Modern Family: Surrogacy and the Science of IVF

Adrian de Luna sat on the living room sofa in his Houston home, cradling his 5-month-old son, Evan, in his left arm and propping up a bottle of formula with his right. The U.S. Marine-turned-full-time-dad looked into his son’s bright blue-gray eyes, still half open after a midday nap.

De Luna’s husband, Enrique Vasquez, sat beside him, with Evan’s twin sister, Lilienne, nestled in his arms.

It was a relatively peaceful moment for the couple, but the sound of their 2-year-old daughter’s erratic footsteps punctuated the silence. Vivienne stomped with excitement on the wooden floor, proudly brandishing a half-eaten Oreo.

Vivienne had just finished a 2-minute meltdown. Even with tears streaming down her face, her brown hair stuck to her cheeks and her mouth open wide enough to reveal baby teeth, she bore a striking resemblance to de Luna. They had the same big brown eyes, the same nose, the same smile.

“There’s no denying that Adrian’s her father,” Vasquez said.

Incomplete
The couple met in 2007 at a bar in downtown Houston. Vasquez, who was working on his degree in mechanical engineering at the University of Houston, was hanging out with a friend when—like a meet-cute scene right out of a romantic movie—he caught a glimpse of de Luna in the crowd.
“It’s going to sound super cliché, but it was love at first sight when I saw him,” de Luna, 35, said.

They’ve been inseparable since then.

In 2011, de Luna and Vazquez filed for a domestic partnership license by mail through the state of Washington. Then, in 2014, a year before the U.S. Supreme Court legalized same-sex marriage across the country, Washington converted domestic partnerships to marriage. Vasquez and de Luna were officially hitched.

But their love story was incomplete. They wanted children.

“I always wanted kids, but I told myself, ‘I’m never going to have kids.’ I made myself understand that was not a possibility,” de Luna said. “When you don’t have the means to go through something this big, you think, ‘Well, how is this going to happen?’”

For Vasquez, who has four siblings, 13 nieces and two nephews, having a big family was always a dream.

“Even when I knew that I was gay in high school, I still wanted a family and … I was going to do whatever I could in my power to make this happen,” Vasquez, 33, said. “I wanted to leave a legacy, if that’s possible.”

The couple briefly considered adoption, but out of fear that the child’s biological parents would take issue with gay parents and try to win back custody, they decided against it. Even after gay marriage became legal in the U.S., de Luna and Vasquez knew that without any statewide protection from anti-discrimination laws, they might find themselves at a disadvantage if a legal battle ever ensued.

Two of their female friends offered to try an unconventional form of artificial insemination. This DIY approach would require one of the men to fill a syringe with his semen, which a female friend would then inject into her vagina.

“Like you’re basting a turkey,” de Luna said, sheepishly.

And then, there was surrogacy. For that, de Luna and Vasquez would need to find an egg donor and hire a woman to carry their child to term by way of in vitro fertilization, or IVF, a procedure in which an egg is fertilized with sperm in a lab. The embryo or embryos formed are then implanted into a woman’s uterus, where a baby or babies are carried to term.

The success rate for pregnancy by embryo transfer for a woman under 35 falls between 55 and 57 percent, according to the U.S. Centers for Disease Control and Prevention (CDC), which monitors and compiles data for all assisted reproductive technology procedures performed in the U.S. But it comes at a steep price.

The average cost of surrogacy ranges from $98,000 to $140,000, including the gestational surrogate mother fee, the surrogacy agency fee, the cost of IVF and fertility treatments, as well as expenses for travel and legal fees.

With such a high price tag, surrogacy was looking more like a distant dream than a viable option.

Giving thanks

In November 2012, Vasquez’s older brother, Marco, 42, and his wife, Nora, 31, brought their three daughters to the couple’s home to celebrate Thanksgiving. As the extended family sat around the dining room table, Marco verbalized what Vasquez and de Luna had only discussed in private.

“You guys would be amazing parents,” Marco said. “You guys need to have a family.”

“Yeah, but how?” de Luna lamented.

Marco volunteered Nora. Although they had never discussed her being a gestational surrogate before that moment, she eagerly agreed.

“I tell them, ‘Do what you gotta do. Do your research. Just tell me where to go, and I’ll show up,’” Nora said.

Gestational surrogacy, in which the gestational mother carries a fertilized embryo implanted by assisted reproductive technology, is legal in Texas. Traditional surrogacy, in which the gestational mother provides the egg, is not. Chapter 160 of the Texas Family Code outlines additional guidelines: the intended parents must be married and the gestational mother and her husband, if she has one, must relinquish all parental rights.

Between 1999 and 2013, about 2 percent (or 30,927) of all assisted reproductive technology cycles used a gestational carrier, according to the CDC. That number is on the rise, particularly since the Supreme Court legalized same-sex marriage.

Vasquez and de Luna considered this new option. At this point, de Luna was working as a communications specialist on an oil rig in South Korea. His salary was substantial enough to cover a majority of the surrogacy and IVF treatment costs, but it was the first time in the couple’s six years together that they would be apart.

“I would go to sleep crying every night because I was homesick and I missed him,” de Luna said.

In their respective workplaces, the couple spoke in code, referring to each other as “she” or “my wife,” out of fear of ostracization from employers and coworkers. It was particularly
hard on de Luna.

“He couldn’t have a picture of me. He couldn’t call me. He couldn’t do anything,” said Vasquez, who works as a project manager for an oil and gas company. “We have to hide who we are because of the industry we work in. On top of having that distance and not being able to see him every day, we have that barrier.”

After two years, de Luna and Vasquez saved enough money for the surrogacy procedure. They had one major condition: Each wanted the opportunity to be a biological father.

Vasquez remembers telling Nora: “I would like both of us to have the chance to have a child. Whether it goes through or not, that’s up to the universe.”

Nora agreed and understood that she would be undergoing two pregnancies, one for Vasquez and one for de Luna, using donor eggs.

Nora and Marco already had three children of their own. After their third child, she underwent a tubal ligation, in 2010. But because the embryos would be implanted directly into her uterus, having her tubes tied would not be an issue.

“It’s special to me because these are my best friends,” Nora said. “For them to want to do this, I was really touched by it.”

Same biological mother
A gestational surrogate mother working with an agency can earn anywhere from $35,000 to $45,000, based on her age and experience. Paid in monthly installments, the fee covers her service as a gestational carrier, the IVF transfer, maternity clothing, housekeeping and post-birth recovery. It’s a typical business transaction.

But the situation with Nora wasn’t typical. On top of the required attorney fees and IVF treatments, de Luna and Vasquez pondered how to compensate their sister-in-law.

“We wanted to make sure she was fulfilled for the miracle that she gave us,” Vasquez said. “There’s nothing in this world we could ever give her for what she gave us.”

They offered to pay her cash, buy her a car and a house, but she refused it all. The only thing she asked for was a “mommy makeover”—a tummy tuck and breast lift—after the final delivery. Nora also agreed to a $300 monthly stipend to purchase maternity clothes and supplies for a single pregnancy, and $400 for a twin pregnancy.

While Texas is considered surrogacy-friendly, the state’s surrogacy law does not provide any special language for same-sex married couples. Vasquez and de Luna hired an attorney who specializes in LGBTQ reproductive law to help them navigate the legal minefield of contracts and insurance.

To prepare for her surrogacy, Nora underwent a mandatory psychological evaluation, followed by an extensive medical examination. The couple’s fertility expert, Mazen Abdallah, M.D., a reproductive endocrinology and fertility specialist with Children’s Memorial Hermann Hospital and McGovern Medical School at UTHealth, and medical director of Houston Fertility Institute, performed an ultrasound to check for fibroids or structural defects in the uterus that would raise concerns. Abdallah also did a hysteroscopy to look inside the uterus for scar tissue, polyps or anything that could have been missed during the initial ultrasound.

Abdallah explained that, if a woman in her 20s or 30s has been pregnant and has successfully given birth in the past, her chance of carrying to term again is higher than if she had not carried to term or been pregnant in the past. Because Nora delivered three children with no complications, and because she had never miscarried, she was considered a perfect candidate for surrogacy.

Then the search for an egg donor began. De Luna and Vasquez pored over nearly 30 different profiles of egg donors, which included a photo of each woman, along with her age, height and complete medical history up to maternal and paternal grandparents. Names and personal information were withheld for privacy reasons. Choosing a donor was like browsing through Facebook profiles until they finally found the right woman.

They purchased 16 eggs from one donor, eight for de Luna and eight for Vasquez, for two cycles of IVF. The couple wanted their children to share the same biological mother.

Pills and shots
To prepare her uterus, Nora underwent a series of hormone therapies to simulate the natural cycle of pregnancy. She first took estrogen pills three times a day to mimic what happens during a natural conception cycle.

“In the beginning, the uterus is exposed to estrogen,” Abdallah said. “We monitor the response of the uterus by doing an ultrasound and measuring the lining of the uterus.”

Once the lining reached an ideal thickness, Nora needed to take a second medication, progesterone, to prepare the uterus to receive the embryos by inducing the production of nutrients necessary for the embryos to thrive. These pills were taken for five to six days to synchronize the uterus with the embryos, creating the optimal window for implantation.

In addition to this combination of estrogen and progesterone, Nora received at-home hormone injections of Lupron to prevent her menstrual cycle from interfering with the surrogacy. Her husband, Marco, diligently practiced injecting a needle into an orange until he was confident enough to administer the Lupron shots himself. Every day for 11 weeks, Nora endured injections in her buttocks.

“Not once did I feel like, ‘You know what, I’m not okay with this,’” Nora said. “My heart wasn’t racing. I wasn’t nervous at all. It felt like this is what I was supposed to do and it felt right to me.
It was harsh, but I made it through.”

Meanwhile, Abdallah and his team inseminated the batch of eggs with de Luna’s sperm and grew the embryos in culture. After the fifth or sixth day, Abdallah implanted two embryos.
Then they waited.

“With every treatment … I can’t say I’m as anxious as the woman or the man, but I’m anxious to see the results,” Abdallah said. “To date, I haven’t lost that anxiety.”

But Nora could not bear to wait the recommended two weeks to find out whether or not she was pregnant. A week after the implantation, she bought a home pregnancy kit, eager to find out if she would be delivering good news to the couple or crushing their dreams.

The test was positive. De Luna and Vasquez were going to be parents.

Fighting stigma
Nora knew it would be confusing for her three children to see their mother pregnant, but not with their brother or sister.

“We told them from day one what I was doing,” Nora explained. “They know their uncles are gay. I told them they wanted to have a family, but they can’t have kids because they’re boys, so they wanted me to carry their baby.”

Every day, she read them a children’s book about surrogacy, The Kangaroo Pouch, so that, little by little, her girls would understand that she was carrying their cousin. But Nora still fought stigma from friends and family.

“I had friends who asked me, ‘What are they going to explain to the kids when they grow up?’” Nora said. “‘Where’s their mom?’”

Others questioned whether or not she would be able to go through with the surrogacy. Even Nora’s mother, whom she describes as “old-fashioned,” worried that she would suffer an emotional breakdown from giving birth to the babies and then giving them away.

But Nora never wavered. She prepared herself to not feel attached, to not view herself as the baby’s mother.

“Once I say I’m going to do something, I’m going to do it,” Nora said. “I keep my word. I don’t back out.”

Labors of love
Towards the end of the 39th week, Nora began experiencing contractions one morning. It was time. As she and Marco sped to the hospital, she repeatedly called and texted Vasquez and de Luna, both of whom had moved to San Antonio by then for work.

“I’m already having the baby!” Nora told them once they finally called back.

“Oh my gosh, really?” they said.

“No, I’m kidding,” she joked.

While they waited for her to dilate, her doctor administered Pitocin to induce labor. The medication didn’t take effect immediately, allowing Vasquez and de Luna to hightail it the 200 miles from San Antonio to Children’s Memorial Hermann Hospital in Houston.

Twelve hours later, Nora delivered Vivienne Katalina Vasquez—born 7 lbs., 1 oz.—at 7:01 p.m. on July 25, 2015, exactly 37 years after the birth of Louise Brown, the first “test tube baby.” It was a milestone in the couple’s lives that coincided with the anniversary of the scientific breakthrough that allowed their dreams to come true.

Six months later, the couple and Nora were ready for round two. They inseminated the eight remaining eggs with Vasquez’s sperm, ready to experience the same elation as their first pregnancy. But of the eight eggs, only one became an embryo. The chances of a single embryo catching were slim.

Abdallah was hopeful, but he couldn’t make any promises. Two weeks later, a blood test confirmed the worst.

“I was devastated,” Vasquez said. “When I thought that I wouldn’t have a child biologically, I prayed on it. I asked for things that maybe I had no right to ask for.”

Financially, de Luna and Vasquez hadn’t prepared for a third attempt. They had already spent $30,000 for the first treatment and another $30,000 for the second.

But they decided to try again. This time, of the 10 eggs they inseminated, eight became embryos. Abdallah selected the best two embryos and implanted them in Nora. One of the eggs was already splitting; there was a good chance they would be having twins.

“Only God knows why He does the things He does,” Nora told the couple. “Maybe that’s why you didn’t come out pregnant the first time. Now, you’ll have two.”

And two it was. Standing at just under 5 feet, Nora’s petite frame carried a single baby easily, but carrying twins would be a new and daunting challenge. Vasquez and de Luna couldn’t imagine how someone her size would be able to hold two babies.

“To me, I was just like, ‘I’m going to be suffering for nine months, but you’re going to be stuck with them for 18 years, so I’m okay,’” Nora joked.

Within three months, Nora’s stomach had doubled in size. By six months, it had tripled in size and protruded so far from her body that it looked like she was ready to give birth any minute.

Her feet were swollen and her legs hit her stomach when she walked. She felt sleepy all the time and experienced dizzy spells and palpitations, a sign that her heart was working on overdrive to support the twins. Cramps left her in agony and she would cry in the middle of the night from the pain. Then the hemorrhoids came.

“It was unbearable to lie down, sit up, walk, anything,” Nora said. “It was so painful that I was crying all the time. I couldn’t sleep. I couldn’t even move because the pain would wake me up.”

But Nora never complained to Vasquez and de Luna, who had moved back to Houston after learning they were expecting twins. She knew how important her role as a gestational surrogate was and felt protective of the babies.

“Every time I was on the road when I was pregnant with their kids, I was always like, ‘God, please make me come back home safely because I’m carrying very valuable babies right now,’” Nora said.
As Christmas Eve 2016 arrived, both families gathered at the home of Vasquez and de Luna to celebrate, make tamales and unwrap presents. When the festivities ended, de Luna tucked Vivienne into bed while Vasquez went to look for his two Yorkshire terriers, who had scampered away at the sound of fireworks going off in the neighborhood.

Suddenly, at 2:37 a.m., they heard someone ringing the doorbell and banging on a window.

“It’s time! It’s time!” Marco yelled through the window. The twins were on their way.

They rushed to the delivery room, where a nurse wearing a sparkly Christmas ornament headband prepped Nora for delivery. Their excitement quickly turned to concern when they learned Nora needed an emergency C-section: One of the babies, the girl, Lilienne, was in a breech position. The medical team needed to retrieve both babies immediately.

“All I knew was that they were going to cut into my sister-in-law, who didn’t want to get cut into,” Vasquez said. “I thought, ‘She’s not going to talk to me. She’s going to hate me the rest of her life because these are my kids, biologically speaking.’ Petty things, but those were things that were running through my head.”

Around 8:40 a.m., the doctor made an incision in Nora’s abdomen, reached in, and carefully pulled out Lilienne. Then the doctor went back in for her brother, Evan, who had inhaled some fluid and was having trouble breathing. A team of specialists from the NICU tapped Evan on the back with a neonatal percussor to help him cough up the fluid from his lungs.

The team reassured the family that the babies were okay, but they needed to be taken to the NICU right away.

De Luna and Vasquez watched all the commotion in horror. They stood beside Nora, trying to keep her from noticing the smoke rising from behind the curtain around her midsection and the smell of burning flesh as the doctor cauterized the C-section incision to stop the bleeding.

They were so frightened, sleep deprived, and emotionally wrecked that it didn’t even dawn on them that it was Christmas Day.

It was a Christmas miracle; the twins were out of the woods. In the weeks that followed, the couple was able to take home two healthy babies and introduce them to their big sister, Vivienne. Finally, their family was complete.

“The level of respect for what Nora’s done and for anybody who is willing to go through this is crazy,” de Luna said. “What word do you use to describe that? The bond is definitely thicker between us.”

Parenthood
Most new parents experience feelings of self-doubt and high stress, and Vasquez and de Luna are no exception. After all, they’re juggling three kids under the age of 2. But every penny, every IVF attempt, every sleepless night and every moment that went into building this modern family was worth it.

“I know that, biologically, the twins are not my blood, but I’m here,” de Luna said. “When Enrique travels for work, the sleepless nights are mine. Those are my memories with my children. Nobody’s going to tell me how Evan likes to be rocked to sleep. Nobody’s going to tell me how Lilienne likes to be on her own when she’s being fed. … Those are things that I know.”

For both de Luna and Vasquez, children are the culmination of a lifelong dream.

“Whenever I would hang out with everyone at a barbecue with my family, we’d be out there and my nieces would come out and say, ‘Hi, uncle!’ But when they’d see their mom or their dad, they’d be like, ‘Hi, dad! I love you!’ and they’d hug them,” Vasquez said. “I’d never bring this up with anyone, but I would say, ‘I want that.’ I have that now. I have somebody who’s going to run to me or to my husband … and say, ‘Dad, dad!’ Give me a hug first. Give me all that emotion and love first! That’s been the most rewarding experience ever.”

It’s been a long road to happiness for the couple. At different points in their lives, they were convinced it wouldn’t be possible for them to have children. But here they sit, on their living room sofa, wiping the twins’ mouths as they watch Vivienne amble around the house “like a tiny drunk human” with a half-eaten Oreo cookie in her hand.

It’s overwhelming. It’s challenging. It’s messy. It’s family.

 

Advancements in IVF

The first major breakthrough with in vitro fertilization (IVF) came in the late 1970s, when two British researchers, gynecologist Patrick Steptoe, M.D., and physiologist Robert Edwards, Ph.D., performed the first successful IVF in a human.

Lesley and John Brown had been trying to conceive for nine years, but an obstruction in Lesley’s fallopian tubes prevented pregnancy. Steptoe and Edwards successfully implanted a fertilized embryo, grown in culture in a lab, in Lesley’s body, resulting in the first IVF pregnancy.

On July 25, 1978, Lesley gave birth to a healthy daughter, Louise, the first “test tube baby.”

“Around that period of the genesis of IVF, we really didn’t know how to culture embryos, so the results were really abysmal,” said Mazen Abdallah, M.D., a reproductive endocrinologist at Children’s Memorial Hermann Hospital and medical director of the Houston Fertility Institute. “You had to do several cycles to get one live birth. It was around 5 to 10 percent chance of live birth per treatment.”

But the science evolved and researchers improved their techniques.

By the mid-1980s, IVF had a success rate of 10 percent. By the mid-1990s, IVF had a success rate of 25 percent. By the early-2000s, researchers learned how to effectively grow embryos in culture to the peak implantation stage.

“Now we’re at the stage where we’re putting one or two embryos at a time rather than putting the average for the 1980s, when you would put as much as you have because the results were not that good,” Abdallah said. “We all remember Octomom. Octomom is basically a mishap. … It’s a risk you take when you put as much as you can at once.”

Another major breakthrough in the field of IVF occurred in 1992, when Gianpiero Palermo, M.D., Ph.D., developed intracytoplasmic sperm injection (ICSI), a method to help overcome male infertility by injecting a sperm into the egg to induce fertilization.

“We used to notice that, when the sperm numbers were low, even if you put a lot of sperm to surround the egg, the egg wasn’t being fertilized,” Abdallah said. “It’s not only sperm numbers. It’s sperm function.”

Using the ICSI approach, scientists were able to fertilize eggs even if sperm quality was poor, effectively expanding the scope of IVF to help infertile men.

Around the same time, scientists developed a procedure called preimplantation genetic diagnosis to test for genetic defects within embryos prior to implantation. By scanning the number of chromosomes in the embryo, scientists can select embryos that are chromosomally normal to use for implantation, improving the delivery rate to 70 percent, Abdallah said.

Today, 1.6 percent of all infants born in the United States are conceived using assisted reproductive technology.