What Is Surrogacy and How Does It Work?

When someone can't get pregnant on their own, they still have a few options for accomplishing their dream of parenthood—including using a surrogate (sometimes called a gestational carrier). This means they recruit someone else to carry and deliver their child.

“In the broadest terms, a surrogate means a substitute. When we talk about surrogacy in the assisted reproduction field, we're referring to a [person] who is carrying a child for another,” explains Stephanie M. Caballero, Esquire, founder of The Surrogacy Law Center.

According to the Centers for Disease Control and Prevention (CDC), about 2% of all assisted reproductive technology cycles between 1999 and 2013 involved surrogacy. This resulted in 13,380 deliveries and a total of 18,400 infants (many were twins, triplets, or other multiples).

Keep reading to learn about the surrogacy process, including the types of surrogates, expected costs, how to find one, and more.

Types of Surrogates

There are two types of surrogates: traditional and gestational. Gestational surrogacy is more common in America today, but there are still benefits and drawbacks, which we break down below.

Traditional Surrogacy

Traditional surrogacy uses the surrogate’s egg. It's mixed with sperm—either from the father or a donor—and inserted into the surrogate's uterus using intrauterine insemination (IUI) or in vitro fertilization (IVF). A traditional surrogate is the baby's biological mother.

Because of the legal and ethical complexities associated with traditional surrogacy, some organizations like the American College of Obstetricians and Gynecologists (ACOG) advise against it.

Gestational Surrogacy

Gestational surrogacy occurs when the intended parents use their own egg and sperm to make a baby, which is then carried by a surrogate. Donor eggs and/or sperm can also be used. Gestational surrogates have no genetic link to the baby they carry.

Why Do People Use Surrogates?

Hopeful parents might choose surrogacy for a variety of reasons. We've listed a few below, but it’s important to keep in mind that people may also hire a surrogate because it simply feels right for them. 

Infertility. Those struggling with infertility may choose to deliver a child via surrogacy, especially if they're using donor eggs or sperm. It can also be used in cases of repeated miscarriage or recurrent implantation failure, or if the intended parent has problems with their uterus.

Medical conditions. Similarly, you may decide on surrogacy if you have a medical condition that makes pregnancy unsafe, such as severe heart or kidney disease. Certain medications can also make pregnancy unsafe. What's more, some people might be advised against carrying a pregnancy due to mental health concerns.

Prior pregnancy complications. People might be unable to carry a child if they've had certain pregnancy complications in the past; one example is postpartum hemorrhage requiring a hysterectomy.

Same-sex couples or single parents. For single males, surrogacy can be a path toward parenthood. Surrogacy is also a viable option for same-sex couples who don’t have both sperm and egg to donate, says Tiffany Hallgren Crook, founder of the TLC Infertility and Donor Services in Houston, Texas. 

Carrier of a genetic disorder. If the egg-bearing partner is known to be a carrier of a genetic disorder, surrogacy (with a donor egg) can help circumvent the risk. The person with the genetic disorder could also carry a donor egg.

Advanced maternal age. People over the age of 35 have an increased risk of birthing a baby with genetic abnormalities, and they can also suffer from diminished ovarian reserve, which can make it more difficult to get pregnant. In cases like this, surrogacy can be a good option. It's important to note, however, that many people with advanced maternal age carry pregnancies to term without any problems.

How to Find a Surrogate

There are a few ways to find a surrogate: you can tap a trusted friend or loved one, peruse social media or surrogacy matching sites, or hire a reputable agency. Read more about your options below. 

Independent surrogacy

By and large, the least expensive and most convenient approach to surrogacy is using a trusted friend or loved one. According to Amira Hasenbush, JD, MPH, an attorney in California, one of the major advantages of independent surrogacy is that the intended parents and surrogate already have a preexisting relationship with each other.

"This can allow for a greater level of trust and ease throughout the process," she says. "Often, the surrogate is willing to carry for free or for a much lower price than what an unrelated surrogate may charge. This can not only save the intended parents a lot of money but can make surrogacy feasible for people who might not otherwise be able to afford it at all.”

Despite this, says Hasenbush, there are some major drawbacks to consider. “Sometimes communication between the parties can become awkward or uncomfortable when difficult topics arise. Both must make sure they're on the same page about things like lifestyle during the pregnancy, money, and termination/abortion." If these issues aren't hashed out ahead of time, it can create a serious rift in the relationship.

Agency surrogacy

Many surrogacy agencies exist today. “But there are so many of them now that due diligence is needed to help ensure that intended parents are working with an ethical, professional, and established agency," says Caballero.

If you choose to go through an agency for your surrogacy, you’ll find that each operates slightly differently. They have somewhat varied price ranges and qualifications as well, though you can rest assured that all candidates have gone through rigorous screenings to ensure they meet the minimum qualifications.

In addition, “parents can certainly set more requirements based on their preferences, however, it may take longer to find a candidate depending on how specific the requirements are,” says Crook. 

Social media or online

If you don’t want to go through an agency to find a surrogate, and you don’t have any obvious candidates in your circle of friends and family, you could always turn to social media. After all, there’s an app for that! Apps like GoStork can help you find a potential match on your own, and a quick Facebook search for “surrogate mother needed” yields hundreds of results. 

A word of caution, though: While potentially more convenient and less expensive, finding a surrogate on social media certainly comes with its share of risks. You’ll want to discuss a background check and health screenings early on, to ensure you’re both on the same page when it comes to expectations about the process.

Caballero warns, “due diligence, including comprehensive background checks, cannot be stressed enough. There are a lot of good people on those sites, but it only takes one bad actor to ruin the dreams and cause havoc and more heartbreak.”

Surrogate Qualifications

Each parent and clinic may have different requirements for surrogates. Here are a few potential qualifications that a surrogate must meet, according to the American Society for Reproductive Medicine:

• Be between the ages of 21 and 45 (though ideally under 35 years old)
• Maintain a healthy BMI
• Have given birth successfully at least once—but no more than five times—with no major complications in the pregnancy
• Have had no more than three C-sections
• Pass necessary psychological and medical screenings
• Don't rely on antidepressants, drug, alcohol, or tobacco use
• Reside in a surrogacy-friendly state
• Have the support of their spouse or partner
• Be mentally and emotionally stable
• Sign the necessary contracts

Note that these requirements vary depending on the surrogacy agency or fertility clinic. The Yale Fertility Center, for example, won't accept surrogates who have had more than two prior C-section deliveries, and who have a BMI over 30.

How Does Surrogacy Work?

If you go through an agency, like most intended parents, here’s a rough outline of how you can expect the surrogacy process to work. 

Preparation. Parents seeking surrogacy will meet with an agency, a lawyer who specializes in surrogacy issues, and possibly even a counselor. ACOG recommends "separate and independent" legal counseling and mental health counseling for intended parents and surrogates. Intended parents will also make an informed decision about which type of surrogacy (traditional or gestational) is right for them. 

Screening. Once you have matched with a surrogate, they will complete comprehensive screenings, including medical, psychological, financial, and physical. A potential surrogate can expect blood work and various examinations. Gestational carriers should understand the risks associated with the surrogacy process, and fair compensation should be determined.

Agreement. Upon being medically cleared by the IVF physician, there's a legal agreement drafted between the surrogate and the intended parents. These contracts can be lengthy and map out many situations to ensure that everyone is on the same page. 

Fertilization. The eggs and sperm of the intended parents or donors are collected and combined in a laboratory to create embryos through IVF. The embryos are tested for quality and genetic abnormalities before being transferred to the surrogate's uterus. 

Pregnancy. The surrogate carries the pregnancy under the supervision of the medical team and the surrogacy agency. They follow a prenatal care plan that includes regular check-ups, ultrasounds, blood tests, medications, etc. They also maintain contact with the intended parents and update them on the progress of the pregnancy. The intended parents provide emotional and financial support to the surrogate throughout the pregnancy. 

The Cost of Surrogacy 

The cost of surrogacy varies widely depending on location and your specific circumstances; for example, if you're using an egg and sperm donor, the cost will likely be higher. The price will also rise if you need multiple IVF cycles to achieve a pregnancy.

According to the Fertility Center of Las Vegas, intended parents can be expected to pay between $110,000 and $170,000. The New York State Department of Health puts the number between $60,000 and $150,000.

This price is steep, but it covers all of the costs associated with the surrogacy process, which can include the following:

• Surrogate compensation
• Medical expenses
• Legal expenses
• Surrogacy agency fees
• Additional and miscellaneous costs

Insurance coverage for surrogacy varies by policy, says Crook. “In some cases, medical insurance may cover some aspects of the pregnancy and childbirth, but it's essential to check with your specific insurance policy to understand what is covered. Surrogacy-related expenses, such as agency fees, are usually not covered by insurance.”