Surrogate Worried She May Contract Hep B From Transferred Embryo

Hello Dr. Ramirez,

I'm currently signed up with an agency as a gestational carrier (surrogate). I have been matched with an international couple and was set to have their fertilized embryo transfered into my uterus this month. However I was just informed that the intended father tested positive for Hepatitis B core antigens. So he has a positive total antibody level but is negative for IgM. I'm told this means the results indicate either a false positve or that he had a past infection but there is NO current infection. Furthermore I'm told that the chances of me contracting hepatitis B is negligible to non-existent since the hepatitis virus lives in the fluid surrounding the sperm but not in the sperm itself and the fluid is always discarded prior to IVF procedures.

Do you have any expereince with or know if this is safe for me to go forward with this transfer via in vitro fertilization using just the sperm from the intended father as mention above and the intended mother's egg which I'm also told does not have recepters for the hepatitis virus?At this point I'm inclined to not take the risk but I feel obligated to find out as much information as possible before I make my descion.Thanks in advance for your time and help. J. from the U.S.

Answer:

Hello J. from the U.S.,

You have submitted a very interesting and difficult question. I think that it is unknown territory, and not being an infectious disease expert, I had to do some research myself to try and answer your question. There is an infectious disease (hepatitis) expert on the All Experts site on About.com, whom you might want to submit this question to as well.

From my research, based mainly via the CDC recommendations, hepatitis B or C are not transmissible via sperm but can be transmitted via semen, if the person is a chronic carrier If the sperm was prepped via thorough washing, there should be little risk of transmission of the virus to the egg, and in most IVF programs, that is the proper method. Transferring that embryo in to your uterus, would have a very small risk of hepatitis B. If you have been immunized for hepatitis B, which many many persons have been, then the chances of transmission are even less.

Based on the information regarding the sperm donor's testing, I cannot draw a conclusion as to his carrier status, except to say that he does not have an active infection. A carrier would have a positive hepatitis surface antigen, hepatitis core antibody but negative IgM. If he had Hep B in the past and recovered and is now naturally immune, he would also have a positive core antibody but also would have a positive surface antibody. This person would not be at risk for transmission of the virus, as no live virus would be present.

So, as a surrogate your chances would be very low, but it is ultimately your choice as to whether or not to take any form a risk. Even a low risk is a risk.

Good Luck,
Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
Monterey, California, U.S.A.

Donor Eggs and Surrogacy: The Possibility Of A Healthy Pregnancy & A Healthy Child

Emily Dickinson said: "Dwell In Possibility". I thought I would start the New Year with a blog post that centers on possibilities. I believe that everyone should leave themselves open to the wide array of options that are available to women and men who are struggling with their family building quest. An interesting example of one possible option was brought to my attention recently through an article on the American Fertility Association website, "The Amazing Story of the Birth of the Twiblings". Iris Waichler reviews an article that appeared recently in the New York Times and reflects on the courage it took for the author to reveal the complex journey she took using an egg donor and 2 different gestational carriers who end up giving birth to twins that are born 5 days apart.

In the December 29th NY Times article, Melanie Thernstrom writes an intensely personal account regarding her infertility journey ("Meet The Twiblings"). Recently married at 41, she and her husband underwent multiple IVF cycles without success. Her physician tells her after she begs to try for the fifth time that she should consider other ways of having a family. He asks, “Is your goal to have the experience of being pregnant or is your goal to have the best chance of having a healthy baby?” Ms. Thernstrom not only writes with feeling and fluency of what follows, but imparts a great deal of important information that would be helpful for any of you who are facing the decision to use donor eggs, surrogacy or a combination of both. What makes this couple's case unique is that they desired to have twins. This meant that in order to avoid the complication of a multiple gestation in one surrogate, they chose to have two surrogates, and each became pregnant with one successfully implanted embryo. The cost involved in doing this is discussed as well, which the author admits is a huge factor in being able to go this route. This is unfortunately always a big part of being able to do any kind of assisted reproduction treatment, as many of you well know.

Yet, all in all, this is an article about the possibility of doing something that would have been impossible a generation ago. Surrogacy and egg donation are still impossible in many states and parts of the world. We are lucky that here in California the laws allow for these types of treatment paths with protection for the intended parents, the donors and the surrogates. As the Times article points out, there are also a number of reputable agencies and counselors that can help with navigating the selection process, with all the legal aspects and with emotional support. Coincidentally, I was emailed recently by a woman in Italy who cannot carry a pregnancy because she has a heart condition and was wondering what her options were. She is 37 years old and wants to use her own eggs. Since surrogacy for financial gain is banned in Italy, I advised her on what was possible here and that her time for using "her own eggs" was growing short. I hope that she will find it possible to have the child she wishes for in 2011.

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
Monterey, California, U.S.A.

41 Yr. Old South African Woman Fails IVF: Needs Higher Stim Protocol, Menopur Dose Too Low

Question:

Hi Dr Ramirez,

I am 41 (42 in March) and have just come through a failed IVF cycle (our 1st attempt). I'm not sure what my FSH levels are but know that I only have 4 and 5 antral follicles left and an AMH of 0.94.

I was put on an 11 day course of 5 amps of menopur a day. I produced 4 eggs, 2 of which fertilised. On day three I had a 6 cell and a 10 cell (neither of which were fragmented) and so the transfer went ahead. Neither took and our result was negative.

I have a 13 month old daughter that we conceived naturally so am reluctant (at this stage) to use a donor egg. The reason we have to go the IVF route is that I have severe Ashermans Syndrome as a result of bad placente accreta from my pregnancy. We are therefore using the services of a surrogate.

I understand that the odds are against us but if we have the means do you think it is worth another attampt or two with my own eggs, and are there any other protocols which may produce a better egg result?

Thanks, M. from Johannesburg, South Africa.

Answer:

Hello M. from South Africa,

As you well understand, IVF pregnancy rates are very dependent on the age effect on eggs. As a woman ages, more and more of her eggs become debilitated leading to poor quality or abnormal embryos. This is the most likely reason for failure after the age of 40 years old. If you absolutely want to have a genetic child, then the only option you have is to continue trying as many times as it takes to be successful. The only things that may stop that plan are if you run out of money (i.e. cannot afford to continue) or the quality of the embryos is consistently poor. Otherwise, persistence can sometimes yield success.

There is a fairly good pregnancy rate at 41-42. In our clinic it is 55% pregnancy/32% deliveries. Miscarriages are increased because of the higher chance of genetically abnormal embryos. The oldest pregnancy to date in a woman using her own eggs was 49 years old in the U.S., but it took her 2 years of trying. Since you have been able to conceive about two years ago, there is already evidence that you do have good eggs. In your case there is the added factor of using a surrogate, but I assume you have selected one that has had successful pregnancies.

In terms of your protocol, every clinic is different and every doctor is different and prescribes/uses different protocols. It does not mean that one is better than the other. In my opinion, however, your protocol is too low for your age. In order to increase the chances of finding a good egg, a lot more eggs need to be recruited and retrieved. 5 amps of Menopur is only 375IU of FSH. As an example, my highest protocol, which is pretty consistent with other clinics in the U.S., uses 450IU of Follistim (pure FSH) + 150IU of Menopur (FSH/LH) for a total of 600IU per day. The bottom line is that the clinic you are working with and their protocol is highly influential on your outcome. You should check and see what their 41-42 year old pregnancy and delivery rates are, then compare them to other clinics. You may find that another clinic is better than the one you are attending.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Comment: Thanks very much! It was great to receive such a quick and informative response.

Guest Blogger Mindy Berkson: Building The Foundation For Surrogacy Brick By Brick

(If the blog radio program comes on, please go to the Oct. 1st blog & pause it. I will be keeping the show up for the month of October.)

Dear Readers:

Mindy Berkson is visiting my blog once again with an excellent guest post on surrogacy. For many, surrogacy is the only option. Recently, I had a patient who had an emergency hysterectomy after the birth of her first child. She was grief-stricken at the prospect of not having the ability to have another child until she decided upon surrogacy as an option. The whole process went forward without a hitch, with her and her husband undergoing IVF at our center with a surrogate they had found through a reputable agency. Her gestational carrier is now pregnant and will be delivering soon.

This is a complicated process and one in which Ms. Berkson has a wealth of experience as an infertility consultant. One of the first in the country to work with infertile couples on a case-by-case basis, she is both professional and compassionate when guiding her clients through what can be a very difficult and emotional treatment path. See the end of the blog post for more information on Lotus Blossum Consulting.

Building The Foundation For Surrogacy Brick By Brick

With so many moving parts to surrogacy it is no wonder the process can be overwhelming. Learning to be your own best advocate, effectively planning financially, physically and financially help you maximize your chances of success and minimize your financial expenditure.

The first step in building the foundation is preparing to pay for treatment and the ancillary costs associated with surrogacy. Finances are specific to individual circumstances. Sometimes savings are available, often the sale of portfolio items are used to fund treatment. A third popular option are various borrowing opportunities. All of the above should be discussed with a tax professional and or financial planner in the context of your individualized circumstances. It is also vital to plan and prepare for multiple treatment cycles. In my experience balancing hope with caution is what helps my clients to approach treatment with clear expectations and realistic parameters.

The second step in building the foundation is to identify the fertility center, the Reproductive Endocrinologist and the Embryologist who have above national average success rates for the type of treatment you are exploring as well as a specialty in treating your specific diagnosis.

The next resource is identifying the right donor and/or surrogate. Seeking ideal criteria in a perfect stranger is often a very intimate process. There is always some level of risk in the decision making process. Being your own best advocate is helpful in mitigating and or eliminating potential stumbling blocks. Identifying a candidate on line can be risky since they are not screened and you will not have the benefits of a third party to act as an intermediary. On the other hand, it is necessary to be aware of onerous contracts with recruiting agencies.

The fourth brick in the foundation is understanding the legal terrain and how it affects your specific situation. Surrogate friendly states vary across the country. Surrogate friendly means that parentage can be achieved at some future point after birth. But from state to state this varies greatly. Some states require pre birth orders to get intended parents names on the birth certificate after the birth and other states require a formal adoption after the surrogate delivers. Other states are favorable in getting intended parents names on the birth certificate at birth, as long as one parent is biologically related to the child. Furthermore, often how the embryos are created, and with whose biological material is relevant to the big picture. Thus, the individualized situation can and does impact the selection of a surrogate candidate from state to state. Finally, selecting a surrogate with like-minded intentions for the term of the pregnancy is essential.

There is still more to consider. Most health insurance policies have exclusions for surrogates. Therefore, it is essential to analyze policy alternatives that may help you to save thousands of dollars in the future. Some states offer maternity policies, other states offer nothing. Disability and complications only polices can often be purchased to offset financial risk. But it is the gap analysis performed by the licensed insurance agent that can help uncover what is best for your given situation, the surrogate, the state where she will deliver, and how these factors impact your individual risk adversity given your personal financial situation.

Another extremely important and often overlooked resource in family building is estate planning. Prior to surrogates going to embryo transfer it is essential to engage an estate planner to draft directives and desires and prepare effectively for any unforeseen circumstances. This provides the most protections for all involved parties.

Building the foundation for treatment is essential. Knowing all available options, researching the viability of each options, interviewing several reproductive specialists to determine if you are in the right place are all very relevant and key factors to consider before patients begin the journey.

When making educated decisions to pursue treatment options, I encourage my clients to take into consideration all the facts. Because making informed medical decisions is the best way to maximize their chances of success and minimize their financial expenditure.

As one of the first infertility consultancies in the United States, Lotus Blossom Consulting, LLC was founded by Mindy Berkson in 2005. With more than a decade of experience at physician’s offices, and egg donor and surrogacy agencies, Berkson assists individuals working through the often-challenging roadblocks of infertility, by providing the best information and resources available to them from around the world – all in one location.

Lotus Blossom Consulting works with individuals on a case-by-case basis, taking into consideration clients’ emotional, physical and financial infertility issues and then develops an individualized, comprehensive plan, to help clients make informed decisions and pull together a team of unbiased professionals to accomplish a treatment cycle. Mindy is a sought-after infertility expert and has appeared on countless media programs and speaker panels educating audiences on the topic of infertility, egg banking and surrogacy. For more information about Lotus Blossom Consulting, LLC, call toll free (877) 881-2685, email mindy@lotusblossomconsulting.com or visit the web at www.lotusblossomconsulting.com or www.infertilityconsultant.com.

Possible Uterine Abnormality Or Immunologic Disorder Causing Four Miscarriages In 32 Year Old: IVF With Surrogate Again?

Question:

Background: I am 32 as is my husband. We had an ectopic pregnancy 10/2005, 8.5 week miscarriage 3/2006, 10 week miscarriage 8/2006, 9 week miscarriage 2/2007 (genetic testing done - female/chromosomally normal), and 9 week miscarriage 8/2007 (male/chromosomally normal).

We had a healthy son via gestational surrogacy with my egg in 2008. During the IVF (in vitro fertilization) procedure for this surrogacy, I only produced 6 eggs and only 1 blastocyte made it to the 5 day transfer as an 8 cell blastocyte. I have Hashimoto's Disease (on medication since 2000), diagnosed with Endometriosis in 2005 (2nd lap in 1/2010 showed it is gone) and diagnosed with Adenomyosis in 1/2010, after which I took Depot Lupron for 4 months.

I have had every genetic test I've heard of and the only issue is one copy of the MTHFR gene. I took 81 ASA and Heperin with my last two pregnancies, and progesteronne with the last four. I even did IVIG with the 5th pregnancy. Two weeks ago I tested my FSH and it was normal. I also had an AMH test and it was 0.2, very low.

My RE has told me that I should try IVF (with me being the carrier) but I'm not sure. I know they are concerned about the number of eggs I have left and the quality of the eggs that are left. What I want to know is if my 2nd through 5th pregnancies could progress to 8-10 weeks with normal hearbeats and the last two we know were chromosomally normal, does this have anything to do with poor egg quality? How could these last two pregnancies test normal but be of poor quality? Is that possible?

Thanks! D. from the U.S.

Answer:

Hello D. from the U.S.,

To answer one of your last questions, since your pregnancies were know to be genetically normal, this is not an indication that you have poor egg quality. Poor egg quality leads to abnormal embryos (genetically) because the chromosomes within are fragile and break during division. It is most likely that you have either an immunologic disorder or a uterine abnormality. The latter might be the case because a surrogate was successful with your eggs.

I don't see any reason for you not to try with your own uterus if you can afford it financially. The only downside is if the uterus is a problem, you will end up miscarrying again and will have spent the money for that IVF cycle. I am not sure that I am convinced that it is a uterine problem, however, because the previous pregnancies progressed as far as they did. I would recommend that you go the gamut with the next in vitro fertilization cycle, using aspirin, heparin and IVIG if you decide to use your own uterus. That may be what it takes. If finances is an issue, then I would recommend that you use a surrogate again.

I know these are tough decisions but your young age, the positives that you have had, in addition to the child you have already had via surrogate two years ago, make your chances for another pregnancy very likely.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

My Sister Has Ovarian Cancer: I Want To Be Her Surrogate, What Is The First Step?

Question:

Hello. My sister has been diagnosed with Ovarian Cancer and is going to have a hysterectomy. We have discussed it, and I would like to carry a baby for her using her eggs and her husbands sperm. I live near Ottawa Ontario and she lives in Calgary AB. I was wondering what the first step would be, and who we should call to get this process started before it is too late.

Answer:

Hello C. from Canada,

I am sorry to hear about your sister, but the good news is that we do have the technology to help her have a child in exactly the way you mention. It is called IVF (in vitro fertilization) with surrogate. Your sister needs to contact an IVF center immediately. They will then have several options: the eggs can be removed to be fertilized and used later, or she could go through the IVF cycle completely and the fresh embryos placed directly into your uterus. In either case, you would be the surrogate. An IVF cycle will take two weeks minimum, so she will need to do this quickly, before her surgery. With ovarian cancer, you don't want to delay much.

The infertility specialist should coordinate things with her Gyn oncologist so that everybody is on the same page. Once the eggs are removed (egg retrieval), she can then undergo her surgery. Stimulation should be strong to try to retrieve as many eggs as possible so that any residual eggs/embryos can be frozen for later use if the first cycle fails or for another sibling. The IVF center will advise you on your role as a surrogate, do all the planning necessary and prepare your uterus to accept the embryos.

For more information, there is a very good non-profit here in the U.S. called "Fertile Hope", (which has recently been acquired by Lance Armstrong's Live Strong organization). This organization has a lot of information regarding cancer patients and their reproductive options. There is a section on the website for healthcare professionals that I have used called "Options At A Glance", which gives you a good idea of all the methods available for fertility preservation. See this link: http://www.fertilehope.org/ .

This is a wonderful thing that you are trying to coordinate and the best of luck to all of you!

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Monterey, California, U.S.A.

Twitter with me at @montereybayivf and follow me on Facebook at http://bit.ly/9Iw9oV