Surrogates more likely to have higher levels of complications during pregnancy ?

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Surrogates more likely to have hypertension and postpartum haemorrhage
by Hannah Flynn

Surrogates experience higher levels of complications during and after pregnancy compared to other IVF patients, a non-peer reviewed cohort study in Canada has shown.

The study of 937,938 singleton births, including 956 women acting as surrogates for intended parents, found that these women were more likely to be older, have had children, reside in low-income areas and have chronic hypertension when compared to other women in the cohort. Authors from Canada presented the results at the 40th annual meeting of the European Society of Human Reproduction and Embryology.

Dr Raj Mathur a consultant gynaecologist and former chair of the British Fertility Society who was not involved in the research told BioNews: 'This study shows that gestational surrogates are at increased risk of serious complications in pregnancy. This highlights the importance of careful screening and counselling of surrogates. Surrogacy organisations should take on board this need and ensure that they have criteria to ensure that women at increased risk of complications such as high blood pressure are not encouraged to act as surrogates.'

Surrogates were found to have a 14.9 percent risk of hypertension and postpartum haemorrhage, compared to an 11 percent or 12 percent risk, respectively, for women who have a baby following IVF. Women who conceived naturally experienced a six percent risk of postpartum haemorrhage, and seven percent risk of hypertension. The cohort was followed between 20 weeks' gestation and 42 days after the delivery.

One in 14 surrogates experienced severe health conditions linked to their pregnancy and birth compared to one in 22 women giving birth following IVF, and one in 42 women who conceived naturally. There was no difference in the rate of poor outcomes for babies up to 28 days old, born to women following IVF or natural conception and those born to surrogates.

Authors said that the results could reflect that surrogates are likely to have poorer overall health before pregnancy, despite there being clear calls for only women with 'favourable characteristics for a healthy pregnancy' to be selected for surrogacy.

'Gestational carriers were also less likely to be in the highest income bracket, and we know that lower socioeconomic status is associated with higher serious maternal morbidity rates. However, sociodemographic characteristics were accounted for in the analysis, and the results were similar, which suggest potential different mechanisms,' said Dr Maria Velez, study supervisor and senior author.

Considering that surrogates were more likely to have had previous pregnancies and be older it was important to 'ensure that any woman intending to be a surrogate is both medically assessed as fit for pregnancy and given the opportunity to have implications counselling where all risks, including health risks, are made known to her prior to trying to conceive. If she knows and understands these risks and continues the surrogacy journey, her decision should be respected,' Kirsty Horsey, professor in law at Kent University, who was not involved in the study, told BioNews.

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Comment
Surrogacy health risks – Do UK surrogates need to be worried?
by Sarah Jones

As an experienced altruistic surrogate in the UK, I found Marina Ivanova's research paper as presented at the ESHRE 40th Annual Meeting in Amsterdam interesting (see BioNews 1246). The study suggested that gestational carriers (known as surrogates in the UK), face higher risks of maternal morbidity and pregnancy complications in comparison to those who experience pregnancy and childbirth after natural conception or IVF.

Any study that includes nearly 1000 surrogate pregnancies should be looked at closely by the UK surrogacy community and any conclusions considered when looking at the risks to surrogates in the UK. Dr Raj Mathur, a consultant gynaecologist and former chair of the British Fertility Society told BioNews that surrogacy organisations should take on board the need for careful screening and counselling of surrogates 'and ensure that they have criteria to ensure that women at increased risk of complications, such as high blood pressure, are not encouraged to act as surrogates'.

In fact, surrogacy organisations in the UK are already quite diligent about this. The organisation that I undertook my own surrogacy journeys with, SurrogacyUK, who I now work for, carefully consider the health of the surrogates they accept. Historically we have rejected over two-thirds of all applications to be a surrogate that we receive.

SurrogacyUK has implemented a robust admissions policy for several years. The comprehensive risk assessments undertaken during the admissions process evaluates various factors including obstetric health, BMI, age, physical health, emotional health, previous and current medical conditions, and any medications taken.

Social factors such as family composition and support systems are also thoroughly considered. Further checks include background checks on all adults in the household, social services checks, and an assessment of the applicant's understanding and potential vulnerability. This includes identifying any risks of coercion, including financial coercion.

It is important to acknowledge that every pregnancy, whether naturally-conceived, through IVF, or via surrogacy, carries some risks. Some risks may be unpredictable and remain unknown despite comprehensive research and consultation, such as such as low-lying placenta, placenta previa, baby lying in a breach or transverse position, hyperemesis gravidarum or symphysis pubis dysfunction - these can happen in a pregnancy, without ever having been experienced in previous pregnancies. However, many can be mitigated through careful monitoring and adherence to medical advice for example. For example gestational diabetes, can be controlled using diet and medication, or c-sections can be planned if a surrogate has had one previously. However, potential risks can never be entirely eliminated.

As an experienced surrogate, I weighed these risks carefully as part of my decision-making process, just as I did when deciding to have my own children. Surrogacy organisations have an ethical duty to establish criteria that help reduce risks and ensure potential surrogates are given sufficient information to provide informed consent. However, it is equally important that surrogates are not infantilised or stripped of their autonomy. At present SurrogacyUK, Brilliant Beginnings and My Surrogacy Journey all have admissions policies and surrogate eligibility criteria, but they are not required to do so as they are not regulated.

My most recent surrogacy journey resulted in the birth of a wonderful little boy, now aged three, who was born into his genetic family, joining his genetic mum, dad, and siblings. During this pregnancy, two risk factors were identified: I was classified as being of advanced maternal age (over 35) and having a high parity (over five births).

These risks were known to me, and my decision to embark on a surrogacy journey was made after carefully assessing them. Before offering to help my friends complete their family, I discussed the potential risks with my IVF clinic, my GP, and my obstetric consultant. With the support and guidance of medical professionals who evaluated my individual circumstances, I felt confident making an informed choice.

In my case, I was well aware of my risk factors, a blanket ban would have removed my ability to make an informed choice, disregarding my individual history, level of understanding, and the personal medical advice I received. It is essential that policies consider each woman's unique situation and allow for personalised decision-making based on medical advice.

Interestingly, when I decided to have my own children, I did not face the same level of scrutiny. No one evaluated my understanding or ensured I was making an informed choice before expanding my family. My medical history was not reviewed by a medical professional, the stability of my family unit was not considered, nor was my support network or the potential risks to myself. No one questioned my decision to have my own children. In contrast, my decision to be a surrogate was a much safer one to make, as it involved thorough assessments and consultations with medical professionals, ensuring I was fully informed and supported.

The study author Marina Ivanova summarised a number of possible causes for their findings: baseline health, IVF treatment, differing prenatal care and monitoring, as well as the physiological and psychological impact of carrying a pregnancy for someone else. The author floated surrogates' lower socioeconomic status, as a possible reason, but showed that adjusting findings for socioeconomic status did not explain the discrepancies they had found.

Considering the possible causes, and considering if they are relevant to UK surrogates results in more questions: Are Canadian surrogates offered the option of mild or natural IVF like UK surrogates? At SurrogacyUK we advise our surrogates that it may be possible to have a non-medicated cycle, purely because it reduces the risks and side effects. Would this impact the results?

Are the risks only higher for surrogates because they are more likely to have had more children before embarking on a surrogacy journey? Those undertaking IVF for themselves are far less likely to have a parity over five. How would the results compare to a similar survey of non-surrogate pregnancies where the mothers had a parity of five or more?

These questions could be addressed by a similar large-scale study in the UK which would ideally include parity and IVF-type comparison groups. We know that maternal morbidity is relatively low within the surrogate community, as most surrogates obtain medical approval for subsequent surrogacy journeys and are deemed fit to receive treatment by UK clinics. Comparing data from both countries could provide much needed information to elucidate mechanisms underpinning increased risks of pregnancy complications, that could lead to real improvements for UK surrogates.

As a surrogate, and CEO at SurrogacyUK, I passionately believe that having access to comprehensive information, including up-to-date research is crucial to being able to make fully informed choices. Every surrogate, like any woman planning a pregnancy, should have absolute clarity on the risks they face before making their decision. At SurrogacyUK, the health and wellbeing of surrogates is, and must remain, the highest priority. Marina Ivanova's study is an important and interesting addition to the research already undertaken on surrogacy. For me, though, it raises as many questions as it answers and highlights the need for UK-specific clinical and academic research.

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