Shots, Doctors, and Getting Ready for Surrogacy

While making a good match requires a little bit of magic, this next part of the surrogacy journey is all about the science. You, the intended parents, your surrogacy agency, a fertility clinic and lawyers will work closely together in this next phase to ensure it moves as smoothly as possible.

Three distinct phases make up the medical portion of pre-pregnancy and the pregnancy:

1. Medical Clearance
2. Pre-Transfer
3. Transfer

The medical clearance and transfer take place at a fertility clinic. Most intended parents have already chosen a fertility clinic to create and store their embryos. If one hasn’t been selected by now, or the IPs want to choose a different one that is more conveniently located for everyone, a good surrogacy agency will help select a reputable clinic. Your agency can also help find a nearby satellite clinic for pre-transfer monitoring. 

The fertility clinic is also where you’ll go for your medical clearance, to learn how to give yourself hormone injections (or for your partner to learn), for the embryo transfer, and for follow-up appointments until about your 10th week of pregnancy.

Medical Clearance

Remember, as part of your application process to become a surrogate, you’ll undergo a pre-medical clearance. This involves a review of your medical records related to any previous pregnancies, prenatal care, delivery records, and vaccinations / immunizations as well as a clear PAP test within the last three years. You will also have already spoken with your own OBGYN about becoming a surrogate. They will complete a physical exam, noting your blood pressure, weight and height.

After your Match Meeting, your surrogacy agency will send a packet of information to your fertility clinic, which includes your pre-medical clearance results as well as copies of everyone’s psychological evaluations. Your clinic will review the information and schedule your medical clearance appointment.

Fertility clinics are regulated by the Food and Drug Administration (FDA) and follow strict policies and procedures for the transfer of an embryo into a “third party” (surrogate). This means you are required to complete the medical clearance to continue on your surrogacy journey.

You and your partner will attend the medical clearance appointment together. Blood draws are taken for infectious disease testing, and the doctor will also conduct a physical exam including a sonohysterogram. This step is all about the safety and viability of a successful embryo transfer.

What to expect at the medical clearance appointment

As a surrogate, in addition to the infectious disease testing and the physical exam, the wonderful nurses at the fertility clinic will spend time with you and your partner going over the timeline for getting pregnant, the drug protocols and injection training. You’ll also sign consent forms. 

The medical clearance appointment is usually a two- to four-hour appointment, depending on the clinic. Your surrogacy agency will work with you to plan your travel to and from the clinic. They’ll ensure you’re comfortable and well-informed for this critical part of your surrogacy timeline.

Sonohysterogram

A sonohysterogram uses an ultrasound to look at the structure and shape of your uterus. To perform the procedure, a specialist will fill the uterine cavity with saline solution (fluid) using a thin catheter that passes through the cervix. (Most women say it feels like a Pap smear.) The doctor wants to be sure the uterus is free of obstructions for a safe transfer, so they’ll look for any polyps, fibroids, or an atypical uterus shape. 

If you have polyps (small growths in the lining of your uterus that could interfere with a successful embryo transfer), they will be removed before the transfer is scheduled.

Blood Tests

The fertility specialist is also required by the FDA to draw some blood to test you for certain infectious diseases, any Vitamin D deficiency, and your thyroid hormone levels. One of the viruses women are tested for is cytomegalovirus (CMV). It rarely causes symptoms but can be harmful to a developing baby, especially during the first trimester. If you have an active CMV infection, it will be treated and the embryo transfer will be paused until the infection clears.

Any vitamin D deficiency or unbalanced thyroid levels will also be treated before you begin preparations for an embryo transfer. If you are taking antidepressants, you will need to discuss if and how to stop taking them.

 

Medical Clearance Checklist Clear PAP test from within the last three years Current on all vaccinations / immunizations, including any boosters as recommended by the CDC Cleared by OBGYN for pregnancy, with recommendation to be a gestational carrier Clear sonohysterogram Any uterine polyps or fibroids removed Any vitamin deficiencies or thyroid imbalances addressed

Draft & Sign Legal Contract

Your fertility clinic will let everyone know as soon as the lab results are back. This usually takes around 10 business days. Once you have received medical clearance, the lawyers will draft a legal contract between you and the Intended Parents. (We talk more about the legal process later).

Pre-Transfer Preparation

Are you ready to learn the details of how a woman’s body prepares for pregnancy? This next part of your journey will get you up close and personal with the ebb and flow of your reproductive hormones.

It is very important that you follow the fertility specialist’s directions about when to take and stop taking birth control, when you can and can’t have intercourse with your spouse, and when you should begin hormone injections.

Some fertility specialists will work with your natural menstrual cycle. Others will want to have more control over what your hormones are doing at specific times and will put you on a protocol similar to this one:

Pre-Transfer Schedule

• End birth control pills.
• Day 1 – The first day of your cycle is when bleeding begins. Begin subcutaneous (below the skin) Lupron injections to shut down ovaries so you don’t ovulate. These are once a day, injected into your leg or stomach.

• Day 7 – Vaginal Ultrasound / Monitoring Appointment to see if the Lupron injections are working or if you need to increase the dose.

• Start estrogen injections to prepare your uterine lining. Continue Lupron.

• Vaginal Ultrasound / Monitoring Appointment to ensure Lupron and estrogen are working. Your uterine lining should be thickening to about 7-8mm.

• Day 21 — Final Vaginal Ultrasound / Monitoring Appointment to ensure your ovaries are not preparing any eggs to release and that your uterine lining is thick.

• Begin progesterone injections in the buttocks. Progesterone is suspended in oil, which requires a thicker needle. You will do this daily for 8-10 weeks. Progesterone is the hormone that sustains the pregnancy. (In a natural pregnancy, progesterone spikes when the egg implants.)

 

HOW AN EMBRYO IS MADE An embryo is made by a process called in vitro fertilization (IVF). The Intended Parents provide their own gametes (sperm and egg) or donor gametes. The egg and sperm are put together in a petri dish or test tube. Once the sperm fertilizes the egg, it grows for five days into a blastocyst. The resulting embryos are frozen (vitrified), graded, and stored for future use. The highest graded (healthiest) embryo is used first.

Embryo Transfer

Add this day to your list of exciting days in the surrogacy journey! It’s the day when the intended parents’ embryo will be transferred to your uterus.

You’ll schedule an appointment at the fertility clinic for the embryo transfer. If the clinic requires you to travel some distance, your surrogacy agency will arrange your travel and transportation. Some gestational surrogates travel with their spouse and arrive a day early. This can help reduce your stress and give you and your spouse some much needed alone time before the pregnancy begins.

Here’s what to expect:

The embryo transfer is actually quite simple and will feel very similar to a Pap smear or the vaginal ultrasounds you have become accustomed to. You won’t need anesthesia or sedation. A thin embryo transfer catheter will be loaded with the embryo (or embryos). Guided by an abdominal ultrasound, the physician will pass the catheter through your cervix and into your uterus. Then, the embryos will be released to the uterine lining. The catheter will be gently removed.

And that’s it!

After The Transfer

Many fertility clinics will ask you to lie on your back for an hour after the transfer and to limit your activity for the rest of the day. You can resume normal activity the next day, but avoid strenuous activity or intercourse.

Ten days after the transfer, you’ll go to the fertility clinic (or satellite clinic) for a blood draw. This is often referred to as a “beta blood test.” The doctor will look at your hCG blood levels. Anything above 25 mIU/mL is considered positive for pregnancy. You’ll return again in two days for another test and then again two days later to see if hCG is increasing at the right rate.

If all the numbers are doubling and quadrupling as planned — congratulations, you are pregnant! Continue injecting progesterone until at least 8-10 weeks gestation. (You will rarely need to stay on progesterone longer than 16 weeks.)

Frequently Asked Questions About Surrogacy Science

Do intended parents need to go through a medical clearance, too?

Intended parents complete their medical screening when they create their embryos, which is most often done before they meet their surrogate. Whether they are using their own genetic material to create the embryos, or using donor egg and/or sperm, the FDA requires infectious disease testing. Intended parents and any donors involved will also fill out a family history in order to account for any genetic factors when creating the embryos. 

Your health and the health of the baby is the most important part of this process, and your care team at the fertility clinic will be extremely careful in respect to the embryos they are creating for this process.  

How active can I be after the embryo transfer?

Clinics suggest taking a day of low activity the day after the transfer. Enjoy a calm, relaxing day while you can!

What about sex?

The fertility doctor may ask you to abstain from intercourse for a period of time before and after the transfer.

What about side effects?

Discuss these with your medical professional. Side effects aren’t regularly reported, but it’s best to check with your doctor. If you feel like the hormone injections are difficult for you, it’s important to reach out to your agency as soon as possible. The injections and hormones can be challenging. And if they are affecting your mental health, it is much better to tell your agency right away.

What if the transfer doesn’t work?

Yes, you and your IPs will be disappointed. It’s a given — something you have all been focused on and planning for months didn’t turn out the way you expected. It’s OK to feel disappointed. Remember, you are not a failure. Your body is not failing you. Not every embryo transfer works. And science doesn’t know why. Sometimes it’s simply a numbers game. You can try again when you’re ready and cleared by your doctor.

If the 10th day blood draw does NOT indicate pregnancy, then you will be asked to stop taking the progesterone. This will signal to your body that you’re not pregnant and that your period should come. Your cycle will begin again and you and your IP could have another opportunity to do an embryo transfer.

Remember, there are no guarantees that every embryo transfer will succeed, but following these steps provide the best odds. Sometimes, science can’t explain why a perfect embryo and a perfect surrogate uterus don’t turn out the way everyone hopes. And that’s OK. Your agency will walk you and the intended parents through every part of the process — whether it’s sad, confusing, or happy news.

 

Organization is your friend! Some gestational surrogates organize their daily injections in an over-the-door shoe hanger.  Others create a calendar with each day’s medication listed. We’ve also seen some women use a tackle box. However you choose to do it, create a system that you and your partner will be able to stick with for about 10 weeks.