Gestational Carrier Pregnancies Research Articles

Gestational Carrier Pregnancies: Legal and Ethical Considerations for Pediatricians.

This case explores the legal and ethical considerations for pediatricians surrounding gestational carrier pregnancies in the United States. Because of high success rates for assisted reproduction, state laws supporting same-sex adoption and surrogacy, and established legal precedents, gestational carrier pregnancies are increasingly common. The case presented involves a gestational carrier in preterm labor at 30 weeks' gestation with malpositioned twins who declines a cesarean delivery. Three commentaries are presented. The first highlights the importance of understanding the ethical implications of gestational carrier pregnancies in prenatal counseling. The second commentary emphasizes the pregnant person's right to autonomy and bodily integrity, and discusses considerations in surrogacy pregnancies, including the authority to authorize a cesarean delivery, valid informed consent, and decision-making for neonates. The third commentary discusses autonomy, emphasizing the importance of contracts in surrogacy pregnancies, and suggests that, in the case of a conflict between the gestational carrier and the intended parent(s), the gestational carrier's preference should be decisive regarding medical care during pregnancy. These discussions highlight key concepts for ethically informed and family-centered care in gestational carrier pregnancies and deliveries.

Genetic counseling decisions in gestational carrier pregnancies.

Pregnancies conceived as contracted gestational carriers are a relatively new phenomenon for reproductive medicine. Since the intended parents control genetic screening decisions, there may be differences in genetic decisions made for gestational carrier (GC) in vitro fertilization (IVF) pregnancies as compared to traditional non-gestational carrier IVF pregnancies. Our goal was to investigate the frequency and types of these genetic testing decisions. We performed a retrospective study of GC pregnancies counseled at a private maternal-fetal medicine practice between January 2006 and January 2021. Inclusion criteria were pregnancies thatcompleted counseling with a certified genetic counselor and obtained high-resolution imaging. Controls were non-GC IVF pregnancies seen in the same period matched by parity, estimated delivery date (EDD), and the oocyte age utilized in conception. Statistical analysis included patient demographics, pre-implantation genetic testing (PGT-A) frequency and results, ultrasound imaging results, and the frequency with results of prenatal genetic screening (first or second-trimester serum screens), non-invasive prenatal testing (NIPT), or diagnostic testing (chorionic venous sampling (CVS) or amniocentesis). One hundred and ninety onegestational carrier pregnancies were identified and 167 met inclusion criteria. Gestational carrier pregnancies were significantly more likely to pursue PGT-A, PGT-A with NIPT, first-trimester screening, and second-trimester screening. There were no differences in rates of amniocentesis or CVS over controls. Regarding genetic counseling and screening options, our series is the first to demonstrate that gestational carrier parents seek additional genetic counseling resources, even with reassuring PGT-A and ultrasound.

Examining pre-term birth and cesarean section rates in gestational carrier pregnancies.

This study sought to report on the route and gestational age at delivery of gestational carrier (GC) pregnancies with respect to the GCs' prior obstetric history. A retrospective analysis of all GC pregnancies from one of the largest surrogacy agencies in California between 2008 and 2018 was performed. Available demographic data and obstetric history, including a history of prior cesarean section (CS) and preterm birth (PTB), were collected for each GC and correlated to outcomes of the index GC pregnancy. Primary outcomes for the index GC pregnancies included delivery route and gestational age at delivery. Eight-hundred-thirty-six GCs were included in our analysis. 319 (38.2%) delivered via CS, and 517 (61.8%) delivered vaginally. 60 (18.8%) of the CS deliveries were due to multifetal gestation. Primary CS rate in singleton GC pregnancies was 38.5%. In women without a history of CS, neither age, BMI, interpregnancy interval, prior parity, nor year of delivery impacted the primary singleton CS rate (all, P > 0.05). Of GCs with a history of a prior CS (n = 350, 41.9%), 218 (62.3%) had a vaginal delivery after CS (VBAC) and 132 (37.7%) had a repeat CS. Women who had successful VBACs were significantly younger than those who had repeat CS (mean 33.7 vs. 35.2years, P = .003). BMI was lower in patients who had a VBAC compared to those that had a repeat CS (mean BMI 24.6 vs. 25.5, P = 0.074), although this did not reach statistical significance. In GCs with a history of CS, interpregnancy interval, year of delivery, prior parity, and multiple gestation in the index GC pregnancy did not impact mode of delivery. VBAC rates did not change over the study period (P = 0.757). Overall PTB rate was 15.1%. Most PTB in GC pregnancies were in those with a history of PTB, and PTB was more likely in singletons rather than multifetal gestations (76.7% in singletons vs. 30% in multiples) in patients with history of PTB (P < 0.001). Those with no history of PTB and who carried multiples had a low rate of PTB; in fact, in this group, only 1 out of 35 patients had a PTB with multiples. Both primary CS and PTB rates in singleton GC pregnancies are higher than national averages. CS rates are independent of age, BMI, and interpregnancy interval. In GCs with a history of a CS, VBAC rates well exceed national averages and are higher in younger GCs with a lower BMI. PTB rates are impacted primarily by the GCs obstetric history. In those GCs without a history of PTB, rates of PTB are low, even in those with a multifetal gestation.

Association of multifetal gestation with obstetric and neonatal outcomes in gestational carrier pregnancies.

Multifetal gestation is more frequent among gestational carrier pregnancies than non-surrogacy IVF pregnancies. We aimed to evaluate the association between multifetal gestation and obstetric and neonatal morbidity among gestational carrier pregnancies. Pooled cross-sectional study of birth certificate data from gestational carrier pregnancies in Utah from 2009 to 2018. Our primary outcome was a composite of severe obstetric morbidity; secondary outcomes included cesarean delivery (CD), hypertensive disorders of pregnancy, preterm birth (PTB), and a neonatal morbidity composite. Logistic regression was utilized to compare odds of these outcomes between gestational carrier pregnancies with and without multifetal gestation. A total of 361 gestational carrier pregnancies resulted in the delivery of 435 neonates during the study period. Of these, 284 were singleton pregnancies, and 77 were multifetal, a multifetal gestation rate of 21.3%. Baseline demographic characteristics did not differ between singleton and multifetal gestations. Multifetal gestation was not associated with higher rates of severe obstetric morbidity (odds ratio [OR] 1.87, 95% confidence interval [CI] 0.34-10.39). Multifetal gestation was associated with increased odds of neonatal morbidity (OR 9.49, 95% CI 5.35-15.83); PTB < 37, 34, and 32weeks (OR 21.88, 95% CI 11.64-41.12; OR 11.67, 95% CI 5.25-25.91; OR 8.79, 95% CI 3.41-22.68); and CD (OR 4.82, 95% CI 2.81-8.27). Severe obstetric morbidity did not differ between singleton and multifetal gestations among gestational carrier pregnancies. However, multifetal gestation was associated with increased odds of neonatal morbidity, CD, and PTB. This information may be useful when counseling prospective gestational carriers and intended parents.

Obstetric morbidity in gestational carrier pregnancies: a population-based study.

We sought to characterize severe obstetric morbidity among women who are gestational carriers compared to other patients. This was a population-based study comparing gestational carrier pregnancies to non-surrogate pregnancies (non-surrogate IVF pregnancies, all non-gestational carrier pregnancies, and a cohort of matched controls) delivering in Utah between 2009 and 2018, using birth certificate data. Our primary outcome was a composite of severe morbidity, including death, ICU admission, eclampsia, HELLP syndrome, transfusion, and unplanned hysterectomy. Our secondary outcomes were cesarean delivery (CD) and hypertensive disorders of pregnancy. During the study period, 361 gestational carrier pregnancies and 509,015 other pregnancies resulted in live births. Severe morbidity was less common among gestational carrier pregnancies than IVF pregnancies (1.7% versus 5.5%, odds ratio [OR] 0.29, 95% confidence interval [CI] 0.12-0.70), but was not different when compared to all other pregnancies (1.0%, OR 1.61, 95% CI 0.72-3.60), or a cohort of matched controls (1.0%, OR 1.37, 95% CI 0.55-3.40). CD was less common among gestational carrier pregnancies than IVF pregnancies, but not different than all other pregnancies or matched controls. While frequency of hypertensive disorders of pregnancy was lower among gestational carrier pregnancies than IVF pregnancies, it was higher than all other women who delivered and comparable to matched controls. Severe obstetric morbidity is uncommon among gestational carrier pregnancies. Women who are gestational carriers are at lower risk of morbidity and CD than others who conceive through IVF and do not appear to be at increased risk compared to matched controls.

How Far Will They Go: A Look at Reproductive-Related Travel

For gestational carrier pregnancies, intended parents' contract with a surrogate to carry a pregnancy created with assisted reproductive technology

Reproductive Travel of Intended Parents for Delivery of Gestational Carrier Pregnancies.

To explore the role of reproductive travel (travel to another state or country for reproductive services) for intended parents at the time of delivery of gestational carrier pregnancies and to analyze the sociodemographic characteristics of those who build families through gestational surrogacy. We conducted a cross-sectional study of births involving gestational surrogacy in Utah from 2009 to 2018. Data were obtained from birth certificates. State and country of residence were collected for intended parents, and the legal climates of these locations were assessed by reviewing laws at the time. Sociodemographic characteristics were compared among intended parents, parents with pregnancies resulting from assisted reproductive technology (ART) without gestational surrogacy, and parents with spontaneous pregnancies. A total of 361 gestational carrier pregnancies resulted in the birth of at least one liveborn neonate during the study period, involving 715 intended parents. Additionally, 50,434 parents delivered children after nonsurrogacy ART, and 950,460 parents delivered children after spontaneous fertilization. Many intended parents (17.2%) lived in countries outside of the United States, the majority of which (69.9%) had laws against surrogacy. Of those who lived within the United States, 57.4% lived outside of Utah, but only 15.9% lived in states that banned compensated surrogacy. Statutes in Utah support compensated and uncompensated gestational surrogacy. Intended parents were significantly older than parents with both nonsurrogacy ART pregnancies and spontaneous pregnancies (median age 38, 31, and 29 years, respectively) and had higher levels of education; 70.2% of intended parents had a bachelor's degree or above, compared with 48.2% of parents with nonsurrogacy ART pregnancies and 33.1% of parents with spontaneous pregnancies. A majority of intended parents live outside of Utah, which may be an important consideration for health care professionals caring for women with gestational carrier pregnancies. However, most intended parents live in places that do not have laws banning surrogacy, suggesting that there may be other reasons that intended parents travel for delivery.

Association of Obstetric and Neonatal Outcomes With Deviation From Guidelines for Gestational Carriers.

To evaluate whether deviation from American Society for Reproductive Medicine (ASRM) safety guidelines for women who are gestational carriers is associated with increased risk of severe obstetric and perinatal morbidity and mortality. This is a cross-sectional study of births from gestational carrier pregnancies in Utah from 2009 to 2018 with data collected from birth certificates. Deviations from ASRM guidelines include women aged younger than 21 years or older than 45 years, nulliparity, prior stillbirth, tobacco or percutaneous drug use, more than five prior deliveries, more than three prior cesarean deliveries, major comorbidities, and mental health conditions. The primary outcome was a composite of severe obstetric morbidity and mortality (death within 1 year of delivery; intensive care unit admission; eclampsia; hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome; transfusion; unplanned hysterectomy). Secondary outcomes were cesarean delivery, gestational diabetes mellitus, hypertensive disorders of pregnancy, preterm delivery (analyzed per pregnancy), and a composite neonatal outcome. Associations were analyzed using descriptive statistics and multivariable logistic regression. A total of 361 gestational carrier deliveries of 435 neonates were included in this analysis. Sixteen percent (58/361) of pregnancies did not meet guidelines. Rates of severe obstetric morbidity or mortality did not differ between gestational carrier pregnancies that deviated from guidelines and those that did not (1.7% for both, odds ratio [OR] 1.04, 95% CI 0.12-9.12). Rate of cesarean delivery was higher among pregnancies that deviated from guidelines (36.2% vs 23.4%, OR 1.85, 95% CI 1.02-3.37). Rates of gestational diabetes mellitus and hypertensive disorders of pregnancy did not differ. Preterm delivery was also more common among pregnancies that deviated from guidelines, particularly after controlling for multifetal gestation (36.2% vs 23.4%, adjusted OR 2.16, 95% CI 1.04-4.48). Neonatal complications were significantly more common in pregnancies that did not meet guidelines, even after adjusting for gestational age and multifetal gestation (adjusted OR 3.66, 95% CI 1.44-9.29). Nearly one in five gestational carrier pregnancies in this cohort did not meet ASRM guidelines. Deviation from guidelines is associated with increased rate of cesarean delivery, neonatal morbidity, and preterm birth. Future research should focus on the safety of women who are gestational carriers and on why deviation occurs.

Decreasing rates of multiple gestation and number of embryos transferred in gestational carrier pregnancies: a longitudinal analysis

The recent national push towards elective single embryo transfer (eSET) has decreased rates of multiple gestations. However, how this translates to gestational carrier (GC) pregnancies has not been well established.1 We sought to evaluate the number of embryos transferred (ET) and the incidence of multiple gestations in GC pregnancies as well as if these metrics have changed over time. A retrospective analysis of all GC deliveries from a single agency between 2008-2019. Data from a large agency that consisted of matched GCs and intended parent (IP) couples for an index GC pregnancy were reviewed. GCs were excluded if the number ET or number delivered were not reported. Data collected for analysis included number ET, number delivered for the index GC pregnancy as well as a history of surrogacy or multiple gestations for each GC. All variables were analyzed using unpaired student’s t-test and Pearson’s correlation for continuous variables where appropriate and chi-squared for dichotomous variables. Of 836 GC pregnancies, 187 (22.4%) were multiple gestations, consisting of 183 (21.9% of all pregnancies) twins, 3 (0.4%) triplets, and 1 (0.1%) quadruplet pregnancy. 116 (13.9%) GCs overall had a history of a multiple gestation prior to the current GC pregnancy, of which 53.6% were due to another prior GC pregnancy. There was a similar rate of multiple gestation in the index GC pregnancy when comparing GCs with a history of prior singleton vs multiple gestations (P = 0.882). There was also no difference between first-time or repeat surrogates in likelihood of having a multiple gestation (P=0.435). In terms of number of ET, 422 GCs (61.7%) had 2 or more ET, and 14 (1.7%) had four or more. Number of ET was positively correlated with number of infants delivered in the GC pregnancy (r=0.207, P<0.001). Number of ET declined significantly over the study period; in 2008-2010, 89% of GCs had ≥2 ET compared to 30.6% in 2017-2019 (P<0.001). This paralleled a declining incidence of multiple gestations (29.4% in 2008-2010 vs. 11.5% in 2017-2019, P<0.001). Neither women with a history of twins nor repeat surrogates were more likely to have two or more ET (both, P>0.05). In line with trends in autologous transfers, the number of ET and incidence of multiple gestation is declining in GC pregnancies. A GC’s prior obstetric history, specifically a history of multiples or history of surrogacy, does not impact the number of ET or incidence of multiple gestation in the index GC pregnancy. To minimize obstetrical risks to GCs and maximize healthy singleton deliveries for IPs, eSET in appropriate candidates should be encouraged.

Incidence of pre-term birth (PTB), low birth weight (LBW), very low birth weight (VLBW), and macrosomia in gestational carrier (GC) pregnancies

Incidence of pre-term birth (PTB), low birth weight (LBW), very low birth weight (VLBW), and macrosomia in gestational carrier (GC) pregnancies

Mode of delivery in gestational carrier (GC) pregnancies in women with and without a history of cesarean section (CS)

Mode of delivery in gestational carrier (GC) pregnancies in women with and without a history of cesarean section (CS)

Can birth weight and gestational age at delivery of singleton gestational carrier pregnancies be predicted by the gestational carrier’s own previous singleton pregnancies?

Gestational carriers (GC) represent a unique population in which to study the effect of assisted reproductive technology on obstetric outcomes, as they are not infertile and have usually had favorable obstetric outcomes in the past. In GC pregnancies, important questions remain regarding how perinatal outcomes are differentially impacted by the genetic parents versus the GC. This study sought to compare birth weight and gestational age at delivery between a GC’s prior own pregnancies versus the current GC pregnancy. A retrospective analysis of all GC singleton deliveries from a single agency between 2008-2019. Data from a large surrogate agency that consisted of matched GCs and intended parent couples for an index GC pregnancy were reviewed. GCs with a history of or current multiple gestation as well as with a history of or current preterm delivery were excluded. All available birth weights of the GCs own children as well as the gestational age at delivery for the GC’s last own birth were collected. Both average birth weight and last singleton birth weight of the GC’s prior own deliveries were correlated to the birth weight of the index GC pregnancy. Gestational age at delivery of the GC’s last own delivery was compared to the gestational age at delivery for the index GC pregnancy. Of 836 GCs, 101 were eligible for inclusion in this study. Average age of GCs at time of delivery was 34.9 years (SD 4.4) and their average BMI was 24.3 (SD 3.13). 93 GCs (76.9%) had a prior parity of ≥3, and 27 (22.3%) had grand multiparity (≥5). The average birth weight of all GC’s prior spontaneously conceived singletons was 7.83 lbs (SD 3.01) and 7.68 lbs (SD 1.01) for the GC’s most recent own singleton delivery. Average BW of index GC pregnancies was 7.62 pounds (SD 1.05). While average birth weight of all the GC’s prior singleton children was not correlated with the birth weight of the index GC pregnancy (r=0.051, P = 0.623), the birth weight of the GC’s most recent own singleton birth was significantly correlated with the birth weight of the index GC pregnancy (r=0.298, P = 0.003). Birth weight of the index GC pregnancy was not correlated with GC BMI (r = 0.083, P = 0.423). Mean gestational age at delivery was similar between the GC’s last own singleton delivery and the index GC pregnancies (mean 39.1 (SD 0.993) vs. 39.1 (SD=0.983), P<0.001). Gestational age at delivery of the GC’s last own singleton pregnancy was also significantly associated with the gestational age at delivery for the index GC pregnancy (P<0.001). While birth weight and gestational age at delivery are likely multifactorial and impacted by both genetic and environmental factors, we found that in singleton GC pregnancies birth weight and gestational age are correlated with birth weight and gestational age of a GC’s last own delivery.This data is of value when counseling both intended parents and evaluating candidacy for potential surrogacy.

Screening of gestational carriers in the United States

To assess medical and psychosocial screening and evaluation received by gestational carriers and compare those using agencies to those not using agencies. Cross-sectional questionnaire. Not applicable. A total of 204 women who completed a survey on their experiences as gestational carriers in the United States. None. Self-reported screening received before gestational carrier pregnancies. Overall, 97.1% of gestational carriers had a complete medical evaluation and 94.6% had an evaluation or counseling by a mental health professional. Most participants indicated that they had been informed of at least some medical risks (92.6%) and psychological considerations (89.7%). Participants most often recalled being informed of the risks of multiple pregnancy (89.2%) and medical procedures and medications (87.2%), but least often recalled being informed about the risks of impact on their own employment (46.6%) and to their own children (61.3%). There were no differences in outcome measures between those using an agency and those who did not. Self-reported screening and evaluation was high, but still not 100% on all measures. Further education of providers regarding guidelines for the screening and evaluation of gestational carriers may be needed.

Obstetrical complications in gestational carrier pregnancies

To report two cases of severe obstetrical complications in gestational carrier pregnancies and to review our clinical experience and compare our results with those reported in the literature. Retrospective analysis. A university IVF program. Women without a functioning uterus or those whose pregnancy would exacerbate a medical condition were enrolled in the gestational carrier pregnancy program. IVF cycles using oocytes from genetic mothers (or oocyte donors) were performed, with ET to gestational carriers. Clinical pregnancy rates, obstetrical complications, and neonatal outcomes. Ten couples underwent a total of 13 cycles using gestational carriers. A clinical pregnancy rate of 69% (9/13) was achieved. An intrapartum hysterectomy and a late puerperal hysterectomy were required because of severe obstetrical complications. The late puerperal hysterectomy was performed for placenta accreta in a triplet gestation. This carrier sustained multiple cerebral infarcts and blindness. One triplet infant died secondary to a hypoplastic left ventricle and complications of prematurity. A second gestational carrier with a singleton gestation underwent a hysterectomy for a uterine rupture, and the infant has cerebral palsy. The past medical and obstetrical histories of potential gestational carriers must be closely scrutinized, and candidates must be thoroughly counseled about the potential risks involved in the procedure.

Obstetrical and perinatal complications in gestational carrier pregnancies

Obstetrical and perinatal complications in gestational carrier pregnancies

Obstetrical and perinatal complications in gestational carrier pregnancies

Obstetrical and perinatal complications in gestational carrier pregnancies