In this webinar session, Dr Manuel Izquierdo, Director of Medical Quality & Consultant Gynaecologist at IVF-Life Madrid, has discussed the pros and cons and options of embryo donation.
Dr Izquierdo started his presentation by explaining the definition of embryo donation, which is the adoption of embryos coming mostly from the patients who have already fulfilled their dream of having a family. Sometimes we have more available embryos than the couple, or the woman is going to use. One of the options by the Spanish Regulation is donating these embryos to any other couples or women. At this moment, there are 80 000 embryos stored in the IVF Life clinics in Spain from many years of treatments being performed. Most of these embryos are coming from couples that are not allowed to donate these embryos. The alternative is double donation embryos coming from fertilization with donated sperm and eggs.
Once we have these embryos, we need to do the endometrial preparation, which is very easily most of the time. Sometimes, we even take the advantage of the woman’s natural cycle, every woman with a regular period is ready most of the time for the embryo implantation every month, so sometimes, we take advantage of this endometrial uterine cavity preparation promoted by the natural cycle. However, most of the time, we take control of the endometrial preparation, if we want to perform the preparation in advance and we want to set a day in the future for the day of the embryo transfer, we can set up the use of hormonal preparation. This is a very light hormonal treatment because we try to get a similar preparation like the body is producing in the natural cycle. The basis of this preparation is mainly oestrogens, and they will promote endometrial preparation. We can measure this preparation after 2 weeks of taking estrogen pills most of the time, we have available estradiol patches as well. These oestrogens are taken orally or through patches will make the endometrium grow and have a good lining, we will measure it by ultrasound scan, we will check blood hormonal levels, and if confirmed, we are ready to implant these embryos once we start with progesterone supplementation.
The key is having a good lining, but at the same time to set the best moment to start progesterone supplementation and taking this progesterone at least for the same days the embryo is, this is the general rule. Sometimes we need to adjust the starting of progesterone in terms of very narrow windows of implantation, but the main rule is more or less to take progesterone the same days the embryo is. Most of the time, we need to supplement for 5 days with progesterone before embryo transfer. Embryo transfer is a regular procedure, it’s very easy to transfer the embryo and place it with the ultrasound scan guidance most of the time, and there’s no problem.
Phenotype matching is mandatory in Spain, we always need to match race, size, hair, and eye colour), blood type doesn’t have to be matched, but it is considered if the couple wants to make sure that their future child will have the same blood type.
According to the Spanish law from 2006, 4 options can be done with the remaining embryos that are not going to be used, destroying the embryos, donating the embryos for research, keeping these embryos for the woman or the couple just in case and the alternative of donating these embryos to other couples, but the woman must be under 35, and the male is under 50 years old. The nature of donating such embryos must be anonymous, voluntary, and altruistic, as the Spanish law requires.
Sometimes we recommend the patients perform PGT-A on those embryos to check the aneuploidies, hereditary diseases or other alterations that may affect the viability of the embryo. However, the main thing is if we consider the egg donor or embryo donation is needed in a woman being under 35 years old having all these genetic testing, most of the time, there’s no need to consider genetic testing.
The pregnancy rate of embryo donation is about 60-70%, this is the same pregnancy rate as with double donation. The prognosis of the statistics of embryo implantation depends mainly on the woman’s age, and women donating eggs or embryos must be under 35 years old, therefore, the pregnancy rates are the same.
Yes, we have couples who are donating embryos and most of the time we have no waiting list. We have a huge amount of embryos here in Spain, coming from all the years of fertility treatments. Usually, that would take more or less 2-3 weeks if we need to find some other ethnicity like Asian or Black. We always inform the patients about these circumstances, so it is not even more than 1 month.
The main message is that it is related to a woman’s age and the conditions for egg donation and embryo donation are the same in terms of woman’s age. Egg donation and embryo donation have the highest pregnancy rates of all. The answer is very clear, it’s 60-70% with the transfer of 1 day-5 embryo. It’s also important to mention that 30-40% of the patients don’t get pregnant after the first embryo transfer, most of the time, we offer to transfer a new embryo, second embryo and even a third embryo, we talk about this as a cumulative pregnancy rate, this means if we add all the pregnancies coming from the first embryo transfer, the second, and third embryo transfer. Cumulative rates are showing that more than 93- 95% of the patients are pregnant, and only 5-7% of the patients are not getting pregnant.
We have 10% of miscarriages, so we are not free of miscarriages. The mean number you need to think about is this 50-60% of the live birth rate.
I cannot tell 100% of the patients are getting day-5 embryos because we have donated embryos from some years before. Around 5-10 years ago, we performed day-3 embryo transfer most of the time, today we perform almost all transfers on day-5, and so most of the donated embryos are blastocysts (Day-5).
This embryo is big enough for a possible condition that will prevent the embryo implantation, and when it comes to removing this fibroid, there’s no general rule. Our protocol usually tells about waiting for 6 months after the surgery to try to get pregnant. The thing is that the uterine wall needs to recover after this removal and be strong enough for the pregnancy to go ahead. The cumulative pregnancy rate going to egg donation or embryo donation is very high, and most patients get pregnant in the first embryo transfer.
I want the patients to know that our body inside recovers very quickly. In my opinion, there’s no problem if the surgery for endometriosis is not touching the uterus and endometriosis, by definition, is not inside the uterus, it’s outside. There’s no issue to try to get pregnant starting from the first period after the surgery. In my opinion, there’s no issue at all.
I’ve been working in fertility treatments for 25 years, and I remember the time when the Spanish regulation did not allow using embryos longer than 5 years after being frozen. This limitation was removed in the last regulation because we know that the time of the embryo being frozen is not important for embryo viability. There’s no limitation for storing frozen embryos. I always tell the patients that our embryos could survive us, and the limitation for using this embryo is the health condition of the woman, not the years the embryos are stored for. Less than 1% of the embryos do not survive thawing. If they survive freezing, they are as if they’ve never been frozen.
I have no clear statistics regarding this. We inform the patients about their options, and sometimes they do tell us that they would like to help some other patients with the same difficulties. Possibly half of the patients are thinking about donating, and another half are on the other side, but it’s hard to tell the exact numbers.
It depends on if we find any condition that could tell us what caused this miscarriage. We have a lot of things that we could check including thrombophilia factors, immunological factors, endometrial receptivity factors and anatomical conditions in the uterus, so it depends on if you find any alteration or not. If there is a problem with thrombophilia, we could suggest anticoagulants, low-dose aspirin, and heparin. If there is some uterine condition like fibroids, we would need to look into everything, so it’s hard to answer this.
Sometimes patients are asking for this, but we cannot guarantee several embryos, we are guaranteeing 1 embryo. Sometimes we have more than 1 embryo, and if you succeed with this embryo and you are thinking of increasing your family if we have more embryos coming from the same egg donor etc., we can do it, it’s easy for us and it’s more natural.
At the same time, we need to remember we don’t know if we are going to get pregnant in the first attempt, if you have 2 embryos, maybe you will succeed with the first and the second one, but sometimes you might get pregnant with the second embryo transfer, and you start it with 1 embryo. We never know how many embryos we need for having 1 or 2 children etc., so it depends on the personal response. Even though we have 2 embryos doesn’t mean we will have 2 children. We have an opportunity of having 2 children, but we are looking for the first one.
I always tell my patients that the ovaries get older, but the uterus doesn’t, most of the time. This means that even if a woman is in menopause, we can prepare the uterus with hormonal supplementation to be ready for embryo implantation. Here in Spain, we consider performing these treatments up to 50 years old, a woman who has demonstrated to be in good health. We can perform embryo transfer, and we know a woman in menopause or with premature ovarian reserve can get pregnant because we know how to prepare the uterus even though there is no ovarian function.
Ectopic pregnancy is not so frequent, it is about under 2-3% of the embryo transfers and it doesn’t depend on where you’re placing the embryo because we check the embryo by ultrasound scan at the time of embryo transfer. Sometimes the embryo gets inside the tubes by itself and implants there. Sometimes the treatment of ectopic pregnancy implies removing the tubes, sometimes 1 of the tubes. I remember my gynaecological reproductive fertility treatment manual was saying that if a woman is having an ectopic pregnancy and is involved in IVF treatment and is going to be removed from the tube because of an ectopic pregnancy, you must consider removing the other tube as well.
I know few people acting like this, they sometimes remove the 2 with ectopic pregnancy, and the probability of having a new ectopic pregnancy in your remaining tube is very low. At this point, it could happen, you can have a new ectopic pregnancy in the other tube, but then the frequency of ectopic pregnancy is very low, so I would not be scared about this embryo transfer, and I would act as a usual.