MaryJane Carnahan is a former intended parent, and a professor at a business school in St. Louis Missouri. She wanted to leverage her teaching skills to create a program with interactive forums, to inform anyone interested in pursuing surrogacy – either as an intended parent or surrogate.
She created “The Biggest Ask” to share all the knowledge that she gained from going through her own surrogacy journey with others. In this interview, we talk about surrogacy, and what it means to be an intended parent.
Mary Jane Carnahan of The Biggest Ask hosted this conversation with Dr. Aimee on Instagram.
Mary Jane: Today it is our pleasure to have the one and only Egg Whisperer, Dr. Aimee. In case you don’t know, she’s a fertility specialist based in the San Francisco Bay area. She has been practicing for over 15 years.
Today, we’re going to talk about surrogacy. Let’s start with my first question. During your tenure as a fertility specialist, have you seen any significant shifts in patients using a surrogate or a gestational carrier? For example, is it becoming more or less common?
Dr. Aimee: I think it’s becoming more common. Don’t you think? I feel like it’s something that people are talking about before they’ve run out of embryos, so that’s a really nice thing. I think it’s something that I also see fertility doctors talk to their patients about more and more without making it feel like it’s what you do when you’re done, like it’s your last hope. That’s nice for me to see.
I also feel like there are more people that are considering surrogacy because they hear these great stories of really amazing journeys. It’s not the snap of the fingers and all of a sudden you have a surrogate, everything is amazing, the pregnancy is wonderful, and there’s no hiccups. Certainly, there is stuff that happens along the way. I just feel like it’s more acceptable now to at least talk about it as a possibility during your journey.
Mary Jane: That’s good. I’ve only kind of been here throughout the last two-and-a-half years. My impression is that it is growing. It could be biased because I’m in this very small world. I keep meeting more and more people, but it’s just nice to know from your perspective that you also think that it’s growing.
These days, what types of patients tend to use a surrogate? Do you have a typical patient diagnosis that you would recommend a surrogate to?
Dr. Aimee: The obvious is people without a uterus.
Mary Jane: Yes.
Dr. Aimee: That’s obvious. Then, for me, I feel like every woman over the age of 45 should at least talk to their doctor about whether it would be safer or better for them to use a surrogate for their embryo or for them to carry themselves. Especially if they worked really hard for a long time to create the embryo with their own eggs.
Not that donor egg embryos aren’t precious, but typically but that is a renewable resource that you can create more from. When it’s your own eggs, and let’s say you’re 44 and you have that one golden embryo from that golden egg, it is something to consider just because there are things that can happen to our bodies as we get older.
Certainly, we do think that older women do have just as good a chance of carrying a pregnancy to term. But if you’ve never been pregnant before, how do you know you don’t have an issue with preterm labor or recurrent pregnancy loss? You haven’t had an opportunity to reveal to your doctor that this is your problem.
There’s also severe adenomyosis and endometriosis. That’s a lot of ‘osis’ that I just threw out there. It just means your uterus is a little bit on the larger side and there might be a little bit more inflammation. Those two things can make it harder for you to carry a pregnancy to term. When I have a patient with those issues, and it’s not like every single person that has that diagnosis needs a surrogate, but if it’s severe enough, your doctor might bring up using a surrogate.
There are also women that have a thin lining of the uterus. That condition is called Asherman’s Syndrome. Uterine synechiae is another term for just a really thin lining. If you can’t build that plush landing pad for an embryo to snuggle into, it makes it harder for implantation to occur, so sometimes women have to consider using a surrogate in that type of situation as well.
There are other people that are on medications for different medical conditions, and it’s just not safe for them to carry a pregnancy because of the medications that they’re on. If they stop the medication, it might harm their own health. They might also consider a surrogate.
The thing is most men who want to have babies – and I’m talking about cis men – they can have a baby without ever getting pregnant. As women, it’s something that I feel like it’s okay to say I want to be a mom, but I’m not going to be able to carry the pregnancy myself. It should be just as acceptable for a woman to say that as a man.
Mary Jane: I guess it’s related to another question that I had for a little bit later. You were talking about all of these diagnoses, and I was wondering 10 years ago or 15 years ago, would you be less hesitant to suggest using a gestational carrier versus now, because now it’s more accepted, so now you’re more likely to offer that? Not you specifically, but just in general.
Dr. Aimee: I think in general, from a societal norms standpoint, I feel like these things are more talked about, more acceptable, there’s less shame and less stigma. We’re all social people and we all still, unfortunately, like to seek approval of our family members, our friends, our partners. So, sometimes if you think you want to do something, and someone says to you, “I don’t agree,” then you might be influenced by the things that they’re saying.
I feel like more and more people are seeing stories of other people going through this process, and they feel more empowered and they have the strength to be able to stand up for themselves and what they believe should be part of their journey, and they go and they do it.
Mary Jane: Amazing. That’s what we love to hear. There’s that part, too, which is great, more acceptance. I’m just guessing here that assisted reproductive technology has also increased. There’s more innovation, so there might be more things to try that might solve the issue and have a patient avoid using a gestational carrier. I was wondering if that effect was also going on, where maybe we don’t use gestational carriers as much because we have these other innovations that we might use to help.
Dr. Aimee: Everyone listening is going to be surprised to hear that we really don’t have as many innovations. I really wish that we did. The IVF that I’m doing today is pretty darn similar to the IVF that I did five years ago and the IVF that I did 10 years ago.
Some of the protocols have changed. There are some things that we might be doing differently. Like intrauterine PRP, a lot of people are talking about that, for example, before you go to a surrogate.
For the most part, we really haven’t been able to figure out, especially when you have a euploid, which means a genetically normal embryo, based on the technology, why the embryos aren’t sticking 100% of the time. It’s heartbreaking, it’s heart-shattering, it’s all those words. And those words don’t even come close to the feeling of finding out that an embryo that you worked so hard for didn’t attach. I wish that we had better tools, and we just don’t.
I don’t think that we’re in a situation where people are using surrogacy less, because we as a scientific community haven’t been able to figure this out. We’re just not there yet.
Mary Jane: Somebody asked, and I also have the same question, do you have an understanding of why?
Dr. Aimee: The why of a lot of this is in our genes and it’s genetic. It’s also in the embryos. But we’re only looking at chromosomes. There’s so much more genetic information for us to learn. We’re not efficient as human beings. Just because an embryo has normal chromosomes doesn’t mean that it’s normal everything. People think that normal chromosomes means healthy embryo. Normal chromosomes just means normal chromosomes based on the technology’s limitations, and that’s it.
Mary Jane: Why is there this lag?
Dr. Aimee: It’s very expensive. It is really hard. I’m a human. Genome sequencing is just now a thing for a human. An embryo, obviously, it’s small. You can’t even see it with your eyes. These embryos are microscopic. To be able to actually fully sequence an embryo’s genome, it’s not impossible, but people are trying to make the near impossible possible.
Once we can do that, then we’re going to have this huge a-ha moment and it’s going to be incredible for people like me who really want every procedure I do, hours of my time in preparation, and if that doesn’t work, it’s devastating. If I can have more answers before I even put an embryo in, that can guide people to pick the embryo that truly is best from a genetic competency standpoint, then I think we’re going to be able to increase pregnancy rates closer to what I think they should be.
It would be amazing if they were 100%. That’s the hope, that one day they will be.
Mary Jane: Right. It sounds like there will be long periods of not a lot of progress, and then boom, some big thing will happen, and then shift.
Dr. Aimee: The big shift, yes. Just like ‘The Biggest Ask,’ the biggest shift. It is going to happen. There are companies, they’re working probably secretly and they don’t want me to talk about it. Soon, you guys won’t see me and you’ll be like, “Where did she go,” because I talked about it. But there are scientists out there that are working on this as we’re speaking right now.
The technology is so expensive, the cost to even be in a trial like this, we’re talking about you have to enroll and front like $50,000. That’s what we’re talking about.
Mary Jane: I guess there are also ethical concerns, too. I don’t even know how much.
Dr. Aimee: We’re not talking about polygenic risk scores and that kind of stuff. For me, it would be looking at genes. I would love to see if an embryo has a gene that is abnormal that’s related to implantation, for example. That would be nice to know ahead of time that this embryo is not as good as another one.
Mary Jane: So, gestational carriers must be medically cleared before proceeding. What is the most common reason for a gestational carrier not to pass clearance? Do you have any tips for any intended parents with gestational carriers before medical clearance?
Dr. Aimee: The most common reason for a surrogate not to pass is that she thought she had an uncomplicated pregnancy, but it actually was complicated. Her blood pressure was high and she had pre-eclampsia, but she didn’t realize it. By the time I get the records, I’m like, “Your blood pressure was really high,” and they’re like, “They said it was fine, though. They gave me magnesium. It was not a big deal. I just took a little bit of labetalol.” No, you’re not passing medical clearance. Or, “I bled, but it was just a little bit, and I needed just one unit of blood.”
That’s obviously someone who wants to do this for someone else, like they loved pregnancy, and they didn’t think that what could be a complication to one person would be a disaster to somebody else. I get it. That’s the number one reason is some sort of pregnancy complication.
The other stuff would be maybe a history of postpartum depression. I have a hard time ever considering someone who has that, and I think 10 out of 10 doctors would agree. Active anxiety, let’s say they’re taking anxiety meds, in the last six months especially. People have anxiety. If you just go look at the news, you’re going to have anxiety. I think those are the two biggest reasons.
Your other questions, as far as tips for intended parents and surrogates before medical clearance, I’ll just share with you what I do. I try to troubleshoot these issues ahead of time. Still, despite what I do, sometimes things come up later that I would have never been able to predict would happen.
What I do for my patients… This is such an emotional journey, I don’t want my patient talking to surrogates and getting emotionally involved and connected until I’ve done my medical part.
That’s the one thing I think can really help intended parents is have a doctor review medical records for you first and then do a match meeting. Don’t do a match meeting first, match with someone, and then bring them to a doctor, because then it feels like something has been taken away from you like you were so close and then so far.
It’s hard because obviously, you’re excited, you want to meet someone, you want to move forward. But if it doesn’t work out, now you’ve made this relationship and you feel bad, you feel sad, and there was a friend that you thought you had and now they’re not your friend anymore. They still could be, because obviously surrogates are amazing people. Even when I’ve had patients meet a surrogate that didn’t qualify for medical reasons, sometimes they’re still lifelong friends afterward.
As far as tips for surrogates before medical clearance, start your prenatals now. Don’t start after. I would say 50% aren’t on a vitamin, and their Vitamin D is really low, so I have to spend after medical clearance making sure that their Vitamin D goes up. So, that’s my biggest tip.
Mary Jane: How long does that take?
Dr. Aimee: Not that long. Vitamin D takes time to go up, but it’s not going to delay us at all. But that’s number one.
Number two, if you’re thinking about being a surrogate and you’re okay with being on birth control pills, get on a birth control pill so I can start your clearance appointments sooner than later. I have surrogates, a lot of them are done with their babies and their tubes are tied. Then I explain to them to get on a birth control pill and they’re like, “But I’m not trying to get pregnant.” I know that. We use birth control pills as medical clearance planning pills and frozen embryo transfer planning pills. They’re not to prevent you from getting pregnant. We already know that you cannot. That’s one thing that a surrogate can do so they’re not waiting an entire month for their period to start so that I can start the birth control pill.
Mary Jane: So, taking the birth control before the medical clearance won’t interfere with anything that would happen.
Dr. Aimee: It can only help. It just gets the show on the road, so to speak. That’s what I wait for, period starts, get on birth control pills, saline sonogram, preconception labs, those are the steps. Let’s say you’re on cycle day seven and you haven’t started your birth control pills, and I can’t coordinate things in a day, then I’m waiting an entire month to start that process.
Mary Jane: How far in advance, how many cycles do you need for them to be on the birth control? Is it just one cycle?
Dr. Aimee: I can do medical clearance within two weeks.
Mary Jane: Okay. Wow.
Dr. Aimee: If someone is already on the pill, saline sonogram, preconception labs, they come back, and they’re cleared. I interview the surrogate after I’ve reviewed all of their medical records and they do clearance, so it can be fairly efficient.
Mary Jane: Amazing. Where do you think the surrogacy industry is headed, in general?
Dr. Aimee: I’m going to be in charge of everything very soon. Just kidding. I have all of these ideas and things that I’m going to be bringing to everybody, I’m going to predict probably in the next three months.
I would say there is so much fraud out there and I am just sick and tired of it, gosh darn it. What I mean by that is people present themselves one way, but it’s a different way. I’ll just share an example with you. A surrogate, for example, who said that she has never carried for anyone before, has never been a surrogate before, but in fact she had two miscarriages and has been through several journeys and is not being truthful.
It’s hard to know. How would you know if someone is lying about that or not? You would have no way of knowing.
Mary Jane: In the records?
Dr. Aimee: If she doesn’t disclose it, if she doesn’t provide a medical record, I would have no way of knowing looking at her uterus that any of that had happened. That’s just one of many situations. I feel like you’re probably on some surrogacy private groups, on Facebook for example.
Mary Jane: Yes.
Dr. Aimee: I feel like if we had a way to get surrogates third-party certified so that they basically have had criminal background checks, drug screens already, they’ve done the psych, by someone who is not related to the agency or doctor, someone else that has no motivation to push a surrogate through, that might be a better system. Sometimes you have psychologists that work for agencies and they’re very motivated to pass, otherwise they won’t have that job with the agency, so there is a bias because of that. I’m trying to remove the bias, make sure that screens are done as well as possible so that parents aren’t deceived.
At the same time, the other direction, too. You have parents that have also not gone through proper psych education. We also need to do better along those lines, where parents are offered psychological counsel. There should be milestones throughout the pregnancy where a psychologist outside of the agency is facilitating meetings to make sure that the relationships continue to be healthy throughout the surrogacy journey.
Mary Jane: This is not the agency. You’re saying this should be somebody else.
Dr. Aimee: Ideally, if I were to rule the world, which I might not do that, but I would like to with what’s going on in the world right now. I might just quit my job and you’re going to see. I’d have to change my last name, it’s too long to be on a ballot. But someday you might see my name on a ballot to rule the world in some way. For now, all I can do is talk about surrogacy and fertility.
That’s what I would propose is that the agency would arrange for it, but it would be an unbiased psychologist that has no allegiance to the agency and no allegiance to the surrogate, but is on everyone’s team just trying to facilitate healthy relationships throughout the surrogacy journey.
Mary Jane: This is what you would like to see.
Dr. Aimee: I do. I try to mirror it in my practice. Every day I feel like today is the day, this is when I’m going to do it. So, I’d like to see more of this. If I can be the model, then perhaps other people will replicate this in their own practice, and then surrogates will start asking for it. The surrogate will be like, “Where’s my psychologist on-demand? I need a session and I need to pull in the intended parent, because we need to have healthier communications right now.” Maybe I’ll call it that, “Surrogacy Psychologist OnDemand.
Mary Jane: That was the one thing with our journey. I wish that we had a therapist. We were great with communication and there wasn’t anything, but if I were to make it even better. It never really came up. There are some points in the pregnancy that are scary. Our surrogate was bleeding and we thought for sure she had a miscarriage, and she’s trying to deal with my feelings, and it’s not fair to her. It would have been nice, if I had to do it again, if we could get her somebody that she could talk to. So, I totally agree with that.
Dr. Aimee: The other thing that I’d do if I ruled the world is sensitivity training for OBGYNs as it pertains to dealing with intended parents.
Mary Jane: Oh, yes.
Dr. Aimee: I just want to spray whipped cream. I don’t want to hit them, but that whipped cream thing where whipped cream smacks you in the face. I feel like some of the things OBGYNs say, I’m like seriously, this patient of mine worked so hard for this pregnancy and you’re going to treat them like that right now in a stressful situation. There should almost be someone that would help the intended parent, like a concierge person – it should be automatic, not concierge. Concierge makes it seem like only some people have access to it.
I feel like when you go to the Hyatt, everyone can walk up to the concierge and be like, “What’s the best restaurant?” As an intended parent, you could go to the concierge and be like, “I’d like to communicate with my baby’s doctor just to be filled in on what’s going on with the visit and how everything is going.” More times than not, the OBGYN will say, “You’re not the patient.” Stop talking like that to my patients. That’s so rude and mean. I can’t even imagine saying that to a human who has their baby in someone else’s tummy and treating them like they’re an alien. It’s just not fair.
Mary Jane: I totally agree. We have an intended parent support session, and that was something that came up. A lot of people have this experience like you’re describing.
Dr. Aimee: The OBGYN could have a certification and we’ll send them Starbucks cards. Go to the sensitivity training, and whatever your special drink is, we’ll send it to you unlimited for a year. I don’t want it to be hard. Whatever your drink is, whatever your favorite flower is, your plant, we’ll get those plants delivered to your office for just being such a flower and a gem of a person.
Mary Jane: Absolutely. I would 100% support that. The last question. Is there any such thing as the perfect uterus?
Dr. Aimee: I call them the unicorn uterus. I’ve seen them before. When you see them, you know them.
Mary Jane: You can see it? Oh…
Dr. Aimee: You can’t. It’s hard. Obviously, there’s a shape to a uterus, a texture, a thickness of the lining that we look for. Most of my surrogates will obviously have that.
There are some situations where you’re like, “I don’t know. The lining is too thin. Should we wait? Should we give her another chance?” Sometimes you give her another chance and she makes a nice lining, and it’s like cool. Sometimes you don’t get to transfer, her lining is thin, and you give her another chance, and the lining is still thin, and you say I think we have to move on. So, you thought the uterus was great, but then now we’re in a different situation, we’re on medications, and it’s maybe been the passage of time since her last pregnancy, and you notice that things aren’t as good as they used to be.
Mary Jane: I guess the reason why I asked that question, and I’m not here to call out any particular agency, but I did notice when I was searching for a surrogacy agency that there was one that would charge a different price depending, they had a golden feature versus a standard or silver feature. Let’s just say the golden feature they said you will get matched with a gestational carrier with these qualifications, they’re younger, fewer pregnancies, lower BMI. Versus the standard where your gestational carrier could be older or more pregnancies.
When I saw that, I was horrified. I don’t know if I was overreacting. To me, the idea that you could say that this particular person with these characteristics would be a better gestational carrier than this one, to me, just didn’t seem like it was based on anything. I guess I’m biasing you to say something one way, but I am totally open for you to tell me.
Dr. Aimee: What I would say is when information is presented like that, it makes you assume that there is an issue with someone who is over 35, who has had pregnancies, and the reality is that’s not true. If I have someone who is 38 or 39 years old, and they’ve had a pregnancy in the last three years that was perfect, no complications, that person to me is just as good of a surrogate as someone who is 27 years old.
Believe me, I have patients who come in that are like, “I want a 21-year-old surrogate.” I’m like no. Most women who are surrogates, most of the time, I would say over 50% of the time, are done with their own family building. Someone who is 21, who has had one baby, that wants to have another baby, they’re not usually done with their family building.
That’s one thing that I usually encourage surrogates to do. When they come to see me, because I’m also a fertility doctor, if I have a 37-year-old surrogate and she’s actually not done and wants one more baby, I’ll check her AMH level. I’ll tell her, “You should actually have your own baby first and then be a surrogate for somebody else.”
Mary Jane: That was wonderful. I cannot even begin to thank you enough for spending your time with me and us. Thank you so much.
Dr. Aimee: You’re welcome. Thank you. It’s so nice to meet you, finally, and see you here and hang out. I hope you have a lovely weekend.
Mary Jane: Thank you. You too.
Dr. Aimee: Bye, everyone.
Mary Jane: Bye.
Catch more of me and topics like this through The Egg Whisperer Show. Episodes are aired on YouTube, Facebook, Twitter, IGTV and Apple Podcasts . Sign up to get my newsletter. Tune in to The Egg Whisperer Show on YouTube. and Sign up for The Egg Whisperer School.
