Transcript The Ins and Outs of Egg Donation-Key Strategic Points

THE INS AND OUTS OF EGG
DONATION-KEY STRATEGIC
POINTS
Maria M. Jackson RN, MA
Learning Objectives




List the parties involved in egg donation
Review the available donor options and the
feasibility of in house recruitment
Examine the ED process in terms of each of the
parties involved
Consider the impact on the offspring from ED
Strategic Points

Strategic points differ depending on the one’s
perspective
 Clinic
 Donor
 Recipient
 Offspring

Affected parties have, “distinct but, at times,
competing interests”
ASRM Ethics Committee Opinion. Interests, obligations, and rights in gamete
donation. Fertil Steril 2014; 102: 675-81.
Clinic Perspective
Clinic Perspective

Clinicians have an obligation to all the parties
involved
 Safety
and well-being of the donor
 Protecting the health of recipients
 Ethically obligated
to screen donors for infectious diseases
and genetic risk factors
 Protecting
the health of the unborn child
ASRM Ethics Committee Opinion. Interests, obligations, and rights in gamete
donation. Fertil Steril 2014; 102: 675-81.
The Clinic’s Perspective

Obligation to do this in the most ethical way
possible
 Definition
of “ethical” may be interpreted differently
 Psychological
screening over the phone?
 Recipients age limits

Must be done in a cost efficient manner
Clinic Perspective

Multiple donor
options available
 Clinic
recruited
 Egg banks
 MEB,
DEB USA, Fairfax,
World Egg Bank
 Agencies
 Known/directed
Clinic Perspective: Clinic recruited
•
•
•
Economic feasibility
– Advertising
– Weeding out
inappropriate candidates
– Online questionnaires
Screening desirable
candidates
– Financial exposure
– <10% candidates are
accepted*
Labor intensive process
Gorrill M, Johnson L, Patton P, Burry K. Fertil
Steril 2001; 75: 400-04.
Clinic Perspective: Clinic recruited
Advantages
• Multiple cycles
• Recipients trust judgment of staff
–
•
•
May give them greater comfort
Donors are screened and ready to cycle
Throughput increased
–
Recruit donors that will be desirable to recipients
Clinic Perspective: Clinic recruited
•
•
•
Time consuming process
Orientation classes
Traditional synchronization
–
•
Multiple schedules to consider
Cycle management
–
–
–
–
Hand holding
Ordering meds
Med teaching
Post donation follow-up
Clinic Perspective: Egg Banks
•
•
•
Efficient use of donor eggs
Appeals to older recipients who may not want lots
of frozen embryos
Experimental label removed by ASRM
–
–
•
Insurance coverage
Costs ~$10k less than conventional OD
Inventory ebbs and flows-may not be quicker
Clinic Perspective: Egg Banks

Easier to manage the cycle
 No
Prep/Mock cycle
 No synchronization
 No donor recruitment

PR comparable
So-are egg banks the more cost effective route?
Clinic Perspective: Agencies

Offer a larger pool of potential donors
 Especially
helpful for certain ethnic groups that are
difficult to recruit

Cost is significantly higher
 Travel,
meals and lodging expenses in addition to cycle
coordination

Donors are not pre-screened
 Emotional

let down if donor is rejected
Cycle management is more complicated
Clinic Perspective
Factors to consider:
 Competition
 SART
clinic success rates
 Comparisons
 May


may be misleading
drive up the cost of donor compensation
Financing options offered to patients
Marketing

Outreach to LGBT community
SART National Data Summary
https://www.sartcorsonline.com/rptCSR_PublicMultYear.aspx?ClinicPKID=0
Clinic Perspective: Media
“Her horrifying personal story about
using a host of assisted reproductive
technologies (ART), including in vitro
fertilization (IVF) and egg donation,
in an effort to have a child is part
memoir and part exposé of an
unscrupulous, high-profit industry. It’s
a compelling read.”
Book describes a 6 year struggle
with infertility that ended with the
couple adopting

Clinic Perspective: Media
The Donor’s Perspective
Donor Perspective

Donor is a patient
 Often


clueless when she comes in for orientation
ASRM Guidelines should be followed
Donors must be counseled and educated
 Normal
reproductive physiology
 IVF process
 S/E of medications
 Complications
 Time commitment
Recruitment Ethics
207 websites examined/102 (53%) agencies or IVF
clinics actively recruited donors online



Was there mention of increased payment for certain
traits?
Did they recruit donors <21?
Did they note potential risks?
Keehn J et al. Fertil Steril 2012; 98: 995-1000.
Results

34% offered increased compensation for particular
traits
 Prior
donation most common
 Agencies more than clinics
 West
 Not SART member (clinic) /ASRM endorsement
(agency)


41% recruited donors <21
56% presented risks alongside compensation
Are we exploiting donors?




Donors derive no benefit from medical treatment
only financial
Different risk/benefit decision
Different ethical considerations
No longitudinal studies looking at long term effects
Pearson H. Nature. 2006; 442(7103): 607–8.
AMA Opinion 2.055. Ethical conduct in Assisted Reproductive Technology. Available at:
http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medicalethics/opinion2055.page
Donor Perspective

Donation is not a one time
event
 Anonymity not guaranteed
 Implications are far
reaching
 Ongoing communication is
essential
 Benefits recipient and
offspring
 May benefit the donor
Donor Perspective

Recipients are not just heterosexual couples
 They
are within their rights to say to whom their eggs
can be donated
 Most

do not stipulate
There may be frozen embryos resulting from their
donation
 Issues
of consanguinity
 Possible donation of unused embryos to another
recipient
Donor Perspective




Do they want contact with the recipient/offspring?
They have an interest in knowing the cycle outcome
but are usually not told
Should be counseled about advances in genetics that
may impact them
Advised that laws and circumstances may change
 Promises
of anonymity or future contact by offspring
cannot be assured
The Recipient’s Perspective
Recipient Perspective


I can’t believe I’m considering this option
Who are the donors?
 What’s
their motivation?
 How are they screened?
 Do you validate the information they provide?


What do my partner and I need to do?
What are my chances of taking home a baby?
Recipient Perspective

I can’t believe I’m considering this option
 Fears,
concerns, doubts are normal when using a third
party to conceive
 Nontraditional
 No
form of family building
one expects to give over control of their
reproduction to strangers
 It may take some time to get comfortable with the idea
of using another person’s eggs
 Using donor eggs is not a cure for infertility
Recipient Perspective
Recipient Perspective

Who are the donors?
 21-32
year old women
 Motivated by altruism and financial compensation
 Compensation
varies greatly by region
 Should not exceed $10K
 Often
know someone who’s been through infertility
 Can do 6 cycles maximum
Repetitive oocyte donation: a committee opinion. Fertil Steril 2014 Article in press.
Recommendations for gamete and embryo donation: a committee opinion. Fertil Steril 2013;
99: 47-62.
Recipient Perspective

ASRM Guidelines for
donor screening
FDA
 Genetic
 Ovarian Reserve
 General health
 Psychological

Recommendations for gamete and
embryo donation: a committee opinion.
Fertil Steril 2013; 99: 47-62.
Recipient Screening








Infectious diseases
TSH, PRL, CBC, CMV
Rubella, Varicella
Blood type/Rh ,
Antibody screen
Pap, cultures
PE, BLUS, Cath check
Mammogram
Cavity evaluation
Patients 44+
EKG
Chest X-ray
GTT
Medical clearance letter
Partner Screening






Infectious disease
testing
Blood type/Rh
CBC
Genetic testing
Semen analysis/ ASA
Cryo back-up if
needed

BOTH partners should
meet w/ MHP as part
of their checklist
Too much of a good thing…
“I/we wouldn’t mind twins…
20% preferred multiples to
singleton
94% wanted twins
76% aware of increased
maternal risks
95% aware of increased risk of
premature delivery
Ryan et al Fertil Steril 2004; (81): 500-04.
Why?





Nullaparity*
Lower family income*
Previous infertility evaluation
Longstanding infertility
Lack of knowledge
*Only factors independently associated w/ desire for
multiples
Source: CDC/NCHS National Vital Statistics System. http://www.cdc.gov/nchs/data/databriefs/db175.htm
Multiple Pregnancy Risks:
Increase when multiple embryos are transferred
•
•
•
•
•
Gestational hypertension
Gestational diabetes
Placenta previa (placenta covers the cervix)
Preterm labor and delivery
Premature babies

Cerebral palsy, learning disabilities, slow language
development, behavioral difficulties, chronic lung disease,
developmental delay, and death
http://www.marchofdimes.org/pregnancy/multiples-twins-triplets-and-beyond.aspx#
Multifetal Reduction

Research ahead of time
 Examine


personal feelings
Necessary but stressful decision
Psychological distress
 Sadness
and guilt
 Eases over time

Compared to families w/ triplets overall functioning
was better
Garel et al. Hum Reprod 1997; 12: 617-22.
Age cutoff?

Concerns for the mother’s health
 Careful
screening required
 Adequate counseling re: risks of complications


SET strongly recommended
Discouraged/denied in women 50 and over with
underlying medical conditions & >55 regardless of
health
ASRM Ethics Committee Report: Oocyte or embryo donation to women of advanced
age. Fertil Steril 2013; 100: 337-40.
Is She Too Old For This?

“Old parents face a version of the judgment implicit
here: They have no idea what they’re in for. More
than that: This is just not right. A new child may be a
blessed event, but when a 50-year-old decides to
strap on the Baby Björn, that choice is seen as
selfish and overwhelmingly prompts something like
a moral gag reflex. “
Important Points to Share


Using donor eggs minimizes but does not eliminate
the risk of miscarriage
Maternal risk at age 25
 Down
Syndrome: 1 in 1250
 Any chromosomal abnormality: 1 in 476

IVF bypasses natural selection
 Blastocysts
can be chromosomally abnormal and implant
Available at: http://www.acog.org/About-ACOG/News-Room/News-Releases/2007/
ACOGs-Screening-Guidelines-on-Chromosomal-Abnormalities
Offspring’s Perspective
Rights of Offspring

Focus for clinics is to “overcome” fertility issues of
the recipient
 Recipient
gets to experience pregnancy
 Child genetically related to one of them

Didn’t anticipate the effects on offspring
 Need
to know where they come from
 Knowledge is essential to forming their identity
Rights of Offspring: Disclosure Issue
Proponents of disclosure believe:
 Everyone has the right to know how they were
conceived
 It a violation of the child’s autonomy if the
information is withheld
 This knowledge enhances the child’s understanding
of their identity
McGee et al. Hum Reprod 2001; 16: 2033-36; Frith L. Hum Reprod 2001; 16: 818-24.
Disclosing the use of donor eggs


Avoid secrets that can strain the family
relationships
Avoid inadvertent disclosure that can be far more
damaging than planned disclosure
 Especially

true in light of advances in genetic testing
Internationally laws have been enacted to facilitate
access to information about the donor
Hahn S, Craft-Rosenberg M. JOGGN 2002; 31: 283-93. Golombok S. Hum Reprod 1999; 13: 2342-47.
Turner A, Coyle A. Hum Reprod 2000; 15: 2041-51.
Arguments for Nondisclosure



Protect the child from
social & psychological
turmoil
Protect the child from
disapproving family
members
Protect the nongenetic parent from
rejection by the child
McGee et al. Hum Reprod 2001; 16: 2033-36: Mahlstedt P, Greenfeld D. Fertil Stril 1989: 52: 908-14.
Offspring: Are My Parents Too Old?



Possibility that one or
both parents could die
before the child reaches
adulthood
Stresses of parenting as
an older parent
Difficulties of meeting the
emotional and physical
demands of parenting
ASRM Ethics Committee Report: Oocyte or
embryo donation to women of advanced age
Fertil Steril 2013; 100: 337-40.
http://nypost.com/2014/09/08/meet-thebusinesswoman-single-mom-whospregnant-again-at-51/
Recipient Age:
Ethical considerations



Ageism still an acceptable bias in 2014
 Hypocritical given how many US grandparents are primary
care givers to young children today
 3 mil (2011) Pew Research Center
Older parents often have more resources
Age alone does not make one a good parent
 Less parental stress reported by older moms
 ART children outperformed peers on standardized test scores
in a comparison study
 Older the mom the better the better they did
http://www.pewsocialtrends.org/2013/09/04/at-grandmothers-house-we-stay/
Van Voorhis et al. Hum Reprod 2010; 25: 2605. Paulson Fertil Steril 2007; 87: 1327- 1332
Definitions of Family 2015
Offspring


In 2011 46% of all US births were to unmarried
women
Currently, there is estimated 6-14 million children
being raised by at least one gay parent usually as
a result of a heterosexual relationship
Available at: http://www.cdc.gov/nchs/fastats/unmarry.htm
Paterson C. Child Dev 1992; 63:1025-42.
Concerns for the welfare of the offspring




Is the best rearing environment a married, two-person,
heterosexual couple?
Do children of gay and lesbian parents experience
social isolation?
Do children of gay and lesbian parents have
problems with gender- identity or sexual orientation?
Are single men less caring or nurturing than women?
Avison W. Can Med Assoc J 1997; 156:661-3. Cairney J et al. Soc Psychiatry Psychaitr Epidemol
2003; 38: 442-9. Golombok S Tasker F. Dev Psychol 1996; 32: 3-11.
APA review would disagree




No scientific evidence that parenting effectiveness is
related to parental sexual orientation
Lesbian and gay parents are as likely as
heterosexual parents to provide supportive and
healthy environments
Sexual identities develop in much the same way
Children have normal social relationships with peers
and adults
American Psychological Association. Sexual orientation, parents, & children. 2004. Available at:
http://apa.org/about/policy/parenting.aspx
Offspring
ASRM Ethics Committee Opinion:
 Moral objection to homosexuality or single
parenthood is not itself an acceptable basis for
limiting childbearing or reproduction
 Programs should treat all requests for assisted
reproduction equally without regard to
marital/partner status or sexual orientation
Fertil Steril 2013; 100: 1524-27.
Summary




There are multiple parties involved in egg donation
Interests of these parties may have competing
agendas
Clinicians are facilitators and educators
The interests of the offspring must be considered
Thank you