Fertility and Sterility On Air - Roundtable: Elective Surrogacy

Welcome to Fertility & Sterility Roundtable! Each month, we will host a discussion with the authors of "Views and Reviews" and "Fertile Battle" articles published in a recent issue of Fertility & Sterility. 

This month, we welcome Dr. Brian Levine and Dr. Kate Schoyer to discuss if physicians should be facilitating gestational carrier arrangements in the absence of a medical indication, also known as elective surrogacy. 

Dr. Brian Levine is the founding partner and practice director of CCRM New York, where he has helped countless families on their path to parenthood. Dr. Levine is also the founder of Nodal, the premier online gestational surrogacy platform, which connects intended parents and surrogates in a trusted and transparent way.

Dr. Kate Schoyer is an Associate Professor of Obstetrics and Gynecology and Reproductive Endocrinology and Infertility at the Medical College of Wisconsin. She is the Director of the Division of Reproductive Endocrinology and Infertility and is the Medical Director of the Reproductive Medicine Center at Froedtert Hospital. Her research interests include factors contributing to success with ART, the impact of BMI, and therapies for patients with diminished ovarian reserve.

View Fertility and Sterility at https://www.fertstert.org/

Welcome to Fertility and Sterility Roundtable. This podcast will delve into sections of the journal previously unexplored in the Fertility and Sterility podcast family. Articles that we would consider some of the most timely, cutting edge, thought provoking, and dare I say, controversial.

We will be joined by a couple of the authors each month to explore the themes, debate the pros and cons, and generally expand our knowledge in a conversational format. I'm your host and F&S Interactive Associate, Dr. Emily Barnard. And I'm your co-host and producer, Dr. Ben Peipert.

We will be covering articles in the fertile battle and views and reviews portions of Fertility and Sterility. This podcast is brought to you by the Fertility and Sterility family of journals in conjunction with the American Society for Reproductive Medicine. Welcome everyone to Fertility and Sterility Roundtable.

I'm your host, Dr. Emily Barnard, and I'm joined by my producer and co-host, Dr. Ben Peipert. Today, we will be discussing the fertile battle from the February 2025 edition of Fertility and Sterility. The article is entitled, "Should Physicians Be Facilitating Gestational Carrier Arrangements in the Absence of Medical Indication"? We are joined by two of the esteemed authors today who will go head to head to debate this issue.

The disclaimer for both our interviewees today is that they have been chosen to represent the full breadth of opinions. And as individuals, even when they appear to be taking one side of the debate, they do not necessarily agree with all the viewpoints expressed. So I'd like to introduce our guests today.

And I'm going to start with the pro side of the argument that physicians should be facilitating gestational carrier arrangements in the absence of a medical indication. I'd like to welcome Dr. Brian Levine. Dr. Levine is a highly accomplished and recognized leader in Reproductive Medicine.

He holds a Bachelor's of Science from Cornell University and got his MS and MD degrees from New York University. He later completed his residency at Columbia University, followed by a fellowship at Cornell. He currently serves as the founding partner and practice director of CCRM New York, where he has helped countless families on their path to parenthood.

Dr. Levine is also the founder of Nodal, an online gestational surrogacy platform, which connects intended parents and surrogates in a trusted and transparent way. Welcome, Dr. Levine. Thanks for having me.

And here to represent the con side of the argument, I would like to welcome Dr. Kate Schoyer. Dr. Schoyer is an Associate Professor of Obstetrics and Gynecology and Reproductive Endocrinology and Infertility at the Medical College of Wisconsin. She is the Director of the Division of Reproductive Endocrinology and Infertility and is also the Medical Director of the Reproductive Medicine Center.

She earned her medical degree from the Johns Hopkins School of Medicine. She then completed her residency in Obstetrics and Gynecology at Northwestern University and her fellowship in REI at Cornell as well. Following fellowship, she joined the faculty at Cornell, where she practiced several years until moving back to Milwaukee and joining the Medical College of Wisconsin faculty.

Her research interests include factors contributing to the success of ART, the impact of BMI on fertility and therapies for patients with diminished ovarian reserve. Thank you so much for joining us today, Dr. Schoyer. Thanks for inviting me.

So just to start us off, I think one of the most challenging parts of this topic is just the language that we use around the type of surrogacy that we're talking about today. And so in some circumstances, this could be referred to as elective surrogacy or social surrogacy. What do each of you think in terms of how you'd like to refer to the topics we'll be discussing today? I, obviously being on the pro side here, and the crux of our argument is really about autonomy.

And so we believe that social surrogacy, in which there's a surrogacy relationship between intended parent and gestational carrier that lacks a medical indication of the intended parent, is really one which is based upon autonomy. Autonomy of decisions for both the intended parent to choose to enter into this agreement and autonomy of the gestational carrier who chooses to participate in this agreement. I will speak about the con side, meaning that physicians should not facilitate elective gestational carrier arrangements.

I would define elective as an arrangement in the absence of a medical indication for using a carrier. So essentially, in my mind, it's elective when an intended parent would essentially have the same like medical and psychological risks as an age-matched healthy patient who would conceive spontaneously, but that intended parent still wants to use a gestational carrier. You know, the risk is typically defined in terms of both physical and mental health, whereas I also feel strongly about the principles of reproductive freedom and bodily autonomy.

We do not feel that those rights give an intended parent the ability to transfer any risk then to a gestational carrier. So I'll kick this off to Dr. Levine, kind of from the pro side of the argument. In your article, you talk about that the intended parent's decision to build their family through surrogacy is always elective, whether that's based on medical necessity or not.

When you think about these arrangements, medical and elective or social surrogacy, do you see them as entirely equivalent or are there some kind of inherent differences that make these distinct entities when we think about this topic? So I think one of the concepts that we should dive in here, which is common to all four of us on this Zoom tonight, is what does the patient say to you on their initial office visit? And as we all know, when patients come to you asking for help, help in starting, growing, or completing their family, they pretty much all end up saying something that's very similar or the same thing, which is, I want a baby. And quite often, people say that they have this desire to start, grow, or complete their family. And a lot of people don't actually talk about the modality of how they hope to get there.

We've all seen the patient with diminished ovarian reserve or the patient with advanced maternal age, where you know almost from the offset, because we've all done this long enough, that their chances of conceiving with their own egg is pretty low. But they still say to you, I want to have a baby. They don't say to you, I want to have a baby via donor egg.

They say, I just want to have a baby. And sometimes when a couple comes to you, or even an individual comes to you, and you know they have a history of having recurrent implantation failure or multiple failed transfers, or maybe they've had multiple miscarriages, or asherment, or any of the other issues that can happen, they don't say to you, I hope to have a baby via gestational surrogacy. They say to you, I want to have a baby.

When I think about this, I do think about it in that sense, in that as physicians, we have taken an oath to do no harm, and it is our job to keep both our patients and those associated with our patients out of risk. And I do understand the con side of this, which is that the surrogates are assuming a risk that is above and beyond that they would have naturally. However, what I also think we're doing is we're helping our patients achieve their reproductive goal.

And the goal that they say to you is, I'd like to start, grow, or complete my family. And for some patients who cannot be pregnant or choose not to be pregnant, surrogacy is their only option. And so as someone who proudly believes that patients deserve autonomy in both their decision-making and with informed consent can proceed with medical procedures, I feel strongly that we should advocate for our patients that if they want to pursue gestational surrogacy outside of a medical indication of the intended parent, it is truly no different than a patient who comes to you who says, I can't get pregnant, I shouldn't be pregnant, or I can't stay pregnant.

So I would respond that patient autonomy and patient choice does give the patient the ability to accept or refuse treatment. It doesn't mean that the physician has to do everything the patient asks the physician to do. And again, admittedly, oftentimes these are difficult cases, I would like to say as an aside.

I wish I had said that in my introduction. These are decisions that we often struggle with as a group. We try to follow ASRM guidelines, but ultimately we don't feel that facilitating a gestational carrier arrangement without a medical indication is something as physicians we are obligated to do.

It's our right as physicians to decline, to do something a patient asks us to do. I argued in my piece that that's something as reproductive endocrinology specialists, it is not uncommon patients will ask us to do unindicated treatments or treatments that we do not believe have benefit, and it's our prerogative to decide when that is the case, when we draw the line. And so as much as I agree with patient autonomy, I don't feel that physicians have to, again, defer to everything patients want.

And I actually quoted Dr. Judith Daar, who I think has written very eloquently that providers are not obligated to meet every patient demand, and that this is actually a concerning area in a way in reproductive medicine. In our article, I used an example of a female athlete. And by the way, when the article was written, the newest recommendations from the Women's Tennis Association did not happen yet, right? And that's pretty awesome.

And I'll spoil it for all of our listeners here, but basically, women can be on the official tennis tour, can leave the tour to have a family come back and not lose their ranking and status on the tour. But that didn't exist when I wrote this article. And that is a change and an update since this article was published.

What most people may not know this is that even though we're sitting here in June of 25, Kate and I wrote our pieces last summer, and we actually submitted them around September of last year. And so I use the example of a female athlete where she could be completely sidelined by a pregnancy. Now, this might seem trite to some people here.

But if that is her entire career, and that's her entire earning potential for her family, and that's her entire opportunity for any of the growth for her family, to then say that pregnancy potentially would preclude her from continuing her profession, well, then I actually don't feel like this is so gray. It feels a little more black and white to me. Because for example, in that scenario, this woman saying, I want to have a family, and I want to keep providing for my family.

And if I were to be pregnant and have a child myself, there's a chance that I actually won't be able to continue to provide for the family that I dream of having. Now, again, that's a small esoteric one-off. And as Kate shared, I think very eloquently before, these are not common cases, right? Like we're actually talking about something that's not a very common request.

Now, I'm in New York City, so I probably get more weird requests and more requests than most. But again, I think that this goes back to patient autonomy. And especially in a world post-Dobbs, I mean, I'm going to be a fearless advocate for autonomy in every sense of the word.

So good points. I would give the example of Serena Williams, of course, who was a great tennis player, but she did have medical risks. So truthfully, in the examples you wrote, the one of a competitive high-level athlete, truthfully, if after discussing with that patient that it would cause her significant psychological distress, it could affect her providing for her family to have a pregnancy, that would be a case of a medical indication, I think, or a psychological indication where truthfully, after talking to the patient, if she'd spent years training to get to this point, that would be an arrangement I would be comfortable arranging.

Amazing. It's funny, it's New York City, right? And so Kate used to practice in New York, so you know that patients are highly motivated, educated, and forceful. And I had this patient walk into my office, I'll never forget this, years ago, right after surrogacy got legalized.

And for the people who are listening here, you may not realize that surrogacy has only been legal in New York State since 2021. Prior to 2021, it was actually not legally protective of intended parents and gestational carers. But shortly after it was legalized in New York State, this patient comes in, and I said, why are you here today? And she's like, oh, I suffer from tokophobia.

I was like, I'm sorry, excuse me? And she's like, I have a terrible case of tokophobia. And I was like, I am so sorry, I like to think that I'm well-read, but I'm actually trying to piece these two words together, and I'm thinking tokometer from my L&D days and phobia and fear, like, are we talking about fear of contractions? And she was like, I am psychologically scarred from losing my best friend who died in labor. And I was like, wow, that is not what I was expecting the patient to say.

And this patient was so scared of being pregnant and was so scared of having a delivery because she had a traumatic thing happen to her friend, which by the way, the likelihood of that happening to her was so low, and we talked about that. But this patient really wanted to proceed with gestational surrogacy. And this was probably one of the first cases that my group had to deal with where there really was no clear medical indication.

And to Kate's point before, what we said was that there's no clear medical indication, but there was a very clear psychological indication here that this patient was deathly afraid of being pregnant, was deathly afraid of delivery. She thought she was going to die during her pregnancy or her delivery. We had her actually see a psychologist.

When the psychologist agreed with her, we actually had her see another psychologist just to make sure that everyone was aligned. And then we proceeded with the case. Now, in 2025, we never would have gone through all this rigmarole.

We've had much more case studies. There's much more papers written about. But there are patients where the psychological harm of pregnancy could be the loose medical indication because it could feel like it's not her having a thin lining.

It's not her having implantation failure. It's not her having recurrent pregnancy loss, but it feels medically enough to perceive a surrogacy arrangement. I think a similar example, and maybe this was in your paper or it was posed in the questions, is of gender dysphoria, which to me is a slam dunk.

It's not even debatable. That would be a very clear indication. I do think many of these cases can be more nuanced.

And I think it's also important in those settings to have... We find in our group, we have a team. And I think many fertility groups do. And that helps us avoid any sense of paternalism or that one person is making the decisions about the case or having one's own individual bias too much determine the care for that patient.

So we discuss them as a group with a psychologist, nurse practitioners that are dedicated nurses, often embryologists, and come up with kind of a group decision about these cases. On the rare occasion we've consulted with our ethics committee for our hospital. But I think having the input of everyone, including sometimes pulling in MFM, like the Maternal Fetal Medicine team can be really helpful.

And you know, what's interesting is you and I have been practicing medicine long enough, Kate, to remember two embryo transfers being pretty standard. And it's funny, it's almost now, it's something that we did so routinely. We now go back and we now go to a group meeting.

And I say to the patients all the time, you've had two negative transfers, three negative transfers. I know you're begging for a two embryo transfer, but the data really supports another single euploid embryo transfer. And I tell the patient all the time, we got to talk as a group and this is what you want.

And by the way, part of the conversation of what Kate and I are talking about is called consenting and right, like informed consent. And part of the process is speaking to a patient and helping them understand that you're not the only one making a decision, that you're part of a group practice. And that a bunch of people who are smarter than me, hopefully, are going to put their heads all together.

We're going to discuss a case live. And patients actually sometimes like hearing that, right? They like hearing that you're going to go take their case and you're going to discuss it with a bunch of people to offer them an objective opinion. Because of course, I might know the patient herself or himself.

But in the end of the day, you want to get an objective opinion from people who don't know the patient who really say we're providing the best care for them. Dr. Levine, I think you've brought up some really good borderline cases. It almost seems like Dr. Schoyer would agree would be good cases for a gestational carrier or a surrogate.

Are there any cases where you wouldn't be comfortable with using an elective gestational carrier? So by the way, one piece of vocabulary, because we talked about vocabulary that I'll say, is that in my practice, and again, this is just me, but in my practice, I correct patients every day. We don't say using surrogates because I think that puts a negative connotation on how we take care of people. Instead, we work with surrogates.

We partner with surrogates. We provide care to surrogates. But I try to empower intended parents to understand that you're not using someone.

You're working with them, partnering with them. You're working together towards a common goal with them. With that said, yes, there is something very clear, Ben, that bothers me that I don't like doing.

And I think Kate would agree with this. And that is when people want to have staggered pregnancies and have multiple surrogates pregnant at once. Actually, ASRM has come pretty clearly in their statements to recommend against.

And this is a very common request. And patients get angry. And they're like, who are you to say that I can't handle two children? And, you know, the example would be, and this is actually the way it usually plays out, is that you have an intended parent who's had something terrible happen, intrauterine field demise, or sudden infant death syndrome, like where they've really had something traumatic happen.

And there's part of them that want to pursue surrogacy as almost part of a replacement therapy, as like they want to replace the loss that they had. And they want to fast track things with a sure bet. And so they think that working with a surrogate is a sure bet, which I also counsel people that surrogates are humans and that they have the same risks of a failed embryo transfer that someone else can have as well.

But sometimes what we see is that they want to replace that missing child and then grow their family faster. Like they want to make sure they didn't miss time out of having two children or three children. And I literally sit down with people and I explain the ASRM recommendations.

And people look me square in the eye and say, that's great. I don't want to do that. I want to have, you know, two kids in 12 months.

Why can't I do this? And I explain to them that if God forbid your surrogate delivers early, the second surrogate, and now you have a baby in the NICU in one state, and you have a baby that's born full term in another state, who's the parent to take care of that child? Who's the caretaker that's going to take care of that child? And when you phrase it like that, people kind of stop right there. But to answer your question, Ben, I would say that is a place where I actually draw the line. And I say to people, I follow the guidelines.

And by the way, we all know they're actually from ASRM, they're not guidelines, they're recommendations for care, right? They're not true. Like there's no teeth behind these guidelines, but there's really recommendations and a code of ethics that we all practice by. But that is an example where if someone says, I want to, you know, run two surrogates in parallel and stagger them so that I can grow my family as quickly as possible.

I tell them, that's just not something I'm going to participate in. There might be practitioners who do, but ethically and morally and medically, that is not the right way to approach this problem. So I think that's probably an example where that's where you draw the line, right? Like that's, again, referring again to like the physician code of ethics, the response to patient demands and how physicians handle that, right? And there's, as we've talked about, there's not necessarily like an absolute right answer, but that's where you draw the line, which is totally appropriate to say to a patient, no, I don't feel comfortable doing that.

I will not help you with a requested scenario. Just to build on that a little bit, it's when you think about the parties involved in these arrangements, it sounds like, Brian, you're thinking about the first do no harm to both those potential children in this situation. And I think part of Dr. Schoyer's comments in the con side is thinking about that first do no harm to the surrogate in these relationships and the fact that they're putting their body in harm's way in a situation where they otherwise wouldn't be.

I would say as physicians, like we have an ethical duty to act in a patient's best interest. And we shouldn't forget this extends both to the intended parent and the gestational carrier, in this case, potentially the children conceived. And there's also the concept of justice.

Is it, again, back to the elective argument, is it fair to ask a potential carrier to take on any pregnancy risks, which we know generally for a young, healthy patient are not excessive, but ART pregnancies are higher risk. I mean, there's no doubt about it. So that's where we've chosen to draw the line.

Do either of you think there should be more set in stone guidelines or do you think it should be more recommendations that providers can kind of interpret as they would? So we're in a weird time. We're in a weird time as a country. We're in a weird time in women's reproductive health.

And the reason I'm saying it's a weird time is that in this current administration, there's really a push for the states to control their own medical practices. I live in a state like New York, that's the first state to ever regulate gestational surrogacy. So I don't know if you guys know this or not, but certain agencies are not able to practice or do business in the state of New York unless they have a licensure within the state of New York.

And they have to apply to New York State Department of Health to even have a contractual relationship between an intended parent and gestational carrier. Now, there is some interpretations by some agencies that say the intended parents live in New York, but the surrogate does not. Do they really need to be licensed? I just, again, for my practice, we only work with agencies that are licensed in the state of New York because we want to be above the board.

My point is that there's heterogeneity throughout this country and which many people who work with surrogates like we do will become painfully aware is that the rules, regulations, and the steps that are required for parentage, for example, which is actually assigning the legal responsibilities to the intended parents, vary almost county by county and state by state. Therefore, I don't think we could have a national guideline. Now, we could have recommendations.

We could have strong recommendations. And by the way, one of the ways that we could actually see that there's some consistency across the country is, I think, back at the level of the malpractice insurers, that if the insurers required that we actually practice medicine to certain ways and they said, look, if you violate this, we're not going to insure you because, of course, no one wants to practice medicine without medical malpractice insurance. But it's really hard.

It's really, really hard to make national guidelines and to require them everywhere. When we do have this system today that's allowed for really confusing heterogeneity state by state and like, look, I practice medicine in New York. The states that touch my state have different rules and different ways that they practice.

And that's really confusing because we have patients driving from Connecticut to New York and from New York to Connecticut. The rules are different. And so that's a very long-winded answer to, I would love it.

I would love to see some strong, really strong, well-written, well-articulated recommendations, but the actual implementation is hard to do. I would say the way they define it as serious psychological or medical indication, I think there are innumerable scenarios, right? There really are of the patients, of their request-wise. So I think it is harder, truthfully, to go into any more detail than the way ASRM currently has it stated.

There's an interesting thing that's happened also in the practice of surrogacy in US. When I started in the field of reproductive endocrine, we saw quite often, especially in same-sex male couples, you'd have a two-embryo transfer and it would be one from each male component. And that practice has almost gone out the window, thankfully.

It's almost been a function of both surrogates and agencies. Surrogates coming together on Facebook groups and surrogates coming together to say, I don't want a high-risk pregnancy because people forget that by definition, a surrogate is a mom, right? You cannot be a surrogate unless you have children that are well, that live at home, that are stable. You have a stable home, stable food, stable resources, stable family resources, whatnot, but you have to be a surrogate.

And so women don't want to assume unnecessary risk by having a twin pregnancy or a high-risk pregnancy. The other thing that's interesting is the agencies have recognized that it's not a good practice because if a surrogate ends up having a preterm delivery, even with twins, her likelihood of being able to be a repeat surrogate in the future is almost eliminated because most clinics, not all, but most clinics would not work with that surrogate in the future should she have a preterm delivery. So the agencies almost recognize that they need to limit the amount of risk exposure to these surrogates so these women can, if they want to do it again, provided they meet the guidelines.

So it's just a very interesting culture shift. And I think now in same-sex male couples, you see what I would call the serial pregnancies, one partner, one embryo, one year, a year or two later down the road, the second partner with another surrogate. To change gears a little bit, this is something that wasn't really mentioned in either of your pieces.

But when I think about this topic, I kind of think about the limited supply of people who are willing and able to be a gestational carrier. And I'm kind of curious what you both think about this because it's one of the more compelling things for me when I kind of think about who should be able to access this. There are long wait and things and there are some people who cannot build their family if they don't use a gestational carrier.

So I'm kind of curious how you kind of factors into how you both approach having a more perhaps loose indication for using a gestational carrier. I would say this is an issue, although I'm always amazed by patients' ability to find carriers, not only through agencies, but through social media or through friends or someone who hears a compelling story. So it can be hard and it's such an important relationship.

I think we all probably have had patients who've maybe matched initially and it's just not a good fit for various reasons. So probably that plays a role in our feeling that we shouldn't facilitate these arrangements for elective reasons, but it's probably more of an issue for someone who offers carrier arrangements even to elective cases in his practice. So I'll let Brian comment on that.

Sorry. So I have this schizophrenic life where some days I play doctor and other days I play founder. And so at CCRM, of course, I painfully understand that we're supply constrained and I understand fully that the wait times have gone from three to six months to now nine to 18 months.

And that's the industry standard. And the cost of surrogacy, by the way, when it was legalized in New York was $75,000 all in. And now that's gone.

And now we're at 150 to 250. And by the way, for the listeners to know, the cost of surrogacy has not gone up because the surrogates have unionized and demanded higher compensation. It is because the agencies have now charged more for their management fees and have really recognized that this is so supply constrained that supply and demand economics have taken hold.

With that said, when I put on my founder hat from Nodal, I'm amazed at the number of individuals who are unaware of an opportunity of becoming a gestational carrier. So since starting Nodal in 2022, we've had over 30,000 women apply to become surrogates on our platform. And I was like, 30,000 people have applied? Like it's nuts when I think about that number.

But in reality, only 1% were qualified. The gross majority were not qualified either. They were not done with their childbearing, which by the way, is a very important thing for people to understand that you must be done completing your own family because of the risk of having a hysterectomy or having a pregnancy related complication.

They were too young. They were too old. They were too overweight, too underweight.

They had a comorbidity, things like that. But what I think is interesting about the supply constrained argument is that we're also just probably as an industry, society, professional group, however you want to phrase it, also probably not doing a good enough job at educating people about surrogacy. I think in this country, surrogacy continues to be cloaked in this opaque nature where it feels like it's only accessible by the famous.

The only surrogacy stories that you ever hear about in the news are Kim Kardashian or Paris Hilton or Priyanka Chopra, all of these famous celebrities. And what most people don't realize is that those three individuals each had a medical indication, by the way, for working with their gestational carrier. And Kim Kardashian's actually been the most public because she had severe preeclampsia and she had a terrible case of preeclampsia for her second child, which is why she proceeded with surrogacy for her third and fourth.

But what a lot of people don't realize is that we don't talk about surrogacy. In fact, Kate and I trained at the same institution, and I can guarantee neither of us had a single lecture to talk about how does surrogacy work in America. I think that was also because at that time in New York State, carrier arrangements weren't being facilitated.

But even in having an SREI-approved fellowship, learning for national practice, because we all don't end up practicing in New York, we never even had a conversation about how does surrogacy work? How do you synchronize someone's endometrium? How does this happen? I even think a lecture on what are important criteria in a gestational carrier. That's where having done an OB-GYN residency ultimately in just common sense comes into play. But we get presented cases all the time from agencies, do you think this would be an acceptable carrier? And it's like, sometimes things are borderline, sometimes they're challenging.

So I agree there probably is room for more education of trainees on not only how to select a carrier, navigating the relationship as a provider. I mean, I'll tell you, I have privileges at Lenox Hill, which is a small community hospital on the Upper East Side of Manhattan. And I was talking with some OB-GYN residents at our graduation party a few weeks ago for the resident graduation.

And one of the residents goes, hey, have you ever had one of these surrogacy things? I was like, yeah, all the time. I was like, I ended up doing probably three surrogacy cases a week. And she's like, what do you call the woman in the room? I'm like, what do you mean the woman in the room? She's like, the woman who gives the birth.

And I'm like, she's the gestational carrier. And they're like, but what about the woman who gets the baby? I'm like, she's the intended parent. She's like, but who's the mother? And I was like, it's the intended parent.

But what I realized from this conversation of this very bright eyed and bushy tail and super enthusiastic first year resident who probably wants to be an REI and just wanted to go talk to an REI during the graduation party is that we don't talk about surrogacy. It is part of obstetrics. And we don't talk about how this works.

And by the way, if you go look at hospitals, hospitals don't even know what to do for the intended parents and where they should stay. Do they stay in the hospital? Do they not stay in the hospital? Are they allowed to have a room? Are they taking up a room on postpartum? Like, even the culture of how this all happens or like, my favorite is, I found an SOP, you know, a standard operating procedure for what's called surrogacy handoff. I was like, this sounds terrible.

Like surrogacy handoff, and that's your SOP. But like hospitals want to know how to communicate this to their staff. And so I think this is really cool in that there's an educational gap here.

And I think it's our responsibility as REIs to educate our OBGYN colleagues about how surrogacy works to hopefully remove the veil, help them understand it's still a facet of taking care of patients, help them understand that it's in its early nascent stages, but that this is the only place on earth, meaning the United States, where you can have these ultimate protections for intended parents and carriers equally in legally binding contracts that protect everyone there. I do think that traditionally, I mean, obviously no one does traditional surrogacy anymore, right? The patient is both the carrier and the provider of the egg. But they are extremely meticulously handled by legal teams.

That's one thing I'll agree with you with, Brian, that there is room for education and increasing public awareness that this can be, when medically appropriate, like a very safe and reliable option. Yeah, and actually can be fulfilling. And it really can be good.

Because by the way, I don't know if you've seen this, Kate, when surrogacy got legalized in New York State, what I started seeing was obstetricians who were upcharging for surrogacy births. And I'm like, you're doing no extra work. What are you doing? And they're like, just trying to take advantage of an emotionally vulnerable situation.

And then there are providers who are like, oh, I don't do surrogacy. I'm like, but you do elective C-sections on maternal request, but you won't participate with someone who needs to have a surrogate carry their pregnancy. They're like, nope, I don't want to be part of that handoff.

It's too emotionally charged. Like, I don't do that stuff. And what's amazing is there's an educational gap that's there.

But OBGYN should appreciate caring for the carrier who would have a lower medically risk pregnancy. I do love that we're giving some very good credibility to the argument that we have to have this strong generalist foundation to be good REIs. It is great to hear.

Well, Brian, you were talking about the fact that compensated surrogacy became legal in New York. And I think the elephant in the room that we really haven't talked a lot about here is this balance between the surrogates autonomy and the influence of financial compensation in these elective surrogacy arrangements. And so I'd love to hear both of your guys perspective on that.

So compensation to surrogates in America as of 2025 is on the rise and it is going high and fast. I saw a surrogate the other day, a profile for my intended parents who is requesting $105,000 as a first time surrogate. And I was like, oh my gosh, like I've never seen a number like that before.

By the way, the average surrogacy compensation in America is approximately today about $48,000. That's like the industry standard for compensation. And I asked the parents, you know, the compensation that she's requesting.

Why are you sending me this profile? And they were like, well, we fell in love with her when we met her. And so whatever she wants, we'll pay. And it's interesting because I do think, Ben, you bring up a really valid point, which is it's illegal in the United States to sell your kidneys.

It's illegal in the United States to sell your blood. It's not illegal to be compensated for the time and effort required to become an oocyte donor. And it's not illegal to be compensated for the time and effort required to become a sperm donor.

And of course, it's not illegal to be compensated for the time and effort and risk associated with it to become a gestational carrier. But I do think that we need to have some guidelines and recommendations placed about compensation so that people fully understand what they're doing going into these arrangements. Either so they're not taken advantage of, right? So it's not an arrangement where someone's being compensated $20,000 and the agency's charging $200,000, but also not where a surrogate is being encouraged to charge $105,000 because the agency can then upcharge their fee so then they can charge $350,000, $450,000 for their arrangement.

So it's a really slippery slope. And I think money complicates a lot of things. Yeah.

I mean, obviously, it's very ethically justifiable that carriers are compensated. It's appropriate. I think many studies written about carriers say that the primary motivating factor was altruism.

But a secondary factor is the financial aspect. I suppose, just from an ethics standpoint, would there be a case for some carriers where the financial compensation became the largest reason? And would that be reflected in someone charging a high amount? Who is the person to screen that? I think that's a hard case, like the case that Brian gave about his patients who really liked a specific carrier. So I think it's probably a very hard area.

And there probably is a lot of geographic variability as well. So what's fascinating is, again, through Nodal, we actually ask carriers, why do you want to become a carrier? And so right now we have 30,000 patients of data. And by the way, spoiler alert, if you go to ASRM this year in San Antonio, we're actually presenting our findings as an abstract for the third party reproduction.

Because I think it's important to talk about these things, like what are the motivators behind people becoming a surrogate? And here's the crazy part of the story, is that when you talk to people about the awkward part, the compensation, you then dig deep for a second, you say, what are you going to use the money for? And it's almost always for a major life expense. The most common life expense that we hear is we live paycheck to paycheck, and we haven't saved a dime for our kids' college education. We have zero educational savings.

Or we have been living in an apartment forever, and we finally have the ability to elevate our family to buy a house, and we can make a down payment. Now, is that ethically right or wrong? I think that puts a lot of pressure on that woman to become a surrogate. You wonder if there's an element of coercion there.

But this is what people are really doing with their compensation. I will say that the educational component is the most common one. By the way, Nodal, I thought the most common thing I was going to hear is like credit card debt or student debt, like paying off some sort of bill that's looming.

And it's almost always related to the family that they have. And it's either we're looking for a home, we're hoping to move, especially, by the way, in military families, the partner's looking to leave the military, we have questions about what we can do next or whatnot. But the compensation is this sticky, icky part that is fascinating about what is the monetary motivation and why.

And yes, you're right, Kate. Almost always they tell you first, I feel guilty, I loved being pregnant, if I could help someone else, I'd love to. I mean, you're closer to Canada than I am.

And in Canada, it's illegal to be compensated as a surrogate, right? All of it has to be altruistic. Yeah, I mean, I would also that's very interesting to hear what carriers plan to do. But ultimately, it's irrelevant, right? They do the compensation due to the role they play in helping someone build a family.

I absolutely agree. It is not our place to say how to spend their money. I have one other thing I would say.

And that is, you know, we in, back to the concept of like reproductive autonomy, I live a state, in Wisconsin, I at times have missed living in New York for more than one reason. But one reason has been the last few years, you know, since the Dobbs decision and 1849 law concerning abortion was put into place.

So for a period of time, access to abortion was not available in Wisconsin. So we have seen firsthand how valuable and how tenuous state to state these rights are. And it's been a stressful time.

We all have followed cases like the case in Birmingham, you know, in Alabama, assigning personhood to embryos. So these have been things we've all followed closely. In some states, we worry more about these things.

We have really felt though, that using the elective use of a carrier without an indication is separate. And we've kind of separated that from the concept of reproductive choice, because of the physician rights to the second patient, that being the gestational carrier. And ultimately, our stance we feel is a way to protect gestational carriers with kind of the concern for the second patient in the relationship.

The one thing I'd like to leave everyone who's listened to this conversation is to recognize that this conversation is unique. You probably cannot find any other content on the internet right now, of two highly trained individuals who are debating something that seems rather benign, but overall is very important. And what this means is that there is a dearth of conversation that's happening about surrogacy in America.

And what I hope someone takes away from this conversation, maybe it's a trainee, maybe it's someone who's early in their career, or someone who's established in their career who doesn't feel comfortable working with surrogacy today, but looking to expand their practice, is that they reach out to Kate and I. These are conversations that we should be having with our colleagues all the time. What are our best practices? What works for us? Where do we draw the line? Where is our icky zone? What feels comfortable, doesn't feel comfortable? But I actually hope this goes to more of a national conversation, and I would love to see that ASRM has more conversations about third-party reproduction. Because if we look at the political climate today in America, much of what's going on puts third-party reproduction at risk.

And those are communities of individuals who, without REIs, cannot start, grow, or complete a family. That's members of the LGBTQ+ community. Those are women who have a medical indication, for example, for surrogacy, who may have had a devastating diagnosis of cancer.

Those might be people who have no eggs, have no sperm. But more importantly, as a bigger conversation, what I hope we see here is that third-party reproduction is not just kind of the stepchild of REIs, but actually becomes a focus of topics of conversation for further development of conversations about how we could all be doing better to help elevate the groups that we take care of. And because in the end of the day, a third-party reproduction patient is still a patient.

And I think as Kate said really well, we have an ethical responsibility to the patient sitting in front of us. And when you work with surrogates, sometimes you could have three patients sitting in front of you, four patients sitting in front of you. And I think that together, we need to have more conversations about third-party reproduction in America.

Right. I mean, I agree with that because family building is a right and is something that all of our patients should have access to. We hope this podcast inspires both those experienced with advocacy efforts and newcomers alike, as this is a critical time in our field, both with potential opportunities and new challenges.

Thank you so much for listening. Until next time.