Watch the webinar with Gad Lavy, M.D., F.A.C.O.G, a medical director and founder of New England Fertility (NEF), who is talking about surrogacy for patients after multiple failed IVF attempts. Dr Lavy has presented some case studies of his own patients.
What is surrogacy? Surrogacy involves a woman (the surrogate) carrying a pregnancy for the intended parents. There are two types:
Various individuals turn to surrogacy, each with their own unique circumstances. These include heterosexual couples, same-sex couples, single men, and single women. When discussing the medical aspects of surrogacy, same-sex couples are not typically the focus, as surrogacy is often their only option. People seek surrogacy for various reasons, including medical issues. Some women have conditions that prevent them from carrying a pregnancy safely, such as cancer, heart conditions, kidney conditions, or clotting disorders. While these women may have viable eggs and a normal uterus, their medical conditions make carrying a pregnancy unsafe. Additionally, there are cases involving anatomical issues, such as women who have had a hysterectomy or have a damaged uterus.
Another reason for surrogacy is emotional concerns, such as anxiety about becoming pregnant or carrying a pregnancy. There is even a medical term for this, called tocophobia. While it’s not a common cause, it can occur.
Some turn to surrogacy after experiencing infertility. They undergo IVF, but it doesn’t work, even after repeated attempts. Everything seems fine—the embryos look good, and sometimes the uterus looks great—but it still doesn’t work. For same-sex couples and singles, surrogacy is a must. They need to use an egg donor and a surrogate, so they come to surrogacy from a different place. Heterosexual couples often come to surrogacy after failing more traditional treatments, carrying with them a much more significant emotional burden.
In cases where couples undergo IVF—whether using their own sperm and eggs or donor sperm and eggs—and experience repeated failures with embryo transfers, a realization often emerges that something might be wrong. This realization represents a significant turning point for many couples, leading them to consider alternative options after numerous unsuccessful IVF attempts. When the issue is related to the uterus, surrogacy is highly successful, though it represents a major emotional and financial step.
Here are 2 cases where a couple needed to undergo a surrogacy procedure, these cases demonstrate different angles of failed IVF leading to surrogacy or successful surrogacy.
They underwent a fertility workup, with normal evaluations for both male and female factors, including ovulation and sperm analysis. Everything appeared normal. They started with first-line, more traditional treatments, like ovulation drugs and inseminations. Those are usually limited to 2 or 3 attempts because if it hasn’t worked by then, the chances of success are slim. They moved on to IVF. The female was young, healthy, and had good ovarian function, and the male had normal sperm, IVF resulted in very good embryos. However, 3 attempts failed.
During their initial treatments, despite hormone therapy, the uterine lining was thin. Sometimes the lining thickens, but not as much as expected. If you have good embryos, then you are even more suspicious that it’s not an embryo factor but a uterine factor. This couple’s woman went through an evaluation of the lining. The evaluation of the lining is something that is developing. There is still no final test for it, but there are some new tests available that were not available in the past. These tests allow a deeper look into the development of the uterus. One of them is the ERA test (Endometrial Receptivity Assay), a new test based on the genetics and gene expression of the endometrium, which helps identify the window of implantation. This couple went through this evaluation, and the results were normal. After many tries and quite a bit of time, the doctor finally recommended that the Swedish couple consider surrogacy.
One of the surrogacy issues is that in most European countries and Western Europe in particular, surrogacy is not legal. Additionally, doctors there are often ambivalent or reluctant to recommend surrogacy because they don’t consider it a real option. This can delay the decision, or at least the step where the couple needs to consider it.
They found a surrogate, a 42-year-old from Florida. The surrogate was healthy, had 2 children, and had normal pregnancies and deliveries. The surrogate was screened, tested, and ready. The embryos were created embryos using IVF, and PGT-A testing has been performed to make sure the embryos are genetically normal. A high percentage of embryos are found to be genetically abnormal, even in young women and egg donors.
A single embryo transfer has been performed, a natural cycle protocol has been used, relying on the surrogate own cycle to prepare the uterus because these women have normal cycles, conceived naturally, and had their own children. The transfer didn’t work on the 1st attempt, but was successful on the 2nd attempt. The pregnancy and delivery were good. The success rate with IVF is around 70 to 80%. Most cases that don’t work the 1st time do work the 2nd time. The cumulative success between the first and second cycles is over 90%. Most people are successful on the first try, and those who are not often succeed on the second.
A significant part of surrogacy is the legal aspect, which must be handled very carefully. Being from Europe adds another level of complexity. Once the baby is born, the couple wants to go back home and ensure the baby is registered in their home country and has all the necessary papers. In the U.S., there is a legal contract signed with the surrogate that covers all aspects of the process before, during, and after. The contract is detailed and covers costs, expectations during the pregnancy, how many embryos will be transferred, and considerations related to COVID-19 safety. The surrogacy contract is done before scheduling the embryo transfer. Once that’s done, it’s possible to proceed with the transfer.
In the U.S., it’s possible to register the parents as legal parents during the pregnancy. The lawyer goes to court, and the court declares you as the parents, meaning both parents’ names are on the birth certificate as soon as the baby is born. This simplifies the whole process and can be done for same-sex couples as well. Additionally, the baby born in the U.S. automatically becomes an American citizen. Although it may not be a big deal anymore, the baby immediately gains citizenship and can get a passport within a few days. It then depends on where you are in the world and your local laws. Sometimes it’s easier to get local paperwork or citizenship through the consulate, or most people travel back home with their American passport and visa and then make arrangements with a local lawyer in their country. This is what this couple did.
They had 1 child, and the pregnancy was normal with no problems. The delivery was a bit complicated; she suffered a haemorrhage. She required a D&C, and part of the placenta was left behind. Such a situation can damage the uterus, which may not fully recover.
After the baby was born, they waited a little while and tried to conceive again, but were not successful. They waited 2 years and finally went to see a doctor. The evaluation revealed, that after all the trauma the uterus had been through, she had scarring of the endometrium, a condition called Asherman’s syndrome. This is difficult to treat because the uterus cannot fully recover if the entire thickness of the lining is damaged.
She underwent a hysteroscopy, where a scope was used to look inside and remove the scar tissue. Unfortunately, scar tissue often recurs. Following this, she tried IUI and then IVF. They obtained a good number of embryos, but the uterus did not respond well. During IVF, hormone stimulation is used to create a receptive lining, and if the uterus doesn’t develop well despite high doses of hormones, it raises a red flag.
In Germany, they had several attempts with embryos, but it didn’t work. Finally, after numerous attempts and still having embryos left, they decided to explore surrogacy. Their embryos were sent from Germany, and they found a 40-year-old surrogate from Connecticut. She passed the screening, and a single embryo transfer was performed, which resulted in pregnancy on the first attempt.
The surrogacy contract and pre-birth order were completed, listing the parents, and the baby received an American passport. The couple then travelled back home with the American passport. This case demonstrates how surrogacy can be helpful after failed IVF, particularly in cases of mechanical damage like surgery or scarring.
There are various tests to diagnose issues with the uterus. Structural defects are usually assessed through ultrasound and hysteroscopy. For example, a vaginal ultrasound can show the uterine lining, which can be either thick and normal or thin and inadequate for supporting a pregnancy. Hysteroscopy can reveal scar tissue or abnormalities inside the uterus.
Endometritis, an infection, can be diagnosed with hysteroscopy but is not always visible. Sometimes, more sophisticated tests are needed to detect endometritis, even if the uterus appears normal on ultrasound and hysteroscopy. Functional assessment of the uterus involves evaluating how well the uterus responds to hormones. If hormones are administered and the uterus does not respond, it indicates a functional problem, even if standard tests are normal.
The concept of the implantation window has been known for many years, but previously there were no good tools to evaluate it. ERA test test allows to determine if embryos are placed at the right time in the cycle. During this entire cycle, there is a very narrow window when the uterus is receptive to pregnancy. Most of the time, the uterine lining will not allow an embryo to attach. This window, known as the window of implantation, is usually about 48 hours. When we do IVF and place the embryo into the uterus, we assume it’s during this optimal time. This assumption is based on experience with many people. If you have a five-day-old embryo, we place it about five days after ovulation or after starting progesterone, thinking this should be the right time.
There is a receptive phase and a post-receptive phase. In other words, the uterus is not receptive before or after this implantation window. It’s possible to take a sample of the lining when it is assumed it’s the right time to place the embryo and check if the timing is correct. If the timing is off, it’s possible to adjust it. For instance, it might be needed to place the embryo a couple of days earlier.
If there are issues such as endometriosis unless the damage is extremely severe, it can be treated with antibiotics, which will help. With uterine scarring, like in Asherman syndrome, the prognosis is not always great. Treatment might be surgical or hormonal, but if the damage is too severe, it might not be successful.
IVF cycle with a surrogate requires 2 parts. First, the embryos need to be created, grown, tested, and then frozen. This step involves standard IVF treatment: usually 2 weeks of medication, egg retrieval, fertilizing the eggs with sperm, making embryos, growing them to day 5 or 6, and then performing genetic testing before freezing them. This first step usually starts immediately, and within 1 month, the couple will learn how many good embryos they have. Genetic testing will reveal if the embryos have the right number of chromosomes and are therefore viable.
During this time, the surrogate is being evaluated, screened, and tested. Once confirmed and with a contract in place, preparing starts, usually with a natural cycle and some medication. This process takes about 3 weeks from when she starts her cycle until she’s ready for the embryo transfer. This is the frozen embryo transfer stage, where typically a single embryo is transferred and there is about 70 to 80 % success with PGT-A. Occasionally, 2 embryos are transferred if the situation is right, but for regular IVF couples, usually only 1 embryo is transferred.
In the U.S., surrogacy has many advantages, including legal protections, access to advanced technology like PGT-A testing, and higher success rates, making it a preferred option for many international patients.
American surrogates generally have a higher standard of living and are healthier, which is crucial since they carry your baby. The IVF process in the U.S. is highly successful, more so than in other countries, partly due to advanced technology and PGT-A testing.
Other advantages include:
In summary, surrogacy can be a highly successful solution for some IVF failures. It’s essential to rule out other factors and identify a uterine factor as a reason for failure. New tests can help diagnose and sometimes treat uterine factors, potentially avoiding surgery. IVF in the U.S. is safe, legal, and very successful.
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As part of the preparation of the surrogate, we review her medical history, her health history, her diet, so and of course, we recommend prenatal vitamins. As as soon as we introduce ourselves to the surrogate, we make sure that she goes on the prenatal vitamins. The reality is that actually if the woman is healthy, she doesn’t have any medical issues, and has a balanced diet, the need for supplements is questionable, but we always do it.
Once you get pregnant, you have to take prenatal vitamins because your body requirements increase. This is an ongoing debate about whether organics are better, I personally don’t think that makes much of a difference. I think you just have to get whatever vitamins you get, you have to get from a reliable manufacturer, there’s really no difference in my opinion between folate and folic acid, and again, mostly because folic acid is a water-soluble vitamin and it doesn’t stay much in your system, you want to make sure that the person their diet is good, it’s balanced and that they take a prenatal that usually has enough folic acid. I like to add a little bit extra folic acid to what’s already in the prenatal vitamins just basically for good measure and just because it does help prevent certain defense.
I think the most important is that they have a well-balanced diet. I think taking prenatal vitamins especially, with the newer preparations that have DHEA, is enough. I think sometimes people tend to overdo it with their vitamins and we discourage that. One of the prenatal vitamins, I mean, we usually use ones that are a prescription, and I think that’s very complete for a healthy person, and you don’t need anything else. Most of these vitamins, as I said, don’t get stored long term in your body, and they need to be taken regularly, which also means that it doesn’t take very long for even people who are deficient to get to normal levels.
The pregnancy is a pregnancy, it’s not a disease, but it’s something that carries risk, so again one of the reasons to pick women who have children is to try to mitigate, to reduce that risk as much as possible. So somebody who’s had normal uncomplicated pregnancies, normal deliveries, their chance of having any complications is much, much less than someone who conceives for the first time, so that’s sort of just going into the process and picking the surrogate. Now, on the embryo side, as I said doing PGS, for me, it is a big advantage because it allows you to select the more viable embryos, has a better chance of being successful.
For example, the risk of having a pregnancy loss, a miscarriage is much reduced by picking PGS normal embryos, but of course, things can happen, there are certain defects, the developmental defects that the baby can have that are not genetic, that we cannot test for, things that develop during the pregnancy and then there are things that can happen to the surrogate. She can develop hypertension and diabetes and pre-eclampsia and all those other things that can happen in pregnancy. Again much less likely for someone who has a good history, so the answer to the question is that there’s no way to be 100% sure that everything will go well. All we can do is prepare, and we do our best to make sure we’ve covered all the different aspects and lower the risk as much as possible.
As far as a guarantee, I mean it’s a difficult thing to do because you can’t guarantee for sure that the pregnancy will be okay, but there are ways, if you’re going through this process, there are ways that you can plan or sign up for what we call a baby guarantee, in other words, you continue trying with a surrogate until there’s a baby, it’s more like an insurance policy, it can be done, it’s more expensive, we e offer that package and certainly we can talk to you about that.
No, certainly not in the U.S., so certain countries require that you have some genetic connection to the baby, but in the U.S., it’s not necessary, it’s not required, so it depends on the laws in your own country. We often do surrogacy with donor eggs, or with donor sperm, and we sometimes do surrogacy with both. If there’s someone, f.e. a woman who is a little bit older who doesn’t have eggs or doesn’t have good eggs and needs an egg donor, she doesn’t have a partner, that person can use an egg donor, a sperm donor, and a surrogate. Again, the process in the U.S. is very transparent, very legal, that way, and you just have to check in your country if that’s something that is allowed.
I don’t have a simple answer for that because you can see f. e. in Europe, there are some countries where surrogacy is legal, Eastern Europe like Russia, Georgia, Ukraine, but it’s only legal for heterosexual, married couples. Then there are other countries where it’s illegal, and those countries are very different. I mean, you can look at Scandinavia where it’s illegal, and you can say well this is a very progressive country maybe there the reasons are more that have to do with fear of exploiting women, and I think that’s probably, what is the motivation behind it. Then there are countries like Spain, Italy, and France, where it’s probably more, has to do with either cultural or religious or other reasons, so I think it’s different in different countries. Even in the U.S., surrogacy is legal in only some states and not legal in others, some of it is religious, some of it is political, so I think in every case, it’s different.
Unfortunately, the trend, in my experience as I was working in India and in Thailand, Nepal, Georgia, and Ukraine actually, strange things are actually going the wrong way in most places because f. e. people used to travel to India for surrogacy because it was easy and not very expensive, and that closed down, and then the same thing happened in Thailand, and then the same thing happened in Nepal, which was sort of big surrogacy destination. I don’t know how to answer that, is it going to change soon? I hope so, I think mostly in the U.S., it’s changed because of grassroots movements and pressure, but I don’t know.
