SURROGACY (GESTATIONAL CARRIER)
In the United States, surrogacy is not legal in all states and laws vary widely from state to state. Legal stances vary from surrogacy friendly laws in California to highly unfriendly laws in New York and several mandates in between. IVF surrogacy involves the transfer of one or more embryos derived from the infertile woman’s eggs and from sperm of her partner (or a sperm donor) into the uterus of a surrogate. In this case, the surrogate provides a host womb but does not contribute genetically to the baby. While ethical, moral, and medico‑legal issues still apply, IVF surrogacy appears to have gained more social acceptance than classic surrogacy.
Candidates for IVF surrogacy can be divided into two groups: (1) women born without a uterus or who because of uterine surgery (hysterectomy) or diseases (congenital malformations, severe adhesions, multiple fibroids), are not capable of carrying a pregnancy to full term; and (2) women who have been advised against undertaking a pregnancy because of systemic illnesses, such as diabetes, heart disease, and hypertension, severe musculoskeletal abnormalities, Rh isoimmunization, or certain malignant conditions, necessitating the use of chemotherapy, or associated with contraindications to the extremely high levels of estrogen associated with pregnancy.
As in preparation for other assisted reproductive techniques, the biological parents undergo a thorough clinical, psychological, and laboratory assessment prior to selecting a surrogate. The purpose is to exclude sexually transmitted diseases that might be carried to the surrogate at the time of embryo transfer. They are also counseled on issues faced by all IVF aspiring parents, such as the possibility of multiple births, ectopic pregnancy, and miscarriage.
All legal issues pertaining to custody and the rights of the biological parents and the surrogate should be discussed in detail and the appropriate consent forms completed following full disclosure. It is recommended that the surrogate and biological parents get separate legal counsel to avoid the conflict of interest that would arise if one attorney counseled both parties. Furthermore, since many cases of surrogacy are performed on international couples, it is important that the legal team is well versed in family law, international laws and knowledge of how to expedite the birth certificates. Experience in this area is one of the keys to arriving at a successful outcome.
Selecting the Surrogate:
Many infertile couples who qualify for IVF surrogate parenting solicit the assistance of empathic friends or family members to act as surrogates. Other couples seek surrogates by advertising in the media. It is extremely important that in such situations, appropriate counseling of the gestational carrier be undertaken, to ensure that she has well intentioned motives. Many couples with the necessary financial resources retain a surrogacy agency to find a suitable candidate. We direct our patients to a reputable surrogacy agency with access to many surrogates. Reputable agencies usually work with competent professionals, capable of uncovering “unhealthy motives” in advance, thereby enabling them to eliminate unsuitable candidates. Working with agencies provides a layer of safety to this potentially risky matching process. Because the surrogate gives birth, it is rarely possible or even realistic for her to remain anonymous. Furthermore, a well written surrogacy contract, frequently provided by the agency, or else required to be constructed through private legal counsel, must address important topics such as: a) amniocentesis and what to do in the event of an abnormal result, b) what to do in the event of a high order multiple pregnancy (selective reduction) c) nutrition and travel during pregnancy, d) compensation for unanticipated prolonged periods of bedrest or absence from work due to medical complications in the pregnancy e) mode of delivery or critical decisions during labor.
Screening the Surrogate:
Once the surrogate has been selected, she will undergo thorough medical and psychological evaluations including:
- Screening for chlamydia, gonorrhea and other infections that might interfere with a successful outcome.
- Blood tests for HIV, hepatitis, and other infectious and sexually transmitted diseases, immunity for rubella (German measles), varicella and other hormone tests such as the measurement of thyroid stimulating hormone (TSH).
- Uterine assessment: This can take the form of a sonohysterogram, a hysteroscopy and or a hysterosalpingogram. It is important to exclude polyps, fibroids or adhesions prior to the initiation of treatment.
Whether recruited from an agency, family members, or through personal solicitation, the surrogate should be carefully evaluated psychologically as well as physically. This is especially important in cases where a relatively young surrogate or family member is recruited. In such cases, it is important to ensure that the surrogate has not been subjected to any pressure or coercion.
The surrogate should also be counseled on issues faced by all IVF aspiring parents, such as multiple births. She should also visit with the clinical coordinator, who will outline the exact process step by step. She should be informed that she has full right of access to the clinic staff and that her concerns will be addressed promptly at all times and she should be aware that if pregnancy occurs, she will be referred to an obstetrician for prenatal care and delivery.
Once the pregnancy and a good heart beat is confirmed at 7 weeks, the risk of miscarriage is less than 5% and most pregnancies reach term and result in healthy babies. In our setting, we anticipate approximately a 50% birthrate every time embryos are transferred to a surrogate, provided the biological mother (the egg provider) is under 35 and the surrogate has a healthy uterus. The birthrate declines as the age of the egg provider advances beyond 35. It is important to note that there is no convincing evidence to suggest an increase in the incidence of spontaneous miscarriage or birth defects as a direct result of IVF surrogacy.
If the surrogate’s blood pregnancy tests are negative, treatment with estrogen and progesterone is discontinued, and she can expect to menstruate within 4 to 10 days. In the event that the pregnancy test is positive, estrogen and progesterone therapy will continue until 10-12 weeks of pregnancy.
After the evaluations and counseling of both the couple and the surrogate have been completed, the three of them will meet. Once all the evaluations have been completed, the couple will select a date to begin treatment.
Follicle Stimulation and Monitoring the Female Partner (Egg Provider):
The procedure used to stimulate the female partner of the infertile couple with fertility drugs and monitor her condition, strongly resembles that used for an egg donor. In order to stimulate ovulation of enough eggs to increase the chances of a viable pregnancy, the female partner will be stimulated with gonadotropins. Approximately seven days after ovulation occurs (as assessed by blood testing and/or an ultrasound), GnRHa (Lupron) is administered daily to prepare the ovaries for stimulation. Once the period is observed, estrogen level is checked with/without an ultrasound and ovarian stimulation is initiated with FSH injections.
Patients are followed up after 5-6 days of FSH injections for follicle measurements and an estrogen level. Based on the response, 1-2 additional office visits may be necessary to confirm maturation of the eggs. Once monitoring confirms that the female partner’s ovarian follicles have developed optimally, she is given an injection of HCG for ovulation. Then, in order to capture the eggs prior to their release into the pelvis, they are harvested 34-36 hours after the HCG injection by transvaginal ultrasound needle-guided aspiration.
Synchronizing the Cycles of Surrogate and Aspiring Mother:
The surrogate will receive estrogen orally, by skin patches, or by injections, and then progesterone to help prepare her uterine lining for implantation. As with preparing the recipient for IVF/ovum donation, we use biweekly estradiol valerate injections in our program. GnRHa is administered for a period of 7 to 12 days in order to prepare the ovaries prior to administration of estradiol valerate. The duration of GnRHa therapy is adjusted to synchronize the cycle of the woman undergoing follicular stimulation with that of the surrogate. Once the prospective mother starts follicular stimulation, the surrogate will be given estradiol and progesterone injections while continuing GnRHa therapy. In the uncommon event of poor endometrial development, the couple will be given the choice of either having the aspiring mother’s eggs harvested, fertilized and frozen for transfer to a surrogate’s uterus in a subsequent cycle or canceling the procedure. The egg provider (aspiring mother) then undergoes a routine transvaginal ultrasound-guided egg retrieval, egg fertilization, and embryo culture.
Transferring the Embryos to the Surrogate’s Uterus:
Embryos are transferred to the surrogate’s uterus 3-5 days following egg retrieval and 2-3 days of rest is recommended for optimal outcome.
Management and Follow up After the Embryo Transfer:
The surrogate will be given daily progesterone injections and biweekly estradiol valerate injections and/or suppositories in order to maintain an optimal environment for implantation and approximately 7-10 days after the embryo transfer will undergo a pregnancy test. A positive test indicates that implantation is taking place. In such an event, the hormone injections will be continued for an additional four to six weeks. In the interim, an ultrasound examination will be performed to confirm a clinical pregnancy. If the test is negative, all hormonal treatment is discontinued, and menstruation will follow within three to 10 days. If the surrogate does not conceive, the aspiring mother may have her remaining embryos (if any) frozen, be thawed and transferred to the uterus of another woman at a later date. If the surrogate does not conceive, after both the initial attempt and subsequent transfer of thawed embryos, the infertile couple may schedule a new cycle of treatment. At this point, consideration could be given to interventions such as PGD, CGH or other markers of embryo competency.
Anticipated Success Rates with IVF Surrogacy:
Like the pregnancy rates for egg donation, the rates for surrogacy have traditionally paralleled those achieved through conventional IVF. However, in the case of surrogacy where the age of the egg provider cannot be controlled, success rates are influenced by the effect of age on egg and embryo quality. The implementation of a new method of preparing the uterus with estradiol valerate injections for embryo transfer has resulted in birthrates greater than 50% per embryo transfer when the eggs are derived from women under 35 years of age.
Gestational surrogacy is an acceptable treatment modality. It provides intended parents a realistic and viable option for establishing a pregnancy using their own gametes. There are significant benefits for all parties involved, including the commisioning parents, the surrogate who can enjoy a lifetime of personal gratitude from this extraordinary act of selflessness, the medical team and last but by no means least, the many children conceived by these procedures.