|Year : 2017 | Volume
| Issue : 1 | Page : 19-22
A successful gestational surrogacy in Southeast Nigeria
Joseph Ifeanyichukwu Ikechebelu1, Kennedy Ibadin2, Ngozi Nneka Joe-Ikechebelu3, Louis Anayo Nwajiaku4, Kester Nwaefulu5, Somadina I Okwelogu5
1 Life Fertility Centre, Life Specialist Hospital Limited; Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University, Nnewi, Nigeria
2 Department of Obstetrics and Gynaecology, Assisted Reproductive Unit, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
3 Department of Community Medicine, Chukwuemeka Odumegwu Ojukwu University, Awka, Anambra State, Nigeria
4 Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University, Nnewi, Nigeria
5 Life Fertility Centre, Life Specialist Hospital Limited, Nnamdi Azikiwe University, Nnewi, Nigeria
|Date of Web Publication||10-Sep-2018|
Joseph Ifeanyichukwu Ikechebelu
Department of Obstetrics and Gynecology, Nnamdi Azikiwe University, Nnewi, Anambra Sate
Source of Support: None, Conflict of Interest: None
Infertility is a major public health problem and imposes major physical and psychological burden to couples as well as to their relatives. Infertility due to the absence of uterus can be difficult to manage and could even be more challenging in our environment where couples insist on having children with their own genetic component. We present a case of a 35-year-old married graduate trader with primary infertility of 7-year duration due to Mullerian dysgenesis. She had a successful surrogacy.
Keywords: Absent uterus, infertility, in vitro fertilization, Mullerian dysgenesis, surrogacy
|How to cite this article:|
Ikechebelu JI, Ibadin K, Joe-Ikechebelu NN, Nwajiaku LA, Nwaefulu K, Okwelogu SI. A successful gestational surrogacy in Southeast Nigeria. Afr J Infertil Assist Concept 2017;2:19-22
|How to cite this URL:|
Ikechebelu JI, Ibadin K, Joe-Ikechebelu NN, Nwajiaku LA, Nwaefulu K, Okwelogu SI. A successful gestational surrogacy in Southeast Nigeria. Afr J Infertil Assist Concept [serial online] 2017 [cited 2018 Dec 11];2:19-22. Available from: http://www.afrijiac.org/text.asp?2017/2/1/19/241009
| Introduction|| |
Infertility is a major public health problem and imposes major physical and psychological burden to couples as well as to their relatives., Among the various causes of infertility, the cause due to the absence of uterus can be difficult to manage and could even be more challenging in our environment where couples insist on having children with their own genetic component. A childless marriage is sometimes termed a failed marriage due to high premium placed on childbearing. In Nigeria, adoption has low acceptability rate, and there is still no uniform law on adoption in different states of the country. Gestational surrogacy is a treatment option available to women with certain clearly defined medical problems, usually an absent or damaged uterus, to help them have their own genetic children. There are still relatively few publications in the literature of experience with gestational surrogacy; the majority of them come from the developed countries. Surrogacy raises a lot of potential legal, medical, moral, and socioeconomic issues, particularly in Nigeria where guidelines for it barely exist. Even in developed countries, controversies still exist such as noted in 1986 in the popular Baby M issue, in which the surrogate refused to cede the baby to the commissioning couple.
Here, we report a successful case of surrogacy and think that this is not only relevant in our environment due to the very limited reported cases but also knowing that this offers medical practitioners a boost to help patients with similar conditions, particularly in Nigeria. Again, this report further strengthens the call on the need to fix the existing gap in the area of regulations/laws on surrogacy in Nigeria.
| Case Report|| |
A 35-year-old married graduate trader and nulliparous woman referred for surrogacy. She was referred from a private hospital for in vitro fertilization (IVF) and embryo transfer (ET) with surrogacy. She had a history of inability to achieve pregnancy of 7 years despite frequent unprotected sexual exposure and with a background history of absence of menstruation since birth. She had laparotomy in June 2013 at one of the teaching hospitals following a diagnosis of primary amenorrhea due to Mullerian dysgenesis to remove the rudimentary uterus which was not continuous with the vagina.
About 3 months before the presentation, she was seen at the referring private hospital where fertility evaluation for the couple revealed normal male factor and functional ovaries but absent uterus. She was then recommended for surrogacy. She then presented to Life Fertility Centre with a referral for surrogate IVF treatment. The findings on physical examination were essentially normal, but body mass index (BMI) was 31.1 kg/m 2. A transvaginal scan (TVS) confirmed the absent uterus and showed active ovaries.
The patient was counseled accordingly (diagnosis, cost implication of the IVF procedure, compliance with management protocol, and possible outcome), and informed consent was obtained for IVF surrogacy using her own eggs. The couple and undisclosed surrogate mother were worked up for the procedure. Investigations requested for the commissioning female included hormone assay: estradiol – 32.79 pg/ml (18–147), progesterone – 0.34 ng/ml (0.25–54), follicle-stimulating hormone (FSH) – 4.25 mIU/ml (3.9–12), luteinizing hormone (LH) – 2.39 mIU/ml (1.5–8), prolactin – 16.53 ng/ml (5–35.0); urinalysis was normal; chlamydial screening was negative; blood Group is O Rh D positive; HIV I and II test was negative; hepatitis B virus surface antigen (HBsAg) and hepatitis C virus (HCV) were negative; venereal disease research laboratory (VDRL) was nonreactive and liver function test was normal.
For the partner: Seminal fluid analysis showed total sperm count – 35 × 106/ml; motility – 57.1% progressive; hormone assay, FSH – 3.7 mIU/ml (1.7–12.0), LH – 3.34 mIU/ml (1.1–7), prolactin – 44.02 ng/ml (3.0–25), and testosterone – 6.65 ng/ml (9.3–10.6); blood group – O Rh D positive; hemoglobin genotype – AA; HIV I and II – negative; chlamydial screening – negative; HBsAg – negative; HCV – negative; and VDRL – nonreactive.
Long protocol for ovarian stimulation was used for the woman, and downregulation was commenced with subcutaneous goserelin (Zoladex ®, AstraZeneca) 3.6 mg some days after her ovulation (determined via a TVS). An assessment of good downregulation was made 2 weeks later, with TVS showing normal ovaries with good residual follicles. The woman was included in the batch of IVF clients for the commencement of ovarian stimulation a week later. Ovarian stimulation was commenced with subcutaneous human menopausal gonadotropin (Diclair ®-HP-HMG by BBC Biotech GMBH Germany) 300 mg daily for 10 days. She was evaluated with a TVS on day 6 of stimulation, and she had an average of 5 follicles in each ovary measuring 9–12 mm in diameter. An assessment of good response to ovarian stimulation was made, and the dose of HMG was decreased to 150 mg daily. The next TVS review was on day 11 of ovarian stimulation, with right ovary having about eight follicles approximately 17–20 mm and left ovary having about six follicles approximately 15–19 mm. These were mature follicles, and ovulation trigger was given as subcutaneous human chorionic gonadotropin (HCG) 10,000 IU. Oocyte retrieval (OCR) was performed 36 h after under sedation and a total of six eggs were retrieved. The procedure was well tolerated. Three days post-OCR, four embryos (cleaved) were transferred successfully to the surrogate mother. The woman was subsequently commenced on lactation induction at 26 weeks of the surrogate gestation, with oral Progynova 4 mg tds for 3 months and intramuscular Primolut Depot 250 mg weekly for 3 months.
The surrogate was a 28-year-old para 1 woman, referred for evaluation as a surrogate mother. She had attained menarche at 14 years of age and had a regular 4-day flow in a 28-day cycle. Her last menstrual period was 20 days before the presentation. She had agreed to the terms of surrogacy with the referring agency. She was doing it to help herself financially as well as to help her fellow woman to fulfill her reproductive desire. She is not a known hypertensive or diabetic and has not had any surgery in the past or blood transfusion. She takes alcohol occasionally, but does not take tobacco in any form. She had a normal delivery to her first child 3 years ago.
General examination were essentially normal – BMI = 22.34 kg/m 2. Chest and abdominal findings were normal. Vaginal examination showed healthy looking cervix, normal-sized anteverted uterus, mobile, nontender, and no adnexal mass/tenderness. The pouch of Douglas was free. Other systems were essentially normal. An impression of a normal primipara was made.
The surrogate was counseled accordingly and informed consent was obtained for surrogacy. TVS performed showed a normal-sized anteverted uterus, endometrium thickness of 9.4 mm, and normal ovaries. An assessment of normal pelvic organs postovulation was made. Other investigations done were as follows: urinalysis = normal, packed cell volume (PCV) = 0.33%, blood group = A Rh D positive, hemoglobin genotype = AA, HIV I and II test = negative, VDRL test = nonreactive, HBsAg = nonreactive, HCV Ab test = nonreactive, HVS and culture were normal.
Downregulation was commenced with subcutaneous buserelin 0.5 mg daily. She was also placed on folic acid tablets 5 mg daily and low-dose aspirin tablets 75 mg daily for 4 weeks. On the next review on day 28 of downregulation, she had achieved good downregulation (endometrial thickness = 1.4 mm). Endometrial preparation for ET was commenced on the day the commissioning mother was started on ovarian stimulation with the following: Progynova tablets 4 mg tds and prednisolone tablets 5 mg daily all for 2 weeks. Cyclogest suppository 800 mg at night from the day of HCG trigger was administered to the commissioning mother.
On the day of OCR, she was reevaluated with a TVS, which showed endometrial thickness of 5.93 mm. She subsequently had a day-3 ET, and the procedure was well tolerated. The number of embryos transferred was 4. She was continued on the Progynova tablets, cyclogest suppository, folic acid, and Vasoprin tablets at the same dose. Salbutamol tablets 4 mg bd was added for 2 weeks.
On day-14 post-ET, pregnancy test done was positive (chemical pregnancy); she was continued on the already prescribed drugs.
On day-29 post-ET, TVS done showed a single viable gestational sac at 5 weeks of gestational age (GA), giving an expected date of delivery of April 15, 2015 (clinical pregnancy). She was counseled to continue on all her medications till 14 weeks and to book early for antenatal care (ANC).
She subsequently booked for ANC in our facility at 8 weeks of GA and booking parameters and investigations results were: weight = 63 kg, height = 1.66 m, blood pressure = 120/70 mmHg, urinalysis – negative for protein and glucose, PCV = 0.33%, and blood group = A Rh D positive.
She was counseled on elective cesarean section (CS) at 38 weeks and was subsequently seen 2 weekly. Pregnancy remained uneventful, and at 36 weeks, an obstetric ultrasound done showed a singleton fetus in longitudinal lie, cephalic presentation with fetal heart rate of 144 bpm, posterofundal placenta, and adequate liquor volume. At 37 weeks, she was admitted for observation and preparation for the elective CS. A live female baby that weighed 2.5 kg with good Apgar score was delivered. The baby was taken to her biological mother in good condition. The immediate postoperative period was uneventful. The surrogate mother was subsequently discharged home on day 5 postoperative in good condition.
| Discussion|| |
Surrogacy has historically been in practice from the Biblical times [Genesis 16:1–15], when probably traditional surrogacy was practiced using the natural way. However, modern assisted reproductive techniques have provided advances and more refined practice. There are two forms of surrogacy: traditional, also referred to as natural or partial surrogacy and gestational surrogacy, also referred to as IVF or full surrogacy. Our patient had gestational surrogacy. A surrogate, surrogate mother, or surrogate host is the woman who carries the baby and later delivers the baby on behalf of the commissioning couple or partners. The commissioning couple or partners are the individuals who provided the gametes for the surrogate. Pregnancy can be achieved in the surrogate through various means. In traditional or partial surrogacy, the semen of the commissioning couple is used to inseminate the surrogate mother. The resulting offspring have genetic makeup from the surrogate and the commissioning male. This is more refined and socially more acceptable than the use of a natural way. In gestational or IVF surrogacy, the embryo created from the sole gametes of the commissioning couple is transferred to the surrogate who carries the fetus to delivery. The genetic makeup of the resulting offspring is not contributed by the surrogate, but is specifically that of the commissioning couple or partners. This method allows the couple who need a child with their genetic constitution to have their way. Nonetheless, this carries a higher cost and more rigors.
The following are known indications for gestational surrogacy: congenital absence of the uterus, repeated failure of IVF, and removal of uterus in cancer surgery, postpartum hemorrhage or for other reasons, recurrent abortion, and severe medical conditions that may be complicated or complicate pregnancy. The main indications for the treatment by gestational surrogacy are clear: women with congenital absence of uterus and women who have had a hysterectomy for carcinoma or hemorrhage, but who still have functioning ovaries. Unlike posthysterectomy patients, young women with Rokitansky–Kuster–Hauser syndrome usually respond to ovarian follicular stimulation remarkably well. Its suggested that hysterectomy surgeries may have inadvertently compromised vascular supplies to the ovaries.
Selection and counseling of patients for surrogacy should be meticulous. Patients may sometimes be referred or may present primarily. The selection follows a series of detailed discussions and counseling on the steps, possible complications, and implication of every step. The welfare of the child to be born and the ownership are clearly defined. There are no laid down guidelines in Nigeria and so that of the USA and UK are applied. The host in a gestational surrogacy arrangement may be a member of the commissioning couple's family, a close friend, or the couple may be able to find a suitable host through patient infertility support groups if they exist. The arrangement for surrogacy is only approved after a detailed review and agreement signed. The provision of detailed counseling to all the parties involved in surrogacy arrangements is of paramount importance. It is not the treatment of the parties involved in surrogacy that is complicated, but the preparation of them, with the proper provision of advice: legal and medical, the proper provision of counseling, and the careful selection of a suitable host. Breastfeeding of the baby by the genetic mother can be managed using breast milk induction drugs, stimulating the secretion of milk manually, or use of breast pump in few weeks leading to the child's delivery. Breast milk induction drugs were used in our patient as the risk of disappointment is more with the last two options.
The outcome in terms of pregnancy in gestational surrogacy is usually better than in standard IVF, and live birth rates of 37%–43% per commissioning couple and 34%–39% per host surrogate have been achieved, with a mean of only two embryos transferred. The surrogate mothers are usually healthy and may have delivered one or more children and the genetic mother is commonly a young woman. Our surrogate had delivered a child. Long-term outcome of babies delivered through this means as well as effect and consequences on the surrogate and commissioning couple is still under study although good experience has been reported.,,,, This long-term positive outcome counters negative beliefs that are largely based on the assumptions. Among the reason for participation in surrogacy by surrogates, most common motivating factor was a wish to help couples that would not otherwise be able to conceive or carry a child normally. Other reasons may be in women who enjoy being pregnant and for financial reasons otherwise called commercial surrogacy. The surrogate in our case accepted to do this for financial benefit.
A number of ethical, religious, and medicolegal issues may still arise despite detailed evaluation and counseling. These could sometimes pose a serious problem: concerns by the commissioning couples or the surrogate about the long-term effects of procedure on the child born, controversy about the surrogate changing her mind and insisting on having custody of the child, what will happen to the ownership of the baby when baby is born with an abnormality?, guilt on the part of the surrogate giving out her child, rights of the born child in respect to the customs of the land, and when to disclose to the child about his/her parenthood.
| Conclusion|| |
Gestational surrogacy is a veritable option for the management of infertility in our environment, particularly knowing the high degree of premium placed on childbearing in Africa. The need for legislation guiding the procedure is important as well as government support for the financing since this will save the burden and strain placed on marriages in our environment due to childlessness.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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