Sharing a Pregnancy
By Ellen Glazer, Boston Sunday Globe, MA, June 10, 2001

What is it like for a women to bear another woman's child? It is easier than you might expect

‘I certainly hope no one thinks that this route is chosen out of convenience. I would give anything to be carrying my babies.’ Marla Culliton (with the woman carrying the Cullitons’ twins).

Marla Culliton is a dental hygienist with many loyal patients, and she knows they don’t like surprises. So rather than wait until the last minute to tell them she will be on maternity leave later this summer, she began letting patients know in the spring that she and her husband are expecting twins. “Their responses were all over the place. There were patients who quickly said, ’ I knew it! I could see that you were gaining weight around the hips.’ Then there were others who gazed at me from top to bottom and seemed totally baffled. The most that these people could say was, ’ But you are carrying so small.’” Marla Culliton is neither gaining weight nor “carrying small.” The twins that she and her husband, Steven, are expecting – their full biological children – are being cared for in utero by another woman, a “gestational carrier” named Melissa.

When the twins are born, they will come from Melissa’s body, but the names on the birth certificates will be Marla and Steven Culliton.

One of the many ways that in vitro fertilization has revolutionized human reproduction is that it made possible for one woman to carry and deliver another woman’s biological offspring. Women otherwise unable to bear children – perhaps because of a hysterectomy, perhaps because of a medical condition that made pregnancy dangerous – are now able to have their own, genetic children born from an embryo that is transferred to, grows inside, and is delivered by a gestational carrier. Unlike in surrogacy, the woman who gives birth has no biological link to the baby.

“Shared” or gestational carrier pregnancies are by no means common. Although precise numbers are hard to come by, it’s a good bet that about 1,000 babies are born each year to gestational carriers in the United States.

The treatment is reserved for those women who can produce healthy eggs, but who are clearly unable to carry a pregnancy. They are women like Marla Culliton, who spent seven years in a maze of infertility treatments, who lost six pregnancies before seeking a gestational carrier. Or Monica Vachon, who had a hysterectomy when she was 12 because of cancer, and is now a mother. Or Patty Cunha, whose two surgeries to remove her fibroid tumors left her with scar tissue so extensive that it was likely to prevent pregnancy – and whose first baby is due soon. They are but three of the many Boston area women who have experienced a shared pregnancy.

New technology – especially when it involves the intensely personal matter of human reproduction – raises a host of new questions. How do would-be parents and gestational carriers find each other? How does one woman allow another woman – often a stranger – to care for that which is most dear to her? But the perhaps most important question is, how can two women manage the complex feelings that a shared pregnancy produces.

The short answer is this: Gestational carriers try hard not to bond with the child they carry – which, while made easier by the lack of biological tie, can still require some emotional acrobatics. At the same time, the waiting mother and father find ways to bond – sometimes very creative ways.

“Hi, baby, this is your mommy talking. I am going to read you a story. I hope you like it,” says the tape-recorded voice of Patty Cunha, whose gestational carrier, Carol, plays the message each morning as she dresses, so the baby inside her can get used to her mother’s voice. By contracts, Carol never speaks as a mother to the unborn child whose presence she feels every moment of every day.

While gestational carriers may grow fond of the babies they carry, they are careful to maintain an emotional distance. “My feelings during the pregnancies were not at all like my own pregnancies. I never wondered what the baby’s feet would look like. I never thought of what their names would be,” says Linda Reynolds, of La Mesa, Calif., who has twice been a gestational carrier. “Those children need me to walk them across the bridge to their parents. They came through me but are not part of me.”

Says Paula Dill, another gestational carrier in California, of the twin boys she gave birth to, “It felt more like a friendship with the boys than a bond.” At the same time, Dill says she felt quite close to the boys’ intended mother (or IM, as they are known).

“It was an indescribable feeling,” Dill said. “She and I were on a common mission, and now share a common bond.”

Gestational carriers try hard not to bond with the child they carry…At the same time, the waiting mother and father find ways to bond – sometimes very creative ways.

Marla and Melissa have also grown close. One small gesture says much: Melissa, a lifelong consumer of hamburgers and French fries, recently telephoned the more health-conscious Marla (who was privately fretting about Melissa’s prenatal diet, and struggling to accept the fact that she could not control it) to tell her that she is now craving salads.

Marla was enormously grateful. “I don’t know if it’s true or not, but it doesn’t matter. What meant so much to me is that it was yet another example of Melissa’s efforts to include me in any and every way that she can.”

Last month, Marla and Melissa included Marla’s mother – the expectant grandmother – in a doctor’s visit. Watching her mother’s face as she met her grandchildren on ultrasound meant a great deal to Marla. “I realized that even if I was carrying the pregnancy, my mother would be an observer. What mattered now was not where the babies are now, but that they are a part of our family and our history.”

Melissa was also a good sport about visiting Womb with a View in Stoughton, where 3-D ultrasounds of the twins gave Marla and Steve a good view of the babies’ faces – not to mention a videotape, a compact disc, and two 4-by-6 glossies to bring home.

“Melissa doesn’t want to bond with the babies so she is not especially interested in three-dimensional pictures of them,” said an appreciative Marla. “But she knows how much I want it and, as always, she says that it is my pregnancy and I should have what I want.”

Gestational carrier pregnancies begin in many ways. Sometimes a friend or family member makes an offer. More often, a woman will identify a potential carrier and cautiously approach her with the request. Others decide, for a variety of reasons, that they had best seek a stranger.

“I never would have imagined going on the Internet to find the woman who would carry our child. Think of it: we all grow up believing ‘first comes love then comes marriage, then comes the baby carriage.’ The jingle doesn’t include the Internet, the surrogacy chat rooms,” says Patty Cunha.

“Nothing earlier in my life prepared me for e-mailing and talking with a stranger” about carrying my child. “Nor for entrusting my child to another woman at the most important part of his or her life.”

Despite her reservations, Patty ventured into cyberspace. There she met Carol, a married mother of two, living in Florida and eager to carry a child for another couple.

Although contractual gestational carriers, including Carol, receive payments for all that is involved in the process of becoming and being pregnant, these payments – usually between $13,000 and $17,000 – rarely appear to be a woman’s’ only incentive for becoming a gestational carrier. They say they are also motivated by the desire to help another couple feel the joy of parenthood. Such was the cases with Carol, who is now pregnant with Patty and Kirby Cunha’s baby.

Indeed, while in vitro fertilization revolutionized reproduction, the Internet has revolutionized introduction – in this case, to potential gestational carriers. Women seeking to carry a child for an infertile couple can reach their prospective “IPs” (intended parents) through the Web, often through the site maintained by the Organization of Parents Through Surrogacy, or OPTS. It is the only nonprofit organization dedicated to providing support and information to people involved in both surrogacy and gestational carrier arrangements.

A recent visit to www.opts.com yielded several ads including the following:

“Happily married mother of four, 36, 120 pounds, wants to be a gestational surrogate for a deserving couple. Must be willing to do embryo transfer in Missouri or a nearby state. Flexible, loving, ready to help.”

And this: “Gestational surrogate in Illinois is a single woman who has a sit down job and also sews at home. She is busy raising her son, but wants to help a deserving couple build their family.”

Couples and carriers who have met via the Internet describe a process not unlike Internet dating. People introduce themselves, talk about what they are looking for, determine if they have common goals and usually begin to talk by phone. If they decide to proceed, it’s on to physicians and lawyers.

Internet introductions are not for everyone. Many couples and many prospective carriers prefer a more personal matchmaking process. Others turn to a “full service” program like the Center for Surrogacy and Egg Donation in Beverly Hills, where would-be parents can not only be matched with a carrier but also can have their legal and medical services coordinated. Still others seek lawyers who are experienced in these arrangements, offering to locate gestational carriers, match the couples, and provide introductions.

Pursuing a gestational carrier pregnancy is not for the faint of heart, and cannot be done casually. It is a complicated journey, from legal contract to medical evaluations, to counseling sessions and, if all goes well, the careful coordination of a fertility cycle and in vitro transplantation.

Dr. Steven Bayer, a reproductive endocrinologist at Boston IVF-Watham, emphasizes how seriously he and his colleagues consider each situation that comes to them. He recalls recalls months of conversations with a medical ethicist before taking on his first case six years ago. Now, several successful gestational carrier pregnancies later, he is a cautious supporter of this process.

“We need to carefully evaluate both the intended parents and the women who volunteer to carry their babies. We won’t work with a couple if there isn’t clear evidence of medical need and we won’t work with carriers if we have concerns that they are taking undo risks medically or emotionally.”

He notes that would-be parents and potential carriers often weigh risk differently. “My infertile couples are willing to assume risks of pregnancy because they will have a baby to take home if all goes well. Obviously the situation with a gestational carrier is quite different, and it is my responsibility to make her aware of the risks of pregnancy which could prove hazardous to her health.”

Dr. Susan Cooper, a psychologist at the Reproductive Science Center in Waltham and coauthor of “Choosing Assisted Reproduction: Social, Emotional and Ethical Considerations,” counsels many gestational carriers and couples. “I feel it is important that I see the participants separately and then together so that I can raise several issues with them,” she says.

“My feelings during [gestational] pregnancies were not at all like my own pregnancies. I never wondered what the little baby’s feet l would look like. I never thought of what their names would be.’ Linda Reynolds Gestational carrier

“When I meet with prospective gestational carriers I ask them how they think their children will feel about this, how they plan to tell them, whether they are prepared to carry multiples, and how they will manage if the pregnancy is a difficult one. When I see them with the couples I try to confirm, among other things, that people are on the same page about decisions regarding amniocentesis, fetal reduction, and abortion for a genetic problem.”

An occasional role of physicians and mental health counselors is to provide an “out” for people who want it. Every so often someone will volunteer to do this – or be asked – and then have a change of heart. The carrier may encounter objections from her husband, or from others, and decide that she is unable to go ahead. Practitioners see it as their job to help these people out in a difficult situation. This can be accomplished simply by informing the participants of “medical and/or psychological reasons for not proceeding.” No further information is required.

For those who go ahead, lawyers become very much a part of the process, and a contract is essential. It “forces all the parties to think carefully about what is important to them,” says Susan Crockin, herself a lawyer and editor of the book “Adoption and Reproductive Technology Law in Massachusetts.” “It also serves to avoid future misunderstandings and ill feelings.”

Such a contract also makes clear just what role the intended parents have as the pregnancy develops. “I’ve had a lot of very worried expectant parents, [and] their anxiety can be a burden for the carrier,” she says. By giving parents the contractual “right” to talk directly to the carrier’s doctor, Crockin says, their anxiety is alleviated.

Although the legal, psychological, and social steps leading up to in vitro fertilization and embryo transfer are complicated, the medical procedures have become almost routine. Intended mothers undergo ovulation induction for several days, injecting themselves with medications intended to ripen a number of eggs. During this time they are closely monitored with blood tests and pelvic ultrasounds.

When it is evident that several ovarian follicles have matured, the eggs are “harvested” from her body and mixed with semen specimens produced by her husband. A few days later, one or more of the resulting embryos is carefully implanted in the gestational carrier’s uterus. Although the procedure is designed to create just one fetus, the use of several embryos (to increase the odds that at least one “takes”) often results in twins – usually not an unwelcome outcome.

Would-be mothers who have shared a pregnancy get angry when they hear people say that women turn to gestational carriers out of privileged convenience, a way to get around the discomforts or pregnancy. “I certainly hope that no one thinks that this route is chosen out of convenience. I would give anything to be carrying my babies,” says Marla Culliton.

Indeed, women pregnant “out of body” long to feel life within them. As one Boston area expectant mother whose two sons each died within hours of their severely premature births put it, “I look at my gestational carrier’s belly and feel envy…I envy the fact that she can feel my child inside her. I am grateful to her and certainly don’t resent her. I just wish it were me.”

Many gestational carriers and their intended mothers observe that they start to feel just like sisters. For Monica Vachon and Helen McLaughlin – real-life sisters – their gestational carrier experience was a very important part of their lifelong commitment to each other.

Long before Monica knew anything about in vitro fertilization, her older sister, Helen, was reading about the procedure and figuring out how she would carry a baby for her sister. Although Monica had had a hysterectomy at age 12 because of cancer, a portion of one ovary remained intact. Helen knew that meant Monica could still produce eggs.

Helen McLaughlin (right) tried twice to carry her younger sister Monica Vachon’s child. The first baby died. Amy, 5, is the doubly beloved success.

Soon after Monica and her husband, Steve, were married in 1992, Helen made the offer. Or, as Monica recalls it, “perhaps it is better to say she insisted. She told us that this was something that she wanted to do and was going to do and that we’d better not argue with her.”

The first pregnancy ended in tragedy. The baby, Natalie, was born prematurely and did not survive. Although the Vachons were devastated, they longed all the more for a child. So did Helen. “We had come so far. I was crushed, but I did not want to give up hope of delivering a healthy baby for my sister.” When she suggested they try again, the Vachons agreed.

Helen’s second pregnancy brought with it a host of challenges. In addition to the cervical problems that had caused Natalie to be born prematurely, and which meant Helen would now require a cerclage (stitching of her cervix), Helen developed gestational diabetes. All of which made Monica feel especially helpless.

“I couldn’t believe that anyone could be willing to do so much for another person. Not only did she go through all sorts of physical discomforts, but she did it in a most generous way. If we were out and would meet someone who commented on the pregnancy, she would always tell people that I was the one expecting. She didn’t seem to care at all if they were confused. She was simply so happy for us.”

The happiness has continued. The Vachon’s second daughter, Amy, was born without complications. Monica’s eyes fill with tears when she remembers the birth of Amy, and the days that followed. Although Monica, Steve, Helen, and Amy spent the first few days together in the hospital, Helen insisted on leaving the hospital alone. “She wanted us to be able to go home with our daughter. I couldn’t believe that, even then, she thought only of us and our happiness.”

Although Amy is now a regular 5-year-old and Monica a regular mother, their unusual beginning as mother and child remains an important part of their relationship. Amy knows that she grew inside of her Aunt Helen, and for many reasons, they have a very special relationship.

“Amy will always know how much she was wanted and how deeply she is loved. But at the same time, I don’t want her to feel different, “says Monica. “I will always remember what [the doctor] told me shortly after Amy was born, ‘Never forget how special she is, but try not to treat her that way.’”

Marla and Steve Culliton’s babies are due early in September, but because Melissa is carrying twins, they are likely to arrive at least a few weeks early. So the Cullitons are beginning to prepare for their arrival. In addition to buying furniture and setting up a nursery, there are some special tasks associated with gestational carrier birth.

Melissa Brisman, the New Jersey lawyer specializing in reproductive law who represents them, has taken the legal steps necessary to ensure that the Cullitons’ names will be on the birth certificates. (During the sixth month of gestation, a lawyer can petition the court to establish that the genetic parents are the legal parents.) Now they must take the court documents to the hospital and make sure that the staff knows that they are the twins’ parents, and will be making all the decisions about the babies. They also want to be sure the hospital staff will be sensitive to Melissa’s feelings.

In the coming weeks Marla and Melissa will be taking childbirth classes together. As with the 3-D ultrasound, this was Marla’s idea. “I’ve always wanted to give birth and this is the closest I’ll be getting. I want to be as much a part of labor and deliver as I can,” she says, “going to childbirth class is another time that I can enjoy this unique pregnancy rather than feel outside of it.”

That’s not all. She plans, with the help of such herbs as fenugreek and blessed thistle, to induce lactation and “breast feed my babies as best I can,” she says.

Because Marla is Jewish, she has grown up with religious tradition that advises parents to wait until after a baby’s born to celebrate. It’s not been easy.

“I try, but I can’t rein in my excitement,” she says. “We’ve waited too long to be parents and I’m enjoying every minute of this experience.”

What’s in a name? By Ellen Glazer This is a case of language lagging behind medicine and law. Although women have been carrying other women’s babies for nearly two decades, there is no agreed-upon language to describe the process or its participants. Some people regard this as a form of surrogacy, the widely used term for when a woman is artificially inseminated, gives birth to a child (biologically hers), and by prior agreement, places it with its biological father and his spouse or partner. In short, the mother produces a child as part of a pre-conception, step-parent adoption plan. But that differs in important ways from the process by which an embryo – the product of a couple’s egg and sperm – is placed in the uterus of a third, unrelated woman, to grow. In this case, this third woman functions for nine months as caretaker for the couple’s child-to-be, but has no biological connection to it. (One recent high-profile case: the twins born to singer James Taylor and his wife, Kim Smedvig.) Because each process involves a woman pregnant with a baby she does not intend to parent, some practitioners and parents treat the two processes as related, and refer to them both as forms of surrogacy – the first “traditional,” the second “gestational.” The organization for Parents Through Surrogacy, a national nonprofit advocacy group, serves both constituencies and makes little distinction between them. And, defenders of this view note, in both cases the children wanted, planned for, and deeply loved. But professionals working in reproductive medicine, as well as many of the people involved in the undertaking, feel that the processes are so different that the gestational arrangement warrants its own name. The first term considered, “host uterus,” was, fortunately, deemed unsuitable. It was replaced by “gestational carrier,” whish, while serviceable, is an uninviting, awkward term that few are fond of. But nothing better has come along. We are still without a term for the process gestational carriers and intended parents engage in. Some physicians call it “gestational carrier treatment.” Other professionals, even those respectful of the distinction with surrogacy, have grown weary of the semantics and fall back on “gestational surrogacy.” Once again, neither seems adequate. An emerging alternative, “gestational care,” has much to recommend it. With luck, it will catch on.

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Ellen Glazer, a clinical social worker and writer who lives in Newton, is coauthor of “Choosing Assisted Reproduction: Social, Emotional and Ethical Considerations.”