If your patient is a potential surrogate
The surrogate may ask for an opinion as to whether she is medically fit to get pregnant. A surrogacy pregnancy should be “low risk” but currently there is no official guidance or regulation around factors such as age, BMI or previous obstetric history.
Straight surrogacy is usually carried out at home and does not involve medical staff. It is worth noting that if a woman wishes to become a straight surrogate but does not intend to join an organisation such as Surrogacy UK then she could proceed without any checks at all.
Host surrogacy involves egg retrieval and embryo transfer, so has to be carried out at a licensed fertility clinic which will be regulated by the HFEA. The surrogate will be seen by a Consultant in assisted conception. The clinic will usually arrange all the necessary screening tests and implications counselling for the surrogate. The case will usually have to go to the clinic’s ethics committee for approval before treatment starts.
Specific considerations include the following.
There are no HFEA or other guidelines regarding the age of straight surrogates but the straight surrogate is in effect donating her eggs. You may want to bear in mind that the HFEA guidance for egg donors states that unless there are exceptional reasons, eggs for the treatment of others should not be taken from donors age 36 or above. Similarly eggs should not be taken from donors under 18 years of age. Obviously fertility declines with age, while the risk of chromosomal abnormalities increases. Surrogacy UK will not accept surrogates under the age of 21 but there is no upper age limit: each case is dealt with on an individual basis.
In host surrogacy the risk of chromosomal abnormality depends on the age of the woman who provided the eggs, not the age of the host surrogate. The chances of successful embryo implantation are similar whatever the age of the host surrogate. However, the risks of pregnancy to the surrogate increase with age.
Straight surrogacy: it will be up to the surrogate and IPs to decide whether or not to proceed as there is no clinic involved. However it would be advisable to ensure that the surrogate understands that obesity increases the risk to her and the baby. If there was cause for concern Surrogacy UK would make a decision on a individual basis as to whether to accept the surrogate as a member.
Host surrogacy: Most infertility clinics in the UK will not provide treatment to a potential surrogate with a BMI higher than 30 to 32.
Previous obstetric history
If a surrogate has had problems such as hypertension, gestational diabetes or premature delivery in previous pregnancies, they should be made aware of the risk of recurrence in future pregnancies. They should be advised to be completely honest with both their surrogacy organisation and their IPs about their previous obstetric and medical history.
Straight surrogacy: The surrogate and IPs will make the decision as to whether to proceed or not. Organisations such as Surrogacy UK will provide support and advice based on experience but they are not in a position to provide obstetric/medical advice. GPs should consider asking for advice from an Obstetrician.
Host surrogacy: If the surrogate has a previous poor obstetric history then the medical staff and ethics committee at the infertility clinic will decide whether to accept her for treatment.
A potential surrogate with an incomplete family
In this situation the surrogate should be aware of the potential risk that complications during the pregnancy could jeopardise her chances of having more children of her own. She might have an ectopic pregnancy and lose a fallopian tube or she might have catastrophic post-partum bleeding and require an emergency hysterectomy.
Mental health problems
Mental health problems, current or past, may affect a potential Surrogate’s suitability to join the organisation. The GP should describe any known mental health problems, and comment on the possible impact of a surrogate pregnancy. They should also indicate if a specialist psychiatric assessment would be appropriate.
If your patient is a potential Intended Parent (IP)
In straight surrogacy there are no regulations governing the age of IPs. There is no upper age limit for membership of Surrogacy UK but the cases of older IPs would be considered on an individual basis.
In host surrogacy cases of older IPs would also be considered on an individual basis. Following this it would be up to the medical staff and the ethics committee at the IVF clinic to decide whether to allow older IPs to proceed.
Physical and mental health of IPs
There is no guidance on how to assess whether IPs are healthy and fit enough to bring up a child. Surrogacy UK would look at the cases of IPs with significant health problems on an individual basis to determine whether they could become members. IPs who plan to have a baby through host surrogacy would be assessed by the medical staff and the ethics committee at the clinic, and they would make the final decision as to whether the IPs were allowed to proceed.
Antenatal and postnatal care
During the pregnancy
A pregnant surrogate should be treated as you would any other pregnant woman, with routine antenatal care.
Both the surrogate and the IPs should be given the opportunity to attend antenatal and postnatal classes, and both should be referred to the midwife and health visitor during the latter stages of the pregnancy.
In most cases the IPs leave hospital with the baby, so while the surrogate will need to be visited to check on her own health, the baby will need to be visited in the IPs’ home.
The midwife will visit the new baby and parents as they would for any other new baby, and the health visitor will then take over.
Consent for immunisations and any medical procedures
The parental order giving the intended parents parental responsibility will not usually be awarded until the baby is around 6 months old. Therefore in strict legal terms the surrogate is the legal mother until this time. This can cause problems when consent is required, and most frequently arises in the case of immunisations. If the surrogate can attend with the IPs for immunisations there is no problem, but this is often not practical. We recommend that the surrogate signs a letter giving consent for the baby to have the standard immunisation programme. Since any such procedure or treatment would be in the best interests of the child, this is usually sufficient.
There is no case law on this issue so if a Health Professional has any concerns they are advised to seek advice from their Defence Organisation.
Surrogacy UK is unable to provide advice on surrogacy outside the UK.
What is the SUK Ethics Committee?
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