Gestational Surrogacy in Nigeria.

Surrogacy is a third-party medically assisted reproduction option that allows couples with medical conditions, uterine factor infertility, and same-sex couples to have genetic children of their own¹.

There are two types of surrogacy arrangements—partial and complete surrogacy.

In partial, also known as traditional surrogacy, sperm from the male client is used to fertilize an egg from a woman who also carries the resultant pregnancy, whereas in total, also known as gestational surrogacy, sperm from the male client is used to fertilize an egg from a woman and the resultant embryo is implanted in a different woman not genetically linked to the embryo^2,3.

The AFRH, ASRM, and ESHRE recognize all the different types of surrogacy arrangements but caution against partial surrogacy due mainly to legal conundrums^2–5. Our center practices only full surrogacy.

Materials and methods

This was a retrospective descriptive study from a single private-owned fertility center.

Data, such as the age of the commissioning parent and age of the surrogate, indication for surrogacy, the outcome of treatment, number of gestations, gestational age at delivery, and presence of complications related to the pregnancy, were extracted from the medical records of commissioning couples and gestational carriers (GCs) between January 1, 2015, to April 30, 2021.

Descriptive data were then analyzed.

Literature review

The practice of surrogacy dates to the bible story of Abraham, Sarah, his wife, and Hagar, who was Sarah’s servant. Since that time, medical and legal practice have refined the terms and conditions under which surrogacy can be practiced in such a way as to protect all parties involved from exploitation^1,6,7.

Surrogacy is not without its risks, both medical and legal. Some of the medical risks to the GCs include miscarriage, ectopic pregnancy, multiple pregnancies, as well as medical complications of pregnancy, such as hypertension and diabetes^3,4,8.

Further studies have shown that there is increasing evidence that single embryo transfers (SETs) rather than multiple embryo transfers will lead to reduced risk of pregnancy-related complications and increased live births^4,8,9.

On the legal front, two landmark cases in the United States have examined partial and complete surrogacy (GC) arrangements, from which laws and rights about surrogacy have emanated and been adopted in different countries. Legislation on surrogacy in different countries ranges from outright ban in places like France and Germany to permissible only if altruistic in Canada, the United Kingdom, and the Netherlands⁷. In Nigeria, where we practice, there is no legislation when writing this report, and the AFRH guidelines guide surrogacy.

A literature review to see how common GC treatments were showed that the Center for Disease Control reported an increase from 1% (727 cases of in vitro fertilization with GC) in 1999 to 2.5% (3432 cases with GC) in 2013¹. In a 10-year review of 2 large military hospitals in the United States of America, there were 36 pregnancies in GCs out of the 249 assisted reproduction conceived pregnancies in that period¹¹.

In the Czech Republic, Rumpik et al. ⁹ reported 130 in vitro fertilization cycles involving GCs between 2004 and 2017, in which they achieved 43.9% pregnancies and 32.3% live births. Attawet et al. ^12, in another study, reported an increase in cumulative birth rates of 23.5% after the first cycle to 50.6% after the sixth cycle.

Results

The program had 58 pregnant GCs (Fig. 1), otherwise known as GCs. The commissioning mothers aged between 30 and 64 years. All pregnant GCs were aged between 25 and 37 years old. The modal indication for surrogacy was the advanced age of the commissioning mother.

Only one GC had a SET, whereas 48 (82.8%) of the gestational surrogates had double embryos transferred. The remaining nine women had 3 embryos transferred, and one of these was successful accounting for the triplets in 2019 (Fig. 2).

USS confirmed pregnancies at 6–7 weeks gestational age. All received care at the center’s affiliated maternity wing. All except one were delivered at the maternity wing.

Forty-seven (81%) of them progressed to delivery of live births, whereas 11 (19%) had a miscarriage. There were 63 live births, out of which were 14 twin pairs (44%) and 1 set of triplets (5%), and the rest (32 babies) were singletons, as shown in Figure 2. There were 33 babies born preterm (52% of live births), including 7 twin pairs and 1 set of triplets; the multiple gestations accounted for 51.5% of the preterm babies. Thirty babies were born at term, putting the incidence of term births at 48%. One (1.7%) GC had delivery complicated by a hysterectomy.

Discussion

Surrogacy is a highly emotive subject in nearly every country where it is practiced. Our clinic has a policy of transferring two embryos, which explains the high incidence of twin deliveries while planning to transition into elective SET soon. This is mainly because our patients pay out of pocket and prefer to complete their family size in one treatment cycle.

The 81% live birth rate from our surrogacy program compared with the cumulative live birth rate of 32.3%⁹ and a peak of 50.6% after the sixth cycle from another study¹² is impressive. It may be accounted for by our current clinic practice for double (2) embryo transfers.

The high rate of preterm delivery at 51% compared with 0.05% in the study by Attawet12 can also be explained by the fact that multiple pregnancies are usually associated with preterm delivery, as well as the unavoidable low birth weight accompanying the gestational age at birth.

As we move towards elective SET in our fertility practice, the incidence of preterm birth and its sequelae will most certainly decline¹³.

A couple of studies^14,15 examining the relationship between gestational surrogates and commissioning parents have reported a largely acrimony-free relationship. As Nigeria also pushes forward to making laws about surrogacy, it is expected that all parties’ rights are considered and upheld to the highest level of ethics.

Gestational surrogacy is a valid medically assisted reproduction option for individuals wanting children. This option should continue to be supported by ethical, regulatory, and legal frameworks available in Nigeria.