GESTATIONAL SURROGACY AT PFC
by: Dr. Geoffrey Sher, Medical Director

 

The genetic parents are counseled regarding procedural aspects relating to the IVF cycle of treatment and discussions are held regarding issues such as selective pregnancy reduction (where a multiple gestation of greater than twins occurs), termination of pregnancy in the event of a genetic abnormality detected during the first half of pregnancy, birth defects, tubal (ectopic) pregnancy, miscarriage, and the physical and emotional impact of treatment. In addition, the legal aspects of custody following gestational surrogacy are addressed. Following recruitment of a surrogate (from an agency, from family members, or through personal means) she is carefully evaluated physically and psychologically. This is especially important in cases where a relatively young surrogate or a family member is used. In such cases, it is important to ensure that the surrogate has not been subjected to any pressure or coercion.

Special emphasis is placed upon ensuring that a good professional relationship exists between the staff at the medical center and the surrogate. It is important to inform the surrogate that she has equal right of access to medical staff and hat her concerns will be addressed promptly and efficiently at all times. Issues such as the risk of spontaneous miscarriage, multiple pregnancy, the risk of birth defects, the risk of pregnancy complications, and the potential need for prenatal genetic testing through chronic villus sampling or amniocentesis and blood tests ( such as in cases where the genetic mother is over 35 years of age and at greater risk of producing an embryos with trisomy disorders), are discussed.

All legal issues pertaining to custody and the rights of genetic parents and the surrogate are discussed in detail and appropriate contractual agreements/consent forms are completed following full disclosure. We recommend that the surrogate and genetic parents get separate legal counsel to avoid the conflict of interest that would arise were an attorney to counsel both parties. Advanced payment is made for all services so as to protect medical and administrative staff from having to confront couples with a bill in cases where a cycle of treatment fails to result in a healthy pregnancy.

At Pacific Fertility Center, the prelude to the cycle of treatment is initiated by placing both the surrogate and the genetic mother (who is to receive fertility agents and undergo an egg retrieval) on birth control pills in order to synchronize their cycles. Remember, the surrogate's uterus must be ready to receive fresh embryos at exactly the right time (3 days after the eggs are harvested from the genetic mother). In cases where the genetic mother does not have a uterus, an attempt is made to pinpoint the onset of the ovulation cycle by having her use a temperature chart or home ovulation kit for a few months in advance of undergoing ovarian stimulation with fertility agents, and so, to synchronize the cycles.

Both the genetic mother and the surrogate begin receiving daily injections of gonadotropin releasing hormone agonist, Lupron ( Tapp Pharmaceuticals) once both have been on birth control pills for at least 10 days. Lupron is continued until the surrogate menstruates ( usually 8-12 days after starting Lupron) and until both women have low blood estrogen levels.

Thereupon, the surrogate starts taking estrogen (by mouth, by skin, or by twice weekly injections to which vaginal estradiol suppositories may be added) to build the lining of her uterus while the genetic mother receives injections of fertility hormones (gonadotropins). The genetic mother then undergoes serial blood tests to determine whether her blood estrogen level is rising optimally and vaginal ultrasound examinations to evaluate whether she has developed a sufficient number of mature ovarian follicles (fluid-filled spaces in thc ovaries that produce estrogen and contain the eggs) have developed in her ovary(ies). The surrogate in turn undergoes serial blood tests to determine whether she has high enough blood estrogen levels. She also undergoes serial vaginal ultrasound examinations to measure the thickness of her uterine lining. As soon as the genetic mother's follicles are mature, and the surrogate's uterus is optimally prepared, the genetic mother receives an injection of human chorionic gonadotropin (HCG) which completes maturation of her egg(s). Approximately 34 hours later, the genetic mother is given intravenous sedation and an egg retrieval procedure is performed, at which time the physician directs a needle into each follicle, using ultrasound and a vaginal probe. The procedure is almost always completely painless. The surrogate then receives progesterone injections daily (in addition to estrogen).

The eggs are fertilized with designated sperm (usually partner's) in the laboratory and two or three days later a pre-agreed upon number of embryos (usually between 2 and 6 depending upon thc genetic mother's age) are transferred into the uterus of the surrogate.

The embryo(s) are transferred to the surrogate's uterus in a painless procedure known as embryo transfer (ET). A thin catheter (containing the embryos to be transferred), is introduced via the vagina through the cervix into the uterus. 'The surrogate rests for about two hours and is then discharged.

The surrogate continues taking estrogen and progesterone (by injection/vaginal suppositories) for about ten days, and thereupon two blood pregnancy tests are performed two days apart. If the blood HCG level increases appropriately, the surrogate continues her hormone injections for about three additional weeks, whereupon an ultrasound examination is done to confirm the existence of one or more viable gestations and to make sure that the pregnancy(ies) has/have implanted in the surrogate's uterus and not in one of the fallopian tubes (the latter is referred to as an ectopic pregnancy and may be life-endangering). After normal pregnancy has been confirmed by ultrasound, hormone injections/suppositories are continued for approximately one more month and are then stopped.

At this point, the surrogate is referred to an obstetrician or, when indicated, to a perinatologist (a high-risk pregnancy specialist). If a pregnancy reduction is required it is usually performed prior to the end of the l2th week of gestation. If the initial blood pregnancy tests are negative, treatment with estrogen and progesterone is discontinued and the surrogate can expect to menstruate within 4 - 10 days.

In the event that a viable pregnancy is confirmed by ultrasound detection of fetal cardiac activity (usually by the sixth week), the likelihood that pregnancy will proceed to term is greater than 90%. Once the pregnancy has progressed beyond the l2th week, there is less than a 5% chance of a subsequent loss.

PLEASE NOTE: At PFC, we currently report about a 50% birth rate with gestational surrogacy and IVF egg donation every time embryos are transferred, provided the genetic mother (the egg provider) is under 35 years of age and the recipient has a healthy uterus. This rate decreases slightly between ages 35 and 40 and then declines rapidly thereafter.

While birth rates following conventional IVF and gestational surrogacy both decline progressively with, success rates remain higher with gestational surrogacy than with conventional IVF for any given age of the genetic mother (egg provider). This is largely due to the fact that administration of exogennus estrogen better prepares the uterine lining for implantation than that which occurs following ovarian stimulation with fertility drugs.

It is also worthy of mention that there is no reported increase in the incidence of spontaneous miscarriage or birth defects as a direct result of IVF Surrogacy.


A FINAL WORD OF ENCOURAGEMENT

Pacific Fertility Medical Center and it's affiliates have helped bring over 1400 IVF babies into the world. Sometimes the struggle with infertility seems unfair. Other times it will seem impossible. Maybe the words of a former PFC patients will help during those times: "I want you to know that if I had to undergo each injection, each tear, every dollar spent, the miscarriages, the problems with adoptions, and the failed pregnancy tests all over again ... I would. I absolutely mould ... because if we hadn't gone through all that we wouldn't have Nicholas ... we might have someone else, but no one could be as wonderful as our Nicholas."

Geoffrey Sher, M.D., has published numerous scientific papers relating to IVF and infertility treatment and is the co-author of three books "Your Pregnancy" published by Simon and Schuster, "From Infertility to In Vitro Fertilization" published by McGraw Hill in March of 1989, and the recent release of "Invitrofertilization-The Art of Making Babies-Assisted Reproductive Technologies."