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. Reproductive 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. 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

6. 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

7. 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

8. Investigations – blood tests
AMH testing –marker of “ovarian reserve” ie how well ovaries may respond to stimulation
FSH testing – cycle specific therefore more difficult to test

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

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

11. 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

12. 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, HTLV 1 and 2,Hep B and C, syphilis, chlamydia, gonorrhoea, CMV). Testing within 3 months of treatment
Repeat infectious diseases testing after 6 months quarantine of embryos

13. The treatment cycle for you
Aim is to stimulate ovaries to produce upward of 5 follicles
Requires control of ovulation
May use contraceptive pill prior to treatment
Then a series of injections for 2-4 weeks to reach egg collection

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

15. 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

16. 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 !

17. 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

18. 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

19. 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%

20. 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

21. Chances of success with frozen embryos
16-35
35-37
38-39
40-42
Number of FERC transfers
144 73 57 32
% Clinical pregnancy rate
38.9
42.5
35.1
18.8

22. Outcomes of treatment 21 stimulation cycles completed
Average age at treatment 30.6
4 patients laparoscopic egg collection
13 transvaginal egg collection
244 eggs collected in total!
135 embryos and 10 eggs frozen

23. Outcomes of treatment 13 transfer cycles completed 3 livebirths
1 pregnancy 27 weeks

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