Looking back, the person we need to thank most for the success of our pregnancy is John McCain, the late Republican senator from Arizona who, mortally ill, helped block U.S. President Donald Trump’s attempt to abolish Obamacare in July 2017. That made it possible for us to buy health insurance for preemies and avoid economic collapse. The bill we got for six days in the neonatal intensive care unit was 432,000 shekels ($120,000), an unplanned expense that was spared us thanks to the insurance policy we bought on the day of the birth. Although we didn’t have to pay the full amount, the deductible alone cost us 80,000 shekels. Still, that‘s small change compared with the 700,000 shekels ($195,000) that the surrogacy procedure cost us in total.
If you’re upset that this story of the marvelous saga to expand the family is being observed through an economic prism, you have a perfect right to be taken aback. It’s grating to open an article on the miracle of bringing new life into the world by focusing on the cost of an insurance policy. But really, there’s no choice. From the moment surrogacy for Israeli gay men swung away from Asia and landed in the American kingdom of capitalism, having a baby became a complex spreadsheet in which every row carries a price tag.
Pentagonal family unit
We embarked on the journey to parenthood in the spring of 2016, as the 10th anniversary of our relationship approached. The original thinking was to go the route of joint parenthood. A friend made us a match with a lesbian couple, and the chemistry with them was instant. The advantages of this model are obvious, beginning with the shared burden: half a week with us, half a week with them, every second weekend free. The disadvantages are equally plain: Multiple parents translates into multiple approaches to parenting; raising children in two homes (a divorce format) posits many logistical challenges; grandparents’ access to the child is greatly reduced; and the fantasy of relocation fades for good. At the time, the anticipated difficulties were dwarfed by the privilege of becoming a parent without becoming totally enslaved to parenthood.
We dated the girls for eight months, as it were. We went out for a drink once a week, we took a trip to Lake Kinneret, we planned a holiday abroad, and not a single significant warning light flashed regarding the four-sided family unit we had started to create. The plan was for my husband (the older member of our twosome) and the older woman to be the biological parents, with a second pregnancy to take place in the future.
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We passed drafts of contractual agreements back and forth. On the agenda: everything imaginable. There were trivial issues such as medical checks during the pregnancy (who would pay for them? who would be present?) and housing arrangements during infancy. There were bureaucratic matters like the way the newborn and its parents would be registered with the Interior Ministry.
There was the question of the surname, which was liable to consist of four names. There was the division of expenses (savings plans, payment for extracurricular activities), the parents’ places of residence (the distance between homes was not to exceed 15 kilometers), and the child’s future education. There were even horror scenarios: What if one parent died, became religious, developed an addiction or joined a cult?
No significant disagreements cropped up in any of these matters, and we were getting ready to validate the contract legally. The turning point came when we heard the story of a gay couple and a lesbian couple who had a child together but then endured a first separation (the guys) and later a second (the gals). Freedom for them took the form of painful deprivation, with parenting time for each shrinking to two days a week at best. In joint consultation with the women, we decided to abandon the idea. A few weeks later, we set the plan in motion again, this time alone.
The information took us by surprise: At ORM Fertility, in Portland, Oregon, though to be the largest fertility clinic in the United States, 30 percent of surrogacy procedures among foreigners involve Israeli parents, virtually all of them gay couples. It’s possible that the percentage of Israeli clients is lower at other clinics (there are about 20 that specialize in surrogacy in the United States), but the statistic nevertheless reflects Israel’s disproportionate place, relative to its size, in the American surrogate-mother industry.
In fact, the surrogacy trend for gay men, estimated at 200 births a year in Israel, is a phenomenon limited exclusively to this country. In Israel, every same-sex couple has to cope with the typical auntie's question, “Nu, and what about children?” That’s a sign of the community’s normalization here, but normality comes with a rigid requirement. Were we really bubbling with the desire to be parents, or were we only trying to prove that all is fine with us?
We started with the pioneering agency in this field, the one that blazed the trail to surrogacy in India and later expanded to Nepal and Thailand. But, about five years ago, India banned surrogate motherhood for gay men, and in its wake the other countries in Asia also closed their gates to the likes of us. That put an end to the possibility of a surrogacy procedure at the relatively low price of around 200,000 shekels, compared with “First World surrogacy,” which costs about three times as much.
The agency looked for inexpensive alternatives and suggested a new path in Mexico, which was then in its trial stage. We asked how many successful pregnancies this route had already produced. None, the agency admitted. We decided to leave Mexico to the adventurers and go for the expensive, but proven, option – its neighbor to the north.
For Israeli gay men, having a baby is a complex spreadsheet in which every row carries a price tag.
We continued shopping in the most experienced agency in the gay fathers’ realm in Israel, which was founded by a marketing man. He mentioned two options: an American route and a Canadian route. The Canadian path is at least 100,000 shekels cheaper because there’s no need to pay the surrogate mother. How so? In Canada, surrogacy is, by law, completely altruistic, the marketing man explained, and the women are good Christians who want “to grant people the right to raise a family.” He added, with a thin smile, that these surrogate mothers receive “enlarged reimbursement of expenses,” and hinted that this was a way to get around the Canadian ban on paid surrogacy.
In any event, the bulk of the payment goes to the middlemen. Savings like that are nothing to sneer at, but we both agreed that we’d feel better paying the woman who was to carry our offspring in real money, not in currency of Christian grace.
In the meantime, we met with a third party, an American fertility clinic that had opened a branch in Israel. Direct access to the clinic saves the middleman’s commission, which represents a price reduction in itself, albeit not a dramatic one. We met with the representative – an Israeli who speaks fluent American – in his house. “We not only accompany you in the process, we see ourselves as your best buddies,” he said. We were persuaded.
Modern race theory
The first step is to find an egg donor. In this field, America really is the land of opportunity – with a price range to match. We paid the low rate ($8,000) because we made do with the database of candidates that’s attached to the clinic and for which there’s “no charge” to access. It’s a pretty limited database, with about 15 candidates at any given moment.
But hey, this is America, so there’s no upgrade that money can’t buy. An additional payment of $8,500 to $20,000 provides access to premium databases. There’s one consisting of donors who are models (they call it “donors who look like you,” and you can select the desirable physical qualities), while there’s another of donors who are Ivy League graduates. Unfortunately, there’s no overlap between the databases. An egg from a Jewish donor will cost more – around $20,000 (half to the agency, half to the donor). All told, if you go with the select databases, the cost of the egg donation can reach $35,000.
The abundance is a problem. Many of our predecessors wasted weeks in pursuit of the “perfect egg,” disqualifying good-looking, healthy donors on the basis of feeble parameters such as space between the eyes and a mediocre SAT score. We learned from their experience and decided to stick with the freebie database.
What stirs the greatest interest among surrogacy parents seems to be golden curls and blue eyes. As we consider ourselves individualists and definitely not racist, we decided to buck the trend in finding the biological mother.
But even so, the choice of the donor can’t help but be based largely on a fantasy of genetic enhancement – as though a Latin mix were enough to create a kind of super-baby – exotic, smart and skirting the genetic diseases of Ashkenazi Jews. In short, the search for a donor proceeds according to a modern race theory, flexible and personally adjusted but also inconvenient to admit to. “Anything but blondes,” I made my husband vow. A brunette donor with amber eyes was almost chosen because she was one-eighth Native American, but was finally eliminated because of her grandfather’s medical history – manic depression. Another woman, half-Asian, was dropped because her sister was coping with anorexia.
We stuck to a rule of thumb: Mental diseases meant disqualification, whereas physical diseases, provided they weren’t the kind passed on genetically, would be considered on an individual basis. After about two weeks of unproductive searching, the profile of a donor code-named A35 was added to the database. Her medical history was satisfactory: Her mother suffered from obesity (but only after a traffic accident left her immobile), her father was a recovering alcoholic, and one of her seven cousins had a learning disability. The fact that she was 21 worked in her favor, because a young age is a predictor of an ample number of eggs, increasing the prospects of fertility.
And her appearance? As white as snow, bottle-blonde hair. In our defense, I can say that her eyes are green, not blue.
The next stage, then, is to find the surrogate. The clinic put us in touch with five agencies for surrogates, each of which controls a different region of the country.
Because demand for surrogate mothers exceeds supply, hooking up with an agency doesn’t ensure an available woman when the contract is signed. The average waiting time is between four months and a year and a half. We were ready to pay in order not to lose momentum, and we went for the fastest option. The supply of surrogates available in Oregon, where the clinic was situated, had run out, so we had to expand into new territory, particularly in what the Americans derisively call “flyover country.” In other words, although the headquarters of the surrogate-mother industry are located in urban areas, many of the surrogates are recruited from the boondocks.
Were we really yearning to be parents, or were we only trying to prove that all is fine with us?
After two weeks, we were informed that a suitable candidate had been found. Tiffany (her name and that of other family members were changed) was 24, married and the mother of an 18-month-old girl, a part-time preschool teacher living in Oklahoma City. (Motherhood is a condition for surrogacy so that there are no known complications preventing the woman from giving birth.) Oklahoma is considered part of the Bible Belt, but Tiffany, for one, wasn’t put off by the fact that we were a gay couple. On the contrary, this turned out unexceptional. The agencies told us that women from low socioeconomic classes, some of them very pious, like to “grant life” to gay people.
This has nothing to do with a developed pro-LGBT consciousness, it’s related to the dialogue with the intended parents. A straight couple will turn to surrogacy because they have no choice and are usually worn out by futile attempts to achieve parenthood. The disappointment is compounded by a sense of failure, particularly among the woman, and this sometimes causes tension with the surrogate mother. For a gay couple, however, surrogacy isn’t a last resort but is perceived as an integral element from the outset.
Still, the getting-acquainted conversation was awkward and artificial. The platform (Skype) and the forum (a screen split four ways: us, her and two agency representatives) don’t let you get an authentic impression. Not that there’s a choice. In contrast to locating a donor, the agency chooses the surrogate, and if we’d refused we’d have lost our place at the head of the line. Like everyone, we relied on the agency’s filtering mechanism, which is supposed to disqualify unsuitable women, and we also assumed that the surrogate wants the pregnancy to succeed, as she gets money for every month of “carrying.”
Spreading out the surrogate’s salary over nine months is liable to cause a conflict of interest with her. The classic dilemma is whether to have amniocentesis (generally performed at the start of the second trimester). It’s the most reliable indicator of the embryo’s health but also increases the risk of a miscarriage – a scenario we would obviously not want, but one more fraught with problems for the woman. She, after all, would have endured a rigorous selection process, taken medications, undergone invasive medical procedures, and in the case of a miscarriage, would be rewarded for only a few weeks of work. In any case, unlike in Israel, the American medical establishment isn’t wild about this test, on the assumption that less intrusive procedures are enough to rule out Down syndrome at a high level of certainty. We decided not to insist.
American agencies now customarily offer clients a “guarantee to baby” option: In return for a fixed price, the clinic undertakes “to provide” a baby, no matter how many attempts this entails. The deal is also valid for unsuccessful embryo transfer and in case of a miscarriage. Guided by fear of failure and of the need to make a double payment, we – and pretty much all the other couples who face a similar dilemma – opted for the “all inclusive” rate.
The commitment, remember, is for one infant, perhaps to the regret of Israeli gays, who almost always like to have twins. The insistence on twins is a product of the costs and complexities of the process. The extra payment to the surrogate for carrying two embryos is negligible compared to the task of achieving another pregnancy at some future time. In this sense, it’s the most worthwhile “one plus one” special there is.
The American medical establishment, however, is moving toward opposition to pregnancy with twins because of the increased risk, both to the mother and to the embryos. The American Society for Reproductive Medicine recently issued new guidelines in this spirit, which many surrogacy agencies are adopting. One agency announced that henceforth, women under its auspices would not carry more than one embryo. In our case, the medical authorities suggested that we reconsider a pregnancy with twins, citing at length the risks involved. Nonetheless, we were left with the feeling that they didn’t really want to dissuade us.
Today, a year later, the tone is becoming more assertive. Insurance companies, too, having discovered that they were losing money from covering expenses of the birth of twins, have begun to offer unreasonably priced policies, creating an insurmountable obstacle for the would-be parents. In fact, as things stand now, payment for two parallel surrogacy procedures will often be cheaper than insurance coverage for one pregnancy with twins.
In any event, the obsession of Israeli gays with twins is comparable in intensity only to the obsession of the owners of American clinics with their success rates at embyro creation. Our clinic took pride in its impressive 90-percent success rate in creating one embryo – 72 percent in creating twins – on the first try. To a large extent, this is what tipped the scales in its favor.
After we committed – in a Skype conversation with the clinic’s director – to prevent exposure of our semen to dangerous external factors, we flew to Portland to deposit a sample personally. In principle, there’s nothing to prevent this from being done in Israel, with the result being shipped overseas. But because the clinics are determined to ensure an optimum result, they demand that the semen sample be given under their direct supervision. At the clinic, we were taken one after the other into a narrow room, with a stack of magazines that were not in any way relevant to us.
Not long afterward, we received an estimate of our yield (around 40 million sperm per milliliter for each of us, with a narrow victory for me). The sperm is then frozen, filtered and afterward “enhanced.” After thawing, the healthiest sperm of each man is brought together with the eggs from the donor. At the end of this fertilization stage, we had 12 embryos, about half of which bore my genetic makeup and half that of my husband. Each embryo was graded according to criteria such as number and size of cells, a process that left us with eight “outstanding” embryos for use.
We both agreed that we’d feel better paying the woman who was to carry our offspring in real money, not in currency of Christian grace.
The next stage is what’s known as a comprehensive chromosome screening test, a CCS. Using a laser, five to 10 cells are removed from each embryo in order to count the number of chromosomes in each cell and rule out Down syndrome. The test also reveals the gender of each embryo. Of our eight, five were female and three male. We decided that we wanted to be given the information about the distribution of the embryos – how much each of us had “produced” and what their gender was. Other couples we know, who disliked the synthetic character of the process, chose not to be privy to the information and told the doctors to pick two embryos at random without choosing the gender. But we flowed with the engineering, leaving nothing to chance. We gave precise instructions regarding which of us would be father to a son and which would be father to a daughter.
The bonus of the visit to Portland was a meeting with the egg donor – Ms. A35 – a rare privilege that most couples don’t get, as it depends on the woman’s goodwill: The donor has the right to anonymity and owes no one anything once she turns over her eggs. The meeting took place in the clinic and under the supervision of a representative of her choosing, to ensure that we wouldn’t cross the line with probing questions or try, heaven forbid, to find out her full name. The reason for this is the need to prevent a scenario in which we, or our future children, end up harassing her in any way. In our case, the donor signed an agreement, even before the meeting, under which the children would be permitted to write her once they reached age 16. She, for her part, expressed a willingness to reply to them once.
Into the room came a delicate young woman of 21, even blonder than she looked in the photos, accompanied by her fiancé with similar coloring. She’s a nursing student, he’s starting med school, and both aspire to do volunteer work in plague-ridden regions of Africa.
We weren’t present for the next stage – the embryo transfer. In January 2018, Tiffany flew to Portland to have the two embryos implanted in her womb. In the surrogacy process, and particularly if it’s done from a distance, it’s difficult to preserve the moment when you’re told about the pregnancy. No one comes out of the bathroom, face glowing and holding a kit on which two stripes have appeared.
Instead, one random morning, when my husband and I were actually on two different continents, we received an email from the clinic with “Congratulations” as the subject line. There was an embryo. We celebrated in a WhatsApp conversation with poor reception. About two weeks later, more joyful news arrived: Two embryos had been implanted successfully.
Time for restraint
The pregnancy itself is mostly a period of waiting. These months are an opportunity to deepen the ties with the surrogate mother, as far as that’s possible in virtual conversations. Tiffany was merry and communicative, but the video calls seemed to make her uncomfortable. So the communication between us proceeded largely via a WhatsApp group we opened, and the Skype calls fell off considerably. But in light of reports from other couples about a deep bond with the surrogate, we couldn’t help but feel guilty about our rather feeble ties.
Embarrassingly, we compensated for the flawed communication with gifts, like a gift box of Dead Sea skin-care products for her, a drawing board and gouache paints for her daughter, and a shipment of “personalized” ice cream for each member of her family. The gifts were chosen in consultation with a representative of the agency, who also instructed us regarding the milestones of the pregnancy at which to send them.
The difficulty of establishing ongoing communication with the surrogate mother is perhaps an unavoidable result of this unusual relationship. She, as the carrier of the fetus, is ostensibly the senior partner, but still, a form of employer-employee relationship exists. We tried not to over-intervene and sufficed with general questions à la “How are you feeling?” We didn’t try to regiment her nutrition habits, increase her vitamin consumption or order her not to lift heavy things.
An egg from a Jewish donor will cost more – around $20,000.
Indeed, we discovered that restraint is important. We devoted a great deal of attention to nuances, but we learned, at least in this case, that this couldn’t erase the cumulative impression left by the identity group to which we belong. It happened when we discovered that the cost of the insurance was likely to be far higher than the amount cited to us at the start of the process. We emailed the director of the surrogacy agency and asked, politely, for clarification. She wrote an email to the insurance company but got confused and mistakenly sent it as a reply to us: “So are you going to talk to them? These Jewish gay men are such PITAs!” (pains in the ass). When she realized what she had done, she sent an email a page and a half long apologizing from the depths of her heart. She blamed the tasteless remark on the high tension she was experiencing, revealed that she herself was half-Jewish and went as far as confessing to a lesbian experience when she was in college.
First World blues
We embarked on the journey to Oklahoma City last September, about a month and a half before the estimated due date. Our plan was to find lodgings in the city, visit Tiffany and even make a weekend trip to New York. The New York fantasy turned out to be just that. Less than an hour after we arrived, Tiffany texted us to say she was in the hospital, that her water had broken.
It was our first meeting with her, and it, too, was cut short within half an hour when the nurse announced that the time had come to go to the operating room. We were asked to wait outside the ward.
We were flooded by a flurry of feelings. “Excitement” wasn’t one of them. What, then? Tension, anxiety, helplessness. That’s how it goes with a high-risk pregnancy that’s diverted prematurely for emergency surgery performed behind closed doors.
Fortunately, the period of frayed nerves was short. Half an hour later, a nurse appeared to inform us that all had gone well. Only after alleviating the basic fear of a calamity did she add the necessary qualifications about the condition of the newborns, including the fact that they needed help breathing. She added that in the light of the early birth, that was “perfectly normal” – a half-calming standard pair of words in a dialogue with parents fearful for children born half-baked. We would keep hearing it, in different variations, during their first months of life.
The week in the NICU, which was also Tiffany’s week of recovery from the C-section, generated a lot of shared hours with her. We founded a kind of miniseries in which we brought her a takeaway meal of her choice every day.
But beyond that symbolic gesture there were the conversations in which we bridged the gaps that had arisen in these months. Tiffany, it turned out, was “born on the floor,” as she put it, the daughter of two junkies who hadn’t wanted the pregnancy and weren’t fit to care for her. She lived with foster families until finally she was adopted by her grandfather and his partner, who raised her in Arizona. Her biological parents would stray occasionally into her life, do some damage and disappear. She didn’t complete high school (“I was a rebel”), and at age 18, after flirting with alcohol and drugs, she joined the military. She didn’t last there, either, dropping out before the end of basic training.
At age 20 she moved to Oklahoma City, and two months later, on Tinder, met Rod, who’s her age. She was already pregnant when they were married, in a ceremony held in a park near their house attended by friends and a few family members, mainly on Rod’s side. Gemma was born six months later.
Rod walked out when Gemma was still a baby. “He was scared of the idea of settling down at such an early age,” Tiffany told us. After almost a year, however, Rod came back and declared his commitment to them. For the past two years, they’ve been living in relative stability in a private house near a highway. Rod works in maintenance, Tiffany is, as I noted, a part-time assistant at a preschool. She plans to invest the surrogacy money partly in studies for Rod, who dreams of being an animator of computer games, and also in opening a private day-care center of her own.
Tiffany’s life story, which we heard about during her hospitalization, raised a host of ethical questions that had been pushed aside once we’d opted for First World surrogacy over one in India.
The conversations with Tiffany dented the dichotomy. Was her economic plight fundamentally different from the distress of an imagined Indian surrogate mother? Wasn’t the medical risk she took the same? Could we be certain that she had volunteered for the process and not been pushed into it by a relative? Wasn’t her basic salary – about $30,000 – too small compared with the payments received by the doctors and the mediators? And above all, were her feelings substantially different after it was all over and we went home with the children she had carried?
Tiffany often visited the twins in the neonatal unit, knitted them wool blankets and volunteered to pump mother’s milk for them. I tried to sound her out about her feelings ahead of the approaching goodbye. She didn’t deny that she had become attached to the babies, but said that what she felt for them was related to caring for them; it wasn’t “maternal.”
In a farewell meal with her, it seemed as if sparks of such feelings had arisen in her, and she was determined to put them out. She hardly went over to the babies, and when we asked if she’d like us to send photos in the future, she said she’d be happy to get them but hinted politely that we shouldn’t overdo it. She added that we’d be able to stay updated about each other’s lives through Instagram. We couldn’t help wondering what Gemma, who was 3, was feeling, too, as she did express an interest in “Baby A” and “Baby B.”
The general procedure for gays who have children via surrogacy is to have the baby undergo circumcision in the hospital (if it’s a boy) and conversion to Judaism in a Reform synagogue in the area of their temporary lodgings. Why do a conversion at all? An excellent question. The decisive argument wasn’t to force on them a worldview that might stymie them in the future if by chance they were to insist on a Jewish wedding in Israel, where they would have to undergo Orthodox conversion.
The procedure was hindered by the small size of the Jewish community in Oklahoma, where we spent a month or so. A Reform rabbi said she would be willing to perform the conversion but explained that she would have a hard time recruiting two colleagues locally to make up the necessary rabbinical court. We got to another Reform rabbi, who was eager to help but admitted that our request posed a dilemma for him. “I’m afraid that an article will appear in Haaretz about a rabbi who converts people out of hand without knowing them [that is, the parents],” he said in a preliminary phone call. We promised not to publish the name of his city or synagogue.
On a rainy day, we loaded the little ones into the car and traveled to a Jewish enclave with a flourishing community. The conversion certificate was waiting for us, and all that remained was to repeat the traditional blessing upon immersion in a mikveh. The rabbis insisted that the water cover the children’s scalps – and that the act be repeated three times.
A few days later, we set out on the long journey back to Israel. After 24 hours on the road and in the air, with a cargo of 11 suitcases, we got home.
Now five months have gone by, five months in which Israeli bureaucracy has poked us in the eye almost every day to remind us that from its point of view we’re not yet entirely a family. A few weeks ago, after an exhausting legal process and paternity tests at Sheba Medical Center, we successfully registered our children with the Interior Ministry. Whereas in the American documents we’re registered as two fathers, Israel pushed us back a step, required each of us to register only as the father of his biological child, and broke up the double surname we’d given our children. Now we’re waiting for a ruling that will recognize the paternity of both of us. In the meantime, try to explain to someone at an Israeli health maintenance organization why you want to vaccinate a child who’s not yours.
But that’s a secondary matter. We were told by others that parenthood was going to be a nightmare, that with twins a solid night’s sleep is a fantasy and that we were in for at least a year of walking around in a daze with frazzled nerves. So far that isn’t the case. The children are good-tempered, they sleep (almost) full nights, eat well and show their gratitude using a sequence of smiles – moon-shaped (he) or subtly ironic (she). Maybe that’s what happens when you engineer them genetically in the vast, diverse and personally-adjusted-to-the-client supermarket that’s the United States of America.