During this live Q&A, 3 top fertility experts discussed egg donation treatment, when there might be the right time to consider it, and what factors can influence the decision-making process.
Featuring Experts:
Dr José Antonio Domínguez Arroyo – Medical Director of IERA, Portugal
Dr Ernesto Bosch, PhD – Medical Director of IVI Valencia, Spain
Dr Athanasios Garavelas – Director & Founder of Garavelas Medical Group, Greece
The event was hosted by: Professor Alan Thornhill, Fertility Expert & Coach, Founder of The Fertility Guy.
Dr José Antonio Domínguez Arroyo, IERA, Portugal: I work in Badajoz, a small city between Madrid and Lisbon. We have a clinic in Lisbon, too. We started working in fertility in 1998, and since 2000, we’ve had an egg donation program. Well, the law is different in the two countries, so we can talk about the differences between the two countries.
Dr Ernesto Bosch, PhD, IVI Valencia, Spain: I work in IVI Valencia, probably one of the largest clinics in Europe and maybe one of the first. Indeed, we are celebrating our 35th birthday now. It’s a large experience, and we’ve been doing egg donation since 1993. It’s still quite an important volume of our activity, treating patients from most countries in Europe and even from overseas. I’ve been working in IVF for 25 years and became Medical Director in 2010. And yes, we continue with all patients coming from everywhere.
Dr Athanasios Garavelas, Garavelas Medical Group, Greece: I’m one of the founders of the Institute of Life, a Greek IVF unit based in Athens, which is inside the biggest private maternity hospital in Greece and maybe in Europe. We perform several thousand IVF cycles and have 14,000 births per year. Of course, our doors are very open, and we can offer donation programs, IVF programs, and other treatments at this hospital.
Dr José Antonio Domínguez Arroyo, IERA, Portugal: The law in Portugal changed in the last few years. Now, anonymity is not allowed in Portugal, so the donation is non-anonymous. They’ve changed the profile of the donors a little bit, and we have fewer donors now than before. It is a country where donation is not as common as in Spain, for example. But now the profile is a little different, and we have fewer donors than before. Some of our patients want to come to Spain for the donation because they prefer anonymity.
Dr Ernesto Bosch, PhD, IVI Valencia, Spain: Well, first of all, in Spain, there have been some changes in the legislation that are making things a little bit more restrictive, mainly regarding the number of cycles a donor can do. In the recent past, the limitation was the number of babies born from one donor, but now the limit is on the number of cycles that are performed. This is not dramatic, but it slightly reduces the availability because the number of overall cycles that you can do is slightly lower.
Having said that, the proportion of egg donation cycles that a clinic does depend very much on the setting. In the public setting, it’s small. In the private sector, it’s much larger, and once in the private sector, I would say that large cities with better communications to other countries are doing more donation cycles proportionally. This applies mainly to Barcelona because its proximity and communications make egg donation there very big. In Valencia, in particular, we are doing egg donation in about 25% of our cycles. That means last year we did around 700-750 donation cycles.
Dr Athanasios Garavelas, Garavelas Medical Group, Greece: I think the law in Greece is very similar to the Spanish law. We have anonymous donors. The age limit is 50 years old, and it can be extended by the Ministry of Health up to 54 for egg donation for IVF treatments. In our clinic, I think about 15% of our cycles are egg donation compared to own egg cycles. Approximately 20% of our cycles come from abroad.
Dr Ernesto Bosch, PhD, IVI Valencia, Spain: There is no specific legal limit in Spain. Spanish law speaks about the age of menopause, which is a little bit blurry, but in practice, this comes to something between 50 and 52—that’s the limit for any ART treatment. But of course, when speaking about your own eggs, we know that beyond 45-46, the chances are null. Beyond that age, some cases are performed, and some patients insist, but it’s very exceptional.
In the case of egg donation, it’s quite frequent that we treat patients in the age range of 45 to 50. We can exceptionally do treatment for some patients around 51 if, of course, their general condition is really good—no concomitant pathologies, no strong obstetric risk factors. These factors have to be well controlled to ensure that the patient has no specific risk factors before proceeding. So, that’s basically how it goes in general. Although the limit is not established by law, the Spanish Society of Fertility’s age limit of 50 is what most practitioners follow.
Dr José Antonio Domínguez Arroyo, IERA, Portugal: It’s similar, but in Portugal, it’s not allowed above 50 years old. It’s impossible to do treatments above that age. We can do treatments up to around 50 years, but in Spain, as I’ve told you, we can even do treatments above 50. However, we have an agreement between clinics not to do treatments above 50 years old because it can be a little dangerous for women. I think it’s a protection measure. In Portugal, we have a limit.
Dr Athanasios Garavelas, Garavelas Medical Group, Greece: We’re not planning to start the egg donation program right away. What I mean by recurrent implantation failure is after multiple embryos, after 3 or more embryos have been transferred. We check the endometrium, we check the microbiome, and see if there are any infections or endometritis. Also, we must evaluate the sperm. Then, of course, we tell the patient and the couple their options and the realistic statistics to proceed, or maybe try other treatments like PRP injections in the endometrium. After that, we would decide if it’s time to change the plan and move to egg donation. But not as the first choice—if they are willing to stay and work with their own material, we must analyse everything thoroughly and then discuss the next steps. Egg donation is not the answer to everything, and it may not resolve all issues.
When we talk about blind transfers, other colleagues know that Germany is not the first country for IVF treatments. They mainly perform standard procedures. I think the medicine here in IVF is more tailored, personalized. We must analyse everything 360, then proceed. In our case, we must evaluate the type of embryos, the type of endometrium, and whether PGT-A was done, and check for autoimmune problems or immunity issues. Once we resolve those, then we can consider egg donation. That’s my opinion.
Dr José Antonio Domínguez Arroyo, IERA, Portugal: Usually, it’s repeated implantation failure or miscarriage. Some with miscarriages, too. But especially if we don’t have PGT-A. In cases with PGT-A, even with PGT-A, we still see repeated implantation failure in almost half of the cases. Before that, though, we have to do some receptivity tests, hysteroscopy, something like that. I think most of the time, even with good embryos, the pregnancy rate is lower in patients over 40.
Dr Ernesto Bosch, PhD, IVI Valencia, Spain: The first thing that you need to know is whether the couple can produce viable embryos. When we talk about viable embryos, we mean, let’s say, fair-quality blastocysts that are euploid. If you don’t have that, you don’t have strong arguments to go to donation because the problem could be elsewhere. The first thing we need to know is whether the couple is producing viable embryos. If not, regardless of age, regardless of ovarian response, that is when you have to talk about donation.
Now, the conversation comes at the first point when you see that the probability of getting a blastocyst is low from the start. If the patient has a low ovarian reserve and is older, we know that the number of eggs she is going to need to have reasonable chances of having a viable euploid embryo is high. Then, you need to put this on the table in discussion with the patient. For example, we know that at 43, a patient may need an average of 20 eggs to get one euploid blastocyst. If, according to her ovarian reserve, she is not going to produce more than three or four eggs, then that is a straightforward estimation of her probabilities. We need to decide with her. If she is ready to go for small chances of pregnancy, then go for it. But, if not, you cannot recommend continuing.
It has to be a personal decision in the end. Our role is to explain where we are, what the scenario is, what the chances are, and help them with the decision. But it has to be a personal decision. We will see patients whose chances are low, but they still want to try, and that’s okay. Let’s go for it. And we see some patients whose chances are reasonable, but they prefer to go for a more pragmatic approach, a higher success approach, and go directly to donation. You can have all extremes at the end of the day.
Dr José Antonio Domínguez Arroyo, IERA, Portugal: Yes, of course, we have a psychologist in the clinic because we know that for most couples, having to resign themselves to using donor eggs is a process of grieving with different steps. We usually send them to the psychologist for support during the decision-making process during the grieving process, and, of course, we think this support is very important. Patients usually give us positive feedback about this part. They evaluate this kind of help in the clinic very well.
Regarding the second question, I don’t think so. I think that the change in the mindset of the couple happens before that. Facing the issue of needing donor eggs is the real challenge. The problem of anonymity or non-anonymity may be a factor, but it is not the most important one. The most important thing is accepting the fact that they need donor eggs. After that, maybe it’s an important point, but not the first or most significant one.
For some couples, non-anonymity of the donors can be very important. For example, we see some movement between Spain and Portugal— people who want to come to Spain for anonymous donation and Spanish women, especially, but also couples, who prefer to go to Portugal for a non-anonymous donation. But these cases are a small percentage.
Dr Ernesto Bosch, PhD, IVI Valencia, Spain: In Spain, by regulation, clinics must have someone for psychological support—not only for egg donation but for any situation. However, egg donation is probably the case in which it is most frequently needed.
Yes, and psychological support covers many issues, such as the origin of the donors and the motivations for donation. At the end of the day, the psychologist who attends to patients is the same one conducting the psychological evaluation for donors, which is mandatory by law. It is also very important to discuss disclosure in the future with the child. That is a hot topic that frequently arises in consultations. The support of a psychologist in these discussions is really important for couples.
Dr Athanasios Garavelas, Garavelas Medical Group, Greece: Psychological support is fundamental—not only for egg donation but also for maternity itself. Maternity can change the balance of a couple’s relationship, so counselling is very necessary to help them understand the changes that come with having a child.
It is also very important for us because we have many cases from abroad, with people from different religions and cultures. Understanding and supporting couples based on their specific needs is essential.
Regarding anonymity, whether donors are anonymous or not, the most important thing is that the couple has the opportunity to have a baby, which can change their lives. That is the ultimate goal. Sometimes, we focus too much on details and forget the big picture. The main point is that we are here to help couples fulfill their dream of becoming parents. We are not magicians, just fertility doctors trying to assist them in making this dream come true.
Dr Ernesto Bosch, PhD, IVI Valencia, Spain: Yes, and the recommendation from psychologists—particularly in the UK, where there are associations of parents of donation—is to normalize it. The best approach is not to wait until the child is 15 years old, sit them on the couch, and have a serious conversation. That is not the way to go. Instead, when children are five or six years old and start asking questions about how babies come into the world—or even earlier in some cases—it is important to tell them that babies can be conceived in different ways, and in their case, it happened through donation. This way, they grow up with that knowledge, accept it, and it does not become a trauma at any point.
The concern regarding 23andMe and genetic testing has been around for several years. However, the proportion of people taking these types of tests has not grown as expected. It is not yet at the point where anyone can easily identify their genetic origins. If someone does not know they were conceived through egg donation and takes such a test, they might suspect something if their genetic background appears different from what they expected. However, for now, the proportion of people taking these tests is not large enough to make donor identification common.
Dr Athanasios Garavelas, Garavelas Medical Group, Greece: Everybody knows that in Greece, we mostly have fresh donors. We also collaborate with egg banks in Spain and other countries. Most donors are originally Greek or from nearby regions, meaning they are generally Mediterranean in appearance. Finding donors with East European origins, for example, can be difficult with fresh donations. However, through our collaboration with egg banks, we can access a wider variety of donor profiles, including those with blonde hair and blue eyes.
Dr Ernesto Bosch, PhD, IVI Valencia, Spain: If we are speaking about Caucasian phenotypes, we are generally able to meet demand. Naturally, there are more dark-haired, brown-eyed donors than blond-haired, blue-eyed donors. However, the proportion of recipients also follows this pattern, so it balances out.
Difficulties arise with other ethnic groups, particularly Asian donors, as egg donation is not as culturally common among them. Even though there is a significant Asian population, donation is not as widely practiced in those communities. However, for now, we can generally meet demand because the proportion of donors aligns with the proportion of recipients.
Dr José Antonio Domínguez Arroyo, IERA, Portugal: It is almost the same as in Spain. We have, as Ernesto mentioned, a mixture of situations, but now, in cosmopolitan cities like Lisbon, we have more opportunities to find these kinds of phenotypes because Erasmus students usually go to clinics for treatment and donation. We also have women from England and especially Eastern Europe who come and provide us with these phenotypes. However, in general, Portugal and Spain predominantly have brown-haired donors, making other phenotypes less common.
Dr José Antonio Domínguez Arroyo, IERA, Portugal: Usually, couples make this switch due to male factor issues associated with poor embryo development. In some cases—though very few—it is primarily about time constraints, especially for older couples, such as when the woman is around 48 and the husband is also older. Even if there is no male factor, they may want to proceed quickly with treatment. In some cases, cost is also a factor, as embryo donation is almost half the price of egg donation.
Dr Ernesto Bosch, PhD, IVI Valencia, Spain: By regulation in Spain, embryos must come from couples who meet donor criteria. For example, a couple who underwent IVF at age 38 would not be eligible to donate. Both partners must meet the donor criteria. While availability is not high, it is sufficient to meet demand. Most donated embryos come from egg donation cycles where the couple has already fulfilled their reproductive goals and has surplus embryos. Couples who seek this option usually do so for two reasons: either they need donor gametes for both partners or they are looking for a more affordable option, as embryo donation is significantly less expensive than a full egg donation cycle.
Dr Athanasios Garavelas, Garavelas Medical Group, Greece: It is quite similar in Greece. While we have a formal process for embryo donation, culturally, it is less common. Instead, we often proceed with donation by combining an egg donor and a sperm donor.
Dr Ernesto Bosch, PhD, IVI Valencia, Spain: At IVI Group clinics, we offer 3 programs:
The cumulative ongoing pregnancy rate for the basic program is 70%, as the average number of blastocysts is 2 to 3. For the Regular Program, the rate is 84%, with 4 to 5 blastocysts available. For the Baby Guarantee Program, success is almost 98-99%, as it includes up to 3 cycles with strict eligibility criteria.
PGT-A is not routinely performed in egg donation cycles. In Spain, it is not typically recommended for donors under 35 unless there is a known chromosomal issue on the male side.
Dr Athanasios Garavelas, Garavelas Medical Group, Greece: Our model is similar to Spain. We do not have multiple packages but offer a guarantee program. We guarantee at least 2 blastocysts for transfer. The program varies based on whether fresh or frozen donor eggs are used. With fresh donors, we can provide up to 10 oocytes, whereas with frozen eggs, couples purchase a specific package.
We do not use PGT-A for egg donation unless there is a medical condition requiring it. In those cases, we must obtain approval from the Greek authorities. Our success rates are very high—similar to IVI in Spain—around 80% for egg donation cycles and 99% for guarantee programs.
One difference in our approach is that we evaluate all embryos using time-lapse imaging and artificial intelligence scoring before transfer, which helps improve implantation rates.
Dr José Antonio Domínguez Arroyo, IERA, Portugal: Yes, it’s more or less similar. We take into account very, very important things – the male factor—if there is a male factor, for example, very high DNA fragmentation, we only assign a number of oocytes; the couple can choose the number of oocytes that they want.
If there is any male factor, we have a program to ensure 1 or 2 blastocysts—at least 1 or at least 2. For that, we assign 5 to 6 for a single blastocyst and 10 to 12 for 2 blastocysts. We also have the guarantee program, we use Access Fertility; we don’t use our own program; we use Access Fertility. Usually, we don’t use PGT-A for donors except in cases where the couple switches to oocyte donation because they don’t have any euploid blastocysts. In some of these cases, it is the couple who wants to do PGT-A on the embryos because they have had miscarriages. In these cases, they prefer to have more possibilities to avoid going through the same situation again.
Dr Ernesto Bosch, PhD, IVI Valencia, Spain: I can share a recent example. I had a patient who was 41 but had an extremely low response. We were doing modified natural cycles because we couldn’t retrieve more than 1 egg per cycle. However, she was producing good-quality blastocysts and preferred fresh embryo transfer rather than submitting the embryos for analysis.
We discussed it, and I explained that at her age, the probability of producing a euploid embryo is around 25-30%. The probability of implantation, if the embryo is euploid, is around 60%. So, at the end of the day, each embryo transferred has about a 15% success rate. In other words, it’s like rolling a die—the chances of getting a 6 represent the probability of success.
She decided to roll the dice every month, and on her second cycle, she got pregnant. Of course, we still need to see how things go during the first trimester. However, this case shows that PGT-A is not always necessary. If you understand the probabilities, you can make your calculations and decide accordingly.
Dr Ernesto Bosch, PhD, IVI Valencia, Spain: 46. We have never succeeded at 47, although we still have patients at 47-48 who want to try.
Dr José Antonio Domínguez Arroyo, IERA, Portugal: Same—46. It was a single woman, probably from a very fertile family. It happened after 1 insemination, not IVF. But these cases are rare.
Dr Athanasios Garavelas, Garavelas Medical Group, Greece: I had a 47-year-old patient, but it was after ovarian rejuvenation treatment. I remember this case well because it was at the start of the rejuvenation process. The clinic in Florence didn’t want to go with egg donation, so we tried IVF. The situation seemed bad, and we thought there might be no euploid embryos. In the first round, we got 3 blastocysts, but none were euploid. We thought about stopping, but in the second round, we got 3 embryos, 2 of which were euploid. We transferred 2 embryos, and at 47 years old, she had twins. It was the first case like that I had seen. Maybe it was due to the rejuvenation treatment, or maybe it was just luck.
Dr Athanasios Garavelas, Garavelas Medical Group, Greece: The first and most important thing is deciding whether you want to be a parent. If a patient has low ovarian reserve or advanced maternal age and wants a baby quickly, they need to be realistic. It’s a very personal decision. I ask all my patients: “Do you want to become a parent no matter what?” If the answer is yes, then they know what to do.
Dr José Antonio Domínguez Arroyo, IERA, Portugal: The willingness to be a parent. Many couples struggle with the idea, so I try to show them examples of happy families who changed their minds and realized that being a mother or father is an emotional link, not just a genetic one. Many couples change their perspective after hearing these stories.
Dr Ernesto Bosch, PhD, IVI Valencia, Spain: I’ve seen so many couples create barriers for themselves before deciding on donation. However, once they go through with it and see a five-millimeter embryo with a heartbeat on the ultrasound, they realize they made the right choice. Patients often say, “I should have done it earlier.” But I tell them they weren’t ready then, so they shouldn’t blame themselves.
I remember a patient who told me, “Maybe my child doesn’t have my eyes, but they have my look.” That says it all. The bond developed during pregnancy and early parenthood is so strong that all the previous doubts disappear. Patients who hesitate should take their time, but from experience, I can say that they never regret it. The only thing they sometimes say is, “I wish I had done it sooner.”
