How does being a surrogate work

What It Is and How Does Surrogacy Work

Written by Rebecca Buffum Taylor

Medically Reviewed by Jennifer Robinson, MD on November 04, 2021

In this Article

• What Is a Surrogate Mother?
• Who Uses Surrogates?
• Finding a Surrogate
• How to Choose a Surrogate
• Using a Surrogate
• Legal Issues With Surrogates

There's still some controversy about using a surrogate mother to have a baby. The legal process is also tricky because it varies from state to state. Even so, whether it's because of fertility problems or other reasons, surrogacy is an option for you and your partner. Find out how it works and see if it's right for you.

What Is a Surrogate Mother?

There are two kinds:

Traditional surrogate. It's a woman who gets artificially inseminated with the father's sperm. They then carry the baby and deliver it for you and your partner to raise.

A traditional surrogate is the baby's biological mother. That's because it was their egg that was fertilized by the father's sperm. Donor sperm can also be used.

Gestational surrogates. A technique called "in vitro fertilization" (IVF) now makes it possible to gather eggs from the mother (or an egg donor), fertilize them with sperm from the father (or a sperm donor), and place the embryo into the uterus of a gestational surrogate.

The surrogate then carries the baby until birth. They don't have any genetic ties to the child because it wasn't their egg that was used.

A gestational surrogate is called the "birth mother." The biological mother, though, is still the woman whose egg was fertilized.

In the U.S., gestational surrogacy is less complex legally. That's because both intended parents have genetic ties to the baby. As a result, gestational surrogacy has become more common than a traditional surrogate. About 750 babies are born each year using gestational surrogacy.

Who Uses Surrogates?

If you're a woman, you may consider a surrogate for several reasons:

• Medical problems with your uterus
• You had a hysterectomy that removed your uterus
• Conditions that make pregnancy impossible or risky for you, such as severe heart disease

You may want to think about surrogacy if you tried but couldn't get pregnant with a variety of assisted-reproduction techniques, such as IVF.

Surrogates have also made parenthood an option for people who might not be able to adopt a child, perhaps because of their age or marital status.

If gay men decide to use a traditional surrogate, one of them uses their sperm to fertilize the surrogate's egg through artificial insemination. The surrogate then carries the baby and gives birth.

A gay couple might also choose an egg donor, fertilize that donated egg, and then have the embryo implanted in a gestational surrogate to carry until birth.

Finding a Surrogate

There are several ways you can find a surrogate mother:

Friends or family. Sometimes you can ask a friend or relative to be a surrogate for you. It's somewhat controversial. But because of the high cost of surrogacy and the complex legal issues it raises about parental rights, a tried-and-tested family relationship can be simpler to manage.

The American Society for Reproductive Medicine accepts certain family ties as acceptable for surrogates. It generally discourages surrogacy, though, if the child would carry the same genes as a child born of incest between close relatives.

A surrogacy agency. Most people use one to arrange a gestational surrogate. There are about 100 agencies now operating in the U.S. They act as go-betweens.

An agency helps you find a surrogate and make arrangements. It also collects any fees that get passed between you and the surrogate, such as paying for their medical expenses.

How to Choose a Surrogate

Right now there aren't any regulations about who can be a surrogate mother. But experts agree on a few points about how to select one.

You should choose surrogates who:

• Are at least 21 years old
• Have already given birth to at least one healthy baby so they understand firsthand the medical risks of pregnancy and childbirth and the emotional issues of bonding with a newborn
• Have passed a psychological screening by a mental health professional to uncover any issues with giving up the baby after birth
• Sign a contract about their role and responsibilities in the pregnancy, such as prenatal care and agreeing to give you the baby after birth

Using a Surrogate

The American Society for Reproductive Medicine says surrogates should get a medical exam to check that they are likely to have a healthy, full-term pregnancy. The organization suggests they get tests that check for infectious diseases such as syphilis, gonorrhea, chlamydia, HIV, cytomegalovirus, and hepatitis B and C.

Surrogates should get tests to make sure they have immunity to measles, rubella (German measles), and chickenpox. Also, you may want to ask that they get a medical procedure to visually "map" the uterus, which can help the doctor check their potential to carry a pregnancy. Surrogate mothers should have their own doctor during pregnancy rather than use yours.

The cost of surrogacy can range from $80,000 to $120,000. A lot of different things go into the price, such as whether the surrogates have their own medical insurance or whether you need to buy a surrogacy-pregnancy policy for them.

Legal Issues With Surrogates

Parental rights aren't guaranteed after a surrogate pregnancy. The law continues to change as reproductive technology and the very definition of a "parent" changes.

There isn't a federal law on surrogacy and state laws vary. After a surrogate pregnancy in some states, you may still have to pass adoption proceedings to gain legal custody of the child. In other states, a "declaration of parentage" before birth lets you avoid having to "adopt" the baby.

To protect your rights as parents-to-be -- and the rights of the child you're hoping to have -- hire an attorney who specializes in reproductive law in your state. They can write a surrogacy contract that clearly spells out what everyone needs to do.

A contract like that may help if legal issues come up after birth. It can also outline agreements about a variety of possible scenarios with the pregnancy, such as what happens if there are twins or triplets.

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What Is Surrogacy And How Does It Work? – Forbes Health

Table of Contents

• What Is Surrogacy?
• Why Would Someone Choose Surrogacy?
• How Much Does Surrogacy Cost?
• How Does Someone Become a Surrogate?
• Legal Issues Around Surrogacy

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Surrogacy is becoming an increasingly common family-building option that offers a beacon of hope for people who are unable to carry a pregnancy on their own.

But how does surrogacy work, and how is a gestational carrier different from a traditional surrogate? Continue reading to explore what surrogacy is, reasons people may choose this route of family-building and important details to know before considering surrogacy as an option.

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What Is Surrogacy?

At its most basic, surrogacy is when a person carries and delivers a child with the intention that another individual or couple will be the intended parent(s).

More specifically, the most common type of surrogacy in the U.S. occurs when an embryo is created with the egg of an intended mother (or a donor) and sperm of an intended father (or a donor) and then inserted into the uterus of a gestational carrier, says Shiva Landry, founder and executive director of Shared Conception, a surrogacy agency in Houston, Texas.

While surrogacy means another person carries a pregnancy, the intended parent(s) will have full custody of the child, adds Rashmi Kudesia, M.D., a triple board-certified physician in obstetrics and gynecology, reproductive endocrinology and infertility and lifestyle medicine, who is affiliated with Memorial Hermann Health System in Houston, Texas.

Gestational Carrier vs Traditional Surrogate

While surrogacy is often used as a catch-all phrase to describe the process of an individual carrying a child for another person or couple, there are actually two distinct types of surrogacy: A traditional surrogate and a gestational carrier. The difference between the two has to do with the genetic relationship between the person carrying the pregnancy and the resulting child.

• A traditional surrogate, also known as a genetic surrogate, is a person who is biologically related to the resulting child because their egg is used to create the embryo.
• A gestational carrier—or person who carries someone else’s pregnancy from an egg that is not their own—has no genetic relation to the resulting child.

Traditional surrogacy is a rare and legally risky option in the U.S. “After a series of cases where the surrogate found it difficult to surrender the child to the custody of the intended parents, it became the norm to identify one individual as the egg donor and another as gestational carrier,” explains Dr. Kudesia.

For gestational carrier surrogacy, in vitro fertilization (IVF) is used to retrieve eggs and sperm—either from the intended parent(s) or donors, or a combination of both—and then create an embryo to transfer to the carrier.

There are several sperm and egg fertilization combinations in surrogacy.

Traditional surrogacy:

• Intended father sperm + surrogate egg
• Donor sperm + surrogate egg

Gestational carrier surrogacy:

• Intended father sperm + intended mother egg
• Donor sperm + intended mother egg
• Intended father sperm + donor egg
• Donor sperm + donor egg or donated embryo

Note: Some gestational carrier cycles may involve more than one embryo, which increases the chance for multiple births.

Why Would Someone Choose Surrogacy?

There are many reasons, medical and otherwise, intended parent(s) opt for surrogacy.

People may choose surrogacy when there is a medical reason that would make it unsafe for them to carry a pregnancy, says Dr. Kudesia. For instance, they may take medications deemed unsafe for pregnancy or have a condition that would make pregnancy life-threatening, she says.

Additional medical reasons that might cause someone to consider using a surrogate according to Iris Insogna, M. D., a board-certified physician in obstetrics and gynecology and a reproductive endocrinology and infertility specialist at Columbia University Fertility Center in New York, include:

• The absence of a uterus (either an absence since birth or the removal of a uterus)
• Scarring of the uterus
• Recurrent embryo implantation failure
• Recurrent pregnancy loss

Single men, men in same-sex couples and transgender individuals or couples may also build their families with the help of donor eggs (and sometimes donor sperm) and a surrogate.

How Much Does Surrogacy Cost?

Surrogacy can be very expensive compared to other family-building options. Expenses can include:

• Legal fees
• Medical expenses
• Surrogacy agency fees
• Compensation for the gestational carrier or surrogate
• Additional costs

Landry says that while costs are difficult to predict since each journey is unique, gestational carrier surrogacy typically runs between $125,000 to $200,000.

Part of the high cost of modern surrogacy comes down to the inclusion of IVF. “All of the IVF treatment is included, plus the additional cost for the gestational carrier [or surrogate] to carry the pregnancy,” says Dr. Kudesia.

These costs can be much lower in the case of altruistic surrogacy, which is when a carrier does not receive compensation beyond coverage for costs associated with the pregnancy.

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Does Health Insurance Cover Surrogacy?

Insurance typically does not cover the total cost of surrogacy. Some plans may cover some or all of the intended parents’ IVF expenses and the carrier’s maternity expenses, while others may not. Some intended parents use their own insurance when it covers a carrier’s maternity expenses, while others may opt to have the carrier use their own insurance when their policy has a surrogacy exclusion clause, meaning the insurance company will not cover a pregnancy carried by someone else.

Additionally, certain insurance agencies offer special packages designed to cover surrogate pregnancies. But while these tailored plans can be the most comprehensive option, they can also be expensive.

While it’s a good idea to ask an attorney or health insurance professional to review your health care benefit options before proceeding, it’s important to know that insurance plans can change over the course of a pregnancy (such as when an employer changes plans or the carrier leaves a job).

“The financial burden imposed on patients requiring the use of a gestational carrier represents a significant reproductive health care disparity,” says Dr. Insogna. “Improving access to care by expanding insurance coverage for this population is critical to protecting all patients’ fundamental right to reproduce.”

How Does Someone Become a Surrogate?

A person who would like to become a surrogate must undergo screening required by the Food and Drug Administration (FDA) and recommended by the American Society for Reproductive Medicine (ASRM), says Dr. Insogna.

According to both Dr. Insogna and Dr. Kudesia, screening includes:

• A medical and obstetric history evaluation
• A physical exam
• An extensive questionnaire
• A psychological evaluation
• Clearance from an obstetrics provider (ideally a maternal-fetal medicine specialist)
• Blood work, including infectious disease screening
• An ultrasound (to assess the prospective carrier’s status regarding the ability to carry a pregnancy)

Intended parents are also screened to ensure they are physically, mentally, legally and financially able to begin the surrogacy process.

Surrogates may already know the intended parent(s) before entering a surrogacy contract, but a prior relationship is not a requirement. Beyond clearance of the above screening steps, an ideal candidate is 21 years of age or older, has been pregnant previously and delivered a baby to full-term without complication, has a stable social environment and is cleared by references, according to the American Society for Reproductive Medicine.

If you’d like to learn more about becoming a surrogate, Landry recommends researching and then reaching out to a reputable, experienced surrogacy agency for more information.

Legal Issues Around Surrogacy

Surrogacy laws vary widely across the globe with some countries banning any type of surrogacy. In the U.S., surrogacy is legal but not federally regulated. “Each state has its own laws regarding the use of gestational carriers,” says Dr. Insogna. For that reason, intended parents and surrogates are encouraged by the American College of Obstetrics and Gynecologists to seek legal counsel before entering into a gestational surrogacy contract.

Individual states regulate surrogacy based on some or all of the following grounds:

• The intended parent(s)’ marital status
• The intended parent(s)’ sexual orientation
• The source of the egg and sperm (some states require a genetic relationship between intended parents and resulting children)
• Compensation (some states only allow compensation for pregnancy-related costs)
• Pre- and post-birth parentage orders (meaning who is recognized as a legal parent with legal decision-making rights)

If surrogacy is banned in your state, Landry says you can seek out an agency in a surrogate-friendly state.

One way to do that, says Dr. Kudesia, is to speak with a local fertility specialist who can connect you with a reputable specialist in another state where surrogacy is allowed. “Or you can seek out consultation on your own with a specialist in a state where an identified gestational carrier may be or perhaps a state that would be convenient for you to travel to if you have family in the area,” she says.

While cross-border reproductive care can open doors to people looking to grow their family, Dr. Insogna says using a gestational carrier out of state may be more logistically challenging in terms of travel before and during pregnancy, and during and after delivery.

Surrogacy is often not an easy decision and tends to be a lengthy process both medically and legally, but it can also be an extremely rewarding experience for both the intended parents and the surrogate. If you or someone you know is interested in surrogacy, don’t be afraid to start the conversation with your doctor or with a reputable agency.

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Surrogacy program

The surrogacy program is offered to those women who, due to health reasons, cannot carry a pregnancy on their own.

The legislation of Russia allows such type of ART as surrogate motherhood, but with some restrictions. It is impossible to resort to the services of a surrogate mother only because of the desire to avoid pregnancy and childbirth. The list of indications for the program is determined by the order of the Russian Federation dated August 30, 2012 No. 107n "On the procedure for using assisted reproductive technologies, contraindications and restrictions on their use." The main indications are:

Some patients with these indications may have genetically related children (that is, it is possible to obtain their own oocytes for embryo cultivation with the help of hormonal stimulation), others additionally use the oocyte donor program. But in all cases, the surrogate mother is not an egg donor.

Medical surrogacy

The main difference between surrogate motherhood and egg donation is that the surrogate mother is transferred an embryo that does not genetically belong to her. By law, a surrogate mother cannot be an egg donor at the same time.

A surrogate mother always bears a child that is genetically alien to her. The embryo can be cultured from the egg of a future mother or an anonymous donor.

More information for those wishing to become a surrogate mother

Despite the fact that during the entire period of pregnancy the embryo (then the fetus) develops in the body of a surrogate mother, it does not inherit any of its external features. If future parents can choose the most suitable donor (hair color, eye color, height, as well as nationality) when donating eggs, then these factors do not matter when choosing a surrogate mother.

Legal aspect in Russia

In Russia, surrogacy is legal and regulated by law. At the same time, the situation remains when certain medical aspects are not yet clearly spelled out in the law. All conditions in the contract that future parents and the surrogate mother sign with the clinic must be in accordance with the legislation of the Russian Federation.

In particular, the law says that the mother of a child is automatically recognized as the woman who gave birth to him.

When a child is born by a surrogate mother (despite the fact that he is not genetically related to her and there are documents from the reproduction clinic that confirm the fact of embryo transfer), only with the consent of the surrogate mother, the data of biological parents can be indicated in the birth certificate.

In practice, this is implemented as follows: in the near future after the birth of the child, the surrogate mother signs permission to have the data of biological parents entered into the birth certificate. Together with this document and the agreement with the clinic, parents apply to the registry office, where they issue a birth certificate. After that, according to the law, the biological parents of the child are endowed with full rights and obligations, and the surrogate mother is released from them.

Due to the fact that surrogate motherhood programs have been used in Russia for a long time, this procedure has already become routine in the registry offices. A single person can also be a biological parent, in which case only the mother or only the father is indicated on the birth certificate.

What disputes are possible?

In order to avoid any disputes, an agreement is drawn up, which describes in detail the rights and obligations of the parties and all possible situations.

Number of embryos transferred. Now, thanks to the success of IVF programs (especially in cryoprotocols), one embryo is most often transferred, but in some cases, at the request of the parents and with the consent of the surrogate mother, two.

A variant of the development of multiple pregnancy. In about 1% of cases, after the transfer of one embryo, its division may occur in the first days, and as a result, twins will be born. The contract should indicate whether the size of the surrogate mother's fee will increase in this case and by how much.

Surrogate mother's lifestyle: the contract will stipulate the obligation to follow the doctor's recommendations, visit the clinic chosen by the parents to monitor the pregnancy.

The possibility of having a child with congenital defects. Despite the fact that pre-implantation screening is carried out, and then several screenings during pregnancy, there are diseases that can neither be prevented nor diagnosed in early pregnancy. They are far from always associated with the lifestyle of a pregnant woman or her health (or the health of biological parents) and often occur spontaneously.

One of the key ways to avoid conflict situations is detailed counseling of all program participants before it starts and explanation of all possible consequences.

If it is not possible to resolve the conflict peacefully, one has to go to court: today the courts in the Russian Federation have a practice of resolving such disputes.

More information for those wishing to become a surrogate mother

Requirements for a surrogate mother

Before starting the program, a surrogate mother undergoes an examination:

01

Blood test for HIV, RW (syphilis), viral hepatitis B and C, TORCH infection.

02

Screening for STIs (sexually transmitted infections).

03

Fluorography.

04

Ultrasound of the pelvic organs.

05

Oncocytology of scraping from the cervix, smear for the degree of purity of the vagina.

06

Determination of blood group and Rh factor.

07

General and biochemical blood tests, coagulogram.

08

Urinalysis.

09

ECG.

10

Examination by a general practitioner and conclusion that there are no chronic diseases and contraindications to pregnancy.

11

Examination and conclusion of a psychiatrist.

How embryo transfer works

Embryo transfer

Embryo transfer is a fairly quick (about 30 minutes) procedure, it does not require anesthesia or a long stay in the clinic. By agreement of all participants in the program, two embryos can be transferred, but no more, since multiple pregnancy carries a high risk to the health of children.

After the transfer, hormonal support is prescribed, as in any IVF protocol. It is possible to diagnose the onset of pregnancy approximately on the 12th - 14th day after the transfer: you need to donate blood for hCG. An ultrasound is scheduled approximately on the 21st day after the transfer - an earlier ultrasound is not informative.

Multiple pregnancy: what to do?

Two embryo transfers are currently only allowed if the parents are ready to have two children. This is due to the fact that cryopreservation can significantly increase the chances of successful implantation of all transferred embryos. The surrogate mother must agree to the transfer of two embryos, having received all the information about the risks of a multiple pregnancy.

What if only one embryo was transferred but a multiple pregnancy develops? This case should be discussed in advance and spelled out in the contract.

• Either the pregnancy is kept as multiple, the parents are preparing for the birth of two children, the surrogate mother receives an additional payment.

• Or, by decision of the parents, a reduction procedure (removal of one of the embryos) is carried out at an early stage of pregnancy, which carries certain risks for the remaining embryo.

Pregnancy management

Future parents choose a pregnancy clinic where a surrogate mother should be observed. The number of appointments, a set of tests and examinations is standard, as in the management of a naturally occurring pregnancy. At the request of the parents, additional studies can be prescribed, for example, NIPT is a non-invasive prenatal test, in which at the 9-11th week of pregnancy, fetal DNA can be isolated from the blood of a pregnant woman and with an accuracy of 99. 99% determine the sex of the child and the presence of a number of diseases.

Monthly payment

In addition to the basic payment (after the birth of the child), the surrogate mother receives a monthly payment - this condition is prescribed in the contract.

Delivery by a surrogate mother

Future parents choose a clinic or a maternity hospital for childbirth. In most cases, when there is no indication for a caesarean section, childbirth takes place naturally. The child is transferred to future parents immediately after birth. The consent of the surrogate mother to the transfer of the child to the biological parents is also issued.

If you have any questions related to participation in the surrogacy program, please contact the clinic.

Becoming a surrogate mother

Surrogacy process | Extraordinary Conceptions

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The surrogacy process involves many steps and they are all worth it!
Learn about the surrogacy process and the resources we offer to women who choose this wonderful path.

Apply to become a surrogate »

An overview of the surrogacy process

Learn how to become a surrogate

If you are considering becoming a surrogate, Extraordinary Conceptions will help you on your journey. Whether you're doing this for the first time or you've already been a surrogate mother, we suggest you have a few questions before diving into them, and we're here to answer them.

The surrogate procedure is useful, but it is also quite complex. This is clear; this is a big deal and every step is taken to protect you, the child, and their intended parents. That's why we're here - to help guide you through every step of this enriching and wonderful journey.

What is the surrogacy process?

Everything you need to know

The process of a surrogate mother is lengthy but simple. Here at Extraordinary Conceptions, the process starts at home - potential surrogates can check their eligibility and start their online application. Once your application has been accepted, your profile will be added to our Intended Parents database. Eventually, you will be selected and you can begin the steps towards becoming a surrogate mother.

Every agency works a little differently, but in Extraordinary Conceptions we've broken down our process into a ten-step system. This makes it easy for both potential surrogates and intended parents to digest, understand, and prepare for the process ahead.

The Surrogacy Process Step by Step

The Breakdown of the Surrogacy Process

In Extraordinary Conceptions, we have broken down the surrogacy process step by step:

1. Check eligibility

We recommend that surrogate mothers check their eligibility before applying. There are several big city legal, becoming a surrogate is to protect the surrogate, the intended parents and the unborn child. If you are considering surrogacy, take a look at our checklist. If you meet all the requirements, you can proceed to the second step.

All surrogates must:

• Be between the ages of 21 and 45 (the EU has a unique program for carriers between the ages of 39 and 45) 36)

• Have no more than 5 cesareans (EC has a unique program for GCs with 3 or more cesareans)

• Have no more than 8 deliveries (EC has a unique program for carriers with more than 6 deliveries )

• Previously and currently living with their child

• Do not smoke or use illicit drugs and do not have a history of addiction to illicit drugs or alcohol.

• Be financially stable and not on Section 8/HUD

• Be a US citizen or permanent resident

• Have a driver's license and/or reliable transportation

• No previous criminal offenses (same goes for spouse/partner and any other adults living in the family) major depressive disorder.

• Not currently taking any medications that are unsafe for pregnancy, including medications for mental health problems (including anxiety or depression) and/or the possibility of safely weaning the medication.