Medical aspects of surrogacy
Introduction
What is surrogacy?
Surrogacy is when a woman (the surrogate) carries a child for someone else (the intended parent(s)). For example, because someone is unable to get pregnant themselves, or because they cannot carry a pregnancy to term. After the birth, the intended parent(s) take over the baby's care.
A lot's involved in surrogacy on ethical, psychological and legal grounds. This page will primarily explore the medical aspects of surrogacy.
How the pregnancy happens depends on the form of surrogacy. Namely, will the surrogate get pregnant using her own egg or with the egg of the intended mother or egg donor? There are risks in the treatments involved and complications can occur. There are also risks in pregnancy and childbirth. The chance of complications dependents both on the surrogate and on the form of surrogacy.
When complications occur this can have an influence on the income of the surrogate and her family. It is good to think about arranging insurance in case this occurs.
In the following sections you'll learn what you need to know medically about:
Getting pregnant
The risk of complications during treatment depends upon how the surrogate gets pregnant.
Only start trying to get pregnant after completing the necessary preparations and recording the decisions you have taken together in a surrogacy agreement and possibly a donor agreement, drawn up by a specialist surrogacy lawyer.
Also think about taking folic acid and vitamin D.
In the Netherlands, all women who want to get pregnant are advised to take them.
- It is important that you start taking folic acid and vitamin D before trying to get pregnant.
- Pregnancy increases your body's vitamin D requirements so it is wise to take a supplement of this.
- Folic acid lowers the risk of a child with spina bifida or a neural tube defect.
Getting pregnant: surrogate's egg
In surrogacy, where the surrogate becomes pregnant using her own egg, the intervention of a hospital or clinic is usually not required. Pregnancy can occur through self-insemination. This can be done easily at home and is known as low-tech surrogacy.
Self-insemination
The probability of getting pregnant through self-insemination is the same as for couples trying to get pregnant through sexual intercourse. After 12 months, 85 out of 100 women get pregnant through self-insemination.
The likelihood of complications through self-insemination are low.
Sexually transmitted diseases (STDs)
There is a risk of passing on sexually transmitted diseases (STDs) through self-insemination with fresh sperm. It is important for both the surrogate and the intended father to take measures to avoid contracting STDs. If there is a risk of a STD nevertheless, it is important to get tested first for:
- HIV
- Hepatitis B
- Hepatitis C
- Syphilis
- Gonorrhea
- Chlamydia.
It is a matter of mutual trust. Talk things over and make firm commitments recorded in a surrogacy agreement or donor agreement.
procedure
Self-insemination occurs by injecting fresh sperm into the vagina with a syringe. See the website donorconceptie.nl (in Dutch) for instructions on self-insemination
Don't try to inject the sperm straight into the uterus. Sperm contains substances that cause the uterus to cramp. These cramps can be very severe and require pain relief. The uterus uses these cramps to expel sperm from it, so you'd achieve the opposite of what you want. It also increases the risk of pelvic inflammatory disease compared to injecting sperm into the vagina. The best place to inject sperm is directly beneath the cervix.
If you don't succeed in getting pregnant through self-insemination you need to see your general practitioner. You may need treatment. The type of treatment you need determines the likelihood of complications. Get informed by your treating physician.
What if you don't manage to get pregnant?
Sometimes pregnancy fails to occur after a year of self-insemination. Sometimes you know from the outset that a surrogate won't be able to get pregnant through self-insemination because she does not have a menstrual cycle. In this case, you can go to the Amsterdam UMC for diagnosis and potentially help getting pregnant. Part of the care they provide is surrogacy screening and counselling.
To find out more get in touch with: Amsterdam UMC
Getting pregnant: Intended mother's egg
If the intended parents are going to use their own egg and sperm, fertility treatments, such as in vitro fertilisation (IVF), are required to create an embryo which is then transferred to the surrogate's uterus. This is known as high-tech surrogacy.
At the current time, there are two clinics in the Netherlands where you can go for IVF treatment with a surrogate:
Amsterdam UMC Nij Geertgen
IVF (or ICSI) treatment in a few words
We provide a brief summary of what an IVF treatment may entail on this website. Please ensure that you get thoroughly informed by your treating physician regarding the various steps in the treatment, the risks, and complications. They are better placed to indicate the best treatment for your specific case and the risks and complications that apply to your situation.
Intended mother
Procedure
During IVF treatment, the intended mother is stimulated with hormones. The growth of the follicles is monitored by ultrasound. Egg retrieval is scheduled once the follicles are large enough. This takes place with pain relief or sedation.
At the next stage, the eggs and sperm cells from the semen are combined in the laboratory in closely controlled conditions to ensure that fertilisation can take place and an embryo can develop. This embryo will be transferred to the surrogate. If multiple embryos are produced, they will be frozen.
If the semen contains insufficient sperm, IVF may not result in fertilisation. Then ICSI treatment will be necessary. Your doctor will talk to you about what this entails if this is the best option for you.
Risks
The risks and complications of IVF(ICSI) treatment are similar to those for any prospective parents who need help getting pregnant.
The risks are:
- Understimulation (no follicles develop in the ovaries)
- Hyperstimulation (too many follicles develop in the ovaries)
- Fertilisation fails to occur
- No suitable embryo forms
Complications are:
- Side-effects of medication
- Bleeding after puncture
- Infection after puncture
- Hyperstimulation syndrome (symptoms can occur when too many follicles develop in the ovary)
Please consult the costs page to see how costs are affected by complications.
Surrogate
The surrogate's menstrual cycle will be monitored to assess the best time to transfer the embryo to her uterus.
Sometimes the surrogate doesn't have a regular cycle and needs medication to get her uterus to the right stage before transfer. When hormone treatment is required prior to embryo transfer there is a small risk of thrombosis. You need to know that after getting pregnant, you will need to continue taking this medication for a further 12 weeks. We also know that pregnancies resulting from a medicated cycle have a slightly increased risk for high blood pressure problems (for example pre-eclampsia) during pregnancy.
Sometimes the transfer of a fresh embryo is successful. Frozen embryos can be used in later cycles. The transfer of a fresh or frozen embryo makes no difference to the risks.
Ask your treating physician about the best way for you to have the embryo transferred at the right time.
You will have a speculum inserted during embryo transfer so that your cervix is clearly visible. The doctor will then insert a narrow tube through the cervix into the uterus and this will be used for the embryo transfer. You often don't feel much.
The likelihood of complications from embryo transfer for a surrogate are low. The likelihood of an infection from embryo transfer is very low.
Getting pregnant: the number of embryos that should be transferred
How many embryos should be transferred: one, two or possibly more?
We recommend transferring a single embryo.
You do not increase the probability of a pregnancy by transferring two embryos to the surrogate at the same time instead of transferring a single embryo during two consecutive cycles.
The costs for menstrual cycle monitoring and embryo transfer fall to the intended parents. This may make it tempting to opt for the transfer of multiple embryos. This is often encouraged abroad.
The probability of a multiple birth (twins, triplets, etc.) is greater if you transfer more embryos at the same time. You may well think that sounds great. You'll be done in one go. It'll save a lot of money.
Unfortunately, the probability of complications is far greater with multiple pregnancies. The probability of high blood pressure problems in pregnancy (pre-eclampsia) are greater. As the surrogate is pregnant using someone's else's egg the risk is particularly high. The surrogate can become very ill as a result which is dangerous both for her and the children.
Other risks are that twin surrogate children may be born very prematurely or have low birth weight. Premature birth and low birth weight can cause (permanent) problems for the child.
We also know that the parents of twins and multiples have a harder time during the postpartum period. Getting used to looking after one baby is hard enough. When there are two or possibly more of them it is even harder.
Therefore, transferring more than one embryo is not a good idea for either the surrogate or the children.
Getting pregnant: donor egg
When the intended parents can only supply sperm and the surrogate will not become pregnant of her own egg, they require an egg donor. Even then, IVF treatment is necessary to create an embryo, which is then transferred to the surrogate's uterus.
At the current time, there are two clinics in the Netherlands where you can go for IVF treatment with a surrogate and egg donor:
Amsterdam UMC Nij Geertgen
IVF treatment in a few words
Egg donor
Procedure
During IVF treatment, the donor is stimulated with hormones. The growth of the follicles is monitored by ultrasound. Egg retrieval is scheduled once the follicles are large enough. This takes place with pain relief or sedation.
At the next stage, the donor eggs and sperm cells from the semen are combined in the laboratory in closely controlled conditions to ensure that fertilisation can take place and an embryo can develop. This embryo will be transferred to the surrogate. If multiple embryos are produced, they will be frozen.
If the semen contains insufficient sperm, IVF may not result in fertilisation. Then ICSI treatment will be necessary. Your doctor will talk to you about what this entails if this is the best option for you.
If you need the help of an egg donor, this will also influence your costs. See what costs you many need to pay as an intended parents.
Risks
The risks and complications of IVF(ICSI) treatment are similar to those for any prospective parents who need help getting pregnant.
The risks are:
- Understimulation (no follicles develop in the ovaries)
- Hyperstimulation (too many follicles develop in the ovaries)
- Fertilisation fails to occur
- No suitable embryo forms
Complications are:
- Side-effects of medication
- Bleeding after puncture
- Infection after puncture
- Hyperstimulation syndrome (symptoms can occur when too many follicles develop in the ovary)
Please consult the costs page to see how costs are affected by complications.
Surrogate
See the section on using the intended mother's egg for the treatment for the surrogate. Also see: How many embryos should I have transferred, one, two or possibly more?
Donor sperm
Sometimes the intended parents have an egg of their own but no sperm. Then they will need a sperm donor. In this case, the risks for IVF treatment for the intended mother are the same as those in the section on the intended mother's egg.
Using both a donated egg and donated sperm and a surrogate is not advisable. This means that the child would have three to six people involved in their origins with relationships to all of them. If there is no genetic relationship to at least one of the intended parents it can also complicate the legal process.
Pregnancy
Surrogate's require the same treatment and monitoring as someone who is pregnant to fulfill their own desire for a child. The monitoring of a surrogate who uses her own egg can be performed by a midwife, unless the pregnancy is high-risk for other reasons.
If the surrogate uses the intended mother's or a donor egg to get pregnant, it is advisable to have a gynaecologist carry out the monitoring of the pregnancy and birth.
There are risks attached to every pregnancy and birth. Whether you're pregnant to fulfil your own desire for children or someone else's. The risks of pregnancy and childbirth are also influenced by age, lifestyle, BMI, disease, and previous pregnancies and births. Surrogacy increases some risks.
We'll begin by mentioning the risks applicable to every surrogate. Then we'll discuss the risks attached to particular forms of surrogacy.
Frequently occurring risks independent of the form of surrogacy include miscarriages, ectopic pregnancies and pregnancy of unknown location.
Pregnancy: first 12 weeks
Miscarriage
If a pregnancy ends spontaneously before 16 weeks of pregnancy, it is called a miscarriage.
The probability of miscarriage is no greater for a surrogate than for someone who becomes pregnant for themselves. Approximately 15 to 20% of all known pregnancies end in miscarriage. Therefore, this can happen to a surrogate too. There's nothing a surrogate can do about it. Nonetheless this can be a very emotional event for both the intended parents and the surrogate.
It can be very disappointing for the intended parents who seemed to be so close to fulfilling their desire for a child. They find themselves back in a position of uncertainty. A miscarriage can raise questions of the sort: Is it not meant to be? Will the surrogate be willing to continue? Will we ever become parents?
They can also feel very guilty towards the surrogate for what she is going through. She may have to take medicine or have an operation. Did we ask too much of her?
It can be very disappointing for the surrogate too. Her own pregnancies may have been plain-sailing. Now she wants to do it for other people and she feels that her body is letting her down. This feeling can arise despite the fact that the surrogate has no influence upon a miscarriage taking place.
Ectopic pregnancy
Normally a pregnancy implants in the uterus. Sometimes a pregnancy doesn't implant in the uterus but somewhere outside. This is often in the fallopian tube but sometimes elsewhere in the abdominal cavity (although this is very rare).
The probability of an ectopic pregnancy is no different for a surrogate than for someone who gets pregnant for herself. Ectopic pregnancies can require major treatment.
Treatment for an ectopic pregnancy can comprise:
- Waiting until the body clears it up itself
- Medication
- Operation.
What treatment is suitable for you depends on your situation. Let your doctor inform you about what is right for you.
Pregnancy of unknown location
Sometimes a pregnancy test gives a positive result but no pregnancy can be detected by ultrasound. This is called a pregnancy of unknown location. In such cases, the pregnancy hormone is detected in the blood, often on several occasions with several days between them. It may be that the body is clearing out a non-viable pregnancy.
Sometimes medication needs to be given to help the body do this. Sometimes it becomes clear that it's an ectopic pregnancy and that an operation is required.
If the pregnancy hormone shows a good increase, it may be a healthy pregnancy detected too early to be visible on an ultrasound.
Be sure to get properly informed by your treating physician about your situation and what the best next steps are.
Pregnancy: surrogate's medical history
Surrogate who has had a previous c-section
If a woman has had a previous c-section her subsequent pregnancies have increased risk. It makes no difference if she was pregnant with her own child or with the intended parents' child. During a vaginal birth there is an increased likelihood of her uterus rupturing along the scar of her earlier c-section. Even if she has a planned c-section, it may be more difficult due to the scar tissue from the earlier c-section. Talk to your doctor about whether it is wise to become a surrogate in your case.
Surrogate with a previous history of blood loss
If a woman has lost more than a litre of blood during and after a previous birth she is likely to lose even more blood during a subsequent birth. If a surrogate is pregnant with a child from an egg of the intended mother or egg donor, the probability is even greater. Therefore, if you have previously suffered heavy blood loss and are pregnant with a child who is not genetically your own, the likelihood of heavy blood loss is particularly high.
Other complications in your own pregnancy
If you, the surrogate, have previously had complications in pregnancy or childbirth, then your risks as a surrogate are often greater. It is important to get properly informed about the likelihood of complications in your particular case.
If the surrogate has never been pregnant
If you've never previously been pregnant, it's difficult to estimate what your personal risk for pregnancy and childbirth complications may be. What we do know is that the likelihood of complications in first pregnancies is greater than for women who've had previous pregnancies. If your first pregnancy is with a child using an egg that is not your own, the risks are even greater.
Being pregnant can be quite an experience in itself. When you first feel the baby moving in your belly, your feelings around the surrogacy process may change.
In rare cases, a pregnancy can be so complicated that the uterus has to be removed. Think about this carefully if you haven't yet completed your own family.
Pregnancy: surrogate's egg
Even in this form it's sensible to give some thought to pregnancy risks for the surrogate. Talk this through with your general practitioner, gynaecologist or midwife, for example, depending on who you've previously consulted.
Risks for the surrogate
The risks of pregnancy for surrogate and the surrogate child shouldn't be any different to when the surrogate was previously pregnant with her own children.
Some risks can be different because she is pregnant with a child created with sperm from a different man to her own children. If intended fathers have previously caused a pregnancy that was very complicated, it is good to talk about it with the general practitioner or gynaecologist.
Often intended fathers have not previously got anyone pregnant. The likelihood of major complications is low.
Risks for the child
For the surrogate child the risks are no greater than those of children carried by any other mother-to-be.
Pregnancy: Intended mother's or donor egg
In this case, it's important to involve a gynaecologist in monitoring the pregnancy and attending the birth because the risks are higher than when a surrogate gets pregnant from her own egg. Sometimes the gynaecologist will recommend taking additional medication during the pregnancy.
Whether the surrogate is pregnant from the intended mother's or a donor egg doesn't change the level of risk. The risk of complications is not lesser if the intended mother or donor is the surrogate's sister. There has been very little research into the risks for the surrogate and child. The knowledge we have comes from a few studies.
Risks for the surrogate
High blood pressure problems (pre-eclampsia)
The risk of high blood pressure problems appears to be higher if the surrogate gets pregnant using the intended mother's or a donor egg than if she gets pregnant using her own egg. In a study of surrogates with a medical history of uncomplicated pregnancies, the probability of high blood pressure problems was 8%.
Diabetes gravidarum (gestational diabetes)
The probability of diabetes gravidarium appears to be higher for the surrogate when pregnant with a surrogate child than when pregnant with her own children from her own eggs. Unfortunately, there have been too few studies to prove this definitively.
Risks for the child
Premature birth
On average, surrogates appear to give birth to their surrogate child 1 week earlier than they did to their own children. The likelihood of them giving birth before 37 weeks is also slightly higher than during previous pregnancies for their own children. This is dependent on being pregnant with only one surrogate child at a time.
For surrogates who are pregnant with twins (or more) the likelihood of premature birth is definitely increased by the twin pregnancy. The consequences of premature birth can be severe if it is very early. The children may die or survive with lifelong damage. Even children who are born four weeks before their due date may suffer permanent consequences.
The probability of a multiple birth must therefore be kept to a minimum. Therefore, we recommend only ever transferring one embryo at a time instead of two or more.
Low birth weight for the gestational age
On average, surrogate babies are approximately 100 grammes lighter than babies to whom the surrogate has previously given birth. This difference has no consequences for the child.
If a surrogate is pregnant with twins (or more) there is an increased likelihood that the babies won't grow well and will be of low birth weight. This can have consequences upon the children's health in later life.
Congenital defects
The likelihood of birth defects is no different than for other couples who get pregnant with their own egg and sperm after fertility treatment.
Birth: the egg is the surrogate's own
For a surrogate who gets pregnant using her own egg, childbirth risks are no greater than if she were to become pregnant with a child for herself. The risks are no different for the baby either.
Birth: Intended mother's or donor egg
Risks for the surrogate
C-section (caesarian section)
The likelihood of a surrogate needing a c-section is greater than if she were pregnant using her own egg. The likelihood of a c-section depends on whether she previously gave birth by c-section and the country in which she gives birth.
In a group of surrogates who had no medical history of giving birth by c-section, the probability of a c-section during the surrogacy process in the Netherlands was 8%.
Heavy blood loss after childbirth (Fluxus)
The likelihood of heavy blood loss after childbirth is higher for women pregnant using an egg that is not their own. In a group of women with normal blood loss during the births of their own children, 8% lost more than 1 litre of blood during the birth of their surrogate child.
If the surrogate has already had heavy blood loss during the birth of one of her own children, then the likelihood that she has heavy blood loss during the birth of her surrogate child is even greater.
Serious complications
Three serious complications have been described in the literature.
A surrogate had to have her uterus removed after 16 days due to blood loss after childbirth. She had given birth to triplets. This occurred after three embryos had been transferred to her uterus.
A woman's uterus ruptured during childbirth. Her blood loss was great enough to require a blood transfusion.
Finally, there was a case of a surrogate who had previously given birth without complications but who lost four litres of blood after the birth of her surrogate child requiring a blood transfusion and an operation to empty her uterus.
There may be other serious complications than can be found in the literature when formulating this page.
Risks for the child
The risks during childbirth are no different than those for children born to the intended parents themselves. The consequences of a premature birth or low birth weight are not different for surrogate children than for children born to their own parents.
After the birth (postpartum)
Preparation
This period sometimes gets forgotten. It's extremely important to talk to each other about how you want to handle this period. Are you going to spend this period together as intended parents, surrogate parents and surrogate child? Or will you spend it separately? At what point will the intended parents fully take over the baby's care? Immediately after the birth or a little while later?
How is the baby going to be fed? It's good to look into this properly. Is it going to be fed mother's milk or formula? For further information, please visit:
feeding after birth: breast milk or formula
It's important to realise what the consequences of certain decisions are. Certain choices may suit certain intended parents and surrogates best, while other choices will be better for other intended parents and surrogates. Be sure to maintain an open dialogue where everyone feels at ease to say what's on their mind.
Of course, you can never totally predict how things will turn out. Nevertheless, it's still important to talk to each other openly about things. Even if your feelings about your previous decisions change, it is important to be able to talk about this change.
A counsellor with surrogacy expertise can help you both with the preparation and throughout the process. The immediate postpartum period can be a good time to call upon their expertise.
Whether a surrogate got pregnant using her own egg or that of the intended mother or a donor makes no difference to the risk of complications during this period following the birth.
Postpartum depression
As well as the pride and joy that it's over and the child is safe and sound with the intended parents, negative feelings can also arise. You've given birth and are experiencing the discomforts that come with that, but you haven't got a child to care for. While you were the centre of attention during pregnancy, this is less the case now.
For some women this can be a delightful time of relief and recovery while for others it elicits negative emotions. It's important to acknowledge them and think about your needs so as to attend to them as best as possible.
Depression in postpartum surrogates has been described in several programmes. It hasn't been established whether the incidence is higher than in mothers who've given birth to their own children.
A specialiced surrogacy counsellor can play an important role in the immediate postpartum period.
Maternity care reimbursement
The surrogate's insurance pays for the maternity care for the surrogate and child. Intended parents sometimes pay for extra maternity care. It can be good to have some support during the time when you're getting used to a new life and the care of a baby.
What if complications arise?
Talking things through
You can't talk through every complication in advance. It's important to keep talking to one another so as to arrive at mutual decisions. You might be able to agree frameworks on how to deal with unexpected situations and ensure that you maintain dialogue.
It's important to realise that if you can't agree, the surrogate's final decisions for pregancy and childbirth are legally binding. If the surrogate is unable to speak, then her legal representative will take decisions on her behalf.
also see
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