Surrogacy involves conception and the subsequent birthing of a baby by one woman (the surrogate) for another individual or couple. There are two primary types of surrogacy – Traditional (Classical) and Gestational (IVF).A traditional surrogate is a woman who is artificially inseminated with sperm, carries the baby and then surrenders it to be raised by the aspiring parent(s) to be. In this arrangement, the traditional surrogate is the baby’s biological mother. In contrast, Gestational (IVF) surrogacy involves the transfer of one or more embryos derived from one woman’s eggs and designated partner’s or donor sperm, to the uterus of another woman who provides a host womb. With gestational surrogacy, the surrogate does not contribute genetically to the baby and thus is not the biological mother.
While in general, surrogacy has fueled a great deal of legitimate debate and controversy, it is largely Traditional surrogacy that has evoked the most criticism because it involves a requirement that the surrogate contribute her genetic material (her eggs) to the baby she carries and thereupon is called upon to surrender her own biological offspring to another party. It is this very dilemma that has given rise to much heart wrenching struggles, and legal conflict. This is not the case with Gestational surrogacy where the woman carrying the baby has no genetic link to the child she gives birth to.
As far as the ethics of Surrogacy is concerned, my actions are governed by what I term the “two-out-of-three ethical rule”. This rule looks at three elements that combine to make procreation possible, i.e. the egg, the sperm, and the womb and this requires that at least two of these three components be contributed by the intended parents. Gestational surrogacy meets this requirement while Traditional surrogacy does not. Thus I do not offer Traditional surrogacy services.
Candidates for Gestational surrogacy can be divided into two groups: (1) women born without a uterus or those who because of uterine surgery or disease are not capable of carrying a pregnancy to full term and (2) women who have been advised against undertaking a pregnancy because of systemic illnesses, such as diabetes, heart disease, hypertension, or certain malignant conditions.
As with preparation for other assisted reproductive procedures, the aspiring parents undergo a thorough clinical, psychological, and laboratory assessment prior to selecting a surrogate. The purpose is to exclude sexually transmitted diseases that might be carried to the surrogate at the time of embryo transfer. The aspiring parents are also counseled on issues faced by all regular IVF aspiring patients, such as the possibility of multiple births, ectopic pregnancy, and miscarriage.
All legal issues pertaining to custody and the rights of the aspiring parents and the surrogate are discussed in detail and appropriate consent forms are completed following full disclosure. I recommend that the surrogate and aspiring parent(s) get separate legal counsel to avoid any conflict of interest that otherwise might arise were one attorney to counsel both parties.
Many infertile couples who qualify for Gestational surrogate parenting solicit the assistance of empathic friends or family members to act as their surrogate, some seek surrogates by advertising in the media while those who have the required financial resources commonly retain the services of a third party parenting agency to assist them in finding a suitable surrogate.
Once the surrogate has been selected, she undergoes thorough medical and psychological evaluation, including: a) cervical culture and/or DNA test to screen for infection with chlamydia, gonococcus, and other infective organisms that might interfere with a successful outcome., b) blood tests (as appropriate) for HIV, hepatitis, and other sexually transmitted diseases, and rubella (German measles). Other blood tests include hormone tests, such as the measurement of plasma prolactin and thyroid-stimulating hormone (TSH) and on rare occasions, tests for immunologic implantation dysfunction e.g. (natural killer cell activity-NKa and DQ alpha/HLA genotype etc.).
Whether recruited through an agency, family members, or through personal solicitation, the surrogate should in most cases be carefully evaluated psychologically as well as physically. This is especially important in cases where a relatively young surrogate or family member is recruited. In such cases, it is important to ensure that the surrogate has not been subjected to any pressure or coercion.
The surrogate should also be counseled on issues faced by all IVF aspiring parents, such as multiple births. She should also visit with the Nurse Coordinator, who will outline the exact process step by step. She should be offered full access to clinic staff and be assured that her concerns will always be addressed promptly at all times and that if pregnancy occurs, she will be referred to an experienced obstetrician for prenatal care and delivery.
In order to stimulate ovulation of enough eggs to increase the chances of a viable pregnancy, the biological parent is stimulated with gonadotropins and is intensively monitored by a series of blood estradiol hormone measurements and ultrasound examinations. Once monitoring confirms that the ovarian follicles have developed optimally, she is given an injection of the ovulatory “trigger”, hCG. Thereupon, about 36 hours later, while under conscious sedation, her eggs are harvested by transvaginal ultrasound needle-guided aspiration.
The surrogate in turn, receives estrogen orally, by skin patches, or by injection. I personally preferentially recommend twice weekly injections of estradiol valerate (Delestrogen). Once the uterine lining is adequately thickened and this correlates with an ideal blood estradiol level, daily progesterone injections are administered to help prepare her uterine lining for implantation. As when I prepare my patient recipient for IVF/egg donation, I use biweekly estradiol valerate injections. The embryo transfer is effected 5-6 days after the initiation progesterone injections. The surrogate will be given daily progesterone injections and biweekly estradiol valerate injections and/or suppositories in order to sustain an optimal environment for implantation, and approximately 10 days after the embryo transfer she undergoes a pregnancy test. A positive pregnancy test indicates that implantation is taking place. In such an event, the hormone injections are continued for an additional four to six weeks. In the interim, an ultrasound examination is performed to definitively diagnose a clinical pregnancy. If the test is negative, all hormonal treatment is discontinued, and menstruation usually ensues within three to 10 days.
If the surrogate does not conceive, the aspiring mother may have her remaining embryos/blastocysts cyobanked for subsequent use. Thereupon they can be to be thawed and transferred to the uterus at a later date. If in spite of both the initial attempt and subsequent transfer of thawed embryos the surrogate does not conceive, the infertile couple would need to contemplate undergoing a new cycle of treatment.
In the event that a viable pregnancy is confirmed by ultrasound there is usually a better than 80 percent 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 percent. I anticipate that in approximately 50 percent of cases, when two advanced embryos (blastocysts) derived through fertilization of the eggs of a woman under 35y, about 45-50% will conceive and about 40% will have a live birth.