Surrogacy

What is surrogacy?

Surrogacy is a method of assisted reproduction.

The word surrogate originates from Latin word surrogatus (substitution), which means “to act in the place of”.

The term surrogacy is used when a woman who is unable to carry her child during the nine months of pregnancy and give birth to her baby, takes the help of another woman and hires her womb (uterus) to carry her child and deliver it.
Surrogacy is gaining popularity as this may be the only method for a couple to have their own genetic child. Also sometimes the procedure of adopting a baby may be very long and drawn out, because of which some couples use surrogacy as an option of treatment.

What is the history of surrogacy?

  • IVF / Gestational surrogacy – This is more common form of surrogacy. This is where a woman carries a pregnancy created by the egg and sperm of the genetic couple. The egg of the wife is fertilized in vitro by husband’s sperms by IVF/ICSI procedure. The embryo formed is the genetic child of the infertile couple. This is then transferred into the surrogate’s uterus. The surrogate carries the pregnancy for nine months and delivers the baby. On birth of the baby, the child is handed over to the legal parents (genetic parents).

The child is not genetically linked to the surrogate.

  • Traditional / Natural surrogate – This is where the surrogate is inseminated or IVF/ICSI procedure is performed with sperms from the male partner of an infertile couple and using eggs of the surogate. The child that results is genetically related to the surrogate and to the male partner but not to the infertile female partner (who is the legal mother).

Traditional or Natural surrogacy is banned by the Indian Council of Medical Research (ICMR). Gestational Surrogacy is legal in India as the surrogate is not genetically related to the unborn baby and is just a carrier for the legal infertile mother.

To whom surrogacy is advised?

IVF or Gestational Surrogacy is advised in the following conditions:

  1. Most commonly it is indicated in women whose ovaries are producing eggs but they do not have a uterus. Some of the common reasons are as follows:
    • Congenital absence of uterus (Mullerian ageneris)
    • Surgical removal of uterus (hysterectomy) due to cancer, severe hemorrhage in previous Cesarean section or Rupture uterus.
  2. A woman whose uterus is malformed (unicornuate uterus, T shaped uterus, bicornuate uterus with rudimentary horn) or damaged uterus (Tuberculosis of the endometrium leading to severe adhesions and loss of normal endometrium, severe Asherman’s Syndrome).
  3. Women at a high risk of rupture of uterus due to previous uterine surgeries for rupture uterus or fibroid uterus and hence is unable to carry pregnancy to term.
  4. Women who have repeated miscarriages or have repeated failed IVF cycles may be advised IVF surrogacy in view of unexplained factors which could be responsible for failed implantation and early pregnancy wastage.
  5. Women who suffer from medical problems like diabetes, heart or kidney diseases like chronic nephritis, whose long term prospect for health is good but pregnancy would be life threatening.
  6. Woman with Rh incompatibility (One partner may have a positive blood rhesus factor/ blood group and the other negative, leading to repeated miscarriages).

Surrogacy with donor eggs

  1. Women who have no functioning ovaries due to premature ovarian failure or streaky ovaries due to some congenital anamolies. Here egg donation also can be an option.
  2. Sometimes the ovaries may have been removed due to cancer or severe endometriosis etc
  3. A woman who is at risk of passing a genetic disease to her offspring.

There are a few combinations in which surrogacy is used as discussed below:

  1. Wife’s egg + Husband’s semen = Embryo transferred in the surrogate
  2. Wife’s egg + Donor’s semen = Embryo transferred in the surrogate
  3. Donor’s egg + Husband’s semen = Embryo transferred in the surrogate
  4. Donor’s egg + Donor’s semen = Donor Embryo transferred in the surrogate

Is Surrogacy right for you?

  • For some couples opting for surrogacy is a very straight forward decision but for others there are lots of things to be considered and thought about before taking the decision about surrogacy. There are lots of complex issues involved.
  • It is an emotional roller coaster ride for the couple, the families and friends.
  • It is a decision where the ‘right’ and the ‘wrong’ are very individual things.
  • An infertility specialist or a counselor can help the couple seeing things in perspective.
  • Other options to surrogacy like adoption or further infertility treatment can be considered.

What is the success rate of surrogacy?

  • The success rate of surrogacy is very good with a carry home baby rate of around 60%..

What are the screening criteria for surrogate? How is a surrogate chosen?

  • We at Ankoor fertility clinic, have a very meticulous and stringent criteria for choosing a surrogate.
  • The surrogates are between 21-35 years of age.
  • They are married with previous normal deliveries and healthy babies.
  • Detailed medical history, surgical history, personal history, family history is looked into.
  • History of blood transfusion and addiction is also taken. It is made sure that the surrogate has an uneventful obstetric history (like no repeated miscarriages, no antenatal, intranatal and postnatal complications in previous pregnancies).
  • The surrogate and her partner are screened for infectious diseases like sexually transmitted diseases, Hepatitis B, Hepatitis C, HIV, VDRL.
  • Thalassemia screening is also done.
  • Detailed pelvic sonography is done and other tests for uterine receptivity are done to ensure maximum chances of success.
  • A detailed financial and legal agreement is then made between the surrogate and the commissioning couple.

What is the procedure involved?

For IVF surrogacy matching of cycles of the genetic mother and the surrogate is done by adjusting menstruation dates by oral contraceptive pills.
When the cycle starts, the surrogate is put on estrogen tablets to prime the uterus.
Protocol used for genetic mother is day 2 protocol or day 21 protocol depending on the age of the genetic mother and other test results.
For the day 2 protocol called the ‘Antagonist protocol’, oral contraceptive pills are given in the previous month. On 2nd day of the periods gonadotropin injections are started. USG monitoring is done daily. When the size of the follicle reaches 14 mm the genetic mother is given antagonist injection to prevent surge of endogenous hormones.
For the day 21 protocol called the ‘Long protocol’, GnRH analogues are started on day 21 of the previous cycle. Once the genetic mother gets her periods, gonadotropin injections are started.
In both the cases the patients are monitored daily.

When the follicle reaches 18 mm size hCG trigger is given. The surrogate is started on progesterone tablets on the day of hCG injection to the genetic mother.

Oocyte retrieval is done 36 hours later which is generally day 12/13 of the cycle. On the same day the genetic father gives his semen sample. The eggs of the genetic mother are fertilized with sperms of the genetic father in the laboratory by IVF / ICSI procedure.

The embryo which has resulted from the above mentioned procedure is transferred into the womb of the surrogate under ultrasound guidance. The surrogate is then put on luteal support using progesterone tablets / injections and pregnancy is confirmed using a simple blood test done 15 days later.

How is the nine months journey like with surrogate?

  • The surrogate is treated as a high risk pregnancy and is cared for by two consultant gynecologists / obstetricians in our hospital. Appointments are scheduled with the consultants every three weeks for the first 6 months, then every 15 days for the next 2 months and then weekly / biweekly in the last month. Blood tests and ultra sound are done as and when required. Routine blood tests like hemoglobin, blood group, VDRL, HbsAg & HIV are done prior to the embryo transfer also.
  • Special care and tests are done to pick up any obstetric or medical complications like hypertension, diabetes etc. at the earliest. Two doses of Inj. Tetanus toxoid are given during pregnancy. The baby’s growth is monitored stringently. Ultrasound is done at 6 weeks to confirm pregnancy and the viability of the baby, then at 12 weeks to assess growth and certain parameters like nuchal thickness.
  • At 18 -20 weeks a detailed level III ultrasound is done to detect any abnormalities in the baby. At 16 weeks amniocentesis is performed if the genetic mother’s age is more than 35 years after counseling and in consultation with the genetic parents.
  • At 28 weeks and 34 weeks colour Doppler is performed to assess the growth of the baby and rule out intra uterine growth retardation.
  • Fetal well being tests like non stress tests are done as and when required.
  • Detailed information is given to the surrogates about diet during pregnancy. They are regularly provided with supplements from the hospital.
  • Thus it is taken care that adequate nutrition reaches the baby and baby’s growth is maintained.
  • We keep the couple posted on the progress of the baby and send them ultrasound pictures and blood reports as and when they are done.
  • We have an LDRP (Labour Delivery Recovery Puerperium) room for delivery which is equipped to handle any obstetric emergency. Our NICU setup is also completely equipped to handle any neonatal complications, with a neonatologist who is available round the clock.

What are the different ways children born through surrogacy may receive breast milk?

Just because baby is born through surrogacy does not mean he or she cannot receive breast milk and the many health benefits it provides.

Benefits of Breast feeding: Breast fed babies have been found to have higher IQs, more protected from leukemia and less likely to have problems with obesity. Breast milk protects babies from getting diarrhea, ear infections and respiratory problems such as asthma. Premature babies who receive breast milk are more protected from infections and high blood pressure later in life. Breast milk contains the protein CD14 which works to develop B cells which are immunity cells that are needed in the production of antibodies in an infant to build the babies immunity system. The babies may drink breast milk acquired through milk bank, breast milk donor may be located or the intended mother may induce lactation before birth of the baby. Induced lactation has been embraced by the nursing community as a welcome method to enhance the bonding relationship between a new mother and baby born through surrogacy.

How Inducing Lactation Works?

Lactation involves two hormones: Prolactin is considered the milk-making hormone while oxytocin is the hormone responsible for releasing breast milk. Both of these hormones are controlled by the pituitary gland and are therefore not ovarian hormones. This means that even in a woman who has undergone a hysterectomy lactation can be induced.
The hormones involved in inducing lactation both respond to nipple stimulation, and thus respond to manual stimulation such as:

  • breast massage
  • nipple manipulation
  • sucking by baby
  • sucking by a hospital grade electric breast pump

While manual stimulation alone should be sufficient in inducing lactation, hormonal therapy to induce lactation is also available. This typically involves administering high levels of estrogen hormones in order to simulate pregnancy. This is followed by an abrupt withdrawal of estrogen to mimic the hormonal environment in a woman’s body after birth.

Medication to enhance prolactin levels will then be administered, and sucking – whether by baby or a pump – will begin at this point.

Inducing lactation can take anywhere from 5 days to 4 months, so expecting mothers often begin to induce lactation during the third trimester of a surrogate pregnancy. Inducing lactation should only be attempted with the guidance of a pediatrician, lactation consultant and/or doctor.

What are the advantages of surrogacy?

  • This may be the only chance for some couples to have a child which is biologically completely their own (IVF surrogacy using husband’s sperm and wife’s egg ) or partly their own (using either Husband’s sperm with Donor eggs) OR (Wife’s egg and Donor’s sperm).
  • The genetic / legal mother can bond with the baby better than in situations like adoption.

What are the disadvantages of surrogacy?

  • It is highly controversial topic and can involve many legal complexities.
  • The surrogates may face medical / obstetric complications during pregnancy which puts extra financial burden on the commissioning couple.
  • Some surrogates have a problem parting with the baby.
  • In some cases the surrogacy technique may be ‘misused’ like career oriented women, figure conscious woman, models etc. may just ‘hire’ women on ‘rent’ to carry their biological child. Of course, this is strictly not ethical, should be vehemently banned and prohibited.

In short surrogacy is an existing and innovative, yet complex and a little adventurous way to achieve parenthood.