A Guide to the Surrogacy Process
Surrogacy is when a woman agrees to carry a pregnancy and deliver a baby for another couple or individual. Whilst traditional surrogacy involves the use of the woman’s eggs, the now more common gestational surrogacy involves the implantation of an embryo in the surrogate’s womb.
Dr. Sheeva Talebian from CCRM NY shares insight with Dreaming of Baby on the process of surrogacy and what it entails.
CJ: Hello, and welcome to Dreaming of Baby! Today we have with us Dr. Sheeva Talebian from CCRM NY to discuss surrogacy. Dr, would you be so kind as to tell our readers a little about yourself and what you do?
Sheeva Talebian, MD: I am a fertility specialist based in NYC. My practice is largely comprised of couples and individuals with fertility challenges. I perform procedures like IVF and IUI. I am the “Third Party Coordinator” for my center. This refers to working with couples/individuals needing donor eggs, donor sperm, and/or a gestational carrier (aka a surrogate).
When is a surrogate needed?
CJ: To get us started off on surrogacy, who generally needs a surrogate?
Sheeva Talebian, MD: A surrogate is needed by any individual/couple who does not have a healthy uterus, or in a woman who may have medical conditions where carrying a pregnancy is too risky.
CJ: This also includes male only couples?
Sheeva Talebian, MD: Yes exactly. Single male or male/male couples or a woman whose uterus has been surgically removed, damaged from prior surgeries, multiple unexplained miscarriages, or a woman with medical conditions where pregnancy is not advised. By definition, a true surrogate is a woman who is carrying a baby that is from her own egg. This type of surrogacy pretty much does not occur any longer. What is most common place today is “a gestational carrier”- a woman carrying a baby that she is NOT genetically related to, meaning not her egg, and not a partner’s sperm.
The surrogacy process
CJ: Excellent, so now that we know the who, I’d love to learn more about the process itself. When the need for a surrogate is identified, what is the first step once a willing surrogate is found?
Sheeva Talebian, MD: Typically, the sequence of events entails a fertility specialist to start. The process entails undergoing IVF (in vitro fertilization) to make an embryo(s). Some people go through this step first to ensure they can make viable embryos and then they work on obtaining a surrogate. However, sometimes it is done in tandem. Most people use an “agency” to identify a surrogate. The agency recruits potential candidates and does some baseline medical/psychological/family screening. If the woman meets the criteria to be a surrogate, she is presented to the individual/couple. If the individual/couple (termed “intended parent(s)”) are in agreement, a fertility center will coordinate a meeting of the intended parents and surrogate. Most often, they will also undergo a group consult with a psychologist as well. If things continue to proceed smoothly, legal documents are drafted. Once all is cleared, the embryo transfer (implant) is scheduled.
CJ: To ensure I am understanding clearly: Step 1, the parents would either undergo IVF treatment to extract a healthy egg and sperm which are combined and nurtured to become an embryo. In some cases, this may be a donor egg or donor sperm in which case the same nurturing (incubating) for the oocyte to develop into an embryo. Often the surrogate is already identified so that they are ready to proceed once viable embryos are available for implantation? Is this correct?
Sheeva Talebian, MD: Yes! For the most part. However, sometimes the surrogate is NOT yet identified. It can take six months to over a year to identify a suitable surrogate. So many people opt to create the embryos in that interim. Truthfully, if the age of the egg source is over 40 years old, it is often advised to make the embryos first to ensure healthy embryos can be obtained before starting the search for a surrogate. Given how successful IVF has become, and our ability to freeze embryos, it is more common nowadays to do the IVF part first.
For how long can embryos be stored?
CJ: Excellent, so in this case I have to ask, can embryos be stored indefinitely?
Sheeva Talebian, MD: Yes! We use a technology called vitrification- there is no time limit with the freezing.
CJ: Wow ok, I knew sperm and eggs could be vitrified, I was not as certain on embryos. We often hear about live cycles for surrogates, is this becoming less common? I believe one would have to sync their cycle with a surrogate etc; very confusing, I would appreciate if you can clear it up for us?
Sheeva Talebian, MD: Exactly – live or “fresh” cycles with surrogates are becoming far less common given many of our advances in technology. We are becoming very skilled at “testing” the chromosomes of an embryo and better identifying which embryos have the best chance of implanting and lowest chance of miscarriage (or testing + for a chromosomal issue during the pregnancy). We have also improved our freezing technology dramatically. At the top IVF labs in the country, we do not see a compromise in pregnancy rates with frozen embryos. So, for those needing a surrogate, if they can do IVF at a top center, test the embryos and freeze them- that makes the surrogacy process more successful and efficient. This is particularly helpful if the egg source is over 35 years of age because there is a higher risk of chromosomal abnormalities.
CJ: So for the purpose of this interview, and thanks to advancement in science, we will focus on surrogacy with vitrified embryos.
Sheeva Talebian, MD: If using donor eggs (presumably the egg source is young) – there is not as much of an argument to “test” the embryos but still many do so. Once again, this is done to make the embryo transfer process more efficient for the surrogate and also lower the risk of scenarios of finding out during the pregnancy the baby has a chromosomal aberration and having to potentially terminate.
What happens once a surrogate is selected?
CJ: So let’s walk a mile or so in the surrogate’s shoes so to speak. We are going to assume in this scenario that a healthy embryo or embryos already exist. A surrogate has been chosen and all the paperwork and preparation completed. What happens now?
Sheeva Talebian, MD: Prior to all this, the surrogate has undergone physical exams, blood work, interviews, etc. If all that is cleared and legal documents done, then we prepare for a transfer. Really whether frozen embryos or a “live” transfer, the preparation is similar.
CJ: Does the surrogate need to take any treatments, hormones, etc.?
Sheeva Talebian, MD: She takes estrogen to build her uterine lining. Once it’s adequately thick, she starts progesterone and the embryo transfer is scheduled based on the days of progesterone. She travels to the center doing the transfer. The embryo is thawed on the day of the transfer. The transfer is performed after a speculum is placed (visualize the cervix), and a thin catheter (size and consistency of a piece of spaghetti) is placed into the uterus with the embryo (microscopic). An ultrasound is usually done at the same time, abdominally, to confirm proper placement. The procedure does not hurt and does not entail the use of any anesthesia. She is then on bedrest for about 30 minutes and then is free to walk out of the center. She continues estrogen and progesterone for about 8 more weeks (if the pregnancy test is positive).
CJ: Thanks for this overview. How long before the implantation, is estrogen started?
Sheeva Talebian, MD: So, estrogen for about 2 weeks, then overlapped with progesterone for 6 days and the implant. So about 3 weeks of the estrogen-progesterone prep, the implant, continued hormones and pregnancy test about 9-10 days after implant. The hormones usually start on day 2/3 of the menstrual cycle and implant on roughly “day 21”. However, many of the surrogates are given birth control pills and a medication called Lupron to suppress their natural ovulation so as not to interfere the schedule implant.
CJ: Excellent, so once a successful pregnancy is recorded, what happens next? Is the fertility specialist still involved or is there a handover to a different specialist?
Sheeva Talebian, MD: Once there is a positive pregnancy test (considered “4 weeks”) the fertility specialist will monitor the surrogate. Many times, the surrogate is not actually living in the vicinity of where the implant was performed – she can do ultrasounds and blood work locally as ordered by the fertility doctor. Once the surrogate is about 8 to 10 weeks pregnant, she transitions all her care to her local OB (already established).
Sheeva Talebian, MD: Remember that embryos may be created in one state, transported to another state for implant, and the surrogate can live in a third state! The laws are very state dependent. The surrogacy agency helps navigate this aspect with their legal counsel. For example, many states will consider the birth mother the biological mother and this woman’s name is on the birth certificate. However, some states will allow you to do the legal paperwork before the birth so that the intended parents are on the birth certificate (not the surrogate).
CJ: Wow, ok, so this is something a fertility specialist would help handle?
Sheeva Talebian, MD: The agency and agency attorney help navigate this.
CJ: This, I believe, would be a whole subject to itself and very complex but do you know of certain states where it is favorable?
Sheeva Talebian, MD: For example, in NY, we can NOT legally implant an embryo into a paid surrogate (altruistic is ok). So, we can make the embryos here in NY. The embryos can be transported to NJ where the implant can be done. However, the surrogate is not actually a resident of NJ because in the state of NJ, the pre-birth paperwork cannot be done. So, the surrogate may travel from Pennsylvania or even California, or Florida. California, for instance, is favorable to deliver and legal to do the implant. This is the case for a handful of other states too.
CJ: Wow, ok, so I am going to switch us back a little to the less legal side of things. I am guessing and hoping that there is hand-holding in this process and it definitely pays to work with a clinic that has experience in such matters. You mentioned that the surrogate would do as coordinated by the fertility specialist. What type of tests and how frequently is the fetus monitored etc.?
Sheeva Talebian, MD: Yes, it’s very important to work with a good surrogacy agency (one that has been well established and known to do some strong hand holding the ENTIRE time). Also, an IVF center that understands the nuances. For the surrogate, she undergoes a physical exam, assessment of her uterus, psychologic screening, and many times a “home visit” to assess her living situation (stable, safe, etc). These tests are done by a combination of both the agency and the fertility center performing the embryo transfer.
CJ: Excellent, so when does the fertility specialist disengage so to speak?
Sheeva Talebian, MD: At around 10 weeks.
CJ: Ok, so once the baby is pretty much considered healthy and all is well?
Sheeva Talebian, MD: There are still some other big hurdles – there is screening done in the late first trimester (11-12 weeks) looking for “trisomies”- these are chromosomal aberrations that can make it past the 10-week mark. There are also detailed anatomy ultrasounds done at 16-20 weeks where birth defects can be detected.
CJ: Is the fertility specialist involved at this point though? Also if the pregnancy is not successful what generally happens next?
Sheeva Talebian, MD: No, after 10 weeks we are not involved, but of course if there is a miscarriage, etc. they would come back to us for additional implants.
CJ: This has been quite the learning experience, there is definitely more we could cover and learn but we have kept you for quite a while. Thank you for your time today, Dr. Talebian, it’s been a pleasure speaking with you.
Sheeva Talebian, MD is a fertility specialist at CCRM NY.