title: Assisted reproduction involving gestational surrogacy: an analysis of the medical, psychosocial and legal issues: experience from a large surrogacy program.
abstract: OBJECTIVE
  What are the medical, psychosocial and legal aspects of gestational surrogacy (GS), including pregnancy outcomes and complications, in a large series?
  
  
  CONCLUSIONS
  Meticulous multidisciplinary teamwork, involving medical, legal and psychosocial input for both the intended parent(s) (IP) and the gestational carrier (GC), is critical to achieve a successful GS program.
  
  
  BACKGROUND
  Small case series have described pregnancy rates of 17-50% for GS. There are no large case series and the medical, legal and psychological aspects of GS have not been addressed in most of these studies. To our knowledge, this is the largest reported GS case series.
  
  
  METHODS
  A retrospective cohort study was performed. Data were collected from 333 consecutive GC cycles between 1998 and 2012.
  
  
  METHODS
  There were 178 pregnancies achieved out of 333 stimulation cycles, including fresh and frozen transfers. The indications for a GC were divided into two groups. Those who have 'failed to carry', included women with recurrent implantation failure (RIF), recurrent pregnancy loss (RPL) and previous poor pregnancy outcome (n = 96; 132 cycles, pregnancy rate 50.0%). The second group consisted of those who 'cannot carry' including those with severe Asherman's syndrome, uterine malformations/uterine agenesis and maternal medical diseases (n = 108, 139 cycles, pregnancy rate 54.0%). A third group, of same-sex male couples and single men, were analyzed separately (n = 52, 62 cycles, pregnancy rate 59.7%). In 49.2% of cycles, autologous oocytes were used and 50.8% of cycles involved donor oocytes.
  
  
  RESULTS
  The 'failed to carry' group consisted of 96 patients who underwent 132 cycles at a mean age of 40.3 years. There were 66 pregnancies (50.0%) with 17 miscarriages (25.8%) and 46 confirmed births (34.8%). The 'cannot carry pregnancy' group consisted of 108 patients who underwent 139 cycles at a mean age of 35.9 years. There were 75 pregnancies (54.0%) with 15 miscarriages (20.0%) and 56 confirmed births (40.3%). The pregnancy, miscarriage and live birth rates between the two groups were not significantly different (P = 0.54; 0.43; 0.38, respectively). Of the 178 pregnancies, 142 pregnancies were ongoing (surpassed 20 weeks) or had ended with a live birth and the other 36 pregnancies resulted in miscarriage (25.4%). Maternal (GS) complication rates were low, occurring in only 9.8% of pregnancies. Fetal anomalies occurred in only 1.8% of the babies born.
  
  
  CONCLUSIONS
  Although it is a large series, the data are retrospective and conclusions must be drawn accordingly while considering bias, confounding and power. Due to the retrospective nature of this study, follow-up data on 6.3% of birth outcomes were incomplete. In addition, long-term follow-up data on GCs and IPs were not available to us at the time of publication.
  
  
  CONCLUSIONS
  To our knowledge, this is the largest GS series published. We have included many details regarding not only the medical protocol but also the counseling and legal considerations, which are an inseparable part of the process. Data from this study can be included in discussions with future intended parents and gestational carriers regarding success rates and complications of GS.
authors.affiliation: CReATe Fertility Center, University of Toronto, 790 Bay Street, Suite 1100, Toronto, ON, Canada M5G 1N8 Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada.
authors.forename: Shir
authors.initials: S
authors.lastname: Dar
authors.affiliation: CReATe Fertility Center, University of Toronto, 790 Bay Street, Suite 1100, Toronto, ON, Canada M5G 1N8 Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada.
authors.forename: Tal
authors.initials: T
authors.lastname: Lazer
authors.affiliation: CReATe Fertility Center, University of Toronto, 790 Bay Street, Suite 1100, Toronto, ON, Canada M5G 1N8.
authors.forename: Sonja
authors.initials: S
authors.lastname: Swanson
authors.affiliation: CReATe Fertility Center, University of Toronto, 790 Bay Street, Suite 1100, Toronto, ON, Canada M5G 1N8.
authors.forename: Jan
authors.initials: J
authors.lastname: Silverman
authors.affiliation: Law Society of Upper Canada, 130 Queen St W Toronto, ON, Canada M5H 2N6.
authors.forename: Cindy
authors.initials: C
authors.lastname: Wasser
authors.affiliation: CReATe Fertility Center, University of Toronto, 790 Bay Street, Suite 1100, Toronto, ON, Canada M5G 1N8 Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada.
authors.forename: Sergey I
authors.initials: SI
authors.lastname: Moskovtsev
authors.affiliation: CReATe Fertility Center, University of Toronto, 790 Bay Street, Suite 1100, Toronto, ON, Canada M5G 1N8.
authors.forename: Agata
authors.initials: A
authors.lastname: Sojecki
authors.affiliation: CReATe Fertility Center, University of Toronto, 790 Bay Street, Suite 1100, Toronto, ON, Canada M5G 1N8 Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada Department of Obstetrics and Gynecology, Women's College Hospital, Toronto, ON, Canada dr.shirdar@gmail.com drlibrach@createivf.com.
authors.forename: Clifford L
authors.initials: CL
authors.lastname: Librach
mesh_terms: D000328:Adult; D001723:Birth Rate; D015331:Cohort Studies; D032982:Contracts; D003376:Counseling; D005260:Female; D006785:Hospitals, University; D006801:Humans; D008297:Male; D008875:Middle Aged; D009864:Ontario / Q000453:epidemiology; D010044:Outpatient Clinics, Hospital; D016487:Parenting / Q000523:psychology; D010353:Patient Education as Topic; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011256:Pregnancy Outcome; D018873:Pregnancy Rate; D027724:Reproductive Techniques, Assisted / Q000009:adverse effects* / Q000331:legislation & jurisprudence / Q000523:psychology; D012189:Retrospective Studies; D013533:Gestational Carriers / Q000331:legislation & jurisprudence / Q000523:psychology
keywords: assistant reproductive technology; counseling; gestational surrogacy; legal issues; medical indications