Surrogacy is a planned pregnancy which allows the opportunity for pre-conception counselling. For most prospective surrogates/commissioning parents, any advice sought prior to undertaking a surrogate pregnancy is likely to be from the legal profession, but many of the potential risks and conflicts of interest can be anticipated from a medical perspective so pre-conceptual counselling is to be strongly recommended. It affords the opportunity to fully explore the physical and emotional risks of surrogate pregnancy for the prospective surrogate, as well as to clarify the legal implications of different types of surrogacy and raise some of the possibly unanticipated dilemmas or conflicts of interest which may occur. Some aspects of the counselling will be best provided by specialist organisations, such as the British Infertility Counselling Organisation [4].

If the prospective surrogate mother is married or in a Civil Partnership, her partner should be included in the discussions and be aware with the woman of the implications (particularly emotional) for the partnership and any other children in the family. Also, provided the partner consents to the surrogacy process going ahead, he or she will have equal parental responsibility for the baby until any other legally-binding arrangements are made with the commissioning parents after the baby has been born, as in the UK he or she would be the other legal parent (along with the surrogate mother).

As for most aspects of care in a surrogate pregnancy, it is ideal that the surrogate mother and commissioning parents should have a different health professional providing care, to avoid bias in advice for either party. The ultimate responsibility of the obstetrician is unequivocally to the surrogate mother, although with her uninfluenced consent, commissioning parents may appropriately be included in some of the care or discussions.

The suitability of the prospective surrogate mother should be examined with her, and any risks from the pregnancy fully discussed. The risks are likely to be lowest in a parous woman, provided previous pregnancies have been uncomplicated, as she avoids the increased risks due to placental dysfunction (pre-eclampsia, intra-uterine growth restriction) inherent in a first pregnancy and she will have an examinable track record in pregnancy. However, certain findings in the obstetric history may be relative contra-indications to surrogacy. This would include a history of previous caesarean section with an expressed wish to consider vaginal birth (VBAC), as this would introduce a potential conflict of interest between mother and fetus, which could result in conflict between surrogate mother and commissioning parents. Any relevant medical history which may carry a risk to the fetus (known or suspected carriage of genetically transmittable disease, history of pre-term delivery or intra-uterine growth restriction, for example) should be encouraged to be disclosed to the commissioning parents and these risks factored into the care plan for the pregnancy.

As in any pre-conceptual counselling, the prospective surrogate should be encouraged to avoid smoking, alcohol and illicit drug use and should aim for a body mass index within normal range (18–25 kg/m²), as well as to be Rubella immune, on folic acid supplementation and have relevant infectious diseases excluded (syphilis, hepatitis B and C, HIV). Any additional risk due to maternal age should be avoided by the Surrogate being ideally no older than 35 years, and she should be over the age of 18 (21 in the USA). Most licensed fertility clinics have their own guidance on acceptable age range for Surrogate Mothers [5].

The Surrogate should be encouraged to discuss all antenatal screening fully with the Commissioning Parents and reach agreement on those screening tests which will be accepted, as well as how they will proceed if screening detects a problem or an increased risk of a problem. Attitudes of both parties to risk of aneuploidy and fetal anomaly should be as clear as possible, as well as the nature of problems which would make either party wish to consider termination of pregnancy. Although such discussions will not exclude potential conflicts of interest when the time comes, they may help to avoid these being entirely unanticipated, as well as allowing either party to reconsider the surrogacy undertaking if a likelihood of being unable to find a common ground on such areas is identified.

Part of the discussion of assisted conception will need to include the differing types of surrogacy, resultant genetic relationships to the child and implication for achieving legal parenthood, as well as the medical implications for those involved and successful pregnancy rates.