Full analysis of surrogate mother screening criteria: triple evaluation system of medicine, psychology and law

1. Why surrogate mother screening is important

In the entire surrogacy process, the selection and screening of surrogate mothers (also called "assisted pregnancy volunteers" or "pregnant mothers" in some countries) are the core links that determine whether the project can proceed smoothly and whether the mother and baby are safe. Surrogate mothers not only need to bear the physical pressure of embryo transfer, pregnancy and childbirth, but also need to maintain psychological stability and cooperate at the legal level to complete procedural work such as the transfer of parental rights.

According to global data, about 35% of the reasons for surrogacy failure are directly related to the surrogate mother's own health or mental state, and about 15% are due to contract disputes or parental rights disputes caused by incompetent legal qualifications (Source: IFFS 2023 Global Fertility Survey Report). An improper choice not only means a waste of medical resources, but may also cause the entrusting family to lose several years and hundreds of thousands of dollars in funds.

It is crucial for the client to understand the details of the screening criteria. This not only helps you identify whether the screening is strict when choosing an agency, but also allows you to have basic independent judgment when facing the surrogate mother information provided by the agency, instead of relying entirely on the agency's words.

This article will break down the triple screening system layer by layer, and provide an operational verification framework based on the latest guidelines of the ASRM Practice Committee (2022 revised version) and the specific regulations of each destination country.

2. Level 1: Detailed explanation of medical screening standards

Medical screening is the first threshold for surrogate mother evaluation, and it is also the most objective and easily quantifiable level. The core basis is the "Practice Guidelines for Surrogacy in Assisted Reproduction" released by the ASRM Practice Committee in 2022.

2.1 Basic demographic indicators

2.2 Gynecological and reproductive system examination

Gynecological system assessment is a core part of medical screening and usually includes the following items:

• Hysteroscopy:Evaluate the uterine cavity morphology and rule out endometrial polyps, intrauterine adhesions, uterine septum and other structural abnormalities that may affect embryo implantation. Normal uterine cavity morphology is the basic condition for successful embryo transfer.
• Uterine ultrasound:Baseline antral follicle count (AFC), endometrial thickness and echogenicity, and uterine fibroid screening (intramural fibroids >4 cm in diameter are usually contraindicated).
• Fallopian tube patency check:Some institutions require this to rule out the risk of hydrosalpinx affecting endometrial receptivity.
• Cervical Screening:Cervical liquid-based cytology (TCT) examination results within the last 12 months exclude cervical lesions.
• Six items of hormones:FSH, LH, E2, AMH, etc., evaluate ovarian reserve and endocrine environment. The ovarian reserve of the surrogate mother does not directly affect the outcome of the surrogacy (because the client’s embryos are used), but abnormal hormonal environment may affect endometrial preparation.

2.3 Systemic health screening

Systemic health status is directly related to pregnancy safety. The following screening items are industry standard configurations:

• Infectious Disease Screening:AIDS (HIV), hepatitis B (HBsAg/HBcAb), hepatitis C (HCV), syphilis (RPR/TPPA), cytomegalovirus (CMV), Toxoplasma gondii, and rubella antibodies. Any positive results are exclusion criteria (except for CMV-negative surrogate mothers who match CMV-positive clients, which require special treatment).
• Genetic Screening:Thalassemia gene carrier screening (especially important among surrogate mothers in Southeast Asia, the Middle East and the Mediterranean); Fragile X syndrome carrier testing; Cystic fibrosis genetic screening (often required by US institutions).
• Internal Medicine Chronic Disease Assessment:Hypertension (a history of gestational hypertension is relatively contraindicated), diabetes (a history of gestational diabetes requires special evaluation), autoimmune diseases (such as systemic lupus erythematosus, antiphospholipid syndrome), and thyroid dysfunction (TSH requirements are usually in the range of 0.5-2.5mIU/L).
• Hematology indicators:Routine blood test, blood type (ABO and Rh blood type), coagulation function, and thalassemia screening. Rh-negative surrogate mothers need to pay special attention to anti-D immunoglobulin prophylaxis regimens.
• Psychiatric medication history:Current use of psychiatric medications (e.g., antidepressants, anxiolytics, mood stabilizers) is usually an exclusion criterion. Some drugs have teratogenic risks to the fetus and may affect the accuracy of psychological assessment.

2.4 Lifestyle assessment

The daily lifestyle of surrogate mothers has a direct impact on pregnancy outcomes. The following are common assessment contents:

• Smoking:A complete ban on smoking is a unified requirement of surrogacy agencies around the world. Smoking is closely related to premature birth, low birth weight, and placental dysfunction. A certificate of smoking cessation for more than 3 months is usually required before signing a contract, and some institutions require a urine cotinine test.
• Drinking:Zero alcohol exposure during pregnancy is an international consensus. During the assessment phase, the frequency and amount of drinking are usually asked, and moderate to heavy drinkers (more than 14 standard drinking units per week) are excluded.
• Substance Abuse:Urine drug screening (usually covering marijuana, cocaine, amphetamines, opioids, benzodiazepines) is performed during the evaluation phase and repeated prior to transplantation.
• Living environment:A stable living environment (non-traveling status) facilitates regular prenatal care and emergency medical response.
• Occupational Hazard Exposure:Occupational risks such as long-term exposure to radiation, chemical solvents or high-intensity physical labor may require job changes during pregnancy.

"The medical screening standards for surrogate mothers should not lower the threshold due to commercial pressure. Behind each medical standard, there is real risk data. The stringency of the screening standards directly determines the baseline of maternal and child safety during pregnancy." - American Society for Reproductive Medicine (ASRM) Practice Committee, Preface to the 2022 Guidelines

3. The second level: psychological assessment system

If the medical screening is an assessment of "whether the surrogate mother can do it", then the psychological evaluation is an in-depth review of whether she is "suitable to do it". The psychological assessments of mainstream surrogacy agencies around the world are based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as the framework and are performed by licensed clinical psychologists or psychiatrists.

3.1 The purpose and core framework of psychological assessment

The psychological evaluation of surrogacy is not to screen out people with "psychological problems", but to identify candidate surrogate mothers:

1. Fully understand the nature of surrogacy (the child is not genetically related to you) and its emotional implications
2. Be realistic about emotional separation during pregnancy and after childbirth
3. In the current state of life, surrogacy is motivated by free will rather than financial coercion.
4. No mental disorder that may affect decision-making or ability to cope during pregnancy
5. Genuine support from family members (especially partners) for the surrogacy decision

3.2 Standardized assessment tools

3.3 Assessment of surrogacy motivations

Motivation assessment is the most controversial and critical part of surrogacy psychological assessment. Psychologists will judge the authenticity and stability of motivation through the following dimensions:

3.4 Postpartum emotional attachment risk assessment

The surrogate mother releases the child to the commissioning family after delivery, a process that is essentially an organized separation. A psychological assessment needs to specifically assess this risk:

• Does the surrogate mother understand that she has no genetic connection to the child (this is clear in IVF surrogacy)?
• Has she experienced a traumatic history of being separated from her children (such as the loss of a child)? Such experiences are not necessarily precluded, but require in-depth evaluation.
• Was she able to describe her plans for separation after childbirth in an interview that was concrete and emotionally realistic (without being overly dismissive or showing intense anticipatory grief)?
• How would she describe her postpartum emotional state during her past natural childbirth experience? Do you have a history of postpartum depression?

"The goal of psychological evaluation is not to find an 'unemotional' surrogate mother - that would be worrisome. What we are looking for is someone who can make a voluntary decision with full self-awareness based on a full understanding of the meaning of surrogacy." - American Association of Surrogacy Agencies (SAMC) Clinical Psychology Guidance Manual, 2021 Edition

3.5 Family systems assessment

The spouse or partner of the surrogate mother usually also needs to participate in the psychological evaluation, because the stability of the family system during pregnancy directly affects the psychological state of the surrogate mother. Assessment content includes:

• Spouse’s attitude towards surrogacy (real support vs passive acceptance)
• Whether there are young children in the family and their parenting arrangements
• Both parties’ expectations for adaptation to changes in life during pregnancy (such as suspension of sex life, restrictions on pregnant women’s movements)
• Whether the payment from the surrogacy agency goes into the family's joint account and whether there is an economic control relationship

4. The third level: legal qualification review

After passing both the medical and psychological aspects, the legal qualification review determines whether a surrogate mother can legally participate in the surrogacy project under a specific legal framework and successfully complete the transfer of parental rights after delivery.

4.1 Identity and marital status

Different countries have different requirements for the marital status of surrogate mothers:

• Kyrgyzstan:There is no explicit marital status requirement, but institutions generally prefer candidates who are married or have a stable partner to ensure a complete family support system.
• Georgia:According to the Georgia Health Rights Law, the surrogate mother must be married, and her spouse must give informed consent and sign the relevant agreement.
• USA:There is no legal requirement for marital status, but most agencies require surrogate mothers to have a stable living environment to ensure the accessibility of care during pregnancy.
• Kazakhstan:Article 54 of the "Marriage and Family Code" does not clearly stipulate the marital status of surrogate mothers. In practice, single women can also apply.

4.2 Criminal record review

Mainstream surrogacy agencies around the world require surrogate mothers to provide proof of no criminal record. The specific scope usually covers:

• Any violent crime (including domestic violence)
• Child abuse or neglect records
• drug related crime
• Fraud offenses (in some jurisdictions)

In Georgia and Kyrgyzstan, it is usually required to provide a criminal certificate issued by the national police department (in Kyrgyzstan, a document issued by the Ministry of Interior) and certified by a notary public.

4.3 Assessment of economic independence

This standard is extremely important from an ethical perspective and aims to distinguish between "informed voluntary choice" and "coerced consent under economic coercion":

According to the IFFS 2023 Global Survey Report, in approximately 23% of surrogacy dispute cases, financial dependence is identified as one of the factors affecting the surrogate mother's ability to make independent decisions. This is also the core argument of some ethicists against commercial surrogacy. Because of this, rigorous institutions will specifically evaluate this dimension rather than just pursuing candidate numbers.

4.4 Informed Consent Procedure

Informed consent is not only an ethical requirement, but also a legal requirement in most countries where surrogacy is legal:

• Content completeness:The surrogate mother must be informed of all the medical risks of surrogacy (including multiple pregnancy, probability of cesarean section, rare but serious obstetric complications), psychological risks, and legal consequences (the transfer of parental rights is irreversible).
• Language accessibility:Informed consent documentation must be provided in the surrogate mother’s native language, with a professional translator present (if applicable).
• Independent legal counsel:In mature surrogacy markets such as the United States and Canada, surrogate mothers must be represented by lawyers independent of the client to ensure that their interests are not confused by the agent.
• Cooling off period:Some jurisdictions require that after informed consent is signed, a cooling-off period of a certain number of days is required before the contract can become effective.

5. Comparison of differences in screening standards in different countries

The screening standards of surrogacy destination countries are not completely consistent. The client needs to understand the specific regulations of the destination country to evaluate whether the agency complies with local laws and international industry standards.

6. Revealing the internal screening process of surrogacy agencies

Understanding the internal logic of the agency screening process can help principals identify which agencies are truly serious about implementing the standards and which agencies are just a formality. The following is the standard screening process for mainstream international surrogacy agencies:

6.1 Initial screening (weeks 1-2)

Preliminary screening is usually completed through questionnaires or preliminary interviews. The main purpose is to quickly eliminate applicants who are obviously unqualified and reduce subsequent consumption of medical resources:

• Basic verification of age, BMI, reproductive history
• Self-reports of smoking, drinking, and drug use
• Self-report of basic health conditions (chronic diseases, surgical history, psychological treatment history)
• Family structure and residential stability
• Initial motivation assessment (open-ended interview)

Applicants who pass the preliminary screening account for about 40% to 60% of the total applications (there are large differences among institutions, and the passing rate of strict institutions is lower).

6.2 Medical Assessment Phase (Weeks 3-6)

Candidates who enter the medical evaluation stage will go to partner hospitals for a full set of medical examinations, including:

1. Gynecological ultrasound (including endometrial assessment, AFC count)
2. Hysteroscopy (if abnormalities are found on ultrasound)
3. Complete blood screening for infectious diseases
4. Genetic disease carrier screening
5. Comprehensive medical examination (blood routine, biochemistry, thyroid function, coagulation, etc.)
6. Urine drug screening
7. Cervical TCT (within the past 12 months)

After the medical evaluation, a reproductive physician will issue an evaluation report, giving three conclusions: "It is recommended to enter the surrogacy process", "Conditional pass (requires re-evaluation after additional treatment)" or "It is not recommended to participate".

6.3 Psychological evaluation phase (weeks 4-7, usually conducted simultaneously with medical evaluation)

A psychological assessment is usually divided into two parts:

• Standardized assessment:MMPI-2 or PAI, PHQ-9, GAD-7 and other scales are completed, and the results are interpreted by a licensed psychologist
• Clinical interview:It is usually a semi-structured interview of 60-90 minutes, covering core topics such as motivation, family support, postpartum expectations, financial situation, etc.; spouse/partner participates simultaneously, lasting 30-45 minutes

6.4 Legal and Administrative Review (Weeks 6-8)

• Identity document verification (passport, resident ID card)
• No criminal record certificate verification
• Proof of marital status (if applicable)
• Verification of previous birth records (birth certificate, hospital delivery record)
• Proof of residence (utility bill, rental contract)
• Informed consent process starts

6.5 Matching and Contracting Phase (Weeks 8-12)

After passing all three screenings, the agency submits the surrogate mother's files to the client for selection (most agencies provide the client with desensitized files of 3-5 candidates). After both parties confirm their matching intentions, they enter the contract signing process.

7. How does the client verify the screening results?

The surrogate mother profile displayed by the agency to the client is a summary of information screened and compiled by the agency. The client has the right and need to conduct independent verification. The following are feasible verification methods:

7.1 Request for full medical report

The client has the right to request to see the surrogate mother's complete medical evaluation report (with the surrogate mother's informed consent), rather than just the agency's summary document. Key verification items include:

• Original test report for infectious disease screening (including laboratory name, test date, reference value range)
• Gynecological ultrasound report (including endometrial thickness, presence and size of fibroids, and number of AFC)
• Hysteroscopy report (if performed)
• Blood type report (verify Rh blood type and treatment plan)

7.2 Request summary of psychological evaluation report

The complete original psychological evaluation report usually involves the privacy of the surrogate mother, and the client can usually only obtain the summary conclusion written by the psychologist, which should include:

• Psychologist qualifications (license number, practice institution)
• Evaluation conclusion (pass/conditional pass/not recommended) and brief reasons
• Assessment date (should be close to current application date and should not be more than 12 months old)

7.3 Video meeting with surrogate mother

Most formal institutions support a video meeting between the client and the candidate surrogate mother with the intervention of an interpreter. The value of this step is:

• Directly feel the surrogate mother’s mental state and expression stability
• Verify their understanding of the basic concepts of surrogacy (such as the source of embryos and ownership of rights after childbirth) through natural conversations
• Observe the presence and attitudes of family members

7.4 Request independent third-party verification (high-end option)

For more expensive surrogacy projects (especially surrogacy in the United States), some commissioning families will entrust independent medical consultants or reproductive lawyers to independently review the screening records of candidate surrogate mothers. This option is more expensive but provides the highest level of verification assurance.

8. Frequently Asked Questions and Red Flags in Screening

In actual operation, the following situations should alert the client and require an explanation from the agency:

8.1 Medical red flags

• Institutions are unable to provide original laboratory reports for infectious disease screening, only internal summary sheets
• The surrogate mother has a history of more than 2 cesarean sections, but the institution does not provide uterine scar ultrasound evaluation results
• The BMI is clearly over 32, but the agency claims to have "passed medical evaluation"
• The surrogate mother is over 38 years old, but the agency did not indicate whether additional gynecological risk assessment was performed
• The screening report is more than 12 months old and has not been re-examined or updated.

8.2 Psychological red flags

• The institution cannot provide an assessment conclusion issued by a licensed psychologist, only the "judgment" of the institution's consultant
• The surrogate mother showed excessive focus on surrogacy income during the video meeting and made little statement about other aspects.
• The surrogate mother’s partner/spouse refuses to participate in the assessment or video interview
• The conclusion of the psychological evaluation is "conditional pass", but the institution cannot explain what the additional conditions are and whether they have been met.

8.3 Legal red flags

• Unable to provide the original criminal record certificate of the surrogate mother
• The surrogate mother’s previous birth record (child’s birth certificate) cannot be verified
• The agency said it was "inconvenient" for the surrogate mother to let the client see the original identity document.
• In the surrogacy contract, the surrogate mother's signature is signed by the "agent" on her behalf and is not witnessed by a notary.

9. Comprehensive evaluation: three standards are indispensable

Through the in-depth dismantling of the above three levels, we can clearly see that the screening of surrogate mothers is never a single-dimensional evaluation, but an organic and overall system. Medical standards ensure the physiological basis of pregnancy, psychological assessment confirms the authenticity and emotional readiness of decision-making, and legal review ensures that the entire project operates within a compliance framework and achieves a clear transfer of rights.

For the client, understanding the triple screening criteria is not only a tool for self-protection, but also an important frame of reference for measuring the professionalism of partner institutions. An agency that truly takes the surrogacy project seriously will take the initiative to explain its screening process to the client and be willing to provide verifiable original documents within reason, rather than just asking you to believe in verbal promises.

Ultimately, the quality of surrogate mother screening determines whether the entire surrogacy project can be conducted in a safe, compliant, and dignified manner. This is not only the interest of the entrusting family, but also the basis for the protection of the rights and interests of the surrogate mother. It is also the basis for the surrogacy industry to win ethical legitimacy on a global scale.