Have you noticed that some fertility clinics offer egg guarantees and embryo guarantees? Which option is best for you? What’s the difference in cost and treatment success? Watch the webinar recording above “The difference between the number of eggs guaranteed and the number of embryos guaranteed” and find out the answers. Such guarantees are offered by most fertility clinics and we have asked dr Łukasz Sroka from InviMed Fertility Clinic to tell us more about the pros and cons of these two options.
M.D, Ph.D. Łukasz Sroka is an obstetrician and gynaecologist working at InviMed Poznań in Poland. His professional interests include gynaecological endocrinology, reproductive medicine and endoscopic surgery. Dr Sroka is a member of the Polish Gynaecological Society.
The use of IVF using own or donated oocytes inevitably leads to many differing outcomes. The number of eggs collected can vary, as will the all-important development of good quality, healthy embryos. Many clinics offer programs that guarantee a certain number of oocytes and, whilst it’s a popular belief that more eggs retrieved will automatically lead to a higher fertilisation rate; that isn’t necessarily the case.
In this webinar, MD Lukasz Sroka, obstetrician gynaecologist at InviMed clinic, Poland, discusses whether it’s better to guarantee oocytes or embryos, outlining donor selection criteria and the process of IVF with frozen donated eggs.
It’s crucial for patients to understand that egg donation treatment is IVF. It’s not a specialised or differentiated form of treatment, the process is the same; eggs are retrieved, fertilised and transferred. The only difference is that the eggs are collected from one woman and the embryo is transferred into another.
Oocyte (egg) donation is an established standard of practice for the treatment of female related infertility and is associated with increased rates of pregnancy success. It would be recommended where women have experienced difficulties in conceiving, when using their own gametes. Egg donation IVF is highly effective in cases of early menopause, low ovarian reserve and inheritable genetic disorders.
In order to achieve a successful outcome from IVF, quality is key. Embryonic health is vital for implantation, but to create healthy and viable embryos, high calibre sperm and eggs are a necessary requirement. It’s therefore imperative that donated oocytes are of good quality.
Donors will usually be healthy women under the age of 35 with proven fertility. Before they can donate, all potential donors must undergo intensive testing and genetic screening. A full medical history is also required.
Becoming a donor isn’t easy. Once approved, donors are required to go through the usual IVF ovarian stimulation regimen, resulting in general anaesthetic for the egg retrieval procedure. Donor safety is paramount, and donors should not be overstimulated. However, as the embryo isn’t being transferred back into the donor’s uterine cavity, some clinics will use more specialised procedures for stimulating donor oocytes, in order to achieve maximum potential.
It’s also important to note that too many eggs can actually lower the overall quality. The question of how many eggs are optimum has not yet been answered, despite being a constant subject of discussion for many assisted reproductive specialists around the world. Dr Sroka advises that, in his opinion, between 15-25 is a good result.
At InviMed all retrieved donated oocytes are frozen. Again, the arguments surrounding fresh versus frozen are rife and, even though Dr Sroka advises better results are usually obtained from fresh oocytes, he believes that frozen eggs are best for donor egg IVF.
Once the eggs are collected, they are immediately frozen and put into quarantine. Even though donors have been checked and tested numerous times before the treatment, it’s not impossible for a fresh, new infection to develop. Freezing and then quarantining the oocytes ensures the eggs are re-checked, meaning an extra safety measure is in place.
The use of frozen eggs also creates more flexibility and reduces the risk of a missed cycle. Synchronising donors and recipients for a fresh transfer is incredibly difficult to accomplish. Extra time may be needed for the donor stimulation or for thickening the recipient’s endometrium, trying to prepare both women simultaneously will not always be successful. Frozen eggs provide a viable workaround option allowing the transfer to go ahead as scheduled.
Donor egg freezing also allows for larger donor pools and therefore lower waiting times. In most countries, it is a legal obligation to match donor and recipient phenotypes (hair and eye colour, build and ethnicity) in order to go ahead with egg donation IVF. Donors can also become ill or resign, which can delay fresh cycles, however, when using frozen eggs, the donor has already been found and the oocytes have already been retrieved; they are ready to be used immediately.
Clients looking into the various egg and/or embryo guarantee schemes should also think around future family planning. Whilst obtaining a decent number of eggs could help to achieve a good number of viable embryos; it’s not a given. Sperm quality can be low, fertility rates differ, and embryonic development is unique for each situation. A guaranteed amount of embryos allows couples the potential to, more easily, create genetic siblings from any subsequent frozen embryo transfers.
Whilst harvesting a good amount of eggs is obviously intrinsic to the IVF process, Dr Sroka once again stresses the importance of quality over quantity. Whilst schemes which offer an assured number of eggs may be promising, they can be misleading as it’s ultimately embryos, not oocytes, which result in a successful pregnancy and live birth outcomes.
When we use donor eggs and donor sperm, the only thing we need from the patient is a healthy working uterus so we can say that, from a medical point of view, there is virtually no age limit. As I remember, the oldest patient in a successful egg donation program was 66, and the probability of getting pregnant is not much lower at 52 years of age in comparison, for example, to 42. Of course, in many countries and in many clinics there is some code of ethics or some legal issues which limit the highest age for which egg donation is possible. For example, we at InviMed have an age limit of 50 years, but that’s more from an ethical point of view than from a medical point of view. From the medical point of view, if you have three or more high-quality embryos, the probability of pregnancy is still about 50-60%.
As I said, egg donation is IVF treatment, so we use exactly the same morphological and embryological criteria for core embryo selection as we would in any IVF treatment. The embryologists at the clinic assess embryos every day; they assess the number, size and quality of each cell comprising the embryo and give them a special grading according to international norms and regulations. These are the well-accepted, international biological morphological criteria for embryo assessment that are used in all IVF treatment. We don’t usually carry out any invasive tests on embryos, especially for egg donation. The main reason for PGS screening is the advanced age of the patient, but in fact, it’s not a question of patient’s age, but the age of the donor. If we know that the oocytes come from a young donor, then there is no indication for invasive tests on the embryos. In Poland, the law says that we must have some clear indications to perform any genetic testing on the embryo. Usually, in egg donation programs, we don’t have such indications so we use normal routine embryological criteria for embryo assessment and we use these to select those high-quality embryos for transfer or for freezing.
In fact, there is a lot of medical research that shows that when many patients with a history of failed implantation, failed conception or recurring miscarriages are put into egg donation programs as many as 90% of them will get pregnant. I said before, it’s all about the eggs and more we learn about infertility and IVF treatment, the more we believe that good quality eggs and good quality embryos are the main factors for a healthy, ongoing pregnancy. In many cases, implantation disturbances or implantation disorders vanish when we use embryos from egg donation programs. This is also the case with immune issues, although this is a very wide topic and still not very well scientifically described: there are still no good diagnostic procedures and there’s no consensus as to how to diagnose and how to treat many immunological issues. As I said, many patients with problems with implantation or who have been previously diagnosed with immunological idiopathic factors will benefit from an egg donation program.
Theoretically, you can do this and it has already been done in many countries. We don’t do it in Poland at InviMed. It was first done in the UK, not because of the age of the patient, but because of some genetic diseases connected with the DNA outside the nucleus of the oocyte. There are some diseases located in the DNA, in the mitochondria, so we use an egg from the donor with the donor’s mitochondria, and we put the nucleus with the mother’s DNA inside such an egg. This procedure will, in fact, include the DNA of three persons. Of course, this can be done, but for genetic reasons rather than because of the age of the patient. As the patient gets older, the DNA of the oocyte also gets older. The DNA becomes somehow shattered, somehow damaged, and when we put such a nucleus into a donor egg, the oocyte can still have still can have an abnormal number of chromosomes resulting in a bad embryo. There can be no pregnancy or pregnancy with some inborn problems. We don’t carry out such techniques but they can be carried out for reasons other than the age of the patient. It will not help all patients.
I’m personally against any combination or mixing so we have to decide if a patient is still able to be a subject for normal IVF treatment. If the eggs from the patient are viable and their number is enough to get some good embryos and finally pregnancy, we can try one more IVF treatment. But if factors like the patient’s age, the number of previously failed IVF treatments, the level of ovarian reserve or any other factor tells us that the next IVF treatment has a very low probability of success, then we should perhaps decide to go to egg donation. So first, normal IVF treatment, as many times as possible from the patient’s point of view, from a financial or medical point of view, and if we see that next treatment is not going to succeed, we can go to egg donation. Personally, I can’t see any benefit in mixing patient eggs and donor eggs in one cycle.
Yes, egg donation is completely anonymous in Poland because of legal issues. It is not a possibility for the donor or recipient to get any data leading to their identification and because we use frozen eggs and we physically separate donors from recipients this is quite easy to accomplish. Of course, we don’t accept family donors or own donors, mainly because of these legal issues but also from an ethical point of view. It’s much better for the donor and recipient to not know each other. We know of many cases where it was initially very helpful to have a family donor but then it all went wrong. So, from an ethical point of view, it’s much better to have anonymity and from a legal point of view, we are obligated to accept only anonymous donors.
Yes, I sometimes recommend embryo adoption. If we have a couple who have to use donor sperm and donor eggs and for financial reasons are not able to participate in an egg donation program, embryo adoption is quite a good solution. There are some couples who choose embryo adoption over an egg donation program for ethical reasons; they want don’t want to create new embryos but will accept embryos that have already been created. These embryos often come from a couple whose family plans have been fulfilled, meaning that all their best embryos have already been used. And, we have to remember that such embryos come from couples with infertility problems, so their viability may not be as good as embryos from egg donation. Generally speaking, I would better recommend egg donation programs, with partner or donor sperm, to couples without their own eggs. However, in some cases, adoption can be also be recommended.
As I said, from a medical point of view there is no limit. If we prepared even a healthy 70-year-old woman, it would probably be possible to get her pregnant. The majority of clinics set some ethical limits, sometimes 50, sometimes 55 years old, and in some clinics, there is no age limit, especially in the US. Sometimes, it’s also a matter of legal issues. And as you know, there have now been more than few cases of uterus transplant and, in one case, a mother donated her uterus to her doctor, whose own uterus had been removed because of disease. After hormonal preparation and hormonal stimulation, the recipient of the uterus was able to accept patient embryos and to develop pregnancy. So from a medical point of view, there is almost no age limit in many clinics, although, there might be ethical limits, for example, in any new methods.
By ‘mother’, we mean the recipient of the embryo and so from the strictly genetic point of view, none of the mother’s genes are inherited, because all the genes from the female side are located in the oocyte, so when we use donated oocytes, all genes come from the donor. However, epigenetics, quite a modern branch of genetics, is about switching on and switching off different genes according to the environment. When we put an embryo from donated oocytes in a mother’s womb, there are many ways the mother’s recipient body can directly influence the genes of her child over the nine months of pregnancy. The genes can be switched, on switched off and somehow modified, meaning that the recipient has some influence on the genetic activity of the foetus. The mother’s lifestyle during pregnancy also has an influence on the development of the foetus, not only on the development of the phenotype, the external features but also on the activity of different genes.
45 is a little young, I would say. I would put the bar somewhere between 50 and 60 years of age, and maybe even higher. You have to remember one thing; the oldest sperm is about 3-4 months because sperm is produced all the time and is generally between 90 and 100 days old. On the other hand, eggs are created during the fetal life of the woman, so when a woman is 45, her own eggs are also 45. In a 50-year-old man, his sperm is only three or four months old so we cannot compare eggs to sperm. Before IVF treatment or an egg donation program, we check the sperm very carefully, not only with a typical sperm examination, sperm count and sperm motility, but also with sperm DNA fragmentation; we check the percentage of sperm that has fragmented, broken DNA. If this indicator is very high, we can use special methods like ICSI to select the healthiest sperms. At some age, sperm quality does become quite low and the DNA fragmentation very high and then it’s better to think about a sperm donor instead of using partner sperm. But it’s very hard to put one age limit on a man, although we know from research that at a certain age in men the risk of Down syndrome is higher. But I said but as I said, we have to look at the sperm examination results.
We do IVF treatment for a reason and we do egg donation for a reason. That reason can be an independent factor, an increased risk to the health of the child, for example. When we do IVF for a patient with some male genetic disorders, like the CFTR mutation, we know that this mutation can be passed on to male children. It’s hard to answer such a question in a very general way but, to take one example, when there are indications for egg donation and the main indication is a woman’s age, the risk of Down syndrome for a 44-year-old woman is 1 in 30. When we use donor eggs, the risk goes down to 1 to 30,000; many times lower. In this case, we could say that the indication for egg donation has certainly led to a higher chance of having healthy children. Or, indeed, having children at all.
The main test would be to assess the ovarian reserve and we have a very simple laboratory test, AMH, anti-Mullerian hormone test, which is the best indicator of ovarian reserve. There is no single good value for AMH, but if it is very low, suggesting menopause or premature menopause, this would be an indication for egg donation. We have to correlate the AMH level with the patient’s age and then decide what is better for the patient, to have further IVF treatment, to have IVF treatment at all, or to go with egg donation. If we know that the patient is a carrier of a genetic disorder or has previously given birth to a child with a genetic disorder, this is also an indication to egg donation. The main test is to ask about the year of birth and AMH to assess the ovarian reserve. Ovarian reserve can be also assessed using FSH levels or by ultrasound, both of which can be misleading, or an Antral follicle count, but the AMH is the simplest solution.
For legal reasons, we don’t do stem cell instillation. I only know this technique from theory and research so I can’t tell you about any results with platelet-rich plasma or stem cell instillation from personal experience.
For legal reasons, this is not possible. In Poland, you can’t trade in eggs. We have an egg bank for the treatment of our patients but do not offer this to other countries. There are egg banks in the world which export eggs to different countries, so it is possible to find such an institution and to contact them. We have a lot of patients from abroad, mainly from Europe and I also have had some patients from the United States but all the embryological treatment, egg warming, egg fertilization, embryo culture and embryo transfer has to be performed at the clinic.
Our egg donors are of the Caucasian phenotype: white, pale skin, the typical phenotype for central Europe. We don’t have donors from different backgrounds, mainly because it’s quite complicated and there is no special demand for such donors from our patients. We mainly have patients from Poland, Germany, and the surrounding countries, from Central, Western or Eastern Europe and the typical phenotype is Slavic.
As far as I know, in our clinic, we don’t have Chinese donors, but, of course, it’s all matter of supply and demand. If there were more patients from different backgrounds, maybe there would be a need for donors from different backgrounds. I have had few patients with different skin colours, but they were interested in Caucasian donors.
Regarding the legal situation using donor eggs or donor sperm, and legally this is the same, Polish law says that couple either has to be married or has to make a notarized legal statement that they will accept a child born from such a procedure as their own. The fact of making such a statement is registered but is privileged, secret information, not public information available to do anyone.
InviMed cooperates with Intersono egg donation bank and we get eggs from them, so we don’t pick up at our clinic. Because of anonymity issues, we cooperate with an external egg donor bank which supplies us with eggs, mainly from Central European donors.
This can be answered with both a yes and no. In fact, a good quality embryo with the right morphological criteria has a much higher probability of turning into a pregnancy, but we cannot say this is a guarantee of a healthy pregnancy. A lot of things can happen in the early stages of pregnancy and even good quality embryos can result in some disorders. From the other point of view, we don’t transfer bad quality embryos, they are connected with a higher risk of some genetic disorders, and so you could say that there is some correlation. Methods of embryo quality assessment are far from perfect and, worldwide, we are still working in many scientific labs and in many scientific research projects to find that the best method of assessing embryos with a view to getting a healthy pregnancy.
The first thing, as I said earlier, about donor matching criteria, aside from the psychological aspects, we are obliged by law to match the looks of the donor to the recipient, as much as possible. This means that there is a high chance that the baby and will look similar to the mother. The second thing is epigenetics, which can also influence the look of the baby. Sometimes babies resemble only the father and then, with many children born from own eggs and own sperm, there is virtually no resemblance to the parents.
If the only reason for egg donation is some uterine anomaly, like unicornuate uterus or double uterus, egg donation may not be very helpful in comparison to natural conception or IVF treatment. Sometimes, there is a mix of problems, there may be an anomaly in the uterus and also a problem with the egg, so when we use a good quality embryo from egg donation, we can count on a bit higher chance of implantation. Remember that the quality of the embryo is crucial and the most important factor for pregnancy. With ectopic or extrauterine pregnancy, the embryo can implant in very different parts of the body, sometimes even directly into the abdomen, so the potential of an embryo to implant and to develop is very high. When we have a good quality embryo, even with some small uterine anomalies, this can be can be beneficial for pregnancy. Of course, sometimes it’s possible to correct any anomalies by surgical methods and then perform IVF treatment or egg donation treatment. Egg donation is no treatment for uterine anomalies and if the patient is healthy and young and the only problem is some kind of uterine anomaly, egg donation may not the first line of treatment.
Yes, multiple IVF failures with own eggs are one of the main indications for egg donation. We believe, and it’s scientifically proven, that many implantation failure cases can be resolved by using egg donation. I recall one patient for whom, after 10 unsuccessful IVF treatments, some in Germany, a few of them in Denmark, egg donation was central in her becoming pregnant. So yes, it can be helpful because, as I said, everything is the egg, and a good egg means a good embryo, and a good embryo can implant virtually anywhere.