What happens if your surrogate is carrying twins?

How do twins happen in surrogacy?

There are two ways.

1. Two embryos were transferred and both implanted. These are fraternal twins, each from a different embryo. This is the more common route to twins in surrogacy, and the one you can control.
2. A single embryo split. One transferred embryo divides early and becomes two babies. These are identical twins. It is less common, it cannot be predicted, and it cannot be prevented.

Twins in surrogacy are less common than a decade ago because single embryo transfer is now standard. ASRM recommends transferring one embryo to a gestational carrier, and at Private Label Surrogacy (PLS) usually one embryo is transferred. The number is agreed at matching and written into the gestational carrier agreement. See single vs double embryo transfer.

If a twin pregnancy happens, it is usually seen on the first ultrasound at the fertility clinic. From that day the pregnancy is managed as high risk.

What happens next, in order: the clinic tells the surrogate and you, your PLS case manager is informed, and the agreement's multiples provisions apply. PLS checks the surrogate's insurance for high-risk pregnancy coverage, and you confirm your own plan's newborn enrollment rules for two babies. Her release from the fertility clinic to her OB proceeds as usual, often with an early referral to a maternal-fetal medicine specialist.

What are the medical risks of a twin pregnancy for the surrogate?

A twin pregnancy asks more of the surrogate's body than a singleton pregnancy. Compared with carrying one baby, carrying two carries higher rates of:

• Preeclampsia, a pregnancy blood pressure disorder that can become serious for her and the babies.
• Gestational diabetes.
• Anemia.
• Preterm labor, which can mean hospital stays and medications to delay delivery.
• Cesarean delivery, with its surgical recovery.
• Heavy bleeding after delivery.
• Bed rest or reduced activity in later pregnancy, and time off work.

These risks are why the surrogate's medical history matters before she agrees to carry multiples. Mark Silverberg, DDS, MD, reads every PLS candidate's prenatal and delivery records and writes a physician medical summary for your clinic. That review flags candidates whose history argues against carrying twins, such as blood pressure problems or a difficult delivery in a previous pregnancy. Each surrogate also states in her matching criteria whether she will carry multiples.

What are the risks for the babies, including preterm birth?

For the babies, the main risk is being born early.

Per CDC National Vital Statistics data, most twins are born preterm, before 37 weeks. [Report year and current percentage to be pulled from the CDC report before publishing.]

Compared with singletons, twins have higher rates of:

• Preterm birth and its complications, especially for babies born well before term.
• Low birth weight.
• NICU admission for one or both babies.
• Growth differences between the two babies.

Identical twins who share a placenta carry additional risks, such as an imbalance in blood flow between the babies, and need closer monitoring. Your surrogate's OB, often with a maternal-fetal medicine specialist, determines the type of twins early in the pregnancy and plans care around it.

For you, a NICU stay means planning to stay near the delivering hospital, sometimes for weeks, until both babies are ready to go home. Budget for lodging and time off, and for international parents, for a longer stay before the babies' documents and travel are complete.

How does twin care differ: appointments, monitoring, delivery timing?

A twin pregnancy has more of everything.

• More appointments. More frequent prenatal visits and ultrasounds, often with a maternal-fetal medicine specialist as well as her OB.
• More monitoring. Growth scans to track both babies, closer watch of her blood pressure and blood sugar, and cervical length checks for preterm labor risk.
• More planning for delivery. A hospital with a NICU suited to preterm babies. A birth plan that covers both babies and a likely earlier date. Travel plans for you that allow for an early arrival.
• Earlier delivery. Most twin pregnancies deliver before 37 weeks. Her OB sets the timing by the type of twins and any complications. Planned delivery for uncomplicated twins is commonly scheduled in the 34 to 38 week range, depending on the type of twins; confirm current ACOG guidance.

PLS support scales with the pregnancy. Your case manager, Natalie Gaudio-Fricano or Jenni Symons, both former surrogates, keeps closer contact with your surrogate and with you. Julie Bendix, MPH, RD, LD, CLC, provides nutrition consults, at least six across the journey. On one night, the PLS after-hours team rebooked a stranded surrogate's hotel, car and flight while another PLS surrogate delivered twins.

What does a twin pregnancy add to the cost?

In a PLS journey, a twin pregnancy changes several lines of the budget.

• Surrogate compensation: twins add $5,000 to her compensation; triplets add $10,000. Figures confirm with Nancy.
• Maternity clothing: $1,000 instead of $750. Figures confirm with Nancy.
• Lost wages: bed rest and early leave are more likely, so her lost wages, and her partner's, are more likely to apply and for longer.
• Housekeeping: $90 per week from 32 weeks. Ask your attorney whether to start it earlier for twins.
• Her health insurance: a high-risk pregnancy and a likely cesarean mean higher claims. Deductibles and co-pays you agreed to cover may reach their maximum. If her plan excludes surrogacy, a dedicated policy costs $5,000 to $40,000. See surrogate health insurance.
• NICU care: the babies' care, including NICU stays, falls on your health plan as their insurance from birth. Confirm your plan's newborn enrollment rules before the birth.

For the full compensation schedule, see surrogate compensation.

What do contracts say about multiples, bed rest and selective reduction?

The gestational carrier agreement addresses multiples before any transfer. Typical provisions cover:

• Consent to carry multiples. Whether she agrees to carry twins, and triplets, if they occur.
• The multiples payment. The amount and when it is paid from escrow.
• Bed rest. What happens if her OB orders bed rest: lost wages for her and her partner, childcare and housekeeping support.
• Selective reduction. The circumstances, if any, in which you may request that a multiple pregnancy be reduced, and whether she agrees.

Selective reduction is less common than it once was, because single embryo transfer has reduced higher-order multiples. The clause remains standard. At PLS, views on termination and selective reduction are matching criteria, and parents and surrogates who disagree are not matched. A surrogate cannot be compelled to undergo any procedure; the contract sets expectations and financial consequences. Reviewed by counsel. See termination and selective reduction clauses.

How do you lower the chance of twins?

• Transfer one embryo. This is the single most effective step. ASRM recommends it for gestational carriers.
• Use a tested embryo. A euploid embryo has a good chance on its own, which removes the main reason people consider transferring two.
• Plan a sibling journey for a second child instead of a twin pregnancy. PLS charges 50% of the program fee for a sibling journey.

A single embryo can still split into identical twins. That chance cannot be removed, which is why every agreement addresses multiples even when one embryo is transferred.

Sources

• CDC (Centers for Disease Control and Prevention), National Vital Statistics System, births data. [Report year to be confirmed.]
• ACOG (American College of Obstetricians and Gynecologists), guidance on multifetal gestations. https://www.acog.org
• ASRM (American Society for Reproductive Medicine), guidance on the number of embryos to transfer and on gestational carriers. https://www.asrm.org