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Understanding IVF Processes in
Surrogacy
Elizabeth Barbieri, MD
Dr. Elizabeth Barbieri
• Education:– Yale University
– Cornell Center for Reproductive Medicine
• Reproductive Endocrinologist
• Joined ORM in 2009
• Mom of 3
Oregon Reproductive Medicine
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• Founded in 1989 - more than 25 years building families – patients from 40 countries
• One of the largest IVF clinics in the US – top 3 for surrogacy by number of cycles annually
• State-of-the art “clean-room” embryo laboratory designed by engineers who have also designed the fabrication plants at Intel in Oregon
• Consistently high live birth rates – top 1-3% of all US clinics in every reported category
• In-house egg donor program
• Leader in surrogacy IVF
• In-house genetics team and laboratory
IVF in Surrogacy 101
IVF Basics
How IVF in Surrogacy is Different
Reproductive Genomics
Other Considerations When Getting Started
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Spontaneous pregnancy
Inefficient selection of just ONE egg
In Vitro Fertilization (IVF)
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• Process of obtaining eggs and sperm to create embryos
Controlled ovarian hyperstimulation
- Approx 8-12 days
No Meds
Ovary on Meds
In Vitro Fertilization (IVF)
Egg Retrieval
Eggs fertilized in the embryology lab
Embryos growing…
Day 1
Day 2
Day 3
Day 5: Blastocyst
Day 5 options: Fresh Embryo Transfer (FET)
Day 5 options: Embryo biopsy for genetic (CCS or PGS) testing
• Embryos frozen while cells are tested
Putting Things in Context – U.S. data
140,000Transfers
IVF
2,000 Transfers
Patient Eggs + Surrogate
Group A
Group C (two sperm providers)
Group B
2,000 Transfers
Donor Eggs + Surrogate
4,000Transfers
IVF with a Surrogate
3% of IVF
Putting Things in Context
• Surrogacy IVF
• Donor Egg IVF
• International patients
Cycle Type(Recipient + Egg Origin) Transfers Share
Top 5 Clinics(1%)
Top 10 Clinics(2%)
Total IVF 140,000 100.0% 14% 21%
Patient + Patient Egg 118,000 85.5% 14% 22%
Patient + Donor Egg 16,000 11.5% 16% 23%
Surrogate + Patient Egg 2,000 1.5% 20% 32%
Surrogate + Donor Egg 2,000 1.5% 25% 40%
• Embryo biopsy
• PGS / PGD; genetics
• International patients
Based on 2014 CDC and SART reported data.
• +450 US clinics - 93% do donor egg IVF and 87% do surrogacy IVF
• However not every clinic is as experienced
Eggs(Stimulation +
Retrieval)
Embryology(Insemination + Development)
SelectingEmbryos(Grading +
Testing)
Uterus(Stimulation +
Transfer)
Basic Steps in Every IVF Cycle
Uterus(Stimulation +
Transfer)
Sperm Provider(s)
Egg Provider
Patient
Commonly the woman providing the egg and carrying the pregnancy are the same
Patient / Donor Surrogate
IVF in surrogacy adds some complexity and requires many choices
Reproductive Genomics is Revolutionising IVF
Carrier Screening Embryo Testing (PGS/PGD)
Fresh ET Frozen ET
Creation of Embryos, Grading and Testing Selection and Transfer
IVF in Your Surrogacy Journey
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Waiting for a Surrogate
Surrogate’s OB/GYN
PregnancySurrogate
Match Surrogate
IVF
About 18 Months
IVF Physician 4-6 months
9 months1-2 months
2-3 months
Surr
oga
teSp
erm
+
Do
no
r/Eg
g
Frozen Embryo Transfer
DonorMatch
DonorIVF
EmbryoTest
Sperm
Fresh Embryo Transfer
DonorMatch
DonorIVF
Sperm
Selecting Embryos
Morphological Grading
Chromosomally Normal (PGS)
Genetically Healthy (PGD) if called-for
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We can’t tell if an embryo is
genetically normal without a biopsy!
excellent good average poor
44% 57%61% 71%
956 blasts with CCS results (mean MA=37.8)Capalbo et al. Hum Reprod 2014
-------------------- aneuploidy rate --------------------
Maternal age & chromosome abnormalities in embryos
Data from >15,000 embryosFranasiak et al. Fert Ster 2013
Comprehensive Chromosome Screening (CCS) with Next Generation Sequencing (NGS)
• Removal of 5-10 trophectoderm cells
• Next Generation Sequencing
• Detects embryos with abnormal number of chromosomes
– Increase implantation rates/transfer
– Decrease miscarriage rates
– Identify abnormal fetus (e.g. Down Syndrome)
Can minimize surrogate cycles
Egg
Donor <35 35-37 38-40 41-42Normal
Embryo Rate*61% 51% 43% 30% 18%
National Ave
Success Rate**40% 45% 40% 35% 30%
ORM
CCS-tested
Success Rates
75% 64% 73% 68% 63%
Rate of Chromosomally Normal Embryos and Impact of CCS (PGS) Testing
* Combined data from Reprogenetics and Genesis Genetics up to March 2016 – 33,236 embryos tested** 2015 data as reported on the CDC website
Success Rates – Sources for US Clinics
• Two public sources for data on US IVF clinics – same dataset but presented slightly differently
• All US clinics required to report to the CDC – only SART members (ca. 95% of US clinics) report to SART
• Timelag in reporting – 2015 data now available
• Live Birth Rate per Transfer and Number of Embryos per Transfer
www.cdc.gov/art www.sart.org www.fertilitysuccessrates.com
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