Understanding surrogacy: process, parenthood, costs and risks

Two types: with or without the surrogate’s own egg

In gestational surrogacy, an embryo created through IVF is transferred into the surrogate’s uterus. The egg comes from an intended parent or from egg donation. The woman carrying the pregnancy does not contribute her own egg and is therefore not the child’s genetic mother.

In traditional surrogacy, the surrogate’s egg is fertilized, for instance through insemination. She carries the child and is also genetically related to them. The fertility regulator HFEA explains both types and the medical differences between them.

Surrogacy does not therefore automatically mean a child is genetically related to both intended parents. What matters is whose eggs and sperm are used. Regardless of this, pregnancy remains a physical and personal experience for the woman carrying the child.

What do altruistic and commercial mean?

These terms address a different question: is the woman compensated for carrying the pregnancy? An altruistic arrangement does not provide for that compensation, though certain expenses may be reimbursed depending on the rules. A commercial arrangement includes additional compensation. The law differs on which payments are allowed and what qualifies as an expense.

Altruistic does not mean there are no costs. Treatment, counselling, travel and care during pregnancy still need to be funded. Conversely, the term commercial alone does not tell you which services a price covers or how the people involved are protected.

Private arrangements between people who know one another also need clear agreements. Closeness may make trust easier, but can make it harder to refuse a request or express a boundary.

Why people consider surrogacy

People who do not have a uterus, or for whom pregnancy is medically impossible or would involve significant risks, may consider surrogacy. Male couples and single men may consider it as well. Whether this path is accessible is a separate legal issue.

After repeated unsuccessful treatments, it is important to clarify which obstacle surrogacy is supposed to overcome. It cannot solve every difficulty in embryo creation or development. The American Society for Reproductive Medicine’s recommendations, from the US professional society ASRM, describe potential medical reasons and assessment and counselling for the people involved.

What happens in gestational surrogacy?

Before treatment begins, medical suitability, expectations and legal requirements must align. Only then is it meaningful to plan how embryos will be created and transferred. Existing frozen embryos may remove the need for egg retrieval.

1. Assessment and counselling: The people involved discuss medical history, examinations, possible challenges and expectations for the pregnancy and later contact.
2. Legal preparation: Parenthood, permitted agreements, payments and representation of everyone’s interests are clarified before treatment.
3. IVF in the lab: Eggs are retrieved and fertilized. The next decision is which embryos are suitable for transfer or freezing.
4. Embryo transfer: The clinic coordinates transfer with the surrogate’s cycle or uses medication to prepare the lining of her uterus.
5. Pregnancy and birth: If pregnancy develops, care, birth planning and the required legal steps follow.
6. After birth: The child needs care and clear responsibilities. The surrogate needs recovery time, follow-up care and further support where necessary.

These treatments are not the same for everyone. The person whose eggs are used undergoes hormonal stimulation and egg retrieval. The surrogate receives the embryo transfer and carries the pregnancy. The HFEA overview of IVF explains the medical process further.

How long does it take, and is success certain?

Pregnancy is only one part of the overall timeline. Finding a suitable surrogate, examinations, counselling, legal preparation and possibly multiple treatment attempts also take time. In cross-border arrangements, returning home after the birth may be delayed as well. No fixed total duration can therefore be responsibly promised.

There is also no success rate that applies to all surrogacy. Factors include egg age and quality, the embryos and the individual medical situation. A young, healthy surrogate does not offset every problem with eggs or sperm.

If a clinic quotes success rates, ask for specifics: does it mean a positive pregnancy test or a live birth? Is the rate based on one transfer, one egg retrieval or several attempts combined? Only once that basis is clear is the figure useful for your planning.

What are the medical risks?

Different people face different risks. Egg retrieval may involve hormonal side effects and ovarian hyperstimulation syndrome, among other risks. The woman carrying the pregnancy faces the burdens of treatment and the risks of pregnancy and childbirth.

Even a carefully selected surrogate may develop complications such as high blood pressure disorders or bleeding. For the child, premature birth is a particular risk. A cohort study from 2024 found severe maternal complications more often among gestational carriers than in comparison pregnancies with and without IVF. A smaller, earlier study had not shown a clear increase in severe complications compared with similar pregnant women. The studies looked at different groups and cannot provide an individual risk prediction. They do, however, support taking prenatal and follow-up care seriously.

A practical way to reduce risk is to avoid pregnancies with more than one baby as far as possible. The reproductive medicine society ASRM strongly recommends transferring a single embryo in gestational surrogacy. Using several embryos is not a harmless shortcut to a faster outcome.

Who makes decisions during pregnancy?

Intended parents want a child and are deeply involved emotionally. Medical interventions, however, affect the surrogate’s body. Expectations about examinations, birth and possible complications need to be discussed early.

The ASRM ethics opinion stresses that the surrogate gives her own consent to medical care. Independent legal advice means she has her own representative whose duty is to her interests. Intended parents can cover the cost without controlling her advice. This is a professional ethical position; the law that applies needs a separate review.

Discussions about abnormal findings, miscarriage or differing views on pregnancy termination are particularly important. A written agreement can document expectations. It replaces neither ongoing conversations nor medical consent. Any fundamental incompatibility in expectations should become clear before pregnancy.

Parenthood goes beyond a genetic relationship

Legal systems differ on whether surrogacy is permitted, who has access and how parenthood is established. Three questions cannot therefore be settled with one yes: is the treatment allowed? Who is considered a parent after birth? Will that parenthood be recognized where the family will live?

Answers may differ especially across borders. The Hague Conference on Private International Law describes the resulting issues with parenthood, nationality and parental responsibility. A genetic relationship, an agreement and a birth certificate are not simply interchangeable evidence.

Any concrete plan needs legal review at the start. This should explain the steps required to secure parenthood and who may act on the child’s behalf in the meantime. It includes the practical question of who will care for the newborn if the intended parents cannot be present at the birth. A fertility journey abroad also involves travel documents and recognition in the country of residence.

How much does surrogacy cost?

There is no reliable total price that applies worldwide. The term may cover very different services: a private expense-reimbursement arrangement, medical treatment or a comprehensive program with matching and support. A single figure means little while those differences remain unresolved.

For budgeting, it is more useful to itemize the following:

• Examinations, IVF, medication, egg or sperm donation where needed, storage and additional embryo transfers
• Pregnancy and birth care, insurance and medical services not covered
• Permitted expense reimbursements or lawful compensation, as well as matching and support fees where applicable
• Independent legal advice, proceedings, certificates and translations
• Travel, accommodation, lost income and an extended stay after birth
• Additional needs following unsuccessful attempts, complications or hospital care for the newborn

This list helps guide questions; it is not a service package that is identical everywhere. When considering a specific offer, ask what is included, what is extra and who bears each financial risk. Packages advertised with a guarantee also need this review: a contractual refund or additional treatment attempts are different from a guaranteed birth.

The relationship does not automatically end at birth

Surrogacy connects people in a very personal situation. Some want close contact throughout pregnancy; others prefer more distance. Different expectations are not automatically a problem, as long as they are expressed.

Specific agreements help: what information will be shared? Who attends appointments or the birth, if the surrogate wants them there? What should future contact look like? How will the surrogate’s own children be told why the baby will grow up in a different family?

Follow-up care needs equally specific planning: who arranges the surrogate’s medical care, who helps with daily life and who pays if she needs longer-term support? ASRM calls for access to psychological support after birth as well. A change in wishes about contact must not mean agreed care is withdrawn.

What do we know about the children?

How children experience the story of their origins can now be studied over longer periods. A long-term study published in 2023 followed families until the children reached age 20. It compared 65 families formed through egg donation, sperm donation or surrogacy, including 22 surrogacy families, with 52 families formed through conception without that assistance. The two overall groups did not differ in young adults’ psychological well-being or the quality of family relationships.

This is encouraging but cannot be generalized to every family configuration: subgroups were small, and the study focused on mother–child relationships. Early disclosure about origins was associated with better relationships, without establishing a cause-and-effect rule. In practice, preserve information about origins and think early about how to discuss it in age-appropriate terms. The conversation grows along with the child’s questions.

Which alternatives suit your situation?

An alternative must address the actual obstacle. If pregnancy is possible but a person’s own eggs cannot be used, egg donation may be an option depending on medical and legal requirements. If no one in the planned family can carry a child, donation alone does not address that problem.

Co-parenting means sharing parenthood with other people. The person carrying the pregnancy may remain a parent permanently, a fundamental difference from surrogacy. Adoption and foster care have their own requirements and focus on the needs of children who have already been born. They are not interchangeable treatment options.

Sometimes the next step is to take a break or revisit your ideas about family. The question is which path fits the people involved and which responsibilities they want to take on for the long term.

What to clarify before you decide

These questions can help you get concrete answers in an initial conversation:

• Which obstacle is surrogacy meant to overcome in our situation, and which eggs and sperm would be used?
• How will the surrogate and the other people involved receive independent counselling, examinations and follow-up care?
• What happens if a transfer fails, a miscarriage occurs or an unexpected medical finding arises?
• Which steps establish parenthood, and who takes responsibility for the child in the meantime?
• Which costs are included in writing, which remain open and what protection is available if there are complications?
• What does everyone expect about contact, privacy and the period after birth?

If an offer focuses mainly on speed or a low starting price while leaving these questions unanswered, you still lack key information for your decision.

Myths and facts about surrogacy

Myth: A young surrogate makes the age of the eggs unimportant.

Fact: The age of the person providing the eggs remains an important factor in the chances of success. A young surrogate does not make the eggs younger. The HFEA therefore distinguishes between the influence of the eggs and that of the woman carrying the pregnancy.

Myth: Two embryos simply double the chance of having a child.

Fact: More than one embryo increases the risk of a multiple pregnancy. The chance of success cannot simply be doubled, while risks for the surrogate and the children may increase. That is why ASRM strongly recommends single embryo transfer for gestational surrogacy.

Myth: Without compensation, nobody can feel pressured.

Fact: Pressure can also come from family expectations, loyalty or dependence. For arrangements within families in particular, ASRM emphasizes voluntary decisions and independent counselling. It also matters whether someone can say no without putting the relationship at risk.

Myth: Without her own egg, there is no emotional connection.

Fact: Genetic relationships and feelings are different things. Pregnancy, birth and contact with the family can be personally meaningful without the surrogate wanting to take on the parental role. Equally, carrying the pregnancy does not determine what later contact she will want. Expectations and support need to suit the people involved.

Conclusion

Successful treatment is only part of surrogacy. The autonomy and care of the woman carrying the pregnancy, established parenthood and a secure start in life for the child matter just as much. Anyone considering this path needs clear answers about how these responsibilities will be shared before and after birth.