AT TROCHÉ FERTILITY CENTERS
Gestational surrogacy (also known as gestational carrier) is designed to assist women, who for diverse reasons are unable to carry a pregnancy or when there is no female partner. At TFC, we are familiar with all aspects of gestational carrier cycles including screening the carrier, coordinating the cycles and creating and transferring the embryos into a gestational carrier who can carry the pregnancy.
While the potential carrier can be a close personal friend or relative, the carrier may also be selected from a gestational carrier agency. Such agencies are widely available in California and other states, and we can assist you in finding a reputable surrogacy/carrier agency.
Once a potential carrier is chosen, she will undergo a full medical, psychological and laboratory evaluation. Carriers obtained through an agency typically have completed this testing.
This evaluation (pre-cycle testing) involves:
A complete medical and obstetrical history.
A uterine cavity evaluation. This evaluation can be performed by means of an in-office Hysterosalpingogram (HSG), or a "fluid" ultrasound known as a Saline Infusion Sonogram (SIS). These procedures allow us to evaluate the uterine cavity and ensure there are no fibroids, polyps, or scar tissue that could interfere with implantation.
Testing for infectious diseases such as HIV, hepatitis, syphilis, gonorrhea, chlamydia, and CMV (cytomegalovirus) is conducted. We also test for immunity to Rubella (German measles), and Varicella (chicken pox) to maximize a healthy pregnancy.
A psychological evaluation is also required for the carrier. We will provide a list of psychologists for your convenience.
If the carrier lives out-of-town, the pre-cycle testing may be completed at a facility near her home.
Often the intended parents provide the eggs and sperm to create the embryos that are transferred into the carrier, however an egg and/or sperm donor may also be used. The persons providing the eggs and sperm will complete a careful clinical evaluation (pre-cycle testing) to maximize a successful cycle:
For the intended mother, we measure AMH (Anti-Mullerian Hormone), FSH (Follicle Stimulating Hormone), and Estradiol levels. These will determine a woman’s ovarian reserve or ability to produce eggs in response to fertility medications. If an egg donor is used, she is screened in the same manner.
For the intended father, a complete semen analysis is performed to determine if the sperm’s ability to fertilize an egg is compromised or normal. A physical examination by a primary care physician is also required.
For both intended parents, infectious disease testing for HIV, hepatitis, West Nile Virus, syphilis, gonorrhea, and chlamydia, is conducted. The intended father is also tested for CMV (cytomegalovirus) and HTLV I/II. If a sperm donor is used, he is screened in the same manner.
The intended parent(s) also meet with a psychologist to discuss issues related to using a gestational carrier. This consultation is especially important if the carrier is a friend or family member.
Consultation with an attorney is required to clarify the legal responsibilities and obligations of all parties, and to assist with documentation such as the birth certificate.
Once all the evaluations are complete, the cycle is scheduled.
IN VITRO FERTILIZATION CYCLE WITH A GESTATIONAL CARRIER
In IVF (in-vitro fertilization) the eggs and sperm are brought together in the laboratory. Fertilized eggs (embryos) are then transferred to the carrier’s uterus.
Steps of the cycle:
Ovarian Stimulation of the Intended Mother
Before the stimulation begins, birth control pills are used to quiet the ovaries. An ultrasound exam and blood (estradiol) test confirms this and the intended mother/donor begins the fertility medications according to a schedule provided by TFC. The medications (Follistim, Gonal-F and/or Menopur) are injected subcutaneously (SubQ) daily to stimulate multiple follicles to grow. A follicle is a fluid filled sac in which an egg can develop. Another medication (Ganirelix or Cetrotide) is added to help prevent premature ovulation (release) of the eggs.
The eggs are microscopic and can’t be seen directly, therefore we track their development by measuring the size and number of follicles and measuring the level of hormone (estradiol) produced by the follicles. Together, the measurements of follicle sizes and blood tests indicate when the follicles are likely to contain a fully developed egg. A final medication (hCG and/or Lupron) is taken to cause the final maturation of the eggs prior to retrieval so they can be fertilized.
Building the Carrier’s Lining
The carrier also takes birth control pills to synchronize her cycle with the intended mother’s/egg donor’s and to quiet the ovaries. When instructed, medication (Estrace or Estradiol valerate) is started to stimulate the lining of the uterus to thicken. After several days of medication, the uterine lining is measured via an ultrasound to ensure an adequate endometrial thickness is developing. When the intended mother’s/donor’s egg retrieval date is known, the carrier begins progesterone supplementation to ready the lining to accept an embryo (implantation).
At TFC, the egg retrieval is performed using ultrasound to guide a needle through the vaginal wall and into the ovaries. The egg retrieval takes approximately 30 minutes to complete and IV sedation is provided by an anesthesiologist for her comfort and safety. After the retrieval the intended mother/donor stays for a recovery period of 45-60 minutes. Once we ensure she is doing well, she goes home to rest the remainder of the day.
To comply with FDA rules, the intended father/sperm donor collects and cryopreserves (freezes) his sperm when the infectious disease testing is performed (before the cycle starts). The morning of the egg retrieval the frozen sample is thawed, and the sperm is processed (capacitated) so they can fertilize the eggs.
Follicular fluid removed from the ovaries is examined in our lab and the eggs are isolated and placed in culture media where they continue to mature. A few hours after the egg retrieval, the embryologist using a microscope, captures a sperm and inserts it directly into the egg. This technique of injecting an individual sperm into each mature egg is called Intracytoplasmic Sperm Injection (ICSI). All mature eggs are injected in this manner to maximize fertilization. ICSI is especially helpful for men with low sperm counts or low numbers of normally shaped sperm.
Approximately 16 hours following injection, the eggs are inspected under the microscope to determine how many have successfully fertilized. These embryos will remain in the incubator as they continue to grow and develop until the moment of transfer.
Regular reports are provided regarding development of the embryos. Generally, at 2 days normal embryos are 4 cells, at 3 days they are 8 cells, and at 5 days they have over 80 cells with an inner fluid-filled cavity and a small cluster of cells called an inner cell mass (blastocyst stage). The decision of when to perform the embryo transfer is based on the grading of the embryos.
Embryo Transfer into the Carrier’s Uterus
At TFC, we plan for an embryo transfer on day 5 (at the blastocyst stage of embryo development). Blastocysts have a higher implantation rate than embryos incubated only 3 days. Three days after injection, the embryologist will evaluate the embryos for their quality and provide a grade. If there are at least 2 grade “A” or good quality embryos, a day 5 transfer is confirmed and the embryos remain in culture to develop further. At day 5 the best looking blastocyst stage embryo(s) are transferred into the carrier’s uterus. If there are not 2 grade “A” embryos, a day 3 embryo transfer is planned. Any viable good quality embryos not transferred into the carrier may be cryopreserved for future use, if desired.
All embryo transfers are performed using ultrasound guidance as it allows for accurate placement of the embryo in the optimal location in the uterus. The embryo is transferred via a thin plastic tube (catheter) which is carefully guided into the upper part of the uterus and the embryo is placed. The transfer is a painless procedure and the carrier remains resting for 1/2 hour, after which she goes home. We recommend she rests at home through the next day before resuming her activities.
With the goal of decreasing the incidence of multiple births (twins or triplets) TFC uses the American Society of Reproductive Medicine (ASRM) guidelines for the number of embryos to transfer. With the information about the embryo number and quality, and mindful of the ASRM recommendations, the physician and woman/couple/carrier will determine the number of embryos to transfer.
After the Embryo Transfer
The carrier continues Estrace/Estradiol valerate and progesterone supplementation to enhance implantation of the embryo and support an early pregnancy. Fifteen days following the egg retrieval a blood pregnancy test is performed. If the test is positive, an ultrasound confirmation of a clinical pregnancy (presence of a heart beat) is performed about 3 weeks later. The hormone supplementation continues until the pregnancy can sustain itself at 12 weeks.
An option for individuals/couples with remaining embryos that are not immediately transferred into the uterus is to freeze (or cryopreserve) the embryos. After the embryo transfer, any untransferred embryos are placed in culture until they progress to the blastocyst stage. All good quality blastocyst stage embryos are then frozen. Cryopreserved embryos can be used in the event the carrier doesn’t conceive in the “fresh” IVF cycle or for later use to attempt for a sibling. Most patients (approximately 75%) will have 1 or more embryos to cryopreserve. Approximately 80-90% of cryopreserved embryos survive the thawing process.
Assisted Hatching is a common laboratory technique in which an embryologist uses a precise laser to make an opening in the shell of the embryo to facilitate implantation by the embryo into the uterine lining. The hatching is performed prior to loading the embryo into the transfer catheter. It is recommended if embryo quality is less than optimal, for all Frozen Embryo Transfer (FET) cycles, and cycles where cryopreserved eggs are used.
Acupuncture information (medical acupuncture and acupuncturists) is available to patients who request this adjunct therapy as part of their IVF treatment. Acupuncture may improve endometrial receptivity and increase blood flow to the pelvic area which can increase pregnancy rates. Treatments usually involve 1-2 sessions with the acupuncturist before the egg retrieval and then a session immediately before and after the embryo transfer. The sessions surrounding the embryo transfer may occur at the clinic for your convenience.