,000 and include legal fees, agency fees, IVF fees, and payments to the gestational carrier.

A gestational carrier's prenatal care, labor, and delivery might be covered by their insurance plan, but some policies exclude it from coverage. Others will cover it as an infertility treatment. In most surrogacy arrangements, the intended parents will pay all insurance premiums, copays, and deductibles for the gestational carrier's insurance.

In terms of medical costs associated with surrogacy, intended parents should be prepared to pay for all expenses rather than assume some or all will be covered by an insurance policy.

The legal stipulations for surrogacy arrangements vary from one state to another, as well as from one country to another.

A Word From Verywell

If you would like to have children but are unable to carry a pregnancy, a surrogacy arrangement is one option to consider. However, know that surrogacy is a complex, lengthy, and expensive process.

The decision to use surrogacy has emotional, legal, financial, ethical, and religious aspects that you will need to think about. You will also need to decide what type of surrogacy is best for you, as well as work out the details of the arrangement with your partner (if you have one).

Your fertility doctor, a lawyer familiar with reproductive family law, and a counselor can help you make an informed decision and will support you and the gestational carrier you choose throughout the process.

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Article Sources
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