The history of Assisted Reproductive Technology dates back to 1963 when Yanagimachi and Chang reported in-vitro fertilisation of hamster eggs and thereafter, Yanagimachi reported in-vitro capacitation of hamster spermatozoa in follicular fluid.
Capacitation, a term used to describe hyperactivated motility of the sperm, is required for fertilisation to take place. Following this, in 1977, Andrew Schally and Roger Guillemin were awarded the Nobel Prize in Medicine and Physiology for their work in the isolation of LHRH from the hypothalamus.
In 1978, Oladapo Ashiru and Charles Blake also reported FSH positive feedback mechanism on the pituitary. These and many others have been the bedrock for the achievement of the first live birth via in vitro fertilisation, Louis Brown, popularly called the first ‘test-tube’ baby in 1978, after a failed attempt that resulted in ectopic pregnancy. This groundbreaking success was achieved by Steptoe and Edwards in Oldham, England. Robert Edwards was subsequently awarded the Nobel Prize in Medicine/Physiology in 2010.
Other countries reported their successes, Australia by Carl Woods in 1980, USA by Howard and Georgeanna Jones in 1981 and Nigeria by Ashiru, Giwa-Osagie in 1984 and the delivery of a baby through IVF in 1989.
Since then several technologies have emerged to assist human conception. They include pre-implantation genetic diagnosis, gestational surrogacy, stem cell therapy and several others. I want to focus on surrogacy in this review.
What is surrogacy?
Surrogacy involves using one woman’s uterus to implant and carry the embryo and deliver the baby for another person or couple. It is done by utilising IVF ( in vitro fertilisation).
The woman that carries the pregnancy is called the “surrogate mother” or “gestational carrier”. So, surrogacy is an arrangement or agreement whereby a woman agrees to carry a pregnancy for another person or persons, who will become the new-born child’s parent(s) after birth.
In 1985, a woman carried the first successful gestational surrogate pregnancy. By 1986, Melissa Stern, otherwise known as “Baby M,” was born in the U.S. The surrogate and biological mother, Mary Beth Whitehead, refused to cede custody of Melissa to the couple with whom she made the surrogacy agreement.
The courts of New Jersey found that Whitehead was the child’s legal mother and declared contracts for surrogate motherhood illegal and invalid. However, the court found it in the best interest of the infant to award custody of Melissa to the child’s biological father, William Stern and his wife Elizabeth Stern, rather than to Whitehead, the surrogate mother. Since then the legal contract for gestational surrogacy has been influencing the transfer of the baby to the biological parents or the commissioning parents is now hitch free.
This technology is available in Nigeria and several babies have been born through this unique technique here, using the guideline regulation as stipulated by the guidelines of the Association for Fertility and Reproductive Health of Nigeria, whose guidelines are almost similar to that of the American Society for Reproductive Medicine and HFEA in the UK.
Intended parents may seek a surrogacy arrangement when either pregnancy is medically impossible or pregnancy risks present an unacceptable danger to the mother’s health.
Who should be treated with gestational surrogacy?
It is often done for a woman who has had her uterus removed but still has ovaries.
She can provide the egg to make a baby, but has no womb to carry it. Using her eggs and in vitro fertilisation technology, she can utilise a surrogate mother to carry the pregnancy (her own genetic child).
A surrogate is also sometimes used for cases where a young woman has a medical condition that could result in serious health risks to the mother or the baby. These include, but not limited to, patients with lupus, heart decease, uterine anomaly, severe ashermans and congenital absence of the uterus.
It is also done sometimes in couples with recurrent IVF implantation failure. However, success is much more likely using IVF with donor eggs and the infertile woman’s uterus compared to using the infertile woman’s eggs and a surrogate.
Egg quality problems are common, but uterine problems are far less common.
How is gestational surrogacy performed?
An appropriate surrogate is chosen and thoroughly screened for infectious diseases. Physical and psychological evaluations including medical history are done before they are finally considered as a surrogate.
Consents and surrogacy agreement/legal forms are signed by all parties. This is an important step in surrogacy cases. All potential issues need to be carefully clarified by their lawyers, put in writing and signed.
The patient is stimulated for IVF with medications to develop multiple eggs.
The surrogate is placed on medications that suppress her own menstrual cycle and stimulate the development of a receptive uterine lining.
When the patient’s follicles are mature, an egg retrieval procedure is performed to remove eggs from her ovaries.
The eggs are fertilised in the laboratory with her partner’s (Husband) sperm. The embryos develop in the laboratory for three to five days, after which an embryo transfer procedure is done. A maximum of two embryos are placed in the surrogate mother’s uterus where they will hopefully implant. There is a close obstetrics monitoring of the surrogate throughout the pregnancy.
The surrogate delivers the baby.
The baby goes home from the hospital with the “genetic parents”.
Success rates for surrogacy IVF procedures vary considerably.
The age of the woman providing the eggs is one critical factor. In general, pregnancy rates are higher than with eggs from infertile women.
Some programmes are reporting delivery rates of over 50 per cent per transfer for gestational surrogacy cases (using eggs from women under about age 37). The number of successes recorded at our centre has encouraged awareness and huge referrals from Nigeria and the Diaspora. Our experience over a 10-year period is that the need for surrogacy is on the increase.
The following are some of the examples of cases in our centre:
Mrs. A.B is a 35-year-old woman with secondary infertility who had five recurrent pregnancy losses as a result of having multiple fibroids in her uterus.
She consulted with a gynaecologist who scheduled her for myomectomy (fibroid surgery) to improve her chances of successful pregnancies. During the operation, she was found to have adenomyosis (endometrial tissue found in the uterine muscle) and bleeding could not be arrested. To save her life the uterus was removed, leaving the ovaries behind.
Mrs. A.B at 35 years had no uterus and no child. She then decided to go for assisted reproduction (In Vitro Fertilisation) as well as explore the use of a gestational carrier.
Mrs. A.B presented at MART where her treatment options were discussed and the IVF/Gestational carrier process began.
She was stimulated to get eggs from her ovary which was fertilised with her husband’s sperm.
The woman who was to be the gestational carrier was recruited, screened properly and legal agreements were reached. Previous fertility (at least a child or two) is required to pass as an eligible gestational carrier.
The ability of the gestational carrier to carry the pregnancy to term was checked with hystero- sonogram before she was enlisted as a carrier.
Another important thing to note is that there’s no physical contact between the genetic parents and the gestational carriers, the clinic serves as their mediator. However, if the surrogate and the patient do not mind seeing each other, this can be arranged after all due consents have been signed. It will be interesting to know that 99 per cent of the patients do not want to meet with their surrogate for personal reasons.
The uterus of the eligible carrier was now prepared to receive the embryos. Embryos belonging to the genetic parents were transferred and, two weeks later, she had a pregnancy test done, which was positive. Mrs. A.B was overjoyed to hear of it.