"One for Sorrow, Two for Joy?": American embryo transfer guideline recommendations, practices, and outcomes for gestational surrogate patients

Gestational carrier cycles: embryology trends, national guideline compliance, and resultant perinatal outcomes in the United States, 2014-2020

BACKGROUND

The increased use of gestational carriers has expanded family-building opportunities for people and couples unable to carry pregnancies on their own. National American Society of Reproductive Medicine guidelines for gestational carriers have changed over time to reflect advances in reproductive technology and mounting evidence supporting the medical benefits associated with singleton gestations.

OBJECTIVE

Assess changes in gestational carrier cycle practice patterns and resultant pregnancy outcomes in the United States in relation to changing national American Society of Reproductive Medicine guidelines, which changed in 2013 and 2017.

STUDY DESIGN

This retrospective study used data from the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System and included all cycles that were reported from 2014-2020 involving an embryo transfer to a gestational carrier. Binomial regression models evaluated trends in preimplantation genetic testing for aneuploidy, American Society of Reproductive Medicine guideline adherence, number of embryos transferred, and pregnancy outcomes over time.

RESULTS

Of the 40,177 gestational carrier transfer cycles from 2014-2020, there was a significant increase in frozen-thawed cycles (41.3% increase), use of assisted hatching (53.4% increase), intracytoplasmic sperm injection (50.0% increase), and preimplantation genetic testing for aneuploidy (155.7% increase). The likelihood of preimplantation genetic testing for aneuploidy was higher in 2020 than in 2014 for autologous oocyte transfers to gestational carriers, both for those aged ≥38 years (adjusted relative risk, 2.38 [95% confidence interval, 2.11-2.70]) and than those aged <38 years (adjusted relative risk, 2.85 [95% confidence interval, 2.58-3.15]). As preimplantation genetic testing for aneuploidy usage increased, single embryo transfer rose for both autologous (adjusted relative risk, 2.22 [95% confidence interval, 1.94-2.50]) and donor cycles (relative risk, 1.91 [95% confidence interval, 1.81-2.02]). This shift toward single embryo transfer corresponded with a decrease in multiple embryo transfer by 79.2% and subsequent decreases in multiple gestations by 68.8% in donor and 73.6% in autologous oocyte cycles from 2014-2020. Gestational carrier cycles remained highly adherent to changing American Society of Reproductive Medicine guidelines throughout the study period. Among live births, there was a 19.4% and 7.9% increase in term deliveries among donor and autologous oocyte cycles, respectively, from 2014 to 2020.

CONCLUSION

Practice patterns have drastically changed throughout the study period, with major increases in the use of preimplantation genetic testing for aneuploidy, intracytoplasmic sperm injection, assisted hatching, and frozen transfers. In response to changing American Society of Reproductive Medicine guidelines, the use of multiple embryo transfers has decreased for gestational carrier cycles with subsequent decreases in multiple gestations and miscarriages and slight increases in live birth rates.

'Womb for work' experiences of Thai women and gestational surrogacy practice in Thailand

Risks to gestational surrogates became a concern for public health. In commercial gestational surrogacy arrangements, gestational surrogates are commonly recruited from low- to middle-income countries. Thailand is well known as a surrogacy hub in this regard. However, little is known concerning Thai surrogacy practice and the risks that Thai gestational surrogates experiences. The semi-structured interviews with fifteen Thai women who had been gestational surrogates were conducted over the telephone in Thai between March and May 2020 and lasted approximately 30 minutes. Thematic analysis was applied to analyse the translated interviews. The findings indicated that 'womb for work' was perceived as a surrogacy career among Thai women. 'Womb for work' was defined as a superordinate theme that consisted of three subthemes: (i) gestational surrogacy arrangements in Thailand; (ii) the business model of gestational surrogacy arrangements in Thailand; and (iii) risk experiences of gestational surrogates. Clear deficiencies in surrogacy practice and regulations were identified, which put gestational surrogates at risk, including those associated with embryo transfer, transnational gestational surrogacy, and unsupported pregnancies. This study shows the urgent need to introduce regulations to protect women's health transnationally in this domain more effectively.

Gestational carrier pregnancy outcomes from frozen embryo transfer depending on the number of embryos transferred and preimplantation genetic testing: a retrospective analysis

OBJECTIVE

To compare gestational age, birth weight (BW), and live birth rates in gestational carriers (GC) after the transfer of 1 or 2 frozen embryo(s) with or without preimplantation genetic testing for aneuploidy (PGT-A), with the understanding that several social and economic factors may motivate intended parents to request the transfer of 2 embryos and/or PGT-A when using a GC.

DESIGN

Retrospective cohort study SETTING: An assisted reproductive technology practice.

PATIENT(S)

All frozen blastocyst transfers with GCs from 2009-2018.

INTERVENTION(S)

One or 2 embryo frozen embryo transfers with and without PGT-A.

MAIN OUTCOME MEASURE(S)

Live birth, preterm birth, and low BW.

RESULTS

A total of 583 frozen embryo transfer cycles with vitrified high-grade blastocysts (grade BB or higher) to GCs were analyzed. Although the live birth rate was significantly greater in frozen embryo transfers with 2 embryos, after single embryo transfer (SET), the mean gestational age and BW of live births were statistically significantly greater than those of double embryo transfer (DET). The rate of multiple births was 1.9% for SET compared to 20.0% for DET per transfer. Only 3.8% of live births from SET experienced low BW and 0.6% had very low or extremely low BW. By comparison, 12.5% of DET live births were low BW and 5% were very low BW. After SET, 13.4% of live births were preterm, compared with 40% in DET. The analysis also included a total of 194 transfers with PGT-A compared to 389 cycles without. Overall, live births per transfer were not significantly different between these latter 2 subgroups.

CONCLUSION

Frozen embryo transfer cycles in GCs with DET were associated with more preterm births and lower birth weights compared with those of SET. Intended parents and GCs should be counseled that DET is associated with greater risks of adverse pregnancy and perinatal outcomes, which mitigates higher live birth rates. The use of PGT-A did not appear to improve the live birth rate.

The nexus between self-perception and behavioural responses of gestational surrogates' risk experiences

Despite associated risk and public concern, commercial surrogacy remains a thriving business, and opportunities for gestational surrogates continue to exist. Surrogacy arrangements have been found to place gestational surrogates at risk, with little support or guidance to help them understand or mitigate these risk factors. This study aims to investigate the self-perception of gestational surrogates through their reflection of their own risk-related behaviours throughout the surrogacy process. Data were retrieved through interviews with fifteen Thai women who had first-hand experience of commercial surrogacy, and thematic analysis was used to interpret the data. Findings showed that the perceptions of 'trust,' 'commitment to obligation,' and 'unacceptable actions' reflected their behaviours exposing risks to detrimental behaviours, disempowerment, and isolation. Understanding these perceptions would be advantageous for health planning programmes or policies in surrogacy practice to promote women's heath as a whole.

Pregnancy and birth outcomes of single versus multiple embryo transfer in gestational surrogacy arrangements: a systematic review and meta-analysis

Multiple embryo transfer (MET) is associated with both an increased risk of multiple pregnancy and of live birth. In recent years, MET has become standard practice for most surrogacy arrangements. There is limited review of the use of MET versus single embryo transfer (SET) in surrogacy practice. The present review systematically evaluated the pregnancy outcomes of surrogacy arrangements between MET versus SET among gestational carriers. A systematic search of five computerized databases without restriction to the English language or study type was conducted to evaluate the primary outcomes: (i) clinical pregnancy; (ii) live delivery; and (iii) multiple delivery rates. The search returned 97 articles, five of which met the inclusion criteria. The results showed that clinical pregnancy (RR = 1.21, 95% CI: 1.06-1.39, n  =  5, I² = 41%), live delivery (RR = 1.29, 95% CI: 1.10-1.51, n  =  4, I² = 35%) and multiple delivery rates (RR = 1.42, 95% CI: 6.58-69.73, n  =  4, I² = 54%) were statistically significantly different in MET compared to SET. Adverse events including miscarriage, preterm birth and low birthweight were found following MET. Our findings support the existing evidence that MET results in multiple pregnancy and subsequently more adverse outcomes compared to SET. From a public health perspective, SET should be advocated as the preferred treatment for gestational carriers.

Surrogacy and Pregnancy

Importance

Surrogacy allows for parenthood when it is otherwise impossible or exceedingly difficult; however, the risks of surrogate pregnancy for the gestational surrogate and the fetus are not well defined.

Objective

The aim of this study was to review the literature to examine the prevalence and requirements of surrogate pregnancy and maternal and perinatal outcomes.

Evidence Acquisition

A CINAHL and 2 PubMed searches were undertaken using the terms "surrogate mothers" OR "(surrogate or surrogacy)" AND "(mothers OR pregnancy OR pregnant)." The second search used these terms and pregnancy outcomes. The search was limited to the English language, but the years searched were unlimited.

Results

The search identified 153 articles, 36 of which are the basis for this review. The number of surrogate pregnancies is increasing in the United States. Fetal risks associated with surrogacy include low birth weight, increased risk of multiple gestation, and preterm birth. Maternal complications associated with surrogate pregnancy include hypertensive disorders of pregnancy, postpartum hemorrhage, and gestational diabetes.

Conclusions and Relevance

Surrogacy is a route to parenting that is not without risk to the surrogate or the fetus, and surrogate pregnancy is increasing in frequency in the United States.

Incidence of surrogacy in the USA and Israel and implications on women's health: a quantitative comparison

PURPOSE

Gestational surrogacy (GS) has been researched in multiple qualitative studies. In contrast, quantitative aspects of the practice are conspicuously understudied. The present article assesses and compares the incidence of GS in the USA and Israel, two industrialized countries that have maintained active commercial surrogacy practice, for over two decades.

METHOD

The article is a secondary analysis of GS figures published by the Israeli Parliament's Centre for Research and Information (2018) and by the USA's Centers for Disease Control (2016) and related professional publications. Each dataset is analyzed in reference to the respective country, so as to devise local incidence scores that are then juxtaposed in inter-country comparison.

RESULTS

The incidence of GS rises steeply in both countries. Though US surrogates are contracted by local and international, heterosexual and gay, and partnered and single intended parents, the relative incidence of GS is lower in the USA than in Israel, where only local heterosexual couples could contract a gestational surrogate. An exceptionally high rate of multiple births was observed in both settings, suggesting some overlooking of professional recommendations for elective single-embryo transfer.

CONCLUSION

GS incidence appears to resemble the ratio between the countries' respective fertility rates. The paper underscores two main risks facing gestational surrogates: the risk of not conceiving and not being paid and the risk of carrying a multiple pregnancy, which is extremely prevalent in GS pregnancies, and sustaining the short- and long-term health complications that are more prevalent in such pregnancies.

Surrogacy and ethics in women with cancer

Women diagnosed with gynaecological cancer may face unwanted loss of fertility as well as all the other life-changing issues with which cancer and its treatments are associated. The decision to harvest and store gametes has to be made before commencement of treatment, and advances in these techniques have made this successful. Fertility sparing therefore must be discussed and offered at an early stage post diagnosis. Surrogacy is currently an evidence-based method of assisted reproduction, with mainly desirable outcomes for the commissioning mother, surrogate and child, without impacting on the cancer treatment and long-term survival. Surrogacy is therefore ethical as long as the autonomous rights of both the commissioning mother and gestational carrier are equally observed, they both have equal legal protection and due attention is paid to the short- and long-term welfare of any resulting offspring.