By fertility experts from Spain.
Dr. Gad Lavy, M.D., F.A.C.O.G., Medical Director and Founder of New England Fertility, and Melissa Brisman, JD, are explaining everything surrogacy and egg donation related and talking about treatment in the USA.
As far as using a donor as opposed to continuing to try with your own eggs – that’s always a very difficult decision to make. You’ve done IUIs, you’ve done IVF with abnormal embryos – it sounds as if egg donation is probably the right choice. Again as long as the uterus is normal the success with an egg donor is very high. In your case, we have to actually take the issue of adenomyosis into consideration. Adenomyosis is one of those conditions that is sometimes really difficult to know if it actually affects the chances of success. Typically, adenomyosis is a condition that women develop after having a baby. Having adenomyosis in someone who has not been pregnant or has not had a full-term pregnancy is somewhat unusual and it really depends on the severity and the extent of the condition. This condition, essentially, is a situation where the glands that are normally on the surface of the lining of the uterus for some reason grow into the muscle. That can create symptoms like pain, heavy bleeding and in some severe cases can affect fertility. The MRI is probably a good first step but if the MRI looks reasonably normal if the adenomyosis is not very severe, there’s some additional testing that you can have to look at the function of the uterus, not just the structure. Those tests sometimes require an endometrial biopsy where you take a sample of the lining. With those tests, you can actually tell if the uterus is not only structurally normal but also functionally normal. If it is, then it’s definitely worth a try and if there is a question, it’s probably because it’s such a big step to take and it involves no significant cost and emotional investment, sometimes surrogacy is the answer.
Basically, the requirement from the FDA is that the testing should be done at the same time when the sample is collected. It is a blood sample that we sent to the lab and it’s a sperm sample that we freeze. Ideally, they both need to be done at the same time. What we’ve done with the international clients/couples is that we will send you the kit – it’s a small box with some test tubes. When you give the sample for freezing, you can have some blood drawn and that blood is processed and sent directly to the FDA in the US. We have quite a bit of experience with that and we can point you in the right direction to find a clinic that’s willing to freeze the sperm, collect the blood and help with the shipping. We’ve been successful with this for many different countries, not just Europe, also Hongkong, Israel, India so it’s certainly possible. Especially nowadays, saving you a trip abroad can make a huge difference in the process.
n the United States, there is no legal age limit so if you could find someone to treat you at any age, they can. However, most clinics and agencies will have certain limits, the average is in the 50s. Our agency doesn’t like to treat clients unless there is one partner under 60 in the relationship. Basically, 59 and a half is our age limit. We do let people use the same surrogate again if they’re over that age limit for a sibling but, in general, you can technically be any age. But I think once you hit the 60s you’re going have some difficulty finding somebody.
I’m the founder of the agency, Reproductive Possibilities, so we are finding our own surrogates for all our clients. As I said at the beginning, we’ve had 2,500 plus births so that is done in-house. We do have a team of 20 working on finding the carriers and coordinating all the aspects.
It’s a good question because as I mentioned freezing eggs is a relatively new technology. Freezing embryos has been around for a very long time and it’s a pretty standard procedure. The technology we use now for embryos, sperm and eggs is called vitrification. The problem is that eggs have actually been a little bit late to the game because the egg cell is the most difficult cell to freeze. Much more difficult than sperm and more difficult than embryos. From our experience in our laboratory, we get the same success with frozen eggs as we do with frozen embryos. However, for me it’s always a little bit of a dilemma to say that you can send me your frozen eggs from whatever clinic and we will create the embryos here because I need to know a little bit more about the lab where the embryos were created their success, their experience, their exact technology. The simple answer is if you’re going to ship eggs or embryos, I’d rather you ship the embryos, rather they created the embryos because that way we can be much more comfortable that what we end up getting when we thaw is going to be viable. So the simple answer is embryos are better than eggs but, of course, it has to be done on an individual case basis.
Yes, you can. The thing about the success of IVF is that success goes down with age. Usually, it goes down with age because of the woman’s age and the reason it goes down is more to do with the eggs and with the uterus. Assuming that the fibroid surgery was successful and the uterus is structurally and functionally normal, then it comes to the question of what is the likelihood that someone who’s 42 or 43 can actually create a genetically normal embryo. In fact, that’s why I’m a very strong believer in doing the PGS, the genetic testing of embryos because then you know for sure that you have an embryo that’s viable. What we know from experience and statistics is that when you’re 42 or 43 most of your embryos you produce are genetically abnormal, over 90%. Of course, it’s possible that you will generate a genetically normal embryo but you may need to do IVF a number of times and it may never happen.
But again, if you’re going to do IVF and you’re in your 40s, I really think that doing PGS is important, and also growing the embryos through the blastocyst stage because then you know for sure that what you have is really viable. For example, doing a transfer on the second or third day after fertilization is not really enough time to be able to properly evaluate the embryos. Even if the embryo does grow through day 5 and becomes a beautiful blastocyst, there’s still a fairly high probability at 42 or 43, that it will be genetically abnormal. You have to know what you’re getting into when you say I’d like to try with my own eggs. I understand that using an egg donor is s a huge step, is a huge decision, one that you don’t want to take lightly. It may be worthwhile to try but you want to avoid the trend to do another one and another one and another one doing the transfer on day 3 where the embryos look good but it doesn’t work or there’s a miscarriage. Yes, it’s a complex answer but yes it’s possible.
We both offer package deals so our company does have a package that you can get multiple surrogates if it doesn’t work. We can’t guarantee you that a baby will come out but we will offer you a very large number of tries with different surrogates so we do have those programs available.
Here it’s not just your age, it’s more than values. The FSH and AMH. With an FSH of 20 and a very low AMH your chances of actually creating a genetically normal embryo are pretty low. I think your chances of having success with IVF are probably in the low single digits. There is IUI, there’s IVF with your own eggs and there’s egg donation. In my opinion, someone at your age with these numbers should not do IUIs and should think two or three times before they actually commit to IVF because the chances being so low. It’s possible and everyone is different and how they feel but you need to understand what you getting yourself into. There are people who have 2-3% chance of success, some people would say well you know that’s better than zero and let’s do it and for other people, it’s not high enough to justify all the effort that goes into it. It’s a very individual decision but, objectively speaking, someone with this profile should use an egg donor.
The price to do surrogacy if you do everything in the United States including the IVF, use the agency, find an egg donor through New England Fertility is about a USD120,000 to USD 150,000 depending on various factors. We have two different packages: one is a premium package that guarantees you a certain number of surrogates. The price difference in those two packages is only going to be a few thousand dollars so it’s not going be what pushes you to the 120,000 vs. 150,000 is really how many times it takes the carrier to get pregnant, not the different packages that you have. Let’s say you have a package from both New England Fertility and our office, you still are going have to pay for the surrogate’s travel to get to the clinic, her lost wages, her fee of $500 every time she has an embryo transferred, if they have a miscarriage they get certain payment. It’s really based on things that we can’t estimate exactly like whether or not to get pregnant right away and whether or not there’s a miscarriage in the beginning.
The actual cycle itself is pretty quick; it’s between 2-4 weeks depending on exactly where they are in the cycle, how much Lupron, whether or not they ovulate but actually having a pregnant surrogate is an 18-month process on average to have a baby. Usually, by the time they start, it’s about month 9 by the time they’re pregnant and then obviously there are 9 months towards delivery so it’s about 18 months to take home a baby.
I’d like to add that if we’re ready to start I suggest we do it in a parallel track meaning that we get the sperm that’s usually first, find an egg donor if you need an egg donor, that usually takes a couple of months and as soon as we have the sperm and the eggs, we make the embryos and that way by the time we find a surrogate (which takes a little bit longer than finding an egg donor), we already have the embryos waiting. That way we can move right away into the embryo transfer. If someone is anxious to get it done as quickly as possible, that’s the best way to approach it as opposed to let’s make the embryos, make sure we have embryos and then start looking for the surrogate because that’s going to obviously make it a little bit longer.
People always ask me about the timeline and also the timeline is when you start. Somebody can say: I came to see you and it’s taking me two and a half years but when they came for their consultation, they actually didn’t fill out their paperwork or start making their embryos for a year because this is a lot to digest. The timeline starts also when you actually start moving. It doesn’t start from the first time you see us; you have to actively start making your embryos and actively start working with our agency to select our carrier. You have some control over the timeline; we can speed it up a little bit, we can slow it down a little bit like. Right now some people are asking to take a break for a month or two until the travel restrictions are lifted so that’s reasonable as well.
It’s actually simple. First of all, there’s no way to improve your AMH. The AMH really is not a problem; it’s only a marker. It essentially tells you what your ovarian reserve is, how many eggs you have indirectly, how many eggs you would get if you did IVF and indirectly the quality of the eggs and the chances of success. The AMH is not really a problem that you want to fix. The AMH, the egg reserve also does not have any impact and your chances of becoming pregnant when you use an egg donor. Many women that have a low AMH still have normal cycles but even if you don’t, if your cycles are not normal, even if you have no cycles, it’s still possible to create a cycle using hormones and still have exactly the same chance of success with IVF with an egg donor.
We have both available; during the process, New England Fertility has counseling available on staff that is who is going to screen her carrier. We also have a network of providers that we work with in addition to provide counseling. There is post-surrogacy support especially more for surrogates than the intended parents because the surrogates sometimes suffer postpartum depression or when their hormones are fluctuating. You will have lots and lots of support both from the agency, the doctor’s office and the various counselors that both of us have on staff.
The big issue that we face both with egg donation and sperm donation as well is that there is no real control over how many times these donors can donate their genetic material. Of course, the solution would be to have a registry when you donate whether it’s sperm or your eggs, you are registered and the number of times you donated, the number of eggs or sperm that are out there in the world from the same donor. Unfortunately, that does not exist in the US and to my knowledge doesn’t exist elsewhere either. It’s left to us, the providers, to have some kind of accountability or responsibility to make sure that doesn’t happen. I mentioned the fact that we try to limit the number of donations within the country. Outside of the US, we try to limit the donations within the same state in the US but that’s something we do on our own and it’s not required. It would be great if one of those registries actually was created.
This is a lot of different questions wrapped up in one. If your gestational carrier (surrogate) has medical complications, she will have health insurance and those medical complications will come under the health insurance, usually, for up to six months after a miscarriage, birth termination. You will be responsible during that time for what we call in the United States co-pays – those are usually minimal payments but you also have to keep your health insurance in place if you were paying for it. All this will be covered in the contract to limit everybody’s financial exposure – you’re having insurance for this. After six months this is a risk that the carrier takes so if, for instance, she has a lifelong medical problem that is not something that you will be expected to pay for. If the embryo doesn’t implant usually they agree to try up to four times and that’s obviously up to you and the physician if you think it’s worth it to try again. Most of the time if the embryo does not implant, the physician is going to try again. Obviously, if it doesn’t work four times, you’re going change something whether that be the egg, the sperm or the carrier.
As far as issues with the relationship that’s why we have lawyers, psychologists and social workers to help you work through that. There’s always something unexpected. I’ve been doing this for 20 years and I’ve been dealing with unexpected things all month due to the virus. Usually, if you’re at an experienced agency they will know how to handle it. If it’s unexpected, we will know how to handle, if we won’t know exactly but we’ll know where to go, what to do if we have to contact the senator or the passport office so we have to take things as they come sometimes.