IVF and egg donation – the risks, the process and limitations

Explained by: Maria Arqué, MD, Fertty International
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The process, risks and limitations in IVF eggdonation #IVFWEBINARS
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What's in the Video

IVF and egg donation – the risks, the process and limitations

Egg donation is a fertility treatment used by women who can’t use their own eggs to have a child. Deciding on this solution is probably on of the hardest steps of one’s own infertility  journey.

From this webinar you will know:

  • what is the treatment process?
  • what are the advantages (and possible disadvantages) of using donor eggs?
  • are there any risks to consider?
  • what kind of limitations are associated with this treatment?

During this #IVFWEBINARS, dr. Maria Arqué [International Medical Director at Fertty International] is making you familiar with the subject of IVF & egg donation. Process, risks and limitations . When you learn all the treatment details, it may be much easier for you to handle your doubts and deal with all the concerns.

The definition

Before we can start talking about any subject, we have to define it first. Dr Maria Arqué starts with describing egg donation as the process by which a woman donates eggs to enable another woman to conceive as a part of an assisted reproduction treatment. It is basically offered to patients who have early menopause, or low quality eggs or have had previous chemo- or radiotherapy (and as a result, they’re not producing eggs anymore) . Egg donation is also recommended for those who underwent previous fertility treatment that did not give them any pregnancy (failed ART) as well as to those affected with genetic diseases that cannot be diagnosed on the embryo. Finally, it is the only solution in cases where ovaries are not accessible for egg collection.

The legislation

Dr Maria explains how the legislation on egg donation works in Spain. There are a few important issues to take into consideration when deciding on the treatment in that particular country. Firstly, egg donation in Spain is anonymous. It means that neither a donor nor recipient can know each other’s identities. Secondly, egg donation is a truly altruistic act – donors do not receive compensation for it. The only costs that are refunded are those of travel, accommodation, medical tests, etc. And finally, under the Spanish legislation, it is the medical team that selects the donor on the basis of phenotypical and immunological characteristics of the patient. In practice, it means that they are looking for a donor who looks much like a patient.

The donor selection

According to dr Maria Arqué, one of the most frequently asked questions in the topic of egg donation is how egg donors are selected. In the light of the law, egg donors must be healthy women between 18 and 34 years old. The upper age limit is dictated by the fact that over the age of 35, there is a decline in the quality and quantity of eggs. In order to diminish the risk of problems with eggs’ quality, doctors have to prepare a thorough medical and family history of the patient and the donor. The egg donor undergoes psychological tests and an extensive assessment including tests such as blood group and Rhesus, virals (HIV, hepatitis B and C, syphilis) and sexually transmitted diseases (STD). Additionally, there are different genetic tests conducted – karyotype (being ‘a map of chromosomes’) and a panel of recessive diseases (called also ‘the genetic carrier screening’). The latter includes e.g. cystic fibrosis mutation, muscular spinal atrophy, X-fragile syndrome testing, sickle cell and thalassaemia and is used to match the donor not only according to the physical characteristics, but also according to the genetic information and, as a result, to minimise the risk of having a baby with genetic diseases. Apart from the genetic tests, there are also gynaecological tests (AMH and scan) included in the egg donor selection process to make sure that there are no factors possible to affect the ovarian stimulation and the egg collection process.

As egg donation is anonymous in Spain, the only information on donors that can be accessed by patients is age, race/ethnicity, blood group and Rh as well as general phenotype characteristics (hair, eyes and skin colour, height and weight).

The recipient screening

Patients choosing egg donation treatment have to undergo a detailed assessment as well. There are mandatory examinations, necessary in the European legislation on infertility treatment, as well as tests required on the basis of each patient’s individual case. The list consists of tests for virals (HIV, HBsAg, anti-HB core, HCV, RPR/VDRL), Rubella IgG, blood group and RH, full blood count (hemiogram), TSH and vitamin D. Dr Maria says that doctors would also have to screen the patient to see if there are no pap smear test abnormalities and do an ultrasound examination just to make sure that the uterus is normal and free of fibroids or polyps that could interfere with the implantation. Depending on the patient’s age, doctors could ask for a mammogram and a clearance letter from a patient’s GP stating that there are no contradictions for pregnancy.

When a woman is undergoing egg donation treatment with her male partner, he is required to have some tests done as well. These most frequently include virals, blood group and RH, karyotype and semen analysis.

The treatment timeline

In order for us to grasp the timeline of the egg donation treatment, dr Maria goes on to present a full treatment cycle. It starts with an initial consultation – first online, and then usually a presential one at the clinic. During the latter, all the required tests are done and a patient’s male partner is asked to leave his sperm sample to be frozen. In this way, it won’t be necessary for him to come to the clinic on the day of the egg collection from the donor. The results of all the tests will be available after 2-3 weeks and then another (preferably online) consultation takes place. When all the treatment issues are discussed and set with a patient, the clinic goes on to select the egg donor. The egg donor is then required to undergo an ovarian stimulation (lasting for approximately 2 weeks) prior to the egg collection. On the day of the egg collection, the frozen sperm is thawed and afterwards, the eggs and the sperm are put together for fertilisation. Fertilized eggs (embryos) are left in the lab to grow until they reach the stage of a blastocyst (day 5 or day 6 embryo). If the embryos are of good quality, they are frozen. At that point, the patient starts her endometrial preparation. The endometrial preparation usually begins one week before the patient’s period, together with the injection of a GnRH antagonist – just to make sure that the ovulation is done and it does not interfere with the preparation. Once a patient gets her period, she starts the hormonal treatment (with patches or pills) to prepare the lining of the uterus for the embryo implantation. The response of the lining is then checked with a scan and a blood test. If the results are ok, the patient is told when to start a progesterone therapy. After 5 days of progesterone use, the embryo transfer is conducted. After 2 weeks have elapsed since the transfer, the pregnancy test is done and the pregnancy is confirmed. Dr Maria explains that generally the full treatment process takes around 3 months (counting from the initial consultation to the moment of the embryo transfer).

Dr Maria also mentions the possibility of synchronising the patient’s cycle with the cycle of the donor and conducting the so-called fresh embryo transfer. However, it happens that the cycle of the egg donor might not go as well as expected – meaning there are no good embryos available for transfer on time. This might be highly risky when one realises that most patients come for the embryo transfer from abroad and have to travel long distances for that one particular procedure. Taking it into account, doctors prefer to proceed with frozen transfers, especially as the chances of success are pretty much the same in case of fresh and frozen embryos.

The programmes on offer

Clinics nowadays make different egg donation programmes available. The patients can choose among options with various guarantees, tailored especially to their needs. Dr Maria says that the standard programme at her clinic offers minimum 8 mature eggs from the door and 3-4 blastocysts for each egg donation cycle on average. There are also options such as Exclusive Egg Donor (guaranteeing all the eggs from the donor’s stimulation cycle) and Baby Guarantee Program (including 3 cycles of egg donation).

The rates and limitations

Generally, egg donation treatments can boast high success rates. The pregnancy rate per transfer is more or less 55-60% and cumulative pregnancy rate (out of the cycles conducted at dr Maria’s clinic) comes up to 80-85%. However, even though this type of infertility treatment is a great way to overcome obstacles such as patients’ advanced age and the decline of eggs’ quality and quantity, it is not free of risks and limitations. There are infertility problems that cannot be addressed even with egg donation and these include coexisting female infertility factors (e.g. uterine fibroids, malformations or thrombophilia) and male infertility.

Finally, dr Maria stresses one very important thing to remember: biology is not mathematics. One has to remember that even when using egg donor, cycles might not go as we have expected. For example, egg donation is not a guarantee of euploid embryos – the only solution for that is preimplantation genetic testing (PGT). Unfortunately, the latter is not medically indicated in all the cases.

 

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Questions from the event

I have a quite stressful job and I’m about to embark on my second egg donation cycle. I’m 49. Is there any advice you can offer?

Obviously, stress can play a role here and influence the likelihood of success. My advice is: if there is anything you can do to be a little less stressed with your work, that’s going to be helpful. I’d suggest you to find some time for yourself every day. You can practice meditation, start doing yoga or sports. Sport is good not only for your general health but also for relieving stress. I’ve also had patients who had very good experience using acupuncture during their treatment. I know it’s very personal and case-specific but if your main source of stress is your job, then maybe you could try to work fewer hours or find some help? It’s probably going to have a positive effect not only on your cycle but also on your overall life. When we’re doing egg donation, we somehow remove the stress related to your age and the biological clock. It is very important to remind you that in Spain, we treat patients up to the age of 50. It’s important because the sooner you start to contact the clinic and do all the tests and exams, the better. You should make sure if everything is in a proper place and start your treatment relatively quickly. But in case of stress, I don’t think that your age should play a major role here.

Can you give any information on price policy?

If you want the information regarding price policy, I would kindly ask you to contact us through email. The team responsible for prices will give you all the information.

What is the age limit for egg receivers at your clinic?

The age limit for egg receivers at our clinic is 50 years old.

If the egg donor and the partner both did the karyotype tests and both came back normal, is there a risk of chromosomal abnormalities at birth or during a pregnancy?

It’s a very good question indeed. Even if the egg donor and your partner have a normal karyotype, it does not necessarily mean that the baby is going to have a normal karyotype as well. A karyotype of the baby will depend on the chromosomes of the egg and the sperm. And the chromosomes are not exactly the same as a normal karyotype of the egg donor and the partner. It also involves the division of the cells that – because of age or because of the fact they failed – may not divide properly and the number of chromosomes may not be ok. So answering your question: yes, there is still a risk. Obviously, the risk of chromosomal abnormalities is low if we’re using an egg donor – she’s usually young and the security mechanism that the cells have when they’re dividing is working properly. If the male karyotype is also normal, then the risk is low but it’s still there. So if you’re concerned about that, my recommendation would be to do preimplantation genetic testing (PGT) – in this way, you can have certainty that the embryo you’re transferring has an optimal number of chromosomes. But this may not be medically indicated and, obviously, this technique is not for everyone. Another thing that can be done is an early screening for genetic abnormalities. You may do it through a blood test during the first trimester of pregnancy. Apart from that, do all the tests related to a regular screening between 8 and 11 weeks of pregnancy.

I did three IVF cycles in Florida. Every time I had one egg that was big enough to transfer and each time it burst before my doctor could extract it. He said that IVF meds hurt me. I had more eggs on my sonogram before I started IVF. I am 43. I would like to get pregnant this year. Do you advise donor eggs?

Even if you’re still producing eggs at the age of 43, most likely the quality of these eggs is not going to be good. Of course I cannot say that it’s impossible for you to achieve a pregnancy with your own eggs at this age, but the realistic likelihood is very low. If we’re talking about the percentage of live birth with own eggs at 43, it would be around 5% maximum. So if you’re asking me about a treatment option that would give you the best possibilities of achieving a pregnancy and having a healthy baby, it would be to use an egg donor. Taking into consideration that you have already tried IVF with own eggs several times, it could be easier for you to go for egg donation. It’s because you at least have peace of mind, knowing you’ve already tried but unfortunately it didn’t work. In this way, you can close this chapter and say: ok, now I’m ready for the next step. So good luck in whatever you decide to do but I’d probably recommend egg donation.

Have you successfully treated females with adenomyosis in the past? Is there anything you would recommend to do prior to commencing an egg donation cycle?

Adenomyosis can be very tricky sometimes. It’s true that there is some data saying that patients with adenomyosis may have a little less likelihood of embryo implantation. It’s a disease that even fertility experts are still trying to understand. We treated some patients with adenomyosis and they achieved pregnancies. It is important to see if there is another infertility factor that may contribute to your whole situation. I don’t know if there is any endometriosis added to adenomyosis in your case but depending on the symptoms and the situation, it may be good to try to decrease all the inflammatory environment that is often linked with adenomyosis and endometriosis. It’s advisable to take a pill for some time, meaning a GnRH agonist. It may help to have a better environment afterwards for the implantation. But obviously I have very little information on your case so I’m generalising a little bit.

Do you treat patients with HIV?

Yes, we treat patients with HIV but we need such patients to be under the care of an infection specialist. We have to know that the patient is in a stable situation, that Viral Charge is negative and they’re having a good follow-up. For us, it’s also mandatory to have a clearance letter from the infection specialist treating the patient, confirming that the patient is stable, CD4s are fine and we can go ahead with the treatment. If that’s the case, then there is no problem – we can treat such patients.

I am preparing for a second egg donation cycle as the first one was unsuccessful. Will the transfer of 2 embryos maximise my chance of success this time?

When transferring the embryos, the chances of success depend mainly on the quality of these embryos rather than their quantity. It’s true that when we’re looking at the figures for transferring 2 embryos, there’s a slightly higher likelihood of achieving a pregnancy. However, there’s also a risk of having a twin pregnancy. Our policy is to try to minimise the risk of having twins in general. So our general recommendation is to transfer one embryo at a time. And if you do not achieve a pregnancy with one embryo transfer, we can always do another embryo transfer. That, of course, has to be individualised and it mainly depends on the quality of the remaining embryos that you have. So if you have embryos that are frozen, it’s important that you discuss with your doctor the quality of those embryos and he or she makes the assessment with you. If it’s a brand new cycle, it will also depend on the quality of the embryos. Similarly, if you’re having any other risk factors for having any complications with the pregnancy – like previous uterine surgery or a problem with a Pap smear – or other contraindications for having twins. So my recommendation generally is to do a single embryo transfer and avoid transferring two embryos, except if the embryos are of poor quality or the chances of pregnancy are not very good.

How high is the risk of twins in case of egg donation?

If we transfer one embryo at the stage of a blastocyst, the chances of twins are less than 1%. There’s always a risk that an embryo can split but it’s very low. If we transfer two embryos at the stage of a blastocyst at the same time, the risk would be around 25%.

Do you have a BMI limit for egg donation treatments?

We have the cutoff limit for BMI of 40. We don’t treat patients who have a BMI more than 40. With BMIs between 35 and 40, we assess the general situation of a patient. It’s not the same for someone who is super healthy but their only problem is high BMI and for someone who also has heart disease, high blood pressure, diabetes and something else. But apart from what I said, the ideal thing would be to have a normal BMI when we are about to start fertility treatment, to have an embryo transfer and afterwards for the pregnancy as well. It is not only because the chances of a successful outcome are much higher in such a case – it is also because there is a smaller risk of a miscarriage and complications along with the pregnancy for both the baby and the mother. We are very conscious that it can be super difficult at times to lose weight – it’s one of the health problems affecting many people in the world today. But most of the times, through a good programme of a diet, exercise, mentoring and coaching, a lot of things can be done. However, there is something more to consider here as well. It is of course not the same for someone who’s 30 years old and needs to do a fertility treatment – in such a case, we can say: Listen, you should lose some of this weight and then we can start treatment. But it’s completely different for someone who is 48 years old. So there are a lot of factors that have to be taken into consideration. Obviously, someone who is older, has a higher weight, too. And it complicates a lot of things. On one side, it means that we have less time, and on the other – age is also a risk factor with pregnancy, having complications, etc. And for us, it is super important to help patients to build healthy families and healthy babies. So to sum up: our limit for BMI would be 40. Between 35 and 40, we would individualise each case and see if there are any other risk factors for having complications. Finally, in case of BMI less than 35 (between 30 and 35), we would also help to manage the weight for the patient to be in the best possible shape for the transfer and pregnancy.

We had 2 failed ECO IVF treatments. We have stopped this month. How long does it take to start with egg donation?

With egg donation, you’re not going to have an ovarian stimulation. If you have your period, your tests are fine and you have everything ready, you could start as soon as you have all tests done. There is no need to wait. Unless – of course – there is something specific in your medical history that we have to study before. If all the tests are ready, we could start with your next period.

We want a donor with a university education/student, could it be guaranteed? What information on the donor do you provide? Is it possible to know the nationality, completed education, etc.?

Even though most of our donors are young professionals and college students from Spain or abroad, unfortunately, we cannot guarantee 100% that the donor is going to have a university education. Sometimes we simply do not have the information on completed education so there is no 100% warranty. We usually cannot provide the nationality either. We can give the information regarding the ethnicity or race, but not the nationality.

What happens if there is no suitable match? Do you match with a donor of less suitable characteristics or do you wait until there is a donor available that is more suitable?

I think the question is super interesting. If we have no suitable match – which usually does not happen – or when it is very difficult to match a patient with a donor because of some very specific characteristics, we always discuss the situation with the patient and explain everything. Firstly, we of course wait but there are some patients who are very impatient after waiting for a short time. So we explain all the options to them and we discuss the donor that is the most suitable to them. They may either agree or say that they prefer to wait longer for the donor that is more similar to them. So that’s how we try to do it. But we practically have very few cases like that – most of the time we find a good match.

Do donors have to be Spain residents?

Yes, they’re Spain residents. And if they’re students, they’re always here for a longer time.

What do you think about open donors – when a child can know a donor’s ID once she/he turns 18?

That’s a very hot topic. It is a tricky situation. Obviously, nowadays genetic information is getting all over the place. You can go to the Internet, do a genetic test and know about your ancestries. One of the things I always recommend to my patients who are about to do an egg donation is not to keep it as a secret and disclose it to their children – even if the donor is anonymous. As we do not know how things are going to evolve in the future, we do not want the children to find out the truth without you having told them that. I think your children deserve to know at least that they come from an egg donor.

Is there any follow up treatment that you do after a patient gets pregnant in case there is a miscarriage history?

Patients who have a recurrent pregnancy loss or have had several miscarriages, will be always thoroughly studied by us before getting them pregnant. And then, if it’s indicated, we’ll give them some treatment to help them with that as well. Then we follow up with their gynecologist or obstetrician to see how things are evolving and decide whether it’s necessary to keep on taking some medications or not.

Are the donors used only once in your clinic? Answer:

In Spain, in the case of egg donors, there is a limitation saying that a donor cannot have more than 6 children in total. It means both the children they got themselves and the ones they gave to other people through egg donation. So we have donors that we have used more than once but we always take this limit into consideration. Apart from the limit on the number of children, the Spanish Fertility Society also recommends not to do more than 6 egg donation cycles per donor.

What do you look for in sperm quality?

It really depends on each patient and their medical history. Obviously, we always do a semen analysis. In some cases, we may also indicate to do a FISH test to check the percentage of genetically abnormal sperm and see if there is a higher risk of having babies with chromosomal abnormalities. Then we also check for the DNA fragmentation of the sperm – especially in cases of recurrent miscarriages. We also have an andrologist working here in our clinic so we always assess together all the complicated cases from a male side. If necessary, we can employ all other tests that will depend on the context.

I have done 2 ICSI treatments. We have a very low fertilisation date – 1st ICSI treatment: 5 mature eggs, 0 fertilisation; 2nd treatment: 5 mature eggs, only 1 fertilised. It ended up with a failed implantation. I’m afraid if we do ICSI again, we will get the same result. Now we are looking for causes and treatments to improve the fertilisation rate and the chances of pregnancy. My age is 37, my husband is 32. His sperm motility is 5% – hence our first treatment was ICSI.

I do not anything about the quality of the eggs. Obviously, sperm motility is pretty low. We would have to look and see what other tests have been done and if there are any other tests that should be done. We should look at eggs and sperm quality to see how it can be improved. Sometimes, depending on the quality of the sperm, we might also look at the DNA fragmentation which can help to select the sperm that’s less fragmented. We could also use a device called a fertile chip that would help us to select this kind of sperm and have a better fertilisation rate. But with two cycles already done, I think that there is a place for studying your case a little bit more and assessing if there any other tasks to be done before you consider egg donation or other solutions for your treatment.

I’m 48 years old and on menopause, my partner is 39. I need to have an egg donation. Is there anything specific that I should consider when choosing a clinic with egg donation?

What I would recommend is to look for a clinic in which you feel confident and you trust a person you’re consulting. It should be a clinic that has good reviews and a good reputation. Check if they fulfil the requirements of selecting donors and what are the warranties that they can give you – what is the number of embryos to transfer and if they transfer embryos at the stage of a blastocyst. Always trust the feeling that you get when you contact the clinic. Usually, patients have several consultations with several different clinics and once they feel convinced and know they’ve found a place and a doctor they can trust, they decide to have their treatment there.

In case in the future a situation demands a genetic test between a child and a mother, what will the result show in case of an egg donor?

I understand you mean a test to see if a mother is a biological parent to a child. Obviously, it will be seen in a test like this – it will show that genetic information is not hers.

What percentage of success in achieving a live birth would you give to someone who is 44?

If we’re speaking about achieving a live birth with an egg donor, the percentage will be very good. If there are no other medical issues, we’ll be speaking about 40% more or less. Of course, we’ll have to take not consideration that unfortunately 10-15% of fertility treatments – even with egg donors – end up being miscarried. But otherwise, the rate will be very good. If we’re speaking about a live birth rate with your own eggs at the age of 44, it would be less than 5% (3% or 4% ).

What does grade 1 quality embryo mean?

I’m not certain if you’re speaking about embryos on day 3 or day 5 because when we have day 5 embryos, we usually grade them with a number and two letters. But usually grade 1 would be top quality.

Do you recommend clinics with a guarantee programme – meaning we pay double the cost and they guarantee 3 cycles and the money back if the pregnancy is not achieved?

Our baby guarantee programme is also a programme like this one. We offer that as well. I think that it really depends on your individual situation. I think this is a very good programme for couples who’ve already done several cycles and had a really long infertility journey. They have already spent a lot of time, effort, energy, money on doing cycles. For them, it is probably very important to know that even if they do not achieve the pregnancy, at least the money is going to be refunded. Having infertility is already a very difficult situation but let’s not forget about the economical world and about doing fertility treatments. It’s true that when you are doing one of those programmes, you are paying more money. But for a lot of patients, the peace of mind is more important – it helps them to decide on one of those programmes. Having said that, it is important to mention that we also have very good results with the standard programmes that we use. So I do not think that such a programme is a solution for everyone.

Will the genetic test show that the mother is the one who gave birth to the child?

There is no genetic test to say which is the mother who gave birth to the child. But when it comes to the custody of the child and all related things, you should not be concerned because all of it is signed before doing any treatment. The contract the donor has with the clinic is very clear and on the paperwork that you sign, it is clearly stated that you are the legal mother responsible for that child and that the custody is yours.

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Authors
Maria Arqué, MD

Maria Arqué, MD

Dr. Maria Arquè is a specialist in obstetrics and gynecology and reproductive medicine. She has worked in a few renowned IVF clinics in Europe. Dr. Maria Arquè’s professional interests include preserving fertility for men and women, IVF and reproductive health research, fertility education for patients and the impact of lifestyle/diet on IVF with ICSI success rates. She has studied and worked in Ireland, did some of her training in reproductive medicine in the USA and is now an International Medical Director at Fertty International in Barcelona, Spain. Dr Maria is proficient in a few European languages: English, Italian, Spanish and Catalan. "All patients inspire me. Each of the patients I meet every day has a different background and a different approach towards their infertility diagnosis. I learn from all of them every day and I’m grateful for it. The biggest lesson I have learned from my patients is that resilience and perseverance are key if you want to succeed."
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