Gestational Surrogacy Heather Gibson Huddleston, MD Associate - - PowerPoint PPT Presentation

Gestational Surrogacy

Heather Gibson Huddleston, MD Associate Professor of Clinical Medicine Reproductive Endocrinology and Infertility

• I have no disclosures

History

• First Report of Surrogacy

First Modern Report of Surrogacy was reported in 1985 Utian et al NEJM 1985

Genesis 16.1-15

Outline

• Definitions
• Ethical Issues
• Current Practices and Guidelines
• Outcomes

Definitions

Natural or Traditional Surrogacy

Uterus and eggs from one woman. Generally accomplished via IUI with IP sperm.

Gestational Surrogacy

Uterus only provided by surrogate. No genetic connection; requires IVF to generate embryo for transfer

Commercial Surrogacy

Payment for time

Altruistic Surrogacy

Payment for medical expenses only.

Intended Parent (IP)

Commissioning couple

Typical Process: Gestational Surrogate

Intended Parent

Gestational Carrier

Ovarian stimulation * Egg Retrieval * Fertilization * Embryo Culture *

Oral Contraceptives Estrogen Treatment Embryo Transfer Progesterone

The debate

• Contractural surrogacy

represents commodification

• f the body
• Commercial surrogacy

conflicts with the interests

• f the child
• Degrades traditional family

structure

• Emphasis on autonomy:

contractural surrogacy is permissable but only if the woman retains the right end the pregnancy and revoke agreement at any time

• Payment is ethical based on

time, inconvenience, risk and discomfort - similar to compensation for research

Surrogacy on the International Front

Commercial Surrogacy Allowed: U.S: some states Georgia (country) Israel (but not gay men) Ukraine Russia All forms Prohibited: Austria, Bulgaria, Denmark, Finland, France, Germany, Italy, Norway, Spain Sweden Altruistic allowed UK, Australia, Canada, New Zealand, Belgium Greece

Surrogacy State by State

At least one court opinion that upholds some form of surrogacy: , OH, PA, NH, MD, SC, MA Neither statue nor published case: AK, HI, MT, OR, ID, WY, SD, MN, CO, KS, MO, KY, VT, ME, RI, IK, LA, MS, AL, GA

• Legal. Pre-birth
• rders allowed

Not Legal Legal but results may be inconsistent Possible legal hurdles

Audience Question

My patient has a cardiac condition that precludes pregnancy. I think it is ethical for her to pay someone to serve as a surrogate.

• A. True
• B. False

T r u e F a l s e

5% 95%

Audience Question

My patient has a cardiac condition that precludes pregnancy. I think it is reasonable for her to pay someone in a third world country to serve as a surrogate.

• A. True
• B. False

T r u e F a l s e

44% 56%

Audience Question

My patient has travelled from China to seek a surrogacy pregnancy here in the U.S. She has had

• ne miscarriage had faces social pressure since it is

assumed to be her fault. A surrogacy pregnancy would protect her from potential ostracism from friends/family. I believe this is a reasonable option.

• A. True
• B. False

T r u e F a l s e

28% 72%

Audience Question

My patient has had two miscarriages and has a high profile job on television. The trauma and downtime has been hard on her career. She would like to pay a surrogate to carry for her. I think this is reasonable and ethical.

• A. True
• B. False

T r u e F a l s e

31% 69%

. Number and percent of gestational carrier cycles, United States, 1999–2013.

Trends in gestational surrogacy in the United States: 1999-2013

Perkins et al Fertility and Sterility, 2016,

Percent of gestational carrier ART cycles where intended parent was a non-U.S. resident

Perkins Fertility and Sterility, 2016, Available online 14 April 2016

Ethical stance of ASRM toward GC

Gestational Carriers

• Have a right to be fully informed of the risks of

the process and pregnancy

• Should receive psychological evaluation and

counseling

• Should have independent legal counsel
• Reasonable economic compensation to the

carrier is ethical

• Intended parents are considered the psychosocial

parents of any children born by a GC

Current Practice: Indications

Per ASRM Guidelines: GC may be used when a true medical condition precludes IP from carrying pregnancy or would pose risk of death or harm to mother or fetus.

Absence of uterus Medical condition that precludes pregnancy Biological inability to carry child (male couple or single) Recurrent pregnancy loss Medical disorder impacting uterus (Asherman’s)

Selection Criteria: ASRM

• Ages 21-45
• Prior pregnancy and delivery without

complications

• No more than 5 prior deliveries or more than

3 Cesareans

• Stable family environment with adequate

support to help her cope with added stress of pregnancy

Evaluation and Screening

Intended Parents

• Psychosocial evaluation and

screening

• Screened in same manner as

gamete donor according to FDA guidelines

• Infectious disease panel with

30 days of egg and 7 days of sperm collection.

• Quarantining embryos: option
• f freezing embryos for 180

days with release after genetic parents have been retested with confirmed negative results. Gestational Carriers:

• Psychosocial evaluation and

counseling by mental health professional is strongly recommended.

• Medical evaluation
• Infectious disease screening
• Review of prior obstetric history

Counseling and Contracts

• Non-ideal outcomes: Risks of miscarriage,

pregnancy and delivery complications

• Agreement on number of embryos to transfer

and possible risk of multiples

• Management decisions pertaining to

termination

• Management decisions pertaining to delivery
• Ultimate decision making must rest with GC

Outcomes compared to Non-Surrogacy cycles

Adjusted Relative Risk (non donor) Adjusted Relative Risk (donor) Implantation Rate 1.22 (1.17,1.26) 1.11 (1.07-1.15) Clinical Pregnancy rate 1.14 (1.1-1.19) 1.05 (1.03-1.08) Live birth 1.17 (1.12-1.21) 1.08 (1.05-1.11)

• Of 2 million ART between 1999-2013, 1.9% used a GC.
• Increased from 1% in 1999 to 2.5% in 2013.
• GC cycles had higher rates of implantation
• Improved outcomes for gestational carrier compared to non

gestational carrier cycles using fresh non donor or fresh donor

• ocytes (adjusted for age, prior ART, prior SAB, day of Et, use of PGD,

Number of embryos transferred).

Gestational Carrier versus non-Gestational Carrier Outcomes

Outcomes from a Series of 333 cycles in Canada

Shir Dar et al. Hum. Reprod. 2015;30:345-352

Recurrent Implantation failure Same Sex Maternal Medical Uterine malformations/ Ashermans Uterine Agenesis RPL Prior poor pregnancy

• utcome

Series of 333 Surrogacy Cycles in Canada

Canadian Series: The outcomes of autologous-oocyte surrogacy cycles stratified by oocyte age

Shir Dar et al. Hum. Reprod. 2015;30:345-352

Outcomes: Canadian Series (n=333)

• Pregnancy rate for failed to carry (n=96): 50% pregnancy

rate, 35% live birth

• Cannot carry (n=108): 54% pregnancy rate; 40% live birth
• Male couples/single men (n=37): 60% pregnancy rate
• 17 cycles with concurrent transfer: 10 resulted in surrogate

pregnancy and one in IP.

• Of 178 Pregnancies:

20% miscarriage rate 133 births, 175 children, Vaginal delivery rate of 76.7% Twin rate = 28.6% Maternal complications 9/8%(12 minor, 1 major:c-hyst)

The number of gestational carrier cycles performed for same-sex male couples or single men per year from 2002–2012 at the CReATe Fertility Centre (CFC).

Shir Dar et al. Hum. Reprod. 2015;30:345-352

Conclusions

• Surrogacy is important treatment option for

many who desire parenting

• Complex legal playing field requires caution
• Best practices suggest legal counsel for both

parties.

• Outcomes across obstetric and psychological

parameters are very good.

Thank you