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

• I have no disclosures Gestational Surrogacy Heather Gibson Huddleston, MD Associate Professor of Clinical Medicine Reproductive Endocrinology and Infertility • Definitions History Outline • Ethical Issues • First Report of Surrogacy First Modern Report of • Current Practices and Guidelines Surrogacy was reported in 1985 • Outcomes Utian et al NEJM 1985 Genesis 16.1-15

Definitions Typical Process: Gestational Surrogate Intended Parent (IP) Commissioning couple Intended Parent Gestational Surrogacy Natural or Traditional Surrogacy Uterus only provided by surrogate. No Ovarian stimulation * Egg Retrieval * Fertilization * Embryo Culture * Uterus and eggs from one woman. genetic connection; requires IVF to Generally accomplished via IUI with IP generate embryo for transfer sperm. Oral Contraceptives Embryo Transfer Progesterone Estrogen Treatment Altruistic Surrogacy Commercial Surrogacy Gestational Carrier Payment for medical expenses only. Payment for time The debate Surrogacy on the International Front • Emphasis on autonomy: contractural surrogacy is • Contractural surrogacy permissable but only if the Altruistic allowed represents commodification woman retains the right end UK, Australia, of the body the pregnancy and revoke Canada, New All forms Prohibited: agreement at any time Zealand, Belgium Austria, Bulgaria, • Commercial surrogacy Greece Denmark, Finland, • conflicts with the interests Payment is ethical based on France, Germany, Italy, of the child time, inconvenience, risk and Norway, Spain Sweden discomfort - similar to • Degrades traditional family compensation for research Commercial Surrogacy Allowed: structure U.S: some states Georgia (country) Israel (but not gay men) Ukraine Russia

Audience Question Surrogacy State by State My patient has a cardiac condition that Legal. Pre-birth Legal but results may be inconsistent orders allowed precludes pregnancy. I think it is ethical for her Possible legal hurdles Not Legal to pay someone to serve as a surrogate . At least one court opinion that upholds some form of surrogacy: , 95% OH, PA, NH, MD, SC, MA A. True Neither statue nor published case: B. False AK, HI, MT, OR, ID, WY, SD, MN, CO, KS, MO, KY, VT, ME, RI, IK, LA, MS, AL, GA 5% e e u s l r a T F Audience Question Audience Question My patient has a cardiac condition that My patient has travelled from China to seek a precludes pregnancy. I think it is reasonable for surrogacy pregnancy here in the U.S. She has had one miscarriage had faces social pressure since it is her to pay someone in a third world country to assumed to be her fault. A surrogacy pregnancy serve as a surrogate. 56% would protect her from potential ostracism from friends/family. I believe this is a reasonable option. A. True 44% B. False 72% A. True B. False 28% e e u s l r a T F e e u s r a l T F

Trends in gestational surrogacy in the Audience Question United States: 1999-2013 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. 69% A. True B. False 31% . Number and percent of gestational carrier cycles, United States, 1999–2013. e e u s l r a T F Perkins et al Fertility and Sterility, 2016, Percent of gestational carrier ART cycles where Ethical stance of ASRM toward GC intended parent was a non-U.S. resident 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 Perkins Fertility and Sterility, 2016, Available online 14 April 2016

Current Practice: Indications Selection Criteria: ASRM • Ages 21-45 Per ASRM Guidelines: GC may be used when a true medical condition precludes IP from carrying • Prior pregnancy and delivery without pregnancy or would pose risk of death or harm to complications mother or fetus. • No more than 5 prior deliveries or more than � Absence of uterus � Medical condition that precludes pregnancy 3 Cesareans � Biological inability to carry child (male couple or • Stable family environment with adequate single) support to help her cope with added stress of � Recurrent pregnancy loss pregnancy � Medical disorder impacting uterus (Asherman’s) Evaluation and Screening Counseling and Contracts • Non-ideal outcomes: Risks of miscarriage, Intended Parents Gestational Carriers: • Psychosocial evaluation and pregnancy and delivery complications screening • Psychosocial evaluation and • • Agreement on number of embryos to transfer Screened in same manner as counseling by mental health gamete donor according to FDA guidelines professional is strongly and possible risk of multiples • Infectious disease panel with recommended. • Management decisions pertaining to • Medical evaluation 30 days of egg and 7 days of sperm collection. • Infectious disease screening • Quarantining embryos: option • Review of prior obstetric history termination of freezing embryos for 180 • Management decisions pertaining to delivery days with release after genetic parents have been retested with confirmed negative • Ultimate decision making must rest with GC results.

Outcomes from a Series of 333 cycles in Canada Outcomes compared to Non-Surrogacy cycles • Of 2 million ART between 1999-2013, 1.9% used a GC. • Increased from 1% in 1999 to 2.5% in 2013. Prior poor • GC cycles had higher rates of implantation Series of 333 Surrogacy pregnancy • Improved outcomes for gestational carrier compared to non outcome Cycles in Canada gestational carrier cycles using fresh non donor or fresh donor RPL Recurrent oocytes (adjusted for age, prior ART, prior SAB, day of Et, use of PGD, Implantation Number of embryos transferred). Uterine failure malformations/ Gestational Carrier versus non-Gestational Carrier Outcomes Ashermans Same Sex Adjusted Relative Risk Adjusted Relative Risk Maternal (non donor) (donor) Medical Uterine Implantation Rate 1.22 (1.17,1.26) 1.11 (1.07-1.15) Agenesis 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) Shir Dar et al. Hum. Reprod. 2015;30:345-352 Canadian Series: The outcomes of autologous-oocyte surrogacy cycles stratified by oocyte age 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) Shir Dar et al. Hum. Reprod. 2015;30:345-352

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