The gestational surrogacy (also known as gestational carrier) program is designed to assist women, who for diverse reasons are unable to carry a pregnancy. Our program provides the option of using a gestational surrogate, also referred to as a host uterus, to carry a full-term pregnancy.
Throughout this overview, the couple contributing the eggs and sperm is referred to as the “Female Partner” and “Male Partner” or collectively as the “Couple.” The woman receiving the embryos and carrying the pregnancy is referred to as the “Carrier”. Any gestational carrier program requires a great deal of coordination, from selecting the Carrier and matching her with a couple, to synchronizing and performing the related medical procedures. Our goal is to make the gestational carrier process as positive and stress free as possible.
Candidates for the Gestational Carrier Program are usually couples in which the Female Partner has no uterus due to surgery (hysterectomy), has an abnormally shaped (malformed) uterus, has had an endometrial ablation, or has a medical condition that prevents her from carrying a pregnancy. These women usually are good candidates for ovarian stimulation with fertility drugs. If, because of age or decreased egg quality, the woman is not a good candidate for ovarian stimulation, we may recommend using an Egg Donor.
The potential Carrier is usually a close personal friend or relative. On occasion, the Carrier will be selected with the assistance of a private gestational carrier agency that provides a list of possible available Carriers. Such agencies are widely available in California and other states, and we can assist you in finding a surrogacy agency.
Once a potential Carrier is chosen, she will undergo a full medical, psychological and laboratory evaluation. This evaluation (pre-cycle testing) involves:
1. Complete medical and obstetrical history.
2. Uterine cavity evaluation. This evaluation can be performed by means of a hysterosalpingogram (HSG), an office hysteroscopy, or a "fluid" ultrasound (hysterosonogram). These procedures allow us to evaluate the uterine cavity and make sure there are no fibroids, polyps, or scar tissue that could interfere with implantation. Also, the Gestational Carrier should have a "Mock Embryo Transfer" to carefully assess the length of her uterine cavity, in order to accomplish an atraumatic embryo transfer in the IVF cycle.
3. Cervical cultures are taken for ureaplasma/mycoplasma and aerobic organisms, and a DNA probe for Chlamydia and Gonorrhea is also obtained. Organisms such as ureaplasma have been associated with poor reproductive outcome and poor embryonic growth in the laboratory.
4. Testing for transmittable diseases such as Syphillis, Hepatitis (B and C), Rubella, Varicella, CMV, and HIV.
5. A psychological evaluation is also required for the Carrier.
When the Carrier lives out-of-town another qualified physician may perform the pre-cycle testing.
The Couple will also undergo thorough testing which will include a careful clinical evaluation as well as the following tests (called pre-cycle testing):
1. The Female Partner has cervical or vaginal cultures taken before commencing treatment for ureaplasma/mycoplasma and aerobic organisms, and also a DNA probe for Chlamydia and Gonorrhea. Organisms such as ureaplasma have been associated with poor reproductive outcome and poor embryonic growth in the laboratory.
2. Blood tests for the Female Partner early in the menstrual cycle (or in the absence of a period, on a date to be determined) for measurement of Follicle Stimulating Hormone (FSH), and Estradiol levels. These levels help us estimate a woman's ability to produce extra eggs in response to fertility drugs. In general, women with high FSH levels are more resistant to ovarian stimulation requiring a higher dosage of the fertility medications.
3. The Couple is screened via blood tests for Syphillis, Hepatitis (B and C), and HIV. The Male Partner is also screened for HTLV-1/2 and CMV.
4. The Male Partner will undergo a complete semen analysis with strict morphology evaluation (Kruger Criteria) at our laboratory. A brief physical examination by a primary care physician is also required.
5. We require the Couple to meet with a psychologist to discuss issues related to the Gestational Carrier process.
6. Consultation with an attorney is also required to clarify the legal responsibilities and obligations of all parties, and also to assist with documentation such as the birth certificate.
Once all the evaluations have been completed, Troché Fertility Centers, the Couple and Carrier will select an appropriate month to begin the cycle of treatment.
By definition in-vitro fertilization (IVF) is where the eggs and sperm are brought together in the laboratory. Fertilized eggs (embryos) are then transferred to a woman's uterus.
IVF with a Gestational Carrier requires the following steps:
1. Synchronizing the Female Partner's and Carrier's Cycles
Like the Female Partner, The Carrier will be placed on birth control pills in order to synchronize their two cycles. Instead of medication to stimulate egg development, the Carrier requires a medication called Lupron (GnRH agonist) to suppress ovulation, and hormone injections (estradiol and progesterone) to prepare her uterine lining for implantation of the transferred embryos.
2. Ovulation Induction and Monitoring of the Female Partner
ART success rates depend upon the numbers of eggs or embryos available for transfer. Additionally, the egg retrieval must be carefully timed so as to retrieve mature eggs. To accomplish these two goals, ovulation induction medications and careful monitoring are employed.
The start of the ovarian stimulation is timed using oral contraceptive pills (OCP). The Female Partner takes OCP for two to four weeks prior to the beginning of the stimulation. Within 4 days after the last "active" pill is taken a baseline ultrasound is performed to make sure there are no ovarian cysts, and a blood estradiol level is measured. On the fifth day after the last "active" pill is taken the Female Partner begins injections of gonadotropins (Follistim or Gonal-F), according to a schedule that is provided by the clinic. We arbitrarily call this first day of gonadotropin administration Stimulation Day 1.
On Stimulation Day 5 the Female Partner begins the administration of a GnRH antagonist (Ganarelix or Cetratide) to prevent premature ovulation. In order to monitor a Female Partner 's response to these drugs, frequent ultrasounds and serum estradiol levels are performed starting Stimulation Day 7. These help us determine when the eggs are ready for collection.
Once the follicles (containing the eggs) are fully developed, the Female Partner administers an injection of human chorionic gonadotropin (hCG). This hormone replaces the woman’s normal LH surge, and is necessary for the final maturation of the eggs so that sperm can fertilize them. The egg retrieval occurs 35 hours after the hCG injection.
3. Building the Carrier's Lining with Hormonal Injections
In a natural cycle the uterine lining is built up in response to the hormone estradiol that is produced by the developing follicles within the ovaries. In the Carrier, we replace the follicle-derived estradiol with the medication Estradiol Valerate. Estradiol Valerate is injected twice weekly on Tuesdays and Fridays. To monitor the Carrier's response to the medication, blood is drawn on Mondays and Thursdays to measure the serum (blood) estradiol concentrations. These blood levels are used to adjust the Estradiol Valerate dosage for the subsequent injection. An ultrasound examination is performed approximately 2 weeks after the Estradiol injections begin to evaluate whether optimal endometrial development is occurring. In the uncommon event of poor endometrial development, the Couple will be given the choice of having their eggs retrieved, fertilized, and cryopreserved (frozen) for transfer to the Carrier's uterus in another cycle, or to have the procedure canceled.
Approximately 4 to 6 days before the anticipated embryo transfer, daily injections of progesterone begin in order to optimize the gestational Carrier's endometrium for implantation.
4. Egg Retrieval
At Troché Fertility Centers the egg retrieval is accomplished non-surgically using a vaginal ultrasound probe to guide a needle into the ovaries. The procedure does not require general anesthesia and is performed with intravenous sedation. An anesthesiologist administers the sedation to maximize your comfort and safety. As a result, the experience is not painful and recovery is rapid.
5. Sperm Processing
To comply with Federal Government regulations, the Male Partner collects sperm for freezing before the IVF cycle is initiated. The sample is collected when his infectious disease screening is performed. After the egg retrieval the frozen sperm sample is thawed and prepared for IVF. The sperm must undergo biochemical and structural changes called capacitation before they can fertilize an egg. In an IVF cycle, sperm are capacitated in the laboratory, the motile sperm are isolated, and then used to fertilize the eggs.
6. In Vitro Fertilization
In-vitro fertilization literally means "fertilization in glass". Follicular fluid removed from the ovaries is examined in our lab for the presence of eggs. These eggs are isolated and placed in culture media where they are allowed to further mature. A few hours later, the embryologist will remove the outside layer of cells surrounding the egg and, under the microscope, capture a sperm in a thin glass pipette and insert it directly into the egg. All mature eggs are fertilized in this manner. This procedure is called “ICSI” or intracytoplasmic sperm injection and is used to maximize fertilization, especially in men with low sperm counts or low numbers of normally shaped sperm. The injected eggs are incubated in a carefully controlled environment, and after 16 hours are inspected under a microscope to determine how many have fertilized. These embryos will be kept in the incubator as they continue to grow and develop until the moment of transfer.
The Couple receives daily reports keeping them informed of the development of the embryos (fertilization, cell division and quality or grading). Three days after the egg retrieval, a decision is made about when to perform the embryo transfer (Day 3 embryo transfer or a Day 5 blastocyst transfer). The decision to transfer at Day 3 or 5 (blastocyst) is based on the grading of the embryos.
7. Embryo Transfer to the Carrier's Uterus
At Troché Fertility Centers all embryo transfers are performed under trans-abdominal ultrasound guidance. We have found that ultrasound-guided transfers are easier to perform and have resulted in higher pregnancy rates. The ultrasound allows for the accurate placement of the embryos approximately 1.5 centimeters from the top of the uterus. The embryos are transferred via a thin plastic tube and this catheter is carefully guided into the upper part of the uterus where the embryos are placed. After 20 seconds the catheter is gently removed. The transfer is generally a painless procedure and the patient remains resting for 1 hour, after which she is sent home. We instruct our patients to rest at home during the next two to three days after the transfer.
When to transfer Day 3 or Day 5 (Blastocyst)?
Depending on the quality of the embryos and the Couple's preference, the embryos may be transferred into the woman's uterus either 3 or 5 days after egg retrieval. Three days after egg retrieval, the embryos have cleaved (divided) and contain 6 to 10 cells each. If an embryo transfer is performed at this time, approximately 1 to 4 embryos are transferred depending on the woman's age, the Couple's desires and the quality (grading) of the embryos.
Currently, we offer couples that have embryos of exceptional quality the option to transfer their embryos 5 days after egg retrieval when the embryos are at a more advanced stage of development (blastocyst stage). These blastocysts have a higher implantation rate than embryos grown only three days, and as a result, only one or two blastocysts need to be transferred to have the same pregnancy rate usually seen when 2 (or more) embryos are transferred into the uterus on Day 3.
8. Post Embryo Transfer Management and Follow-up
To ensure an optimal environment for implantation, the Carrier continues the hormone injections of Progesterone and Estradiol Valerate during the post-embryo transfer phase. Fifteen days following the Female Partner's egg retrieval (12 or 10 days after the Gestational Carrier's transfer) a pregnancy test is performed. If the test is positive the hormone injections continue for an additional 8 weeks until the placenta is fully functional. A second pregnancy test is obtained approximately 8 days after the first to confirm that the pregnancy is ongoing. Confirmation of a clinical pregnancy is made by ultrasound about 2 to 3 weeks later. If the pregnancy test is negative, all hormonal treatment is discontinued and menstruation will ensue within 3-10 days.
An option for couples with many embryos is to freeze the "extra embryos". This gives couples an additional opportunity to conceive without going through another stimulated cycle and egg retrieval. After a Day 3 embryo transfer, all remaining embryos are cultured for 2 to 3 more days. We then freeze the embryos that reach the blastocyst stage and are of good quality. Our pregnancy rate with the transfer of frozen blastocysts is almost double the expected pregnancy rate with the transfer of frozen Day 3 embryos.
A frozen embryo cycle can be used if the Couple was not successful with the fresh embryo transfer or, if successful, when they wish for another child. Since the Couple already has embryos to transfer, the Carrier's uterus needs only to be prepared to receive the embryos. This preparation is very similar to that already discussed for a "fresh" Gestational Carrier cycle. When blastocysts are to be transferred daily injections of progesterone are started six days prior to the date of transfer, and the Lupron is stopped. Prior to thawing the embryos, an ultrasound assessment of the uterine lining is performed to make sure an adequate endometrial thickness is present. The evening before the scheduled transfer, the embryos are thawed. If successful thawing of the embryo(s) occurs, an embryo transfer will take place as previously described. About 60% of the frozen embryos survive the defrosting process. Therefore, at least 2 blastocysts should be available for a frozen embryo transfer cycle.
Pregnancy rates using a Carrier are reflective of the age of the Female Partner. We anticipate approximately a 50% pregnancy rate for women less than 35 years of age.
Troché Fertility Centers' overriding objective is to provide an efficient and successful mechanism for helping infertile couples achieve their life's dream of having a baby. Our team is committed to provide the highest quality medical care in a sensitive and caring environment. We are here to assist you on your path to fertility.
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