GESTATIONAL SURROGACY AT
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
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
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
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."