Assisted reproduction – insemination and in vitro fertilization
• First IVF-baby born in 1978
• IVF is nowadays a routine treatment procedure
for all indications of infertility
• Tubal
• Endometriosis
• Poor sperm quality
• Unexplained
• Worldwide about 5 million IVF babies born
• In 2015 in Finland 2568 children born after ART
treatment (5.6 % of all children born)
1
ART treatments 1992–2016
Lähde: THL, Hedelmöityshoitotilastot
* Ennakkotieto
Sperman- ja alkionluovutukset 2001 alkaen, inseminaatiot 2006 alkaen
0
2 000
4 000
6 000
8 000
10 000
12 000
14 000
16 000
1992 1995 2000 2005 2010 2016*
Ho
ito
jen
lu
ku
mä
ärä
IVF ICSI FET Koeputki, luovutushoidot IUI IUI, luovutushoidot
19.3% of all treatments with
donated gametes 2015
Docent Viveca Söderström-Anttila
Felicitas Mehiläinen
Helsinki, Finland
Gyllenberg symposium
Helsinki
September 23rd 2017
Surrogacy:
outcomes for surrogate mothers,
children and the resulting parents
Disclosure
▪ Docent, specialist in gynecology, obstetrics and reproductive endocrinology
▪ Main occupation
▪ Felicitas Mehiläinen, Helsinki
▪ Other engagements
▪ Board member of Signe and Ane Gyllenberg Foundation
▪ Member of NFS expert group (unconditional support by Finox)
▪ Conference presentations (Ferring, Merck, MSD)
• Definitions
• Surrogacy legislation in Europe
• Indications for surrogacy treatment
• Experience of gestational surrogacy in Finland
• Concerns related to gestational surrogacy
• Outcomes of surrogate mothers, children and intended parents
Introduction and definitions
Gestational or in vitro fertilization surrogacy (host or full surrogacy)
• an embryo from the intended parents, or from a donated oocyte or sperm, is transferred to the surrogate´s uterus.
• the woman who carries the child has no genetic connection to the child.
• First reported in 1985
Traditional (genetic or partial) surrogacy
• is the result of artificial insemination of the surrogate mother with the intended father´s sperm.
• The surrogate mother´s eggs are used, making her a genetic parent together with the intended father.
6
Surrogacy – carrying the pregnancy for intended parents:
Denmark Finland Iceland Norway Sweden
Gestational
surrogacy
Prohibited
since 1997
Prohibited
since 2007
Prohibited
since 1996
Prohibited
since 1987
Prohibited
since 1988
Traditional
surrogacy
Prohibits
assisting
contact
Unregulated Unregulated Contract not
binding
Unregulated
Surrogacy legislation in different countries
• In Europe, surrogacy is prohibited in the Nordic countries and in Austria, Bulgaria, France, Germany, Italy, Malta, and Spain.
• Altruistic, but not commercial, surrogacy is allowed in Belgium, Greece, the Netherlands, Portugal (since 2016 in certain specific situations) and the United Kingdom.
• Poland and the Czech Republic have no laws regulating surrogacy.
• Commercial surrogacy is legal in Georgia, Israel, Ukraine, Russia, India and California
• Only altruistic surrogacy allowed in many US states, Australia, Canada, and New Zealand.
8
Brunet L, et al A Comparative Study on the Regime of Surrogacy in EU
Member States. 2013. http://www.europarl.europa.eu/studies,
http://www.europarl.europa.eu/studies.
Indications for treatment with gestational surrogacy
1. Congenital absence of uterus; (MRKH) syndrome
2. After hysterectomy for obstetric complications
3. After hysterectomy for cancer or other uterine diseases
4. Uterus anomaly
5. Medical conditions incompatible with pregnancy
6. Biologic inability to conceive or bear a child, such as
same sex male couples or single men
Recommendations regarding gestational carriers
• A gestational carrier should be 21-45 years of age and she should have at least one child.
• Her previous pregnancies should be full-term and uncomplicated
• The carrier should not have had more than a total of five previous deliveries and three deliveries via CS
• General requirements as to the screening and the recommendations related to psychosocial consultations have been summarized by the expert groups from ESHRE and ASRM
• Surrogacy arrangements should not be commercial
10ESHRE Task Force on Ethics and Law, 2005; FIGO Committee Report, 2008; Practice
committee of ASRM, 2015)
Gestational surrogacy treatments performed in Finland
1992-2001
• 12 couples at Väestöliitto• 3 at Felicitas Clinic• 2 at Eira Hospital• 1 at Kuopio University Hospital
• Two Swedish couples, one Norwegian and one Danish couple
18 couples
No of women
Congenital absence of uterus and vagina 6
Ruptured uterus during pregnancy or delivery;
hysterectomy
3
Postpartum bleeding; hysterectomy 2
Hysterectomy due to sarcoma, cervical cancer,
adenomyosis
3
Uterine factors 3
Severe LED 1
• Mother 3• Sister 6• Husband´s sister 1• Cousin 1• Friend 4• Other 3
Mean age of the surrogate mother 36 yrs (29 – 52 yrs)
All had children (1-4) of their own
All surrogate mothers were arranged by the intended parents:
*In one treatment use of donated oocytes
No. of intended parents 17
No. of oocytes per retrieval* 13.2 (1 – 30)
No. of surrogate mothers 18
Clinical pregnancy/fresh ET 50.0 % (8/16)
Clinical pregnancy/frozen-thawed ET 15.8 % (3/19)
Live birth rate /intended parents 58.8 % (10/17)
• Intended mother had IVF: 15 oocytes, 5 embryos
• Elective SET to the surrogate mother
• Normal pregnancy and CS of a healthy boy (bw 2930g)
• The child was handed over to the genetic parents at 12 min of age
• Adoption of the child at the age of 2 months.
36 year old women
First pregnancy
During delivery Ablatio placenta
CS; death of the child
Heavy bleeding
Hysterectomy
Surrogate mother: Sister 42-years
Married
Three normal pregnancies, three children
• Obstetric outcome• No serious complications, one preterm delivery• Caesarean section 70 %
• 11 infants born• Birth weight of singletons 3498 g (2270 – 4650 g), twins 2900 g and 2400 g
• The child handed over to the intended parents soon after the birth
• Adoption of the child at 2 months of age
• Two surrogate mothers suffered from mild and moderate postpartum depression
Why is surrogacy treatment prohibited in many countries?
What are the concerns?
1. Risks of obstetric complications for the surrogate mother
- neonatal outcome
2. Long-term effects on the child?
3. Concern that negative psychological reactions may occur post-
partum in relation to surrendering the child
4. Risk that the intended parents will not accept the child,
especially if he/she is disabled
5. Risk of commercialization
19
Obstetric outcome in surrogate mothers
• The duration of singleton surrogacy pregnancies was similar to or shorter than that of singleton standard IVF pregnancies
• Incidence of preterm birth (<37 weeks) numerically lower than that of standard IVF
• Relatively high incidence of CS (13-78%)
• Three case reports on hysterectomies (uterine atony, placenta accreta, uterine rupture).
• Two of these occurred in multiple pregnancies.
• Multiple pregnancies should be avoided by elective SET 20
Söderström-Anttila et al., Hum Reprod Update 2016
Obstetric outcome in surrogate mothersRisk of hypertensive disease in a singleton pregnancy
• A healthy surrogate mother with a normal reproductive background
might compensate for atypical immunological reactions related to a
foreign embryo
• A surrogate might have a more hospitable uterine environment than
infertile oocyte recipients
21
Surrogatemothers
Oocyte
donation
OD recipients
Standard
IVF/ICSI
Spontaneous
conception
Hypertensive
Disease in Pregnancy
(HDP)
3.2-10% 13.0-39.3 1.9-23.3 2.1-3.8
Pre-eclampsia 9.3-16.9 3.2-11.5 2.4-3.8
Cesarean section 13-78% 31.4-85.0 25.3-56.0 16.3-17.5
Outcomes for children
• Gestational age
• Birthweight
• Birth defects
• Psychological follow-up
22
Outcomes for children
Mean birth weight
• 3309 - 3536 g for surrogate singletons
• 3100 - 3240 g for standard IVF
• 3226 g for oocyte donation
• Similar rates of preterm birth after surrogacy and standard IVF
• Similar or lower rate of low birth weight babies after surrogacy treatment
compared to standard IVF
• Similar rates of birth defects were reported in singletons after surrogacy
treatment, oocyte donation and conventional IVF 23
Söderström-Anttila et al., Hum Reprod Update 2016
• Limited knowledge and almost all studies from the UK
• Follow-up time 1-10 years of 21-42 children
• No major psychological differences between children born after surrogacy,
children born after gamete donation, and after natural conception.
• No differences in psychological adjustment between different ART groups
Outcomes for children – psychological development
Söderström-Anttila et al., Hum Reprod Update 2016
Experiences of being a surrogate mother
25
• 15 studies
• Surrogate mothers generally report being satisfied with their
experiences
• The rate of immediate postpartum depression 0 - 20 %
• Problems with handing over the child were rare
• Slight difficulties one year after surrendering the child 6% – It has been suggested that the surrogate mother may not view the child that
she is carrying as her child, thereby facilitating the relinquishment
– Not always clear whether the child was the result of traditional or gestational
surrogacy
Söderström-Anttila et al., Hum Reprod Update 2016
Psychological outcome for intended parents
26
•16 studies, most from UK
• No major differences in parent’s psychological
state or mother-child interaction between
intended mothers, egg donation mothers and
mothers of spontaneous conception.
• Most parents inform their child of the way of
conception
Söderström-Anttila et al., Hum Reprod Update 2016
Ethical aspects
• The treatment should be non-commercial
• Commercialization can be avoided by legal definitions, clear contracts, licence practice, supervision by authorities
• It is an ethical dilemma that the Nordic countries are pushing their citizens abroad to commercial surrogacy
• Compensation/payment
• The reason for participating should be a wish to help, not money
• Reimbursement of reasonable expenses and compensation for loss of income for the surrogate should be considered
27
• According to published studies most surrogacy arrangements are successfully implemented
• Most surrogate mothers are well motivated and have little difficulty separating from the children born
• The perinatal outcome of the children is comparable to standard IVF and OD
• Surrogacy children are as healthy as other IVF children
BUT
• Most studies reporting on surrogacy have significant methodological limitations.
• No data on outcome for families and surrogate mothers involved in commercial cross-country surrogacy
• No studies on children growing up with gay fathers.
• Long-term follow-up studies on surrogacy children and families are lacking 28
Hum Reprod Update 2016
29
Thank you!