Assisted conception and MRKH syndrome Dr Anna Carby Fertility Specialist IVF Hammersmith

Overview Reproductive options What is surrogacy treatment Treatment pathway Investigations Treatment cycle Outcomes at IVF Hammersmith

Options Freezing embryos for surrogacy (currently in a relationship) Freezing eggs for surrogacy (not currently in a relationship) Adoption

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

Surrogacy in the UK Legal issues surrounding surrogacy Surrogacy Agreements Act (1985) HFEA Act (2008 section 30) Any agreement between a surrogate mother and intended parents is not legally enforceable Important to have surrogacy agreement to make intentions clear and provide evidence of intentions Legal advice important

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

How do you find a surrogate? Family member/friend By chance Through surrogacy agency – Surrogacy UK (recognised by HFEA and BMA) , COTS

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

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

Investigations – blood tests AMH testing – not currently available through NHS but best marker of “ovarian reserve” ie how well ovaries may respond to stimulation FSH testing – cycle specific therefore more difficult to test

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

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

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

Role of the counsellor Legal, financial and emotional implications of treatment Signing of consents (many!) Stress management

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

The treatment cycle for you Aim is to stimulate ovaries to produce upward of 5 follicles Requires control of ovarian cycle May use contraceptive pill prior to treatment Then a series of injections for approx 2 weeks to shut down ovarian function and control ovaries (buserelin) Additional injection for further approx 2 weeks to stimulate ovaries (FSH)

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

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

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 0-20+ !

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

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

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%

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

Chances of success with frozen embryos Jan Feb Mar Apr May Jun Number of FERC transfers 31 35 37 22 26 29 % Clinical pregnancy rate 39 41 36 38

Outcomes of treatment 10 patients (12 cycles of treatment) completed Average age at treatment 29 3 patients laparoscopic egg collection 7 transvaginal egg collection 159 eggs collected in total! 100 embryos and 10 eggs frozen

Outcomes of treatment 2 surrogacy cycles completed 1 livebirth 1 ongoing pregnancy

Any questions Contact IVF Hammersmith 0203 313 4411 Mr Stuart Lavery, Mr Geoffrey Trew, Dr Anna Carby, Sister Cathy Turner Referrals fax 0208 749 6973 www.ivfhammersmith.com www.londonfertilitysurgery.co.uk www.hfea.org.uk