By fertility experts from Spain.
In this webinar, Dr Elias Tsakos, FRCOG, Medical Director at EmbryoClinic, Thessaloniki, Greece, has been discussing the egg donation process, how the egg donors are selected and matched with recipients. He’s also talked about egg donation pros, cons, and dilemmas.
It depends on your age, it’s a different definition if someone is 35 or 40. As you are 39, we would be very happy if we created one or two top quality blastocysts, so this is my definition for your age. It is very important to create blastocysts. I think most of us now, most clinicians and scientists, agree that embryo culture should go as far as the blastocyst stage because this is the time when we have a lot of information about our embryo. At 39, we would like to see one or two top quality blastocysts. If we don’t, we’re probably talking about poor quality. We may see no blastocyst at 39 or one, two blastocysts, which are not of good quality, either lagging in development or showing signs of fragmentation and so forth. For a 35-year-old, I would expect, hopefully, to have maybe at least two or three good quality blastocysts with one stimulation cycle, so the definition varies mainly depending on the age.
In my opinion, no. In Greece, it’s not legal to do PGT-A or Preimplantation genetic screening. In my opinion, it’s not necessary because we’re talking about young, healthy potentially, fertile or donors with non-fertility, so there’s no indication to look for aneuploids.
I’m afraid, yes, is the answer. Absolutely, yes. Generally, the miscarriage rate is lower with egg donation or embryo donation compared to IVF with own eggs. However, miscarriages happen, and no one and nothing in the world can ensure that they’re not going to happen. This is a human issue, of course, egg donation usually is used for women with some sort of adverse reproductive history or advanced age, so the chance of having issues other than embryo quality is there.
The miscarriage rate is a combination of the quality of the embryo, which with embryo donation is as near perfect as possible and the quality of the environment that we implanted in. As well as the quality of the recipient, so yes, it is likely. I mean, we’ve always thought that a big proportion of miscarriages is due to the embryo quality. We’ve always known that the implantation environment, which involves not only the uterus but also all the pelvic environment, the hormonal, the biochemical, the blood environment of the female is also important.
Don’t wait until you become the late 40s before you resort to egg donation. The risk of miscarriages and the ability to carry a healthy pregnancy is one of these reasons. If there is an indication for egg donation and if you exhausted your chances with IVF with your own eggs, do not delay your egg donation too much. Then, there may be additional factors that will adversely affect implantation and pregnancy performance.
The straight answer is yes. Although the question is: how low is low, and how do we measure it? In general, progesterone is an important hormone for both achieving and sustaining a healthy pregnancy. However, our ability to measure the levels and our ability to agree on the perfect level is not near perfect.
Yes, it can cause miscarriage, but no, we can’t be sure how low is low and so forth. I do have anxieties about whether it’s properly absorbed and what’s the best route of administration. We’re having conferences every year regarding what’s the best route of administration and if we should combine it and use the oral, vaginal route, etc. What’s best? Is it injectable? Is it just progesterone, or should we add estrogen, for example, or even other hormones, especially in IVF with own eggs and so forth.
It’s an endless discussion, in my opinion, progesterone is important, and we need to ensure that we’re giving it at the correct dose, maybe a little higher than the standard recommendation, just to ensure that absorption is 100%.
I can’t see a huge difference between the two options, so as I said in my practice, I use fresh eggs and frozen blastocysts. We have audited that in our hands, it produced better results and a better experience. I can’t see any difference in what you’re saying now. Embryo adoption doesn’t much differ from fresh egg donation with sperm donation. Whatever you choose, ensure that the clinic can guarantee that you have top quality blastocysts, whether they’re produced from fresh or frozen egg donation, perhaps is not that important or whether there’s already embryos available of top quality.
I do not have a straight opinion on this with my limited counselling knowledge. I would suggest that you find a good counsellor. Each couple, each individual are different, and there’s no right or wrong, there’s what’s right or wrong for you. For some couples depending on the social circumstances, backgrounds, religion and so forth, it may be best to tell the child at a proper age. What is a proper child’s age depends on the child. Please, do not try to sort everything out before you even get pregnant because it’s virtually impossible.
You’re not going to be the same when you’re pregnant, you’re not going to be the same when you have a newborn, a toddler, a teenager, and you don’t know what kind of child you’re going to have. Although we like to have things organized beforehand, I think it’s too much stress, and I have seen amazing situations. Do not try to fit everything into a pattern because those patterns may change. Overall it’s a very variable decision, it’s a complex decision that has to be addressed and readdressed and depends on the couples or the single mother’s dynamics but also depends on the child’s or children’s dynamics.
Yes, that is the answer. This is one of the indications for egg donation.
At the moment, vastly in Europe, we can’t choose if we are going to have the vaccine or not, so all we do is wait for the national guidelines to tell us if we are candidates or not. I don’t know which country you live in, but nowhere in Europe, as far as I know, we can choose, so in general, fertility patients who are low-risk patients for COVID-19 disease, younger patients in their 30s or 40s, they’re not eligible for the vaccine.
Now, if you are eligible either because you are a health worker or a carer or when your time comes with the vaccine, my general advice, although you have to follow the local guidelines, is to go ahead and have it. I think this is the overall standard of advice. Some scientific societies and this is the standard advice in the UK, in the U.S. related to fertility or even natural conception, advise going ahead with the vaccination. There were some concerns about whether women should have the vaccine or not before conception, but I think it’s very clear now from the American and the UK societies that if your term comes to go ahead and have the vaccine.
Frankly no, not at the moment. It’s been a surprising situation in which many donors, especially in our practice, came forward because of VOVID-19 wishing to donate to help couples. There’s no shortage of donors at the moment. However, there is a concern that most of the clinics, including ours, have. There’s a lot of patients now wishing to come. Our international patients stopped coming out for almost a year now, and so there is this concern not from the donor’s point of view, but from the clinic’s ability point of view to properly treat patients if there’s a huge number coming in, so my straight answer is no.
Thankfully, the donors are coming forward, and we’ve had no shortage, maybe because they’re staying at home, and they’re not going to university, and there’s a lot of altruistic energy in Greece at the moment. People wish to donate eggs, blood and so forth, so thankfully, there’s no shortage of donors, but there is a small concern whether the clinics would be able to deal with a sudden influx of patients that we’re expecting from the middle of May onwards.
Not in Greece, in Greece, it’s anonymous, and as far as I know, the same applies to Spain, The Czech Republic. Most European Union countries like Greece have the legislation of anonymous donations, so there’s no obligation, there’s no connection between the child and the donor. In the UK, it is possible due to the non-anonymous egg donation legislation. So it is possible to be connected between the donor and the child when the child turns 18.
Most of the clinics either do one method or the other, so it’s very difficult to quote. I don’t know, I haven’t got an answer to that. We did a small audit in our clinic, and we found that fresh egg donation with the use of frozen blastocyst gave us the best fertility outcome in terms of success rate but maybe in other clinics hands, it would work differently. I don’t know, you would have to individualize.
With frozen eggs, there are thawing issues. Please remember that an egg, whether fresh or frozen, is a potential embryo, and the overall loss from eggs to blastocysts could be as high as 60-70%. For example, if you have 10 vitrified eggs from an egg donor, yes, you may have 7 or 8 fertilized and, equally, when you have fresh eggs, you have a loss in fertilization, and then you may have another 50% loss in culture. Unfortunately, I am aware of clinics, for example, using frozen eggs, and they’re using a much smaller number than 10, for example, they’re using batches of 3, so maybe 6 eggs. With 6 eggs, yes, you may have only 4 fertilized and then out of those, you may have 1 or 2 blastocysts, so it’s not so much the fresh versus frozen issue as it is the fertilization effect and the culture effect.
We must be prepared for losses, whether it’s fresh eggs or frozen eggs, and in my opinion, this is causing a lot of stress, not only to our couples, not only to the donors because the donors are also stressed, they’re the human beings, they’re making decisions, they want to help, they get very disappointed when they find out that they have, for example, small fertilization or small rate of blastocyst formation.
Also, there’s a lot of stress within the clinic. For us, it’s a very, very bad day when we have maybe one blastocyst out of an egg donation cycle, and if that blast is not perfect. In my practise, we don’t want to face that when the recipient has made all the effort to prepare themselves, to have the scans, to take medication, to have a good endometrium, and then to fly out and come here and to say I’m sorry – we only have 1 more morula, not even a blastocyst. In general, we like to discuss it with recipients and discuss preparations for an embryo transfer once we have blastocysts in hand and when we have secured at least 3 top quality blastocysts in a cycle.
I don’t know about Greece, maybe in Athens because there is a bigger Asian community in Athens. In Thessaloniki, no is my answer. We do have a starting population of Asians, some wonderful people in most of the schools. We have some Asian students, my daughters have Asian classmates. In terms of donors, as far as I’m aware, in my clinic, at least, we don’t have any.
The answer is it depends on the size of the myoma you had removed, on the location of that myoma, on the type of surgery you had, whether it was open laparoscopic, robotic, and of course, depends on the healing process that happened afterwards. In my opinion, the best person to ask is the surgeon who did the surgery. If I can give you some examples, I take 10-centimetre fibroids out, but if they’ve been laparoscopically or robotically, if they’ve been subserosal, so, outside the uterus, it doesn’t matter, if they have a small stem, I can advise my patients to have an embryo transfer in 2 to 3 months. 6 centimetres in the uterus, I would still ask my surgeon. The standard advice is a minimum of 6 months, to be honest.
It’s not one month per centimetre, but a six centimetre is a fairly large fibroid and if it’s in the uterus that means that the incision of the uterus was at least 5-6 six centimetres, so in general, I would allow a good 6 months to heal.
Yes, on both. Yes, we do have donor embryos available for single ladies, and yes, donations are made from couples.
The answer is whenever it’s available. At the moment, in Greece, it’s unlikely for the donors to get a vaccine before maybe July or August. Most of the donors, at the moment, if not all of them, haven’t received the vaccine, they may have received it if they’re health workers or if they care for a disabled person or an older person. By law surrogate mothers, surrogate carriers in Greece are between 25 and 45 years old, so it’s unlikely that they will have the vaccine, and it’s that they will have it before July, so it’s not up to us to choose, it’s the government guidelines. Our advice is whenever your time comes, go ahead and have the vaccine, this is our standard advice.
The cut-off age at the moment is 50. Technically, there is time to go ahead with egg donation, but that means that you will only have one chance at embryo transfer. You shouldn’t be over 50, or you may be a couple of months over. If the embryos are created before you turn 50, there is a leeway of a couple of months due to the epidemic for embryo transfer. Technically, you may even have 2 chances for embryo transfer before you turn 50 which is not bad provided you can travel, or you can get organized fairly quickly.
I can specify what tests they are having. I mean, egg donors in Greece are having extra Karyotype DNA testing, which the majority of own egg patients do not have, and yes, that could reveal some issues that would alter our approach. Egg donors have a full cystic fibrosis screening, the full gene of cystic fibrosis where the majority of all the patients who use their own eggs do not have, most of them haven’t even heard of it before and again. Sometimes, we identify some issues that may affect fertility, they have the fragile X genetic screening, which is some genetic screening affecting mental disorders which may not have an impact on fertility, but it definitely has an impact on the offspring.
They have a full endocrine profile, they have a full screening in terms of psychology, they have biochemical profiles, they have the pap smears sorted, they have all the infection screening and so forth. On top of that, in Greece, they have genetic thalassemia screening. My usual quote to my patients is that I know about my donors more than I know about myself, and this is vastly true, so yes, if own eggs patients had that screening, they may have a better chance.
Why are these extra screenings performed? The answer is I don’t know. Certainly, in the UK they’re not performed. They may be considered after multiple failures. In my practice, in Greece, to be honest, own egg patients have at least the Karyotype test and at least the standard cystic fibrosis gene test, the most common gene which is DF508 test, but yes, unfortunately, in most practices, these are not included in the baseline testing presumably due to cost issues.
With egg donation or embryo donation, the chance of disease of the offspring or chromosomal anomaly depends on the age of the donor of genetic material. If the donor is in her 20s, the chance is negligible, of course, then there is a chance associated with the sperm donor, whether it’s a partner or a sperm donor from a bank. However, pregnancy at 49 is a potentially complex pregnancy, potentially a high-risk pregnancy based on the female age, so it has to be managed, as such, by a very experienced obstetric team.
Provided that all the necessary tests have been performed beforehand and provided that essentially, there are no major medical issues, the vast majority of pregnancies conclude with a healthy pregnancy and a healthy delivery. The miscarriage rate, of course, may depend on some background issues of the carrier of the 49-year-old. Overall even a 49-year-old who is fairly healthy, fit, on no medication, with no serious past medical history, fairly slim, and well looked after by a good team, the vast majority have a good outcome.