CHAPTER 16

Using Donated Eggs

One of the newer ideas in the area of reproductive technology is that of egg donation. This practice is becoming very popular for a variety of reasons, and the technology can now help women overcome fertility issues related to egg quality or quantity. The process of egg donation has not been without controversy, but this has not slowed down the use of this ever-broadening aid in the field of fertility.

When Is Using an Egg Donor Appropriate?

Egg donation is a relatively new technology in the field of infertility treatment. It affords new hope to previously infertile women who have poor egg quality or quantity. Egg donation involves the removal of eggs or oocytes from one woman (the egg donor or donor) and placing them into the uterus of another woman (the recipient). This can be beneficial for a variety of reasons.

Egg donation provides hope if you are suffering from premature ovarian failure, if you have had your ovaries removed, if you have been through menopause, or if you are unable to ovulate for any other reason. It can also be used if for some reason you cannot use your own eggs, as in the case of genetic problems or concerns.

Pregnancy rates with egg donation vary, but are much higher for many couples than doing IVF with their own eggs. This can be due to the factors that are causing your infertility, or simply the fact that the donors are typically younger and are more likely to have a higher degree of fertility. Always be sure to ask about the donor egg success rates of your particular fertility center before starting the process.

Preparing for Your Cycle

Once you've made the decision to proceed with egg donation, you'll need to do some research. There are many things that you'll need to consider before you are ready to select a donor. Using an egg donor is a very extensive process and very much more involved than using a sperm donor. Your donor will need to go through most of the IVF process: She'll take the injectable medications and go through the egg retrieval. That also means she'll be in for monitoring every morning, thus committing a great deal of time and energy to the process.

Cost

A single cycle of egg donation can easily run $15,000 to $30,000, depending on the type of cycle you are doing and if you need any additional treatments, like ICSI or cryopreservation. In addition to your medical costs, like screening, medication, and your embryo transfer, you'll also be paying for all of her expenses, including her medication, monitoring expenses, her egg retrieval, and screening. Most clinics also purchase a temporary health insurance policy for her so that any medical costs (related to potential complications from her cycle) incurred during the cycle are not passed on to her.

Keep in mind that your insurance will not cover any of the expenses related to your donor. Your policy may cover your transfer, medications, and basic testing. You should follow up with your insurance policy to determine what, if anything, will be covered.

Finally, if you are using an anonymous donor, you will need to pay her compensation. This varies widely according to where you live and the standard rate in that area. It can range from $4,000 to $8,000 per cycle, or even higher. You should know that the American Society for Reproductive Medicine ethics committee guidelines state that “Total payments to donors in excess of $5,000 require justification and sums above $10,000 are not appropriate.” There are many clinics and agencies that pay their donors above $5,000 based on the local “going rate,” but you should be wary of any center that tries to charge you more than $10,000 for donor compensation.

Exclusive Cycles

Most clinics offer two types of cycles: shared and exclusive. Which one you choose will depend on you. If you are using a known donor, or sometimes even an agency donor depending on the policies of your clinic, you will need to have an exclusive cycle. When doing an exclusive cycle, all of the eggs retrieved from the donor will become yours.

The cost, of course, is much higher than when sharing the eggs, but you are much more likely to have frozen embryos at the end of your cycle, simply because you are likely going to receive more eggs. Having frozen embryos is beneficial because if it doesn't work, it will be much less expensive to do a frozen transfer than to do a second cycle. Also, if you do become pregnant and want to have more children, having those frozen embryos to use means that your children will be full genetic siblings.

Shared Cycles

The other type of cycle is a shared one. This happens when your donor is matched both with you and another recipient at the same time. All parties involved remain completely anonymous, meaning that you don't know anything about your donor or the other recipient and they don't know anything about you.

Sharing a donor splits the donor's cost between the two recipients, making the cycle significantly cheaper and often more feasible for couples. Keep in mind though that you'll also be sharing the eggs retrieved from the donor.

All three of your menstrual cycles will be coordinated together and you will be dependent on each other as the cycle proceeds. This means that if your other recipient has, for example, a small ovarian cyst that requires waiting a month or two before cycling, you will need to wait too. It also means that they will wait for you if you need to delay cycling for a month.

The eggs retrieved from your donor will be split in half and distributed evenly between you and the other recipient. Some programs may have other policies in place for couples that share a donor, so make sure to ask. However, because you only receive a fraction of the eggs, you might not have embryos left over to freeze.

Using a Known Donor

Using a donor you know, or a known donor, is another popular option in the field of egg donation. You may have a friend or family member who is willing to donate her eggs to you. This is usually a great option for you if you have this available.

Using a known donor, and hence the eggs of someone you know, can give you many benefits. It allows you to be more genetically related to your baby (if your donor is your sister or other relative). It can remove some of the fear of the unknown out of the process. It also allows you to have contact with your egg donor.

While all of these points may be beneficial, they may also weigh heavily on your mind. You may wonder if the stress on the donor is too much. Perhaps you're worried about everything you are putting her through. It's best to be open and to discuss these issues with whomever you've chosen as your donor. This can prevent hurt feelings and feelings of frustration down the road.

Even when you are using a known donor, you will be asked to see the psychologist or mental health professional at your clinic. This meeting will usually include the donor as well as yourself, and may also include the partners of both you and your donor.

Who Should I Ask?

The woman you ask to donate her eggs must match the criteria set forth by your clinic. She should be in her twenties or early thirties, healthy, and, of course, not a blood relative to your partner. She shouldn't use drugs or smoke cigarettes (they can affect egg quality). Most importantly, her hormonal testing should indicate an adequate ovarian reserve.

How Do I Ask Her?

Now, let's say you have someone in mind to be an egg donor, but you don't know how to approach her about the issue. Look for signs that this person might be open to being a candidate and find a time to talk when neither of you will be interrupted. She may or may not know of your struggle to have a child. You might have to fill her in on the details.

Once you have told her of your fertility journey, explain to her the process of egg donation. Tell her that you would be honored if she would help you by being your egg donor; then tell her you want to give her space and time to think about the proposal. This is, after all, a huge decision. Explain that you have a host of people who would be willing to talk to her to get her more information if she needs it. Also assure her that your relationship will not be harmed if she chooses to decline being your egg donor.

Then back away and give her space. She may have questions you can't answer. She will possibly need to consult with other people before making her decision, like her husband or partner, her religious counsel, or her doctor or midwife.

When doing a donor cycle, sometimes you are able to get more eggs than you can use. These eggs belong to you. You will be able to attempt to save them for a later cycle and complete a frozen embryo transfer.

She may not agree to this proposal; this might be something that she cannot do for whatever reason. If this is the case you do need to respect her desire without letting it hurt your relationship.

Selecting an Anonymous Donor

Choosing a donor is a huge deal. The person that you and your partner choose will be the DNA behind your future baby. For some couples, they do not wish to know who this person is or much about her. This anonymity is very important to them.

Your fertility center may also participate in a program for donor recruitment. That means you are allowed to go out and place ads or otherwise solicit egg donors. A potential donor contacts the fertility clinic directly, so you avoid all contact with her, and her eggs are earmarked specifically for you if she is determined to be suitable.

You and your partner may prefer an unknown donor. This may be because you do not know anyone who would make a suitable donor for you, or it may be that you prefer not to know the donor. Either decision is perfectly appropriate. Having an anonymous donor is more common than a known donor in many areas. It also prevents you from having to explain your fertility issues to someone else, if you have chosen to keep your fertility problems a secret.

Your fertility clinic will have a protocol by which a donor is chosen for you. You will be asked to select criteria you wish to base your choice of egg donor on. This could be eye color, hair color, body build, ethnicity, religion, or any number of other factors. Some fertility clinics will offer you physical and educational sketches of potential donors. Some fertility centers may also ask you to send in a photograph. Ask your fertility treatment team or the donor egg coordinator what the actual process is for your center.

No matter how your donor is chosen for you, be sure that you are completely comfortable with the process. As you've read multiple times, this is a huge decision and not one that is made lightly. Talk to the donor egg coordinator at your fertility center about how the process is kept anonymous. This will help you if you fear finding out who the anonymous donor is for your cycle.

The cost of an unknown donor may be slightly higher per cycle than that of known donor. This is because there is usually some form of compensation offered to the donor for her time and trouble in this setting. There are agencies set up to do nothing but provide fertility clinics with egg donors. They are usually more expensive, but often do more extensive searching for the egg donors. This may reduce the wait you have for a donor.

Factors to Consider

Choosing an egg donor may seem very overwhelming, and a lot depends on the system your fertility clinic has in place. You will be given specific instructions and advice on picking a donor. Though the process varies a bit depending on which type of donor — known or unknown — you “choose to use.”

Ask your fertility center about donor matching fees. Do they charge a fee to match you with an egg donor? If so, how much is it? What services are included in the fee? Is it refunded if they do not find a donor? Will it be waived if you find your own donor?

No matter what, when choosing a donor you are likely to have physical, mental, and emotional preferences. If there is something that you feel very strongly about, remember to talk to your egg donor or your fertility center's donor coordinator about your preferences. Here are some typical things that you may have a preference about in your egg donor:

• Age

• Religious background

• Ethnicity or cultural background

• Genetic issues

• Hair color

• Eye color

• Education level

• Hobbies

• Availability for a second donation

• Height

• Weight/body type

Factors used in selecting a donor like hobbies and educational background are not known to directly relate to what your future child will be like. However, they may be more comforting for you or for the potential donor.

Whomever you decide to use as you choose a donor is perfectly acceptable. Do not let the preferences of others influence you as you make your decision. This needs to be a 100 percent decision for you and your partner.

Screening the Donor

Most egg donors are between the ages of twenty-one and thirty-four. This is the current recommendation by the ASRM. Women over the age of thirty-four have an increased risk of genetic problems in pregnancy (for example, Down's syndrome) and a decline in natural fertility. Some fertility centers also require that the egg donor have proven fertility, meaning she has been successfully pregnant prior to her egg donation.

One of the first steps in selecting a woman as a donor is a psychological evaluation. The potential donor will usually have a one-on-one chat with a psychiatrist, psychologist, or social worker, depending on the fertility clinic. This professional is someone who is familiar with the special needs and issues surrounding egg donation.

Once the egg donor clears this stage, the physical exams begin. Some fertility centers choose to start with blood screening. The egg donor's blood will be tested for drug use, medications, diseases, and so forth, to ensure that the donor is in good health.

Most fertility centers will provide the donor with short-term health insurance to cover problems that arise from the donation. This fee is usually charged to the recipient. This prevents the recipient from suddenly having to pay out of pocket should some medical problem arise from the egg donor's harvest or treatment.

In addition to the blood work, the donor will undergo a complete physical exam. Some fertility centers allow this exam to be performed by the donor's own physician, while others choose to have the physical exam done by their office. This will include examining her reproductive tract and screening for reproductive health.

A detailed medical history is also taken at this time from the egg donor. Occasionally, she may be referred to a genetic specialist if there are questions and concerns about her genetic history.

Using an Egg Donor Agency

An alternative to having your clinic find your donor is to contact a private egg donor agency whose sole purpose is to recruit donors. Generally speaking, an agency has a greater selection of donors. Working with an agency to find a donor can also be a lot more expensive. In addition to paying the match fees, which are usually higher then what you'll pay at your doctor's office, you'll also pay travel fees for your donor and a companion. That includes airfare, hotel, and food expenses. The companion needs to be with her for after the egg retrieval, so she's not alone in case of complications.

If you are looking for someone with a very particular set of traits, and your clinic doesn't have anyone who fits that description, it may be beneficial to check out a couple of agencies to see if they have a donor that you might like. You do need to be careful though; if you select an agency donor, she must meet the criteria set forth by your clinic. Before agreeing to work with an agency, you should ask a lot of questions:

• What happens if the donor isn't accepted by my clinic for medical reasons? Can I get my deposit back?

• What happens if she begins taking medications and she doesn't respond well or is canceled because of a medical reason? Do we get a refund?

• Do you have any donors that are local to where I live?

• What kind of information can we get about her?

• What is your financial policy?

• What are my legal obligations?

• Have you worked with our clinic before?

You should get all of this in writing before you agree to use the agency. You can ask to see a copy of their contract and consult with an attorney before you sign any paperwork.

You'll also want to make sure that the agency is licensed to work in the state where your clinic is. The clinic will need a copy of their license before working with them, otherwise they won't be able to do business with the agency.

Cycle Coordination

Once you have selected your egg donor — whether it is a known or anonymous donor — you will choose a time to synchronize your cycles. It is imperative that you both be hormonally regulated to the same cycle, using a variety of medications.

Synchronization is a very important step in the process of using donor eggs. This will ensure that your uterus is at the right phase to accept the eggs from the donor at the time they are ready. If this step is not done, or if it is done incorrectly, it can lead to an entire cycle being wasted.

What She Does

Your donor will begin oral contraceptives during her period. She will then be placed on a medication like Lupron to prevent her from ovulating too early. After the Lupron she will begin taking stimulants to induce ovulation. Remember, the goal is to get as many good-quality healthy eggs as possible in one retrieval. She will be monitored by blood work and ultrasound to choose the day to trigger her for release and retrieval.

What You Do

You will also be preparing your body during this process. You will not be taking stimulants to help you ovulate; instead you will have your ovulation suppressed during this cycle so that you do not spontaneously ovulate, usually by taking Lupron. You will be given estrogen supplements to help build a strong lining (endometrium) in your uterus.

Will I run into my donor at the fertility center?
Great care is taken during anonymous cycles to ensure that the egg donor and the recipient's partner are not in the fertility clinic where they are able to run into each other. Even if the donation is anonymous, and the two parties would have no reason to know one another, this is still very important to many couples.

Once the eggs are retrieved, they will be fertilized with your partner's sperm or donor sperm (whichever you have decided upon). The eggs will typically be incubated for several days before you will take part in the embryo transfer. Any remaining embryos that are not put back into your uterus are normally frozen and are yours to use at a later time.

Once the embryo transfer is done, you begin the two-week waiting period to see if the pregnancy takes hold. Waiting for the pregnancy test is difficult. You will be taking daily progesterone to supplement your body to support the pregnancy. This will continue until your reproductive specialist tells you to stop, usually until you are about twelve weeks pregnant.

Cycle synchronization is a vital element to your egg donation. Talk to your doctor or fertility team if you have any questions about how it will be done. This can be a very exciting time, but it can also be a time of worry. You have to leave the control of the stimulation medications to the egg donor that you may or may not have contact with. Take heart in the fact that many of the egg donors who are anonymous have done this before. The egg donor is also given all the tools she will need for a successful cycle.