Surrogacy, also known as third-party reproduction, uses the assistance of a surrogate to carry a pregnancy to term. Surrogacy is an alternative to adoption for couples who are unable to become pregnant on their own and want to have a child. It is an option for women who are incapable of carrying a pregnancy to term, have other medical conditions that may affect fertility, or have suffered repeated miscarriages. It may also be a family planning option for gay and lesbian couples or older couples who wish to conceive. This treatment involves the insemination of a third party, or a surrogate, who will carry the pregnancy to term on behalf of an individual or couple.

Reasons for Surrogacy

Surrogacy is often considered by women who may have difficulty getting pregnant or carrying a pregnancy to term. This difficulty may be caused by:

  • A prior hysterectomy
  • A history of infertility
  • A history of pregnancy loss
  • Medical problems of the uterus
  • Untreatable intrauterine scar tissue
  • Advanced age

A number of other medical conditions that may cause problems with pregnancy and may also lead to the use of a surrogate may include a history of severe pre-eclampsia, severe diabetes, heart problems, cancer, or kidney disease.

Types of Surrogacy

There are two kinds of surrogacy that may be considered.

Classic Surrogacy

A classic or traditional surrogate is inseminated with sperm from the male patient. Her own egg is fertilized, and she carries the baby to term on behalf of the patient or couple. In this case, the surrogate has a genetic and biologic link to the child. Classic surrogacy may be perceived as controversial with its potential for legal and psychological complications.

Gestational Surrogacy

In gestational surrogacy, an embryo may be produced, using in vitro fertilization, or IVF, entirely by the genetic parents or from a combination of donated or genetic egg and sperm. The embryo is then placed into the uterus of the surrogate and carried to term. The gestational surrogate has no genetic link to the child. Gestational surrogacy is considered a legally-less-risky procedure, and is the most common type of surrogacy.

The Surrogacy Process

The surrogacy process is physically and emotionally complex process that should be carefully considered by all involved parties. Prior to the procedure, the surrogate and the intended parent(s) are counseled to ensure a clear understanding of the legal, financial, psychological, physical, and ethical issues related to the pregnancy and the surrogacy process. There are several stages to the surrogacy process.

Evaluation of Recipient Couple

A couple should be first evaluated for any causes of infertility with a comprehensive medical history and physical exam for both partners. Once surrogacy is established as the best option, the male partner's sperm may receive a genetic screening, or preimplantation genetic diagnosis, in order to ensure genetic viability with the surrogate's egg.

Selection of the Surrogate

Gestational surrogates may be relatives or friends, or they may not have met the couple before. The ideal candidates are highly committed women between ages 21 and 40 with proven fertility and at least one healthy child. Potential surrogates will undergo a complete screening of their overall medical and psychological health and are advised to seek legal counseling before the process. Potential surrogates receive a complete screening for infectious diseases, including HIV, syphilis, gonorrhea, and hepatitis B and C. In addition, a hysterosalpingogram or sonohystogram will evaluate the uterus and viability of the fallopian tubes.

Preparation of the Surrogate

Once a surrogate is selected, she may be inseminated naturally, according to her ovulation cycles, or else undergo a course of ovulation induction hormone treatments. If the surrogate is given ovulation induction medications, she will undergo a "mock cycle," during which she will receive the ovulation induction hormones in order to make sure that there are no problems with the uterine lining.

Sperm Preparation

Once a sperm sample is collected from the male partner (or donor), it will be prepared in a lab. First, a centrifuge is used to separate out the active sperm and concentrates them into a small volume. The sperm is then washed and prepared for insemination. Sperm washing cleanses away potentially toxic chemicals, as well as greatly reduce the risk of HIV transmission.

Intrauterine Insemination

At the time of ovulation, a catheter is used to inject the prepared sperm directly into the uterus. This is a minimally invasive procedure performed quickly in the doctor's office with minimal discomfort. After insemination, the doctor may advise the surrogate to remain lying down for at least 15 minutes up to a few hours to optimize pregnancy.


A pregnancy test is administered two weeks after the insemination procedure in order to ensure success. The surrogate will likely continue to receive hormone treatments and testing until pregnancy is achieved. The surrogate carries the fetus to term if implantation is successful and pregnancy results. Any unused embryos may be frozen.

Considerations of Surrogacy

There are a number of issues which should be considered before choosing surrogacy. The surrogate and recipient parent(s) should be advised of the health risks involved in the gestational surrogacy process. Risk factors for gestational surrogacy are similar to those of IVF procedures, which includes the rare occurrences of birth defects, multiple births, and ovarian hyperstimulation syndrome. Some of the factors that cause infertility may be genetic and passed on to the offspring as adults. Medical complications of medications used for ovulation induction are mild. Side effects of hormonal medications may include hot flashes, nausea, bloating, headache, and blurred vision.

The surrogacy process can be physically, financially, and emotionally stressful. Many of the treatments associated with surrogacy are costly and may not be covered by insurance. This can be a factor in the selection of fertility treatments. Surrogacy may also include legal and ethical issues which should be discussed by all involved parties prior to the surrogacy process.

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