Surrogacy is an important family planning option, but be prepared for a lengthy, expensive and emotional process.
By David Dodge
This guide was originally published on Oct. 11, 2019 in NYT Parenting.
From the time they began dating as teenagers, Rita and Erikson Magsino, now 39 and 43, talked about the family they hoped to have together one day. Almost immediately after marrying in 2005, they tried to make that dream a reality.
But parenthood would have to wait — Magsino learned she had an aggressive form of endometriosis that made it difficult for her to become pregnant. For over a decade, the couple tried everything to conceive — including fertility drugs and advanced treatments like intrauterine insemination and in vitro fertilization. Twice, Magsino became pregnant, only to miscarry late in the second trimester. “After we lost twins at 20 weeks, we decided enough was enough,” she said. A generation ago, the couple’s attempts to have a biological child most likely would have ended there. Instead, thanks to improvements in reproductive medicine, they welcomed a baby boy into their home in May with the help of a gestational surrogate.
Surrogacy has also created an avenue to biological parenthood for thousands of others who can’t conceive or carry children on their own, such as same-sex couples and single men. As a gay, H.I.V.-positive man, Brian Rosenberg, 54, figured biological fatherhood was forever out of reach. But thanks to surrogacy, and a technique known as “sperm washing,” which prevents H.I.V. transmission, he and his husband, Ferd van Gameren, 59, welcomed twins, biologically related to Rosenberg, in 2010. “It’s still hard to believe,” Rosenberg said. “I thought this was a door that was shut to me.”
Still, would-be parents need to be prepared for a process that is far longer, more expensive and emotional than many people expect — it’s called a “surrogacy journey” for a reason. For this guide, I interviewed the types of experts you can expect to encounter during a surrogacy journey, including two fertility specialists, a lawyer, a psychologist and an agency caseworker.
There’s enough jargon within the world of surrogacy to fill a Rosetta Stone course. You’ll no doubt be fluent by the end of your process (which, by the way, is frequently referred to as a “journey”) but here are some basic terms and definitions to help you get started:
A “surrogate,” or a “carrier,” is someone who agrees to carry a child for another individual or couple — who in turn are referred to as the “intended parents.”
In “gestational surrogacy,” the most common form practiced in the United States, eggs from either a donor or intended parent are used to create embryos, so there is no biological relationship between the carrier and offspring. In “traditional surrogacy,” a carrier uses her own eggs to achieve pregnancy — meaning she will be biologically related to the child.
“Compassionate surrogacy,” also called “altruistic surrogacy,” refers to an arrangement in which a carrier agrees to carry a child for intended parents without compensation. In “commercial” surrogacy, a carrier is compensated.
Though the United States is one of the few countries to permit commercial surrogacy, the laws vary “considerably” state to state, said Judith Daar, the dean of Chase College of Law at Northern Kentucky University, and the chairwoman of the American Society of Reproductive Medicine Ethics Committee. Some states have comprehensive surrogacy laws on the books, others are completely silent on the subject, and a couple of states (like New York and Michigan) currently permit only compassionate surrogacy. Research the legal landscape in your state, said Daar, but don’t obsess over the details — that’s what you’ll be paying a lawyer for. An experienced lawyer can help you complete a surrogacy journey even in states with unfavorable laws.
[Read about the legal basics L.G.B.T.Q. parents should know.]
They say it takes a village to raise a child, but with surrogacy it can take a village simply to conceive one. In her book, “Your Future Family: The Essential Guide to Assisted Reproduction,” Kim Bergman, Ph.D., senior partner at Growing Generations, a surrogacy and egg donation agency, outlined the four main types of experts that will make up your team:
Medical specialists: A reproductive endocrinologist will conduct medical screenings, create embryos and help your surrogate achieve pregnancy. Dr. Said Daneshmand, M.D., a fertility specialist at San Diego Fertility Center, described this relationship as “incredibly intimate,” so “find a doctor you feel comfortable with.”
Reproductive lawyers: You will need to negotiate legal contracts with your surrogate and egg donor, if you are using one — both of which are complicated documents. So hire a lawyer with “extensive experience in these areas,” Daar said. Your lawyer will help you navigate two critical issues: the legality of surrogacy contracts in your state, and the steps needed to establish your parental rights and to sever those of your surrogate’s.
Mental health professionals: The American Society of Reproductive Medicine, the largest organization in the United States dedicated to the practice and study of assisted reproduction technologies, recommends that you, your surrogate and your donor — and each of your partners, where relevant — undergo screening by a trained psychologist early on in the process. This is “essential,” not a luxury, according to Dr. Bergman. “Using third parties to create your family can be intrusive and emotional, and a therapist can help you work through some of the unexpected feelings that can arise for you.”
Fertility insurance experts: You also may need to work with a fertility insurance expert to make sure your surrogate’s pregnancy is covered. “Sometimes a surrogate’s own insurance plan will cover her pregnancy, but not always,” said Dr. Bergman. If you plan to use an egg donor, you will also need a special form of insurance for her. Intended parents from outside of the United States will have a particular need to consult an insurance expert.
The ease of your surrogacy journey will depend on the effectiveness of this team, and how well everyone collaborates, “so meet with multiple experts and get recommendations before hiring them,” advised Dr. Bergman. All of these experts should offer free consultations, she added, and should be willing to refer you to previous clients. A good place to start your search is the American Society of Reproductive Medicine.
Independent surrogacy: Many experts caution against attempting surrogacy independently, particularly if your reasons are financial. If everything goes perfectly, you could save yourself roughly $30,000 in agency fees, said Dr. Bergman. “But what if you end up requiring more than one donor or carrier, or need multiple legal contracts?” An agency is paid to handle these complications, she said, but independently, “you’re left to navigate these problems and pay for them on your own.”
Still, you may have a good reason for independent surrogacy. For instance, if you are working with a “compassionate” surrogate, like a friend or a family member, you won’t need an agency’s matching services. If you decide to pursue surrogacy independently, Dr. Bergman suggested you first meet with and hire a qualified lawyer to understand the laws in your state, and build the rest of your team from there.
Surrogacy agency: There is no federal oversight or comprehensive set of standards surrogacy agencies must adhere to, which means the quality varies widely. “Surrogacy agencies are businesses,” Daar said. “Treat them as such when deciding between them.” Experts generally agree that the guidelines developed by the American Society of Reproductive Medicine for the ethical practice of surrogacy are the most comprehensive — so, at a minimum, make sure your agency lives up to those.
There are some online resources that can help you in your search for an agency. All Things Surrogacy and Surrogacy Advisor both maintain a directory of agencies, along with some reviews from past clients. For help finding an L.G.B.T.Q.-friendly agency, the nonprofit Men Having Babies has a directory, along with reviews and ratings from former clients.
But the best way to decide, according to Dr. Bergman, is to meet with several agencies and take an “active role” during these consultations. “Find out how long they’ve been practicing, their success rates, educational backgrounds, and what their screening process is like for donors and surrogates.” For L.G.B.T.Q. and international clients, she also recommended getting statistics on the number of clients they’ve served from these communities.
Surrogates: The relationship you have with your surrogate is unique among the people you will work with during your journey, said Heather Manojlovic, who has worked as a surrogate for two families and is now a surrogate coordinator at Circle Surrogacy, a surrogacy and egg donation agency. “Make sure she and her partner are people you want to go on this journey with,” she said.
If you are working with an agency, ask about its screening process. Some will do comprehensive health, criminal, financial and psychological screenings before you “match” with a surrogate, Manojlovic said. But others do partial pre-screenings, and complete the full process only after you and your surrogate have agreed to work with each other — meaning there is a greater possibility a match will fall through.
Only two percent of the women who start an application with Circle Surrogacy successfully match with an intended parent — those that do share some common characteristics, said Manojlovic. All will already have successfully carried a child to term, for instance, and will generally have had no more than one previous miscarriage. “Surrogates also won’t be dependent on this income as a primary source,” said Manojlovic — noting the average household income for a surrogate at Circle Surrogacy is $74,000.
Manojlovic encouraged intended parents to talk to surrogates about their motivations. “Most of these women are drawn to this work for reasons that go well beyond the financial compensation,” she said. Her inspiration, for example, came from watching her aunt struggle with infertility. “I saw firsthand how devastating it was, and now I’m in a position to help others like her.”
Donor relationships: Egg and sperm donation in the United States has experienced a “sea change” within the last generation, said Sam Hyde, president of Circle Surrogacy. “Fifteen years ago, 100 percent of our clients used anonymous donors when creating embryos.” But today, thanks in part to the popularity of home DNA-testing kits, and the ease of finding people online, “the idea of ‘anonymous’ donation doesn’t really exist anymore.” So intended parents should determine the “degree of openness” they are comfortable having with their donor. “There is no right or wrong way to do this,” Hyde said. Some families connect on social media but little else, he said, while others involve their donor as an integral part of the family.
Known donors and surrogates: Some intended parents come to the surrogacy process with a friend or family member who has offered to be a carrier or donor. Dr. Richard Paulson, M.D., director of U.S.C. Fertility and past president of the A.S.R.M, has seen plenty of these scenarios “play out beautifully,” he said — but known donors and surrogates still need to undergo many of the same rigorous screenings. Known surrogates, in particular, “are the least likely to go forward as a successful match,” he said. Often, they fail to pass the clinic’s health assessments, or drop out after “fully coming to appreciate what it means to carry someone else’s child for nine months.”
There’s no getting around it — surrogacy is expensive. Most of the experts interviewed for this guide put the average price for a surrogacy journey around $150,000. But the final cost will vary, considerably, depending on your circumstances.
Two main factors affecting cost are whether you need an egg donor, and how many rounds of I.V.F. are required before your surrogate conceives. If you don’t need a donor, the cost for each cycle of I.V.F. can be around $15,000 to $20,000, but if you do, this figure can rise to $50,000 per cycle. Dr. Bergman said that, as long as the eggs and sperm are healthy, 70 percent of surrogates achieve pregnancy on the first try, and 99 percent by the third. Still, you could be spending anywhere from $15,000 to $150,000 on I.V.F. cycles.
Travel expenses and insurance can also impact the overall cost, especially for international intended parents pursuing surrogacy in the United States. “Babies born to domestic couples will be covered under their own insurance plans,” said Dr. Daneshmand, who specializes in international surrogacy arrangements. “That’s not the case with international parents — they’ll need to get their newborn’s insurance separately.”
While many families take out loans to afford surrogacy’s hefty cost, there are some other ways to bring down this total. “Definitely check with your employer to start with,” said Dr. Bergman. More businesses are starting to cover the costs of I.V.F. treatments up to a certain dollar amount, and others are starting to cover costs like travel expenses and legal fees. There are also limited grant and scholarship opportunities. The AGC Scholarship Foundation, for instance, helps offset some of the costs associated with surrogacy for those struggling with infertility. Men Having Babies offers sizable grants to gay men interested in forming their families through surrogacy.
Most experts warn intended parents against pursuing surrogacy outside the United States, where reputable agencies adhere to the standards put forward by the American Society of Reproductive Medicine. “It’s risky because you’re leaving a very structured, regulated environment, with professionals with a great deal of expertise,” said Dr. Daneshmand. Intended parents may have a difficult time leaving a foreign country with proper documentation, like birth certificates, he said. And most countries forbid commercial surrogacy contracts — so unless you are working with a compassionate surrogate, where no financial compensation is involved, “you may be out of luck.”
David Dodge is a writer focusing on non-traditional families and a proud father of three.