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Surrogacy 101 – By Nazca Fontes, President, ConceiveAbilities

The road to having a child through gestational surrogacy can be a complicated one. This is why people often turn to a qualified surrogacy agency to help navigate the ups, downs and sideway turns it can take. In order to make the process run as smoothly as possible, there are some basic guidelines to follow:

Working with or without an agency:

Some people have a friend or family member who offers to carry a child for them. With this may come some measure of security, but also some pitfalls. It can be very difficult to tell a friend or loved one not to do certain things when they are making this beautiful gesture. The relationship with a surrogate, who you meet specifically for the purpose of carrying your child, has much more defined boundaries. If do choose to work with an agency, you want to be sure you are selecting one with a good reputation who can help you navigate the bumps that can occur along the way. You need an agency that will work with you through any difficulties that may arise – and while these difficulties can be quite small, without an agency small things can escalate very quickly. Of course, you can see my bias in working with an agency.

Finding a Gestational Surrogate

Gestational surrogates (also called gestational carriers/GCs) come in all shapes and sizes, but they can be single, married, have several children or just one, had vaginal births, C-sections or VBACS. But the major requirements I recommend are:

• Healthy, both physically and emotionally

• Proven fertility

• Uncomplicated pregnancies

• Good support system

• Strong, reliable communication

• Compliant and good at following instructions

• Stable, healthy lifestyle

Between the lines, this can be someone who wants lots of contact, or someone that doesn’t need to you to be there and hold her hand throughout the process. You know who you are and what you need, and it’s good to find someone with similar values.


Medical Examination: Your RE will meet and medically review the intended parents (IPs), gestational carrier and her partner (if she has one). This could include semen analysis, blood work to test the GC and the IPs (and egg donor, if there is one) for infection and sexually transmitted diseases, hysterosalpingogram (HSG), for the doctor to view the uterine lining to detect uterine polyps or other defects which could affect implantation or pregnancy, a "mock transfer" to determine the best type and size of catheter for the embryo transfer, and other medical issues to ensure the surrogate is prepared for transfer and pregnancy.

• Psychological: This typically includes a PAI for the gestational surrogate and a psychological examination. Some evaluations include both the GC’s partner and the Intended Parents, but different psychologists conduct this in their own way. The psychologist will also inform the GC of the possible issues that can arise during the surrogacy and makes a determination if the GC is psychologically prepared to take on the responsibilities of gestational surrogacy.

• Background checks: It is strongly advised that you or your agency run a background check to ensure that she is a responsible person. These checks can be run through online services or agencies to verify the information.

• Some clinics require a "mock cycle" for the GC, where the recipient takes medications, followed by ultrasounds and blood work to ensure that the medication is effective and the uterine lining is appropriate to support a pregnancy.

• It is important to understand if your GC’s insurance will cover her medical expenses once she is released to the care of her OB. Most insurance does not cover any of the fertility treatment leading up to the transfer and through the first 10-13 weeks of pregnancy – at which time her OB will start caring for her.

Contracts and Escrow:

Contracts can be a very emotional process for all involved. They bring up all the possible things that both parties want and expect, as well as all the possible pit falls. A good contract balances the needs of both parties and protects both, but it’s important to remember that this is a collaborative process and not an adversarial one.

• Each party (GC and partner/IPs) will have their own lawyer to represent them. The IP’s attorney will draw up the contracts and will review to ensure it represents what they have agreed to with the GC and also to ensure they understand it. The GC and her partner will also have an attorney to represent them. Even though the IPs cover the financial responsibility, that attorney wholly represents the GC and her partner. Once all parties are in agreement, the contracts are signed. The clinic will be informed that there is legal, medical and psychological clearance and the next part of the journey is ready to begin.

• Within 2 weeks of signing contracts, most agencies ask that an escrow account be funded. This will be used to pay the GC on a monthly basis for her pregnancy, possible allowance, medical expenses, maternity clothes and other expenses agreed to in the contract.

The Cycle:

The clinic will help to oversee all the medical aspects of the journey, but the IPs still need to be very involved. The benefit of a surrogacy agency is that they can help coordinate all aspects of it with the GC and keep things running smoothly. Most cycles look something like this:

• Coordinate cycles of Intended Mother/egg donor and GC. Both take medications such as Lupron (shots), Synarel (nasal spray), and/or birth control pills.

• Some clinics prescribe antibiotics for the donor, surrogate and her partner early in the cycle (often a 10-day treatment) in order to treat any undiagnosed infections that may exist.

• Once both the Intended Mother/egg donor and the GC are down-regulated, the GC begins to take estrogen supplements in some form - either oral, patches or shots. The dosage may be adjusted based on blood tests (measuring E2 levels) and ultrasounds measuring the uterine lining.

• While the GC is taking estrogen supplements to build a thick uterine lining, the Intended Mother/egg donor begins her fertility medications. These medications are often taken for 8-10 days. Her progress is measured through blood work and ultrasounds.

• The date of the egg retrieval will be determined based on the size of the Intended Mother/egg donor's follicles, as measured by ultrasounds. At the appropriate time she will be given a trigger shot of HCG, and the retrieval is generally performed approximately 33-35 hours thereafter.

• On or just before the date of the egg retrieval the GC will begin taking progesterone supplements available as injections, vaginal gel, vaginal or rectal suppositories, or administered in oral form.

• On the date of the retrieval the Intended Father will provide a semen sample or donor semen will be provided. The semen is processed and the eggs are fertilized that same day. In some cases ICSI will be performed (a process where a single sperm is injected into each egg).

• The day after retrieval the lab will provide a fertilization report. The embryos remain in the laboratory until the date of the transfer, which can be between two and five days after the retrieval. Periodic progress reports are provided to the recipient to keep her informed about number, size and quality of embryos.

• If the IPs elect to do PGD (Pre Genetic Diagnosis) on day two, one cell from each embryo will be extracted and sent to a laboratory that specializes in decoding the information in that cell to determine gender and if there are any chromosomal abnormalities.

• Based on embryo quality and other factors, the doctor, the IPs and GC determine how many embryos to transfer to the surrogate's uterus. The rest may be frozen at that time or kept in the laboratory for several more days before freezing. Often clinics will freeze only high quality embryos.

• Some clinics will prescribe a steroid (often Medrol or Prednisone) and another round of antibiotics for the GC to take for several days preceding the embryo transfer.

• The embryo transfer is generally performed in the clinic's office. The embryos are placed into a catheter and transferred through the cervix into the uterus of the recipient under ultrasound guidance. Some clinics prescribe Valium for the GC to take prior to embryo transfer, although the procedure is generally not any more painful than a pap smear or insemination.

• Following the embryo transfer the GC will remain lying down for 30 minutes to several hours, depending on the clinic's protocol. The GC then remains on bed rest or modified bed rest for several hours to several days, depending on the clinic's protocol.

• Several restrictions may be imposed for the period between transfer and the pregnancy test, including limitations on exercise, heavy lifting (over ten pounds), sex, caffeine, etc. Again, this varies from clinic to clinic.

• A blood pregnancy test (beta hCG) may be performed 9-14 days from a day 3 embryo transfer (or sooner for a day 5 transfer). The hCG level in the blood is measured; if the test is positive it is repeated two days later. hCG levels should double every 48-72 hours.

• If the repeat beta test doubles like it should, the surrogate is then scheduled for an ultrasound at the five or six week mark to date and measure the pregnancy. The patient continues to take progesterone and estrogen supplements as directed by her physician, often until the end of week 10 or 12 of pregnancy.

The Pregnancy

Hopefully the pregnancy will be a fruitful journey for all involved, with many happy days (including ultrasounds and, of course, the birth). Communication should be open to ensure everyone is on the same page. Again, this is where an agency can be so important. Even if everyone is in agreement, it is wonderful to have the agency take the responsibility of reminding the GC of her appointments, testing, and to handle other needs like contract payments.

• About way to 2/3 of the way through the pregnancy, the IP’s lawyer should file papers in the court to ensure that the IPs are recognized as the parents and decision-makers upon the birth of their child. This will be given to the hospital administrator or social worker and also the records department when filling out the birth certificate. At this time the parental rights documents are also addressed.

• Agencies encourage discussion about what will happen at the birth and afterwards. Some IPs stay near the hospital weeks before the birth, while others drive or fly to the GC when they get a call that she is in labor. With many surrogate pregnancies, the OB is open to inducing so the IPs have the best chance of being there for the birth.

• Most GCs would like the IPs to be in the room at the time of the birth. It is the moment they have been waiting for! If there are twins or a C-section there may be a limit to the number of people allowed in the delivery room. The GC is able to have her partner or a loved one there for her. After the actual birth the GC is not done (she still has to deliver the placenta and there may be other medical issues to attend to) and at that point the IPs are focused on their newborn. It is good protocol to put her companion number one on the list to be in the delivery room.

• Post birth: it is the event you have been waiting for and you should relish every moment. But don’t forget the person who carried your pride and joy for 9 months. She will be thrilled for you, but she will want some time to say her goodbyes. Sometimes she may want a little private time, but often she is thrilled to have everyone around to celebrate – including her own family who has also been part of your amazing journey. It’s important to consider the post-birth plans and what your future relationship might look like. Since it’s likely a new experience for both parties, an agency can help you through this process as your surrogacy journey comes to an end.

Nazca Fontes, President, ConceiveAbilities

Since founding ConceiveAbilities in 1996, Nazca Fontes has earned a solid reputation as a thought leader in the industry. She is frequently interviewed on the subjects of surrogacy and egg donation, and has been featured in the Chicago Tribune and the Huffington Post, as well as the BBC’s Newshour radio program. Nazca travels around the globe promoting the highest level of professional standards in a constantly evolving field. Nazca’s experience and commitment to quality service gives intended parents, surrogates and egg donors alike the resources, support and information to simplify this unique process. For more information, visit www.conceiveabilities.com.

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