Egg Donor Program
Recipient Information
If you are considering egg (oocyte) donation, you have probably already taken several steps in your quest to have a child. If, like so many other women, you are unable to conceive a healthy pregnancy using your own eggs, egg donation may finally provide the means to allow you to achieve your dream of having a healthy baby.
In order to be considered a candidate for AFS's oocyte donation program, you must meet certain requirements. Recipients must undergo testing to ensure that they are healthy and capable of carrying a pregnancy to term without undue medical risk. Pre-cycle screening may also include consultation with a psychiatrist for counseling and emotional support. The decision to forgo having one's own genetic child is often very difficult, and we are here to help you come to terms with your feelings and understand the issues related to non-biologic parenting.
Most of AFS's egg donors are anonymous, although in some cases recipients who are uncomfortable with the use of eggs from an anonymous donor will recruit a close friend or family member to be their oocyte donor. There are pros and cons involved in choosing either type of donor, and we will be happy to explore these issues with you. At AFS we deeply respect your concerns and desires, and we will do everything we can to ensure that the donor you use is right for you. While we strictly uphold the confidentiality of our anonymous donors, we will be able to provide you with extensive background information regarding a prospective donor's medical, psychological, genetic, educational, and professional background, as well as a detailed family history so that you can be totally comfortable with the donor selection process.
If you have more questions about the process of egg donation, you may wish to read Egg Donation Explained.
If you have other questions or would like more information about AFS's Egg Donor Program, speak with Dr. Galina Karpenko, Medical Director, Egg Donor Program at 212-750-3330 or email us at eggdonation@americanfertility.com. If you would like to complete our Recipient Questionnaire, download here [PDF - 19K].
Egg Donation Explained
Introduction
Oocyte Donation
Oocyte (egg) donation involves the deliberate use of oocytes (eggs) provided by a donor for in vitro fertilization and subsequent embryo transfer to a matched and synchronized recipient. Once pregnancy in the infertile patient has been achieved, it is maintained throughout the first trimester by the prescribed use of hormone replacement. After the first trimester, the pregnancy progresses normally without the need for exogenous hormone support. Following the pregnancy, mothers often breastfeed, no differently than with spontaneous conceptions.
Oocyte donors may be either known or unknown to the recipient. Currently, most oocyte donors in the United States are young women who are compensated for the time and efforts and donate anonymously. Nearly 250 centers nationwide claim to provide oocyte donation as part of their assisted reproduction services.
Who Are Good Candidates for Egg Donation?
The first successful pregnancy resulting from oocyte donation occurred in 1984. The patient suffered from premature ovarian failure. Today, the indications for oocyte donation have expanded to include not only premature ovarian failure but also perimenopausal women with diminished ovarian reserve and women of advanced reproductive age who may already have experienced natural menopause. Also, younger patients who have not benefited from repetitive attempts at in vitro fertilization (IVF) or who have performed poorly with respect to oocyte or embryo quality often consider egg donation. Finally, the method may be chosen in order to avoid the possibility of transferring a significant genetic illness for which the recipient is known to be a carrier.
The Oocyte Donation Cycle
In vitro fertilization (IVF) and embryo transfer requires the harvest of oocytes from the donor who has received ovarian stimulation to increase the number of mature eggs available for retrieval, followed by the insemination of the eggs in the embryology laboratory. Twenty-four hours later, fertilization is documented. The early stage embryos are monitored for several days prior to their transfer into the uterus of the prepared recipient. Most often, the embryo is performed non-surgically, using a thin flexible catheter placed through the cervix into the uterine cavity.
Oocyte donation involves several important steps:
- Evaluating the potential recipient.
- Selecting the donor.
- Screening the donor.
- Obtaining informed consent from the recipient couple or woman and the donor.
- Synchronizing the cycles of the donor and the recipient.
- Prescribing hormone replacement for the recipient.
- Stimulating the ovaries of the donor.
- Retrieving eggs from the donor.
- Compensating the donor (the day of the retrieval).
- Fertilizing the eggs.
- Growing the embryos.
- Transfer of the embryos.
- Maintaining early pregnancy in the recipient.
Evaluation of the Recipient
Evaluation of the recipient includes a thorough infertility history and physical examination. Intensive laboratory testing to insure the health of the recipient most be completed. The decision to forgo having one's own genetic child is typically very difficult. Therefore, precycle screening should included consultation with a mental health professional for counseling and emotional support. A frank discussion of the issues related to non-biologic parenting, past infertility problems, feelings regarding prior failed treatments, and the positive and negative aspects of disclosure to potential offspring should occur. If the recipient chooses to use a known donor, it is important to discuss how the pregnancy might impact any future relationship with the donor as well as defining future interaction between the donor and offspring. In general, pregnancy rates with oocyte donation are quite high, leading some recipients to approach treatment with unrealistic expectations of success. It is also important to address the possibility of failure and determine how the recipient might potentially deal with that outcome.
Prior to attempting oocyte donation, the physical structure of the recipient's uterus is assessed. There are a variety of methods from which the physician may choose to perform an assessment. The results of a recent Pap smear are reviewed and the recipients is also tested for infectious diseases such as HIV, HTLV, Syphilis, and hepatitis. A common indication for oocyte donation is advanced reproductive age, as some recipients are in their mid to late forties. Frequently, recommended tests included a recent mammogram, EKG, chest X-ray, blood chemistries and consultations with a maternal-fetal medicine specialist to consider the risk of pregnancy in an older patient.
How old is too old to undergo oocyte donation? This is a difficult question and there is currently no standard answer. Clinics throughout the country have set their own restrictions based upon individual physicians' consideration of the ethical issues and risk of pregnancy at advanced reproductive age. Increasing numbers of women of advanced maternal age (40 or greater) are interested in oocyte donation. The majority of the 5,000+ cycles performed in the United States are in women over the age of 40. High rates (40-60 percent delivery rates per transfer) have been reported, even in women 50 years of age. Cumulative success rates of 90 percent have also been reported in older women following repeated attempts. Generally, most centers extend care up to the age of natural menopause (approximately 50 years of age). A few programs have experience transferring embryos to even older patients, but most would agree that such exceptions be limited to a case-by-case determination. Age-related complications of pregnancy are of particular concern in the older recipient.
Oocyte Donors
Donor Selection and Screening
Recipients may choose either a known or anonymous donor. There are advantages as well as disadvantages in either choice. For some individuals, the choice of a known donor offers the advantage of meeting the donor face to face and potentially having a relationship with the genetic mother of their future offspring. However, this may also pose problems in the interpersonal relationships that exist between the two parties. Locating and securing the services of a donor is often a daunting task. The majority of individuals use an anonymous donor and rely on the clinic or an independent agency to aid in the search for a donor. Regardless of whether the donor is known or anonymous, she must complete an in-depth questionnaire which asks about her personal, obstetrical, medical, or surgical history. This must also include information about her family as well. A social history to discover tobacco, alcohol, and/or illegal drug use is mandatory. A clinic may choose to have the screens for a donor reviewed by a geneticist to rule out a history of genetic mutation or disease. A donor should be excluded if there is a family history that suggests a significant genetic risk to potential offspring if her eggs are used.
How does one select a donor? There are a variety of factors that should be taken into consideration in making this important decision. Often physical traits and likeness of the donor to the recipient in terms of heritage, weight, coloring, and race are focused upon. Consideration of blood types, which is generally not of medical significance, may be a factor used in the selection of a donor. If there is a potential for Rh incompatibility, the recipient should be counseled regarding potential complications for future pregnancies. Recipients may also wish to consider educational background, fertility history, or other characteristics such as hobbies or interests in selecting a donor. Although none of these factors are known to directly translate to the offspring, recipients are comforted in the knowledge that the donor shares certain personal preferences that they hold in high regard.
According to the American Society for Reproductive Medicine (ASRM), oocyte donors should have attained the age of legal consent. Generally donors are between the ages of 18 and 34. If the donor is 35 or older, the recipient will generally require genetic counseling and should be offered an amniocentesis after conception. An older donor potentially decreases the recipient's chance of success.
How Many Times May a Woman Donate?
A frequently asked question by both donors and recipients related to the number of times a donor may participate in the process. Currently, there are no standards set by the ASRM to track donor participation in programs that would ensure compliance. Essentially, each clinic sets its own standards. Limits to the number of times a donor may donate are related more the concerns regarding the repetitive use of fertility drugs, hyperstimulation, anesthesia, and oocyte aspiration. Presently, most programs limits donors to six procedures in an effort to safeguard them from procedural risks.
The Dynamics of the Oocyte Donation Cycle
Synchronization of Recipient and Donor
Once the screening process is complete, and the consent forms have been reviewed and signed, the recipient couple is ready to begin. Since oocyte donation currently involves obtaining oocytes synchronously with preparing the recipient's uterus, availability of the donor plays a role in the duration of time between the decision to proceed with oocyte donation and completion of the cycle.
The majority of recipients and donors undergoing oocyte donation are placed on Lupron to aid in synchronizing the menstrual cycles of the recipient and the donor. Lupron is administered subcutaneously by injection. Lupron acts as a suppressing agent upon both women's cycles, allowing the physician an opportunity to place both donor and recipient on the same menstrual timetable. In addition, it greatly reduces the likelihood of cycle cancellation due to premature ovulation of a donor's eggs. Typically the Lupron is started on day 2 or 21 of the menstrual cycle and is taken approximately 7-10 days before the patient must return to the clinic for a uterine lining check (through ultrasound scan) and blood hormone analysis. Once it has been established that both the donor and the recipient have been successfully suppressed by the Lupron, the next phase of treatment will begin.
Donor Stimulation and Recipient Hormone Replacement
In a natural ovulation cycle, a woman's ovaries make hormones that prepare the lining of the uterus for implantation of a fertilized egg. Prior to ovulation, the dominant hormonal signal from the ovary is estrogen. Estrogen causes the endometrial lining to develop and induces receptors for progesterone production. To prepare the recipient, it will be necessary for her to take hormone replacement therapy to establish the correct thickness of her endometrial lining for optimal implantation. While the recipient's uterus is being prepared to accept the potential embryo, the donor is undergoing stimulation of her ovaries so that one or more eggs may be harvested. The average donor produces 8-10 eggs under this type of stimulation.
Gonadotropins ((hMG and/or FSH) are injected by the donor daily for approximately 8-10 days. During the stimulation phase of the cycle, the donor will be monitored approximately every other day to unsure that she is responding in the desired way to the medications. She will have ultrasound scans to determine to maturity of the ovarian follicles being produced by the gonadotropins, as well as undergo blood hormone essays to determine the level of hormone in her system. When the donor's follicles are nearly mature, she will be instructed to administer a final, one-time injection of Human Chorionic Gonadotropin (hCG) and egg retrieval will be scheduled to take place approximately 35 hours later.
The HCG helps to ensure that the donor will not ovulate these now mature eggs, and will also help the final stages of maturation prior to egg retrieval.
Egg Retrieval
Once the donor is scheduled for egg retrieval, the recipient will begin supplementing progesterone to prepare the uterus creating the optimum environment for embryo transfer.
Egg retrieval is performed while the donor is sedated, using ultrasound-guided aspiration to harvest all the mature follicles. Once the eggs have been retrieved from the donor, her involvement is complete. The donor is then compensated and asked to return after her first menstrual period for a follow-up examination. Due to the potential risk of infection during egg retrieval, the donor is prescribed a course of antibiotics to take after the procedure.
On the day of retrieval, the recipient's partner typically provides a semen sample, which will be processed for fertilization of the eggs. Donor semen may also used and is processed in the same manner. The eggs are cultured in the same manner as would be customary for any other IVF procedure.
Embryo Transfer
Embryos are usually grown for two or three days and typically transferred to the recipient female three days after fertilization. In some cases an embryo will be grown to the blastocyst stage and will be transferred on the fifth or sixth day after fertilization. It is important for the recipient couple or woman to discuss the quality of the embryos with the physician and embryologist, as the number of embryos transferred may depend upon the quality of the embryos. In most cases, only two embryos of high quality will be transferred at one time to prevent pregnancy of more than twins from taking place.
The remaining high quality embryos may be cryopreserved for future transfer. This is especially helpful in the event that the initial transfer does not produce a pregnancy.
Legal Issues
Donors should be counseled regarding the risk of hyperstimulation of the ovaries during stimulation and the risk of infection during egg retrieval. Other possible risks to the donor include bleeding or an adverse response to anesthesia. At this time there is no risk associated between egg donation and ovarian cancer. Ongoing research will of course continue in this area. The risk factors in a cycle of donation should be well documented and kept in the donor's medical chart.
Recipient couples and women should be advised regarding the legal issues applicable to third part parenting. Although obtaining legal counsel is not obligatory, attorney referral may be helpful in especially complicated cases. The liability for donor injury and possible extra medical expenses and insurance coverage should also be discussed with both the recipient and the donor.