Understanding IVF Processes in Surrogacy Craig Reisser 20 October 2018 Stockholm

Craig Reisser, Global Programs Director Dad through donor egg surrogacy 2 journeys – 3 years minus 3 weeks ORM Patient Same surrogate for both journeys One egg donation, ORM Donor Writer for Fertility Road on surrogacy and egg donation London-based 1

Oregon Reproductive Medicine Founded in 1989 - nearly 30 years building families – patients from 40 countries Among one of the largest IVF full service clinics in the US State-of-the art “clean-room” embryo laboratory designed by engineers who have also designed the fabrication plants at Intel in Oregon Specialist in key treatments: In-house egg donor program Surrogacy IVF In-house genetics team and laboratory

Surrogacy in the USA 1 Gestational Surrogacy vs Traditional Surrogacy +30 years of experience – tens of thousands of US and international families created Full medical, professional, legal infrastructure in place for safe and ethical surrogacy journeys There is the surrogate and egg donor for everyone Greater focus on relationships between intended parents and surrogates and egg donors 2 3 4 5

Putting Things in Context 2,000 Transfers Patient Eggs + Surrogate IVF 4,000 Transfers IVF with a Surrogate 3% of IVF Heterosexual Couples Single Women Female Couples 140,000 Transfers 2,000 Transfers Donor Eggs + Surrogate Heterosexual Couples Male Couples Single Men, Single Women Female Couples

Key Decisions for Getting Started 1 Timing – when do you want to be a parent? What size family do you want? Who will be a genetic parent? Where do intend to live; what nationality(ies) are you? Do you care where your surrogate lives? What is your budget? 2 3 4 5 6

The Key Parties in the Process IVF Clinic Own surrogate Agency surrogate Surrogate Donor The top 10 clinics in the US do 35-40% of these procedures Friend or Family IVF Clinic Donor Agency Donor May provide a different diversity of donors – agencies charge a fee, less likely to be local to your clinic, not fully screened – you pay for medical screening +135 surrogacy agencies in the USA – the top 10 mange about 35% of cases Can be a cheaper, faster, more certain option – fully screened and medically approved – donors typically reflect the local demographics

Role of the IVF Clinic Medical screening and approval of egg provider (yourself or donor) and surrogate Sperm provider medical screening Medical treatment of your egg provider (yourself or donor) and surrogate through the IVF process Embryology Genetic screening 1 2 3 4 5

Choosing an IVF Clinic 1 Experience with the type of procedure you require – surrogacy, egg donation, genetics, international patients Live birth success rates – public databases in the USA In-house egg donor program Team that you trust Cost 2 3 4 5 Physical location of your IVF clinic may be less important

Role of the Surrogacy Agency Recruiting and non-medical screening of surrogates Matching intended parents with a surrogate – helping to facilitate that relationship Helping manage US legal elements of the process Helping manage US medical insurance elements of the process Looking after the interests of both the surrogate and the intended parents 1 2 3 4 5

Choosing a Surrogacy Agency 1 Experience, reputation and service level Screening protocols for surrogates Which states the agency recruits surrogates in Team that you trust – 18 months or more working together Waiting time for a surrogate match and twins policy Cost 2 3 4 5 6 Physical location of your surrogacy agency may be less important

18 Months Journey – 3 Major Blocks of Time About 18 Months 6 months 3 months 9 months Surrogate Match, Legal, Medical Surrogate Waiting for a Surrogate Pregnancy, Parental Rights Legal IVF Physician Surrogate’s OB/GYN Selecting a Donor, Creating Embryos Donor

Where Your Surrogate Lives is Relevant 1 Where your surrogate lives and your child is born is important - This is where you will travel the most - That state’s laws will govern the surrogacy agreement - That state’s law will determine your parental rights process Currently 46 states where compensated surrogacy is legal States differ in the process for establishing parental rights - Pre or post birth - Whether it is an administrative process or a court hearing is required - Legal relationship status / open to couples or individuals - State-wide or county-specific Your surrogacy agency will match you with a surrogate who lives in a state where the legal framework will work for you 2 3 4

Basic Steps in Every IVF Cycle Reproductive Genomics is Revolutionising IVF Carrier Screening Embryo Testing (PGS/PGD) Frozen Embryo Transfer Fresh Embryo Transfer Creation of Embryos, Grading and Testing Selection and Transfer Sperm Provider(s) Selecting Embryos (Grading + Testing) Uterus (Stimulation + Transfer) Uterus (Stimulation + Transfer) Eggs (Stimulation + Retrieval) Embryology (Insemination + Development) Egg Provider Patient / Donor Surrogate IVF in surrogacy adds some complexity and requires many choices Patient Commonly the woman providing the egg and carrying the pregnancy are the same

Eggs - Controlled Ovarian Hyperstimulation Normal Cycle IVF Cycle

Eggs - Retrieval

Embryology - Insemination Standard Insemination Egg Embryologists ICSI

Embryology - Embryos Grow Till Day 5-6 Day 5-6: Blastocyst Day 3 Day 2 Day 1 At Day 5-6 We Either Transfer Fresh or Freeze Day 5-6 is When We Perform PGS / PGD

Average IVF Results – Woman of 25 Years Age 26 Follicles produce 25 Eggs 20 Mature Eggs 15 Fertilized Eggs = “Embryos” 11 Embryos growing on Day 3 8 top quality Blastocysts (day 5 Embryos) 5 chromosomally Normal Blastocysts 50%+ implantation rate

Selecting Embryos Morphological Grading Chromosomally Normal (PGS) Genetically Healthy (PGD) if called-for 1 2 3 1

PGS Screening – Comprehensive Chromosome Screening (CCS) with Next Generation Sequencing (NGS) Removal of 5-10 trophectoderm cells Next Generation Sequencing Detects embryos with abnormal number of chromosomes Increase implantation rates/transfer Decrease miscarriage rates Identify abnormal fetus (e.g. Down Syndrome) Can minimize surrogate cycles

Rate of Chromosomally Normal Embryos   Egg Donor <35 35-37 38-40 41-42 Normal Embryo Rate* 61% 51% 43% 30% 18% * Combined data from Reprogenetics and Genesis Genetics up to March 2016 – 33,236 embryos tested

Impact of CCS Testing

Surrogate Uterus - Uterine Stimulation

Surrogate Uterus – Embryo Transfer

Donor Selection Personal Information - Education and interests - Reasons for donating - Photos (adult and childhood) - Physical and ethnic characteristics - Personal and family medical history - Genetic screening Ovarian Reserve / Donation Success - Donor medical – Age, BMI,AMH, BAF - Prior donation outcomes Relationship - Anonymous v. open Costs Donor Medical Screening / Ovarian Reserve is Key for Success

Surrogate Matching State of residence Marital status Twins Personality match Relationship expectations during journey Views on selective reduction Surrogate medical screening BMI, number of prior pregnancies, number of caesarian deliveries, location to hospital, non-smoker, non drinker, no drug history, no psychiatric issues or medications, no obstetrical or medical history concerns, infectious disease clear, immune to varicella and rubella Surrogate Medical Screening is Key for Safe Pregnancies

Thank you!