The first pregnancy following gestational-surrogacy was described by Utian et al1 and since then surrogacy has become a viable option for many infertile couples to have a biologically related child, especially in whom it is impossible or undesirable on medical grounds for the intended mother to carry the child herself.
In traditional surrogacy, the surrogate mother provides the oocyte as well as the uterus to foster pregnancy. However, in IVF surrogacy (otherwise known as ‘gestational surrogacy’ or ‘full surrogacy’), the surrogate mother gestates the genetically unrelated embryos produced by the gametes of the commissioning couple.
Gestational surrogacy is now been routinely conducted at our centre since 2004. The indications are varied and include: absent uterus (congenital absence or post hysterectomy for carcinomas, severe hemorrhage or rupture uterus), recurrent miscarriages, repeated IVF failures, for severe medical conditions which may make pregnancy life threatening for the intended mother.
According to ICMR (Indian Council of Medical Research) the following guidelines has been laid down for the selection of surrogate mothers which were strictly adhered to while recruiting these surrogates.
Following selection, the potential surrogate undergoes a complete work-up which includes screening for sexually transmitted disease, basic endocrinological test and ultrasound pelvis. We as a routine perform hysteroscopy in a previous cycle for all women to evaluate the uterine cavity. The commissioning couple and the gestational carrier along with their spouses then undergo psychological and legal counseling with appropriate legal contracts.
Both the commissioning mother and the surrogate mother are put on oral contraceptive pills in the previous cycle in order to synchronise there cycles. A long protocol for pituitary desensitization is used for the commissioning mothers Ovarian stimulation is done using gonadotropins starting on cycle day–2. The dose is adjusted according to ovarian response which is monitored by doing transvaginal sonographies and serum estradiol levels. HCG is administered when two or more leading follicles reached ≥ 18mm and oocyte retrieval is done under general anaesthesia after 34–36 hours.
The gestational carriers undergo pituitary desensitization by a long acting GnRh analogue administered in the luteal phase of the previous cycle. All these then receive exogenous estrogen (estradiol valerate) therapy for endometrial preparation before the embryo transfer. Micronised Progesterone is added on the day of ovum pickup of the commissioning mother. Day 3 or day 5 embryo transfers are done. Post transfer luteal support is given to all the recipients in the form of estradiol valerate 6mg/day and micronised progesterone 600mg/day. ß–hcg is done on day 14 post transfer to confirm pregnancy. If pregnancy was confirmed, luteal support is continued till 12 weeks of gestation.
A similar protocol for preparation of gestational carrier is used in case of frozen embryo transfer cycles. Micronized progesterone is started once the endometrial thickness and endometrial blood flow is adequate on sonography. Embryo transfer is subsequently done on day–3 / day–5 of starting of progesterone.
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