Dr Gad Lavy, M.D., F.A.C.O.G., Medical Director and Founder of New England Fertility, and Melissa Brisman, JD, explain everything related to surrogacy and egg donation and discuss treatment in the USA.
Dr Lavy explained that the New England Fertility IVF clinic’s focus has been on what they call third-party reproduction, which involves egg donation, surrogacy, or both. Attorney Melissa Brisman is one of the pioneers of surrogacy reproductive law and surrogacy in the US.
According to Dr Lavy, the medical process is IVF and, in very simple terms, to have a baby it’s necessary to have sperm, eggs, and a uterus. The sperm can either be from the partner or a donor, the eggs can be from a woman or a donor and the carrier could be a woman’s uterus or the surrogate’s.
Dr Lavy remarked that he feels lucky to be able to offer all the different options because everybody has their own story and issues. By having these different options, Dr Lavy can help almost everyone and expand his clientele: heterosexual couples, same-sex couples, and individuals male/female.
The centre of the medical process is In Vitro Fertilization. The first IVF baby was born in the late 1970s, and since IVF came onto the scene it
revolutionized the treatment of infertility. Nowadays, since the beginning, there are around 10 million IVF babies in the world, and it has become one of the primary methods of treating individuals who are trying to have a baby.
The embryo, or fertilized egg, is called a 1-day embryo, 1 one cell with 2 nuclei. The embryo grows extremely fast:
This allows us to perform genetic testing and, essentially, take a few cells from the part of the embryo that will become the placenta. By doing this, it’s possible to know that they’re not harming or affecting the baby. Usually, for the creation of the embryo, they start with an egg donor with about 20 eggs. After the genetic analysis, they normally end up with 6 to 8 genetically normal embryos; however, each one of these embryos has a high chance of success.
Why are young egg donors generally recommended? The table below demonstrates why genetic testing is preferred to be done on young donors. According to Dr Lavy:
The younger the person, the younger the woman, the more likely she is to have genetically normal embryos.
Even though egg donors are young women who’ve been carefully screened and tested, there’s still about 30 or 40% of their embryos being genetically abnormal. Therefore, by doing the genetic testing, the medical team can pick one embryo and expect to have a very high chance of success.
Dr Lavy mentions that he prefers to transfer a single embryo to avoid the risks associated with twins. Nevertheless, some couples interested in having twins, can discuss having two embryos transferred and the chances of having a pregnancy of one or two is very high, and there’s about 60 or 70% chance of having twins.
Unless you really want to have twins, you should only do one embryo. It’s really not worthwhile to transfer two embryos just in order to increase the chances of success if you’re not interested in having twins.
According to Dr Lavy, there are several things to consider, such as the chances of success, the risk to the mother and the baby, and the cost of IVF in general and, particularly, with surrogacy.
In case patients are interested in having twins, Dr Lavy along with Melissa Brisman, they’ll find a surrogate that’s not only willing to carry twins but also someone who’s medically able and with a reduced risk.
Obtaining the sperm sample is usually the first step of the IVF process. However, it must be taken into account whose sperm it will be used.
Nevertheless, no matter where the sperm comes from, the doctor makes sure that the sperm is normal and, once it’s determined they’re normal, the sample will be frozen. At the same time, all the regulatory testing to work with a surrogate, required in the US, is carried out. This is called the FDA testing which is a panel of infectious disease testing that has to be done in an FDA laboratory within a certain time (when the sperm or eggs are given). This is all part of a formality.
This process for Europeans, explains Dr Lavy, can be arranged to be done in Europe, meaning the sperm to be frozen, the testing to be done and then shipped to the US. Therefore, it’s not necessary to go to the US just to give the sperm sample.
What’s the medical process for the eggs?
This will be discussed during the consultation to find the right solution and the right way for the patient to do it.
When using an egg donor, Dr. Lavy says, they look for women who are very healthy and have good eggs. One very initial screening is to take young women. For this reason, they always have donors under the age of 30, mostly between 20 and 28.
They also make sure donors are mentally healthy, non-smokers, have no drugs, good family history and have good ovarian function.
It’s also part of the screening of the donors to make sure they’re doing it for the right reason because the doctor also worries about donors making sure they don’t do anything they’ll regret down the road. Therefore, he spends a bit of time on the psychological and physical assessment of the donors.
With the advancement of technology, especially in the field of genetics, it’s possible to test around 300 different genes and make sure that the sperm and egg of the donors aren’t carriers of the same abnormal gene. This way, it can be guaranteed that the baby won’t be affected by that condition.
Egg donors can come in different varieties.
One of the advantages of egg donation in the US as compared to Europe, for instance, is that the parents can get a lot of information about the daughter up to the point that if the couple is interested in meeting with a donor, either in person, on the phone, on Skype or exchanging emails, it’s possible.
Dr Lavy clarifies that donors from the US have a very detailed profile with information and pictures (patients will be able to see what they look like). It’s also necessary for the patient to decide if they want to have any kind of connection with the donor and this is a very personal decision which is available. Topics such as what options are better and what advantages or disadvantages each one of them has can also be discussed.
Some of the donors have donated before, and in the US, no law controls that. Nevertheless, the guidelines the Doctor has is that the donor doesn’t donate more than 6 times. They try very hard to make sure that once the donor donates, for example, in Europe or a certain country, she won’t do it again just to reduce the risk or the possibility that the siblings can meet.
Nonetheless, some of the donors who have donated before, some people believe they’re better than donors who are doing it for the first time. According to Dr Lavy:
There’s no difference. The success with the first-time donor is just as good as it is with a proven donor, which allows you to have a wider selection.
In most cases, the process goes according to the selection of the donor. Therefore, the patient picks the donor from a list, the donor goes through the IVF process, and her eggs are harvested to create the embryos. These are fresh eggs.
The alternative is to pick eggs that have already been harvested and frozen. This option is relatively new because the technology of freezing eggs is young.
One of the topics discussed with the patient, in a thorough manner, is “What is the right thing to do?”. Whose uterus is better?
Following Dr Lavy’s explanation, medical condition is a very broad term. Sometimes it’s a life-threatening condition that puts the woman’s life at risk if she becomes pregnant, but other times they’re women who just have concerns or anxiety about being pregnant. This is also a legitimate reason to choose a surrogate.
How to find a surrogate in the USA? Similar to the donors, surrogates have to be healthy women. The profile of a surrogate is very different from an egg donor, for instance:
It’s important to know that the egg donor as well as the surrogate’s motivation is right and that they understand the responsibility of taking this job. It’s also necessary to make sure that they’ll be compliant with whatever they’re told to do to maximize their chances of success.
What is the screening and approval for the surrogate?
When starting the surrogacy journey, the patient will see an attorney Melissa first. She will explain and ask questions to find the right match.
Pregnancies, deliveries, c-sections, any complications, compliance all those things we check to see which hospital she delivered, how far the hospitals are from our home and what happens if there’s a complication that requires a higher-level centre for her to go to.
During the meeting, it’s recommended for the surrogate and the parents to get together. For example, for Europeans, it can be done online (Skype or Zoom). This is very important to get a good feel of who the surrogate is. The counsellor or psychological counsellor facilitates the meetings which, during the first meeting, can be a little bit awkward.
In other words, you like the surrogate, the surrogate likes you, we think it’s a good match and if everything is good, then we’ll send you to the agency to finish all the legal arrangements before we move on to the contract.
Dr Lavy emphasizes the topic of choosing a Proven or First-time surrogate by saying the following:
People, basically, intuitively feel that if you look for someone who’s done it before, who was familiar with the process, who’d had a baby through surrogacy before, that woman will make a better surrogate than someone who’s doing it for the first time.
This is considered a misconception by the doctor because there’s data that shows there’s no difference in the success and there’s no reason to narrow the search to dodge the women who’ve done it before. This way may be quicker to find a surrogate.
Melissa Brisman, JD, mentions that it’s excellent to be able to work with a facility that also has egg donors. Therefore, when people go to the US, they only have to go to their office because they have the agency as well as the legal department. Also, the facility has its own egg bank, so people don’t have to have as many facilities which may be confusing for people from abroad.
Melissa has been working in this area for about 20 years and founded an agency Reproductive Possibilities, 20 years ago, and had around 2,500 babies through surrogacy. She had all of her kids through gestational surrogacy.
Why come for surrogacy to the United States? According to Melissa, these are the following reasons to go to the US:
What are the requirements for using a gestational carrier? Melissa Brisman explains some of the elements needed for surrogacy, which are the following:
How to simplify the process? As there are so many elements, Melissa recommends having them all in one place. Therefore, she advises having a one-stop shop, meaning an agency that can do everything except for the medical aspect. For instance, Melissa’s agency has legal escrow and finds the carriers all in one place.
The patient must also find a clinic, like New England Fertility, that has worked with gestational carriers and foreign clients before as they’ll be able to do a lot of things through Zoom and reduce the number of visits to the United States.
Some of the key things to be aware of when doing a gestational surrogacy are the following:
How is the process done, step by step? The agency finds a carrier for you.
In this first step of the process, Melissa wants to make sure of two things. The first one is to see Dr. Lavy if you can use your own eggs to create an embryo and the second one is to know what’s important for you to find a carrier. For instance:
According to Melissa, you should work with a clinic to make the embryos while they look for the carrier to stay in the year-and-a-half timeline. So, you can use your own gametes or donor gametes. In addition, there are a few things Melissa wants you to think about:
Melissa recommends meeting with the carrier via phone or video call in which someone from the agency will be as well. They want to make sure that you’re on the same page on a lot of big issues such as your feelings, how the pregnancy will go, and how the delivery is on par. After this, the carrier will be screened.
As Dr Lavy explained, you have to do a medical screening which involves looking at the medical records of your carrier, making sure it’s safe to have another baby and there were no extreme complications in her last pregnancy.
There will be a psychological meeting as well as a criminal background check on the carrier and her partner or husband, and a home study to make sure it’s a safe place to live, that she takes care of her kids and that’s generally the type of home environment it’s comfortable with a pregnant woman residing.
In the clinic, the following tests will be done:
Some administrative aspects will take place, such as:
During the matching process with the carrier, Brisman will match you with a carrier in a state, not only where surrogacy is allowed, but where it’s okay for your particular circumstances that you’ll be placed on the birth certificate.
For instance, in Tennessee, birth orders aren’t allowed for people using an egg donor. For this reason, Brisman would only get a carrier here if you were using your own gametes, however, if there’s any chance of using a third-party egg donor, there wouldn’t be a carrier. This is very important to be up on the wall and all the states and the different parameters.
It’s emphasized that you should plan to be in the birth 2-6 weeks after birth. What are the legal parts of the process? Some things matter the most while picking the carrier, such as:
When looking at the law, Melissa will consider the following:
All of this is important, and the different states will have different laws based on all these factors.
Once she has all of these factors, she’ll be able to consider the best date for the particular person and gamete being used.
Melissa Brisman goes on by explaining that there are 50 states in the United States and each state has different laws. Therefore, you’ll be matched based on your marital status, the gametes and the state; they need to pick the best law for you.
What does the contract involve? While this is done, it needs to be ensured that the attorney is representing the parents as well as the very important carrier. Moreover, the contract may not be enforceable if the carrier doesn’t have her own representation.
If the carrier doesn’t know someone who specializes in this area of the law, the agency helps her find one. As Brisman says, there are organizations for reproductive law where attorneys can join. In these organizations, they can find someone for their career.
Some of the things that must be in your contract, as explained by Brisman, are:
Once the contract is completed and the carrier’s lawyer has gone over it and it’s negotiated, the funds will be escrowed to pay the carrier. This is done for two reasons:
Moreover, Brisman states that her escrow funds are fully insured, and you should make sure that any agency uses their escrow funds for theft from employees or hacking.
After all of this, you go to the procedure and hopefully, your carrier is pregnant. Most carriers will agree to 4 embryo transfers and, by the first or second, she’ll be pregnant. Here’s when you get the birth order.
If there’s only one parent, it’s called the sole parent order. The order is usually gotten before birth and in some other states, it’s done after birth. For example, in Israel, the birth order is required to be done post-birth. Therefore, Brisman wants to make sure they’re doing the order correctly, so for immigration purposes you can safely leave your home country and get citizenship for your baby.
It’s also important to know if you’re going to possibly use an egg donor. As previously said by Melissa, when you pick a carrier, the state has different laws if an egg donor is used. Therefore, Brisman picks the carrier based on whether you’re using your eggs or not as well as considering the possibility of using an egg donor in the future.
She’s also going to pick a carrier that’s good for an egg donor because if you switch to donor eggs, she’ll have to get you a new carrier.
In the United States, egg donors can be known as not-identified, meaning that all egg donors will eventually be able to be identified with at-home DNA kits that you can get. Nevertheless, you can get a donor who is not identified, which means she doesn’t know who you are and you don’t know who they are, but you can also meet them if you want. In New England Fertility you can find these types of donors.
What is necessary to know for a successful journey? There are two big things to know, according to Marissa, for this journey:
You want to make sure that all the parts are there.
As far as using a donor as opposed to continuing to try with your own eggs – that’s always a very difficult decision to make. You’ve done IUIs, you’ve done IVF with abnormal embryos – it sounds as if egg donation is probably the right choice. Again as long as the uterus is normal the success with an egg donor is very high. In your case, we have to actually take the issue of adenomyosis into consideration. Adenomyosis is one of those conditions that is sometimes really difficult to know if it actually affects the chances of success. Typically, adenomyosis is a condition that women develop after having a baby. Having adenomyosis in someone who has not been pregnant or has not had a full-term pregnancy is somewhat unusual and it really depends on the severity and the extent of the condition. This condition, essentially, is a situation where the glands that are normally on the surface of the lining of the uterus for some reason grow into the muscle. That can create symptoms like pain, heavy bleeding and in some severe cases can affect fertility. The MRI is probably a good first step but if the MRI looks reasonably normal if the adenomyosis is not very severe, there’s some additional testing that you can have to look at the function of the uterus, not just the structure. Those tests sometimes require an endometrial biopsy where you take a sample of the lining. With those tests, you can actually tell if the uterus is not only structurally normal but also functionally normal. If it is, then it’s definitely worth a try and if there is a question, it’s probably because it’s such a big step to take and it involves no significant cost and emotional investment, sometimes surrogacy is the answer.
Basically, the requirement from the FDA is that the testing should be done at the same time when the sample is collected. It is a blood sample that we sent to the lab and it’s a sperm sample that we freeze. Ideally, they both need to be done at the same time. What we’ve done with the international clients/couples is that we will send you the kit – it’s a small box with some test tubes. When you give the sample for freezing, you can have some blood drawn and that blood is processed and sent directly to the FDA in the US. We have quite a bit of experience with that and we can point you in the right direction to find a clinic that’s willing to freeze the sperm, collect the blood and help with the shipping. We’ve been successful with this for many different countries, not just Europe, also Hongkong, Israel, India so it’s certainly possible. Especially nowadays, saving you a trip abroad can make a huge difference in the process.
n the United States, there is no legal age limit so if you could find someone to treat you at any age, they can. However, most clinics and agencies will have certain limits, the average is in the 50s. Our agency doesn’t like to treat clients unless there is one partner under 60 in the relationship. Basically, 59 and a half is our age limit. We do let people use the same surrogate again if they’re over that age limit for a sibling but, in general, you can technically be any age. But I think once you hit the 60s you’re going have some difficulty finding somebody.
I’m the founder of the agency, Reproductive Possibilities, so we are finding our own surrogates for all our clients. As I said at the beginning, we’ve had 2,500 plus births so that is done in-house. We do have a team of 20 working on finding the carriers and coordinating all the aspects.
It’s a good question because as I mentioned freezing eggs is a relatively new technology. Freezing embryos has been around for a very long time and it’s a pretty standard procedure. The technology we use now for embryos, sperm and eggs is called vitrification. The problem is that eggs have actually been a little bit late to the game because the egg cell is the most difficult cell to freeze. Much more difficult than sperm and more difficult than embryos. From our experience in our laboratory, we get the same success with frozen eggs as we do with frozen embryos. However, for me it’s always a little bit of a dilemma to say that you can send me your frozen eggs from whatever clinic and we will create the embryos here because I need to know a little bit more about the lab where the embryos were created their success, their experience, their exact technology. The simple answer is if you’re going to ship eggs or embryos, I’d rather you ship the embryos, rather they created the embryos because that way we can be much more comfortable that what we end up getting when we thaw is going to be viable. So the simple answer is embryos are better than eggs but, of course, it has to be done on an individual case basis.
Yes, you can. The thing about the success of IVF is that success goes down with age. Usually, it goes down with age because of the woman’s age and the reason it goes down is more to do with the eggs and with the uterus. Assuming that the fibroid surgery was successful and the uterus is structurally and functionally normal, then it comes to the question of what is the likelihood that someone who’s 42 or 43 can actually create a genetically normal embryo. In fact, that’s why I’m a very strong believer in doing the PGS, the genetic testing of embryos because then you know for sure that you have an embryo that’s viable. What we know from experience and statistics is that when you’re 42 or 43 most of your embryos you produce are genetically abnormal, over 90%. Of course, it’s possible that you will generate a genetically normal embryo but you may need to do IVF a number of times and it may never happen.
But again, if you’re going to do IVF and you’re in your 40s, I really think that doing PGS is important, and also growing the embryos through the blastocyst stage because then you know for sure that what you have is really viable. For example, doing a transfer on the second or third day after fertilization is not really enough time to be able to properly evaluate the embryos. Even if the embryo does grow through day 5 and becomes a beautiful blastocyst, there’s still a fairly high probability at 42 or 43, that it will be genetically abnormal. You have to know what you’re getting into when you say I’d like to try with my own eggs. I understand that using an egg donor is s a huge step, is a huge decision, one that you don’t want to take lightly. It may be worthwhile to try but you want to avoid the trend to do another one and another one and another one doing the transfer on day 3 where the embryos look good but it doesn’t work or there’s a miscarriage. Yes, it’s a complex answer but yes it’s possible.
We both offer package deals so our company does have a package that you can get multiple surrogates if it doesn’t work. We can’t guarantee you that a baby will come out but we will offer you a very large number of tries with different surrogates so we do have those programs available.
Here it’s not just your age, it’s more than values. The FSH and AMH. With an FSH of 20 and a very low AMH your chances of actually creating a genetically normal embryo are pretty low. I think your chances of having success with IVF are probably in the low single digits. There is IUI, there’s IVF with your own eggs and there’s egg donation. In my opinion, someone at your age with these numbers should not do IUIs and should think two or three times before they actually commit to IVF because the chances being so low. It’s possible and everyone is different and how they feel but you need to understand what you getting yourself into. There are people who have 2-3% chance of success, some people would say well you know that’s better than zero and let’s do it and for other people, it’s not high enough to justify all the effort that goes into it. It’s a very individual decision but, objectively speaking, someone with this profile should use an egg donor.
The price to do surrogacy if you do everything in the United States including the IVF, use the agency, find an egg donor through New England Fertility is about a USD120,000 to USD 150,000 depending on various factors. We have two different packages: one is a premium package that guarantees you a certain number of surrogates. The price difference in those two packages is only going to be a few thousand dollars so it’s not going be what pushes you to the 120,000 vs. 150,000 is really how many times it takes the carrier to get pregnant, not the different packages that you have. Let’s say you have a package from both New England Fertility and our office, you still are going have to pay for the surrogate’s travel to get to the clinic, her lost wages, her fee of $500 every time she has an embryo transferred, if they have a miscarriage they get certain payment. It’s really based on things that we can’t estimate exactly like whether or not to get pregnant right away and whether or not there’s a miscarriage in the beginning.
The actual cycle itself is pretty quick; it’s between 2-4 weeks depending on exactly where they are in the cycle, how much Lupron, whether or not they ovulate but actually having a pregnant surrogate is an 18-month process on average to have a baby. Usually, by the time they start, it’s about month 9 by the time they’re pregnant and then obviously there are 9 months towards delivery so it’s about 18 months to take home a baby.
I’d like to add that if we’re ready to start I suggest we do it in a parallel track meaning that we get the sperm that’s usually first, find an egg donor if you need an egg donor, that usually takes a couple of months and as soon as we have the sperm and the eggs, we make the embryos and that way by the time we find a surrogate (which takes a little bit longer than finding an egg donor), we already have the embryos waiting. That way we can move right away into the embryo transfer. If someone is anxious to get it done as quickly as possible, that’s the best way to approach it as opposed to let’s make the embryos, make sure we have embryos and then start looking for the surrogate because that’s going to obviously make it a little bit longer.
People always ask me about the timeline and also the timeline is when you start. Somebody can say: I came to see you and it’s taking me two and a half years but when they came for their consultation, they actually didn’t fill out their paperwork or start making their embryos for a year because this is a lot to digest. The timeline starts also when you actually start moving. It doesn’t start from the first time you see us; you have to actively start making your embryos and actively start working with our agency to select our carrier. You have some control over the timeline; we can speed it up a little bit, we can slow it down a little bit like. Right now some people are asking to take a break for a month or two until the travel restrictions are lifted so that’s reasonable as well.
It’s actually simple. First of all, there’s no way to improve your AMH. The AMH really is not a problem; it’s only a marker. It essentially tells you what your ovarian reserve is, how many eggs you have indirectly, how many eggs you would get if you did IVF and indirectly the quality of the eggs and the chances of success. The AMH is not really a problem that you want to fix. The AMH, the egg reserve also does not have any impact and your chances of becoming pregnant when you use an egg donor. Many women that have a low AMH still have normal cycles but even if you don’t, if your cycles are not normal, even if you have no cycles, it’s still possible to create a cycle using hormones and still have exactly the same chance of success with IVF with an egg donor.
We have both available; during the process, New England Fertility has counseling available on staff that is who is going to screen her carrier. We also have a network of providers that we work with in addition to provide counseling. There is post-surrogacy support especially more for surrogates than the intended parents because the surrogates sometimes suffer postpartum depression or when their hormones are fluctuating. You will have lots and lots of support both from the agency, the doctor’s office and the various counselors that both of us have on staff.
The big issue that we face both with egg donation and sperm donation as well is that there is no real control over how many times these donors can donate their genetic material. Of course, the solution would be to have a registry when you donate whether it’s sperm or your eggs, you are registered and the number of times you donated, the number of eggs or sperm that are out there in the world from the same donor. Unfortunately, that does not exist in the US and to my knowledge doesn’t exist elsewhere either. It’s left to us, the providers, to have some kind of accountability or responsibility to make sure that doesn’t happen. I mentioned the fact that we try to limit the number of donations within the country. Outside of the US, we try to limit the donations within the same state in the US but that’s something we do on our own and it’s not required. It would be great if one of those registries actually was created.
This is a lot of different questions wrapped up in one. If your gestational carrier (surrogate) has medical complications, she will have health insurance and those medical complications will come under the health insurance, usually, for up to six months after a miscarriage, birth termination. You will be responsible during that time for what we call in the United States co-pays – those are usually minimal payments but you also have to keep your health insurance in place if you were paying for it. All this will be covered in the contract to limit everybody’s financial exposure – you’re having insurance for this. After six months this is a risk that the carrier takes so if, for instance, she has a lifelong medical problem that is not something that you will be expected to pay for. If the embryo doesn’t implant usually they agree to try up to four times and that’s obviously up to you and the physician if you think it’s worth it to try again. Most of the time if the embryo does not implant, the physician is going to try again. Obviously, if it doesn’t work four times, you’re going change something whether that be the egg, the sperm or the carrier.
As far as issues with the relationship that’s why we have lawyers, psychologists and social workers to help you work through that. There’s always something unexpected. I’ve been doing this for 20 years and I’ve been dealing with unexpected things all month due to the virus. Usually, if you’re at an experienced agency they will know how to handle it. If it’s unexpected, we will know how to handle, if we won’t know exactly but we’ll know where to go, what to do if we have to contact the senator or the passport office so we have to take things as they come sometimes.
