Alternative family models for women

Zineb Meski, MD
Specialist in Assisted Reproduction at IVF-Spain Madrid, IVF-Spain Madrid

Category:
IVF Abroad, Same Sex Couples

From this video you will find out:

What is the IVF legislation in Spain?
What is ROPA?
What are the requirements to undergo ROPA in Spain?
What is the ROPA process?
What is the law regarding sperm donation in Spain?
What is the sperm donor selection process?

Alternative family models for women

What are my IVF options if I'm single or in a lesbian relationship?

In this webinar, Dr Zineb Meski, a Specialist in Assisted Reproduction at IVF-Spain Madrid has been discussing some alternative family options for women like the ROPA method for lesbian couples as well as options for single women.

Since 1988, the IVF legislation changed a lot in Spain, nowadays, there are more treatment options for heterosexual, and homosexual couples as well as single women, especially since 2006, the law for same-sex female couples have been approved, it’s called ROPA, which stands for ‘reception of oocytes from the partner’.

ROPA requirements

Female couples need to be married or be in a domestic partnership. There are some steps of the procedure that need to take place. First is the synchronizing of both female cycles, a woman who is going to provide eggs is stimulated, and at the same time, the other woman is going to be prepared for the embryo transfer. There will be a donor and a recipient. Usually, the younger woman or the woman with a better ovarian reserve will provide eggs, and once the egg retrieval is done, the eggs are going to be fertilized by ICSI with a sperm donor. The embryos will develop in an incubator to the blastocyst stage (a day 5 or a day 6 embryo), and then the embryo is going to be transferred into the recipient’s uterus. Therefore, both cycles have to be synchronized to do a fresh embryo transfer, so when the egg retrieval is done, the recipient’s endometrium has to be ready for the embryo transfer.

There is also an option for delayed of a frozen embryo, where the stimulation is performed in the same way, but the embryo will be frozen and can be transferred at a later time, this is a more flexible method. It’s done on some special occasions, for example, when Preimplantation genetic testing needs to be performed because the results are available after 2 weeks or when the recipient cannot do the embryo transfer because her endometrium is not prepared for the embryo transfer.

Other treatment options

Other treatment options include IVF with sperm donation, IVF with pre-implantation genetic testing (PGT-A)and sperm donor or embryo banking with sperm donation for women with low ovarian reserve.

IVF with PGT-A means that instead of transferring the embryos at a blastocyst stage, they are going to be analysed to see if there is any genetic abnormality in the embryos before they are transferred. In such case, a fresh embryo transfer is not possible because when the embryos are biopsied, some cells are taken out, therefore, a blastocyst stage is necessary as more cells are needed. The results are available after 2 weeks, that’s why all embryos need to be frozen then, and once the results are known, the embryo transfer can be performed. In this case, the cycles of both female partners don’t need to be synchronized

Another option is embryo banking with sperm donation, that’s for women with a low ovarian reserve, it aims to accumulate embryos. Sometimes when a woman has a low ovarian reserve, the stimulation has to be repeated, and that way it’s possible to accumulate more eggs, and in turn, there is a higher chance of having more embryos. Only around 50% of all the embryos are going to make it to the blastocyst stage. Therefore, embryo banking starts with the stimulation, fertilizing the eggs, and when the embryos are created, they are frozen, and another cycle is done to get more embryos, 2 or 3 stimulation cycles may be needed to get a good amount of embryos.

Why is the accumulation of embryos needed? It’s because if there are more embryos available, this allows the patients to have an option for more attempts if it is needed. It will also permit to do PGT-A testing and increase the chances of a successful transfer and a healthy baby.

Sperm donation

The sperm donor is a crucial part of ROPA treatment, the sperm donation is strictly anonymous, the patient cannot choose the donor, the medical team will choose the donor for you according to your physical characteristics, your blood type, and there are also some preferences that you can tell the doctor like the colour of the eyes, the skin if you want, that you wish for the sperm donor to be more like the egg donor or the recipient since the recipient is not going to give her eggs. You can select the sperm bank that the clinics cooperate with, but you cannot choose a donor, you won’t have any information about the donor.

Treatment step by step

During the first visit to the clinic, you’ll learn all about the process, and personalized treatment plan, then once the treatment is confirmed and you are ready, you will get the prescriptions for the medication. You will also receive a schedule so you can plan your ultrasound scans, and all your blood tests and then send it back. Once you start the treatment, the team at the clinic will tell you if any further analyses have to be done, like an endometrium biopsy or a Carrier screening, genetic test to see if you are carrying any genetic disease or any mutation, and it’s also done to the sperm donor. Some diseases are always checked in the sperm donor, but there are millions of genetic diseases, and it’s impossible to check them all, therefore, the most common ones are going to be checked, like cystic fibrosis, fragile X syndrome, etc.

There’s also a possibility to do a genetic matching. It means that you will need to do a Carrier screening genetic test, the sperm donor will also go through this test, and then with all this information, the medical team will do the matching to see if you do not carry the same diseases.

- Questions and Answers

Which method do you use for PGS?

We use the new generation tests for the PGS, so that means we do a sequencing of the DNA and, it depends, of course, if we are going to do a PGS or a PGT for the aneuploidy, so aneuploidy, which basically looks for the chromosomal abnormalities like Down Syndrome or any kind of trisomy, that will be the PGS for aneuploidies, so that’s the screening. We are going to look for a specific genetic disease like cystic fibrosis or any other diseases that are known to be carried in the patient. We will use the new generation sequencing method (NGS).

Is there any other diagnosis method not so invasive as the PGS?

You mean without doing the biopsy on the embryo. There is no other method unfortunately, we need to take out some cells from the embryo to analyze those cells and to have some DNA of the embryo, so for now, that’s the only method. There are some other methods, but it’s not a PGS, that means that we are not going to know before the embryo transfer, that’s the new no invasive methods that are used during the pregnancy. We can do a blood test, which means that there is DNA of the embryo in the blood of the mother, of the bearing mother, but she will already be pregnant. If there is a bad result or some abnormality during the pregnancy, there is a decision that needs to be made. Whether to keep going with the pregnancy or terminate the pregnancy. That’s why we prefer to do the PGS because it will be a diagnosis before we implant the embryo, and the only way to know that, is to do the biopsy, but it’s safe. That’s why we need the embryo to get to the blastocyst stage otherwise, the embryo on day-3 will have very few cells, and if we take out one or two cells, first we take the risk that we won’t have enough genetic DNA material to analyze and the results will not be so reliable. Second, we can damage the embryo because it has only a few cells, 8 cells, and if we take 1 or 2, it’s a lot comparing to a blastocyst stage when usually they have around 200 cells, so it’s a safe method.

And with PGS, NGS, will the transfer be one month after the egg collection? Can that date be planned, or is it just down to when it’s best for your body?

When we do the PGS, the transfer can be the month after the egg collection because first, we need to wait for the results, and as I said, it can take around 2 to 3 weeks to get them, so it’s 3 weeks after the biopsy, and the egg collection is done 5 days before that, so if we do the math, it’s almost a month. We can start doing the preparation for the embryo transfer before that, it depends on the period, of course, all the treatments that I’ve talked about they have to start with a period ideally, but we can also trigger the period if it needs to be done if we need to schedule the treatment for a specific date or just start with a birth control pill with your period so we can just pause your natural cycle and start, whenever we want so we don’t need to depend on your period so that date can be planned ahead of time. It’s a little bit better to do it according to your body, but we will control your body with all the preparation, we will give you the medication, so the endometrium gets thicker, and your body gets prepared, so it’s planned actually.

What about embryo adoption for single mothers? Is there a long waiting list, and do you have embryos of various phenotypes?

I didn’t really talk about it, but it’s also an option. When I said double donation, it also means embryo adoption that could also be a good option for these women. There is not a very long waiting list, it’s really up to the embryos that are available now. The patients that have already done treatments with us, and most of them got already pregnant, and they don’t want to use any more of their frozen embryos that are left, they get this option to donate them to other patients, so according to the Spanish law, only the patients that are under 35, female patients that are under 35 when they did their cycles with us can donate these embryos. They donate them, we just need the authorization. These patients need to sign all these consents, so we can use those embryos for other women. Sometimes, we have a number of embryos that are already available but, of course, we need to match the phenotype. The law does not strictly say that we have to match the exact same phenotype, but we always have to respect the ethnicity at least and try to respect blood types. Especially, the most uncommon ones that can be a problem like a negative rhesus blood types, but it’s like secondary, it’s not like when we research a specific egg donor. Then, we have to respect all the phenotypes, but here it’s a little bit different, we just try to get the closest patients to your ethnicity, and if there is an available embryo, we just assign that embryo to you, and you can start right away, so I think that the longest waiting list that we had was about 3 months, so usually, it doesn’t exceed 3 months.

Do you have embryos for embryo adoption of black or mixed ethnicity? Is there a long waiting list?

We do have some embryos that are generated from black or mixed couples. As you know IVF -Spain is a group of clinics that are very open to international patients, so we have all kinds of ethnicities. We have several types of embryos that are listed in our embryo bank and sometimes there could be a little bit of more waiting, but that’s only because maybe there are several patients that are also looking for it. Usually, it’s not an issue, we do have a very wide range of ethnicities.

After one egg retrieval, how fast can you do the next stimulation in case of a low amount of embryos?

This is a very interesting question also because sometimes patients do get a little bit confused about the timings and about all these side effects of the stimulation. Actually, we just need you to get your period again, we need to do a checkup once you have your period after the egg retrieval, usually, it’s a week after the egg retrieval, you’ll get your period, and with that period, we’ll do an ultrasound to make sure that everything is back to normal. If you have no cysts, no side effects of the stimulation, we can start a second stimulation right away, so yes, a week after the egg retrieval when you get your period, we can start the next stimulation, again.

Is it possible to use my brother’s sperm and a donor egg for my baby? I am single.

Here in Spain, you cannot use your brother’s sperm, as I said, it has to be strictly anonymous, so I mean the same-sex couple women can use the eggs, it’s not really considered as an egg donation because it’s a married couple or domestic partnership couple, but for sperm, it has to be an anonymous donor, so, unfortunately, the law, for now, hasn’t changed, and for the male couples, it’s not possible yet, and even for the sperm donors, they have to be strictly anonymous.

What will happen to the remaining frozen embryos in case the couple breaks up after the ROPA program?

It’s a tricky one, well actually, it’s up to how the couple breaks up really because the ROPA program can only be offered for a married couple or domestic partnerships, so they both need to sign the consents, so legally all the embryos belong to both patients. If a couple breaks up, after all, it’s like in a heterosexual couple. If the couple breaks up, they need to see who gets the custody of the embryos, so it could be an arrangement between the couple, or it could be something that could get a little bit complicated, and sometimes, they’re not allowed to use those embryos, neither of them is allowed to use the embryo, so it’s not really up to our clinic, it’s up to the law and the lawyer’s decision, but you have to know that if you do the treatment, both of women will sign the consents as if they were both the parents of the future child.

What are the rates for IVF double donation for a woman over 40?

Usually, age affects the quality of the eggs, the quantity and the quality of the eggs, so it doesn’t really affect the uterus. I mean it affects it but not as much as the quality of the eggs, so if the woman is healthy, if all the blood tests, all the testings are normal, the success rates are the same for double donation for a woman over 40 or a woman under 40 and these success rates can go up to 75% because we are going to make sure that there is a good egg quality from the egg donor and also a good sperm quality from the sperm donor and it’s only up to the uterus to be prepared and to have the best conditions for the embryos that will be generated from this double donation treatment to allow the embryo to implant. We are going to make sure we do all the tests before transferring the embryos, and the success rates usually are very high.

I have PCOS and have had cysts in the past. I’m on the birth control pill now in order to plan my IVF. Do I still need to do an ultrasound before starting the injections to see whether there might be any cysts, or won’t there be any as I’m on the pill? (I didn’t have any cysts in the last ultrasound in the summer).

Actually, we always recommend doing an ultrasound before starting the injections just to make sure there are no cysts. Usually, when you’re on the pill, there are very low chances to have cysts, but sometimes it also happens, so we prefer to do that just to make sure there is absolutely nothing going on there before starting the stimulation because if you have a cyst that could interfere with all the stimulation, all the hormonal treatment and when you do an IVF we don’t want to start on the wrong foot as we say, we just want you to start with the best conditions to get the best outcome from your stimulation. Even if you didn’t have any cysts in the last ultrasound in summer, that was two months ago, and it can change from a cycle to another. I would recommend doing an ultrasound before starting just to make sure everything is fine.

How much does NGS decrease the risk of miscarriage and a sick child?

PGS and the NGS method is quite reliable, actually, it’s like a 99% of reliable results, so it won’t decrease the abnormalities, it will just give us the information, it will just tell us which embryo is healthy and which one has an abnormality. When we do an embryo transfer knowing that the embryo is healthy, doesn’t have any of those genetic abnormalities, the risk decreases a lot, the risk of miscarriage, and of course, it will decrease a lot. I can’t give you a number because we don’t really get the chance to do the study between women that do the PGS and the risks of miscarriage. It’s really difficult to compare because either you do the PGS or you don’t with the same embryos. It’s very tricky to do a study, but it does decrease the risk of miscarriage because most of the miscarriages especially, in women that are close to 40 years old – are caused by a genetic abnormality. You can have also some issues with your coagulation, window of implantation, other issues with your uterus like polyps or fibroids, but the most common ones are the genetic abnormalities. As for a sick child, as I said, PGS will only look for some specific genetic abnormalities, and we cannot look for all those genetic diseases, it’s really impossible, so even if we do PGS, you can still have a sick child, but that would be due to another kind of genetic problems, not chromosomal structure or chromosomal number problems. It would be some genetic mutations that as I said, we cannot test all of them.

Could it be possible that donor embryos can be from couples both over 40? What is done with remaining embryos of couples over 40 if they don’t want to destroy them?

The donors of the embryos can’t be over 40. As I said, according to the law the woman has to be under 35 to be authorized to donate embryos. As for her partner, there are some tests that we will need to do, like karyotype to see the chromosomes, we need to make sure that this couple that is going to donate their embryos don’t have any known genetic disease that can be transmitted to the embryo. If there are over 40 and they cannot donate them to other couples. Here in Spain, they are not allowed to destroy them. There is another option, and that’s to donate them to the investigation, but it’s also tricky because if there are no projects of investigation, the embryos. Sometimes, it is a bit of a problem to donate them for investigation because you need to have a Project, the current project, so they can use those embryos otherwise, they’ll just be frozen and will be waiting for a project to come.

What is the rate of genetic abnormality of embryos for a 40-year-old woman?

This is an interesting question because we haven’t talked much about the numbers, but there are some statistics there that are very interesting, so usually, a woman at 35 years old a woman will have a 60% chance to have healthy embryos. 40% of the embryos are going to be health, then as she gets closer to 40 that range will decrease, the range of healthy embryos, so when she gets to 40 years old usually, it’s around only 40% of the embryos or even between 30-40% of the embryos are going to be health, that range gets like reversed, so 40 is going to be healthy and 60% is going to be abnormal. If we simplify it, only one out of four embryos is going to be healthy more or less. Of course, every woman is different, every person has a different body, different metabolism, so the best way to know is to do that PGS, that’s why we recommend doing it in every woman that is 40 years old or beyond.

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Authors

Zineb Meski, MD

Dr. Zineb Meski is a Specialist in Assisted Reproduction at IVF-Spain Madrid. She has graduated in Medicine and Surgery, with a specialization in Clinical Analysis at the San Carlos Hospital in Madrid (Spain), and in Medically Assisted Reproduction at the New York Fertility Services Clinic and the San Diego Fertility Center (USA). She also has a Master's degree in Clinical Genetics of the University of Alcalá (Spain).

Event Moderator

Caroline Kulczycka

Caroline Kulczycka is managing MyIVFAnswers.com and has been hosting IVFWEBINARS dedicated to patients struggling with infertility since 2020. She's highly motivated and believes that educating patients so that they can make informed decisions is essential in their IVF journey. In the past, she has been working as an International Patient Coordinator, where she was helping and directing patients on their right path. She also worked in the tourism industry, and dealt with international customers on a daily basis, including working abroad. In her free time, you’ll find her travelling, biking, learning new things, or spending time outdoors.

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