Trends and outcomes of gestational surrogacy in the United States

To evaluate trends and reproductive outcomes of gestational surrogacy in the United States.

Retrospective cohort study.

Infertility clinics.

IVF cycles transferring at least one embryo.

Use of a gestational carrier.

Trends in gestational carrier cycles during 1999-2013, overall and for non-U.S. residents; reproductive outcomes for gestational carrier and nongestational carrier cycles during 2009-2013, stratified by the use of donor or nondonor oocytes.

Of 2,071,984 assisted reproductive technology (ART) cycles performed during 1999-2013, 30,927 (1.9%) used a gestational carrier. The number of gestational carrier cycles increased from 727 (1.0%) in 1999 to 3,432 (2.5%) in 2013. Among gestational carrier cycles, the proportion with non-U.S. residents declined during 1999-2005 (9.5% to 3.0%) but increased during 2006-2013 (6.3% to 18.5%). Gestational carrier cycles using nondonor oocytes had higher rates of implantation (adjusted risk ratio [aRR], 1.22; 95% confidence interval [CI], 1.17-1.26), clinical pregnancy (aRR, 1.14; 95% CI, 1.10-1.19), live birth (aRR, 1.17; 95% CI, 1.12-1.21), and preterm delivery (aRR, 1.14; 95% CI, 1.05-1.23) compared with nongestational carrier cycles. When using donor oocytes, multiple birth rates were higher among gestational carrier compared with nongestational carrier cycles (aRR, 1.13; 95% CI, 1.08-1.19).

Use of gestational carriers increased during 1999-2013. Gestational carrier cycles had higher rates of ART success than nongestational carrier cycles, but multiple birth and preterm delivery rates were also higher. These risks may be mitigated by transferring fewer embryos given the higher success rates among gestational carrier cycles.