Last updated 6/24/22

I created this document jointly with Weylin Liew.  Both of us had very positive experiences working with surrogates to grow our respective families, and we wanted to make this information public to demystify the process for people considering it.  We also know many other families that have gone through the surrogacy process and have used that to inform our writing here.

This document will answer key questions including:

• What is gestational surrogacy?
• How does surrogacy work from a medical perspective?
• How does surrogacy work from a legal perspective?
• How does surrogacy work from a health insurance perspective?
• How do you find a surrogate?
• How do you select a good surrogate?
• What is the experience of surrogacy like for the intended parents?
• How much does surrogacy cost?
• Is surrogacy ethical?

What is gestational surrogacy?

Gestational surrogacy is when someone other than the genetic mother of an embryo gestates that embryo to term.  It is usually done when a couple wants to reproduce but has difficulty gestating.  This has become an amazing opportunity for many couples who previously thought it was not possible to have a family.

This can come up in a range of situations, including:

• A male-female couple that is capable of producing viable sperm and eggs, but where the woman has a condition that makes it difficult or impossible for her to bring a baby to term.
• A male-male couple where the sister of one of the men offers to donate eggs so that the couple can have children that are related to both of the parents.
• A male-female couple who created embryos via IVF many years ago, but now the woman has reached a point of declining fertility where the embryos are unlikely to implant in her successfully.

Gestational surrogates are sometimes also referred to as gestational carriers.

Gestational surrogacy differs from biological surrogacy, in which the surrogate acts as both a gestator and as the egg donor.  For simplicity, gestational surrogacy will simply be referred to as surrogacy in the rest of this document.  

How does surrogacy work from a medical perspective?

In order to work with a surrogate, you and your partner (or an egg/sperm donor) will have to use IVF to create viable embryos that can be implanted into the surrogate.  There’s an excellent guide to the egg freezing part of IVF over at cather.io/eggfreezing, and my personal overview of the IVF experience at https://www.mattbell.us/ivf/  The tl;dr of the egg freezing guide is that every woman who thinks they might want to have kids someday should go get a fertility check immediately; it’s simple, cheap, and easy to do, and helps you figure out how proactive you need to be about freezing eggs or embryos.  

When doing IVF, you ideally should have your embryos brought to the 5-day blastocyst stage and then genetically screened for trisomies and deletions, as well as any other serious genetic issues.  This is important because you want to maximize the chance of success of implantation, and screening the embryos ensures you are only implanting viable embryos.  Implantation of genetically screened embryos into a surrogate has a success rate as high as 70% per embryo. Since surrogates undergo thorough medical checkups and are selected for fertility and responsiveness to induced pregnancy, the success rate for implanting embryos in surrogates is about as high as it can possibly get.

In the past, implanted embryos were not genetically tested, and because of the lower success rate that brought on, they were often implanted up to three at a time, which usually led to a single successful pregnancy, but also led to a lot of high-risk twin or triplet pregnancies.  This is no longer considered a best practice, and many surrogates now refuse to do simultaneous multiple embryo implantations.

After implantation the surrogate generally takes a set of hormone injections designed to maximize the chance of successful embryo growth.  The pregnancy is very closely monitored during the early phases, with some additional injections done as needed to create the ideal environment for gestation.  After that, the pregnancy proceeds normally.

How does surrogacy work from a legal perspective?

You, as the intended parents, and the surrogate sign a definitive legal agreement before starting the implantation process.  Each side retains their own lawyer (generally a family law or reproductive law specialist) in order to put together this agreement.  

However, family law, which differs from state to state, can supersede whatever is in the agreement.  Surrogacy is supported by legal statues in some US states, and is on shaky legal ground or explicitly forbidden in others.  Laws related to families and establishing parentage can be very parochial and traditional, so it’s very important to understand the legal framework that governs where you are planning the surrogacy.   California has one of the most surrogacy-friendly legal environments, with a specific legal recognition of various types of surrogacy.  

[Update 6/24/22 – with abortion now banned in several states, including the popular low-cost surrogacy centers of Utah and Idaho, you'll want to be particularly careful about where you choose to do surrogacy, as you may not be able to abort a baby with severe birth defects in those states.]

In California after about three months into gestation, you will usually complete a pre-birth order that establishes parentage from the moment of birth.  

We’re not familiar with the legal environment of surrogacy outside the US, but note that it may require research into citizenship rules for both your own country as well as the country where the surrogacy is taking place.

How does surrogacy work from a health insurance perspective?

Some surrogates can get the surrogacy covered on their own insurance policies, but this is rare.  Usually you will have to purchase a surrogacy-specific health insurance plan.  Once the baby is born, all post-birth expenses (barring surgery immediately after delivery) are on your health insurance instead of the surrogate’s, so you will want to make sure that you line up pediatric appointments that are in your network.  If you and your partner both have the baby on your own insurance policies, you actually don’t get to pick whose insurance the baby goes on because the US insurance system is messed up like that. Finally, you may want to consider NICU-specific insurance as preterm births that require NICU care can get extremely expensive.

How do you find a surrogate?

Generally you complete the process of producing some embryos via IVF before looking for a surrogate.

Most surrogates are found through a matchmaking agency.  These agencies generally work on an upfront fee basis, where you pay a large amount of money upfront to get access to their database.  Agencies vary substantially in terms of how large their database is, how well they pay their surrogates, and how stringent their criteria are.  You’ll want to carefully screen the agency you work with to make sure they are reputable.  Ask how many placements they do per year, how many profiles they have in their database, how long they’ve been in business, what their fee sheet looks like, how long the average customer takes to get a match.  Make sure you understand what typical all-in fees with the agency look like, not just the base fee.  Also understand how their matching process works, how much money they ask for upfront, what happens if a surrogate has to withdraw etc.  Some agencies do a lot more hand-holding than other ones.  Note that surrogates will shop around between multiple agencies, so the best surrogates will go to the agencies with the best pay and benefits, and you should go there too.  

We went with an alternative meta-surrogacy-agency called Donor Concierge, which searches across multiple surrogacy agencies to find you a best match.  We found in practice that they didn’t do as much upfront filtering as we would have liked, but we eventually found someone amazing through their service.  More importantly, they aligned incentives such that multiple agencies competed to get our business, and showed us really good matches in hopes of getting us to sign with them.  Thus, we were able to choose a surrogate before paying the agency, which was a huge benefit.

A large fraction of American surrogacy agencies are located in California, though there are some in other states as well.  California’s surrogacy environment is so good that around ⅓ of couples seeking surrogates in California come from overseas, mostly China.  

There are also low-cost surrogacy agencies in developing countries (eg India, Ukraine), but the quality of these arrangements is often low, with many of these clinics engaging in shady or unethical practices that lead to bad outcomes for both the surrogates and babies.  Many prevent the surrogates from leaving their facility for the entire length of the pregnancy.  We’re both aware of multiple reports of these clinics inducing labor very prematurely (at 34 weeks) solely to save costs.  

In general, it’s advantageous to have the surrogate within driving distance of you, as that simplifies visits to the IVF clinic as well as the process of getting your baby home at the end.  You never know when there might be some cataclysmic event that shuts down global air travel, right as your baby is about to be born.

It is possible, though difficult, to have a friend act as your surrogate.  Usually IVF clinics will require potential surrogates to have had at least one kid of their own already, attest that they do not want any more kids of their own, and pass a range of physiological and psychological exams.  

It takes a widely variable time to find a surrogate; some people find one almost immediately, while others take a year.  You’ll start by reviewing profiles, and then move to an interview with someone who seems like a good mutual fit.  If everyone is interested in proceeding, the surrogate does an additional medical evaluation at the IVF clinic, and you do a psychological evaluation.  If everyone passes this, you negotiate and sign a definitive legal agreement that covers fees and responsibilities as well as a lot of the difficult questions around what to do in situations such as discovering the baby has a birth defect.  This process of paperwork and testing takes a while; in general, it takes about 4-6 months from agreeing to work with a particular surrogate to doing the first implantation.  

How do you select a good surrogate?

It’s most important to find a trustworthy surrogate who has good value alignment with you.  Ultimately you are trusting her to take care of your growing baby for you, and no amount of legal language can guarantee she’ll follow your wishes, so you will want to pick someone who has similar values and priorities to you in order to quickly build trust, make communication easy, and maximize the chance that she’ll make the same decisions you would.  Surrogacy is an oddly intimate relationship given you usually share this experience while having no prior relationship with them, and it can presumably become very difficult or awkward if it’s not going well.

In general you’ll want to find someone who’s kind, maternal, responsible, and detail oriented.  You want someone who will approach carrying your child with the same care that you would.

Agencies in the US will already screen for a variety of criteria -- they’ll perform a background check and a thorough psychological evaluation, make sure they don’t smoke or use illegal drugs, and check them out for a variety of health markers.  In the US, all surrogates are also required to have had at least one child of their own already, and not plan to have any more children of their own.  This helps with proving fertility and ability to gestate a fetus to term, and also gives the surrogate a sense of what to expect when they carry a child for someone else.  

The IVF clinic may also have additional health requirements of the surrogates that are more stringent than what the agency will accept.  For example, our IVF clinic had a tighter acceptable range of BMI (admittedly an imperfect measure of obesity) than the agency did, as well as numerous other more stringent criteria.  The IVF clinic will also do an in-person health evaluation and STI testing of the surrogate to make sure their physical health matches their profile.  It may be worth getting your IVF clinic's requirements for surrogates upfront to help you more quickly screen surrogates presented by the agency.  

When looking at potential surrogates, here are some other things we looked for:

• Low stress home environment and work environment (if they work).  This is super important as babies will be affected by the epigenetics they’re exposed to in the womb.
• Supportive partner and/or good support network, especially if they’re a single parent.  If they end up needing bed rest, they need someone who can come care for them.  The agency screens for this, but it’s worth making sure you agree with their assessment.
• Work environment should not pose a health risk to fetuses.
• No gestational diabetes or other complications during previous pregnancies
• Most recent pregnancy was at most a few years ago (and thus ability to gestate is likely still high), and did not have trouble getting pregnant.
• No health conditions that could worsen pregnancy outcomes.
• Healthy weight range
• Up to date on vaccinations
• Good philosophy around COVID risk management.  High fevers are bad for fetuses.
• Age and maturity -- you want to make sure they are old / mature enough to have a sense of what they are getting into, but there are potential increased risks in the pregnancy at the older end (beyond late 30s).
• Find a surrogate who’s done surrogacy before, if possible.  It’s great to be able to reference-check how the first surrogacy went and whether the surrogate maintained a good relationship with the genetic parents throughout the process.  However, note that about 80% of the candidates are first-time surrogates, so this drastically limits your selection. A really good first-time surrogate is probably still a lot better than a mediocre repeat surrogate.
• History of light or no alcohol consumption and no tobacco consumption over the last several years.
• Lives in an area that’s relatively free of air pollution
• Lives in an area that has a hospital with a good NICU (many surrogacy agencies screen for this)
• Already has a healthy diet (minimal junk food consumption, low sugar intake)
• Up for taking basic supplements to maximize chance of success (eg folic acid, mercury-free omega-3 oils, choline, prenatals)
• Is within a healthy weight range
• OK with terminating in the case of developmental birth defects (eg spina bifida, congenital heart defects).  You can use PGD to screen for severe genetic defects prior to implantation.
• Willing to pump breastmilk.  They will freeze and ship it to you every week, allowing you to feed the baby breastmilk supplemented with formula..

You will also want to think about how much contact you will want with the surrogate during the pregnancy and after the birth.  Some surrogates prefer high-touch where you are sending photos back in forth and keeping in touch regularly, while others prefer a low-contact approach with minimal interaction.  There isn’t a right answer here, just personal preferences, and it’s important to be aligned on them upfront.

What is the experience of surrogacy like for the intended parents?

This will obviously be different for different people, but here are some common experiences that come up:

• At least for us, our journey to parenthood has been much less visceral and more abstract.  We’re constantly texting with the surrogate and getting photos and videos of the pregnancy in progress, but there’s some deep animal part of our brains that still doesn’t know a baby’s about to show up.  Until the last few weeks of the pregnancy, we could easily go several days without thinking about the fact that we have a kid on the way.  This obviously isn’t possible if there’s a tiny human inside you, literally kicking your abdominal wall.
• Many women can have unexpected latent grief about not carrying the pregnancy themselves.
• Many women report they feel like the father and not the mother.
• You’ll want to consider how you message pregnancy via surrogacy with your friend network.  It can lead to a lot of confusion if you don’t mention anything about having a kid on the way and then suddenly appear with a baby, or if you announce you’re pregnant but several months later your friends see you without a baby bump drinking alcohol at a party and they assume you miscarried.

How much does surrogacy cost?

In California, surrogates earn anywhere between $35k - $70k for a surrogacy in direct payment, plus additional payments for pregnancy milestones, additional implantation rounds, lost wages, maternity wear, health insurance etc.  The highest-paid surrogates are usually ones who have already had a successful surrogacy.  The total all-in cost of a surrogacy in California including IVF clinic fees, agency fees, etc usually ends up being around $130k-$160k, though it can go higher if multiple implantation attempts are needed.  (Note that this total does not include the IVF rounds to create the embryos, which can run $10k-$15k per round and could require several rounds.)  This amount is apparently somewhat lower in other states (by 30-50%) and much lower overseas, but there are challenges to working with a surrogate who is more distant, and you should be very careful with overseas surrogacy clinics as many of them behave unethically toward their surrogates and the parents.  We’ve heard of multiple bad experiences with surrogacy agencies in Ukraine and India.

Is surrogacy ethical?

I believe it can be when practiced well, and it is generally ethical the way it is done by reputable agencies in the US.  While pregnancy carries some risks for everyone, the distribution of risk is very uneven.  Pregnancy is low-risk for some people and high-risk for others.  Everyone who works as a surrogate in the US is someone whose past pregnancies have been relatively low risk.  If someone for whom pregnancy would be high risk hires someone for whom pregnancy is low risk to have their baby for them in exchange for money, that lowers overall risk at a societal level by transferring the work to the person who can do it more safely.  

In our society, people with natural talent in one area often go to specialize in that area.  Some people who have a combination of physical strength and dexterity end up working as loggers, and the rest of us pay them to do so whenever we buy wood furniture or a house.  Logging is one of the most dangerous common professions in the US, with an annual death rate of 136 per 100,000 workers.  By comparison, the average job carries an annual risk of 3.6 deaths per 100,000 workers.  Annually, electricians have 10.0 deaths per 100,000 workers; taxi drivers have 13.2, farmers have 17.4, delivery drivers have 24.7.  (Source) The average maternal mortality in the US is 17.4 per 100,000 pregnancies, so we can use this number as a rough estimate of the danger of surrogacy.  As long as the doctors are not implanting multiple simultaneous embryos (which would increase risk due to twin pregnancy), we could assume that surrogates have a lower maternal mortality than average, as their past pregnancies were low risk and they tend to receive better-than-average medical care.  

Generally, we can think of surrogacy as a job that carries some risk, but is in the same ballpark as other common jobs such as farmer and delivery driver.  If you feel that people should not hire surrogates because the job carries some danger, then to be ethically consistent you should also build your own house, grow your own food, repair your own roof, and drive to the factory every time you want to buy something.  

Some people claim that surrogacy is inherently exploitative due to the financial pressures created by capitalism.  At least in the US, surrogacy agencies screen surrogates for a demonstrated *lack* of financial need.  They want to make sure that the surrogate is not desperate for money, and isn’t being forced into surrogacy to make ends meet.  In general the people who become surrogates love the experience of being pregnant and are excited to help a couple have a child.

I once met a couple at a parenting meetup who said “we are looking for a surrogate, but it’s important to us that she do it for free because capitalism is inherently exploitative.”  This seems like a terrible cop-out masquerading as noble intentions.

One thing I like about surrogacy from a gender equality perspective is that it puts a price on something women have always been expected to do for free as part of creating a family.  I definitely know couples where they have strived for complete equality in all things, and then it comes time to have kids and the husband says something to the effect of “I can’t make a baby, so you have to do it”.  At least now there’s a formally-recognized high price to formerly unpaid labor.  

From a societal perspective, it’s true that surrogacy’s high price puts it above the budget of a large fraction of Americans, and the cost of surrogacy is unlikely to drop significantly over time as it becomes more common.  Ultimately, the only solution that could become low-cost enough for mass adoption is artificial wombs, and that technology is probably 20+ years away.  

This does create a situation where wealthier families are able to pay to avoid infertility issues or unusually dangerous pregnancies, whereas poorer families cannot.  I think there’s a bigger systemic issue to address here, which is that modern American society has uniquely high healthcare costs relative to healthcare quality, and has made it very difficult from a financial and career perspective to have children.  The right solution is a universal paid pregnancy / maternity / paternity leave system that minimizes the financial cost of pregnancy in general, paired with a simpler and more straightforward universal healthcare system and universal preschool and daycare.  This is not easy but is achievable, as Scandinavia already has similar policies with tax rates that aren’t much higher than California + US taxes.

Thanks!

This document was written by Matt Bell and Weylin Liew.  Both of us had separate surrogacy journeys, with Matt and his partner doing surrogacy in California while residing in California, and Weylin and her partner doing surrogacy in the US while residing in Singapore.  Both of us know several other couples that have had surrogacy journeys as well.  We hope it will be useful to you!