Tips On Psychologically Screening Surrogates

Dreams come true image

When a mental health professional is retained to screen a surrogate, they are not screening for the “perfect” person.   Clearly, that would be an unrealistic goal.  They are screening for a woman who ideally demonstrates empathy, responsibility, dependability, relationship stability, academics, employment history, and parenting.   An ideal surrogate is a woman who can show that she takes care of herself and copes when challenges come up by seeking outside support; there is evidence through discussion that she has proven resilience and can overcome mistakes or adversity and grow from these experiences. 


The first step to psychologically screening a surrogate is to ensure that the candidate complies with the minimum standards for acceptance:



Recommended criteria to be satisfied before being interviewed:


  1. She has given birth and has or is raising that child.
  2. She has self-reported that her pregnancies were uncomplicated.
  3. She should be between the ages of 21-42 (exceptions may be made by a medical professional on the upper age limit). However, because of the risks involved in carrying a pregnancy, it is recommended that she be at least 25 years old.  Special attention must be paid if the surrogate is younger than 25 years old.
  4. Acceptable weight parameters are ultimately a medical decision, but the counselor should pay attention to her weight and, where necessary, open a discussion.
  5. Self-reports that she has a good health history. Prior social diseases, cancer, significant medications, hepatitis, etc., should be discussed as a potential to being denied medical clearance.
  6. The counselors should have knowledge of the laws of the location where the surrogacy will take place. If the arrangement is illegal in that location, the surrogate should be informed, and the counselor should decline to continue her screening.  The surrogate should be advised that the intent is to have the intended parents’ names appear on the birth certificate.  If, for legal reasons, the surrogate’s name must appear on the birth certificate, even briefly, she needs to be informed, and a discussion should occur.
  7. Surrogate indicates she has support from her spouse or significant other and family.
  8. She must be a non-smoker for at least one year.
  9. She indicates that she has no criminal history. However, if she has one, this should not automatically exclude her.  A discussion of circumstances and details should occur before any decision is made.



The Investigator


Once the counselor is assured that the surrogate, at first review, passes the initial requirements, a more in-depth look at her written application should take place.  The screening counselor should insist on receiving a copy of the surrogate’s application.   If the surrogate cannot write, a video recording should occur of the questions being read to the surrogate, and she can voice her answers.  Even if a sister or best friend has volunteered to be a surrogate, she should still take the time to complete an application.   There are psychological benefits to be gained from completing the application.  In addition, the fact that she completed an application can contribute to the proof that the surrogate voluntarily participated in surrogacy.   If there is a concern about the application, the counselor should make a detailed note and report this to the surrogate, intended parent, agency, and IVF clinic.



Intake Interview


The Counselor’s intake interview should be educational and interactive. This screening should be a collaboration in that the surrogate and counselor evaluate surrogacy in terms of what is expected and the possible risks and determine if surrogacy is the right path and if the timing is suitable for all involved.  A counselor should start by explaining the role of a counselor: to guide, encourage, educate, teach good communication, provide resources, put in safeguards, manage expectations, and act more like a coach for this journey.

Some issues a counselor needs to assess before clearance is given:


  1. Psychological history and family history.
  2. Marital conversation – strengths and weaknesses of the relationship. Can their marriage take on the stress of a pregnancy that is not theirs?
  3. Personality traits.
  4. What are her strengths and weaknesses?
  5. Maturity, judgment, and decision-making skills.
  6. Ability to see another person’s point of view.
  7. Encourage the surrogate to discuss her concerns about the process openly.
  8. Ask her what she believes the agency and or intended parents’ expectations of her are.  The counselor should share with the surrogate the typical expectations she can expect from an agency and an intended parent.
  9. Surrogate’s wish list:
    • With regards to the intended parent(s)
    • With regards to what they expect at the end of this journey
  10. What are her motivations for becoming a surrogate?
  11. The counselor should ascertain if the surrogate can see another person’s point of view.
  12. Determine what resources she has around her to help, especially if there is bed rest or hospitalization.
  13. Review medical protocol to the extent that the counselor understands.
  14. The issue of termination, pro-life vs. pro-choice, and the grey zone should be discussed. A frequent answer given is, “I will terminate if there is a medical reason to do so.”   What does this mean?  What if there are conflicting medical opinions?   What if the doctor is vague on this medical condition?
  15. How will they deal with loss: failure to achieve a pregnancy, miscarriage, termination? Most surrogates have experienced healthy pregnancies and believe their bodies will not disappoint them. Sometimes it is difficult to get a surrogate to understand that not all pregnancies are the same. 
  16. Multiple gestations should be discussed in-depth, and the risks and reality of carrying a twin or more pregnancies should be understood.
  17. Social media use is complicated since surrogates use this everyday tool. Does she intend to blog about her pregnancy?   How much information about her intended parent or parents will she reveal?   Will she friend her intended parents and want them to do the same to her? 
  18. Does she display sufficient self-assertion to protect her interests?
  19. Is she absent of rigid, dogmatic thinking?
  20. Is there any history or indication of abuse or an abusive relationship?
  21. Does she have any plans for the next two years that could be interrupted by a pregnancy?
  22. Does she have religious beliefs that may influence her behavior?
  23. A discussion of how she will cope if her participation results in her learning that she has infertility problems.
  24. How will she handle being rejected from participation in surrogacy or not being permitted to help her sister or best friend?
  25. Thoughts and ideas about contact with the intended parent or parents and child before, during, and after birth.



Psychological Testing


Some counselors send the psychological testing to the applicant with a request that it be completed and returned before the screening meeting.  In contrast, other counselors have the surrogate take the testing after their interview.  Both options are commonly used.   The guidelines issued by each test provider must be followed to ensure the testing is taken in a controlled environment free of outside influence, and these guidelines should be strictly implemented.



Journey Coach


If the counselor is retained for the entire surrogacy journey, her role can be seen as a journey coach.  Her role is frequently preventative.  The counselor will endeavor to discuss behaviors and actions that have caused problems or miscommunication in past cases she has worked on.  Generally, those who know they need help will ask for help.  This is an easy situation for a counselor to participate in and support.   However, there are times when people do not know they need help, so it never occurs to them to ask for help.  The counselor needs to be vigilant in these situations and, where possible, chase the parties down and help them realize they need help.


“Many surrogates have complained that I am “in their business” to other surrogates.  But when something goes wrong, they are grateful that I know the dynamics of their life and marriage and are thankful for the help.”



The most frequently used Psychological Testing


  1. Measure of psychopathology (MMPI-2, PAI)
  2. Projective screen (e.g., Sentence Completion for marriage, TAT)
  3. Personality Measure (e.g., 16PF)
  4. Measure of current stressors (e.g., Life Event Check List, SCL 90R)



image of a sad gestational carrier who has been rejected by the mental health professional

Rejecting a Candidate


The hardest part is deciding not to issue a psychological clearance for a woman.  The applicant may dislike the mental health professional, the intended parents, the fertility clinic, and the agency for rejecting a candidate. 

Occasionally, a fertility clinic or agency has refused to send further referrals to a counselor because that counselor rejected a candidate.   A rejection is not necessarily the final decision.   


Sometimes, changes in the applicant’s life will result in her acceptance as a candidate.   Here are some of the reasons that a candidate can be rejected:


  1. Cognitive or emotional inability to comply with the contractual agreement or to understand the informed consent involved in the process (due to language, education, or personality).
  2. Evidence of emotional or financial coercion.
  3. Testing is not within normal limits.
  4. History of major depression, bipolar disorder, untreated substance abuse, currently diagnosed personality disorder, unresolved physical or sexual abuse, and an eating disorder.
  5. Unresolved sorrow about a tragic pregnancy loss.
  6. An insufficient support system.
  7. Marital or relationship instability.
  8. Stressful family demands include disabled or difficult children or caring for an elderly or disabled parent.
  9. Overwhelmed or overcommitted with life or a rigid work schedule.
  10. Inability to maintain a respectful and caring relationship.
  11. History of conflict with authority.
  12. Motivation to use compensation to resolve infertility issues (e.g., she needs the funds to pay for a tubal reversal for herself).
  13. Unresolved issues from a prior termination.
  14. Serial surrogates – multiple repeat surrogate pregnancies, which can harm her health, children, marriage, or relationships.
  15. Cross-generational family relationships in which the counselor cannot determine whether a twin, sister, daughter, or niece is psychologically free of emotional coercion. These are the most challenging situations to deal with.   An option is to request a further consultation with each party and then the parties together to permit the counselor more time to evaluate their interactions.                  



Mental health professionals are trained to evaluate a surrogate’s motivations and stability, understand her support system and her underlying beliefs about surrogacy, her religious leanings or spiritual awareness, etc.  This professional will assist the surrogate in communicating with her intended parent or parents, the infertility doctor and staff, and the agency (if one is involved).  


The mental health professional can help the surrogate articulate her expectations clearly to the intended parents while potentially recalibrating certain expectations.  This collaborative approach enhances the likelihood of a successful journey for all parties involved.



Author: Karen Synesiou, Infertility Portal, Inc.