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How Does Surrogacy Work?

How Does Surrogacy Work? 5 Simple Steps

Surrogacy works in five simple steps, starting with the donation of sperm and eggs, the ‘in-vitro’ conception of embryos, and then the transfer of the embryos to a surrogate mother. In addition to these clinical steps, couples also must find a qualified surrogate, and finally arrange their parental rights in their local courts.

How-does-surrogacy-workGestational surrogacy has become a popular fertility option for childless couples. It may seem complex, but it’s easy to understand how surrogacy works. This guide will help any couple through every step of the process. Following our advice, you can start your new family with the help of a surrogate mother.

Surrogacy always starts with a thorough review of your options at clinics worldwide. Your surrogacy agent (or “representative”) should provide as much help as you need for as long as you need it. Your agent’s top priority is to give all the information you need, and he shouldn’t demand any contract or payment.

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Once you feel comfortable with the available fertility options, the complete process of how surrogacy works starts below. Click each topic to learn more…


Step 1: Find Your Qualified Surrogate

How Does Surrogacy Work Step 1Gestational surrogates (aka, surrogate mothers) are typically recruited and managed by specialist agencies. Your agent will be connected with one or more reliable surrogate recruiters. That recruiter will become an integral member of your surrogacy team.
Read more about finding a qualified surrogate and egg donor


Step 2: Egg/Sperm Donation & Fertilization

How Does Surrogacy Work Step 2Both your surrogate and egg donor will need fertility treatments to ensure an excellent egg donation and positive pregnancy. The treatment process takes about 8 weeks. While the donor and surrogate re being prepared, the genetic father can make his sperm donation at the clinic. If the Future Mother intends to donate her own eggs, she will need fertility treatments as well.
Read more about donations and embryo fertilization


Step 3: The Embryo Transfer

How Does Surrogacy Work Step 3The fertilization process typically results in several viable embryos. The two best will be used first. Others will be frozen in case the IVF procedure needs to be repeated. The success of your embryo transfer will depend on the quality of the embryos, the receptivity of your surrogate, and simple good luck.
Read more about your embryo transfer.


Step 4: Pregnancy & Prenatal Care

How Does Surrogacy Work Step 4After a successful pregnancy has been confirmed, the surrogate is placed under the immediate care of the clinic’s obstetric team. In Western countries like the United States, the surrogate will live at home and attend regular prenatal exams. In developing countries the surrogate is often given a personal apartment.
Read more about prenatal care of your surrogate.


Step 5: Birth & the Return Home

How Does Surrogacy Work Step 5When the surrogate is ready to give birth, the clinic will arrange a convenient date for the delivery. The parents are notified and will travel to the clinic to welcome their new son or daughter. Once born, the bureaucracy begins with the baby’s birth certificate, passport, and the birth registration process.
Read more about the birth and return home of your baby.

How surrogacy works is slightly different for every intended parent. Each couple has many available avenues to reach their new family. While this site offers general descriptions of the process, you should contact a Sensible Surrogacy consultant to get a complete understanding of how surrogacy works in your individual situation. Consultations are free with no obligation.

Also review what you should know about Birth Certificates and Passports.

Didn’t find what you need? Search our Surrogacy Guide for all the answers…

…or return to the ‘Sensible’ Surrogacy Guide.


Step 1: Find a Qualified Surrogate

How Surrogacy Works - Find a SurrogateSurrogate recruiting agencies specialize in finding and managing Gestational Carriers (aka, surrogate mothers). Your agent will be connected with one or more reliable surrogate recruiters who will provide your surrogate. That recruiter not only will find and evaluate your surrogate, but they will manage her care, arrange her clinic appointments, and handle her compensation. The recruiter will be an integral part of your surrogacy team (along with the clinic, the egg donor’s representative, and your own agent).

Surrogates receive a variety of medical and other evaluations — and these should be done by objective service providers. Medical evaluation should not be performed by doctors financially linked to the surrogate’s recruiter.

Surrogates are in short supply — so surrogate agents will not provide a catalog of donors to review (like with egg donors).  Instead they will evaluate surrogates based on medical criteria and forward those candidates they think are suitable.  The parents and their representative will then review the candidates and either approve/disapprove.  If parents disapprove, the recruiter will move to the next most qualified candidate.

Evaluating Your Surrogate

Most surrogate agents will have a short list of women already signed up for the program – these may or may not be suitable for your needs.  When new Intended Parents request a surrogate, the agent also will actively recruit additional candidates. Parents often can give their own requirements at this point (most often her age, marital status, fertility history, education, etc.).  More in-depth tests and evaluations are done once a candidate is matched with a family. Would-be parents often must make a financial commitment before the final evaluations are performed.

  • Psych screening
  • Fertility and OBGYN evaluation
  • Blood/hormone analysis
  • Insurance review (in the United States)
  • Legal/ contracts review.

The steps above take approximately two months from start to finish. Sometimes a surrogate that has been matched to a couple does not pass the above steps.  (Failing a psych evaluation doesn’t mean your surrogate’s crazy, only that the doctor feels she may not fully realize the difficulties of letting go of the baby.)  If that happens, her recruiter goes to the next suitable candidate.

The entire process can take a couple of months.  Meanwhile parents and their representative can be looking at egg donors (if needed).

Options for choosing an egg donor

Here are the possible sources to consider if you need an egg donor. Your best options will depend on your personal preferences and cost. Searching for a donor can be done while you are evaluating your surrogate.

Choose an egg donor through the local agency and/or clinic.

This is the least expensive option. However the limitation is that local donors are always the ethnicity of the local population (Hispanic for example). For some couples it is important their donor “look like them”, often meaning a specific heritage. But if appearance is less important, a local donor is often an excellent option. The cost of local donor is typically quite low because cost of living overseas is often lower than in the US, plus the donor will not need to travel.

Choose an egg donor through an international donation agency.

International agencies have donors of almost any ethnicity. They also are generally the most thoroughly screened and evaluated donors available. The cost of a donor is high — about $14,000 to $24,000 USD. This cost includes her travel expenses to the overseas clinic for the stimulation and donation (which takes about 15 days).

Your representative should be able to introduce you personally to a few excellent donation agencies. Your agent should then work closely with you and the agency to facilitate the donation process. Part of your representative’s responsibility is to make sure you have an excellent egg donation, which will be critical for the success of your surrogacy program.

Have a friend or family member donate for you.

Not many people choose this route, but it’s an option. If you know someone who is willing to donate, she should first have a series of basic fertility tests to ensure she’s fertile. She will then need to spend up to 20 days at the overseas clinic for the stimulation and donation process.

Regardless of where your donor comes from, the cost of your IVF & Surrogacy program is generally unchanged. Your clinic should include the cost of the donation procedure in the standard IVF package. You only need to pay for the compensation to your donor, the costs of her travel, and any fees to her representing agency.

For more details, read these articles in the Surrogacy Guide:

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Step 2: Egg/Sperm Donation & Fertilization

Egg Donation Step 2Both your surrogate and chosen egg donor require fertility treatments to ensure an excellent egg donation and positive pregnancy. The treatment process takes about 6 to 8 weeks. During this time Future Parents can travel to the clinic and leave their sperm donation and sign the required contracts.

If the Future Mother intends to undergo her own egg donation, she will require the appropriate fertility treatments as well. Treatments can best be described in 3 steps, each is required of every egg donor:

Egg Donation Made Simple

1) Check that you are a qualified donor. Blood tests and ultrasound scans will reveal if the egg donor has an adequate supply of eggs and whether she will respond to fertility treatments. Poor tests results mean you should find a different donor.

2) Plan your cycle. The egg donor must travel to the clinic on either Day 1 or Day 8 of her cycle. The egg donation will require two weeks of treatments. Those two weeks will begin on Day 1 of her natural cycle.

In many cases donor’s cycle can be “timed” by taking standard 21-day oral contraceptives (OCP) – this will suppress the donor’s natural cycle. When the woman is read to donate, she can simply quit the pills and her cycle will start about 4 days later. In this way it is possible to manage the donor’s fertility schedule.

It’s important the egg donor be under the care of her fertility doctor when her cycle begins. In most cases this will be the doctor at the overseas IVF clinic, but in some cases may be her own private doctor.

3) Stimulate your follicles. On Day 1 of the egg donor’s cycle she must immediately begin 15 days of stimulation injections. Stimulation will mature the ovarian follicles and produce the viable eggs. A successful donation will result in at least 15 mature eggs. Stimulation injections typically happen at our clinic, although the first week can be done at a local clinic in coordination with our fertility specialists.

Throughout the stimulation program the donor will receive regular blood tests and occasional ovarian scans. The doctor may adjust the medication based on how well she is responding. A final ovarian scan around Day 12 will determine when the donor will donate.

In Vitro Fertilization

Human eggs do not freeze well, so we advise that all eggs are fertilized as soon as they are retrieved. Embryos freeze much better. Frozen eggs have about an 75% survival rate during freezing/thawing, while frozen embryos have about a 90% survival rate. In addition research also shows that pregnancy rates with frozen eggs are about 5% lower than with fresh eggs. For this reason most clinics prefer to perform IVF immediately and freeze the resulting embryos.

Most IVF clinics now use a process of Intracytoplasmic Sperm Injection (ICSI) to fertilize eggs. This process identifies a single healthy sperm cell under a microscope and directly injects it into an egg. This process alleviates problems related to poor sperm count or quality.

Once the eggs have been retrieved they are left to develop in the laboratory for 5 days. After 5 days most embryos will have developed to Blastocyst stage. Blastocyst is the development stage just before the embryo begins to grow into a fetus.

On Day 5 the clinic will present the parents with a summary of the IVF procedure showing the final development of all the surviving embryos. A typical IVF procedure will result between 50% and 70% of all fertilized eggs should develop into Blastocysts.

To learn more about the quality of your embryos, check this article at the Surrogacy Guide: Understand the quality score of your embryos. []

At the Blastocyst stage the embryos must either be transferred into the surrogate’s uterus or frozen for transfer later on.

Shipping Frozen Embryos

In many cases the IVF clinic will ship embryos to clinics worldwide for transfer to a surrogate. Conceiving embryos at an overseas clinic and then sending them to the United States is one way to reduce the cost of your surrogacy program. Many couples also ship their frozen embryos internationally to take advantage of secure surrogacy legislation in countries like Ukraine.

Your surrogacy representative can manage the transport of frozen embryos to clinics worldwide, including shipping costs and paperwork.

For more details, read these articles in the Surrogacy Guide:

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Step 3: The Embryo Transfer

embryo transfer IVFThe fertilization process typically results in several viable embryos. The two most viable will undergo embryo transfer immediately. The others will be frozen in case the IVF procedure doesn’t produce a pregnancy and needs to be repeated.

The success of your embryo transfer will rely on the quality of the embryos, the receptivity of your surrogate, and (most importantly) simple good luck. There is no guarantee that a transfer will result in a pregnancy, but a good representative can advise you of several steps to improve your chances.

The receptivity of your surrogate is measured in the thickness of her endometrium, which is the lining of the uterine wall in which the embryos will lodge and develop into a fetus. stimulation injections given to the surrogate in the first 2 weeks of her cycle will accelerate her Endometrial development. An ultrasound scan will show the results of the stimulation (and the suitability of your surrogate). If the endometrium is not adequate after 15 days, the clinic may either increase the stimulation treatments, or they may recommend a different surrogate.

On Day 15 of the surrogate’s cycle (more or less) the clinic will transfer the embryos to her uterus.

Ten to 15 days following the embryo transfer the clinic will perform your pregnancy test. The typical test is the Beta HCG (or bHCG) test, which is a blood test that looks for hormonal changes resulting from pregnancy. A positive bHCG means that the woman is pregnant. A negative bHCG means that the woman is NOT pregnant. A very high bHCG test result may indicate twins.

Frozen vs Fresh Embryo Transfer

Because new embryo freezing (or ‘Vitrification’) techniques are so effective, many clinics now prefer that all embryos are frozen at Day 5. This allows the clinic to focus on the surrogate’s cycle and fertility. The clinic can then perform the Embryo Transfer when the surrogate reaches her maximum fertility. (In previous cases when ‘fresh’ embryos were used, the transfer had to happen on Day 5 whether the surrogate was ready or not.) The use of frozen embryos has generally improved pregnancy rates.

With the highest quality embryos, each as a 40% chance of a resulting pregnancy. This allows a 65% chance of at least one pregnancy, but also a small chance that two pregnancies will result.

Some options exist to increase the likelihood of pregnancy. The most effective may be Preimplantation Genetic Screening (PGS or PGD), which has a proven benefit for most couples. Other treatments such as Embryo Glue or Intralipid Injections are less certain (or may have benefits only in specific cases).

For more on the benefits of PGD check the Surrogacy Guide: Should I perform PGD on my embryos?

The first attempt at embryo transfer is made with the highest quality embryos. Subsequent attempts are made with lower grade embryos, and the success rate is also lower for these transfers. The pregnancy rate will depend on the quality of each embryo transferred. Each subsequent embryo transfer is typically an additional fee.

For more details, read these articles in the Surrogacy Guide:

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Step 4: Pregnancy & Prenatal Care

How Surrogacy Works Step 4After a successful pregnancy has been confirmed, the surrogate is placed under the immediate care of the clinic’s obstetric team. In well-developed countries like the United States, the surrogate will live at home and attend regular prenatal exams and ultrasounds. In other countries, the surrogate and her family are often provided a personal apartment, ensuring she has a clean, stress free environment in which to complete the pregnancy.

Pregnancy “concierge” services are often available to assist the surrogate during the pregnancy. These may include house cleaning and cooking, transportation to clinic appointments, visiting nurses, and clothing allowances. A caretaker is assigned to look after the surrogates; plus there should be an assigned doctor on call 24 hours a day.

Most importantly, the Intend Parents’ representative ensures the continued support, clinic updates, and guidance to both the Future Parents and the surrogate. Ultrasound scans are regularly sent to the Future Parents, along with the results of all tests and examinations.

Paying for Prenatal Care

The Intended Parents will pay for the prenatal care and selected concierge services. Payments are often made over the course of the pregnancy. The first payment is made when pregnancy is confirmed, then additional installments are made on the second and third trimesters. In the United States the full cost of the surrogate’s compensation must be paid into escrow at the beginning of her program – and her payments are disbursed from the escrow account throughout the pregnancy.

NOTE: The beginning of the third trimester is a good time for the Future Parents to contact their embassy or consulate overseas and begin arranging a passport and a VISA for the newborn. Consulate requirements often change, so it’s important for the parents to be in-touch with the local officials both early in the pregnancy and just before the anticipated birth.

Post-natal care for the Surrogate

Even after parents leave the hospital with their baby, their agent will continue ensure the well-being of the surrogate. Some agents provide a range of options that allow parents to show their gratitude to the surrogate and her family.

For more details, read these articles in the Surrogacy Guide:

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Step 5: Birth, Passports & the Return Home

Stage5US-big_When the surrogate is preparing to go into labor (naturally or induced when the time is right), the Intended Parents’ representative will call them to arrange a convenient date for the delivery. The parents will then travel to the clinic to welcome their new son or daughter.

The parents are generally encouraged to stay in the hospital for 2 to 3 days with the baby under observation — the hospital staff provides routine care for the baby and often offers coaching for the parents. After a few days the parents and baby can leave the hospital and spend the remainder of their time overseas getting to know each other at a local hotel apartment.

Of course for American couples having children in the US, there is no need for passport or visas and the new family can return home immediately. For others, our local team is available to help with the local bureaucracy to make returning home simple and straightforward.

Your agent should recommend a local hotel/residence if needed. It’ important that your hotel is familiar with the special needs of newborns and new parents – from sterilizing bottles to changing diapers. Your agent should also assist in finding additional help to care for the baby.

While the parents and their agent arrange for the baby’s passport and birth registration (a process which can take 3 to 6 weeks), the child will be able to receive regular check-ups and medical treatments from the local pediatric hospital. (Note, fees for additional medical treatments are paid directly to the hospital by the Intended Parents.)

Once the passport and exit VISA are obtained, the parents can leave for home.

Passports & Citizenship for Overseas Couples

When your child is born, your representative will arrange for a local birth certificate and other local documents registering the birth of the child. In some countries, this may include a local passport or citizenship papers. This may also include affidavits from the clinic, surrogate, and hospital as required by your embassy. In all cases the new parents will receive copies of the surrogacy agreements and affidavits from the surrogate waiving her parental rights in favor of the Future Parents.

Sensible Surrogacy will help you complete and submit all the paperwork (both medical and legal) with your local consulate to obtain the baby’s permanent citizenship and travel documents. We have a team of family law specialists ready to assist you, with first-hand experience of almost every embassy or consulate’s requirements.

Please note that the embassy/consulate will require the parents to submit the paperwork directly, often with a personal interview (and possibly with the child). Our role will be to guide you and assist you with the paperwork. If the surrogate is required to appear at the embassy/consulate, we will make arrangements for her time and travel and accompany her.

For more details, read these articles in the Surrogacy Guide:

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Didn’t find what you need? Search our Surrogacy Guide for all the answers…

…or return to the ‘Sensible’ Surrogacy Guide.



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