Egg donation

Egg donation
Intervention
MeSH	D018587

Egg donation is the process by which a woman provides one or several (usually 10-15) eggs (ova, oocytes) for purposes of assisted reproduction or biomedical research. For assisted reproduction purposes, egg donation involves the process of in vitro fertilization as the eggs are fertilized in the laboratory. After the eggs have been obtained, the role of the egg donor is complete. Egg donation is part of the process of third party reproduction as part of ART (Assisted Reproductive Technology). The ASRM (American Society of Reproductive Medicine) has issued guidelines for these procedures, and the FDA has a number of guidelines as well. There are boards in countries outside of the US who have the same regulations.

History

The first transfer of a fertilized egg from one human to another resulting in pregnancy was reported in July 1983 and subsequently led to the announcement of the first egg-donation-produced human birth on February 3, 1984.^[1] This procedure was performed at the Harbor UCLA Medical Center under the direction of Dr. John Buster and the University of California at Los Angeles School of Medicine.^[2]

In the procedure, a fertilized egg that was just beginning to develop was transferred from one woman in whom it had been conceived by artificial insemination to another woman who gave birth to the infant 38 weeks later. The sperm used in the artificial insemination came from the husband of the woman who bore the baby.^[3][4]

This scientific breakthrough established standards and changed the outlook for those who were unable to have children due to infertility or were at high risk for passing on genetic disorders. Donor oocytes and embryo transfer has given women a mechanism to become pregnant and give birth to a child that will be their biological child, but not their genetic child (assuming that the recipient woman carries the baby.) In many cases, a gestational surrogate is used, and the embryos are implanted into her, per an agreement with the recipients. Oocyte and embryo donation as practiced today now accounts for approximately 5% of in vitro fertilization recorded births.

Another beneficiary of this technology is the gay parent community. Surrogacy has enabled gay men to have biological children.

Prior to this, thousands of women who were infertile, single men and gay couples had adoption as the only path to parenthood. This set the stage to allow open and candid discussion of oocyte and embryo donation as a common practice.^[3][4] This breakthrough has given way to the donation of human oocytes and embryos as a common practice similar to other donations such as blood and major organ donations. At the time of this announcement the event was captured by major news carriers and fueled healthy debate and discussion on this practice which impacted the future of reproductive medicine by creating a platform for further advancements in woman's health.

This work established the technical foundation and legal-ethical framework surrounding the clinical use of human oocyte and embryo donation, a mainstream clinical practice, which has evolved over the past 25 years.^[3][5] Building upon this groundbreaking research and since the initial birth announcement in 1984, well over 47,000 live births resulting from donor oocyte embryo transfer have been and continue to be recorded by the Centers for Disease Control(CDC)^[6][7] in the United States to infertile women, who otherwise would not have had children by any other existing method.

The process is done today in other countries as well, but many couples come to the U.S. due to laws in many other countries which severely limit or prohibit compensation given to an egg donor. Since this process is so invasive (much more so than its counterpart, sperm donation), the lack of compensation results in an extreme dearth of young women willing to go through this procedure.

Indication

A need for egg donation may arise for a number of reasons. Infertile couples may resort to acquiring eggs through egg donation when the female partner cannot have genetic children because she may not have eggs that can generate a viable pregnancy. This situation is often, but not always based on advanced reproductive age. Early onset of menopause which can occur in women as early as their 30’s can require a woman to use donor eggs to grow her family. Some women are born without ovaries or other reproductive organs. Sometimes a woman's reproductive organs have been damaged due to disease or circumstances required her to have them surgically removed. Another indication would be a genetic disorder on part of the woman that can be circumvented by using eggs from another person. Many women have none of these issues, but continue to be unsuccessful using their own eggs.

If desired, (and if the egg donor agrees), the couple can personally get acquainted with the egg donor, her children and family members. More often, egg donations are anonymous. As stated above, egg donation is also helpful for gay male couples using surrogacy (see LGBT parenting).

• Congenital absence of eggs
  • Turner syndrome
  • Gonadal dysgenesis

• Acquired reduced egg quantity / quality
  • Oophorectomy
  • Premature menopause
  • Chemotherapy
  • Radiation therapy
  • Autoimmunity
  • Advanced maternal age
  • Compromised ovarian reserve

• Other
  • Diseases of X-Sex linkage
  • Repetitive fertilization or pregnancy failure
  • Ovaries inaccessible for egg retrieval

Types of donors

Donors includes the following types:

• Donors unrelated to the recipients who do it for altruistic or monetary reasons. They are often anonymous donors typically recruited by egg donor agencies or, sometimes, IVF programs.
• Designated donors, e.g. a friend or relative brought by the patients to serve as a donor specifically to help them. In Sweden, couples who can bring such a donor still get another person as a donor, but instead get advanced on the waiting list for the procedure, and that donor rather becomes a "cross donor".^[8]
• Patients taking part in shared oocyte programmes. Women who go through in vitro fertilization may be willing to donate unused eggs to such a program, where the egg recipients together help paying the cost of the IVF procedure.^[9] It is very cost-effective compared to other alternatives.^[10] The pregnancy rates with use of shared oocytes is similar to that with altruistic donors.^[11]

Procedure

Egg donors are first recruited, screened, and give consent prior to participation in the IVF process. Once the egg donor is recruited, she undergoes IVF stimulation therapy, followed by the egg retrieval procedure. After retrieval, the ova are fertilized by the sperm of the male partner (or sperm donor) in the laboratory, and, after several days, the best resulting embryo(s) is/are placed in the uterus of the recipient, whose uterine lining has been appropriately prepared for embryo transfer beforehand. The recipient is usually, but not always, the person who requested the service and then will carry and deliver the pregnancy and keep the baby.

The egg donor's process in detail

Each egg donor is required to undergo a thorough medical examination, including a pelvic exam, blood draw to check hormone levels and to test for infectious diseases, and an ultrasound to examine her ovaries, uterus and other pelvic organs. In addition, she will be referred to a psychologist who will evaluate if she is mentally prepared to undertake and complete the donation process. These evaluations are necessary to ensure that the donor is fully prepared and capable of completing the donation cycle safely and successfully.^[12]

Once the screening is complete and a legal contract signed, the donor will begin the donation cycle, which typically takes between three and six weeks. An egg retrieval procedure comprises both the Egg Donor's Cycle and the Recipient's Cycle. Birth control pills are administered during the first few weeks of the egg donation^[13] process to synchronize the donor's cycle with the recipient's, followed by a series of injections which halt the normal functioning of the donor's ovaries. These injections may be self-administered on a daily basis for a period of one to three weeks. Next, follicle-stimulating hormones (FSH) are given to the donor to stimulate egg production and increases the number of mature eggs produced by the ovaries. Throughout the cycle the donor is monitored often by a physician using blood tests and ultrasound exams to determine the donor's reaction to the hormones and the progress of follicle growth.^[12]

Once the doctor decides the follicles are mature, he/she will establish the date and time for the egg retrieval procedure. Approximately 36 hours before retrieval, the donor must administer one last injection of HCG hormone to ensure that her eggs are ready to be harvested. The egg retrieval itself is a minimally invasive surgical procedure lasting 20–30 minutes, performed under sedation. A small ultrasound-guided needle is inserted through the vagina to aspirate the follicles in both ovaries, which extracts the eggs. After resting in a recovery room for an hour or two, the donor is released. Most donors resume regular activities by the next day.^[12]

Results

Nationwide, egg donor cycles have a success rate of upwards of 60%. (See SART statistics at http://www.sart.org.) When a "fresh cycle" is followed by a "frozen cycle", the success rate with donor eggs goes up to approximately 80%. With egg donation, women who are past their reproductive years or menopause can become pregnant.

The oldest woman thus to give birth is Adriana Iliescu, age 66.

Babies born after egg donation are not genetically related to the recipient.

Donor motivation

An egg donor may be motivated by a number of reasons to provide eggs. Some egg donors may be altruistic and feel that participation in the reproductive process provides a benefit for another person, sometimes a person they know or are related to. A survey of 80 American women showed that 30% were motivated by altruism alone. Others, 20%, were attracted only by monetary compensation, while 40% of donors were motivated by both reasons. The same study reported that 45% of egg donors were students the first time they donated and averaged $4,000 for each donation.^[14] In the European Union the standard for reimbursement is based on compensation, not payment limiting egg donation to, at most, $1500. In some countries, most notably Spain and Cyprus this has limited donors to the poorest segments of society.^[15]

Risks

Egg donor

Egg donation carries risks for both donor and recipient, although it must be made clear that the procedure for the donor, and the medication given, is basically the same as the medication given for any IVF procedure (with or without a donor). The egg donor may suffer complications from IVF, such as bleeding from the oocyte recovery procedure and reaction to the hormones used to induce hyperovulation (producing more than one egg), including ovarian hyperstimulation syndrome (OHSS) and, rarely, liver failure.^[16]

According to Jansen and Tucker, writing in the same ART (assisted reproductive technologies) textbook referenced above,^[16] the risk of OHSS varies with the clinic administering the hormones, from 6.6 to 8.4% of cycles, half of them "severe." The most severe form of OHSS is life threatening. Recent studies have found that donors were at less risk of OHSS when the final maturation of oocytes was induced by GnRH agonist than with recombinant hCG. Both hormones were comparable in the number of mature oocytes produced and fertilization rates.^[17][18] A larger study in the Netherlands found 10 documented cases of deaths from IVF, with a rate of 1:10,000. "All of these patients were treated with GnRH agonists and none of these cases have been published in the scientific literature." Hormone treatments that can be dangerous in the short-term may have long-term health effects.

The long-term impact of egg donation on donors has not been well studied, but apparently some evidence suggests an increased risk of ovarian cancer, and effects on fertility.^[16][19] 1 in 5 women report psychological effects from donating their eggs, both good and bad. However two-thirds women were happy with the decision to donate their eggs. The same study found that 20% of women didn’t recall being aware of any physical risks.^[14] This does not mean they were told the risks involved but were not concerned about them at the time. This is worrisome since some short-term effects can be severe and the long-term effects are not well studied.

However, it appears that repetitive oocyte donation cycles does not cause accelerated ovarian aging, evidenced by absence of decreased anti-Müllerian hormone (AMH) in such women.^[20]

Recipient

The recipient has a minimal risk of contracting a transmittable disease. While the donor may test negative for HIV, such testing does not exclude the possibility that the donor has contracted HIV very recently, so the recipient faces a residual risk of exposure. However, the FDA governs this and requires full infectious disease testing no more than 30 days prior to retrieval and/or transfer. Most clinics now require, however, that donors be retested a few days prior to retrieval so the risk to the recipient is minimal. Intimate partners of both the egg donor and the recipient are also tested.

The recipient also trusts that the genetic and medical history of the donor is accurate. This factor of trust should not be underestimated in importance. Donors are paid thousands of dollars; monetary compensation may attract unscrupulous individuals inclined to conceal their true motivations. However, a full psychological evaluation is required by most IVF clinics, giving an indication if the donor is trustworthy or not.

In more cases than not, there is no ongoing relationship between the donor and recipient following the cycle. Both the donor and recipient agree in formal legal documents that the donation of the eggs is final at the time of retrieval, and typically both parties would like any "relationship" to conclude at that point.

Multiple birth is a common complication if the physician transfers too many embryos. Incidence of twin births is very high. At the present time, the ASRM clearly recommends that 1 or 2 embryos are transferred in any given cycle. (Any remaining embryos are typically frozen for future transfers.)

Custody

Generally legal documents are signed renouncing rights of ownership and custody on the part of the donor, so that there can be no claims on the part of the donor concerning the offspring. Most IVF doctors will not proceed with administering medication to any donor until these documents are in place and a legal "clearance letter" confirming this understanding is provided to the doctor.

Legality

Egg donation is regulated and /or prohibited in many countries. In the United States, having an attorney draft a contract is often necessary to establish and confirm the parental rights over any child. Using an attorney that specializes in reproductive law is highly suggested.

The Buzzanca versus Buzzanca, 72 Cal. Rptr.2d 280 (Cal. Ct. App. 1998), established the role of the recipient, the father of the conceived child, and the child. It stated that both the recipient and the father of the child by virtue of their procreative intent, are the legal parents of the child. Therefore, the father must pay child-support even if he claims a divorce before the conception of the child.^[21]

The Uniform Parentage Act (updated most recently in 2002) establishes the role of the egg recipient to the conceived child. The recipient under this act, is given complete parental responsibility of the conceived child.

Before the retrieval of the eggs from the donor, the donor must sign the Egg Donor Contract which specifies the rights of the donor with respect to the conceived child and the recipient. In this contract the donor agrees to undergo a thorough medical and psychological screening, genetic testing, and screening for communicable diseases (i.e. HIV). Also, it specifies that the egg recipient and the father of the child are the legal parents.

Donor registries

Main article: Donor registration

A donor registry is a registry to facilitate donor conceived people, sperm donors and egg donors to establish contact with genetic kindred. They are mostly used by donor conceived people to find genetic half-siblings from the same egg- or sperm donor.

Some donors are non-anonymous, but most are anonymous, i.e. the donor conceived person doesn't know the true identity of the donor. Still, he/she may get the donor number from the fertility clinic. If that donor had donated before, then other donor conceived people with the same donor number are thus genetic half-siblings. In short, donor registries match people who type in the same donor number.

Alternatively, if the donor number isn't available, then known donor characteristics, e.g. hair, eye and skin color may be used in matching.

Donors may also register, and therefore, donor registries may also match donors with their genetic children.

The largest registry is the Donor Sibling Registry- with more than 25,000 members, the DSR has matched almost 7,000 donor conceived people with their egg and sperm donors, as well as with their half siblings. Alternate methods of providing an information link between the donor and recipient (both agreeing to stay registered on the DSR) are often provided for in the legal document (referred to as the "Egg Donor Agreement".)

Embryo Donation

An alternative to egg donation in some couples, especially those in whom the male partner cannot provide viable sperm, is embryo donation, sometimes called “embryo adoption”. Embryo donation is, as its name implies, the donation of embryos remaining after one couple’s IVF treatments have been completed, to another individual or couple, followed by the placement of those embryos into the recipient woman’s uterus, to facilitate pregnancy and childbirth. Embryo donation has been shown in a recent study to be more cost-effective than egg donation on a “per live birth” basis ^[22]. Another study has found that embryos created for one couple, using an egg donor, are often made available for donation to another couple if the first couple chooses not to use them. ^[23]

Psychological and social issues

Further information: Donor conceived people#Psychological and social

Common reasons to donate are to help childless couples, and, for some, the monetary compensation. Reluctance to donate may be caused by a sense of ownership and responsibility for the well-being of the offspring.^[24]

Most psychological and social issues of egg donation are likely comparable to those of sperm donation.

Telling the child

Most psychologists recommend being open and honest with children from an early age. Groups for donor conceived children make a strong case for the rights of children to have access to information about their genetic background. For donor conceived children who find out after a long period of secrecy, their main grief is usually not the fact that they are not the genetic child of the couple who have raised them, but the fact that the parent or parents have kept information from or lied to them, causing loss of trust.^[25] Furthermore, the overturn of the sense of who were the parents through the whole life may cause a lasting sense of imbalance and loss of control.^[26]

However, there are certain circumstances where the child very likely should be told:

• When many relatives know about the donation, so that the child might find it out from somebody else.^[25]
• When the recipient carries a significant genetic disease, relieving the child from fear of being a carrier.^[25]
• Where the child is found to suffer from a genetically-transmitted disorder and it is necessary to take legal action which then identifies the donor.

Families sharing same donor

Having contact and meeting among families sharing the same donor generally has positive effects.^[27][28] It gives the child an extended family and helps give the child a sense of identity^[28] by answering questions about the donor.^[27] It is more common among open identity-families headed by single women.^[27] Less than 1% of those seeking donor-siblings find it a negative experience, and in such cases it is mostly where the parents have disagreed with each other about how the relationship should proceed.^[29]

Other family members

Grandparents of donors, often the oldest surviving progenitors, may regard the donated genetic contribution as a family asset, and may regard the donor conceived people as grandchildren.^[30]

Religious Views

Some Christian leaders indicate that IVF is all right (but they should ensure that no fertilised embryos are discarded in the process). Many Christian couples who cannot have children thus can go for IVF, with both the husband's sperm and the wife's egg and this is all right in line with the church's teaching.

However the question gets trickier when the egg does not belong to the woman.

There are also some Christian leaders (especially Catholic) who are concerned about all in vitro fertility therapies because they disrupt the natural act of conceiving a child where gamete donations, both egg and sperm donations, are seen to “compromise the marital bond and family integrity”.^[31] and they encourage infertile couples to consider adoption instead.

In the Muslim Community, Sunnis are allowed fertility treatments that do not involve third parties. This rule does not allow for the donation of gametes. Shi’ite Muslims on the other hand are allowed to accept egg donations, although there are some details that prevent egg donation in some countries and regions.^[32]

The permission to use an egg donor for Jewish couples is based on the decision of a rabbi, although there is no consensus in the orthodox community as to whether a child is Jewish based on the religious status of the genetic or gestational mother.^[33] This distinction is important since a Jewish egg donor may be needed. This is not an issue in the reform community since only one parent, either the mother or father, must be Jewish for the child to be considered Jewish. In the orthodox community the mother must be Jewish for the child to be Jewish.

See also

• Sperm donation
• Donor conceived people

References

1. ^ Blakeslee, Sandra (1984-02-04). "Infertile Woman Has Baby Through Embryo Transfer". The New York Times. http://query.nytimes.com/gst/fullpage.html?sec=health&res=9404EEDC143BF937A35751C0A962948260. Retrieved 2009-11-05. 
2. ^ http://www.humc.edu/calendar/careacc.html HUMC - Celebrating 50 Years of Caring
3. ^ ^{a b c} Friedrich, Otto; Constable, Anne; Samghabadi, Raji (1984-09-10). "Medicine: A Legal, Moral, Social Nightmare". Time. http://www.time.com/time/magazine/article/0,9171,952517,00.html. Retrieved 2010-05-01. 
4. ^ ^{a b} Wallis, Claudia (1984-09-10). "The New Origins of Life". TIME. http://www.time.com/time/magazine/article/0,9171,952514,00.html. Retrieved 2009-11-05. 
5. ^ Friedrich, Otto; Constable, Anne; Samghabadi, Raji (1984-09-10). "Medicine: A Legal, Moral, Social Nightmare". Time. http://www.time.com/time/magazine/article/0,9171,952517-6,00.html. Retrieved 2010-05-01. 
6. ^ http://www.obgmanagement.com/srm/pdf/first_live_birth_donation.pdf
7. ^ http://www.obgmanagement.com/srm.asp?id=5030
8. ^ cross donor is termed korsdonator in Swedish
9. ^ Check, JH (2002). "The shared donor oocyte program: the advantages and insights it provides in determining etiologic factors of infertility". Clinical and experimental obstetrics & gynecology 29 (4): 229–34. PMID 12635736. http://www.ccivf.com/pdf_files/pdf%20articles/CATEGO~6/003.PDF. 
10. ^ Cost analysis of shared oocyte in vitro fertilization Peskin B D, Austin C, Lisbona H, Goldfarb J M. "Cost analysis of shared oocyte in vitro fertilization." Obstetrics and Gynecology, 1996; 88(3): 428-430
11. ^ Prognosis of oocyte donation cycles: a prospective comparison of the in vitro fertilization–embryo transfer cycles of recipients who used shared oocytes versus those who used altruistic donors Fertility and Sterility. Volume 92, Issue 3, Pages 930-936 (September 2009). Olufunso A. Oyesanya, M.D.ab, Olufemi Olufowobi, M.D.a, Wendy Ross, R.N.a, Khaldoun Sharif, M.D.a, Masoud Afnan, M.D.ab
12. ^ ^{a b c} https://bhed.com/pub_donor_info.php#donation Beverly Hills Egg Donation | Become an Egg Donor
13. ^ Egg donation Egg donor bank
14. ^ ^{a b} Kara N. Maxwell, Ina N. Cholst, Zev Rosenwaks. (2008). The incidence of both serious and minor complications in young women undergoing oocyte donation, Fertility and Sterility. 90: 2165-2171.
15. ^ http://pulitzercenter.org/blog/untold-stories/it%E2%80%99s-not-altruism-it%E2%80%99s-selling
16. ^ ^{a b c} Textbook of Assisted Reproductive Techniques, Laboratory and Clinical Perspectives, edited by David K. Gardner, 2001
17. ^ Galindo, A.; Bodri, D.; Guillen, J.J.; Colodron, M.; Vernaeve, V.; Coll, O. (2009). "Triggering with HCG or GnRH agonist in GnRH antagonist treated oocyte donation cycles: a randomized clinical trial". Gynecol Endocrinol 25 (1): 60–6. doi:10.1080/09513590802404013. PMID 19165664. 
18. ^ Bodri, D.; Guillen, J.J.; Galindo, A.; Mataro, D.; Pujol, A.; Coll, O. (2009). "Triggering with human chorionic gonadotropin or a gonadotropin-releasing hormone agonist gonadotropin-releasing hormone antagonist-treated oocyte donor cycles:findings of large retrospective cohort study". Fertil Steril 91 (2): 365–71. doi:10.1016/j.fertnstert.2007.11.049. PMID 18367175. 
19. ^ http://health.usnews.com/articles/health/healthday/2008/12/26/risks-and-benefits-of-egg-donation-reported.html?PageNr=1
20. ^ Bukulmez O, Li Q, Carr BR, Leader B, Doody KM, Doody KJ (July 2009). "Repetitive oocyte donation does not decrease serum anti-Müllerian hormone levels". Fertil. Steril. 94 (3): 905–12. doi:10.1016/j.fertnstert.2009.05.017. PMID 19631321. 
21. ^ http://www.law.uh.edu/healthlaw/perspectives/Reproductive/980408Child.html
22. ^ Finger R, Sommerfelt C, Freeman M, Wilson CK, Wade A, Daly D. A cost-effectiveness comparison of embryo donation with oocyte donation. Fertil Steril 2010;93:379-81.
23. ^ Hill GA, Freeman MR. Embryo disposition: Choices made by patients and donor oocyte recipients. Fertil Steril 2011;95:940-3
24. ^ McMahon CA, Saunders DM (November 2007). "Attitudes of couples with stored frozen embryos toward conditional embryo donation". Fertil. Steril. 91 (1): 140–7. doi:10.1016/j.fertnstert.2007.08.004. PMID 18053994. 
25. ^ ^{a b c} Donor insemination Edited by C.L.R. Barratt and I.D. Cooke. Cambridge (England): Cambridge University Press, 1993. 231 pages.
26. ^ A generation of sperm donor children are discovering the father they know and love is NOT their father at all. By Alison Smith Squire in Daily Mail. Last updated at 11:18 AM on 19th March 2009
27. ^ ^{a b c} Scheib JE, Ruby A (July 2008). "Contact among families who share the same sperm donor". Fertil. Steril. 90 (1): 33–43. doi:10.1016/j.fertnstert.2007.05.058. PMID 18023432. 
28. ^ ^{a b} T. Freeman, V. Jadva, W. Kramer, and S. Golombok. Gamete donation: parents' experiences of searching for their child's donor siblings and donor. Human Reproduction, 2008; 24 (3): 505 DOI: 10.1093/humrep/den469
29. ^ Contact with donor siblings a good experience for most families By HAYLEY MICK. From Thursday's Globe and Mail. February 26, 2009 at 8:58 AM EDT
30. ^ My scattered grandchildren The Globe and Mail. Alison Motluk. Sunday, Sep. 13, 2009 07:53PM EDT
31. ^ http://www.albertmohler.com/commentary_read.php?cdate=2006-05-10
32. ^ Inhorn, M.C. 2005. IVF and gamete donation in the Muslim world. Religion and Reproductive Technologies. 46:14. http://www.aaanet.org/press/an/0502Inhorn.htm
33. ^ http://www.yoatzot.org/article.php?id=112

ASRM Practice Committee Reports, Fertility Sterility 82, Suppl. 1, Sept. 2004.

External links

• Egg Donation