The management of intersex conditions and anomalies of the development of the female genitalia can only be properly achieved with appropriate input from a number of health professionals. Furthermore, the needs of the individual may change over time and so both the patient and her family must be provided with a seamless transition between the various stages of care — from the diagnosis, which may be in early infancy or in the teenage years, through childhood, adolescence and then to adulthood. Therefore, although intersex conditions are rare, it is imperative that they are managed in centres by a multidisciplinary team that includes paediatric surgeons, urologists (often paediatric and adult), plastic surgeons, endocrinologists, specialist nurses, psychologists and also the gynaecologist. The role of the gynaecologist is to help to coordinate the transition from childhood through adolescence and then womanhood and to help with issues relating to sexual function and sexual identity, endocrinology and fertility. It is during the difficult time of adolescence that the patient usually first realises that there are serious problems and it is often the specialist gynaecologist who helps her to understand the diagnosis and requirements for management. The support of a skilled nurse and clinical psychologist is invaluable at this time.

The Department of Health in the UK is currently reviewing the national provision of services for the management of intersex. Parathentically, those units that have the skills to manage intersex conditions also have the appropriate facilities to treat complex developmental anomalies of the Müllerian tract (for example cervical and vaginal agenesis).

Surrogacy

Until recently, women born with severe abnormalities of development of the Müllerian duct system have been unable to have their own genetic children. Adoption or childlessness have been their only options. The introduction of gestational or in vitro fertilization (IVF) surrogacy during the 1990s as a treatment option has changed the prognosis for women in this situation. Now, women with congenital absence or severe malformations of the uterus, or hysterectomy and abnormalities of the uterus incurred as a result of trauma or cancer treatment, have a chance of having their own genetic child, albeit gestated by another woman. As IVF surrogacy has become increasingly acceptable as a treatment option, both to the medical profession and to the general public (British Medical Association, 1996; Bromham, 1992, 1995), these young women can now have their own children, provided, as most of them do, they have normally functioning ovaries. However, some who have survived the treatment of a malignancy in childhood may have lost not only their uterine function, but also their ovarian function. This section reviews the indications for IVF surrogacy and the selection and management of women seeking this treatment, particularly relating to those with congenital abnormalities. The following section discusses the use of egg donation.

Indications

The main indications for considering treatment by IVF surrogacy are:

• congenital absence or abnormality of the uterus

• hysterectomy following malignancy or haemorrhage

• recurrent abortion

• severe medical problems precluding pregnancy and childbirth

• repeated IVF failure.

Congenital absence of the uterus and following hysterectomy are the commonest indications for surrogacy.