By fertility experts from Spain.
Watch the recording of the Online Patient Meeting with Gad Lavy, M.D., F.A.C.O.G, the medical director and founder of New England Fertility (NEF), USA. He answered patients’ questions on egg, embryo & sperm donation in the USA – availability, legal aspects & costs.
The egg donation is legal in the US, and we don’t have any restrictions on age and what that means, it sort of puts the burden on me, and us to determine what is the maximum age, and I personally think, that the age is just a number. I think we have to look at the person, the couple and decide individually if they’re healthy enough to have a child and you talk about it, you explain it, and basically, if that’s what you decide to do, I don’t have any ethical-moral issues with that. You need to take into consideration that if you’re in your 60s and you have a baby, there’s a good chance that you may not be around when a child gets older, and you need to make arrangements for that, but I don’t feel that it’s my place to tell anyone young or old whether they can have a child.
There’s no real legal issue, so essentially, when you pick a donor, these donors have already been through an evaluation. We’ve already asked them how they feel about donating their eggs, and f. e., I just spoke to a couple today who picked a donor, and we actually matched them with this donor because she only agreed to donate to married heterosexual couples, that was her preference, and we respect their wishes, so essentially, in this case, there will be some contract between the donor and the recipients, that will state that in the agreement, but as long as everyone has their position and as I said, I advise people to have a contract, even if it’s an anonymous donor, just to protect yourself.
One of the things about the US is, especially in our area, here on the East Coast, that there’s a tremendous variety of different people from different places. We have European donors, and we have African -American donors, many Latino donors, Chinese donors, we just connected with the Japanese agency, so essentially we have that advantage, the famous melting pot. I think that’s happening all over the world now, definitely in Europe which means that whatever donor you have in mind, we will find it. It may take a little bit longer, so certain ethnic groups are more difficult to find, like Chinese donors or Jewish donors and so forth, but ultimately you have to decide, and we’ll help you find what you’re looking for.
I can’t give you the exact cost, if anyone is interested, we can definitely send you the breakdown of the cost. I can just tell you that one of the reasons that egg donation in the US is more expensive than in Europe is that the donors require more money, they receive more compensation, we pay our donors minimum of 8,000 USD to go through the process, to donate their eggs, but the donors can name their own price, and as long as they find someone who’s willing to pay, so some donors that are considered more high-level donors, difficult to find ethnic groups, highly educated and so on, they sometimes ask for more money. For me, it’s always been about doing and making it fair and making sure the donor is compensated enough. We don’t look at it as you’re buying the eggs, we pay her for her effort, and for the fact that she’s willing to do it, so we can send you a very detailed list of fees for the different parts of this process.
What I showed in the diagram of how we do IVF, and this is true for egg donation, this is true for regular IVF and surrogacy. A few years ago, we’ve switched from doing fresh cycles to doing frozen cycles. The reason we do that, in general, is because that allows us to focus on maximizing the number and the quality of the eggs that we get, and on the other hand to maximize the development of the uterus, to get the best success. We always felt that that was the right way to go, however, the problem was the freezing technology wasn’t good enough, so that held things back. We used to do synchronised cycles and to do that, you need to synchronize your cycle with the egg donor cycle, it’s not so difficult to do, it was working quite well, but it’s not as good as it is now. The fact that that we can freeze the embryos allows us to do the important genetic testing. So we focus on your end and create the best uterus, and also it is much more convenient because once the embryos are frozen, they can stay frozen for a week, a month or six months without any change in quality and success. So, that makes the whole process a lot more convenient.
I definitely recommend PGS because we find in about 30% or 40 % of embryos that come from donors are genetically abnormal. So, by doing the PGS, it makes it easier to pick the one embryo that will give you the high success immediately, so that’s the reason that we’ve incorporated PGS. This technology has improved dramatically, we do the PGS now on day-5 embryos and not day-3, the way it was done in the past, and we use new technology it’s called NGS which is highly accurate, so we trust the results completely.
Yes, it is possible. We’ve been doing gender selection for a while now. We have patients who come to us, just to do IVF for gender selection. They have 2,3 children of the same gender, and they want to do, what we call family balancing, so that’s allowed and it’s fairly common. The thing about gender selection, the way we do it, we fertilize all the eggs and then check to see what we end up with, and make a decision based on that. We still don’t have a good way to affect the ratio of male and female because as I’m sure you all know, the gender is determined by the sperm, so this half of the sperm is male, and half is female, and it as a matter of who gets to the egg first. So, we still don’t have a way to separate the male and female sperm, so there are situations when somebody comes in, and wants to have a boy and then somehow they end up with a girl embryos only, and that’s something you have to take into consideration. Most people that come for egg donation, don’t look at that, as their first goal, if they have embryos of both genders and they have a preference, why not.
I mentioned that, and we try to make it simple. For the people who are travelling in, we try to minimize the amount of time that they need to spend here. You’re welcome to spend the whole cycle here, but most people want to minimize the number of trips and the number of length of stay. We take advantage of the fact that we have some clinics that we’re partnered with, in London and in other places in Europe where you can go and do your evaluation. You can do your prep, we will determine the protocol, we will connect with the doctor, and then you can maximize the time at home, and come here just for the embryo transfer for 4 or 5 days.
The sperm donation is always anonymous, at least with the sperm banks that we work with. There are about 3 or 4 large sperm banks in the US. Those are the only ones we work with, they’re all reputable, they’re all been around for a long time. We’ve had a lot of experience with them, and all of them have a large variety of donors, you can very easily go on their websites. I can mention a few names f.e., there is a bank called California Cryo Bank (CCB), it’s the one we work with the most, they have offices on the East Coast and the West Coast, they have many donors, they do a great job with screening the donors, and they also do a good job, as far as trying to find a donor that meets your requirements. The laws in the US for sperm donations are that the donor has to go through screening including HIV and all the infectious disease testing. Then the samples are frozen, and they are frozen for 6 months, then they have to bring the donor back, we screen them, we test them before the samples are released, so that’s a federal rule, so no matter where the sperm bank is, they have to abide by this rule. The donors usually donate a few times, they create multiple samples and generally, for IVF, we require 1 or 2 samples to be purchased, as I said the donors in the US are essentially anonymous. Their anonymity is more so with sperm donors than it is with egg donors. Mostly with sperm donors, you won’t be able to see a picture, but you still get a very extensive profile.
Yes, you’re right. The chance is not zero, but what we’re talking about when we transfer a single embryo is that there’s an extremely low chance of twins, which is way less than 1%, and when you have twins with a single embryo transfer what you have is identical twins. It’s an embryo that splits, it rarely happens, it’s not so much of the ICSI, because the ICSI just introduces the sperm into the egg, but for some reason, the embryo can split, it usually happens after the transfer, after the embryo has already been placed in the uterus, and that way, you can end up with identical twins, but as I said because the incidence is so low, we don’t consider that to be a significant risk.
We count the chromosomes, but that’s the purpose of the PGS. What I didn’t say is, that in addition to counting the chromosomes, we also look for more subtle abnormalities in the chromosomes. F.e., there’s a condition called a deletion, where a piece of DNA is missing, so the number of chromosomes is correct, but part of the DNA is missing. Depending on how big that part is, that can lead to an abnormal embryo. There are deletions, there’s duplication where a piece of DNA is duplicated which can cause abnormalities inversions, whether with a part of the DNA strand is the reverse, any kind of chromosome breaks, we can identify. It’s definitely more accurate and more helpful than doing just a typical karyotyping.
I think the terms can sometimes be confusing. We talk about two categories which are PGS and PGD. The new name is PGT-A at PGT-M, the difference between the two, is the PGS which I’ve described, that’s what we usually do because for IVF when there’s an older person, and we are worried that they don’t have any normal embryos. The PGD is a whole different process because PGD stands for pre-implantation genetic diagnosis which is the procedure by which you actually identify what we call a single gene defect so cystic fibrosis, muscular dystrophy, these are genes that are abnormal gene that can cause disease in the child. The PGD allows you to identify those embryos that carry that particular abnormal gene, it’s a different procedure, it’s more complex, more expensive to do the PGD, you have to identify that specific genetic defect, which means that you have to take samples from different family members, and try to identify the particular mutation in the gene and then once you’ve done that, you create what’s called the probe. A probe is like an antigen or antibody that will identify that particular mutation and that way you can screen out those abnormal embryos. I didn’t mention PGD because for most people that’s not really relevant, but of course, people come to do IVF when they have this kind of genetic history in the family and then we can do one or both to make sure, we have a healthy embryo.
When you have 75-80% success which means that 20-25% of the time, it doesn’t work, it’s not always clear. As much as we rely on the PGS to tell us everything we want to know about the embryo, it’s still lacking because there are other things other than the PGS results that determine the viability. Even with the PGS, the way we do it today, we still get almost a doubled success rate compared to no PGS. But, what happens when the IVF doesn’t work, this is true in general, whether it’s a donor or a non-donor, then you have to look at other factors, and you know immunology is one aspect, and there are some cases where for some reason the woman’s immune system fights off the pregnancy. Interestingly, that was a concern when we first started doing egg donation because they said, well you’re taking an egg from a different person maybe the woman would reject the embryo, but it happens to be not at all true, we know from studying the immune system and pregnancy which is sort of a protected area, the immune system if you think about it, any pregnancy is like a foreign, body because at least half of the embryo, the sperm part is a foreign body, so the pregnancy has created, or the body has created a system of protecting the pregnancy from the immune system. Now, having said that, of course, there are cases where the woman’s immune system is overactive and would reject her embryos, as well as a donor embryo, in those cases, we try to identify ahead of time, and we try to treat it, so that’s when I said that we do a review of the history, that’s part of what we look at if someone’s done IVF and had great embryos, and no success, either no pregnancy at all or miscarriages. We have to look at the immune system before we switch over to egg donation.
Yes, we do. I mean we’re very confident in our success. There are certain restrictions, such as sperm. The sperm has to meet certain criteria for us to say, that we’ll do as many cycles as it takes to have a live birth, but we do offer that as well. I didn’t emphasis that enough, that women in her late 30s, early 40s we start to see a very quick decline in fertility, and that mostly has to do with the egg quality and ovarian function in egg quality, interestingly the uterus doesn’t age very much, even in women who are in menopause. We have quite a bit of experience with women who are in menopause by just giving the proper hormones for a very short period, you can make the uterus as receptive as it was for someone who is 30, so there’s not much of a restriction as far as age and uterine function, guarantee program doesn’t have much to do with the age.
That’s a really good question because I think again, regardless of age, it sounds as if there is an issue with ovarian function, ovarian reserve which translates into fewer eggs, probably poor egg quality. I’m a very big proponent of PGS, even in those cases, where you have low embryo numbers. It is something to consider doing at the very least blastocyst culture but also possibly PGS because what we found, is that in most of these failed cycles, the reason the cycle failed is that, the embryos were not normal, to begin with. Those embryos had no chance of success from the start, so I think if you’ve done two cycles and you have no normal embryos, then I think it’s easier to say, okay well I did the best I could. If on the other hand, you do the transfer with day-3 embryos where you can’t tell the difference between good and bad embryos, then it’s hard to tell. I think from the early days of IVF, and you know I was involved in some of those studies, we asked how many attempts are reasonable because people are going through a cycle after cycle, after cycle with no success, and it’s expensive, and it’s just physically and mentally exhausting, it’s just difficult. This was 20 years ago, and it’s still true today. I was at Yale at the time, we worked with somebody from the math department, and we came up with this sort of formula, he took all the data and put it together, and what we found is basically that 95% of the success we get within three attempts, which means that if you’ve done 3 attempts, it didn’t work unless you can find a really clear explanation, and you can change it, then you shouldn’t do any more treatments because you will get to a point where you have to weigh all that goes into the treatment versus what you get out of it. It’s hard to justify, putting all the effort into IVF when you know that your chances are 1%, 2% 3%, so again I mean if you’re 35 and you’ve done IVF, maybe it’s never a zero chance, but if the chances are really low in the single digits, I think that’s the time to consider changing something, and maybe, in this case, it would be the donor eggs.
Well, one of the differences in women but as far as fertility is concerned, the big difference between men and women is that women are born with all their eggs, so they don’t make any new eggs by the age of 50, most women run out of eggs and go into menopause for about 10 years before menopause, then the exit is not the best eggs, few eggs remain that they’re not the good quality eggs. Men, on the other hand, continue to make sperm forever. In fact, they had done a study where they looked at sperm counts for men that came in with their wives when they were in labour, they found there’s no difference. So, in other words, the sperm counts, the sperm profile account, the motility, the morphology of the sperm, the way they look, doesn’t change with age. The fertility potential of the sperm is a different question, that’s still being studied,f. e., there is a sort of concern about the fact that older dads have a higher incidence of children with autism, so there are more subtle things that are not so easy to determine, that a result of older dad’s, as opposed to older moms. In the older moms, the genetic defects are what we fund, so chromosomal mismatch, Down syndrome is a perfect example. In men, it’s more about the quality of the DNA, these are things that are much more difficult to quantify, and we don’t have any good tests for that. There are some tests to look at how intact the DNA is, and there are some studies that show there’s maybe a slightly higher risk of cancer in children of older dads and things like that. The data is very inconclusive at best. So to answer your question if you have sperm that’s 7 years younger, I would use it because if it was frozen and stored properly, that sperm probably has better fertility potential than the sperm today.
The embryo adoption is very attractive for some people because those are the embryos from couples who have been through IVF, often with an egg donor, often they ended up with way more embryos than they needed, and then they completed their family, and have some embryos left, and they have a choice of either destroying the embryos or donating to another couple. Unfortunately, most couples that have extra embryos, don’t donate them to other couples, and it’s understandable because it’s having full siblings that are carried and those are somebody else’s children. We do offer that, and occasionally we have people who have donated their embryos, so if it’s something you’re interested, then we can keep you on the list, and just keep in mind that they’re much more difficult to get, and when you do, you won’t have as much information as you want on those donors most of the time. If it’s an egg donor and a husband’s sperm that created those embryos, you can have the profile of the donor, and I can gather information on the husband that will be protecting their anonymity, so the answer is yes, we do it. We do it anonymously, the donating couple doesn’t have any say to whom the embryos go to, and you don’t have any specific information about the donating couple.
The thing about frozen eggs compared to fresh eggs, it is something that continues to evolve. I would say that right now, frozen eggs are almost as good as fresh eggs. There is a small difference in the success rates, but I don’t think that difference is significant enough. You have to have a reason to use frozen eggs whether it’s the financial reason, whether you don’t want to create too many embryos, so I don’t think the difference in success should be something that should deter you from using frozen eggs. It’s true that if you accept frozen eggs, this will broaden your choices. The difference in success between fresh and frozen is something that we worry about less and less.
Yes, it is possible. We have people that come with their own donors, not very often though. These are usually women who are a little bit older, some of them come with their nieces or other family members etc. But keep in mind that the family member may not fit the criteria that we have. Many of the known donors, many of the people who bring donors, those donors are a little bit older than what we would normally accept, but we will test them exactly the same way as we would test our donors, and it’s even more important when you’re using a family member to have a good legal contract.
We were part of that study, of the company that was called micro sort, and they came up with an innovative way of sorting male & female sperm. The sorting sperm has been an area of interest of mine for many years. None of the methods that were traditionally suggested, as far as the timing of intercourse, position, diet, all these other things, none of them works. The company, the micro sort came up with a new way of sorting sperm, and it uses a what’s called a cell sorter, it’s an instrument that allows you to sort cells based on certain characteristics, like size etc. In the case of sperm, the male sperm is slightly larger and heavier than the female sperm. You put it through that machine, it’s called a flow cytometer, and that sort of pushes the sperm one way or the other. There are a few problems with that, number one is that the company after a few years of trials, could not get approval from the FDA in the US, so essentially the process in the US is not legal, and I’m not 100% sure why that happened, there was some safety concern, and they shut down their operations in the US. Interestingly, if you look at their results they were much better with sorting female sperm, than male sperm. Years ago, we used to combine the gender selection IVF with sperm sorting because it makes sense that you put it through the sorter and then you fertilize the eggs, you can have a higher ratio of the sex that you want. Their success with females was much higher than with male, so if you did this sperm sorting to have a girl, you’d have about 90% girl sperm and 10% of male sperm. With the male sperm, it was not so good, it was maybe 70%, a little bit better than in nature. But, that’s all sort of right now a non-issue because we cannot legally do it in the US.
It’s a great question, and this is something we discuss immediately with couples that come here, specifically for gender selection. In the first consultation, I always tell them that it’s 50/50, especially if we have lots of eggs and embryos as we do with donors, so it may not be exactly 50/50, but it’s almost certain that you’ll have embryos of both genders. You have to consider the following. Number one, you have to consider the possibility that you will not have a gender that you want. I’ve had a few cases like that, the couple came in and wanted to have a boy, and they had all-girl embryos, and vice versa. Number two, you need to consider that you’re going to have genetically normal embryos that you’re not going to want, so you have to think if you are comfortable with destroying those embryos, or if you want to donate them, so you need to get all that information sorted in your head upfront before you start. You don’t want to be in that situation later on where you will not know what to do with all the embryos. We will talk about it, make sure that you’re comfortable before we move forward with that.
PGS is best done on the fresh embryos. The embryo grows to the blastocyst stage, it has about 200 cells, it’s already differentiated, so you can tell the difference between the part of the embryo that would be the baby, and the placenta and then you take a few cells from the placental side, and you freeze the embryo, that’s the standard way of doing it. That’s the recommended way of doing it, and if you do it that way, you will not affect the viability or the success of the procedure. Now, we come across cases where people already have embryos frozen that have not been PGS tested, and they ask us to test those embryos, the answer is yes, it is possible. It isn’t recommended so much because, in order to do that, you need to do the following, you have to take those frozen embryos, thaw them, you have to grow them a little bit, and then extract the cells and then freeze them again. When you get the results, you thaw them again to do the transfer, so this can’t be good for the embryo, and we do have some experience with it, we have good success with it overall, but you are putting the embryo through a lot, and you have to think twice before you take frozen embryos and apply the PGS.
Actually, we almost never do it. I don’t remember the last time we did it. It’s theoretically possible that it’s going to be necessary, especially for someone who’s had repeated miscarriages that were related to HLA, so the answer is, we can do it, but again it depends very much on your history.
That’s a topic for another webinar. Generally speaking, the evaluation before doing IVF includes a very careful evaluation of the uterus, fibroids can be a factor. It depends on their location and their size, so if the fibroid is growing in the cavity, if it distorts the uterine cavity, there is a possibility it will affect the implantation, and we recommend for it to be removed. If the fibroid is going outside of the uterus, either in the wall of the uterus or towards the other side, then unless it’s large, it probably doesn’t have an impact, so this is something that Leeds to be evaluated individually based on history, on the findings, and then we can decide if the fibroid could be a factor if it needs to be removed.
Yes, I mean it doesn’t matter where this sperm comes from, as long as it goes through proper freezing. Just remember that the eggs, embryos, sperm are frozen in liquid nitrogen, so as long as they’re held at the right temperature and transported appropriately, it doesn’t matter how far they have to go. We look a little bit differently at transporting embryos and sperm. We look at embryos as they are irreplaceable, it took a lot of work to create them, so those are usually transported with a courier, with a person who personally picks up the tank and gets on the plane, and delivers the embryos. With sperm, it depends, we often do it through FedEx or DHL, they have a program to do that. The distance doesn’t matter, as long as it’s done properly.
I would say yes if you’re married, but again it’s something you need to check with your attorney. As long as you are pregnant and whether the sperm is his sperm, or not, that’s really the difference. I think that technically, they would still be considered a legal father, and have all the responsibilities that go with that.
Immunology testing is mostly blood work, and we have a panel that looks at all the different immune factors that can cause women to miscarry, or not get pregnant. We call it the thrombophilia evaluation, it looks at clotting factors and antibodies that can be in the way. So it’s a pretty simple test, the interpretation is sometimes difficult, then again you have to know the person, you have to look at their history, and it has to correlate with the results of the test.
It’s one of those things that you need to find out what works for you. Most of the embryo donations we’ve done were anonymous. So, if you want to donate your embryos and you have certain conditions f. e. we have someone now who wants to donate her embryos and wants to know who the embryos go to. So we’re still waiting because many people that want the embryos prefer not to have that connection. Nothing is out of the question, it’s just a matter of how realistic it is, and how you want to do it.