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The concept of surrogacy is not a new one. Surrogate mothers and intended parents can be traced back to the book of Genesis in the Old Testament. Abraham’s wife Sarah used her maid, Hagar, as her surrogate, and Isaac’s wife, Rachel, recruited her servant, Bilbah, to carry Isaac’s child. Commercial surrogacy began in the United States in the late 1970’s, when an attorney, named Noel Keane, arranged the first surrogate contract and started the first agency dedicated to surrogacy.

There are three types of surrogate arrangements:
Traditional Surrogacy using Artificial Insemination
In this arrangement, the surrogate agrees to donate her eggs and to be artificially inseminated with the sperm of the intended father. Most states require the intended mother to do a step-parent adoption, after the birth of the baby, in order to establish her parental rights and to have the surrogate give up her rights to the child.

Gestational Surrogacy
In this arrangement, the surrogate agrees to carry the embryos made from the sperm and eggs of the intended parents. The offspring from this arrangement are the genetic child (ren) of the intended parents, and the surrogate functions as a “host” uterus. The surrogate in this arrangement may also be called a “gestational carrier.”

Donor Egg/ Gestational Surrogacy
In this arrangement, the surrogate agrees to carry the embryos made from the sperm of the intended father and the eggs from a third party donor (who may be known or anonymous). There is no biological tie to the surrogate, so she functions as a “host” uterus or “gestational carrier”.

Since the 1970’s, there have been over 35,000 births as a result of surrogacy. Any condition that causes significant ovarian dysfunction can be an indication for surrogacy, while any condition that causes uterine or tubal damage can be an indication for gestational surrogacy. Medical conditions that threaten the mother’s life, or physical disabilities that impact a woman’s ability to carry a pregnancy, can also be indications for this reproductive option.

Indications for Surrogacy/ Gestational Surrogacy

Ovarian Dysfunction

Advanced maternal age / menopause
Premature ovarian failure
Genetic disorders of the female partner
Severe ovulatory disorders not remedied by therapy with fertility drugs
Chemotherapy or radiation that has destroyed ovarian function
Surgical menopause

Uterine Dysfunction

Severe endometriosis
Hysterectomy
Myomectomy (that may affect the uterus’s ability to hold a pregnancy to term)
Severe endometritis or intrauterine scarring
Congenital anomalies of the uterus
Severe pelvic adhesions that distort the uterus or bowel

Medical Conditions

Severe cardiac or renal disease
Brittle diabetes
Active Disseminated Lupus Erythematosus
Estrogen dependent cancers
Conditions that require the female partner to take medications that are teratogenic

Others

Numerous failed IVF cycles for unexplained reasons
History of ectopic pregnancies
Physical disabilities that will be exacerbated by the weight gain of pregnancy
Same sex couples
Restrictive adoption policies that would disqualify a couple

In most clinics, there must be demonstrated medical necessity to use a surrogate or carrier. The surrogacy arrangement requires the expertise of many professionals to run smoothly. Many arrangements are facilitated by an agency, who matches surrogates and intended parents.
In addition to the staff of the fertility clinic, the couple and surrogate should be prepared to meet with a psychologist for screening and psychoeducational counseling and an attorney to draw up contracts between the parties. Finally, meetings with the obstetrician and hospital staff may also be preemptively arranged.

There are two types of surrogates: compassionate and compensated. The compassionate surrogate is usually someone known to the couple. Compassionate surrogacy is done less frequently than compensated or recruited surrogacy. These arrangements may be known or anonymous and are often coordinated by agencies or attorneys who specialize in this field. These agencies pre-screen and exclude inappropriate candidates, anticipate the questions and concerns of the intended parents, facilitate and mediate potential areas of conflict, and help with the post-birth transition for both the surrogate and the intended parents.

The pregnancy rates using surrogates are comparable to those with IVF. As in IVF the age of the female partner or traditional surrogate will impact success rates significantly. The limited data published in peer reviewed journals suggest no disadvantage to surrogacy as a reproductive option.

References:
Goldfarb J, Austin C, Peskin B, Lisbona H, Desai N, deMola J. Fifteen years experience with an in-vitro fertilization surrogate gestational pregnancy programme. Hum Reprod 2000; 15: 1075-8.

Hanafin H. Overview of surrogacy parenting. [Internet]. Marietta (GA): TASC; c1999 [cited 2004 Dec 14]. Available from: http://www.surrogacy.com/psychres/article/eval.html.

Jacobson A, Weckstein L, Galen D, Hampton K, Ivani K. High pregnancy rates with IVF surrogacy. [Internet]. Gurnee (IL): OPTS, Inc.; c 1997-2003 [cited 2004 Dec 14].
Available from: http://www.opts.com/med4.htm.

Stewart D. When should a couple consider surrogacy or a gestational carrier. [Internet]. Marietta (GA): TASC; c1999 [cited 2004 Dec 14]. Available from: http://www.surrogacy.com/medres/article/whenshou.html.