As a facilitator with all parties involved, fertility counselors are presented with two sets of clients — the intended parents and the gestational carrier — each with their own agendas, concerns, and perspectives. While this type of arrangement has the inherent potential of being transformative for all parties, it also holds great complexities and the potential for complications. In order to minimize risks and maximize the positive outcome for both families, fertility counselors provide valuable and thoughtful guidance, education, and assist in clarifying and exploring roles, expectations, and potential outcomes for all parties involved.

Why is preconception counseling important?

There are published guidelines in regards to practices with gestational carriers for mental health professionals that outline a standard of care. More specifically, these publications highlight the importance of psychological counseling, education, assessment, and support by a qualified fertility counselor of all participants as well as they provide for rejection or denial of participants. Counseling is an important part of medical care and should occur before treatment begins.

Fertility counselors traditionally meet separately with the intended parents; separately with the gestational carrier for psychological assessment and consultation (with husband/significant other, if applicable); and finally with both the intended parents and gestational carrier in a group session. Each of these sessions has different purposes and goals, yet all are components in building, planning, and navigating the family-building process with a gestational carrier.

A significant goal of preconception counseling with a potential gestational carrier is helping her decide if being a carrier will serve a positive purpose or have a negative impact on her life. Being a gestational carrier involves a wide array of ambiguity and potentially emotionally stressful situations, and assessing how a carrier will respond to and resolve such issues is key to protecting her and all parties involved. She needs to be able to provide informed consent, be able to relinquish the child, and, along with her family, exit the experience whole and unharmed.

In an effort to serve both parties, the fertility counselor must assess the candidate’s motivations, her ability to accurately perceive situations, her personality, and her intellectual competency. Assessing decision-making processes, social and family relationships and supports, manner of resolving problems and ability to take care of herself and others (e.g., her own children) is important.

Why is it essential that the gestational carrier has previously given birth?

It is recommended, and in fact crucial, that a gestational carrier has previously given birth, in large part so that she can provide informed consent. Excluding women with risky medical conditions, or who have mental health or substance abuse histories is also recommended. It is critical to assess for any significant current stressors or anticipated life transitions, such as unemployment, divorce, or deployment of a spouse. If her participation is strictly due to acute financial need, then confounded, compromised decision-making may be present. Finally, lack of marital/social support, lack of empathy, and unrealistic expectations about the time and process are also all negative indicators in a woman’s potential role as a gestational carrier.

Why are assessment questions important?

Assessment questions may vary depending on whether the gestational carrier is already known to the recipients and as to whether the contract is altruistic surrogacy or fee-based surrogacy. In known gestational carriers arrangements, a potential motivator is gestational carrier’s perception of coercion to participate therefore the history of the relationship, perceived differences of the power amongst participants, and the anticipated impact between all parties should be included in the assessment.

Psychological testing is useful in identifying any number of factors including personality style, psychopathology, and/or potential behavioral problems (e.g., chemical abuse/addiction, hostility toward authority figures, or stress at work). It can also be helpful in identifying the potential candidate’s ability to be truthful and forthcoming.

It is imperative that a candidate be educated about the IVF protocols and other liabilities associated with pregnancy that she may encounter such as the risks of multiple pregnancies, potential pregnancy terminations, bed rest, hospitalization, Caesarean delivery, and neonatal death. The potential gestational carrier’s cultural and religious environment and belief systems should be considered during the evaluation, particularly around the issues of pregnancy termination and multi-fetal pregnancy reduction.

Know and understand expectations prior to entering into the surrogacy.

Related to a gestational carrier’s motivations and goals are a woman’s expectations and concerns about her relationship with the intended parents. A discussion of about the wishes surrounding the relationship with the couple during and after pregnancy, and with the future child, is essential. It will also help ensure that she works with intended parents who have similar wishes and expectations of the relationship.

In addition, fertility counselors can provide ongoing support to the intended parents and gestational carrier as the relationship unfolds during fertility treatment, pregnancy, and postpartum. This is a set of relationships that, one could make a case, needs just as much attention and tending to during the pregnancy, following delivery, and across time as the child(ren) grow up and the families — both of them — develop and mature.

Contributed by: Dr. Tara Simpson