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Bill Klaproth (Host): So, on this episode of the Fertile Edge, we're going to talk all about gestational carrier cycles and answer your most asked questions such as what is the difference between gestational carrier cycles and surrogacy? Are there really a lot of people that need to do this type of IVF? Is there a genetic link between the gestational carrier and the baby? What you should look for in a gestational carrier. And many other questions are going to be answered in this podcast as we talk with Dr. Mary Hinckley, the Medical IVF Director at Reproductive Science Center of the San Francisco Bay Area, Rachel DePuy, she is a third party case manager there, and we're going to talk with Heather Thompson, she was an actual gestational carrier. So, they are all on the panel today. And we are looking forward to bringing you this really informative discussion.

This is Fertile Edge, a podcast by Reproductive Science Center of the San Francisco Bay Area. I'm Bill Klaproth. Dr. Hinckley, Rachel and Heather, thank you all for your time. We appreciate it. And we're looking forward to this great discussion about gestational carrier cycles. Dr. Hinckley, let me ask you this. It seems like surrogacy and gestational carrier cycles are something only in the tabloids. Are there really a lot of people that need to do this type of IVF and why?

Mary Hinckley, MD, REI (Guest): Well, it's great to be here. I love getting the chance to share some of the knowledge that we have and encourage other people to not be afraid of this field of medicine. And so I'm glad to answer any questions that you have, especially ones about gestational carrier cycles and yeah, they do make the tabloids, because it really is a miraculous work of science to be able to create an embryo through IVF and transfer it to someone unrelated and solve what is likely an otherwise unsolvable fertility or health problem.

I mean, it is a miracle, but there are true medical indications for this. Things such as absence of the uterus, estrogen sensitive cancers, medical contra-indications to pregnancy like severe heart disease, things like same sex male partners that want to have a baby or women who have recurrent miscarriage. These are true medical indications for gestational carrier cycles and something that we love to be able to see and take care of here. But we do hear about celebrities using gestational carriers and we don't always know what those indications were. It could be that those were by choice or personal preference, which is not truly an admissable indication, according to the American Society of Reproductive Medicine Guidelines. These guidelines were put in place to protect gestational carriers as well as the intended parents and the babies. So, it's in the tabloids. We often try to think about why people are doing it and we don't have the full story.

But it is becoming more and more common. You also asked me about, you know, how many people really do this? Well at RSC, we perform about 2,500 transfers a year and about 5% are transfers into a gestational carrier. So, about 125 cycles a year. Across the US, about two to 3% of cycles use gestational carriers.

Our program does a little bit more than the average and this number has been rising. And approximately 16% of these cycles are by non-US residents who have come to the US because it may not be allowed in their country. And even in California, we see patients that come from other states where it's not allowed in other states to do it here at our center, because we're a center that sees more of these, does more of these and has really good success rates.

Host: Well, that is really good to know. And so we're all on the same page. Can you tell us what is the difference between gestational carrier or as we're going to call GC, gestational carrier cycles and surrogacy?

Dr. Hinckley: Yes. And actually those of us who've been in the field long enough, we'll sometimes use these interchangeably, but truthfully surrogacy or traditional surrogacy involves finding a person who could produce the egg as well as provide the uterus and sperm was then put inside this woman through an insemination to allow her to get pregnant, carry the pregnancy, deliver the baby and then give it to the couple, the original sperm donor and typically his wife. Gestational carriers came about, and that term became a term for a third party who is only providing the uterus. So, her eggs are not used. So, often a husband and a wife or egg donor and a gay couple will come and provide the eggs and sperm.

They will be used to create embryos in the IVF lab. And then those embryos, typically one at a time will be put back into a gestational carrier's uterus. So, she will have no biological connection genetically to the embryo.

Host: So, when you say a male couple use something like this, that's what we're talking about. This really allows a male couple to have a baby without using the egg from the female surrogate.

Dr. Hinckley: Exactly. So, they would find it an egg donor, maybe through a profile bank or through an egg bank that fits what they're looking for, choose the egg donor and eggs would be here at our center. And then they choose a sperm provider and the sperm would be put with those eggs to create embryos. And then the best of those embryos would be transferred to the gestational carrier and the extra embryos would be frozen for the future.

Host: So you talked about indications for this, correct? Do many couples choose this then? Or do they just go the surrogacy route?

Dr. Hinckley: Yeah. So, most people will use a gestational carrier in this day and age. And that's the only type of cycles we actually do here at Reproductive Science Center, as opposed to traditional surrogacy. The reason we do that is because legally they're a much safer way to proceed so that there is no, there are no issues or complications when the baby is born about who the true parent is because the laws in California regarding the birth mother and the laws that would be set for through a lawyer who would say these are the true intended parents would be different. And so we use gestational carriers to carry the embryos and they would therefore not have any genetic connection to that infant.

Host: I wasn't even thinking about the legality of this, but this is really interesting. And hence, I could see where people do come from out of state to see you. Is that right?

Dr. Hinckley: It's great. We love to be able to serve as a resource for people where this is not available, where they are. We feel that this is a right, a reproductive right to be able to have a child. And so we like to be able to take care of them and help them through this process.

Host: Absolutely. Wow. This is really fascinating. Thank you for that. And Rachel, let me ask you a question. So, how does a cycle begin? How do you find a GC?

Rachael Dupuis, MA (Guest): Well, the first part is the doctor identifies the patient as needing a gestational carrier, and then they get forwarded to our team, a third party team. There are several of us that work doing different items. So, Diana, she is our GC screener and she will contact the intended parent to provide agency or if they already have a person identified as somebody they want to be their GC. So some people may have like a private GC, like, a cousin or a sister that volunteers to be their gestational carrier, or they can go through an agency. So, we give them that information. And then I will work with the intended parent to get them ready for their gestational carrier.

Host: Again really interesting when you think about this. So, then you talked about maybe it's a family member, maybe it's a sister or somebody. So how does that work? What are the relationships like then with a GC and the intended parent or IP, if you will.

Rachel: Yeah, I think when you have a family member or a friend that's willing to be your gestational carrier, I think that it can strengthen their relationship. And even if it's an agency GC, I feel like as they're going through the GC screening process, and the IVF cycle or the frozen embryo transfer cycle, they do get to know each other extremely well. And I think it's great when they come back, when they're ready for say baby number two, sometimes they'll use the same GC that they used in their previous cycle. And again, I feel like that just drinks strengthens their relationship and watching those kids grow up.

Host: I was just going to say, thinking about the kids growing up, is it an added benefit if you do use a sister or a close family friend, you can say, I gave birth to you.

Rachel: Yeah, I better be your best auntie.

Host: Yeah I better, right come Christmas time. You better take care of me kid. Is that an added benefit having somebody so close be the woman that actually gives birth?

Rachel: I think it can be, I feel like you know, they could be your best auntie. And they know, they know the person that gave birth to them. I feel like children's birth stories are really important and to be able to have all the pieces to share even if it is a little different, a little alternative. I feel like those stories are even more special to be shared with those children.

Host: Yeah, I could see that in the case of a male couple, again, this sister to one of the males that would be interesting birth story, wouldn't it?

Rachel: Yes. And it also keeps it in, you know, like they get to keep that link with that child. So let's say the male couple does use their sister. It, again I feel like it just brings it more closer where they have that extra benefit of family.

Dr. Hinckley: One thing I thought would be interesting to add at this point is that we go through a lot of careful screening and evaluation to make sure it is a good match. So, some people are worried about whether this would affect that relationship with a family member or how the gestational carrier's husband may feel about this process, how the neighbors and the family will feel. What questions will be asked. And so, as part of the process for applying and becoming a gestational carrier and using a gestational carrier, we have them see therapists or licensed clinical social workers or psychologists and psychiatrists to really go through a thorough evaluation and feel comfortable proceeding that they really understand each party. And that this is a good fit.

Rachel: And I also feel like, the use of an attorney where they have a legal contract between them also sets good boundaries, which I also think is very important when using a private gestational carrier.

Host: Absolutely. And as you were talking, Dr. Hinckley, let me ask you this about using a family member. That also brings in genetics too, because you'll know the family history, the genetic makeup, if there's any diseases that run in the family. So, do you test the embryo for genetic diseases? And what about things like knowing the sex of the baby? And another question, can an IP have twins? How about those questions Dr. Hinckley?

Dr. Hinckley: Okay, those are great questions. So I think it's really clear, first of all, that the embryo is going to have the genetics of the parents. Now of course, sometimes an egg donor is used and they'll have the genetics of the egg donor. But for the most part, the embryo's genetics, you already know because you are the parent. For the gestational carrier, we like to know their medical history. Did they have safe pregnancies in the past? Have they had heart disease? And so their medical history is important, but their genetic history does not participate in the cycle, in this gestational carrier cycle. There have been some studies that will show, that have shown that the gestational carrier can alter the expression of genes in the baby.

But these are new studies on imprinting and they do not pass on their DNA in any way. So that, that's important to understand in this situation. In terms of understanding genetics of the embryo, there are many couples who do choose to test the embryo for genetic diseases. And this may be things such as chromosome abnormalities that would cause miscarriages, things that might cause an abnormal pregnancy such as sex chromosome abnormalities, Down Syndrome, or some of the other trisomies. These things can be tested before the embryo is transferred. And with that testing also comes the sex chromosomes. So, you do know whether the embryo is male or female and couples are allowed at our center, to choose which embryo they want transferred to the gestational carrier.

Now, not every couple may make both boys and girls and have a choice, but if they do, we will review with them the success of each embryo and allow them the choice of that. What we do not allow though, is to transfer more than one embryo in the majority of cases. So at RSC, we transfer one embryo in about 99% of our cycles, especially if preimplantation genetic testing was done.

Identical twinning can occur even when you transfer one embryo, but this is very rare. However, in the past, about 50% of cycles in the United States with gestational carriers used to have twins, and this is a big change. So, nowadays putting one embryo at a time is the safest and healthiest both for the gestational carrier as well as for the intended parents and their child. So we really encourage that and enforce that at Reproductive Science Center.

Host: So one embryo at a time lessens the likelihood of twins or eliminates that possibility?

Dr. Hinckley: It does lessen it. It does not eliminate it. There is still about a 2% chance of monozygotic twinning or identical twinning, but by putting one in at a time, we can have a higher chance that the gestational carrier gets to a full term pregnancy and a nice delivery, hopefully even a vaginal delivery, as opposed to a C-section. There are less risks of preterm delivery, which have all the problems with prematurity and eye development and brain development that can happen if the baby's born too prematurely. So, one baby at a time as our goal here at RSC.

Host: Got it. And thank you for clearing up that genetics question. So, no genes or DNA, if you will, are passed on from the GC to the child.

Dr. Hinckley: Correct.

Host: Got it. All right. Well, thank you. I wasn't thinking about that, but now that you say that, it makes sense. So thank you for explaining that.

Dr. Hinckley: It's a common question. And it's one of the ones that people do sometimes, in the lay public, they, if a sister is carrying the pregnancy for a brother, people have questions about this, but we have to just explain and educate and that's what's so great about this field is that we can educate people and family members about this and how it happens and really try to build families like Rachel said, even if they're a little different or alternative from what most people have heard.

Host: Right. Exactly. That's what I was thinking about a sister carrying a baby for a brother. So, that's why I was thinking that her genes would be in there too, but obviously that's not the case. So, thank you for explaining that to us. I appreciate it. So, Rachel, let me ask you this then. This costs a lot of money, right? Like a hundred K and takes at least six months to get matched? So, are there some real hurdles to get through. In general, are patients happy that they did this?

Rachel: Yes, it is very costly. And it does sometimes take a while to find a suitable GC candidate either private or through an agency. I think there are some hurdles especially if the intended parents may have like hepatitis, the GC would have to do some additional screening to make sure that they can continue to be a suitable candidate for this intended parent.

So, we do, have to screen them appropriately per the intended parent. So not everybody gets the same kind of screening. We do make sure that it is suitable for the intended parent embryo. There's other hurdles. So, the hurdles are usually trying to find good quality gestational carrier candidates, which can sometimes take some time. So, when we get the match from the agency, sometimes they don't do the, they don't look through her medical records. They don't look through previous pregnancies and deliveries, especially with the way we do things. We do things very, with a fine tooth comb. So we definitely look through everything. And if there are questions or things that may be a red flag, we do bring those up. We'll have a chance to talk to their patient to see if this is still a good candidate for their GC. So, sometimes that can take a little bit of time to find the right one for them.

Host: And Rachel, let me ask you this. You mentioned good quality GCs. And you said that you will look at their medical records and you look for previous pregnancies. What constitutes a good GC? What are you looking for?

Rachel: That is a good question. So RSC does go by the ASRM guidelines for gestational carriers and what we're looking at are things like age, weight, and BMI, prior deliveries. They also have to go through psychological screening just to make sure that those, that she would be a good gestational carrier for that intended parent.

Host: Okay. Absolutely. And if a man brings his sister in, that sister would go through that same screening process, is that right?

Rachel: Correct. So even if they are a private GC versus an agency GC, they do have the same screening. There are some things that we may bend a little bit for, just because it is a private gestational carrier, but for the most part, yes, we do screen them all the same.

Host: I like that the private GC and the agency GC. Okay. That's good. Well, thank you for that. Well, Heather, you've been listening to this great discussion, so you're a former GC. Tell us what was it that made you want to offer to do this?

Heather Thomson (Guest): Hi. Thank you. Yes, I'm so excited to, I love sharing my story. So, I have been a gestational carrier three times actually. I delivered triplets for a couple in 2003. Then I delivered twins for another couple in 2005 and then a singleton in 2009. So after I had my second child of my own, I was in the pediatrician's office one day and just flipping through a magazine there. And there was a little ad in the back that said, is your heart open to helping an infertile couple? And I immediately was like yes, it is. I do want, my heart is totally open to that. So I reached out to an agency at the time. And just sort of inquired about it. Like, what does this mean? One of my first biggest questions was that I wanted to make sure there wasn't any DNA attachment to myself. So once I got educated on the process and what it actually meant to be a gestational carrier, I approached my kids' dad at the time, and it took us almost a year before I actually filled out the application to really make sure it was something we wanted to do. And really, I just loved being pregnant, which is I used to council gestational carriers as well, and that is a common theme.

They love being pregnant, but we're done raising our own children. And it was just a way for me to help. I knew that I had good pregnancies of my own. I knew this was something I could do. And I went to a seminar at the time to meet prospective, like parents just to talk. And once I heard the stories of these couples and why they needed GCs, I just really wanted to help. So I signed up and got matched and off and running.

Host: Well, it's got to give you great satisfaction knowing that you've given birth to, I think I checked my math, six children. Right. So three times, six children?

Heather: Yeah. Yes.

Host: So it's got to give you great satisfaction, knowing that you've helped bring six kids into the world for people that couldnt have children on their own.

Heather: It honestly has been some of the most rewarding years for me. I wasn't sure how I'd feel about it after the first time, but it was so rewarding and such an amazing experience for me that I did it again. My children who are grown adults now joke with me, you know, they call those the surrogacy years. Oh yeah. With mom and the surrogacy years.

Host: Right.

Heather: But for the our whole family, it really ended up being something just so rewarding. And it's a time in my life that I'm very proud of.

Host: Yeah. So let me ask you this. I'm sure you get this all the time. Was it hard for you to give the baby up? I know that you did it for the right reasons, but after that child was born and the new parents took the baby away, was that tough?

Heather: That is the number one question people ask me when they find out I've been a gestational carrier and, and for the gestational carriers that I've spoken to, you know, in the past as well, we all kind of feel the same way that you go into it knowing ahead of time that this is not your child. So, I think it's a little different as opposed to maybe giving a child up for adoption or something where you know the DNA is yours. So, you go into it with an open mind that you're just the oven, so to speak. And I think that is helpful. So, for me, it's not that it wasn't hard to let go. But I didn't see it as letting go as opposed to giving something.

So, when the children were born, I didn't see that as a loss for myself. I saw that as a gain for this amazing couple that I was trying to help. It's not to say you don't get attached to these child, to the child or children that you carried for nine months. There certainly was a bond there, and I was fortunate enough to have a really great relationship with all three couples where you know, I got to hold the babies and I got to go visit the babies a week or two later, just to satisfy that sort of mothering urge that you have after delivery.

Host: Right.

Heather: So I didn't feel a loss so much as like your mother instinct kicks in and you want to go check on them and you want to make sure they're okay. And how are they doing? But it wasn't so much a giving up as was a rewarding sort of, here you go. Look what did and congratulations to you, to the parents.

Host: Right. I'm just asking. And I know this is a, you know, probably goes both ways. Do you have a relationship with any of these six kids at all?

Heather: So I do still, the parents of the triplets we're not in contact as much anymore, but we were for a long time in the beginning, they had to move back to London and that's how it sort of faded away. The parents of the twins we're in contact all the time. The twins know who I am and that I did carry them. But we get Christmas cards and we exchange letters and, you know, I send birthday cards and like that. And same for the parents of the singleton. It's the same where we exchange Christmas cards and things like that. And the children do know that they were carried by a different woman.

Host: Right. So overall your experience as a GC, it sounds like it was overwhelmingly positive.

Heather: For me, yes, absolutely. For me, it was really a wonderful experience. It was tough. You know, you're pregnant and you go through all the pregnancy signs and your back hurts and you have morning sickness and it's all for somebody else. But yeah, for me, just overall, incredibly positive and just very rewarding.

Host: Wow. That is wonderful. So, you're the perfect person to ask this question then. So, so what would you say to prospective intended parents? And then the second part is what would you say to potential GCs? So, if you could tell us, what would you say to any intended parent listening to this?

Heather: I would say first and foremost, if you're going to use an agency, make sure you are using a very reputable, respectable agency that is going to thoroughly screen their, their gestational carriers. I know for at RSC, we double, triple screen them once they even come from the agency. And just to get to know the GC yourself, before you actually decide on her. I met some perspective intended parents at the time that wanted more of a business relationship. For me that just, I wanted something a little more close.

So get to know your GC, find out if she's looking for the same relationship that you're looking for before you absolutely decide to move forward. And just know that she is very likely doing it out of, you know, just the goodness of her heart and that she truly wants to help you, because I can only imagine from the intended parents perspective, it must be so weird to have another woman carry your child and that's gotta be tough. And so I would say to the intended parents you know, do try and bond with her, do try and get to know her, you know, meet her children, meet her husband so that you can really feel comfortable about that before moving forward.

Host: Right. Just so I heard you correctly, make sure there's a good match. Because a GC might want more of a business relationship, as you said. And so look for a couple of them might want more of a business relationship over someone who might want a closer relationship. Right. So, for the intended parents, look for that right match and get to know them and meet them, right?

Heather: Yeah, for both sides, GC and the intended parents, sure it's a really good fit and that you're looking for the same, you know, overall relationship. The relationship's going to take on a life of its own once, once it gets going. But I think a clear understanding of what each other expects in the beginning is important.

Host: Absolutely. And then how about for a potential GC, obviously match for her would be good too. Any other thoughts for her or recommendations or counselor advice?

Heather: Yeah, I would just say for the GC to make sure that you really think it through. Don't do it on a whim and first and foremost, don't do it just for the money, which is not enough anyway. But to make sure that you really are coming from a good place in your heart and that you know, in your mind that you're going to be okay with delivering someone else's child and then maybe never hearing from that couple again.

Host: Right. Yeah. Really good point. And then Rachel, let me ask you a question or Dr. Hinckley. So, and if you said this earlier and I missed it, I apologize. So, do you help an intended parent find the GC?

Rachel: We don't. We do have agencies though, so we do refer them out to several agencies that we work with and they that's the agencie's since it's their GCs, they know them better than we would. That's what they do for their intended parents is try to match them with a gestational carrier that they think might be a good fit for them.

Host: So you're there to at least help the IP get hooked up with a potential GC.

Rachel: Correct. And a lot of times they do work with many different agencies or looking at different agencies to find different candidates and we may get records or matches from different agencies for one intended parent. And you know, that's, that's our job, our responsibility would be to help them kinda narrow down those GC candidates. But not necessarily to find them.

Host: All right. Well, thank you so much. If I could just get some final thoughts from each view. I think that would be great to cap off this discussion. Can I start with you Dr. Hinckley, any final thoughts on this topic from your physician point of view?

Dr. Hinckley: Well, I think, you know, for us, some of what has been said here is just that this is a fabulous way to build families, if you have a medical indication and we're here to help you, and that can also include psychological indications and that we do follow the ASRM guidelines. And that's very important because this does have legal and psychological ramifications on all parties.

And so it's really important that we take this seriously and that you take this seriously to give us the best outcomes. You know, the children that are born from gestational carrier cycles are well adjusted, happy children and society is becoming more and more accepting and access is easier now. And we are here to help those families that want to pursue this.

Host: Yeah, great points. And thank you for adding that in about these children growing up and how well adjusted they are. So, thank you for that. And then Rachel, how about you from your point of view? Give us your final thoughts.

Rachel: Sure. I definitely think that using a gestational carrier is more common these days than say 10, 15 years ago. And I feel like you do hear a lot about it in the tabloids, and I just feel like using a gestational carrier may be more accessible nowadays. And maybe not so, you know, far reaching, like we, know, we can, I can make this work. We can have our, we can expand our family using a gestational carrier. So, I definitely feel that you know, we, RSC is here for all of those patients that feel like that can be part of their life.

Host: Yeah, absolutely good thoughts. And then Heather it sounds like, if you could still provide this service today, you probably would. Right? It sounds like you had such a great experience with this.

Heather: I would, if I wasn't over the acceptable age limit now I would absolutely do it again.

Host: Yeah, absolutely.

Heather: But I'm not allowed anymore.

Host: Well, we appreciate what you've done. That's for sure. So wrap this up for us. You're kind of the star of the moment, so give us your final thoughts on this discussion today.

Heather: Well, I think I would just piggyback on what Dr. Hinckley and Rachel said, just to take it seriously. But also go into it with an open heart and an open mind. Understand that there are legal and psychological ramifications, but not to be afraid of those, not to believe everything you hear in the tabloids. And it's really not so taboo anymore. It's really becoming very mainstream and acceptable and not to feel, you know, any less worthy if you have to use a GC, it's still an amazing way to, to create a family.

Host: Absolutely. This has just been a fabulous discussion and you're absolutely right about that. Well, Dr. Hinckley, Rachel and Heather, thank you so much for your time today. This has been a great discussion. Thank you each. I appreciate it.

Dr. Hinckley: Thank you. And hope to talk to you again.

Heather: Thank you.

Rachel: Thank you.

Host: And once again, as Dr. Mary Hinckley, Rachel Dupuis and Heather Thompson. And for more information, please visit rscbayarea.com. And if you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. This is Fertile Edge a podcast by Reproductive Science Center of the San Francisco Bay Area. I'm Bill Klaproth. Thanks for listening.