# Surrogate Requirements: ASRM Guidelines and Agency Standards

The medical, psychological, and lifestyle criteria for gestational surrogates based on the ASRM 2022 committee opinion and typical agency requirements. What intended parents should confirm their agency screens for.

Updated 2026-11-01. Also on the [web page](https://surrogacyagencies.fyi/guides/surrogate-requirements-asrm).

Intended parents do not choose the surrogate's medical criteria — the agency and fertility clinic do. But you should confirm your agency follows **ASRM (American Society for Reproductive Medicine) guidelines** and understand what they cover.

**Primary source:** ASRM Practice Committee, "Recommendations for practices using gestational carriers: a committee opinion", *Fertility and Sterility* 2022;118(1):65–74. https://www.asrm.org/practice-guidance/practice-documents/ (checked 2026-11-01)

## ASRM 2022 recommendations for gestational carriers

### 1. Obstetric history
- **Ideally at least one prior term, uncomplicated pregnancy** before carrying for someone else. Most agencies make this a hard requirement.
- Ideally no more than **5 prior deliveries** or **3 prior C-sections** (some agencies set lower limits).
- Many agencies also screen out a history of:
  - Preterm birth (<37 weeks) without a known, non-recurrent cause
  - Placental abruption
  - Uterine rupture
  - Severe preeclampsia or HELLP syndrome
  - Postpartum hemorrhage requiring transfusion
  - Unexplained stillbirth or neonatal death

### 2. Age
- **Legal age, and preferably 21–45 years**. ASRM notes a carrier older than 45 may be considered if all parties are informed of the risks of pregnancy with advancing maternal age.
- Most agencies prefer **21–40** for first-time carriers; **up to 42–45** for experienced carriers with recent uncomplicated delivery and medical clearance.

### 3. Body Mass Index (BMI) — agency/clinic practice, not an ASRM limit
- ASRM does not set a BMI cut-off. Most agencies and clinics require **BMI < 32** (some require < 30).
- Rationale: Higher BMI correlates with increased pregnancy complications, anaesthesia risk, and lower IVF success rates.

### 4. General health — largely agency/clinic practice
- ASRM's psychosocial evaluation reviews substance use (tobacco, alcohol, marijuana, recreational and prescription drugs). Most agencies go further and require:
  - Non-smoker for ≥6 months (verified by cotinine test).
  - No illicit drug use.
  - Alcohol use within moderate limits.
  - No uncontrolled chronic medical conditions (hypertension, diabetes, thyroid disease, autoimmune disorders).
  - No contraindications to pregnancy (e.g., severe cardiac disease, active malignancy).
- ASRM also recommends preconception testing: blood type/Rh, cervical cancer screening per ACOG guidance, mammogram per ACOG guidance, varicella and rubella titers, and a urine drug screen.

### 5. Infectious disease screening (ASRM-recommended)
The FDA does **not** require screening or testing of the gestational carrier; ASRM recommends testing the carrier and her partner **before embryo transfer**. ASRM's recommended panel:
- HIV-1 antibody, HIV-2 antibody, HIV group O antibody
- HIV/HBV/HCV nucleic acid test
- Hepatitis B surface antigen and core antibody (IgG and IgM)
- Hepatitis C antibody
- Syphilis serology
- *N. gonorrhoeae* and *C. trachomatis* NAAT (urine or swab)
- HTLV-1/2 and CMV (IgG/IgM) — for the carrier's male partner only
- Clinics may add tests per their own protocols

### 6. Psychological evaluation and counselling
- ASRM recommends a psychosocial evaluation and counselling by a **qualified mental health professional** experienced in third-party reproduction, for the carrier and her partner or support person.
- Includes a clinical interview plus psychological testing, which can include personality inventories (for example the PAI or MMPI) — the specific instrument is the professional's choice, not a fixed requirement.
- The interview typically covers:
  - Motivation (altruistic vs. financial)
  - Understanding of the process and emotional demands
  - Support system (partner, family, friends)
  - History of mental health treatment, postpartum depression, trauma
  - Relationship stability
  - Attitudes toward selective reduction, termination, prenatal testing
  - Employment, income sources, and financial circumstances
  - Plans for post-birth contact
- The evaluation happens before legal counselling and signing contracts.

### 7. Uterine evaluation
- ASRM says a uterine cavity evaluation by **saline infusion sonogram (SIS)** or another modality is **highly recommended**.
- Clinics check for fibroids distorting the cavity, large polyps, septum, or adhesions.

### 8. Cervical length screening — clinic practice
- Not an ASRM requirement. Some clinics screen transvaginal cervical length (≥25 mm) at baseline or in early pregnancy.

### 9. Social and lifestyle — mixed ASRM and agency practice
- **ASRM**: the carrier must have a stable family environment with adequate support to help her cope with the added stress of pregnancy; the psychosocial evaluation covers living situation, support system, and finances.
- **Typical agency additions**: reliable transportation, no current involvement with child protective services, a clear **criminal background check** on the surrogate (and often her partner), and confirmation she is **not reliant on surrogacy compensation for basic needs** (reduces coercion risk).

### 10. Insurance review — agency practice
- Surrogate's health insurance **must be analysed** for surrogacy exclusions.
- If excluded: intended parents must secure a surrogacy-friendly policy (ACA marketplace, employer plan, or specialised surrogacy insurance).
- Confirmation of coverage (or plan to obtain) **before matching**.

### 11. Legal capacity and counsel
- ASRM requires each party — the carrier (with her spouse/partner) and the intended parents — to have **independent legal counsel** licensed in the applicable state before entering the agreement.
- Legally able to enter a contract in her state of residence.
- Spouse/partner (if married) typically must consent and sign the agreement.
- A fully executed agreement and a legal clearance letter must be in place before treatment starts.

## Typical agency additions to ASRM baseline

These are not in the ASRM committee opinion; they are common industry standards on top of it.

| Requirement | Common agency standard |
|-------------|------------------------|
| BMI limit | < 32 (some < 30) |
| Non-smoker | Cotinine test, typically ≥6 months nicotine-free |
| Criminal background check | On the surrogate, and often her partner |
| Home visit / social assessment | Environment, support system, safety |
| Financial stability | Not reliant on compensation for basic needs |
| Prior surrogacy experience | Preferred but not required; experienced carriers often matched faster |
| Maximum prior C-sections | 2–3 (some agencies cap at 2) |
| Maximum prior deliveries | 4–5 |
| Citizenship/residency | US citizen, permanent resident, or valid long-term visa (for US-based journeys) |
| Geographic proximity | Within 1–2 hours of a partner clinic; or willing to travel |
| No history of gestational diabetes | Preferred; some agencies accept if well-controlled and recent delivery uncomplicated |
| No history of postpartum depression | Preferred; if history, requires current mental health clearance |
| Willingness to travel | For medical screening, embryo transfer, and delivery if not local |
| Agreement to follow clinic protocol | Including medication compliance, appointment attendance, lifestyle restrictions |

## Screening timeline (typical)

| Stage | Who | What |
|-------|-----|------|
| **Pre-screen application** | Agency | Online questionnaire: medical, obstetric, social history |
| **Initial interview** | Agency | Phone/video: motivation, support, basic eligibility |
| **Medical records collection** | Agency | OB records from prior deliveries; operative reports if C-section |
| **Psychological evaluation** | Licensed MH professional | Clinical interview + psychologic testing (surrogate + partner) |
| **Medical screening** | Fertility clinic | Physical, labs, infectious disease, uterine eval, cervical length |
| **Insurance review** | Agency/insurance specialist | Policy analysis for surrogacy coverage |
| **Background check** | Agency/third party | Criminal, CPS, financial (soft pull) |
| **Home visit** | Agency social worker | Environment, support, safety |
| **Match meeting** | Agency | Intended parents + surrogate (video or in-person) |
| **Legal clearance** | Attorneys | Independent counsel review and execution of GCA |
| **Cycle sync & transfer** | Clinic | Medications, monitoring, embryo transfer |

## What intended parents should verify

Ask your agency for **written confirmation** that the surrogate has completed:

- [ ] ASRM obstetric history criteria (prior term delivery; delivery and C-section counts within limits)
- [ ] Age and BMI within agency limits
- [ ] Infectious disease panel (current, negative) before embryo transfer
- [ ] Psychological evaluation by a qualified mental health professional
- [ ] Uterine cavity evaluation (SIS or other modality) normal
- [ ] Cervical length normal (if the clinic screens it)
- [ ] Non-smoker (cotinine negative)
- [ ] Background check clear
- [ ] Home visit completed
- [ ] Insurance reviewed and confirmed (or plan documented)
- [ ] Independent legal counsel retained and GCA executed

## Red flags in surrogate screening

- Agency matches before **all** medical and psychological screening is complete
- Agency accepts surrogates without prior full-term delivery
- Agency does not require psychological evaluation with standardised testing
- Agency cannot provide insurance review documentation
- Agency skips home visit or background check
- Agency pressures you to match with a surrogate who has unresolved medical or psychological flags

## For international intended parents

Confirm the agency verifies the surrogate's eligibility **under US standards** even if your home country has different rules. The child's US birth certificate and your parentage order depend on the surrogate meeting the requirements of the state where she delivers.

## Summary

| Category | ASRM 2022 recommendation | Typical agency standard |
|----------|---------------|------------------------|
| Prior delivery | Ideally ≥1 term, uncomplicated | Same, usually a hard requirement |
| Age | Legal age, preferably 21–45 | 21–40 (first-time); ≤45 (experienced) |
| BMI | No cut-off | <30–32 |
| Smoking | Reviewed in psychosocial evaluation | Negative cotinine ≥6 mo |
| Psych eval | Clinical interview + psychologic testing (e.g. PAI or MMPI), surrogate + partner | Same |
| Infectious disease | ASRM-recommended panel negative before transfer | Same |
| Uterine eval | SIS or another modality, highly recommended | Same |
| Background check | Not specified | Criminal + CPS |
| Home visit | Not specified | Usually required |
| Insurance | Not specified | Reviewed, coverage confirmed |
| Legal counsel | Independent counsel for each party | Same |

**Bottom line:** A reputable agency will show you the surrogate's completed screening checklist (redacted for privacy) before you commit to the match. If they cannot, keep looking.

**Sources:**
- ASRM Practice Committee, "Recommendations for practices using gestational carriers: a committee opinion", Fertil Steril. 2022 Jul;118(1):65-74. Checked 2026-11-01.
- FDA, "Eligibility Determination for Donors of Human Cells, Tissues, and Cellular and Tissue-Based Products", 21 CFR 1271.
- SEEDS, "Ethical Standards for Surrogacy Agencies", accessed 2026-11-01.

## Questions

### Can a woman be a surrogate if she has never given birth?

ASRM recommends a carrier ideally has had at least one term, uncomplicated pregnancy before carrying for someone else, and most agencies make it a hard requirement. This demonstrates the ability to carry a pregnancy to term and reduces medical and psychological risk.

### What is the upper age limit for surrogates?

ASRM recommends carriers be of legal age and preferably 21–45 years; older carriers can be considered with counselling about the risks of pregnancy at advanced maternal age. Most agencies set a cap at 40–42 for first-time surrogates.

### Does the surrogate need her own health insurance?

Yes. The surrogate's health insurance is the primary payer for prenatal care and delivery. If her policy excludes surrogacy, intended parents must purchase a surrogacy-friendly policy or pay cash. This can add $10,000–$30,000+.