Severe Maternal and Neonatal Morbidity Among Gestational Carriers : A Cohort Study

BACKGROUND

Use of a gestational ("surrogate") carrier is increasingly common. Risk for maternal and neonatal adversity is largely unknown in this birthing population.

OBJECTIVE

To determine the risk for severe maternal morbidity (SMM) and severe neonatal morbidity (SNM) in gestational carriers.

DESIGN

Population-based cohort study.

SETTING

All of Ontario, Canada.

PARTICIPANTS

All singleton births at more than 20 weeks' gestation, from 2012 to 2021.

MEASUREMENTS

Exposure was type of conception, namely, gestational carriage (main exposure), unassisted conception (comparison group 1), and in vitro fertilization (IVF) (comparison group 2). Main composite outcomes were SMM and SNM. Modified Poisson regression models generated weighted relative risks (wRRs) using propensity score-based overlap weighting. Secondary outcomes included hypertensive disorders of pregnancy, cesarean delivery, preterm birth, and postpartum hemorrhage.

RESULTS

Of all eligible singleton births, 846 124 (97.6%) were by unassisted conception, 16 087 (1.8%) by IVF, and 806 (0.1%) by gestational carriage. Respective risks for SMM were 2.3%, 4.3%, and 7.8%. The wRRs were 3.30 (95% CI, 2.59 to 4.20) comparing gestational carriage with unassisted conception and 1.86 (CI, 1.36 to 2.55) comparing gestational carriage with IVF. Respective risks for SNM were 5.9%, 8.9%, and 6.6%, generating wRRs of 1.20 (CI, 0.92 to 1.55) for gestational carriage versus unassisted conception and 0.81 (CI, 0.61 to 1.08) for gestational carriage versus IVF. Hypertensive disorders, postpartum hemorrhage, and preterm birth at less than 37 weeks were also significantly higher contrasting gestational carriers to either comparison group.

LIMITATION

Absence of information about indications for choosing a gestational carrier, and oocyte or sperm donor source.

CONCLUSION

Among singleton births of more than 20 weeks' gestation, a higher risk for SMM and adverse pregnancy outcomes was seen among gestational carriers compared with women who conceived with and without assistance. Although gestational carriage was associated with preterm birth, there was less clear evidence of severe neonatal morbidity. Potential mechanisms for higher maternal morbidity among gestational carriers require elucidation, alongside developing special care plans for gestational carriers.

PRIMARY FUNDING SOURCE

The Canadian Institutes of Health Research.

Obstetric Characteristics and Outcomes of Gestational Carrier Pregnancies: A Systematic Review and Meta-Analysis

Importance

Advancements in assisted reproductive technology (ART) have led to an increase in gestational carrier (GC) pregnancies. However, the perinatal outcomes of GC pregnancies remain understudied, necessitating a deeper understanding of their associated risks.

Objective

To assess maternal characteristics and obstetric outcomes associated with GC pregnancies.

Data Sources

A comprehensive systematic search of publications published before October 31, 2023, using PubMed, Web of Science, Scopus, and Cochrane Library databases was conducted.

Study Selection

Two authors selected studies examining obstetric characteristics and outcomes in GC pregnancies with 24 or more weeks' gestation. Studies with insufficient outcome information, unavailable data on gestational surrogacies, and non-English language studies were excluded.

Data Extraction and Synthesis

Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, 2 investigators extracted and synthesized both quantitative and qualitative data. Both fixed-effect and random-effect analysis were used to pool data.

Main Outcomes and Measures

The primary outcomes were obstetric characteristics and outcomes, including hypertensive disorders, preterm birth, and low birth weight. Secondary outcomes included severe maternal morbidity and mortality associated with GC pregnancies.

Results

Six studies from 2011 to 2023 involving 28 300 GC pregnancies and 1 270 662 non-GC pregnancies were included. GCs accounted for 2.5% of in vitro fertilization cycles (59 502 of 2 374 154 cycles) and 3.8% of ART pregnancies (26 759 of 701 047 ART pregnancies). GC pregnancies were more likely to be conceived by frozen embryo transfer compared with non-GC ART pregnancies (odds ratio [OR], 2.84; 95% CI, 1.56-5.15), and rates of single embryo transfer were similar between the 2 groups (OR, 1.18; 95% CI, 0.94-1.48). GCs were rarely nulliparous (6 of 361 patients [1.7%]) and were more likely to have multifetal pregnancies compared with non-GC ART patients (OR, 1.18; 95% CI, 1.02-1.35). Comparator studies revealed lower odds of cesarean delivery (adjusted OR [aOR], 0.42; 95% CI, 0.27-0.65) and comparable rates of hypertensive disorders (aOR, 0.86; 95% CI, 0.45-1.64), preterm birth (aOR, 0.82; 95% CI, 0.68-1.00), and low birth weight (aOR, 0.79; 95% CI, 0.50-1.26) in GC pregnancies vs non-GC ART pregnancies. Comparatively, GC pregnancies had higher odds of hypertensive disorders (aOR, 1.44; 95% CI, 1.13-1.84) vs general (non-GC ART and non-ART) pregnancies with comparable cesarean delivery risk (aOR, 1.06; 95% CI, 0.90-1.25). Preterm birth and low birth weight data lacked a comparative group using multivariate analysis. Severe maternal morbidity and maternal mortality were rare among GCs.

Conclusions and Relevance

In this systematic review and meta-analysis, although GC pregnancies had slightly improved outcomes compared with non-GC ART pregnancies, they posed higher risks than general pregnancies. Contributing factors may include ART procedures and increased rates of multiple gestations which influence adverse perinatal outcomes in GC pregnancies.

Parenthood desire, perceived parenthood stigma, and barriers to achieving parenthood in childless sexual minority men

PURPOSE

To examine the parenthood desire, perceived parenthood stigma, and barriers to achieving parenthood among sexual minority men (SMM) in Canada, and to investigate factors influencing their fertility and assisted reproductive knowledge.

METHODS

Data were collected from March to mid-June 2023 using a 78-item anonymous online survey. Childless cisgender SMM (age 18+) living in Canada were recruited from the LGBTQIA+ community outside the fertility care networks. Chi-square, t-tests, ANOVA, reliability tests, Spearman's correlation, and hierarchical regression model were used for analysis.

RESULTS

Over 160 people clicked the survey hyperlink during the study period and 112 completed surveys were analyzed. The mean age of participants was 33.2±8.5 (range: 19.7-60.0). Having a child by any means was "quite"/"very" important to 35.7% (n=40), yet 56.0% (n=61) thought it was "unlikely" to achieve parenthood. Financial readiness (n=90, 85.7%) and relationship stability (n=86, 81.9%) were the two most "important" parenthood considerations. Participants who were non-white (p=0.017), under age 30 (p=0.008), and had no siblings (p=0.024) had significantly higher means of parenthood desire compared to others. The final hierarchical regression model explained 43% of the variance in the knowledge scores (R2adj =0.353), predicted by the levels of (i) education (β=0.37, p<0.001), (ii) family acceptance of sexual orientation (β=0.39, p=0.004), and (iii) parenthood desire (β=0.27, p=0.002).

CONCLUSIONS

With an increasing number of SMM desiring children, it is pivotal to advance family-building equality through improving their fertility and assisted reproductive knowledge, removing disparities in accessing adoption and assisted reproductive services, and decreasing social stigma against SMM having children.

Surrogacy: An important pathway to parenthood. A call for international standardization

This comprehensive review examines the multifaceted landscape of surrogacy, a revolutionary treatment for infertility. The study examines historical origins, shifting trends, medical considerations, psychological implications, legal complexities, international variations, and ethical dilemmas surrounding surrogacy. With the advent of assisted reproductive technology, gestational surrogacy allows intended parents a genetic connection to their child. Medical facets encompass indications for gestational surrogacy, drawing attention to maternal health risks and infertility factors. Evidence indicates that medical outcomes are comparable to conventional pregnancies, suggesting a viable reproductive solution for intended parents. Due to the complex nature of surrogacy psychological and emotional vulnerability is inevitable; yet studies underscore positive psychological well-being and satisfaction among gestational carriers (GCs), intended parents (IPs) and children. Surrogacy also has many religious dimensions, as each religion has its own perspective on the distinctive process of creating life and its outcomes, such as, the determination of the child's mother according to their beliefs. Legal considerations emerge as a fundamental aspect, with differing regulations globally. The review emphasizes the significance of comprehensive agreements to safeguard the rights and responsibilities of surrogates and IPs. The unique surrogacy laws in Israel serve as a noteworthy example, reflecting a progressive approach that provides a promising template to establish crucial international guidelines on surrogacy. The absence of international consensus necessitates attention from the global community to address key concerns, including the well-being of GCs, legal recognition for IPs, and the child's best interests, with the goal of establishing a universal standard of care in the field.

A qualitative analysis of gestational surrogates' healthcare experiences during the COVID-19 pandemic

OBJECTIVE

No empirical data are available on the healthcare experiences of surrogates during the COVID-19 pandemic. This study aimed to examine the impact of pandemic-control measures on surrogates' fertility, pregnancy and birthing experiences.

METHODS

Sampling frame included eligible surrogates who were actively involved in a surrogacy process at an academic IVF centre during the pandemic (03/2020 to 02/2022). Data were collected between 29/04/2022 and 31/07/2022 using an anonymous 85-item online survey that included twelve open-ended questions. Free-text comments were analysed by thematic analysis.

FINDINGS

The response rate was 50.7% (338/667). Of the 320 completed surveys used for analysis, 609 comments were collected from 206 respondents. Twelve main themes and thirty-six sub-themes grouped under 'vaccination', 'fertility treatment', 'pregnancy care', and 'surrogacy birth' were identified. Three in five surrogates found the control measures highly or moderately affected their surrogacy experiences. Themes involving loneliness and isolation frequently emerged when essential surrogacy support was restricted by the visitor protocols implemented at healthcare facilities.

DISCUSSION

Our findings show that restricting or limiting intended parents' in-person involvement increased surrogates' feelings of isolation and made the overall surrogacy experience less rewarding and fulfilling. Furthermore, the childbirth experiences of surrogates were mostly negative, suggesting that hospitals were ill-equipped to manage all births, including surrogacy births, during the pandemic.

IMPLICATIONS FOR PRACTICE

Our findings highlight the needs to rethink how surrogacy care and maternity services could be strengthened to better serve the needs of surrogates during times of public health crises, such as COVID-19, while still allowing for risk mitigation and maximising patient safety.

Surrogates' experience during the COVID-19 pandemic: mental health, social support, and relationship with intended parents

PURPOSE

To examine surrogates' mental health, social support, and relationship with intended parents (IPs) during the COVID-19 pandemic from March 2020 to February 2022.

METHODS

Data were collected between April 29, 2022 and July 31, 2022, at an academic IVF center in Canada using an 85-item online anonymous cross-sectional survey that included three standardized scales measuring mental health (PHQ-4), loneliness, and social support. Eligible surrogates actively involved in surrogacy during the study period received email invitations.

RESULTS

The response rate was 50.3% (338/672); 320 submitted surveys were analyzed. Two-thirds (65%) of respondents experienced mental health concerns during the pandemic and were significantly less comfortable about seeking mental health support than those without concerns. Nonetheless, 64% were highly satisfied with their surrogacy experience; 80% received a high level of support from their IPs, and 90% reported a good relationship with them. The final hierarchical regression model identified five significant predictors, explaining 39.4% of the variance in PHQ-4 scores: a prior mental health history, COVID-19 impact on personal life, surrogacy satisfaction, loneliness, and social support.

CONCLUSIONS

COVID-19 created an unprecedented challenge to surrogacy care, increasing surrogates' risk of experiencing mental health symptoms. Our data show that IP support and the surrogate-IP relationship were fundamentals to surrogacy satisfaction. The findings are relevant to fertility and mental health practitioners in identifying surrogates who are more susceptible to mental health challenges. Fertility clinics should ensure adequate psychological screening of surrogate candidates and proactively offer mental health support services.

Donated-embryo pregnancies are associated with increased risk of hypertensive disorders even for young recipients: a retrospective matched-cohort study

OBJECTIVE

To determine whether pregnancies with donated embryos are at a higher risk of complications than the pregnancies from autologous frozen-thawed embryo transfer (FET).

DESIGN

Anonymous, multicenter, comparative, observational, retrospective, matched-cohort study.

SETTING

Six French assisted reproductive technique centers from 2003 to 2018.

PATIENT(S)

Seventy-three singleton pregnancies with donated embryos (exposed) and 136 singleton pregnancies after autologous FET (nonexposed) were matched at 7-8 weeks of gestation (pregnancy date, parity, and women's age) (2:1 ratio, respectively). In accordance with French practices, all women were <44 years old and donated embryos were discarded frozen embryos from other couples.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Percentages of hypertensive disorders of pregnancy (HDPs) with donated embryos versus autologous FET.

RESULT(S)

Groups were comparable (mean age: 34.5 years) and HDPs (24.6% vs. 11.9%) were significantly more frequent among the donated-embryo pregnancies, mostly in its severe forms (17.5% vs. 4.6%). In contrast, their respective isolated hypertension frequencies were comparable (7.0% vs. 7.3%). Multivariate analysis retained increased severe HDP risk with donated embryos (odds ratio 2.08 [95% confidence interval: 1.08-4.02]). No significant effect of endometrial preparation was observed. C-sections were more frequent for donated-embryo pregnancies (47.3% vs. 29.2%). Newborns from embryo donation or autologous FET were comparable for prematurity, birth weight and length, Apgar score, small for gestational age, large for gestational age, neonatal malformations, and sex ratio.

CONCLUSION(S)

Even for young women, the risk of severe HDP was 4 times higher for donated-embryo pregnancies than for autologous-FET pregnancies. The HDP risk must be acknowledged to inform donated-embryo recipients and provide careful pregnancy monitoring.

Management of recurrent implantation failure: British Fertility Society policy and practice guideline

Recurrent implantation failure (RIF) is defined as the absence of a positive pregnancy test after three consecutive transfers of good quality embryos. There remains significant variation in clinical practice in the management of RIF. This British Fertility Society (BFS) Policy and Practice guideline analyses the evidence for investigations and therapies that are employed in RIF and provides recommendations for clinical practice and for further research. Evidence for investigations of sperm and egg quality, uterine and adnexal factors, immunological factors and thrombophilia, endocrine conditions and genetic factors and for associated therapies have been evaluated. This guideline has been devised to assist reproductive medicine specialists and patients in making shared decisions concerning management of RIF. Finally, suggestions for research towards improving understanding and management of RIF have also been provided.

A reproductive health-care program for surrogate mothers: A mixed methods study

BACKGROUND

Surrogacy has become an alternative family formation option for women who are unable to carry a pregnancy. There is no comprehensive care program despite the different nature of this pregnancy. The present study aimed to develop a reproductive health-care program for surrogate mothers within the cultural and social context of Iran.

MATERIALS AND METHODS

In the present sequential exploratory mixed methods study, first through a qualitative approach surrogate mothers, care providers, and policy makers of reproductive health services were selected purposefully. Data were collected by using the in-depth semi-structured interviews and analyzed. A care program draft was designed by integrating results of the qualitative study and reviewing the literature and guidelines, then appropriateness of each proposed care was assessed by a two-Rounds Delphi technique (RAM), and the final reproductive health-care program for surrogate mothers was developed.

RESULTS

The surrogate mothers' reproductive health needs were summarized in four main categories: surrogate mothers' extra care, educational training, psychological support, and protecting against surrogacy's social and familial consequences. The reproductive health-care program for surrogate mothers were developed in four sections: prepregnancy health screenings and legal counseling; special care during embryo transfer until pregnancy confirmation; psychological support and prenatal care of surrogacy until delivery and follow-up postpartum care.

CONCLUSION

Women face many challenges in surrogacy and need special care such as legal counseling, reproductive health care, and psychological support. Implementation of this care program seems to help improve the reproductive health of these mothers.

First clinical report of 179 surrogacy cases in the UK: implications for policy and practice

RESEARCH QUESTION

What implications for policy and practice can be derived from outcomes and trends observed across 8 years of a surrogacy programme in two UK-regulated IVF centres (London, Cardiff)?

DESIGN

Retrospective cohort study analysing surrogacy treatments undertaken between 2014 and September 2021.

RESULTS

Surrogacy continues to rise in popularity in the UK despite the inability of those supporting safe and professional practice to advertise to recruit surrogates. In two IVF centres regulated by the Human Fertilisation and Embryology Authority (HFEA), both the number of surrogacy treatments and the proportion of those undertaken on behalf of same-sex male intended parents increased year on year in the period studied. From a cohort of 108 surrogates, 71 babies were born to 61 surrogates (with five pregnancies ongoing) by February 2022. No statistically significant difference in live birth rates (LBR) was observed between the heterosexual couples and same-sex male couples. Sample sizes of single and transgender intended parents were too small (n < 5) to compare. The use of vitrified oocytes in surrogacy treatments has increased year on year, while fresh oocyte use has declined since peaking in 2019. There was no significant difference in LBR between fresh and vitrified oocyte usage across the cohort.

CONCLUSIONS

The number of surrogacy treatments steadily increased, with clear evidence that the proportion of same-sex male couples accessing surrogacy is a major contributor to this growth. Vitrified/warmed oocyte use now outstrips the use of fresh oocytes in the surrogacy treatment cycles studied here. The results represent a strong basis for supporting the liberalization of regulatory reform expected to be introduced in the UK later in 2022.

Factors Associated With Long-term Survival in Women Who Get Pregnant After Surgery for WHO Grade II Glioma

BACKGROUND AND OBJECTIVES

Women with a WHO grade II glioma (GIIG) often question clinicians on the effects of pregnancy on their disease. Previous reports have indicated a higher risk of glioma progression during and after pregnancy. Here, the aim was to investigate post-pregnancy outcomes and predictive factors impacting overall survival in female patients who underwent GIIG surgery.

METHODS

Inclusion criteria were adult women who have been pregnant after a GIIG resection and with a stable oncological status at the time of pregnancy (no ongoing oncological treatment, no contrast enhancement, no debilitating clinical condition). Relevant cases were identified from a databank (1998-2021) of patients who underwent surgical resection for a histologically-confirmed GIIG in our department.

RESULTS

Among 345 GIIG women within their reproductive years (age<45y), 16 patients (4.6%, mean age at delivery: 30.9±5.1 years) were pregnant (twice in 5 cases). The mean interval between the last oncological treatment (surgery alone in 11 patients while followed by chemotherapy and/or radiotherapy in 5 patients) and pregnancy was 3.5 years (range 0.75-10 years). Two patients experienced seizures during pregnancy. The delivery was vaginal and uneventful in all cases but one (1 caesarean). All children had normal mental and physical development. The glioma behavior changed in 7 patients (43.7%), with an acceleration of the velocity of diameter expansion (VDE) and/or the occurrence of a contrast enhancement during or within the 3 months after pregnancy, resulting in medical treatment and/or reoperation in the early post-partum period in 7 cases. The median clinical follow-up from delivery was 5.3 years (range 1.25-11.6 years). Four other patients received delayed adjuvant therapy for glioma progression. Seven patients (43.7%) died at a median time from delivery of 3.9 years (range 1.25-5.9 years). Overall, the median survival from delivery was 5.75 years. Crucially, patients who underwent a complete surgical resection and patients with stable lesions before pregnancy lived longer (log rank, p=0.046 and p=0.0026, respectively).

CONCLUSIONS

Tumor residual volume and tumor speed growth are strong predictive factors conditioning post-pregnancy long-term survival in patients with GIIG. Identifying patients at risk is critical to provide relevant counsel to GIIG women with a desire for motherhood.

Experiences of gestational surrogacy for gay men in Canada

This paper reports on findings from a qualitative study that examined how Canada's socio-political context influenced gestational surrogacy for same-sex male couples. Semi-structured interviews were conducted with gay fathers and gestational surrogates to investigate supports and barriers of pursuing surrogacy. Questions explored publicly available information, policies and practices of fertility clinics and hospitals, post-birth resources and cultural attitudes regarding same-sex parenthood. Findings suggest that in Canada, a global leader in LGBT rights and inclusive same-sex parenting legislation, participants encountered inadequate same-sex inclusive resources and insufficient provider competencies. The aim of this study was to inform individual and institutional recommendations to counteract biases in fertility care and post-birth services. Following interview analysis, five key strategies were identified: (1) more accessible information on paths to same-sex parenthood; (2) more inclusive fertility clinic and hospital practices; (3) recognition of same-sex fatherhood in formal documentation; (4) post-birth resources such as formula feeding, play groups and first aid courses intended for same-sex parent families; and (5) shifts in cultural attitudes of same-sex parenthood and, specifically, gay fatherhood. Approaches that subvert heteronormative discourses embedded in fertility and reproduction are required to legitimise and support same-sex parent families.

An Ethics-Informed, Comparative Analysis of Uterus Transplantation and Gestational Surrogacy for Uterine Factor Infertility in High-Income Countries

Interest in the future, clinical implementation of uterus transplantation for uterine factor infertility was recently boosted by the demonstration of proof-of-concept for deceased uterus donation/transplantation. The ethical dimensions of living and deceased uterus transplantation are explored and addressed in the paper through their comparison to the ethical elements of an existing, legal, assisted reproduction practice in some high-income countries, i.e., gestational surrogacy. A set of six ethics lenses is used in the comparative analysis: reproductive autonomy and rights, informed choice/consent, relevant critical relational theories, health equity, theoretical application of the accepted living donation standard, and comparative benefits and burdens considerations. Gestational surrogacy, as currently practiced in some high-income countries, is the assumed, theoretical base-threshold for determination of ethical acceptability in assisted reproduction practices. The analysis demonstrates that (at the present time): 1) the ethical acceptability of living uterus donation/transplantation is less than that of gestational surrogacy in high-income countries, and 2) the ethical acceptability of deceased uterus donation/transplantation is roughly equivalent to that of gestational surrogacy. This leads to the conclusion that, at the present time, only one version of uterus transplantation practice, i.e., deceased uterus transplantation, should be considered ethically acceptable for possible clinical implementation in high-income countries.

Development and validation of a risk prediction index for severe maternal morbidity based on preconception comorbidities among infertile patients

OBJECTIVE

To develop and validate a preconception risk prediction index for severe maternal morbidity (SMM), defined by the Centers for Disease Control and Prevention as indicators of a life-threatening complication, among infertile patients.

DESIGN

Retrospective analysis of live births and stillbirths from 2007 to 2017 among infertile women.

SETTING

National commercial claims database.

PATIENT(S)

Infertile women identified on the basis of diagnosis, testing, or treatment codes.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The primary outcome was SMM, identified as any indicator from the Centers for Disease Control and Prevention Index except blood transfusion alone, which was found to overestimate cases. Twenty preconception comorbidities associated with a risk of SMM were selected from prior literature. Targeted ensemble learning methods were used to rank the importance of comorbidities as potential risk factors for SMM. The independent strength of the association between each comorbidity and SMM was then used to define each comorbidity's risk score.

RESULT(S)

Among 94,097 infertile women with a delivery, 2.3% (n = 2,181) experienced an SMM event. The highest risk of SMM was conferred by pulmonary hypertension, hematologic disorders, renal disease, and cardiac disease. Associated significant risks were lowest for substance abuse disorders, prior cesarean section, age ≥40 years, gastrointestinal disease, anemia, mental health disorders, and asthma. The receiver operating characteristic area under the curve for the developed comorbidity score was 0.66. Calibration plots showed good concordance between the predicted and actual risk of SMM.

CONCLUSION(S)

We developed and validated an index to predict the probability of SMM on the basis of preconception comorbidities in patients with infertility. This tool may inform preconception counseling of infertile women and support maternal health research initiatives.

Regenerative Medicine Approaches in Bioengineering Female Reproductive Tissues

Diseases, disorders, and dysfunctions of the female reproductive tract tissues can result in either infertility and/or hormonal imbalance. Current treatment options are limited and often do not result in tissue function restoration, requiring alternative therapeutic approaches. Regenerative medicine offers potential new therapies through the bioengineering of female reproductive tissues. This review focuses on some of the current technologies that could address the restoration of functional female reproductive tissues, including the use of stem cells, biomaterial scaffolds, bio-printing, and bio-fabrication of tissues or organoids. The use of these approaches could also be used to address issues in infertility. Strategies such as cell-based hormone replacement therapy could provide a more natural means of restoring normal ovarian physiology. Engineering of reproductive tissues and organs could serve as a powerful tool for correcting developmental anomalies. Organ-on-a-chip technologies could be used to perform drug screening for personalized medicine approaches and scientific investigations of the complex physiological interactions between the female reproductive tissues and other organ systems. While some of these technologies have already been developed, others have not been translated for clinical application. The continuous evolution of biomaterials and techniques, advances in bioprinting, along with emerging ideas for new approaches, shows a promising future for treating female reproductive tract-related disorders and dysfunctions.

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.

Bioethical issues and legal frameworks of surrogacy: A global perspective about the right to health and dignity

Modern advances in assisted reproduction technology (ART) have disrupted the traditional concept of parenthood. Every year, thousands of people travel abroad from their home countries in order to circumvent restrictive legislation or to benefit from lower fees. In a similar context, surrogacy raises many bioethical and legal issues. The present paper will address the main questions arising from the debate prompted by surrogacy, focusing on international legislation, and looking critically at the different legislative models. As a result of worldwide heterogeneity in policies, legal approaches, and access to ART throughout the world, a growing number of would-be parents are seeking treatment abroad. The lack of regulation on cross-border surrogacy in low income countries can undermine the dignity and rights of women as even modest economic compensation determines a significant purchasing power. The international effort should be aimed at creating an international regulatory framework from which guidelines useful to national governments derive. An international agreement would provide a solid legal basis for the protection of surrogate women. In order to limit the economic interests linked to procreative tourism, so as to truly protect global health and women's rights, legislative uniformity is therefore necessary between the various states.

Same-sex male couples and single men having children using assisted reproductive technology: a quantitative analysis

RESEARCH QUESTION

How do same-sex male couples (SSMC) and single men perceive their experience of using assisted reproductive technology (ART) in Canada; what factors contribute to their experience and the decisions made throughout the ART process?

DESIGN

This cross-sectional study used an anonymous online survey to gather exploratory data (between August 2018 and August 2019) about participant experience and decision-making considerations, for SSMC and single men internationally who had undergone ART in Canada. The survey was accessed by 145 individuals; 98 participants were included in the final analysis. Statistical Package for the Social Sciences (SPSS) was used for quantitative analysis.

RESULTS

Four out of five participants had a positive overall experience of using ART in Canada. Having the social support of knowing others who had previously pursued ART, and needing to work with multiple egg donors, were found to affect overall experience significantly. Agencies were the most common way for intended parents to connect with third parties. Major factors men considered when choosing an egg donor included medical history, physical attributes, personality and temperament, ethnicity, and education; they tended to select gestational surrogates who had similar lifestyle values to themselves. Most coupled survey respondents created embryos using each partner's spermatozoa (73.6%).

CONCLUSIONS

This exploratory study expands on limited knowledge of the current topic, identifying key areas for future research. Most SSMC and single men, domestic and internationally, had a positive experience pursuing ART in Canada to have children. Research on the experiences of SSMC and single men and decision-making considerations should continue.

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.

Analysis of gestational surrogates' birthing experiences and relationships with intended parents during pregnancy and post-birth

BACKGROUND

This study investigated the surrogates' birth experiences, their levels of emotional struggle at relinquishment, how often they thought about the surrogacy children, and the surrogate-parent relationship dynamics during pregnancy and post-birth.

METHODS

Data were collected from 06/2016 to 02/2017 using an anonymous questionnaire. Participants were Canadian gestational surrogates who had completed the process with or without a successful live birth, and who were at various stages of an ongoing surrogacy. For this paper, only a subgroup of cases with a successful live birth was selected for analysis.

RESULTS

The data set included 131 births involving 90 surrogates who delivered 157 babies (105 singletons and 26 sets of twins). Their mean age at the time of surrogacy was 31.7 ± 5 years (range: 21-47y). More than one-third (37.4%) of the cases were for intended parents who were same-sex male couples and single men. Surrogates assisting Canadian-resident intended parents had an overall better birthing experience compared with those assisting nonresidents. There was none or very little struggle with the relinquishment of the baby in 96.9% of cases. Continued contact with parents after the births was reported in 93.0% of cases. Surrogates were significantly more likely to have frequent post-birth contact with same-sex and single fathers compared with heterosexual parents and single mothers (76.6% vs 54.3%).

CONCLUSIONS

Same-sex male couples and single men can develop a long-lasting relationship with their surrogates even when no intended female partners are involved. The development of institutional practice guidelines in standardizing surrogacy birth practice is paramount in optimizing surrogates' care.

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.

Use of gestational surrogates for women with Eisenmenger syndrome: a cost-effectiveness analysis

Objective: Eisenmenger syndrome (ES) is regarded as a contraindication to pregnancy, with therapeutic abortion recommended in the event of unintended pregnancy. However, women with ES continue to desire and attempt pregnancy despite grave risks to their own health. This study compares the costs and outcomes of pregnancy in women with ES to the use of gestational surrogates in their pregnancies.Study design: A decision-analytic model was built using TreeAge software that compared use of gestational surrogates and pregnancy in women with ES. Maternal death and neonatal outcomes including intrauterine fetal demise, preterm birth, cerebral palsy, and death were assessed. All probabilities and costs were derived from the literature. Utilities were discounted at a rate of 3% across the expected lifespan to generate quality-adjusted life years (QALYs). Univariate and multivariate sensitivity analyses were performed to evaluate the robustness of the model given changes in baseline assumptions.Results: In a theoretical cohort of 1000 women with ES, pregnancy would result in 360 maternal deaths, 100 stillbirths, 477 preterm births, and 157 neonatal deaths . In these highly desired pregnancies, use of gestational surrogates would prevent 99 and 98% of maternal and neonatal death, respectively. Cases and costs of preterm birth and associated cerebral palsy are also significantly reduced. Use of a gestational surrogate would save $518,255 per woman with a gain of 6.77 QALYs, a dominant strategy. The approach is cost-effective up to a cost of surrogacy of $1.2 million and even if the surrogate achieves pregnancy only 30% of the time.Conclusions: The use of surrogate mothers for those with ES is cost-effective and results in significantly improved maternal and neonatal outcomes. These benefits are robust in the face of high surrogacy costs largely due to the marked reduction in maternal mortality and preterm birth. These findings should be used to underscore the importance of broadening health care financing for medically-indicated assisted reproduction.

Surrogacy: Challenges and Ambiguities

Surrogacy is an increasingly frequent form of family building and allows individuals to become parents despite an infertility diagnosis or a biological impossibility. Positive outcomes for both the surrogacy child and the surrogate mother have been reported, including in cases of same-sex male couples and single persons. There is an on-going debate because remuneration does not necessarily involve undue inducement of the surrogate or transformation of the child into a commodity. The right to regret and the doctors' autonomy are also addressed in this paper. Nevertheless, literature on surrogacy is scarce, and most of the existing studies have important methodological limitations, so further investigation is much needed. We believe that counselling should be granted for both intended parents and surrogate, in order to prevent the majority of problems. We also agree that parental vetting should be possible, focusing the doctor's responsibility also in the future child.

Reproductive and sexual Health of surrogate mothers, developing a care program: a protocol for mixed methods study

Background

Gestational surrogacy is one of the options for women whom pregnancy is contraindicated. Despite of increasing demand for gestational surrogacy, its various aspects are controversial. The unique nature of surrogacy causes surrogate mothers to face a variety of problems such as, ethical confusion, psychological disturbance and reproductive health matters. Therefore, it is necessary to develop a comprehensive care program for reproductive and sexual health providing specific care at prenatal and pregnancy as well as delivery and postpartum period in socio- cultural context of Iran.

Methods

This research is an exploratory study with the qualitative-quantitative sequencing design (mixed) that is consisted of three sequential phases. In the first phase, following a qualitative approach, the researcher will explain needs of reproductive and sexual health in surrogate mothers. In the second phase, a primary reproductive and sexual health care program is designed for surrogate mothers in which, in addition to using the qualitative study results, related papers and texts will be also used. In the third phase of the study, reproductive and sexual health care program will be evaluated by RAND method (RAM).

Discussion

The results of this mixed method study are expected to lead to the development of a reproductive and sexual health care program meeting the needs of surrogate mothers and are in accordance with the cultural conditions of the research community, ultimately leading to improvement in reproductive and sexual health of surrogate mothers.

Gestational Surrogacy: Current View

Surrogate motherhood is an assisted procreation practice by which a woman gestates an embryo with which she has no biological relationship on behalf of a contracting couple or individual, having to relinquish the child to them after its birth. This practice normally entails a financial remuneration for the pregnant woman; when this is not the case, it is called altruistic surrogacy. From a medical perspective, potential problems for the surrogate and for children born through this practice should be taken into account, especially the existence of possible disabilities in the child. The bioethical aspects are of most interest because the practice of surrogacy objectifies the expectant mother, by using her body for a purpose other than her own good, treating her as a commodity, as a thing. The same is true for the child because it makes him a disposable object, something that can be instrumentalized, similarly objectifying him.

Surrogacy Wars: Notes for a Radical Theory of the Politics of Reproduction

State regulation of reproductive practices secure the heterosexual infrastructure of kinship through means that include elitization, institutional hostility, and plain criminalization. This article draws on personal experiences of gay fathers through transnational gestational surrogacy in Spain to show the extent to which that is the case even in those contexts where some gay and lesbian kinship rights are available. Public and academic debates on the possible regulation of gestational surrogacy will be analyzed through the lens of Gayle Rubin's intervention in the sex wars that divided feminism in the 1980s, with which contemporary anti-surrogacy movements show crucial genealogical links. In addition, in order to unearth some gendered assumptions on the ahistorical link between surrogacy and motherhood, the role of the gestational carrier will be read in relation to the figure of the "bad mother."

Perspectives and attitudes of Jordanian medical and paramedical students toward surrogate pregnancy

PURPOSE

This study aims at investigating the perspectives of Jordanian medical and paramedical students on surrogate pregnancy.

METHODS

A questionnaire-based cross-sectional study design was used. The sample consisted of n=328 students of both genders. The questionnaire responses were numerically coded and analyzed across gender and the level of education.

RESULTS

Approximately, 18% of the students reported good awareness about the ethical dilemmas of surrogacy. The results showed a general reluctance to accept surrogate pregnancy as the majority (80.5% of male students and 97.6% of female students) had a negative attitude toward surrogacy. In addition, undergraduate students were less supportive to surrogate pregnancy than graduate students. Religious considerations were the main reason (accounts for about 70%) for driving negative attitude toward surrogacy.

CONCLUSION

The findings of the study indicate a general reluctance toward accepting the concept of surrogate pregnancy, which is mainly due to religious reasons.

Gestational surrogacy in the Czech Republic

BACKGROUND

Gestational surrogacy, is a treatment option for women with certain clearly defined medical problems, usually an absent uterus, to help them have their own genetic children. The aim of our study was to review, evaluate and share our experience and outcomes over the last 13 years of the largest surrogacy program in the Czech republic.

METHODS

A total of 75 intended mothers and 82 surrogate mothers participated in this study. A retrospective cohort study was performed. Anonymized data were collected on 130 cycles of gestational surrogate (2004-2017) directly from the Clinic database.

RESULTS

We performed 130 in vitro fertilization cycles with gestational surrogacy which involved 73 fresh embryo transfers and 57 frozen embryo transfers. We achieved 57 (43.9%) pregnancies and 42 (32.3%) live births. The rate of multiple pregnancies was only 2.3 %. The most common indication for using was an absent or damaged uterus (65%), followed by medical conditions precluding pregnancy (23%) and repeated in vitro fertilization cycles or pregnancy failure (12%).

CONCLUSION

In the 14 years of our experience, we have shown that treatment of young women with specific indications for gestational surrogacy is beneficial, successful and relatively free of complications. However, it is imperative to follow the medical indications for this treatment and specialist recommendations.

Risks in Surrogacy Considering the Embryo: From the Preimplantation to the Gestational and Neonatal Period

Surrogacy is an assisted reproduction-based approach in which the intended parents assign the gestation and birth to another woman called the surrogate mother. The drivers of surrogacy refer largely to infertility, medical conditions, same-sex couples' parenting, and cases of diversity regarding sexual identity and orientation. Surrogacy consists of a valid option for a variety of conditions or circumstances ranging from medical to social reasons. However, surrogacy may be associated with risks during the preimplantation, prenatal, and neonatal period. It became obvious during the exhaustive literature research that data on surrogacy and its association with factors specific to the IVF practice and the options available were not fully represented. Could it be that surrogacy management adds another level of complexity to the process from the ovarian stimulation, the subsequent IVF cycle, and the techniques employed within the IVF and the Genetic Laboratory to the fetal, perinatal, and neonatal period? This work emphasizes the risks associated with surrogacy with respect to the preimplantation embryo, the fetus, and the infant. Moreover, it further calls for larger studies reporting on surrogacy and comparing the surrogate management to that of the routine IVF patient in order to avoid suboptimal management of a surrogate cycle. This is of particular importance in light of the fact that the surrogate cycle may include not only the surrogate but also the egg donor, sperm donor, and the commissioning couple or single person.

Gestational carrier in assisted reproductive technology

OBJECTIVE

To compare clinical outcomes of in vitro fertilization (IVF) cycles with the use of gestational carriers (GCs) with non-GC IVF cycles.

DESIGN

Retrospective cohort study of assisted reproductive technology (ART) cycles performed with (24,269) and without (1,313,452) the use of a GC.

SETTING

ART centers.

PATIENT(S)

Infertile patients seeking IVF with or without use of a GC.

INTERVENTIONS(S)

Autologous and donor oocyte cycles, fresh and cryopreserved embryo transfer cycles.

MAIN OUTCOME MEASURE(S)

Live birth rate (LBR), twin and high-order multiple birth rates.

RESULT(S)

Approximately 2% of embryo transfers used a GC. Per embryo transfer, GCs had greater pregnancy rate and LBR across all IVF types compared with non-GC cycles in crude models and models adjusted a priori for potential confounders. For women with uterine-factor infertility, embryo transfer with the use of a GC resulted in a higher odds of live birth for autologous fresh embryos and for cryopreserved embryos compared with patients with non-uterine-factor infertility diagnoses.

CONCLUSION(S)

GC benefits LBRs for some patients seeking ART. The highest LBRs occurred when the indication for GC was uterine-factor infertility.

Gestational surrogacy. Medical, psychological and legal aspects: 9 years of experience in Mexico

STUDY QUESTION

What are the medical, psychological and legal aspects involved in running a gestational surrogacy (GS) program in Mexico?

SUMMARY ANSWER

The correct and complete implementation of a medical protocol, adherence to legality and psychological screening are key elements for the success of a GS program.

WHAT IS KNOWN ALREADY

To our knowledge, this is the first reported GS case series in Mexico.

STUDY DESIGN, SIZE, DURATION

This was a retrospective, descriptive study of 135 cycles performed between 2007 and 2016 at a fertility center in Villahermosa, Tabasco, Mexico.

PARTICIPANTS/MATERIALS, SETTING, METHOD

We analyzed data from 135 GS cycles, 57 intended parents (IP) and 63 gestational carriers (GC).

MAIN RESULTS AND THE ROLE OF CHANCE

GS in Mexico is only allowed in its altruistic mode. The legal requirements for the GCs are age 25–35 years and a complete medical examination that certifies no pregnancy during the last 365 days before embryo transfer and excludes infectious and chronic diseases. The IPs must be aged 25–40 years of age, have Mexican citizenship, and provide life insurance and medical expenses for the GCs. The GC recruitment was carried out by word of mouth. Of the 150+ women that requested information, 89 were identified as possible candidates. In total, 77 underwent the psychological evaluation protocol and nine were rejected owing to behavior and emotional alterations, giving 68 who began the medical selection protocol. Five women were not accepted as they were positive for human papilloma virus, or had experienced endometrial polyposis or recurrent pregnancy loss. Finally, 63 women entered the IVF protocol as GCs. The indications for GS were: hysterectomy 32%, implantation failure 21%, single fathers 14%, maternal medical condition 14%, recurrent pregnancy loss 11%, previous pregnancy complication 5% and uterine pathologies 3%. The mean age of intended mothers was 38.8 years. The average number of embryos transferred per cycle was 1.9, with 22.2% of cycles resulting in pregnancies. The live-birth rate per IP was 33.3%, 18.5% of cycles resulted in live births, with 24% of live births being twins.

LIMITATIONS, REASONS FOR CAUTION

Owing to the retrospective nature of this study conclusions must be drawn accordingly.

WIDER IMPLICATIONS OF THE FINDINGS

As the first article addressing GS in Latin America, it may serve as a reference for future practice and publications. The results demonstrate the importance of having an assisted reproduction program in the form of GS.

STUDY FUNDING/COMPETING INTERESTS

There was no external funding used and there are no conflicts to report.

Surrogacy: Pathway to Parenthood

Assistive reproductive technology has progressed significantly over the past few decades. In spite of the advances, people may still resort to a surrogate for bearing and birthing a baby. Surrogacy, though an altruistic act, has been commercialized in the past few years, leading to emergence of several ethico-legal concerns. Nurses care for the surrogates, the infants, and the intended parents through their journey with sensitivity, advocacy, compassion, and confidentiality. This article intends to explore the implications of surrogacy to individuals, families, nations, and health care.

Outcome of gestational surrogacy according to IVF protocol

PURPOSE

Surrogacy remains the only option for having a biologic child for a unique population of women with severe medical conditions. However, no study has looked at surrogacy outcome as a result of the type of ovarian stimulation of the intended mother [controlled ovarian stimulation (COH), modified natural cycle (MNC), and in vitro maturation (IVM)] for oocyte retrieval.

METHODS

This is a retrospective study, including all intended mothers and gestational carriers in a tertiary, university affiliated, medical center, from 1998 to 2016.

RESULTS

Fifty-two women underwent 252 oocyte retrieval cycles. The pregnancy outcome of 212 embryo transfer cycles (64 gestational carriers) was reviewed according to the origin of the embryo. The number of retrieved oocytes was significantly higher following COH (n = 132) compared with IVM (n = 58) and MNC cycles (n = 62) (p = 0.013 and p < 0.0001, respectively). Pregnancy rates for embryos transferred according to each protocol were similar. All pregnancies that ended in live births when oocytes from IVM cycles were used derived from transfers of retrieved mature and mixed mature and immature oocytes. Pregnancies that involved embryos derived solely from immature oocytes that further matured in vitro and were transferred to gestational carriers were unsuccessful.

CONCLUSIONS

MNC protocol is a good option to achieve pregnancy for intended mothers using gestational surrogacy who have contraindications to COH. The yield of IVM cycles in which immature oocytes are retrieved is inconclusive.

Risk of adverse pregnancy and perinatal outcomes after high technology infertility treatment: a comprehensive systematic review

In the literature, there is growing evidence that subfertile patients who conceived after infertility treatments have an increased risk of pregnancy and perinatal complications and this is particularly true for patients who conceived through use of high technology infertility treatments. Moreover, high technology infertility treatments include many concomitant clinical and biological risk factors. This review aims to summarize in a systematic fashion the current evidence regarding the relative effect of the different procedures for high technology infertility treatments on the risk of adverse pregnancy and perinatal outcome. A literature search up to August 2016 was performed in IBSS, SocINDEX, Institute for Scientific Information, PubMed, Web of Science and Google Scholar and an evidence-based hierarchy was used to determine which articles to include and analyze. Data on prepregnancy maternal factors, low technology interventions, specific procedures for male factor, ovarian tissue/ovary and uterus transplantation, and chromosomal abnormalities and malformations of the offspring were excluded. The available evidences were analyzed assessing the level and the quality of evidence according to the Oxford Centre for Evidence-Based Medicine guidelines and the Grading of Recommendations Assessment, Development, and Evaluation system, respectively. Current review highlights that every single procedure of high technology infertility treatments can play a crucial role in increasing the risk of pregnancy and perinatal complications. Due to the suboptimal level and quality of the current evidence, further well-designed studies are needed.

Trends and outcomes of gestational surrogacy in the United States

OBJECTIVE

To evaluate trends and reproductive outcomes of gestational surrogacy in the United States.

DESIGN

Retrospective cohort study.

SETTING

Infertility clinics.

PATIENT(S)

IVF cycles transferring at least one embryo.

INTERVENTION(S)

Use of a gestational carrier.

MAIN OUTCOME MEASURE(S)

Trends in gestational carrier cycles during 1999-2013, overall and for non-U.S. residents; reproductive outcomes for gestational carrier and nongestational carrier cycles during 2009-2013, stratified by the use of donor or nondonor oocytes.

RESULT(S)

Of 2,071,984 assisted reproductive technology (ART) cycles performed during 1999-2013, 30,927 (1.9%) used a gestational carrier. The number of gestational carrier cycles increased from 727 (1.0%) in 1999 to 3,432 (2.5%) in 2013. Among gestational carrier cycles, the proportion with non-U.S. residents declined during 1999-2005 (9.5% to 3.0%) but increased during 2006-2013 (6.3% to 18.5%). Gestational carrier cycles using nondonor oocytes had higher rates of implantation (adjusted risk ratio [aRR], 1.22; 95% confidence interval [CI], 1.17-1.26), clinical pregnancy (aRR, 1.14; 95% CI, 1.10-1.19), live birth (aRR, 1.17; 95% CI, 1.12-1.21), and preterm delivery (aRR, 1.14; 95% CI, 1.05-1.23) compared with nongestational carrier cycles. When using donor oocytes, multiple birth rates were higher among gestational carrier compared with nongestational carrier cycles (aRR, 1.13; 95% CI, 1.08-1.19).

CONCLUSION(S)

Use of gestational carriers increased during 1999-2013. Gestational carrier cycles had higher rates of ART success than nongestational carrier cycles, but multiple birth and preterm delivery rates were also higher. These risks may be mitigated by transferring fewer embryos given the higher success rates among gestational carrier cycles.

Behavioral outcomes in children exposed prenatally to lamotrigine, valproate, or carbamazepine

OBJECTIVES

To evaluate adaptive behavior outcomes of children prenatally exposed to lamotrigine, valproate, or carbamazepine, and to determine if these outcomes were dose-dependent.

METHODS

Data were collected from women enrolled in the North American Anti epileptic Drug (AED) Pregnancy Registry who had taken lamotrigine, valproate, or carbamazepine monotherapies throughout pregnancy to suppress seizures. The adaptive behavior of 252 exposed children (including 104 lamotrigine-exposed, 97 carbamazepine-exposed, and 51 valproate-exposed), ages 3- to 6-years-old, was measured using the Vineland-II Adaptive Behavior Scales, administered to each mother by telephone. Mean Adaptive Behavior Composite (ABC), domain standard scores for communication, daily living, socialization and motor skills, and adaptive levels were analyzed and correlated with first trimester drug dose.

RESULTS

After adjusting for maternal age, education, folate use, cigarette and alcohol exposure, gestational age, and birth weight by propensity score analysis, the mean ABC score for valproate-exposed children was 95.6 (95% CI [91, 101]), versus 100.8 (95% CI [98, 103]) and 103.5 (95% CI [101, 106]) for carbamazepine- and lamotrigine-exposed children, respectively (ANOVA; p=0.017). Significant differences were observed among the three drug groups in the ABC (p=0.017), socialization (p=0.026), and motor (p=0.018) domains, with a trend toward significance in the communication domain (p=0.053). Valproate-exposed children scored lowest and lamotrigine-exposed children scored highest in every category. Valproate-exposed children were most likely to perform at a low or moderately low adaptive level in each category. Higher valproate dose was associated with significantly lower ABC (p=0.020), socialization (p=0.009), and motor (p=0.041) scores before adjusting for confounders. After adjusting for the above variables, increasing VPA dose was associated with decreasing Vineland scores in all domains, but the relationships were not statistically significant. No dose effect was observed for carbamazepine or lamotrigine.

CONCLUSIONS

Unlike carbamazepine and lamotrigine, prenatal valproate exposure was associated with adaptive behavior impairments with specific deficits in socialization and motor function, along with a relative weakness in communication. Increasing valproate dose was associated with a decline in adaptive functioning. This finding of a linear dose-dependent teratogenic effect suggests that valproate should be avoided at any dose during pregnancy. However, some women with epilepsy controlled only by valproate will decide, in consultation with their provider, that the benefits of continuing valproate during pregnancy outweigh the fetal risks. Faced with difficult choices, clinicians should be supportive as these patients consider their options.

The reproductive potential of patients with Mayer-Rokitansky-Küster-Hauser syndrome using gestational surrogacy: a systematic review

Women with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome may reproduce after uterine transplantation or IVF using a gestational surrogate. As uterine transplantation is still an experimental procedure, data on their clinical outcome using assisted reproduction techniques are imperative to allow evidence-based counselling. For this purpose, a systematic non-restricted electronic literature search was conducted. The 14 studies included in this review were published between 1988 and 2011. From a cohort of 140 patients with MRKH syndrome, mostly from the the USA and Israel, only four studies contained data on more than 10 patients; the others were case reports or small series. In the studies reviewed, 125 patients underwent 369 cycles of IVF with gestational surrogacy, and delivered 71 newborns. The reporting of outcome of patients with MRKH syndrome undergoing assisted reproduction techniques in the available literature is less than optimal and is characterized by bias of publication, inconsistent reports, including few patients, treated over a long time span, and lacking systematic reports from large IVF centres. None of the national registries contain specific outcome data on patients with MRKH syndrome. The paucity of data limits the possibility to draw firm conclusions but substantiates the need for a systematic multicentre reporting system.

Gestational carrier BMI and reproductive, fetal and neonatal outcomes: are the risks the same with increasing obesity?

OBJECTIVE

Data suggest that female obesity impairs uterine receptivity and increases the risk of fetal and neonatal mortality. We analyzed the reproductive outcomes of gestational carriers (GCs) undergoing donated oocytes and assisted reproductive technology according to body mass index (BMI).

DESIGN

A retrospective analysis of 163 GCs undergoing 226 in vitro fertilization (IVF) and embryo transfer cycles.

METHODS

GCs undergoing in vitro fertilization and embryo transfer cycles were analyzed and divided according to their BMI (healthy weight: 20-24.9 kg m(-2) (n=77 in 114 cycles); overweight: 25-29.9 kg m(-)(2) (n=55 in 71 cycles); and obese: 30-35 kg m(-)(2) (n=31 in 41 cycles)). All GCs underwent a complete medical evaluation and were cleared for pregnancy before being selected. Overweight and obese GCs also underwent a metabolic screening, including an oral glucose tolerance test and lipid profile. The main outcomes measured were clinical pregnancy and live birth rates, antenatal and neonatal outcomes.

RESULTS

Clinical pregnancy and live birth rates were similar despite increasing BMI. There were no statistically significant differences in the implantation rates, clinical pregnancy rates or live birth rates per embryo transfer among patients in the three BMI groups. In the healthy weight, overweight and obese GCs, the clinical pregnancy rates per GC were 72%, 84% and 79%, and per embryo transfer rates were 52%, 49% and 56%, respectively; P=NS. The live birth rates per GC were 70%, 84% and 75%, and per embryo transfer rates were 50%, 49% and 53%, respectively; P=NS. Twin rates were similar between the groups (35%, 31% and 29%, respectively; P=NS). There were no differences in gestational diabetes, preterm admissions or cesarean section rates. Neonatal intensive care unit admissions were similar (11%, 13% and 12%, respectively; P=NS), and no maternal, neonatal or infant mortality occurred.

CONCLUSIONS

These data show that increasing obesity does not impair the reproductive outcome in GC cycles. Larger sample size is indicated to verify these findings. Furthermore, this study suggests that the standard metabolic screening used for GCs may lead to selection of healthier patients compared with women of comparable BMI who conceive outside of a fertility clinic setting, indicating the metabolic profile, rather than BMI, may better explain differences in pregnancy outcomes.

Deficiencies in reporting results of lesbians and gays after donor intrauterine insemination and assisted reproductive technology treatments: a review of the first emerging studies

At a time when increasing numbers of lesbians and gays consider parenthood using reproductive assistance in infertility centers, the present review aims to summarize the results obtained so far by lesbians after intrauterine insemination (IUI) and in-vitro fertilization (IVF) using donor spermatozoa (D-IUI and D-IVF, respectively) and gays entering into gestational-surrogacy programs. Data show that gays display normal semen parameters and lesbians exhibit no specific causes of female infertility except perhaps for polycystic ovary syndrome (PCOS) and some PCOS-related factors. Pair-bonded lesbians entering into D-IUI programs, tend to have higher pregnancy and delivery percentages following spontaneous or induced ovulation than single or pair-bound heterosexual women. The only single study reporting success percentages of lesbians after D-IVF provides, however, puzzling results. In particular, pair-bonded lesbians have lower pregnancy and live-birth percentages than pair-bonded heterosexual women in fresh D-IVF cycles but percentages are similar in frozen/thawed D-IVF cycles. Like in lesbians after D-IUI, surrogate women recruited by pair-bonded gays/single men tend to have higher pregnancy percentages and lower miscarriage percentages than surrogate women recruited by heterosexual couples. Notably, all the reports reviewed in the present study are methodologically flawed because of sampling bias, small sample sizes and inadequate use of statistical methods to control for the effects of influential covariates including age, smoking habits, previous gynecological problems, hormonal stimulation type and protocol, and number of prior treatment types and pregnancies/deliveries. Clinicians, reproductive biologists and editors of fertility/infertility journals should make efforts to prevent these deficiencies in future data reporting.