Frontiers in Gynecological Endocrinology: Volume 1: From Symptoms to Therapies (ISGE Series)

13. Treatment with Donor Eggs

Michael Savvas¹ , Haitham Hamoda¹ and Monica Mittal¹

(1)

The Assisted Conception Unit, King’s College Hospital, London, UK

Michael Savvas

Email: Mike.savvas@nhs.net

13.1 Introduction

Treatment with donor eggs is a highly successful treatment option for women with Premature Ovarian Insufficiency (POI) and is also indicated for those who have had unsuccessful IVF due to poor response to ovarian simulation or have repeated implantation failure. It may also be indicated in cases where the woman is known to be a carrier of an inherited disorder.

This treatment requires careful assessment of the Donor as well as the Recipient and her partner.

13.2 Assessment of Donors

In the UK, the law requires that the donor is altruistic although reasonable expenses may be claimed, up to a maximum of £750. The donors need to be healthy and between the ages of 18 and 35 years of age. All potential donors are carefully assessed to exclude any inheritable conditions. A detailed medical history is obtained to assess the potential donor’s health and exclude any familial conditions which may be genetic. All potential donors undergo a number of investigations (Table 13.1). The potential donor is screened for blood-borne viruses to avoid the risk of transmission to the recipient or the foetus and are carried out at the first visit and repeated again just before treatment is commenced. The screening for Haemoglobinopathies and Tay–Sachs is carried out in the appropriate racial groups.

Table 13.1

Donor screening test

The donor’s ovarian reserve is also assessed with an Antral Follicle Count and biochemically with measurement of FSH LH and E2 in the early follicular phase of the cycle though increasingly the AMH is used instead.

In addition to this, we write to the General Practitioner of all potential donors asking them to confirm that there is no relevant medical history.

The process involved is fully explained to the patient and in particular and the risks involved are discussed. This includes possible side effects of the drugs including the risk of Ovarian Hyperstimulation Syndrome and the potential risks associated with the egg collection procedure.

All women seeking to be egg donors are also required to see a specialist counsellor at which time the woman’s reason for wishing to be a donor explored and the legal implications are explained.

13.3 Assessment of the Recipient

Before the recipient can proceed with treatment, she will need to be assessed very carefully. The Human Fertilisation and Embryology Authority (HFEA), the body that regulates this form of treatment in the UK, requires that the welfare of any children born as a result of this treatment must be considered. This involves taking a detailed medical history and the potential recipient and her partner are required to complete a form, which specifically enquires about any medical, social or psychological issues that may impact on the quality of parenting.

The potential recipients and her partner receive counselling where the implications of embarking on this treatment are discussed and the legal position regarding parenthood is explained. In the UK, the woman who gives birth and her husband will be the legal parents. If the recipient is unmarried, her male partner can be the legal further if he consents to his partner undergoing treatment and signs the relevant documents. Similarly, if the recipient is in a same sex relationship, her partner will be the legal “second parent” if they are in a civil partnership. If not in a civil partnership, her partner can still be the second parent if the relevant forms are completed.

The egg recipient can receive non-identifying information about any donor such as hair colour, eye colour, height and ethnicity. She can also receive a copy of the pen portrait written by the donor primarily for the use of the donor-conceived child.

Prior to commencing treatment, the recipient usually undergoes a “dummy cycle” where she is given 6 mg Oestradiol orally an ultrasound scan is performed after 10 days to assess endometrial thickness; we aim to achieve a thickness of 8 mm or more. If the endometrial thickness is inadequate, the dose or duration is increased. In this way, the appropriate dose and duration of Oestradiol required to achieve optimal endometrial thickness is determined and allows us to synchronise the recipient’s endometrium with the timing of the donor’s egg collection.

13.4 The Law

In the UK, donors have no legal rights or obligations towards any children born as a result of their donated eggs; however, they can be told whether any children were born as a result of the donation, the sex and the year in which they were born.

In accordance with HFEA Code of Practice, we encourage patients to tell their children that they were conceived with donor gametes. Donor anonymity was removed in 2005 and their identity can be revealed to donor-conceived people once they reach the age of 18. Only the donor-conceived person can initiate contact with the donor, the donor cannot be given the identity of the recipient or the donor conceived person.

Donor anonymity was removed in response to the need for donor-conceived people to know their genetic origin as this may have an important role in the formation of their personal identity. Studies have shown that concealment of such information could have a detrimental effect on individuals’ familial and social relationships, particularly if that information is later discovered in an unplanned manner [1].

When donor anonymity was removed in 2005, there was much anxiety that this would lead to a marked reduction in altruistic donors. However, the number of egg (and sperm) donors has continued to rise since 2005 (Fig. 13.1) though the absolute numbers are relatively small. Similarly, in Sweden when a change in the law in 1985 removed sperm donor anonymity, there was an initial reduction in donor numbers although numbers subsequently increased to their original levels [2].

Fig. 13.1

The number of egg and sperm donors in the UK since 2003

The absolute number of donors in the UK is small and is inadequate to meet current demand. Many women who require treatment with donor eggs cannot find an anonymous altruistic donor and instead find their own donors from within their family or circle of friends while others seek treatment overseas. Some women may opt for egg sharing, where a woman who is undergoing IVF/ICSI for a male factor diagnosis agrees to share her eggs and the recipient subsidises her treatment. We have concerns about this form of treatment because we feel that women who require such treatment are vulnerable and may choose to share their eggs simply to enable themselves to get “free or subsidised treatment”. We also have concerns that the donor may have profound issues to cope with if she failed to get pregnant while the recipient was successful.

13.5 The Process

Stimulation protocols vary but the donor usually undergoes pituitary downregulation with a GnRH analogue starting on day 21 of the preceding cycle, a baseline down regulation scan is performed and then stimulated with FSH, the dose being calculated on the basis of her age and ovarian reserve. Transvaginal Egg collection is usually carried out under intravenous sedation. The eggs are then fertilised with the recipient’s partner’s sperm. The recipient commences progesterone usually in the form of vaginal pessaries (Cyclogest 400 mg bd) on the day the donor undergoes egg collection. Embryo transfer is increasingly performed at the blastocyst stage and any surplus embryos can be cryopreserved for future use.

Alternatively, the eggs can be frozen so that they can be thawed and fertilised at a later date. The advantage of freezing eggs is that it is more convenient and reduces the likelihood of cancelling a cycle if there is any problem with the recipients. A further theoretical advantage is that it allows eggs to be quarantined until viral tests have been carried out. Though there have been no recorded cases of viral transmission with donor eggs, the techniques of egg freezing has improved in recent years with introduction of vitrification, where the eggs are frozen rapidly thus avoiding the formation of intracellular water crystals that can damage the egg. In recent years, the results from vitrified donor egg treatment have improved and have been shown to be as successful as when using fresh eggs [3].

13.6 Obstetric Outcomes

Women who conceive with donor eggs have a higher incidence of bleeding in the first trimester, pre-eclampsia and small-for-gestational age. There has also been reported a significantly increased rate of caesarean section [4].

It has been reported that the age of the recipient does not affect the rate of implantation; however, a more recent study indicates that the implantation rate is reduced if the recipient is 45 five years or older [5]. Other factors that can affect implantation rate include smoking and the presence of hydrosalpinx. The effect of weight is unclear, but a recent study indicated that the implantation rate is significantly reduced if the BMI of the recipient is greater than 35 [6].

13.7 Conclusion

Donor egg treatment is becoming increasingly popular and highly successful; however, access to this treatment is limited by the shortage of donors. The improvement in egg freezing techniques and the establishment of egg banks may prove helpful.

Better outcomes are achieved if the recipient is less than 45 years of age, is a non-smoker and has a normal BMI. These pregnancies tend to have a higher incidence of pre-eclampsia, antepartum haemorrhage and small-for-gestational age.

References

1.

Frith L (2001) Gamete donation and anonymity: the ethical and legal debate. Hum Reprod 16(5):818–824PubMedCrossRef

2.

Daniels K, Lalos O (1995) Ethics and society: the Swedish insemination act and the availability of donors. Hum Reprod 10:1871–1874PubMed

3.

Cobo A, Meseguer M, Remohi J, Pellicer A (2010) Use of cryo-banked oocytes in an ovum donation programme: a prospective, randomised, controlled clinical trial. Hum Reprod 25(9):2239–2246PubMedCrossRef

4.

Stoop D, Baumgarten M, Haentjens P, Polyzos N, De Vos M, Verheyen G, Camus M, Devroey P (2012) Obstetric outcome in donor oocye pregnancies: a matched pair analysis. Reprod Biol Endocrinol 10:42PubMedCentralPubMedCrossRef

5.

Gupta P, Banker M, Patel P, Jhosi B (2012) A study of recipient related predictors of success in oocyte donation programm. J Hum Reprod Sci 5(3):252–257PubMedCentralPubMedCrossRef

6.

Bellver J, Pellicer A, García-Velasco JA, Ballesteros A, Remohí J, Meseguer M (2013) Obesity reduces uterine receptivity: clinical experience from 9,587 first cycles of ovum donation with normal weight donors. Fertil Steril 100(4): 1050–1058. pii: S0015-0282(13)00695-X. doi:10.​1016/​j.​fertnstert.​2013.​06.​001