In vitro fertilization surrogacy requires the transfer of embryos most often transcervically during an optimal window for implantation. Previous good studies from the Norfolk Virginia In Vitro Fertilization Program have shown excellent pregnancy rates during transfers on luteal day 17 through 19 of a replaced medicated cycle (day 15 being the first day of progesterone treatment).

Fresh cycles almost always have an advantage over frozen cycles in most in vitro fertilization programs. During a fresh in vitro fertilization surrogacy cycle, the surest way to coordinate the donor and surrogate cycles is to medicate the surrogate. Medication of the surrogate has some minuses, obviously. For the medicated cycle there are hassles and discomfort particularly involving the injections of the different medications. The chief advantage of the medicated cycle is almost always(greater than 95%) being able to achieve a fresh embryo transfer.

Typical medications used to medicate the surrogate include daily GnRH agonists,typically Lupron 0.5 mg. subcutaneously daily starting in the preceding mid-luteal phase. The Lupron is then continued on a daily basis until progesterone is started, which typically is on the day the donor has the oocytes extracted or, occasionally, on the preceding day. Estrogen is administered either orally in the form of oral estradiol valerate or micronized estradiol, by transdermal estradiol patches or by injections of estradiol valerate. Estrogen can be administered at a constant dose or at increasing doses to try to more closely mimic the normal cycle, but there is no substantial evidence that one approach has great advantages over the other. Estrogen can maintain the endometrium for 1-2 weeks until such time as the oocyte donor is ready. Estrogen then is continued at a slightly reduced dose along with progesterone.

Progesterone is administered as progesterone in oil given intramuscularly, or progesterone suppositories or progesterone capsules, both given vaginally. The embryo transfer is typically carried out on the third, fourth or fifth day of progesterone therapy.

Estrogen and progesterone then need to be continued for approximately eight weeks following the transfer. In our program, we use Lupron .5 mg.subcutaneously starting in the mid-luteal phase. Our preferential estrogen is micronized estradiol which is given starting in 2-4 mg. doses on a daily basis, increasing typically to the 6 or 8 mg. daily dose and then decreasing typically to 6 mg. in the luteal phase.

Progesterone in oil 50 mg. daily is started on the day of the oocyte aspiration along with micronized progesterone per vagina 400 mg. twice a day.

Embryo transfer is carried out on the third or fourth day of progesterone therapy. Using the above protocol, our success rate for in vitro fertilization surrogacy has been approximately 50% delivered pregnancy per transfer in the fresh cycle.

An optional approach in surrogates who wish no or minimal supplemental medication would be to try to align the surrogate cycle with the donors so that the surrogate's mid-cycle surge occurs on the day following the donor receiving her mid-cycle HCG injection. If the surge occurs that day or on the preceding or following day, then the fresh transfer can successfully occur. If the surge occurs outside that time interval, then all embryos can be frozen for use in a subsequent cycle.

For a frozen embryo transfer cycle in a normal cycling woman under the age of forty, an unmedicated or minimally medicated cycle can be used.

In our program, in a frozen embryo transfer cycle we do the embryo transfer three days following a spontaneous LH mid-cycle surge. We also use supplemental vaginal progesterone capsules 200 mg. twice daily starting the day before the transfer. Using this approach we have had approximately a 30% delivered pregnancy rate with frozen embryo transfers. If a satisfactory endometrium is not obtained with the nonmedicated or minimally medicated cycle, a medicated cycle is used.

In summary, with in vitro fertilization gestational surrogacy in the fresh transfer cycle, we have achieved a 50% delivered pregnancy rate with full medicated cycles for the surrogates. In frozen embryo transfer cycles we have achieved a 30% delivered pregnancy rate with essentially unmedicated cycles for the surrogates.

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