Although large, prospective, multicentre studies are indicated, we have clearly demonstrated that individualized, AMH-guided, controlled ovarian hyperstimulation protocols significantly improved positive clinical outcomes, reduced the incidence of complications and reduced the financial burden associated with assisted reproduction.
The incidence of surrogacy is rising.
Literature on associated obstetric risks is scarce and caution must be exercised when labelling surrogate pregnancies as low risk.
Although obstetricians’ responsibilities lie with the surrogate mother, they must ensure her wishes do not conflict with the best interests of the baby.
Prepregnancy counselling is the key to a successful surrogacy arrangement.
Learning objectives:
To gain an awareness of the different types of surrogacy.
To understand the law surrounding surrogacy.
To learn about antenatal, intrapartum and postpartum care in surrogacy.
Ethical issues:
When the surrogate mother's wishes and the interests of the child conflict, do obstetricians have the right to discuss this with the commissioning parents without her consent?
When should obstetricians seek ethical and legal support?
Please cite this article as: Bhatia K, Martindale EA, Rustamov O, Nysenbaum AM. Surrogate pregnancy: an essential guide for clinicians. The Obstetrician & Gynaecologist 2009;11:49–54.
Pelvic surgery can affect ovarian reserve, but estimates of the potential effect of different surgical procedures are lacking. This study examines the markers of ovarian reserve after different procedures in order to help the provision of informed consent before surgery. Anti-Müllerian hormone (AMH), antral follicle count (AFC) and follicle-stimulating hormone (FSH) of women with a history of salpingectomy, ovarian cystectomy or unilateral salpingo-oophorectomy were compared to those without history of surgery using cross-sectional data adjusting for patient and clinical factors in multivariable regression model. There were 138 women who had had salpingectomy, 36 unilateral salpingo-oopherectomy, 41 cystectomy for ovarian cysts that are other than endometrioma and 40 women had had excision of endometrioma. There was no significant difference in AMH (9 %; p = 0.33), AFC (−2 %; p = 0.59) or FSH (−14 %; p = 0.21) in women with a history of salpingectomy compared to women without surgery. Women with a history of unilateral salpingo-oophorectomy were found to have significantly lower AMH (−54 %; p = 0.001). These women also had lower AFC (−28 %; p = 0.34) and higher FSH (14 %; p = 0.06), the effect of which did not reach statistical significance. The study did not find any significant associations between a history of cystectomy, for disease other than endometrioma and AMH (7 %; p = 0.62), AFC (13 %; p = 0.18) or FSH. (11 %; p = 0.16). Women with a history of cystectomy for ovarian endometrioma had 66 % lower AMH (p = 0.002). Surgery for endometrioma did not significantly affect AFC (14 %; p = 0.22) or FSH (10 %; p = 0.28). Salpingo-oopherectomy and cystectomy for endometrioma cause a significant reduction in AMH levels. Neither salpingectomy nor cystectomy for cysts other than endometrioma has appreciable effects on ovarian reserve.Electronic supplementary materialThe online version of this article (doi:10.1007/s10397-016-0940-x) contains supplementary material, which is available to authorized users.
STUDY QUESTION
How much variation in oocyte yield after controlled ovarian stimulation (COS) can be accounted for by known patient and treatment characteristics?
SUMMARY ANSWER
There is substantial variation in the COS responses of similar women and in repeated COS episodes undertaken by the same woman, which cannot be accounted for at present.
WHAT IS ALREADY KNOWN
The goal of individualized COS is to safely collect enough oocytes to maximize the chance of success in an ART cycle. Personalization of treatment rests on the ability to reduce variation in response through modifiable factors.
STUDY DESIGN, SIZE, DURATION
Multilevel modelling of a routine ART database covering the period 1 October 2008–8 August 2012 was employed to estimate the amount of variation in COS response and the extent to which this could be explained by immutable patient characteristics and by manipulable treatment variables. A total of 1851 treatment cycles undertaken by 1430 patients were included. The study was not subject to attrition, as cancelled cycles were included in the analysis.
PARTICIPANTS/MATERIALS, SETTING, METHODS
Women aged 21–43 years undergoing ovarian stimulation for IVF (possibly with ICSI) using their own eggs at a tertiary care centre.
MAIN RESULTS AND THE ROLE OF CHANCE
Substantial unexplained variation in COS response (oocyte yield): was observed (3.4-fold (95% CI: 3.12 to 3.61)). Only a relatively small amount of this variation (around 19%) can be explained by modifiable factors. A significant, previously undescribed predictor of response was the practitioner performing oocyte retrieval, with 1.5-fold variation between surgeons with the highest and lowest yields.
LIMITATIONS REASONS FOR CAUTION
Although a large number of covariables were adjusted for in the analysis, including those that were used for dosing and determination of the stimulation regimen, this study is subject to confounding due to unmeasured variables and measurement error.
WIDER IMPLICATIONS OF THE FINDINGS
The present study suggests that there are limits to the extent that COS response can be predicted on the basis of known factors, or controlled by manipulation of treatment factors. Moreover, modifiable variation in response appears to be partially attributable to differences between surgeons performing oocyte retrieval. Consequently, consistent prevention of ineffective or unsafe responses to COS is not likely to be possible at present. Our results highlight the importance of blinding surgeons in RCTs. The data also suggest that there is likely to be limited scope for personalized treatment unless additional predictors of ovarian response can be identified.
STUDY FUNDING/COMPETING INTERESTS
J.W. is funded by a Doctoral Research Fellowship from the National Institute for Health Research...
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