Most infertility clinics have protocols and guidelines for managing surrogacy. Such clinics only accept couples for treatment if both the genetic and host couples fulfill their criteria.
Consultation with a medical doctor to assess whether the couple are medically suitable for treatment.
Assessment of genetic couples
For IVF surrogacy, the ages of commissioning genetic couple should be under 35 years for women and under 55 year for men. In natural surrogacy, no restrictions are placed on the mans age. An in depth review of the medical history from both partners and a physical examination is normally performed. The male partner will usually have a semen analysis.
Assessment of the host – the carrier
The ideal surrogate should be married or in a stable relationship and relatively young, less than 38 years old to minimize the obstetric risk to the host and her family. It is also preferable if the surrogate has at least one previous live birth without complications. In addition, it is important that potential surrogates do not have habits of smoking, alcohol, illicit drug use, or a history of medical disorders such as diabetes or Rhesus (Rh) antibodies that could jeopardize the health of the fetus.
In order to ensure the above criteria are met, the patients medical history is reviewed, physical and internal examinations are performed, and the surrogates uterus is evaluated by ultrasound scan or hysteroscopy. Furthermore, a psychological evaluation is usually carried out.
The independent counseling of both genetic and host couples is strongly recommended. This is because of many psychological, ethical and legal issues surrounding surrogacy. The role of the counselor is to ensure that all implications of the procedure have been carefully explored and help all parties concerned to come to an understanding of the tremendous impact that surrogacy will have on their life, on the child born as a result of treatment and other children the couple have as well as the difficulties that lies ahead.
The counselor may also address issues of confidentiality, the payment of expenses to the host, and the adoption of the baby by the genetic couple.The counselor may address antenatal screening for example for spina bifida and Down’s syndrome and what should be done if the baby is found to have congenital abnormalities. In addition the counselor may discuss the risk of multiple pregnancy and what the parents will tell the child when they grow up. The distress generated when surrogacy arrangements breaks down can be catastrophic and great care should be taken to provide adequate counseling before embarking on this treatment.
If the couple seeking surrogacy are found to be suitable, then their case will be put before the ethics committee. This is an independent body of professional and lay people. The ethics committee will evaluate the case and come to a conclusion on whether surrogacy is viable and recommended. The committee will assess the reason for surrogacy and the motives for the host to carry a child for somebody else. In addition, the committee will evaluate the welfare of the child born as a result of the treatment and for any existing children.
Screening before surrogacy treatment
The genetic woman, genetic couple, female host and host couple, must all be screened before beginning surrogacy treatment. The genetic mother may have blood tests and ultrasound scans to assess her ovaries and ovarian function. The genetic couple may have their blood group and Rhesus (Rh) status determined, if the hosts blood is Rhesus negative. The genetic couple are also screened for HIV (AIDS), hepatitis B and C to ensure that neither the host nor the child is at risk. The female hosts blood group and Rhesus status is determined. While the host couple is screened for HIV, hepatitis B and C.
What are the sources of surrogates?
The surrogate can be known or anonymous. Known surrogates can be relatives such as sisters or friends. Whereas anonymous surrogates can be arranged privately.
The steps involved in IVF surrogacy
The procedure for IVF surrogacy in itself is a straight forward. It involves the commissioning woman undergoes IVF treatment, fertilizing her/donor eggs with her partners sperm. Then subsequent embryo transfer into the host uterus.
Ovarian stimulation using fertility drugs
The commissioning woman will have to undergo ovarian stimulation using fertility drugs. She will undergo cycle monitoring by scans and blood tests. When the follicles are mature an hCG injection is given and about 36 hours later egg collection is performed by vaginal ultrasound guidance under light sedation or a general anesthetic. The eggs will then be inseminated with her partners sperm. All resulting embryos of good quality are then frozen for a minimum period of six months. The commissioning woman may have to undergo more than one cycle of IVF treatment to generate enough embryos to have a fair chance of success.
Repeated HIV tests
HIV tests are then repeated at the end of six months and if negative, the frozen embryos are thawed and transferred to the host’s uterus. An alternative is to freeze the genetic male sperm for a minimum period of six months and repeat the HIV test before starting treatment. If the test is negative, inseminate the eggs with the frozen thawed sperm and resulting embryos can be transferred.
The 6-months quarantine of either embryos or sperm is required by the Human Fertilisation and Embryology Authority (HFEA) in the UK.
Embryo transfer can be performed either in a natural or a hormone replacement cycle.
Natural cycle frozen embryo transfer
Natural cycle frozen embryo transfer is recommended if the host menstrual cycles are regular and she ovulates regularly. Either she was sterilized or her male partner has had a vasectomy. The menstrual cycle is monitored by ultrasound scan and blood or urine test to check her hormones. Frozen embryos are then thawed and replaced 2-3 days after ovulation.
Hormone replacement frozen embryo transfer
Hormone replacement frozen embryo transfer is recommended if the host menstrual cycles are irregular or there is concern about the possible occurrence of a pregnancy as a result of a natural intercourse between the host and her male partner. The host is given a drug (GnRh agonist) to lower her hormone, and then she will be given. Hormone treatment to prepare her endometrium (lining of the womb) for embryo transfer.
How many embryos are transferred?
Because multiple pregnancy imposes increased risk to both the mother and the babies, most clinics will restrict the number of embryos to be transferred, to two.
What is the traditional surrogacy procedure?
The surrogate is inseminated with the male partner’s sperm. The insemination may be either intracervical insemination (ICI) using neat sperm or intrauterine insemination (IUI) using washed and prepared sperm.
Success rates of surrogacy
For traditional surrogacy, the success of the treatment will depend on the fertility of both the female and male and is in region of 5-15% per cycle. For IVF surrogacy, a live birth rate of about 20-30% per cycle is expected. The live birth rate per treatment cycle was 29.8% (SART report 1999).
Surrogacy isn’t inexpensive. Except in the case where a sister or friend agrees to act as a surrogate without a fee, total costs and expenses may include the surrogate’s fee and possible expenses, lawyers’ fees, fertility specialists’ fees, and fees connected with an adoption, if that is required. Cost estimates for traditional surrogacy range between $40,000 and $65,000 and for gestational surrogacy, between $75,000 and $100,000 in Western Countries, While in India, the successful single surrogacy may cost upto Rs 8,00,000 to Rs 10,00,000.