Update on Gestational Surrogacy – Using IVF and Having a Surrogate Mother Carry the Child for You
The history of Assisted Reproductive Technology (ART) dates back to 1963 when Yanagimachi and Chang reported in-vitro fertilization of hamster eggs. After that, Yanagimachi demonstrated in vitro capacitation of hamster spermatozoa in follicular fluid. Capacitation, a term used to describe hyperactivated motility of the sperm, is required for fertilization. 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 fertilization (IVF), Louis Brown, popularly called the first ‘test-tube’ baby, in 1978, after a failed attempt that resulted in ectopic pregnancy in 1976. Steptoe and Edwards achieved this groundbreaking success in Oldham, England, and 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 & Georgeanna Jones in 1981 and Nigeria by Ashiru, Giwa-Osagie in 1984 following a miscarriage attempt successfully delivered the first GIFT/IVF baby in 1986, and the delivery of a baby Olusola through IVF in 1989.
Since then, several technologies have emerged to assist human conception. They include preimplantation genetic diagnosis, gestational surrogacy, stem cell therapy, and 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 to another person or couple. It is done utilizing IVF – in vitro fertilization.
The woman that carries the pregnancy is called the surrogate, “surrogate mother,” or “gestational carrier.” Surrogacy is an arrangement or agreement whereby a woman agrees to carry a pregnancy for another person or persons who will become the newborn 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 infant’s best interest 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 bound to all, and the transfer of the baby to the biological parents or the commissioning Parents is now very hitch-free.
This technology is available in Nigeria. Several babies have been born through this unique technique in Nigeria using the guideline regulation stipulated by the Association for Fertility and Reproductive Health of Nigeria (AFRH) guidelines. Their guidelines are almost similar to that of the American Society for Reproductive Medicine & HFEA in the U.K.
Intended parents may seek a surrogacy arrangement when either pregnancy is medically impossible. 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 fertilization technology, IVF, she can utilize a surrogate mother to carry the pregnancy (her genetic child).
A surrogate is also sometimes used for cases where a young woman has a medical condition that could pose serious health risks to the mother or the baby. These include but are not limited to patients with lupus, heart disease, 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 than using the barren woman’s eggs and a surrogate.
Egg quality problems are common, but uterine issues 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 being considered a surrogate.
All parties sign consents and surrogacy agreement/legal forms. It is an essential 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 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 fertilized in the laboratory with her partner’s (Husband) sperm. The embryos develop in the laboratory for 3-5 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 programs report delivery rates of over 50% per transfer for gestational surrogacy cases (using eggs from women under about age 37). The number of successes recorded at our center has encouraged awareness and huge referrals from Nigeria and the diaspora. Our experience over fifteen years is that the need for surrogacy increases.
The following are some of the examples of cases in our center.
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 (Womb).
She consulted with a gynecologist who scheduled her for myomectomy (fibroid surgery) to improve her successful pregnancies. During the operation, she was found to have adenomyosis (endometrial tissue found in the uterine muscle), and bleeding could not be stopped; hence, 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 Fertilization) and explore the use of a gestational carrier.
Mrs. A.B presented at MART, and the treatment options were discussed, and the IVF/Gestational carrier process began.
We stimulated her to get eggs from her ovary, fertilized them with her husband’s sperm.
The woman to be the gestational carrier was recruited, appropriately screened, and reached legal agreements. Previous fertility (at least a child or two) must pass as an eligible Gestational carrier. The gestational carrier undergoes counseling and psychological evaluation.
We checked the ability of the gestational carrier to carry the pregnancy to term with a hystero- sonogram before she was enlisted as a carrier.
Another essential thing to note is that there’s no physical contact between the genetic parents and the gestational carriers. The clinic serves as its mediator. However, if the surrogate and the patient do not mind seeing each other, it can be arranged after all consent is signed. It will be interesting to know that 99% of the patients do not want to meet 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 delighted to hear of it.
Then comes the serial intensive monitoring of the gestational carrier and the fetus during the duration of the pregnancy by our highly skilled obstetricians.
At term, a date is chosen for the delivery of the baby. The genetic mother (Mrs. A.B) was around to take custody of the baby. Mrs. A.B had a baby of her own without a uterus, and she subsequently had another twin using the services of a gestational carrier.
The beautiful thing about this story is that she sought the proper treatment early, while her fertility was still optimum. Worldwide 750 babies are born through surrogacy every year. To date, there are over 300 babies that have been carried through surrogacy in Nigeria. Recently, in Nigeria, the High court ruled in favor of surrogacy. Furthermore, the Guidelines for the procedure have been approved in several countries worldwide. They
are in the pipeline in Nigeria and should be available by January 2022.
(This presentation, in part, was presented at the 6th conference of the Francophone Fertility Society GIERAF in Grand Bassam, Cote De Ivoire, February 7-10, 2017, and the FIGO/IFFS/WHO virtual meeting on October 21-28, 2021, by OAA).