By fertility experts from Spain.
In this webinar, Dr. Victoria Walker, a Fertility Specialist at Institut Marques, Barcelona, Spain. Dr. Walker has explained how egg donation procedure looks like in Spain, and also provided the reasons and when it is best to turn to egg donation.
I’m sure you have been taking the medication that they have recommended for you. When you see them, you can ask whether your embryo looks good, ask everything that you haven’t asked so far. Do you know about your donor, you’re not going to be able to see a photograph but have you got all the information that you want about the donor. Have you got all the information that you need about the medication? Do you know how to take the medication because you do need to continue medication if you’re successful usually, so just ask everything, ask all the things that you have in your mind, make sure you’ve had time to ask the questions that you have.
We would strongly recommend transferring just 1. You may be feeling that you want 2, you’ve been trying this for so long, let’s put 2 back as it’ll increase my chances of success, but in most clinics now, I don’t believe that 2 embryos really significantly increases your chances of success following egg donation and particularly when you know that both embryos are normal, it sort of may push your chance of success, let’s say with us it may push it towards 60 rather than 50%, but it won’t double it. What it will give you is a 20 to 30% chance of having twins, and we don’t feel that having twins is necessarily a good idea.
As I mentioned in the presentation, twins are really complicated to look after obstetrically, so when you’re pregnant with them, even if you’re slim and healthy and still young yourself, they are complicated to look after, they often arrive early, the babies are often, very small, so we would recommend that you take your pregnancies and have them one by one and have healthy children sequentially rather than several together.
At our clinic, yes, it is pretty much a policy for all women over the age of 44 to have a single embryo transfer, and we recommend it for all other patients who are younger than 44 just as good practice. Occasionally, we do have patients who want to transfer 2, so then it’s a question of explaining to them why we think 1 would be better, but if they still believe that 2 is what they want, then we ask them to provide a letter from the doctor who will be looking after them when they go back home to make sure that their doctor is happy for them to have 2 embryos transferred and will be willing to look after them in their pregnancy whether they have a singleton or a twin pregnancy. That’s just to make sure that when they go back home, they will have a safe pregnancy, even if it’s a twin pregnancy.
We do have a donor egg bank, but we principally stimulate donors, so one donor for one recipient. That’s the way our system is set up, and occasionally, we can freeze some eggs but usually, it’s one to one with a fresh stimulation and a fresh transfer. When we’re doing egg donation, it’s not like IVF, when you’re doing IVF, you will tolerate very high doses of medication, you’ll tolerate side effects, you’ll tolerate feeling really uncomfortable, and you’ll do that because you want this big carrot of having a child of your own, from your own gametes.
Egg donors aren’t like that, they are young women, they’re generous women, but they don’t want to feel unwell, they don’t want to feel sick with the medication, they don’t want to feel really bloated or anything, so we don’t give them the same kind of doses of medication. In principle, it is one stimulation for one recipient because we don’t use such high doses.
Some people say to me, why don’t the donors produce like 20 eggs every time? It’s because we don’t use the same kind of doses that we might use for you in your IVF. Having said that, some of the donors are very young, some of the donors are extremely sensitive to the medication we give them, so even when we give them very low doses, they might respond and produce loads of eggs like a kind of popcorn machine and if that’s the case then occasionally, we would accept all their eggs and give them to 2 recipients. It doesn’t happen very often, and the system isn’t set up for that.
Yes, a donor can donate to one clinic on several occasions, and she can donate to several clinics. In Spain, there is a law that states that the donor is not allowed to create more than 6 live births here in Spain, but to the best of my knowledge, there isn’t any limit, any international law. The law might be changing, there have been some rumors. We do monitor this, it is really important, and we would generally not allow a donor to create more than maybe 10 live births in the entire world, and we do monitor where the donor’s eggs are going. Sometimes, you’ll see that a donor can’t be used in a particular country.
That’s concerning how many times a donor can donate, let’s say in our clinic. When we see a donor, we do ask her if she has donated elsewhere, and if she has donated elsewhere, then we’ll ring the clinic and find out what the results were of her previous donations and so if we can see maybe she’s created 2 pregnancies in another clinic. Then, we’ll only allow her to make maybe 3,4 more with us as a maximum. Then, it’s being monitored, it’s something that people are very aware of, you don’t want to create loads of pregnancies from just one person.
A lot of them are quite similar, you’re going to need to do your HIV tests, Hepatitis B, C, syphilis, that kind of thing. We’ll usually want to know that you’ve got normal thyroid function, we will want to know maybe your vitamin D levels. We generally want to know your blood group. That’s something that might not have been done before, and that’s used because it’s part of the matching process. That’s different and then we’d need an ultrasound, which you’ll have had millions of in your IVF. In the ultrasounds, we’re looking at the uterus more than the ovarian reserve, and we’ll be interested to know if you’ve had hysteroscopies whether you’ve had endometrial biopsies just to make sure that we think that you can implant embryos well. There’s a lot of overlap, there isn’t anything that’s totally different except maybe just the blood group that’s something that’s not usually tested in IVF.
You were very lucky to have a pregnancy at 42. I have many IVF patients who’d be delighted to have a pregnancy at 42, but at 46, it’s really rare to fall pregnant with your own eggs naturally or in IVF. The only way is if you’ve got frozen eggs when you were much younger and then using them when you’re 46, that’s a possibility, but if I’m assuming from your question that you haven’t done that. I would say that egg donation is probably the main way, you can carry on trying, no harm in continuing to try naturally, and you may be lucky, you had a good ovarian reserve for a long time, but realistically your chances of success will lie with egg donation in the future.
If you’re not using an Embryoscope, then you just use the standard incubators, which were, of course, fabulous until the Embryoscope has been invented, so actually, my boss did a blog about that and essentially, the laboratory when you look at laboratories, you can look back at the video, they’re quite dark places, and there is a body temperature there, and they are strict about the staff and what they can wear in terms of perfume and things like that and they’ve got triple filtration of the air that comes in from the outside, so although in traditional incubators what you do is you put them in and then take the embryo out after 24 hours and put them under the microscope to have a look at them, in theory, they’re not going to be negatively affected by that movement, and because we do try to control the environment of the laboratory very closely, ideally, you wouldn’t fiddle with them.
If you imagine what an embryo is doing in the body, it is moving all the time as it comes down the fallopian tube and into the uterus, but it’s being exposed to just very constant body temperatures and things like that. That’s what we’re trying to reflect and trying to do in the lab, but I think it’s probably done better in the Embryoscope itself, but the embryologists are very careful, they really are, so they try to make things go as perfectly as possible if you don’t use an Embryoscope or one isn’t available for you.
When you’re 40, a donor will probably give you a higher success rate just because she’ll be under 35, and it’s a question of age. From what you’re telling me, there may be something else going on, it may be to do with your eggs, but it may be to do with your husband’s sperm. Mild fragmentation is something that you can sometimes work on. You can take supplements to try and improve it, but there are other sorts of slightly more profound abnormalities that could occur in the sperm, and that’s seen sometimes when the embryos sort of conk out on about day-3 and just can’t get any further.
I would suggest to try and consider egg donation, but you also might want to try and work on the fragmentation and try and bring that down, and you may want to try and do IVF with genetic analysis of the embryos to try and see if you can create a genetically normal embryo, and if you can’t, then that might help you to seek that egg donation is the way forward for you. If you’ve had a very long history of infertility, I would consider doing maybe IVF with some genetic testing before moving to egg donation, but it’s hard to know with the amount of information that I’ve got.
I think egg donation or embryo donation would be the best option for you at 48. As I mentioned to the patient who was 46 a little bit earlier, it’s just incredibly rare to fall pregnant and naturally at 48. It used to happen generations ago when women had like 15 children, and the last one appeared when they were in their mid to late 40s, but nowadays, it hardly ever happens. Life just isn’t that way anymore, and you’re single as well, so falling pregnant naturally would be maybe a bit harder, so I think you could consider embryo donation, which is a cheaper option. Otherwise, you’re going to need an egg donor and you’re probably going to need a sperm donor because you’re single. An embryo is already created, we would do a matching of your racial type to whatever you are, and that’s usually a really nice option, and it’s an easier treatment to do as well.
I have to say in Spain, we don’t have many Indian or Pakistani donors, we have had a few over the years, but they’re few and far between. We do, however, get an awful lot of people of Indian and Pakistani origin coming particularly from the UK for treatment, and when we explain to them that we don’t have a lot of donors of their racial origin, we offer them a Mediterranean donor with dark hair, dark eyes, olive skin and for many of them that are acceptable, not all of them, but for many of them that are acceptable.
It’s the same for Arab donors, we do have a few Arab donors, but not very many, so again it’s a question of looking at the recipient’s characteristics and seeing whether maybe a Caucasian or Mediterranean donor would be acceptable to them. This is a conversation that we have with the patients based on what is available at the time that they come to us.
Sometimes, they’re okay with it, and sometimes they’re not. If you’re really keen to have a donor of your own origin, so let’s say you’re Indian, maybe you are UK based, secondo, third in generation Indian, so you’re English, but you might be able to go back to India to get an Indian donor, you should know that India does offer egg donation, but only will treat people who have an Indian passport, for example, so look around. In the United States, there is a lot of egg donors there, but of course, egg donation is much more expensive in the U.S than it is in Europe, but they have a wide range of donors of the type that you’re particularly seeking.
It’s anonymous egg donation in Spain, so we choose the donor for you based on your physical characteristics, your racial group, your psychological parameters, your temperament, your blood groups, and so to that extent, we choose a donor for you. As a patient, you can express your preferences, but we can’t always guarantee them. For example, patients who might say to me, well me my husband and I have both a Ph.D., we’re really highly educated people, we’d really like to have a donor who is a university student, and I tell them that 50% of our donors are university students, but that’s not something I can guarantee, so I make a note of it and if possible, the patient will get such a donor. They understand that this is not something I can guarantee, so we note down your preferences, but there are certain things that we can’t guarantee, so that’s what we do.
Your preferences have to be also reasonable, so asking to have someone who is a university student seems quite reasonable if you are both university-educated or something like that. I had a patient that once asked me for a donor with high cheekbones because she had high cheekbones, and that’s the kind of thing that we can’t deal with. We can’t go with that kind of detail, we’re going to try and find the best donor for you, a healthy woman who matches you according to your hair color, eye color, skin color, race and blood group, and psychological parameters. We can’t cope with that kind of preference, so it depends on your preferences.
It depends on your history, and it depends on your age, so we would often recommend that women over the age of 45 might have a mammogram before they start. Alternatively, women who might have a strong family history in particular of breast cancer or something like that, so yes, it’s something that’s quite often requested.
The center in Dublin is the same. The staff, we’ve got 2 doctors over there at the moment, they’re both Spanish, and they’ve been with us, they’ve trained with us in Barcelona before they went over there and it’s true, with the embryologists as well, they’ve all been trained in our center in Spain before they went over, to Dublin. In Ireland, I believe the admin staff is Irish, and that helps with communication, but everything else is kind of Spanish run and according to the Spanish lines as dictated by the owners of the Institut Marques and the directors. They should be as efficient as the Spanish clinic.
People have looked at that over the years, there’s quite a lot of research and essentially the summary has a normal life, just do normal things. If we felt that standing on your head for two weeks after the embryo transfer would help with implantation, we tell you to do it and if they’re not, we don’t say anything it’s because there’s nothing that’s been shown to be helpful. We would say after embryo transfer just carry on with your life, probably try not to lie down too much just carry on with normal life, go to work, walk around, you can do sport as long as you remember to take our medication you just need to carry on. The only exception to that would be if you have a physically hard job, then maybe you could ask to have a few days off. Generally, carry on with your normal life and try to think of something else because it’s really hard to get through those sort of 10 days and just wondering whether it’s worked or it hasn’t worked, so distract yourself, go to the cinema, well not now obviously people can’t at the moment, but that kind of thing, keep yourself active.
Absolutely, we treat patients with Hepatitis B, we treat patients with Hepatitis C although you don’t see them very often, and HIV, we can help people with all the transmissible illnesses, depends on which partner it is, what we do, and things like that but we have protocols to be able to help everyone.
Actually, for egg donation, there is a very standard protocol that we start by using in everyone if you’ve never done egg donation before, that’s where you would start. It’s usually a contraceptive pill to synchronize with the donor, and then you come off that at the same time as the donor, you have your period and would start estradiol at that stage, so you and the donor having your periods at the same time, she’s starting the IVF medication, so injections but you’re with estradiol. It used to always be patch form, but nowadays, it’s quite difficult to get hold of patches, so it’s oral form. After a week of patches, you have a scan in the country in which you live, you send us that result, and then we wait for the donor to be ready. When she’s ready, we fertilize the eggs and organize the embryo transfer usually, 5 days later if you’re doing a blastocyst transfer. Once we know when the transfer is going to occur, we’ll confirm when to start progesterone into the vagina, so that’s usually, vaginal pessaries and after the transfer, you’d continue with both the oral estradiol and the vaginal pessaries until the pregnancy test. If that’s positive, then you increase the doses and keep going for another eight weeks after that. That’s the standard protocol, very occasionally, you get people who don’t respond well to that stimulation to that protocol. Then, you have to sort of jiggle it around a bit and try something different, but that works for the great majority of people to try and get them ready for egg donation.
Your prolactin has increased, that’s a very high level if you’re in Spain, and it’s a relatively high level if you’re in the UK because we use different ranges. I don’t know if that would have been a cause of your implantation failure, I don’t think it would have been the implantation failure that made your prolactin go up. In my opinion, yes it is something to have a look at, it is something to investigate further, and it’s something that can be treated to bring the prolactin level down if you wanted to have another treatment. About the supplements, if you’re doing egg donation, the main supplement would be folic acid at 400 micrograms a day orally. If you are a normal person, and 5 milligrams a day, if you’re somebody who has some other illnesses, maybe diabetes or epilepsy or you take certain types of medication, but that’s the main supplement we would recommend. A lot of people who live in the northern hemisphere are missing a bit of vitamin D. You have better success rates if your vitamin D replete, so if you think you might be lacking in vitamin D, then taking that supplement can be helpful, and today we weren’t really talking about IVF, so I think those are the main supplements you might be thinking of.
I think this is more of a question if you are going for IVF with your own eggs. In IVF, we don’t use it here, but it can be considered. For egg donation, you don’t need it. You use DHEA to try and improve the quality of your own eggs, and when you’re using egg donation, you don’t need DHEA anymore for that reason.
Currently, yes, COVID is a huge problem, we all know it is. Ourselves, we are not requesting a covid test for patients before they come and see us. The only thing we do is test their temperature on arrival at the center, and obviously, we will turn them away if they have a temperature and send them away to have a blood test but otherwise, we wouldn’t test them before they come. We follow all the protocols to keeping people separate and protecting staff and protecting the patients. If you’re 48 and you do find a partner, then an egg donation would probably be what you want as a couple because when someone is in a couple usually, they like the idea of keeping the genetic link with at least one person, so if you can keep the link through the sperm, that would be lovely, but if you don’t find a partner, then an embryo donation is a very nice option.
As I mentioned earlier, the dose depends on you. Actually, it’s usually a lower dose of folic acid for most people 400 micrograms a day that’s mcg. Then you can go up to 5 or even 10 if you’ve got other things, as I mentioned earlier, diabetes, epilepsy, certain types of medication, or you’ve had a problem in a previous pregnancy with a baby being formed incorrectly. And it’s been advised that you take higher doses of folic acid. Generally, most people will still take the lower dose, the lower dose can be bought over the counter whereas, the higher dose, you need a prescription for. The total cost of egg donation depends on what you need in terms of additional things, but the basic cost for egg donation is around 6600 EUR with us, and then you need to add to that the medication for the donor, which is about 1 500 EUR and then about 500 EUR for using the Embryo cope and about 500 EUR to have a day-5 transfer, so in general the egg donation can cost between 8 000 and
9 000 EUR for the fresh transfer. There is a more expensive option, that’s the refunding scheme, and that’s where you pay 24 400 EUR, so a large amount of money but for that, you get a guarantee of live birth. You get a chance to do 3 cycles of egg donation, so if you don’t achieve your live birth, then they would return 70% of your original sum, so 16 to 17 000 EUR back, it’s up to you. These details you can discuss with your doctor if you decide to go ahead with that treatment.
Most people will just respond with estradiol, it’s quite rare that you need anything else. Some people don’t respond very well to estradiol, and if that happens then, occasionally just a natural cycle will help build up the endometrial lining better. Finally, very rarely, we would use IVF medication just to make the endometrium grow a bit, so those are sort of medications that we would use to make the endometrial lining grow. We don’t generally recommend nutritional supplements to try and help build up the endometrium. Some patients take vitamins E and C because those are thought to improve the blood flow to the uterus.
Basically, it’s not important medically, it doesn’t really matter if we match the blood groups. We match them because a lot of couples who come to us for egg donation have not yet thought about whether they would, or wouldn’t tell any child created that they’ve been made using egg donation. If you think that you would not tell the child or you don’t yet know what you would do, then it’s better to match because what you don’t want is for a child to sort of wandering home age 15 saying, mom I’m blood group B and what are you? Mom’s 0, and dad’s 0 because then you have to have a conversation that you weren’t necessarily prepared to have with your child, and the child finds out in a rather unpleasant way that they’ve been created from egg donation.
We match the blood groups if you are certain, you do not want to tell the child, or you don’t yet know what you’re going to do with regard to telling the child. If you are absolutely certain that when the time comes, you will tell your child that they have been created from egg donation, then you don’t need to match the blood groups.