What are the main embryo donor conception dilemmas and concerns? To help us with the answer to this and more questions, we’ve invited Vladimiro Silva, Founder & IVF Lab Director at Ferticentro, Coimbra, Portugal.
Dr Silva started off by explaining the definition of embryo donation as many patients often ask about it, although what they are really interested in is a double donation which is a different option. In double donation, there is the sperm donor, and the egg donor and the embryos are created, while in embryo donation, the embryos were donated by other patients that were doing their own treatments. These embryos are not created specifically for this treatment.
The first thing you need to know is the legislation, the legislation varies in different countries, and when we talk about Portugal, it’s crucial to know that the donation is non-anonymous, and so embryo donation is done with non-anonymous embryos. However, because our law is in a period of transition until the 31st of July 2024, it’s still possible to transfer donated embryos from anonymous donors, those are the embryos that were donated before the anonymity law changed.
Non-anonymous donors mean that at the age of 18, all children born from non-anonymous donations have the right of access to the identity of the donors. In the case of embryo donation, the identity of both elements of the couple will be released. If the embryos come from a donation, either a double donation or just sperm donation or egg donation, the identity of the patient and the donor will be released.
Patients who donate embryos need to accept and disclose their identity to the children that will be born from the donation. They have to sign an informed consent. First, they receive proper counselling, and so not only they are at peace with revealing their identity, but they did it in a conscious deliberate way.
Dr Silva emphasised that nowadays there is no such thing as an anonymous donor because if you go to a DNA bank, you can order a DNA test at home for less than 50EUR, they will send you a swab and a home kit, and you will send it to one of these DNA banks, and then the answer you will get is something like you are 50% European, 10 African, etc. If you pay some extra money, you will be able to know the identity of those persons if they also agreed to share their identities with unknown relatives. Therefore, with the current technologies, it’s already very easy to discover the identity of an egg donor or a sperm donor. 20 years from now, it would certainly be even easier because science is evolving at a very fast rate.
The reason children born from the donation many times want to have access to the identity of their donors is that they feel that their donors are a part of their genetic heritage of who they are and it can be devastating if they get to meet that person and at the end of the day that moment doesn’t go well. The donors can be surprised by the fact that they are found, so it is very important to do all sorts of donations with non-anonymous donors, otherwise, you will be cutting off an essential right of your future child.
The donations are controlled by the states. In Portugal, egg donors can donate up to 4 times in their lifetime, and sperm donors can donate to up to 8 families.
Point number three is transparency, payments to donors are fixed by law and are the same in public and private centres in Portugal. In the case of embryo donation, there is no payment at all, embryos are donated free of charge to those who donate them, in the case of egg donors, donors received 878 EUR, and every sperm donor receives 45 euros per donation, this is defined in the law, it’s the same for all public and private centres.
Another very significant thing about the donation process is safety. When you are doing treatment with any kind of donation, including embryo donation, you need to know that access to the identity of the donors is something that is guaranteed by the state, and that information is kept for a very long time. For example, if your child at the age of 18 is not interested in getting to know the identity of the donor, he or she can change their mind at the age of 20, 30, 40 or 50, and that information will always be there. It’s the Portuguese state who has the responsibility to give access to that information. If there are some health issues, access to the identity of the donors can be granted earlier. Another important argument in favour of non-anonymous donors.
All donated embryos come from other patients, so we cannot create embryo banking All donated embryos are surplus embryos that have been created during treatment for a single woman or a couple between a man and a woman or probably 2 women, and so those embryos must stay frozen for at least 3 years before they can be donated. It’s impossible to donate the embryos before 3 years, after 3 years patients have to decide whether they want to renew the cryopreservation or they want to donate the embryos to another patient, destroy them or give them for scientific research.
Embryos are donated individually, so it’s not possible to donate sets of 5 embryos. This means that nowadays, we are in 2022, the most recent embryos that we have available for donation have been frozen in 2019, and since the anonymity law in Portugal changed in the middle of 2018, we are still in the early days of open embryo donation, so there are not many donated embryos available.
There are many advantages of doing treatment with embryo donation. The first one is that all donated embryos meet good standards of quality and prognosis because while doing the patient’s treatments, we only freeze morphologically viable embryos, we are very demanding when we are assessing the embryos, if the embryo is not good if it doesn’t have a very good quality and development parameters, we don’t freeze them.
Another advantage is that these embryos are already formed, so there is no uncertainty associated with a double donation when we are fertilizing donor eggs with donor sperm, we have to check the embryos every day, and see how many blastocysts we have, it’s a very good prognosis treatment but we need to confirm that we’re going to get very nice embryos. The advantage of donor embryos is that we already know how the embryos are, they have already developed, and they’ve already reached day-5 mostly. The other advantage is that those are embryos that wouldn’t be used if it wasn’t for the patients who are using them. Those are good prognosis embryos that were frozen and were waiting to be adopted. If they are not adopted, they will be thrown away.
We have two years to transfer anonymous embryos that we had before that were created before 2018, and a lot of them because patients typically don’t want anonymous embryos, and so if we don’t find patients to adopt them in the next 2 years, those embryos will have to be discarded and thrown away, and a lot of them are viable. Those are potential lives of children that will be wasted for this legal reason. This is kind of an ethical value in embryo donation because we are giving these embryos an opportunity to implant and develop into a baby. Embryo donation is the least expensive treatment of all. The embryos are already formed, so we don’t need to do another ICSI, we don’t need to do another embryo culture, stimulate the donor, do the blood on the donor and so on, so the costs are way lower than a full double donation treatment. They are immediately available.
There are also downsides of embryo donation like there is limited availability of these donors. We depend on the patients deciding to give the embryos to another patient, so we don’t control whenever these embryos enter the system. Sometimes it takes 2-3 weeks or a month without new embryos into the system, then on the same day, we have 10 or 20 embryos. This has to do with bureaucracy, people signing documents, people answering the phone, sometimes patients have divorced, and one of the persons wants to donate, and the other doesn’t. There are a lot of fluctuations and factors that are independent.
Another disadvantage is that the embryos already have certain characteristics, the egg donor possibly was a Portuguese woman with brown eyes and white skin, and then the male partner could be the same, so it’s kind of take it or leave it. There is no way of interfering with the physical characteristics because the embryos are already created, and embryos are donated individually, so it’s unlikely to have the possibility of having multiple embryos from the same donors.
Another thing about donated embryos is that typically these are not first-choice embryos. When a patient is doing treatment, we transfer the best embryo, and we leave the other ones for later. The typical story of donated embryos is that someone tried to do the treatment, they got pregnant, they had 1 or 2 surplus embryos, and then they donate the embryos to someone else, but they’ve already transferred the best embryos from that group. Naturally, those are very good prognosis embryos because they belong to a group of embryos that already originated the pregnancy, but the reality is that we never know how it is going to be. Theoretically speaking, we are talking about the second best, the third-best embryo, which happens a lot. We have lots and lots of babies from donated embryos, and we even have babies from donated embryos where the patients didn’t get pregnant in the initial cycle and then divorced. The remaining embryos and the patients who received the donated embryos got pregnant and did have a baby, which happens a lot.
The pregnancy rates of donated embryos are associated with the type of the characteristics of the initial embryo. They depend on the age of the woman, for example, if it was an egg donation, then it’s the probability of pregnancy for an egg donation cycle if it’s a patient age 37 it’s the probability of at 37 that information is always given beforehand so when patients are doing embryo donation with us we tell them this embryo comes from an egg donor that was 23 at the time of donation and the sperm is from a male partner who was 42 at the time of donation. It can be from double donation, it can be embryos that belong to a couple just sperm donation, we have all the situations and the probability of pregnancy is associated with the origin of the embryos. Naturally, a double donation treatment has the highest probability while someone doing treatment with their own embryos at the age of 40 will have a very low prognosis.
Embryo donation is the ideal solution if you, for example, wish to have a child without a male partner or for women with a very low ovarian reserve instead of doing a double donation, embryo donation is a more straightforward, cheaper approach with a very good prognosis. Sometimes it’s a good option for people that are in a couple but have problems from both sides. There are a lot of indications, and fortunately, we don’t have this many embryos available.
Embryo donation is not the ideal solution, for example, when patients want to have more than 1 child from the same donor, it’s very unlikely that there would be more than 1 embryo available from the same origin. If patients want to be sure that donors share a very specific physical characteristic, it’s a question of chance we might or might not have that.
A lot of patients want to access more detailed information on the donor’s background and they will ask for genetic matching between the sperm donor and the egg owner, so unless we are lucky enough to have a double donation embryo where both donors had what we call an extended profile and have done the matching which can happen. However, it’s not very likely to happen, it’s really a question of luck that can happen or not, but if that’s something important for the patients, then it’s preferable to think about a double donation.
The bottom line is that embryo donation is a very ethical approach, it’s a very cheap approach with very effective results because the frozen embryos have been approved when they were evaluated for the treatment of the initial recipients, and so it’s a very straightforward treatment and a very effective alternative for those who are in these circumstances.
First, the age of the recipient woman is not that important because the uterus stays with the same capacity to receive and implant an embryo. In Portugal, the age limit is 50 years old. If there are no other issues that affect the integrity of the uterus, such as fibroids, and previous surgeries, the rates will be similar. Sometimes older patients have a higher risk of having multiple interventions for previous miscarriages and treatment failures in the past, so the uterus can lose quality, but it’s a very low decline. In principle, pregnancy rates stay relatively stable up to the age of 50.
There is not much of a difference when compared to younger women aside from the obstetric factors like preeclampsia, gestational diabetes, and so. All of those age-related complications, then the success rate depends on the origin of the embryos. If we have the donated embryo from a double donation, it’s 70%, if we have a 25-year-old woman using her own eggs with a sperm donor, it’s probably 60% or so because statistically speaking, we know that donors have their fertility optimized. Naturally, if it is a 37-year-old woman with her own eggs and her husband, maybe we’re just talking about 30 or 35%. The most important thing here is we have to be transparent, we talk to the patients, we explain the origin of the embryos, we share the information that the law allows us to share, we explain what are the chances, and then the patients can take an informed independent decision. It’s hard to answer in a very straight area, what is a success rate? I would say it’s the same success rate as the embryo had before it was frozen and used and saved for the patients who want it before donating it.
There are rules on embryo testing, if the embryos have been tested before they were donated, then we share that information as well. We only share euploid embryos. We can’t even do that from a legal perspective. A different thing is we test the embryos before they were donated and not tested before being frozen. Can we test them before donating them? It will depend, we have to see because, for example, in double donation cases, it makes no sense to donate, and the Portuguese law wouldn’t allow it, but for example, if it is a patient with a past previous history of IVF failure and so on then we can test the embryos. It’s something that we need to evaluate on a case-to-case basis, but in some cases yes, in some other cases, no.
With early menopause, the only solution to have a baby is to use either embryo donation or egg donation. This is something that we cannot avoid, it’s inevitable, and then it depends on the origin of the embryo. As long as the person in question responds to the estrogens that we need to give to build a lining if we get a good lining if we get an endometrium with good characteristics, then the prognosis is very good.
A lot of our patients are single ladies who come to Portugal because they want to do treatment with donated embryos. Especially, with donors that can be contacted by the children once they get to the age of 18. In Portugal, we have one of the most progressive IVF laws in Europe, and single women can do IVF.
It’s a very difficult question because we need to evaluate it first. 42 is an age of transition. If you want to get pregnant with your own eggs, we need to evaluate your ovarian reserve. By ovarian reserve, I mean 3 different parameters, the antral follicle count (AFC), the FSH levels and the AMH, and then we will have a notion of the chances. Statistically, for all women of all infertility causes at the age of 42 chances will be at around 12.5%, that’s the average pregnancy rate with the women’s own eggs at the age of 42. If we are working with donor eggs or donor embryos, it can be up to 70%, depending on the male factor and the characteristics of the uterus, but assuming that everything is fine at those levels, it can be as high as 70%.
I don’t have this number, but unfortunately, the percentage of embryos donating their surplus embryos is very low. It’s disappointing, we respect and understand the reasons and that patients sometimes don’t want to share their embryos with other people. Nowadays, at our clinics, we have around 100 to 150 donated embryos available to be used, but the vast majority of the patients don’t donate their surplus embryos.
There is also a tendency for that to change, but since Portuguese law allows the embryos to be donated after 3 years of storage, it will take us some time to have that notion, so we need to wait and see. We also have a lot of embryos that have been abandoned by people who are not reachable that have changed their phone numbers, their email addresses, and sometimes even their home addresses, and if they have authorized us to donate the embryos, then it’s fine, but many times that don’t happen then we need to contact them, and there is some bureaucratic issue to be taken care of. A lot of embryos are lost because patients just stop answering our contacts for one reason or another.
It’s difficult to answer without knowing all the details because many factors can interfere with the chances of an embryo’s implant. There are immune factors, haematological factors, and morphological issues in the uterus. There are also issues with the lining, the window of implantation, chronic infections, and the microbiome, so we also need to see the kind of quality the embryos were. Whether you did genetic testing or not because having this story alone can be a completely different situation. Whether you have transferred perfect embryos0 within the window of implantation after proper preparation, taking care of doing prophylactic protocols for the immune and the methodological issues associated with immunization failures and so that too is one thing.
I would say it’s a serious issue if you don’t get pregnant with that, and if the lining is a triple layer with at least 8 millimetres of thickness, then that would be an issue. However, if one of these parameters wasn’t met, maybe that explains the failure, and maybe we can correct it, so it’s not easy to say, but unless there is a very serious situation, I would say in more than 95% of the cases, there is a solution. There are cases where, unfortunately, medicine doesn’t have a good solution, but those cases are luckily rare, so I would say that there’s a good chance that there is hope for you.
In Portugal, we do have a lot of African donors and African donated embryo embryos donated from African patients, that is not a problem at all, however, our law doesn’t allow us to take to treat patients after the age of 50. so, unfortunately, we cannot help naturally mentally the fact that the uterus is to the right in principle, this shouldn’t be an issue, it’s something that happens a lot, but obviously, we would need to see it to give an opinion, but um so but the main issue here is the age and the law that doesn’t allow us to treat um patients after the age of 50. In Europe, I would say maybe Cyprus would be the only country where that can be done. I don’t know if they changed the law in Greece recently, I believe so, but it is what it is, we have to live with the laws.