SURROGACY

Surrogacy is when another woman carries and gives birth to a baby for the couple who want to have a child.The HFEA does not regulate surrogacy.Surrogacy may be appropriate if you have a medical condition that makes it impossible or dangerous to get pregnant and to give birth.

Intended parents may seek a surrogacy arrangement when either pregnancy is medically impossible, pregnancy risks present an unacceptable danger to the mother's health or is a same sex couples preferred method of procreation. Monetary compensation may or may not be involved in these arrangements. If the surrogate receives compensation beyond reimbursement of medical and other reasonable expenses, the arrangement is considered commercial surrogacy; otherwise, it is referred to as altruistic. The legality and costs of surrogacy vary widely between jurisdictions, sometimes resulting in interstate or international surrogacy arrangements.

Types of surrogacy            

•  Gestational surrogacy (GS)
• Gestational surrogacy with embryo from both intended parents (GS/IP)
• Gestational surrogacy and egg donation (GS/ED)
• Gestational surrogacy and donor sperm (GS/DS)
•  Gestational surrogacy and donor embryo (GS/DE)
•  Traditional surrogacy (TS)
•  Traditional surrogacy and donor sperm (TS/DS)

The type of medical conditions that might make surrogacy necessary for you include:

• absence or malformation of the womb
• recurrent pregnancy loss
• repeated in vitro fertilisation (IVF) implantation failures

Full surrogacy (also known as Host or Gestational) - Full surrogacy involves the implantation of an embryo created using either:

• the eggs and sperm of the intended parents
• a donated egg fertilised with sperm from the intended father
• an embryo created using donor eggs and sperm.

Partial surrogacy (also known Straight or Traditional) - Partial surrogacy involves sperm from the intended father and an egg from the surrogate. Here fertilisation is (usually) done by artificial insemination or intrauterine insemination (IUI).

DONOR INSEMINATION

Donor insemination (DI) uses sperm from a donor to help the woman become pregnant.
Sperm donors are screened for sexually transmitted diseases and some genetic disorders. In DI, sperm from the donor is placed into the neck of the womb (cervix) at the time when the woman ovulates.
DI - IUI uses intrauterine insemination with donor sperm.
Donor sperm can also be used for in vitro fertilisation (IVF).

• In vitro fertilisation (IVF)
• Intrauterine insemination (IUI)

A clinic is likely to recommend donor conception if:

• you are not producing eggs or sperm of your own
• your own sperm or eggs are unlikely to result in conception
• you have a high risk of passing on an inherited disease
• you are in a same sex relationship, or
• you are single.

If you are considering using donated sperm, eggs or embryos, you will need to think about some complex issues before starting treatment. For this reason, you will be offered counselling; many clinics regard it as essential and will not offer donor conception treatment without it. Try to also talk to people who already have donor-conceived children.

How does DI work?

Using donated eggs

Donated eggs can be used in either in vitro fertilisation (IVF) or intra-cytoplasmic sperm injection (ICSI). Read more about these treatments in the previous sections.
The procedure for using donated eggs varies depending on your clinic and the fertility treatment you are undergoing. A typical procedure may involve the following steps:

 

For women:

1. You and your donor will be given medication to synchronise your menstrual cycles. You will also be given medication to prepare the endometrium lining of your womb for embryo transfer.
2. The donated eggs will be fertilised using IVF or ICSI. 
3. When the embryos begin to develop, they will be transferred to your womb as in conventional IVF. As the eggs will be from donors aged 35 or younger, no more than two embryos will be transferred.

Alternatively, the embryos may be frozen after they have been fertilised. This avoids the need to synchronise your menstrual cycle with that of the donor and may reduce the stress of the treatment.

For men:

1. Unless you are using donor sperm, before treatment takes place you will give a sperm sample to check that your sperm are healthy and active.
2. On the day that the eggs are collected, you will give another sperm sample.
3. The sperm sample is mixed with the donor eggs in vitro to fertilise them, or fertilised by ICSI and then transferred to the womb.

Using your eggs in your partner’s treatment

If you are in a same sex female couple and you want to use your eggs and your partner carry the baby, the process for collecting your eggs will be as follows:

1. After being screened for sexually transmitted diseases and some genetic disorders, you will be given a series of hormone injections to help develop and mature the eggs within the ovaries.
2. Once the eggs are matured, they are collected while you are sedated by inserting a needle into the ovaries through the vagina.

The eggs will then be fertilised, usually using IVF.

Donor insemination (DI) - chance of success

Female fertility diminishes with age, so if you are using your own eggs, on average, the younger you are, the higher your chances of success.
Some women receive fertility drugs to boost egg production before the sperm is transferred. We now present the stimulated and unstimulated cycles seperately.
In 2010 (the year for which the most recent data is available) women receiving unstimulated donor insemination (DI) - including intrauterine insemination (IUI) and GIFT - the percentage of cycles started that resulted in a live birth was:

• 14.6% for women aged under 35
• 11.4% for women aged 35-37
• 9.4% for women agend 38-39 
• 4.7% for women aged 40 and over

In 2010 (the year for which the most recent data is available) women receiving stimulated donor insemination (DI) - including intrauterine insemination (IUI) and GIFT - the percentage of cycles started that resulted in a live birth was:

• 20.7% for women aged under 35
• 17.1% for women aged 35-37
• 11.9% for women agend 38-39
• 5.3% for women aged 40 and over

EMBRYO TRANSFER

So you've had an embryo transplant, but still do not conceive. It is normal to blame yourself for something you may or may not have done during this time. Therefore, try not to do anything for which you will blame yourself if you do not get pregnant. In general practice the following guidelines:
 

• No tub baths or swimming for 48 hours after embryo transfer.
• No douching or wearing tampons. 
• No intercourse or orgasms until the fetal heartbeat is seen on ultrasound, or the pregnancy test is negative.
• No excessive physical activity such as jogging, aerobics, or tennis.
• No non-prescription medications or other prescribed medications without the approval of your doctor.
• No heavy lifting.
• You may return to "work" after 24 hours of bed rest (getting up for bathroom and meals only) and one to two days of light activity.

Doctors used to advise "strict bed rest" after an embryo transfer. However, remember that physical activity does not affect your chances of getting pregnant. Resting when you are well can be very emotionally taxing, and we encourage patients to lead as normal a life as possible. 

After a transplant, there are numerous stages which must be reached and completed before conception.

• More than one egg should develop.
• Eggs should mature.
• Ovulation should not occur before the eggs can be collected.
• Eggs must be retrieved during the "pick-up".
• Sperm must fertilize at least one egg
• Fertilized eggs must divide and grow healthily.

The embryos might get implanted in the uterus.

Think of it as a series of hurdles, all of which have to be cleared, in order to win the race!

 

Maximizing Chances for Success

Women:

• Avoid all medications. If you are taking other prescription medications check with your doctor prior to beginning your treatment cycle. 
• No smoking or alcohol use. Studies show both can result in lower pregnancy rates and a greater risk of miscarriage. Why put yourself through this if you are not doing everything YOU can to insure your success.
• No more than two caffeinated beverages per day.
• Avoid change in diet or weight loss or fad diets during IVF cycle. A healthy well balanced diet works best.
• Refrain from intercourse three to four days prior to egg retrieval and following embryo replacement until the pregnancy test has been done. 
• Normal exercise may continue unless enlargement of your ovaries produces discomfort.
• Avoid hot tubs or saunas.

Men:

• Fever greater than 100.4o one to two months prior to IVF treatment may adversely affect sperm quality. Be sure to let your doctor know. If you are sick, please take your temperature and report any febrile illnesses. 
• Sitting in hot tubs and saunas is not recommended. Even a single episode in a hot tub can adversely affect sperm function. Please refrain from this for at least three months prior to treatment.
• Drugs, alcohol, and cigarette smoking should be avoided for three months prior to treatment and at all times during the ongoing IVF treatment cycle to get the best results.

Abstain from intercourse for at least three days, but not more than seven days prior to collection of semen for egg collection and during treatment.

Intra-cytoplasmic sperm injection (ICSI)

Intra-cytoplasmic sperm injection (ICSI) differs from conventional in vitro fertilisation (IVF) in that the embryologist selects a single sperm to be injected directly into an egg, instead of fertilisation taking place in a dish where many sperm are placed near an egg.  

ICSI enables fertilisation to happen when there are very few sperm available.

Your clinic may recommend ICSI if:

·         you have a very low sperm count

·         other problems with the sperm have been identified, such as poor morphology (abnormal shape) or poor motility (not moving normally)

·         during previous attempts at IVF there was failure of fertilisation or an unexpectedly low fertilisation rate

·         you need sperm to be collected surgically from the testicles or epididymis (a narrow tube inside the scrotum, where sperm are stored and matured); for example because you have had a vasectomy, you do not ejaculate sperm, or because you have extremely low sperm production

·         you are using frozen sperm in your treatment which is not of optimum quality

·         you are using embryo testing.

How does ICSI work?

Before your treatment starts you will need to complete various consent forms and you, and if applicable your partner, may need to have blood tests to screen for HIV, hepatitis B and C and human T cell lymphotropic virus (HTLV) I and II.

Treatment then typically involves the following:

For women

You take fertility drugs to stimulate your ovaries to produce more eggs, as for IVF, and your progress will be monitored through vaginal ultrasound scans and possibly blood tests.

The eggs are then collected using the same procedure as IVF and each egg is injected with a single sperm from your partner or donor. The rest of the process is also the same as IVF.

You are more likely to become pregnant with twins or triplets if more than one embryo is transferred so your clinic will recommend single embryo transfer (SET) if they feel it is the best option for you. An embryologist will examine your sperm under a microscope and decide whether ICSI could increase your chances of fathering a baby.

The next step depends on whether you are able to provide sperm without a medical procedure:

·         If you can, you produce a fresh sperm sample on the same day as your partner’s eggs are collected.

Or:

·         Sperm can be collected directly from the epididymis using a type of fine syringe. This is known as ‘percutaneous epididymal sperm aspiration’ or PESA.

·         Sperm can also be retrieved from the testicles, a process known as ‘testicular sperm aspiration’ or TESA.

·         It is also possible to remove tiny quantities of testicular tissue from which sperm can be extracted. This procedure is called ‘testicular sperm extraction’ or TESE. For more information about PESA, TESA and TESE, speak to your doctor.

·         If you have stored sperm, it will be removed from frozen storage, thawed and prepared for treatment.

A single sperm is then injected into each egg. ICSI provides the opportunity for fertilisation to happen, but it is not guaranteed to succeed.

Finally, if fertilisation does take place, the embryos will be cultured in the laboratory for up to six days and then between one and three of the best-quality embryos will be transferred to the womb.

Zero sperm count

If you have a zero sperm count (other than caused by vasectomy), the chances of retrieving sperm surgically by PESA, TESA or TESE may be very low.

In this situation, you might consider having a surgical retrieval as a ‘dummy run’ and storing any sperm that are obtained. If no sperm are retrieved, you may want to consider donor insemination (DI) or IVF with donor sperm instead.