Surrogacy: What You Need to Know

Area 1: What surrogacy is and how it works

A surrogate is a woman who carries a pregnancy for another person or persons. We refer to them as intended parents.

I refer patients to surrogates, or carriers, some of which describe themselves as the ultimate babysitters. In other words, they take care of your baby for 9 months and are happy to let the parents take over following that period of time.

Who is eligibile to become a surrogate?

You must be over the age of 21, younger than 40, have a healthy body mass index (BMI), no medical problems, and no psychiatric issues. Additionally, you must have previously delivered, have a child at home with a stable home life and if in a relationship have it be with a partner that’s supportive of the choice to become a surrogate.

When I meet a carrier for the first time, I really want to get to know them personally. Most important is understanding their motivation for wanting to be a surrogate.

Then we get into more specifics.

• What kind of relationship do they want with the intended parent and future child?
• Do they want to be closely involved with the intended parents during the pregnancy? What about after?

It’s important for everyone to be on the same page and to run through hypothetical scenarios.

For instance:

• Would they consider transferring 2 embryos in scenarios where the embryo quality may be lower?

The surrogate goes through a battery of tests. From a medical standpoint, we are looking at infectious diseases, routine preconception labs, and also conduct a drug screen.

Depending on whether a carrier is a repeat carrier or first time carrier it may be worth doing a mock or rehearsal cycle with implantation testing.

The bottom line: I would disqualify a surrogate who doesn’t pass any medical exams, or I find isn’t suitable because it may not be the right time in her life because of a personal situation potentially impacting her emotional health.

Once a surrogate is chosen:

I review the different protocol options and talk about different types of medications we can use and then I plan a cycle based on the surrogate’s lifestyle preferences.

For example, there are some surrogates that would prefer to do one shot of estrogen every 3 days rather than taking tablets orally twice a day. It’s important for me to discuss this with the surrogate in advance.

On the transfer day, we discuss dos and don’ts of pregnancy as well as for after the transfer. If a surrogate is coming from out of town, she’ll typically come in the day before and leave a few days later.

Surrogates sign up for this because they’re great at being pregnant. They’re not used to miscarriages. And sadly, not every transfer works on the first time.

As the carrier and intended parents it’s important to talk about pregnancy expectations up front and what you would do as a collective team if an embryo doesn’t take or results in an abnormal pregnancy. You want to make sure everyone is united and there is not blame pointed in any direction should things not go perfectly.

So where do I come into the process?

I watch surrogate pregnancies through the first trimester and then do a well timed hand-off to the OBGYN. That said, I’m always there as a shoulder to lean on or for everyone involved. Both the intended parents (IPs) and surrogates know they can call, email, or text me with any pregnancy related questions even after they graduate from my office. I want to be there to troubleshoot any issues they may be having.

Thinking about twins?

I have many families who want twin pregnancies. I strongly urge patients to transfer one embryo at a time. There are surrogates who have successfully carried twins even more than twice! And want to do it again. So I certainly review each case very carefully before agreeing to transfer two. I generally recommend transferring the number of embryos that will give the family I’m working with the highest chance of having one baby at a time.

Area 2: My advice for intended parents looking to engage with a surrogate

Take your time picking a surrogate.

Visit with your surrogate. Get to know here, get to know her family. Ask her if she is considering any life changes. Bring her a card, flowers, small tokens of your appreciation can go a long way. Make sure she knows how much her sacrifice means to you.

Learn as much as you can.

Ask: Has your carrier been screened before? If she did go through this process before, what happened that she didn’t end up matching? What didn’t work? Why did the contract fall apart? Learning about past misunderstandings would help save you time and effort when putting together your contract.

If a surrogate comes to me and was repeat surrogate, I’ll ask: what worked for you and what didn’t? What would you like to see differently this time? And I pass that on. And some of the best things I’ve heard have been: “Everything worked out great! My only complaint is the I didn’t get my epidural in time!”

The contract is really important.

If let’s say the carrier wants to travel at a certain stage of pregnancy, you should always be able to refer back to the contract and say: per the contract we agreed that after 32 weeks you wouldn’t travel. Then that’s that. You don’t have to worry about having misunderstandings about things that perhaps you’re not comfortable with as an intended parent.

Same with things like intercourse. If for example, your surrogate is single. Make sure that you have it in the contract that any sexually intimate partner would get tested before sexual intercourse by either the ObGyn or fertility doctor.

Here are the very common misunderstandings that I have seen:

• Doppler Technology: How much or how little. Let’s say a surrogate wants to use a Doppler daily and the intended parents don’t want her to. Or visa versa! Let’s say the surrogate doesn’t want to but the intended parents want her to daily and send them recordings. Make sure this is discussed in advance.
• Pregnancy testing after the transfer: I talk to everyone about when we going to test and who is going to communicate the results. I like to test only by blood and be the one to communicate results very clearly once we know for sure.
• Surrogate relationship status changes during the 9 month term:Imagine she gets divorced during the surrogacy and no one had any idea there were even issues during the pregnancy. Then she starts dating and moves out of state. This is why knowing people really well is important. Making sure the partner is on-board and supportive is key.
• Surrogate becomes pregnant and then quits her job and then intended parents have to pay wages. The surrogate planned on doing this from the beginning but this was never communicated to the IPs. This is actually a question I ask of surrogates all the time: “Do you plan on continuing to work during the pregnancy?” If the answer is no, I make sure that everyone is aware so that there are no surprises.
• Something happens to the agency. For instance, the agency files for bankruptcy. You need to have plan B. Ask these questions up front: How is the escrow account set up? If something happens to the agency, how will you get money out of escrow? Ideally you would have the ability to pay directly from escrow without any middle man or permission from the agency.
• Have a communication plan for if there is an abnormal pregnancy.Surrogates feel awful when a pregnancy stops growing and it’s worse when the intended parents don’t reciprocate communication should a surrogate gives her condolences. It is important for everyone to realize that while we’re using a whole lot of science we’re still relying on way more nature and human biology to make a baby happen.
• Be fully aligned and detailed on how the relationship between the carrier, intended parent, and future child will be handled. I have surrogates come to me sad that a family they intended staying in touch with completely dropped communication. No answers to emails. No cards. Nothing. This can be traumatizing to a carrier. It’s important that everyone is on the same page on involvement during the pregnancy and after. Not everyone is going to be best friends for life and be at every life event for the future child. However, most carriers do have an expectation of at least getting photo updates. The smallest gestures of thanks can go a long way.

Area 3: The emotional elements of surrogacy

Some common questions I hear are…

How do I tell family that I’m using a surrogate?

The answer to that question entirely depends on the level of involvement your family has had in your journey to becoming a parent.

If they know what you’ve been through to get to the stage of using a surrogacy, odds are they will be there to support you.

Honest communication never fails. If you’d like you can get cute and share the news in a clever way like sending them a children’s book about surrogacy with a card thanking them for their support.

If that seems silly to you, then it’s not for you.

Ultimately, this is about you. Not your family. If any issues arise, your fertility psychologist is there to help you cope with any hurt feelings from loved ones or family members.

How can I stay emotionally stable and healthy during the process of surrogacy?

Have a fertility psychologist that you work with and are in close contact with. This is an emotional journey, and one that requires trust in the process and a third party that’s unbiased to help with communication and establishing trust among surrogates and carriers.

Can you predict how you’ll feel during the process of using a surrogacy? Absolutely not. In fact, the one thing you can count on is that as the pregnancy changes and grows, your feelings will change too.

You won’t feel the same way the entire time. But rest easy knowing that you are in control of establishing clear communication expectations with your carrier and as an intended parent (IP) get to choose your level of involvement. For some families, going to every appointment isn’t something they will be doing. For others they want to be at every single appointment, and ultrasound throughout.

As an intended parent, should I openly discuss my inner fears with the surrogate or utilize a support system like a fertility psychologist?

An intended parent (IP) should ideally use their psychologist to talk through their inner fears but certainly a surrogate has been through pregnancy as well and can be a great pregnancy coach too.

What’s helpful to a surrogate is knowing that the family trusts them. What’s helpful to the family, is knowing that the surrogate is always going to be in touch and ask questions of the doctor if anything ever comes up. This just makes everyone feel better.