Third Party Reproduction
This article is part of the October 2006 INCIID Insights Newsletter
special reprint from the 2006 ART Resource Directory
Joel Batzofin, M.D. and Daniel Levine, M.D.
Third party parenting refers to those situations where an alternative pathway to pregnancy is utilized by an individual or couple. These options encompass donor sperm, donor egg, gestational (IVF) surrogacy and true surrogacy. Though ethical, moral, religious and legal concerns play a significant role in these treatments, they have allowed the miracle of childbirth to those who might otherwise be unable to achieve this goal.
Donor sperm is extensively used in reproductive medicine. This was introduced in 1884, 100 years before the first reports of successful egg donation! The indications for this use include uncorrectable male factor, the presence of undesirable genetic diseases, and for backup in the setting of advanced reproductive procedures such as in-vitro fertilization (IVF). Additionally, for women for whom a sperm source is not readily available, such as in same sex couples and single women, the use of donor sperm is likewise indicated. The preferred source of the donor sperm is that of a certified sperm bank that allows for the anonymous donation of sperm for these uses. The use of frozen sperm from these banks allows for the appropriate testing for sexually transmitted diseases (STD), such as HIV, in the donor over an extended time period prior to its use by the recipient, thus ensuring the safety of the specimen. Additionally, appropriate legal consents by a reputable bank will prevent future legal difficulties for the prospective parent(s). Although an alternative, a non-anonymous source of sperm, including friends and family members are occasionally utilized, this option may lead to a myriad of emotional, psychological and legal difficulties, as well as the potential for STD’s if fresh sperm is used. In the case of family members, however, the possibility of a genetic linkage is occasionally desirable, and therefore should be considered a potential option in certain cases.
Though certainly more complicated than donor sperm, the use of donated eggs has similarly allowed for pregnancy and childbirth through advanced reproductive technology (ART). The indications for using donated oocytes include advanced age of the woman with associated decreased ovarian reserve and poor egg quality, premature ovarian failure (either spontaneous or after radiation or chemotherapy for certain cancers), the presence of certain genetic diseases, and in the setting of multiple failed IVF cycles in women who have tried with their own oocytes. Since donor egg cycles utilize fresh embryos created with IVF, there is an increased potential for STD exposure. As in donor sperm, legal contracts are crucial to protect the parents and child(ren) created with this technology, as well as to specify the disposition of the embryos that are cryopreserved (frozen) in the event of death or divorce. Although non-anonymous donors are utilized by some individuals and couples, the use of anonymous donors are preferable for the same reasons as for donor sperm. Screening for the donors is therefore a critical part of the donor egg process, including a detailed history, with exclusion of women with high risk exposures such as multiple STDs, multiple medical problems, advanced age, genetic/familial concerns, or any other social or psychological concern that might lead to future difficulties.
Though the donor is usually paid for her services, the majority of women have altruistic motivation. One of the real problems, however, is that donors, as well as the agencies which recruit them, have created an “industry” from this approach. A real question and ethical dilemma is whether so called “market-forces” apply in egg donation. It seems fair and appropriate that egg donors get compensated a reasonable amount of money for their time, efforts and risks (minimal though it is) for donating eggs. Exactly how much money is reasonable is open to debate. However, when exorbitant amounts of money are charged by the donors (e.g. $10,000 and higher), this amounts to usury and a form of “black mail”. It is the opinion of these authors that the fees allowed for egg donation should come under some sort of regulation and donors should also be subjected to heavy taxation if the fees they charge are excessive. There are several reports of donors charging in excess of $50,000 on the basis of “superior genetics”. We do not believe in this practice and will strongly encourage recipients to use a different donor in such circumstances.
Just as for sperm donors, egg donor recipients should be able to obtain sufficient information about the physical and personality traits of the donor they are selecting. This allows the recipients to get a comfort level which will inevitably translate into an improved relationship with the resultant offspring.
In a donor egg cycle, the cycles of the donor and recipient are synchronized using medication called GnRH agonist (Lupron). When the cycle is initiated, the donor is administered gonadotropin stimulation medication, which contains Follicle Stimulating Hormone (FSH), and occasionally Leutinizing Hormone (LH), which will directly stimulate the ovaries of the donor to make multiple ovarian follicles, to enable the collection of multiple oocyctes. During this stimulation, the recipient is administered estrogen, and ultimately progesterone to prepare the uterine lining for an embryo transfer. When the follicles are sufficiently stimulated, an injection of human chorionic gonadotropin (hCG) is administered to the donor, and a transvaginal ultrasound-guided procedure under anesthesia is performed to collect the oocytes. These oocytes are subsequently fertilized in the laboratory with sperm from the husband, significant other or donor, either by deposition in dish surrounding the egg or by direct injection of the egg (ICSI). Fertilized embryos are then transferred back to the recipient on day 3 or day 5 after the retrieval, and the balance of oocytes are cryopreserved. Since the eggs of the donor are usually of very good quality, a critical decision about the number of embryos to transfer needs to be made, since this decision will directly impact on the risk of a multiple gestation pregnancy. Generally no more than three donated embryos are transferred to the recipient on day 3, and no more than two if transferred on Day 5.
Following embryo transfer, additional progesterone and occasionally hCG is administered to support the early phase of implantation and pregnancy. Blood pregnancy tests and ultimately ultrasound are performed when pregnancy is diagnosed, and the recipient is referred to her obstetrician once a viable pregnancy has been confirmed. Unlike standard IVF, where age and other factor may lessen pregnancy and live birth rates, with donor egg cycles, rates that exceed 60% may be reasonably excepted if conditions are optimal. While it is a rather expensive treatment, the success rates make this treatment a very viable alternative for certain couples.
IVF/ Gestational Carrier Surrogacy
In certain situations, a gestational carrier is required to carry a pregnancy after an IVF-generated embryo is transferred. This situation, sometimes called partial surrogacy or IVF surrogacy, is utilized for specific indications. These indications include prior hysterectomy, abnormal uterus due to multiple fibroids, congenital absence or malformations or DES exposure, or in women with medical diseases that would contraindicate a pregnancy.
Screening of the surrogate is a critical process as in egg donation cycle, with carriers excluded if medical, emotional or psychological issues would pose difficulties. As in donor egg cycles, a legal contract is critical to ensure the protection of the child and prospective parents, and requires the services of an attorney that specializes in this field. Since many states do not allow this treatment, it is often necessary to perform these procedures in a state where surrogacy laws are more favorable. Some states recognize the legal status of the biologic parents in a gestational surrogacy situation, but do not allow the actual IVF procedure to take place in that state. Some states will allow the IVF procedure and recognize the legal status of the biologic parents, but only if no money changes hands.
Other legal considerations include concerns about inclusion of the biologic/genetic parents on the child’s birth certificate, a significant issue for most prospective parents going through this procedure. Though the carrier has no genetic connection to the child, certain states will define the birth of a child as the factor that dictates who is the mother, confirming the contracts that specify genetic parentage, which have been upheld in court cases. In disputed cases, often the intent of the original participants in this procedure is assessed as a deciding factor if contractual and or custody issues arise.
As in donor egg cycles, the egg producer (the patient) and the egg recipient (carrier) are synchronized with Lupron. Stimulation with gonadotropin stimulation medication is then performed on the woman, with hCG administered after 10-12 days when ultrasound and blood work confirm adequate number of follicles. The carrier, in a similar fashion to egg donor recipient, is administered estrogen and ultimately progesterone in preparation for the embryo transfer. The IVF retrieval is then performed on the stimulated woman, and the oocytes obtained are fertilized with sperm from the husband, significant other or sperm donor. The fertilized eggs are transferred as embryos on day 3or day 5, similar to standard IVF or egg donor cycles, with again discussion concerning number to transfer. Since the egg quality is reflective of the age of the donor and related issues, however, the decision with regard to number of embryos to transfer needs to be individualized. Continued support of the uterine lining with progesterone or hCG is administered to the recipient carrier, who will have the pregnancy confirmed by blood tests and ultrasound, and be referred to an obstetrician with experience in gestational carrier cases once pregnancy viability is established.
Upon birth or the infant via either vaginal delivery or cesarean section, the infant is delivered to the couple utilizing an adoption type procedure specified in the contract. Since pregnancy rates in gestational surrogacy reflect predominantly the age of the egg producer, in combination with other factors, rates will be individually determined by the circumstances and may be less than those with egg donor cycles.
Surrogacy, sometimes called traditional surrogacy, encompasses a situation where the carrier is also the egg donor. The indications for this include many issues as in the gestational carrier, plus potential issues of ovarian reserve as in egg donor cases. These cases present more potential difficulty, on emotional as well as legal grounds, since the surrogate is now producing the egg, carrying the pregnancy and delivering the child. Certain states such as California are very “surrogacy friendly”, though many states outlaw this treatment. Moreover, the legal requirements are greater, with the surrogate having more potential claim to the child produced with this treatment. The actual procedure, however, is less involved than gestational surrogacy, since IVF is not necessary, and cost as well as availability of the surrogate issues may play a role in the decision to utilize this treatment. Done appropriately, however, with adequate medical and psychological screening, adequate counseling and appropriate legal preparation, surrogacy represents another viable path to parenthood for many people.
Third party parenting represents a significant treatment in reproductive medicine. Extremely favorable success rates can be achieved using these modalities. As technology grows and more awareness is generated as to our ability to offer these services, the ability to offer parenthood to more people also increases. These treatments, however, require that continued attention to personal, moral and ethical issues also continues, to ensure that these treatments are readily available to those in need of such assistance.
Joel Batzofin M.D. is an internationally recognized expert in the field of ART. Among his many accomplishments he founded the Huntington Reproductive Center in Pasadena, California in 1988. Dr. Batzofin now is the Medical Director of Sher Institute for Reproductive Medicine -New York City. Dr. Batzofin has a special interest and expertise in third party parenting (i.e. egg donation and gestational surrogacy). He is an active clinical investigator and remains committed to the needs and interests of the consumer in a rapidly evolving area of medicine.
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