Donor Options

The primary indication for egg donation was originally for women with premature ovarian failure (POF), defined as menopause occurring before the age of 40 years. POF affects approximately 1% of the female population; in effect, this condition indicates depletion of a woman’s own eggs and cessation of ovarian function. The causes of POF are varied, and a thorough medical evaluation to seek an underlying or associated process is important prior to treatment.

In recent years, the predominant indication for egg donation at most IVF centers has been for women with diminished ovarian reserve but with intact ovarian function. It has long been known that women over 40 years old have reduced fertility in general, and a poorer chance for success after IVF. This gradual, age-related decline in fertility is a direct result of aging of the eggs. The fertility evaluation may also uncover evidence of diminished ovarian reserve even in women younger than 40 years, as reflected by elevated FSH (follicle-stimulating hormone) and/or estradiol levels early in the menstrual cycle, determined by a blood sample taken on cycle day 2 or 3.

Other potential candidates for egg donation include: women who have previously failed multiple IVF attempts, particularly when poor egg quality is suspected, and women carrying transmittable genetic abnormalities which could affect their offspring (this latter indication has declined with the development and use of pre-implantation genetic diagnosis, or PGD).

Women considering using egg donation should undergo a medical evaluation including a complete history and physical examination, to assure that their health would not be significantly jeopardized by pregnancy. It is also important to seek and correct any abnormalities, which could otherwise compromise the success of IVF with donor eggs (i.e., factors which could affect fertilization, implantation or pregnancy).

Such testing should generally include, but is not necessarily limited to, cervical cultures for bacteria (e.g. chlamydia) a hysterosalpingogram, saline sonogram or hysteroscopy to assess the normality of the uterine cavity and a semen analysis to rule out a coexisting male factor. If the recipient has an RH-negative blood type, some precautions are indicated if either the donor is RH positive or the recipient’s male partner is RH-positive. A uterine sounding (trial transfer) may be performed to determine the uterine depth and how easily an embryo transfer catheter can be passed through the cervix.

At some IVF centers, the donor egg recipient will undergo a preparatory cycle of programmed hormone replacement (as outlined below) prior to the actual treatment cycle. Such a “prep cycle” or “mock cycle” is undertaken in an effort to ensure that the prescribed hormonal regimen will achieve the desired blood levels and uterine/endometrial effects. This is determined by ultrasound measurement of the endometrial stripe thickness and/or an office endometrial biopsy during the “mock cycle.” Pre-treatment counseling prior to egg donation should include not only a detailed discussion of the procedural aspects, risks and expected likelihood of success associated with the treatment, but should also include an exploration of the psychological and social aspects of “third party” reproduction.

A thorough evaluation or screening of each potential egg donor is of critical importance, whether the donor is known to the recipient (e.g., a sister) or is anonymous. This screening should serve to protect all parties involved (the donor, the recipient and the resulting offspring). Briefly, the donor should generally be younger than 35 years old, with laboratory evidence of normal ovarian reserve and no indication of impaired fertility.

She must undergo testing for communicable infectious diseases (e.g., hepatitis, HIV, syphilis) and genetic screening both via a detailed family history and specific blood tests which are determined by her ethnic/racial background (e.g., for cystic fibrosis, Tay Sachs disease, sickle cell disease, thalassemia). A formal psychological evaluation is also performed.

Some centers will “split” an anonymous egg donor’s eggs which two recipients can use. This may shorten the waiting time and cost for the recipients but reduces the likelihood of freezing excess embryos.

Effective synchronization of the development of the recipient’s uterine lining (endometrium) with the growth of the donor’s follicles and eggs and the resulting embryos is key to the success of egg donation. Recipients with ovarian failure (i.g., premature menopause) will require uterine preparation with estrogen and progesterone as they lack ovarian function. Recipients with intact ovarian function (the majority of patients at most IVF centers) require treatment with estrogen and progesterone to align their cycle with those of the egg donors. Recipients with ovarian function are often pre-suppressed with a medication such as Lupron®, prior to the initiation of estrogen.

Recipients usually take estrogen (most commonly estradiol either by mouth, injection or by a transdermal skin patch) for two weeks, typically on a dosage designed to mimic the natural cycle. It is unusual for a recipient to ovulate before an embryo transfer because most recipients are on GnRH-a (Lupron®). However, if the recipient ovulates before embryo transfer, the embryos will be frozen for use in a future cycle.

All recipients take progesterone daily, generally starting the day before or the day of the donor’s egg retrieval. The embryo transfer is usually two to five days later. Progesterone may be administered in various formulations, including intramuscular injection, vaginal suppositories and vaginal gel (Crinone ). (Assisted hatching may be done on the embryos at the time of embryo transfer if the embryos appear to have a thick outer wall or zona.)

Following the transfer of one or more embryos, the recipient continues treatment with both estrogen and progesterone until her pregnancy test on cycle day 28. Donor egg pregnancies are supported with estrogen and progesterone until blood work shows that the placenta is self-sufficient (usually by the tenth week of pregnancy), at which time these medications are discontinued.

As the recipient does not undergo ovarian stimulation or egg retrieval, she is not exposed to the potential risks of these procedures (e.g., ovarian hyperstimulation syndrome). The principal risk for the recipient is multiple pregnancy, because egg donors are young (usually less than 35 years) and pregnancy rates are high because of this. The age of the recipient, even if over 40, does not affect pregnancy rates.

It is important that the number of embryos transferred be limited, generally to no more than two or three embryos for a day 2-3 transfer or one or two embryos if transferred on day 5, at the blastocyst stage. Other theoretical risks to the recipient include transmission of infectious diseases such as HIV; it is unknown whether eggs can transmit the AIDS virus, and, to date, no cases of HIV transmission through egg donation have been reported. Nevertheless, meticulous screening of potential egg donors is critical.

Building a Family through Donor Egg Treatment
Genetic Screening and Testing
Medications
What is IVF?

It is very important that the couple or individual be psychologically ready to move forward with using donor sperm. Most doctors recommend that any patients considering Donor Insemination (DI) see a counselor who is skilled at clarifying feelings about infertility, and about trying DI. It is crucial that both partners feel comfortable with the decision and that all fears and questions be openly discussed. For some, it may mean dealing with various moral and ethical questions; for others, exploring questions about donor selection and whether to be open about the decision to do DI and whether to tell a child conceived by DI how they were conceived.

Most clinics will not allow couples to mix the donor’s and husband/partner’s sperm in an insemination because clinics feel if a couple requests this they may not have done the necessary psychological work involved in deciding to do DI.

Couples or individuals usually have the right to decide which sperm bank and which donor to use. Information about a donor’s physical characteristics, race, ethnic background, educational background, career history, and general health should be available. Many banks provide written profiles about the donors they have available. Some sperm banks are open to providing non-identifiable information about the donor (even photographs) as well as providing a service for adult offspring to obtain information about the donor.

The American Society for Reproductive Medicine recommends that physicians use only frozen semen and that the specimen be frozen and stored for at least 180 days. The donor should have an initial HIV blood test (the test for the AIDS virus), and should then be retested and have a negative result on the HIV test before the frozen specimen is used.

All donors should have tests for certain infections such as syphilis, hepatitis B, cytomegalovirus (CMV), gonorrhea, chlamydia, streptococcal species and trichomonas. All these organisms can be transmitted via semen to a woman. Some can have grave effects on the fetus; others principally affect the woman. The donor’s semen should also be checked for the presence of white blood cells which can indicate an infection within the reproductive tract.

Donors are excluded from a donor program if he or his sexual partner have experienced any of the following: a blood transfusion within one year, a history of homosexual activity, multiple sexual partners, a history of IV drug use, or a history of genital herpes.

Before starting DI, a careful medical and reproductive history should be taken on the woman and a rubella titer, blood type, and antibody test for CMV should be done. If the woman tests negative for CMV, only a CMV-negative donor should be used. Some practices want to document normal ovulation patterns and many doctors order a hysterosalpingogram to document that the woman’s fallopian tubes are open.

The DI procedure involves inseminating the woman as close to the time of ovulation as possible. Many women monitor their ovulatory cycles by testing their urine for an LH surge which indicates that ovulation will soon take place. Inseminations are usually done about 24 hours after a surge of LH is noted on the urine test. Clinics do one or two inseminations per cycle.

Cervical insemination is a simple procedure. A soft catheter is passed through the speculum to the cervical opening and the semen is released from the catheter. The woman may be instructed to stay lying down for 15-20 minutes and then a small plastic covered sponge with a string attached may be inserted to keep the semen as close to the cervix as possible. The woman is instructed to remove the sponge in 2-3 hours. With cervical insemination, the nurse can take a cervical swab several hours after the insemination which will reveal how well the sperm are surviving in the cervical mucus.

Intrauterine insemination is often used to increase success rates with frozen sperm. Some sperm banks process the sperm for intrauterine insemination before shipping. If not, the thawed specimen is processed to remove the seminal plasma from around the sperm cells (Intrauterine insemination without doing this process would cause uterine cramping and possible allergic response.) After the sperm is processed, it is injected, using a syringe and thin catheter, into the uterus via the cervix. The insemination is usually painless; some women who have a tight cervical opening experience cramping if an instrument (tenaculum) is used to open the cervix.

Many women find it helpful to have their partner/husbands with them, especially the first time DI is done. This helps affirm that choosing DI was a mutual decision and a potential beginning to their parenting experiences. Other women bring along a favorite book, music, or a relaxation tape to help make the insemination more pleasant.

The highest success rates for DI are reported in women who have no infertility problems, are under 35 years old and whose partner/husbands have azoospermia (no sperm). Lower success rates are reported where there is a female factor (ovulation problem, endometriosis, DES, etc.) Or the woman is over 35.

Success rates vary from 60-80% but achieving pregnancy may take many cycles. In one study the overall cumulative pregnancy was 86% in the IUI patients and 49.5% in pericervical insemination group (Matorras, et al, Fertility and Sterility, vol. 65, no. 3, March 1996). Success rates for insemination may increase with two inseminations per cycle and correct timing.

If no pregnancy occurs after several cycles, the doctor will continue an evaluation of the woman. This involves a hysterosalpingogram, a laparoscopy and hysteroscopy to be sure there are no adhesions or endometriosis, and an evaluation of the luteal (post-ovulatory) part of the cycle by endometrial biopsy and/or checking progesterone levels in the blood. Other hormonal tests as well as ultrasound monitoring of follicular development may be indicated.

Ovulatory stimulating drugs such as clomiphene or injectable gonadotropins can be given to the woman. Closely tracked ovulation monitoring as well as IUI can help increase the likelihood of success for some women.

A good resource for obtaining a list of sperm banks is the American Association of Tissue Banks, 1350 Beverly Road, Suite 220-A, McLean, VA 22101, 703-827-9582 or the American Society for Reproductive Medicine, 1209 Montgomery Hwy., Birmingham, AL 35216.