Gestational carriers (surrogacy)

What is gestational surrogacy?

Gestational surrogacy is an arrangement in which a woman carries and delivers a baby for another person or couple. The woman who carries the baby is the gestational surrogate, or gestational carrier. The parents-to-be are known as the intended parents, and they are involved in the pregnancy, can be present at the birth, and become the child's parents after the baby is born.

In gestational surrogacy, the baby isn't genetically related to the gestational surrogate – the egg comes from the intended mother or an egg donor, and the sperm comes from the intended father or a sperm donor. Donor embryos may also be used.

Without a donor embryo, in vitro fertilization (IVF) is necessary because eggs from one woman are used to create embryos to be implanted in another woman's uterus. In IVF, fertilization occurs after eggs and sperm are combined in a laboratory. One or more of the resulting embryos are then transferred to the gestational surrogate's uterus.

Only 1 percent of all assisted reproductive technology procedures involve gestational surrogacy. It's likely that cost is a major factor preventing more people from using a gestational surrogate.

Is using a gestational surrogate for me?

Using a gestational surrogate may be a good option if:

• You don't have a uterus.
• You have problems with your uterus.
• You can't carry a pregnancy safely.
• Other fertility treatments have failed.
• You're a single man or gay male couple.

What are the challenges of gestational surrogacy?

Whether you set up the arrangement through an agency or negotiate it privately, using a gestational surrogate is a legally complex and emotionally intense process. If you decide to go this route, be prepared to commit a lot of time, money, and patience.

Currently, a handful of states allow gestational surrogacy contracts, but they aren't always enforceable, depending on what's legal. Some states require couples to be married, and some don't allow gestational surrogates to be compensated. Also, there may be requirements about sexual orientation.

Most states don't have specific laws covering gestational surrogacy, so it's important to work with a licensed attorney in your state who has expertise in third-party reproduction. An attorney can advise you on your options and draft a legally binding contract.

We've decided to try gestational surrogacy. How do we get started?

Get ready for a complex process that can be stressful. Although you won't carry the baby, you'll be very involved in the pregnancy. You'll probably pay the gestational surrogate's expenses, including medical appointments, health insurance bills, travel costs, legal bills, and agency fees (if you're using one). Here's how to get started:

1. Find a gestational surrogate. Decide whether to ask a relative or friend to be the gestational surrogate, or use an agency that can match you with someone. Most experts recommend choosing someone who:

• Is between 21 and 45 years old
• Previously gave birth without any complications
• Has a supportive family
• Is in good physical and emotional health

2. See a fertility counselor. Most doctors require that you and the gestational surrogate speak with a mental health professional (individually and together) to help you consider the pros and cons of the arrangement, process your emotions, and discuss the potential impact of a relationship with each other.

3. Schedule a medical exam for the genetic parents. If you're using your own eggs or sperm, you'll have a checkup and genetic evaluation to make sure you're healthy enough for IVF. (If you're using donated sperm, eggs, or a donor embryo, they'll be screened during the donation process.)

4. Schedule exams for the gestational surrogate. She'll need to have a medical exam and drug screen, and her partner or spouse will undergo psychological and medical screening as well.

5. Sign a legal agreement.You and the gestational surrogate should each hire separate attorneys experienced in gestational surrogacy to avoid potential conflicts of interest. Create a legal agreement that protects everyone and includes such important details as compensation, parental rights, legal custody, delivery location, future contact between the parties, insurance coverage, and control over medical decisions made during the pregnancy.
In some states, as long as one parent is genetically related to the baby, the gestational surrogate signs away parental rights before the baby's birth, and the intended parents' names are listed on the birth certificate. In other states, the gestational surrogate signs over parental rights after the baby is born.

How does gestational surrogacy work with fresh eggs?

Your doctor uses IVF to produce one or more embryos that will be transferred to the surrogate. Here's how it works:

• Match menstrual cycles. If you're using your own egg, you and the gestational surrogate take medication to synchronize your menstrual cycles. That way, the surrogate's uterus will be ready to support an embryo by the time your eggs are retrieved and fertilized. (Similarly, an egg donor will need to sync her cycle with the surrogate.)
• Stimulate egg production. Once you (or the egg donor) are in sync with the surrogate, taking gonadotropins stimulates the ovaries to develop multiple eggs.
• Fertilize the eggs. When mature eggs are ready to be fertilized, the doctor retrieves them during a minor outpatient procedure. Unless you're using donor sperm, the intended father may need to provide a sperm sample at this time. Then the eggs are fertilized in the laboratory.
• Transfer embryos. After fertilization, the embryos are transferred to the surrogate's uterus.

The surrogate becomes pregnant when at least one embryo implants in her uterus. The chance of a successful pregnancy varies with the age of the woman who provided the egg.

How does gestational surrogacy work with frozen eggs?

Here's how gestational surrogacy works when using frozen eggs:

• Take medication. The surrogate takes medication over several weeks to prepare her uterus for a possible pregnancy.
• Thaw and fertilize the eggs. Unless you're using donor sperm, the intended father may need to provide a sperm sample, so the eggs can be fertilized in a laboratory.
• Transfer embryos. After fertilization, the embryos are transferred to the surrogate's uterus.

The surrogate becomes pregnant when at least one embryo implants in her uterus. The chance of a successful pregnancy varies with the age of the woman who provided the egg.

How does gestational surrogacy work with frozen embryos?

Using frozen embryos is similar to the process for using frozen eggs. Menstrual cycles don't need to be synced, and the surrogate only needs to take medication to prepare her uterus for a possible pregnancy before the embryos are thawed and transferred into her uterus.

How long does gestational surrogacy take?

Finding a healthy, willing gestational surrogate can take months or even years, whether you screen candidates through an agency, decide to ask a friend or relative, or search for someone online.

Once you've finalized the agreement and have begun treatment, it can take at least three or four IVF cycles to achieve a successful pregnancy. Each IVF cycle takes four to six weeks.

What's the success rate for gestational surrogacy?

Using your own eggs, your chance of having a baby through gestational surrogacy is as good as or higher than that of a woman your age using traditional IVF.

Recent national data on gestational surrogate IVF cycles using the intended mother's eggs show the following live birth rates per cycle (ages refer to the intended mothers' age):

• 55 percent for women age 34 and younger
• 41 percent for women age 35 to 37
• 27 percent for women age 38 to 40
• 13 percent for women age 41 to 42
• 4 percent for women age 43 and older

The donor egg data in the national report wasn't grouped by age, but it showed that the overall live birth rate was 45 percent when fresh donor eggs were used in gestational surrogacy. When frozen donor eggs were used, the birth rate was 41 percent. When frozen embryos created from donor eggs were used, the birth rate was 49 percent.

What are the pros of gestational surrogacy?

• If you and your partner are unable to conceive or carry a pregnancy to term, using a gestational surrogate can give you the chance to parent your own biological child.
• You can be intimately involved in the details of your gestational surrogate's pregnancy.

What are the cons of gestational surrogacy?

• In addition to the possible side effects from fertility medication, your gestational surrogate goes through the discomfort and usual risks of pregnancy.
• Using a gestational surrogate is expensive and legally complex. It involves intricate contracts and arrangements. In several states, using a gestational surrogate is illegal, which usually means that people must contract with a gestational surrogate who delivers in a surrogacy-friendly state.
• You not only experience the usual suspense and anxiety of waiting for a pregnancy to safely reach full term, you may also have to deal with friends and relatives who don't understand why you chose gestational surrogacy.
• You might worry about legal snags and the possibility that your gestational surrogate could back out and not carry your baby. If she goes ahead with it, you might worry that she'll have a hard time letting the baby go.

How much does gestational surrogacy cost?

The cost for gestational surrogacy depends on factors including your health insurance, the gestational surrogate's expenses, and the cost of IVF where you live. Relatives or friends who serve as a gestational surrogate usually aren't paid.

Most people find a gestational surrogate through an agency, and the cost can be almost $150,000. Here's an estimated breakdown:

• Agency fee: $22,000
• Gestational surrogate fee: $25,000 to $35,000, though compensation is typically higher for a multiple pregnancy
• Health insurance: $15,000 to $30,000 for supplemental or special coverage for the gestational surrogate
• Gestational surrogate's nonmedical expenses: $10,000 to $15,000
• Legal fees: $14,000
• Counseling services: $7,000
• IVF: Up to $20,000 (Gestational surrogacy IVF is generally more expensive than traditional IVF, which averages around $12,400.)