Infertility is a deeply personal and often misunderstood journey. For many, surrogacy offers a path to parenthood that is filled with hope, challenges, and complexities. The Golden Hour podcast spoke to Dr. Brian Levine, a board-certified reproductive endocrinology and infertility specialist and founder of Nodal— a healthcare startup revolutionizing gestational surrogacy in America. In this conversation, Dr. Levine shares his insights on the realities of surrogacy, dispels common myths, and discusses the emotional and logistical intricacies involved in this life-changing process.
Dr. Brian Levine’s Journey to Fertility Medicine
Dr. Levine’s path to becoming a fertility specialist was far from straightforward. Initially drawn to genetics after a personal family loss, he pursued molecular biology and genetics before realizing that clinical genetics within fertility medicine was his true calling. A pivotal moment came on the second day of medical school when he learned about genetic testing of embryos and the potential to prevent the transmission of disease. This “aha” moment ignited his passion for reproductive endocrinology and infertility (REI).
Despite the competitive nature of the field, Dr. Levine secured a fellowship at one of the top programs and today dedicates his career to helping families start, grow, and complete their journeys. His enthusiasm and commitment to patient care are evident, and his mission extends beyond clinical practice to addressing systemic issues in fertility care.
The Complex Landscape of Surrogacy in the U.S.
Surrogacy is a specialized and often misunderstood part of fertility care. Dr. Levine explains that surrogacy in the United States is a patchwork of laws, practices, and costs that can be confusing for both providers and patients. Until 2021, New York State did not legally protect surrogacy contracts, leaving intended parents and surrogates without clear legal safeguards. This changed when legislation legalized gestational surrogacy, but the system remains fragmented and often expensive.
Surrogacy involves multiple players: intended parents, surrogates, fertility clinics, agencies, lawyers, and mental health professionals. The process is highly regulated in some states and nearly unregulated in others, contributing to inconsistent experiences and outcomes.
The History and Evolution of Surrogacy
The modern surrogacy system in America has its roots in the 1980s, marked by landmark legal cases such as the “Baby M” case in New York. This case shaped the legal framework by affirming that surrogacy contracts are binding and emphasizing the rights of the biological parents. However, surrogacy was banned in New York for many years following this decision, pushing the practice underground or to other states.
Meanwhile, other states like California became hubs for surrogacy, especially for the LGBTQ+ community seeking to build families.
Dr. Levine states that surrogacy agencies began as small operations—often informal and lacking medical expertise—connecting intended parents with surrogates and managing the case process. Today, there are about 450 surrogacy agencies across the U.S., roughly the same number as fertility clinics, but with no uniform standards or regulations. According to Dr. Levine, this leads to wildly varying practices, costs, and experiences for families navigating surrogacy.
Debunking Common Surrogacy Myths
One of the most persistent myths about surrogacy is that women become surrogates simply to make easy money. Dr. Levine emphatically dispels this notion, explaining that surrogates are motivated primarily by altruism and a genuine desire to help others build families. Most surrogates are mothers themselves, who have had healthy pregnancies and want to provide for their families through surrogacy compensation.
Financially, surrogacy is not an easy or quick way to earn money. In fact, surrogates often face the same physical and emotional tolls of pregnancy, yet they typically return to work just two weeks postpartum, without the immediate joys of caring for their newborn. Their compensation, while significant, is not exorbitant compared to the overall costs of surrogacy, and many surrogates use the funds to support their children’s education or household needs.
What Makes a Good Surrogate?
According to Dr. Levine, what makes a good surrogate goes beyond physical health. Motivation plays a crucial role—a strong surrogate candidate is someone with a genuine desire to help others and a positive attitude toward pregnancy.
A solid health history is also essential: she must have experienced at least one healthy pregnancy and delivery without significant complications. Equally important is a stable living situation, including financial security, reliable housing, and no dependence on government assistance, to ensure she can fully manage the emotional and physical demands of surrogacy.
In addition, all surrogates must meet specific medical and psychological requirements established by the fertility clinic overseeing the process. Because each clinic applies slightly different standards—such as variations in acceptable body mass index (BMI) or number of previous births—the ideal surrogate for one program might not be eligible for another. This variation highlights the importance of personalized matching and thorough screening.
Understanding the Financial Realities of Surrogacy
Surrogacy costs in the U.S. have skyrocketed in recent years, often doubling or tripling without corresponding benefits to surrogates or intended parents. Dr. Levine highlights how fees charged by agencies and middlemen have inflated costs, while surrogate compensation has seen only modest increases.
The average total cost of surrogacy journeys in the U.S. can range from $250,000 to $300,000, which includes surrogate compensation, medical expenses, agency fees, and legal costs. This price tag puts surrogacy out of reach for many hopeful parents.
How Nodal is Changing the Surrogacy System
Dr. Levine founded Nodal to address the inefficiencies and inequities in the surrogacy process. Nodal leverages technology to streamline matching, reduce administrative costs, and empower surrogates by allowing them to choose intended parents, reducing dropout rates dramatically.
Nodal’s approach cuts agency fees to around $30,000—approximately 45% less than the industry standard—making surrogacy more affordable without compromising quality of care. The platform also emphasizes transparency and prioritizes the well-being of surrogates by encouraging fair compensation and providing mental health support through partnerships like Maven.
The Emotional Journey of Surrogacy
Surrogacy is not just a logistical process; it is deeply emotional for both intended parents and surrogates. Dr. Levine stresses the importance of community and support, noting that surrogacy can provoke feelings of hope, fear, joy, and anxiety.
To support surrogates emotionally, Nodal pairs them with mentors who have been through the process, offering guidance and companionship through pregnancy and postpartum. This peer support helps surrogates navigate challenges such as delivering a baby they will not raise and explaining the journey to their own families.
Intended parents also experience a rollercoaster of emotions, from excitement to frustration, especially when faced with long waits or failed matches. Providing psychological support and clear communication throughout the process is critical to helping all parties cope and thrive.
Legal Considerations in Surrogacy
Surrogacy involves complex legal arrangements to protect the rights of intended parents, surrogates, and the child. Because laws vary widely by state and even by county, legal counsel is essential for drafting contracts, establishing parental rights, and navigating birth orders.
Typically, both intended parents and surrogates have their own lawyers who collaborate to ensure fair agreements. Contracts may include specific provisions such as transportation costs, medical care preferences, and escrow arrangements to manage financial milestones and payments.
Legal protections also address common fears, such as the possibility of a surrogate wanting to keep the baby – a scenario that Dr. Levine assures is extremely rare. The contracts and state laws are designed to honor the intentions and rights of all parties involved.
Surrogacy in the Global Context
While the United States is considered the safest and most legally protective place for surrogacy, many other countries have restrictive or prohibitive laws. For example, gestational surrogacy is illegal in India, China, Russia, and much of Western Europe, or allowed only without compensation.
These restrictions have sometimes pushed surrogacy into unregulated or unsafe environments abroad. Ukraine, once the global capital of surrogacy, became inaccessible due to war, forcing intended parents to seek alternatives in countries with even less legal protection, such as Poland or Mexico.
Dr. Levine encourages those considering surrogacy to choose the U.S. for its comprehensive legal framework and protections, despite the costs, to ensure safety and security for all involved.
How Healthcare Providers Can Support Surrogacy Families
According to Dr. Levine, obstetricians and other healthcare providers play a vital role in supporting surrogacy families during pregnancy and delivery. He offers three key recommendations for care providers.
First, use respectful language—avoid saying “use” when referring to surrogates, and instead emphasize the partnership and collaboration with intended parents.
Second, include intended parents by treating them as expectant parents, involving them in medical discussions, and recognizing their emotional investment.
Third, ask questions and seek help when needed; given the complexity of surrogacy, consulting legal or fertility experts can help ensure the best possible care.
Hospitals and clinics should also implement policies that accommodate surrogacy families, including appropriate postpartum accommodations and clear procedures for newborn care and custody.
Since its launch, Nodal has saved intended parents over $5 million in agency fees and over a century of waiting time collectively. The company’s mission is to provide affordable, transparent, and supportive surrogacy experiences, driven by a passionate team deeply connected to the fertility community.
You can learn more about Nodal here.
