Understanding surrogacy: the process, parenthood, costs, and risks

The two types: with or without the surrogate’s own egg

In gestational surrogacy, an embryo created through IVF is transferred to the surrogate’s uterus. The egg comes from an intended parent or from 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 fertilized, for example through insemination. She carries the child and is also genetically related to them. The fertility regulator HFEA explains both types and their medical differences.

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

Altruistic and commercial: what do they mean?

These terms answer a different question: is the woman carrying the pregnancy paid for being a surrogate? An altruistic arrangement does not include that compensation, although certain expenses may be reimbursed under the applicable rules. A commercial arrangement includes additional compensation. The law varies on which payments are allowed and what counts as an expense.

Altruistic therefore does not mean free. Treatment, counseling, travel, and care during pregnancy still need to be funded. Likewise, the word commercial alone tells you neither what a price includes nor how the people involved are protected.

Even a private arrangement between people who know each other needs clear agreements. Closeness can make trust easier, but it can also make it harder to turn down a request or set a boundary.

Why people consider surrogacy

Surrogacy may be a consideration for people who do not have a uterus or for whom pregnancy is medically impossible or would involve substantial risks. Male couples and single men may also consider it. Whether this path is available is a separate legal question.

After repeated unsuccessful treatments, it is important to clarify which obstacle surrogacy is meant to overcome. It does not solve every difficulty with creating or developing an embryo. Guidance from the American Society for Reproductive Medicine, ASRM, describes possible medical reasons, along with assessment and counseling for the people involved.

How gestational surrogacy works

Before treatment begins, medical suitability, expectations, and legal requirements need to align. Only then does it make sense to plan how embryos will be created and transferred. If frozen embryos are already available, egg retrieval may not be needed.

1. Assessment and counseling: Everyone involved discusses medical history, examinations, possible challenges, and expectations for pregnancy and future 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 fertilized. The next step is to decide which embryos are suitable for transfer or freezing.
4. Embryo transfer: The clinic coordinates the transfer with the surrogate’s cycle or prepares the uterine lining with medication.
5. Pregnancy and birth: If a pregnancy develops, care, birth planning, and the necessary legal steps follow.
6. After the birth: The child needs care and clearly assigned responsibilities. The surrogate needs recovery time, follow-up care, and further support if needed.

Not everyone undergoes the same treatment. Hormonal stimulation and egg retrieval involve the person whose eggs are used. The surrogate undergoes embryo transfer and carries the pregnancy. The HFEA’s IVF overview explains more about the medical process.

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

Pregnancy is only part of the overall timeline. Finding a suitable surrogate, examinations, counseling, legal preparation, and possibly several treatment attempts also take time. In cross-border arrangements, the journey home after the birth may be delayed too. A fixed overall timeline therefore cannot responsibly be promised.

There is also no single success rate for surrogacy as a whole. Egg age and quality, the embryos, and the individual medical situation are among the factors that matter. A young, healthy surrogate does not compensate for every problem with eggs or sperm.

When a clinic gives success figures, ask exactly what they mean: a positive pregnancy test or a live birth? Does the figure refer to one transfer, one egg retrieval, or several attempts combined? A figure is only useful for your planning when that basis is clear.

What are the medical risks?

The risks affect different people. Egg retrieval can involve hormonal side effects and ovarian hyperstimulation syndrome, among other risks. For the woman carrying the pregnancy, there are the burdens 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, being born too early is a particular risk. A 2024 cohort study found serious maternal complications more often among gestational carriers than in comparison pregnancies with and without IVF. A smaller earlier study had found no clear increase in serious complications compared with similar pregnant women. The studies examined different groups and cannot predict an individual’s risk. They do, however, provide a reason to take prenatal and follow-up care seriously.

One practical way to reduce risk is to avoid pregnancies with more than one baby where possible. The reproductive medicine society ASRM strongly recommends transferring a single embryo in gestational surrogacy. Transferring several embryos is not a harmless shortcut to a faster result.

Who makes decisions during pregnancy?

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

The ASRM ethics opinion emphasizes that the surrogate gives her own consent to medical care. Independent legal advice means having her own representative, whose duty is to her interests. Intended parents can cover that cost without controlling her advice. This is a professional ethical position; the applicable law must be examined separately.

Discussions about abnormal findings, miscarriage, or differing views on ending a pregnancy are particularly important. A written agreement can record expectations. It replaces neither ongoing conversations nor consent to medical treatment. Fundamental disagreements should become clear before pregnancy.

Parenthood is more than a genetic relationship

Whether surrogacy is permitted, who can access it, and how parenthood is established differ between legal systems. Three questions therefore cannot be answered with a single yes: may the treatment take place? Who is a legal parent after the birth? Will that parenthood also be recognized where the family will live?

The answers can differ particularly across borders. The Hague Conference on Private International Law describes resulting problems with parenthood, nationality, and parental responsibility. A genetic relationship, an agreement, and a birth certificate are therefore not simply interchangeable forms of evidence.

For any specific arrangement, legal review belongs at the beginning. It should explain the steps needed to secure parenthood and who can act for the child in the meantime. That includes the practical question of who will care for the newborn if the intended parents cannot yet be there at the birth. Fertility care abroad also raises questions about travel documents and recognition in the country where the family lives.

How much does surrogacy cost?

There is no reliable worldwide total price. The term itself can cover very different services: a private arrangement with expense reimbursement, medical treatment, or a comprehensive program with matching and support. A single figure says little while those differences remain unclear.

For a budget, it is more useful to list these items separately:

• Examinations, IVF, medication, egg or sperm donation if needed, storage, and further embryo transfers
• Care during pregnancy and birth, insurance, and medical services that are not covered
• Permitted expense reimbursement or compensation, plus matching and support fees where applicable
• Independent legal advice, proceedings, certificates, and translations
• Travel, accommodation, lost earnings, and a longer stay after the birth
• Additional needs after failed attempts, complications, or hospital care for the newborn

This list helps you ask questions; it is not a universally identical package of services. For a specific offer, ask to see what is included, what costs extra, and who carries each financial risk. A package advertised as guaranteed needs the same scrutiny: a contractual refund or additional treatment attempts are different from a guaranteed birth.

The relationship does not automatically end at birth

Surrogacy brings people together in a deeply personal situation. Some want close contact during pregnancy; others prefer more distance. Different expectations are not automatically a problem, as long as they are 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 afterward? How will the surrogate’s own children be told why the baby will grow up in another family?

Follow-up care needs equally clear planning: who will arrange the surrogate’s medical care, who will help her day to day, and who will pay if she needs support for longer? ASRM calls for access to psychological support after the birth as well. A change in wishes about contact should not mean that agreed care disappears.

What do we know about the children?

Researchers can now examine how children experience their origins over longer periods. A longitudinal study published in 2023 followed families until the children were 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. There were no differences between these two overall groups in the young adults’ psychological well-being or the quality of family relationships.

This is encouraging, but cannot be generalized 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; that does not establish cause and effect. In practice, keep information about your child’s origins and think early about how to discuss it in an age-appropriate way. The conversation grows with the child’s questions.

Which alternatives fit your situation?

An alternative needs to address the actual obstacle. If pregnancy is possible but your 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 does not solve that problem.

Co-parenting means sharing parenthood with other people. The person carrying the pregnancy may remain a parent permanently, which makes it fundamentally different 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 discuss your idea of family again. The question is which path suits the people involved and what responsibility they want to take on in the long term.

What to clarify before deciding

These questions can help you leave an initial conversation with concrete answers:

• Which obstacle is surrogacy meant to overcome in our situation, and whose eggs and sperm would be used?
• How will the surrogate and everyone else involved receive independent counseling, examinations, and follow-up care?
• What happens after an unsuccessful transfer, a miscarriage, or an unexpected medical finding?
• Which steps establish parenthood, and who is responsible for the child until then?
• Which costs are included in writing, which remain open, and what protection is in place if complications occur?
• What does everyone expect regarding contact, privacy, and the time after the birth?

If an offer mainly emphasizes speed or a low starting price while leaving these questions unanswered, you are missing information you need 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 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: Using 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 increase. That is why ASRM strongly recommends transferring one embryo in gestational surrogacy.

Myth: Without payment, no one can be pressured.

Fact: Pressure can also arise from family expectations, loyalty, or dependence. Particularly in arrangements within families, ASRM emphasizes voluntary decisions and independent counseling. Another key question is whether someone 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 be the parent herself. Equally, carrying the pregnancy does not tell you what kind of later contact she will want. 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 matter just as much. Anyone considering it needs clear answers about how that responsibility will be shared before and after the birth.