Once a surrogate and intended parents have matched, there are several medical steps before pregnancy can begin.
The process generally includes:
The exact protocol is not the same for every surrogate.
Some gestational surrogates have a programmed frozen-embryo-transfer cycle using estrogen and progesterone.
Others may use a natural or modified-natural cycle.
Some embryos have already been frozen months or years before the surrogate is matched.
In other cases, embryo creation and surrogate preparation occur closer together.
The fertility clinic—not the surrogacy agency—determines the medical protocol.
At Simple Surrogacy, our role is to help coordinate between the surrogate, intended parents, fertility clinic, monitoring providers, and other professionals so everyone understands what comes next.
Here’s what the modern gestational-surrogacy medical process actually looks like.
In gestational surrogacy, the surrogate does not provide the egg.
An embryo is created using:
The embryo is created through IVF and transferred to the gestational surrogate’s uterus.
Because she does not provide the egg, the gestational surrogate has no inherited genetic relationship to the baby.
If you’re new to this distinction, read our complete guide to Gestational Surrogacy vs. Traditional Surrogacy.
Simple Surrogacy pre-screens surrogate candidates before matching.
But agency screening and fertility-clinic clearance are not the same thing.
Once the surrogate has matched with intended parents, the intended parents’ fertility clinic performs its own medical evaluation and makes the final decision about whether she is approved for embryo transfer.
Depending on the clinic and individual history, evaluation may include:
The clinic may also review records already obtained during the agency screening process.
Our separate Gestational Surrogate Medical Screening Guide explains this stage in detail.
The important distinction is:
Simple Surrogacy determines whether a woman appears to meet our program requirements.
The fertility clinic determines whether she is medically cleared for that particular embryo transfer.
The match cannot proceed to embryo transfer with that surrogate.
That can be disappointing for everyone, especially after a connection has already formed.
But medical screening exists to identify concerns before pregnancy.
A clinic may decline a surrogate because of:
A clinic declining a candidate does not necessarily mean she is unhealthy.
It means the physician does not believe she is appropriate for that particular gestational-carrier cycle.
If that occurs, the intended parents return to the matching process according to the agency’s rematching terms.
Medical clearance is not the only clearance required.
Before the surrogate begins the embryo-transfer treatment cycle, the intended parents and surrogate should complete the legal process.
Each side has separate legal counsel.
The attorneys negotiate and finalize the gestational-carrier agreement.
Once everything is signed and the appropriate requirements are satisfied, legal clearance is sent to the fertility clinic.
That sequence protects everyone.
The surrogate should not begin a treatment cycle only to discover later that the parties disagree about an important legal or financial term.
Our Surrogacy Legal Process Guide explains this stage in detail.
This is where many older surrogacy articles become inaccurate.
There is not one universal surrogate medication protocol.
Older descriptions frequently say:
That can describe one type of treatment.
It should not be presented as the standard sequence for everyone.
Modern gestational-carrier journeys frequently involve frozen embryo transfer, meaning the embryos already exist and may have been frozen long before the surrogate begins medication.
The clinic creates an individualized protocol based on factors such as:
The surrogate should follow the calendar issued by her fertility clinic rather than a generic medication schedule found online.
Surrogates may hear terms such as:
programmed cycle
medicated cycle
natural cycle
or
modified-natural cycle.
These describe different ways of preparing the uterine lining and timing embryo transfer.
In a programmed frozen-embryo-transfer cycle, medications are used to prepare the endometrium and control transfer timing.
That may include estrogen followed by progesterone.
Some clinic protocols may include other medications as well.
In an appropriately selected patient who ovulates regularly, a clinic may instead monitor the body’s own cycle and coordinate transfer around ovulation, sometimes using medication to help control timing.
Neither approach should be selected by the agency or surrogate.
The reproductive endocrinologist determines which protocol is medically appropriate.
Maybe.
Maybe not.
Lupron has historically been used in many fertility-treatment protocols to suppress natural hormonal activity and allow the clinic greater control over timing.
But not every modern gestational-carrier cycle uses Lupron.
This is why we would remove language from older Simple Surrogacy articles implying that every surrogate will:
“start Lupron about 14 days into birth control pills.”
That is one possible protocol—not a universal rule.
Your clinic will tell you exactly which medications you need and why.
Possibly.
Some fertility medications are taken as:
Progesterone, for example, may be administered differently depending on the fertility clinic’s protocol.
Many surrogates are understandably nervous about injections before their first transfer cycle.
Your clinic should provide instructions for:
Do not change a medication or dose based on another surrogate’s protocol.
Two women preparing for embryo transfer at different clinics may have very different medication calendars.
The intended parents are responsible for the agreed surrogacy-related fertility expenses.
The surrogate should not be personally financing medications required for the intended parents’ embryo-transfer cycle.
The exact payment and reimbursement process is governed by the surrogacy agreement and financial arrangements established for the journey.
At Simple Surrogacy, financial coordination is handled so the surrogate understands how approved medical and journey expenses will be paid.
The fertility clinic needs to confirm that the surrogate’s uterus and hormone environment are appropriately prepared before embryo transfer.
Monitoring may include:
The clinic uses those results to determine whether the cycle is progressing appropriately.
Sometimes medication doses change.
Sometimes another monitoring appointment is needed.
Occasionally a transfer is delayed or cancelled.
The important thing to remember is that the original calendar is a plan.
The surrogate’s actual medical results determine what happens next.
This is very common.
The surrogate may live in one state while the intended parents’ embryos are stored at a fertility clinic somewhere else.
She generally does not need to fly to the IVF clinic for every blood draw and ultrasound.
Instead, some monitoring can often be performed by an approved local provider.
The results are then sent to the primary fertility clinic, which reviews them and gives instructions.
Simple Surrogacy helps coordinate outside monitoring when needed so results reach the fertility clinic promptly.
The fertility clinic remains responsible for interpreting those results and making medical decisions.
The clinic may:
A delayed or cancelled transfer can be frustrating.
But the purpose of monitoring is to avoid proceeding when the physician does not believe conditions are appropriate.
A calendar change does not mean anyone did something wrong.
It means the treatment plan is responding to the surrogate’s actual medical information.
Once the fertility clinic determines that the surrogate is ready, the clinic confirms the transfer date and medication instructions.
If travel is required, the agency helps coordinate the approved arrangements.
The clinic will provide specific instructions about issues such as:
Follow the fertility clinic’s instructions rather than advice from social media, online forums, or another surrogate’s previous cycle.
This has changed considerably from older IVF practice.
Current ASRM guidance strongly recommends single embryo transfer in gestational-carrier cycles because multiple pregnancy creates additional medical risk for the surrogate and babies.
A twin pregnancy is not simply one pregnancy that happens to produce two babies.
Multiple gestation is associated with increased risks, including:
The number of embryos transferred is ultimately a medical decision involving the fertility clinic and the surrogate’s informed consent.
Embryo-transfer preferences should also be discussed during matching and addressed during the legal process.
A surrogate should never discover on transfer day that intended parents expected her to accept more embryos than she had agreed to carry.
Some intended parents may ask about transferring two embryos.
There can be individualized circumstances in which a fertility specialist discusses more than one embryo, but ASRM’s preferred approach for gestational-carrier cycles is single embryo transfer.
The surrogate has the right to understand the risks and consent to the procedure.
At Simple Surrogacy, our goal is not to maximize the number of babies from one pregnancy.
The goal is a healthy pregnancy and healthy outcome for the surrogate and child.
Embryo transfer itself is usually a relatively brief procedure.
The embryology laboratory identifies the embryo selected for transfer.
A physician then places a thin catheter through the cervix and into the uterus.
The embryo is transferred through that catheter into the uterine cavity.
Ultrasound guidance is commonly used to help guide placement.
ASRM has found good evidence supporting transabdominal ultrasound guidance and the use of a soft embryo-transfer catheter as part of embryo-transfer practice.
The procedure generally does not require anesthesia.
Some people experience:
Experiences vary.
Depending on the clinic’s equipment and process, the surrogate and intended parents may be able to watch the procedure on an ultrasound screen.
This can be an emotional moment.
For the intended parents, the embryo may represent years of infertility treatment, egg retrievals, donor treatment, or previous loss.
For the surrogate, it is the medical moment when the pregnancy attempt truly begins.
But the transfer itself does not mean pregnancy has occurred.
Implantation still has to happen.
Routine bed rest after embryo transfer is not supported by the evidence.
Older IVF protocols sometimes required patients to lie flat for hours—or even days—because of concern that getting up could somehow interfere with implantation.
ASRM’s embryo-transfer guideline specifically concludes that there is good evidence not to recommend bed rest after embryo transfer.
In fact, immediate ambulation after transfer is part of ASRM’s evidence-supported recommendations.
That does not mean a surrogate should ignore her clinic’s instructions.
Her physician may recommend temporary restrictions for an individual medical reason.
But the old idea that someone must remain flat for two hours, 24 hours, or three days so the embryo does not “fall out” should be retired.
No.
The uterus is not an open container from which an embryo simply falls out when someone stands up.
Walking to the bathroom, getting into a car, or climbing into bed does not cause the embryo to fall out.
This is one reason routine prolonged bed rest has not been shown to improve pregnancy rates.
The clinic may still give reasonable post-transfer activity instructions, and the surrogate should follow those.
But she should not spend the waiting period afraid that ordinary movement will physically dislodge the embryo.
Follow the fertility clinic’s instructions.
Clinics may recommend temporary limitations on certain activities during the transfer period and early pregnancy.
Those instructions can differ.
The most useful rule is:
Do what your treating physician tells you—not what someone else’s clinic told them five years ago.
The same applies to:
After embryo transfer comes one of the hardest parts:
waiting.
The surrogate continues whatever medications the fertility clinic prescribed.
She may feel completely normal.
She may have symptoms.
Neither tells you reliably whether the transfer worked.
Early symptoms such as:
can occur for several reasons, including fertility medications.
Likewise, having no symptoms does not mean the transfer failed.
Some surrogates do.
Some intended parents desperately want to know early.
Others prefer to wait for the clinic’s blood test.
The problem with testing very early is that it can create additional uncertainty.
A test may be:
Discuss expectations about home testing before transfer.
It can become emotionally complicated if the surrogate discovers a result before the intended parents or if everyone has different expectations about when results will be shared.
The fertility clinic’s scheduled blood test provides the medically relevant result.
The fertility clinic typically orders a blood pregnancy test after embryo transfer.
This measures human chorionic gonadotropin, or hCG.
The timing depends on:
That is another reason older articles should not universally say testing happens “14 days after egg retrieval.”
In a frozen embryo-transfer cycle, egg retrieval may have happened months or years earlier.
The pregnancy test is scheduled relative to the embryo transfer, according to the clinic’s protocol.
There is no single hCG number that every surrogate must reach on the first blood test.
The fertility clinic interprets:
A second blood test is commonly used to evaluate how the hormone level is changing.
Do not compare one person’s beta number with another person’s and assume it predicts the outcome.
The clinic should interpret the result.
No.
A higher hCG level cannot reliably diagnose twins.
There is substantial overlap between hCG levels in singleton and multiple pregnancies.
Ultrasound—not one beta hCG number—is what determines how many gestational sacs and embryos are present.
Older Simple Surrogacy content says an hCG level over a particular number is “usually indicative” of multiples.
We would remove that statement entirely.
The fertility clinic will tell the surrogate what to do with her medications.
She should not stop progesterone, estrogen, or another prescribed medication on her own because of a home pregnancy test or symptoms.
A failed embryo transfer can be emotionally difficult for everyone.
The surrogate may feel:
“My body failed them.”
The intended parents may wonder whether something happened after transfer.
Neither assumption is fair.
Embryo transfer does not guarantee implantation, even with an apparently excellent embryo and appropriately prepared uterus.
A failed transfer does not automatically mean:
The fertility specialist should interpret the cycle and determine what happens next.
There may be one or more follow-up hCG tests.
The fertility clinic then schedules an early ultrasound according to its protocol.
The first ultrasound may evaluate:
Exactly what can be seen depends on gestational age.
A very early ultrasound may simply be too soon to answer every question.
Cardiac activity is often visible during early pregnancy ultrasound around the sixth week of gestation, but exact timing varies.
A scan performed too early may not yet show everything expected later.
The fertility clinic interprets findings according to:
If another ultrasound is recommended, that does not automatically mean something is wrong.
Sometimes the answer is simply:
It is too early.
Not immediately after a positive pregnancy test.
In a programmed transfer cycle, estrogen, progesterone, or other medications may continue into early pregnancy.
The fertility clinic determines:
Older articles sometimes describe a universal week when the placenta “takes over” and medications stop.
In reality, the clinic’s protocol determines the schedule.
Never stop fertility medications without instructions from the treating clinic.
Once the fertility clinic is satisfied with early pregnancy development, the surrogate transitions to routine obstetric care.
The exact timing varies.
Some clinics release patients earlier.
Others continue monitoring longer.
There is no universal rule that every surrogate remains with the fertility clinic until exactly 10 or 12 weeks.
After release, the surrogate generally receives prenatal care from:
Simple Surrogacy continues coordinating the journey after the fertility clinic’s role decreases.
In many ways, prenatal care eventually resembles any other pregnancy.
But we would avoid saying—as some older surrogacy articles do—that after fertility treatment:
“the rest of the pregnancy is the same as any other pregnancy.”
Every pregnancy is different.
A gestational-surrogacy pregnancy may involve additional:
The medical pregnancy may become routine.
The overall surrogacy journey still has additional layers.
Our Surrogacy 101: Pregnancy and Delivery explains what happens next.
The surrogate does.
She is the medical patient.
The intended parents have an enormous emotional interest in the pregnancy and should receive the agreed information and opportunities for involvement.
But current ASRM ethics guidance recognizes the gestational carrier’s medical decision-making authority throughout embryo transfer, pregnancy, delivery, and postpartum care.
This applies during the medical process too.
A surrogate should receive enough information to give genuine informed consent to:
An agency, attorney, contract, or intended parent cannot substitute for that consent.
A surrogacy agency should coordinate the process.
It should not practice medicine.
At Simple Surrogacy, our role may include helping with:
But questions such as:
“Should I increase my progesterone?”
“Is this ultrasound finding normal?”
“Should I stop this medication?”
“Is this bleeding concerning?”
belong with the fertility clinic or treating medical provider.
Knowing the limits of the agency’s role is part of good coordination.
Contact the appropriate medical professional.
Depending on the stage and severity, that might mean:
The agency should also be informed according to the communication plan, but the agency is not a substitute for medical care.
No surrogate should delay calling a physician because she is waiting for permission from intended parents or an agency.
No. The medication protocol depends on the fertility clinic and type of transfer cycle.
No. Some protocols use Lupron and others do not.
These medications are common in programmed frozen-transfer cycles, but the exact protocol depends on the fertility clinic.
Not necessarily. Many surrogacy journeys use frozen embryos, so the egg retrieval and embryo transfer can occur months or even years apart.
Fresh-transfer cycles may still occur in some circumstances, but they should not be described as the only or standard surrogacy process.
No. A gestational surrogate does not provide the egg and therefore does not undergo ovarian stimulation and egg retrieval as part of her surrogate role.
ASRM strongly recommends single embryo transfer in gestational-carrier cycles because multiple gestation creates additional health risks.
Embryo transfer is a medical procedure involving the surrogate’s informed consent. Transfer preferences should be discussed during matching and legal planning, and the fertility clinic makes medical recommendations.
For many patients it causes little discomfort and feels similar to a speculum examination, but individual experiences vary.
Typically not, although the clinic determines its own procedure.
Routine bed rest is not supported by evidence. ASRM specifically recommends against routine bed rest after embryo transfer.
No. Normal movement does not cause an embryo to fall out of the uterus.
The fertility clinic schedules a blood pregnancy test according to the transfer protocol. Home testing is a personal choice but can create uncertainty when done too early.
Not reliably. Ultrasound determines the number of developing pregnancies.
The fertility clinic determines timing, often during early pregnancy when appropriate structures should be visible.
Only when the fertility clinic instructs her to do so.
After the fertility clinic determines early pregnancy is appropriately established and releases her to obstetric care. Timing varies by clinic.
The reproductive endocrinologist reviews the cycle and determines the medical next step. One failed transfer does not automatically mean the surrogate cannot continue.
Read our Gestational Surrogate Medical Screening Guide.
Continue with our Surrogacy 101: Pregnancy and Delivery and Surrogate Labor and Delivery Guide.
One of the biggest changes in fertility medicine since Simple Surrogacy began in 2002 is that there is no longer a good reason to describe the surrogate medical process as one fixed medication recipe.
A surrogate might use Lupron.
She might not.
She might have a programmed frozen transfer.
She might have a natural or modified-natural transfer.
The embryos may have been created last month.
They may have been frozen for years.
Her clinic may monitor her locally.
She may travel to the IVF clinic more than once.
What should remain consistent is the structure around the process:
The surrogate is medically screened.
The attorneys complete legal clearance before treatment proceeds.
The fertility clinic determines the medical protocol.
The surrogate receives informed consent and remains in control of her medical care.
The transfer plan prioritizes the health of the surrogate and baby.
The agency coordinates rather than practices medicine.
And everyone understands that embryo transfer creates an opportunity for pregnancy—not a guarantee.
At Simple Surrogacy, our coordinators include women who have personally been through surrogacy themselves. We know that a medication calendar can look intimidating the first time you see it and that the days between embryo transfer and the pregnancy test can feel exceptionally long.
Our job is to make sure you know where you are in the process, who to contact, and what comes next.
If you are considering becoming a surrogate, review our current Surrogate Requirements, read How to Become a Surrogate, or apply to become a surrogate.
If you are an intended parent, start with our Surrogacy Process for Intended Parents or contact Simple Surrogacy to discuss your journey.
The medical details may vary from one clinic and one transfer to another.
The standard should always be the same:
informed, individualized, medically appropriate care.
Go backSurrogacy 101: Becoming an Intended Parent Through Surrogacy Becoming an intended parent through surrogacy can feel exciting, hopeful—and, at first, a little overwhelming. Most people begin the process with far more questions than answers. Do you need embryos before contacting…
Lern more →Why Surrogates Should Think Twice Before Choosing an Agency That Also Represents the Intended Parents Choosing a surrogacy agency is one of the most important decisions a gestational carrier will make during her journey. Your agency is often the central…
Lern more →Surrogacy Pregnancy and Delivery: What Intended Parents and Surrogates Should Expect Quick Summary Once an embryo transfer results in an established pregnancy, a surrogacy journey enters a very different stage. The fertility clinic eventually releases the gestational surrogate to her…
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