Egg donation is a complex process – not only from the medical point of view but also from the patient’s mental perspective. Getting ready for it requires completing thorough clinical and psychological evaluations as well as learning various responsibilities – both on the part of donor and recipient. In this webinar, dr. Jon Aizpurua (Founder & CEO IVF Spain) not only explains egg donation process in detail but also addresses the most common concerns and doubts related to it.
Defining the time when one should go for egg donation is really difficult. Generally, most patients who face such a challenge, have already had a story of the standard IVF treatment. Dr. Jon Aizpurua admits that egg donation is surely the most efficient and the easiest way to achieve a pregnancy and the most successful treatment in ART (assisted reproductive technologies). However, fighting for patient’s own eggs and gametes should be the doctors’ initial approach – in any case. Going for donor eggs is, on the other hand, a pragmatic solution.
Dr. Aizpurua says that choosing egg donation is sometimes the only possible road to parenthood, taking into account all unsuccessful attempts with own eggs. As he stresses it out, we are all somehow the victims of delaying motherhood and not being educated in the right way about methods of preserving one’s fertility (like e.g. egg freezing). That’s the reason why a lot of patients are confronted with the necessity of considering egg donation at some point in their treatment.
In order to help fertility patients come to terms with the decision of egg donation, dr. Aizpurua collected the most common questions related to the subject. By answering them, he wants to provide support and assistance to all those who find themselves on this surely most demanding stage of the fertility journey.
According to dr. Jon Aizpurua, this question stresses the cumulative frustration on the part of a patient. However, he says that it is not the frequency of IVF cycles that is decisive here – but it’s their quality. That should be the basis for exploring the reasons for the failure. So it’s not only about ‘how often’ – it is also about ‘when’, ‘ where’, ’with what technology’ and ‘what the results show’. The precise diagnosis of failure is crucial here – one should ask if it was related to bad eggs’ quality, high aneuploidy risk, woman’s advanced age or metabolic disorders (e.g. polycystic ovaries). Because of all the latter, it is not possible to give one and the same answer to everybody. It is not possible to define the number of suggested IVF attempts precisely. This number should be estimated for every patient individually.
According to dr. Aizpurua, the decision about egg donation always depends on various factors. Apart from everything that was mentioned before, there are also additional ones, such as emotional distress, economic factor or the timing of one’s desired parenthood. In the end, it is very difficult to give a general answer that would suit everyone. That’s why it is a conscious decision that patients have to take themselves – doctors can only provide them with information, evidence and advice about possible options.
Unfortunately, there are no real parameters to find out if eggs have good or bad quality. There are just some indicators and prognostic factors, such as appearance and blood supply to the ovaries, the volume of ovaries, antral follicle count (AFC), the stimulation capability of follicles and anti-Müllerian hormone (AMH). However, all this data is quite difficult to know in advance – most of the investigation on the egg can be done once it is retrieved. That’s why there is no advanced way of predicting how the egg will behave. The only way to classify eggs as the bad quality ones is when they fail during fertilisation or produce embryos of bad quality. Dr. Aizpurua admits that, in the end, it is a very useful way – it is about the functionality of the eggs. The only fact about eggs that we can take for sure is the link and dependency between woman’s age and eggs’ chromosomal imbalance. Aneuploidy and the age of eggs is something that can be defined in advance. Dr. Aizpurua mentions statistics which show that in the case of a 35-year old woman, more than 50% of eggs after stimulation would have some genetic disorder (this number rises in 40-year old women – then its even up to 60-70%). When it comes to the molecular capacity of eggs, it can be checked during the embryo development using Time-Lapse technology. It gives a reliable picture if the mitochondrial supply of the egg is correct. Together with genetic competence, the metabolic competence of the embryo can give us enough information if the egg was good quality or not. That’s why at IVF Spain some mathematical algorithms were created on the basis of those two, in order to predict how an embryo (coming from a particular egg) will behave in terms of implantation.
And although implantation does not refer only to the embryo and there are other factors to be considered (e.g. endometrium, immunology, receptivity of the uterus, blood supply), about 70%-80% of its success (or failure) is because of chromosomal instability of the embryo. Only when all of these factors are taken into account, doctors receive the information about the quality of the eggs that helps a lot in giving further recommendation on when to change the treatment strategy. Dr. Aizpurua says that the doctors’ aim is to make a patient aware of how much time and resources each of the paths to pregnancy (IVF or egg donation) will take. Only in such a way they can compare their efficiency, cost and time and make a conscious decision.
In this case, dr. Aizpurua leaves no doubts – the best way would be to turn back time. Unfortunately, it’s not possible. Of course, there are some new methods, such as regenerative medicine that aims at reprogramming tissues to let them behave younger. However, although these methods look promising, they are still under clinical trials. Apart from that, there are recommendations of a healthy lifestyle and supplement intake. But having said all that, dr. Aizpurua admits that improving eggs’ quality is congenital: if there is a hormonal disruption in the maturation of the eggs, this is usually inborn. And doctors cannot turn the way nature works. They can help patients keep in the best possible shape – but that’s all they can do. In the case of eggs’ quality, everything is restricted by one’s own congenital conditions. And although doctors can turn the eggs to their best possible stage (thanks to e.g. rejuvenation therapy), in the end they cannot change that much. According to dr. Jon Aizpurua, eggs’ quality is only one of the constant parameters in the bigger equation.
Egg donation is surely the best option in case of a serious surgery (such as e.g. ovaries removal) or congenital genetic disorder with both ovaries. Dr. Aizpurua mentions also chromosomic disorder, like translocation, resulting in very poor-prognosis embryos. These are the primary indications for egg donation – and the real reason why egg donation appeared in the late 80s of the twentieth century. In the meantime, fertility experts have learned that there are other indications for that kind of treatment as well. Nowadays egg donation is recommended in cases of recurrent abortions or implantation failures, too. It is also chosen for pragmatic reasons, such as safety or efficiency of treatments.
According to dr. Jon Aizpurua, mental preparation is the first step towards egg donation. Most patients at some point face the dilemma: whether to continue with own eggs or go for egg donation. What would happen if they admitted the so-called ‘third party’ into their family? This process entails psychological, philosophical and ethical dilemmas and consists of a few stages, including rejection, accommodation and assumption. The final stage, after a successful pregnancy and child-delivery, is simply happiness. Original fears and doubts disappear once the patient has a child in her arms. The treatment itself, on the other hand, starts with the consultation with a doctor. After considering all the options and possibilities, the second stage begins. This is the preparation of the endometrium with endometrial receptivity test (ER Map), immunological tests or HLA-profiles of the couple to make genetic matching with the donor. Once all of this is done (together with sperm analysis) and the donor is found, the patient is prepared for the embryo transfer. Patients generally have to come to the clinic once or two times – firstly, for the consultation and secondly – for the final transfer.
This one of the typical questions I get. 6 times – this is a big effort already. I would understand that you feel tired. But in order to give you a reliable answer, I would need to know more about the quality of those cycles. The fact that PGS was not performed is not enough. If, at the age of 38, you have good AMH (above 1.2), AFC (antral follicle count) between 8 and 12 and the blastocyst rate of the previous cycles (despite not having a success) was good – this all keeps the window of hope open. Studying other possible reasons for implantation failure and focusing on generating genetically tested and metabolically competent embryos still gives us hope. I’m coming back to my first recommendation here – we always fight for own gametes as long as possible. So this is what I may answer you in terms of the medical/technical part. Then there is the mental part. If the patient tells me: ‘I’m not only tired – I’m close to frustration. I’ve spent so much money, I don’t have time for more IVF trials. I’m close to my nervous collapse – what I need is success in a short time’ – then (having said all I said before) I’d say: ‘Let’s go for egg donation now.’ Of course, I know I didn’t give you the exact answer you expected – as I said, I miss a lot of information on your individual case here. Remember that we can have an online consultation – Caroline will give you all the contact data. If you gather all the information I mentioned before and forward it to me, then I can give you a much more reliable and detailed answer.
Yes, you are classified as a biological mother. This obviously depends on the law of each country but the legal mother is the mother who delivers the baby. This is the basic law in our Constitution. This is also the reason why surrogate mothers are not allowed in Spain. Obviously, there are three parties there: the donor, the husband and the biological mother. It is true that DNA of the biological mother also gets included into the growing embryo. There are quite recent findings around that, according to which it is not only possible to find the embryonic DNA in the mother’s blood but also to find the mother’s DNA in the tissues of the embryo. It all makes sense in the end. Placenta is the interface organ with two directions – if it is possible to integrate DNA in one sense, it is also possible to integrate it in the other way. There are very small soluble factors of epigenetics, like microRNAs, that influence both sides. The gene expression of the mother influences the gene expression of the fetus – and otherwise. It is amazing but understandable as this is a unit, where one belongs to the environment of the other. There is an active bidirectional exchange – not only of nutrients, hormones and fluids but also of the genetic material. So in the end, it is not only about the so-called ‘hardware’ of the genes – it’s more about the ‘software’: when and how which genes in which chromosomes get activated, etc. This all depends on the environment of the biological mother very much. It’s the biological mother who is the ‘driver’ of the epigenetic events on the very early fetus. This is why we talk about the three-party genetic environment.
For sure – as long as your ovaries are ok, you have time and there are no other impairments, such as poor egg quality, metabolic disorders, endometriosis, etc. As long as you belong to the group of 42-year old women with good AMH and good ovarian reserve – there is still a chance. Using approaches such as embryo banking and PGS (as we do), until the age of 43 there is still 60-70% of take-home baby rates. And it’s really a lot.
Unfortunately, this does not sound good. But firstly: fibroids have nothing to do with the fertilisation failure. I think that a more possible reason for the failure was the quality of your egg. The quality and quantity of eggs – in terms of ovarian reserve – are very closely linked. The fewer eggs the woman is able to produce in the stimulation cycle, the lower the quality they usually have. So having only one egg at 42 is not only a problem of age – it is a problem of a very poor response. The problem of impaired egg quality with the fertilisation failure is very difficult to overcome – so trying with own eggs may be hard. The only solution in your case would be regenerative medicine – in order to have at least a couple of better quality eggs more. Then, there would still be a window of success open for you. But remember that you are 44 years old in a couple of months. So the whole process is like climbing the Himalayas – the higher you climb, the less oxygen you have. Then, in order to come up to the top of the mountain, you need to take an oxygen mask – and it is egg donation in your case.
The basic information here is what I mentioned before: the aneuploidy rate in a 35-year old woman is 50% and in a 40-year old woman – 60-70%. However, a lot of people do not know that even a 20-year old has already 20% of blastocyst aneuploidy. And egg donors are usually between 20-35 years old. So I think that PGT-A in such a case is not only an option – I think the time will come when it is mandatory. Why should we transfer embryos not knowing if they have chances of making you pregnant? Why should we transfer embryos that could make you suffer from e.g. miscarriage? Why should we delay your time to success, having the technology to avoid that? So the pluses are very clear: you can increase the success rate per transfer, you can shorten the time to pregnancy, you can bring down the risk of miscarriages. And in the end, you could come to the same effect of cost-effectiveness. Because if you consider that you could make one cryotransfer for nothing, this also has the cost that could be compensated this way. The minuses refer to ethical or religious issues. This is about the people who wouldn’t also perform prenatal screening. If they get a baby with Down syndrome, they would decide to deliver it and create a family together – which I profoundly respect. However, most of our patients would come to the dilemma: to use PGT-A or not to use it. The costs are high nowadays – but if they decrease, I see no reason why not to perform it to everybody.
Absolutely yes. Our regenerative program ends at 47. And our law in Spain sets the limit for egg donation at 50 years of age. So the moment you reach 51, all the process should be closed. It means that you should be in a hurry to start an egg donation program as soon as possible. Otherwise, you will miss the opportunity to get pregnant or you will need to take into consideration more risks endangering your pregnancy, yourself and your newborn. So go for that as soon as possible.
Good health history is what every donor should have. This is not an attribute the clinic should be proud of. Donation programs have to focus on selecting only those donors who: are checked genetically with a preconception carrier screening (checking for more than 200 recessive diseases), are chosen on the basis of the family and medical history, have undergone physical tests and are free of toxins, drugs and nicotine, etc. These are the basics. Choosing the donor that doesn’t look like you is not optimal, in my opinion. In Spain, the law says that the donor has to be as physically similar as possible to the recipient. Of course, in bigger clinics with 500 donors, it is much easier to find someone who is similar to you in terms of ethnicity, shape, body mass index, your face, etc. This is something that is relevant – to find yourself somehow reflected in this person. But having the same blood group is non-relevant. A blood group does not help. Historically, it was one of the criteria to match the donor with the patient. The only sense it has is when you do not want to tell your child that he or she came from egg donation – which is, as we have learned in the last decades, a wrong approach. I think it is important to explain everything transparently and clearly to the child as you have nothing to hide and you loved the baby before it was born. So selecting the blood group is only reasonable if you do not want to tell your child and you are afraid they may somehow find out that they have a different blood group from their parents. And finding that out could be catastrophic for your child – because of you hiding it from them. If you share it openly from the very beginning, then you have absolutely no benefit in matching genetically blood types and blood groups. You would have much more benefit if you – as I mentioned before – matched genetically HLA and KIR haplotypes. This is relevant because it could help your body not to reject the embryo and decrease your miscarriage rate and increase your success rate. But not blood group – we let our patients disclaim us from the obligation of matching the blood group.
I’d say you have to not only because they would ask about the family health history – but just for your mental hygiene. Living with a lie and hidden truths is not something I would recommend to anybody – in any situation. If you become parents from double donation, it is not because you are e.g. so sophisticated and have chosen that way because you wanted to. It was so because you had no other option. This is a very difficult decision and it shows a very strong wish on your side to have a baby. I think this is a very honourable attitude and explaining it to the kid should not be anything dramatic. You should obviously take care to choose the best time for it, wait till the child is mentally prepared for it, etc. – there are a lot of recommendations and support groups dealing with that. Of course, you should go along psychologists’ recommendations in this matter. And then you will feel much more relaxed and comfortable. Your child will understand it and be happy – because otherwise he or she would not exist, would they? I don’t think that your parents asked for permission of generating you – this is just nature.
The law in Spain actively restricts the flow of lot of information between the clinic and future parents. This is also to avoid the situation in which a medical act – egg donation – could convert into a commercial issue. In the end, it’s a matter of confidence, seriousness and professionalism. Creating new lives is an act that requires a lot of responsibility. In our clinic, we apply much stronger filters in the selection of donors than only a family history, education, interests, etc. We put emphasis on safety and healthy status. Then we are obliged to match physical looks, we have also adapted genetic matching which improves the immunologic implantation. Once this is given and the process of donor selection is fulfilled, this is the guarantee and the evidence for the patient that all of this is respected. For sure, there are patients who say: ‘Can I look at the donor’s education? I’d like to have a donor with the same education level as I have’ etc. And we can do it – but only after all of these initial steps of donor selection are fulfilled. In this way, we put emphasis on the law and medical conditions. Of course we cannot give you any record saying: “This is your donor. This is her family history/education/interests, etc.’. The law simply does not allow that. In the end, if you trust your doctor, you don’t need that. And, on the other hand, if you don’t trust your doctor, then don’t trust the document he shows you either. It’s a more complex issue where a lot of different interests have to be aligned. Professionalism and seriousness are basic requirements here.
I think you’ve already given us the answer. If you have energy for one more round with own eggs, then I’d do a lot of things in another way beforehand. These miscarriages are not normal – there has to be a very deep analysis of your immunology as their possible cause. For sure, the genetic part of the sperm also has to be studied in advance before making another round. So if you’re ready for only one shot more with own eggs, then it is important to take extreme care of genetics and immunology before. If you mean one shot more at all, then please go immediately for egg donation. After all this story of unsuccessful trials and at the age of 40, it is possible that also under the best conditions and using the best technology, you don’t get a stable pregnancy with high percentage of success. Knowing all we know, I assume in the best case you could achieve about 60% of the success rate. And this still means 40% of non-success. In case of egg donation, you will have 3 transfers and the expectation of take-home baby rate higher than 90%.
Go straight for egg donation. I mean, in case when regenerative medicine – which is a very promising technology but still under clinical trials – is not an option for you because you e.g. do not fulfil inclusion criteria. Assuming you do not like it, then go ahead for egg donation.
The same as in the previous case. Possibly, you will not fulfil the criteria of being included into the study with regenerative medicine. However, if you do – then it is the only way to avoid egg donation. But if you do not want it then – after learning your story – I would go for egg donation directly.
The first thing evident to me: ‘no underlying issues for miscarriages’ is wrong. I’m sorry but if you started in 2018 and now you’re 46 – it means you started at the age of 44. And with 44, the blastocyst rate for aneuploidy is around 90%. You should have had 10 transfers in order to have just one with a true chance of giving you a healthy newborn. So it is not surprising that it did not happen. The most probable reason for those miscarriages is the genetic one. But of course, we cannot exclude other reasons – because there are so many cases you report here. So my advice would be to test genetically the sperm of your partner and go for egg donation as soon as you can. Check also the possible immunological reasons or receptivity impairments on your endometrium that may apply for an egg donation cycle as well.
DHEA is a precursor hormone to the human growth hormone which is implied in the maturation of eggs and which fails in cases like PCOS or ageing ovaries. It has showed to improve the quality of eggs in many circumstances. It is cheap, safe and it has no contraindications and adverse effects – so there is nothing to lose if you take it. It’s like a mild anti-aging program. It is of course more efficient to take growth hormone directly – but my view on DHEA is positive.
Q10 is a co-enzyme and it has less impact on egg quality than the endocrine hormonal way with DHEA and growth hormone. But it improves some of the metabolic processes of the cells that surround the egg and provide it with growth and maturation signals. So I have nothing against that – just remember it is less effective than hormones.
Optimally, only one. As I mentioned before: we think that pre-implantation genetic screening (PGS) on embryos from donated eggs makes sense. In our experience, transferring one single embryo which is metabolically competent (meaning good Time-Lapse shape) and genetically competent (proven euploidy through a biopsy and PGS) has the implantation potential of 72-77% on average. And this is a lot. So it is much more probable that you get pregnant with the first embryo in the first shot than not. And if you still have one or two more embryos, this accumulates your chances up to 90%. And this all in one single treatment. So the probability of take-home baby is as high as 90%.
The age of 41 is encouraging but very low AMH tests over a long time is a very bad predictive factor. If you have been advised not to consider using your own eggs, this is probably because of the reasons such as the architecture of your ovaries, antra follicle count (AFC), etc. So taking all of this into consideration, the strongest predictive factors (AFC, AMH and age) are simply not on your side. If you are ready to use donor sperm anyway, then embryo donation could be a very easy, very efficient and very affordable option for you. Some embryos also get donated from other couples and in such a case, the clinic does not charge you for the full treatment but only partially. So if you are mentally prepared to accept embryo donation, this would probably be the shortest way to success and the easiest solution for you.