As a gestational surrogate, your patient will need to undergo in vitro fertilization (IVF) to achieve the intended pregnancy. IVF pregnancies are associated with a higher risk for pregnancy complications than naturally conceived pregnancies. Even after matching for maternal age, ethnicity and background medical risks, IVF pregnancies are associated with a higher chance for spontaneous abortion, ectopic and heterotopic pregnancies, vanishing twin, fetal anomalies, abnormal placentation, multiple gestation, preterm birth, low birthweight and stillbirth.
IVF pregnancies are associated with a 2 fold increased risk for fetal nervous system abnormalities.
The risk for aneuploidy is not increased in IVF per se unless conception is achieved using Intracytoplasmic Sperm Injection (ICSI). In these cases, the risk for sex chromosome aneuploidy is 8 per 1000 pregnancies. IVF pregnancies are also associated with a higher than expected incidence of imprinting disorders such as Beckwith-Wiedemann and Angelmann syndrome. Many patients are prescreened with preimplantation genetics but it is essential for the patient to understand that these conditions may NOT have been tested for in their screening. Single gene disorders and imprinting disorders are NOT assessed by PGD. Furthermore, PGD is not 100% accurate. Furthermore, with surrogate IVF pregnancies we often do not know the background of the biological parents and there may be population-specific recommendations such as alpha-thalassemia screening, hemoglobin electrophoresis, Tay-Sachs screening, or other assessments. Additionally, based on family history, there may be recommendations made for additional biochemical , DNA, or sonographic of the biologic parents, or of the pregnancy.
Genetic Counseling is strongly recommended for ALL patients who have undergone IVF regardless of the age or other risk factors. If biological parents are unable to attend a genetic counseling session in person, there is an option to attend in person or by Skype. Another alternative is for the biological parents to see a certified Genetic Counselor close to where they live.
In addition, all patients who have undergone IVF should also have nuchal translucency screening, a targeted second trimester ultrasound and a fetal echocardiogram at around 22 weeks regardless of any other risk factors.
We recommend NIPT for all IVF pregnancies. This has a much higher sensitivity and specificity for the diagnosis of Down syndrome and trisomy 18 than does State Program screening or ultrasound. We encourage parents of IVF pregnancies to consider extended NIPT, which also has the potential to screen for sex chromosome aneuploidy and for other disorders.
One of the most significant risks associated with IVF is multiple gestation. Compared with a natural multiple gestation rate of 3%, IVF pregnancy in the United States is associated with a 43% rate of multiple gestation. Fortunately, this rate is declining due to a trend toward single embryo transfers since 2009. But even with single embryo transfers, monozygotic twinning can occur in 1-5% of IVF pregnancies, which is 5-10 fold greater than the baseline chance of 0.4%.
Multiple gestations are high risk pregnancies. Over 50% will deliver before 36 weeks, 12% will deliver before 32 weeks and there is data to suggest that African American women may deliver even earlier. Multiple pregnancies are at higher risk for gestational diabetes, preeclampsia, growth abnormalities, abruption, cesarean delivery, stillbirth and postpartum hemorrhage.
IVF pregnancies associated with a 2.9-6.0 relative risk for placenta previa. In patients with a prior cesarean section, placenta previa increases the risk for invasive placentation. Delivery with placenta accreta, increta and percreta can require hysterectomy, massive blood transfusion, injury to bowel or bladder, need for treatment in intensive care and possible maternal death. The risk for invasive placenta with placenta previa is as follows:
1 prior C/S: 25% risk invasive placenta
2 prior C/S: 45% risk
3 prior C/S: 60% risk
Vasa previa is seen in 1 in 200 IVF pregnancies. Hospitalization is often required as early as 26 weeks gestation and delivery by cesarean section at 35 weeks to avoid fetal exsanguination is recommended.
IVF pregnancies have an increased risk of fetal growth issues, and, therefore, monthly scans are recommended.
Finally, we recommend twice-a-week nonstress tests and fluid checks starting no later than 34 weeks (earlier start-up time might be recommended based on other circumstances) until delivery, and then delivery no later than the EDC.
Because of these potential risks, the intended surrogate and family need to discuss and have a contractual agreement about:
- Invasive testing
- Multifetal pregnancy reduction/selective termination
- Management of lethal fetal anomalies
- Childcare and compensation for lost wages if the surrogate is hospitalized
ASRM guidelines for the selection of surrogates suggests:
- Age 21-45
- Has had a prior successful term pregnancy
- No more than 5 previous vaginal deliveries
- No more than 2 prior cesarean section
- No contraindications to pregnancy
Prospective surrogates need a detailed history and physical exam with their primary care provider. They need detailed laboratory evaluation including:
- Prenatal Panel
- HIV, Hepatitis B and C, CMV, Gonorrhea, Chlamydia and Syphilis
- Glucose Tolerance test
- Complete Metabolic Panel
- Hemoglobin electrophoresis
Psychological evaluation of the surrogate and the intended parents is recommended. Maternal Fetal Medicine consultation prior to pregnancy is in order for the surrogate to understand the risks unique to IVF and pregnancy. Strong consideration for single embryo transfer should be given due to the increased risks associated with multiple gestation.
For privacy and security reasons, we cannot communicate about your care directly with intended parents. We are delighted to have them attend your appointments or phone/video conference in during your visits.