How Does Surrogacy Work, Exactly?
August 23, 2021
Reproductive experts unpack the surrogacy process from start to finish and explain everything in between (think: costs, laws, agencies, the list goes on).
Kim Kardashian did it. So did Gabrielle Union. And now, Lance Bass is doing it as well.
But despite its A-list affiliation and considerable price tag, surrogacy isn’t just for stars. Families turn to this third-party reproductive technique for a variety of reasons — yet surrogacy remains a bit of a mystery to those who haven’t pursued it.
But how, exactly, does surrogacy work? Ahead, the answers to all of your surrogacy-related questions, according to experts.
What Is Surrogacy?
“Surrogacy is a general term for an arrangement between two parties: The surrogate agrees to carry a pregnancy for the intended parents or parent. There are two types of surrogacy: gestational surrogacy and traditional surrogacy,” says Barry Witt, M.D., medical director at WINFertility.
“Gestational surrogacy uses the egg of the intended mother (or a donor egg) and the sperm of the intended father (or sperm donor) to create an embryo, which is then transferred into the uterus of a surrogate,” says Dr. Witt.
On the other hand, “traditional surrogacy is where the surrogate’s own eggs are used, making her the biological mother of the child. This can be accomplished by inseminating the carrier with sperm from the father (or sperm donor) who then conceives, and the resulting child belongs to the intended parent,” says Dr. Witt.
But traditional surrogacy is far from the norm in 2021, according to Dr. Witt. “[It’s] now performed very rarely because it’s more complicated, both legally and emotionally,” he explains. “Since the genetic mother and the birth mother are the same, the legal status of the child is more difficult to determine than in a gestational surrogacy situation where the egg is from the intended parent.” (Related: What Ob-Gyns Wish Women Knew About Their Fertility)
So odds are that when you hear about surrogacy (be it in the case of Kim Kardashian or your neighbor) it’s likely gestational surrogacy.
Why Pursue Surrogacy?
First thing’s first: Let go of the idea that surrogacy is all about luxury. There are several situations that make this a medically necessary procedure. (Related: What Is Secondary Infertility, and What Can You Do About It?)
People pursue surrogacy due to lack of a uterus (either in a biological woman who had a hysterectomy or in someone who was assigned male at birth) or a history of uterine surgeries (e.g. fibroid surgery or multiple dilation and curettage procedures, which are often used to clear the uterus after a miscarriage or abortion), explains Sheeva Talebian, M.D., a reproductive endocrinologist at CCRM Fertility in New York City. Other reasons for surrogacy? When someone has previously experienced complicated or high-risk pregnancies, multiple unexplained miscarriages, or failed IVF cycles; and, of course, if a same-sex couple or single person who can’t carry is pursuing parenthood.
How Do You Find a Surrogate?
Stories of a friend or family member volunteering to carry a child for a loved one? That’s not just the stuff of movies or viral headlines. Some surrogacy arrangements are, in fact, handled independently, according to Janene Oleaga, Esq., an assisted reproductive technology attorney. More commonly, though, families use a surrogacy agency to find a carrier.
While the process can vary from one agency to another, at Circle Surrogacy, for example, “matching and legal teams work together to determine the best possible matching options based on a variety of factors,” says Jen Rachman, L.C.S.W., outreach associate at Circle Surrogacy. These include the state in which the surrogate lives, whether they have insurance, and the matching preferences from both intended parents and the surrogate, she explains. “Once a match is found, redacted profiles of the intended parents and surrogates (with no identifying information) will be exchanged. If both parties express interest, Circle arranges a match call (typically a video call) together for the surrogate and intended parents to get to know each other.”
And if both parties agree to pursue a match, the process doesn’t end there. “An IVF physician medically screens surrogates after a match is made,” says Rachman. “If for any reason the surrogate does not pass the medical screening (which is rare), Circle Surrogacy presents a new match free of charge.” (Related: Should You Get Your Fertility Tested Before Even Thinking About Having Kids?)
In general, “the potential surrogate will meet with a fertility specialist to do specific exams to assess the interior of the uterus (usually an in-office saline sonogram), a trial transfer (mock embryo transfer to make sure the catheter can be inserted smoothly), and a transvaginal ultrasound to assess the structure of the uterus and ovaries,” says Dr. Talebian. “The surrogate will need an updated Pap smear and if she is over 35, [a] breast mammogram. She will also meet with the prospective obstetrician who will manage her pregnancy.” While the medical screening is underway, a legal contract is drafted for both parties to sign.
What Do the Laws Around Surrogacy Look Like?
Well, that depends on where you live.
“[There’s incredible variation] from state to state,” says Oleaga. “For example, in Louisiana, surrogacy for compensation [meaning you pay a surrogate] is not permitted at all. In New York, compensated gestational surrogacy wasn’t legal until this past February. If you follow the rules it’s perfectly above board and completely legal, but that’s how greatly the states vary.”
Resources such as the Legal Professional Group of the American Society for Reproductive Medicine (LPG) and Family Inceptions, a reproductive service, both offer comprehensive breakdowns of states’ current surrogacy laws on their websites. And if you’re considering going abroad for surrogacy, you’re also going to want to read up on the nation’s rulings on international surrogacy on the U.S. Department of State’s website.
So yes, the legal particulars of surrogacy are incredibly complex — how do intended parents navigate this? Oleaga suggests meeting with an agency and possibly seeking out a free legal consultation from someone who practices family law to learn more. Some services, such as Family Inceptions, also have an option on their website to contact the organization’s legal services team with any questions to help potential future parents get started. The thing to remember, though, is that both the intended parents and the surrogate need legal representation in order to undergo the process of implanting the embryo in the surrogate’s uterus. This prevents heartbreaking scenarios from playing out down the line.
“For a long time, everyone was afraid that a surrogate [was] going to change her mind. I think a lot of states have these laws in place for a reason,” says Oleaga. “[As a surrogate], you sign a pre-birth order saying ‘I am not an intended parent,’ which should give the [intended] parents some sense of security knowing that their legal rights as parents are recognized while the baby is still in utero.” But, again, it depends on where you live. Several states do not allow pre-birth orders while others allow post-birth orders (which are essentially the same as their “pre” counterpart but only attainable after delivery). And in some states, the way in which you can secure your parental rights (pre-birth order, post-birth order, or post-birth adoption) depends on your marital status and whether part of a hetero- or homosexual couple, among other factors, according to the LPG.
How Does the Surrogate Get Pregnant?
Essentially, gestational surrogacy uses in vitro fertilization; the eggs are surgically harvested (extracted) from a donor or an intended parent and fertilized in an IVF laboratory. Before the embryos can be inserted into the gestational carrier’s uterus, it must be “medically prepared to receive the embryo for implantation,” says Dr. Witt.
“[This] typically includes a medication that suppresses ovulation (so [she] doesn’t ovulate her own egg during the cycle), followed by estrogen which is taken for about two weeks to make the uterine lining thicken,” he explains. “Once the uterine lining is adequately thick the [gestational carrier] takes progesterone, which matures the lining so that it becomes receptive to the embryo which is placed into the uterus after about five days of progesterone. This somewhat mimics the natural hormonal preparation the uterine lining goes through each month in menstruating women.” (Related: Exactly How Your Hormone Levels Change During Pregnancy)
“In many cases, the intended parents do genetic testing on the embryos to choose embryos that have normal chromosome numbers in order to increase the odds of it working and lower the risk for miscarriage during the gestational carrier pregnancy,” adds Dr. Witt.
What Are the Costs of Surrogacy?
Spoiler alert: The numbers can be staggeringly high. “The process can be cost-prohibitive for many,” says Dr. Talebian. “IVF cost can vary but at the minimum is about $15,000 and can increase to as high as $50,000 if donor eggs are also needed.” (Related: Is the Extreme Cost of IVF for Women In America Really Necessary?)
In addition to the IVF expenses, Dr. Talebian points out that there are also agency and legal fees. For those who are using donor eggs, there’s a cost associated with that as well, and intended parents typically cover all medical costs during the surrogate’s pregnancy and delivery. On top of all that, there’s the surrogate’s fee, which can vary based on the state in which they live, whether they have insurance, and the agency they work with and its set fees, according to Circle Surrogacy. As noted above, some states don’t allow surrogates to be compensated. For those that do, however, surrogacy fees range from about $25,000 to $50,000, says Rachman — and that’s before you factor in compensation for lost wages (time taken off for appointments, post-delivery, etc.), childcare (for any other children when you go to, say, appointments), travel (think: to and from medical appointments, delivery, for the surrogate to visit, etc.), and other expenses.
If you’ve guessed it all adds up to a hefty sum, you’re right. (Related: The High Costs of Infertility: Women Are Risking Bankruptcy for a Baby)
“The surrogacy process [overall] can range from $75,000 to over $100,000,” says Dr. Talebian. “Some insurances that provide fertility benefits may cover various aspects of this process, decreasing the out-of-pocket expenses.” That said, if surrogacy is the necessary and best route, individuals might be able to receive financial assistance through grants or loans from organizations such as Gift of Parenthood. (You can find a list of organizations that offer these opportunities and their application processes online, such as on reproductive services’ websites.) “I’ve known people who have created GoFundMe pages to help raise money for the process,” adds Dr. Talebian.
There’s great variation surrounding what is and is not covered by your insurance, though, according to Rachman. Coverage is often minimal and many costs are out-of-pocket expenses. The best way to learn what will and will not be covered is to speak directly with an insurance agent who can break this down for you.
How Can You Become a Surrogate?
The first step is to fill out an application with a surrogacy agency, which you can typically find on an agency’s website. Surrogates should be between 21 and 40 years old, have a BMI under 32, and have given birth to at least one child (so physicians can confirm surrogates are able to carry a healthy pregnancy to term), according to Dr. Talebian. She also says that a surrogate shouldn’t be breastfeeding or have had more than five deliveries or more than two C-sections; they should also have had uncomplicated previous pregnancies, a history of no more than one miscarriage, be in generally good health, and avoid smoking and drugs.
The Mental Health Impacts of Surrogacy
And while it’s natural to wonder about the emotional ramifications of carrying a baby you won’t raise, experts have some reassuring words.
“Many surrogates have reported that they do not have the same kind of bond that they developed during pregnancies with their own children and that it is more like an intensive babysitting experience,” says Dr. Witt. “The surrogates experience incredible joy at their ability to help parents achieve their family goals and know from the start that the child is not theirs. (Related: How I Learned to Trust My Body Again After a Miscarriage)
While the support available for surrogates depends on the agency, “all surrogates in our program are connected to a support social worker that checks in with the surrogate on a monthly basis to see how she is doing/feeling in the surrogacy,” says Solveig Gramann, director of surrogate services at Circle Surrogacy. “The support social worker will stay in touch with the surrogate until she is two months postpartum to ensure she’s adjusting well to life post surrogacy, but we’re available to remain with surrogates much longer than that if they need the support (for example, she had a challenging delivery or postpartum experience and wants to continue checking in several months after the delivery).”
And as for intended parents, Rachman warns that it can be a long process that may bring up some tough emotions, particularly for someone who has already experienced infertility or loss. “Typically, intended parents will undergo counseling sessions at their IVF clinic to ensure they have thought through their surrogacy plans and are on the same page as their surrogate once matched,” she says. (Related: Katrina Scott Gives Her Fans a Raw Look Into What Secondary Infertility Really Looks Like)
“I encourage intended parents to take a pulse on whether they are emotionally and financially ready to move forward with a surrogacy,” says Rachman. “This process is a marathon, not a sprint, and it is important to feel ready to take that on. If you are ready to open your heart to this process, it can be amazingly beautiful and rewarding.”