César Díaz García, MD PhD Assoc Prof, Medical Director at IVI Clinic London, is discussing anonymous vs. non-anonymous egg donation that is available to patients.
My advice would be to go to IVI Portugal. We have a very nice clinic in Lisbon and I really know how they work there. Every time I send patients for treatments overseas I personally supervise the KPIs of the clinic because we have a quality control system that is global for the whole IVI group. I can look at the different statistics of the different clinics. I can say that I have never seen any of our clinics not matching the benchmarks but if they don’t, we wouldn’t advise the patients to go there. So IVI Lisbon could be a very good option. I would like to say that, in fact, the prices in the UK are not so expensive if you are considering double donation maybe you could also consider an embryo donation. Embryo donation is a treatment that is much cheaper and is extremely effective because the embryos that have been donated or had been generated with donor gametes both eggs and sperm are usually the quality is super good so that’s something that maybe you could consider.
Yes, I can tell you and I’m going to be very honest with you. We don’t have that many Spanish donors in IVI London but we have a lot in IVI Spain. Here you have two possibilities: if you are looking for donors with features close to those of South Asian people but obviously some of the Spanish subpopulations we have. My advice to you is to go to Spain. You can do it through IVI London if you want so if you live in the UK or if you live close to London, probably it could be a good idea just to come to us. You can do all the medical assessment, we can have a look at the uterus to be sure that everything is OK, do all the pre-treatment tests, send your file to one of the Spanish clinics, look for a donor for you. Once they have a donor, you can travel to produce a sperm sample and do the embryo transfer. Or you can go to Spain before if you want to produce the sample. So when they find a donor, you don’t have to come back. They can generate the embryos and only when they have the embryos, you can organize another trip to Spain. You can basically do everything in 1-2 visits maximum. That would also be a good possibility for you because we do satellite services for our own Spanish clinics.
The rates that I have shown you today are clinical pregnancy rates. It’s not a positive test. It’s a pregnancy that has been defined by an embryo with a heartbeat. Now when that happens there is a slight risk of having a miscarriage which happens in about 5% of the cases in our hands. The statistics that I have shown you today, you can take out 5% more or less if you want to consider live birth rates instead of the last table in which there were the rates.
I would like to tell you that if you already have undergone three unsuccessful embryo transfers with donated eggs, I think the moment has come to do further investigation. It’s not completely normal as I have shown in the statistics. Your chances per embryo transferred are not going to be better. Obviously, the cumulative pregnancy rate – yes, but per cycle no. When we see so many failed attempts, especially with donated eggs, you have two questions, two different things.
The first one is how they are doing things in the lab, which I cannot judge from the outside and I’m not suggesting that they are doing anything bad. The second is to rule out the presence of any problems in yourself that could potentially justify why the treatments are not working. This is what we call an implantation failure or recurrent miscarriage failure study. Sometimes implantation failure and recurrent miscarriage share the same causes. In fact, you have had two implantation failures and one miscarriage so you are somewhere in the middle. Probably it would be a good idea to do thrombophilia screening, 3D ultrasound scan, look at functional aspects of the implantation, look at potential infections and eventually even doing a hysteroscopy depending on the findings of the other tests. Also karyotyping for your husband, not for you because you are using donated eggs but your husband still produces the sperm. There are quite a couple of things that I would look at if you were my patient.
I completely agree with that. Sometimes, as we have just mentioned, there are problems. But, in fact, believe it or not those cases are very insignificant when it comes to general statistics. I’m going to share with you some data from our group data that is not still published just to illustrate this answer. We did a study in one of our clinics in New Jersey specifically, in which we put one embryo back, a genetically tested embryo back, so we knew that the embryo was normal. When the patient didn’t get pregnant, we put a second embryo back also genetically tested. When the patient didn’t get pregnant or had a miscarriage, we put a third embryo back. Sometimes we even had to generate the embryos because the patient didn’t have three normal embryos. We did that with a large series of patients. The cumulative live birth rate, the number of patients who had a baby so not even get pregnant but who had a baby after three embryo transfers of euploid embryos was over 95% so very similar to the egg donation scenario. It means that there is only a very tiny percentage of patients who really have a real problem related to other causes that are outside the embryo. These can be clotting problems, morphological problems with the uterus, immunological problems. There is a whole bunch of things that in some cases need to be tested as the patient presented. But we have to keep in mind that that only represents a very small percentage of the population. Sometimes, from a psychological point of view, it could be very challenging to do extra investigations when things have gone wrong, even after just one embryo transfer. For example, my point of view is that we always have to listen to patients and also take into account other aspects such as psychological aspects, their own psychological wellbeing. If there are other investigations that the patients want to do we can always do it but we have to be very honest when it comes to informing the patients about the utility of those tests.
When it comes to medical results, there is no evidence about one being better than the other. The only impact is the age of the donor. If, for example, a patient is using her sister’s eggs, the donor is, not always but usually closer to the patient’s age so, in general, if we adjust for the confounding effect of the age the results are the same from a medical point of view.
When it comes to the psychological well-being of the future child, the mother, the donor, there is a lot of studies. Most of the studies include only small series of patients although there are also a couple of large series. In general, undergoing a process of non-anonymous donation is beneficial most of the time for all the parties involved and also for the future child. When it comes to an anonymous donation, in fact, again there are also many studies proving that even the fact of donating can be beneficial from a psychological point of view. When it comes to the future psychological well-being of the child, most of the studies agree that it’s important that the parents talk with the child about the way he or she has been conceived. Obviously, there are many ways of talking to the child and those ways of doing it have to be adjusted according to the age of the child so you cannot explain the whole picture to a very little child. There would be moments in their lifetime in which you have to get the information in different ways. For example, there are many different associations working with this type of subject, they even produce very beautiful materials, books about how to how to inform the children. In fact, this is to some extent also the role of the counselors. When you decide to undergo egg donation or sperm donation treatment, you need to have this conversation before you do it.
This is why we always offer it in our clinic. We think is crucial, it’s is really important because you have to be prepared for that moment later on in life. It is beneficial to know. There is no study showing that one type of egg donation is better than the other when it comes to the welfare of the child.
Again, this is a little bit similar scenario to the one with the patient who had two cycles failed. It depends. If the embryos that you use in your previous egg donation, were OK, your chances of having good outcome per treatment are slightly reduced. But obviously they will add to the treatment. Again if you have undergone already two egg donation treatments and you were not successful, my advice is to think about it very carefully and try to rule out the presence of any other cause that could potentially jeopardize the treatment. That’s not a norm that a patient has had two failed egg donation treatments.
The question is a little bit tricky for various reasons. From a strictly reproductive point of view, your chances of success using donated eggs are going to be the same or very similar to pregnancy rates of women between 40 and 60. But the chances of you having very serious problems during pregnancy increase at the age of 45, and especially after the age of 50. Therefore, in countries such as Spain, the UK and most of the clinics in the US, they will not do a treatment in a patient over the age of 50. If you want to do a treatment and you are 52, you really need to discuss that with your consultant but you will need to find a clinic that will want to do it. From a medical point of view, I would strongly advise you against and, again, this is just to protect yourself and protect the health of your future baby. The prematurity rate is very high, the preeclampsia rate is very high, the risk of pre-term delivery, infant morbidity and mortality are also increased. If you find someone who agrees to do the treatment, my advice also would be to do a very thorough check-up, including the cardiovascular system which is extremely important.
First of all, I want to highlight that this program works in our Spanish clinics, fro example in IVI Alicante; it does not work in any our clinics in the world; it does not work in our UK clinics, it does not work in our United States or Italy clinic. We decided not to implement it elsewhere because the success rates are so high that we think that is not necessary. In this program, first of all, you need to pay in advance for the three cycles and, obviously, if you get pregnant after the first or the second treatment, you will not get any reimbursement for the cycle that you haven’t done.
If you do three treatments and you don’t get pregnant, you will get 100% money back. I have also to say that not everybody can be included in this type of program. You have to meet some criteria so basically patients with known factors for implantation failure will not be accepted in these type of programs, for example, patients who are really obese with a BMI that is very high, or patients with uterine malformations. Why? Because in such scenarios no matter how good the egg donation is, how good the embryo is, the chances of having a successful treatment are going to be always lower. Some of those causes we can correct and then you can benefit from these types of programs, some of them cannot be corrected, for example, a patient having a unicornuate uterus. But other causes like obesity can be corrected. I’m not saying that is easy but they can be correctly so before you think about it, my advice is again that you discuss it with your doctor. Also, see if the program is interesting for you, especially knowing that you have to pay all the money upfront and, secondly if you can benefit from it.
We have 30 clinics in Spain including satellites but we only work with 9 of them. Why? Because those are the cleanest clinics, with the strongest egg donation programs – they have a lot of donors, they even share donors in between clinics so it’s very easy to access a huge number of donors and also because they also have international departments which means that there will be someone speaking English, French, Italian or German who can deal with you directly so there will be no communication problems. Obviously, if you do it through IVI London, we will also give you a hand with that but those clinics include Alicante, Madrid, Barcelona, Majorca, Valencia, Seville, Canary Islands. Murcia and Bilbao.
In the UK they are a little bit longer I have to be very honest with you. It takes about 2-3 months to find a Caucasian donor. You can also find a donor through an external agency. We collaborate with an agency called Nurture but our program I would say is strong enough. In Portugal, the waiting list is slightly shorter. They have a bank that is bigger than ours so maybe you don’t even have to wait.
If you have fibroids, first of all, we do an ultrasound scan, depending on the findings a hysteroscopy to be sure that the fibroids are not encroaching the cavity. If the fibroids touch the endometrial cavity, the implantation rate will be reduced by 70% – that’s a lot. Then after ruling out the presence of fibroids distorting the endometrial cavity, I would do a thrombophilia screening to be sure that there are not clotting problems, the karyotype of the partner, comprehensive microbiological analysis of the endometrial cavity, too, and, eventually, and endometrial receptivity assay but that would be at the very end of the list.
This is a very good question. I think that unless they do a specific law for egg donation, the answer is going to be no. We have a law in Spain called the Organ, Tissue and Cell Donation Law and because they decided to put the eggs as if they were other type of cells like they were bone marrow or skin cells, they put them under the same law. I would say that it’s going be very difficult that they change that law because that law is, from my point of view, designed to protect the anonymity of organ donors. I don’t know if you are aware but we have probably the biggest and most important organ donation program in the world. We are very proud of it so they will do everything to protect that program. For me, the only way of having non-anonymous egg donors in Spain would be today create a new law in line with the fertility law that regulates other types of IVF treatments and then put the egg donation under the umbrella of that law, as it happens in the UK. We, the doctors, are debating that a lot in Spain. We are also debating another type of treatment such as surrogacy which is not legal in Spain but it is in the UK. I’m pretty sure that probably the perfect model in the future will be a model allowing for both types of egg donation – that’s my point of view.
Usually, when someone has such a complicated medical history I usually like to have a careful look at the records but just by having a look at what is written in the message I will say, first of all, if you have hydrosalpinx and it has been clamped, you have to be sure that it has been clamped correctly. Sometimes when clamping the fallopian tubes, you do not completely isolate the fluid that then goes into the cavity. Secondly, having Atosiban in an embryo transfer is something that still is done in the research context but it could be a good solution for hypercontractility so I agree with that.
The endometrial biopsy – I don’t know what type of endometrial biopsy do you refer to. I would say that the first thing that you need when doing an endometrial biopsy is to have a very good pathologist who can read it. Because it’s not so simple and usually pathologists are not used to dealing with fertility samples, they don’t know how to do it. For example, looking for plasmatic cells is very difficult. Nowadays, we rely more on regular methods rather than on the anatomy study of the biopsy.
As for polyps, unfortunately, sometimes they can be missed or it can happen that the polyp was not there in the first treatment and it grew between the first and the second cycle. A polyp can be removed so this does not create a problem. As for scratch, we don’t do a scratch. We abandoned that a couple of years ago. There was a huge randomized control trial proving that they were useless. Still, after all of these, you had a miscarriage so I will say that the two tests that you have not undergone yet which is a thrombophilia screening and karyotype for your partner. I would do those.
I don’t know anyone working in Poland. I am sure that there will be very good clinics also there but I don’t know anyone, unfortunately. When it comes to the endometrial receptivity assay that will tell us the day to put the embryo in but it will not tell us if there is any problem with the bacteria living in the uterus, called the microbiome. You can do another test called EMA test at the same time that you do the ERA test, it is done by the same company, Igenomics. Then another possibility that you should discuss with your doctors is changing the donor. Even though we screen the donors very intensively sometimes donors can also have fertility problems. It’s not usually the case and it happens very rarely but that’s something that you should consider and discuss.
This can be a little bit tough to read but my recommendation would be to read peer-review academic journals such as Human Reproduction, Human Reproduction Update or Fertility and Sterility – probably, those are the three best journals in the field of reproductive medicine. I feel very proud because I have been an associate editor of two of them and I collaborate with a third one. If you want to be really up to date those are the journals to read but, on the other hand, the way the papers are written is very technical. Those are journals for doctors. Nowadays, a lot of the patients know even more than doctors; they read a lot so if you feel comfortable with that, that will be my suggestion. Otherwise, there are general books for Reproductive Medicine, even on a specific subject such as reproductive immunology, recurrent implantation failure, so the choice is very broad. If you want just to stick with one option, probably my recommendation would be Human Reproduction Update. Why? Because they basically summarize the findings of other journals and other studies so it’s a very good digest of what is already there.
Yes, it is. You have to be very honest. That’s not a good result but I also have to say that maybe the problem is not the donor. We will also need to have a look at the parameters of your partner and maybe there is something else. This is why I also insisted in the karyotype of your partner.
You can do it in 1-2 visits one day each or if you want to do the whole thing there, you can spend up to 15-21 days in Spain so it really depends on how you want to organize it.
If by the extra genetic test you mean the CGT, the compatibility genetic Testing, I think this is a personal decision based on efficiency and cost. My recommendation would be to do it because you are covering many more things for a very little increase in the price as compared to the cystic fibrosis test. This is also extremely important because we are talking about conditions that are very rare so the chances of matching to a carrier are very low. For example, if finding a donor for you is very difficult and you don’t want to restrict your choice by adding more tests, you could decide not to do it but, in general, I think it’s a very good thing to do.