For an ever-increasing number of infertile women, disease and/or the onset of ovarian failure precludes producing fertilizable eggs. This prevents them from achieving a pregnancy with their own eggs. Since the vast majority of such women are otherwise quite healthy and physically capable of bearing a child, egg donation (ED) provides them with a realistic opportunity to go from infertility to parenthood.
Egg donation is associated with definite benefits. Firstly, in many instances, more eggs are retrieved from a young donor than would ordinarily be needed to complete a single attempt at achieving an IVF pregnancy. As a result, there are often supernumerary or left over embryos for freezing (cryopreservation) and storage. Secondly, since eggs derived from a young woman are less likely to produce aneuploidic (chromosomally abnormal) embryos, the risk of miscarriage and birth defects such as Down’s syndrome are considerably reduced.
Indications For Egg Donation:
- Advanced reproductive age
- Decreased ovarian/egg
- Premature ovarian failure
- Surgical removal of the ovaries or exposure to chemotherapy or radiation
- Recurrent IVF failure due to “poor quality eggs or embryos”
Choosing An Egg Donor:
Majority of egg donation in the United States is done by soliciting the services of anonymous donors who are recruited by the donor agencies. Alternatively, a known egg donor may be an option is some cases such as donation between sisters, friends or cousins. Whereas using an anonymous egg donor is more common, there is a tendency to approach close family members in an attempt to retain the family gene pool as much as possible. Many recipients feel the compulsion to know or at least to have met the ovum donor so as to gain first hand familiarity with their physical characteristics, intellect, and character. The other reason to use a known donor is to reduce the fees associated with using an anonymous donor through an agency.
The benefit of using an anonymous donor through an agency is the presence of a protective barrier between the donor and the recipient in the event of an unwanted complication, suboptimal treatment or non-compliance. Most donor agencies screen egg donors before making them available for egg donation by using screening questionnaires, psychological evaluations and detailed screening of family and medical history. Some agencies are able to provide or be available as a third party in verifying some of the specific characteristics of egg donors including certification of education and degrees obtained.
The other benefit of using an anonymous donor is the termination of interaction with the donor on the day of the egg retrieval. The donors don’t have any information about the recipients and the recipients have no identity information on the egg donors. This is not the case in non-anonymous (known or directed) egg donation, in which the interaction can be lifelong. This may potentially create a challenging environment in social interactions between the parties and the offspring. In most cases, it is believed that this is not an issue but rather something to consider before using a directed egg donor. It is believed that there is more personal information known in cases of non-anonymous donation and such an approach would eliminate donor agency fees as well as donor stipend in most cases.
Matching The Donor And Recipient:
Ovum donor agencies usually prepare rather extensive donor profiles. Aside from offering direct personal and telephone-based access to both donors and recipients, they also offer abundant amount of information and online services via a dedicated web site where donor profiles can be viewed for free.
Important points to consider when choosing an egg donor are to find similarities in background, education, appearance, personal history, occupation, hobbies and future goals. It is not possible to find an exact match because each person is unique by their distinctive DNA, but similarities exist which may be enough for most people when deciding on their egg donor. Regardless of using donor or self eggs each embryo or individual is unique and has different characteristics, which may help some individuals in making the decision to move forward and use donor eggs.
Once the desired egg donor is chosen by the recipient, a telephone or an in-person consultation is done by Dr. Bayrak to screen the egg donor candidate initially. Then, a series of blood testing, physical examination and screening are carried out as required by FDA guidelines and entire process is overseen by the treating physician, IVF nurse and donor agency coordinators. Repeat screening and testing are required just prior to donation once again required by FDA guidelines to make sure the egg donor is eligible to donate.
Donor Recruitment:
Donor agencies as well as Dr. Bayrak usually limit the age of ovum donors to under 30 years in an attempt to minimize the risk of ovarian resistance and negate adverse influence of the “biological clock” (donor age) on egg quality. Another factor involved in selecting an ovum donor is the need to accurately assess ovarian reserve. We measure blood FSH and estradiol levels on the 3rd day of a spontaneous menstrual cycle, as well as a vaginal ultrasound assessment of the number antral ovarian follicles. A total antral count of less than ten in each ovary will often lead to disqualification from serving as an anonymous egg donor.
If the egg donor has children or her prior donation resulted in a healthy pregnancy, she is generally considered to be eligible and a good candidate. Such a track record makes it far more likely that the ED will have good quality eggs. The current limited supply of ovum donors makes it both impractical and unfeasible, to confine donor recruitment to those women who could fulfill such stringent criteria for qualification. Besides, all egg donors become donors for the first time they donate and most first time donors do well and treatment results in healthy pregnancies.
Evaluating Prospective Egg Donors:
Appropriate and careful history taking is essential in order to identify any personal or family history that might point towards potential medical problems that might arise during or after the cycle of stimulation, and the egg retrieval. Systemic disease, allergies to known medications, hemorrhagic diseases and mental disease are a few significant examples. It is also extremely important to try and rule out potentially debilitating hereditary and chromosomal disorders that could affect the quality of any offspring arising out of the ovum donation.
Most programs in the United States follow the American Society of Reproductive Medicine’s (ASRM) recommendations and guidelines for selectively genetic screening of prospective ovum donors for conditions such as sickle cell trait or disease, thalassemia, cystic fibrosis and Tay Sachs disease, when medically indicated.
Most recipients tend to be very much influenced by the character of the prospective ovum 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 and accordingly are unlikely to be genetically transmitted. Nevertheless, all donors should be subjected to counseling and screening and should be selectively tested by a qualified psychologists, and when in doubt, should be referred to a psychiatrist for definitive diagnosis. Significant abnormalities, once detected, should lead to disqualification of such donors.
When it comes to choosing a known donor, it is equally important to make sure that she was not coerced into participating. We caution recipients who are considering having a close friend or family member serve as their designated ovum donor, that in doing so, the potential always exists that the donor might become a permanent and an unwanted participant in the lives of a new family.
Assessing the egg donor’s ovarian responsiveness:
Assessing an individual’s follicle recruitment potential is accomplished by measuring FSH and E2 on the 3rd day of a spontaneous menstrual cycle. An FSH of less than 9 mIU/ml in association with a plasma estradiol concentration between 20 and 40 pg/ml on CD3 usually points to the woman being a potentially good responder to gonadotropin stimulation. However, recipients must be made aware of the possibility of a suboptimal ovarian response in spite of these tests all being within normal limits.
ASRM guidelines recommend that all ovum donors be tested for sexually transmittable diseases before entering into a cycle of IVF. It is highly improbable that DNA and RNA viruses are vertically transmitted to an egg or an embryo through sexual intercourse or IVF. Nevertheless the albeit remote possibility (as well as the legal consequences) of the ovum donation process being blamed for an unrelated occurrence of disease states such as hepatitis B, C or HIV such disease states, demands that potential donors so infected be disqualified from participating in IVF with ovum donation. In addition, evidence of prior or existing infection with chlamydia or gonorrhea introduces the possibility that the ovum donor so affected might have pelvic adhesions or even irreparably damaged fallopian tubes that might have rendered her infertile.
We place great emphasis on evaluating the integrity of the uterine cavity and endometrial lining in all embryo recipients. The presence of any surface lesion protruding into the uterine cavity, whether polyps, uterine synechea, fibroids or congenital defects, are all capable of eliciting a macrophage response, similar to that produced by a uterine contraceptive device. Such a “foreign body response” might seriously compromise implantation. Similarly, an inadequately estrogen-proliferated endometrium could likewise reduce the chances of a successful outcome. The performance of hysteroscopy or hydrosonography can readily identify all relevant uterine surface lesions while ultrasound measurement of endometrial pattern and thickness around the time of normal or induced ovulation, will assist in the assessment of implantation potential. 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.
Preparation For The Ovum Donation Process:
Preparation for ovum donation begins with full disclosure to all participants regarding each step of the process from start to finish, as well as potential medical and psychological risks. This requires a significant amount of time and a willingness to address all concerns posed by all parties involved. Full disclosure involves clear interpretation of the medical and psychological components assessed during the evaluation process. All parties should be advised to seek independent legal counsel so as to avoid conflict of interest from legal advice given by the same attorney. Appropriate consent forms are then reviewed and signed independently by the donor and the recipient couple.
Most embryo recipients fully expect their chosen 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 are 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. No one can ever promise an optimal outcome. All parties should be made aware that no definitive representation can or will be made as to the number or quality of eggs and embryos that will or are likely to become available, the number of supernumerary embryos that will be available for cryopreservation or the subsequent outcome of the IVF-ED process.
The Treatment Cycle:
The basic format used by most ovum donor programs is as follows:
First, the menstrual cycles of both the recipient and the donor must be synchronized. In some cases where the recipient is anovulatory or post menopausal, this requires establishing cyclicity through hormone replacement therapy, using sequential estrogen – progesterone therapy or through by way of a birth control pill. Placing donor and recipient on such hormone replacement and then selectively lengthening or shortening the duration of such therapy, both parties start with gonadotropin releasing hormone agonist (GnRHa – Lupron) together and both can be expected to initiate a subsequent withdrawal bleed following pituitary down regulation on or around the same time. The donor thereupon receives gonadotropins at a prescribed dosage while the recipient receives sequential estrogen therapy.
Once most of the follicles measure 18 to 22 mm on ultrasound, HCG is administered for triggering ovulation. The egg retrieval is scheduled 35 hours later. Following the egg retrieval the donor receives an injection with 100 mg of progesterone or progesterone pills and is scheduled for a follow up examination following ensuing menstruation. The recipient starts receiving progesterone injections on the day of the donor’s egg retrieval and continues with such daily injections until the 12th week of pregnancy or evidence of a negative outcome (whichever occurs sooner). On the day of egg retrieval, the eggs are fertilized with the partner’s sperm and an embryo transfer is performed 3 or 5 days post egg retrieval. Two tests of beta HCG are performed two days apart on the 8th and 10th day post transfer of Day 5 embryos. Supplemental hormone therapy is continued throughout the first trimester.
The Influence Of Age On Outcome:
While conventional IVF birth rates decline with increasing age of the mother, the birth rate in ovum donor recipients remains relatively constant in all age categories (50-60% per attempt). It is the age of the egg provider that influences outcome, regardless of the method of conception. Natural conception rates, conception following intrauterine insemination and conventional IVF conception rates all decline with advancing age of the woman. This is not the case in embryo recipients where the egg provider is of a younger age.
The miscarriage rate increases with the age of the egg provider rather than with advancing age of the recipient. Advancing age is associated with an increased incidence of miscarriage following natural conception, IUI and conventional IVF while the incidence of miscarriage remains constant regardless of the advancing age of the embryo recipient in egg donor cycles.
Financial Aspect of Egg Donation:
Egg donor treatment fees include the donor stipend and the agency fees and can range from $4,000-15,000 depending on the agency and the donor chosen.
