Donor egg and embryo treatment can offer different routes to building a family, but the practical details—from donor information to what a guarantee actually covers—deserve close attention, says Dr Roisin Mortimer, IVF Specialist, Waterstone Clinic, Ireland.
Hosted by: Dr Shabana Bora, MBBS, MRCOG, Consultant Gynaecologist, Fertility Specialist & Co-founder of ALMA Fertility, UK.
The choice of donor eggs can begin with finding out which eggs a clinic will accept, rather than selecting a donor. Egg banks in Ireland are limited, largely because of the small gene pool, so eggs are often sourced from Cyprus or Spain. Many clinics import frozen eggs only from clinics whose freezing procedures they trust.
That confidence matters because freezing eggs is technically harder than freezing embryos, and protocols can vary. A receiving laboratory will want to know how the eggs were frozen, what they were frozen on and how many were frozen per straw. A clinic’s affiliation with an overseas bank and its willingness to accept that bank’s eggs are worth checking before making a choice.
The route also has implications for donor information. Ireland does not allow anonymous donation; when imported eggs are used to create embryos that are transferred in Ireland, a resulting child should theoretically be able to obtain more information about the donor in the future. In Spain, patients can receive only six pieces of phenotypic information, such as height and weight. Whether treatment uses fresh or frozen eggs can affect which country’s rules apply, so patients should clarify the arrangements for their particular pathway.
A guarantee can provide financial reassurance, but the details determine its value. One bank may guarantee that eggs survive thawing; another may guarantee one or more embryos reach the blastocyst stage.
A common arrangement offers one blastocyst guarantee for a batch of six to eight eggs. When 12 eggs are purchased, the guarantee may increase to two or three blastocysts. Some programs offer a live birth guarantee, but at a much higher upfront cost.
The conditions can be as consequential as the headline promise. Some programs have strict semen-testing requirements, including completely normal results within the past six months, even when sperm morphology is 3% rather than 4% normal forms. Policies may also change when eggs are transported between clinics.
Patients can also ask whether a pregnancy after transfer affects a guarantee when treatment produces fewer embryos than promised. Some banks may not honour the remainder of a blastocyst guarantee in that situation because their goal is live birth. Before committing, it is worth establishing exactly what outcome is covered, which eligibility criteria apply and whether moving eggs between clinics affects the agreement.
Embryo donation offers a different pathway: embryos already created by others are made available to recipients. It can appeal to people who have surplus embryos, do not want them discarded and wish to help create another family. Recipients may include single women using donor sperm, women who have reached the end of treatment with their own eggs, and couples with both male and female factor infertility.
Availability is limited because not everyone with embryos in storage wants to donate them. The pathway described used the same donor eligibility criteria as egg and sperm donation: ages 18 to 35 for an egg donor and 18 to 45 for a sperm donor. It also required counselling and screening for medical and inheritable conditions.
Already-created embryos undergo retrospective screening at the point of donation. This includes virology and other infectious disease considerations, as well as carrier typing and cystic fibrosis carrier testing. Retrospective screening involves assumptions about whether infectious disease issues were present when the embryos were created.
In the clinic pathway described, more than two top-quality embryos were required for donation. Recipients were given the number and quality of the embryos, along with characteristic information such as height and weight, before deciding whether to accept or decline. One set of embryos was generally assigned to one recipient to create one family, unless donors had multiple embryos and consented to creating two families.
Unlike the donor egg programs described above, embryo donation did not come with a guarantee or refund policy. The pathway is relatively cost-effective, with the main costs arising from screening, workup, administration and frozen embryo transfer. That difference makes it particularly important to consider both availability and cost when comparing the routes.
Questions about genetics can be especially personal when considering donor eggs. Nuclear DNA is contained in the nucleus, where the chromosomes discussed in maternal and paternal inheritance are found. Mitochondrial DNA is separate: mitochondria sit outside the nucleus and act as the cell’s energy engines.
The mitochondrial contribution was described as about 37 genes and 1% of genetic material. It is small compared with the rest of the genetic material, but it is part of the inheritance picture patients may want to discuss.
After unsuccessful treatment with their own eggs, patients may wonder whether they should investigate other possible problems before moving to donor eggs. Maternal age is a major predictor of pregnancy after transfer, and clinicians may investigate failed transfers sooner at age 30 than at age 44 or 45. Whether previous embryos were tested can also shape that discussion.
If transferred embryos were tested and all were euploid, meaning chromosomally normal, possible investigations include hysteroscopy and evaluation for endometritis. With untested embryos, it can still be reasonable to discuss those tests, an HbA1c test to check for diabetes, and possibly karyotype or antiphospholipid testing. Proceeding directly to donor egg treatment without a workup can also be reasonable; the choice depends on the circumstances and the patient’s wish to look for other potential issues first.
A separate decision is whether to use PGT-A, a test of embryos for chromosomal normality, in a donor egg cycle. A paper discussed from Fertility and Sterility found that testing in donor egg cycles did not lead to live birth faster and may slightly reduce the chance of live birth. The test is invasive and cannot improve an embryo, so the recommendation presented was against routinely testing embryos in this setting. A program that requires PGT-A raises questions about why the test is needed, its added cost and its effect on any guarantee.
Different donor pathways meet different patient priorities. Some people may place the greatest weight on future donor information; others may focus on cost, embryo availability or the reassurance offered by a guarantee. A clear discussion with the clinic about the legal route, screening, testing and the exact terms of any promise can help patients choose with more confidence.
First, check whether your clinic will import eggs from the clinic or bank you have chosen. Freezing eggs is technically harder than freezing embryos, so clinics may only accept eggs from affiliated clinics whose freezing protocols they trust.
Legislation also differs between countries. Anonymous donation is not allowed in Ireland. If imported eggs are thawed, inseminated and transferred there, a child born from treatment should theoretically be able to obtain more information about the donor in future.
For an anonymous route, a fresh donor egg cycle in Spain may be an option. Donation must be anonymous there, and only six phenotypic pieces of information, such as height and weight, can be provided. The main decisions are whether your clinic will import the eggs and whether you want an anonymous or non-anonymous route.
The lab director and clinician should understand exactly how the eggs were frozen, what they were frozen on and how many were frozen per straw.
A guarantee can indicate how confident the clinic is in its freezing ability and how the eggs are expected to thaw and perform. Ideally, a guarantee would extend to blastocyst stage or beyond. A blastocyst guarantee often provides a good balance between price and expected success, although a more extensive guarantee generally comes at a higher premium.
The most common arrangement is a blastocyst guarantee for a batch of approximately six to eight eggs. If you purchase 12 eggs, the guarantee may increase to two or three blastocysts.
Some programs, such as Shady Grove in the US, offer a live birth guarantee, but the upfront cost is much higher. Guarantees have specific eligibility criteria, particularly for male factor. Some require a WHO morphologically normal semen analysis, even where the difference is 3% versus 4% normal forms. Programs usually require all criteria, including a normal semen analysis, to have been met within the past six months.
Yes. The outcome depends on the bank and the exact wording. A guarantee may only cover the eggs surviving thawing, with no promise of an embryo. Alternatively, it may guarantee one or two blastocysts.
Policies can also contain conditions. For example, if you buy 12 eggs with a two-blastocyst guarantee but the first transfer results in pregnancy, a bank may not honour the rest of the guarantee, citing its goal of live birth. Terms may also change when eggs are transported between clinics, particularly if another clinic handles thawing, fertilisation, culture and transfer.
Dr Shabana Bora: Embryo donation is less common than donor egg treatment in the US, but it can be a good option for people with surplus embryos who do not want them discarded and wish to help another family.
Eligibility follows egg and sperm donation criteria, including age limits and screening. The donor age criteria were 18–35 for egg donors and 18–45 for sperm donors. Because the embryos already exist, retrospective screening at donation includes virology screening, carrier typing, cystic fibrosis carrier testing and counselling.
The clinic required more than two top-quality embryos. Recipients received information such as height, weight, embryo number and quality, then accepted or declined. Generally, one set went to one recipient family, unless donors had multiple embryos and agreed to two families.
There was no guarantee or refund. Costs mainly covered screening, workup, administration and frozen embryo transfer.
Mitochondrial DNA is separate from nuclear DNA, which is contained in the nucleus and includes the chromosomes discussed in maternal and paternal inheritance. Mitochondria are outside the nucleus and are passed on maternally because they are present in the egg.
Mitochondrial DNA accounts for about 37 genes and 1% of genetic material. When a donor egg is used, that 1% comes from the donor, not the father.
At 46, after a miscarriage at nine weeks and three failed IVF cycles with your own eggs, it is understandable to feel hesitant about donor eggs. Maternal age is the biggest predictor of pregnancy after transfer. Three failed transfers at 30 may prompt investigation sooner than three at 44 or 45, when success is much less likely.
If the embryos were tested and all were euploid, I would want a hysteroscopy and evaluation for endometritis. Some clinicians also perform an antiphospholipid screen and recurrent pregnancy loss evaluation.
If the embryos were not tested, it is still reasonable to discuss hysteroscopy, endometritis testing, HbA1c to check for diabetes, and possibly karyotype or antiphospholipid testing. Proceeding with donor eggs without a workup is also reasonable, although wanting to investigate other causes first is understandable before investing emotionally and financially.
I do not think clinics would offer guarantees based on embryo testing. The broader question is whether PGT-A should be done in donor egg cycles.
Donor eggs generally come from younger donors: up to age 35 in the UK and often up to 32 at many banks. The study discussed found that testing for euploidy did not lead to live birth faster and may slightly reduce the chance of live birth. The test is invasive and cannot improve an embryo.
There is a relatively strong recommendation not to test embryos in this setting. If a clinic offered a testing-based guarantee, I would question why testing was necessary, as it adds expense without benefit to the patient.
