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
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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
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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
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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-
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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
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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
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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
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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
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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
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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
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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
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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
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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
50
45
40
39
41
37
36
38
38
May
Jun
35
30
25
20
15
10
5
0
Jan
Feb
Mar
Apr
2010 month
Jan
Feb
Mar
Apr
May
Jun
Number of FERC
transfers
31
35
37
22
26
29
% Clinical
pregnancy rate
39
37
41
36
38
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
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completed
1 livebirth
1 ongoing pregnancy
Any questions
• Contact IVF Hammersmith 0203 313 4411
• Mr Stuart Lavery, Mr Geoffrey Trew, Dr Anna
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Carby, Sister Cathy Turner
Referrals fax 0208 749 6973
www.ivfhammersmith.com
www.londonfertilitysurgery.co.uk
www.hfea.org.uk