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FAMILY SURROGACY

When a family member offers to serve as surrogate, it may seem like a dream come true. Thousands of dollars in agency fees can be saved, and it is comforting to have personal knowledge of the surrogate's medical history and background. However, the closeness of the family relationship can lead to other areas of difficulty. It is important to carefully evaluate the situation and to consider the following issues before proceeding.

Surrogate Fee and Expense Reimbursement:

While the surrogate may view her participation as an *act of love* and adamantly refuse any financial compensation, the intended parents may feel uncomfortable with this *imbalance*. Alternatives to a surrogate fee include making a contribution to her children's college fund or sending the family on a deluxe vacation after the birth. Similarly, the surrogate may deny reimbursement for out-of-pocket expenses including childcare, maternity clothes, lost wages and transportation. While the surrogate may not want to realize a profit, accumulated expenses can be substantial and place a financial burden on her family. Making regular deposits (i.e. $200/month) to the surrogate's checking account, can eliminate dealing with receipts and reimbursements. If the surrogate is employed, securing a pregnancy disability policy may provide coverage for lost wages in case of a prolonged absence from work. (Note that this insurance is not available for all occupations or income levels.)

Psychological Evaluation:

It may seem absurd to schedule a psychological evaluation for your sister, aunt, cousin or niece. However, an experienced mental health professional will be able to provide an independent assessment and help the surrogate take a careful look at whether this is an appropriate choice for her and her family. Most evaluations involve an oral interview as well as written psychological testing. Factors that will be considered include the surrogate's motivation, her concerns regarding medical procedures, her ability to separate emotionally from the child post-birth, moral and religious attitudes regarding surrogacy, support from family and friends, comprehension and acceptance of medical risks, and emotional maturity. A referral to an experienced mental health professional can be obtained through Resolve, OPTS or your treating physician.

Independent Legal Counsel:

Family members may prefer to keep their dealings on an informal level, but it must be remembered that surrogacy involves an important legal transaction. The surrogate is placing herself at risk both physically and financially. While she may want to waive her right to independent counsel in order to avoid legal fees, her attorney will serve several crucial functions. An experienced attorney can educate the surrogate about the legal process involved, review the agreement with her best interests in mind, and bring up issues that may be difficult for the parties to discuss directly (such as financial compensation, disability coverage, expense reimbursement and life insurance). Rather than depending on a verbal understanding, all terms should be explicitly stated in the written agreement to avoid misunderstandings that may jeopardize the relationship.

Guardianship:

A provision for guardianship of the child should be set forth in the surrogate agreement as well as in the intended parents' will before embryo transfer or insemination. This will clearly state the parties' intentions and offer the surrogate protection in case the intended parents predecease the child. The surrogate may have an expectation of being named guardian or godparent of the child. If your surrogate does not live close by, you may prefer to select someone who does. This issue, though often difficult to discuss, should be resolved before the surrogacy agreement is executed.

Counseling Facilitation:

Using a family member as surrogate usually eliminates the need for agency involvement. It also eliminates a third party to act as a "support" or "buffer" between the parties. Counseling before commencement of cycle will help family members voice their expectations and concerns. Is everyone in agreement regarding selective reduction and therapeutic abortion? How many cycles will be attempted? How will the obstetrician be selected? Will the surrogate be expected to make lifestyle changes (diet, exercise, alcohol consumption, etc.)? Who will be present at the birth? As in any assisted reproductive cycle, the parties will no doubt ride the roller coaster of emotional ups and downs. Unresolved family issues may surface during these stressful times. After a failed pregnancy attempt, the surrogate may blame herself for not resting enough, for picking up her toddler a few times, or for not eating right. The intended mother may hide her feelings of loss, while trying to take care of others. Counseling can help the parties move through the grieving process and decide on a next step.

When there are unresolved family issues or motivation based on obligation, using a family member as surrogate can result in difficulties throughout the pregnancy and beyond. The above topics can provide a starting point for initial discussions. Professional guidance can help to determine whether surrogacy is an appropriate choice for those involved. With adequate preparation and careful thought, using a family member as a surrogate can be a rewarding experience for all.

Gestational carrier (otherwise known as gestational surrogacy or host uterus), like many other aspects of assisted reproductive technologies, began with utilizing family volunteers and then moved on to involve recruited volunteers. Currently, it appears that more recruited volunteer carriers are involved than family members.

There is not as much known about how families fair when choosing to go through a gestational carrier situation. Nonetheless, the early experiences with gestational carrier often involve family members. Therefore, there is clinical experience to learn from for those individuals who are exploring the possibility of using a family member as a gestational carriers.

Unlike recruited volunteer gestational carriers, family members are drawn to being a gestational carrier after having direct experience of watching a loved one go through infertility or being asked directly. Often, it is a dramatic medical situation which propels a person into needing a gestational carrier such as a racial hysterectomy, life long illness such as diabetes or a congenital absence of the uterus. Family members are aware of the medical situation, and respond to the need at hand.

Consequently, it is hard for the prospective genetic mother and father to ascertain whether the family member is volunteering because they want to or because they feel that they have a duty or obligation to volunteer. This situation is probably the most difficult one to evaluate for both the woman who is volunteering to be a carrier as well as for her family member.

Just like other forms of gestational carrier, a good assessment prior to beginning any cycle is absolutely necessary. Certainly there are advantages to using a family member as a gestational carrier. Specifically, the genetic mother and father know the history and daily routine of the carrier. There is a great deal of comfort that can be gained from having easy and ready access to their gestational carrier during both the attempts and the pregnancy. In addition, they do not have to negotiate any type of relationship for after the baby is delivered, because there is already an established relationship.

Yet, it is the very fact that there is a relationship that exists, that the carrier and her partner as well as the genetic mother and father need to explore how this collaborative reproductive effort is going to affect their future relationship. It is ridiculous to assume that going through a gestational carrier experience together would not alter a relationship. This does not mean to say that it would alter the relationship for better or for worse, but rather any significant life relationship changes a relationship. For example, when a sister marries, it inevitable alters her relationship with other siblings. There is no relationship that we have as adults, that is not subject to change over time and life experience.

Consequently, it behooves any group going through this experience to look long and hard at how this will change their relationship. Clearly, there will be the issue of how, what and when to tell any child born through the gestational carrier experience about his or her special origins. In addition, the carrier and her partner have children that they need to incorporate into the carrier experience. If the children are very small, different accommodations need to be made then if the children are older. Regardless of their age, children that are already involved in the carrier process, need to be brought into the experience and their feelings and reactions need to be anticipated.

THE GESTATIONAL CARRIER

The family member who chooses to serve as a gestational carrier has the same personal evaluation process to go through to determine whether or not gestational carrier would be a positive experience in her life. The carrier and her partner need to look at both their feelings about this situation. It is imperative that both partners feel equally committed to going through the carrier experience. The carrier's partner will have his life impacted upon as much as the gestational carrier. Should the carrier need to be at doctor's visits or on bed-rest, the partner will find that his duties within the household will change. In addition, the gestational carrier experience will affect everything from their sex life to their travel plans. Both the potential carrier and her partner both need to feel comfortable that this will not affect their children adversely. Often, both partners are not in the same place either emotionally or in their concerns about participating in the gestational carrier program. This issue can emerge very strongly with regard to the potential effects on the children.

Listed below are some questions that may be helpful to explore with a friend or family member when considering embarking on a gestational carrier program:

* Why do you want to be a gestational carrier?
* What are your expectations about your relationship with the child?
* What do you imagine how you will feel if the procedure is not successful?
* Do you expect any legal relationship with the baby?
* What are your expectations, if any, around receiving a fee for your participation?
* Are you willing to participate in a counseling session with us to discuss relevant concerns? Are you willing to continue counseling indefinitely if the need arises?
* Have you had the opportunity to thoroughly discuss the medical risks associated with the procedure, medication and pregnancy?
* If you have a husband/partner, how does he feel about you being a gestational carrier?
* What is your understanding of the medical procedure that will be involved?
* Who will be your support person during the attempts? Who will give you your injections?
* Are you aware that we may have multiple pregnancies? How do you feel about this possibility? How do you all feel about selective reduction?
* Are there people that you have shared your interest to be a gestational carrier? If there were any, what were their reactions?
* Why do you think you would be a good gestational carrier?
* What do you believe your strengths and weaknesses are?
* Do you have any ethical or religious viewpoints which might affect your decision to be a gestational carrier?
* What are your feelings about the unlikely prospect that we might choose or need to abort a fetus? (First explore your own feelings before raising this issue with your prospective carrier)
* Are you aware that the legal issues surrounding gestational carrier and parental rights differ from state to state?
* Do you want publicity about your decision to be a gestational carrier if the possibility arises?
* Is there anything significant about your relationship with me/us that contributed to your decision to be a gestational carrier?
* How do you imagine your relationship will change?
* How do you imagine your relationship will change?
* How does your family feel about your decision to be a gestational carrier?
* Who will know about this decision and who will not?
* If you have a husband or partner, how does he feel about the possibility of a baby born of this procedure? Will he participate in counseling if requested?
* Have you discussed with your partner the risks associated with this procedure and with the medication you must take?
* What do you think the impact will be on the extended family?
* How do you think being a carrier will effect your children?
* What do you think the community reaction will be? Your children's teachers or friend's parents?
* Do you feel that it would be helpful to discuss this with your minister, priest, rabbi, etc.?

WHO NEEDS SURROGACY?

Unfortunately, many couples are unable to have their own children. Up until the last couple of decades, those couples had only two alternatives: adopt or remain childless. Today, due to advances in reproductive technology, couples now have medical means to have children. Reproductive techniques such as artificial insemination, in vitro fertilization/pre-embryo transfer (IVF/ET, also known as test-tube babies) and other Advanced Reproductive Technologies (ART) allow otherwise infertile couples a chance to have children.

However, there are still some couples for whom these techniques are not successful and for whom adoption is not an attractive or viable option. These couples may still wish to have children who are their genetic offspring. Often the mother cannot give birth for reasons that may include lack of a uterus or where pregnancy would be medically risky. For these or other reasons, the only way to have genetic offspring is to have another woman carry and give birth to their child: a Surrogate Mother. The couple wishing to obtain a child through a surrogacy arrangement are often referred to in the law as "Commissioning Couple" or "Intended Parents."

HOW DOES A SURROGACY WORK?
There are two types of surrogacy. 1). A genetic surrogate is where the surrogate mother is also the biological mother. This is where surrogate's eggs are and inseminated (usually artificially) with the intended father¹s sperm. 2). A gestational surrogate is where both the egg and sperm of the intended parents are joined and the pre-embryo(s) are placed into the surrogate who will carry and deliver the child. The gestational surrogate has no genetic link to that child.

The medical technique for gestational surrogacy most commonly used is IVF/ET and/or its variations. Details of this procedure, along with its risks, should be discussed with a qualifies Reproductive Endocrinologist who performs such procedures.

WHO CAN BE A SURROGATE?
This is basically a medical question and the Reproductive Endocrinologist is the person who evaluates the surrogate¹s medical qualifications. Generally, the surrogate should be a healthy woman who is capable of a safe pregnancy and delivery.

WHERE DOES ONE FIND A SURROGATE?
Since a surrogate cannot be paid a fee for being a surrogate, she will be someone who is motivated by something other than money: i.e. a relative or close friend of the intended parents. Surrogates cannot be obtained through or by some other paid intermediary. Thus the intended parents will usually find the surrogate. Some Reproductive Endocrinologists keep lists of women who may consider being a surrogate.

WHAT CAN A SURROGATE BE PAID?
She can be reimbursed for any expenses or losses due to the surrogacy such as all medical and psychological care costs, living costs, prenatal care, maternity clothes, transportation costs and possibly lost wages directly resulting from her role as a surrogate.

HOW IS THE PREGNANCY MANAGED AND WHO MAKES THE DECISIONS?
After pregnancy is achieved, the surrogate¹s care is managed by an obstetrician of the surrogate¹s choosing. While the intended parents usually pay for the OB and may be involved in the surrogate¹s care, ultimately the surrogate has final control over her care.

WHAT ABOUT AMNIOCENTESIS AND ABORTION?
These decisions are also made solely by the surrogate. It is expected that prior to entering into a surrogacy arrangement, the surrogate and intended parents will discuss these matters in detail. An amniocentesis may be advisable even if the surrogate is young since the eggs and sperm may be from an older couple. Issues such as abortion if the fetus has genetic defects should be thoroughly discussed in advance between the parties so that if any when a decision is required the decision made by the surrogate will be one everyone agrees with.

WHAT IF THE CHILD IS BORN WITH BIRTH DEFECTS?
As with a traditional pregnancy and birth, the responsibility and care will be with the intended parents. The surrogate will have no responsibility after birth even if the birth defect(s) may have been caused by some activity or behavior of the surrogate.

WHAT IF IT IS DISCOVERED THAT THE CHILD IS GENETICALLY THE SURROGATE¹S?
If it turns out that the child is genetically the child of the surrogate (in a gestational surrogacy), then the surrogate has the responsibility for the child after birth (as does the intended father if he is the biological father). If the intended parents still wish to have the child, they must go through an adoption.

WHAT HAPPENS IF PREGNANCY IS NOT ACHIEVED OR THERE IS A MISCARRIAGE?
If pregnancy is not achieved or there is a miscarriage, the parties can try again as often as they agree.

ARE THERE ANY MEDICAL RISKS TO THE INTENDED PARENTS OR SURROGATE AND SHOULD ADDITIONAL INSURANCE BE OBTAINED?
Any and all risks should be thoroughly discussed with the Reproductive Endocrinologist. The medical risks to the intended parents are generally very low (though in a gestational surrogacy there may be some related to egg retrieval). The risks to the surrogate are normally those associated with any pregnancy and delivery. All parties should attempt to have applicable medical and hospitalization insurance in place, including maternity coverage, to cover all anticipated medical contingencies.

WHAT ARE THE COSTS AND WHO WILL PAY THEM?
The costs can be extensive and will vary depending upon the circumstances involved in each surrogacy. Typically they involve the following: medical costs of evaluation, both medically and psychologically; costs of the procedure in getting pregnant; prenatal care and delivery; legal fees; and, reimbursements to the surrogate. The total costs will usually be no less than $15,000.00 and average around $21,000.00 in gestational surrogacies. For genetic surrogacies, the costs are considerably lower since the medical techniques to achieve the pregnancy are much lower. These costs are the responsibility of the intended parents. Insurance coverage should be used or obtained, to mitigate these costs.

WHAT GUARANTIES AND SAFEGUARDS ARE THERE?
As for the medical certainty of getting a child, only a Reproductive Endocrinologist can answer that for each case. As for legal and monetary safeguards, a written contract should be prepared by an attorney.

In a gestational surrogacy the intended parents take custody of the child immediately after delivery. They immediately petition the Court for approval of the agreement and notify all persons interested including the surrogate and Reproductive Endocrinologist. The Court will examine the agreement and the facts of the case and, barring unforeseen difficulties, confirm the parentage of the intended parents as the legal parents.

In a genetic surrogacy the intended parents go through a modified adoption procedure. A consent (after delivery of the child) is obtained from the genetic surrogate. Then a petition is filed for adoption naming all appropriate parties including the intended parents, the genetic surrogate and the surrogate¹s spouse (if any). In some instances HRS is notified in advance to do a home study, though often after delivery they treat the adoption as a step-parent adoption (since the intended father is the biological father) and thus bow out of further involvement. The Court reviews the case and if approved, names the intended parents as the legal parents and orders the issuance of a new birth certificate. This procedure is more involved and takes longer than that involved in a gestational surrogacy.Furthermore, the home study and background investigation by HRS or other approved agencies must be completed prior to the child going home with the intended parents. Thus this should be done in advance of delivery. If it in not, the attorney involved with the procedure must procure temporary housing for the child.

HOW WOULD I GET INVOLVED IN A SURROGACY ARRANGEMENT?
If you are reading this, you may have already taken the first step which is to see a Reproductive Endocrinologist to determine if surrogacy is a viable medical option. If so, a surrogate must be obtained. During the medical and psychological evaluation the intended parents and surrogate should seek the counsel of independent attorneys knowledgeable in this area of the law to discuss the legal requirements and ramifications of surrogacy and draw up the appropriate documents.

Surrogacy involves a great deal of emotional, physical and financial commitment over a long period of time. Before entering into such an arrangement, all parties should examine the consequences. Communication is very important to determine if everyone's philosophy and goals are the same, especially between the intended parents and surrogate. Therefore, no question is too dumb or embarrassing to ask.