SART Fertility Experts - Gestational Carriers

The information and opinions expressed in this podcast do not necessarily reflect those of ASRM and SART. These podcasts are provided as a source of general information and are not a substitute for consultation with a physician. Welcome to SART Fertility Experts, a podcast that brings you discussions on important topics for people trying to build a family.

Our experts are members of SART, the Society for Assisted Reproductive Technology, an organization dedicated to ensuring you receive quality fertility care. Hello, thank you for joining the SART podcast series. My name is Brooke Rossi and I am a practicing reproductive endocrinologist and infertility specialist in Columbus, Ohio.

And today we have the pleasure of talking with Dr. James Goldfarb and we will be discussing gestational carriers. Dr. Goldfarb retired from clinical medicine in September of 2019. He is also a clinical professor of reproductive biology at Case Western Reserve University School of Medicine.

Dr. Goldfarb has been a past president of SART and in addition he also is responsible for the world's first surrogate or gestational carrier pregnancy. Thank you so much Dr. Goldfarb for joining us today. You're welcome.

All right, so the first thing that we'd like to talk about for the audience would be just to help them understand what a gestational carrier is and specifically some of our patients may have heard the term surrogate or gestational carrier used and they might not know the difference between the two. And I'm wondering if you can tell us a little bit about the differences and in general what a gestational carrier is. Yeah, in fact the terms are interchangeable to a lot of people, but in if you look at from the scientific standpoint, a surrogate is considered when the person who is going to have the baby is actually using her own eggs.

So it's just a simple procedure where the surrogate is inseminated with sperm. She has the baby and then the baby is adopted by another couple. And that's also sometimes to differentiate between the gestational carrier that we'll talk about.

The simple procedure that we just talked about is sometimes called a traditional surrogate whereas with the gestational carrier, the procedure is much more complex. But what it involves is the eggs are not the eggs of the woman who's carrying the baby. So the eggs are either an infertile woman or an egg donor.

Those eggs are fertilized by sperm and then the resultant embryo is put into the gestational carrier's uterus. So in contrast to the quote traditional surrogate, the gestational carrier is actually carrying a baby that is not genetically related to her at all. Okay, so I understand.

So the big difference is surrogate or traditional surrogate means that the woman carrying the pregnancy is genetically related to that pregnancy and a gestational carrier, the woman carrying the pregnancy is not genetically related to that pregnancy. Correct. And as they say, from our fertility profession, we like to call these people who are carrying a baby that's not related to a gestational carrier.

But in fact, a lot of people use the word surrogate or gestational surrogate as well. So even in this conversation, the terms may get conflated a bit. I understand.

Just so we understand, do people even necessarily do traditional surrogacy anymore? To my knowledge, it's not being done anywhere. Because it's such a simple procedure, it could be done by a gynecologist with no real interest or extra knowledge in fertility. So whether it's done behind the boards, I don't know.

But certainly, from my understanding, it's not being done at all anymore. So most of the time, if a patient was thinking about using a gestational carrier and heard the word surrogate, really, they'd be thinking about using a gestational carrier in what we're talking about today? Yeah, in today's world, absolutely. Okay.

How common is the use of gestational carriers? Well, it's increasingly common. In the early 2000s, there was an average of around 32 cycles a year being done with the gestational carrier. And in the most recent data that we have from 2017, it was up to about 4,600 gestational carrier cycles.

And not only is the absolute number increased, but also the percentage of overall IVF cycles versus surrogate. In the early 2000s, it was about 2.6% of IVF cycles were being done with a gestational carrier. And in 2017, it was up to 4.2%. So it's increasing not only in numbers, but also in proportion to other variations of IVF.

Okay. What are some of the reasons that a couple may choose to use a gestational carrier? The classic reason when gestational carrier first got started was women who either had no uterus, either because they were born without a uterus, which occasionally happens, or they had had a hysterectomy. So that was the first wave of patients.

But since then, it's expanded quite a bit to the point where if the uterus is considered to be abnormal and not being able to carry a pregnancy, a gestational carrier could be used. Similarly, if the patient has a medical disease that would be exacerbated by the pregnancy, she can use a gestational carrier. Most recently also in the last five or 10 years, there are certain patients, not all, but certain patients who've had multiple failed routine IVF cycles where they have not been successful using their own uterus, they could use a gestational carrier.

And similarly, some, not the majority certainly, but some people who have recurrent miscarriages will be much more likely to carry using a gestational carrier. The other thing that has really, I think, been a big reason for increasing the number of gestational carriers, and particularly the number of gestational carriers that are using donor eggs, is the prevalence now of same-sex male couples who want to have a baby or single male who wants to have a baby. So with those patients, they'll get donor eggs and they'll use their sperm, and then that resulting embryo will be put into a gestational carrier.

So it sounds like some different reasons would be maybe, you know, if a woman is born without a uterus or like congenital absence of the uterus, maybe if she's had a hysterectomy either because of cancer or because of an issue maybe with like a postpartum hemorrhage at the time of a prior delivery. Sometimes I think we've also seen patients who have maybe had a, you know, a surgery on their uterus and they have significant scarring that, you know, we just can't get the uterus good enough to carry. You mentioned medical conditions.

I think we've seen patients before that have, maybe they have a cardiac issue where the doctors think it's not safe for them to carry a pregnancy, and they may use a gestational carrier. But I agree with you, one of the biggest things we've seen over the years has been increase in gestational carriers also for same-sex couples and that sort of thing. So although, you know, it's not a treatment that everybody needs, it's definitely, you know, something that we all see and that patients will need over the years for sure.

Dr. Goldfarb, one of the main questions that my patients have when they're thinking about using a gestational carrier is they have concerns or questions about who is a gestational carrier. So what's the testing that needs to be done if someone's considering being a gestational carrier? Do they need any type of evaluation? Can you talk a little bit about that? Yeah, well, first of all, as far as how they choose the gestational carrier, there's a broad range of ways of choosing a gestational carrier. The majority of the patients actually find a gestational carrier by going through an agency.

These agencies recruit patients or women who are interested in becoming a gestational carrier. They do some preliminary screening just to make sure that patients or potential carriers understand what's involved with it. And that's probably the most common way people choose a carrier.

But other patients and quite a few, they find their own carrier by either advertising for a carrier or very often they will actually have a friend or other acquaintance that they will use. People have used sisters. They have used sometimes even a mother if the mother is young in the late 40s, early 50s.

We've had patients, I have one patient who used her next door neighbor. The patient herself had diabetes and the neighbor was willing to carry the baby for her. And I think one that's most remarkable in my mind was the patient who used the checkout girl in the grocery store.

She had two previous gestational carriers who had given birth babies for her. And she mentioned to the checkout woman when the woman was looking at the babies and saying how wonderful they look, she told them that they were all from gestational carriers. And the checkout woman said I'd love to do that for somebody someday.

About six months later, the patient decided to have a third child. She went back to the checkout counter in the grocery store and found her carrier. As far as the screening goes, it's really important.

The one thing is that you don't want to cut any corners when you're screening these gestational carriers because if you cut corners at a time, then maybe it could become more problematic with the whole pregnancy. But the most important thing is for both the carrier and her family to be completely comfortable with the process, the legal issues and such. The need to have had a previous uncomplicated pregnancy for two reasons.

One is that the first pregnancy, as you know, is sort of a test pregnancy. If somebody's going to have problems with pregnancy, it usually shows up in the first pregnancy. So we want from a medical standpoint to know that they've had safe pregnancies, uncomplicated pregnancies.

But also from an emotional standpoint, there's all the issues with bonding with the baby and things like that that if somebody's not been pregnant with, they would not be aware of. And obviously it could become a problem if they were unaware of how emotionally taxing that can be. They obviously have to have a normal uterus along with the normal pregnancy.

They have to have no significant medical problems that would be problematic during the pregnancy. They have to be cleared psychologically. And we always do sexually transmitted disease testing and drug screening as well.

The other thing we want to do is make sure that, unlike when people donate eggs, a lot of times that's anonymous. The carriers and the families, the intended parents always get to know each other. And they need to get together and make sure that they have some certain questions.

There's no right or wrong answer, but it has to be the same answer, particularly with anything with genetic screening. Because as you know, now there's a lot of screening done in the first trimester routinely for pregnancies looking for genetic issues, chromosomal issues. And they really need to agree that number one, do they screen or do they not screen? If they screen and they're positive, do they do further testing? And if the further testing shows that there is a chromosomal abnormality, do they abort the pregnancy or do they continue the pregnancy? And those things are very important.

As I say, there's no right or wrong answer. It just has to be the same answer. And the other thing that we insist that the carrier and the intended parents both have independent legal advice with lawyers that are separate from the two of them.

So it sounds like in the process of picking a gestational carrier, it involves potentially an agency. It may involve a psychologist. It may involve your IVF doctor helping you medically evaluate the carrier.

And so there's a lot of steps to making sure that the carrier is the right one for that particular person who wants to be the intended parent. And the intended parent is the person who will be taking that child and parenting that child. So maybe this goes without saying, but just to make sure that our listeners understand, using a gestational carrier does involve in vitro fertilization.

Do you want to discuss briefly how the IVF works when you're using a gestational carrier? Yeah, just looking at it sort of from the helicopter, so to speak, the egg donor, which is either the female part of the couple that want to have a baby, but for some reason can't carry, or as it happens in 50% of our patients now, the egg donor. So either one of those, they have to produce eggs. And the way that's done is they're given a series of shots that stimulate the ovary to make multiple eggs.

In a normal menstrual cycle, the ovary only makes one egg. When you stimulate with these fertility shots, you can make upwards of 10 eggs per cycle. So obviously it increases the chances of getting pregnant.

And while the patients are getting the injections to make multiple eggs, they're monitored by ultrasound and blood tests about every other day. And then when the ovary is showing by both the blood tests and the ultrasound that the eggs are ready to be matured, they get a final shot. And then about 36 hours after that injection, a very minor surgical procedure is done to extract the eggs from the ovaries.

So it's a fairly simple procedure, but there's multiple days involved. So patients have to put away a lot of time for it. And the time is probably more of an issue to them than the medical issues for this type of thing.

And then what's the carrier doing during that time? Well, it's interesting because in the past, we would have the carrier be given hormones to stimulate her uterus to be receptive to the embryos that were going to be developed. Because once we get the eggs from the egg donor, they're fertilized with the husband's sperm or the partner's sperm. And then we used to have to, it's a little bit tricky coordinating to make sure the lining of the uterus was receptive at the time that we had these embryos.

But now the majority of cases we do, we actually freeze the embryo. So we'll stimulate the egg donor and then we fertilize the eggs with the sperm. And then approximately five days later, we freeze the embryos.

And this is actually now because embryo freezing has become so efficacious, it's a much simpler way of going. In the past, the embryo freezing wasn't very efficacious. So you had to use fresh embryos and try to coordinate the cycle.

But now, number one, with doing it this way, we don't have to coordinate the cycle. What we do is we get the embryos, we freeze the embryos. And then in the future, usually a couple of weeks later, a month later, whatever, all we do is stimulate the lining of the uterus of the woman who's going to carry the baby, the gestational carrier, we stimulate it with some hormones.

And then we start her on a second hormone called progesterone about halfway through the cycle. And on the fifth day of the progesterone, we put the embryos back into the uterus with the procedures like having a pap test done. So having the frozen, being able to use the frozen embryos rather than fresh makes it simple, makes the procedure much simpler because you don't have to coordinate the cycles.

The second thing it does though, which is not important in a lot of patients, but in some it is, it makes sure that we have viable embryos before we involve the gestational carrier with taking medication. There's some patients, for instance, the patients who are 30, 39 or 40 years old, that we may not get the viable embryos. So we can wait to make sure we get the viable embryos before we involve the gestational carrier with all the medications.

In fact, sometimes we don't have the gestational carrier do the legal work and such, because that's a lot of expense. And if we don't get embryos, it would be wasted money. So it really makes things much simpler, the fact we can use frozen embryos.

Great. Okay. And so that brings up one of the next questions.

We've talked a lot about the medicine, but kind of the logistics of the attorneys and the agencies and the cost of using a gestational carrier. Can you discuss that? Yeah. As far as the logistics, as I say, it's become easier because of being able to feed the embryos.

But the logistics are really, as I say, gotten much simpler. The biggest issue is the cost without any question. There's a real range of costs depending on how a couple gets the gestational carrier.

For instance, in the best case scenario, if they're using a gestational carrier, a friend or a relative who they're not going to be paying to do that, and they have insurance that covers the OB care for the gestational carrier, including the delivery, they can probably get away, and still it's a lot of money, but compared to the others, you can probably get away with $30,000 to $40,000 for the cycle. On the other end of the spectrum is if you're going with a gestational carrier through an agency paying the gestational carrier, then you have those things plus the legal fees and the medical procedure that you'd have with anybody else. And there you're going to be talking probably an $80,000 category because generally the agency fee is around $10,000, and the payment to the gestational carrier is usually $20,000 or $30,000.

And then even with that $80,000 there, it assumes that there's coverage for the OB care and the delivery. Because if that isn't, that could add another $20,000, $30,000 to it if it isn't. So it's a big range, anywhere from $30,000, which is unfortunately rare, up to over $100,000.

Right. Yeah. So it can depend on where the gestational carrier lives, the arrangement that the intended parents have made with a gestational carrier.

Like you're saying, sometimes you're paying for clothes and for her to take off work because she may have a job that she's not working because she's a carrier and legal fees. But I agree with you, it can be very expensive to use a gestational carrier. Yeah.

It really is. And that's one of the main reasons people can't go through is probably because of that, if they're comfortable. Obviously, a lot of patients are uncomfortable with this type of thing.

But even those who are comfortable, the costs become a real issue. Right. Dr. Goldfarb, can you talk a little bit about, and our listeners might not even be aware of this, but my understanding is that there are different laws in different states and even within the states, different laws about gestational carriers.

Can you discuss that a little bit? Yeah, that's a very important thing. It's very important that the gestational carrier deliver in what we call a quote surrogate friendly state. The state laws vary greatly.

If you look at Michigan and Louisiana, they don't recognize the contract. So no matter how much contract you have, if you have 20 pages of contract from the lawyer, they don't recognize it because they don't think it's in the public interest to be doing gestational carriers. In fact, in Michigan, it's against the law to pay a gestational carrier.

In contrast, with California, you can use a gestational carrier, all gestational carriers, the contracts, the state says the law says it's acceptable for any kind of gestational carrier, including those where you use gametes from donors, so donor sperm, donor eggs, or both. There's some states that are sort of in between that they allow gestational carriers, but only if the sperm and the egg are from an infertile couple. The most common laws, in fact, where Dr. Rossi and I are in Ohio is indicative of this.

Most states don't have stated laws, but California does. California law says the gestational carriers are okay, are legal for both donor gametes or their own gametes. Most states, what happens is that the courts have ruled that it's a legal thing to do, so it's not legislated.

And as Dr. Rossi said, there's always a potential of having one county feel differently than another county. In most states, including Ohio, that has not happened. All the counties have gone on the precedent of the previous counties and are fine with a gestational carrier, which also allows them to do what's called a pre-birth order.

So around 26 weeks of gestation, six months of gestation, the lawyers actually have the doctors sign an affidavit saying that the carrier is carrying a baby that is not genetically related to her. And the purpose of that pregnancy was for the intended parents to have the baby once the baby's born. And in the vast majority of states, that pre-birth order can be done, which is nice because then the couple doesn't have to worry once the baby's born, they don't have to go out and try to adopt the baby.

The couple's name is on the birth certificate. And as I say, that's probably the most common thing is that. And the trends are in the right direction.

Up until about a year ago, New Jersey was like Michigan and Louisiana, and now they've passed a very surrogate friendly law with it. And the one thing most of these, in fact, I think all the state laws that have been passed clearly differentiate what we started the conversation with between a traditional surrogate and a gestational carrier. So these laws only apply to gestational carriers, not to traditional surrogates.

Thank you for that explanation. Well, I think that we're about up with our time. Are there any other sort of last words of wisdom you have for us, Dr. Goldfarb, for our patients regarding gestational carriers? No, the one thing I would say, though, doesn't pertain to the patient as much as just the overall attitude.

You know, there's always some ethical issues that people bring up about this, and they're legitimate ethical issues. You know, are these people, especially if they're a relative, are they being coerced to do this? Or if they're being paid $30,000, are they being coerced by the financial aspects of it? So there's always these ethical issues, which are legitimate issues. But I think when, you know, and Dr. Rossi's been involved with this for as long as I have, but for quite a while, when you see these couples and how much it does for them to have a family that's genetically theirs, I think that, yes, there's these ethical issues, but on balance, it's the right thing to do and the right thing to offer patients.

And I agree with you. And similarly, when you really meet the gestational carriers, I mean, these are often very nice women who feel that they are at their best when they're pregnant, and they just want to be able to help somebody. And often you get a feeling from them that they are, you know, their heart's in the right place when they're doing it too.

Absolutely. I think it's, you know, that the carriers are screened properly because having been involved with this as long as I am, I sometimes get calls when there's something's gone wrong with this, which is fortunately very rarely, but almost always it's because somebody cut corners. They didn't have the patients, the psychologist, the patient had not had a baby before, things like that.

But I really think that if you do a proper screening, and it's important not to cut corners with it, that the outcomes have been wonderful. And you're absolutely right. The carriers are just so happy to be able to help these couples who, if it wasn't for this program, would not be able to have a baby that's genetically theirs.

Thank you again, Dr. Goldfarb for your insight. Again, this is the SART podcast series. And today we were with Dr. Goldfarb discussing gestational carriers.

Again, my name is Brooke Rossi, and I am a reproductive endocrinologist in Columbus. Thank you so much for listening today. Thank you for listening to SART Fertility Experts, your resource for information on IVF.

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