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Gestational
Surrogacy – An Overview:
DR. B.N. Chakravarty
[Read in the Bulletin of Institute of Reproductive Medicine
Vol 55, Dec 2006 Pg1]
Definition-changing Concept:
The term “Surrogate” or “Surrogate Mother” is used to denote a
woman who carries and delivers a child on behalf of another
person(s) with an agreement prior to conception that the child
would be handed over to that person after birth. The procedure
is known as “Surrogacy”.
This definition becomes some what confused if someone argues
that the woman who rears the child should be termed as
“Surrogate mother” and the woman who has given birth is the
“real mother”. This argument gets support (not very
authentically) by the fact that in many countries (as in Israel)
the woman who will give birth. Even to a genetically unrelated
child is considered as the legal mother of the child.
However, since the introduction of Assisted Reproductive
Technology (ART), definition of surrogacy has been made clearer.
In the pre-ART period, “Traditional” Partial” or “Natural”
surrogacy was the only means of helping women who had either no
uterus or severely damaged uterus- incapable of bearing a child.
In this procedure, husband was allowed to stay with a woman for
the purpose of producing a child with the knowledge and
permission of his infertile wife. Subsequently, when artificial
insemination became popular, husband’s semen has been used to
inseminate surrogate host in order to have a child. This
procedure was more socially or ethically acceptable than what
was previously practiced as “Natural”, Partial” or “traditional”
surrogacy.
Finally with IVF treatment an infertile couple, (when surrogacy
is indicated), can use their own gametes to create their own
unique embryos: and these embryos may be transferred to a
surrogate host. This means that a female partner of an infertile
couple, not having a uterus, may still be able to have her own
genetic child through a surrogate host. This type of surrogacy
has been designated as “Gestational Surrogacy”, “Full
Surrogacy”, “Host Surrogacy” or “IVF Surrogacy”. Under these
distressing circumstances, IVF surrogacy has been legally
accepted as a form of treatment in many countries of the world.
It is also possible that sometimes the female partner of an
infertile couple may have dual problem. That is, in addition to
absent or damaged uterus, she may have evidences of premature
ovarian failure. That means that she will not be able to produce
eggs for IVF. Under these circumstances, if the couple is
desperate to achieve a pregnancy with only 50% genetic
contribution to the offspring through husband’s spermatozoa,
then through special arrangement, the surrogate host, in
addition to lending her uterus can also donate her oocytes.
Alternatively, if the law of the country desires that oocyte
donor should remain anonymous, then oocyte can be retrieved from
an anonymous donor whom can be fertilize with spermatozoa
collected from infertile couple’s husband. The resulting embryo
may then be transferred to another woman who is acting as a
surrogate host. Unknown donor will be arranged by the accredited
semen bank, and the authorized semen bank will maintain all the
records regarding identity about the anonymous donor. Though, it
is expected and desired that the oocyte donor should remain
anonymous. But in practice, it may be difficult to maintain
anonymity of the oocyte donor, b because she has to pass through
different protocols of IVF treatment at the clinic namely,
ovarian stimulation monitoring of response to stimulation and
oocyte retrieval. Maintenance of anonymity of oocyte donor
(though not in relation to surrogacy) has been emphasized in the
ICMR guideline for accreditation, supervision and regulation of
ART clinics in India which is waiting to be cleared by the
parliament.
However, on principle, this type of surrogacy (i.e. surrogacy
with oocyte donation) should be considered as “Partial
Surrogacy” but because the procedure is performed through IVF,
so in practice this an also been termed as “Gestational
Surrogacy”. Legal and ethical acceptability varies from country.
In our “ICMR Guideline” surrogacy with oocyte donation has not
been specifically mentioned.
Compared to “Partial surrogacy”, IVF surrogacy is very much
sophisticated and therefore the degree of commitment and the
cost involved are also very high. In this chapter couples with
regard to surrogacy, donating their own gametes will be
designated as “Commissioning Couple”, “Biological Parents”. The
woman who will carry the pregnancy will be termed as “Surrogate
Mother”, Surrogate Host” or only “Host”.
Also in many areas of this present communication,
indications, social and legal aspects of surrogacy in Indian
context have been quoted from “ National guidelines for
accreditation, supervision and regulation of ART clinics in
India” compiled by expert committee appointed by Indian
Council of Medical Research (ICMR), ministry of Health, New
Delhi. This information has been referred to in the text
under the abbreviated heading of “ICMR guideline” or “Indian
guideline” or “Our guideline”.
Indications:
The following are the indications for surrogacy:
A)
Uterus is absent but functioning ovaries are present
a) Example is:
congenital absence of uterus and vagina (Rokistansky Custer
Hauser Syndrome)
b) Surgical
removal of uterus at a young age because of intractable post
partum hemorrhage, multiple fibroids, Adenomyosis with
intractable pain and menorrhagia or due to advanced pelvic
endometriosis
B)
Uterus is present but irreversibly distorted or irreparably
damaged-
Examples are: Uterine synechia, multiple fibroids or adenomyomas
distorting uterine cavity.
C)
Repeated IVF failure because of dense pelvic adhesion or for
unknown causes
D)
Certain medical conditions like heart threatening if the woman
becomes pregnant, provided she is considered fit enough to look
after the child after birth and her life expectancy is
reasonable.
E)
Recurrent miscarriage has been suggested as a remote indication
of surrogacy. But unless recurrent miscarriage is due to
uncorrectable uterine defect, like synechia or uterine
malformation, recurrent miscarriage cannot be considered as an
indication for surrogacy. If recurrent miscarriage continues to
occur inspite of attempts of repair of uterine defect, surrogacy
may be considered. Here re current miscarriage is not the
indication: rather uncorrectable uterine defect is the
indication for surrogacy.
In addition to these, a few more indications as described below,
which may or may not have a social acceptance at present, may be
included in near future.
The permissive social outlook and the fast-moving lifestyle of
the western society are rapidly migrating in to the Indian
subcontinent. Unmarried couple living together: single
woman seeking IVF with donor’s sperm are becoming accepted both
socially and legally. Similarly married women are requesting for
surrogacy purely for career or event to maintain her youth and
body figure. Such requests at least in our clinic are not
entertained. Very occasionally, a woman has remained
unmarried in order to avoid social and legal marital bondage but
at the same time in order to satisfy her biological need, she
wants to have a baby through surrogacy. Though ICMR guideline
has approved these issues and perhaps will be enacted by law,
whether or not to accept surrogacy arrangement in such women
will depend on the individual clinic’s discretion. In our
clinic, we don not approve such request.
Historical Background with Review
of Literature:
The term “surrogacy” has been mentioned in the old testament of
the Holy bible (genesis 16.1-15). It has been mentioned in the
Bible that, because Sarai was unable to bear a child for
Abraham, she suggested Abraham to go to her maid Hagar who may
obtain a child for her. Abraham did as he was suggested and at
the age of 90, he could father a child through Hagar, and
Ishmael was born. It may be possible that through ages,
surrogacy must have been practiced for women who were unable to
bear a child but no specific references are available in medical
literature. The first authenticated report of gestational
surrogacy came from the USA. And until now, reports on surrogacy
whether “partial” or “gestational” have mostly been available
from USA-where commercial surrogacy arrangements have been
allowed and socially accepted.
In Europe, U. K. is one of the countries, where gestational
surrogacy has been permitted but the U.K. guidelines has made
clear that “gestational surrogacy” can only be carried out for
exceptional reasons and after intensive investigation and
counseling but without commercial involvement. The most recent
report from the British Medical Association (1996) states that
“surrogacy is an acceptable option of last resort in cases where
it is impossible or highly undesirable for medical reasons for
the intended mother to carry a child herself”. In England Mr.
Patrick Steptoe and Professor Robert Edwards treated the first
couple by gestational surrogacy after extensive discussion. In
U.K. the ethics committee drew up guidelines for the treatment
of women by surrogacy and the full surrogacy progrmame was
formalized in 1990. The review has been published in British
Medical journal”.
Very few papers have been published in the literature related to
surrogacy. Similarly, few long-term follow-up studies of the
babies or the couples involved in surrogacy arrangement have
been published. However, up till now the papers which have been
published related to follow-up studies on the children, hosts
and commissioning couples, reveal reassuring data and positive
outcome about pregnancies following gestational surrogacy.
Sourcing of Surrogate Mother:
The surrogate mother may be known to the commissioning couple
either a friend or relative, or may have been unknown to them
prior to surrogacy arrangement. There are conflicting views
about this. Some believe that arrangement with unknown surrogate
mother may create problem. Because the ultimate outcome of
handing over the baby to the genetic parents will depend on
trust between strangers. In other forms of assisted
reproduction, involving gamete donation, the donor generally
remains anonymous. But in surrogacy a “forced friendship” must
be established between a previously unknown surrogate mother and
the commissioning couple. On the other hand, problems may also
arise when surrogate host is selected from commissioning
couple’s On the other hand; problems may also arise
when surrogate host is selected from commissioning couple’s own
family or friends. Sometimes this may complicate normal life
within the family often to a damaging extent. In Israel, law has
been made in such a way that the commissioning couple will not
like a relative to become a surrogate mother because the law in
this country accepts surrogate mother as the real mother”. In
U.K. the surrogate (host) may be a member of the family of the
genetic parents (commissioning couple) or may be procured
through patient infertility support groups e.g. childlessness
Overcome through Surrogacy (COTS) which is a charitable
non-profit making organization. In the USA, highly
professional commercial agencies, exist many of them are run by
lawyers who make contact between intended couples and women who
are willing to act as surrogate hosts.
In India, regarding sourcing of surrogate host, ICMR guidelines
suggest the following:
·
Surrogate mother
will be procured by law firms or semen banks. All semen banks or
law firms require accreditation.
·
However,
negotiation between a couple and the surrogate mother must be
conducted independently between them.
·
Payments of
surrogate mothers should cover all genuine expenses associated
with pregnancy. Documentary evidence of financial arrangement
for surrogacy must be available. The ART center should not be
involved in this monetary aspect.
·
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regarding surrogacy should not be made by the ART clinic. The
responsibility of finding a surrogate mother, through
advertisement or otherwise, should rest with the couple, or a
semen bank.
·
The bank will
ensure that all criteria (age screening for medical genetic
disorders, HIV, Hepatitis b, hepatitis C etc) are met and
suitable records of surrogate mother is kept for 10 years, after
which, or if the bank is wound-up during this period, the
records should be transferred to the ICMR repository.
·
The bank may
advertise suitable for surrogate host who may be appropriately
compensated financially.
·
A Surrogate
mother should not be over 45 years of age. Before accepting a
woman as a possible surrogate for a particular couple’s child,
the ART clinic must ensure (and put on record) that the woman
satisfies all treatable criteria to go through a successful
full-term pregnancy.
·
In India context, a
known person, as well as a person unknown to the couple may act
as a surrogate mother for the concerned infertile couple. In the
case of a relative acting as a surrogate mother, the
relative should belong to the same generation as the woman
desiring the surrogate
·
A prospective
surrogate mother must be tested for HIV and shown to be
seronegative for the virus just before embryo transfer. She must
also provide written certificate that (a) she did not have a
drug intravenously administered in to her through a shared
syringe (b) she has not undergone blood transfusion; and (c) she
and her husband 9to the best of his/her knowledge) has had
no extra marital relationship in the last six months (
this is to ensure that the person would not come up with
symptoms of HIV infection during the period of surrogacy).
The prospective surrogate mother will also declare that she will
not use drugs intravenously and not undergo blood transfusion
excepting blood obtained through a certified blood bank.
·
No woman may act as
a surrogate more than thrice in her lifetime.
·
From monetary point
of view Indian regulation at the moment is unlike those existing
in U.K. and we have more or less followed U.S.A. principle of
“Hired” surrogacy
·
Full details of the
treatment are explained to the proposed host and, provided that
they are considered to be emotionally and physically fit to act
in this capacity, they are accepted to undergo the procedure of
surrogacy.
Additional Considerations for
Surrogacy Agreement;
·
In U.K. and USA
couples are advised to consult lawyers who can advise on the
potential legal problems associated with surrogacy. In India,
However the procedure of gestational surrogacy is still in
infancy and therefore, lawyers and not very much conversant
about the legal issues arising out of surrogacy. But hopefully,
in course of time when the ICMR guideline becomes enacted as a
law, the lawyers have to be actively involved in all procedures
of ART in general and use of donor gametes and surrogacy in
particular.
·
However Indian
guideline has suggested that “A child born through surrogacy
must be adopted by genetic (biological parents unless they can
establish through genetic (DNA) fingerprinting (of which records
will be maintained by the clinic) that the child is theirs.
·
Adoption is neither
absolutely essential, nor this will be desirable by the
commissioning parents. Because in order to avoid adoption,
biological parents have accepted surrogacy. This point in the
Indian guideline needs modification. The suggested modification
would be to get the agreement of surrogacy between the
commissioning couple and the surrogate host signed in the
presence of a lawyer, who will legally confirm the agreement.
After all the commissioning couple are the biological parents of
the child.
·
This issue becomes
somewhat complicated when commissioning couples desires a
pregnancy not only through surrogacy but with oocyte donation as
well. It is desirable though not always possible or practical to
procure eggs for an anonymous donor. The anonymous donor is
arranged by the accredited, semen bank or a law firm. The
donor’s eggs are then fertilized with the commissioning couple’s
husband’s sperm. The resulting embryo (s) is then transferred
into a surrogate host, who is also arranged by the accredited
semen bank. This means that “surrogate host’ and ‘Oocyte Donor’
are separate individuals helping an infertile woman who has
neither a uterus not any oocyte.
·
Ideally and legally
babies born through such type of surrogacy need to be adopted.
Commissioning couples will not like adoption. This complicated
procedure, the commissioning couple has accepted only because
the procedure will be more socially accepted than the previously
practiced “Natural or “Partial” surrogacy.
In this desperate situation,
in order to avoid future legal complications, the following
procedures may be suggested:
·
a)
The surrogacy arrangement between the commissioning couple and
surrogate host should be made in the presence of a lawyer
·
b)
Donor if procured by the semen bank should sign the agreement of
relinquishing her right on the resulting offspring in presence
of a lawyer. If this is done, question of adoption does not
arise. Legally the commissioning parents are not bound to
disclose the name of the oocyte donor. But medical records,
social status and other information’s regarding the donor
which will be available in the same bank (organization which has
procured the donor) may be communicated to the child if occasion
arises when the child becomes major ( after the age of 28 years)
·
In case of
surrogacy with donor oocyte, there may be confusion regarding
writing the birth certificate of the newborn baby. Though
Indian guideline has not specified on this point (surrogacy with
donor’s oocyte), it is obligatory that the birth
certificates should be issued in the name s of the commissioning
infertile couple, provided that agreement among egg donor,
surrogate host and commissioning couples has already been made
in the presence of a lawyers before the procedure of eggs
9donor’s consent is to be taken by the concerned semen bank/say
firm) donation and surrogacy commenced. Adoption in that case is
not absolutely essential. Because in case of straight forward
IVF with oocyte donation, child is not adopted after the child
is delivered by the infertile couple’s wife. The same rule is
also applicable in case of “gestational Surrogacy” using donor’s
egg.
Social and Psychological
Issues of Surrogacy:
Experience and information’s
about psychological aspects of surrogacy is very limited. The
merits and demerits of following aspects of gestational
surrogacy may require further evaluation.
A)
Maintaining contact with surrogate mother after the child is
born:
* While some people report
benefits achieved by maintaining contact between the parties,
others feel that this does not suit everybody.
B)
Disclosure to the family members and to the child about
surrogacy arrangement:
*
This is also controversial. Studies of families where a child
has been created by gamete donation indicate that majority of
parents do not wish to disclose the method of conception to the
child though recently, there has been a greater tendency for
open discussion with family members and the child.
*
It has been suggested that secrecy about the conception method
may have a negative impact on the child’s psychological
development.
*
Evidence from research on adoptive families indicates that
children are more likely to develop emotional and behavioral
problems when their parents conceal about the adoptions.
*
Surrogacy resemble adoption, therefore, it may be argued that
children are likely of fare better when the fact about surrogacy
is disclosed to them at a very early age.
*
Surrogate mother feels better when she discloses her surrogacy
agreement to other members of the family
Counseling:
Counseling is of paramount
importance in surrogacy arrangement. The objective is to prepare
both the couples contemplating this treatment and to consider
all these have been recommended by British Medical Association.
Discussion with the
Commissioning Couples
·
Review of
alternative treatment options and if not available implication
of not having children in future
·
Possibility of
adoption instead of surrogacy
·
Possibility to find
their own host where they might find Potential practical
difficulties of treatment by gestational surrogacy
·
Potential medical
and psychological impact of surrogacy on the surrogate mother
·
Potential
psychological risks, short and long term, to a child born of
surrogacy
·
Risks that the
child may be born with a handicap and both the host and
commissioning couple may refuse to accept the child.
·
Host may wish to
retain the child after birth 9this happens more with altruistic
then with paid surrogate0
An interesting issue may
sometimes be raised whether the genetic mother may be able to
breast-feed her baby is handed over to her by the surrogate
host. This hold is encouraged mainly in order to help them to
bond with their child. It has been reported that 50% or women
were able to produce some breast milk although
babies may have required supplementation of breast feeds. The
genetic mother may prepare for the possibility of breast-feeding
by stimulating the secretion of milk manually or by breast pump.
There is always a possibility of disappointment, but at least
they will have the satisfaction that they have tried their best.
Counseling of the proposed
Host (Prospective Surrogate Mother)
·
The physical and
psychological implications involved in the treatment of IVF
surrogacy.
·
The possibility of
her family and friends being against her to accept to become a
surrogate for others.
·
The possibility of
multiple pregnancy
·
Medical risks like
hypertension and diabetes associated with pregnancy and the
possibility of delivering by caesarean section.
·
Feeling of guilt on
both sides if the surrogate mother spontaneously aborts the
pregnancy
·
Feeling the sense
of bereavement when the surrogate mother hands over the child to
genetic parent.
·
The potential
effect on her own children while she is acting as a surrogate
for others.
There is still a psychological
conflict amongst couples seeking assisted reproduction about
what they will tell when the child is born as a result of
treatment specially by surrogacy about their origin. Also
similar conflict may affect surrogate host as what she will tell
to her existing children. However recent publications indicate
that there is a greater willingness for all couples involved
with treatment by surrogacy to inform their children abut the
means by which they were conceived and born.
Management:
Management of Genetic Mother:
Genetic mother should be less
than 40 years old. Relevant blood examination of the
commissioning couple should include routine Hb%, Blood group, Rh
factor, hepatitis B, hepatitis C, human Immunodeficiency Virus
(HIV) and other relevant tests.
Ovarian reserve assessment by
estimation of baseline FSH, LH and Oestradiol are mandatory in
addition to ultrasound count of basal antral follicle (BAF). It
is not essential to perform routine laparoscopy and hysteroscopy
except in cases where they are indicated e.g. laparoscopy in
congenital Mullerian anomalies (Rokitansky Kuster Hauser
Syndrome- RKH Syndrome).
The management of IVF treatment
cycles of genetic mother is normally straight forward. Oocyte
retrieval under TVS guidance is not difficult in women with RKH
syndrome. Because vaginal reconstruction has been performed in
all these women prior to their marriage. Otherwise, the
procedures are very much similar as for conventional IVF except
the transfer of embryos, which is withheld. It is not the
treatment, which is complicated but the following points are of
utmost importance:
·
Mental preparation
of commissioning couple and the surrogate host
·
With provision of
advice, legal and medical
·
Selection of a
suitable host
·
Proper counseling
to both of them
Management of Surrogate Host:
In India recruitment of
surrogate host appears to be a social problem. Though ICMR
guideline has suggested recruitment of surrogate host through
semen bank but this may not be practically possible because
there are not adequate numbers of accredited semen banks in the
country to provide requisite number of surrogates to
approximately 200 IVF clinics currently functioning in the
country. Therefore at present it will be logical to request the
genetic parents to find out their own host. This alternative
option has also been suggested in the ICMR guidelines.
Commercial surrogacy is allowed
in USA, whereas this is not permitted in UK. ICMR guideline for
regulation of ART practice in Indian ART clinics has allowed
commercial surrogacy.
The surrogate host should be
married, less than 45 years old and should have a family at
least she must have one child. The husband or the partner should
be fully involved in the counseling process and should be made
aware of the implications of his partner acting as a surrogate
host.
The surrogate host with her
husband should be tested for HBV, HCV and HIV status and other
routine tests including hysteroscopy before embryo transfer.
Embryo transfer to the surrogate host may be carried out either
in a natural cycle or in hormone treated cycle.
RESULTS:
A. Results--- Pregnancy Rate:
Though rate of oocyte retrieval
from biological mother may be less than in the conventional IVF
progrmame, pregnancy rate per surrogacy host transfer is better
then conventional IVF treatment cycle transfer. Oocyte retrieval
in women (genetic mother) who underwent hysterectomy may be
lower than those in women with Rokitansky Kuster Hauser
Syndrome.
Live birth rate has been reported
as 37.45% per surrogate host. Similar figures have been reported
from USA-ongoing or delivery rate as 36% per surrogate host.
Our viable delivery rate is about
50%. Pregnancy rate in different categories of surrogacy (in
relation to variables in surrogate host and in genetic mother)
has been detailed in Tables II and III.
B. Result---Perinatal Outcome and
Babies:
a)
Incidence of pregnancy induced hypertension (PIH) in surrogate
hosts were five times lower than in standard IVF patient
control.
b)
There was no increase in the incidence of lower birth weight
prematurity and congenital anomalies in babies born through
surrogacy compared to those delivered through standard IVF
protocols.
c)
Our observation did not indicate increased risk of PIH in
surrogate pregnancies and the neonatal outcome was similar to
those recorded in standard IVF protocols. One patient had twins
and one had placenta previa-accreta the placenta was adherent to
the previous caesarean section scar for which hysterectomy had
to be performed. The possibility of such outcome was discussed
with the patient (surrogate host) and her husband during
antenatal period when placenta was seen on US scan on anterior
wall of uterus encroaching to lower uterine segment.
C. Results—Psychological Features
of the Surrogate Mother:
It is generally presumed that
after delivery, it may be difficult for the surrogate mother to
relinquish the child to the genetic parents. Jadva et al ,
interviewed quite a large number of surrogate mothers and have
reported that surrogate mothers did not experience any
distress or difficulties in terms of depression or anxiety while
handing over the child to the commissioning parents. The minor
difficulties surrogate mother did experience were short lived.
During pregnancy both surrogate
host and her husband had ‘mixed feelings’ but then attitude
towards pregnancy was still positive and a few parents were
rated as having ‘high anxiety’ anxiety was the predominant
feeling about the pregnancy.
Concerns about pregnancy were
compared between those with know and unknown surrogate mothers
and between those with ‘gestational surrogacy’ and “partial
surrogacy”. No significant differences were found from either
comparison
D. Results—Satisfaction with
openness of the Commissioning Couple:
These information’s have been
nicely analyzed by McCollum et al. their observation based on
interview with 42 couples with one year child born through
surrogacy are details below:
a)
All genetic parents disclosed to maternal and paternal
grandparents about surrogacy arrangement. The reasons for
disclosing the news to the family were; i) to share
the experience with the family ii) there was no choice but to
tell iii) there was no reason not to tell.
Majority of the couples relatives
were happy and reacted positively. Only a minority (7%) reacted
with negative attitude. This positive or negative attitude did
not depend on whether the surrogate host was known or unknown to
the couple.
b)
100% of commissioning couple 0both mother and father) reported
that they planned to tell the child about surrogacy in near
future. The more common reason for planning to tell the child
was that the child had a right to know the truth. Another reason
suggested that the child may be psychologically upset it the
disclosure comes from any one else.
E. Results –Post Delivery
relationship of genetic Parents with Surrogate Host:
It is generally assumed that
after delivery, keeping contact with surrogate mother may be
detrimental for the family and the baby. In the study of
McCollum et al, it appears that there is not reason to presume
that commissioning mothers feel insecure about the surrogate
mother’s involvement with the child since in this study all the
commissioning mothers were positive about this and feel that
their child would benefit from it. But in another report it has
been stated that some of he surrogate mothers expressed sorrow
and distress about parting with the child which the
commissioning couples did not know or were not aware of the
negative feelings of the surrogate mother.
Complications of Gestational
Surrogacy:
Provided the counseling is clear
and adequate, there should not be any major complication of
gestational surrogacy. Most of the major problems which can
arise during and after treatment are invariably discussed with
couples as part of the counseling process before treatment
starts. The following are some of the notable complications of
gestational surrogacy:
A. Psychosocial Complication:
*
The surrogate host after delivery may wish to retain custody of
the child. This has occurred, but should be rare specially
in gestational surrogacy where there is no genetic link between
the child and the gestational mother.
·
There is a concern
about what would happen if an abnormal child is delivered. In
that event, both the couples may reject a grossly abnormal
child.
·
It is not yet very
clear about the long-term psychological impact on the child born
following gestational surrogacy. For this long term follow-up
studies are essential.
B. Technical Complications:
·
Complications of
surrogacy will be less if it is performed only within licensed
clinics. If appropriate health screening and counseling are
provided, fewer complications would occur.
·
During IVF, some of
the commissioning women may respond poorly to this protocol of
standard ovarian stimulation regimen. This has been reported
specifically in commissioning women who had precious
hysterectomy. A similar case was also recorded by us. She had
hysterectomy twenty-five years ago for intractable post partum
hemorrhage. As ovaries were preserved, she planned for
surrogacy. Her ovarian reserve was average 9FSH) 9.5 IU/ml.).
Following standard ovarian stimulation protocol she produced
only one follicle and one egg was retrieved. Following repeat
ovarian stimulation three months later she again produced one
egg. However, both these eggs fertilized and resulted in two
good-looking embryos. They were transferred resulting in the
delivery of twin baby.
·
The reduced
stimulation response observed in these women is perhaps because
of disruption of blood supply to the ovaries following surgery.
Possible Confusion During
Admission and Discharge of Surrogate mother to Hospital for
Delivery and issuing Birth certificate for the Baby:
In order to avoid confusion, the
facts regarding delivery of the baby conceived through surrogacy
must be correctly recorded, in the hospital /nursing home
records, surrogate mother’s discharge certificate and the new
born baby’s birth certificate. ICMR guidelines indicate the
following:
a)
At the time of delivery, surrogate mother is to be admitted in
her own name and address
b)
Discharge certificate of surrogate mother should contain the
reason for admission and the procedures and outcome related to
delivery (e.g. 3rd
pregnancy surrogate- delivery
by elective LSCS at 38 weeks of pregnancy) In addition,
discharge certificate should also contain facts about the baby
–e.g. sex of the baby, birth weight, time and date of delivery,
Apgar’ birth weight, time and date of delivery, apgar’s score at
birth. Finally it should be mentioned that: baby was handed over
to genetic mother immediately after delivery.
c)
The hospital/nursing home records, should also contain names and
address of genetic parents in addition to name and address of
surrogate mother and her spouse (this is usually recorded)
d)
the baby immediately after birth should be handed over to
genetic mother-in order to avoid mother 9 surrogate) baby
bondage.
e)
The breast-milk of surrogate mother should be suppressed by
appropriate medication.
f)
The birth certificate of the baby is to be issued in the name of
the genetic parents.
g)
All these facts should be recorded in the history sheet of the
hospital/nursing home.
SUMMARY OF THE SIGNIFICANT
INFORMATIONS REGARDING GESTATIONAL SURROGACY
Categories of Women acceptable
for Gestational Surrogacy:
·
Absent uterus
either congenital or after surrogacy
·
Repeated IVF
failure-(unexplained) no reasonable prospect of achieving
pregnancy in future.
·
Uterine synechia,
enlarged, distorted uterus, as in Adenomyosis or multiple
fibroid
·
Health of the c
commissioning woman and stress of pregnancy may be deleterious
for the genetic mother e.g. Heart disease, renal disease etc.
Ethical Considerations which
Apply to All Cases:
·
Clinic must not be
involved in settling financial transaction between the
commissioning parents and the surrogate host.
·
Selection of the
surrogate host must be carefully done so as not to create
conflicting relationship between the genetic parents and the
host.
·
Independent
counseling should be offered to both genetic and host couples
·
The age of genetic
mother should not exceed 40 years. The surrogate host preferably
should be less than 45 years.
·
Both genetic and
surrogate host couples should be screened against HIV, hepatitis
band hepatitis C antibody. It is desirable that the principal
motive of a prospective host should always be to help an
infertile couple.
·
A prospective host
should have at least one child before becoming a surrogate
·
The commissioning
couple in a surrogacy arrangement should be married. For social
and or personal reason opting for surrogacy by a married or
unmarried woman should not be encouraged.
Law and Regulatory Bodies for
Surrogacy:
Surrogacy, though practiced in
many parts of the world, has not been either uniformly or
strictly regulated.
In the USA, because of the
autonomy of the individual states, specific regulations
regarding surrogate motherhood differ and some are more specific
than others about the regrets of genetic parents over those of
the birth mother (surrogate mother). By the year 2000, 23 states
in the United States had laws on the practice of surrogacy, but
they still differ widely.
Like the USA, Australia also has
different regulations in different states. In some parts of the
continent (Victoria, South Australia and Tasmania) it is not
illegal, but certain strict regulations and bindings make
surrogacy almost impossible to carry out.
In Europe, the countries which
allow surrogacy are U.K., Belgium, Holland and Finland in U.K.
gestational surrogacy is fully regulated. Because the procedure
involves IVF, gestational surrogacy can only be practiced in
centers licensed by the HFEA. This sufficiently ensures the full
provision of clinical, scientific, counseling and legal services
to commissioning couples and the surrogate host.
In India, in the recently
compiled ICMR guideline, surrogacy has been included in the
treatment of infertility. The regulations for gestational
surrogacy in Indian context are more or less similar to those
which have enacted in the U.K. law. The only difference lies in
the financial involvement in the surrogacy arrangement between
the commissioning couple and surrogate host. While in U.K.
regulation prohibits commercial surrogacy by law, Indian
regulation has allowed appropriate remuneration to be paid by
the commissioning parents to the surrogate host.
Religious Considerations:
Christian religion is divided in
accepting surrogacy. Catholic Church is strongly against all
forms of assisted conception- specially those associated with
gamete donation and surrogacy. On the other hand, Anglican
Church is less rigid and is not against the practice of
surrogacy.
In Jewish religion, surrogacy is
not forbidden. But Jewish religion, the child born as a result
of surrogacy, will belong to the father who gave the sperm and
to the woman who delivered the child.
Muslim law does not allow
surrogacy directly but this may be permissible between wives
with the same husband. Even then, debate still continues and
there are differences in the degree to which Muslims will adhere
to the faith.
In India, there is no such
religious prejudice but at the initial stages there is
possibility of social stigma associated with surrogacy. This can
be overcome by ensuring the full provision of clinical,
scientific, counseling and legal services to be offered to the
commissioning couples and the hosts. The entire scientific
scenario with adequate socio-legal back-up requires rational
media coverage to generate a positive public awareness about
surrogacy in India. There is good evidence that the public in
the U.K. are reassured about the current situation on surrogacy
in Britain. But is essential to take stock frequently and
reassess the adequacy of the existing law in each country in
this difficult area.
Conclusion:
Indications of gestational
surrogacy are absence of uterus-either congenital or following
surgical removal, distorted shape and size of the uterus as in
Adenomyosis or multiple fibroids, repeated IVF failure or few
medical indications where the women is unable to bear the child
as in kidney or heart disease. The special areas where
gestational surrogacy requires special attention are selection
of surrogate host and in-depth counseling of both the host and
the commissioning couple. The support of independent counselors
and ethics committee is essential to assess the suitability of
the individuals to be treated by surrogacy and of the
arrangements made as a whole between the commissioning couple
and the surrogate host.
While planning the treatment, the
primary objective is to ensure the welfare of the children who
will be born as a result of treatment in addition to looking
after the welfare of the surrogate mothers’ already existing
children. Openness is a better option than confidentiality both
from commissioning couple as well as surrogate host’s point of
view. It is expected that this attitude will provide better
psychological stability for the child to grow and develop.
Nevertheless it must be admitted that future studies and
observation of more number of babies born through
surrogacy can provide further information of the real impact of
‘confidentiality ‘ or ‘openness’ abut their mode of origin.
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