Back in the 1980s, when Mary Beth Whitehead battled an infertile couple for custody of the baby she had carried on their behalf, surrogacy was a little-known practice that raised big ethical questions about what it meant to be a parent.

In the decades since, public perception has evolved, as has the medical technology that makes surrogacy possible. Still, today people know less about this avenue of reproductive assistance than others.

Whitehead — who, by the way, was awarded visitation rights — was what is called a “traditional” surrogate, meaning that the fertilized egg was her own. Today, those types of arrangements are a rarity in the surrogacy landscape, explains Stephanie Levich, the founder and president of Family Match Consulting.

When people say “surrogacy” now, they are typically referring to a gestational carrier, meaning the pregnant woman has no genetic relationship to the embryo. Rather, it consists of gametes from the intended parents, or donated eggs and/or sperm.

While rumors have circulated in recent years that the wealthy elite sometimes turn to surrogacy in order to avoid the hassle of pregnancy, that’s a myth.

“If you’re looking at using a gestational carrier, there have been events leading up to that decision,” says Kathleen Brennan, an OBGYN at UCLA Medical Center. Those events may include serious complications during pregnancy, severe renal diseases, a cardiac condition, congenital heart problems or infertility complications — in other words, health issues that pose a high risbut ultimately joyful  route k or make carrying a pregnancy to term impossible.

Mary Beth Whitehead
Mary Beth WhiteheadAP

People seeking out a surrogate are also committing to a major investment. In the United States, the average cost of a gestational carrier is between $125,000 and $150,000. “That’s everything: the physician, the surrogate, the legal [fees], the medication, the health care insurance for when your baby is in the hospital,” says Stephanie Caballero, an attorney and founder of a firm that specializes in surrogacy law.

Intended parents also navigate a warren of red tape. Surrogacy laws vary from state to state in the US and contracts must be entered into in surrogacy-friendly states in order to be enforceable. California is known for its generous policies, while in New York, surrogacy is allowed only if the carrier is not being compensated.

“It’s literally illegal for me to transfer an embryo into a carrier who is being paid,” says Frederick Licciardi, a reproductive endocrinologist at NYU Langone. For that reason, an embryo that was created at a lab in Manhattan might be shipped to a carrier in California to be transferred in a clinic there. “I always joke that I wish I had a FedEx map of all the eggs, sperm, and embryos in the air at any given time,” says Licciardi.

Rumors that celebrities pay surrogates hundreds of thousands of dollars are just plain wrong. “You can’t go above or below the standard,” says Caballero. Typically, a carrier receives between $45,000 and $50,000. (If she carries twins, the compensation may increase.)

In fact, one condition to become a surrogate is financial stability, a requirement meant to protect women from vulnerability. “It’s not good to have someone using surrogacy as a way to support their family,” says Levich. Furthermore, if they are on government assistance, “we don’t want to impact their income in a way that could get them kicked off support.”

Surrogate exploitation is also a global issue. Last year, India banned commercial surrogacy, to curb the expanding high-risk “womb for hire” economy there. And another requirement for surrogates in the US is that they have their own children and have a history of medically uneventful, healthy pregnancies. Without oversight or regulations, women’s future fertility, and even lives, are threatened.

“Just do it the right way and do it in the US,” Caballero says. “Work with people who are experienced in this area, and with competent doctors and health professionals.”

Where to start

The search for a surrogate begins with a decision about what will go into the embryo, i.e. the origin of the sperm and eggs.

Options include: donated sperm, either from someone you know or from a bank; your own eggs, retrieved through IVF; donor eggs purchased through an egg bank, or selected from a specific person, anonymous or known, who then goes through the IVF process.

Next comes the surrogate herself. While some agencies place clients on a waiting list, others proceed on a first-come-first-served basis, explains Levich. Her company works with clients and a network of agencies to facilitate the matching process to, ideally, speed things along.

The next steps are somewhat similar to online dating. Agencies present clients with candidates based on their desired traits; intended parents review profiles and “swipe right” on the ones they like. The agency goes back to the chosen surrogate, and if she wants to move forward, her medical records will be vetted by a physician to confirm eligibility.

Surrogates must live in a surrogacy-friendly state. In addition to healthy pregnancies in the past and their own children they are raising themselves, surrogates must meet certain lifestyle requirements (such as not smoking or engaging in drug use) and also have a BMI that is generally below 30.

If the medical records pass muster, then comes a “match meeting,” either in person or via video, where the surrogate and intended parents discuss their desires for the pregnancy experience — for example, how involved the parents want to be in the day-to-day, the relationship each hopes for after the baby is born, even social media policies.

Next comes a medical screening, where the surrogate is seen by a doctor, who is chosen by the parents; her partner may be required to have a screening, too.

What happens next

There are three outcomes, explains Levich. “One: Everything is good. Two: Something needs to be treated — like a polyp or thyroid levels — but you can move forward. Three: Something comes up that prevents this person from being a surrogate.”

If it does work out, it’s time to talk contracts. The surrogate will be represented by her own attorney to eliminate conflicts of interest, but by the time she and the parents sign on the dotted line, the agreement, and understanding, is airtight. A “parental order” gives the intended parents all parental rights.

The contract also outlines other agreements, like eating organic food or avoiding hair-dye. On the intended parent’s side, “the obligation is to pay the surrogate and support her in whatever way the contract says.”

Money is put into a trust and released on a schedule. In the event that the surrogacy is “compassionate,” meaning not compensated, the intended parents may provide other items, such as maternity clothes.

The end result

Despite the legal complications, “the medical part is surprisingly basic,” says Licciardi, a founding partner of the New York University Fertility Center since 1992. “It’s no different than for a woman who is using donor sperm for IVF.”

A surrogate will take progesterone to prepare her uterus, and potentially other medications like estrogen, antibiotics, baby aspirin and prenatal vitamins.

After the embryos are transferred, she will continue on certain pregnancy-promoting hormones for the first 10 to 12 weeks. Beyond that, says Licciardi, “the pregnancy is no different than any other..”

It’s wise to have a birth plan to state who will hold the baby first and cut the cord.

“It’s a two-way street,” says Levich. “[Your surrogate] wants to look at your baby after the birth and say, ‘Gosh, look what I did!’ Then she wants to give the baby to their parents and take a nap.”

After nine months and more of bringing a dream to life, “she needs to say hello. She needs to say goodbye.” And then, “that baby is yours.”