Physician-Led, Comprehensive Surrogacy and Egg Donation
How Surrogacy Works in the US: A Complete Step-by-Step Guide for Intended Parents
Surrogacy is one of the most profound journeys a family can take — and for many intended parents, it's also one of the most unfamiliar. The terminology, the legal complexity, the medical process, the emotional weight of it all: it can feel overwhelming before you've even started. This guide exists to change that.
Whether you're a same-sex male couple for whom surrogacy is the primary path to parenthood, a single parent building a family on your own terms, a woman who cannot carry a pregnancy, or an international family exploring US surrogacy options — this is your complete step-by-step guide to how surrogacy actually works in the United States in 2026.
Gestational vs Traditional Surrogacy: The Foundation
Gestational surrogacy is by far the most common form practiced in the US today. The surrogate — also called a gestational carrier — carries a pregnancy created from an embryo that is genetically unrelated to her. The embryo is created through IVF using eggs and sperm from the intended parents, donors, or a combination, and transferred to the surrogate's uterus. The gestational carrier has no genetic connection to the child she carries.
Traditional surrogacy involves the surrogate using her own egg — meaning she is both the carrier and the genetic mother. Traditional surrogacy is rarely practiced today due to significant legal complexity and the ethical and emotional complications arising from the genetic connection between surrogate and child.
💡 Gestational surrogacy accounts for the vast majority of surrogacy arrangements in the US. It is the method used at New England Fertility Institute — ensuring a clear legal and genetic separation between the gestational carrier and the intended parents from the outset.
Who Pursues Surrogacy?
Same-sex male couples and single men — for whom carrying a pregnancy is not biologically possible — pursue surrogacy combined with egg donation as the primary path to a genetically connected child. NEFI is a recognized leader in LGBTQ+ family building with deep expertise in guiding same-sex male couples and single fathers through every step.
Women and couples with uterine conditions — including uterine absence, severe Asherman's syndrome, fibroids, or repeated implantation failure — for whom carrying a pregnancy poses significant medical risk or is not possible. Individuals and couples who have experienced recurrent pregnancy loss, and international intended parents who choose the US for its strong legal framework and high medical standards, also frequently pursue surrogacy at NEFI.
What does the journey look like if you’re considering surrogacy?
Step 1 — Initial Consultation
Every surrogacy journey at NEFI begins with a free consultation — a conversation, not a commitment. It's the opportunity to understand your options, ask every question you have, and map out a realistic plan. NEFI's team includes specialists in LGBTQ+ family building, third-party reproduction, and international surrogacy coordination. During this consultation, your team will review your medical history, discuss whether you need an egg or sperm donor and outline embryo creation options.
Step 2 — Finding and Matching a Gestational Carrier
Gestational carriers can be matched through NEFI's network and trusted partner agencies, which rigorously screen, psychologically evaluate, and medically qualify all carriers before matching. Some intended parents work with a known surrogate — someone in their existing network who has offered to carry. NEFI supports known carrier arrangements with the same rigor as agency-matched arrangements.
A fertstert.org/article/S0015-0282(1662549-9/fulltext text: 2021 review in Fertility and Sterility) examining gestational carrier screening outcomes found that comprehensive psychological and medical pre-screening significantly reduced the rate of arrangement disruptions and legal complications — reinforcing why thorough vetting is non-negotiable, not optional.
Step 3 — Medical and Fertility Workup
Before embryo creation begins, both intended parents (or donors) and the prospective gestational carrier undergo comprehensive medical evaluation. For intended parents providing genetic material, this includes semen analysis, ovarian reserve testing, and blood work. The gestational carrier undergoes uterine assessment, infectious disease screening, psychological evaluation, and a full medical history review. For families using donor eggs, NEFI's in-house donor agency means the process is fully coordinated within the same clinical team.
Step 4 — Legal Agreements
Before any medical treatment involving the gestational carrier begins, a legal contract must be in place. The surrogacy agreement covers compensation and expense reimbursement for the carrier, medical decision-making authority, contact expectations during and after pregnancy, and life insurance and health coverage arrangements.
Connecticut is a surrogacy-friendly state with a clear legal framework. Pre-birth orders — legal orders establishing the intended parents as the legal parents before the baby is born — are obtainable under Connecticut law, meaning intended parents are named on the birth certificate from the outset without the need for post-birth adoption. The Connecticut Parentage Act (2022) further strengthened this framework, explicitly recognizing gestational carrier agreements across all family structures.
Step 5 — Embryo Creation (IVF)
Once legal agreements are signed, embryo creation begins via IVF. Egg retrieval involves 10–14 days of hormone stimulation followed by retrieval under light sedation. Retrieved eggs are fertilised using conventional IVF or ICSI. Embryos are cultured for 5–6 days to blastocyst stage, then many intended parents choose preimplantation genetic testing (PGT-A) to screen for chromosomal abnormalities and optimize transfer success rates. Some families also use PGT for family balancing (gender selection). Tested embryos are frozen and stored until the gestational carrier is ready for transfer.
Step 6 — Egg Donation (If Needed)
For many intended parents — including same-sex male couples, single fathers, and women with diminished ovarian reserve — egg donation is an essential part of the surrogacy journey. Donor eggs are used to create embryos via IVF, fertilised with sperm from one or both intended parents, before transfer to the gestational carrier. The egg donor and the gestational carrier are always two different people in a gestational surrogacy arrangement — the donor provides the genetic material, while the carrier carries the pregnancy with no genetic link to the child.
Egg donors undergo rigorous screening before acceptance, including ovarian reserve testing (AMH and antral follicle count), genetic carrier screening, infectious disease testing, and psychological evaluation. Intended parents can typically choose between fresh donor cycles, frozen donor eggs, and known donors, and select a donor based on detailed profiles.
Because NEFI operates its own in-house donor agency, donor selection, screening, cycle synchronisation, and embryo creation are all coordinated within a single clinical team — eliminating the delays and communication gaps that can arise when a separate external egg bank or agency is involved. Donor eggs can also be combined with PGT-A testing to maximise the chance of a successful transfer.
💡 In donor egg surrogacy arrangements, the child is genetically connected to the sperm-providing intended parent(s) and the egg donor — never to the gestational carrier.
Step 7 — Gestational Carrier Preparation and Embryo Transfer
The gestational carrier's uterus is prepared using a hormone protocol of oestrogen and progesterone. A mock transfer cycle is often performed first to optimize the approach. A 2022 study in BMJ found that frozen embryo transfers produced significantly higher clinical pregnancy rates than fresh transfers in gestational carrier arrangements.
The transfer itself is non-invasive — no anesthesia required. A thin catheter delivers the embryo into the uterine cavity under ultrasound guidance in a matter of minutes. The gestational carrier rests briefly and returns to her normal routine.
Step 8 — Pregnancy Confirmation and Monitoring
Approximately 10–14 days after transfer, a blood test measures hCG (the pregnancy hormone). A positive result triggers an early ultrasound at around 6–7 weeks to confirm a heartbeat. Once the pregnancy is established, the gestational carrier transitions to her OB for the remainder of the pregnancy, with NEFI remaining a point of coordination and support throughout.
Step 8 — Legal Parentage and Birth
In Connecticut, intended parents obtain a pre-birth order during the pregnancy — meaning they are recognized as the legal parents before the birth and named on the birth certificate directly. No post-birth adoption is required. NEFI's team supports international intended parents in parentage documentation requirements in their home countries.
The Connecticut Advantage for Surrogacy
Connecticut's legal environment makes it one of the most secure US states for surrogacy. Pre-birth orders are routinely granted. There is no genetic connection requirement — meaning single intended parents and same-sex couples using both donor eggs and donor sperm can obtain full legal parentage. Surrogacy agreements are enforceable under Connecticut law. The Connecticut Parentage Act (2022) explicitly recognizes gestational carrier agreements across all family structures, providing legal certainty for domestic and international families alike.
How NEFI Is Different
New England Fertility Institute is a global leader in surrogacy and third-party reproduction with specific expertise in LGBTQ+ family building. NEFI's in-house donor agency means egg and embryo donor matching is handled within the same clinical team. Connecticut legal expertise means NEFI's team navigates the state's surrogacy-friendly framework daily and maintains relationships with experienced reproductive law attorneys. The international program serves intended parents from around the world with established processes for cross-border legal and documentation requirements. As part of CSG.BIO Group, NEFI has access to an internationally connected network of reproductive medicine expertise.
Frequently Asked Questions
How long does the surrogacy process take from start to finish? From initial consultation to birth, the surrogacy journey typically takes 18 to 24 months. The matching process is often the longest variable — finding and medically qualifying a gestational carrier can take several months. Once a match is confirmed and legal agreements are signed, the IVF and transfer phase typically takes 2–4 months, followed by the pregnancy itself.
Can same-sex male couples have a genetically connected child through surrogacy? Yes. One or both partners can provide sperm to fertilize donor eggs — creating embryos genetically connected to one or both intended fathers. Some couples create embryos from both partners' sperm and transfer the embryo most likely to succeed; others choose one partner for the genetic connection. This is a deeply personal decision NEFI's team discusses with care and without judgement.
Does NEFI work with international intended parents? Yes. NEFI has an established international programme and regularly supports intended parents from Europe, Asia, the Middle East, and beyond who choose Connecticut for its legal protections and medical standards.
Can single individuals pursue surrogacy at NEFI? Absolutely. Single intended parents — whether single men, single women who cannot carry, or single LGBTQ+ individuals — are welcome and regularly supported at NEFI. The process is the same; the legal and donor pathways are simply tailored to a single-parent structure.
Every Family's Journey Starts with a Conversation
Surrogacy is complex — but it doesn't have to feel that way. NEFI's team has guided hundreds of families through every variation of this journey, and the first step is always the same: a conversation. No pressure, no commitment, no assumptions about your family structure. Just the information you need to decide if surrogacy is the right path for you.
Written and reviewed by: Dr. Gad Lavy, MD, FACOG