To Save on Surrogacy Costs, More Parents Are Aiming for "Twiblings"

After Wendy Weilbacher lost a pregnancy during the third trimester, she and husband Kenneth Nagle took a three-week road trip from their home in the Seattle area to find the woman who would carry their future child. They ended up in Boise, Idaho, the so-called "Surrogacy Capitol of America," where, according to PBS, 100 babies were delivered by surrogates in 2018.

But instead of one surrogate, the couple found two women to separately carry two transplanted embryos for the couple, using Weilbacher's egg and Nagle's sperm. The babies were due about five weeks apart, and born in the summer of 2021.

These simultaneous surrogacy journeys have earned the nickname "twiblings." And, the trend is catching on—as much for medical reasons as financial.

Medical Reasons for Twiblings

In 2012, with a medical history that would make it difficult for the couple to conceive naturally, including a blood clotting disorder and Polycystic Ovarian Syndrome, Weilbacher and Nagle began exploring IVF.

The couple hadn't heard of twiblings when, both aged 41, they lost their daughter in utero in October 2018 at 29 weeks, and their fertility doctor suggested surrogacy. The couple wanted two children, but they did not want multiples because they knew about and feared the risks of multiple embryo transfers.

Risks of multiple pregnancy

According to the American Journal of Obstetrics and Gynecology, twins account for 20% of preterm births in the United States, with 60% born before 37 weeks and 10.7% born before 32 weeks. Further, twin pregnancies are five times as likely to result in neonatal and infant death related to preterm birth.

In addition, according to the March of Dimes, multiple pregnancy carries higher risks of the following:

• Anemia
• Gestational diabetes
• High blood pressure
• Preeclampsia
• Hyperemesis gravidarum (severe morning sickness)
• Polyhydramnios (too much amniotic fluid)
• Postpartum depression
• Postpartum hemorrhage

Medical advances that make viability more likely

While historically multiple embryo transfers were used in surrogacy—as a way to increase the chance that at least one would take—a lot has changed in the past decade. Fertility doctors have begun moving away from double embryo transfers because of the risks of a multiple pregnancy both to the fetuses as well as the surrogate.

Leading this change is, in part, preimplantaion genetic testing that can predict which embryos will be viable. The result is increased success rates for single embryo transfers—from about 40% to 80%, says Karen Schafer, CEO of United Surrogacy in Boise.

A 2013 study confirms a pregnancy rate of 60.7% after a single genetically tested transfer and 65.1% after two untested transfers. Notably, those who received the single transfer were nearly twice as likely to continue their pregnancy compared to those with a double transfer.

All these factors have led the American Society for Reproductive Medicine (ASRM) to change its guidelines to recommend one embryo transfer at a time.

Financial Reasons for Twiblings

In addition to the decreased medical risks, twiblings were the right financial decision for Weilbacher and Nagle with respect to their careers and lifestyle.

Less parental leave

"It's a lot easier for me to want to be home and get through those little baby mushy years if they're really close in age," says Wilbacher. "If I did them the standard two years apart, then I'm going to be out of work for about four years before I could really get back into the industry. That was a very big financial thing for me in making this decision." Weilbacher is a fourth-generation realtor.

Less expensive than multiple surrogacy

A twibling journey means paying for two surrogates and the associated costs—such as legal fees, clinic fees and agency fees—all at the same time. But, because there are so many financial unknowns and additional costs that can crop up with multiples, having twiblings can, in the long run, save intended parents (IPs) money. Not only can it save thousands of dollars compared to singletons born a few years apart—but possibly hundreds of thousands over multiples.

In a study published in the American Journal of Obstetrics & Gynecology, lead researcher Dongmu Zhang writes that "for singleton pregnancy, maternal expenses accounted for about 60% of overall cost, whereas for twins or higher-order multiple births, expenses for infant care accounted for about 70% and 85% of total expenses, respectively." The researchers found that the average cost for singleton delivery was $21,000—where as for twins and triplets, it was $105,000 and over $400,000, respectively.

"That's what we try to educate the parents the most on," says Schafer. "It's not so much what the cost will be but how much is unseen; how much we don't know." Schafer says she tells parents who want more than one child that twiblings "take a lot of that what-if scenario off your shoulders of what the cost could climb to if things go wrong."

To encourage single embryo transfers, Schafer says IPs will often find discounts offered by clinics and lawyers. Schafer's agency offers a 30% discount for parents who opt for twiblings. She tells clients who remain focused on multiples to "allocate about $50,000 for the just-in-case bucket. That's what I call it."

The Hidden Costs of Multiples

There are at least five major "what-ifs" that can send the cost of multiples skyrocketing over the twiblings price tag.

Increased surrogate fees

Most surrogates will charge an additional $5,000-10,000 for each multiple on top of their base compensation, which runs from $25,000-50,000, depending on geography and experience. (It's typical for first-time surrogates to receive less).

The increased cost is in part because surrogates are heeding the recommendations of the ASRM for single embryo transfers over multiples. Schafer says fees for multiples are fast drifting closer to the additional $10,000 mark nationally.

Bed rest expenses

Surrogates carrying multiples are more likely than singleton carriers to end up on bed rest, says Schafer. That's because bed rest is sometimes prescribed for people at high risk for preterm birth. Therefore, an IP needs to be prepared to compensate their surrogate for their time in bed for everything they normally do in their life that they can't do because they're on bed rest" explains Schafer.

Expenses you may need to cover include:

• Lost wages
• Childcare
• Housekeeping

NICU Costs

According to the Centers for Disease Control and Prevention (CDC), 10% of infants are born premature. Some of them end up in the neonatal intensive care unit (NICU). According to the American Medical Association (AMA) Journal of Ethics, daily NICU stays cost around $3,500 per infant, and for some, prolonged stays can top out at $1 million.

IP's insurance covers newborn costs and care, but coverage and out-of-pocket costs vary from policy to policy. "It's not uncommon to see insurance companies and hospitals that don't want to play nice with each other," says Schafer, leaving parents with multiples paying hundreds of thousands of dollars in NICU hospital costs.

IP relocation expenses and unpaid time off

If their newborns are in the NICU, new parents may need to temporarily relocate to the city in which the surrogate gave birth and, possibly take unpaid time off from work. Therefore, Schafer tells IPs who are focused on having multiples that they should allocate for the cost of staying near their baby. Costs to consider include:

• Hotel or Airbnb
• Rental car
• Food

Those costs can really add up, Schafer says, especially if babies remain in the NICU for weeks.

Lifelong health expenses for preemies

According to the Institute of Medicine, premature birth costs in the United States account for more than $26.2 billion each year. NICU costs for multiples are only the beginning of what can be a lifetime of expenses: According to the March of Dimes, premature births can lead to costly, long-term health problems, including:

• Cerebral palsy
• Behavioral problems
• Neurological problems
• Intellectual disabilities
• Chronic lung disease
• Vision loss
• Hearing loss

Emotional Costs

Of course, in addition to all those financial "what-ifs," for Weilbacher and Nagle there was also an emotional price tag.

"We were motivated to pay for two at the same time in case one miscarried," Weilbacher explains. "We knew, statistically, the other baby would still make it. We could not go through the emotional heartache of losing another child if we didn't have one pregnancy to look forward to."

Twiblings may be an unusual choice, but for Weilbacher, Nagle, and so many others, it's the best choice for their family—emotionally and financially.