1. Assisted conception and MRKH syndrome
Dr Anna Carby
Fertility Specialist
IVF Hammersmith

2. Overview Reproductive options What is surrogacy treatment
Treatment pathway
Investigations
Treatment cycle
Outcomes at IVF Hammersmith

3. Options Freezing embryos for surrogacy (currently in a relationship)
Freezing eggs for surrogacy (not currently in a relationship)
Adoption

4. What is surrogacy?
Term used to describe situation where a woman agrees to become pregnant and have a baby for another couple
Woman who carries the baby is the surrogate
Couple who intend to be the parents are called the intended parents

5. Surrogacy in the UK Legal issues surrounding surrogacy
Surrogacy Agreements Act (1985)
HFEA Act (2008 section 30)
Any agreement between a surrogate mother and intended parents is not legally enforceable
Important to have surrogacy agreement to make intentions clear and provide evidence of intentions
Legal advice important

6. Types of surrogacy arrangement
Full/host surrogacy – intended parents use IVF treatment to create embryos form their own eggs and sperm and these are replaced in to the uterus of the surrogate
Partial /straight surrogacy – surrogate’s eggs are used with intended fathers sperm for IVF or IUI

7. How do you find a surrogate?
Family member/friend
By chance
Through surrogacy agency – Surrogacy UK (recognised by HFEA and BMA) , COTS

8. Pathway IVF Hammersmith
Referral from GP/specialist
Out-patient appointment within 4 weeks NHS (or private appointment if desired)
Assessment - initial consultation, medical history and investigations
Follow-up appointment
Application for funding if NHS
Counselling and nurse appointments
Pre-treatment blood tests
Treatment cycle
Quarantine embryos
Transfer in to surrogate

9. Investigations – ultrasound scan
May be either internal or transabdominal
Internal gives better picture of ovaries and allows assessment of accessibility
Volume of ovaries and activity

10. Investigations – blood tests
AMH testing – not currently available through NHS but best marker of “ovarian reserve” ie how well ovaries may respond to stimulation
FSH testing – cycle specific therefore more difficult to test

11. Investigations – semen analysis
Extremely important!
Produce sample on-site
Analysis of count and motility

12. Review appointment Results of investigations
Plan for funding and treatment
NHS funding approved?
Referral to counsellor
Referral to specialist nurse

13. Funding of treatment
All surrogacy treatment cycles must be approved by the female partners PCT (primary care trust)
PCT is defined by the female partners GP location
If funding is granted it covers the cost of producing embryos and most usually freezing and storage for the first year
The costs of the surrogate transfer are not included and this has to be performed privately

14. Role of the counsellor
Legal, financial and emotional implications of treatment
Signing of consents (many!)
Stress management

15. Role of the specialist nurse
Communication with GP for surrogate and commissioning female – medical history, welfare of the child
Screening blood tests - obligatory
Karyotyping (chromosomal testing for commissioning couple), blood grouping, cystic fibrosis screening
Potential transfer of infectious diseases with embryos (HIV, Hep B and C, syphilis, chlamydia, gonorrhoea, CMV). Testing within 3 months of treatment
Repeat infectious diseases testing after 6 months quarantine of embryos

16. The treatment cycle for you
Aim is to stimulate ovaries to produce upward of 5 follicles
Requires control of ovarian cycle
May use contraceptive pill prior to treatment
Then a series of injections for approx 2 weeks to shut down ovarian function and control ovaries (buserelin)
Additional injection for further approx 2 weeks to stimulate ovaries (FSH)

17. The treatment cycle (injections)
Sub-cutaneous
Daily at home
Similar to diabetic pen with dial-up dosage

18. The treatment cycle - monitoring
Transvaginal or transabdominal scans and hormonal blood tests (estradiol)
Approx 4 visits per treatment cycle
Early appointments – from 7am
Perfectly possible to work whilst stimulating

19. The treatment cycle – egg collection
Either transvaginally or laparoscopically
Transvaginal - better egg yield, intravenous sedation, possible for majority. Quick recovery time
Laparoscopically – for ovaries that can’t be reached safely transvaginally. Requires general anaesthetic, day case operation
Average numbers collected – approx 10 but may be anything from !

20. The treatment cycle - fertilisation
Partner produces sample on the day of egg collection
Purified to remove non-viable sperm and achieve concentrated sample
Egg fertilised - normally by a process called ICSI

21. The treatment cycle - freezing
Embryos frozen either day 1, 3 or 5
Quarantine period of 6 months
Repeat viral screening
Available for subsequent transfer in to surrogate
Can be frozen for use for up to 10 years

22. The treatment cycle - risks
No treatment is without risk
But risks with IVF are low
Over-response OHSS (ovarian hyperstimulation syndrome) approx 3-5% cycles
Under-response and cancellation – approx 3%
Bleeding – less than 1%
Damage to other structures (bowel, bladder) less than 1%
Infection – less than 1%

23. The treatment cycle – for the surrogate
Preparation of the womb for transfer of embryos
Transfer in the natural menstrual cycle if regular
May be achieved with control of menstrual cycle and hormonal support with estrogen patches and progesterone pessaries up to 12 weeks of pregnancy

24. Chances of success with frozen embryos
Jan
Feb
Mar
Apr
May
Jun
Number of FERC transfers 31 35 37 22 26 29
% Clinical pregnancy rate 39 41 36 38

25. Outcomes of treatment 10 patients (12 cycles of treatment) completed
Average age at treatment 29
3 patients laparoscopic egg collection
7 transvaginal egg collection
159 eggs collected in total!
100 embryos and 10 eggs frozen

26. Outcomes of treatment 2 surrogacy cycles completed 1 livebirth
1 ongoing pregnancy

27. Any questions Contact IVF Hammersmith 0203 313 4411
Mr Stuart Lavery, Mr Geoffrey Trew, Dr Anna Carby
Referrals fax