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Assisted conception and MRKH syndrome. Dr Anna Carby Fertility Specialist IVF Hammersmith. Overview. Reproductive options What is surrogacy treatment Treatment pathway Investigations Treatment cycle Outcomes at IVF Hammersmith. Options.

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assisted conception and mrkh syndrome

Assisted conception and MRKH syndrome

Dr Anna Carby

Fertility Specialist

IVF Hammersmith

overview
Overview
  • Reproductive options
  • What is surrogacy treatment
  • Treatment pathway
  • Investigations
  • Treatment cycle
  • Outcomes at IVF Hammersmith
options
Options
  • Freezing embryos for surrogacy (currently in a relationship)
  • Freezing eggs for surrogacy (not currently in a relationship)
  • Adoption
what is surrogacy
What is surrogacy?
  • Term used to describe situation where a woman agrees to become pregnant and have a baby for another couple
  • Woman who carries the baby is the surrogate
  • Couple who intend to be the parents are called the intended parents
surrogacy in the uk
Surrogacy in the UK
  • Legal issues surrounding surrogacy
  • Surrogacy Agreements Act (1985)
  • HFEA Act (2008 section 30)
  • Any agreement between a surrogate mother and intended parents is not legally enforceable
  • Important to have surrogacy agreement to make intentions clear and provide evidence of intentions
  • Legal advice important
types of surrogacy arrangement
Types of surrogacy arrangement
  • Full/host surrogacy – intended parents use IVF treatment to create embryos form their own eggs and sperm and these are replaced in to the uterus of the surrogate
  • Partial /straight surrogacy – surrogate’s eggs are used with intended fathers sperm for IVF or IUI
how do you find a surrogate
How do you find a surrogate?
  • Family member/friend
  • By chance
  • Through surrogacy agency – Surrogacy UK (recognised by HFEA and BMA) , COTS
pathway ivf hammersmith
Pathway IVF Hammersmith
  • Referral from GP/specialist
  • Out-patient appointment within 4 weeks NHS (or private appointment if desired)
  • Assessment - initial consultation, medical history and investigations
  • Follow-up appointment
  • Application for funding if NHS
  • Counselling and nurse appointments
  • Pre-treatment blood tests
  • Treatment cycle
  • Quarantine embryos
  • Transfer in to surrogate
investigations ultrasound scan
Investigations – ultrasound scan
  • May be either internal or transabdominal
  • Internal gives better picture of ovaries and allows assessment of accessibility
  • Volume of ovaries and activity
investigations blood tests
Investigations – blood tests
  • AMH testing – not currently available through NHS but best marker of “ovarian reserve” ie how well ovaries may respond to stimulation
  • FSH testing – cycle specific therefore more difficult to test
investigations semen analysis
Investigations – semen analysis
  • Extremely important!
  • Produce sample on-site
  • Analysis of count and motility
review appointment
Review appointment
  • Results of investigations
  • Plan for funding and treatment
  • NHS funding approved?
  • Referral to counsellor
  • Referral to specialist nurse
funding of treatment
Funding of treatment
  • All surrogacy treatment cycles must be approved by the female partners PCT (primary care trust)
  • PCT is defined by the female partners GP location
  • If funding is granted it covers the cost of producing embryos and most usually freezing and storage for the first year
  • The costs of the surrogate transfer are not included and this has to be performed privately
role of the counsellor
Role of the counsellor
  • Legal, financial and emotional implications of treatment
  • Signing of consents (many!)
  • Stress management
role of the specialist nurse
Role of the specialist nurse
  • Communication with GP for surrogate and commissioning female – medical history, welfare of the child
  • Screening blood tests - obligatory
  • Karyotyping (chromosomal testing for commissioning couple), blood grouping, cystic fibrosis screening
  • Potential transfer of infectious diseases with embryos (HIV, Hep B and C, syphilis, chlamydia, gonorrhoea, CMV). Testing within 3 months of treatment
  • Repeat infectious diseases testing after 6 months quarantine of embryos
the treatment cycle for you
The treatment cycle for you
  • Aim is to stimulate ovaries to produce upward of 5 follicles
  • Requires control of ovarian cycle
  • May use contraceptive pill prior to treatment
  • Then a series of injections for approx 2 weeks to shut down ovarian function and control ovaries (buserelin)
  • Additional injection for further approx 2 weeks to stimulate ovaries (FSH)
the treatment cycle injections
The treatment cycle (injections)
  • Sub-cutaneous
  • Daily at home
  • Similar to diabetic pen with dial-up dosage
the treatment cycle monitoring
The treatment cycle - monitoring
  • Transvaginal or transabdominal scans and hormonal blood tests (estradiol)
  • Approx 4 visits per treatment cycle
  • Early appointments – from 7am
  • Perfectly possible to work whilst stimulating
the treatment cycle egg collection
The treatment cycle – egg collection
  • Either transvaginally or laparoscopically
  • Transvaginal - better egg yield, intravenous sedation, possible for majority. Quick recovery time
  • Laparoscopically – for ovaries that can’t be reached safely transvaginally. Requires general anaesthetic, day case operation
  • Average numbers collected – approx 10 but may be anything from 0-20+ !
the treatment cycle fertilisation
The treatment cycle - fertilisation
  • Partner produces sample on the day of egg collection
  • Purified to remove non-viable sperm and achieve concentrated sample
  • Egg fertilised - normally by a process called ICSI
the treatment cycle freezing
The treatment cycle - freezing
  • Embryos frozen either day 1, 3 or 5
  • Quarantine period of 6 months
  • Repeat viral screening
  • Available for subsequent transfer in to surrogate
  • Can be frozen for use for up to 10 years
the treatment cycle risks
The treatment cycle - risks
  • No treatment is without risk
  • But risks with IVF are low
  • Over-response OHSS (ovarian hyperstimulation syndrome) approx 3-5% cycles
  • Under-response and cancellation – approx 3%
  • Bleeding – less than 1%
  • Damage to other structures (bowel, bladder) less than 1%
  • Infection – less than 1%
the treatment cycle for the surrogate
The treatment cycle – for the surrogate
  • Preparation of the womb for transfer of embryos
  • Transfer in the natural menstrual cycle if regular
  • May be achieved with control of menstrual cycle and hormonal support with estrogen patches and progesterone pessaries up to 12 weeks of pregnancy
outcomes of treatment
Outcomes of treatment
  • 10 patients (12 cycles of treatment) completed
  • Average age at treatment 29
  • 3 patients laparoscopic egg collection
  • 7 transvaginal egg collection
  • 159 eggs collected in total!
  • 100 embryos and 10 eggs frozen
outcomes of treatment26
Outcomes of treatment
  • 2 surrogacy cycles completed
  • 1 livebirth
  • 1 ongoing pregnancy
any questions
Any questions
  • Contact IVF Hammersmith 0203 313 4411
  • Mr Stuart Lavery, Mr Geoffrey Trew, Dr Anna Carby, Sister Cathy Turner
  • Referrals fax 0208 749 6973
  • www.ivfhammersmith.com
  • www.londonfertilitysurgery.co.uk
  • www.hfea.org.uk