Surrogacy is a beautiful, yet complicated process with plenty of administrative, medical, and legal terms. As an intended parent or prospective surrogate, it’s easy to get overwhelmed when faced with confusing technical language and not much support interpreting it. With this in mind, we’ve created a comprehensive list of the common terms you will come across in your surrogacy journey.
First things first: let’s review the basics.
To understand surrogacy, it helps to first take a look at where it fits in the journey to having a baby. Let’s start from the very beginning.
Third party reproduction
The American Society for Reproductive Medicine describes this as the involvement, in the reproductive process, of someone other than the individual or couple who will raise the child. This includes pregnancy through donated eggs, sperm, or embryos, as well as gestational-carrier arrangements where the pregnancy is carried by someone other than the parents who will raise the child. For the purposes of this article, we’ll explore gestational-carrier arrangements, widely known as surrogacy.
In Vitro Fertilization (IVF)
IVF involves the combination of an egg with sperm in a laboratory setting. There are five main steps to this procedure:
Surrogacy is a method of assisted reproductive technology where a woman (or ‘surrogate’) carries a pregnancy for an individual or a couple. There are various types of surrogacy arrangements:
With this type of surrogacy, the woman who becomes pregnant also provides the egg, meaning that the baby has a genetic link to the surrogate. This is becoming less common due to the legal and emotional complexities involved. Traditional surrogacy requires the termination of parental rights. Once these rights are terminated, the genetically unrelated intended parent will have to complete a stepparent adoption. In some states, traditional surrogacy is illegal even if gestational surrogacy is allowed.
Through this process, the gestational carrier is a woman who carries a pregnancy from an embryo created by the intended parents, either through their own egg and sperm or through donations. Unlike in traditional surrogacy, the surrogate has no genetic link to the fetus. While this process requires in vitro fertilization (IVF), it is still more common in the US than traditional surrogacy.
Surrogacy arrangements are further distinguished by other criteria:
This is when the surrogate mother is financially compensated for her role, beyond the reimbursement of medical expenses.
An altruistic surrogate volunteers to carry a pregnancy, most often for family members or close friends, and is not financially compensated beyond her medical costs being covered.
When the surrogacy journey takes place via an agency, it’s called an agency surrogacy. Agencies assist by providing expertise and support throughout the process.
Also known as private surrogacy, the independent surrogacy process does not include the services of a surrogacy agency. In this case, only a lawyer and a fertility clinic are necessary at different points in the process.
Working with a surrogate one knows in advance is called ‘identified surrogacy’. There are many benefits to identified surrogacy: potentially less expensive, stronger sense of trust, and easier to stay in touch. That said, there are other factors to take into consideration, including the possibility of financial disputes with someone important in your life, difficult feelings, and a source of stress on family relationships.
Assisted Reproductive Technology (ART)
ART is the term used to describe medical infertility procedures, such as IVF (see below), in which the fertilization of oocytes (eggs) occurs in a laboratory setting. The Centers for Disease Control and Prevention (CDC) define ART as fertility treatments in which both eggs and embryos are handled. ART procedures involve the surgical removal of eggs from a woman’s ovaries, combining them with sperm in the laboratory, and returning them to the woman’s body or donating them to someone else.
Here are the individuals and agencies involved in the process:
The person or persons who become the legal parents of the child born through surrogacy and who will raise the child – often abbreviated to IPs.
A person who carries a pregnancy for someone else.
A woman who donates her eggs or oocytes for use in fertility treatments. The egg donor can be the intended parent or anonymous.
A man who donates his sperm for use in artificial insemination or other fertility treatments.
Fertility clinics are medical clinics that assist individuals and couples become parents, when pregnancy cannot otherwise be achieved. The fertility clinic is integral to the surrogacy process. The surrogate will have to be approved by a doctor at the fertility clinic before the process can start. Both the intended parents and the surrogate then work closely with the clinic to complete IVF and the embryo transfer.
A surrogacy agency provides intended parents with all – or at least the majority of – services required throughout the surrogacy process. Agencies aim to make the process as straightforward and stress-free as possible so you can focus on what’s important: the excitement of building a family.
Surrogacy attorneys are essential for ensuring that the rights of both the surrogate and the intended parents are protected. They help intended parents understand local surrogacy laws and regulations, ensure that the process is completed in a legal manner, finalize the surrogacy contract, and establish intended parents’ parental rights as early as possible (more on this is specified in the ‘surrogacy contract’ definition, below).
Local Monitoring Clinic
This clinic will monitor the donor and the surrogate, providing medical treatment during both the egg donation process and the surrogate’s pregnancy. The monitoring clinic is usually local to the surrogate.
Now let’s continue to the surrogacy process itself, in the order it most commonly occurs:
This part is exciting. Matching is the process of finding a surrogate mother or intended parent(s). The surrogate mother decides what kind of intended parents she’d like to work with and what type of relationship will be pursued once the child is born.
Depending on the country’s surrogacy laws, as intended parents, you may have the option to either play a role in selecting the surrogate or to leave it all in the hands of the surrogacy agency. Eitherway, in the US, you can choose what your preferences are in terms of the surrogate’s age, her BMI, medical and pregnancy history, the lifestyle led, costs, her health insurance, and her location and support system. Decisions should also be made on the number of cycles you’d like to try, and a standpoint taken on multiple births and pregnancy reductions or terminations. Once decided, this information should be provided to the agency.
Once a match is made, the surrogate and intended parents get to know each other through contact mediated by the agency or attorney. You can read more about choosing a surrogate, here.
Minnesota Multiphasic Personality Inventory (MMPI-2)
The MMPI-2 is a clinical assessment tool used by mental health professionals to diagnose mental health disorders. Donors, surrogates, and intended parents may be asked to take this test as part of the screening process. In some states, a psychological evaluation by a licensed mental health professional is a legal requirement.
Personality Assessment Inventory (PAI)
This test assesses adult psychopathology. Donors, surrogates, and intended parents may be asked to take this test or the MMPI-2 as part of the screening process.
Hysterosalpingogram (HSG) or Sonohysterogram
Both are procedures that evaluate the inside of the uterus, with a focus on whether or not the fallopian tubes are open, ensuring that the surrogate can carry a pregnancy. These exams are part of a complete medical screening that prospective surrogates are required to undergo.
Also known as a Carrier Agreement or Surrogate Mother Contract, this legal document sets out the rights and obligations of both the surrogate and the intended parents. The contract also outlines the parentage to be assigned to the baby once born, with clear clauses that the surrogate agrees to terminate her parental rights, and that custody will be relinquished to the intended parents as soon as possible after birth. Once both parties agree, the contract is signed.
Surrogate Mother Cycle Schedule
Once contracts are signed, a nurse at the IVF clinic coordinates with the surrogate mother to plan all the dates of the treatment cycle leading to the embryo transfer. The process includes an evaluation cycle, where each part of the cycle is duplicated as a ‘trial’ before the actual embryo transfer. Once the response of the uterus to hormonal stimulation is known, cycle synchronization can take place. This is where the menstrual cycles of the surrogate and the intended parent or egg donor are synchronized to maximize the chances of pregnancy, if using fresh eggs.
The egg donor or intended mother will undergo the egg retrieval procedure. A combination of hormonal medications is given to stimulate the development of multiple eggs within the ovary which are then retrieved.
Embryo Gender Selection
A technique used by intended parents to choose the sex of their baby, either to better balance out their family or to avoid gender-specific disorders. Gender selection is performed through sperm separation or genetic testing with the embryo(s) of the preferred gender then transferred into the surrogate’s uterus.
A blastocyst is an embryo that has developed for five to seven days after fertilization and has two distinct cell types and a central cavity filled with fluid (blastocoel cavity). This is the stage that precedes implantation into the uterus.
Preimplantation Genetic Testing for Aneuploidies (PGT-A)
Previously known as preimplantation genetic screening (PGS), PGT-A provides information on the embryo’s genetic health, specifically the number of chromosomes, to help select the best embryo for transfer and improve the chances of a successful pregnancy.
Preimplantation Genetic Testing for Monogenic disorders (PGT-M)
Formerly known as preimplantation genetic diagnosis (PGD), PGT-M tests for inherited disorders caused by mutations in a single gene, such as cystic fibrosis or Huntington’s disease.
Once the egg fertilizes and begins cell division, the resulting embryo is transferred into the surrogate mother’s uterus. A fertilized egg cell begins cell division after approximately 30 hours. Cell division is monitored to check which embryos are healthiest and most likely to lead to a successful pregnancy. Once this is determined, embryo transfer takes place between day three and five. The embryo transfer is the last part of the IVF process.
Fresh Embryo Transfer
For a fresh embryo transfer, the egg donor takes hormones to stimulate egg production. The eggs are retrieved and fertilized, then the embryo is transferred to the surrogate. IVF experts disagree about whether fresh embryos offer better success rates than frozen ones. Studies show there is no one-size-fits-all solution as it greatly depends on factors such as age and number of eggs produced.
Frozen Embryo Transfer
In this process, frozen embryos from a previous IVF or donor egg cycle are thawed and transferred into the uterus. Thanks to advances in technology, frozen embryo transfers have comparable success rates to fresh embryo transfers.
Single Embryo Transfer (SET)
One embryo is selected and placed directly in the uterus or fallopian tube. This single embryo can be frozen or chosen from a fresh cycle with multiple embryos. The remaining embryos can be stored for later use. SET lowers the chances of a multiple pregnancy (a pregnancy with more than one fetus). Several factors must be considered when deciding on SET, or otherwise. These include age, number of previous IVF cycles, and the quality of the embryos, among others. The CDC notes that for women who are good SET candidates, transferring one fresh embryo followed by one frozen embryo (if a second transfer is needed), offers the best chance of having one baby without increasing the chance for twins.
Multiple Embryo Transfer
In a multiple embryo transfer, two or more embryos are transferred during an IVF cycle. While this helps improve the chances of a successful pregnancy, it also increases the possibility of a multiple pregnancy (twins or more). It should be noted that the risk of premature birth and low birth rate increases with multiple births.
The surrogate mother undergoes a blood test to check if she’s pregnant or not. This is typically done 10 days following the embryo transfer.
Chorionic Villus Sampling (CVS)
A test carried out as early as week 10 of pregnancy, to check for chromosomal conditions such as Down syndrome and other genetic conditions, such as cystic fibrosis. In this case, a catheter is inserted into the uterus to obtain a sample of cells from the placenta.
This test is carried out between the 15th and 20th weeks of pregnancy – it checks for genetic or chromosomal conditions through a study of the cells in the amniotic fluid.
Pre-Birth Order and Post-Birth Order
A pre-birth order assigns parentage to the intended parents and removes any rights or obligations from the surrogate. Although a pre-birth order is not possible in all states, in those where it is, a legal document assigning parentage can be started in the fourth month of pregnancy and signed by the seventh. While a pre-birth order is issued prior to the birth, it is not effective until the child is born. In states where this is not possible, intended parents are seen in court within three to five days following birth, where a post-birth order is acquired. If a birth order is not in place by the time of birth, other guardianship documents protect the parties.
Click here for a list of surrogacy laws by state.
Again, it’s easy to feel overwhelmed when faced with all the technicalities involved in surrogacy. However, a good understanding of the key terms you’ll encounter and what the process entails can help ensure a smoother journey.
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