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Surrogacy – A Tale of Two Mothers

Since the birth of the first test-tube baby, Louisa Brown in the year July 7th, 1978, there has been a rapid advance in the field of assisted reproduction. Miraculous discoveries of micromanipulation and ET, cloning, genetic engineering, gametes freezing, and electro fertilization have been achieved and research
being carried on testicular sperm fertilization and oocyte freezing. The more the scientific discovery, the more the newer indications! This has lead to the transfer of an embryo from the infertile couple to an unrelated recipient! The human embryo-like other mammalian embryo is immunologically and genetically different from the mother and therefore a rejection phenomenon is present. Since the implantation physiology is the same in all, it should make no difference when the embryo implants in the mother or the host.

The first surrogate birth was reported in 1987. Since then around 180 births have occurred worldwide. India’s first surrogate singleton was born on 23 June 1994 in our hospital. Our second surrogate conception was triplets who were born on 21 September 1995.

Our third surrogate conception were twins born to a case of Mayer-Rokintansky-Kuster-Hauser syndrome (A woman without a uterus but with normal functioning ovaries).on 19 January 2001. This was the first reported pregnancy in South East Asia. Surrogacy is the only hope for a certain group of infertile couples. A surrogate carrier is a woman who gestates the embryo of a couple. The egg and the sperm of the genetic the couple is fertilized outside and the resulting embryo is transferred into the uterus of the surrogate woman.

Types of surrogacy

  • A woman is inseminated with the sperm of a man who is not her partner in order to conceive and carry a child to be reared by the biologic father and his partner. In this procedure, the surrogate is genetically related to the child.
  • Another type is a gestational carrier, i.e. a woman who is implanted with the fertilized egg of another couple in order to carry the pregnancy. The gestator is not genetically related to the child in this case.

Patients without Uterus

  • Women with congenital absence of the uterus; Mullerian agenesis (Mayer Rokitansky -Kustner Hauser syndrome).
  • Women who have had a hysterectomy for various reasons like uterine fibroids, carcinoma, Ante-partum or postpartum hemorrhage, uterine rupture, severe adenomyosis and so on.

Patients with uterus and functioning of one or both the ovaries

  • Women who suffer from repeated miscarriages
  • Repeated failures in IVF cycles- the non-receptive uterus.
  • Women with certain medical conditions making pregnancy life-threatening.
  • Women with a very busy career or for social reasons (should be discouraged)

Patient selection

The ‘genetic parents’ and the ‘host couple’ are usually seen together at the first consultation for a full explanation of all that is involved in the treatment, followed by a full history and medical examination of both the women. If there are no medical reasons stopping the genetic mother and the host to undergo superovulation and oocyte recovery, they are further counseled on the medical details of the treatment as well as
the potential complications. It is important that the host and her husband should be fully aware of all that is involved.

If both the medical assessment and examination, as well as the counseling sessions are satisfactory, then reports are prepared by the Medical Director and the counselor who considers the suitability of each case in detail. If the arrangement is considered suitable, then preparations are made for the treatment of the genetic mother to start.

Screening and selection of surrogate

  • Presence of infectious disease.
  • Sexually transmitted Diseases
  • HIV and hepatitis-B
  • Family history of nontrivial malformation, mendalian disorders, chromosomal rearrangements.
  • Health risk-multiple pregnancies.
  • Attitude towards amniocentesis and abortions.

Screening of Patients

The best surrogate is the ‘genetic parent’ mother or sister. Or it could be the best friend or cousin. The American Fertility Society provides specific guidelines to help identify and reject a potential surrogate. They are :

1. Infectious / transmissible diseases

a). Infectious diseases screening. b). Sexually transmissible diseases. c). High-risk group for AIDS and persons who have had more than one sexual partners with in the last six months

2. Genetic factors

In addition, genetic screening of potential surrogate mothers is appropriate. The American Fertility society guidelines recommended rejecting prospective surrogate mothers with a family history of nontrivial malformation, nontrivial mendelian disorders, on a chromosomal rearrangement (unless the surrogate has a normal karyotype).

3. Medical disorders

The surrogate should not have any severe medical disorders such as asthma, diabetes, hypertension,
epilepsy, psychosis, rheumatoid arthritis etc.

4. Psychological factors

Psychological assessment, especially possessiveness.

Screening / selection of a surrogate

  • Age <35 years.
  • Personal habits like smoking, alcohol and drug abuse.
  • No severe medical disorders
  • Psychological risk-possessiveness
  • Possibilities of change of mind.
  • Possible maternal / binding.
  • Mode of payment

The host may be treated in one of 2 ways

1. Frozen / thawed embryo replacement in a natural cycle

This method is only considered suitable for those women who have been sterilized, or whose husbands
have had a vasectomy and who have been confirmed azoospermic. Replacement in a natural cycle is not
considered suitable for women practicing barrier contraception because of the risk of themselves
conceiving in the replacement cycle and the awful consequences of either giving their own child away, in the belief that it was from the transferred embryo, or there being a twin mixed conception. The risks of this happening are managed using a hormone-controlled cycle as described below. In a natural cycle replacement, the host is monitored daily from about day 8 of the cycle until the natural LH surge is detected. Frozen pronucleate embryos are thawed 24 hours after the LH surge and transferred to the host
uterus after a further 24hours. Frozen cleaved embryos are thawed and transferred 48 hours after the LH surge. Luteal support is not usually necessary. 15 days after the transfer a serum beta-human chorionic gonadotrophin test for pregnancy is carried out.

2. Frozen/thawed embryo replacement in a hormone controlled cycle

Control of the host’s replacement cycle is recommended for two main reasons

  • If the menstrual cycles of the host are irregular, or if they are found to be anovulatory, or if the luteal phase
    insufficiency is suspected.
  • If the host is fertile and has to rely on barrier contraception.
  • By ‘down-regulating’ the host and controlling the cycle with a GnRH analog and then replacing estrogen in increasing doses, creating an artificial proliferative phase, the chance of implantation of the embryo is increased. Similarly, by taking control of the cycle, natural conception with the host’s partner is prevented. This control is achieved by the administration of the buserelin 500 microgram subcutaneously from the 20th day of the previous cycle until day 2 of the following menstrual period. The downregulation is found to be adequate when the serum estrogen level is less than 50 pg/l, the LH is less than 4 IU / l and the progesterone is less than 0.3 pg/l and the ovaries are inactive, then the dose of buserelin is reduced to 250micro gram. Estrogen is supplemented in the form of estradiol valerate tablets in the step-up dose from day 2.

    Progesterone is supplemented in the form intramuscular injections or vaginal pessaries from day 15 onwards and the embryos are transferred on any one day between 16th to 19th of the artificial cycle. Estrogen and Progesterone are continued till the 30th day. Serum βhCG is done on 27th and 29th day to confirm pregnancy. If it is positive, then estrogen and progesterone are continued until 14 -16 weeks gestation, by then the placenta takes over.

    The most difficult aspect of treatment by IVF-surrogacy is, in fact, the extreme care with which the host needs to be selected by the genetic couple and also the great detail in which both couples need to be counseled on all aspects of the arrangement. Surrogacy is made easier in the USA because it is ethically acceptable in most states for surrogates to receive payment for their services, in the same way as ovum donors may be paid there.

    There are certain basic principles in considering any surrogacy case

    • The clinical indications of host - surrogacy must be clearly defined and will probably be limited.
    • Careful and extended counseling should be provided
    • Proper independent legal advice should be sought by genetic and host couples.
    • Cases should not be considered if there is any doubt that the genetic couple will not be able to adopt the child
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