Medical Clearance for Our Surrogate
I am always excited to write about the progress in our own rainbow family building journey, and I am thrilled to report that we are in the final stages before pregnancy.
A couple weeks ago, our amazing surrogate / gestational carrier (GC) flew from her home state of Texas to our fertility clinic in Los Angeles for her final medical clearance. All her results have come back, and she is healthy and ready to go except for one thing. Her titers, or immunity, to varicella (the virus that causes chicken pox) is low. She will need a booster vaccination.
The varicella vaccination is given in 2 doses, one month apart. After the second dose, it is not recommended to get pregnant for at least a month. So, we will have another brief pause (I’m trying to stop calling things ‘delays’ in this process), and we will hopefully be ready to attempt our first transfer in the summer!
As a physician, I’m always curious about the medical and scientific aspects to assisted reproduction. While my husband, myself, and our egg donor went through medical testing prior to donating sperm and eggs, the medical screening and evaluation for the GC is unique.
I wanted to take this opportunity to review the guidelines and recommendations for medical testing for GCs in the United States. Then, I wanted to evaluate this testing with other comparable countries for surrogacy: Canada and the United Kingdom. This article will focus exclusively on the medical clearance. All intended parents (IPs), egg donors, and GCs in the U.S. also undergo psychological and social screening to ensure they completely understand, are mentally fit for the process, and are not at risk for any coercion. I will not discuss these aspects in this article, but if there is interest, leave a comment or email me at bryan@babymoonfamily.com, and I will write a future article about these topics.
Medical Screening for Surrogates in the United States
The guidelines for assisted reproduction in the U.S. are drafted by the American Society of Reproductive Medicine (ASRM). These guidelines serve as the minimum recommendation for fertility clinics, and clinics are able to add additional criteria. For example, our clinic - Pacific Fertility Center of LA - includes an additional ultrasound to measure the length of the GCs cervix. There is some evidence that shorter cervical lengths can indicate a higher risk for pre-term delivery, and so our clinic has opted to include this in the GC medical screening process (1).
The ASRM guidelines for medical screening of GCs can be found on the ASRM website (2). After reviewing this, I have broken the medical screening down into three categories: Physical examination, laboratory testing, and imaging. I will go through each individually.
The physical examination includes the medical history and observations made by the physician during the initial evaluation. This includes:
Age between 21 and 45 years
At least one, term, uncomplicated pregnancy
No more than five previous deliveries or three deliveries via cesarean section
No evidence of nonmedical percutaneous drug use, such as needle tracks
No evidence of recent tattooing, ear piercing, or body piercing (within the past 12 months) where sterile technique was not used
Physical exam findings consistent with any number of infectious diseases, which will be further detailed in the laboratory testing category
In the laboratory testing category, the goal is to screen for a large number of infectious diseases that could affect the GC and/or be transmitted to the fetus (3). The tests include:
HIV (all types)
HTLV (or Human T-lymphotropic virus, all types)
Hepatitis B and C
Syphilis
CMV (or Cytomegalovirus)
STIs (Sexually transmitted infections) such as gonorrhoeae and chlamydia
If positive, some of these could prevent the woman from ever being a GC, including those who are found to have HIV or any hepatitis. Other positive results just warrant appropriate treatment and then retesting, such as positive STIs.
The laboratory testing category includes additional, non-infectious testing, such as:
Blood type and Rh factor. The Rh factor is especially important as you have to ensure that the GC does not have a mismatch with either the sperm donor(s) or egg donor.
Pap smear for cervical cancer screening
Titers for varicella and rubella immunity
Urine drug screen
The final category is imaging. This includes:
Mammogram for breast cancer screening
Uterine cavity evaluation
The uterine cavity evaluation is another general recommendation that is left up to the discretion of the fertility clinic. There are several options for this evaluation: Transvaginal ultrasound, sonohysterography or saline infusion sonography, or hysteroscopy. All these are different ways to visualize the inside of the uterus and detect any abnormalities such as fibroids that would prevent pregnancy. Recent publications have reviewed the evidence for each of these modalities, and there is currently no consensus as to the one, ‘best’ evaluation, as it depends on the overall clinical picture (4).
Medical Screening for Surrogates in Canada
The Canadian Fertility and Andrology Society (CFAS) have developed guidelines for third party procreation (5).
Interestingly, from a medical screening perspective for the GC, these are remarkably similar to the ASRM guidelines in the U.S. with one exception: Body mass index (BMI).
The ASRM guidelines do not list any lower or upper limits for BMI, but the CFAS guidelines state the following:
BMI should be between 18.5-24.9 kg/m2 and preferably under 30 kg/m2 (cutoff for overweight). Surrogates with a BMI above 35 kg/m2 (cutoff for obese) should be discouraged.
While the Canadian guidelines do not say that potential GCs with a BMI over 35 are ‘not able’ to be surrogates and just ‘discourages’ them, it is interesting that this is not present in the American guidelines. Frankly, this is likely due to the overweight/obesity epidemic in the U.S., and adding this restriction would make it even more challenging to screen potential surrogates. That being said, many fertility clinics and surrogacy agencies in the U.S. will have their own BMI cutoffs, often at 33 kg/m2 (6).
Medical Screening for Surrogates in the United Kingdom
Like Canada, the UK allows for altruistic surrogacy, and the country has done so for decades. Interestingly, I was not able to find clinical guidelines for the medical screening of GCs. I searched the British Fertility Society, the Human Fertilisation and Embryology Authority, and the Royal College of Obstetricians and Gynaecologist.
While I found useful, consumer friendly links to articles about IVF and surrogacy, there were no medical guidelines written by reproductive endocrinologists.
While this could have been a limitation of my online searching abilities, it could also be that the UK follows the American or Canadian guidelines. However, it would be interesting to know, so if you are a reproductive endocrinologist in the UK, please reach out to bryan@babymoonfamily.com to discuss.
Medical Screening for Surrogates in Mexico, Colombia, and Georgia
Given the proliferation of surrogacy in Mexico and my two recent interviews with IPs who finished their journeys there (From New York to Mexico and From Texas to Mexico), I tried using Google Translate to search for clinical guidelines for GC medical screening in Mexico. However, I was unsuccessful. I also attempted this for Colombia and Georgia (the country, not the U.S. state), given they are also two increasingly popular international destinations for compensated surrogacy, but I could not find reliable information. If you are a reproductive endocrinologist in Mexico, Colombia, or Georgia who has this information, please reach out to bryan@babymoonfamily.com.
Conclusions
While I embarked on this exercise as a way to fill the most recent pause in our own surrogacy journey, I found it to be a medically interesting review of the extensive screening and testing required of surrogates in the U.S. and Canada. Also, I was pleasantly surprised to learn that clinics also have additional testing that they consider based on evolving literature, and that the U.S. and Canada are almost identical in their medical approach to GCs.
Reviewing this process in detail also puts the timing of GC matching and medical screening into perspective. While GCs - whether independent or with an agency - can do some pre-screening for things like age and pregnancy history, a lot of the medical testing is expensive, needs to be done within a certain time frame of becoming pregnant, and/or is invasive (i.e. imaging). The standard practice is to wait until there is a match between IPs and a GC before doing all the formal medical screening. However, this does mean that some matches may need to be broken if there are medical discoveries that cannot be addressed. I used to think this was not ideal, but now understanding all the testing done in screening, I agree with the standard practice and order of operations.
While we wait for our own GC to build that immunity to the chicken pox virus, my husband and I will begin to review the surrogacy contract with our lawyer. I have previously written about the egg donor contract review, and I will do the same for the surrogacy contract. We have a couple months to make sure we can work through the 50+ pages and get all our questions answered to ensure that we and our GC are aligned and excited for the next step: Pregnancy!
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