Manuscripts

Is concurrent gestational surrogacy an ethical practice?

Gestational carrier use has gained significant attention over the last three decades as an important family-building option for individuals and couples unable to carry a pregnancy. It is used by women with uterine factor infertility or medical contraindications to pregnancy, as well as by single men and same-sex male couples. Although gestational surrogacy represents a relatively small proportion of assisted reproductive technology (ART) cycles in the United States, it is one of the fastest-growing groups. In 2022, the Centers for Disease Control and Prevention reported that 1.5% of all ART cycles involved gestational carriers—a four-fold increase from 1999. As the practice expands, so too does the surrounding conversation about its social, ethical, and legal complexity. Ethical concerns have been raised regarding medical risks to gestational carriers, the psychological implications for intended parents and future offspring, and broader societal issues such as commodification, power dynamics, and the potential exploitation of carriers. Nevertheless, professional societies, including the American Society for Reproductive Medicine, the Society for Assisted Reproductive Technology, and the American College of Obstetricians and Gynecologists, continue to support gestational carrier use as a reasonable and ethically acceptable option for individuals who cannot conceive or carry a pregnancy.

Conclusions: The concurrent use of two gestational carriers highlights the tension between reproductive autonomy and professional responsibility. Ethical practice in assisted reproduction demands that the clinician carefully weighs the fulfillment of patient preference against their broader implications. Balancing autonomy with beneficence, nonmaleficence, justice is essential to protect the best interests and safety of GCs. This approach minimizes unnecessary risk to the GCs and promotes equitable access to a limited avenue of reproductive care. As reproductive medicine continues to evolve, we must continue to remain grounded in ethical integrity.

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Prognostic utility of serum beta human chorionic gonadotropin level following single euploid embryo transfer for live birth

Objective: To evaluate live birth outcomes on the basis of initial serum human chorionic gonadotropin (hCG) level following single euploid embryo transfer.

Design: Retrospective cohort study.

Subjects: Single center study that included patients who underwent single euploid embryo transfer with initial positive hCG (>2.5 mIU/mL), measured nine days after transfer. Cycles were grouped by hCG range: Group 1 (hCG 2.5 to <11 mIU/mL), group 2 (11 to <25), group 3 (25 to <50), group 4 (50 to <75), group 5 (75 to <100), and group 6 (≥100).
Exposure: Initial serum hCG level.

Main Outcome Measures: The primary outcome was live birth per positive hCG. Subgroup analysis was performed by blastocyst biopsy day (days 5, 6, or 7). Poisson regression models were used to estimate stepwise comparisons between adjacent hCG groups; receiver operating characteristic analysis was performed to determine the predictive value of initial hCG level for live birth.

Results: A total of 6,410 single euploid embryo transfer cycles with initial positive serum hCG were included. Overall live birth after positive hCG was 71.0%. Higher initial hCG level increased live birth chance in a stepwise fashion, with lowest chance of live birth in group 1 (hCG 2.5 to <11) (1.6%), and highest in group 6 (hCG ≥100) (87.8%). Adjusted analysis demonstrated increasing probability of live birth between adjacent groups: group 2 vs. 1 aRR 6.76 [3.02–15.11], group 3 vs. 2 aRR 3.08 [2.27–4.19], group 4 vs. 3 aRR 1.80 [1.59–2.04], group 5 vs. 4 aRR 1.16 [1.08–1.25], and group 6 vs. 5 aRR 1.15 [1.10–1.21]. Live birth was similar across blastocyst biopsy subgroups, except in group 3 (25 to <50 mIU/mL), where day 5 blastocysts had the lowest live birth (28.8%) vs. days 6 and 7 blastocysts (42.7%, 41.9%). The area under the receiver operating characteristic curve was 0.83 (0.81–0.84), with an hCG of 75.7 mIU/mL representing the optimal threshold.

Conclusion: Initial serum hCG level after single euploid embryo transfer is a strong predictor of live birth, with a stepwise relationship between rising hCG thresholds. Findings from this study provide a valuable counseling tool for both physicians and patients utilizing single euploid embryo transfer.

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