In gestational surrogacy, usually referred to as “surrogacy,” the child is not genetically related to the woman carrying the pregnancy, known as the gestational carrier or surrogate. A fertility doctor uses the process of IVF to create the embryo and then implants the embryo into the surrogate. The egg and sperm might come from the intended parent(s) (the person with CF and their partner), or from egg or sperm donors. A surrogate might be a friend or family member, or they might be someone who a surrogacy agency matches with the intended parents. The prospective parents have the option of continuing their relationship with the surrogate after the baby is born.

The intended parent(s) and gestational carrier are required to create a legal contract before implantation that states the embryo belongs to the former. This contract defines the financial agreement between both parties, detailing how medical costs will be paid. It also defines the prospective parents’ expectations for the surrogate’s behavior while pregnant, and what will be done if there is an issue during the pregnancy. The intended parent(s)’ insurance may or may not cover prenatal, labor and delivery, postnatal medical care costs, and medical insurance coverage for the surrogate, so it is important to check one’s insurance benefits and the surrogate’s insurance benefits to see what each will cover. You may need to obtain additional or different insurance or pay these costs out of pocket. These costs are separate from those of reproductive technology used to create and implant the embryo.

Surrogacy laws and legal precedents can vary by state or even by county. These laws may dictate where the intended parent(s) choose to use a gestational carrier and how the intended parent(s) become legal guardians of the baby.

 Potential Advantages of Surrogacy: 

• Your child may be genetically related to you and/or your partner
• Through the IVF process, you can opt for pre-implantation testing /diagnosis to test embryos for CF, other genetic diseases, and chromosomal conditions that increase the miscarriage risk [See the (In)Fertility chapter in this guide].
• Someone else carries the baby for 9 months, so:
• Your health is not impacted by pregnancy.
• Your baby’s health is not impacted by your illness or medications (also allows you to safely take newly approved medications, teratogenic medications, or participate in clinical trials).
• You don’t risk having to choose between prioritizing your health or the baby’s during the pregnancy.
• There is no pressure to breastfeed (societal or otherwise) because you won’t produce milk. Bottle feeding allows your partner to assist with night feedings– or even do all night feedings — allowing you to get more sleep after the baby is born.
• You have 9 months to prepare for your baby, including:
• Maximizing your own health (e.g. a strategically timed tune up, if needed).
• Reading and learning how to care for the baby, and setting up your home without the fatigue of pregnancy.
• You can be a part of the pregnancy journey with the gestational carrier by attending appointments and ultrasounds, either virtually or in-person.
• You can choose your gestational carrier — someone you feel comfortable with, and someone you feel is medically and emotionally able to carry a pregnancy.
• You can experience the selflessness of someone else who carries a baby for you, which may lead to friendship.

Potential Challenges of Surrogacy: 

• If you wish for a biologically-related child, you will need to undergo egg harvesting, which, in some cases, can be difficult on your health. [To get more information about egg harvesting, read the (In)Fertility chapter in this guide]. 
• Surrogacy is very expensive. Costs may include:
• Egg harvesting, or purchasing donor eggs or sperm
• Legal fees – an attorney for yourself and for the surrogate to create a legal and binding contract, court costs to name you as the legal guardian of the baby after birth
• Medical Costs – pregnancy, labor and delivery expense, or additional insurance; some gestational carrier screening expenses may not be covered at all
• Agency and surrogate fees – reimbursement of surrogate travel costs, childcare fees the surrogate may require for appointments, reimbursement for missed work, a maternity clothes allowance, etc. Using a surrogate through an agency is typically more expensive than engaging a friend or family member.
• The legal aspects of surrogacy can be complicated. Laws could force you to use a surrogate in another state, which could require additional travel or affect how you and your partner are named the child’s legal guardians. 
• Determining insurance coverage for this method of family building can be complicated. It can be emotionally difficult for some women not to carry the pregnancy. 
• You may feel disconnected during the pregnancy. Since you are not the one pregnant, you need to relinquish a level of control over the pregnancy; the surrogate may not select the same lifestyle, diet, and activity choices that you would. In some cases, the surrogate will feel an emotional connection to the baby, especially right after birth. Be prepared to navigate these possible circumstances.

Fostering a child provides a home for someone in need of support, stability, and love. Fostering offers a flexible family building option for people with CF, depending on which type of fostering the person/couple chooses. 

There are several types of fostering arrangements, which vary mainly in the length of time one takes care of the child: 1) respite fostering lasts 1-7 days; 2) short- term and emergency care fostering lasts anywhere from 1 week to 1 month; and 3) long-term placement lasts from months to years with the same child. 

As a foster parent, you are able to choose the level of care you feel able to provide, including what type of placement, how many children, ages of the children, any  additional needs the children require, etc. You may have the option of adopting a child as a foster parent (fost-adopt) if it proves impossible for the natural family to reunify; however, one of the key goals of the child welfare system is biological family preservation and reunification, so it is advisable to manage and temper expectations (See https://www.childwelfare.gov/topics/permanency/legal-court/fedlaws/).  

Becoming a foster parent requires an application process. Because the foster child is officially under the guardianship of the state, the process involves a state background check, home inspection, medical exam, foster parent training, and a lot of paperwork. This multifaceted process ensures the child will be safe in your home and helps to prepare you, as potential foster parents, for this type of parenthood.  

To find out more about fostering, consult local resources through the Department of Child and Family Services (DCFS) in your state and local foster agencies. To see if fostering is a good fit for you, you can consult with your CF care team and people knowledgeable about the foster care system and experience, including women with CF who are foster parents. 

Potential Advantages of Fostering: 

• You are helping children in need. 
• You are not risking a change in your health status that pregnancy can cause.
• You get to experience parenthood. 
• It is not a lifelong commitment and it is flexible for how often, how long and when you have a child in your house.
• You can take a break from parenting in between placements to attend to your health or plan a tune-up, etc.
• You receive compensation as a foster parent, which typically takes the form of a daily stipend. The state provides this compensation to subsidize the care of the foster child. The compensation amount depends on the level of care the child requires. Some states even pay for daycare and cover all education-related costs.
• Other approved foster parents can provide respite care as needed. Respite care can be very helpful if you have a pulmonary exacerbation that requires you to be hospitalized or to be on home IVs. Respite care costs are deducted from the foster parent stipend so that a check can be sent to the respite care providers.
• In some cases, you are able to adopt the child (e.g. reunification efforts with the natural family have failed or are impossible, natural family relatives cannot adopt the child, etc.).
• You have the flexibility to foster specific ages & levels of care that align with your health needs. For example:
• if you need more sleep and don’t have the physical strength to carry around a little one, you can choose to open your home to kids ages 5 and up.
• You can choose to only foster teens, or only ages newborn to age 3. 
• You can request certain levels of care; meaning you can delineate if you can or cannot care for a child with health or disability needs, and what level of severity you are able to consider. 
• You can always decline if/when you are offered a placement. You can wait for a placement that sounds like it will be a good fit for you.
• As a female with CF, you are an expert in navigating the health care system and, as such, have the knowledge to be an effective advocate for children in your care.

Potential Challenges of Fostering: 

• It can be emotionally difficult when a child moves to a new foster home or reunites with parent(s) after you have established an emotional connection with them. 
• Sometimes the foster care agency provides little information about the child’s past history when they are placed with you, leaving you with gaps in understanding their needs and how to best support and take care of them. 
• Children can come with a variety of challenges, including varying levels of trauma. You can obtain additional training to care for children who may have more intense needs.
• Fostering involves a lot of paperwork, licensing rules, training, and continued training education. This is required to keep one’s fostering license current.
• As with any child, foster children require multiple appointments you must attend, which can be a burden for people with CF who already require many doctors’ appointments of their own. These include: 
• Biological family visits (can include separate visits for parents, siblings etc)
• Court appearances 
• Doctor and behavioral health appointments
• School meetings to sort out any needed individualized education program plans (IEPs), often needed for trauma, or emotional or academic support.
• Fostering will impact your entire family; this aspect of fostering is something to seriously consider before embarking on this family-building path.
• Members of your support system who wish to babysit your foster child(ren) will have to undergo background checks or become foster-certified to do so.

Adoption is the process of legally becoming the parent of a child. Once adopted, the child has the same legal rights as your natural child. 

There are many types of adoption: domestic or international; open or closed; relative or non-relative. In non-relative adoption, the child does not have the adoptive parents’ genetic profile. Relative or kinship adoption occurs when a family member adopts a child relative whose birth parents have either died, have neglected or abandoned the child, are experiencing an illness, or have other circumstances that prevent them from being able to continue caring for the child. In current adoption practice, kinship adoption is preferred over non-relative adoption because it maintains family ties. In cases when relatives cannot be found, adoption can occur with “fictive kin,” meaning individuals who are known to the child/family, are considered by social workers to have a positive relationship with the child, but who are not related.5 

The adoption process involves medical, social work, and legal components. A social worker will help facilitate and coordinate the adoption process and all the intricate details it involves. If you would like, a pediatrician trained in adoption medicine can assess the child for physical and mental medical needs that may need attention (see www.aap.org for more information). Because adoption is a permanent, legally binding process that determines the future of a child, an adoption’s finalization usually takes one year after initial placement. 

Like other forms of family-building, it takes a lot of research and time to decide upon domestic or international adoption, find the most suitable agency, and go through the adoption process. Like surrogacy laws, state laws about adoption also differ. Whatever you do, it is inadvisable to base your ideas about adoption upon movies or books. Remember, each person’s experience with adoption and with family-building is different. 

Most adoption agencies require an adoptive parent applicant to submit letters of support as part of the application process. Friends, clergymen, or colleagues can write these letters. Sometimes, when asking your support system for such letters, you may find out that friends or family do not view you as fit to parent because of your CF. As such, make sure to ask people who you deeply trust to support you and your decision to adopt. 

Your doctor will also need to write a letter of support stating that your health will not impact your ability to parent. It is important to know that for domestic adoption, the Americans with Disabilities Act prevents agencies from discriminating against you on the basis of your CF, as long as you do not pose a safety hazard to the child. Depending upon the country, however, international adoption agencies/countries can consider CF in their decision in your candidacy to adopt a child. 

Potential Advantages of Adoption: 

• You are not risking a change in health status that pregnancy could cause.
• You are providing a home to a child/baby who needs one. 
• Parenting classes that are required for the adoption process are generally affirming; they can provide you with the tools and resources necessary to parent different types of children. They also can either solidify the decision to adopt or can bring prospective parents to realize that adoption and/or parenting is not for them. 
• Adoption communities provide support and new friendships.
• Good adoption agencies can be quite supportive during the process. 
• You have time to think through the responsibilities, parenting philosophies, attitudes, and family histories that come with parenting. Couples can become closer in the process of thinking through all the considerations.
• Adoption is deliberate; there are no unplanned adoptions that catch partners off guard, so every decision during the process is intentional. 
• Public domestic adoption can be much less expensive than other parenting options. Oftentimes, if a parent is willing to adopt a child with a disability, there are incentives that are provided to lower the cost and provide a home to a child.

Potential Challenges of Adoption:

• Prospective adoptive parents often have to navigate others’ opinions about adoption, including from friends and relatives, even their own parents. 
• International adoption applications can consider health status and exclude people on the basis of their health. Each country has specific standards, so thorough research is helpful. 
• In an open adoption, the birth mother can choose the adoptive parents and use health status like CF against those particular potential parents. 
• Some agencies give biologic parents a lot of say over who adopts their child; for example, the parents may want their child to have siblings. The parents might make assumptions about your CF and ability to parent.
• International adoption and private domestic adoption can be expensive, but costs are similar to IVF.  
• Transracial adoption has its challenges because of racism in our society and preconceived notions of what families should look like.
• Adopted children can have complicated feelings about their identity.
• For some countries in an international adoption, the wait to adopt can be quite long.

Many people with CF do not have children. Some women with CF are childless because they do not want children. Other women may have chosen to forego parenthood for health reasons. Still others may have felt like they never had the opportunity to become a parent. All these groups of women can lead fulfilling lives without children.

If a woman with CF wants to be a parent but is unable to become a mother, she can address these desires by becoming a caregiver to her nieces and nephews and/or her cousins’ or friends’ children. She can make these children a large part of her life. She can also include children in her life by volunteering or working with children at a local YMCA, Boy or Girl Scouts, athletics, tutoring, or becoming involved in a community-based or religious organization. Working in professions that cater to children, like teaching, nannying, or pediatrics (as a physician, nurse, therapist, or other professional), can also allow a female with CF to care for children. Other women with CF may choose to have pets, fulfilling a similar desire to nurture and parent animals. 

Of course, women can also decide they do not want to be a caregiver at all. Not having children provides certain advantages.

Potential Advantages of Not Having Children:

• You do not risk a change in health status that pregnancy or parenthood could cause. 
• You will have fewer financial obligations, reducing general financial stresses in life, and possibly have more disposable income.
•  You will have more time and flexibility to get enough sleep and do medical treatments, exercise, and maintain your health.
• You will have more time to pursue a career, hobbies, or other interests, like travel.
• You will likely be less exposed to germs that trigger CF exacerbations or post-transplant infections. 
• If you have a partner, you can spend time with them alone, including time for intimacy.
• If you have a partner, you may have fewer arguments, and will not have to divide up parenting duties. 
• You will have more time to develop other relationships in your life.

Potential Challenges of Not Having Children:

• You may feel societal or family pressure to have kids, especially from parents who desire grandkids.
• Deciding to not become a parent can lead to conflict with a partner or spouse, especially if they want children.
• You may experience feelings of guilt, sadness, or loss if you and/or your partner wanted children and were unable to have them.
• Finding peers with similar lifestyles may be difficult. 
• You may feel left out when friends start having babies or raising children.
• You may feel socially awkward or sad when friends’ primary topic of conversation becomes their children.
• Loss of the benefits of parenthood:
• Kids can be a great motivator to keep active, healthy and compliant with treatments.