Surrogate is a gestational carrier who carries a pregnancy from an embryo(s) that was/were created by the intended parent(s), using their own or donated sperm and egg. A typical gestational carrier has no genetic link to the fetus she will be carrying.
Using a gestational carrier is both a medically and emotionally complex process that requires careful evaluation by medical professionals, MHPs, and legal professionals to ensure that the procedure is satisfactory for both the carrier and the intended parents.
Reasons for Using a Gestational Carrier
Often, a gestational carrier is used when a woman has normally functioning ovaries but doesn’t have a uterus. Women who were born without a uterus (müllerian agenesis) or who had a hysterectomy are obvious candidates. Other candidates include women who are born with abnormalities of the uterus (congenital müllerian anomalies), such as a T-shaped or hypoplastic uterus, and/or who have a history of infertility or recurrent miscarriages. Women with untreatable scar tissue in their uterus are also candidates.
A gestational carrier also may be used for women with a medical condition that makes being pregnant unsafe. Examples of medical conditions that may prompt the use of a gestational carrier include severe heart disease, systemic lupus erythematosus, history of breast cancer, severe renal disease, CF, severe diabetes mellitus, and women who have a history of severe preeclampsia with HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count).
Selection of a Gestational Carrier
Gestational carriers are known to the intended parents. They can be relatives or friends who volunteer to carry the pregnancy. Others are found through agencies that specialize in recruiting women to become a gestational carrier. Carriers should be at least 25 years old and have delivered a liveborn child at term. The use of an older carrier is challenging because pregnancy complications, especially hypertension or gestational diabetes, are much more common in older women. When considering an older gestational carrier, it is important to consider her overall health and screen for underlying medical conditions that might complicate a pregnancy. An older gestational carrier and intended parents must be counseled regarding the obstetric risk and thus women older than 35 years aren’t recommended.
Evaluation of the Intended Parents and Gestational Carrier
The intended parents should undergo a complete medical history and physical examination. Semen analysis should be obtained for the male partner, and an evaluation of ovarian function should be performed for the female partner. The gestational carrier should undergo a complete medical history including a detailed obstetric history, lifestyle history, and physical exam.
Infectious-disease screening for syphilis, gonorrhea, chlamydia, CMV, HIV, and hepatitis B and C should be performed on the intended parents and the gestational carrier. The carrier also should be screened for immunity to rubella, and varicella. In addition, her blood type and Rh factor should be noted. Other screening may be needed in areas of outbreak of infections, such as Zika virus.
Counseling of Gestational Carrier and the Intended Parents
Counseling of gestational carriers is intended to give the carrier a clear understanding of the psychological impact and potential issues related to pregnancy. With the assistance of an MHP, the gestational carrier (and her partner, if there is one) should explore managing a relationship with the intended parents, coping with attachment to the fetus, and the impact of a gestational carrier arrangement on her children and her relationships with her partner, friends, and employers. The intended parents should explore their ability to maintain a respectful relationship with the carrier. The carrier and intended parents should meet with the MHP to discuss the type of relationship they would like to have and expectations they have regarding a potential pregnancy. This includes discussion of the number of embryos to be transferred, prenatal diagnostic interventions, fetal reduction and therapeutic abortion, and managing the relationship while respecting the carrier’s right to privacy.
Third-party reproduction involves several legal issues. Written consent should be obtained for any procedure. In situations of known sperm or egg donors, both donors, as well as intended parents, are advised to have separate legal counsel and sign a legal contract that defines the financial obligations and rights of the donor with respect to the donated gametes. With embryo donation, in the absence of statutes defining rights and responsibilities, a pre-donation agreement and a judicial determination of parentage are suggested prior to the donation taking place. With gestational carrier arrangements, legal contracts, in addition to delineating financial obligations, may include details regarding the expected behavior of the carrier to ensure a healthy pregnancy, prenatal diagnostic tests, and agreements regarding fetal reduction or abortion in the event of multiple pregnancy or the presence of fetal anomalies. Finally, many Countries allow for a declaration of parentage before the child’s birth, which avoids the need for adoption proceedings. Because laws regarding third-party reproduction are either nonexistent or different from one country to another, all couples are advised to consult with an attorney knowledgeable in reproductive law in their individual Country. Potential donors and recipients also should be made aware that laws may change and anonymity cannot be guaranteed for the future. Additional challenges can be encountered when third-party donation or gestational carrier arrangements cross international borders. Indian government intends to make Surrogacy laws very stringent in future.