The Surrogacy Process

For gay couples, the decision to have a biologically related child through assisted reproductive technology (ART) is often fraught with uncertainties, complications, expenses, and emotions. But when you yearn for the deep love that comes with the pitter patter of little feet, and the exponential love that it can bring between you and your partner, the journey to have a child can be one of possibilities and optimism. Through a process called gestational surrogacy, where a third-party gestational carrier—also known as a surrogate—will agree to carry your child to term, it is possible to have a child who shares your family’s genes.

Far from weird science, the procedure of fertilizing egg with sperm in a laboratory dish and then transferring the resulting embryo into a healthy uterus, also known as In Vitro Fertilization (IVF), is common. For gay men, however, there are additional pieces to the IVF puzzle: choosing an egg donor, a gestational carrier, and deciding upon which father will share a biological link to the child. But the science of surrogacy is fascinating, and staying focused on the interesting details of the process can help you persevere, despite the length and cost of the journey. In order to help you understand, we’re breaking down the process step by step in order to give you everything you need to know about surrogacy.

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There are a dizzying number of elements and moving parts to consider when preparing for surrogacy, including the cost, the law, institutional support, and the emotional toll. First, you’ll need to pick a trusted fertility clinic in order to start fertility testing and begin the IVF process. You may also want to find a surrogacy agency to match you with a gestational surrogate, and to help you iron out everything from the legal paperwork to how many times per week you’ll FaceTime with this person. At the least, you’ll need a reproductive attorney to make sure your rights, your child’s rights, and your surrogate are all legally protected.

You will also need to consider the financial commitment of the process, including understanding your insurance benefits, so that you can plan accordingly. Also important to consider are the state-by-state laws around surrogacy. Is surrogacy legal in your state? What are the laws regarding intended verses birth parents and surrogacy compensation in your state? Lastly—but most importantly—make sure to have a support system in place for you and your partner, because the surrogacy process can be stressful with its overwhelming number of decisions. Consider seeing a counselor that specializes in LGBTQ family building.

Going through the surrogacy process is a bit like planning a wedding from start to finish—and every bit as exciting and draining. Instead of contracting with a venue, caterer, wedding planner, florist, officiant, and more, you’ll spend a copious amount of time choosing your fertility practice, surrogacy agency, finding an egg donor, and then waiting for all of it to come together through the IVF process. And just like getting married, the fun won’t end once your surrogate is pregnant and gives birth to your child. Many life adventures await with your growing family!

Although you’ll start the process with an unyielding amount of excitement, the long and complicated process can weigh on your dreams of parenthood. Plan for the surrogacy process to take anywhere from 15 months to two years—and potentially more. Although some steps can overlap—such as starting the IVF process while trying to match with a surrogate—the time and energy that takes can be overwhelming atop of lives, jobs, and existing relationships. Have patience, celebrate each small step forward, and make sure to have good support systems in your corner.

Most steps in the surrogacy process will revolve around your chosen fertility practice. This practice is where three key elements of this process will come together to grow your family. You, your egg donor, and your surrogate complete this reproductive trifecta. Trusting your providers and feeling connected with their medical expertise, philosophy, and communication is important to the long-term success of your fertility journey. There are many reputable practices—so how do you choose?

Quality fertility centers seek out membership in national organizations that promote high standards of medicine and transparent reporting of fertility results. Health care practitioners who treat patients with infertility may become members of the American Society for Reproductive Medicine (ASRM). The ASRM oversees the Society for Assisted Reproduction Technology (SART), which provides accreditation for fertility practices. SART is essentially an organization for quality assurance. It keeps a record of IVF outcomes from fertility practices—requiring member fertility practices to report their results—and also sets standards and guidelines to assure practices are upholding federal requirements.

Check to see if your fertility practice options are members of SART, and compare statistics.

ASRM also oversees the Society for Reproductive Endocrinology and Infertility (SREI), which requires that doctors have undergone specialty training in reproductive endocrinology in the form of a 2-3 year fellowship following their OB-GYN residency. Additionally, members must have also passed board exams in both OB-GYN and reproductive endocrinology and infertility, certification that must be maintained on an annual basis. At minimum, reproductive physicians should be board-certified, meaning they have the additional training and have passed an exam in their specialty.

Additionally, the IVF laboratory at a fertility practice can achieve accreditation through the College of American Pathologists (CAP), and should meet the standards outlined by the Clinical Laboratory Improvement Act (CLIA). Accreditation and certification through The Joint Commission is yet another layer of protection for laboratory centers.

Certification through a national organization isn’t the only way to gain credibility in the field. Many health insurance companies denote certain centers as ones with consistently high care, which they call Centers of Excellence or Institutes of Excellence. There are other organizations, too, that rate practices based on key measures, including the live birth rate and the rate of multiples. Be sure to check that your chosen practice is reputable, accredited, and gets consistently high ratings within the healthcare industry.

Now that you know you’ve found reputable fertility centers, what else should you consider? Remember that IVF is just one part of the process, so make sure your clinic is also experienced in supporting surrogacy. How many surrogacy cycles does your clinic perform each year? Additionally, compensated surrogacy is legal in most states but not all, so it’s important to make sure your chosen clinic is located in one of them.

At the end of the day, picking a fertility practice isn’t all about quantitative measures. This is a long-term collaboration, so you want to be sure you and your fertility practice mesh well together. Do you feel at ease with the practice and its practitioners? Do they communicate clearly and efficiently? Do they have flexible scheduling? Talk to your clinic about their LGBTQ inclusivity. Do they treat many same-sex couples, and are they committed to helping non-traditional families grow? Make sure to take advantage of tools like the Human Rights Campaign’s Healthcare Equality Index to help inform your choice of practice.

Without doubt, you are brimming with questions about the process you will embark on with your fertility practice. The initial consultation is where you get to ask all your questions—anything at all—and get a first impression of how the practice responds to your concerns and demonstrates their competency. You’ll meet with the doctor one-on-one and get to know their team. You can also get a sense of how they will build a treatment plan specifically for you and your partner’s health and needs. Based on those factors, your next step will most likely involve some kind of diagnostic or fertility testing.

Much of the surrogacy process is hands-off for dads-to-be, as you support your egg donor and surrogate throughout treatment or pregnancy. But the first step of the surrogacy process is to make sure that your own reproductive materials are given a green light to make a healthy baby.

In order to make sure you and your partner have the best chance in the IVF process, your doctor will first require a semen analysis. A semen analysis will indicate things like sperm concentration, motility (the percentage of moving sperm in a sample), morphology (the shape of your sperm) and the volume of your semen. Both you and your partner will get tested. This is a quick and easy test you can do locally that’s usually covered by insurance. Don’t fret if your results aren’t optimal. Your doctor may recommend some lifestyle changes or supplements to help you be at your healthiest, or you may be referred to a urologist.

The common adage "you are what you eat" is pretty much true when it comes to reproductive health. The best way to ensure a smooth and healthy process is to make sure you take care of your overall health and well-being. The good news is that you can start this part before testing even begins—and it’s never too late. Your body is continuously making sperm, so even short-term changes can yield positive results.

Here’s how you can optimize your body for healthy sperm:

• Keep alcohol usage at a minimum (no more than seven drinks per week).
• Reduce smoking and vaping—inhaling heated vapor is not good for reproductive health.
• Exercise, maintain a healthy weight, and reduce stress as much as possible.

There’s no one like you—and the same will be true of your baby. The human gene pool is full of endless variations for height, build, hair and skin color, intellect, personality, and more. Here’s where you get to put your imagination to work and dream of all the characteristics you hope your baby might inherit. Choosing an egg donor is a little bit like online dating. You will sift through profiles, baby pictures, and even videos made by the donors to pick out the traits you most value and hope will be passed onto your baby. After all, your egg donor is contributing 50% of your future child’s genetic makeup! Bonus: no bad dates required!

Your clinic may have their own database of pre-screened donors, or you might find independent donor agencies and databases to sift through.

But remember that there’s more than just physical characteristics to consider. Family history, hobbies, and other personality and character traits you can discern might be important to the story of your child. Your child may someday have questions about the woman who contributed their genetic materials for half of his or her existence.

There are two types of donor situations you will consider: a known donor vs. an anonymous donor.

Known/open door donor

Some donors are opened to communication before matching, usually through online video conferencing and rarely in person. This option allows you to ask your donor questions that you think your future child may want to know or that can help with medical history.

In other scenarios, dads-to-be may ask a friend or family memberto be their donor. In these instances, all parties would be fully screened and counseled so they know what the process and this decision entails!

Anonymous donor

In this arrangement, you won’t know the donor's name or identifying information before matching, except for their medical and family history. For some, this level of distancing is emotionally easier. However, know that with all the popular ancestry programs and the prevalence of commercial genetic testing the anonymity of the donor is not always in your—or your donor’s—control.

Experience and a proven track record is key for job interviews—but it may also be something of consideration when selecting an egg donor. After all, you want the best chances of egg and sperm combining to create viable embryos. A proven donor is someone who has previously donated. A first-time donor hasn’t yet contributed her eggs as a donor. Remember that all egg donors are required to offer a complete medical background and undergo comprehensive testing. However, donor history may be important if you and your partner both want to be genetically-intended fathers, as there is a natural rate of attrition during the IVF process.

Your fertility clinic should help guide you through the egg donor process and help complete this screening. Even with expert guidance, it may take up to three months to select and screen an egg donor. After egg donor selection, an IVF cycle is the next step.

Your sperm is healthy and you’ve picked your egg donor—now it’s time to create embryos! The IVF process will combine your sperm with your donor’s egg and then transfer the resulting embryo into your surrogate’s healthy uterus. It sounds simple when reduced to a single sentence, but there’s a complex process involved that may require patience from dads-to-be.

Your egg donor is in the starting position. She’ll first be stimulated with medication that will cause her body to release more eggs than it normally would in a single cycle. Remember, the more eggs retrieved, the better your chances -- even in young, healthy women, not every egg is “mature” on retrieval day. Once her eggs have matured, they are then gathered in a short procedure called an “egg retrieval” - this will most likely take place at your clinic. Those eggs will be evaluated for quality and maturity.

On the same day as retrieval, the sperm from one or both partners will be combined with the mature eggs in the laboratory to create embryos. Don’t worry if you can’t be there on the exact day—your sperm can be frozen on another day, and thawed for the retrieval. With this method, everything is ready to go on retrieval day!

At this point you have the option to do genetic testing on the embryos prior to the transfer. This is called preimplantation genetic testing for aneuploidy, otherwise known as PGT-A. This test makes sure your embryos are chromosomally normal, and can test for certain chromosomal abnormalities, like Down Syndrome.

People often ask - why do the PGT testing if I’m healthy, and my egg donor is a young, healthy woman? Even with optimal conditions, the IVF process does not guarantee success, or a certain number of high-grade embryos. Oftentimes, transferred embryos that are chromosomally abnormal just won’t lead to an ongoing pregnancy - leading you to more weeks of waiting before another embryo transfer. Despite the extra cost of the test, PGT-A testing can serve as an extra protective measure towards achieving a viable pregnancy, potentially saving the time and cost of multiple embryo transfers. Want to know if you’ll have a boy or girl? This genetic testing can also reveal gender, if you choose to know.

The embryos are supervised for three to five days in the lab as they grow. At this point, you can either do a fresh embryo transfer into your surrogate or you can cryopreserve your embryos for future transfers. Cryopreservation is simply a fancy word for freezing - in this case, freezing embryos. Cryopreservation rates do not differ from fresh transfers and freezing can allow for easier coordination between your clinic and your surrogate. It can also buy more time as you search for a surrogate and as she gets ready for the transfer. Embryos can be frozen for years at a time without damage, so you’ve got plenty of time.

Although the IVF process itself is typically the length of a normal menstrual cycle, the total time between your egg donor’s treatments and implantation-ready embryos can be up to three months.

Dads-to-be using a surrogate might think they’ll miss out on the moment their child is conceived through this process. But you can be present, if you wish, and if your surrogate allows it! Often, intended dads will opt to be in the office for the transfer date, along with the surrogate and the surrogate’s partner. If you’ve chosen cryopreservation for the embryos, they will be thawed in advance of the transfer.

Here’s how the transfer happens: The embryo is placed into a catheter and is then gently inserted into your gestational carrier’s uterine cavity. The procedure is painless and quick. Because doctors use ultrasound to guide the catheter, you can even watch!

The not-as-quick part: It will take around 9 days until a pregnancy can be detected. Take some assurance in the fact that every parent at your fertility clinic has to go through that same wait, regardless of how their family building plan takes shape.

Following the transfer, your reproductive endocrinologist will oversee the monitoring of your gestational carrier through her local clinic until 8-10 weeks of pregnancy. After that time, your gestational carrier will be discharged to her OB-GYN’s care.

It’s a common estimation that it takes nine months for a pregnant woman to give birth. Closer to accurate, though, is the weekly average of a healthy pregnancy: 40 weeks. Don’t be fooled by either number. Childbirth rarely happens right on schedule! This is the time when you take a backseat and let your surrogate’s body do the work of growing your baby. Trust her judgments and take comfort in knowing that your baby will be monitored through your gestational carrier’s regular OB-GYN appointments. She’s happy to follow the plan that you, your partner, and she have agreed to in your contract and hopes very much to give you your healthy baby at the end of the pregnancy. This is the time to be in awe of a woman’s body and all it goes through during pregnancy. Recent studies have shown that pregnant women are expending an amount of energy that is at least equivalent to or higher than running a 40-week marathon. Pregnancy is basically the upper limit of energy that a human body can expend.

You won’t be totally off the hook over these months. During this period, you will consult with your surrogacy agency, who will help you draw up a birth plan with your surrogate and assist with any pre-birth legal documents that you may need to ensure you receive parent rights in your state and/or the surrogate’s state.

Oh, and you’ll be doing plenty of nesting, collecting baby gear, readying your home for life with a baby, and testing out baby names. Preparing for a baby is an incredible way to bond with your partner and build excitement for the bundle of joy that will be delivered to you in due time.

Choosing a fertility clinic and egg donor may have sapped you of some of the initial energy you had heading into the surrogacy process, and you may be feeling some burn out, but don’t forget the final part of the surrogacy trifecta - your surrogate. Because this is a long-term relationship, there’s a lot to consider. Although it is possible to complete a surrogacy journey relying only on a reproductive attorney,many fertility clinics will insist you work with an agency. But it’s for a good reason. An agency will help you coordinate the surrogacy process and manage both the emotional and legal aspects, from matching with your surrogate all the way through pregnancy and birth.

A surrogacy agency will offer matching services to ensure a good fit between you and your surrogate, and they will help nurture the relationship from start to finish. They will also offer screenings to make sure everyone is emotionally and physically ready for the process. They will help coordinate services and information with your fertility clinic. And, should you need it, they can offer counseling services.

But critically, they’ll help you negotiate the legal contract with your surrogate and help with the legal legwork for you to become the legal parents of your child. Examples of the legal paperwork needed may include a pre-birth order, a voluntary acknowledgement of parenthood, a custody order, and even a second-parent adoption.

Surrogacy agencies aren’t all one of the same. There are two different types you might encounter:

Full service agency - A full service agency will have an in-house legal staff and will assist with all the administrative work. The matching process times might be quicker, if they have a larger pool of surrogates and more staff to help you. However, you may also pay a premium for these services.

Smaller agency—Smaller surrogacy agencies might have the ability to offer more of a personalized one-on-one experience. They may likely also be less expensive than the big agencies. Often, they are run by former parents who have gone through surrogacy, or social workers with surrogacy experience. But smaller “shops” may also mean longer wait times for responses and paperwork. Another critical point - some agencies outsource their legal work, which is important to consider when comparing costs.

Choosing a surrogate is much more than just finding a healthy uterus for your developing baby. This is the person responsible for the gestational well-being of your baby. Solid communication, mutual trust, and agreement on decisions related to the baby will be important for your peace of mind.

You’re asking for a big commitment from a gestational carrier both in terms of the physical strain and time, so how do you find someone willing who has mutual feelings about important issues? Some couples find a friend or relative to serve as their gestational carrier. The benefit is that you already know and trust this person. However, because the emotionally-involved process can strain relationships, you may prefer to go with someone neutral to you and your family. Agencies help link intended dads with screened surrogates, and will help you manage the details of the relationship.

You’ll pick a surrogate based on personality, trustworthiness, health, ethical decisions, and contact during pregnancy. Primarily, you want to pick a healthy woman between the ages of 21-42 years to successfully carry your baby. If working with an agency, your gestational carrier will be screened for her overall and reproductive health, and also for her mental and emotional health. There are stringent requirements about prior drug use and they will agree to abstain from smoking and alcohol during the preimplantation period, and after. Ideally, she will also have a strong support network of her own as she goes through pregnancy.

What kind of relationship do you envision having with your surrogate? Everyone has different thresholds for the sweet spot between trusting space and micromanagement. Do you have strong feelings about what this person eats during pregnancy? If you have cultural or religious reasons to maintain a certain diet, be sure to bring that up early on in the search process. While you may request that your surrogate avoid certain foods or adhere to a strict diet, remember that your surrogate will be getting regular medical counseling and monitoring from her OB-GYN and will be following their sound nutritional advice. Further, what arrangements will you make for being present for ultrasounds and for the birth? How about a birth plan and plans for the first contact with your baby after birth?

Also consider the relationship you want with your gestational carrier post-birth. For instance, you might think that breast milk isn’t an option as a dad, but you can make arrangements with your surrogate to breastfeed directly after birth. Colostrum, the early form of milk produced directly after childbirth, is filled with antibodies that can help protect your newborn and ease their developing digestive systems. You may even consider an arrangement to receive pumped milk for a specified period of time. And would you like to maintain a relationship with your surrogate? Because of how intimate the process is and the depth of the relationship you will likely develop, many couples do maintain some level of contact after their gestational carrier gives birth. All that matters is that you, your partner, and your surrogate are in agreement with the type of contact and relationship that feels natural.

The hardest discussions tend to revolve around the decisions parents must make in worse-case scenarios. Many of these choices are invasive and carry emotional strain for all involved. For instance, will you want an amniocentesis—an invasive procedure that can accurately screen for serious genetic conditions—performed on the fetus? If the fetus were found to have a severe condition such as Down Syndrome, would you want to continue the pregnancy, or would you choose to terminate? If the pregnancy results in multiples, would you want to selectively terminate to best ensure at least one has the best chance at a healthy development and delivery? Will your surrogate agree with all your wishes for these hard decisions? A surrogacy agency should have social workers trained to moderate these discussions, and your agency will ultimately include these decisions as part of your contract with a surrogate.

Once you and your partner agree on the type of relationship you are seeking, an agency can match you with a gestational carrier who will be happy to work with you to build your family. Knowing what you want in a surrogate relationship can help expedite the matching process. Just be aware that the more specific and unique the requirements you have for a surrogate, the longer the match process can take.

Forget about college savings for just a minute. Instead, surrogacy costsmight end up being one of your biggest expenses when having a child. It is a major financial undertaking, as gay couples can spend at least $100-150K for a single surrogacy journey. Imagine if you went through the surrogacy process and the pregnancy wasn’t viable or there was a major complication. Could you afford to try again? Financial planning for surrogacy—and honesty about what you can afford—is often the biggest hurdle in the surrogacy process.

What could possibly cost $150K? We can break down the costs in a number of categories:

· IVF cycle costs (around $10 to 15K)
· Egg donor compensation (around $8 to $15K)
· Surrogacy agency costs (variable)
· Surrogate compensation (around $40 to $60K)

To afford surrogacy, many couples apply for bank loans, borrow money from relatives, or take out a second mortgage. Before you rack up debt, seek out all the outside financial support you can. First, there are some grants and financial resources available to help same-sex couples navigate the IVF portion of the journey. They can be dependent on financial need, location, religious affiliation, and more. Here’s an overview of grants and charities available for LBTGQ couples.

Some larger, more inclusive employers offer benefitsfor same-sex couples. Companies like Progyny are already offering reproductive assistive technology as an add-on insurance policy. Testing costs for you and your partner are often covered by insurance, even if IVF is not—and remember, every bit helps. Some insurance companies even offer some coverage for IVF, depending on state laws.

Surrogacy, unfortunately, is typically not covered under most insurance plans. But the landscape for reproductive assistance and surrogacy is changing. More and more employers are beginning to offer reimbursement for surrogacy. If your company offers reimbursement to heterosexual couples, there could be an opportunity for you to make a case to your HR department for equal coverage for same-sex couples.

The surrogacy process is a complicated legal agreement that is further complicated by state laws. This is why it’s so important to have a reproductive attorney or a surrogacy agency with in-house legal services. It is your agency or attorney’s job to help negotiate the terms of your surrogacy contract. This includes everything from medical procedures to compensation to the post-birth relationship.

Some of the legal legwork might include a pre-birth order and custody order, which declares you and your partner are the legal parents, with full custody as a couple, and gives you the right to make medical decisions for your baby. Another common document is an acknowledgement of parenthood, a voluntary statement by you and your surrogate that you are the biological parent, since some states won’t automatically recognize a parent who isn’t married to the birth mother. The partner who is not the biological link to the child may need to go through a legal adoption of the child, known as a second-parent adoption. A full adoption would also have to be granted if neither of you were biologically related to your baby (for instance, if you used both donor sperm and eggs).

To top it off, not only do you need to be sure your fertility clinic is located in a surrogacy-friendly state, but that your surrogate lives and/or delivers in a surrogacy-friendly state. A surrogacy-friendly state is one where compensated surrogacy is legal, and where parental rights are easily granted to gay couples in surrogacy arrangements. As you can see, there are many potential situations and they all vary by state laws, making legal representation so critical. It’s one more reason to go with a surrogacy agency—you can let them worry about the legal details so you can focus on the rest of the surrogacy process.

Managing Surrogacy Relationships

The surrogacy process can be all-consuming, long, expensive, and complicated. It’s a challenge that you and your partner will face together, which will both strengthen and test your relationship. Many couples going through surrogacy choose to see a counselor who specializes in LGBTQ family building. A third party can help you both communicate your wishes and needs, and find ways to connect and support each other, especially if the surrogacy process doesn’t go as smoothly as anticipated.

The strain you are under can also affect your outside relationships with family and friends. It can be difficult for people on the outside to fully understand your decision to pursue a family through surrogacy or to empathize with the challenges you are facing. And relying on others for things like financial support can add even more pressure to your relationship. Feel confident in your choices, be patient with those who you love, and make sure to have a people in your corner who you can lean on for emotional support.

Sharing your Child’s Conception Story

It’ll be a number of years before your future child is old enough to understand why and how they have two dads. Nonetheless, you’ll expend plenty of time worrying about how you might tell your child how they came to be. It’s an eventuality that they’ll be curious about how you chose a donor and details about the woman who is their biological mother. You don’t have to navigate these conversations alone. Fertility clinics and surrogacy agencies are staffed with licensed social workers who can help you find age-appropriate ways to introduce your child to their story. There are also outside family counselors who specialize in LGBTQ family building and work with donor-conceived families who can be a great resource to turn to. With support, you can find a way to share the incredible process it took to get your child in your arms and express the amount of love and commitment that resulted in their existence.

Surrogacy Success Rates

You might be surprised to know that out of all couples seen at a fertility center, gay male couples building a family through surrogacy tend to have the top chances of success. That’s because you don’t have infertility, you’re reproductively healthy! You simply need the assistance of two other people to make the biology work. Because you have the choice of young, healthy egg donors and gestational carriers with a proven history of healthy pregnancies, the chances of conceiving a child through surrogacy look quite good. Plus, children conceived through IVF are some of the most studied cohort of people in modern medicine, so you can be sure that you are going through a safe and well-studied process.

You can also increase your likelihood of success by picking a reputable fertility clinic with well-reported success rates. Reproductive Medicine Associates of Connecticut maintains transparency with success rates as directed by SART. You can see our statistics here.

Due to the wonders of scientific research, it is possible for you and your partner grow a family that is genetically linked to you. Your dream to complete your family can become a reality. Now that you know all about surrogacy, are you and your partner ready to start trying for a baby?

If so, get the process started and request a consult with Gay Parents To Be and Illume Fertility.