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