This article includes:
- Understanding Surrogacy Prevalence and Medical Risks
- How Do I Prepare Physically and Emotionally to Become a Surrogate?
- Establishing Medical and Psychological Screening Standards
- Long-Term Psychological Effects and Postpartum Adjustment
- Frequently Asked Questions About Surrogacy
- Strengthening Patient Care and Referral Partnerships
Surrogacy is increasingly part of fertility and obstetric care, and the questions that come with it require clinics to remain informed. Prospective surrogates ask about the physical and emotional aspects, and clinical teams need consistent answers.
Without standardized assessment protocols, readiness screening varies across clinicians, increases risk, weakens ethical safeguards, and leaves patients unevenly supported. Standardizing how healthcare organizations evaluate and communicate surrogate readiness protects patients, supports clinical teams and builds confidence with the agencies they partner with.
Understanding Surrogacy Prevalence and Medical Risks
Gestational carrier use has developed as part of assisted reproductive technology (ART) cycles. Considered as useful as fertility treatments, such as in vitro fertilization (IVF), clinical teams must consider prevalence and medical risk. According to research published in JAMA, gestational carriers were used in 4.0% of embryo transfer cycles between 2014 and 2020, rising from 2.7% in 2014.
Physical preparation begins with baseline guidance that any prospective carrier should review with her clinician. The CDC recommends increased folic acid a month before pregnancy to help prevent neural tube defects of the brain and spine. The health agency also advises against alcohol, smoking and certain drugs, and notes that being overweight or obese raises the risk of pregnancy complications.
Risk profiles require individualized attention. An Ontario population-based cohort study of singleton births from 2012 to 2021 examined severe maternal morbidity (SMM), meaning serious complications during pregnancy or delivery, across comparison groups. The study found that SMM risk was 2.3% for unassisted conception, 4.3% for IVF and a 7.8% risk of severe maternal morbidity among gestational carriers. The authors called for special care plans for gestational carriers given the elevated risk.
A meta-analysis by Matsuzaki and colleagues offers a different lens. Covering six comparator studies with 28,300 gestational carrier and 1,270,662 non-carrier pregnancies, it found that odds of hypertensive disorders were higher than in general pregnancies, while preterm birth and low birth weight were comparable to other ART pregnancies. Findings differ by comparison group, which is why individualized care planning matters for each carrier and why physical and emotional readiness must be assessed together.
How Do I Prepare Physically and Emotionally to Become a Surrogate?
Preparing physically and emotionally to become a surrogate is the question prospective surrogates most often ask fertility specialists and OB/GYNs. According to Circle Surrogacy, a full-service agency with over 30 years of experience, “It is a life-changing commitment and an emotional experience for everyone involved.”
The agency sets a BMI ceiling of 33 because carriers take IVF medications, and clinics set their own guidelines. It advises identifying diet, exercise or health changes before applying. On the emotional and mental side, the agency asks for a commitment of roughly two years, and the full process can run 14 to 20 months or longer. Carriers self-administer some injections, and every carrier needs a primary support person.
The agency also asks applicants to consider the impact of postpartum and handing the baby to the intended parents. Your clinical team should assess and communicate what health changes to make before applying, the time and support capacity required and emotional readiness needed for the full arc of the arrangement.
Establishing Medical and Psychological Screening Standards
Moving from what carriers should expect to the protocols healthcare organizations should put in place requires reference standards. The American Society for Reproductive Medicine (ASRM) publishes guidance that serves as the standard reference for gestational carrier programs. A psychological evaluation is required for all potential carriers and their partner or primary support person.
ASRM standards include:
- Carrier age and history: Carriers are preferably aged 21 to 45, with at least one uncomplicated term pregnancy and no more than five deliveries or three cesareans.
- Psychological evaluation: The evaluation should include clinical interview, testing and implication counseling, and should come before legal counseling and contract signing. ASRM calls for a joint session with the intended parents led by a mental health professional. Carriers need a stable family environment with adequate support during the pregnancy.
- Medical evaluation: Complete medical evaluation, infectious disease and preconception testing and uterine cavity evaluation are required. Single embryo transfer is strongly recommended.
Because surrogacy law varies by state, readiness protocols should also account for legal coordination before treatment begins. A pre-birth order can establish the intended parents as the child’s legal parents at birth, helping ensure their names appear on the birth certificate and reducing the need for post-birth adoption or parentage proceedings. The legal process also includes the surrogate’s psychological well-being.
According to Circle Surrogacy, “Mental health is just as important as physical health screening.” Its process includes a Personality Assessment Inventory interpreted by a licensed psychologist, which ASRM names as an example instrument for psychological readiness evaluation.
Clinical teams do not provide legal advice, but they should understand why legal review is part of a well-managed gestational carrier arrangement. Patients should be directed to qualified surrogacy counsel before contracts, embryo transfer and delivery planning move forward.
Long-Term Psychological Effects and Postpartum Adjustment
Psychological readiness does not end at delivery, and leaders should be aware of the research findings and their limitations. According to researchers, most surrogates in a UK follow-up study, “Did not experience psychological problems 20 years after the pregnancy.”
The study included 21 surrogates, 17 of whom completed the questionnaires, with arrangements dating back to about 20 years and a mix of gestational and traditional surrogacy. However, background research cited in the same study notes that some surrogates had difficulties in the weeks after birth, but that this decreased over time.
ASRM screening addresses these concerns prospectively. The evaluation reviews perinatal mood and anxiety history, and rejection criteria include a history of postpartum mood disorder or inability to emotionally separate from the child. Implication counseling covers relinquishment, attachment and the carrier’s support system. This is how screening prepares carriers for the postpartum period and helps clinical teams identify candidates who may face psychological readiness for surrogacy challenges before arrangements begin.
Frequently Asked Questions About Surrogacy
Clinical teams and administrators evaluating a surrogacy arrangement tend to ask similar questions.
What are the physical requirements to become a surrogate?
Prospective surrogates typically must meet age, pregnancy history and health criteria before acceptance into a program. These include being between 21 and 45, having at least one prior term uncomplicated pregnancy, having no more than five deliveries or three cesareans, completing medical evaluation, infectious disease testing and uterine cavity evaluation. Potential surrogates must meet agency BMI guidelines, often at or below 33.
How long does the surrogacy process take?
Circle Surrogacy, a full-service agency, notes that the process typically runs 14 to 20 months or longer, within a roughly two-year commitment. The stages covered in screening and treatment include medical evaluation before acceptance, psychological evaluation before legal counseling and contracts, a joint session with the intended parents before treatment, single embryo transfer, then pregnancy and delivery. Each stage requires time for thorough assessment and informed decision-making.
Why do gestational carriers need a primary support person?
A primary support person provides essential emotional and practical support throughout a lengthy process. ASRM’s standards require a stable, supportive family environment and include the support person in the evaluation to ensure the carrier’s network can sustain her through the arrangement.
Strengthening Patient Care and Referral Partnerships
The use of gestational carriers is increasingly common in ART practice, and baseline physical preparation must be paired with individualized risk review because findings vary across comparison groups. Long-term psychological indicators are reassuring but limited, and support systems matter at every stage.
Improved outcomes and stronger agency partnerships follow when organizations implement standardized protocols. Healthcare leaders who establish clear readiness criteria position their teams to deliver consistent, evidence-based care and to build referral relationships that best serve patients.
