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!