Fertility patients may need a surrogate — also referred to as a gestational carrier — for many reasons, whether they are a single parent, a cisgender male couple or have uterine abnormalities.
However, this option is only open to prospective parents who can afford it. On average, working with a gestational carrier costs between $50,000 and $200,000. According to Allied Market Research, $112.80 million was spent on surrogacy in 2015 globally and that number is expected to increase to $201.40 million by 2025.
The tremendous financial and emotional cost often results in a complex parent and surrogate relationship. Reproductive specialists should familiarize themselves with the complexities of gestational surrogacy to help patients navigate this process.
Examining Surrogacy Laws
Intended parents should do their research during the early stages of the surrogacy journey so they know what options are legally available to them. According to the European Society of Human Reproduction and Embryology fact sheet "Regulation and legislation in assisted reproduction," surrogacy is illegal in Austria, Bulgaria, Finland, France, Germany, Hungary, Italy, Lithuania, Norway, Serbia, Slovakia, Slovenia, Spain and Sweden.
For countries where some form of surrogacy is legal, intended parents should understand what the law requires in their state or country (and possibly in their carrier's place of residence) and hire a surrogacy attorney from the start. Any surrogacy agreements need to be created in accordance with local laws.
Surrogacy laws can even vary within countries. For example, under the Michigan Surrogate Parenting Act MCL Section 722.851, the state of Michigan does not allow compensated surrogacy, and parents who enter agreements other than compassionate or altruistic surrogacy are subject to criminal penalties. In the state of Delaware, however, Delaware Code 13, § 8-801 through § 8-810 permits surrogacy and establishes guidelines "for the protection of all parties."
If intended parents hope to find a carrier abroad, the same advice applies: Determine the legalities of surrogacy in that country first. Thailand, Mexico and Cambodia have banned or heavily regulated compensated international surrogacy within the past 10 years, mainly due to concerns about the exploitation of surrogate mothers.
Understanding Surrogacy Types
There is no one-size-fits-all approach to surrogacy. A surrogate is a person who carries the child to term with the intention of placing that child with the intended parent(s). There are two different types:
- Traditional surrogacy: The carrier is the child's biological mother. Her egg is fertilized during intrauterine insemination or in vitro fertilization (IVF).
- Gestational surrogacy: The carrier is not the child's biological mother. Another person's egg is fertilized and transferred during an IVF cycle.
Although it was not always this way, gestational surrogacy is now far more frequent than traditional surrogacy. This might be due to the fact that traditional surrogacy comes with additional legal and sometimes emotional or cultural difficulties. Furthermore, traditional surrogacy agreements are not recognized by all states or countries. Gestational surrogacy's removal of the pregnant person as the biological parent can eliminate some of these problems.
There are several possible genetic combinations for both traditional and gestational surrogacy:
- Traditional surrogacy: Carrier's egg and intended parent's sperm; or carrier's egg and donor sperm.
- Gestational surrogacy: One intended parent's egg and one intended parent's sperm; intended parent's egg and donor sperm; donor egg and intended parent's sperm; and donor egg and donor sperm.
Finding and Reimbursing a Surrogate
In general, there are three ways to find a gestational carrier. A parent may contact an independent carrier, or someone not already known to the intended parent(s), without the assistance of an agency. They may ask a known carrier, such as a friend or family member, to be their surrogate. Or, they may go through a surrogacy agency that matches intended parents with a surrogate who meets their needs. Agencies frequently offer additional support, such as scheduling medical procedures or counseling.
There are also several possible financial arrangements between intended parents and their carriers. A compassionate or altruistic surrogate may only be reimbursed for direct expenses; for instance, if a parent asks a sibling to be a known carrier, that person may decline any financial compensation. Compensated carriers, on the other hand, are formally paid for their time and effort in carrying the child, as well as reimbursed for direct expenses.
Available options for the process of finding and paying a surrogate depend on what is legal in a patient's home country or state.
Negotiating Complex Relationships
The surrogate relationship between carrier and intended parent(s) is unlike any other, and it can be difficult to navigate both the personal and impersonal aspects of sharing the surrogacy journey. It is a relationship that requires trust and commitments from all parties, but it can be difficult to establish healthy expectations and boundaries. With a guiding principle of patience and willingness to assist each other, intended parents can create a meaningful connection with their gestational carrier that meets all of their needs.
Negotiating these terms will depend on how the intended parent(s) found their carrier. It is up to the intended parent(s) and an independent or known carrier to come to terms with what their relationship will be like on their own, potentially with the help of an informed counselor or lawyer. In contrast, a surrogacy agency will often consider what level of involvement or relationship a prospective family expects from their carrier before matching them with a surrogate.
Before any pregnancy occurs, intended parents and their carrier need to discuss their preferred methods of communication and a realistic frequency for contact. If one party wants text messages throughout the day while the other prefers weekly updates by email, both parties need to find a way to feel supported throughout the surrogacy process. Working together — possibly with a mental health professional — establishes expectations and boundaries for the surrogate relationship.
Once a good foundation is established, understand that the situation can evolve over time. What was working at the beginning of the process might cause tensions later on. Intended parents should have a check-in with their carrier at the beginning of each trimester. Be honest about what is working and what is not. Focus on communicating needs in a way that does not imply the surrogate has done something wrong. There needs to be room for growth and change.
Gestational Carrier Screening
Reproductive specialists and OB/GYNs are not involved in the legal side of surrogacy, but they do have a role to play. The American Society of Reproductive Medicine recommends that physicians oversee:
- Psychological evaluation and counseling
- Full physical examination, including a sonohysterogram or ultrasound, Pap smear, and mammogram
- Complete medical history, including previous pregnancies and deliveries
- Infectious disease screening (including any sexual partners of the carrier)
- Signed legal agreement (not provided by the medical professionals involved but required to proceed with treatment) and informed consent paperwork
- Medical insurance for the carrier
Mediating Disagreements
Mediating disagreements is not the responsibility of medical providers, although they might offer some recommendations about what to include in the surrogacy agreement prior to starting treatments.
Any financial aspect of a surrogacy agreement must be straightforward. When and how payments are made and whether or not the intended parent(s) will cover additional expenses should be decided in advance. Both parties should be clear on these details.
Intended parents may also want to discuss with their carrier:
- How many transfer cycles will be attempted and over what time period
- Whether the surrogate will abstain from alcohol, recreational drugs and smoking or vaping
- The birth plan, including whether the carrier will receive an epidural, whether to use a midwife or doula, and who is allowed in the room during the birth
- The desired relationship after a baby is born, including whether or not the carrier will provide breast milk for the child and occasionally see the child during the first few weeks to help with their transition
The more challenging parts of the contract are those questions with more flexible answers. How late into the pregnancy can the gestational carrier travel? How often will the surrogate contact the intended parents? Who gets to choose which doctors to use? It cannot be overstated how important it is to have open communication among all parties about the expectations throughout the process — the more detailed, the better.
