Lydia Gatton’s first in vitro fertilization appointment was just a week away when the fifth-grade teacher fell to the floor in the cafeteria of Hopewell Elementary in Bettendorf, Iowa, suffering a grand mal seizure. She was rushed to the hospital, where doctors diagnosed the then 29-year-old with a brain tumor.
Gatton and her husband had struggled to conceive naturally for years and completed six unsuccessful intrauterine inseminations. After the brain tumor diagnosis in 2016, Gatton would undergo two brain surgeries, radiation treatment, chemotherapy, followed by an embryo transfer that failed. But after all that, another embryo transfer had worked, and in fall 2019, Gatton was expecting.
“The fertility stuff was so much harder than the cancer stuff,” Gatton said. “Cancer was just something that happened to me, and we’ll take care of it. But I wanted nothing more in the world than to have a kid.”
Eight months into the pregnancy, Gatton was standing next to her husband at a college football game when she mentioned she hadn’t been feeling the baby move. Soon after, at her 37-week appointment, a nurse struggled to find a heartbeat. More nurses came in, and then a doctor.
“I asked a stupid question. I said, ‘Are you sure? Did they do an ultrasound?’” Sarah Roed, Gatton’s older sister, recalled saying to her on the phone. “I think she was in just such shock…neither of us was absorbing it.” Two days later, on October 2, 2019, Jackson Dean Gatton was delivered stillborn. As Roed drove the two and a half hours from her home in Cedar Falls to the hospital, she thought about how to help. The older sibling by just shy of two years, Roed felt the need to take charge. Doctors told her sister to wait a year before trying again with one of the remaining embryos. Couldn’t she herself help even sooner, she thought?
“So I got this idea,” Roed said. “Let’s just defrost another one of these suckers.”
Gatton was initially surprised by Roed’s offer to be her surrogate. Her pregnancy hadn’t been easy, and she couldn’t understand why her sister would want to go through the same experience for someone else. Weeks went by and the sisters discussed the potential plan, worrying over what it would look like. How would Roed’s three children take the news? Would it even work? Around Christmas, they made their decision. The sisters found a fertility clinic and an agency, and underwent a battery of physical and psychological exams.
“People do a lot of things for other human beings to help them be healthy,” said Angeline Beltsos, a clinical reproductive endocrinologist who works for Kindbody Fertility in Chicago. “What a gift to give when it’s a sister.”
Surrogacy has grown more common in the U.S., but still remains relatively rare. The most recent data, from 2013, suggests there were over 30,000 IVF cycles involving a carrier that year. But it remains an emotionally taxing, time-consuming, and incredibly costly path to pursue — so some, like Gatton, have turned to relatives to carry their children. While there’s little to no data on how many surrogates personally know the intended parents, fertility care experts said such a relationship can make it easier and more affordable to move forward, and comes with a kind of built-in trust that is crucial to making shared decisions. But it also brings its own set of challenges, as close-knit families have to navigate new dynamics and unexpected complications.
“We knew we were gonna go through all sorts of emotional rollercoasters,” Roed said. “We had no idea the kind of rollercoasters we were getting. We didn’t even know they were out there.”
Surrogacy is fraught with ethical and emotional challenges, and carrying a pregnancy for a close relative only compounds some of those concerns.
“It takes a village to be a surrogate,” said Silvia Fox of Fertility Resilience in Glencoe, Ill. “Surrogacy affects not just the woman but her partner, her family, her extended family, and often her community.”
Fox, a fertility psychologist for nearly 25 years, routinely conducts psychological exams for fertility agencies. Before meeting with potential gestational surrogates, Fox sends a lengthy questionnaire that helps her understand the person’s overall background, followed by an even lengthier survey of the potential surrogate’s mental health. A potential surrogate gets asked everything from what they see as their greatest loss in life to how much weight they gained during past pregnancies, and whether they were bothered by it. Fox’s psychological evaluation plays a key part in making sure each party’s expectations are aligned, and that they’re on the same page about what it means to move forward with an implantation. Potential surrogates also have to go through a series of medical tests, and most clinics also require them to have previously experienced an uncomplicated pregnancy and delivery.
Often, Fox said, siblings who pursue surrogacy don’t fully realize how their decision will affect others in their closely intertwined social circles. In some cases, a sibling may feel guilty saying no to carrying for their sister. Fox has had sisters change their minds about carrying after going through initial screening.
Bita Makarachi, a research assistant at the MacLean Center for Clinical Medical Ethics at the University of Chicago, said it’s critical for people to separate their roles as family members and their roles in the surrogacy. Those boundaries, she said, help everyone get “the best outcome, and the least amount of harm is done.”
Even if both siblings are on board, there are a string of other questions they have to talk through, and ultimately agree upon, to proceed. What will they do if prenatal tests turn up a chromosomal abnormality, or a genetic disorder? What do they want their birth plan to look like? How often should the siblings see one another during the pregnancy?
“It’s a very stressful process,” said Rebecca Reeder, a genetics counselor for GeneScreen Counseling. “There hasn’t been a lot of attention given to voices that have gone through infertility.”
If they do pursue surrogacy, close relatives can encounter other unexpected challenges. Managing conflicts or disagreements between the surrogate and the intended parents can be especially sensitive, because there are already family dynamics at play. Gatton and Roed, for example, disagreed on what precautions were necessary to protect against Covid-19 during the pregnancy.
“It gets a little bit more heated because we are so connected as sisters,” Gatton said.
But in other ways, carrying for a family member can alleviate some of the significant burdens of surrogacy. It can be far cheaper to pursue surrogacy if potential parents don’t have to pay an agency to find a surrogate. The total cost of surrogacy can run between $120,000 to $150,000 dollars, with about $50,000 going towards the surrogate, said Ann Wieczorek, a social worker for Alternative Reproductive Resources in Chicago who has also been a surrogate. She runs the surrogate management program where clients work with known surrogates, which she said costs dramatically less.
And with a close relative, there can be an innate sense of trust and transparency. Intended mothers don’t feel the need to tip-toe around their sister’s feelings like they would a stranger carrying for them. They are connected to each other’s lives, so they typically have a better sense of how the pregnancy will be treated — with diet, changes in health, travel plans, and more.
“People would probably prefer to use someone that they know and are comfortable with,” said Wieczorek. “Sometimes they don’t know how to ask [because] it’s such a private thing.”
That trust may become all the more important after the overturning of Roe vs. Wade, which could make it all but impossible for surrogates to get lifesaving care if something goes wrong with the pregnancy.
“It’s not a common thing that happens,” said Wieczorek. “But you can’t count on that – you could be that one in a one in a million.”
Deciding whether to proceed with a surrogacy is deeply personal. And so, too, are the feelings that emerge as it happens. Alison Green, a 33-year-old stay-at-home mother in Michigan, found herself constantly anxious while her step sister-in-law was carrying for her.
“I felt like I was burdening people’s lives,” said Green, who was unable to get pregnant due to her treatment for a condition called adenomyosis, in which the inner lining of the uterus grows into its muscle wall, causing severe bleeding. Her step sister-in-law, Jamie Bowman, approached Green and her husband with the idea of surrogacy last fall.
“I am 100% not a religious person,” said Bowman, a labor and delivery nurse in Marshall, Michigan. “I felt a weird calling. I don’t often feel that way. But I always felt like it was going to work.”
Bowman worked the night shift at Oaklawn Hospital while pregnant, sleeping in the car as her husband drove to ultrasound appointments an hour and a half away. It was an easy pregnancy, and she gave birth to baby Audrey in May.
“I don’t think it could have gone smoother than it did,” Bowman said. “It was easy, because I knew it wasn’t my baby.”
Because of the patchwork policy around surrogacy in the U.S., though, Audrey is still legally Bowman’s baby. Michigan is one of the three states that either extremely restricts or prohibits any surrogacy contracts. Green currently has guardianship rights and is working on adopting Audrey. Even as it still unfolds, the experience has forged a powerful bond between Green, Bowman, and Audrey.
“There’s another awesome woman figure in my daughter’s life now,” Green said.
Gatton, like Green, struggled with how she felt about the pregnancy. Her family and friends were supportive of the decision, and knew she would bond with her baby after delivery. But she still felt disconnected from the pregnancy. Roed wrote in a pregnancy journal, so Gatton could read about the experience even though she couldn’t experience it herself. When strangers were confused about their situation, Roed would step in to explain. Gatton recalled one instance when her sister insisted on speaking to a supervisor on the phone, because hospital staff would not let Gatton be in the room for an ultrasound appointment.
“We were very grateful in a lot of ways that that is my sister’s personality, because she will take charge and make sure that things run smoothly,” Gatton said.
When it came time for Roed to deliver in November 2020, Gatton and her husband set up in a room next to Roed’s at Allen Hospital in Waterloo, Iowa. The two sisters chatted between Roed’s strong contractions, a shared delivery experience grounded in Roed wanting her sister to experience as much as possible. Her one request was to not ask her if she needed anything — it was something she’d found grating after delivering her own three children. With Gatton on her right and Roed’s husband on her left, she delivered a 6-pound, 8-ounce baby girl, Rowan.
“My sister basically caught her,” Roed says. “I said, ‘We did it!’ We just started crying.”
Shortly after Rowan was born, the doctor who delivered her made a remark about her eye shape. As a newborn, Rowan became ill and lost weight, unable to digest Roed’s breast milk or formula. Doctors also discovered she had a hole in the heart. It wasn’t until December 2020 that Rowan was diagnosed with Down Syndrome.
It was a curveball they didn’t see coming. Roed’s prenatal tests, which can reveal markers of Down syndrome or other chromosomal abnormalities, didn’t raise any significant concerns. Now, at 20 months old, Rowan is behind on certain developmental benchmarks like sitting up and standing on her own. And though Rowan still struggles with eating and had a gastrostomy tube inserted directly in her stomach, Gatton describes her as the “chillest” baby.
“It probably was good to not know,” said Roed. “It probably would just be something to worry about, and they couldn’t enjoy the pregnancy.”
Roed, who is 37 now, said she would likely not be a surrogate again — she wants to be fully present for her kids, and is concerned about reproductive health care after the Dobbs decision. Gatton, for her part, said she would use a surrogate again. But she has three embryos remaining and wants to try to carry herself through IVF again. For now, though, she’s finding joy in motherhood.
“She’s starting to reach for me and touch my face. I know she knows who I am,” Gatton said. “What an incredible thing.”
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