Surrogacy 101 for Intended Parents

Welcome

We built Roots to be the agency that we would like to use if we were an intended parent or if we were a surrogate. That was back in 2015, and now, in 2026, we manage 150 surrogacy cases a year and have had over 500 babies born through surrogacy across the globe.

This educational format is intended to help guide, educate and serve all of our parents. We know that no parent's journey is the same in surrogacy. I tell my clients that when you get into surrogacy, it feels like you're dropped in the middle of the ocean. You know you're supposed to swim, but you don't know how far or how long. The intent here is to get you oriented, make sure you understand the basics about surrogacy and specifically about Roots, and get you to a place where you feel comfortable and confident moving forward. So welcome, and I can't wait to get to know you.

The Three Boxes

The format of this is to talk high level first, and then we'll go into the details of each category. The way I think about it, surrogacy is broken into three boxes.

The first box for intended parents is wait time. This is where you're waiting for a profile, waiting to get to know somebody. During that time, we're vetting surrogates.

The middle box I call prep. This is preparation for IVF and the transfer itself, from the time you're matched until the time you transfer. A lot happens in this box. We're getting your surrogate's medical records reviewed, we're matching you, we're doing a medical screening of your surrogate, we're doing a psychological evaluation, she's starting medications and we're doing the transfer.

The last box is pregnancy. There are a couple of differences between natural pregnancies and surrogate pregnancies, and we'll go through those. So wait time is box number one, prep is box number two, and pregnancy is box number three.

Box 1: Wait Time

Okay, let's get into it. Box number one, wait time. This is agency specific. All you're doing is waiting on somebody's wait list to get from the bottom to the top, where you're eligible to see profiles as they become available. One agency may be 12 months; another may be six months. All good agencies have a wait time, not because we want to, but because we have a parent surplus. Many parents are accessing US surrogacy, and there aren't enough healthy women to carry those babies.

So you've onboarded with Roots and you're waiting. What the agency is doing at that time is vetting surrogates. We spend all of our time, 365 days a year, vetting surrogates, getting them introduced to surrogacy and making sure they're the right fit for our community.

Here's what happens in the vetting process. The surrogate has to apply, and that application covers all of the things your clinic is going to look for. She's between 22 and 39 years old. She has a healthy BMI. She has a healthy pregnancy and delivery history: she has to have had a full-term pregnancy with no complications. She can't have had more than five pregnancies. She can't be breastfeeding. She can't have any mental health diagnosis, et cetera. There's a long list that qualifies surrogates for our program. Those lists vary agency to agency and doctor to doctor, and ours is very specific and very strict.

Assuming she can move forward, next is a four-month process for us to get to know the surrogate and make sure she's a qualified candidate. Ultimately, we want to make sure this woman is the same kind of person we would want to carry our own children.

In month one, we educate her about surrogacy. We want her to understand all of its complexities. This is not going to be the same as carrying her own pregnancy. She's going to meet with doctors she doesn't know. She's going to have to travel and be away from her family. She's going to have to do a medical screening. All of these things are new to her, and we want her to understand what that looks like. Even if she's a repeat carrier, we go through the same process, because the doctor she meets with or the clinic's parameters may be different this time.

At this time we're also doing a social media audit of her Facebook, Instagram, Snapchat and TikTok. We want to know what she's putting out in the world and whether she's a good fit for our culture. We're looking for responsible, respectful, communicative human beings who have their heart in the right place and want to carry a baby for somebody else. For example, if you're promoting your very successful OnlyFans page or you're dancing on a bar in Cabo, you're probably not the best fit for surrogacy at this time.

Next month, we gather all of her medical records. This is arguably the most important part of vetting a surrogate. We need to know what's happened in her prior pregnancies; the best indication of future pregnancies is past pregnancies. So we look in depth. The records are reviewed first by a nurse with a PhD in our field, who writes us a report to make sure there were no complications in her pregnancies or deliveries. We also have them reviewed by an MFM, a maternal-fetal medicine specialist, who is an OB-GYN who specializes in neonatal babies. They read all the records, meet with the surrogate, go through her past health history and also write us a report. So we have a good picture of her health history, pregnancy history, delivery history and postpartum.

Next, we do a background check. We are the only agency in the country that uses a private investigator. The reason is that there's no federal or statewide database that catches every criminal arrest or conviction. So we have Phil. Phil is our private investigator. He calls every county the surrogate has ever lived and worked in, and we find out about any criminal arrests, convictions, civil disputes, litigation, bankruptcies or divorces. Anything that's happened in that surrogate's life, we want to know about it. We also do that for anybody in her household over the age of 18. If she has a partner, a nanny, a spouse, or her mom or grandma lives there, whoever it is, they get a background check as well.

Then we do a random drug screen. We tell her, "We have this lab for you. Can you please go get it done?" It covers drugs, alcohol, nicotine, an STI panel and a CBC, so we know about any complications ahead of time.

Lastly, we do a psychological evaluation. This happens in multiple parts, but this part is an evaluation of the surrogate's emotional and psychological health, related to surrogacy and in her past. She meets with a provider in our space, talks through her emotional history and gets educated about the emotional complexities of surrogacy. She also does some behavioral testing related to telling the truth, honesty, et cetera. All of that happens while she's in box number one and you're waiting.

Box 2: Prep

Box number two, prep. This is the exciting part, when things really start to move quickly. You've been waiting however long, you get to the top of our list, and now you're ready to match. The surrogate has completed her psychological evaluation and is moving into box number two too.

That doesn't mean the two of you will automatically match. We're looking at your personality, your expectations, her personality, her expectations and your clinic's expectations. At the very bottom of that list is geography. We don't take geographic requests. I would love for your surrogate to live very close to you, but it probably won't happen. We have to focus on the best match, not necessarily the closest. If those two things align, of course we'll make that happen; it's easier for everybody. But if not, beautiful relationships happen across the entire US. We're looking for alignment.

We review profiles internally twice a week. Once we find a profile that seems great for you, we'll send an email that highlights the best parts of, say, Erin, and any flags, like "Erin doesn't have health insurance; we need to get that for her." It comes with her profile, a detailed document about Erin: her hobbies, interests and likes, what she's willing to do and not do in surrogacy, all of her pregnancy and delivery history, and some pictures of her and her family. It also comes with a surrogate benefits package, a document that lists line item by line item how much the surrogate costs. She's already signed it, so she knows what to expect. We send it so that you know what to expect too, and nobody has to fight about money.

If you like Erin, great. You say yes, we want to move forward. Then I do the exact same thing on the other side and send your profile to Erin. She'll review it, ask questions and get to understand what you're looking for, and we facilitate all the answers. If she's a yes, then you're pre-matched.

At this point we take a pause. Welcome to surrogacy: hurry up and wait. We pause because we're sending all of her documentation (her medical records, her psych evaluation and her background check) to your clinic. How long your clinic takes to review them varies, but it's generally somewhere between two and six weeks, so it's a longer pause. Your doctor goes through the records and says either "We see what you see; everything looks great" or "We need more information or documentation."

If a match is going to fall apart, it generally happens right here. There's so much gray area in medical records that we can't know for sure a doctor won't say, "It's okay for this parent, but not this one," or "We like this, but not in combination with that." It's unlikely your surrogate will fail medical screening once we've gotten her all the way to your clinic, but it is possible they'll say they don't like her on paper. If that happens, you stay at the top of the list and we find you a new surrogate. Hopefully it doesn't happen: they love her, they say yes, and the surrogate moves forward.

Then we do a match call. We facilitate it, because we don't want you to fumble through the first meeting with your surrogate, or her with you. The match call has a few purposes. First, to introduce you and make sure you're connecting and have some things in common. Second, to build a plan: two weeks, two months, two years. What does this all look like, and how will it function? Lastly, to talk about the big components of surrogacy: communication, termination, money and travel. If there are specific requirements or requests, like "We only have one embryo," or "We'd like you to eat organic food," or the surrogate wants to know more about your mosaic embryo, this is the time to talk through the nuts and bolts of this particular match, so that everybody makes an informed decision about moving forward. If everybody loves each other, great. You're matched.

The next step is the medical screening. We fly your surrogate to the clinic where your embryos are stored or being created, and a doctor in that practice evaluates her medically. That includes a physical; a transvaginal ultrasound, looking inside her uterus for any polyps, scarring, tissue, fibroids or anything else that could be problematic in pregnancy; and labs: her general health, red and white blood cell counts, liver function, thyroid function, any communicable disease that could be passed to the baby, and drug, alcohol and nicotine testing again.

She'll be there about 36 hours. If you want to meet up with your surrogate in person, that's amazing, and it's a great time to do it, since she'll be at your clinic. You can take her out to Jamba Juice, or go to dinner. I would love for you to connect. She'll go home after the medical screening, and we usually wait about seven days for the labs to come back.

When the labs come back and everything looks great, we go through the legal process. Legal is collaborative in nature. We don't call it opposing counsel. We're not forcing people to do things they don't want to do; we're trying to protect everybody involved, which means the parent, the surrogate and ultimately the baby. You'll be separately represented: parents by one attorney, the surrogate by her own attorney. You'll go back and forth through your attorneys on the gestational carrier agreement, which is the legal relationship between you and your surrogate.

It details everything required by the state where the surrogate lives. That state governs what happens here. If your surrogate is in Colorado, the GCA happens in Colorado. If she lives in Missouri, it happens in Missouri. It doesn't matter where the parent lives; it matters where the surrogate lives. The GCA is specific: these are the players, this is what the surrogate will do and won't do, this is what the parents will do, and this is what the state says needs to happen. That process usually takes a couple of weeks, sometimes a little longer depending on schedules. Then everybody signs and notarizes, and we're ready to go.

This is the exciting part for everybody except the surrogate, who now has to start injectable medications. It's literally a pain in the butt. She generally starts on Lupron, which turns off her ovaries, because we don't need them; we're going to use one of your embryos. Then we start her on estrogen, and seven days before transfer, progesterone.

We monitor her locally at a fertility clinic, so she doesn't need to keep going back to your clinic just to make sure the medication is working. This process is called outside monitoring. She'll be checked to make sure her lining is growing and everything looks good. Then we do the transfer at your clinic. We get her there the night before, she transfers the next day, usually stays that night and goes home the day after.

There's no such thing as bed rest anymore; surrogates don't need to be on bed rest. Again, if you want to meet up with your surrogate at transfer or after, I absolutely love that. It's not required, but surrogates would love it, and parents usually love it too. Then she goes home.

Ten days post-transfer, we test to see whether it worked. This is the most frustrating part of surrogacy, because the average first-time transfer success rate in the United States is 40 to 60%, so roughly 50-50. The first transfer may or may not work, so we're cautiously optimistic at this point. If you only have one embryo, we can talk through what that looks like, but most people have two, three, four or ten embryos. You would stay with the same surrogate for a second transfer, and up to a third.

We test for the hormone hCG 10 days post-transfer. If that number is over 50, great. We'll keep testing every couple of days to make sure the number is doubling, which is a good indication of embryo health. We can confirm a fetal heartbeat at about six weeks gestation. The surrogate stays on her medications until about 10 or 11 weeks. At that point we know the placenta is big enough to maintain the pregnancy on its own, so she can wean off the medications and move from reproductive endocrinology into obstetric care with her OB.

Box 3: Pregnancy

This is box number three. She's now about 10 or 11 weeks along and moving into obstetric care.

A question we get often is whether we know who the OB will be. Yes and no. We will know who the obstetrician is, but it depends on where she starts. If the surrogate has an OB who has delivered all three of her babies and she loves them and they have an established relationship, we're not changing that. But if she doesn't have that relationship, or she does but the OB doesn't take the surrogate-friendly insurance we need to get for her, she'll have to move OBs. We have somebody on our team who specifically vets the clinic and OB she'll be going to. What is their online presence? Have they managed surrogates before? What is their relationship to the LGBTQ community? There's a list of 30 questions she asks, so we know the surrogate is going to a good OB who is licensed and in good standing with the board.

At this point the power dynamic shifts a bit. Up until now, she's been with your doctor. Technically it's her doctor too, but you established care with that doctor first. Now she's establishing care with an OB, and you're the other people involved. The way to navigate this is to show up for appointments. You don't have to be there in person; you can join by telemedicine. FaceTime with your surrogate and ask your questions. It's a good opportunity to bond with the OB and ask all of your medical questions. I'd rather you weren't playing telephone: "Hey Erin, can you ask the doctor why the heartbeat is 153 beats per minute?" The doctor will tell you that's totally normal for babies. Those questions are better directed to the OB, so you get the information you're looking for.

There are a few differences in obstetric care for IVF surrogacy compared with a natural pregnancy. First, she moves into OB care a little later than normal. Usually you'd start at six or eight weeks; here it's 10 or 11 weeks. We still do all the same testing as in a natural pregnancy: NIPT, first-trimester screening, second-trimester screening, glucose testing and so on. Even though you have genetically tested normal embryos, testing is done by humans, so we want to make sure.

Second, the pregnancy will be deemed high risk. That's a somewhat outdated understanding. IVF pregnancies are generally considered high risk because the person going through IVF has some sort of infertility, which isn't the case in surrogacy. But it will be deemed high risk, just so you know.

A couple of other things. In natural pregnancies, the embryo splits into identical twins 2 to 3% of the time; in surrogacy it's 4 to 5%. So there's a slightly elevated risk of multiples. And for managed care, as we talked about, you'll need to establish a cadence with your surrogate to get you into the room by FaceTime, Google Meet or whatever you decide to use.

The pregnancy then goes just like it normally would. The surrogate generally meets with the OB once a month through the end of the first trimester and most of the second. Closer to delivery, she'll meet more frequently to make sure the baby is still growing and moving.

Delivery

Delivery is a little different, because there are a lot more people in the delivery room. When the surrogate delivers, yes, you should be there. Your baby's being born. You can cut the cord, and you can do skin-to-skin.

We'll already have gone through a legal process called a pre-birth order. We only work in states that have pre-birth orders. Your attorney or the surrogate's attorney goes to the judge and says, "We're going through surrogacy. These are the parents, this is the surrogate, and this is the attestation of the embryologist or reproductive endocrinologist saying this was always the intention: to have a baby through surrogacy." The judge says, "Great, no problem," and signs off, and you are now the parents. We share that with the hospital's birth clerk and social worker, so they know there's going to be a surrogate birth. As soon as the baby comes out and takes its first breath, you are the parents.

The first five or 10 minutes are a flurry of activity. One nursing team is looking after you and the baby, and another is still looking after the surrogate, who still has to deliver the placenta. One of the things they're doing is separating the patients: we came in as one patient and now we're two. Once that happens, you get your own room. You can take the baby there, do skin-to-skin bonding and work through newborn care with your own nurses. You can go back and forth to see the surrogate and show her the baby. Her kids will probably come to see her and give her some love, and it's really good for those kiddos to be able to say goodbye to the baby too, because they've been loving on that baby for the last nine months.

You're usually there 24 to 48 hours, and then you can go home. Babies can fly, so if you live far away, you can get on a plane in the first week. The baby will be checked by a pediatrician in the hospital, who checks input, output and hearing: Is the baby eating and healthy? Is the baby peeing and pooping? Can the baby hear?

Breastfeeding

One question that comes up a lot is whether my surrogate is willing to breastfeed, and what that looks like. It depends entirely on the surrogate and the intended parents and what their needs and wants are.

In the hospital, milk doesn't usually come in right away. What does come in is colostrum, a nutrient-rich, very thick liquid that sustains the baby until breast milk comes in. Because it's so thick, the best way to get colostrum from breast to baby is to put the baby on the breast. Some parents don't feel comfortable with that, and some surrogates don't either. You can pump colostrum too; you just lose a lot of it, because it has to go into an eyedropper and then from the eyedropper to the baby. It's totally up to you, but that is the easiest way to get colostrum.

If the surrogate is willing to pump after the hospital, we have a whole system in place. She pumps, puts the milk in the freezer, labels and dates it, and it's shipped overnight to your house. You put it in your freezer, and you have breast milk.

If your surrogate is unwilling to pump and you do want breast milk, luckily we have 150 other surrogates who are postpartum and either done pumping for their own parents or whose parents didn't want them to pump. I'd rather connect you with those surrogates than go to a milk bank, because I don't know anything about the people in a milk bank. We're happy to facilitate breast milk for any length of time. Some people do it for the first two weeks, some for two months, some for two years. It just comes down to alignment, and we'll have that conversation.

Overall Timeline

From here to baby, it's generally about a 16-month process, not counting the wait time. Going backwards: wait time is agency specific and can vary even within an agency. At Roots, we have different plans and pricing, which we'll go through.

The middle box, prep, is usually four to five months. It isn't agency specific; all agencies have to do it. This is when we're preparing surrogates for IVF. Then there are nine months of pregnancy. So it's four or five months plus nine months, plus the wait time. If you're matched today, it's four or five months to get your surrogate ready and then nine months of pregnancy. That's how the process works overall. Let's get into the next chapter.

Legal & Escrow

Let's talk about legal and escrow. A couple of things to note right away. Agencies have guidelines they should be following, and two of them relate to legal and to the financial side, escrow.

First, you should not be using in-house attorneys. If somebody tells you they have an attorney who works for their agency, that attorney works for the agency, not for you. If there's a problem, they have a conflict of interest, and they'll protect the people they work for. You need independent counsel. We're happy to refer you to an attorney in the state you need, but it's important to use independent counsel.

Second, there is absolutely no reason in 2026 for any agency to be holding escrow. Escrow is a big beast all on its own. Just like when you're buying a house, it's a bank account associated with you specifically. We put all of the money in there so that you don't run out of money while your surrogate is pregnant. There are two major players in escrow, SeedTrust and Clarity Trust. They're big fintech platforms, and they hold 90% of the wealth in surrogacy and egg donation. There's no reason not to use one of them.

The Gestational Carrier Agreement

So what does legal actually look like? You'll have an attorney, and your surrogate will have an attorney. You pay for both, and we facilitate that through escrow. Your attorney is the drafting attorney, and they work on two parts: the gestational carrier agreement (GCA), and the pre-birth order.

For the GCA, the agency gives your attorney all of the information about the match: what the surrogate benefits package says, what our agency requirements are, who the surrogate is and who you are. Your attorney drafts the agreement and sends it to you to review. This isn't like your Verizon contract where you just sign. It's a negotiated document, so read through it and highlight any questions. Your attorney will meet with you, go through it, make sure you understand everything in it and make any necessary changes.

Then we send it to the surrogate's attorney, and she goes through it with her attorney and asks about anything she has questions on. It goes back and forth between the two attorneys. It's not that complicated and shouldn't take that long, but we want to make sure everybody understands it and is comfortable with the language.

What goes in it? All ACOG recommendations: the surrogate won't eat hot dogs, soft cheeses, sushi or high-mercury fish, and won't drink alcohol or smoke. Behavioral activities she shouldn't do: she won't jump out of an airplane, go scuba diving or go mountain biking. All the things not to do while you're pregnant. Then what the parent will do: the parent will pay her this amount, at this time, for this reason, line item by line item. And any specifics for your case: "I have a peanut allergy, and I want my surrogate eating peanuts every day because exposure is good for the baby," or "I want her to eat organic food," or "We want her to deliver at a particular hospital because my husband has privileges there and we want the right doctor." Whatever it is, the specifics of your case go in there. Once everybody agrees on all the parameters, you sign and notarize, and the GCA is done. That happens before transfer.

Funding Your Account & Using Escrow

Right when you sign your legal agreement, you fund your escrow. How much is agency specific. For us, parents fund the surrogate's base compensation plus $75K. So if your surrogate's base compensation is $60K, it's $60K plus $75K. If it's $100K, it's $100K plus $75K.

What comes out of it? Everything except agency fees and clinic fees. All of the surrogate's payments, insurance, travel, medications: everything for the remainder of the pregnancy is paid through escrow.

Who's in charge of escrow? It's a fintech platform, and you have access through a portal. You'll see every distribution that's requested, every distribution that's granted and all of the receipts associated with them. We're the disbursement requesters. For example, we know the surrogate is paid once a month, which is how her base compensation is paid, so we request that she's paid once a month pursuant to the gestational carrier agreement.

If it's in the GCA, it's approved, no problem. Clarity or SeedTrust will say, "Yep, it's in the GCA. We'll pay it." We don't need parent approval. If it's not in the GCA, we need parent approval to pay it. We can't just say, "We want to pay this person this amount for whatever." For example, I might say, "I know you're really busy, and Erin's birthday is coming up. Do you want us to get her a present? Give me a budget." You say, "Yep, $100. Please get her something." We buy it on the Roots credit card and then get reimbursed through escrow. When I submit the $100 receipt for Erin's birthday flowers, SeedTrust or Clarity will come back and say, "That's not in the gestational carrier agreement. I don't see her birthday in here." And I'll say, "You're right, we need parent approval. Parents, can you give a thumbs-up so Roots can be reimbursed?" That's how escrow works: if it's in the GCA, it's paid automatically, and if it isn't, we need parent approval.

How Surrogates are Paid

A couple of notes about how surrogates are paid. Surrogates get a base compensation and a bonus structure. Base compensation is paid on the first of the month for eight months during pregnancy. As long as she remains pregnant, she gets her base compensation divided over eight months. So we don't pay a lot up front, and we don't pay a lot at the end.

The bonuses are timed events, generally early on, before base compensation starts. The first time she's ever paid is a legal bonus when she signs her legal agreement. That's not because she signed it; it's because she's had no compensation for all the time she's spent onboarding with us, the IVF, the medical screening and all of that. So we pay her a bonus at that point. She also gets a maternity clothing allowance and a housekeeping allowance. There are a few bonuses along the way to make sure we're valuing her time and her commitment to the process. All of that comes through escrow.

At the end, we do an audit of escrow. We make sure all the bills are paid: the hospital bills, the doctor, everything. If there's any remaining balance in escrow, it's returned to you. The only exception is if you're a Total Assurance client, because that's an all-inclusive package. We'll talk through that in plans and pricing.

The Pre-Birth Order

So that's the gestational carrier agreement and how it works together with escrow. I told you legal has two pieces. The other is the pre-birth order.

The pre-birth order generally starts at about 24 weeks, which is the baby's viability, and we use one attorney or the other who's involved in the case: your attorney or the surrogate's attorney, it doesn't matter. They put together a document that says, "Judge, we're part of a surrogacy arrangement. These are the players: the parent or parents, the surrogate, and the embryologist or reproductive endocrinologist. On such and such a day, we transferred this embryo, we subsequently have this pregnancy, and we intend to be parents through surrogacy." The judge says, "Understood," and signs. Now you're not only the assumed parents but the legal parents of the baby.

As soon as the baby comes out and takes its first breath, you're the parents who make all the medical decisions. You have all the rights any parent would, and you're on the birth certificate. There's no mention of surrogacy. You're simply the parents: parent one and parent two, or mom and dad, depending on the state.

This document is put in place while the baby is in utero, which is what "pre-birth" means, so you establish parentage before the baby is born. If the baby were born early, before the order was in place, you're still the assumed parents, because we only work in states where pre-birth orders exist. Your attorney will go ex parte, meaning the same day, and get that document for you. Even so, you'll be the assumed parents, with all the same rights and responsibilities to your baby in the hospital and beyond.

So legal has two parts. First, your gestational carrier agreement, which happens before transfer, where you work with your attorney on the document that governs the pregnancy. Then, mid-pregnancy, the pre-birth order that says you're the parents, you'll be on the birth certificate, and this baby is your right and responsibility.

Insurance

Insurance is a complicated topic, and I'm glad we're here to discuss it. I'm not an insurance expert by any means, but I've gone through lots and lots of these, so here's how it breaks down.

Four ways a surrogate can be insured

There are a few ways we look at a surrogate to determine whether she has surrogate-friendly insurance. That means she currently has a policy, through her employer, her partner's employer or an independent ACA policy, that covers her medical costs, including pregnancy.

However, over about the last 15 years, insurers have started excluding surrogate pregnancies. What they're saying is: if Erin got pregnant on her own with her partner, we'd cover that baby. But if Joe and Bob want to have a baby through surrogacy, they're not members of United or Blue Cross Blue Shield or whoever, so we don't want to pay for them to have a baby. It's happening more and more. So your surrogate may have a policy that's surrogate unfriendly, and in that case we need a new policy that will cover the pregnancy.

Or your surrogate may have a surrogate-friendly policy. We've had it reviewed, and it says that no matter what, it will cover the pregnancy for Erin, whether it's a surrogate pregnancy or her own, because she's a member. This is great. It just saved you about 30 grand.

She could also have no insurance at all, or a policy we know isn't eligible, like TRICARE or Medi-Cal. We can't use any government-assisted policy. TRICARE is a government policy through the military, and Medi-Cal is California's Medicaid program. If she has either, we'll need to get a policy for her.

The last option is a lien policy. A lien policy says, "We'll cover the pregnancy, but we want to recoup some of the cost." So the insurer takes a lien on the surrogate's base compensation. With Kaiser, for example, the lien is negotiated at 33% of the surrogate's base compensation. If the base compensation is $60K, they'll recoup costs up to $20K. If it's $10K, you'll pay $10K. If it's $100K, you'll pay $20K, which is the maximum.

Then there are other insurers who are greedy and want to recoup 100% of the cost. Blue Shield of California is one of them, so we won't use them, because you could be on the hook for any amount of money. One hundred percent of what they supposedly covered becomes a lien on the surrogate's compensation. If your surrogate's base compensation is $100K, plus $10K in bonuses, plus her deductible, you could be on the hook for over $100K.

So there are four ways a surrogate can be insured: she isn't insured, or her insurance won't cover a surrogate pregnancy; she has surrogate-friendly insurance, which is great; she has insurance that isn't eligible, so we can't use it; or she has a lien policy. When you see your surrogate's profile, it will say which one.

Buying a policy for your surrogate

If we need to buy insurance for the surrogate, there are two ways to do it. One is through the ACA, during open enrollment. It's state specific, but generally it opens November 15th and closes around the first of the year. During that window, all Americans can purchase insurance, and we can purchase insurance for our surrogate. We go to the ACA and say, "We have a surrogate. She's this many years old and lives in this county and this state. We need a surrogate-friendly policy." We use a broker called ART Risk, which has been doing surrogate and egg donor insurance for 25 years. They find the policies that will cover surrogates and surrogate maternal care, and we purchase one of those.

"Brooke, there's a problem. We're going to transfer in June. We can't insure our surrogate until November 15th, and that policy won't even start until January 1st. What happens?" A couple of things can happen. One is a policy called Bridge the Gap, made for exactly this reason: it covers the time from when you don't have insurance until you can get insurance through open enrollment.

Or there's Lloyd's of London, which came in and said, "We have a better idea. Let's insure surrogates any time of year." We can use a Lloyd's of London policy that's specific to maternal care. It covers only the surrogate's maternal care. If we bought a policy on the ACA and the surrogate tripped and broke her ankle while pregnant, the ACA policy would cover that emergency visit. The Lloyd's of London policy is maternal care only, so if she breaks her ankle, she'll have to use whatever insurance she has or pay cash. Those are the differences between the policies. I know it's a little confusing, and I'm happy to talk through the specifics for each surrogate.

Generally speaking, if we have to purchase a policy, it'll either be through the ACA, with a bridge until coverage starts, or a Lloyd's of London policy. The cost varies significantly, because it depends on how old the surrogate is and where she lives. A Lloyd's of London policy generally runs about $40K. An ACA policy is usually somewhere between $25,000 and $45,000, depending on the state.

Your insurance and your baby

A couple of other questions people ask me. Can we use our insurance to cover the surrogate? No. You're not married to her, and she's not your dependent, so you can't use your insurance.

However, your insurance will cover the baby when the baby is born. Pregnancy isn't a qualifying life event, but birth is. Once the baby is born, your insurance is required to cover the baby, no matter where the baby is born. It may be, and probably will be, out of network, because your surrogate lives in Kansas and you're insured through United in New York. But the baby will be covered. If the baby has to go to the NICU or needs any intervention, that will be covered by your insurance. You just can't insure your surrogate through your policy.

When we estimate the overall cost of surrogacy, we assume the surrogate will need insurance and put in a $30,000 placeholder. If your surrogate ends up having insurance that covers it, great: you just saved $30K off the estimated total. If she doesn't, it isn't in addition to what we've estimated your journey will cost. That's insurance.

Plans And Pricing

Let's talk about plans and pricing. Some agencies work this way: "We have one wait list. It takes a year to get from the bottom to the top, and that's how we work." Roots has changed the model so there are multiple ways to enter our space, depending on what you're looking for, your timeline, your budget, and the pace you want to move at. We have four plans: Harmony, Premium, Executive Bliss and Total Assurance.

For Harmony, the agency fee is $50,000. The timeline (remember box number one, how long you're waiting) is 12 to 16 months. The total overall cost is around $200,000 to $225,000.

What does that estimated cost include? It's soup to nuts: what it's currently costing Harmony clients to get from here to baby. What it doesn't include is an egg donor or embryo creation. It's solely your experience from the beginning of surrogacy until you have your baby and beyond.

Those three components are available for each plan. Premium is $72,000 for the agency fee, about nine months to match, and an overall cost of $225,000 to $250,000. Executive Bliss is $150,000 to the agency, three to four months to match, and an overall cost of $300,000 to $325,000.

Where do these overall costs come from? Twice a year, we look back through the entire escrow of, say, a Harmony client and see what it actually cost them in total. That's how we estimate all of these components. The reason I can't give you a line-item cost is that a lot of it depends on choices you make. How much does your clinic cost compared with the clinic next door? If you're using one clinic versus another, or CCRM versus Shady Grove, the costs will be different. That's why these are estimates: you'll make a lot of choices that can make things less or more expensive.

The fourth plan is different: Total Assurance. It was built for clients who say, "I want to give you all my money, and I want you to manage all of the expectations, risk and money. I don't want to have to deal with any of it." If something tragic happened, the worst-case scenario, and we had a loss at the end of pregnancy and had to start all over, we would not ask you to put any more money into your escrow account. It would be Roots' responsibility to get you back to baby. Until you run out of embryos or until you have a baby, Total Assurance is there to get you from here to baby. It's a two-to-four-month guaranteed match and a $400,000 overall cost, paid entirely to the agency, and we manage all of the funds.

So it depends on what you're optimizing for. If it's time, Executive Bliss or Total Assurance is probably a better fit. If it's price, Harmony is probably a better fit. It really comes down to the specifics of what you're looking for and how Roots can best fit those needs.

After Birth: The Fourth Trimester

Let's talk post-birth, otherwise known as the fourth trimester. There are three trimesters of pregnancy, and the fourth is the recovery period, specifically for the surrogate. Her body is returning to normal, and it will take some time for her to recover, emotionally and physically.

During that time, you'll have a newborn, so don't worry about the surrogate's health and recovery. We've got it. We're taking care of her and checking in on her to make sure there are no baby blues or postpartum depression, and that she has everything she needs to recover. She works with a pelvic floor specialist to help her regain her physical strength. If she needs additional nutrients or is having a hard time, support is always available through case management and mental health.

That's not to say your relationship ends there. If you've had a great relationship with your surrogate, it will likely continue past your child's birth. Surrogates really respect that you get very busy with a newborn. We're all moms; we understand what that looks like. But surrogates generally would love to see some updates: the baby's growing, doing well and healthy. Sometimes she feels a little timid about asking, because she knows how busy you are and how important those first four weeks are. So it's great if you can reach out, and she may reach out too.

It will take some adjustment from your normal cadence, because you'll be really tired and busy and she'll be recovering. But maintaining the relationship matters for both of you. This is your child's birth story, and this surrogate just gave birth to this baby. We help facilitate that. If you have questions about cadence or how to honor her time and space, we're available to help you navigate it.

If you need or want additional services, like help finding a nanny, postpartum care, childbirth classes or childcare classes, we have all of those available for our intended parents and will help you navigate them. We'll talk through those on your pre-birth call and get those pieces in order for whatever you need going into the fourth trimester.

Talking About Surrogacy

So you bring the baby home, you're getting oriented to your new life, and you weren't pregnant. How do you talk about this with children you may already have, with your neighbors, your friends and your family? There are lots of books available for kiddos, so you can start reading those.

Our understanding, from both the mental health community and from donor-conceived people and people born through surrogacy, is that it's never too early to talk about these things. If you feel shame, they feel shame. If you don't feel shame, they don't. There was a whole group of people who loved and cared about you, your family and the baby enough to make this happen. That's your story.

Not every piece of that story feels comfortable for everybody, so your narrative should be something you practice at home and that feels genuine to you. You don't have to share everything about how you conceived your child. But some version of it that's easy for the other person to understand, and that feels genuine and comfortable for you, is the best place to start. It could be something like, "Yes, my husband and I chose surrogacy. We're eternally grateful to our surrogate, and it was a really beautiful decision." That is really your story to tell.

When you have to explain things over and over again, and people are very curious about surrogacy, it's good to have a one-line narrative. It should feel genuine to who you are, not give away so much that it feels invasive to your privacy and your family's space, and give enough information that people say, "Cool," and move on.

Another tip, from earlier on: during the pregnancy, it's probably best to keep your circle small. Just like when you start trying to conceive naturally, you don't go on Facebook and announce it. It could take longer, or there could be a miscarriage or a chemical pregnancy. So keep that circle small until about 12 weeks, and then you can talk about it more freely and openly if you choose. It's not required.

Privacy is of the utmost value to you and to your surrogate. Your surrogate isn't allowed to disclose your information, and you aren't allowed to disclose hers. But if you want to start telling friends, family and neighbors, I'd recommend waiting until about 12 weeks. Then you can start to say, "We're going to have a baby, and it's really exciting." That's where your one-line explanation of surrogacy for you and your family comes from.

The Roots Family

Once you've had your baby through surrogacy, we would love for you to remain part of our community. It's the greatest gift to receive pictures of babies being born, then starting kindergarten and beyond, so we'd love to keep in touch.

Often, new parents coming into Roots would love to talk with intended parents who've used Roots and gone through surrogacy. If you're willing to share your experience, that's great; just let us know. If you're not, that's totally fine. We would never require it or ask unless you were willing.

We are always available to you to talk through surrogacy and any part of it. Once you're in the Roots family, you're always in the Roots family. And there's an opportunity for you to be part of our community in a larger way, talking with new intended parents about your experience and about surrogacy in general, because it's such a new way for a lot of people to build their families.