By fertility experts from Spain.
Considering egg donation treatment in South Africa? Dr. Femi Olarogun, Fertility Specialist at HART Fertility Clinic, Cape Town, discusses legislation, IVF law and procedures in South Africa.
There’s an age limit for recipients Around the world the concern is if you have somebody much older about a 60 or 65 years old having a child what is the ethics around that. That’s always a concern, so there are different bodies around the world have put limits on what they think the practitioner should do. For egg donation at about 50 up to the age of 52 years old, there are no questions asked, especially if the woman is healthy without any issues. You can go ahead and do it up until the age of 55. In other words, between 52 and 55 you have to be sure that the recipient is healthy and doesn’t have any major chronic illnesses and she needs to be in a good sort of state of health before one considers that so that would probably be the upper limit. As you know, it’s not about the uterus, as the uterus can carry a pregnancy much later. The problem will be that, by the time the child is five if you are a 65-year-old getting pregnant, the mother is 70, so you don’t want to do that. The ultimate age would be 55, maybe 56. As to patient relationship status, some patients who approach egg donation cycles have relatives, who want the eggs donate for them, so that’s possible. We do advise, even though this might be close relatives for them, to have lawyers deal with the donation later. We insist they should have a contract drawn by a lawyer that explains what the pros and cons may be, and what could happen later on. So one needs to get a contract between the recipient and the donor, and one needs to see a psychologist who then helps you pay attention to certain things that they might not have thought of. Once that’s in place, we can go ahead. As to the donors, most of the donors we have are anonymous donors. They are donors that are recruited by the donor agencies. We’ve done all the work, in terms of screening these donors. Then they come to the clinic to donate. About 95% of the cycles we do is probably anonymous, so the donors are completely anonymous, and they don’t have access to the recipients.
Yes, there are no issues there. Whether it is a single woman or same-sex relationships, that’s all done in South Africa.
Standard tests that I’ve done include the infectious disease screen like HIV, syphilis, VDRL, hepatitis B, hepatitis C. They will have a blood count and all the basic tests. Depending on what the recipient is looking for, if they want extra things done on the donors, for instance, if they have been worried about sickle cell anaemia, we can do it. None of our donors suffers from sickle cell anaemia, but some patients fear that. The full infection screen is done on these patients and has to be done shortly before the cycle is commenced, and then they have to have a psychological assessment. They all have a meeting with the psychologist, usually once a year sometimes, twice a year. Then the doctor treating the patient needs to see the patient or see the donor and examine them. We see the donors and make sure that there are no obvious abnormalities, and at the same time, we make sure that they have not missed out on anything and we interview the donors before every cycle is commenced.
In South Africa, the information is pretty detailed. The patients often have a very extensive history, and a very extensive background check is made and available to the recipients. It would include physical characteristics like age, height, eye colour, hair colour, race. They also can have access to a picture of the donor, but when the donor is young, so it’s going to be a picture of the donor at an age of less than ten years old. That’s also because, for an anonymous donor, you can’t have a picture of an adult. It gives you an idea of what exactly to expect. If there is anything that might be significant in the greater family history of the donor, you will also be able to read about it. It’s quite a detailed screening you get both about the donor and her extended family background.
It is also possible to find out the level of education. You may not find out the details of what degree they have, but if they did go as far as having a degree, educational stages are highlighted in the materials.
The good thing about South Africa is that we are lucky to live in a rainbow country, so every colour of donor you want is present in South Africa. The predominant race is the black population, there is never a shortage of black donors. But you get donors across racial lines: white donors, Indian donors, black donors. We have colour donors that we call it in South Africa, which refers to the mixed-race between blacks and whites. As I said, you have access to a picture of a donor as a child, so you can pick from it.
Unfortunately, that is not allowed. I think probably about seven or eight years ago we were able to do that, but the government a few years ago passed a law that one could not legally do sex selection strictly for reproduction purposes. If there’s a medical indication, a condition one could then select a different gender to – or to avoid the disease that is probably something one can do. It is restricted gender selection.
Traditionally, the fresh synchronized cycles are what most clinics do. But because it’s just easier than coordinating and less expensive, clinics are moving towards frozen egg donation cycles with obvious advantages. I mean, if you have frozen donor eggs available in a lab, it’s quite easy to prepare the recipient and just work with the recipient alone. The timing is a lot easier to synchronize. We have both types available in our clinic, and I think in most clinics in South Africa. The idea will be if you have a fresh synchronised cycle, the risk is that in a very unlikely event, the donor does not respond well to the treatment, then you may get fewer eggs, for example. That is the downside of a fresh cycle, but the upside is that every egg that is retrieved on that particular cycle belongs to the recipient. If the donor produces a lot of good quality follicles, then you have access to a good number of embryos, which means you can always come back for frozen embryo cycles. There are pros and cons. Both are available. From the logistics point of view, and with the fact that we’ve got very good egg vitrification labs available in the country, the frozen eggs cycles are probably a better thing to plan. A lot of laboratories already have strictly frozen egg donation cycles with very few synchronised fresh ones. It depends on which lab you’re dealing with, but both can be offered at our clinic.
No, there isn’t. If it’s a fresh cycle, whatever number that donor brings up in that particular cycle, it belongs entirely to the recipient. If you’re talking about the frozen ones, you get a set number, but if you’re talking about fresh synchronised cycles, all that is produced in that cycle goes to the recipient. If the donor produces fifteen or twenty oocytes, which happens most of the time, you would not need that number of embryos. In theory, however, whatever that donor produces in that cycle belongs to the recipient.
It varies depending on which clinic you go to, as everywhere in the world. Speaking about the HART clinic, you’re looking at a straightforward IVF cycle including medication is up to 60,000 ZAR which I will try and convert quickly into U.S. dollars for you. If you’re looking at an egg donation cycle, which is what we’re talking about, the cycle itself is probably about 80,000 ZAR and if you look at the egg donation agency fees, which is about 20,000, that comes to about a hundred thousand rands. Converted to euros it will be probably about 5500 or 5600 Euro thereabout. In U.S. dollars just about 5000$. For a normal IVF cycle, it is about 3,500 $, so I think compared to parts of North America, for instance, it’s not too bad.
If we have frozen embryos, then it is easier to work out. If the recipient is coming with their partner, we will need to have the recipient here at least three, usually five or six days before the embryo transfer. Provided we have the partners out of the country, we can get the stimulation or the preparation of the recipient. If you have a doctor outside the country or outside of Cape Town, who can do the scans and start preparing the endometrial lining and all that, then you probably only have to be in the country or Cape Town for maybe just over a week. However, if all the monitoring and the stimulation and the preparation of the recipient has to be done by us, then we will need a few more weeks to do that. Even if you start some preparation while being away, you’ll probably still be looking at about perhaps three weeks to get things properly prepared here and to get the transfer done. It could be as short as just over a week, or it could be a bit longer than that, depending on how much preparation one can do outside Cape Town.
We’ve mentioned most of this. It is freely available. We have lots of egg donation agencies, which is where you start from. Every kind of embryo donation is legal in South Africa. Two things could happen there. One is a case of embryos that have been stored in the clinic and that the couple will not use. They have already signed a disposal letter, a legal letter saying that it could be given away, so it is legally possible to do cycles with those embryos. We have a few cycles like that. It’s not very common, but it is possible, and it is legal. Another thing, is a known donation, in other words, if it’s a donation from a couple that knows another couple. In such a case, it is always better to get legal representation and draw a contract between the two parties as well as a clinic, so everybody is covered legally. Then you can go ahead and do the transfer.
At the moment most cycles have been on a slow down up until now, so I think the chances are that the donor will still be available even beyond September. We don’t know what will happen in August or September. It might be that we can travel and we can move around maybe freely at that point. It might not be a problem. If the donor gets selected, we will probably then contact you to work something out. We will see what your time is and what we can do at that particular point in time. It shouldn’t be a problem, and you should be able to still come at the right time. If something changes with the donor, then we would communicate with you and let you know what the story is and try something out from there.
I suspect that the genealogist sites are going to get better. I don’t know too much about them, but I presume they can change chances of tracking back your genes quite far back. They may be able to narrow down what your genetic composition is. You still have to be able to get a confirmation, though. I think donor anonymity will still be protected. As long as you could get quite close, you will not get that confirmation easily. The only concern there is, whether or not it gets to a point, where the court rules that one has to lift the anonymity of the donor or reveal it for whatever reason. Apart from that, I don’t think these sites are going to be as close to what you’re describing.
The donor’s pictures are available, but they were taken when they were younger, usually below the age of ten. The pictures taken of that age group will be projected onto the screen. You can see them on the website of the egg donation agency that we use.
The availability of these varies, but more often than not, we do have African donor eggs that are vitrified, and that could be used. We can offer you that.
Not at all. It’s not necessary to do that. The phenotype does not affect the success of the cycle, so we don’t actually do that routinely. It is possible to request it, if someone of African ethnicity would like to have Caucasian donors, for example. It’s their choice if that arises I will perhaps ask the couple to see a psychologist, which we often recommend anyway, and explore what the reasons of the decision might be. We would look into the background of the person or where that child would grow up, or where that particular sibling would grow up, or if there are any disadvantages that we might subject that child to from the beginning. In theory, it shouldn’t be a problem, but one might be a bit more careful and perhaps get the second opinion.
I don’t know exactly how much of a match you want. If everything you want that you’ve put on this list is exactly what you want, it might be difficult to match exactly that. Having said that, there are lots of Caucasian donors available in our clinic, so I wouldn’t think that it’s going to be a long wait. You could contact the egg donor agency and see what they have, and they’ll send you a list of what’s available and see how close you can get to this list. But generally speaking, you won’t have to wait long to find it.
With the IVF success rates are pretty high. Most clinics around the world will achieve between 50 and 60% success rates, and that’s where we are. These are young oocytes, young donors usually and if the patients are properly prepared in terms of the uterine side of things, then usually we have a good response. With egg donation, the idea is highly recommended if patients have had failed IVF cycles that have not worked out so well.
Most of our donors are between the ages of 21 and 35, actually, legally it is between 18 and 35. We prefer your donors to be at least 21 years old, and the upper limit will be about 30 for most donors. There are probably some at the age of 30 to 33, so I would say roughly between the ages of 21 and 33 is where you’ll find most egg donors.
We need to be sure that the recipient and husband have seen a doctor, made sure that the recipient has a background that we do not need to worry about in terms of things that could go wrong in pregnancy. Then you will see one of our doctors when you are in the country just to make sure everything is alright. The testing essentially includes an infectious disease screen, as well as all the routine test that we do for patients who are trying to get pregnant which include things like HIV. Tests for syphilis, hepatitis B and C, and also rubella. We need to be sure that the patient has rubella immunity. Sometimes we check on the blood group of the patient because they want to know and usually a full block count. Things like thyroid levels are indicated in most panels as well it doesn’t change what we do, but we’ll be good to have a TSH level as. I guess one could include in that broad category of test, an ultrasound scan, perhaps the hysteroscopy to make sure that the uterine cavity is actually ready for the embryo transfer.
The clinic at the moment is in the Foreshore, which is close to Cape Town waterfront. It’s a brand new hospital, state of the art Medicare Hospital. It is three or four years old only, located in a beautiful place really. We are on the 11th floor of that building and the reasons to come to Cape Town, I could spend all day and all evening telling you why. The weather is great, people are friendly, there’s so much to see when the restaurants are open, you don’t get much better. The question will not be why you should come to Cape Town the question would be why should you not come to Cape Town for treatment. We have a lot of local patients obviously then we have lots of patients from Australia, other African countries, we get patients from North America and Europe, especially the UK.
No, it doesn’t matter. I might have mentioned that it doesn’t really matter what the blood groups are. We would check it, but it doesn’t change what we do. We would not actually be looking for a blood group of the patient or recipients as that’s not necessary to do that. Unless, the recipient wants to know that specifically, for whatever reason. It’s an easy thing to do. The person sends us what their blood group is, we will then check within our donor bank for similar blood group. It narrows down your choice, but I’m sure it will be possible to do it.
It’s a very rare thing that happens now and then. You have a donor whom you’ve prepared, and everything is going well and then the donor, for some reason, might have taken injections wrong and the donor just doesn’t have enough eggs. It happens extremely rarely. If that does happen, then we will have to discuss with the patient as to what we have. The options would be to look into the bank. If we have frozen eggs at that point, especially if the patient is from out of town or and look at what can be offered with the patient’s consent. The other option would be to discuss with the patient and get some kind of refund that will then enable them to come back and have another cycle done and prepared with the same donor if they want. We would preferably suggest a different donor. But in any way, they would have to pay less for that if this happens. We have things in place that we can offer to help the recipient. There’s no form of guarantee really, we just we work with it as it happens. With every IVF cycle, you’re aiming for between 8 and 15 eggs and that’s what get in 95%. The donors would give you that kind of number. It’s impossible if you are doing a synchronised fresh cycle, to tell the recipient what an exact number of eggs to expect. We will tell them that these are good donors, but there is no way you can be sure what number of eggs you will get. If you’re talking about a frozen eggs cycle, it is different. Usually, oocytes are frozen in straws, so you’ll be paying for a straw that’s six frozen oocytes or eight frozen oocytes, and that’s what you’re paying for. That’s what the clinic is offering, and then you work from there. With the fresh synchronized cycles, you expect you will get lots of good oocytes, but if you don’t then you work from whatever number you get.
It would take a long time to try and answer all that but what we do advise patients is to try and have a healthy lifestyle in the run-up to their cycles. Avoiding noxious substances like smoking, excessive alcohol intake. Not enough rest, for instance, might be things that one would want to address to get yourself in a state of mind or body where the chances are very good that you’re going to conceive. Beyond that, things like a diet, nothing is entirely proven, but we will advise a diet, that is very rich in vegetables and the run-up to the cycle, lots of water and lots of exercises, lots of rest. So those are kind of things that we need to do, avoid noxious substances, have a healthy lifestyle and try and get your body in the best state possible before receiving treatment.
In our clinic, we would never put back more than two embryos. A default mode in South Africa will be two embryos. There are probably few clinics that are moving towards a single embryo transfer, and on the request of a patient, we can do the single embryo transfer. We won’t go beyond two embryos for most of our patients.