Have you been considering surrogacy for your next child? Or have you always wondered what the process would be like in Canada? Dr. Prati Sharma, a Reproductive Endocrinologist answers your top questions about surrogacy.

What is a surrogate?

A gestational surrogate is a person who carries a pregnancy that is not their own to assist another family to start a family.

Gestational surrogates are screened by a fertility clinic and tested to ensure that they have a good chance of carrying a pregnancy to term. These women altruistically offer to carry a pregnancy, usually for intended parents who cannot carry due to various reasons. Surrogates are often between the ages of 20 to 45 and do not have any prior medical issues and are overall healthy. Such as male same-sex couples using an egg donor, women who cannot carry a pregnancy due to medical issues, women who have had a hysterectomy or who have had multiple miscarriages or failed embryo transfers as a result of uterine/implantation issues.

The ASRM (American Society for Reproductive Medicine) defines a gestational surrogate as:

A Gestational Carrier is a woman who agrees to have a couple’s fertilized egg (embryo) implanted in her uterus. The gestational carrier carries the pregnancy for the couple, who usually has to adopt the child. The carrier does not provide the egg and is therefore not biologically (genetically) related to the child.

What’s the difference between traditional and gestational surrogacy?

A traditional surrogacy is when the surrogate provides both the egg and embryo to the IPs. Whereas in a gestational surrogacy, the surrogate is carrying the pregnancy but is not the genetic parent. With traditional surrogacy, the surrogate is both the carrier and the genetic mother of the pregnancy.

Depending on the clinic, some might offer traditional surrogacy options. Further, a traditional surrogate does not necessarily need to conceive with IVF, they can conceive through insemination or IUI as they are the genetic parent and the carrier. However, it is important to keep in mind that traditional surrogacy does have other psychological and ethical concerns therefore appropriate counselling and legal discussions should be considered.

When should you consider getting a surrogate?

Reasons for using a surrogate may vary, family to family. Below are a list of following reasons why an individual or couple may choose to use a surrogate:

• Same sex male couple using an egg donor and surrogate
• Lack of a uterus due to a congenital anomaly or prior hysterectomy
• Medical issue or taking medication that is risky for pregnancy and can compromise the health of a pregnancy
• Recurrent IVF failure, recurrent implantation failure or recurrent miscarriage
• Elective surrogacy for those who do not want to carry a pregnancy or go through labor
• Uterine problems or gynecologic issues including, fibroids, endometrial cancer, and adenomyosis

What is the surrogacy process like in Canada?

In Canada, intended parents (IPs) can look for a surrogate through an agency and then coordinate with a fertility clinic or connect with an agency through their fertility doctor, if they already have one.

Gestational surrogates are recruited through external agencies, such as Canadian Fertility Consulting. Surrogates are preliminarily screened and introduced to intended parents (IPs) who are seeking a surrogate. Once a meet and greet has been completed and the surrogate and IPs are matched, the surrogate completes a medical screening at the fertility clinic that the IPs are using. The surrogate undergoes medical screening with blood tests (STD testing, blood type, thyroid testing, sugar testing any other necessary bloodwork for them and their partner if they have one), psychological counselling regarding surrogacy, an ultrasound and sonohysterogram to assess their uterus.

The fertility clinic will also complete a full consultation to assess the surrogates pregnancy history, medical history, review the process and assess their ability to be a suitable surrogate. Once the medical screening and consultation is completed, a legal contract is required between the IP and surrogate. Once the contract is signed, the surrogacy process can be planned.

With respect to the process, it typically involves a programmed frozen embryo transfer (FET) of a single embryo to reduce potential complications between the IP and surrogate. Pregnancy success rates will also depend on the embryo used - whether an egg donor or the IP’s eggs are used and whether genetic testing of embryos are completed. As such, surrogates will need to take estrogen and progesterone medication for 12 weeks (the length of the first trimester), followed by serial ultrasounds and prenatal testing by the fertility clinic and followed up by either an OB or midwife.

How does the surrogate become pregnant?

The surrogate becomes pregnant by either a fresh or frozen embryo transfer. Currently, most embryo transfers are programmed FETs (frozen embryo transfers) for ease of scheduling. However, the main reason is that most patients choose to do Preimplantation Genetic Testing for Aneuploidy (PGTA), a type genetic testing of their embryos to improve pregnancy rate, reduce the risk of miscarriage, failed implantation, and aneuploidy rates (which refers to having extra or missing chromosomes).

Surrogates also take estrogen and progesterone to prepare their endometrial lining for the embryo transfer and once the endometrial lining is deemed adequate by transvaginal ultrasound, the embryo transfer occurs.

The embryo transfer is a simple procedure and does not require sedation. It is not painful and takes only about 5 minutes. (Refer to our IVF article to learn more about embryo transfers).

Using an ultrasound for guidance, the transfer is completed using a small catheter that is inserted through the vagina and into the cervix and then uterus where the embryo is placed approximately 1-2 cm above the uterus. The surrogate will also need to have a full bladder during the process. Usually, only single embryo transfers occur to minimize any risks and complications.

An alternative to a programmed FET using estrogen and progesterone is a natural FET whereby less medication is taken and the embryo is placed during the implantation window of a natural menstrual cycle. Some surrogates and fertility doctors prefer this type of cycle to avoid the hormonal burden to the surrogate and potentially improve success and reduce pregnancy complications that may be related to hormones.

What requirements do surrogates have to meet? Do intended parents have to meet requirements too?

Both intended parents (IPs) and surrogates have to undergo rigorous medical and psychological counselling, medical testing and independent legal counselling, followed with the signing of a legal contract. The specific requirements for a surrogate is outlined in the earlier questions.

Health Canada also has recently updated their surrogacy guidelines, therefore it is important to work with a clinic and an agency that understands and adheres to these guidelines.

Are surrogates paid, and if so, how much? Will insurance cover surrogacy?

In Canada, surrogates cannot be exclusively paid for carrying the pregnancy. However, they are reimbursed for their expenses, time lost from work, pregnancy related expenses and/or care/travel expenses.

This is one of the nice things about surrogacy in Canada (versus other countries like the US) as the cost is much lower and surrogates are doing this because they want to help IPs expand their family and are mostly doing this altruistically.

Some insurance companies also offer health benefits that cover IVF, related-medications or the Assisted Reproductive Technology (ART) process. Additionally, for Ontario residents with OHIP coverage under age 43, they are eligible for one publicly funded IVF cycle which partially covers the surrogacy process. This also includes same sex male couples who use an egg donor and surrogate.

How long does surrogacy take?

The process matching with a surrogate can take up to one year. As such, it is worthwhile to consider multiple agencies to find a surrogate sooner. These wait times vary depending on the availability of surrogates.

However, finding an Ontario surrogate under the age of 43 for a funded cycle can sometimes take longer. Once a match is made, the surrogate can usually be screened by the fertility clinic within 2-3 months and a cycle can be started.