There are many different reasons why you and your partner may be dealing with infertility. Fortunately, there are also many assisted reproductive technologies (ART) now available to help you reach the goal of having a healthy baby.
Some infertility challenges may call for trying approaches known as “third-party reproduction.” This involves another person/other people beyond the intended parents.
While these advances may help you become a parent, they also call for careful consideration and consultation with experts on the medical process and the emotional and legal implications.
What are third-party techniques?
Third-party techniques include using donated eggs, sperm or embryos. Less often used is a gestational-carrier arrangement where the intended parents supply the egg and sperm (or they may use donors) but the pregnancy is carried by someone else who has no genetic link.
Surrogacy, also known as “traditional gestational carrier” refers to when the woman who carries the pregnancy also provides the egg. This latter arrangement is controversial, rare and banned by some states. It, is, however, sometimes used by gay couples and gay single men.
RESOLVE, The National Infertility Association offers resources on using a gestational carrier including myths and facts, information on counseling, legal agreements, and the experience of others.
Each of the third-party arrangements involves various social, ethical and legal complexities. Attitudes towards these technologies have evolved as their use has become more common as is the case with egg donation.
What is a typical gestation-carrier arrangement?
A typical gestational-carrier arrangement is where a woman – a family member, friend or a candidate selected from an agency – carries a pregnancy from one or two embryos created or donated by the intended parents. The embryos are created by using their own or donated eggs and sperm and implanted using in vitro fertilization (IVF).
Using a gestational carrier can be an expensive process. Costs can vary widely based on factors such as
- whether the carrier is compensated
- whether the mother uses her own eggs
- whether there is any insurance coverage
If there is no coverage, a supplemental policy may be purchased for approximately $30,000 that would cover unexpected medical expenses.
Total costs for a gestational-carrier arrangement can be significant
Total costs for a gestational-carrier arrangement include the following:
- agency fees,
- attorney fees
- counseling fees
- medical fees for screening all participants
- IVF to get pregnant
- obstetrical fees
- hospital fees for delivery
- fees for the carrier
The costs of supporting the pregnancy can be up to $100,000 to $200,000.
These costs are almost never covered by insurance. Some clinics, including many in the ARC network, offer a package that covers many of the medical procedures and monitoring.
Why Would I Use a Gestational Carrier?
There are many reasons a woman might choose to use a gestational carrier. These include problems with the uterus that make getting pregnant or carrying a pregnancy to term difficult or impossible. This includes women without a uterus such as those born without one or who have had a hysterectomy.
There may also be structural problems such as a hypoplastic or t-shaped uterus, fibroids or scar tissue from infection, surgery or tuberculosis, or adenomyosis. It may also be the right option for women with multiple miscarriages or a history of unsuccessful IVF cycles for no known reason.
The gestational-carrier option may also be used if a woman has a serious medical condition for which pregnancy poses a health risk including,
- a history of breast cancer
- severe heart disease
- severe diabetes
- major kidney disease
- severe preeclampsia.
Older women are more likely to use a gestational carrier as most of these risks increase with age.
How to Choose a Gestational Carrier
You will know the identity of your gestational carrier, unlike other third-party arrangements where this is not always the case. The person you select might be a family member, close friend or selected through an agency that specializes in recruiting candidates to serve as a gestational carrier.
Reputable agencies use a rigorous screening process similar to selecting egg donors. They review the potential carrier’s medical and pregnancy history and assess her emotional well-being.
Any carrier you select should be at least 21 years old and already have delivered a healthy child at term. Age and overall health are an important part of the screening process.
The carrier’s age is important
It’s best to use a younger carrier if possible because older women have a higher risk of experiencing complications from pregnancy such as gestational diabetes and high blood pressure.
If you’re considering using an older woman, you should be well-informed and receive counseling about the potential risks associated with her pregnancy that might compromise her delivering a healthy baby.
Compassionate vs. commercial carrier arrangements
Carrier arrangements may be “compassionate” or commercial. The former does not involve a fee, only coverage of medical expenses.
In a commercial arrangement, the carrier is paid for her service. It is important to check and see what your state allows or prohibits as some states ban compensation for gestational carriers.
Everyone needs a medical evaluation
The parents-to-be should each have a complete evaluation including medical history, a physical exam including ovarian function and semen analysis.
For the potential gestational carrier, an evaluation should include a complete medical history including their detailed obstetric experience, lifestyle history and a physical exam including evaluation of the uterine cavity.
If you’re thinking about using an older woman as a carrier, an evaluation must include their overall health and any underlying medical conditions.
All three participants also need to be screened for infectious-disease including sexually transmitted diseases (STD) such as chlamydia, syphilis, gonorrhea, HIV, plus hepatitis B and C.
Depending on where the participants live or have traveled, other screening tests such as for the Zika virus may be needed. Blood type and rh factor and immunity to rubella, rubeola, and varicella should be checked for the carrier.
Counseling for Gestational Carrier Participants
There is a range of psychological issues to consider when using a gestational carrier. The mother-to-be is dealing with the fact she will not be experiencing a pregnancy. This also affects her partner. The woman serving as the carrier will likely deal with attachment issues.
Counseling can play a critical role in helping each person clearly understand and deal with their varied emotions and potential issues. Working with a mental health professional who specializes in infertility can help each participant explore how to create and manage a positive relationship between the intended parents and carrier (and her partner).
For parents, discussion of how to have a respectful relationship with the carrier including her right to privacy is key. There should be a discussion among all participants to determine what type of relationship they’d like to have during treatment, pregnancy, delivery and for the years following delivery.
Other specific topics should be covered as well, including
- the number of embryos to be transferred
- prenatal diagnostic interventions
- fetal reduction
Counseling of the carrier is needed too
Besides helping the parents to be, it’s also important to provide the right counseling support to the gestational carrier and her partner.
Support will likely be needed to deal with attachment issues and how to explain carrying a pregnancy for another person to her children, other family members, friends and those in the workplace.
Your fertility clinic may have mental health professionals on their team who specialize in infertility. If not, they should be able to provide a referral to an outside mental health professional.
Legal Issues for Gestational-Carrier Arrangements
All third-party reproduction arrangements have legal implications. Involved parties should have separate counsel to help create legal documents that clearly state all details and responsibilities including written consent for specific procedures.
For those using a gestational carrier, a legal contract might contain details for the carrier’s expected behavior to ensure a healthy pregnancy, prenatal diagnostic tests, and agreements regarding fetal reduction or abortion in the case of a multiple pregnancy or if there are fetal anomalies. The contract would also specify the financial obligations if any.
Any legal contract must follow state law on reproductive law/gestational-carrier arrangements where requirements are in place. Some states have no such laws.
Finding an attorney who understands and is up-to-date on these laws is critical as laws may change. For example, many states do allow for a declaration of parentage before the child’s birth, avoiding the need to pursue an adoption.
There are additional challenges if the gestational carrier arrangements cross international borders. RESOLVE has resources to help guide you through the process including specifics on what your domestic legal agreement should include.
The bottom line
If using a gestational carrier helps you and your partner fulfill your dream of having a child, it’s worth considering.
Keep in mind there are many different factors and complexities to consider and consulting with fertility specialists, mental health professionals, and attorneys – not to mention all the arrangement’s participants – is key.
In this case, it might feel like it takes a village to have a baby!
David Adamson, M.D.
G. David Adamson, BSc, MD, FRCSC, FACOG, FACS is a reproductive endocrinologist and surgeon, Clinical Professor ACF at Stanford University, and Associate Clinical Professor at University of California San Francisco.
His undergraduate, medical school, and obstetrics/gynecology residency training were at the University of Toronto, and his Reproductive Endocrinology and Infertility fellowship training at Stanford University. Currently, he is Director of Equal3 Fertility, APC, and CEO of ARC® Fertility.
Dr. Adamson has over 300 peer-reviewed and scientific/medical publications and has lectured extensively for more than 30 years nationally and globally on assisted reproductive technologies, endometriosis, reproductive surgery, infertility, and access to quality reproductive health care. Dr. Adamson led the committee that created The FIGO Fertility Toolbox and the organization that created the global Endometriosis Phenome and Biobanking Harmonization Project (EPHect). He created the Endometriosis Fertility Index, all digital tools used globally to improve health care for reproductive-age women.
He is Chair of the International Committee Monitoring ART (ICMART), which is a non-State actor (NSA/NGO) in official relations with the World Health Organization (WHO) and President of the World Endometriosis Research Foundation (WERF). Dr. Adamson is on the Board of the International Federation of Fertility Societies (IFFS) and FIGO Committee on Reproductive Medicine of which he is Past Chair. He is the Founder, Chairman, and Chief Executive Officer of Advanced Reproductive Care (ARC® Fertility), the largest United States network fertility company.
Dr. Adamson is Past President of the American Society for Reproductive Medicine (ASRM), Society for Assisted Reproductive Technology (SART), AAGL, and several other major gynecological societies. He has been recognized as one of the best 400 physicians for women in America. He has received many awards, including the Outstanding Achievement in Medicine award from the Santa Clara County Medical Society, a Certificate of Special Congressional Recognition for contributions to the community, Distinguished Surgeon award from the Society of Reproductive Surgeons, Honorary Life Membership from the Canadian Association of Internes and Residents, the Barbara Eck Founders Award from RESOLVE, numerous honorary memberships and professorships, and the ASRM Distinguished Service award for his outstanding achievements in advancing the practice of reproductive medicine.
Dr. Adamson enjoys spending time with his family, reading, hiking, traveling, and ice hockey.
In addition to being a contributing author for The Doctor Weighs In, Dr. Adamson also serves on the TDWI Editorial Board, where he medically reviews articles submitted for publication.