How does IVF gestational surrogacy work?

How does IVF gestational surrogacy work?
Surrogacy can be a worthwhile option for some couples and individuals. Here, we breakdown what surrogacy entails and things to consider before choosing to embark on this journey.
Written by Orchid Team 
Medically reviewed by Cristina Vidal, RN
  • Cristina Vidal, RN, is the IVF-Donor-Surrogate nurse coordinator at Stanford Reproductive Endocrinology and Infertility with over 20 years of experience in the fertility and reproductive clinic.

Gestational Surrogacy vs. Traditional Surrogacy

Surrogacy is the process of a woman offering to carry a child on behalf of another individual or a couple. There are two types of surrogacy options out there:

  • Gestational surrogacy, in which the surrogate is not genetically related to the baby
  • Traditional surrogacy, in which the surrogate is the biological mother

Gestational surrogacy (also known as gestational carrier), on the other hand, is an arrangement in which a surrogate carries a pregnancy for an intended parent(s). It’s the most common form of surrogacy and the gestational carrier is not genetically related to the baby. The intended parents can use their own genetic material (eggs and sperm) or use donor gametes to create an embryo through IVF that is then transferred to the gestational carrier. In the US, it’s legal in all states except New York, Nebraska, Michigan, and Louisiana.

Traditional surrogacy is not a commonly used option in the United States but just so you know what it is — a traditional surrogate donates her eggs and also carries a pregnancy for intended parents. This makes the surrogate the biological mother. It’s often done through intrauterine insemination (IUI) with the intended father or donor’s sperm. Traditional surrogacy is banned in many states, and even in states where it is legal, many medical professionals won’t offer this option due to the legal and emotional complexities involved. That’s because the surrogate has parental rights as the biological mother and can change her mind.

When is it recommended to use a gestational carrier?

According to the American Society of Reproductive Medicine (ASRM) guidelines, the use of a gestational carrier is reserved for intended parents who have a medical condition that precludes them from carrying a pregnancy or would pose a significant risk of death or harm to the woman or baby. The medical indication needs to be clearly documented. Examples of such indication can include:

  • The absence of a uterus — either congenital or acquired 
  • A significant uterine anomaly such as irreparable Asherman syndrome or unicornuate uterus associated with pregnancy loss
  • A serious medical condition that could be exacerbated by pregnancy or cause significant risk to the developing baby
  • A biologic inability to conceive or bear a child, such as a single male or homosexual male couple

A gestational carrier may be considered for patients who have experienced multiple unexplained failed IVF attempts despite the transfer of viable, good quality embryos, or history of recurrent pregnancy loss. In addition, a therapist may also highly recommend the use of a gestational carrier if the intended mother had a traumatic life event or difficult previous pregnancy experience.

Where can I find a gestational carrier?

Gestational carriers can be found through an agency or privately. Agencies help by providing intended parents a database of potential surrogate candidates. Gestational carriers can also be someone that the intended parent(s) knows, such as a friend or family member.

In both cases, the IVF clinic will review their records and perform the necessary screening and testing to evaluate if they will be good candidates to carry a pregnancy.

How does someone become a gestational carrier?

In order to be considered as a gestational carrier, individuals need to meet the following recommended criteria:

  • Age  — 21-40 years old 
  • BMI  — under 32 and higher than 18.5
  • Pregnancy history  — no more than 2 previous C-sections and 5 previous deliveries
  • Review of OB medical history by the IVF clinic prior to their initial visit
  • Normal PAP report within last 3 years
  • Psychological Evaluation with personality testing (PAI or MMPI) of candidate surrogate and, if applicable, her partner

A note about the psychological evaluation piece to bring more context and normalize the process — Gestational surrogacy is a big emotional undertaking for all involved parties. The purpose is to properly evaluate a gestational carrier's psychological state, past history, and emotional stability. Their partner needs to participate in the evaluation as well.

On the other end, intended parents will need to speak with a marriage and family therapist to help them make informed decisions about their family building plans. Topics may include how they plan on sharing the use of a gestational carrier with the child and others, expectations for future contact with the surrogate, and education about the many emotional, ethical and logistical considerations to keep in mind. Part of the evaluation process includes an assessment of compatibility and mutual shared values between the gestational carrier and intended parents.

Once the initial pre-clinic visit requirements are met, individuals need the following screening and testing to become a gestational carrier:

  • A physical examination
  • Vaginal ultrasound
  • Infectious diseases testing panel 
  • Complete blood count 
  • Blood type and Rh
  • Comprehensive metabolic panel
  • Urine drug screening
  • Hemoglobin A1 C
  • TSH
  • Check immunity for  Rubella, Measles, Hepatitis B Surface Ab, and Varicella

If the gestational carrier has a partner, they will also need an infectious diseases testing panel.

When the gestational carrier has been medically cleared, a legal agreement is needed. It’s important to check your state laws. In California, a surrogacy contract requires that the intended parents and gestational carrier each have legal representation by independent legal counsel. If an agency was used to find the surrogate, they will facilitate the legal process. If privately found, both parties will need to find two lawyers specialized in reproductive law. After legal clearance, the cycle planning can begin.

The IVF Surrogacy Process

Once the intended parents choose their surrogate and have completed all the necessary legal agreements, the reproductive endocrinology team will make a plan.

Nowadays, the most common process is for the intended parents to have already created and frozen embryos before looking for a gestational carrier.

A less common option is to transfer fresh embryos that haven’t been previously frozen. In such cases, the intended mother or egg donor synchronizes her cycle with the gestational carrier to make sure that by the time egg retrieval happens, the gestational carrier’s endometrial lining is ready for the embryo transfer.

From there, the gestational carrier takes a blood-based pregnancy test about 9-13 days after embryo transfer. If the pregnancy test is positive, repeat hCG levels are tested. If the levels are appropriate, then the first OB ultrasound will follow about two weeks later. After around 8 weeks of pregnancy, the gestational surrogate/carrier will continue to receive medical care throughout the pregnancy from her OB/GYN doctor. Once she gives birth, the lawyers will have the declaration ready for the intended parents to take the baby home.

The Costs of IVF Gestational Surrogacy

Since IVF gestational surrogacy involves several medical procedures, the first thing you want to do is take into consideration the combined costs before moving forward. This is especially important since legal and agency fees can add to your expenses, as can travel.

For example, agency fees can range from $20,000 to $30,000. Surrogate compensation can be as high as $65,000, which doesn’t include legal fees, insurance, or clinic costs. Realistically, IVF gestational surrogacy can cost intended parents between $65,000 to $200,000, with an average cost being around $120,000.

You can get a better idea of the cost breakdown here.

The Bottomline

IVF gestational surrogacy can be an option for couples or individuals who have a medical condition (or a history of failed embryo transfer or recurrent pregnancy loss) that precludes the intended parent from carrying a pregnancy, or would pose a significant risk to the woman or baby.

We know there many ways to build a family, so it’s important for us to highlight all aspects of the family planning spectrum — here’s a guide to fertility preservation for those who want kids at a later time as well as a guide to preparing for a pandemic pregnancy in 2021 for those planning on conceiving now. You have the tools and resources to take charge of your fertility in a way that works the best for you.

Everyone’s IVF journey is different — it can often feel both exciting and stressful for couples at the same time. That’s why we have plenty of resources that can help answer your fertility questions. Explore more of Orchid Guides here.
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