SURROGACY – information and resource article
“Things You Should Know About Surrogacy”
DEFINITION: Surrogacy is defined as an arrangement whereby a woman agrees to undergo pregnancy and delivery for another Intended Parent (IP).
Surrogacy is a complex process that involves medical, mental health and legal professionals to ensure the procedure is successful for both intended parents and surrogate.
There are 2 types of surrogacy; Traditional Surrogacy and Gestational Surrogacy (or IVF Surrogacy.)
Traditional Surrogacy is which the surrogate is biologically related and will become both the egg donor and surrogate host. This is performed by either the natural method (sexual intercourse) or Intrauterine Insemination (IUI). With Traditional Surrogacy, there are complex emotional, ethical and legal issues involved, therefore this method is seldom utilized today.
Gestational Surrogacy, or IVF Surrogacy, is the preferred method, because the gestational carrier does not have genetic ties to the baby. Therefore, there are potentially far less emotional, psychological and legal risks compared to traditional surrogacy.
IVF surrogacy involves creating embryos by IVF with the couple or donor gametes transferred to a gestational carrier, (gestational surrogate). Depending on the location where the surrogacy is performed, the Intended Parents are able to have their names on their child’s birth certificate without having to adopt their child.
For example: in California, the Intended Parents have there name on the child’s birth certificate about 6 months into the pregnancy, so at birth, the Intended Parents are already the legal parents and make all the medical decisions for the baby legally, (a big plus with California Law).
MEDICAL INDICATIONS FOR IVF/GESTATIONAL SURROGACY. There are several medical conditions why a woman may have to utilize IVF Surrogacy to have her own biological child.
Some examples of medical conditions include: Severe Heart or Pulmonary Disease, Severe Kidney Disease, Systemic Lupus, History of Breast Cancer, Cystic Fibrosis or Severe Diabetes.
Other medical causes may include Mayer Rokitansky Kuster (MRK) syndrome, when a woman is born without a uterus. Also, several women have undergone a Hysterectomy for fibroids, endometriosis or cancer. A woman’s uterus may become non-functional from a prior infection or surgery resulting in scar tissue inside the cavity of the uterus, known as Ashermann’s Syndrome.
OTHER INDICATIONS FOR IVF/GESTATIONAL SURROGACY. Other reasons why a woman may required a surrogate to carry her child is having an obstetrical complication such as severe hypertension, severe diabetes or complications of childbirth resulting in a hysterectomy, Recurrent Pregnancy Loss (secondary to anatomical problems) which is not surgically repairable.
Some patients have undergone repeated IVF failures and therefore require a Gestational Surrogate. Although, there is no specific test for implantation failure, most causes of failed IVF are secondary to poor quality embryos and eggs. Typically, these patients fail to conceive after IVF/Donor Egg. Not getting pregnant, yet having an apparently normal uterus and normal-looking embryos is still usually embryo-based weakness and is usually not cured by surrogacy.
Another Indication for IVF Surrogacy is Same Sex Couples. For same sex male couples their dreams of becoming parents may be realized by using IVF/Gestational Surrogacy and an Egg Donor.
The safest procedure is Gestational Surrogacy or IVF Surrogacy when the gestational carrier is not related to the baby since she does not donate the egg. This is the preferred method because the surrogate does not have genetic ties to the baby, therefore as mentioned earlier, there are far less emotional, psychological and legal risk compared to traditional surrogacy.
IVF/GESTATIONAL SURROGACY MEDICAL SCREENING: OBSTETRICAL HISTORY SCREENING/MEDICAL RECORDS REVIEW. So how do we screen our surrogates? Ideally, a potential Surrogate is someone who enjoys being pregnant and wants to help another couple have their child. An ideal candidate is someone who is the ideal age for pregnancy. The ideal is 25 to 37 years of age.
It is required that she has delivered at least one prior baby without any complications. No Surrogate should have a history of more than three Cesarean Sections or more than two sets of twins. This is due to the increased risk of placental problems or post-delivery risks of bleeding and possible hysterectomy. She should have no history of any medical complications during pregnancy such as Hypertension, Diabetes or incompetent cervix.
Also, overall good health is required including normal pap smears, no history sexually transmitted diseases, no IUD for last six months, good overall medical and dental health, and no chronic medications.
Past Surgical History: no complicated uterine surgeries
No Smoking/ ETOH/ Drugs (urine testing) and updated vaccinations.
IVF/GESTATIONAL SURROGATE MEDICAL EVALUATION. The growing fetus should have a healthy environment. At CACRM, we require that the Surrogate’s Physical Exam is completely normal. She must not be obese, and she must have normal vital signs, including normal blood pressure. We perform an echograph of the uterus and ovaries which must appear normal. She is required to have a normal evaluation of her uterus with an In-Office hysteroscopy, which is performed with a very small telescope that actually shows the inside of the uterine cavity where the embryos will be placed.
Laboratory evaluation is also required, and includes the following; prenatal blood work including a hemoglobin (which is a blood panel called a CBC), a thyroid function, infectious panel, CMV, (Cytomegalovirus), Toxoplasmosis (if she has a cat), evidence of Immunizations including Rubella and Varicella, blood type and RH (if RH negative, she will need to document receiving Rhogham).
Both Surrogate and her spouse should be tested for any infectious diseases. Both are also required to have a urine drug screen for smoking, drugs and alcohol.
IVF SURROGACY PSYCHOSOCIAL EVALUATION: Counseling of Gestational Surrogate AND the Intended Parent(s). Counseling of Surrogate is intended to provide the Surrogate with a clear understanding of the psychological issues related to pregnancy. With the assistance of a mental health professional, the Gestational Surrogate is evaluated for any Mental Health Disease and to make sure there is no underlying psychopathology. The evaluation also includes a personality assessment and the evaluation of her motivations for becoming a Surrogate.
The Surrogate is also evaluated for her capacity to trust, empathize, respect and bond with the intended parents. One of the most important aspects is for the Gestational Surrogate to be psychologically stability and to have a good support system, and if she is married to be martially stable.
We encourage the Intended Parents along with the Surrogate and the Surrogates partner to all meet together with the counselor. It is important for them to discuss group expectations they have regarding a potential pregnancy. This discussion should include the number of embryos for transfer, multiple gestation, fetal reduction, prenatal diagnostic interventions, and therapeutic abortion, as well as managing the relationship while respecting the Surrogate’s right to privacy.
Psychological Clearance of the Surrogate is required before legal contracts or medical treatment can be started.
IVF SURROGACY: LEGAL ISSUES. There are a number of legal issues that concern third party reproduction. The laws regarding third party reproduction vary and are different from one state to another in the United States. Thus, all couples are advised to consult with an attorney who is knowledgeable in the area of reproductive law, within their individual state. And this attorney needs to be legally able to practice law in the state where the surrogate will deliver. For example, if an attorney has a Florida license, he can not practice law in California. Therefore, the attorney can only protect you in the state where he holds license which should be the same state where the Surrogate will deliver your baby.
You should be sure to discuss all of your legal rights with your attorney and it is important to go over all of your questions. For instance, what would happen if the Surrogate changes her mind. Does your state (or country if outside of the United States) protect the contractual agreement between the Intended Parent and the Surrogate? What states give legal rights to the Intended Parent PRIOR to the birth of the baby?
There are very few states that protect the Intended Parents by issuing pre-birth orders through the court system which places the name of the Intended Parents on the birth certificate PRIOR to the baby being born. This makes the IP’s the Legal Parent(s) at birth and they do not have to adopt their baby. These states also allow compensation to the surrogate and therefore have laws protecting the contractual arrangements between the intended parents and surrogate.
In the United States, the surrogate must live, be a legal resident, and deliver in one of the surrogate-friendly states.
States that allow Commercial Surrogacy include; California, Florida, Illinois, Nevada, New Hampshire, Texas (excludes same-sex), and Virginia.
States the DO NOT allow Commercial Surrogacy (in fact, it is illegal) include; Arizona, Delaware, Indiana, Michigan, New York, North Dakota, and the District of Columbia (Washington D.C.).
If you perform surrogacy where it is not allowed or does not permit Commercial Surrogacy (payment to the Surrogate) then there are no laws protecting the contractual arrangements between the Intended Parents and the Surrogate.
You should avoid any surrogate living, or planning to deliver, in any of the states where surrogacy is illegal.
Along with other surrogacy arrangements, the legal contracts, delineate financial obligations, may include details regarding expected behavior of the Surrogate to ensure a healthy pregnancy, may delineate required prenatal diagnostic tests, and other agreements regarding fetal reduction or abortion in the event of multiple pregnancies or the presence of fetal anomalies.
In situations of known Sperm or Egg Donors, both Donors, as well as Intended Parents, are advised to have separate legal counsel and sign a legal contract that defines the financial obligations and rights of the Donor with respect to the donated gametes (i.e. sperm, egg or embryo(s)).
For all Medical procedures a medical consent form will need to be signed by both parties; Intended Parents and Surrogate. These consents should be explained thoroughly by the Medical Doctor performing the In Vitro Fertilization (IVF) treatment. The risk and benefits (Informed Consent) should be understood well by all parties before the treatment process is begun.
Pre-Birth Judgment of Maternity and /or Paternity. In California, once the surrogate is pregnant there is a pre-birth Judgment of Maternity and/or Paternity. The process in California is simple and makes it the most popular state for surrogacy. At around 16-18 weeks of pregnancy, the Intended Parents retain an attorney to do the Parentage Process. The attorney drafts the court documents which are emailed to the Parties to review and sign.
The IVF Physician will also need to sign and return a declaration that the Surrogate conceived through IVF in order to carry for the Intended Parents.
The Judgment will declare that the Intended Parents are the sole legal parents of the child to be born and that the Surrogate and her husband are not the parents. It also directs the hospital to record the Intended Parents’ names on the original birth certificate. The attorney submits all the signed documents and sets a court date and appears on behalf of all the parties. Typically the court hearing done and the Judgment signed by the 25th week of pregnancy so that everything is in order in consideration of the chance of premature birth.
It is best to have the Judgment done PRIOR to birth so the IP’s may have legal authorizations for medical care of the newborn. This is a very important reason why one should use a Surrogate living in California. If for some reason this Parentage Process is not completed prior to birth, the IP’s can get the Judgment post-birth – HOWEVER it must be done very quickly. The case law in CA is pretty clear on Gestational Surrogacy and the CA Supreme Court has upheld the rights of the Intended Parents in California.
INTENDED PARENT/EGG DONOR EVALUATION: Evaluation of the recipient couple or Intended Parents(s) for IVF/Gestational Surrogacy is similar to that of couples undergoing routine IVF. The physician should obtain a comprehensive medical history from both partners.
One of the first steps in the process of undergoing IVF/Surrogacy is choosing who will be providing the gametes. The following will discuss when the Intended Parent provides the eggs. If an Egg Donor will be utilized along with an IVF/Gestational Surrogate (IVF/GS) please read the Egg Donor Evaluation section under Egg Donor. (hyperlink this sentence to that section).
If the woman is undergoing IVF/GS for medical reasons, then Medical Clearance for her particular condition must be given her by her primary doctor. She must have no contraindications to undergo an IVF cycle, i.e. exposure to high levels of estrogen and undergoing a surgical procedure with transvaginal aspiration of her follicles under anesthesia.
The Intended Parent (when providing the egg) needs to have at least one ovary – so that eggs can be obtained for fertilization with IVF, otherwise she will need to have a known egg donor willing to help her.
In either case, the egg must come from someone who is 35 years of age or younger for the chance of successful pregnancy for the Surrogate to be greater. The chances of the surrogate getting pregnant is highly unlikely if the egg provider is more than 43 years old.
The Intended Parent as Egg Provider should provide a complete history and physical and pelvic echograph. The echograph is performed to evaluate the normalcy of the ovaries and Antral Follicle Count (AFC). AFC measures the number of resting follicles that may potentially form into mature follicles with mature eggs.
All Egg Donors/Providers, both anonymous and known, should be screened according to the most recent guidelines recommended by the American Society for Reproductive Medicine.
Donors should have attained their state’s age of legal majority and preferably should be between the ages of 21 and 34. The rationale for the younger limit is to ensure that the donor is mature enough to provide true informed consent. The rationale for the age of less than 34 is that younger women typically respond favorably to ovulation induction; produces more eggs and high-quality embryos with high implantation and subsequent high pregnancy rates. If the donor is over the age of 34, recipients should be informed as to the cytogenetic risk of having a child with a chromosomal abnormality such as Down syndrome and the impact of donor age on pregnancy rates.
Both anonymous and known donors should complete an extensive medical questionnaire that details their personal and family medical history. Included in this questionnaire should be a detailed sexual history, substance abuse history and psychological history.
In the United States, the Food and Drug Administration requires that all egg donors be screened for risk factors for, and nonclinical evidence of, communicable infections and diseases. A donor is ineligible if either screening or testing indicates the presence of a risk factor for, or clinical evidence of, a communicable infection or disease. For anonymous donors, the questionnaire should assess the donor’s motivation for donating her eggs and provide insight into the donor personality, her hobbies, educational background, and life goals. This document ultimately will be shared with the recipient and provides her with insight into a donor she will never meet. A medical professional reviews this history with the donor and conducts a comprehensive physical examination.
The donor generally completes a written psychometric test prior to meeting with a mental health professional (MHP). In addition to reviewing the psychometric test, the MHP has the opportunity to further evaluate the donor, discuss the many complex ethical, and psychosocial issues she may encounter, and confirm the donor is truly able to provide informed consent for egg donation.
All infectious disease testing must be done and noted to be negative within 30-days before egg donation. Donors should also have documentation of their blood type and Rh status and complete blood count.
There are blood tests to evaluate the ovarian reserve, (how young the ovaries are or how they should stimulate to fertility medications). One of the tests is the AMH (antimullerian hormone); this is the most specific test and can be performed anytime in a woman’s menstrual cycle. The other two tests: FSH with Estradiol levels are performed either day two, three or four of the menstrual cycle. Other hormone tests may include Thyroid function and Prolactin levels. Donors may be required to undergo drug, nicotine and alcohol urine testing.
Genetic screening of donors should be based on ethnicity. Caucasian donors should be tested for the presence of a cystic fibrosis (CF) mutation. Donors of Asian, African, and Mediterranean descent should undergo a hemoglobin electrophoresis as a screen for sickle cell trait and thallasemias. If the donor is of Ashkenazi Jewish origin, CF mutation analysis, and screening for Tay-Sachs disease, Canavan disease, and Gaucher disease is indicated. Donors who are of French Canadian descent should be screened for CF as well as Tay-Sachs disease. Additional genetic testing such as Fragile X and karyotyping of the donor is not required but may be offered by individual programs as part of their standard procedure or upon the request of the recipient couple.
PLEASE NOTE: each of these tests cost the Intended Parent separately and can become quite costly. Be sure to ask directly the additional fees for any of these tests.
In addition, the male will have a semen analysis to determine the quantity and quality of both semen and the sperm it contains.
IVF SURROGACY: FDA REGULATION. FDA donor eligibility is required for both the oocyte donor and sperm donor. If the genetic parents are providing their gametes then both members of the couple are considered Donors because they are transferring their embryos produced form the woman’s oocytes and the man’s sperm into a surrogate. If the couple utilizes an egg or sperm donor, they will be required to undergo the same testing. The following Screening and Infectious Disease testing are required by FDA regulations; not only are the type of tests important but also the timing. The egg giver must have blood work within 30 days of egg retrieval and the sperm provider within 7 days of collection. Both members will be required to have a focused FDA required medical history and physical exam.
In summary, the following are required testing for a couple to transfer their embryo(s) into a Surrogate:
- FDA questionnaire (screening)
- FDA physical
- FDA registrar lab FDA labs Within 30 days for egg donor (intended parent) 7 days within giving sperm sample
- HIV I & II
- HTLV I& II
- Hepatitis C
- Hepatitis B (Hep B core & surface Ag)
- Syphilis
- Chlamydia trachomatis & Neisseria gonorrhea (urine)
- CMV core AB (sperm donor only)
IVF SURROGACY: MEDICAL, PSYCHOLOGICAL & LEGAL CLEARANCE. In summary there are three steps that must be done before the IVF Surrogacy treatment is begun:
1. Medical Evaluation: Medical evaluation should be free of any infectious disease (negative FDA screening testing) and severe abnormalities. Then medical informed consents for the procedure are explained by the IVF Physician and signed by both members of the couple, Physician and witness. Some issues that should to be reviewed before treatment begins includes the risk and benefits of the procedures ( Informed Consent) .Other important issues of the IVF/Surrogacy process includes :the number of embryos to transfer (Age dependent), risk of multiple gestation, selection reduction, prenatal diagnostic interventions and therapeutic abortion. One should also consider whether they want to give permission to freeze embryos and what to do with the embryos if something happens to one or both of the parents.
2. Psychological Evaluation: NO psychopathology or Mental Health Issues. This should be one of the first steps in the process.
3. Legal Contracts: Preconditions & Contingencies: Agreement of health-related behavior and financial issues. Contracts reviewed and signed by the couple and surrogate and her partner, if applicable.
Once the above is completed the IVF treatment process may begin.
IVF SURROGACY: CYCLE COORDINATION.
Surrogate: Agonist down-regulation/ Estradiol Valerate and Progesterone Injections
Genetic Mother, Egg Donor: Ovarian Stimulation, Antagonist Protocols
Genetic Father, Sperm Donor: Fresh vs. Frozen, IVF/ICSI
The steps for controlled stimulation of the infertile woman’s (or egg donor’s) ovaries and for egg retrieval are generally the same as those for anyone else undergoing IVF (please see the relevant separate information for details).
Intended parent: The female partner of the intended parent couple will be undergoing an In Vitro Fertilization cycle (IVF cycle) if using her own eggs. If using an egg donor, the donor will be placed through an IVF cycle. This is a cycle where her ovaries will be stimulated by high doses of the same hormones that are secreted by her brain each month (that normally stimulate one ovary to produce one egg) in order to get both ovaries to produce many eggs (usually 10-20). These hormones (Follicle stimulating hormone and luteinizing hormone) are given via subcutaneous injections (using small needles given directly into the fatty tissue underneath the skin). She will be monitored in the office with transvaginal ultrasound frequently to measure the size of the developing follicles (the fluid filled sacs that contain the eggs) until they reach a size of 18 – 20mm. She will also have her blood tested for estradiol levels as well. Once the lead follicles reach 18mm – 20mm in size, she will be given an intramuscular injection to “trigger” egg maturity and in 36 hours exactly, her eggs will be retrieved in a procedure called“transvaginal oocyte retrieval”.
Her eggs will then be brought into the lab. The male intended parent’s sperm, previously frozen, will be thawed and one normal appearing sperm will be injected into each mature egg, via a procedure called ICSI (intracytoplasmic sperm injection). Typically 75% of mature good eggs fertilize into embryos. The embryos will then be allowed to grow in the lab and a certain number of embryos (depending on embryo quality and age of the intended parent or egg donor) will be transferred into the GC.
Gestational Carrier: While the intended parent is undergoing the IVF cycle, the GC will be given estrogen and progesterone, in sequential fashion, via intramuscular injections, in order to prepare her uterine lining for implantation. Before the GC starts the preparation, she will come in to be sure the lining is thin and the ovaries have no cysts. If everything looks normal, she will start the estrogen. Approximately two weeks later, she will come in for another transvaginal ultrasound and blood work. to be sure the lining is developing adequately- if so, she will start the progesterone when instructed by her nurse.
If embryos result (which is usual but not inevitable) they then need to be transferred to the uterus of the surrogate mother after the lining of her uterus has been prepared with sequentially administered estrogen and progesterone (similar to the hormones normally produced in this sequence by the ovaries in a natural menstrual cycle Typically, the embryo transfer is technically straightforward, involving placement of a soft catheter through the cervix while having a speculum exam (similar to having a PAP smear). If the intended parent giving the eggs is over 35 it is strongly recommended the embryos undergo PGD.
Pre-implantation genetic diagnosis (PGD) is a technique used in conjunction with in vitro fertilization (IVF) to test embryos for specific genetic disorders prior to their transfer to the uterus. It refers to specialized laboratory testing procedures that are performed on embryos prior to being transferred into back a women’s uterus. It is in essence the earliest form of prenatal diagnosis and is an exciting technology that has the potential to transform a couple’s hopes of having healthy children.
PGD makes it possible for couples or individuals who have or who carry serious inherited disorders to decrease the risk of passing the disorder on to their child. One of the most common reasons to have PGD performed is the mother’s age, since the risk of having a child with a chromosomal abnormality , such as Down Syndrome, increases as a woman ages. Genetic testing of the pre-implantation embryo can determine whether the embryo could potentially be affected by a chromosomal abnormality. Therefore, the chance of conceiving a baby with a chromosomal abnormality will be reduced by more than 90% after PGD.
Additionally, if both parents are carriers for a genetic condition, PGD makes it possible for couples or individuals who have or who carry serious inherited disorders to decrease the risk of passing the disorder on to their child.
For more information on PGD, see CACRM Website Section entitled, PGD. (hyperlink to: www.cacrm/pgd )
INTERNATIONAL NEWBORN CARE: MEDICAL INSURANCE AND ADDITIONAL COSTS FOR INTENDED PARENTS. When considering surrogacy or mother-carrier in the United States, please keep in mind you will need a medical insurance plan for your newborn.
The Healthcare coverage you may have for you and your family, will not apply to your newborn in the United States. This is due to Healthcare costs being different in the United State than other countries around the world. The United States health care system is principally funded through private insurance. Reciprocity between countries which both have socialized health care does not occur in the United States.
New Life Agency, Inc. can provide a policy for approximately $10,750 (This can be made in four payments / installments of US $2,687.50 each). IN ADDITION, there is a $15,000 Deductible. This deductible is due, in advance, at six months of pregnancy. A refund will be issued on any Over-paid funds.
Premium $10,750 - Due at six-week ultrasound
Deductible $15,000 - Due at six months of pregnancy.
This is based on single-newborn only. (should you be considering twins, the rates could differ). Please make sure to consider the costs of this additional premium when coordinating your financial planning. Your agency or IVF coordinator will be able to put you in contact with the appropriate insurance carrier for your needs.
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