For many women, disease, the physiological decline in ovarian reserve (DOR) and spontaneous or pathologically induced menopause will preclude pregnancy using own eggs. For such women, the performance of IVF using the eggs of a chosen young third party (egg donor-ED) offers an excellent opportunity to go from infertility to family. For such women, ED offers several advantages:
- More eggs are retrieved from a young donor than would ordinarily be needed to complete a single IVF cycle. As a result, there are often supernumerary (leftover) embryos for cryopreservation and storage.
- Since eggs derived from a young woman are far less likely to be chromosomally abnormal (aneuploid) and “incompetent”, the risk of miscarriage and birth defects such as Down’s syndrome is considerably reduced.
It has been estimated that in the United States alone, more than 20, 000 IVF procedures involving the transfer to the uterus of embryos (fertilized eggs) derived from donor eggs are performed annually. This comprises approximately 10-15% of all IVF treatment cycles in the United States. In addition, a growing number of couples seeking IVF/egg donation travel abroad in search of lower cost treatment.
Most, if not all, egg donor agencies provide a detailed profile, photos, medical and family history of each prospective donor for the benefit and information of the recipient. Agencies generally have a website through which recipients can access donor profiles in the privacy of their homes in order to select the ideal donor.
Interaction between the recipient and the egg donor program can be conducted in-person, by telephone or online in the initial stages. Once the choice of a donor has been narrowed down to two or three, the recipient is asked to forward all relevant medical records to their chosen IVF physician. Upon receipt of her records, a detailed medical consultation will subsequently held and a physical examination by the treating physician or by a designated alternative qualified counterpart is scheduled. This entire process is usually overseen, facilitated and orchestrated by one of the donor program’s nurse coordinators who, in concert with the treating physician, will address all clinical, financial and logistical issues, as well as answering any questions. At the same time, the final process of donor selection and donor-recipient matching is completed.
In the last 2 decades, the emergence of cryobanks where the frozen eggs of a wide variety of egg donors are housed and catalogued, has significantly enhanced access to donor eggs. However, while this has improved convenience, success rates remain well below that which is achievable using fresh donors …see below
What are the characteristics of the “ideal egg donor”?
- A mentally and physically, fully informed egg donor
- Age between 24 and 35 years.
- Normal ovarian reserve (an AMH of >o ng/ml or 15pmol/L)
- Regular ovulatory menstrual cycles
- A history of previously having generated numerous mature eggs in prior egg donation cycles.
- A woman who herself has previously experienced one or more pregnancies that advanced beyond the 1st trimester.
- Someone whose eggs previously were able to propagate embryos which propagated one or more healthy babies in herself or in a recipient.
Testing of Egg Donors
Genetic Testing: The vast majority of IVF programs in the U.S. follow the recommendations and guidelines of the American Society of Reproductive Medicine (ASRM) for selectively genetic testing of prospective egg donors for a variety of genetically transmittable conditions such as sickle cell trait or disease, thalasemia, cystic fibrosis and Tay Sachs disease. Consultation with a geneticist is readily available through about 90% of programs.
Psychological Screening: Since most donors are “anonymous,” it is incumbent upon the donor agency or the selected IVF program to determine the donor’s degree of commitment as well as her motivation for deciding to provide this service. Many recipient couples in the U.S.A tend to be very much influenced by the “character” and demeanor of the prospective egg donor, believing that a flawed character is likely to be carried over genetically to the offspring. In reality, unlike certain psychoses such as schizophrenia or bipolar disorders, character flaws are usually neuroses and are most likely to be determined by environmental factors associated with upbringing. They are unlikely to be genetically transmitted. Nevertheless, whenever possible, egg donors should be subjected to counseling and screening and/or should be selectively tested by a qualified psychologists.
Drug Screening: Because of the prevalence of substance abuse in our society, we selectively call for urine and/or serum drug testing of our egg donors.
Screening for STDs: All egg donors should be tested for sexually transmittable diseases .While it is highly improbable that DNA and RNA viruses could be transmitted to an egg or an embryo through sexual intercourse or IVF, women infected with viruses such as covid-2; hepatitis B, C, HTLV, HIV etc., should in my opinion be disqualified from participating in IVF. Although evidence that prior or even existing bacterial infection with Chlamydia or Gonococcus will affect egg/embryo competency, the existence of such infections introduces the possibility that the egg donor might have pelvic adhesions or even irreparably damaged fallopian tubes that might have rendered her infertile. Such infertility, if subsequently detected might be blamed on infection that occurred during the process of egg retrieval, exposing the caregivers to potential litigation.
- Medical Evaluation:while advancing age, beyond 40 years, is indeed associated with an escalating incidence of pregnancy complications, such risks are largely predicable through careful medical assessment prior to pregnancy. The fundamental question namely: “is the woman capable of safely engaging a pregnancy that would culminate in the safe birth of a healthy baby” must be answered in the affirmative, before any infertility treatment is initiated. For this reason, a thorough cardiovascular, hepato-renal, metabolic and anatomical reproductive evaluation must be done prior to initiating IVF in all cases.
- Infectious Screening:the need for careful infectious screening for embryo recipients cannot be overemphasized.
- Immunologic Screening:Certain autoimmune and alloimmune disorders (see elsewhere) can be associated with immunologic implantation dysfunction (IID). In order to prevent otherwise avoidable treatment failure, it is advisable to evaluate the recipient for autoimmune IDD and also to test both the recipient and the sperm provider for alloimmune similarities that could compromise implantation.
- Disclosure and Consent
Preparation for egg donation requires full disclosure to all participants regarding what each step of the process involves from start to finish, as well as potential medical and psychological risks. All parties should be advised to seek independent legal counsel so as to avoid conflicts of interest that might arise from legal advice given by the same attorney. Appropriate consent forms are then reviewed and signed independently by the donor and the recipient couple.
- Choosing a Known versus an Anonymous Egg Donor:While I strongly recommend to aspiring parents that their chosen egg donor be anonymous, I do accommodate the needs of those individuals/couples who prefer to use a known egg donor. However, the arrangements to use a known donor must be clearly defined and agreed upon at the outset. In the USA, >90% of “egg donation is done through the use of eggs derived from anonymous donors. Far less frequently, some egg donor agencies, provide access to “known donors” by special arrangement. However, in the majority of cases where known donor are used, it is by virtue of a private arrangement with friends or family members. In cases where recipients feel the need to know or at least to have met their chosen egg donor, they should be cautioned that once the donor knows the recipient, there is often a risk that they might consciously or unconsciously make subsequent efforts to maintain a visible link and this can cause considerable disruption in recipient couple-family dynamics.
A word of caution: Most embryo recipients fully expect their chosen egg donor to yield a large number of mature, good quality eggs, sufficient to provide enough embryos to afford a good chance of pregnancy as well as several for cryopreservation (freezing) and storage. While such expectations ore often met, this is not always the case. Accordingly, to minimize the trauma of unexpected and usually unavoidable disappointment, it is essential that in the process of counseling and of consummating agreements, the respective parties be fully informed that by making best efforts to provide the highest standards of care, the caregivers can only assure optimal intent and performance in keeping with accepted standards of care.Obviously, when eggs are purchased from an egg bank, this does not apply.
Categories of Egg Donation:
- Conventional egg donation: The standard (traditional/conventional) approach to IVF-Egg donation involves using fresh/non-frozen eggs. It involves having to match egg donors with recipients and the simultaneous coordination of the egg donor and recipients. It starts with the chosen egg donor undergoing medical and psychological screening followed by ovarian stimulation with fertility drugs to promote egg development. Synchronously, the embryo recipient (i.e. the patient) receives injections and other hormones to prepare her uterus in order to maximize the chances of successful embryo implantation. Once the egg donor has been optimally stimulated with fertility drugs, she is given a “trigger shot” (usually of hCG) and 34-38h later an egg-retrieval (ER) is performed, her eggs are harvested (usually conscious sedation) though ultrasound guided transvaginal needle aspiration and are then fertilized with designated partner’s (or donor) sperm. Three to six days later (depending bon embryo development), the most advanced (best quality) one or two (rarely more) embryos are transferred to the recipient’s hormonally prepared uterus. She then receives daily intramuscular and intravaginal supportive hormones. About 7-10 days later, a blood hCG measurement is made and if positive, is repeated 2 -4 days later. In the event of an adequate rise in blood hCG levels, supplemental estrogen/progesterone therapy continues and an ultrasound is performed 2-3 weeks later to determine whether a viable clinical pregnancy has taken hold. If so, hormone therapy continues to the 10th week of pregnancy at which time it ceases. The process is both painstaking, complex and emotionally and physically taxing. Moreover, it requires exquisite timing and coordination between the (usually anonymous) egg donor and the recipient.
- Using of Frozen embryo transfers (FET) with Staggered IVF -the preferred apprfoach:With this approach, there is no need for the egg donor and recipient cycles to be synchronized. Here, the donor’s cycle of stimulation and egg retrieval are conducted independently. The fresh donor eggs are fertilized with designated sperm, embryos are generated and ultra-rapidly frozen (vitrified) in advance and kept (stored) until a subsequent embryo transfer time is established for months or even years The ability to separate the ER cycle from the FET cycle, markedly increases the convenience for all parties without compromising success. At the same time, it removes a great deal of stress from the equation because it provides the embryo recipient with confidence that there will almost certainly be advanced embryos (blastocysts) available when she comes for FET. Moreover, the FET cycle can be scheduled to be performed at the convenience of recipient, and the time needed at our center to perform FET is virtually cut in half. Most important of all is the fact that embryo vitrification by and large will not compromise good quality embryos. This means that the freeze/thaw survival rate of pre-vitrified blastocysts is >85% and the pregnancy rate per transferred pre-vitrified blastocyst is at least as good as when fresh embryos are transferred. Also, the cost for Staggered IVF/FET with egg donation is also no greater with Conventional Egg Donation. Staggered IVF with Egg Donation is best suited to those couples/individuals whose location (usually from afar) and/or calendar, requires much tighter scheduling of their egg donation experience. There is currently a definite shift in the paradigm, away from “conventional fresh donor egg IVF” to “Staggered IVF embryo cryobanking/FET”. The process is far less complex, less stressful, more convenient and no more expensive.
- Frozen eggs from a Commercial Egg Bank: In this scenario, viable eggs derived from young egg donors are stored and subsequently made commercially available for IVF and embryo transfer to women for whom egg donor-IVF provides the only means by which they can go from infertility to family. In spite of the convenience associated with the use of donor eggs available through commercial egg banks, it should be appreciated that there is little financial benefit in using such banks. Also, for reasons cited above, frozen eggs are less likely than are fresh eggs, to generate viable embryos. Finally embryos derived from fresh (non-frozen) eggs and subsequently transferred to the uterus yield an overall success rate that is about 20-25% higher than when those derived from cryobanked eggs are used..
In all cases, whether a fresh egg donor is used or the eggs are derived from an egg bank, every attempt is made to find an egg donor that meets the embryo recipients’ needs. Issues such as physical characteristics, race, ethnic background, religion, etc. are all taken into consideration and fully disclosed. In all cases the donor is screened and undergoes a detailed medical evaluation (see above).
If a fresh egg donor is used, the couple and the egg donor both independently visit with a clinical nurse coordinator/ case manager who will outline the exact process step-by-step and develop a calendar that outlines every step they will go through. Once all the evaluations have been completed, a date to begin treatment will be selected.
Subsequent Disclosure to Offspring: A “Tough “decision to make! Then there is the issue of whether and when disclosure should be made to the children resulting from egg-donor IVF, regarding their discordant genetic roots. While I respect the intent/motives and the right of recipient parents to inform their offspring regarding their genetic link to a third party, I personally do not favor doing so. However if it is ultimately decided to make such a disclosure, I would suggest waiting until the children have reached maturity (well into their teen years) before doing so. A young immature child is in my opinion, less likely to be able to handle such an emotional event
- Financial Considerations: The fee paid to an egg donor agency per cycle usually ranges between $2,000 and $8,000. This does not include the cost associated with psychological and clinical pre-testing, fertility drugs, and donor insurance, which commonly range between $3,000 and $6,000. The medical service costs of the IVF treatment cycle ranges between $8,000 and $14,000. The donor stipend can range from $2,000 to as high $50,000 depending upon the exotic requirements of the recipient couple as well as supply and demand. Thus the total out of pocket expenses for an egg donor cycle in the United States range between $15,000 and $78,000, often putting egg donation outside the financial capability of many couples needing this service. When a donor egg bank is used, there is usually an amount paid per purchased egg. Some Egg banks sell a few eggs for a package fee. However, the fee paid in no way assures that the eggs will fertilize and or progress to the blastocyst stage for transfer to the uterus.
- Moral, Legal & Ethical Considerations:The “Uniform Parentage Act” which has been adopted by most states in the United States declares that the woman who gives birth to the child will be regarded as the rightful mother. Accordingly, there has to date not been any grounds for legal dispute when it comes to maternal custody of a child born through IVF with egg donation in the majority of states. In a few states such as Mississippi and Arizona the law is less clear but nevertheless, as yet, has not been contested. The moral-ethical and religious implications of egg donation are diverse and have a profound effect on cultural acceptance of this process. The widely held view that everyone is entitled to their own opinion and has the right to have such opinions respected, governs much of the attitude towards this process in the U.S. The extreme views on each end of the spectrum hold the gentle central swing of the pendulum in place. This attitude is a reflection of the general acceptance in the united states of diverse views and opinions and the willingness to allow free expression of such views and beliefs provided that they don’t infringe on the rights of others.
- The growing gap between need and affordability: This has spawned a number of creative ways to try and make IVF with egg donation more affordable. Here are a few examples:
- Frozen egg banks:: As stated, this approach does not necessarily translate into significant cost saving. Afterall the cost of IVF relates to the financial and emotional toll paid to achieve a viable pregnancy and this should be seen against the backdrop that the chance that any frozen egg will thaw , fertilize optimally, generate a quality blastocyst which upon transfer to the uterus will propagate a viable pregnancy is significantly reduced as compared to the use of :”fresh” (non-frozen) eggs.
- Egg Donor Sharing, where one comprehensive fee is shared between two recipients and the eggs are then divided between them. The downside is that fewer eggs are available embryos for transfer and/or cryopreservation.
- Egg Bartering, where in the course of conventional IVF, a woman undergoing IVF remits some of her eggs to the clinic (who in turn provides it to a recipient patient) in exchange for a deferment of some or all of the IVF fee. In my opinion, such an arrangement can be fraught with problems. For example, in the event that the woman donating some of her eggs fails to conceive while the recipient of her eggs does, it is very possible that she might suffer emotional despair and even go so far as to seek out her genetic offspring. Such action could be very damaging to both her and the recipient, as well as the child.
- Financial Risk Sharing. Certain IVF programs offer financial risk sharing (FRS) which most recipient couples favor greatly. FRS offers qualifying candidates a refund of fees paid if egg donation is unsuccessful. FRS is designed to spread the risk between the providers, and the recipient couple.
So where do we go from here? Can and should we, cryopreserve and store eggs or ovarian tissue from a young woman wishing to defer procreation until it becomes convenient? And if we do this, would it be acceptable to eventually have a woman give birth to her own sister or aunt? Can or should we store viable ovarian tissue through generations. Should egg donation simply become a future source of embryos generated for the purpose of providing stem cells, to be used in the treatment of disease states or to “manufacture” fetuses as a source of spare body parts? If the answer to even some of these questions is yes…what about the checks and balances. Who will exercise control and where what form should such control take? Are we willing to engage this slippery slope where the disregard for the dignity of the human embryo leads us to the point where the rights of a human being are more readily ignored? I HOPE NOT!