Patient Information Package about Gestational Surrogacy working with a Surrogate Agency
The 13 Steps to a Successful Surrogate Cycle
Step 1: The intended parents schedule a consultation with one of our physicians (This may also be a phone consultation).
Step 2: IPs to consult with a legal advisor and/or surrogate agency on surrogacy requirements; this should include a legal agreement and medical coverage for the Surrogate.
Step 3: IPs to determine along with our Caroline Connor, Nurse Practitioner, if they require a Surrogate consultation to review the surrogacy process. If IPs are comfortable with the process, IPs may proceed to the Surrogate screening appointment without this consultation.
Step 4: Financial consultation / Benefit check / Authorizations. This is designed to protect IPs from any surprises or denials from your insurance provider.
Step 5: Financial Coordinator, Kimberly Carnevale, to collect $1,000 and establish a trust fund for Surrogate screening requirements. Deposit increases to $2,000 if cycle is an Egg Donor plus Surrogate cycle. IPs’ deposit applied towards global cycle fee.
Step 6: Surrogate to schedule an initial screening appointment.
A physical examination is done including a pelvic ultrasound.
Lab slips will be given to the surrogate for mandated infectious disease screening requirements and overall health screening.
Lab slips will also be given to the partner for infectious disease screening (if indicated).
Sonohysterogram may be done depending on the surrogate’s current menstrual cycle. This is to thoroughly evaluate the uterine cavity.
Step 7:Surrogate to call on Day 1 of her menstrual cycle and she will begin the evaluation cycle. This takes approximately 3 weeks to complete. After the evaluation cycle is complete; the Surrogate will begin birth control pills for cycle coordination. *See Surrogate Cycle Overview.
Step 8: Sonohysterogram to be performed on Surrogate. This may also be done during the evaluation cycle.
Step 9: Psychological consultation to be completed (for all intended parties).
Step 10: Legal contracts must be established between the IPs and Surrogate. SDFC requires a written statement from IPs’ attorney indicating that the contract is complete and final.
Step 11: Documentation of a current Pap smear is mandated for the Surrogate. The primary care physician must have done pap within the past year.
Step 12: Cycle Coordination: Caroline Conner to finalize and review the exact dates for treatment cycle. Medications will also be ordered. This cannot be scheduled until above steps are completed.
Step 13: Financial Coordinator, Kimberly, to collect full payment for the cycle prior to the egg provider starting medication.
SURROGATE CYCLE
Once a suitable surrogate has been identified and the screening process is complete the cycle can be initiated. The timing of cycle initiating depends on the menstrual cycle of the surrogate and the intended parents keeping in mind any scheduling conflicts of the surrogate, intended parents or professional staff.
Evaluation Cycle
The surrogate needs to prepare her uterus for implantation with natural estrogen and progesterone. Because each woman is a little different; the dose, duration and method of administering these hormones may need to be individualized. This can be determined ahead of time by conducting an evaluation cycle. This is a “dry run” where we duplicate each part of the cycle except the actual transfer of embryos ahead of time in order to determine how to maximize the chances of success. The evaluation cycle can be completed anytime before the actual procedure. In some circumstances, the evaluation cycle can be waived when the response of the uterus to hormonal stimulation is well known. This is fairly common for women who have undergone many treatment cycles in the past.
Surrogacy Cycle Synchronization
It is necessary to synchronize the menstrual cycles of the surrogate and intended parents in order to obtain mature eggs and embryos and transfer these back into a perfectly prepared endometrium (uterine lining) to maximize the chances of pregnancy success. This is done using a variety of hormonal manipulations including birth control pills, leuprolide (Lupron) or Synarel. We will determine which technique will work best for each circumstance. Once both women (surrogate and intended parent) are suppressed and their cycles synchronized they can begin the process of preparing for pregnancy.
Surrogacy Treatment Cycle
Hormonal Therapy
On about the same day, the surrogate and intended parent will begin hormonal therapies to prepare the appropriate target for pregnancy success. The surrogate will begin taking estrogen to stimulate endometrial (uterine lining) growth and the intended parent will begin taking FSH to stimulate egg production. These treatments are monitored with ultrasound and blood estrogen levels until the eggs are ready to be retrieved and the uterus is ready to accept an embryo. Usually these treatments will take approximately 2-3 weeks and requires 3-5 office visits for ultrasounds and blood tests.
Egg Retrieval
When the ultrasound monitoring of the ovaries and uterus determines that the eggs are mature and ready to be retrieved and the endometrial lining is appropriately grown, the intended parent is scheduled for retrieval. On the day of the egg retrieval the intended parent undergoes a vaginal, ultrasound-guided, procedure under a light anesthetic at Del Mar Surgery Center. The ultrasound used for egg retrieval is just like the one used to monitor the process of the cycle in the office. When the follicle that contains the eggs is seen with the ultrasound, a needle can be directed through the top of the vagina into the follicle and the follicular fluid and eggs aspirated into a test-tube. An embryologist works with the physician in the operating room to examine the fluid under a microscope and finds the eggs. On the same day as the egg retrieval, the husband provides a fresh sperm sample and the surrogate begins progesterone treatment. Once the eggs are retrieved, they are taken to the IVF laboratory and placed with sperm in the incubator. The following morning we can determine how may of the eggs have successfully fertilized into embryos.
Embryo Transfer
The embryos are allowed to grow in the lab for several days to make sure they are healthy and dividing properly. Nature tells us that not all human embryos are perfect and by allowing them to grow in the laboratory incubator, we can see which embryos are healthiest and most likely to result in a successful pregnancy. We usually allow the embryos to grow in the laboratory for somewhere between 3 and 5 days, and then select a few of the best embryos for transfer into the surrogate uterus. The number of embryos placed into the uterus can greatly influence the success of the cycle, but also affect the risk of multiple births. The determination of how many embryos to transfer is made carefully and only after we have all the information available about embryo quality, quantity, etc. This means waiting until the day of the transfer to make our final decision about the number of embryos to place into the uterus. Typically, we will recommend transferring 2-3 embryos into the uterus.
The actual embryo transfer procedure is a gentle, painless process. A soft tube (outer catheter) is inserted by the physician to a pre-determined position in the uterus. A smaller tube (inner catheter) is then loaded with the embryos and guided into the uterus through the outer catheter. The embryos are then injected into the uterine cavity and the catheter set removed. The embryologist inspects the catheters for retained embryos once the procedure is completed. The surrogate is then instructed to remain at home in bed for the next 3 days and continue her estrogen and progesterone treatments. A pregnancy test 2 weeks after egg retrieval will determine if the cycle is successful.
Pregnancy Success!!
In successful cycles, the hormonal supplements are continued through the first trimester (12 weeks) of the pregnancy. Once the first trimester is completed, the placenta has matured to the point where it will provide for all the hormonal needs of the pregnancy and no further supplements are required. We will monitor blood levels of estrogen and progesterone at the end of the first trimester and taper off the hormone supplements gradually. Once the hormone supplements are stopped, the rest of the pregnancy is indistinguishable from any other pregnancy!
SURROGATE MEDICATIONS
- Birth control pills calm the ovaries and prevent cysts form forming prior to ovarian stimulation
- Baby aspirin increases circulation to the uterus and ovaries, prevents blood clots
- Folic acid reduces the chance of birth defects
- Azithromycin antibiotic for the surrogate and partner treats potential bacteria such as mycoplasma, uroplasma and chlamydia
- Lupron or Synarel hormone prevents ovulation while stimulating the uterine lining
- Estrace or Estradiol Valerate hormones stimulate the growth of the uterine lining
- Progesterone hormone is needed for luteal phase support of implantation and early pregnancy
- Doxycycline antibiotic for the suurogate treats possible bacterial infection from the embryo transfer
- Prednisone prevents the body from rejecting the embryos after the transfer
PROGESTERONE
(Surrogate)
Progesterone is a hormone produced by the ovarian corpus luteum during the last two weeks of the menstrual cycle and during early pregnancy. After the seventh or eighth week of pregnancy the placenta takes over progesterone production, and continues until shortly before the onset of labor. Its decline is thought to be a key initiating mechanism of labor. Natural progesterone is prescribed in many fertility treatments for luteal phase support of implantation and early pregnancy. Natural progesterone is also prescribed to support the luteal phase for patients in virtually every IVF/GIFT program today. In these instances, the progesterone prescribed is derived from natural sources and is identical to that produced in the body.
Synthetic forms of progesterone (progestins) are manufactured into medications like oral contraceptives and Provera, which are not used to support the luteal phase.
Synthetic progestins have been associated with a slight increase in birth defects if taken during early pregnancy. Unfortunately, both natural and synthetic forms of progesterone are grouped together by the FDA. As a result, the natural progesterone medication that you receive may contain a package insert advising against its use during pregnancy. At present, there is no known risk of birth defects associated with natural progesterone, and the benefits of this medication are thought to outweigh any potential risk.
IMPORTANT: Do not stop your progesterone until we notify you. You will continue progesterone through the first trimester (12 weeks) of pregnancy.
SIDE EFFECTS include bloating, vaginal spotting, uterine cramping, breast fullness, light-headedness, and vaginal irritation. Do not discontinue your progesterone until directed by your doctor.
IVF EMBRYO TRANSFER
The Embryo Transfer takes approximately 10-15 minutes, and is very similar to the uterine measurement taken at your baseline appointment. There is no need to abstain from eating before your ET. An embryologist will speak with you and provide pictures of your embryos. The embryologist and your physician will discuss and recommend how many embryos to transfer.
Following the Embryo Transfer you will remain laying for 30 minutes in the procedure room, then discharged to your car via wheelchair. You must have someone accompany you and drive you home.
Continue taking the doxycycline every 12 hours, with meals, until your prescription is finished.
GUIDELINES AFTER EMBRYO TRANSFER
- For 72 hours following your Embryo Transfer try to take it as easy as possible. Stay in bed or keep your feet up. You may get up to go to the bathroom, shower, and eat. You may also use stairs. Do not bathe.
- For two weeks following your Embryo Transfer, avoid strenuous physical activity or heavy lifting. You may return to work 72 hours after the procedure.
- You may experience spotting and cramping after your Embryo Transfer. This is normal, caused by the instrumentation used during your procedure.
- There may be fluid leakage from your vagina after the Embryo Transfer. You may wear a minipad, but do not use tampons.
- Continue taking the Doxycycline as directed.
- Progesterone supplementation will be continued for two weeks following the Embryo Transfer, and continue thereafter if your serum pregnancy test is positive.
PREGNANCY TEST
- Bleeding or spotting can occur. This does not mean that you are not pregnant! Do not discontinue any medication until you have spoken with someone at our office.
- Blood will be drawn for a serum pregnancy test at least two weeks from the date of your egg aspiration. A blood pregnancy test is extremely important because it is more accurate and provides more information than a urine pregnancy test, and it is critical for detecting situations such as an ectopic pregnancy. Therefore, even if you feel that you are not pregnant, a blood test must be run for thoroughness.
- Your pregnancy test will be performed at The San Diego Fertility Center. We can give you accurate results, within the same day, directly from our office.
- If your pregnancy test is positive, it will be repeated in 48 hours, and possibly repeated a third time in another 48 hours. This is to help assess the quality of the pregnancy. Your medications will continue, so check your supply and have us renew your prescription if necessary.
- If your pregnancy test is negative, you will discontinue all medications. Your menstrual cycle may take several days to 1-2 weeks to start and may be slightly heavier than normal. Progesterone may delay your period, even if you are not pregnant.
A POSITIVE PREGNANCY TEST !
(Surrogate)
1. CONGRATULATIONS! But be cautiously optimistic because this positive test is just the first milestone in a long process.
2. Repeat your quantitative beta-HCG blood test in 48 hours (2 days).
3. Continue taking your Progesterone and Estrogen as directed. You will stay on this medication until approximately your 12th week of pregnancy. We will notify you when you can stop the hormonal supplementation and documentation of blood hormone levels.
4. Continue taking prenatal vitamins, Extra Folic Acid (4mg), and one baby aspirin (81mg) everyday.
5. Eliminate caffeine, alcohol, smoking, and all drugs (including any over-the-counter medications). Consult with your physician regarding any prescription medications.
6. Tylenol may be taken in the event of minor discomforts and should be taken if you have an elevated temperature over 100 degrees.
7. Have intercourse as desired.
8. Limit activity to a sedentary level. No exercise.
9. Avoid any increase in body temperature (hot tubs, saunas, etc.) as it is suspected that this may cause neural tube defects. Avoid situations in which you may increase your exposure to colds, flu.
10. It is advised that pregnant women be cautious to avoid contacting toxoplasmosis
(an organism found in cats that can cause severe injury to a developing fetus). The toxoplasmosis eggs are carried in cat feces. You should remember to wear gloves when gardening, wash your hands and vegetables well, and have your partner change the litter box.
11. An ultrasound will be performed at approximately two weeks after a positive pregnancy test. At this first ultrasound we will confirm the pregnancy viability and the number of gestational sacs. You will have a follow up ultrasound once a week for the next two weeks. After your third ultrasound we will assist you in transitioning to your OB-GYN.
View a list of surrogate agencies we are working with ...
Last updated:
May 13, 2008
Authors: Dr. William Hummel and Dr. Michael Kettel