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Gestational surrogacy: results of 10 years of experience in the Netherlands
Abstract
Research question:
What are the reproductive and obstetric outcomes of the gestational surrogacy treatment in the Netherlands?
Design:
This retrospective cohort study reports all data of gestational surrogacy treatment in the VU University Medical Centre over a period of 10 years. Data was collected from 60 intended parents and 63 gestational carriers, including reproductive and obstetric outcomes.
Results:
All intended mothers had a medical indication for gestational surrogacy and used autologous oocytes, and semen of the intended father. Ninety-three IVF cycles were initiated in 60 intended mothers, with subsequent 184 single embryo transfers in 63 gestational carriers. This resulted in 35 ongoing singleton pregnancies. At least one live birth was achieved for 55.0% of intended couples. Pregnancy was complicated in 20.6% by a hypertensive disorder. Labour was induced in 52.9%, and the Caesarean section rate was 8.8%. None of the pregnancies was complicated by preterm birth. Postpartum haemorrhage (>500 ml) occurred in 23.5%.
Conclusions:
This study shows the effective results of the non-commercial gestational surrogacy programme in the Netherlands, in a multidisciplinary team setting. An increased risk for adverse obstetric outcomes in surrogate mothers is noted for hypertensive disorders and post-partum haemorrhage compared with the incidence in non-surrogacy pregnancies.
... GS is typically reserved as an advanced option for select cases with specific indications, such as in this case, and has become popular recently. Data from the USA indicate that GS was representing 1% of all ART procedures in 1999 and 2.5% in 2013 [10,11], with this upward trend being likely to continue. While data is still lacking, due to the small number of available cases, a study by Attawet et al. [12] that included a total of 81 gestational surrogates with 170 frozen embryo transfers, demonstrated a cumulative live birth rate of 50.6%. ...
... The majority of gestational surrogates, similar to our case, underwent frozen embryo transfer and delivered vaginally, however, no data is provided on the duration of embryo cryopreservation prior to embryo transfer. Peters et al. [11] included 63 gestational surrogates in their study and demonstrated a live birth rate of 55.5%, however, these results are from synchronized cycles with fresh embryo transfers in addition to frozen ones. Overall, GS was regarded as an effective program for women with anatomical or other pathology that constituted a contraindication for pregnancy [11,12]. ...
... Peters et al. [11] included 63 gestational surrogates in their study and demonstrated a live birth rate of 55.5%, however, these results are from synchronized cycles with fresh embryo transfers in addition to frozen ones. Overall, GS was regarded as an effective program for women with anatomical or other pathology that constituted a contraindication for pregnancy [11,12]. ...
Assisted reproduction technology (ART) has made considerable progress in recent years; in particular with regard to cryopreservation, long-term storage, successful thawing, and embryo transfer of cryopreserved embryos. Regarding gestational surrogacy, progress has been made in the areas of awareness, social acceptance, regulation, legislation, availability, streamlining, and optimization of cross-border care. The above is being highlighted in the current presentation of a particularly challenging and novel case. A 43-year-old woman visited our clinic in Greece, seeking international gestational surrogacy due to recurrent breast cancer which rendered her medically unfit for pregnancy. Ten years before her initial visit to our clinic the patient had undergone fertility preservation due to breast cancer, her oocytes had been fertilized with her husband's sperm, and the embryos were cryopreserved and stored in a fertility clinic based in the United Kingdom. The stored embryos were transported to Greece, thawed, and successfully implanted to the selected gestational surrogate. Following an uneventful pregnancy, the surrogate delivered a healthy girl. This successful outcome exemplified innovation, motivation, and hope and may represent a paradigm of team scientific excellence associated with positive patient outcomes. Furthermore, this case constitutes the successful culmination of major advances made in various different sectors of cross-border reproductive care; laboratory, clinical, legal, ethical, and logistical.
... One additional study from the Netherlands looked at the outcomes of IVF surrogacies. 36 Peters et al 36 performed a retrospective review of 10 years of surrogacy experience and found that the rate of hypertensive disorders in IVF surrogates was 20.6%. This rate is double the expected 10% of pregnancies affected by hypertension. ...
... One additional study from the Netherlands looked at the outcomes of IVF surrogacies. 36 Peters et al 36 performed a retrospective review of 10 years of surrogacy experience and found that the rate of hypertensive disorders in IVF surrogates was 20.6%. This rate is double the expected 10% of pregnancies affected by hypertension. ...
... These risks included a higher rate of twins, preterm birth, neonates with a lower birth weight, and maternal complications such as gestational diabetes, hypertension, and postpartum hemorrhage. 35,36 Whereas maternal obesity is known to be associated with increased pregnancy complications, increasing BMI specifically in surrogate patients has not been shown to convey an additional increased risk of maternal or neonatal complications. Yet, a normal BMI may serve to decrease the likelihood for maternal comorbidities, and assessing a metabolic profile may be helpful in identifying optimal surrogate candidates. ...
Importance:
Surrogacy allows for parenthood when it is otherwise impossible or exceedingly difficult; however, the risks of surrogate pregnancy for the gestational surrogate and the fetus are not well defined.
Objective:
The aim of this study was to review the literature to examine the prevalence and requirements of surrogate pregnancy and maternal and perinatal outcomes.
Evidence acquisition:
A CINAHL and 2 PubMed searches were undertaken using the terms "surrogate mothers" OR "(surrogate or surrogacy)" AND "(mothers OR pregnancy OR pregnant)." The second search used these terms and pregnancy outcomes. The search was limited to the English language, but the years searched were unlimited.
Results:
The search identified 153 articles, 36 of which are the basis for this review. The number of surrogate pregnancies is increasing in the United States. Fetal risks associated with surrogacy include low birth weight, increased risk of multiple gestation, and preterm birth. Maternal complications associated with surrogate pregnancy include hypertensive disorders of pregnancy, postpartum hemorrhage, and gestational diabetes.
Conclusions and relevance:
Surrogacy is a route to parenting that is not without risk to the surrogate or the fetus, and surrogate pregnancy is increasing in frequency in the United States.
... Furthermore, we emphasize the importance of weighing in the possible delay of FP in patients with high-risk disease and feel that an individualized risk assessment regarding oncological safety should be carefully evaluated for each patient. Gestational surrogacy is considered to be a good reproductive option for patients without a (functional) uterus with an ongoing pregnancy rate of 66.7% [29]. We report a live-birth rate of 21.4% among the women who started gestational surrogate treatments. ...
... We report a live-birth rate of 21.4% among the women who started gestational surrogate treatments. Barriers explaining this discrepancy include the challenge of finding a suitable gestational carrier who is approved by the regulations in centers performing surrogate treatments [29]. The process of finding a gestational carrier is additionally complicated by the Dutch law, that prohibits commercial surrogacy and the public search for a surrogate. ...
Objective:
To evaluate the desire for parenthood and reproductive outcomes of young cervical cancer survivors who underwent fertility-sparing surgery or fertility preservation procedures for invasive cervical cancer.
Methods:
All women <45 years who underwent fertility-sparing treatment for invasive cervical cancer in a tertiary referral center in the Netherlands between January 2009 and January 2020 were identified. Fertility-sparing treatment options included Vaginal Radical Trachelectomy (VRT) for patients with early-stage disease and fertility preservation techniques (FP) when requiring Radical Hysterectomy (RH) or chemoradiotherapy. Data on reproductive intentions - and outcomes were retrieved from medical files and questionnaires.
Results:
75 patients were identified of whom 34 underwent VRT, 9 RH and 32 had (chemo)radiotherapy. 26 patients started FP of whom 23 (88.5%) successfully preserved fertility through cryopreservation of embryos, oocytes and ovarian tissue. After a median follow-up of 49 months, 5 patients developed recurrent disease and died. Reproductive outcomes were retrieved in 58 patients. 89.6% maintained their desire for parenthood after cancer treatment. Following VRT, we report a pregnancy rate of 61.9% among the patients attempting conception (n = 24). 15 patients conceived 21 pregnancies which resulted in 15 live-births, yielding a live-birth rate of 75.0%. Following RH or (chemo)radiotherapy, 3 surrogate pregnancies were established (21.4%) using frozen-thawed material with good neonatal outcomes.
Conclusion:
Many cervical cancer survivors maintain the desire to become parents eventually. In early-stage disease, VRT shows good reproductive outcomes without compromising oncological safety. For those requiring gonadotoxic treatment fertility preservation and gestational surrogacy provides a promising alternative for achieving a biological offspring.
... This is a means of mitigating the relationship and emotional stresses that could emerge throughout the evolving stages of the surrogacy arrangement. Worldwide, however, counseling practices pertaining to surrogacy are diverse (12)(13)(14)(15); they are shaped by contextual factors including the presence or absence of legislation, statutory guidelines, and guidance by expert mental health professional organizations associated with reproductive medicine (see, for example, the International Infertility Counseling Organisation at http://www.iico-infertilitycouns eling.org/1216-2/). Across Australia, pretreatment psychological assessment by an independent psychologist and additional implications counseling are legally mandated for all parties to a surrogacy arrangement, inclusive of intended parents, surrogates, and their partners (16). ...
... It reveals that intended parents contemplating an altruistic surrogacy arrangement predominantly seek support for their family formation journey from close family and friendship networks rather than alternative networks. This result to some extent was anticipated: people do not tend to make reproductive decisions in isolation from the influences of their cultural and living contexts (15,37). Also, within Australia formal surrogacy intermediary agencies do not exist, so intended parents are likely in the first instance to rely on those who are close to them. ...
Objective
To characterize the sociodemographic and psychological profiles of participant groups involved in altruistic surrogacy in Australia.
Design
Cross-sectional study.
Setting
Single psychological practice in Sydney, Australia.
Patient(s)
Six hundred and two individuals involved in 160 altruistic surrogacy arrangements: 143 intended mothers, 175 intended fathers (including 17 same-sex intended father couples), 160 surrogates, and 124 surrogate partners.
Intervention(s)
None.
Main Outcome Measure(s)
Responses to a presurrogacy sociodemographic assessment counseling protocol and the Personality Assessment Inventory (PAI).
Result(s)
The surrogates were primarily sisters, sisters-in-law, mothers (48.6%), or other extended family or friends (46.3%) of the intended parents. Most participants resided in residential postcode areas within the highest socioeconomic status quintile; however, intended mothers were more likely than surrogates to live in the most advantaged residential areas, to be younger and be more educated, and to be employed in professional occupations. Most participant psychological profiles were normal. A statistically significantly elevated PAI Somatic Complaints–Health Concerns subscale for intended mothers was observed compared with other participant groups. The higher PAI Warmth scale scores of intended mothers and surrogates were statistically significantly different from their respective partners, although not different from each other.
Conclusion(s)
Sociodemographic and some psychological differences between participant groups were observed that warrant exploration in pretreatment surrogacy counseling. Importantly, the higher scores on the PAI Warmth scale exhibited by intended mothers and surrogates in the context of close family and friendship relationships are likely to serve as protective mechanisms for the altruistic surrogacy outcome.
... The only hospital in the Netherlands to perform this treatment is the Amsterdam UMC, location VU University Medical Center (VUmc). In the past 10 years, 34 live births were achieved by gestational surrogacy (Peters et al., 2018 To investigate the possibility of performing uterus transplantations in the Amsterdam UMC, we performed a feasibility study to search for ethical, medical and financial support for this innovative, yet ethically and morally challenging, technique. Additionally, we performed a questionnaire study in women with the MRKH syndrome to study the support in patients. ...
... The psychological implications for gestational carriers and parents have not been studied in detail. In children born after surrogacy, good psychological adjustment is reported although the psychological follow-up is currently very limited (Soderstrom-Anttila et al., 2016;Peters et al., 2018). ...
Study question:
Is it feasible to perform uterus transplantations (UTx) in a tertiary centre in the Netherlands?
Summary answer:
Considering all ethical principles, surgical risks and financial aspects, we have concluded that at this time, it is not feasible to establish the UTx procedure at our hospital.
What is known already:
UTx is a promising treatment for absolute uterine factor infertility. It is currently being investigated within several clinical trials worldwide and has resulted in the live birth of 19 children so far. Most UTx procedures are performed in women with the Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, a congenital disorder characterized by absence of the uterus. In the Netherlands, the only possible option for these women for having children is adoption or surrogacy.
Study design size duration:
We performed a feasibility study to search for ethical, medical and financial support for performing UTx at the Amsterdam UMC, location VUmc.
Participants/materials setting methods:
For this feasibility study, we created a special interest group, including gynaecologists, transplant surgeons, researchers and a financial advisor. Also, in collaboration with the patients' association for women with MRKH, a questionnaire study was performed to research the decision-making in possible recipients. In this paper, we present an overview of current practices and literature on UTx and discuss the results of our feasibility study.
Main results and the role of chance:
A high level of interest from the possible recipients became apparent from our questionnaire amongst women with MRKH. The majority (64.8%) positively considered UTx with a live donor, with 69.6% having a potential donor available. However, this 'non-life-saving transplantation' requires careful balancing of risks and benefits. The UTx procedure includes two complex surgeries and unknown consequences for the unborn child. The costs for one UTx are calculated to be around €100 000 and will not be compensated by medical insurance. The Clinical Ethics Committee places great emphasis on the principle of non-maleficence and the 'fair distribution of health services'.
Limitations reasons for caution:
In the Netherlands, alternatives for having children are available and future collaboration with experienced foreign clinics that offer the procedure is a possibility not yet investigated.
Wider implications of the findings:
The final assessment of this feasibility study is that that there are not enough grounds to support this procedure at our hospital at this point in time. We will closely follow the developments and will re-evaluate the feasibility in the future.
Study funding/competing interests:
This feasibility study was funded by the VU Medical Center (Innovation grant 2017). No conflicts of interest have been reported relevant to the subject of all authors.
Trial registration number:
n.a.
... [5] In a retrospective study in the Netherlands, 20.6% of surrogate pregnancies were complicated by a hypertensive disorder and postpartum hemorrhage (>500 ml) which occurred in 23.5% of the pregnancies, which was higher than expected. [24] In our study, some surrogate mothers mentioned experiencing twin or triplet pregnancies, which caused them many physical problems during the pregnancy. IVF surrogacy with multiple gestations is associated with an increased risk of preeclampsia, postpartum hemorrhage, hysterectomy, gestational diabetes, higher risk of hyperemesis, and anemia. ...
... [26] In the Netherlands, surrogate mothers are under the supervision of a specially trained team of psychologists to evaluate their motivation and psychological well-being. [24] Undoubtedly, the psychological and emotional states of the surrogate mothers play an important role in the well-being of the fetus. It is a double-edged sword; the surrogate mother might not accept the embryo emotionally and would not care about it or, on the other hand, she may recognize the embryo as her own and there would be a possible risk for attachment to the fetus. ...
Background: Surrogates are women who bear a genetically unrelated child for another individual or couple. Experiences of surrogate mothers need further investigation. Objective: The objective of the study was to answer the questions of what were the experiences of surrogate mothers and what problems they confronted during the process of surrogacy. Methods: The present study was a qualitative content analysis. Purposive sampling was used in the study. Pregnant women with various ages and educational levels were invited for semi-structured interviews. Graneheim and Lundman's method was used for analyzing the data. Results: In this study, 15 participants were interviewed. The codes extracted from the interviews were categorized into five main themes and 13 subthemes. The main themes were: (1) desperation; (2) pain and suffering with the subthemes of physical pain, emotional suffering, suffering caused by others, and fears; (3) emotional involvement and self-alienation; (4) looking for the positive aspects of the surrogacy with subthemes of positive interpretation of the experience, and the sense of pride; (5) and supportive systems including the commissioning parents, the surrogate's family, the health system, and the community as subthemes. Financial motivations were the reason for surrogacy which made women endure many physical, psychological, and social problems. The women expressed some positive feelings about surrogacy and also mentioned several support sources. Conclusion: Surrogate mothers reported numerous physical, emotional, and social problems that require better counseling services. A supportive system, especially the health system, should provide better and more humanistic services for surrogate mothers.
... Obstetric complications are not higher (if not lower) in surrogate singleton gestations, since surrogate mothers are usually young and healthy. [99][100][101][102][103] Nevertheless, no gestation is exempt from risk. 104,105 Also, double embryo transfers are quite common in surrogate processes, because it is usually cheaper than having two separate pregnancies, resulting in more multiple pregnancies. ...
Objective Surrogacy is the process in which a woman carries and delivers a baby to other person or couple, known as intended parents. When carriers are paid for surrogacy, this is known as commercial surrogacy. The objective of the present work is to review the legal, ethical, social, and cultural aspects of commercial surrogacy, as well as the current panorama worldwide.
Methods This is a review of the literature published in the 21 st century on commercial surrogacy.
Results A total of 248 articles were included as the core of the present review. The demand for surrogate treatments by women without uterus or with important uterine disorders, single men and same-sex male couples is constantly increasing worldwide. This reproductive treatment has important ethical dilemmas. In addition, legislation defers widely worldwide and is in constant change. Therefore, patients look more and more for treatments abroad, which can lead to important legal problems between countries with different laws. Commercial surrogacy is practiced in several countries, in most of which there is no specific legislation. Some countries have taken restrictive measures against this technique because of reports of exploitation of carriers.
Conclusion Commercial surrogacy is a common practice, despite important ethical and legal dilemmas. As a consequence of diverse national legislations, patients frequently resort to international commercial surrogacy programs. As of today, there is no standard international legal context, and this practice remains largely unregulated.
... However, like Turkey, Dutch laws assign the woman who gives birth to a baby the designation of mother. For that reason, intended parents have to follow a formal adoption procedure after birth (Peters et al., 2018) In the case of the Netherlands, we see that although surrogacy treatment is lawful, the paternity relation is not enacted. ...
Statistics show that one in every six couples are currently infertile. Due to new artificial reproductive techniques, infertile couples have a whole new range of possibilities to become parents. Surrogacy tourism is a type of medical tourism in which couples with infertility travel to other countries to rent wombs of surrogate woman. At present, surrogacy tourism is a multi-billion-dollar industry. One of the main reasons for surrogacy tourism is that surrogacy is not legal in some countries. It appears that legislation, ethical understanding, and concerns that human rights will be violated prevent people from benefiting from such developments while medicine continues to develop and advance. Economics also drive surrogacy tourism. Religion is also a significant factor in choosing the destination for the treatment. Infertile couples are more likely to prefer countries where their religious beliefs are respected and considered during the treatment. This paper seeks to highlight the effects of the legal provisions and precedents about surrogate motherhood on surrogacy tourism.
... Some studies suggest an increased risk for hypertensive disorders of pregnancy, gestational diabetes mellitus, abnormal placentation, and postpartum hemorrhage. 17,18 This increased risk, however, may be related to use of ART or selection of an inappropriate control group in published studies. 1 In order to reach their desired family size more expeditiously, many couples hiring a surrogate opt for implantation of two embryos despite a recommendation from the American Society for Reproductive Medicine and a 2011 consensus statement from 17 organizations in the UK advocating for single embryo transfer. 19,20 A published survey indicates that a majority of couples hiring a surrogate choose two embryo transfer to increase the odds of a successful pregnancy or reach their family size goal sooner. ...
Introduction
Individuals seeking a gestational surrogate often turn to U.S. military dependents due to favorable insurance coverage. Surrogate pregnancies, including multiple gestations, may be at increased risk for adverse outcomes. The objectives of this study were to determine the incidence of surrogacy in a twin population conceived by assisted reproductive technology (ART), assess the impact on the military healthcare system, and determine if there is an increased rate of complications in twin surrogacy pregnancies.
Materials and Methods
We conducted a 10-year retrospective cohort study of ART-conceived twin gestations at two military hospitals. Charts were reviewed for demographic data, surrogacy status, and obstetric complications. Number of prenatal visits and formal sonograms were tabulated for surrogate pregnancies. Complication rates were compared between groups using Fisher’s exact test.
Results
Over the 10-year period, 36 of the 249 pregnancies were identified as gestational surrogates, equating to a rate of 14.4%. Surrogate mothers were younger than non-surrogates (29.58 years vs. 33.11 years, P < .001). Care of surrogate pregnancies required a total of 306 prenatal visits and 98 formal ultrasounds. The incidence of gestational diabetes was higher among surrogates compared to other ART-conceived twin pregnancies at 27.8% vs. 12.2% (P < .05), while other complications did not significantly differ.
Conclusions
Approximately one in seven ART-conceived twin gestations were surrogacy pregnancies, requiring significant clinical resources. The incidence of gestational diabetes was higher among surrogate gestations.
... Swanson et al. reported a 26% CS rate in 361 GC pregnancies. Another study of 34 GC pregnancies in the Netherlands reports a 9% CS rate, although the different study population may limit generalizability to our population [15]. In terms of candidates with a history of CS, our findings support the inclusion of these GCs, given the high rates of VBAC, particularly in younger GCs with normal BMI, a history of CS should not necessarily preclude candidacy for becoming a GC or preclude discussion of VBAC in these pregnancies. ...
Purpose
This study sought to report on the route and gestational age at delivery of gestational carrier (GC) pregnancies with respect to the GCs’ prior obstetric history.
Methods
A retrospective analysis of all GC pregnancies from one of the largest surrogacy agencies in California between 2008 and 2018 was performed. Available demographic data and obstetric history, including a history of prior cesarean section (CS) and preterm birth (PTB), were collected for each GC and correlated to outcomes of the index GC pregnancy. Primary outcomes for the index GC pregnancies included delivery route and gestational age at delivery.
Results
Eight-hundred-thirty-six GCs were included in our analysis. 319 (38.2%) delivered via CS, and 517 (61.8%) delivered vaginally. 60 (18.8%) of the CS deliveries were due to multifetal gestation. Primary CS rate in singleton GC pregnancies was 38.5%. In women without a history of CS, neither age, BMI, interpregnancy interval, prior parity, nor year of delivery impacted the primary singleton CS rate (all, P > 0.05). Of GCs with a history of a prior CS (n = 350, 41.9%), 218 (62.3%) had a vaginal delivery after CS (VBAC) and 132 (37.7%) had a repeat CS. Women who had successful VBACs were significantly younger than those who had repeat CS (mean 33.7 vs. 35.2 years, P = .003). BMI was lower in patients who had a VBAC compared to those that had a repeat CS (mean BMI 24.6 vs. 25.5, P = 0.074), although this did not reach statistical significance. In GCs with a history of CS, interpregnancy interval, year of delivery, prior parity, and multiple gestation in the index GC pregnancy did not impact mode of delivery. VBAC rates did not change over the study period (P = 0.757). Overall PTB rate was 15.1%. Most PTB in GC pregnancies were in those with a history of PTB, and PTB was more likely in singletons rather than multifetal gestations (76.7% in singletons vs. 30% in multiples) in patients with history of PTB (P < 0.001). Those with no history of PTB and who carried multiples had a low rate of PTB; in fact, in this group, only 1 out of 35 patients had a PTB with multiples.
Conclusions
Both primary CS and PTB rates in singleton GC pregnancies are higher than national averages. CS rates are independent of age, BMI, and interpregnancy interval. In GCs with a history of a CS, VBAC rates well exceed national averages and are higher in younger GCs with a lower BMI. PTB rates are impacted primarily by the GCs obstetric history. In those GCs without a history of PTB, rates of PTB are low, even in those with a multifetal gestation.
... No targeted legislation. Articles 151b and 151c of the Criminal Code make promoting commercial surrogacy illegal [28][29][30]. ...
Background and objectives: To explore the ethical and legal complexities arising from the controversial issue of surrogacy, particularly in terms of how they affect fundamental rights of children and parents. Surrogacy is a form of medically-assisted procreation (MAP) in which a woman “lends” her uterus to carry out a pregnancy on behalf of a third party. There are pathological conditions, such as uterine agenesis or hysterectomy outcomes, that may prevent prospective mothers from becoming pregnant or carry a pregnancy to term; such patients may consider finding a surrogate mother. Many issues relating to surrogacy remain unresolved, with significant disagreements and controversy within the scientific community and public opinion. There are several factors called into play and multiple parties and stakeholders whose objectives and interests need to somehow be reconciled. First and foremost, the authors contend, it is essential to prioritize and uphold the rights of children born through surrogacy and heterologous MAP. Materials and methods: To draw a parallel between Italy and the rest of the world, the legislation in force in twelve European countries was analyzed, eleven of which are part of the European Union (France, Germany, Italy, Spain, Greece, Netherlands, Belgium, Denmark, Lithuania, Czech Republic and Portugal) and three non-members of the same (United Kingdom, Ukraine and Russia), as well as that of twelve non-European countries considered exemplary (United States, Canada, Australia, India, China, Thailand, Israel, Nigeria and South Africa); in particular, legislative sources and legal databases were drawn upon, in order to draw a comparison with the Italian legislation currently in force and map out the evolution of the Italian case law on the basis of the judgments issued by Italian courts, including the Constitutional and Supreme Courts and the European Court of Human Rights (ECHR); search engines such as PubMed and Google Scholar were also used, by entering the keywords “surrogacy” and “surrogate motherhood”, to find scientific articles concerning assisted reproduction techniques with a close focus on surrogacy. Results: SM is a prohibited and sanctioned practice in Italy; on the other hand, it is allowed in other countries of the world, which leads Italian couples, or couples from other countries where it is banned, to often contact foreign centers in order to undertake a MAP pathway which includes surrogacy; in addition, challenges may arise from the legal status of children born through surrogacy abroad: to date, in most countries, there is no specific legislation aimed at regulating their legal registration and parental status. Conclusion: With reference to the Italian context, despite the scientific and legal evolution on the subject, a legislative intervention aimed at filling the regulatory gaps in terms of heterologous MAP and surrogacy has not yet come to fruition. Considering the possibility of “fertility tourism”, i.e., traveling to countries where the practice is legal, as indeed already happens in a relatively significant number of cases, the current legislation, although integrated by the legal interpretation, does not appear to be effective in avoiding the phenomenon of procreative tourism. Moreover, to overcome some contradictions currently present between law 40 and law 194, it would be appropriate to outline an organic and exhaustive framework of rules, which should take into account the multiplicity of interests at stake, in keeping with a fair and sustainable balance when regulating such practices.
... How ever some studies have found out that a few of these women feel a sense of gratitude for being alive despite the near death experience [13][14][15]. ...
Background
Emergency peripartum hysterectomy (EPH) is a known remedy for saving women’s lives when faced with the challenging situation of severe post partum hemorrhage not responsive to conservative management. However, EPH by its nature is also a traumatic birth event that causes serious physical, emotional and psychological harm. Unfortunately at St. Francis Hospital Nsambya nothing much is known about these experiences since no study has been undertaken and these women are not routinely followed up. The purpose of this study was to explore these emotional experiences.
Methods
This was a qualitative phenomenological study carried out between August and December 2018. All those women who had undergone EPH between January 2015 and August 2018 were eligible to participate in the study. Purposive sampling was used. 18 women were interviewed before saturation was reached. All interviews were audio-recorded and then transcribed verbatim. Thematic analysis was used to analyze the data.
Results
Three major themes were identified as the main experiences of these women in this study and they were; Loss of Womanhood, Joy for being alive and Loss of marital safety.
Conclusion
Women experience serious emotional consequences following EPH. We recommend routine follow-up to help appreciate these experiences and advise them on appropriate mitigating measures.
... Sin embargo, al comparar los embarazos obtenidos por gestación subrogada con sus propias concepciones espontáneas previas, un estudio demostró un mayor riesgo de resultados adversos, incluyendo una mayor tasa de gemelos, PP, BPN, diabetes gestacional, SHE y hemorragia posparto 55 . Adicionalmente, un reciente estudio holandés reportó que la incidencia de SHE en las gestaciones subrogadas fue del 20,6%, el doble de lo esperado 56 . ...
The use of assisted reproduction techniques (ART) has increased worldwide, including procedures such as gamete donation, subrogation and preimplantation genetic diagnosis. Growing evidence confirms that pregnancies following these treatments have an increased risk of adverse perinatal outcomes. It is not clear whether the cause of these findings is due to the underlying infertility or the treatments themselves. This review aims to summarize the current evidence regarding the effects of both the different ART procedures and some special types of ART on maternal and perinatal outcomes.
... Sin embargo, al comparar los embarazos obtenidos por gestación subrogada con sus propias concepciones espontáneas previas, un estudio demostró un mayor riesgo de resultados adversos, incluyendo una mayor tasa de gemelos, PP, BPN, diabetes gestacional, SHE y hemorragia posparto 55 . Adicionalmente, un reciente estudio holandés reportó que la incidencia de SHE en las gestaciones subrogadas fue del 20,6%, el doble de lo esperado 56 . ...
The use of assisted reproduction techniques (ART) has increased worldwide, including procedures such as gamete donation, subrogation and preimplantation genetic diagnosis. Growing evidence confirms that pregnancies following these treatments have an increased risk of adverse perinatal outcomes. It is not clear whether the cause of these findings is due to the underlying infertility or the treatments themselves. This review aims to summarize the current evidence regarding the effects of both the different ART procedures and some special types of ART on maternal and perinatal outcomes.
La utilización de técnicas de reproducción asistida (TRA) ha aumentado en todo el mundo, incluyendo procedimientos como la donación de gametos, la subrogación y el diagnóstico genético preimplantacional.
Creciente evidencia confirma que los embarazos de pacientes sometidas a estos tratamientos tienen un mayor riesgo de complicaciones perinatales. No queda claro si la causa de estos hallazgos se debe a la infertilidad subyacente o los tratamientos en sí. Esta revisión tiene como objetivo resumir la evidencia actual acerca de los efectos sobre los resultados maternos y perinatales tanto de los diferentes procedimientos propios de la fecundación in vitro como de algunos tipos de TRA especiales.
... A study from the Netherlands of women acting as uncompensated surrogates also found increased rates of hypertensive disorders and postpartum hemorrhage, although the generalizability to a US cohort of largely compensated women who are GCs is, of course, limited. 28 Birth defect rates in GC pregnancies have been reported from 0% to 6.5%, and appear to be equivalent to the population risks for patients undergoing IVF. 26 Psychosocial outcomes Most data addressing psychosocial outcomes for women who are GCs, the families of women who are GCs, IPs, and the children resulting from surrogacy have been performed outside of the United States. The longitudinal results primarily stem from a small group of traditional and gestational surrogates within the United Kingdom. ...
As gestational surrogacy (a process by which intended parents contract with a woman to carry a fetus that the intended parents will raise) increases across the United States (US), it is imperative that obstetrician/gynecologists understand the unique nuances of caring for patients who are gestational surrogates. Gestational surrogacy offers a route to parenthood for individuals and families who may otherwise have limited options. Understanding surrogacy requires multiple ethical considerations about the potential medical and psychosocial effects on gestational surrogates as well as the families built through surrogacy. There is a dearth of research on the subject, particularly in the US and other countries that practice compensated surrogacy. Here we seek to review the process of gestational surrogacy in the US including the legal landscape, current trends in gestational surrogacy utilization, and what is known about the medical and social effects of this process on all participants. We also aim to highlight the limitations of available data and identify topics for future research to provide optimal evidence-based and just care for these patients.
Cross-border reproductive care is a complex issue of the modern world that also impacts the Russian Federation. The main reasons for engaging in cross-border reproductive care are various legal, social, cultural, economic and religious factors, as well as national healthcare quality. In many countries, reproduction involving third parties, i.e., their sperm, eggs and embryos, is prohibited by law. This is why gamete donation is one of the main causes of pursuing CBRC in a foreign country, with Russia holding leading positions in this industry. Current stage of healthcare development makes Russia a major surrogate tourism destination, due to its common European culture and improved public health standards. Besides, Russia, as a multiethnic state where all religions are represented, has the most liberal legislation concerning infertility treatment. Fertility tourists have the same rights as Russian citizens in terms of assisted reproduction procedures, including obtaining the birth certificate regardless of biological relation to the child.
Objective
To determine whether pregnancies with donated embryos are at a higher risk of complications than the pregnancies from autologous frozen-thawed embryo transfer (FET).
Design
Anonymous, multicenter, comparative, observational, retrospective, matched-cohort study.
Setting
Six French assisted reproductive technique centers from 2003 to 2018.
Patient(s)
Seventy-three singleton pregnancies with donated embryos (exposed) and 136 singleton pregnancies after autologous FET (nonexposed) were matched at 7–8 weeks of gestation (pregnancy date, parity, and women’s age) (2:1 ratio, respectively). In accordance with French practices, all women were <44 years old and donated embryos were discarded frozen embryos from other couples.
Intervention(s)
Not applicable.
Main Outcome Measure(s)
Percentages of hypertensive disorders of pregnancy (HDPs) with donated embryos versus autologous FET.
Result(s)
Groups were comparable (mean age: 34.5 years) and HDPs (24.6% vs. 11.9%) were significantly more frequent among the donated-embryo pregnancies, mostly in its severe forms (17.5% vs. 4.6%). In contrast, their respective isolated hypertension frequencies were comparable (7.0% vs. 7.3%). Multivariate analysis retained increased severe HDP risk with donated embryos (odds ratio 2.08 [95% confidence interval: 1.08–4.02]). No significant effect of endometrial preparation was observed. C-sections were more frequent for donated-embryo pregnancies (47.3% vs. 29.2%). Newborns from embryo donation or autologous FET were comparable for prematurity, birth weight and length, Apgar score, small for gestational age, large for gestational age, neonatal malformations, and sex ratio.
Conclusion(s)
Even for young women, the risk of severe HDP was 4 times higher for donated-embryo pregnancies than for autologous-FET pregnancies. The HDP risk must be acknowledged to inform donated-embryo recipients and provide careful pregnancy monitoring.
A case report from Sri Lanka on surrogacy leading to a tragic maternal death; medico-legal and ethical aspects.
Surrogacy, with multiple ethical and legal issues associated with it, is practised worldwide. Although regulations are not available in Sri Lanka, we report a woman who had a tragic death as a complication of surrogate pregnancy.
The body of a young mother with four living children was brought for autopsy examination. According to the documents provided, there was a controversy about the deceased's identity. A woman volunteered to show a pillow trapped in her abdomen, simulating a pregnancy. By surrogacy, her husband's sperm were inseminated in this woman's uterus artificially according to a contract.
She was diagnosed and managed for pregnancy-induced hypertension in the second trimester. At 36 weeks of gestation, she was admitted to the hospital in labour. On admission, she was icteric with elevated blood pressure. A cesarean section delivered a baby, and it was noted that she had an abruption of the placenta. She developed a postpartum haemorrhage following delivery, and resuscitation failed, resulting in her death. She had elevated liver enzymes and low serum proteins before death. Autopsy findings included intense icterus, congested lungs, global ischemic changes in the myocardium, pale kidneys and fatty soft yellow liver.
This case discusses many unanticipated legal and ethical issues related to surrogate pregnancy, especially in a lack of regulations regarding the practice and relatively cheap medical expenses.
Importance:
As assisted reproductive technology has advanced, there has been an increase in gestational carriers/surrogate pregnancies. Information is needed to determine if these pregnancies are high-risk pregnancies and should be managed by maternal fetal medicine or if they are not high risk and should be cared for by residency-trained obstetricians and gynecologists.
Objective:
In this review of the literature, we explore whether surrogate pregnancies should be classified as high-risk pregnancies and managed by subspecialists.
Evidence acquisition, results:
Our literature search discovered 28 relevant studies that evaluated surrogate pregnancy and pregnancy complications/outcomes. We learned that the overall risk by using artificial reproductive technology and risks for hypertension, preterm delivery, cesarean delivery, low birth weight neonate, fetal anomalies, and stillbirth did not seem to increase maternal/perinatal risk to the level where a subspecialist was required for the inclusive management of a gestational surrogate. Given that the ideal gestational carrier is healthy, has previously had a term pregnancy, has a single embryo implanted, and has had no more than 3 prior cesarean deliveries, these pregnancies should be lower-risk pregnancies.
Conclusions:
We recommend that close monitoring and high index of suspicion should be maintained for complications, but care for the surrogate pregnancy can be accomplished by a residency-trained obstetrician-gynecologist.
Relevance:
An uncomplicated surrogate pregnancy can be managed by a residency-trained obstetrician-gynecologist and does not need to be managed by high-risk obstetric subspecialists.
Objective:
To compare gestational age, birth weight (BW), and live birth rates in gestational carriers (GC) after the transfer of 1 or 2 frozen embryo(s) with or without preimplantation genetic testing for aneuploidy (PGT-A), with the understanding that several social and economic factors may motivate intended parents to request the transfer of 2 embryos and/or PGT-A when using a GC.
Design:
Retrospective cohort study SETTING: An assisted reproductive technology practice.
Patient(s):
All frozen blastocyst transfers with GCs from 2009-2018.
Intervention(s):
One or 2 embryo frozen embryo transfers with and without PGT-A.
Main outcome measure(s):
Live birth, preterm birth, and low BW.
Results:
A total of 583 frozen embryo transfer cycles with vitrified high-grade blastocysts (grade BB or higher) to GCs were analyzed. Although the live birth rate was significantly greater in frozen embryo transfers with 2 embryos, after single embryo transfer (SET), the mean gestational age and BW of live births were statistically significantly greater than those of double embryo transfer (DET). The rate of multiple births was 1.9% for SET compared to 20.0% for DET per transfer. Only 3.8% of live births from SET experienced low BW and 0.6% had very low or extremely low BW. By comparison, 12.5% of DET live births were low BW and 5% were very low BW. After SET, 13.4% of live births were preterm, compared with 40% in DET. The analysis also included a total of 194 transfers with PGT-A compared to 389 cycles without. Overall, live births per transfer were not significantly different between these latter 2 subgroups.
Conclusion:
Frozen embryo transfer cycles in GCs with DET were associated with more preterm births and lower birth weights compared with those of SET. Intended parents and GCs should be counseled that DET is associated with greater risks of adverse pregnancy and perinatal outcomes, which mitigates higher live birth rates. The use of PGT-A did not appear to improve the live birth rate.
Background
The use of interventions in childbirth has increased the past decades. There is concern that some women might receive more interventions than they really need. For low-risk women, midwife-led birth settings may be of importance as a counterbalance towards the increasing rate of interventions. The effect of planned place of birth on interventions in the Netherlands is not yet clear. This study aims to give insight into differences in obstetric interventions and maternal outcomes for planned home versus planned hospital birth among women in midwife-led care.
Methods
Women from twenty practices across the Netherlands were included in 2009 and 2010. Of these, 3495 were low-risk and in midwife-led care at the onset of labour. Information about planned place of birth and outcomes, including instrumental birth (caesarean section, vacuum or forceps birth), labour augmentation, episiotomy, oxytocin in third stage, postpartum haemorrhage >1000 ml and perineal damage, came from the national midwife-led care perinatal database, and a postpartum questionnaire.
Results
Women who planned home birth more often had spontaneous birth (nulliparous women aOR 1.38, 95 % CI 1.08–1.76, parous women aOR 2.29, 95 % CI 1.21–4.36) and less often episiotomy (nulliparous women aOR 0.73, 0.58–0.91, parous women aOR 0.47, 0.33–0.68) and use of oxytocin in the third stage (nulliparous women aOR 0.58, 0.42–0.80, parous women aOR 0.47, 0.37–0.60) compared to women who planned hospital birth. Nulliparous women more often had anal sphincter damage (aOR 1.75, 1.01–3.03), but the difference was not statistically significant if women who had caesarean sections were excluded. Parous women less often had labour augmentation (aOR 0.55, 0.36–0.82) and more often an intact perineum (aOR 1.65, 1.34–2.03). There were no differences in rates of vacuum/forceps birth, unplanned caesarean section and postpartum haemorrhage >1000 ml.
Conclusions
Women who planned home birth were more likely to give birth spontaneously and had fewer medical interventions.
STUDY QUESTION
Are live birth rates (LBRs) after artificial cycle frozen-thawed embryo transfer (AC-FET) non-inferior to LBRs after modified natural cycle frozen-thawed embryo transfer (mNC-FET)?
SUMMARY ANSWER
AC-FET is non-inferior to mNC-FET with regard to LBRs, clinical and ongoing pregnancy rates (OPRs) but AC-FET does result in higher cancellation rates.
WHAT IS ALREADY KNOWN
Pooling prior retrospective studies of AC-FET and mNC-FET results in comparable pregnancy and LBRs. However, these results have not yet been confirmed by a prospective randomized trial.
STUDY DESIGN, SIZE AND DURATION
In this non-inferiority prospective randomized controlled trial (acronym ‘ANTARCTICA’ trial), conducted from February 2009 to April 2014, 1032 patients were included of which 959 were available for analysis. The primary outcome of the study was live birth. Secondary outcomes were clinical and ongoing pregnancy, cycle cancellation and endometrium thickness. A cost-efficiency analysis was performed.
PARTICIPANT/MATERIALS, SETTING, METHODS
This study was conducted in both secondary and tertiary fertility centres in the Netherlands. Patients included in this study had to be 18–40 years old, had to have a regular menstruation cycle between 26 and 35 days and frozen-thawed embryos to be transferred had to derive from one of the first three IVF or IVF–ICSI treatment cycles. Patients with a uterine anomaly, a contraindication for one of the prescribed medications in this study or patients undergoing a donor gamete procedure were excluded from participation. Patients were randomized based on a 1:1 allocation to either one cycle of mNC-FET or AC-FET. All embryos were cryopreserved using a slow-freeze technique.
MAIN RESULTS AND THE ROLE OF CHANCE
LBR after mNC-FET was 11.5% (57/495) versus 8.8% in AC-FET (41/464) resulting in an absolute difference in LBR of −0.027 in favour of mNC-FET (95% confidence interval (CI) −0.065–0.012; P = 0.171). Clinical pregnancy occurred in 94/495 (19.0%) patients in mNC-FET versus 75/464 (16.0%) patients in AC-FET (odds ratio (OR) 0.8, 95% CI 0.6–1.1, P = 0.25). 57/495 (11.5%) mNC-FET resulted in ongoing pregnancy versus 45/464 (9.6%) AC-FET (OR 0.7, 95% CI 0.5–1.1, P = 0.15). χ2 test confirmed the lack of superiority. Significantly more cycles were cancelled in AC-FET (124/464 versus 101/495, OR 1.4, 95% CI 1.1–1.9, P = 0.02). The costs of each of the endometrial preparation methods were comparable (€617.50 per cycle in NC-FET versus €625.73 per cycle in AC-FET, P = 0.54).
LIMITATIONS, REASONS FOR CAUTION
The minimum of 1150 patients required for adequate statistical power was not achieved. Moreover, LBRs were lower than anticipated in the sample size calculation.
WIDER IMPLICATIONS OF THE FINDINGS
LBRs after AC-FET were not inferior to those achieved by mNC-FET. No significant differences in clinical and OPR were observed. The costs of both treatment approaches were comparable.
STUDY FUNDING/COMPETING INTEREST(S)
An educational grant was received during the conduct of this study. Merck Sharpe Dohme had no influence on the design, execution and analyses of this study. E.R.G. received an education grant by Merck Sharpe Dohme (MSD) during the conduct of the present study. B.J.C. reports grants from MSD during the conduct of the study. A.H. reports grants from MSD and Ferring BV the Netherlands and personal fees from MSD. Grants from ZonMW, the Dutch Organization for Health Research and Development. J.S.E.L. reports grants from Ferring, MSD, Organon, Merck Serono and Schering-Plough during the conduct of the study. F.J.M.B. receives monetary compensation as member of the external advisory board for Merck Serono, consultancy work for Gedeon Richter, educational activities for Ferring BV, research cooperation with Ansh Labs and a strategic cooperation with Roche on automated anti Mullerian hormone assay development. N.S.M. reports receiving monetary compensations for external advisory and speaking work for Ferring BV, MSD, Anecova and Merck Serono during the conduct of the study. All reported competing interests are outside the submitted work. No other relationships or activities that could appear to have influenced the submitted work.
TRIAL REGISTRATION NUMBER
Netherlands trial register, number NTR 1586.
TRIAL REGISTRATION DATE
13 January 2009.
FIRST PATIENT INCLUDED
20 April 2009.
Background
Oocyte donation has been associated to gestational diabetes, hypertensive disorders, placental abnormalities, preterm delivery and increased rate of caesarean delivery while simultaneously being characterized by high rates of primiparity, advanced maternal age and multiple gestation constituting the individual risk of mode of conception difficult to assess. This study aims to explore obstetrical outcomes among relatively young women with optimal health status conceiving singletons with donated versus autologous oocytes (via IVF and spontaneously).
Methods
National retrospective cohort case study involving 76 women conceiving with donated oocytes, 150 nulliparous women without infertility conceiving spontaneously and 63 women conceiving after non-donor IVF. Data on obstetric outcomes were retrieved from the National Birth Medical Register and the medical records of oocyte recipients from the treating University Hospitals of Sweden. Demographic and logistic regression analysis were performed to examine the association of mode of conception and obstetric outcomes.
Results
Women conceiving with donated oocytes (OD) had a higher risk of hypertensive disorders [adjusted Odds Ratio (aOR) 2.84, 95 % CI (1.04–7.81)], oligohydramnios [aOR 12.74, 95 % CI (1.24–130.49)], postpartum hemorrhage [aOR 7.11, 95 % CI (2.02–24.97)] and retained placenta [aOR 6.71, 95 % CI (1.58–28.40)] when compared to women who conceived spontaneously, after adjusting for relevant covariates. Similar trends, though not statistically significant, were noted when comparing OD pregnant women to women who had undergone non-donor IVF. Caesarean delivery [aOR 2.95, 95 % CI (1.52–5.71); aOR 5.20, 95 % CI (2.21–12.22)] and induction of labor [aOR 3.00, 95 % CI (1.39–6.44); aOR 2.80, 95 % CI (1.10–7.08)] occurred more frequently in the OD group, compared to the group conceiving spontaneously and through IVF respectively. No differences in gestational length were noted between the groups. With regard to the indication of OD treatment, higher intervention was observed in women with diminished ovarian reserve but the risk for hypertensive disorders did not differ after adjustment.
Conclusion
The selection process of recipients for medically indicated oocyte donation treatment in Sweden seems to be effective in excluding women with severe comorbidities. Nevertheless, oocyte recipients-despite being relatively young and of optimal health status- need careful counseling preconceptionally and closer monitoring prenatally for the development of hypertensive disorders.
Women with Mayer–Rokitansky–Küster–Hauser (MRKH) syndrome may reproduce after uterine transplantation or IVF using a gestational surrogate. As uterine transplantation is still an experimental procedure, data on their clinical outcome using assisted reproduction techniques are imperative to allow evidence-based counselling. For this purpose, a systematic non-restricted electronic literature search was conducted. The 14 studies included in this review were published between 1988 and 2011. From a cohort of 140 patients with MRKH syndrome, mostly from the the USA and Israel, only four studies contained data on more than 10 patients; the others were case reports or small series. In the studies reviewed, 125 patients underwent 369 cycles of IVF with gestational surrogacy, and delivered 71 newborns. The reporting of outcome of patients with MRKH syndrome undergoing assisted reproduction techniques in the available literature is less than optimal and is characterized by bias of publication, inconsistent reports, including few patients, treated over a long time span, and lacking systematic reports from large IVF centres. None of the national registries contain specific outcome data on patients with MRKH syndrome. The paucity of data limits the possibility to draw firm conclusions but substantiates the need for a systematic multicentre reporting system.
What are the medical, psychosocial and legal aspects of gestational surrogacy (GS), including pregnancy outcomes and complications, in a large series?
Meticulous multidisciplinary teamwork, involving medical, legal and psychosocial input for both the intended parent(s) (IP) and the gestational carrier (GC), is critical to achieve a successful GS program.
Small case series have described pregnancy rates of 17-50% for GS. There are no large case series and the medical, legal and psychological aspects of GS have not been addressed in most of these studies. To our knowledge, this is the largest reported GS case series.
A retrospective cohort study was performed. Data were collected from 333 consecutive GC cycles between 1998 and 2012.
There were 178 pregnancies achieved out of 333 stimulation cycles, including fresh and frozen transfers. The indications for a GC were divided into two groups. Those who have 'failed to carry', included women with recurrent implantation failure (RIF), recurrent pregnancy loss (RPL) and previous poor pregnancy outcome (n = 96; 132 cycles, pregnancy rate 50.0%). The second group consisted of those who 'cannot carry' including those with severe Asherman's syndrome, uterine malformations/uterine agenesis and maternal medical diseases (n = 108, 139 cycles, pregnancy rate 54.0%). A third group, of same-sex male couples and single men, were analyzed separately (n = 52, 62 cycles, pregnancy rate 59.7%). In 49.2% of cycles, autologous oocytes were used and 50.8% of cycles involved donor oocytes.
The 'failed to carry' group consisted of 96 patients who underwent 132 cycles at a mean age of 40.3 years. There were 66 pregnancies (50.0%) with 17 miscarriages (25.8%) and 46 confirmed births (34.8%). The 'cannot carry pregnancy' group consisted of 108 patients who underwent 139 cycles at a mean age of 35.9 years. There were 75 pregnancies (54.0%) with 15 miscarriages (20.0%) and 56 confirmed births (40.3%). The pregnancy, miscarriage and live birth rates between the two groups were not significantly different (P = 0.54; 0.43; 0.38, respectively). Of the 178 pregnancies, 142 pregnancies were ongoing (surpassed 20 weeks) or had ended with a live birth and the other 36 pregnancies resulted in miscarriage (25.4%). Maternal (GS) complication rates were low, occurring in only 9.8% of pregnancies. Fetal anomalies occurred in only 1.8% of the babies born.
Although it is a large series, the data are retrospective and conclusions must be drawn accordingly while considering bias, confounding and power. Due to the retrospective nature of this study, follow-up data on 6.3% of birth outcomes were incomplete. In addition, long-term follow-up data on GCs and IPs were not available to us at the time of publication.
To our knowledge, this is the largest GS series published. We have included many details regarding not only the medical protocol but also the counseling and legal considerations, which are an inseparable part of the process. Data from this study can be included in discussions with future intended parents and gestational carriers regarding success rates and complications of GS.
There was no external funding used and there are no conflicts to report.
© The Author 2014. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.
Abstract OBJECTIVE: To assess the obstetric outcomes of pregnancy following intracytoplasmic sperm injection (ICSI) using donor oocytes. METHODS: Twenty-six deliveries from oocyte donor ICSI (d-ICSI) were compared to the next two consecutive deliveries from homologous ICSI (h-ICSI group) (n=52) and with the two consecutive deliveries from women older than 40 years (Advanced Maternal Age: AMA) (n=52). We evaluated the occurrence of gestational hypertension (GH), preeclampsia (PE), fetal growth restriction (IUGR), gestational diabetes (GDM), preterm premature rupture of membranes (pPROM), preterm birth, placental anomalies, mode of delivery, hemorrhage, gestational age at birth and birthweight. RESULTS: d-ICSI had significantly more PE (d-ICSI 19.2%, h-ICSI 0%, AMA 0%, p<0.001); higher rates of IUGR than AMA pregnancies (d-ICSI 19.2%, AMA 3.8%, p<0.025). Placental accretism was found only in the d-ICSI group (15.4%, p<0.043). No postpartum bleeding was observed. CONCLUSIONS: This is the first study that compares the obstetric outcomes of donor pregnancies to the outcomes of h-ICSI and AMA. Obstetricians who deal with pregnancies from oocyte donation need to be aware of the more severe obstetric outcomes, especially placenta accreta and preeclampsia. All women who conceive through oocyte donation should be counseled as early as the pre-conception period and referred to specific centers for high-risk pregnancies.
Egg donation (ED) makes it possible for subfertile women to conceive. Pregnancies achieved using ED with unrelated donors are unique, since the entire fetal genome is allogeneic to the mother. The aims of this review were to evaluate the consequences of ED pregnancies and to place them in the special context of their atypical immunologic relationships.
This review comprised an online search of English language publications listed in Pubmed/Medline, up to 29 January 2010. Seventy-nine papers met inclusion criteria. Using the literature and the authors' own experience, the relevant data on pregnancy outcome and complications, placental pathology and immunology were evaluated.
Multiple studies document that ED pregnancies are associated with a higher incidence of pregnancy-induced hypertension and placental pathology. The incidence of other perinatal complications, such as intrauterine growth restriction, prematurity and congenital malformations, is comparable to conventional IVF. During pregnancy, both local and systemic immunologic changes occur and in ED pregnancies these changes are more pronounced. There is almost no information in the literature on the long-term complications of ED pregnancies for the mother.
ED pregnancies have a higher risk of maternal morbidity. Owing to the high degree of antigenic dissimilarity, ED pregnancies represent an interesting model to study complex immunologic interactions, as the fully allogeneic fetus is not rejected but tolerated by the pregnant woman. Knowledge of the immune system in ED pregnancies has broader significance, as it may also give insight into immunologic aspects of tolerance in solid organ transplantation.
Surrogacy was prohibited in the Netherlands until 1994, at which time the Dutch law was changed from the general prohibition of surrogacy to the prohibition of commercial surrogacy. This paper describes the results from the first and only Dutch Centre for Non-commercial IVF Surrogacy between 1997 and 2004.
A prospective study was conducted of all intended parents, and surrogate mothers and their partners (if present), in which medical, psychological and legal aspects of patient selection were assessed by questionnaires and interviews developed for this study.
More than 500 couples enquired about surrogacy by telephone or e-mail. More than 200 couples applied for surrogacy in the Centre, of which, after extensive screening, 35 couples actually entered the IVF programme and 24 completed the treatment, resulting in 16 children being born to 13 women. Recommendations for non-commercial surrogacy are given, including abandoning the 1-year waiting period before adoption, currently dictated by law, avoiding a period of unnecessary psychological distress.
Our study has shown that non-commercial IVF surrogacy is feasible, with good results in terms of pregnancy outcome and psychological outcome for all parents, and with no legal problems relating to the adoption procedures arising. The extensive screening of medical, psychological and legal aspects was a key element in helping to ensure the safety and success of the procedure.
The purpose of our study was to review and evaluate retrospectively the experience of an in-vitro fertilization (IVF) surrogate gestational programme in a tertiary care and academic centre. In a 15 year period from 1984 to 1999, a total of 180 cycles of IVF surrogate gestational pregnancy was started in 112 couples. On average, the women were 34.4 +/- 4.4 years of age, had 11.1 +/- 0.72 oocytes obtained per retrieval, 7.1 +/- 0.5 oocytes fertilized and 5. 8 +/- 0.4 embryos subsequently cleaved. Sixteen cycles (8.9%) were cancelled due to poor stimulation. Except for six cycles (3.3%) where there were no embryos available, an average of 3.2 +/- 0.1 embryos was transferred to each individual recipient. The overall pregnancy rate per cycle after IVF surrogacy was 24% (38 of 158), with a clinical pregnancy rate of 19% (30 of 158), and a live birth rate of 15.8% (25 of 158). When compared to patients who underwent a hysterectomy, individuals with congenital absence of the uterus had significantly more oocytes retrieved (P < 0.006), fertilized, cleaved and more embryos available for transfer despite being of comparable age. IVF surrogate gestation is an established, yet still controversial, approach to the care of infertile couples. Take-home baby rates are comparable to conventional IVF over the same 15 year span in our programme. Patients with congenital absence of the uterus responded to ovulation induction better than patients who underwent a hysterectomy, perhaps due in part to ovarian compromise from previous surgical procedures.
This 10th statement of the Task Force on Ethics and Law considers ethical questions specific to varied surrogacy arrangements.
Surrogacy is especially complex as the interests of the intended parents, the surrogate, and the future child may differ.
It is concluded that surrogacy is an acceptable method of assisted reproductive technology of the last resort for specific
medical indications, for which only reimbursement of reasonable expenses is allowed.
( BJOG 2017;124:561–572)
There are over 50,000 oocyte donation (OD) treatments performed annually in the United State and Europe. OD pregnancies have been linked with increased risks of preeclampsia, low birth weight, preterm birth, and cesarean section. This systematic review and meta-analysis was performed to determine if OD pregnancies are associated with higher incidences of adverse pregnancy outcomes. Obstetric complications and neonatal outcomes were compared between OD pregnancies and pregnancies conceived by other methods, including autologous in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), and spontaneous conception (SC).
Anonymized data were obtained from the Human Fertilization and Embryology Authority to determine whether gestational surrogacy influences perinatal outcomes compared with pregnancies after autologous IVF. A total of 103,160 singleton live births, including 244 after gestational surrogacy, 87,571 after autologous fresh IVF and intractyoplasmic sperm injection (ICSI) and 15,345 after autologous frozen embryo transfers were analysed. Perinatal outcomes of pretern birth (PTB), low birth weight (LBW) and high birth weight (HBW) were compared. No difference was found in the risk of PTB and LBW after gestational surrogacy compared with autologous fresh IVF-ICSI: PTB (adjusted OR 0.90, 95% CI 0.56 to 1.42), LBW (adjusted OR 0.90, 95% CI 0.57 to 1.43) and gestational surrogacy compared with autologous frozen embryo transfers: PTB (adjusted OR 0.96, 95% CI 0.58 to 1.60), LBW (adjusted OR 1.16, 95% CI 0.69 to 1.96). The incidence of HBW was significantly higher after gestational surrogacy compared with fresh IVF-ICSI (adjusted OR 1.94, 95% CI 1.38 to 2.75); no difference was found in HBW between gestational surrogacy and autologous frozen embryo transfers. The dataset is limited by lack of information on confounders, i.e. ethnicity, body mass index, underlying medical history, which could result in residual confounding.
Infertility is a condition affecting an increasing number of individuals all over the world. In recent years, this phenomenon has spread across both western countries and developing countries, thus developing the features of a pandemic. For this reason, the World Health Organization (WHO) acknowledged that infertility should be considered a disease to all intents and purposes, as it diminishes the health and wellbeing of the individuals who suffers from it. At present, the most effective means to contain the spread of infertility are essentially prevention and Assisted Reproductive Technologies (ART). With reference to the latter, although most of these techniques are routinely used in the majority of countries, they are still subject to medical, ethical and political debates. There are huge variations noted when the regulatory legislation adopted by different countries to govern infertility treatment in various countries all over the world are reviewed. In fact, it has to be recognised that ART legislation depend on a variety of factors, such as social structure, political choices, ethical issues and religious beliefs. This makes it apparently impossible to create a standard regulation for different countries, especially in case of controversial issues like gamete and embryo donation, embryo cryopreservation or surrogacy.
Background:
Surrogacy is a highly debated method mainly used for treating women with infertility caused by uterine factors. This systematic review summarizes current levels of knowledge of the obstetric, medical and psychological outcomes for the surrogate mothers, the intended parents and children born as a result of surrogacy.
Methods:
PubMed, Cochrane and Embase databases up to February 2015 were searched. Cohort studies and case series were included. Original studies published in English and the Scandinavian languages were included. In case of double publications, the latest study was included. Abstracts only and case reports were excluded. Studies with a control group and case series (more than three cases) were included. Cohort studies, but not case series, were assessed for methodological quality, in terms of risk of bias. We examined a variety of main outcomes for the surrogate mothers, children and intended mothers, including obstetric outcome, relationship between surrogate mother and intended couple, surrogate's experiences after relinquishing the child, preterm birth, low birthweight, birth defects, perinatal mortality, child psychological development, parent-child relationship, and disclosure to the child.
Results:
The search returned 1795 articles of which 55 met the inclusion criteria. The medical outcome for the children was satisfactory and comparable to previous results for children conceived after fresh IVF and oocyte donation. The rate of multiple pregnancies was 2.6-75.0%. Preterm birth rate in singletons varied between 0 and 11.5% and low birthweight occurred in between 0 and 11.1% of cases. At the age of 10 years there were no major psychological differences between children born after surrogacy and children born after other types of assisted reproductive technology (ART) or after natural conception. The obstetric outcomes for the surrogate mothers were mainly reported from case series. Hypertensive disorders in pregnancy were reported in between 3.2 and 10% of cases and placenta praevia/placental abruption in 4.9%. Cases with hysterectomies have also been reported. Most surrogate mothers scored within the normal range on personality tests. Most psychosocial variables were satisfactory, although difficulties related to handing over the child did occur. The psychological well-being of children whose mother had been a surrogate mother between 5 and 15 years earlier was found to be good. No major differences in psychological state were found between intended mothers, mothers who conceived after other types of ART and mothers whose pregnancies were the result of natural conception.
Conclusions:
Most studies reporting on surrogacy have serious methodological limitations. According to these studies, most surrogacy arrangements are successfully implemented and most surrogate mothers are well-motivated and have little difficulty separating from the children born as a result of the arrangement. The perinatal outcome of the children is comparable to standard IVF and oocyte donation and there is no evidence of harm to the children born as a result of surrogacy. However, these conclusions should be interpreted with caution. To date, there are no studies on children born after cross-border surrogacy or growing up with gay fathers.
This study investigated if metabolomic profiling of culture media using near infrared (NIR) spectroscopy was related to live-birth rates after single-embryo transfer of frozen-thawed embryos. Analysis of culture media of frozen-thawed embryos was performed by NIR spectroscopy. A viability score was calculated using a predictive multivariate algorithm of fresh day-5 embryos with known pregnancy outcomes. This algorithm generated with fresh day-5 embryos could help to identify the live-birth group from the no live-birth group. Multivariable regression models that tested the predictive ability of the viability score for live birth showed an odds ratio in the crude analysis of 1.50 (P=0.008), after adjustment for embryo morphology, 1.44 (P=0.022), and after adjustment for all variables, 1.71 (P=0.005); based on a 0.1 step increase in viability scores. In conclusion, higher viability scores resulted in higher live-birth rates. An algorithm generated from fresh embryos might be used to predict viability of frozen-thawed embryos. Frozen-thawed embryos have different metabolic activity which is related to implantation potential. Therefore, this method might be useful to select the best embryo for transfer within a group of embryos with similar morphology.
To study the obstetric outcome of ovum donation pregnancies.
A retrospective analysis of 232 ovum donation pregnancies in the six years from 1988 to 1993.
Infertility clinic in a private hospital.
All ovum donation recipients that achieved pregnancy in the clinic during the stated time period.
Percentages of live birth and miscarriages and ectopic pregnancies; number of sacs identified in the uterus at early (four weeks after transfer) and later scans; incidence of antepartum and postpartum haemorrhage; incidence of pregnancy-induced hypertension; incidence of preterm, low birthweight and small-for-gestational age babies; and incidence of operative deliveries.
Of 232 pregnancies, 151 babies were born (live birth rate of 20%); and 81 were lost (57 before eight weeks, 17 after eight weeks and seven ectopic pregnancies). In nine cases there were no intrauterine sacs at the early scan (two 'chemical pregnancies' and seven ectopic pregnancies). In 169 cases there was initially one intrauterine sac, ending with 102 singleton deliveries (60%); in 47 cases there were initially two intrauterine sacs, ending with 11 singleton deliveries (23%) and 32 twin deliveries (68%); in the seven cases where three sacs were identified initially, there were no singleton deliveries, three twin deliveries (one selective fetal reduction) and three triplet deliveries. Women with premature ovarian failures had a significantly higher pregnancy rate compared with those with functioning ovaries (P < 0.02). However, in the former group, the miscarriage rate was also significantly higher (P < 0.03) so that the number of term births was similar. The incidence of vaginal bleeding was 12% in the first trimester, 1.5% in the second trimester, and 2% in the third trimester. The incidence of postpartum haemorrhage was 12%. Thirty-two women had pregnancy-induced hypertension (23% of all deliveries). This occurred in 22/105 singletons (21%), 7/32 twins (22%) and in all three (100%) of the triplets. In the singleton group 13% of infants were preterm, 18% had a birthweight < 2.5 kg and 15% were < 3rd centile for birthweight at delivery (small-for-gestational age). Ovarian function was found to be the only factor that significantly influenced the incidence of small-for-gestational age babies (odds ratio 8.84; 95% confidence interval 1.1-70.0; P = 0.007). The overall operative delivery rate was 85% with the caesarean section rate being 69%.
Women who become pregnant following oocyte donation should be considered obstetrically as high risk, especially those with ovarian failure because of the increased incidence of small-for-gestational age infants in these pregnancies. They are also at higher risk of pregnancy-induced hypertension and postpartum haemorrhage.
To determine placental pathology and immune response at the maternal-fetal interface in pregnancies conceived by IVF via egg donation compared with nondonor IVF pregnancies.
Retrospective case-control study.
Academic medical center.
The study population included 20 egg donor and 33 nondonor IVF pregnancies of >24 weeks' gestation.
None.
Perinatal complications (gestational hypertension, abruption, preterm delivery, cesarean section), microscopic features indicating an immune response and trophoblast damage, and characterization of inflammatory cells using immunohistochemistry.
There was an increase in gestational hypertension and preterm delivery in egg donor pregnancies. Dense fibrinoid deposition in the basal plate with severe chronic deciduitis containing significantly increased numbers of T helper and natural killer cells were demonstrated in egg donor placentas. Trophoblast damage was also increased in the preterm egg donor group.
There are significant histological and immunohistochemical differences between the placentas of egg donor and nondonor IVF pregnancies. The increased immune activity and fibrinoid deposition at the maternal-fetal interface of egg donor pregnancies could represent a host versus graft rejection-like phenomenon.
We wish to present a report of a pregnancy in which fertilization of an ovum obtained from a woman who had had a hysterectomy was followed by transfer of the embryo to a surrogate.
The perinatal outcome of pregnancies (both single and multiple) established after in-vitro fertilization (IVF)-surrogacy was evaluated and compared to the outcome of pregnancies that resulted from standard IVF. Analysis of medical records and a telephone interview with physicians, IVF-surrogates, and commissioning mothers were conducted to assess prenatal follow up and delivery care in several hospitals. 95 IVF-surrogates delivered 128 liveborn (65 singletons, 27 sets of twins and two sets of triplets). The commissioning mothers and the IVF-surrogates average ages were 37.7 +/- 5.0 and 30.4 +/- 4.7 years old respectively. IVF-surrogates carrying twin and triplet gestations delivered substantially earlier than those who gestated singleton pregnancies (36.2 +/- 0.4 versus 35.5 versus 38.7 +/- 0.3 weeks gestation respectively; P < 0.001). Twin newborns were significantly lighter than singleton infants born through IVF-surrogacy (2.7 +/- 0.06 versus 3.5 +/- 0.07 kg; P < 0.001). The incidence of low birth weight infants rose from 3.3% in the single births to 29.6% (P < 0.01) in the twins and to 33.3% in the triplets born through IVF-surrogacy. The incidence of prematurity was significantly greater in both twins delivered by IVF-surrogates (20.4%) and infertile IVF patients (58%). The occurrence of pregnancy-induced hypertension and bleeding in the third trimester was four to five times lower in the IVF-surrogates, independently of whether they were carrying multiples. The incidence of Caesarean section was 21.3% for singleton gestations, while two times higher in the IVF-surrogates carrying multiples (56.3%). Postpartum complications occurred in 6.3% of patients and the incidence of malformation was similar to those reported for the general population. The results provide general reassurance regarding perinatal outcome to couples who wish to pursue IVF-surrogacy.
In vitro fertilization (IVF) surrogacy makes it possible for women who do not have a functional uterus to have their own genetic offspring. We describe here our experience of IVF surrogacy in Finland over a 10-year period.
This retrospective study included 17 women who underwent ovarian stimulation in connection with surrogacy in 1991-2001 at four clinics. The surrogate mothers were unpaid volunteers: six sisters, three mothers, one husband's sister, one cousin, four friends and three other volunteers. Thorough counseling was given to the commissioning couples and to the surrogate mothers and their partners. The commissioning couples were prepared to adopt their biological children.
Twenty-eight surrogate IVF cycles were started in 17 women. One couple received donated oocytes. Trans-vaginal oocyte retrieval was feasible in every case, including those five women with congenital absence of the vagina and uterus. An average of 1.8 embryos was transferred at a time, and 11 pregnancies were achieved [50% per fresh embryo transfer (ET) and 16% per frozen-thawed ET]. Nine healthy singletons and one set of twins were born. One pregnancy ended in miscarriage. The mean birth weight of singleton infants was 3498 g (2270-4650 g). The birth weights of the twins were 2900 and 2400 g. In all cases the genetic parents took care of the infant immediately after birth. Two surrogate mothers had postpartum depression.
Altruistic IVF surrogacy works well, but careful counseling of all parties involved is essential.
Group National Assisted Reproductive Technology Surveillance System. Trends and outcomes of gestational surrogacy in the United States
- K M Perkins
- S L Boulet
- D J Jamieson
- D M Kissin
Perkins, K.M., Boulet, S.L., Jamieson, D.J.,
Kissin, D.M. Group National Assisted
Reproductive Technology Surveillance
System. Trends and outcomes of gestational
surrogacy in the United States.
Assisted reproductive technology in the United States: 2001 results generated from the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology registry
American Society for Reproductive Medicine.
Assisted reproductive technology in the
United States: 2001 results generated from
the American Society for Reproductive
Medicine/Society for Assisted Reproductive
Technology registry. Fertil Steril 2007; 87:
1253-1266