Case Report: Recurrent IVF Failure due to Uterine Adenomyosis and Intrauterine Fibroid Polyps, Requiring Gestational Surrogacy

Linda (43y) and her husband Graham (49y) had been trying to conceive for 6 years. She had been pregnant once before in 1993. This pregnancy, which was initiated in a previous relationship was aborted, without subsequent complications. Linda had been having regular ovulatory menstrual cycles. Her general health was excellent but her family history was positive for amyotrophic lateral sclerosis (AML).

In 2016 Linda underwent a hysteroscopic myomectomy for the removal of a small fibroid polyp. A follow-up hysteroscopy done the following year, revealed her uterine cavity to be normal. In 2018, she was diagnosed with diminished ovarian reserve-DOR (AMH=0.08ng/ml and her basal [FSH} was 17MIU/ml).

Graham was fertile. He had excellent sperm parameters.

Between 2017 and 2019, the couple had undergone 6 cycles of egg retrieval (ER) with intracytoplasmic sperm injection (ICSI). A total of 12 blastocysts had been generated. These had all been subjected to preimplantation genetic screening (PGS). Later in 2017, Linda, had a single (1) euploid blastocyst thawed and transferred to her uterus by frozen embryo transfer (FET) but did not conceive. She presently has 1 remaining banked, euploid blastocyst.  All the rest (10) were complex aneuploid and were discarded. In September of 2018, Linda underwent hormonal preparation for a second FET attempt. The transfer was canceled because she was found to have a significant and persistent collection of fluid in her uterine cavity, had a thin endometrial lining and there was also a suggestion of a surface lesion in her uterine cavity. Uterine magnetic resonance imaging (MRI) was thereupon performed, and this revealed a 2 cm fibroid polyp protruding into the uterine cavity as well as the presence of extensive uterine adenomyosis,

Upon discussion, the couple insisted that since they under no circumstances, were willing to undergo another ER or ever use of donor eggs/embryos, they wanted their only remaining blastocyst to have the best possible chance of propagating a viable pregnancy.  Upon learning that Linda had a healthy and close, younger sister who had previously successfully conceived and delivered 3 full-term babies, I suggested that the couple approach her to serve as their gestational surrogate. The couple subsequently approached Linda’s sister who readily agreed to serve in this capacity. This treatment will shortly take place.

I intend to follow this couple and will report on their progress as treatment is implemented


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ADDENDUM: General concepts Relating to Gestational (IVF) Surrogacy:

Gestational (IVF) surrogacy involves the transfer of one or more embryos into the uterus of a surrogate, who provides a host womb and carries the baby to term, but does not contribute genetically to the baby. Typically, the intended mother provides the eggs and her partner (the intended father) provides the sperm. However, at times eggs and/or sperm may be derived from gamete donors. While ethical, moral, and medico‑legal issues still apply, IVF surrogacy appears to have gained social acceptance. We offer IVF surrogacy as an option at most SIRM programs.

Candidates for IVF surrogacy can be divided into two groups: (a. women who are not capable of carrying a pregnancy to full term due to: their uterus having been surgically removed (hysterectomy), diseases of the uterus, or congenital absence of the uterus (from birth) and, (b. women who have been advised against undertaking a pregnancy because of systemic illnesses such as diabetes, heart disease, hypertension, etc.

As in preparation for other assisted reproductive (AR) techniques, the biological/intended parents, the surrogate and/or donors undergo a thorough clinical, psychological, and laboratory assessment prior to embarking on the process. The purpose is to exclude sexually transmitted diseases that might damage eggs, sperm and embryos, or be carried to the surrogate with embryo transfer. They are also counseled on issues faced by all IVF participants such as the possibility of multiple gestation, miscarriage and ectopic pregnancy.

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. We recommend that the surrogate and biological/intended parents get separate legal counsel to avoid any conflict of interest that could arise were one attorney to counsel both parties.

Selecting a Surrogate

Couples with the necessary financial resources will usually retain a surrogacy agency to find a suitable IVF surrogacy candidate. We direct our patients to reputable surrogacy agencies who have access to quality surrogates. Because the surrogate gives birth, it is rarely possible or even realistic for her to remain anonymous.

Since recruiting a gestational surrogate from an agency can be very expensive, many infertile couples who qualify for IVF surrogate parenting solicit the assistance of empathic friends or family members to act as surrogates.

Other couples independently seek surrogates by advertising in the media.

Screening the Surrogate

Once the surrogate has been selected, she will undergo thorough medical and psychological evaluations, including:

  1. Cervical cultures and/or blood tests to screen for infection with sexually transmitted bacteria such chlamydia, ureaplasma, gonococcus and syphilis or viruses such as cytomegalic virus, HIV, HTLV, and hepatitis.
  2. A variety of blood‑hormone tests, such as the measurement of plasma prolactin and thyroid‑stimulating hormone (TSH) and tests to ensure that the surrogate is immune to the development of rubella (German measles).
  3. 3. Physical evaluation
  4. Psychological assessment

When friends or family members serve as IVF surrogates they should be carefully assessed to ascertain whether they might have been coerced to participate. This is especially important when a young family member is being recruited.

The surrogate should also be counseled on issues such as risks and consequences of multiple pregnancies. Such discussions should include agreement on the number of embryos to be transferred and the delicate issue of selective pregnancy reduction , in the event of a high order multiple pregnancy (triplets or greater).

The surrogate should visit with her designated IVF physician who should take her medical history and perform a thorough physical examination. Thereupon she should have a full consultation with the nurse coordinator charged with oversight of her treatment. The coordinator will outline the exact IVF-surrogacy process step by step, will make certain that the surrogate understands that she has full right of access to the clinic staff and that her concerns will be addressed promptly at all times. The surrogate should also be informed that if pregnancy occurs, she will be referred to a qualified Obstetrician for prenatal care and delivery.

Once a viable pregnancy is confirmed by ultrasound recognition of a fetal heartbeat (at the 6th-7th week), there is about an 80% chance that the pregnancy will proceed normally to term. Once the pregnancy has progressed beyond the 12th week, the chance of a healthy baby being born is upward of 90%.

Depending on the quality of medical treatment and ther age of the egg provider (under 39y) and her having normal ovarian reserve, we would anticipate approximately a 40% pregnancy rate every time good quality advanced embryos (expanded blastocysts) are transferred. The birthrate falls with further advancement in the age of the egg provider and with diminishing ovarian reserve. 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, progesterone and corticosteroids is discontinued, and she can expect to menstruate within four to 10 days. In the event that the pregnancy test is positive, estrogen, progesterone and steroid therapy are continued till the 10th week of pregnancy.

After the evaluation and counseling of both the couple and the surrogate has been completed, the three parties should meet. And, once all the evaluations have been completed, the intended parents will select a date to begin treatment.

Bioethics of IVF Surrogacy

The determination of ethical guidelines has not kept pace with the exploding growth and development in IVF. However, some leaders in the field are working together, sharing experiences and advice, to formulate a code of ethics.

The genetic combination of the male and the female provide two of the essential elements which, along with gestation, are necessary to produce a human being. The two‑out‑of‑three rule basically looks at these three elements: the egg, the sperm, and the gestational component. If at all possible, I recommend that at least two of these three components be contributed by the intended parents. If they can only contribute one, it is important to make every effort not to have the other two contributed by the same person (i.e., the egg provider should not also be the surrogate) as this can cause a variety of problems.

2 Comments

Julieta Alvarez

Dr. Sher, I just wanted to tell you how thankful I am for this informational blog and all your great advice! You are a wealth of knowledge and a huge contributor to the success of many couples dealing with infertility.

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Dr. Geoffrey Sher

That is so very kind of you to say Julieta. BUT the truth is, I get as much out of doing this as readers do. I love doing it. Thank you for following me here!

Geoff Sher

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