How Does Surrogacy Work?

By Lisa Esposito
December 10, 2021

When people pursue surrogacy, it’s a journey fueled by a strong commitment to becoming parents. When a woman carries an embryo and goes through pregnancy to help someone else have a child, it’s a unique contribution.

Gestational surrogacy is uncommon, representing only about 2% of all U.S. medical procedures to address infertility, according to the National Assisted Reproductive Technology Surveillance System Group. It’s much less common than treatments like intrauterine insemination or fertility drugs. However, it’s a real option and in some cases, the only option for an individual or couple to have a child.

Experts describe what happens as intended families and gestational carriers go through the surrogacy process.

Surrogacy Terminology

It helps to understand the language used in this field:

Types of Surrogacy

Gestational surrogacy. “Gestational surrogacy typically means that an embryo is placed into the uterus of a gestational carrier,” says Dr. Dorette Noorhasan, the medical director and co-founder of CCRM Fertility in Dallas–Fort Worth. “The sole purpose is for that person to carry the pregnancy and give birth nine months later.” The woman carrying the embryo has no biological relationship to the egg or sperm that created it.
Compassionate surrogacy. A surrogate does a carrier cycle for someone they know – a family member or friend – and is not financially compensated.
Compensated surrogacy. “This is where the gestational carrier received compensation for her time and effort in carrying the pregnancy,” says Dr. Jamie Massie, an OB-GYN, reproductive endocrinologist and infertility specialist at the ORM Fertility Clinic in Bellevue, Washington.
Traditional surrogacy. Rarely practiced in the U.S. because of the legal and emotional complexities, traditional surrogacy is when the surrogate uses her own egg and is artificially inseminated with sperm from a donor or the intended father, so she is actually the biological mother.

Carriers

Gestational carrier. Also called a gestational surrogate, this woman carries and gives birth to a baby for another individual or family. This encompasses both compassionate and compensated surrogacies.

Medical Terms

Carrier cycle. This process involves an in vitro fertilization cycle (see definition below) to produce the embryo, which is then transferred to the gestational carrier at the chosen time. Pregnancy is the next phase.
In vitro fertilization (IVF). A technique, done in a laboratory, which uses the egg and sperm from the intended parents to create the embryo.
Embryo transfer. In this procedure, which is typically done in a fertility clinic, the embryo is placed in the uterus of the gestational carrier.
Third-party reproduction. In this approach, someone other than the intended parents is involved in the process of reproduction, through egg donation, sperm donation or an embryo-gestational carrier arrangement.

Other Terms

Intended family/parents. People who seek gestational surrogacy to have a child are called intended parents. “A lot of people do surrogacy because they have to,” says Noorhasan, author of the book “Miracle Baby: A Fertility Doctor’s Fight for Motherhood” published in 2019, which describes her personal experience as an intended parent.
Reproductive attorney. Attorneys who specialize in assisted reproduction are experts in legal issues such as gestational carrier contracts, parental rights and widely varying state laws regarding surrogacy arrangements.
Surrogacy agency. This type of business screens potential gestational carriers and helps match them with intended families. Agencies coordinate between all parties including clinics and surrogacy attorneys, mediate contracts between the intended parents and surrogate and provide counseling and support.

Pathway to Parenthood

Two main paths lead people to a fertility clinic to consider surrogacy, Massie says. One is the inability to carry a child whatsoever, such as for same-sex male couples. “So they need somebody to participate in their family building.” Similarly, there are people who come to a fertility clinic already aware that an existing medical condition prevents them from safely carrying a pregnancy.

“The other group of parents are people who have undergone fertility treatments on their own and have been using their own eggs, own sperm, own uterus, and have been unsuccessful in carrying a pregnancy, whether that’s due to recurring pregnancy loss or failed implantation,” Massie says. “They come to the decision to try a gestational carrier journey.”

In addition, “women in heterosexual relationships will use surrogates, as well, if, for example, the woman just can’t carry the pregnancy because of chronic medical problems, or she’s had a history of multiple miscarriages where her uterus is seen to be the reason why those miscarried,” Noorhasan says. “Or she has severe chronic disease and it would cost her the pregnancy or her life to be physically pregnant.” Women who’ve had a hysterectomy or a uterine ablation procedure may also consider surrogacy.

“If you are a patient, or somebody who potentially uses a surrogate, first of all you want to get an infertility workup,” Noorhasan says. “It’s not common that somebody needs a surrogate. You’d want to do testing, get a good assessment and talk to your doctor to find out if you do need one.”

Preparing for surrogacy involves a lengthy process. “There’s a huge lead time for these types of journeys,” Massie says. “It takes anywhere from about eight to 18 months for this pathway to play out with all the pieces. There are big access-to-care issues that families have to consider, such as lack of insurance coverage for fertility services and limited availability of gestational carriers.”

Chance for Success

According to the SART Final National Summary Report for 2018, the overall live birth rate using a patient’s own egg and a gestational carrier was about 52% for a first embryo transfer, and nearly 57% for a second or later embryo transfer (if a first embryo transfer doesn’t succeed) among younger women. Statistics reflect SART (Society for Assisted Reproductive Technology) member clinics.

“The biggest factor in terms of reproductive success is actually linked to the quality of the eggs, secondarily linked to the quality of the sperm and the uterine environment,” Massie says. “So, if we’re using an egg from a young, reproductive-age female as we might see from a donor-egg cycle, per-cycle success rates for gestation carrier cycles are quite high.”

However, “If you’re using the eggs from an older ovary, or perhaps from an ovary that we know provides eggs of poor quality, or from a couple that we know creates embryos that are of poor quality, success rates really reflect that more significantly,” Massie says.

Becoming a Gestational Carrier

Women interested in becoming gestational carriers can reach out to a surrogacy agency that can coordinate the entire process, working with the fertility clinic.

“In order for a gestational carrier to be approved to carry someone else’s pregnancy, first they have to go through quite an evaluation in order to even start on that journey,” Massie says. “The biggest piece is the medical record review, where a physician or a nurse practitioner reviews that medical record, looking for any signs or warning flags that might put that gestational carrier at undue risk if they carry another pregnancy or that would put the baby at undue risk. So, we need a gestational carrier to be a healthy individual, somebody who’s had at least one successful pregnancy and live birth in the past, a medical history that’s unremarkable and no significant complications related to the pregnancy itself.”

Gestational surrogates undergo a psychological evaluation as part of initial screening. In addition, before finalizing arrangements, “The surrogate, and typically her husband, will meet with the therapist for psychological screening to make sure they’re comfortable with the process,” Noorhasan says. “So, making sure that she has support in her family structure and he’s comfortable with her being pregnant and it’s not his baby.”

Women who become gestational carriers are typically able to step aside and relinquish the child without regrets after delivery. As intended parents, “If you do everything right – you picked the right surrogate, there’s a contract, there’s a great relationship – most of the time they just want to be pregnant, deliver (the baby) and go,” Noorhasan says.

“Time and again, seasoned carriers tell us that they have an entirely different mindset toward the baby in a gestational carrier surrogacy than a pregnancy of their own,” says psychologist Britta Dinsmore, clinical director of psychological services for ORM Fertility. “Though they often report feeling warm, nurturing, and protective toward the baby, they aren’t relating to the baby throughout the pregnancy in a maternal way by visualizing a future mothering this child or imagining what it will be like to bring the baby home to meet siblings.”

Making the Match

Surrogacy agencies help connect intended parents with potential gestational carriers. Deciding on a compatible surrogate is an important choice for the family.

“What I will tell people is: It’s really a match,” Noorhasan says. With this major commitment, having someone you can relate to well is essential, she adds. “It’s kind of like you’re going to be dating this person for nine months,’ she says. “We’re all great people, but not all of us are meant to match certain people. Finding the right person that’s the right match is going to be important.”

Once a potential match arises, negotiations occur and legal documents are written. “It’s extremely important for intended families and gestational carriers to obtain legal representation to guide them,” Massie says. The Academy of Adoption and Assisted Reproduction Attorneys provides an attorney directory.

Pregnancy Process

To create the embryo, intended parents undergo IVF. The embryo transfer is the beginning of the actual pregnancy.

“That’s where we place an embryo that’s already been created into the uterus of the gestational carrier,” Massie says. “The procedure is actually quite straightforward – it takes about 10 to 15 minutes.” Using a floppy plastic catheter, about the size of the tip of a pen, she says, “Under ultrasound guidance we place it into the uterus and the embryo is placed into the uterine cavity.”

After embryo transfers take place, “The pregnancies are really the same as they are when people conceive on their own,” Massie says. “You get the full range of people who feel great and people who feel crummy, and individuals who have morning sickness and who don’t.”

After early evaluation visits, maternity care is also similar to that of a standard pregnancy for the surrogate. “She goes to the fertility clinic for a few ultrasounds to make sure the pregnancy looks good,” Noorhasan says. “And then, once she’s about two months pregnant, they send her off to the obstetrician.”

Hurdles and Challenges

Cost is a significant challenge for intended parents. “The surrogacy journey can be a very expensive one,” Massie says.

On average, costs range from about $90,000 to $150,000 for a gestational carrier cycle and pregnancy. Fees and compensations for which intended parents are responsible may include:

Fertility treatments (such as embryo creation, IVF).
Surrogacy agency fees.
Gestational surrogate screening (medical and psychological) costs.
Gestational surrogate compensation.
Mental health costs for surrogate and intended parents.
Legal fees, expenses and establishment of parenting rights.

Additional costs can arise, such as for medical/pregnancy procedures and maternity insurance for pregnancy-related health care for the surrogate.
In some cases, financial help is available for families struggling to afford infertility solutions including gestational surrogacy. RESOLVE: The National Fertility Infertility Organization, offers a wealth of resources and guidance on their website, including information on insurance coverage, financial relief for fertility treatments, infertility treatment grants and scholarships.

In addition to cost challenges, there’s been an increasing paucity of available gestational surrogates.

“The second biggest barrier is the limited number of individuals who are willing and medically healthy enough to act as gestational carriers,” Massie says. With the COVID-19 pandemic, there’s been a “pretty significant decline,” she adds.

Emotional Scenario

Intended parents and gestational surrogates face certain emotional issues. For both parties, counseling is an important part of the process.

“Having someone else carry your baby requires a tremendous amount of ‘letting go,’ and the lack of control inherent to the situation is often a source of anxiety and can be one of the challenging aspects of gestational surrogacy for intended parents,” Dinsmore says. “Finding healthy ways to manage this anxiety is essential.”

Communication is key. “Negotiating mutually agreed-on expectations early in the process can be helpful,” Dinsmore adds. “Focusing on building good rapport and a good relationship with the carrier may yield the biggest benefits,” she says. “A personal connection with one’s carrier tends to promote a greater sense of trust, which can help reduce anxiety and can also make it easier to navigate any unexpected challenges that may arise.”

Gestational carriers can feel emotionally as well as physically invested in the pregnancy’s success.

“It’s important for a gestational carrier to recognize that she is giving someone an opportunity to have a child and to feel a sense of reward and pride in that, rather than have her sense of fulfillment and success be tied to an overly narrow, idealized vision of how the journey should play out,” Dinsmore says.

“Things don’t always go as planned,” Dinsmore points out. “The first embryo transfer may be unsuccessful, shared decision-making during pregnancy may present occasional challenges, medical considerations may interfere with best-laid plans for the delivery or the intended parents may not maintain contact after the delivery to the extent that was hoped for.”

At the end of it all, Dinsmore says, “Regardless of how smooth or bumpy the journey was, hopefully the carrier can feel good knowing that she has contributed to someone’s life in an incredibly life-changing and significant way.”

Moving Forward

Transparency about surrogacy is another issue for parents to consider once children are old enough to understand, using age-appropriate concepts and language. Parental attitudes vary. “I think it’s up to the intended parents to decide whether they’re going to tell their children or not,” Noorhasan says, and each case is individual.

However, transparency can be helpful and proactive. “(Data) on that really suggests that children do beautifully if they’re informed where they came from, from the very beginning,” Massie says. “There’s been no demonstrated negative psychologic impact on children born through third-party family-building methods – except in circumstances where they found that information out unexpectedly.”

Gestational surrogacy is doable, Massie emphasizes. “This is a joyous way for people to create their families,” she says. “The people who act as gestational surrogates do so because they’re wonderful people who have enjoyed being pregnant, who want to support other people in their journey to parenthood, because they’ve enjoyed that process so much. There are a million ways that you can build a successful family – this is just one.”