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Surrogacy

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surrogate motherSurrogacy is an arrangement between a woman and a couple or individual to carry and deliver a baby.  Women or couples who choose surrogacy often do so because they are unable to conceive due to a missing or abnormal uterus, have experienced multiple pregnancy losses, or have had multiple in vitro fertilization attempts that have failed. The advantage of gestational surrogacy to the parents is that the embryo is created from the woman’s egg and the man’s sperm, so it is biologically theirs. Surrogacy is a method of assisted reproduction. The word surrogate originates from Latin word surrogatus (substitution) - to act in the place of. The term surrogacy is used when a woman carries a pregnancy and gives birth to a baby for another woman. Surrogacy is gaining popularity as this may be the only method for a couple to have their own child and also because adoption, process may be a long drawn out process.

What are the Types of Surrogacy?

1.  IVF / Gestational surrogacy

2. Traditional / Natural surrogacy


IVF / Gestational surrogacy - This is a more common form of surrogacy. In this procedure, a woman carries a pregnancy created by the egg and sperm of the genetic couple. The egg of the wife is fertilized in vitro by the husband's sperms by IVF/ICSI procedure, and the embryo is transferred into the surrogate's uterus, and the surrogate carries the pregnancy for nine months. The child is not genetically linked to the surrogate.

Traditional / Natural surrogacy - This is where the surrogate is inseminated or IVF/ICSI procedure is performed with sperms from the male partner of an infertile couple. The child that results is genetically related to the surrogate and to the male partner but not to the female partner.

To whom Surrogacy is Advised?

A. IVF Surrogacy

1. Primarily, IVF surrogacy is indicated in women whose ovaries are producing eggs but they do not have a uterus. For e.g., in the following cases:

a) Congenital absence of uterus (Mullerian agenesis)

b) Surgical removal of the uterus (hysterectomy) due to cancer, severe hemorrhage in Caesarian section or a ruptured uterus.

2. A woman whose uterus is malformed (unicornuate uterus, T shaped uterus, bicornuate uterus with rudimentary horn) or damaged uterus (T.B of the endometrium, severe Asherman's Syndrome) or at high risk of rupture, (previous uterine surgeries for rupture uterus or fibroid uterus) and is unable to carry pregnancy to term can also be recommended IVF surrogacy.

3. Women who have repeated miscarriages or have repeated failed IVF cycles may be advised IVF surrogacy in view of unexplained factors which could be responsible for failed implantation and early pregnancy wastage.

4. Women who suffer from medical problems like diabetes, cardio-vascular disorders, or kidney diseases like chronic nephritis, whose long term prospect for health is good but pregnancy would be life threatening.

5. Woman with Rh incompatibility.

B. Traditional Surrogacy

1. Women who have no functioning ovaries due to premature ovarian failure. Here egg donation also can be an option.

2. A woman who is at a risk of passing a genetic disease to her offspring may also opt for traditional surrogacy.

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

What are the screening criteria for surrogate? How is a surrogate chosen in India?
surrogacy1Medical Tourism's network of hospitals in India, has a very meticulous and stringent criteria for choosing a surrogate. The surrogates are between 21-35 years of age. They are married with previous normal deliveries and healthy babies. Detailed medical history, surgical history, personal history, and family history is looked into. History of blood transfusion and addiction is also taken. It is made sure that the surrogate has an uneventful obstetric history (no repeated miscarriages, no ante-natal, intra-natal and post-natal complications during previous pregnancies). The surrogate and her partner are screened for infectious diseases like sexually transmitted diseases, Hepatitis B, Hepatitis C, HIV, VDRL. Thalassemia screening is also done. Detailed pelvic sonography is done and other tests for uterine receptivity are performed to ensure maximum chances of success. A detailed financial and legal agreement is then drawn up between the surrogate and the commissioning couple.

What does India IVF surrogacy procedure involve?
For IVF surrogacy in India, matching of cycles of the genetic mother and the surrogate is done by adjusting menstruation dates by oral contraceptive pills. When the cycle starts, the surrogate is put onto estrogen tablets to prime the uterus. The protocol used for the genetic mother is day 2 protocol or day 21 protocol, depending on the age of the genetic mother and the other test results. For the day 2 protocol, called the antagon protocol, oral contraceptive pills are given in the previous month. On the 2nd day of the periods, gonadotropin injections are started. USG Monitoring is done daily.

When the size of the follicle reaches 14 mm, the genetic mother is given an antagon injection to prevent the surge of the endogenous hormones. For the day 21 protocol, called the long protocol, GnRH analogues are started on day 21 of the previous cycle. Once the genetic mother gets her periods, gonadotropin injections are started. In both the cases, the patients are monitored daily. When the follicle reaches 18 mm size hCG trigger is given. The surrogate is started onto progesterone tablets on the day of hCG injection that is given to the genetic mother. Oocyte (egg) retrieval is done 36 hours later, which is generally day 12 or 13 of the cycle. On the same day the genetic father gives his semen sample. The eggs of the genetic mother are fertilized with sperms of the genetic father in the laboratory by IVF / ICSI procedure. The resulting embryo is then transferred into the womb of the surrogate under ultrasound guidance. The surrogate is then put on luteal support using progesterone tablets / injections, and pregnancy is confirmed 15 days later.


What is the nine-months journey like, with Indian surrogate?
The surrogate is treated as a high risk pregnancy and is cared for by 2 consultant gynecologists in our hospital. Appointments are scheduled with the consultants every three weeks for the first 6 months, then every 15 days for the next 2 months and then weekly / biweekly in the last month. Blood tests and ultra sound are done as and when required. Routine blood tests like hemoglobin, blood group, VDRL, HBsAG & HIV are done. Special care is given, and tests are done to pick up any obstetric or medical complications like hypertension, diabetes etc., at the earliest. 2 doses of injection Tetanus are given during pregnancy. The baby's growth is monitored stringently. Ultrasound is done at 6 weeks to confirm pregnancy and the viability of the baby, then at 12 weeks to assess growth and certain parameters like nuchal thickness. At 18 -20 weeks, a detailed level III ultrasound is done to detect any abnormalities in the baby. At 16 weeks, after councelling and with the consultation of the genetic parents, amniocentesis is performed, if the genetic mother's age is more than 35 years. At 28 weeks and 34 weeks, color Doppler is performed to assess the growth of the baby and rule out intra uterine growth retardation. Fetal well being tests, like non stress test, are done as per the requirement. Detailed information is given to the surrogates about nutrition and diet during pregnancy. They are regularly provided with supplements from the hospital.

Thus, adequate care and precaution is taken, to ensure that sufficient and optimum nutrition reaches the baby. We have a LDRP (Labor Delivery Recovery Puerperium) room for delivery which is equipped to handle any obstetric emergency. Our NICU setup is also completely equipped to handle any neonatal complications, with a neonatologist who is available round the clock. We keep the couple posted on the progress of the baby and send them ultrasound pictures and blood reports as and when they are done.

What is the success rate of surrogacy in India?
The success rate (carry home baby) of surrogacy is around 45% in case of fresh embyos. In case of frozen embryo's it is about 25%. High success rates and low medical costs are the highlights of surrogate pregnancy in India. No wonder many couples from the US, Australia, the UK, and other European countries seek surrogacy in India.


What are the different ways children born through surrogacy may receive breast milk?
surrogacy fertilityJust because the baby is born through surrogacy, it does not mean he or she cannot receive breast milk and the many health benefits it provides. Breast fed babies have been found to have higher IQs, are better protected from leukemia and are less likely to have problems regarding obesity. Breast milk protects babies from getting diarrhea, ear infections and respiratory disorders such as asthma. Premature babies who receive breast milk are more protected from infections and high blood pressure later in life. Breast milk contains the protein CD14 which works to develop B cells, which are immunity cells that are essential for the production of antibodies in an infant, to build the babies immunity system.

The babies may drink breast milk acquired through a milk bank, breast milk donor may be located or the intended mother may induce lactation before the birth of the baby. Induced lactation has been embraced by the nursing community as a welcome method to enhance the bonding relationship between a new mother and baby born through surrogacy. Prolactin and oxytocin are the two pituitary hormones that cause lactation to occur. They may be stimulated despite the woman's inability to carry a child. Lactation may be induced in a number of ways, and the amount of milk a non lactating woman can produce through inducement varies from woman to woman. The most common way women induce lactation is through manual or mechanical stimulation. With this method lactation is induced by massage, nipple manipulation and sucking either by the baby or breast pump. The second common method used is hormone therapy whereby a woman uses herbal remedies such as Fenugreek or is prescribed medications such as Domperidone and Metoclopromide (Reglan*) to induce and increase her milk supply. Induced lactation milk, skips the colostrum phase. and resembles mature breast milk.

Manual stimulation of lactation usually takes between two and seven weeks and hormone therapy usually takes between one to four months. For this reason intended mothers usually begin during the final trimester of their surrogate mother's pregnancy.

What are the advantages of surrogacy?

a) This may be the only chance for some couples to have a child, which is biologically completely their own (IVF surrogacy) or partly their own (gestational surrogacy)

b) The genetic mother can bond with the baby better than in situations like adoption.
Read 422067 times Last modified on Wednesday, 30 May 2012 18:20
Dr. Neeraj Pahlajani

Dr Neeraj_Pahlajani 
Obstetrician & Infertility Specialist

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