Scope of the Issue

Egg donation has become a mainstay of infertility therapy in the United States. According to the most recent CDC statistics1, slightly more than 11% of all IVF cycles in this country involved donor eggs or embryos. With women delaying childbearing for professional, financial, educational, or personal reasons – or a combination of all of these – many women who are ready to start a family find out that their eggs have a poor prognosis in establishing a pregnancy. The miscarriage rate goes up and the ability to deliver a live birth goes down with age, most notably after 35. In addition to population statistics that depict an age-related decline in fecundity for women, a particular woman might also suffer from decreased ovarian reserve regardless of her age. Typically assayed with the clomiphene citrate challenge test, there are values on this test above which a woman has very little chance of delivering a live birth with her own eggs. For both of these groups of women, a donor egg cycle is a highly efficacious way of starting or continuing their families. Recent CDC statistics1 demonstrate a national average of 47% live birth rate per fresh embryo transfer for donor egg. Further, the concept of aggregate pregnancy rate is relevant. With donors providing adequate numbers of high quality eggs, good programs take advantage of this by culturing suitable embryos to the blastocyst stage and freezing those embryos not transferred. These frozen blastocysts are then transferred to the recipient woman in a subsequent cycle, either if the fresh attempt was unsuccessful or at a later date in an attempt for an additional child, but this time without the cost and procedures associated with stimulation and retrieval of a donor.

Comparison with Adoption

While adoption clearly has a valued role in our society, for the infertile woman who cannot use her own eggs, there are a number of distinct advantages of using donor egg over adoption.

First, it is completely anonymous. The woman donating her eggs does not know the identity of the recipient couple, and the recipient couple does not know the identity of the donor. And while there have been instances of the birth mother coming back at a later date and seeking custody of the child she has given up for adoption, there has not been a case to date where a similar situation has occurred with donor egg. This is attributable to the high level of anonymity preserved throughout the entire process, the fact that gametes are being donated as opposed to an infant being given up for adoption, and the fact that informed consent is signed by both parties at the outset. Non-anonymous egg donation can also be accomplished, and this commonly involves a fertile sister or cousin donating her eggs to her infertile sister or cousin.

Finally, while adopting children that are not infants or toddlers is both appropriate and preferable for many couples, many women desire the value and benefit of gestating with their baby and delivering their newborn. And if the gamete of the male partner is used, then the child has a 50% genetic linkage to the couple.

Why and how do women become donors?

Top IVF programs employ clinical psychologists who meet with prospective egg donors to determine their motivation, ability to handle the process, and appropriateness for egg donation. When properly screened and selected, the number one reason women become egg donors is that they sense an altruistic purpose in helping infertile women achieve pregnancy.

Compensation to the donor, which is part of the recipient couples’ fees, averages $5000 for a completed cycle. The donor will undergo a complete medical and genetic history, physical and infectious disease screening.

Programs with an adequate donor pool of women will allow the recipient couple to pick their donor. They are able to review physical, social and psychological characteristics of the donor all while keeping the actual identity of the donor anonymous. The recipient woman undergoes a history and physical, and an assessment of her uterine cavity via either a hysteroscopy or saline sonography to rule out polyps, myomas, scar tissue or malformation that might interfere with implantation and the ability to carry a live birth. The recipient will then undergo a mock cycle where the adequacy of her response to estrogen and progesterone is assayed and optimized. The donor and the recipient are then synchronized so that the recipient woman’s endometrium is ready to receive the fresh embryos resultant from stimulation and retrieval of the donor’s eggs fertilized with the sperm of the recipient’s partner or the sperm of a donor.

What are the risks to the donor?

There are two main considerations for the donor with regard to risks. The first is do the drugs used to stimulate her ovaries make her more likely to have ovarian cancer in the future, and second, what is ovarian hyperstimulation syndrome and is she likely to get it. With regard to ovarian cancer, recent studies suggest that the drugs we use to stimulate the ovaries are safe. In a meta-analysis of 7 case control and 3 cohort studies, cases of ovarian cancer were compared with infertile controls for exposure to fertility medications, and the odds ratio was not elevated (0.99; 95% CI 0.67, 1.45) . Comparing outcome in treated infertile patients with untreated infertile patients suggests treated patients may actually have a lower incidence of ovarian cancer (odds ratio 0.67; 95% CI 0.32, 1.41)2.

Ovarian hyperstimulation syndrome is a condition associated with the use of fertility medications and can lead to severe medical complications, notably fluid in the abdomen and lungs, blood clots and kidney impairment. There are two characteristics of the donor that help us avoid the severe form of this process. First, donors normally ovulate (those patients that do not normally ovulate are predisposed to the syndrome), and second, the donor uses contraception after retrieval of her eggs thus avoiding pregnancy and preventing the second phase of the syndrome. It should also be noted that good programs have a track record of avoiding this syndrome in their donors and are experts in treating it should it develop. The overall incidence for moderate and severe ovarian hyperstimulation is 3.1- 6% and 0.25 – 1.8%, respectively3.

References

Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA, 30333, 2001 Assisted Reproductive Technology Success Rates, www.cdc.gov
Kashyap, et al, Obstet Gynecol, Vol. 103, No. 4, April 2004, pgs.785-94.
Lunenfeld, et al, Diagnosis and treatment of functional infertility, 3rd ed, Blackwell Wissenschaft, Berlin, 1993, p 98.

Mark Bush, M.D. is a reproductive endocrinologist with Conceptions Reproductive Associates
In Littleton, Boulder, and Denver, Colorado.
Phone: 303-449-1084
Website: http://www.conceptionsrepro.com