A Gestational Carrier is the Healthy, Perfect Needle in a Haystack

Dec 31

Any queer man who has gone through surrogacy knows that the rate limiting step in the process is the gestational carrier (GC).

In the U.S., the average waiting time for matching with a GC through an agency is about 1 year.

This is not due to a shortage of applicants. One agency stated they have between 300 to 400 applications per month, but only about 1% of those are accepted (1).

So what are the qualifications required to be a GC? And given these criteria, what is the estimated number of women who would even qualify in the U.S.?

I wanted to embark on this epidemiological exercise to better understand how rare GCs are, in order to have an even better appreciation for the amazingness of their work in helping gay, bi, queer men become fathers.

Qualifications to be a Gestational Carrier

In this article, I will focus exclusively on the U.S. That is because the U.S. is the world leader in assisted reproductive technologies (ART), and has the most strict criteria for women to become gestational carriers. I believe this strict criteria is necessary and important to maintain the ethical nature of surrogacy.

The American Society of Reproductive Medicine (ASMR) has detailed the guidelines for screening and selection of a GC (2). The guidelines are broadly separated into three main categories: Medical criteria, psychological criteria, and social criteria.

I would highly recommend reading the full guideline document, as it provides great detail in terms of the medical history, physical examination, laboratory testing, and psychosocial history that a GC should undergo from a range of healthcare professionals, including physicians, psychiatrists/psychologists, and social workers.

However, for the purpose of this exercise, where I want to estimate the number of women in the U.S. who would qualify to be a GC, I wanted to focus on the main criteria that could lead to exclusion. I have also select those criteria that could overlap or cover other criteria, so as to not double-count on exclusion. For example, a body mass index (BMI) cutoff is one exclusion criteria, as is diabetes. However, there is a large overlap in the occurrence of a BMI in the obese range as well as diabetes. Therefore, I will only use the epidemiology data for BMI, assuming that those with diabetes will also be captured in this as a nested subset. Similarly, there are a number of mental health issues that would be grounds for exclusion, and so I have estimated these by looking generally at the percentage of women who are on psychiatric medications.

I am aware that this is not a perfect analysis, and that I will be using various data sets from different time points to piece together the information. However, I believe this crude estimation is still valuable in highlighting the rarity of a GC.

How Many Women Qualify to Be a Gestational Carrier

Let’s go through the criteria, and at the same time, I will explain the demographic data and then continue to refine the total estimate of potential GCs in the American population.

Age between 21 and 45 years old

54.99 million women in the U.S. are between the ages of 20 and 44 (3).
Although this is not the exact range, I believe the estimate does capture a similar overall demographic.
Total: ~55 million

At least 1, uncomplicated pregnancy

Among women aged 40 to 49, 84.3% had given birth (4).
Although the age is slightly higher than the cutoff, the goal of this is to estimate the number of women who have already given birth at least once.
Total: ~46.4 million (55 million x 0.843)
About 80% of women have uncomplicated pregnancies (5).
This would cover other exclusion criteria such as gestational diabetes.
Total: ~37.1 million (46.4 million x 0.8)

Polycystic ovarian syndrome (PCOS)

This condition makes it more challenging for a woman to get and maintain a pregnancy.
Average estimate for American women is 9% of the population.
Total: ~33.8 million (37.1 million x 0.91)

BMI over 32

Most research statistics focus on obesity, or a cutoff BMI of 35, so this will be used as an estimate. A slightly higher percentage for the BMI estimate will also cover those with diabetes who are not overweight.
40% of adult women are classified as obese (6)
Total: ~20.3 million (33.8 million x 0.6)

Endometriosis

This condition, like PCOS, makes it painful and challenging for a woman to successfully maintain a pregnancy.
Estimates for American women are about 11% (7).
Total: ~18.1 million (20.3 x 0.89)

No more than 5 previous vaginal deliveries or 3 previous c-sections

Data is only available for family size, so the exclusion for total c-sections will not be included.
About 5% of American families have 5 or more children (8).
Total: ~17.2 million (18.1 x 0.95)

Intravenous (IV) drug use

0.84% of American women use IV drugs, and, although not all drugs are IV, this would also overlap and cover excluding those with a positive urine drug screen (9).
Total: ~17.1 million (17.2 x 0.9916)

HIV

Of the more than 1.1 million people living with HIV in the U.S., 258,000, or 23%, are women (10).
To estimate this, let’s take the total female population of the U.S. (50.4% of 334,914,895 or 168,797,107), and then get the percentage of HIV positive (0.15%) (11).
While there are other infectious diseases in the ASRM exclusion criteria such as syphilis and gonorrhea, they can be treated with antibiotics and then the women could be cleared to proceed.
Total: ~17.07 million (17.1 x 0.9985)

Current use of psychoactive medication

This estimate is about 21.2% of adult American women (12).
As stated above, this covers other criteria such as those diagnosed with severe depression, anxiety, and other psychiatric exclusions, but it is likely an underestimation.
Total: ~13.7 million (17.07 x 0.8)

Evidence of financial coercion

Although only one metric, households on the Supplemental Nutrition Assistance Program (SNAP) is an estimate of those who are not financially stable.
There are about 17.9 million households each month that receive SNAP (13).
In the 2022 U.S. Census, there were 83.3 million households, so that means about 21% of households were receiving SNAP.
Total: ~11 million (13.7 x 0.8)

These are the main criteria across the medical, psychiatric, and social dimensions for which I could find good data to make estimates.

However, given the other, nested criteria such as psychiatric disorders not requiring medication, or social issues like an unstable home environment, I believe there should be a general reduction applied to capture these criteria. For this, I would estimate about another 30% reduction, bringing the total number of American women who would qualify to be a GC to about 7.7 million at any given moment.

How Many Women Want to be a Gestational Carrier

While this number still seems quite high, the most important criteria has yet to be applied, and it is not something that is included in the ASRM guidelines:

How many women actually want to be a GC?

I couldn’t find any statistics on this, and so it would be an interesting area of further research. However, based on my previous article looking at the type of women who do become GCs (https://www.babymoonfamily.com/original-articles/why-gestational-carrier or https://medium.com/@babymoonfamily/why-do-women-become-gestational-carriers-79000af00d31), I would estimate the proportion to be very small, or about 1%.

Being a GC is a tremendous, almost herculean effort. It not only requires the commitment from the woman herseful, but also from her partner and their own children. They are all agreeing to be linked and bonded to the intended parents (IPs) forever through this experience.

Also, it has to be mentioned that the criteria applied above would not necessarily apply evenly to those women who actually want to be GCs. For example, women who are ‘good’ at pregnancy often become GCs. However, this may mean that they are more likely to have a larger family themselves, so the estimate of 5% for those having 5 or more children (and 3 c-sections) may actually be higher for those who want to be a GC.

Another element that isn’t in the ASRM guidelines is the regulatory differences across states in the U.S. There are ‘friendly,’ ‘unfriendly,’ and illegal states for commercial surrogacy. The illegal states include Louisiana, Michigan, and Nebraska. The ‘unfriendly’ states — or states where surrogacy can be practices but there are legal hurdles and challenges — include Tennessee, Virginia, Arizona, and Indiana (14).

Taking this into consideration, we can assume (again, a rough estimate here) that the women are equally distributed across all the states (not likely, but for the sake of estimation). Therefore, 7 out of 50 states or 14% of women would could not be GCs based on geography.

In conclusion, my very rough estimate for the total number of GCs in the U.S. at a given moment in time is 66,220. This takes into consideration the estimated ‘desire to be a GC’ (7.7 million x 0.01 or 77,000) and incorporates the geographic reduction (77,000 x 0.86 or 66,220).

Needles in a haystack, but truly incredible gifts to find and work with.

References:

Gestational CarrierSurrogacyLGBTQMedicalASRM

Bryan McColgan, MD

A Gestational Carrier is the Healthy, Perfect Needle in a Haystack

Science Says: Being a GC During the Pandemic was Very Hard

Ireland is Taking a Modern Regulatory Approach to International Surrogacy and the European Union Should Take Note

BABYMOON FAMILY