Understanding surrogacy: the process, parenthood, costs and risks

The two types: with and 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 through egg donation. The woman carrying the pregnancy does not provide her own egg and is therefore not the child’s genetic mother.

In traditional surrogacy, the surrogate’s own egg is fertilised, for example through insemination. She carries the child and is also genetically related to the child. The fertility regulator HFEA explains both types and their medical differences.

Surrogacy therefore does not automatically mean that a child is genetically connected to both intended parents. The eggs and sperm used determine that connection. Regardless of genetics, pregnancy remains a physical and personal experience for the woman carrying the child.

Altruistic and commercial: what is the difference?

These terms answer a separate question: is the woman paid for being a surrogate? An altruistic arrangement does not provide for such payment, though certain expenses may be reimbursed depending on the rules. A commercial arrangement includes additional payment. Which payments are allowed and what counts as an expense differ under the applicable laws.

Altruistic does not mean free of cost. Treatment, counselling, travel and care during pregnancy still need to be funded. At the same time, the word commercial alone does not explain which services a price includes or what safeguards the people involved have.

Even a private arrangement among people who know one another needs clear agreements. Closeness can build trust, but may also make it harder to turn down a request or express a boundary.

Why people consider surrogacy

Surrogacy may be considered by people who do not have a uterus, or for whom pregnancy is medically impossible or would carry significant risks. Male couples and single men may also think about it. Whether this path is available to them is a separate legal question.

After repeated unsuccessful treatments, it is important to clarify what obstacle surrogacy is intended to overcome. It does not solve every problem in creating or developing an embryo. The recommendations of the American Society for Reproductive Medicine, ASRM, describe possible medical reasons, along with assessment and counselling for the people involved.

How gestational surrogacy proceeds

Before treatment starts, medical suitability, expectations and legal requirements need to align. Only then can the creation and transfer of embryos be planned meaningfully. If frozen embryos are already available, egg retrieval may not be needed.

1. Assessment and counselling: The people involved discuss medical history, examinations, possible difficulties and expectations about pregnancy and later contact.
2. Legal preparation: Parenthood, permitted agreements, payments and representation of each person’s interests are clarified before treatment.
3. IVF in the laboratory: Eggs are retrieved and fertilised. The next step is to decide which embryos are suitable for transfer or freezing.
4. Embryo transfer: The clinic coordinates transfer with the surrogate’s cycle or prepares the uterine lining using medicines.
5. Pregnancy and birth: If a pregnancy develops, care, birth planning and the necessary legal steps follow.
6. After birth: The child needs care and clearly defined responsibilities. The surrogate needs rest and recovery, follow-up care and further support if required.

Not everyone goes through the same treatment. Hormonal stimulation and egg retrieval concern the person whose eggs are used. The surrogate has the embryo transfer and carries the pregnancy. The HFEA’s IVF overview gives more information on the medical process.

How long does it take, and how certain is success?

Pregnancy is only part of the total time involved. Finding a suitable surrogate, examinations, counselling, legal preparation and possibly several treatment attempts also take time. Where arrangements cross borders, travelling home after the birth may also be delayed. A fixed overall duration therefore cannot responsibly be promised.

There is no single success rate for surrogacy as a whole either. The age and quality of the eggs, the embryos and the individual medical situation all play a part. A young, healthy surrogate does not make up for every issue with the eggs or sperm.

When a clinic gives success figures, ask what they actually measure: a positive pregnancy test or a live birth? Is the figure for one transfer, one egg retrieval or several attempts together? Only with that basis clear can it help with your own 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. For the woman carrying the pregnancy, there are the demands of treatment and the risks of pregnancy and childbirth.

Even a carefully selected surrogate can develop complications such as high blood pressure disorders or bleeding. For the child, premature birth is a particular risk. A 2024 cohort study found severe maternal complications more often in 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 examined different groups and cannot predict an individual person’s risk. They do, however, show why antenatal and follow-up care should be taken seriously.

One concrete way to reduce risk is to avoid pregnancies involving more than one baby wherever possible. The reproductive medicine society ASRM strongly recommends transferring a single embryo in gestational surrogacy. Transferring several embryos is not a harmless way to achieve a quicker result.

Who takes decisions during pregnancy?

Intended parents want a child and are deeply involved emotionally. Medical procedures, however, affect the surrogate’s body. Expectations regarding examinations, birth and possible complications should therefore be discussed early.

The ASRM ethics opinion emphasises that the surrogate gives her own consent to medical care. Independent legal advice means having her own representative who is committed to her interests. Intended parents can pay for this without controlling the advice she receives. This is a professional ethical position; the applicable law must be reviewed separately.

It is especially important to discuss abnormal findings, miscarriage or differing views about ending a pregnancy. A written agreement can record expectations, but it does not replace ongoing discussion or medical consent. Fundamental differences that cannot be reconciled should be identified before pregnancy.

Parenthood is more than a genetic connection

Legal systems differ on whether surrogacy is allowed, who can access it and how parenthood is established. Three questions cannot therefore be answered with a single yes: may the treatment take place? Who is considered a parent after birth? Will that parenthood also be recognised where the family will live?

These answers can differ particularly across borders. The Hague Conference on Private International Law describes the resulting difficulties concerning parenthood, nationality and parental responsibility. A genetic connection, an agreement and a birth certificate are not simply interchangeable forms of proof.

Legal review belongs at the start of any specific plan. It should explain which steps are needed to secure parenthood and who can act for the child in the meantime. This includes the practical question of who cares for the newborn if the intended parents cannot yet 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 worldwide total price. The term itself can include very different services: a private arrangement with reimbursement of expenses, medical treatment or a comprehensive programme with matching and support. A single number says little while these differences remain unclear.

For budgeting, it is more useful to record these costs separately:

• Examinations, IVF, medicines, egg or sperm donation if required, storage and further embryo transfers
• Care during pregnancy and birth, insurance and medical services that are not covered
• Permitted reimbursement of expenses or lawful payment, and any matching and support charges
• Independent legal advice, proceedings, certificates and translations
• Travel, accommodation, lost earnings and an extended stay after birth
• Additional needs after unsuccessful attempts, complications or hospital care for the newborn

This list helps you ask questions; it is not a standard set of services that applies everywhere. For a specific offer, ask what is included, what is charged separately and who carries each financial risk. A package advertised with a guarantee needs the same scrutiny: a contractual refund or additional treatment attempts are different from a guaranteed birth.

The relationship does not automatically end after birth

Surrogacy brings people together in a very personal situation. Some want close contact during pregnancy, while others prefer more distance. Different expectations are not automatically a problem as long as they are openly discussed.

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

Follow-up care should be planned just as clearly: who arranges the surrogate’s medical care, who helps her with daily life and who pays if she needs support for longer? ASRM calls for access to psychological support after birth too. A change in wishes about contact must not result in agreed care being withdrawn.

What do we know about the children?

It is now possible to study how children experience their origins over longer periods. A long-term study published in 2023 followed families until the children reached 20 years of age. It compared 65 families formed through egg or sperm donation or surrogacy, including 22 surrogacy families, with 52 families formed through conception without this assistance. There were no differences between the two overall groups in the young adults’ psychological well-being or the quality of family relationships.

The findings are encouraging but cannot be applied to every family arrangement: the subgroups were small, and the focus was on mother–child relationships. Early disclosure about origins was associated with better relationships; this does not establish a cause-and-effect rule. In practice, preserve information about origins and think early about how to discuss it in an age-appropriate way. The conversation develops with the child’s questions.

Which alternatives fit your situation?

An alternative needs to 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, egg donation alone will not resolve that problem.

Co-parenting means sharing parenthood with other people. The person who carries the pregnancy can remain a parent permanently, which makes this path fundamentally different from surrogacy. Adoption and foster care have their own requirements and centre 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 idea of family. The question is which path suits everyone involved and which responsibilities they want to take on in the long term.

What to clarify before deciding

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

• What 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 after an unsuccessful transfer, a miscarriage or an unexpected medical finding?
• Which steps establish parenthood, and who takes responsibility for the child until then?
• Which costs are included in writing, which remain open and what protection is available if complications occur?
• What are everyone’s expectations about contact, privacy and the time after birth?

If an offer mainly highlights speed or a low starting price but does not answer these questions, you do not have all the information needed to make a decision.

Myths and facts about surrogacy

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

Fact: The age of the person providing the eggs remains an important influence on 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 to the surrogate and the children may rise. This is why ASRM strongly recommends transferring one embryo in gestational surrogacy.

Myth: Nobody can come under pressure if there is no payment.

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

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

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 herself. Equally, pregnancy does not predict what kind of contact she will want later. Expectations and support need to fit the people involved.

Conclusion

In surrogacy, successful treatment is only one part of the journey. The autonomy and care of the woman carrying the pregnancy, established parenthood and a secure start in life for the child are equally important. Anyone considering this path needs clear answers about how these responsibilities will be shared before and after birth.