If the arrival of Beyonce's twins wasn't enough of a hint, let's just state plainly that it's officially Celeb Baby Season. And some are going about the pregnancy process in less conventional ways than others: Not only are Kim and Kanye apparently ready to add another member to the family, they're allegedly hiring a surrogate to carry the pregnancy. So how does that work — and what does that process actually entail for the Normal People among us?
"[Using a surrogate] is probably more common than people realize, but it’s not all that common," says Kristin Bendikson, MD, assistant professor of obstetrics and gynecology at the USC Keck School of Medicine. Just over one percent of all pregnancies in the U.S. are achieved with in vitro fertilization (IVF), and just a fraction of those are surrogate pregnancies, she says. (To be clear, we're only talking about using third-party surrogates, a.k.a. "gestational surrogacy.")
That's largely due to the high cost of the procedure (which can easily top $100,000 if you include the cost of IVF). But for others, choosing surrogacy may simply be a result of not having many other options for a healthy pregnancy. "In most situations that we encounter, a woman has to do surrogacy either because she has some medical condition that makes it inadvisable for her to get pregnant or it would be very difficult for her to get pregnant," Dr. Bendikson says.
That includes conditions that affect the entire body that would be made more dangerous by going through the pregnancy process. "When you get pregnant, your blood volume goes up significantly," Dr. Bendikson says. So in people with certain heart conditions, for instance, "the heart can’t keep up with the demands of pregnancy."
Others may need to use a surrogate thanks to conditions specific to the uterus, such as scarring after a previous surgery, that would also make it difficult for them to become pregnant or would make a pregnancy dangerous or complicated. In other cases, Dr. Bendikson says, women who had their eggs frozen prior to treatment for breast cancer may opt for a surrogate if pregnancy would put them at risk for recurrence. Of course, same-sex couples may also want to use a surrogate for totally non-medical reasons.
Once you've decided you want to go with a surrogate, you can find one through an agency or call on someone you know personally. If you're going through an agency, your surrogate will already have gone through extensive medical and psychological exams to make sure they are physically and mentally able to carry a baby that will, ultimately, be someone else's child. Whether you already know your surrogate or not, "it's a good idea to make sure that person has had a successful pregnancy before," Dr. Bendikson says, partly because so many potential issues only become apparent during pregnancy.
After you've settled on a person to be your surrogate, you'll have to go through some legal logistics, the details of which vary from state to state. But it's at this point that the surrogate and the intended parents will agree to all sorts of important considerations, such as the expected type of birth (e.g. if your surrogate has had two C-sections, they're probably going to also need one this time around), how you'll approach the possibility of needing to terminate the pregnancy should it come up, and what sort of relationship the surrogate will have with the baby and intended parents after delivery.
When the surrogate has been chosen, medically and psychologically cleared, and has agreed to the terms of the contract, the actual pregnancy process can begin. "You can’t just take a surrogate and put an egg and sperm [in their uterus]," Dr. Bendikson says. The intended parents need to have embryos implanted into the surrogate, meaning they need to already have their own frozen embryos ready to go (possibly from their own previous IVF cycle) or use donated eggs or embryos.
The surrogate also has to do their own preparation, which will be a bit different depending on whether they're using frozen or fresh embryos. But in either case, they'll need to use oral, vaginal suppository, or (sometimes) injectable hormones in the weeks leading up to the embryo transfer in order to prepare the uterus.
Here's where it gets a bit more complicated: The surrogate will have to stay on those hormones for the entirety of their first trimester. "In a normal pregnancy, your ovaries make hormones that support the pregnancy until the placenta can take over at the end of the first trimester," Dr. Bendikson explains. "In a surrogacy situation, we are not letting them ovulate on their own — it's not their eggs that are being used." But without ovulation, the ovaries aren't making those pregnancy-supporting hormones. So surrogates have to stay on those supplemented hormones until the placenta can handle things.
From there, however, the pregnancy is treated just like any other IVF pregnancy, Dr. Bendikson says. So there may be a few more ultrasounds and checkups than a non-IVF pregnancy, but there's nothing particularly worrying about a surrogate pregnancy. The only extra consideration is how many appointments and exams the intended parents want to be part of, which often depends on whether or not they live in the same state as their surrogate, Dr. Bendikson says.
In general, the intended parents make it to the major ultrasound appointments, but not necessarily every single checkup. And if they can't be there in person, Dr. Bendikson says her office sends videos of the big moments to the intended parents via email. Someone from the surrogate's agency may also tag along to appointments make sure the surrogate fully understands any instructions from the doctor.
After delivery, "there are many situations where the intended parent wants a surrogate to stay in the life of the child," Dr. Bendikson says. "How involved they want the surrogate to be is up to the intended parent." And that's something that's outlined and agreed upon in the contract at the beginning of the whole process.
But Dr. Bendikson is clear that just because you may not be carrying the pregnancy, that doesn't mean the intimacy of the whole experience is necessarily lessened. "It usually is a pretty special bond between the surrogate and the intended parent," she says. "Some women want to keep them at more of a distance, but others really want to let the surrogate into their heart and into their life."