Surrogacy

It is estimated that one out of every six couples of childbearing age has suffered the heartbreak of infertility. Although modern assisted reproductive techniques can overcome many causes of infertility, there are some couples who will never be able to conceive for various reasons. For those couples, adoption is one alternative. However, in today's society adoption can't even begin to fill the needs of the infertile couples who want to have families. At least 60 couples wait for every available healthy child, and the adoption process usually takes years.

Although there are many "special needs" children waiting for adoption, it takes extraordinary resources, both emotional and financial, to raise these children. Couples who have already suffered years of emotional stress caused by their own infertility are often not prepared psychologically to take on such enormous responsibilities. For these couples gestational surrogacy is an excellent way to achieve their dreams of parenthood.

What does gestational surrogacy mean to you?

In gestational surrogacy, the infertile couple are the true biological parents.  They provide both sets of gametes and is known as the "the genetic couple or intended parents." The woman receiving the embryos created from the gametes of the genetic couple is known as the "surrogate host, host, or gestational carrier." Thus, the gestational carrier has no genetic relationship to the child, unlike traditional surrogacy in which the surrogate is the genetic mother of the child.

What does surrogacy mean to us at CRH?

Our mission is to work with you and your chosen surrogate in the fulfillment of everyone's dream in a timely, legally and medically sound, safe and cost-effective manner.

Gestational Surrogacy

Why gestational surrogacy? Unlike adoption, gestational surrogacy enables a couple to parent a child who is their biological offspring, the genetic product of both parents. By setting up an open arrangement based on mutual trust and respect with a suitable surrogate, the couple can be intimately involved in all the details of their baby's gestation and can have a say in the surrogate's nutrition and healthcare during the pregnancy. The majority of gestational surrogate parenting arrangements are successful. The gestational carrier feels great personal satisfaction by helping an infertile couple become parents, and the couple has a long awaited child whose creation was made possible through the miracle of reproductive medicine and loving co-operation.

At the Center for Reproductive Health (CRH) the gestational carrier program is a natural offshoot of our highly sophisticated and successful assisted reproductive technologies (ART). Because the ART program at CRH has one of the highest success rates in the nation when treating complex infertility problems, we can expect unusually high birth rates when using normal hosts who receive excellent quality embryos obtained in our sophisticated state-of-the-art laboratories. This dramatically decreases the expenses per birth and minimizes medical expenses.

Although the use of gestational carriers for surrogacy is not accepted in many states in the United States, surrogacy is an acceptable option in Tennessee for patients when it is unfeasible or medically contraindicated for the intended mother to become pregnant or carry a child herself.

Extensive medical and psychological screening is required with both the genetic parents and carrier as part of the preliminary evaluation. Because of the obvious legal implications, legal counsel for appropriate contracts is also a necessary part of the preliminary process.  Referrals to qualified psychologists are attorneys are available.

The medical process requires that the genetic mother's and the gestational carrier's menstrual cycles be synchronized. The genetic mother undergoes ovarian superovulation and egg retrieval. The eggs are then inseminated with her husband's sperm, or donor sperm if medically indicated, and then fertilized in the laboratory. After embryo development has occurred, blastocysts (or pre-embryos) are transferred to the uterus of the carrier who will be at the appropriate time in her cycle due to the synchronization.

Choosing Surrogacy

The use of a gestational carrier is appropriate for women who meet the following criteria. This is by no means an all-inclusive list; so if you have a condition not listed here, please contact our medical offices for specific questions. 

Gynecological Indications

1. Patients with no uterus, but with one or both ovaries functioning.

2. Patients after surgical removal of their uterus (hysterectomy) for carcinoma.

3. Patients after hysterectomy for severe hemorrhage or ruptured uterus.

4. Patients with congenital absence of their uterus.

5. Patients with a congenitally deformed uterus.

6. Patients with acquired pathology of the uterus (i.e., inoperable uterine fibroids, adenomyosis).

7. Other patients with surgically irreparable uterus (i.e., DES-exposed, previous radiation).

8. Patients with multiple in vitro fertilization (IVF) and/or oocyte donation treatment failures.

9. Patients with recurrent miscarriages, and for whom the prospect of carrying a baby to term is deemed remote.

10. Perimenopausal women with recurrent miscarriages.

11. Patients with lower genital tract malformations (i.e., abnormal cervix, absent vagina).

12. Patients with unresectable intrauterine synechiae (intrauterine scar tissue).

13. Patients with poor obstetrical outcomes due to untreatable conditions (i.e., irreparable cervical incompetence, pre-term labor, fetal death in uterus, fetal growth retardation, prematurity).

14. Patients with connective tissue disorders or high obstetrical risk for either life-threatening maternal hemodynamic and renal compromise or poor fetal outcomes.

15. Patients with cardiovascular disease at risk for morbidity from the hemodynamic challenges of pregnancy.

16. Older patients with increased risk of hypertension or preeclampsia that may lead to renal impairment.

Medical Indications

1. Patients with a medical condition that precludes them from carrying a pregnancy.

2. Patients with a carcinoma that contraindicates them from carrying a pregnancy.

3. Patients expected to undergo radiation therapy, chemotherapy or other invasive treatment that contraindicates them from carrying a pregnancy.

4. Patients with any other medical condition that, in the view of their referring and consulting physicians, is deemed as an appropriate medical indication.

5. Perimenopausal women with medical illness that renders pregnancy life threatening.

6. Patients counseled against pregnancy by an oncologist following treatment for neoplasia.

Patient Selection & Matching with Gestational Carrier

The genetic couple is seen for an office visit and in-depth consultation. If they are considered medically suitable for treatment, the couple is informed of their acceptance and given the option of using a gestational carrier whom they have recruited (i.e., relative, close friend, or carrier found by a commercial agency).

Recruitment of Gestational Carriers

Gestational carriers recruited by the biological parents or their designees should be carefully screened using the guidelines provided by The American Society for Reproductive Medicine. The assessment requires a detailed medical history, a physical exam, comprehensive laboratory testing and medical screening. Included in the work-up are a thorough gynecological exam, blood count, blood chemistry tests, ABO-Rh grouping, antibody screening, drug toxicology, and screening for rubella, Cytomegalovirus, syphilis, gonorrhea, Chlamydia, Ureaplasma, Mycoplasma, toxoplasmosis, hepatitis A, B, and C, and HIV. Multidisciplinary consultations with internists and specialists, psychologists, geneticists, and attorneys may also be required.

Counseling

The role of counseling is to prepare all parties involved in the treatment and to consider all factors which may influence the outcome. Counseling ensures that everyone is confident and comfortable with their participation and trusts each other. Counseling also minimizes foreseeable risks, thereby avoiding the placement of unacceptable burdens on any of the parties, including the future child.

Patient Management

Evaluation of the genetic Couple

The referring physician may have already carried out the work-up of a genetic couple referred for surrogacy. The philosophy at CRH is not to duplicate testing, thus, couples are encouraged to obtain copies of their previous testing to avoid duplication.

If there has been no previous work-up or if the testing is outdated, the couple's work-up may include:

1.Initial consultation of the couple with a staff physician of the program to review previous medical  records.

2.Physical examination of the female partner to ensure general good health.

3.Female laboratory testing

>> Rubella Immunity   >> Blood type and Rh   >> HIV antibody   >> Hepatitis B and C surface antigen   >> RPR for Syphilis   >> Cytomegalovirus (CMV)   >> Cervical cultures for Gonorrhea, Chlamydia, Ureaplasma, and Mycoplasma (when appropriate).   >> FSH - cycle day 2 or 3

4.Male laboratory testing

>> Blood type and RH   >> HIV antibody   >> Hepatitis B and C surface antigen   >> RPR for Syphilis   >> CMV

5.Semen analysis within the past 6 months

6.Consultation with the IVF nurse coordinator regarding the treatment protocol, medication and teaching of injections. Review and sign the consent forms for the procedure.

Treatment of the Genetic Mother

During the treatment cycle both genetic parents should eat healthy food, take vitamin supplements and refrain from smoking or drinking more than one alcoholic beverage per day. They should not take any additional medication other than that prescribed by the CRH.

The genetic mother will undergo ovarian stimulation that requires the use of fertility drugs such as Humegon, Repronex, Metrodin, Fertinex and other commercially available products. This treatment is known as superovulation, and it is used in conjunction with Lupron. To assist in evaluating the response to the superovulation treatment and predicting the time of the expected ovulation, the genetic mother will be carefully monitored. This is accomplished by several blood testing and vaginal ultrasound examinations.

When most ovarian follicles have reached adequate development, the genetic mother will receive human chorionic gonadotropin (HCG), an injection to produce the simultaneous development of several oocytes.  The HCG also  controls the timing of ovulation, so that the oocytes can be retrieved before they are spontaneously released. The oocyte retrieval is usually scheduled 36 hours after HCG administration.

Oocyte Retrieval from Genetic Mother

Vaginal ultrasound oocyte retrievals are the routine method because they are less invasive and more cost effective. An aspiration needle is inserted alongside the transducer and through the upper part of the vagina directly into each large ovarian follicle under mild conscious sedation. The fluid contained in the follicles is withdrawn, collected into test tubes and examined under the microscope in the IVF laboratory for the presence of the oocytes.

Sperm Collection from Genetic Father

The genetic father is asked to produce a sperm specimen before his wife's egg retrieval. The sperm sample is prepared in the normal manner as for fertilization in vitro.

In Vitro Fertilization

The mature oocytes from the genetic mother are combined with the sperm from the genetic father (insemination) about six hours after the oocyte retrieval. If the genetic couple is diagnosed with male factor infertility, another procedure called Intracytoplasmic Sperm Injection (ICSI) will be required to assist the sperm to fertilize the oocyte. Each oocyte is observed the following morning for fertilization. The normally fertilized oocytes are then returned to the incubator for an additional 24 hours to allow cell division (cleavage) to occur, and thereafter the fertilized oocyte is called an embryo.

Embryo Transfer

When the embryos have developed satisfactorily in the laboratory, up to three of them are selected and placed in the gestational carrier's uterus three to five days after the oocyte retrieval. The embryo transfer is a simple painless procedure performed without anesthesia. A speculum is placed into the vagina to visualize the opening into the womb. The embryos are then loaded into a narrow catheter, which it is gently introduced into the uterine cavity, where the embryos will be released for implantation. The gestational carrier is required to stay at the CRH in the transfer room for about two hours, and to limit all her activities for the following 96 hours. A pregnancy test is done approximately ten days after embryo replacement. If a pregnancy occurs, the Progesterone and Estradiol supplementation is continued for ten more weeks.

Embryo Cryopreservation

Any excess fertilized oocytes and/or normally developing embryos may be cryopreserved at the genetic couple's request and stored for their future use.

Screening of the Gestational Carrier

The host undergoes medical and psychological screening, as well as legal counseling. Complete medical screening includes:

1.Complete Gestational Carrier Profile screening.

2.Initial consultation with a physician.

3.Physical examination.

4.Psychological and legal counseling as appropriate through outside sources.

5.Hysterosalpingogram or Sono-hysterosalpingogram

6. Mock Cycle

7. Laboratory testing

>> Blood type and RH   >> HIV Antibody   >> Hepatitis B and C Surface Antigen   >> RPR for Syphilis   >> Cytomegalovirus (CMV)   >> Cervical Cultures for Gonorrhea, Chlamydia, Ureaplasma, and Mycoplasma.

Treatment of the Gestational Carrier's Cycle

Most gestational carriers undergoing a surrogacy treatment cycle receive Lupron, a medication used in women to prevent the pituitary gland from releasing the hormones that usually stimulate the ovaries. This is required to synchronize both the carrier's and genetic mother's oocyte cycles. Approximately two weeks later, the carrier will begin treatment with Estradiol to prepare the uterine lining for implantation. In addition, close to the time of embryo transfer, the gestational carrier will start the Progesterone supplementation, another hormone required for implantation of the developing embryos. The hormonal treatment is continued until the pregnancy test is performed. If a pregnancy is established, the hormonal treatment will continue through the first trimester.

Legal Aspects of Gestational Surrogacy at CRH

The backbone of any surrogate arrangement is the contractual agreement between both parties that fully informs them of their legal obligations. The genetic couple and the gestational carrier and her husband should retain different attorneys to execute the contract, ensuring that everyone's interests are represented.

Costs

Expenses at CRH are minimized by keeping medical expenses low as well as by eliminating "management fees" charged by commercial surrogate agencies. An additional practical factor that helps to minimize expenses is the very high IVF success rates of CRH, which has one of the lowest ratios of treatments per birth in the country.

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