Assisted conception and Assisted conception and MRKH syndromeMRKH syndrome

Dr Anna CarbyDr Anna Carby

Fertility SpecialistFertility Specialist

IVF HammersmithIVF Hammersmith

OverviewOverview

• Reproductive optionsReproductive options

• What is surrogacy treatmentWhat is surrogacy treatment

• Treatment pathwayTreatment pathway

• InvestigationsInvestigations

• Treatment cycleTreatment cycle

• Outcomes at IVF HammersmithOutcomes at IVF Hammersmith

OptionsOptions

• Freezing embryos for surrogacy Freezing embryos for surrogacy (currently in a relationship)(currently in a relationship)

• Freezing eggs for surrogacy (not Freezing eggs for surrogacy (not currently in a relationship)currently in a relationship)

• AdoptionAdoption

What is surrogacy?What is surrogacy?

• Term used to describe situation Term used to describe situation where a woman agrees to become where a woman agrees to become pregnant and have a baby for pregnant and have a baby for another coupleanother couple

• Woman who carries the baby is the Woman who carries the baby is the surrogatesurrogate

• Couple who intend to be the parents Couple who intend to be the parents are called the intended parentsare called the intended parents

Surrogacy in the UKSurrogacy in the UK

• Legal issues surrounding surrogacyLegal issues surrounding surrogacy• Surrogacy Agreements Act (1985)Surrogacy Agreements Act (1985)• HFEA Act (2008 section 30)HFEA Act (2008 section 30)• Any agreement between a surrogate Any agreement between a surrogate

mother and intended parents is not legally mother and intended parents is not legally enforceableenforceable

• Important to have surrogacy agreement to Important to have surrogacy agreement to make intentions clear and provide evidence make intentions clear and provide evidence of intentionsof intentions

• Legal advice importantLegal advice important

Types of surrogacy Types of surrogacy arrangementarrangement

• Full/host surrogacy – intended Full/host surrogacy – intended parents use IVF treatment to create parents use IVF treatment to create embryos form their own eggs and embryos form their own eggs and sperm and these are replaced in to sperm and these are replaced in to the uterus of the surrogatethe uterus of the surrogate

• Partial /straight surrogacy – Partial /straight surrogacy – surrogate’s eggs are used with surrogate’s eggs are used with intended fathers sperm for IVF or IUIintended fathers sperm for IVF or IUI

How do you find a How do you find a surrogate?surrogate?

• Family member/friendFamily member/friend

• By chanceBy chance

• Through surrogacy agency – Through surrogacy agency – Surrogacy UK (recognised by HFEA Surrogacy UK (recognised by HFEA and BMA) , COTSand BMA) , COTS

Pathway IVF HammersmithPathway IVF Hammersmith

• Referral from GP/specialistReferral from GP/specialist• Out-patient appointment within 4 weeks NHS (or private Out-patient appointment within 4 weeks NHS (or private

appointment if desired)appointment if desired)• Assessment - initial consultation, medical history and Assessment - initial consultation, medical history and

investigationsinvestigations• Follow-up appointmentFollow-up appointment• Application for funding if NHSApplication for funding if NHS• Counselling and nurse appointmentsCounselling and nurse appointments• Pre-treatment blood testsPre-treatment blood tests• Treatment cycleTreatment cycle• Quarantine embryosQuarantine embryos• Transfer in to surrogateTransfer in to surrogate

Investigations – ultrasound Investigations – ultrasound scanscan

• May be either internal or May be either internal or transabdominaltransabdominal

• Internal gives better picture of Internal gives better picture of ovaries and allows assessment of ovaries and allows assessment of accessibilityaccessibility

• Volume of ovaries and activityVolume of ovaries and activity

Investigations – blood testsInvestigations – blood tests

• AMH testing – not AMH testing – not currently available currently available through NHS but through NHS but best marker of best marker of “ovarian reserve” ie “ovarian reserve” ie how well ovaries how well ovaries may respond to may respond to stimulationstimulation

• FSH testing – cycle FSH testing – cycle specific therefore specific therefore more difficult to testmore difficult to test

Investigations – semen Investigations – semen analysisanalysis

• Extremely Extremely important!important!

• Produce sample Produce sample on-siteon-site

• Analysis of count Analysis of count and motilityand motility

Review appointmentReview appointment

• Results of investigationsResults of investigations

• Plan for funding and treatmentPlan for funding and treatment

• NHS funding approved?NHS funding approved?

• Referral to counsellorReferral to counsellor

• Referral to specialist nurseReferral to specialist nurse

Funding of treatmentFunding of treatment

• All surrogacy treatment cycles must be All surrogacy treatment cycles must be approved by the female partners PCT (primary approved by the female partners PCT (primary care trust)care trust)

• PCT is defined by the female partners GP PCT is defined by the female partners GP locationlocation

• If funding is granted it covers the cost of If funding is granted it covers the cost of producing embryos and most usually freezing producing embryos and most usually freezing and storage for the first yearand storage for the first year

• The costs of the surrogate transfer are not The costs of the surrogate transfer are not included and this has to be performed included and this has to be performed privatelyprivately

Role of the counsellorRole of the counsellor

• Legal, financial and emotional Legal, financial and emotional implications of treatmentimplications of treatment

• Signing of consents (many!)Signing of consents (many!)

• Stress managementStress management

Role of the specialist nurseRole of the specialist nurse

• Communication with GP for surrogate and Communication with GP for surrogate and commissioning female – medical history, welfare of commissioning female – medical history, welfare of the childthe child

• Screening blood tests - obligatoryScreening blood tests - obligatory• Karyotyping (chromosomal testing for commissioning Karyotyping (chromosomal testing for commissioning

couple), blood grouping, cystic fibrosis screeningcouple), blood grouping, cystic fibrosis screening• Potential transfer of infectious diseases with Potential transfer of infectious diseases with

embryos (HIV, Hep B and C, syphilis, chlamydia, embryos (HIV, Hep B and C, syphilis, chlamydia, gonorrhoea, CMV). Testing within 3 months of gonorrhoea, CMV). Testing within 3 months of treatmenttreatment

• Repeat infectious diseases testing after 6 months Repeat infectious diseases testing after 6 months quarantine of embryosquarantine of embryos

The treatment cycle for youThe treatment cycle for you

• Aim is to stimulate ovaries to produce Aim is to stimulate ovaries to produce upward of 5 folliclesupward of 5 follicles

• Requires control of ovarian cycleRequires control of ovarian cycle• May use contraceptive pill prior to May use contraceptive pill prior to

treatmenttreatment• Then a series of injections for approx 2 Then a series of injections for approx 2

weeks to shut down ovarian function and weeks to shut down ovarian function and control ovaries (buserelin)control ovaries (buserelin)

• Additional injection for further approx 2 Additional injection for further approx 2 weeks to stimulate ovaries (FSH)weeks to stimulate ovaries (FSH)

The treatment cycle The treatment cycle (injections)(injections)

• Sub-cutaneousSub-cutaneous

• Daily at homeDaily at home

• Similar to diabetic pen with dial-up Similar to diabetic pen with dial-up dosagedosage

The treatment cycle - The treatment cycle - monitoringmonitoring

• Transvaginal or Transvaginal or transabdominal scans transabdominal scans and hormonal blood and hormonal blood tests (estradiol)tests (estradiol)

• Approx 4 visits per Approx 4 visits per treatment cycletreatment cycle

• Early appointments – Early appointments – from 7amfrom 7am

• Perfectly possible to Perfectly possible to work whilst stimulatingwork whilst stimulating

The treatment cycle – egg The treatment cycle – egg collectioncollection

• Either transvaginally or laparoscopicallyEither transvaginally or laparoscopically• Transvaginal - better egg yield, Transvaginal - better egg yield,

intravenous sedation, possible for intravenous sedation, possible for majority. Quick recovery timemajority. Quick recovery time

• Laparoscopically – for ovaries that can’t be Laparoscopically – for ovaries that can’t be reached safely transvaginally. Requires reached safely transvaginally. Requires general anaesthetic, day case operationgeneral anaesthetic, day case operation

• Average numbers collected – approx 10 Average numbers collected – approx 10 but may be anything from 0-20+ !but may be anything from 0-20+ !

The treatment cycle - The treatment cycle - fertilisationfertilisation

• Partner produces Partner produces sample on the day of sample on the day of egg collectionegg collection

• Purified to remove Purified to remove non-viable sperm and non-viable sperm and achieve concentrated achieve concentrated samplesample

• Egg fertilised - Egg fertilised - normally by a normally by a process called ICSIprocess called ICSI

The treatment cycle - The treatment cycle - freezingfreezing

• Embryos frozen either Embryos frozen either day 1, 3 or 5 day 1, 3 or 5

• Quarantine period of 6 Quarantine period of 6 monthsmonths

• Repeat viral screeningRepeat viral screening

• Available for Available for subsequent transfer in subsequent transfer in to surrogateto surrogate

• Can be frozen for use Can be frozen for use for up to 10 yearsfor up to 10 years

The treatment cycle - risksThe treatment cycle - risks

• No treatment is without riskNo treatment is without risk• But risks with IVF are lowBut risks with IVF are low• Over-response OHSS (ovarian Over-response OHSS (ovarian

hyperstimulation syndrome) approx 3-5% hyperstimulation syndrome) approx 3-5% cyclescycles

• Under-response and cancellation – approx 3%Under-response and cancellation – approx 3%• Bleeding – less than 1%Bleeding – less than 1%• Damage to other structures (bowel, bladder) Damage to other structures (bowel, bladder)

less than 1%less than 1%• Infection – less than 1%Infection – less than 1%

The treatment cycle – for the The treatment cycle – for the surrogatesurrogate

• Preparation of the womb for transfer Preparation of the womb for transfer of embryosof embryos

• Transfer in the natural menstrual Transfer in the natural menstrual cycle if regularcycle if regular

• May be achieved with control of May be achieved with control of menstrual cycle and hormonal menstrual cycle and hormonal support with estrogen patches and support with estrogen patches and progesterone pessaries up to 12 progesterone pessaries up to 12 weeks of pregnancyweeks of pregnancy

Chances of success with frozen Chances of success with frozen embryosembryos

3937

41

3638 38

0

5

10

15

20

25

30

35

40

45

50

Jan Feb Mar Apr May Jun

2010 month

JanJan FebFeb MarMar AprApr MayMay JunJun

Number of FERC Number of FERC transferstransfers

3131 3535 3737 2222 2626 2929

% Clinical % Clinical pregnancy ratepregnancy rate

3939 3737 4141 3636 3838 3838

Outcomes of treatmentOutcomes of treatment

• 10 patients (12 cycles of treatment) 10 patients (12 cycles of treatment) completedcompleted

• Average age at treatment 29Average age at treatment 29

• 3 patients laparoscopic egg collection3 patients laparoscopic egg collection

• 7 transvaginal egg collection7 transvaginal egg collection

• 159 eggs collected in total!159 eggs collected in total!

• 100 embryos and 10 eggs frozen100 embryos and 10 eggs frozen

Outcomes of treatmentOutcomes of treatment

• 2 surrogacy cycles 2 surrogacy cycles completedcompleted

• 1 livebirth1 livebirth

• 1 ongoing 1 ongoing pregnancypregnancy

Any questionsAny questions

• Contact IVF Hammersmith 0203 313 4411 Contact IVF Hammersmith 0203 313 4411

• Mr Stuart Lavery, Mr Geoffrey Trew, Dr Mr Stuart Lavery, Mr Geoffrey Trew, Dr Anna Carby, Sister Cathy TurnerAnna Carby, Sister Cathy Turner

• Referrals fax 0208 749 6973Referrals fax 0208 749 6973

• www.ivfhammersmith.comwww.ivfhammersmith.com

• www.londonfertilitysurgery.co.ukwww.londonfertilitysurgery.co.uk

• www.hfea.org.ukwww.hfea.org.uk