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Growth of ART, IVF, and Surrogacy

Updated: Nov 11, 2021

Here we provide a glossary of terms (page bottom) and some information from respected sources about assisted reproductive technologies (ART), third party reproduction and fertility. We share our experiences and market knowledge of costs.

Assisted reproductive technologies (ART) are largely centered on in vitro fertilization (IVF). This is the creation of an embryo in the laboratory. The embryo can be placed back into the woman from whom the egg (oocyte) was obtained or another (surrogate). The embryo can be transferred within five days of egg retrieval or it can be frozen. Doing a transfer within 3-5 days is termed a fresh transfer and transfer after freezing is termed a frozen transfer. There are pros and cons to each procedure. Fertility IQ, a resource for fertility information, provides more information.

The use of IVF has been growing dramatically as means of overcoming fertility problems. The bar graph below shows the increased use of IVF in the United States over the past 14 years. Note: data obtained from the CDC.

What is surrogacy?

It is an arrangement where a woman agrees to gestate or carry a baby for another party. There are two types. One is termed traditional surrogacy where the surrogate herself contributes her DNA to the resulting child. Her egg (oocyte) is used. This type of surrogacy is rare and not encouraged for many reasons.

The second type of surrogacy is termed gestational surrogacy and the woman does not contribute her DNA. An embryo is transferred into her uterus.

Who uses surrogacy?

Surrogacy is a last resort in the creation of family. It takes place after in vitro fertilization has created an embryo. The most recent (2017) guidelines released by the American Society of Reproductive Medicine (ASRM) state surrogacy should be medically warranted. With single males and male couples it has to be used.

Surrogacy Trends

Finding a surrogate is getting harder each year due to demand. Waiting times are growing and many have to wait on a list for a year.

Surrogacy is a rapidly growing solution to infertility. In the United States surrogacy is growing at over 25% per year (Chart A). In 2020 it is estimated that over 6000 gestational surrogacies will take place in the United States. This represents over 4 % of all embryo transfers are to a gestational carrier (Chart B). The chart below is made with data from the CDC.

lChart A

Chart B

Information and Good Practice Methods in Surrogacy

No twins via transfer of two embryos

We suggest that only one embryo be transferred at a time to greatly reduce the chance of twins. This is called elective single embryo transfer (eSET). Twins are not desired as they often deliver preterm and can have medical issues. Both the European Society for Human Reproduction and Embryology (ESHRE) and the American Society for Reproductive Medicine (ASRM) advise eSET.

Why Would I Choose to Have Elective Single-embryo Transfer (eSET)?

When a woman undergoes in vitro fertilization (IVF), she is usually given medicines to stimulate her ovaries to develop more than one egg at a time. Typically, all the eggs that are collected are fertilized with sperm. The fertilized eggs are monitored to see if any develop into embryos. One or more embryos are then transferred back to her uterus.

What is elective single-embryo transfer or eSET?

Elective single-embryo transfer (eSET) is when a woman undergoing IVF chooses to have a single embryo transferred when multiple embryos are available.

Here it's a link from the ASRM explaining eSET. This is a link to a position paper from ASRM on eSET. Here

How do we know we need a gestational carrier?

Fertility procedures follow a logical course of try this treatment first, if that does not work, then try this, etc., If you are reading this you probably, and are a heterosexual couple, you likely have been though a number of progressively aggressive procedures to achieve pregnancy's. Likely your physician has told you using a gestational surrogate is your final option. If you have not gotten to this point in your fertility progression, you may not be ready for a surrogate.

If you have not been advised no more treatment options are feasible, you may not be ready for a gestational surrogate. Use of a gestational surrogate is only used as a last resort unless you are a homosexual couple. Only after exhaustion of other treatment options will surrogacy be right for you. It is expensive and should only be used when medically warranted.

You will need to be able to create embryo(s) for the procedure. The source of the gametes (sperm, eggs) is of your choice. Heterosexual partners are the most likely gamete donors. If one of them cannot produce viable gametes, the use of a donor would be indicted.

For same sex male couples, or a single male, an egg donor and gestational carrier are required. For same sex female couples, or for a single female, a sperm donor is required and one of the couples or the individual might gestate the baby.

How to choose a surrogate?

Choose the one you like-why? In our experience working with 500 plus intended parents has taught us a few things. As mentioned in the Process and Outcome Page of this site, surrogate candidates are screened on four basic parameters. The parameters are: Medical, Psychological, Background Check, and Social. Before you meet your potential surrogate she has been screened, but not completely. In most all cases she will still need a medical exam and a psychology screen. She will have been screened for background and social aspects. The medical and psychological professionals will step in and do their jobs after you match with her.

The point of choosing the one you like is that professionals have already screened her on everything possible. The success of your embryo transfer and pregnancy journey, while it cannot be guaranteed, is virtually equal with all other surrogates. You will be with her for the journey and many after for years to come. Hence, liking her, and her liking you is important.

How can we be sure we will be successful in our family creation?

Biology is something that cannot be guaranteed. However, regarding fertility treatments, the medical technology is getting better and best practice methods emerge each year in the area of IVF and surrogacy. Many factors can be stacked in your favor to enhance success.

The largest factor that determines success is the age of the egg (oocyte) used to create the embryo. Choosing the best embryo(s) to transfer is a matter of consideration with many new embryo quality metrics advancing each year. The condition of the uterus can play into the acceptance of the embryo. Note: In surrogacy, gestational carriers are screened for uterine responsiveness.

Finally, you should be prepared that more than one embryo transfer might be necessary. According to Fertility IQ , with data from over 23,000 patients surveyed, 47% of the time a pregnancy is achieved with one embryo transfer. Two embryo transfers yield a pregnancy 22% of the time, three embryo transfers are needed 14% of the time. And with about 15% of all cases needing four or more transfers.

What if we cannot afford the fertility work and the use of a gestational carrier?

First, you do not have to complete all the procedures at one time. For example, if you can get to the embryo creation stage, they can be frozen for years, and you can obtain your surrogate after saving for a few years.

Offshore, Medical Tourism Options

Surrogacy used to be commercially legal in a number of countries such as Thailand and India. This is now longer the case, but Ukraine is an open option for those with a lower budget. Closer to the United States is Central America. Unknown to many, gestational surrogacy takes place in many Central American Countries. Our team conducts surrogacy in Guatemala and we cost half of the USA prices.

Insurance Options

The vast majority of services provided by fertility clinics is not covered by insurance. For most patients, these expenses are paid out of pocket and in some cases amount to one half of total household income. For example, a single IVF cycle can be upwards of $20,000 (Wu, 2014: Chambers et al., 2009). These costs dramatically increase when more than one cycle is needed.

As of December 2019 nine US states mandate some type of insurance coverage. The extent of the coverage varies. The states with mandates are the following: Connecticut, Delaware, Illinois, Maryland, Massachusetts, New Jersey, New Hampshire, New York and Rhode Island. (ASRM source). About 71% of the women who went through IVF in 2018 had no fertility treatment coverage, according to FertilityIQ.

Employer Benefits and Egg Banking Offerings

In addition to state mandates driving for increased insurance coverage. Many employers are offering fertility coverage and support with fertility preservation. The ability to effectively freeze eggs (oocytes) and thaw has only come about since 2016. Cost has also come down for this type of fertility preservation. With more and more women postponing childbirth, this is gaining in popularity, and more and more companies are providing financial support. A growing number of companies are offering much more expanded fertility insurance coverage to attract talent. Some of these are tech giants such as Google, LinkedIn, Salesforce, Facebook and Instagram. However, older more conservative organizations such as Bank of America, Unilever, Conair, Pyramid Hotel Group, and The City of Baltimore are following the trend of fertility benefits.

Finance Options

Since 2016 more and more finance companies are entering the area of fertility financing. At this writing there are at least three companies specializing in fertility financing. Interest rates tend to be very low and the area is getting competitive. Below is a listing of finance companies.


Fertility Finance

Future Family

Light Stream



From the American Society of Reproductive Medicine (100% reproduced) Why are multiple pregnancy rates and single embryo transfer rates so different globally, and what do we do about it?

In the early years of in vitro fertilization, overall pregnancy rates were low, and it was considered necessary to transfer more than one embryo to increase the chances of pregnancy. It was not until advances in assisted reproductive technologies resulting in increased pregnancy rates that the concept of transferring just one embryo was considered possible. A consequence of improvements in implantation rates was also an increase in multiple pregnancies when more than one embryo was transferred. Although some countries have reduced the number of embryos transferred, international data show that in many parts of the world high twin and higher order multiple pregnancy rates still exist. Even in developed countries these problems persist depending on clinical practice, funding of health services, and patient demands. Perinatal and other outcomes are significantly worse with twins compared with singleton pregnancies and there is an urgent need to reduce multiple pregnancy rates to at least 10%. This has been achieved in several countries and clinics by introducing single embryo transfer but there are many barriers to the introduction of this technique in most clinics worldwide. We discuss the background to the high multiple rate in assisted reproduction and the factors that contribute to its persistence even in excellent clinics and in high-quality health services. Practices that may promote single embryo transfer are discussed. Source:

Glossary of Medical Terms Related to Fertility and Surrogacy

ART: Acronym for Assisted Reproductive Technologies, defined by many to mean the handling outside the body of both egg and sperm. This definition is the one used by the United States Center for Disease Control (CDC), who has the mission of tracking and monitoring fertility clinics in the United States.

Blastocyst: An embryo that has developed for approximately five days after fertilization. At this point the embryo has two different cell types and a central cavity. The surface cells (trophectoderm) will become the placenta, and the inner cell mass will become the fetus (baby).

Ectopic Pregnancy: A pregnancy that occurs outside the uterus. The developing embryo implants and grows in a location other than inside the uterus. Ectopic pregnancies often take place in the fallopian tube.

Endometriosis: is a gynecological condition in which cells from the lining of the uterus (endometrium) appear and flourish outside the uterine cavity, most commonly on the membrane which lines the abdominal cavity, the peritoneum.

ESET: Elective single embryo transfer, which means only placing one embryo in the uterus.

Embryo: The developing baby in the early stages of fetal growth, from conception to the eighth week of pregnancy. In infertility treatments this term is restricted to mean a fertilized egg, between 1 and 5 days old, used in IVF treatments. See also Blastocyst.

Fallopian tube: Anatomical structures attached to the uterus where eggs pass on their way to the uterus from their origin in the follicle of the ovary. In the course of ART, fertilized eggs (at times termed zygotes) are commonly placed here rather than directly in the uterus. Eggs are naturally fertilized in the fallopian tube.

Fibroids: are non-cancerous growths in the womb (uterus).

Fecundity: 1. characterized by having produced many offspring 2: capable of producing : not sterile or barren.

Gamete: in the case of the male, this would be a sperm cell, in the case of a female this would be the egg or ova

Gestational Surrogate (also called a Gestational Carrier [GC] or Uterine Carrier): is an individual in which embryos created by the intended parents are transferred into the surrogate’s uterus, which has been prepared hormonally to carry a pregnancy. The gestational surrogate has no genetic link to the baby she is carrying because she did not use her egg.

GIFT: Gamete Intrafallopian tube Transfer is when the eggs are removed from the ovaries and are placed in the fallopian tubes along with the sperm.


ICSI: Intracytoplasmic Sperm Injection is the process in an in vitro fertilization in which a single, viable, sperm is injected into the egg.

IVF: In-Vitro Fertilization is the fertilization of the egg by the sperm outside of the body. In Vitro, literally translated from Latin, means in glass. The fertilized egg is then implanted into the uterus.

Infecundity: is the condition where the woman has the ability to conceive (have egg fertilized), but is not able to carry the baby to term.

Nulliparous: a term meaning a woman has never had a child.

Ovum: The egg; the reproductive cell from the ovary; the female gamete; the sex cell that contains the woman's genetic information.

Oocyte: The egg cell produced in the ovaries. Also called the ovum or gamete.

Polycystic ovary syndrome (PCOS): is a condition characterized by the accumulation of numerous cysts (fluid-filled sacs) on the ovaries

Retrograde ejaculation: a condition in which sperm are ejaculated into the bladder instead of out of the penis

Semen: The fluid portion of the ejaculate consisting of secretions from the seminal vesicles, prostate gland, and several other glands in the male reproductive tract. The semen provides nourishment and protection for the sperm and a medium in which the sperm can travel to the woman's vagina. Semen may also refer to the entire ejaculate, including the sperm.

Sperm: The microscopic cell that carries the male's genetic information to the female's egg; the male reproductive cell; the male gamete. When ejaculation occurs the sperm are discharged in a fluid called semen.

Surrogate: A woman who agrees to carry (gestate) a child for another couple (intended parents) or individual. Note; a gestational surrogate does not use her eggs and hence is not genetically related to the child. A traditional surrogate will use her egg (see traditional surrogate).

Surrogacy: An arrangement where another woman is hired to carry the child (gestate) for another couple (intended parents) or individual.

Third Party Reproduction: refers to the use of eggs, sperm, or embryos donated by a third person (donor) to enable an infertile individual or couple (intended parent) to have a child. Donors of eggs or sperm may be known or anonymous to the intended parents. Third-party reproduction also includes traditional surrogacy and gestational carrier arrangements.

Traditional Surrogacy: is when a woman is inseminated with sperm for the purpose of conceiving for an intended recipient (intended parents). The surrogate in this scenario has a genetic and biological link to the baby she carries as her egg was used.

Varicocele: A varicocele (physical structure) is like varicose veins of the small veins next to one testis or both testes. It usually causes no symptoms.

ZIFT: Zygote intrafallopian tube transfer is when the developing embryo (termed zygote in the first few days) is placed in the fallopian tube.

Zygote: A fertilized egg, or embryo, in the early stages of development. It is multicellular and of a development stage prior to being a blastocyst.

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