What medications do surrogates take?

What is the purpose of each medication?

A surrogate takes three kinds of medication, over about 10 to 14 weeks in total. Each one has one job.

• Lupron (leuprolide) switches off your own cycle, so the clinic controls the timing instead of your ovaries.
• Estrogen builds the uterine lining, the layer the embryo implants in.
• Progesterone makes the lining receptive and holds the early pregnancy until the placenta takes over.

You are not stimulating your ovaries, and no eggs are retrieved from you. In gestational surrogacy the embryo comes from the intended parents or from donors. Your medications prepare the uterus only, which is why they are simpler than an IVF patient's.

Many clinics also add a baby aspirin, prenatal vitamins, and a short antibiotic and steroid course around the transfer. Your clinic decides the full list.

Everything on this page describes a typical protocol. Your clinic writes your exact calendar, doses and timing, and that calendar is the one to follow. Doses and durations on this page are under review by Mark Silverberg, MD.

Lupron: what it does and side effects

Lupron is usually the first medication. It is a daily small subcutaneous injection, meaning a short, thin needle just under the skin, usually in the belly. You take it for two to three weeks.

Lupron quiets the signals from your brain to your ovaries. That stops you from ovulating on your own schedule and gives the clinic a clean starting point to build the lining on its own timeline. It also lets the clinic line your cycle up with the embryo transfer date.

Common side effects are hot flashes, headaches and mood changes. They usually last a couple of weeks and stop once estrogen begins, because estrogen replaces the hormone Lupron has turned down. Drinking water, sleeping well and dressing in layers help. Tell your partner what to expect. A few short-tempered days are a known side effect, not a personality change.

Some clinics use a different medication or skip this step. If your calendar looks different, that is normal.

Estrogen: patches, pills or injections

Estrogen builds your uterine lining. It comes in three forms, and your clinic chooses one or a combination:

• Patches worn on the lower belly or hip and changed on a schedule.
• Pills, taken by mouth or placed vaginally.
• Injections, usually intramuscular, given every few days.

You take estrogen for about two to three weeks before transfer. The goal is a lining of 7 to 8 millimeters or more, with the right appearance on ultrasound. Your local monitoring clinic checks it with ultrasounds and blood work, and the fertility clinic adjusts the dose if the lining needs more time.

Estrogen continues after transfer, alongside progesterone, until the clinic tells you to stop.

Common side effects include breast tenderness, bloating, nausea and mood changes. Patches can irritate the skin; moving the patch to a new spot each time helps.

Progesterone in oil: how to inject and how to manage soreness

Progesterone is the medication most surrogates talk about. It is usually given as progesterone in oil: a daily intramuscular injection in the upper outer buttock. It starts about five days before transfer and continues until roughly week 10 to 12 of pregnancy.

Progesterone tells the lining to accept the embryo and keeps it stable while the pregnancy begins. Without enough of it, an early pregnancy cannot hold.

The shot is intramuscular and the oil is thick, so the needle is longer and the injection is slower than Lupron. Most surrogates have a partner or friend give it. These steps reduce soreness:

1. Warm the vial. Hold it in your hand or tuck it in your bra for several minutes. Warm oil flows more easily.
2. Use the right spot. The upper outer part of the buttock. Your clinic or case manager shows you exactly where.
3. Rotate sides every day.
4. Inject slowly.
5. Massage the spot afterward for a minute or two.
6. Apply warmth with a heating pad after the shot, and walk around to move the oil through the muscle.

Small, tender lumps under the skin are common. Massage and warmth help them fade. Most surrogates manage well, and many say the first week is the hardest.

Some clinics use vaginal progesterone instead of, or together with, the injections. Your clinic decides.

What the full calendar looks like

Your clinic sends a written calendar. The medications arrive by FedEx with clinic instructions. A typical frozen embryo transfer calendar looks like this:

Through the cycle, you go to a clinic near your home for monitoring: blood work and ultrasounds to check your hormone levels and lining. Your first and last appointments are at the intended parents' clinic. See mock cycles, which some clinics run first to see how your lining responds before the real cycle.

You are paid $500 when injections start. Medications are paid for by the intended parents.

Side effects and when to call the clinic

Most side effects are uncomfortable and expected. A few are reasons to call the clinic the same day.

Expected, and fine to mention at your next check-in:

• Hot flashes and headaches on Lupron.
• Breast tenderness, bloating and mild nausea on estrogen.
• Soreness, small lumps or bruising where you inject.
• Mild mood swings.
• Light spotting, which can happen on these medications.

Call the clinic right away if you have:

• Heavy bleeding.
• Severe belly pain.
• A hot, red, swollen or very painful injection site, or a fever. These can be signs of infection.
• Swelling, pain or warmth in one leg, chest pain or sudden shortness of breath. Estrogen raises the risk of blood clots, and these are possible signs of one. Call 911 for chest pain or trouble breathing.
• Hives, itching or swelling of the face or throat after an injection. This can be an allergic reaction.
• A missed dose. Do not double up without asking.

Call your case manager too. She can help you reach the clinic and keep the intended parents informed if you want her to.

Who teaches you to do injections

Your case manager will teach you, or your partner, how to give the shots. Natalie Gaudio-Fricano and Jenni Symons, the PLS case managers, have both been surrogates and have done these injections themselves. Natalie has worked in medicine since 2002.

The clinic's nurses also review injection technique with you, often by video or at your screening visit.

Before your first shot, you should know:

• Which medication goes in which spot.
• How to draw up the dose, change needles and get air bubbles out.
• How to dispose of needles safely, in the sharps container the pharmacy sends.
• What time of day to inject, and how to stay consistent.

Ask for a video call for the first progesterone shot if you want someone watching. Plenty of surrogates do.

When do medications stop?

Lupron stops once estrogen has started. Estrogen and progesterone continue after transfer day and through the two-week wait. Your pregnancy blood test is 9 to 11 days after transfer.

If the test is positive, you keep taking estrogen and progesterone. Progesterone usually stops at 10 to 12 weeks of pregnancy, on the clinic's instruction, because by then the placenta produces enough of its own. The clinic often tapers estrogen around the same time. Do not stop either medication on your own, even if the pregnancy feels secure.

If the test is negative, the clinic tells you when to stop and when your period should come.

Once you finish the medications and the clinic sees a healthy pregnancy, you move from the fertility clinic to your own OB. Read pregnancy through OB release.

A typical cycle and early pregnancy involve 60 to 90 injections: daily Lupron for two to three weeks, then daily progesterone in oil for 10 to 12 weeks, plus estrogen if it is injectable.

If you are ready to start, the first step is the prescreen: see if you qualify.

Sources

• American Society for Reproductive Medicine (ASRM), patient resources on frozen embryo transfer and gestational carriers. https://www.asrm.org
• American College of Obstetricians and Gynecologists (ACOG), patient information on early pregnancy. https://www.acog.org