What Is Surrogacy & How Does It Work? – Everything You Should Know

By Babygest Staff
Last Update: 09/03/2018

Surrogacy is an infertility treatment that involves a surrogate, commonly referred to as surrogate mother, who carries a child for someone else who receives the name of intended parents or commissioning parents.

In the majority of cases, the embryos are created by means of in vitro fertilization (IVF using the eggs and the sperm cells of the intended parents, although donor gametes can be used as well). Once created, the resulting embryos are transferred to the surrogate’s womb.

Provided below is an index with the 13 points we are going to expand on in this article.

What is surrogacy?

Surrogacy is a fertility treatment whereby a woman carries a child for someone else. While the woman who bears the pregnancy is referred to as gestational carrier, by someone else we refer to the intended, prospective or commissioning parents. For gestational surrogacy, one or more embryos are created through IVF, and transferred to the womb of the gestational carrier.

The embryo or embryos are created upon the request of the intended parents—as long as possible, their desire will be to use their eggs and sperms for the creating of the embryo(s). If this was impossible, using donor eggs or sperm would be the option of choice.

In general, the role of the gestational carrier, as the name suggests, is to carry and deliver a baby. However, when we talk about traditional surrogates, they also contribute the egg for fertilization. This type of surrogacy has fallen into disuse nowadays, though.

From an international perspective, surrogacy is illegal in most countries around the globe. And, in those where it is permitted, the surrogate and the biological mother cannot be the same person. In fact, in those countries where the law does not include this as a pre-requisite, the trend is to avoid traditional surrogacy arrangements to avoid potential legal issues.

The intended parents will keep the baby following birth, as stated in the surrogacy agreement that they signed with the gestational carrier, in which the surrogate agreed to deliver a baby for them, thereby waiving all maternity rights to the child.

What is a surrogate?

Firstly, we should learn to distinguish between a surrogate and a gestational carrier, two terms that are often used interchangeably but actually do not mean the same. What follows is the definition of each:

Someone who donates her egg and subsequently carries the child. In other words, she is genetically linked to the baby. It should be used only if you enter into a partial or traditional surrogacy arrangement (i.e. surrogacy using IUI).
Gestational carrier
Someone who carries the pregnancy but is in no way biologically related to the baby she is carrying. Instead, eggs and sperm from the intended parents or donors are used (i.e. surrogacy using IVF).

So, even though both are correct, we should use them appropriately depending on the type of surrogacy we opt for. However, despite the widespread use of the term surrogacy, perhaps we should refer to it as gestational surrogacy to ensure that everyone understands that she will not be the genetic mother of the child.

In this sense, we recommend to take into account the definition offered by the World Health Organization (WHO) back in 2001:

A gestational carrier is a woman in whom a pregnancy resulted from fertilization with third-party sperm and oocytes. She carries the pregnancy with the intention or agreement that the offspring will be parented by one or both of the persons that produced the gametes.

Types of surrogacy

There exist four types of surrogacy, which at the same time can be classified into two major groups:

  • Depending on the person contributing the egg cells, we can distinguish between traditional surrogacy and gestational surrogacy
  • Depending on the financial compensation paid to the surrogate, we can distinguish between commercial surrogacy and altruistic surrogacy

Get more information about the four kinds of surrogacy here: What are the different types of surrogacy?

Traditional vs. gestational surrogacy

Based on whether the intended mother uses her own eggs or donor eggs, we can define traditional surrogacy and gestational surrogacy as follows:

Partial, traditional, or genetic surrogacy
The surrogate is the biological mother of the child born as a result.

This type of surrogacy arrangement is simpler than gestational surrogacy from the technical point of view, as the surrogate uses her own egg. For this reason, IVF is not the fertility treatment of choice but intrauterine insemination (IUI). She can be inseminated with donor sperm or sperm from the intended parent. This type of surrogacy has fallen into disuse nowadays.

Full, host, or gestational surrogacy
It means that the surrogate just carries the baby, without using her egg cells, and for that reason the term gestational carrier is more accurate. The role of a GC is to carry the pregnancy and deliver the baby, who is genetically related to the intended parents or donors, if necessary.

The egg is fertilized by means of IVF or ICSI, and the resulting embryo transferred to the uterus of the GC. From a technological perspective, this option involves a higher degree of complexity.

This type of surrogacy arrangement is the one used today.

Commercial vs. altruistic surrogacy

Also, now that we have learned that gestational surrogacy arrangements are the preferred option today, we can reclassify them into one of the following groups, depending on whether the GC receives a financial compensation or not:

Commercial or gainful surrogacy
The GC receives a payment for carrying someone else's baby, in addition to the reimbursement of any expenses incurred during the process.
Altruistic or uncompensated surrogacy
No financial compensation is involved except for a reimbursement of expenses, including maternity clothes, medical consultations, special diet, travel expenses, etc.

Obviously, choosing one type over the other will affect the total cost of the treatment. For example, commercial surrogacy, along with a need for using donor eggs and/or sperm, would shoot up the price. Also, one should keep in mind that the cost can vary depending on the country chosen, depending on the characteristics and the legal requirements of each destination.

Who can opt for surrogacy?

During the last decades, social media and other digital media have shown us a number of cases of celebrities who have become parents through surrogacy. Unfortunately, this has spread the wrong idea that surrogacy is an option for people with a high socio-economic level only. The good news is that it is actually very different.

Though it is true that surrogacy cannot be considered a low cost fertility treatment, many people in the medium socioeconomic status group have been able to become parents through surrogacy in the past few years.

This quote is a common argument given by intended parents:

If some people apply for a mortgage and/or a car loan, why can't we get a mortgage to fulfill our dream of starting a family?

Single men and gay couples have no alternative but to turn to a surrogate to have a baby, due to their physiological inability to carry a pregnancy. As for single women, lesbian couples, and straight couples, the following are the main reasons why they opt for surrogacy:

  • Women without uterus, either for congenital reasons (Rokitansky Syndrome) or acquired causes (hysterectomy)
  • Serious uterine conditions such as severe endometriosis, incurable Asherman's syndrome, severe adenomyosis...
  • Uterine anomalies leading to adverse pregnancy outcomes
  • When other fertility treatments have failed, including IVF, IVF with ICSI, or PGD.
  • Recurrent pregnancy loss (RPL)
  • Medical contra-indication. Certain existing health conditions can be aggravated with pregnancy or even lead to death if the patient becomes pregnant. Autoimmune diseases, cardiovascular diseases (CVD), and some types of cancer are common examples.
  • Medication use. If you are using prescription drugs that are incompatible with pregnancy or can have a teratogenic effect (i.e. may cause birth defects in a developing fetus), you should stop taking them to become pregnant. Unfortunately, this is not possible in all cases.

Contrary to common belief, most babies born via surrogacy are children of straight couples who have no alternative but to use a gestational surrogate to start a family, due to medical conditions that prevent the intended mother from becoming pregnant or to carry a pregnancy to term.

Positives and negatives of surrogacy

Today, surrogacy is still a controversial fertility option because it involves several actors in a process where, traditionally, only three parties were involved: a mom, a dad, and a baby.

However, in some situations, this ideal concept is not possible due to certain medical conditions, the age of the prospective mother, having a history of miscarriage, etc.

So, from the perspective of heterosexual couples, surrogacy is a major advantage because it allows them to create a family in spite of not being able by natural means. There is, however, a negative side in this: The high cost of this treatment, which may not be within the grasp of everyone.

Even if intended parents have everything in place, facts such as religious beliefs, historical background, laws, and the influence of certain family members can prevent them from entering into a surrogacy arrangement.

For same-sex couples and single parents, it is clear that surrogacy is not only a major advantage, but actually the only chance for them to become parents, as in the case of gay male couples and single fathers. In fact, it brings them the possibility of having a baby and share their genes with him or her.

Also, another positive of surrogacy if compared to traditional adoption is that it allows intended parents to have a child who has the genes of at least one of them. With adoption, this is not possible, as the child was conceived by another couple (the biological parents).

As regards being a surrogate or gestational carrier, there are also advantages and disadvantages. Issues such as the financial compensation, the treatment received by the agency and the prospective parents, and the scope of the journey she is embarking herself can turn it into a gratifying experience if tackled properly.

Finally, it should be clear that a pregnancy is not a mathematical equation and many factors can influence the process. For this reason, there are time factors involved that all the parties involved should take into consideration.

Before the gestational carrier gets pregnant, intended parents may need to spend long hours learning about the legal and medical procedures that will be happening throughout. Although this may seem to be a drawback, dedicating time to being familiar with these procedures is the secret to succeeding in the surrogacy journey.

Understanding the terminology

Surrogacy is the most commonly used term as well as the most appropriate and neutral one when it comes to referring to this infertility treatment. The word is a noun that was born after the union of surrogate + -cy, so we have to look into the meaning of the word surrogate to understand its use.

The term surrogate comes from Latin surrogatus and literally means “put in another’s place, substitute”. It started to be used with the meaning of “woman pregnant with the fertilized egg or another woman” in 1978 approximately.

Taking into account the original meaning of the word surrogate, we would like to clarify which terms are considered correct, and which ones are incorrect or even offensive. Terms such as “womb for rent”, “womb to rent”, “womb on rent”, “rent-a-womb”, and similar phrases are rude forms that should be avoided.

Firstly, because the verb rent means, according to Merriam-Webster Dictionary:

To grant the possession and enjoyment of in exchange for rent.

The intended parent or parents do not possess the womb of the surrogate: She decides to enter into an agreement with the fundamental motivation of helping a couple that would not be able to have children by their own means. These forms are considered offensive and using them to make reference to this treatment is totally unadvisable.

Our classification includes another group: those forms that are actually incorrect, that is to say, mistakenly used. Examples include surrogate mother, surrogate motherhood, surrogate mom, and so on.

The problem of these terms lies with the concept of motherhood, which actually means something different from that we are making reference to. Motherhood is not what is being substituted or replaced, but the pregnancy. Because we believe that the concept of mother goes beyond the mere fact of giving birth—it involves rearing and taking care of a child.

Situation and cost in the USA

Surrogacy and its legality fall under state jurisdiction, which means that the legal situation of this treatment in the USA varies greatly from state to state. While some states have written legislation, others have developed common law regimes, and others refuse or even penalize this type of arrangements. According to this, we can classify them into 3 groups:

Permissive states
including Nevada, California, Texas, Arkansas, Illinois, Virginia, Florida, New Hampshire, Delaware, New Jersey, Tennessee, and Washington.
Surrogacy-friendly states
including Alaska, Oregon, Colorado, Georgia, Idaho, North Carolina, Minnesota, Maryland, Wyoming, North Dakota, New Mexico, Montana, and Rhode Island.
Prohibitive states
including, Michigan, New York, Indiana, Kansas, and Nebraska.

Moreover, it is important to put emphasis on the fact that traditional or partial surrogacy arrangements are forbidden, that is, by no means can the surrogate be biologically linked to the child. In the USA, thus, when we talk about surrogates, we are actually referring to gestational carriers.

While the main advantage of undergoing surrogacy in the USA is that those states which allow or are favorable to surrogacy grant a pre- or post-birth order to guarantee that the intended parents will be the legal parents of the baby, the main disadvantage is related to its great cost—from USD $90,000 to USD $280,000.

For this reason, and with the purpose of reducing the costs of the treatment, many US intended parents decide to pursue surrogacy overseas. However, they must make sure that at least one of them is the genetic parent of the child. Otherwise, the child will not obtain US citizenship at birth.

The information you've just read is just a summary of the situation in the United States. Want to learn more? Do not miss this: Is Surrogacy Legal in All 50 States?

Surrogacy in the world: destination countries

Despite surrogacy is allowed in a number of foreign countries, one should be aware of the fact that not all of them are valid for all intended parents, especially depending on the family type. Moreover, one should not keep in mind the law of the destination country, but also the regulations in the home country.

In general, the following are the most recommendable options for intended parents who are pursuing surrogacy abroad:

  • Canada
  • Greece
  • Russia
  • Ukraine
  • Georgia

The requirements to be met according to the law in each country should be considered as well. Being married or providing a medical certificate to prove that there exists a medical condition that prevents pregnancy in the intended mother are common requirements in various countries.

In the case of same-sex couples, Canada and the United States are the only possible destinations for them, as the law in the rest expressly excludes them from entering into surrogacy agreements there.

Surrogacy is the most challenging of all fertility treatments. For this reason, it's crucial that you rely on well-versed professionals. Therefore, we recommend you to visit this article to read some tips before getting into this process.

Surrogacy professionals involved

Several professionals are involved throughout the entire process to ensure that everything is done as it should, and to avoid potential mishaps:

Normally, surrogacy consultants work from the country of origin. They provide information to intended parents about the steps involved in the process, put patients in contact with the rest of professionals involved, and coordinate the procedure. They travel with you during your trips to the destination country, and help you overcome any potential linguistic barrier.
Surrogacy and egg donation agency
They find the most appropriate woman to carry the pregnancy, and the egg and/or sperm donors, if necessary.
Fertility clinic
It is the place where the in vitro fertilization (IVF) cycle to achieve a pregnancy in the gestational carrier takes place.
Their function is to review the surrogacy contract to make sure that every formality required to ensure that the baby is able to enter your country of origin without legal complications is done properly.
Escrow account manager
It is strongly recommendable to hire the services of a escrow account manager to supervise all the transactions that are made during the process.

The surrogacy debate: good or bad?

It is no secret that surrogacy is a controversial fertility treatment. Even though, from the technical viewpoint, it is nothing but another IVF process, there is a major international debate on whether it should be allowed or banned, and the extent to which it respects human rights.

In this sense, the world is divided into two major groups: Those who are in favor of surrogacy, and those who are against.

Proponents of surrogacy arrangements see it as another way of becoming parents for those who cannot achieve it naturally. It is a just a method whereby a woman "donates" her ability to become pregnant freely and voluntarily. Thus, as long as her rights as a woman are respected, as well as the rights of the child and the parents-to-be, surrogacy cannot be considered immoral, as it is not contrary to human dignity, and no human right is violated.

On the other side of the coin, those who are against consider that being a surrogate equals exploitation of women. Moreover, it translates into the commodification of children.

FAQs from users

In which cases should you use a surrogate to have a baby?

By Mark P. Trolice MD, FACOG, FACS, FACE (gynecologist).

In general, the two reasons for the use of surrogacy are the absence or abnormality of the uterus or a medical contraindication.

Cases of absent/abnormal uterus:

  • MRKH syndrome. Mayer-Rokitansky-Küster-Hauser syndrome is a disorder where the female is born with an underdeveloped or absent uterus and vagina.
  • History of hysterectomy – a surgery to remove the uterus
  • Multiple fibroid tumors of the uterus that cannot resolved by a surgery
  • Severe intrauterine scarring (Asherman’s syndrome) irreparable
  • A single male or gay male couple
  • Unexplained recurrent pregnancy loss or unsuccessful embryo implantations
  • Inability to develop the uterine lining (endometrium)

Cases of medical contraindications (relative and absolute):

  • A serious medical condition that worsens with pregnancy posing risk to mother and fetus
  • Pulmonary hypertension
  • Turner’s syndrome
  • Uterine cancer

What are the different types of surrogacy?

By Mark P. Trolice MD, FACOG, FACS, FACE (gynecologist).

There are two types of surrogacy:

  • Traditional surrogacy involves the woman who will carry the pregnancy also to be the source of the egg. She usually will ovulate naturally and undergo intrauterine insemination (IUI). Countries vary in their laws overseeing this arrangement so it is imperative that you consult, in advance of your treatment cycle, with an attorney who is well versed in this area.
  • IVF surrogacy is the process of using an egg donor and a separate gestational carrier. Following hormonal stimulation of the egg donor and egg retrieval, the eggs are fertilized with the sperm of one or both partners in a reproductive laboratory through IVF. The embryo is then transferred into the gestational carrier’s uterus, previously prepared hormonally to synchronize optimal receptivity. The resulting baby is genetically unrelated to the carrier.

How is surrogacy seen from a psychological viewpoint?

By Amalia Bayonas MD (psychologist).

My opinion is that the existence of surrogacy means that science is evolving, which is something that cannot be stopped.

Why do we have no objection with the fact that a woman gives a child for adoption and disagree with a woman that offers her womb to carry a baby for another person? Why do we see it normal that someone lives with the vital organ of someone else but do not accept that a woman carries a baby for someone else? I can understand that it causes an initial shock in our society. However, if it is treated with responsibility, based on ethical principles and lawfully, like in those countries where it is permitted, it should not be different or "worse" than donor conception or fertility treatments.

I think that, actually, it is a religious fear after all, generated from the idea that humans have the divine ability of creating life, and there are more detractors due to religious reasons than medical, social, or legal.

Obviously, abusive situations must be prevented, including mercantilism and reproductive exploitation, especially in underdeveloped countries, since we are talking about human dignity.

From a psychological point of view, is it believed that surrogacy can be a problem for both participants, that is to say, for the parents of intention as well as the pregnant woman and the foetus?

By Amalia Bayonas MD (psychologist).

Anything that is not purely "natural" and involves external intervention in reproductive matters requires mental processing work. This is even more the case when gestation takes place externally. Usually, it causes us some apprehension and even rejection. But when this reaction comes into conflict with the strong desire to have a child, we necessarily move on to evaluate other options and end up agreeing most of the time on the alternative or technique that provides a solution to our problem.

In addition to the reaction generated by the technique itself, then taking part in the psychological acceptance process are the cultural and family "internal mandates", the possible "stigma" of not being able to gestate, having to explain to third parts...which increase the difficulty of the subject.

As for the child, these tend to integrate life events according to how they are presented by their loved ones. If parents explain it naturally and focus on the joy of their birth, the child will not live it negatively. Children are born as blank books and we are the ones who write in them.

Can a woman have a baby for someone else and get paid back?

By Andrea Rodrigo (embryologist).

Yes, in fact, that's how it usually works. What this question is referring to is known as commercial surrogacy, gainful surrogacy, or compensated surrogacy. All three terms mean that the surrogate gets a financial compensation for carrying someone else's child. So, the answer is yes, a woman can carry and give birth to a baby for someone else and be paid a sum that should be established by contract beforehand.

How much does it cost to have someone carry a baby for you?

By Andrea Rodrigo (embryologist).

The cost of surrogacy varies on a case-by-case basis. Each case is unique and may require additional treatments or more time for the treatment to be successful. In any case, the average cost of surrogacy ranges from $90,000 to $115,000. Again, it should be clear that it depends on the situation of each intended parent. This estimation might be higher if done in California, where the high demand for surrogates increases the overall cost.

Can a woman carry another woman's egg?

By Andrea Rodrigo (embryologist).

Yes, this is what we know as gestational surrogacy, host surrogacy, or IVF surrogacy, and the woman who carries another woman's egg is a gestational carrier (GC) or gestational surrogate. Note that the name IVF surrogacy means that in vitro fertilization (IVF) is the technique of choice when the surrogate is not genetically linked to the child.

For this to be possible, it is necessary that the intended mother or an egg donor, if the intended mother cannot use her own eggs, undergoes follicle puncture to have her oocytes retrieved. Then, they are fertilized in the lab with the husband's, partner's, or donated sperm to create embryos.

Finally, the resulting embryo or embryos are transferred to the uterus of the gestational carrier. So, actually, what the GC carries is an embryo or embryos that have been created using the gametes or another person or persons, but not an egg.

Can someone else carry your baby?

By Andrea Rodrigo (embryologist).

Yes. As a matter of fact, that's a very brief definition of surrogacy. For having someone to carry your baby, your eggs have to be fertilized in the laboratory with sperm, thereby creating an embryo that will be transferred to the womb of the woman who is going to carry your baby. If the embryo implants and everything goes as expected, that's how you can have someone else to carry your baby.

Can you be a surrogate for a family member?

By Andrea Rodrigo (embryologist).

Yes, it is an option. According to the ASRM (American Society for Reproductive Medicine), it can occur intragenerationally between siblings or cousins, (e.g. a sister carrying her sister's baby), or intergenerationally, as when a mother carries a baby for her daughter. So, while surrogacy laws vary by state, normally it's possible for intended parents to use a family member or a friend to be their GC.

Is a surrogate mother the biological mother?

By Andrea Rodrigo (embryologist).

It depends on the type of surrogacy chosen. With traditional surrogacy, the surrogate gets inseminated by IUI. If the sperm meets the egg, she will become pregnant and be the biological mother of the child born as a result.

Conversely, with gestational surrogacy, the embryo created with the gametes of either the intended parents or donors is transferred to the uterus of the GC, so there is no possible way that she can be the biological mother of the child. If her eggs are not used, she cannot share her DNA with the baby.

In fact, traditional surrogacy arrangements are banned in all 50 US states due to the number of issues raised by previous cases, being the Baby M case the most popular one. Also, to reduce the emotional attachment that the GC could develop with the baby if the is genetically linked to the baby she's been carrying for 9 months.

What is 'womb for rent'?

By Andrea Rodrigo (embryologist).

It is a pejorative term that makes reference to surrogacy. Although it is commonly used, especially in the Internet in womb-for-rent ads, we do not recommend it to be used in any context.

There is no such a thing as a womb for rent—a womb or uterus is not a materialistic thing or an object that can be hired our or rented as if it was a house or a car, for example. When a woman becomes a surrogate, she helps someone else have a baby by "lending" her ability to bear a pregnancy to term.

Does insurance cover a surrogate?

By Andrea Rodrigo (embryologist).

In some cases, yes. If your health insurance plan does not state specifically that a surrogate pregnancy would not be covered, in principle your insurer must cover the costs associated with the surrogate pregnancy as if it was a natural pregnancy. However, you should know that finding an insurance policy that covers this treatment is not an easy task.

How do I find a woman to have my baby?

By Andrea Rodrigo (embryologist).

We strongly recommend that all intended parents pursuing a surrogate to have their baby look for a surrogacy agency and an attorney to be counseled and supported throughout their journey. Doing it without an agency is a risky decision that can lead to problems, especially legal issues. Your agency will help you find a gestational carrier that is compatible with you, and whom you feel comfortable with.

How does a surrogate mother get pregnant?

By Andrea Rodrigo (embryologist).

By means of IVF embryo transfer (ET). If everything goes as expected, which usually does, the embryo will successfully implant into her uterus. After that, the GC can take a pregnancy test approximately within 15 days after the ET. If it's positive, your journey through surrogacy will start.

How does a surrogate work for gay couples?

By Andrea Rodrigo (embryologist).

If it is a gay male couple, they have two options for creating the embryo. On the one hand, they can decide who is going to contribute the sperm for fertilization, and create the embryo using his sperm and the egg from a donor. On the other hand, they can mix their sperm so that the egg is fertilized by a random spermatozoon, without knowing if the DNA belongs to father A or to father B.

How much does a surrogate get paid in America?

By Andrea Rodrigo (embryologist).

Typically, gestational carriers in the United States are paid between $35,000 and $45,000 plus expenses, a rate that can increase if they have previous experience.

What is the difference between altruistic and commercial surrogacy?

By Andrea Rodrigo (embryologist).

The difference is quite simple: While commercial or gainful surrogacy is where a surrogate is paid a certain sum of money for carrying someone else's child, altruistic or uncompensated surrogacy is just the opposite—she receives no financial gain except a reimbursement for the expenses incurred during the pregnancy.

Suggested for you

You can delve deeper into the types of surrogacy that can be found today by visiting this guide: What Are the Different Types of Surrogacy?

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