1. Understanding IVF Processes in Surrogacy
Craig Reisser
20 October 2018 Stockholm

2. 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

3. Oregon Reproductive Medicine
Founded in 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

4. 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

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

6. Key Decisions for Getting Started1
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

7. 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

8. 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

9. 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

10. 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

11. Choosing a Surrogacy Agency1
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

12. 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

13. Where Your Surrogate Lives is Relevant1
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

14. 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

15. Eggs - Controlled Ovarian Hyperstimulation
Normal Cycle
IVF Cycle

16. Eggs - Retrieval

17. Embryology - Insemination
Standard Insemination
Egg
Embryologists
ICSI

18. 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

19. 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

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

21. 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

22. 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

23. Impact of CCS Testing

24. Surrogate Uterus - Uterine Stimulation

25. Surrogate Uterus – Embryo Transfer

26. 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

27. 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

28. Thank you!