Induction of Lactation in the Biological Mother After Gestational Surrogacy of Twins: A Novel Approach and Review of Literature

Introduction

With the apparent increase in the prevalence of infertility, the options for resolving the same with the use of assisted reproductive technology have expanded. ¹ Gestational surrogacy is an assisted reproductive method in which a woman accepts to become pregnant for giving birth to a baby for others and has no genetic link unless the surrogate mother is closely related to the commissioning mother.^2–4 Indeed, the biological or genetic mother is a nonpuerperal woman who has not experienced the physiological changes of pregnancy. Thus after birth, as per the normal physiological concept, she would not be expected to initiate breast milk production.

Lactation is a biological fact, a sign and aspect of “mothering” and the constructed bonding between a mother and her baby. ⁵ Becoming a mother is a process that begins with pregnancy or even before. ⁶ One of the dilemmas in surrogate pregnancy is the ability of biological mother for breastfeeding (nonpuerperal lactation) that is intriguing and has been reported in various societies. ⁵ Similar interest has been mostly documented by adoptive mothers desiring to breastfeed their adopted infants. ⁷ Induction of lactation is a worth option to allow skin-to-skin and eye contact between mother and infant. ⁸ This mother to infant relationship is an essential element of the bonding process that helps relaxation of both mother and the infant.^9,10

A case of induction of lactation in a nonpuerperal mother who opted for a related surrogate pregnancy was reported in 1988 in Australia. ¹¹ The first case of a mother breastfeeding her infant born through an unrelated surrogate host was reported in 2001.^8,12

Indeed, human body is a “wonderful machine” and induction of lactation is possible either in adopting mothers or in biological mothers of surrogacy.^1,2 Procedures used to induce lactation are based on the stimulation of prolactin and oxytocin secretion that results in milk production. Stimulation techniques involve breast stimulation (nonpharmacological methods) and the use of pharmacological methods called lactogogues. ¹³

Effects of emotions, visual, olfactory, and auditory stimuli on prolactin secretion are less well established and are limited to often animal researches. ¹⁴ The first published report of emotionally induced galactorrhea with the aid of visual and auditory stimuli in a nonlactating female for an unrelated newborn infant was in 2014. ¹⁴

In this report, we present a case of induced lactation and breastfeeding by the biological mother after the birth of her preterm twins after a surrogate pregnancy. In our case, nonpharmacological methods, especially imagination and targeted tactile breast stimulation, were utilized effectively, more than the pharmacological options. Thematic maternal accounts were recorded and we review the reported literature on induction of lactation with different methods.

Case Report

Twin girls born at 30 weeks of gestation weighing 1,740 and 1,850 g were admitted with respiratory distress syndrome (RDS) to the neonatal intensive care unit (NICU) of Mazandaran (Sari) University Hospital, Iran. They were conceived by the in vitro fertilization (IVF) technique as the biological mother underwent hysterectomy after the rupture of uterus during her first pregnancy 3 years back at the age of 20 years. After the IVF technique, parents requested the use of a gestational surrogate host. Embryos were transferred to an unrelated surrogate host that resulted in a twin pregnancy. Appropriate prenatal care was offered for the surrogate woman.

The commissioning (biological or genetic) mother at 12 weeks of pregnancy started the active imagination of lactation of her babies and according to her thematic account, “after 25 weeks of pregnancy my imagination changed to a strong belief and I stimulated my breasts and nipples”; perhaps assisting in the physiological feedback and sensory pathway. At 29 weeks of gestation, metoclopramide at a dose of 10 mg three times in day was commenced, and at 30 + 2 weeks of gestation, an emergency cesarean section was performed because of the initiation of preterm labor and fetal distress. RDS required the respiratory support with nasal continuous positive airway pressure (CPAP) for only 3 days and the infants were stable to be commenced on preterm formula.

Maternal thematic account with context and rigor denoted, “I think that I can feed up babies with my breast milk, I have been thinking of breastfeeding them from start of this pregnancy.” She had a small amount of colostrum after the effective use of breast pump. At this time, breast pumping was initiated by using a double electric hospital-grade pump (Medela symphony®, Switzerland). Pumping of both breasts was initiated simultaneously for 15 minutes every 4 to 6 hours, then mother gradually increased the time and frequency of pumping to 15 minutes every 3 hours. After the successful application of stimulating maneuvers, regular intake of metoclopramide 10 mg three times in day, and the use of herbal lactation stimulation agents as culturally accepted and practiced in Iran, by the 10th day she was able to supply approximately half of needed 150 mL/kg of milk for each twin.

She successfully pumped (Table 1) ∼30 to 40 cc milk every 3 hours (about 300 cc per day) and infants fed alternately with 35 cc every 3 hours with breast milk and preterm formula. We could not offer donor breast milk as there was no functioning “breast milk bank” in the region, because of a mix of religious, social, and economic reasons. Parents did not consent to obtain milk from the surrogate woman or other “private donors.” Preterm formula was given to infants with a feeding tube attached to the breast and placing the babies at the breast, again for using the effect of frequent sucking on induction of lactation.

Kangaroo Mother Care was initiated on day 3, initially with 4 hours per day and progressively increased to 8 hours per day for each infant. Husband, family, and lactation consultant strongly supported her efforts to breastfeed. The twins were discharged after 20 days while biological mother was able to breastfeed her infants several times a day. At the follow-up after 2 months, she successfully continued breastfeeding, and because of inadequacy of the volume of breast milk for two infants, supplemental formula feeds were used as well.

Discussion

In this article, we report lactation induction, leading to initiation and continuing breastfeeding in the biological (genetic) mother after a surrogate pregnancy. Induction of lactation described in this article is a process by which a nonpuerperal woman is stimulated for lactation. This technique is used for adopted mothers who desire to breastfeed an adopted baby or after surrogate pregnancy. American Academy of Pediatrics recommended that “pediatricians need to be familiar and supportive of the option and techniques of induced lactation,” in cases when adoptive families are interested in breastfeeding their adopted infants. ¹⁵ Most recommendations in the area of induced lactation are based on anecdotal experience or case reports.^16,17 In comparison with adoption, surrogate pregnancy allows a long period of preparation before birth, and treatment with galactogenic agents and the breastfeeding attempts could be initiated sooner after delivery, thus increasing the chance of successful breastfeeding.^5,16

One of the interesting points to note in our case report is that the mother already had a pregnancy and stillbirth. Recent reports suggest that the mamillary glands remembers prior pregnancy that primes it to respond to the hormonal changes and the memory lasts throughout an individual's reproductive years. Indeed, breast tissue retains a “cellular memory” of prior pregnancy that makes response more rapid in subsequent pregnancies. ¹⁸ Their data indicate that physiological experience functionally modifies the capacity of the affected cells to respond to later stimulatory events and epigenetic memory of past pregnancy. ¹⁸ This could also be a contributory factor for the establishment of lactation in our case.

Normal lactation process is the culmination of the maintenance of a delicate balance of various hormones with the regular stimulation of the breasts. ⁷ Pharmacological technique is the use of galactagogues medications that are useful to induce and augment lactation, but one of the most important physiological components and feedback loop of the lactation process described in our case report is the antenatal breast expression and nipple and areolar stimulation. ¹⁹ Nipple stimulation as well as auditory, olfactory, and visual cues and emotional considerations induces oxytocin release.^12,16 Role of beliefs in the theory of planned behavior has been demonstrated already and influencing intention to practice breastfeeding. ²⁰

In our presented case, surrogacy was the only option for parents to have a baby who is genetically and biologically related to them. Kirkman and Kirkman reported a case of induction of lactation in a nonpuerperal mother who opted for a surrogate pregnancy because of hysterectomy. ¹¹ However, in this presentation, the host of surrogacy was her sister, and after birth of the infant for enabling the baby to be fed exclusively on breast milk, several other women donated breast milk to supplement mother's own milk. ¹¹

In our report, the mother opted for preterm formula to supplement her breast milk. Szucs et al. reported an induction of lactation and exclusive breast milk feeding in adopted premature twins. The authors believed that this case was the first published case of premature twins whose adoptive mother induced lactation. ²¹ Our report also describes the establishment of lactation for premature infants, however, born by surrogacy and not after adoption. Wilson et al. described in their case report, breastfeeding experience of a baby from “all three of his mothers.” One was his birth mother and two others were his two adoptive mothers who had a same-sex marriage and induced lactation to nurse the baby, and the authors discussed the difficulties inherent in this multimother family dynamics. ²²

Shiva et al. reported a successful pharmacological induction of lactation in surrogate pregnancy. They used metoclopramide for induction of lactation and introduced it as a safe agent. Further studies to consider the risks versus benefits of such drugs are needed. ¹⁶ Sujata reported establishment of lactation in a cohort of 11 adopted mothers by using chlorpromazine for 3–4 weeks (along with nipple stimulation) that was considered as a safe pharmacological agent for initiation of breastfeeding in adopted mothers. ¹

In addition to pharmacological agents, nonpharmacological methods to induce lactation have been described. Nipple stimulation seems to be the most important factor in promoting lactation of nonpregnant mothers, but a great challenge for a mother to initiate preparation for induction of lactation is with adequate amount of time with privacy. ⁷ Hand stimulation of the nipple should occur several times a day for about 5 minutes for each breast, ideally at least 6 weeks before the birth of infant. One of the preferred methods of choice would be use of a hospital-grade electric breast pump.^7,23

The mother who wishes to induce lactation as described in our case would require extra support in her efforts, so healthcare team and family should offer to help the mother to achieve her personal breastfeeding goal. ⁸ An observation worth further evaluation through thematic analysis methodologies is maternal account of “self-structured regular thinking and imagination of the babies and concurrent stimulation of nipples with self-massage relatively early in pregnancy” and the commencement of metoclopramide just from 1 week before delivery of babies. ²⁴ Another contributory factor in induction of lactation in our case was the “cellular memory” of breast from previous pregnancy. Therefore, regular postdelivery breast pumping would “awaken” the already primed breast tissue and allow milk production. ¹⁸

Perrin et al. in a pilot study revealed that composition of nonpuerperal human milk by the induced lactation has similar or higher level of proteins, IgA, lactoferrin, and lysozyme than puerperal mother's own milk. ²⁵ For premature infants in the NICU, breast milk also offers additional benefits such as prevention of necrotizing enterocolitis (NEC). ²⁶

Conclusion

Journey to breastfeeding through induced lactation is with challenges and fears. Although at present the possibility of induced lactation and its relative ease of success are not fully appreciated and may not be regularly discussed with the patient, presentation of our case and the thematic synthesis approach of maternal emotional account demonstrate that induction of lactation after surrogacy is achievable and sustainable, offering a variety of benefits. With the apparent increase in the rate of infertility, this choice and the needed support should be offered to all genetic mothers choosing surrogacy.