21/10/2025
IVF and Surrogacy: A Comprehensive Guide
CONTENTS
(1) Outline the comprehensive step-by-step procedure for In Vitro Fertilization (IVF), detailing the major medical phases: ovarian stimulation, egg retrieval, laboratory fertilization and embryo culture, and embryo transfer.
(2) Detail the preparatory steps and initial consultations required before starting an IVF cycle, focusing on diagnostic testing, medical screening, and cycle planning for the intended parents.
(3) Detail the preliminary, non-medical steps in a gestational surrogacy journey, including: (a) criteria and process for the selection and screening of a surrogate mother and (b) the development and ex*****on of legal contracts and agreements.
(4) Describe the medical timeline of a gestational surrogacy arrangement, including the surrogate's cycle synchronization, preparatory medications, and the subsequent embryo transfer procedure. (5) Analyze the legal landscape of surrogacy, summarizing key laws and regulations governing the process (e.g., altruistic vs. commercial, international laws, legal risks) and outlining the administrative steps for finalizing parental rights post-birth.
(6) Investigate common variations, success rates, and potential risks associated with both IVF cycles (e.g., frozen versus fresh transfers, complications) and the surrogacy process.
(7) Determine the typical overall timelines and estimated financial costs associated with a complete IVF cycle and the comprehensive services required for a gestational surrogacy arrangement.
(8) Find resources and guidance related to the psychological and emotional support recommended for individuals undergoing IVF and those involved in a surrogacy arrangement (intended parents and surrogates).
The Comprehensive Guide to Gestational Surrogacy and In Vitro Fertilization: A Clinical, Legal, and Financial Roadmap for Intended Parents
Section I: Foundations of Assisted Reproductive Technology (ART) and In Vitro Fertilization (IVF)
The journey toward parenthood via gestational surrogacy begins with the establishment of the clinical framework for embryo creation, managed through In Vitro Fertilization (IVF). This initial phase requires rigorous screening and precise medical protocols for the intended parents (IPs) or genetic donors.
1.1. Preliminary Steps: Consultation and Diagnostic Screening for Intended Parents
The essential first step involves a consultation with IVF specialists to formulate an individualized treatment plan tailored to the specific circumstances of the IPs. During this crucial initial meeting, comprehensive screening tests are determined, and potential logistical or medical concerns are raised, such as the need for egg or s***m donors or the presence of familial diseases that necessitate genetic consideration.
For prognostic modeling and accurate assessment of success potential, detailed background information is collected. This includes demographic data—age, weight, and height—as well as comprehensive reproductive history. The data collection covers the number of prior IVF cycles used (categorized as never used, one, two, or three or more), the number of prior pregnancies, and the number of prior births. This information, allows for success estimates based on the experiences of patients with similar clinical characteristics, although the tools are limited to providing estimates only for individuals between the ages of 20 and 50. Clinical diagnoses, such as male factor infertility, tubal factor issues, endometriosis, diminished ovarian reserve (DOR), or ovulatory disorders like Polycystic O***y Syndrome (PCOS), are also collected to refine the protocol design.
1.2. The Standard IVF Cycle: Ovarian Stimulation and Monitoring Protocols
The core of the IVF process involves preparing the egg provider (IP or donor) to produce multiple mature oocytes. This typically involves several sequential steps:
1. Ovarian Stimulation: Medications, often gonadotropins such as Follistim, Gonal-F, or Menopur, are administered to stimulate the ovaries, promoting the growth of multiple follicles.
2. Monitoring: The development of these follicles is rigorously monitored. This involves frequent transvaginal ultrasound examinations coupled with serum estradiol level measurements to track growth and ensure patient safety.
3. Final Maturation: Once follicles reach the optimal size, an artificial ovulatory surge is induced using an administration of human Chorionic Gonadotropin (hCG) (e.g., Ovidrel, Pregnyl) or a GnRH agonist (e.g., Lupron). This triggers the final maturation of the oocytes before retrieval.
1.3. Oocyte Retrieval, Fertilization, and Embryo Management
Following maturation, the medical procedures shift to retrieving and managing the resulting gametes:
• Oocyte Retrieval: This is performed using transvaginal ultrasound guidance, a minor surgical procedure where a needle is used to aspirate the fluid containing the eggs from the mature follicles.
• Fertilization and Culture: The retrieved eggs are then fertilized with s***m, either through standard insemination or via Intracytoplasmic S***m Injection (ICSI), where a single s***m is injected directly into the egg. The resulting fertilized eggs, or embryos, are cultured in the laboratory over several days.
• Cryopreservation: In gestational surrogacy, embryos are typically cryopreserved (frozen) for later use. This allows for necessary pre-implantation genetic testing (PGT), legal contract finalization, and synchronization of the gestational carrier’s cycle.
1.4. The Decision Point: Fresh Versus Frozen Embryo Transfer Analysis
IVF offers the logistical option of transferring the embryo either during the same cycle as the ovarian stimulation (fresh transfer) or during a subsequent cycle after freezing (Frozen Embryo Transfer, or FET). This choice carries important clinical implications, particularly regarding success rates.
Clinical analyses indicate that in intention-to-treat cohorts, fresh embryo transfers historically demonstrate higher live birth rates (40%) compared to frozen embryo transfer groups (32%). This represents a relative ratio of 0.79, demonstrating a statistically significant difference favoring fresh transfers in overall live birth outcomes. Furthermore, the cumulative live birth rate of transfers performed within one year of randomization was also found to be lower in the frozen embryo transfer group (44%) compared to the fresh group (51%).
The clinical reality that FET is the dominant method used in surrogacy—necessary for logistical synchronization, legal finalization, and PGT—means that intended parents must enter the process with an understanding that maximizing success may necessitate multiple transfer attempts compared to a fresh cycle scenario. This logistical preference for FET, despite the initial statistical disadvantage per cycle, directly influences the expected financial and emotional commitment over the full arc of the surrogacy journey. It is critical to note, however, that while initial live birth rates may differ, studies have found no difference in the rate of healthy singleton live births, birth weight, risks of pre-eclampsia, or other maternal and neonatal complications between the frozen and fresh groups.
1.5. Clinical Risks and Mitigation Strategies for Intended Parents
The primary clinical risk for the egg provider during the stimulation phase is Ovarian Hyperstimulation Syndrome (OHSS). While the severity varies, serious symptoms include rapid weight gain (more than 10 pounds or 4.5 kilograms in 3 to 5 days), severe abdominal pain, decreased urination, shortness of breath, nausea, vomiting, diarrhea, and, in rare instances, blood clots.
Mitigation strategies rely on careful medical management, including vigilant monitoring of serum estradiol levels. Physicians often use specific trigger protocols, such as using Lupron instead of hCG, to minimize the risk of OHSS. Should symptoms arise, patients are advised to immediately contact a medical professional, particularly if experiencing excessive weight gain (more than 2 pounds or 1 kilogram a day), severe abdominal pain, or significantly reduced urine output.
Section II: Surrogate Selection, Screening, and Matching
The selection and qualification of the gestational carrier (GC) represent the most critical administrative and medical phase of the surrogacy process. This phase is characterized by rigorous standards designed to ensure the carrier’s safety, the health of the fetus, and the legal security of the intended parents.
2.1. Defining Gestational Carriers: Clinical, Ethical, and Legal Distinctions
Gestational surrogacy, involves a carrier who is genetically unrelated to the child, as the embryo is created using the egg and s***m of the IPs or donors. This distinguishes it from traditional surrogacy, where the carrier provides her own egg.
Surrogacy agreements generally fall into two categories: commercial surrogacy, where the carrier receives financial compensation beyond reimbursed expenses, and altruistic surrogacy, where the carrier only receives reimbursement for out-of-pocket costs. While altruistic arrangements may foster a closer emotional connection, commercial surrogacy, provides a highly structured, professional framework that ensures legal protections, defined compensation, and comprehensive support services for both the carrier and the IPs.
2.2. Rigorous Pre-Screening Criteria for Gestational Candidates
Surrogacy agencies and fertility clinics maintain stringent criteria to evaluate the physical, reproductive, and psychological suitability of prospective carriers. These requirements include:
• Age and Reproductive History: Candidates must generally be between 21 and 35 years old. A fundamental requirement is a verified reproductive history that includes at least one previous, uncomplicated pregnancy and delivery. This demonstrates proven uterine competence and capacity to carry a pregnancy to term.
• Physical Health Metrics and Limitations: Candidates must maintain a Body Mass Index (BMI) between 19 and 32. Exclusionary criteria often prohibit candidates with major pre-existing medical conditions, such as Type 1 diabetes, severe endometriosis, PCOS, or untreated mental health conditions. Agencies also impose limits on prior Cesarean section deliveries, typically accepting no more than two, or three with specific clinical approval.
• Lifestyle and Stability Requirements: The candidate must be a non-smoker and demonstrate stability, including legal residency, residency in a surrogacy-friendly state, and financial self-sufficiency (not dependent on government assistance.
2.3. Adherence to Medical and Regulatory Screening Standards
The medical screening process is exhaustive and mandatory, these are:
• Physical Assessment and Imaging: The process involves a complete history and physical examination, a detailed medical history review, a physical/pelvic examination, and specialized pelvic ultrasound imaging of the uterus to assess its receptivity for implantation.
• Infectious Disease and Laboratory Testing: A comprehensive battery of blood tests and laboratory screens is required , eg viral infections, including HIV, hepatitis, gonorrhea, chlamydia, syphilis, and Cytomegalovirus (CMV). Additionally, a urine drug screen is standard protocol as well hormones profile.
• Timeline: Due to the comprehensive nature of the medical screening, including genetic risk evaluation and laboratory analysis, the return of all necessary results and final clearance typically takes between 14 and 21 days.
This stringent, multi-layered screening serves as a critical risk-filtration step. Because the ultimate act of carrying an IVF pregnancy carries measurable, elevated physical risks, the high entry standards are essential to minimize clinical complications for both the carrier and the fetus, thereby ensuring the ethical and financial viability of the entire arrangement.
2.4. Psychological Evaluation and Establishing Boundaries
A psychological assessment is a mandatory component of the screening process. This evaluation ensures the emotional well-being and stability of the carrier and confirms her deep understanding of the non-parental role she is undertaking.
The psychological well-being of both parties is sustained through a strong support network. Establishing clear emotional boundaries is paramount for fostering respect and trust between the carrier and the IPs. Agreements must be made regarding communication frequency, the level of involvement of the IPs in prenatal appointments, and the final birth plan. Professional support, including individual and joint counseling sessions, is essential throughout the duration of the agreement to help both parties process the complex feelings and challenges that arise, ensuring a collaborative and emotionally healthy partnership.
Section III: The Medical Protocol for Embryo Transfer and Pregnancy
Once the carrier is legally and medically cleared, the focus shifts to the clinical protocol for preparing her endometrium for the successful implantation of the frozen embryo. This process relies on precise hormonal timing.
3.1. Synchronization of Cycles: Hormonal Preparation and Monitoring
The fundamental objective of the pre-transfer medical protocol is to synchronize the gestational carrier’s natural menstrual cycle with the optimal window for the frozen embryo transfer (FET).
The medication protocol often initiates with the use of birth control pills, which grants the medical team control over the start date of the carrier's cycle, a necessary step for synchronization with the IPs' or clinic's schedule. The subsequent preparation of the uterus for implantation involves hormonal therapy, specifically the administration of exogenous estrogen and progesterone to artificially replicate the natural uterine environment. This hormonal phase typically requires the surrogate to take medication for 3 to 6 weeks, though the precise duration is determined by the individual carrier's response and the synchronization requirements.
3.2. Detailed Pharmaceutical Regimen: Estrogen and Progesterone Supplementation Schedules
The success of the FET hinges upon achieving a specific, high-quality uterine lining that is receptive to the embryo.
• Estrogen Phase: Estrogen supplementation is administered to stimulate the growth and thickening of the endometrium. Monitoring of the lining thickness is conducted via transvaginal ultrasound (TVUS) 7–10 days after the initiation of estrogen.
• Progesterone Phase and Timing: Progesterone supplementation is the critical final step, begun only if the endometrial thickness is favorable (generally defined as greater than 7 mm). Serum progesterone levels are measured before initiation to rule out premature ovulation, which would disrupt the cycle. Typically, vaginal micronized progesterone (200 mg three times per day) is started after the favorable lining measurement.
• Transfer Window: The timing of the frozen-thawed blastocyst transfer is precisely calculated to occur 5 days after the initiation of progesterone supplementation, mirroring the natural window of implantation. This clinical precision highlights that the surrogacy medical process is highly standardized, but also subject to potential delays if the carrier’s endometrium does not achieve the required 7 mm thickness within the initial timeframe.
3.3. The Embryo Transfer Procedure and Confirmation
The selected, thawed embryo(s) are gently transferred into the prepared uterus under ultrasound guidance. Following the transfer, the carrier continues progesterone supplementation to provide robust support to the uterine lining, sustaining the potential pregnancy.
A clinical pregnancy test, measuring beta hCG levels, is performed approximately 2 weeks post-transfer. Confirmation of a successful implantation is typically achieved via ultrasound visualization and the detection of a fetal heartbeat, which often serves as the first major financial milestone for surrogate compensation.
3.4. Unique Medical Risks to the Gestational Carrier
Despite the rigorous screening protocols, gestational carriers face measurable, elevated medical risks compared to women who conceive without assistance. Acknowledging and planning for these risks is paramount for responsible surrogacy.
The evidence demonstrates that:
• Severe Pre-eclampsia: The risk of severe pre-eclampsia among surrogates is 1.86%. This compares unfavorably to women who had unassisted conception (0.42%) and those who conceived via standard IVF (0.94%).
• Premature Birth: Gestational surrogacy is associated with a higher risk of premature birth (less than 37 weeks gestation). The risk ratio for surrogacy compared to unassisted conception is 1.79, and compared to standard IVF is 1.27.
This statistical elevation in severe outcomes reinforces the ethical and financial necessity for comprehensive contractual protections. The intended parents must ensure that all potential contingencies—from necessary bed rest and high-frequency monitoring to catastrophic outcomes—are fully covered by specialized insurance and financial provisions, an obligation that extends beyond the base compensation fee.
Section IV: The Legal and Regulatory Landscape of Gestational Surrogacy
The legal framework is arguably the most complex component of the surrogacy process, as it involves navigating diverse state and international laws to secure parental rights and enforce the contractual relationship.
4.1. Global and Domestic Legal Diversity
The legal validity of surrogacy agreements varies significantly worldwide. This distinction profoundly impacts the legal feasibility of international arrangements.
In the many countries, the choice of jurisdiction is critical. Agencies typically require the gestational carrier to reside in a "surrogacy-friendly state". This logistical requirement is intrinsically linked to the enforceability of the Gestational Surrogacy Agreement (GSA) and the process for establishing parental rights.
4.2. The Gestational Surrogacy Agreement (GSA): Essential Contractual Elements
The GSA is the legally binding instrument negotiated by independent legal counsel for the IPs and the carrier, and it must be executed prior to the commencement of any medical procedures. Key components include:
• Parental Rights and Intent: This is the most crucial clause. It explicitly outlines that the intended parents retain full legal parental rights to the child and mandates that the surrogate (and her partner, if applicable) relinquish any claim to parental rights post-birth. The clause specifies the legal mechanism and timeline for this transfer to occur.
• Compensation and Reimbursement: For commercial agreements, the GSA defines the surrogate's base compensation and establishes a transparent payment schedule, often milestone-based (e.g., confirmation of heartbeat, 8th or 12th gestational week). Furthermore, it details reimbursement for all pregnancy-related expenses, including medical costs, travel, lost wages (if applicable), maternity clothing, and incidentals like childcare or housekeeping during extended periods of incapacitation.
• Health and Medical Care Stipulations: This section obligates the surrogate to adhere to specific medical responsibilities, including attending regular prenatal care appointments, following health-related behavior guidelines, and adhering to the prescribed medication protocols. It also clarifies who holds authority for medical decisions throughout the pregnancy, especially in unforeseen circumstances.
• Contingency Planning: Given the inherent unpredictability of pregnancy, contracts must include contingency clauses for "what if" scenarios, such as extended bed rest, medical complications, premature delivery, or, in the case of multiple pregnancies, fetal reduction decisions. Planning for these eventualities is necessary to mitigate the financial risk posed by the carrier's elevated complication rates.
4.3. Finalizing Parentage: The Judicial Process
The final legal step involves securing a court order to confirm the IPs as the legal parents. An attorney prepares and files necessary court documents, which include declarations from the IPs, the gestational carrier, her spouse/partner, the fertility physician, and respective attorneys, seeking a judge's approval on the proposed parentage order.
4.3.1. Pre-Birth Parentage Orders (PBOs)
In jurisdictions with favorable surrogacy laws, the court may issue a PBO, legally establishing the IPs as parents before the birth. This is typically only possible when the carrier is not genetically related to the child, which is true in gestational surrogacy. Securing a PBO is the preferred outcome, as it simplifies the birth registration process and ensures the IPs’ names appear directly on the initial birth certificate.
4.3.2. Post-Birth Parentage Orders (PPOs)
Conversely, many jurisdictions only provide for a post-birth order. This regulatory stance often stems from a reluctance to legally compel the gestational carrier to relinquish parental rights if she should change her mind after birth, thereby safeguarding her bodily autonomy. In these jurisdictions, a secondary, post-birth process is necessary to complete the court order and finalize the legal parentage.
The differing jurisdictional approaches to parentage orders require careful legal consultation. The law’s reluctance to force the relinquishment of parental rights pre-birth in certain states demonstrates that the contract serves primarily as a documented statement of intent and a financial framework, rather than an absolute guarantee of parental status without subsequent judicial finalization. For international intended parents, securing a parentage order in the U.S. is essential, as this legal document is required to have their parental rights recognized and honored in their home country.
Section V: Financial Planning and Long-Term Considerations
Gestational surrogacy represents a significant financial investment, characterized by high variability driven by the need to manage clinical risks and legal complexities. Comprehensive financial planning is indispensable.
5.1. Deconstructing the Total Financial Commitment
In the Kenya, the average cost of gestational surrogacy, encompassing professional fees, carrier fees, expenses, and insurance, typically ranges from Kes 1,500,000 – 2,500,000. However, the variability is substantial, and costs can be higher depending on complications, the need for multiple embryo transfer attempts, and agency/legal fees and number on unborn child. Generally, any additional child translate to additional pay out to the carriers/surrogate mother.
5.2. Surrogate Compensation and Reimbursement Structure
The carrier’s compensation is a major component of the overall cost:
• Base Compensation: This base fee remunerates the surrogate for the physical, emotional, and time commitments required, with high-end estimates reaching kes 900,000-1,200,000 or more. This may vary based on whether Intended parents are locals or Internationals.
• Variable Compensation and Fees: The financial plan must include additional payments triggered by specific medical events, such as fees for multiple pregnancies, compensation for Cesarean section delivery, and fees associated with invasive medical procedures.
• Allowances and Incidentals: Intended parents cover necessary monthly expense allowances, cycling allowances for each embryo transfer attempt, maternity clothing, and reimbursement for surrogate travel expenses. Furthermore, reimbursement often covers lost wages if the carrier requires time off work for appointments or mandated bed rest, and may include childcare or housekeeping services during late pregnancy.
The cost variability is profoundly influenced by the necessary financial buffers required to mitigate the statistically higher medical risks (e.g., pre-eclampsia, preterm birth) that the carrier undertakes. A responsible budget must fully anticipate potential failure, delays, and medical complications to ensure all contractual and ethical obligations are met.
5.3. Managing Insurance: Health, Life, and Specialized Policies
Insurance is a non-negotiable financial component for risk management:
• Health Insurance: Intended parents must secure health insurance coverage for the gestational carrier to cover all pregnancy-related medical expenses, whether through a specialized surrogacy-specific policy or by coordinating coverage with the carrier’s existing plan.
• Life Insurance: Given the elevated risks of severe maternal complications associated with gestational surrogacy , IPs are contractually obligated to purchase a life insurance policy for the carrier, providing financial security for her family should an unforeseen event occur during pregnancy or childbirth.
5.4. Legal and Agency Fee Structures
The professional services required contribute significantly to the fixed costs:
• Professional Fees: These fees cover the agency's rigorous screening, matching services, and case management.
• Legal Fees: Comprehensive legal fees cover the drafting and negotiation of the complex GSA by independent counsel for both parties, as well as the preparation and filing of the necessary parentage orders.
• Escrow Management: An escrow account is utilized to hold and disburse funds transparently, managed by an independent third party, ensuring that payments are made accurately and promptly according to the GSA milestones. Transparency in these financial arrangements is identified as essential for preventing conflicts and maintaining mutual trust between the IPs and the carrier.
5.5. Psychological and Emotional Support
Beyond the clinical and financial aspects, the psychological well-being of all parties is critical for success. Surrogacy is an emotionally taxing process, making psychological support a mandatory component, often stipulated within the GSA.
Intended parents require a support system of trusted friends and professionals to help them navigate the inevitable challenges and celebrate milestones. For carriers, individual and joint counseling sessions with mental health professionals are essential for processing complex feelings, managing stress, and maintaining clear boundaries. Connecting with other surrogates can provide valuable camaraderie and shared wisdom, further stabilizing the carrier's emotional foundation throughout the duration of the journey. The provision of professional mental health resources aids both parties in coping with the pressure and complexity of this partnership.
Conclusions and Recommendations
The path of gestational surrogacy and IVF is defined by a convergence of highly technical medical protocols, complex legal requirements, and significant financial commitment. Success depends less on individual medical skill and more on the precise management of these interconnected variables.
1. Prioritization of Jurisdictional Security: The most critical decision preceding the medical phase is the selection of a legal jurisdiction that is favorable to intended parents. The analysis confirms that the requirement for the carrier to reside in a "surrogacy-friendly state" is a fundamental legal firewall, mitigating the risk posed by jurisdictions that may favor a Post-Birth Order (PPO) model over the more secure Pre-Birth Order (PBO). Intended parents are strongly advised to seek legal counsel specializing in ART to ensure the carrier’s residence supports the most robust parental rights enforcement possible.
2. Financial Mandate for Risk Mitigation: The substantial cost variability in surrogacy (ranging up to $250,000 or more) is primarily a function of necessary risk mitigation. Budgeting must account not just for the base fees, but for the statistically elevated medical risks faced by the carrier, including severe pre-eclampsia and premature birth. Financial planning should mandate comprehensive life and specialized health insurance for the carrier, and generous contingency allowances for lost wages and bed rest to ensure the ethical and contractual support structure remains solvent even under adverse conditions.
3. Adherence to Clinical Precision: The success of the FET relies on achieving a specific physiological state, such as an endometrial thickness greater than 7 mm. The fact that FET, the standard in surrogacy, exhibits a statistically lower initial live birth rate compared to fresh transfers necessitates that IPs enter the process prepared for potential repeat cycles, financially and emotionally. Transparency and meticulous compliance with the GSA’s medical behavior clauses are essential for maximizing the utilization of the expensive embryos and hormonal protocols.
4. Integration of Support Systems: Given the high stakes and emotional complexity of the process, professional psychological support and the establishment of clear, contractually defined boundaries are not optional elements, but necessities. Maintaining transparency, particularly in financial disbursement through an escrow system, is critical to sustaining the collaborative partnership required for a successful outcome.
Footnotes
1) Always recommend to your patients for Laser Assisted Hatching(LAH) and
Embryo glueing as extra services at NO extra Costs, this is a secrets to increase the chances of implantation and pregnancy rates.
2) Not all IVF centers offers above services. Contacts us for information.
3) Where AMH levels are low(diminished/low ovarian reserve), you can recommend platelet rich plasma(PRP) for ovarian rejuvenation before making decision for egg donation program. Likewise for obstructive azoos***mia, recommended testicular s***m aspiration(TESA) before s***m donation program. We always try to give couples an opportunity to have their biological children.
4) insurances and corporate covering IVF treatment in Kenya ; Department of Defence, Kenya seeds, Safaricom, KRA, GDC(Geothermal devt corp), Kenya pipeline, Kengen, NIS, TSC, KPLC,Safaricom,Bupa global, Aetna, Judiciary,Nairobi bottlers, TSC secretariat, Kenya seeds, First Assurance, KCB. Other local insurance companies require pre-authorization for IVF treatment.
5) Always consider knowing the performance and track record of Local IVF centres through us, in terms of Success rates, professionalism and costs of fertility services, while referring your fertility clients.
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