Mothers Via Egg Donation - Frequently Asked Questions
Introduction
This information has been compiled by the members of the MVED listserv for use by other members. It is the compilation of our knowledge and experience, and is presented in the hopes that it will help others become more proactive in their own healthcare by asking the right questions and making educated decisions.
Although this information is correct to the best of our knowledge, we are not medical professionals, so please use the information as a reference only and confirm anything in question with your physician.
Updated 4/5/99 v1.2
Infertility and DE Specific Acronyms and Abbreviations
General Internet Abbreviations
The DE process. Step by step.
Insurance and DE
Selecting a Clinic
Finding an Egg Donor
Questions to Ask Egg Donors
Known Donor vs. Anonymous Donor
Giving Up a Genetic Link
How Long Does it Take To Find a Donor?
Is There an Optimal Number of Times a Young Women Should Donate Eggs?
How Do Age and Prior Pregnancy Status Affect the Choice of an Egg Donor?
Sample Egg Donor Contract
Gift for Donor?
Money-back Guarantee Programs
Shared-Cycle Programs
Cytoplasmic Transfer
Advanced Maternal Age
Tests You May Be Required To Take
Medications You and Your Donor Will Be Taking
Options for Obtaining Medications
Projesterone and DE
Methods of Easing the Pain of IM Progesterone Injections
Coasting
Methods for Increasing Thickness of Uterine Lining
Blastocyst Transfer
How Many Eggs To Expect at Retrieval
Fertilization Rates
Bedrest After Transfer?
Antiphospholipid Antibodies
RH Factor
Pregnancy Tests after DE
A Comparison of Home Pregnancy Tests
To Tell or Not To Tell?
How Do the Chances of Success Differ Between a Fresh or Frozen Transfer?
When to Cancel a Donor Egg IVF Cycle
After a Failure
When To Move On
DE In Other Countries Outside the US
Other Web Sites That Might Be Helpful
Infertility and DE Specific Acronyms and Abbreviations
ACA = Anti-cardiolipin Antibodies
ACTH = Adrenal Corticotropic Hormone
AF = Aunt Flo (menstruation)
AH, AZH = Assisted Hatching
AI = Artificial Insemination
ANA = Anti-nuclear Antibodies
APA = Anti-phospholipid Antibodies
APTT = Activated Partial Thromboplastin Time
ART = Assisted Reproductive Technology
ASA = Anti-sperm Antibody
ASRM = American Society of Reproductive Medicine
ATA = Anti-thyroid Antibody
AVA = Anti-ovarian Antibody
BBT = Basal Body Temperature
BCP = Birth Control Pills
BMS= Baby-making Sex
CAD = Carbohydrate Addict's Diet
CAH = Congenital Adrenal Hyperplasia
CASA = Computer-assisted Semen Analysis
CCCT = Clomiphene Citrate Challenge Test (Clomid Challenge)
CD = Cycle Day
CD56+ = Natural Killer Cells
CF = Cervical Fluid
CM = Cervical Mucus
CMV = Cytomegalovirus
CNM = Certified Nurse Midwife
CVS = Chorionic Villae Sampling
D&C = Dilation & Curettage
D&E = Dilation & Evacuation
DE = Donor Eggs
DES = Diethylstilbestrol (a synthetic estrogen)
DHEAS = Dihydroepiandrosterone Sulfate
DI = Donor Insemination
DIPI = Direct Intra-peritoneal Insemination
DOST = Direct Oocyte-Sperm Transfer
DPO = Days Post-ovulation
Dx = Diagnosis
E2 = Estradiol
EB, EMB = Endometrial Biopsy
ENDO = Endometriosis
EPT = Early Pregnancy Test
ET = Embryo Transfer
ETF = Embryo Toxic Factor
ETA = Embryo Toxicity Assay
FET = Frozen Embryo Transfer
FHR = Fetal Heart Rate
FSH = Follicle Stimulating Hormone
FTTA = Fertile Thoughts To All
GIFT = Gamete Intra-fallopian Transfer
GnRH = Gonadotropin Releasing Hormone
GP = General Practitioner
hCG, HCG = Human Chorionic Gonadotropin
HCP = Health Care Practitioner
HEPA = Hamster Egg Penetration Assay
hMG, HMG = Human Menopausal Gonadotropin
HP = Hannah's Prayer (Christian infertility / pregnancy loss group)
HPT = Home Pregnancy Test
HRT = Hormone Replacement Therapy
HSG = Hysterosalpingogram
IBT = Immunobead Binding Test
ICI = Intra-cervical Insemination
ICSI = Intra-cytoplasmic Sperm Injection
IF = Infertility
IM = Intra-muscular (WRT injections)
INCIID = International Council on Infertility Information Dissemination
IOR = Immature Oocyte Retrieval
ITI = Intra-tubal Insemination
IUGR = Intra-uterine Growth Retardation
IUI = Intra-uterine Insemination
IVC = Intra-vaginal Culture
IVF = In Vitro Fertilization
IVIg = Intravenous Immunoglobulin
LAD = Leukocyte Antibody Detection Assay
LAP = Laparoscopy
LH = Luteinizing Hormone
LIT = Leukocyte Immunization Therapy
LMP = Last Menstrual Period (start date)
LPD = Luteal Phase Defect
LUF, LUFS = Luteinized Unruptured Follicle Syndrome
MAI = Miscarriage After Infertility (mail list)
MC, m/c, misc. = Miscarriage
MESA = Microsurgical Epididymal Sperm Aspiration
MIFT = Micro Injection Fallopian Transfer
MMR = Measles-Mumps-Rubella Vaccine
MRI = Magnetic Resonance Imaging
NEST = Non-surgical Embryonic Selective Thinning
NK = Natural Killer Cells (CD56+)
NORIF = Non-stimulated Oocyte Retrieval In (office) Fertilization
NP = Nurse Practitioner
NSA = Non-surgical Sperm Aspiration
OB = Obstetrician
OB/GYN = Obstetrician/Gynecologist
OHSS = Ovarian Hyperstimulation Syndrome
OPK = Ovulation Predictor Kit
OTC = Over The Counter
PA = Physician's Assistant
PCO, PCOD = Polycystic Ovary Disease
PCOS = Polycystic Ovarian Syndrome
PCP = Primary Care Physician
PCT = Post Coital Test
PESA = Percutaneous Epididymal Sperm Aspiration
PG = Pregnant
PI = Primary Infertility
PID = Pelvic Inflammatory Disease
PLI = Paternal Leukocyte Immunization
PMS = Pre-menstrual Syndrome
POC = Products of Conception
POF = Premature Ovarian Failure
PROM = Premature Rupture of Membranes
PTSD = Post-traumatic Stress Disorder
RE = Reproductive Endocrinologist
R-FSH, R-hFSH = Recombinant Human Follicle Stimulating Hormone
RI = Reproductive Immunologist
RIP = Reproductive Immunophynotype
ROS = Reactive Oxygen Species
RPL = Recurrent Pregnancy Loss
RSA = Recurrent Spontaneous Abortion
Rx = Prescription
SPA = Sperm Penetration Assay
SA = Semen Analysis
SART = Society of Assisted Reproductive Technology
SCORIF = Stimulated Cycle Oocyte Retrieval In (office) Fertilization
SI = Secondary Infertility
SLE = Systemic Lupus Erythematosus
SPA = Sperm Penetration Assay
STD = Sexually Transmitted Disease
SUZI = Sub-zonal Insertion
TeBG = Testosterone-estradiol-binding Globulin
TESA = Testicular Sperm Aspiration
TESE = Testicular Sperm Extraction
TET = Tubal Embryo Transfer
TNF = Tumor Necrosis Factor
TORCH = Toxoplasmosis, Other, Rubella, Cytomegalovirus and Herpes test
TRH = Thyroid-releasing Hormone
TSH = Thyroid Stimulating Hormone
TUFT = Trans-uterine Fallopian Transfer
Tx = Treatment
US, u/s = Ultrasound
UTI = Urinary Tract Infection
WBC = White Blood Cells
ZIFT = Zygote Intra-fallopian Transfer
Back to Top of Questions
General Internet Abbreviations
AFAIK = As Far As I Know
AOL = America Online
BTW = By The Way
CGU = Can't Get Up (as in "I've fallen and can't get up")
DH = Dear Husband, Darling Husband
DHAC = Don't/Doesn't Have A Clue
DITD = Down In The Dumps
DW = Dear Wife, Darling Wife
FAQ = Frequently Asked Question(s)
FWIW = For What It's Worth
HTH = Hope This Helps
IIRC = If I Recall/Remember Correctly
IMHO = In My Humble Opinion, In My Honest Opinion
IMO = In My Opinion
IRC = Internet Relay Chat
LOL = Laughing Out Loud
MIL = Mother In-law (also FIL, SIL, BIL for the others)
NBD = No Big Deal
NG = Newsgroup
OTOH = On The Other Hand
POA = Plan Of Action
POV = Point Of View
ROTFL = Rolling On The Floor Laughing
ROTFLOL = Rolling On The Floor Laughing Out Loud
ROTFLMAO = Rolling On The Floor Laughing My A** Off
SO = Significant Other
TIA = Thanks In Advance
TTFN = Ta Ta For Now
TTYS = Talk To You Soon
WRT = With Respect To
YMMV = Your Mileage May Vary
Back to Top of Questions
The DE Process. Step by step.
Resolve of Northern California has a good web site with a wealth of information on the donor egg IVF process. To access their "Complete Donor Ovum Consumer Guide", go to http://www.ihr.com/resolve/ar-egg.html
This site provides articles on deciding whether donor eggs are appropriate in a particular situation, selecting a clinic, when to cancel a cycle, in addition to an excellent article entitled "What to Expect When You Go Through A Donor Egg IVF Cycle": http://www.ihr.com/resolve/articles/cycle.html
Although there might be a slight variance from clinic to clinic, in general, the donor egg process is as follows:
1. Locate a donor (see "Finding a Donor")
2. Complete medical screening for the recipient, the spouse of the recipient, and the donor: psychological (includes MMPI for donor, counseling for the donor and the recipient couple, individually and jointly, if the donor is a known donor) and physical (includes semen analysis, bloodwork to test the donor and the recipient for infection and sexually transmitted diseases, hysterosalpinogram for the recipient to allow the doctor to view the uterine lining to detect uterine polyps or other defects which could affect implantation or pregnancy, "mock transfer" to determine the best type and size of catheter for the embryo transfer, etc.).
3. Some clinics require a "mock cycle" for the recipient, where the recipient takes medications (generally lupron, followed by estrace and then progesterone) and has ultrasounds and bloodwork to ensure that the medication is effective and the uterine lining is appropriate to support a pregnancy.
4. Coordinate cycles of donor and recipient. For pre-menopausal recipients, this is accomplished by both the recipient and the donor taking medications such as lupron (shots), synarel (nasal spray), and/or birth control pills. For recipients past menopause, only the donor will be down-regulated using lupron or synarel.
5. Some clinics prescribe antibiotics for the donor, recipient, and recipient's spouse early in the cycle (often a 10-day treatment) in order to treat any undiagnosed infections that may exist.
6. Once both the donor and the recipient are down-regulated, the recipient begins to take estrogen supplements in some form - oral, patches, or shots. The dosage may be adjusted based on blood tests (measuring E2 levels) and ultrasounds to measure the uterine lining.
7. While the recipient is taking estrogen supplements to build a thick uterine lining, the donor begins her fertility medications. These medications are often taken for 8-10 days. Her progress is measured through bloodwork and ultrasounds.
8. The date of the egg retrieval will be determined based on the size of the donor's follicles, as measured by ultrasounds. At an appropriate time, she will be given a shot of HcG and the retrieval is generally performed approximately 33-35 hours thereafter.
9. On the date of the retrieval, the recipient's partner will provide a semen sample. The semen is processed and sperm are added to the eggs that same day. In some cases, ICSI will be performed. This is a process where a single sperm is injected into each egg.
10. The day after retrieval the lab will provide a fertilization report. The embryos remain in the laboratory until the date of the transfer, which can be between two and five days after the retrieval date. Periodic progress reports are provided to the recipient to keep her informed about number, size, and quality of embryos.
11. On or just before the date of the donor's egg retrieval, the recipient will begin taking progesterone supplements, available as injections, vaginal gel, vaginal or rectal suppositories, or in oral form.
12. Based on embryo quality and other factors, the recipient couple determines how many embryos to transfer to the recipient's uterus. The rest may be frozen at that time or kept in the laboratory for several more days before freezing. Often clinics will freeze only high quality embryos.
13. Some clinics will prescribe a steroid (often medrol or prednisone) and another round of antibiotics for the recipient to take for several days preceding the embryo transfer.
14. The embryo transfer is performed either at a hospital or in the clinic's office. The embryos are placed into a catheter and transferred through the cervix into the uterus of the recipient under ultrasound guidance. Some clinics prescribe valium for the recipient to take prior to embryo transfer, although the procedure is generally not any more painful than a pap smear or insemination.
15. Following the embryo transfer, the recipient will remain in the hospital clinic for 30 minutes to several hours, depending on the clinic's protocol. Then the recipient remains on bedrest for several hours to several days, depending on the clinic's protocol.
16. Several restrictions may be imposed for the period between transfer and the pregnancy test: limitations on exercise, heavy lifting (over ten pounds), sex, caffeine, etc. Again, this varies from clinic to clinic.
17. A blood pregnancy test may be performed 9-14 days from a day 3 embryo transfer (or sooner for a day 5 transfer). The HcG level in the blood is measured; if the test is positive, it is repeated two days later. HcG levels should double every 48-72 hours.
18. If the test is positive, the recipient continues to take progesterone and estrogen supplements as directed by her physician - often until the end of week 10 or 12 of pregnancy.
Back to Top of Questions
Insurance and DE
This information will cover the following questions:
1. Will my insurance cover donor egg IVF fully? In part?
2. Where can I buy insurance that will cover IVF or donor egg IVF?
3. Where can I buy insurance that will cover the donor in event of complications arising from her donation?
4. What states have mandated IVF coverage and does that mean that if I live in that states, I will be covered? Does mandated IVF coverage imply that donor egg IVF will also be covered?
1. Will my insurance cover donor egg IVF fully? In part?
To determine if your insurance will cover in vitro fertilization (IVF), you will need to review a copy of the actual insurance contract. What is provided to employees when they are hired is NOT the contract, but is a summary called a "Summary Plan Description." By law, your employer is required to make a copy of the actual contract available for your review, although the contract is generally large and the employer is not required to provide you with a personal copy. The relevant sections are generally called "Exclusions" or "Limitations of Coverage" or "Procedures Not Covered Under This Plan." Many contracts will cover diagnosis of infertility but specifically exclude procedures performed with the intent of achieving pregnancy, such as artificial insemination and in vitro procedures. Often, indictable medications are excluded from coverage as well.
Some plans have a dollar limit on the infertility coverage provided. If your plan will cover you up to a certain limit, be sure that you understand what is included in that limit (All diagnostic testing? All treatment? Laparoscopies to treat endometriosis?) and plan your treatment accordingly. Do not assume that expensive surgeries such as laparoscopies or tubal repair or removal are excluded from the coverage limit.
If your review of the plan indicates to you that some or all of the IVF procedures would be covered, you will still need to determine if donor egg IVF (IVF/DE) would be covered. In many cases, procedures and medications that would be covered for a standard IVF procedure will not be covered in a donor egg situation. With IVF/DE, many of the procedures are performed on the donor rather than the insured, and the most expensive medications are taken by the donor rather than the insured,. This may affect insurance coverage.
Some plans which cover ultrasounds and medications for insemination cycles will not cover these same items in conjunction with IVF. On the other hand, some plans which exclude IVF coverage will cover parts of the treatment - ultrasounds, hormone tests, medications, etc. Each plan is different and often though the plan wording may suggest that none of these will be covered, some may in fact be covered.
If, based on your review of the insurance contract and discussions with the insurance company or your employee benefits coordinator, you believe that part or all of the IVF/DE process will be covered under your insurance plan, be sure to obtain a confirmation in writing of the benefits to be covered. Also, be sure to find out if pre-authorization or a referral number is required for each procedure and for each cycle, and file the appropriate paperwork with the insurance company. Your clinic may be able to help with this process, but ultimately you are responsible for the bills, so keep in close contact with the clinic on these matters.
If you find that your plan covers IVF but does not cover the clinic or doctor that you would prefer to use, you may be able to change to another insurance option (e.g., a "point of service" plan rather than an HMO). Certain options provide partial coverage of an out-of-network doctor or clinic. Generally, changes between plans and plan options may be made only during the annual "open enrollment" period for employee benefits, often one month late in the year.
See section below for a discussion of the states with mandated infertility coverage. You may also wish to obtain a copy of the booklet published by Resolve (http://www.resolve.org ), "Infertility Insurance Advisor", which provides tips on reviewing your contract along with other insurance-related issues. Insurance coverage of infertility treatment is constantly changing as new states propose or pass legislation requiring coverage. You should become an advocate for coverage in your state of residence. Also, a recent supreme court ruling stating that reproduction is a "major life activity" under the Americans with Disabilities Act may have consequences in defining what must be covered by insurance plans.
2. Where can I buy insurance that will cover IVF or donor egg IVF?
If your employer's group insurance plan does not cover IVF, you will most likely be unable to purchase IVF insurance on an individual basis. In rare situations, individual plans will be available that provide this type of coverage. The best way to find these plans is by networking with other infertility patients.
The rationale for most individual plans not covering IVF or IVF/DE is as follows. For insurance companies to make a profit selling infertility insurance only to a group of infertility patients (others would not buy this kind of insurance), the premium would have to be higher than the average cost of treatment. Since no one would be likely to pay $20,000 per year in IVF insurance premiums, this type of insurance coverage is generally not offered on an individual basis. The concept works much better in a group setting, where everyone is covered regardless of his/her desire for this particular type of coverage. Then the cost is spread over a larger base of policyholders and can be reasonable, while still providing the insurance company with a profit margin.
3. Where can I buy insurance that will cover the donor (or the recipient) in event of complications arising from her donation?
Some clinics using anonymous donors require patients to buy a policy for the donor through the clinic. These policies are written by large insurance companies on a group basis. One such policy is underwritten by a company called American Insurance Group in Wilmington, DE and costs approximately $500 per cycle. These policies are generally not sold to individuals.
Although many policies exclude IVF from coverage, complications arising from IVF treatment will often be covered. Review your insurance contract to see if the exclusions list includes complications from uncovered procedures. Most insured donor egg recipients do not buy supplemental insurance to cover risks from IVF/DE.
However, in the event that the donor does not have medical insurance or for other reasons, it may make sense to buy a short term individual major medical policy to cover any catastrophic consequence (hospitalization of donor, etc.). Some companies offer short-term plans with limited underwriting (meaning that the donor will not have to undergo medical testing to qualify for coverage). These plans are generally intended to provide coverage for a short period between jobs or between school and a job. The plans are relatively inexpensive but there is a deductible and co-payment in the event that a claim is filed. Your contract with your donor should spell out who would pay the deductible and co-payment in the event of complications. One source for an inexpensive short-term policy is through Blue Cross/Blue Shield. However, each BC/BS is independent from the others, so short-term plans may not be available in all states.
Flexible Spending Accounts
Even if your insurance company does not cover IVF or IVF/DE, you may be able to offset the cost somewhat by putting money aside in your employer's "flexible spending account." The money put into these funds is pre-tax, so you never pay taxes on the portion of your income that is put into this type of fund. However, the funds must be spent during the calendar year during which you make a contribution to a FSA or the money is forfeited, so you need to be very certain that you will spend at least what you have withheld from your pay in the current year. Also, the IRS places limits on the amount of money that is placed in this type of account annually.
4. What states have mandated infertility coverage and does that mean that if I live in one of those states, I will be covered? Does mandated IVF coverage imply that donor egg IVF will also be covered?
Twelve states have mandates related to infertility coverage: Arkansas, California, Connecticut, Hawaii, Illinois, Maryland, Massachusetts, Montana, New York, Ohio, Rhode Island, and Texas. Note that these mandates do not apply to federal employees and other self-insured plans as those plans are not subject to state mandates. Many (perhaps most) large employers are self- insured and therefore exempt from these mandates. In many states, the mandate is merely a requirement that insurance companies must offer an infertility benefit to the insurer, but the mandates do not require that the insurer accept (and pay extra for) the infertility coverage offered.
A summary of the mandates in each of these states is available at http://www.asrm.org. This site can also be accessed by a link provided from Fertile Thoughts (go to http://www.fertilethoughts.net, then click on "insurance info" then click on "Summary of State Infertility Insurance Mandates from ASRM").
Fertile Thoughts provides a good FAQ on insurance coverage for infertility treatment, which can be accessed at http://www.fertilethoughts.net (go to website, then click on "Infertility FAQs" then on "Infertility Insurance FAQs").
Even if an insurance plan provides IVF coverage, donor egg procedures may not be covered. Often medications taken by the insured (recipient) are covered, but the donor's medications may not be covered.
The most comprehensive mandate is provided under the laws of the state of Massachusetts. In Massachusetts, insured plans must cover IVF, including donor egg procedures. However, even in Massachusetts there are limits on coverage, and age limits may be imposed (examples from sample plans: 42 in one plan, 45 in another). In addition, if any portion of the treatment is to occur out-of-state, it may not be covered, and the fee paid to the donor may not be covered. If one company limits the number of cycles, it may be possible to change to another plan at the open enrollment period, and obtain coverage for additional cycles.
To determine if your employer provides coverage for IVF or IVF/DE, you will need to review the insurance plan document and discuss coverage with the insurance company. Once again, before initiating any treatment, you should request pre-authorization from the insurance company in writing, and ask if there are other procedures which must be followed before beginning treatment.
In states in which IVF coverage is mandated, if your insurance does not cover IVF, you may be able to obtain a discount by telling the clinic that you will be paying cash and requesting a discount. This approach generally does not work in states in which most patients are paying cash.
Back to Top of Questions
Selecting a Clinic
Questions to Ask A Clinic About:
- Statistics
- Clinic Operations and Philosophy
- Recruited Donors
- Costs
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Clinic Statistics
It is important to ask the right questions when requesting statistical information and success rates concerning the clinic's experience with IVF with donor egg. The following questions are suggested as a starting point for gathering specific and accurate information about a clinic's track record and having that information be meaningful when comparing it to other clinics under consideration.
1. How long have you been doing IVF with donor eggs at this location with the same assisted reproductive team (IVF doctors, embryologists, nurse coordinator)?
2. What are your statistics for IVF with donor eggs, fresh and frozen cycles, broken down by: year, number of attempts initiated, number of completed cycles (through transfer), ongoing pregnancies, live births, age range of donors, age range of recipients, infertility diagnosis of recipient (i.e., premenopausal and postmenopausal)
3. Survival rate for thawing frozen embryos
4. Ongoing pregnancy rate for frozen embryos
5. Live birth rate for frozen embryos
6. How do you account for multiple births in your statistics?
7. Do you report your statistics to the IVF-ET Registry?
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Clinic Operations and Philosophy:
Coordination with the clinic is more complex than IVF procedures because it requires the care and timing of two patients instead of one. Communication becomes critical to the overall success of the procedure. The following list of questions is suggested as preliminary to the selection of a clinic and/or physician.
1. How long will it take to schedule the first consultation?
2. What is the current ratio of physician to patient? Is this above or below average?
3. Does your program operate year round? How many doctors in the practice are trained to do IVF with donor eggs? To do just IVF?
4. How many IVF nurse coordinators and/or nurse practitioners are in the practice?
5. Do you provide weekend hours for appointments for those who work or come from out-of-town, and early morning ultrasound appointments?
6. Whom do we talk with if we have questions? Who is available on a 24-hour basis to answer questions and to deal with emergencies?
7. What is the office protocol for returning phone calls?
8. Does the clinic meet minimal standards as outlined by the American Fertility Society?
9. Is the clinic a member of the Society for Assisted Reproductive Technology?
10. What kind of medical screening does the recipient and her partner receive? Does it include a medical history, a psychological history, lab tests and a physical examination?
11. How many embryos do you recommend are transferred? What are the chances of multiple births if 3 embryos are transferred? What are the chances if 4 embryos or 5 embryos are transferred?
12. What are the risks of multiple pregnancy? If we desire and require it, what are the risks of selective termination and what are the indications for it? Will you provide us with the name of a doctor who will do selective termination if this procedure is necessary?
13. Do you have the capacity and experience to freeze extra embryos? If we want to try a frozen embryo cycle, how long do we need to wait after a failed cycle before we try again?
14. (For those out of area) Will you support our local doctor to work with us and/or our donor for the trial cycle and the first week of the donor's cycle?
15. Can you recommend a place for us and/or our donor to stay?
16. Is there an age limit for recipients?
17. As the recipient, how much work can I expect to miss? How about my partner and our donor?
18. What is the nature of the legal contract you have with the donor (and her partner)?
19. What is the nature of the legal contract you will have with me and my partner?
20. What is the nature of the legal contract between the donor (and her partner) and me and my partner?
21. Do you require psychological clearance with the donor and ourselves before the procedure?
22. Will you recommend a counselor for us if you don't provide counseling as part of the program?
23. Are other couples available to talk with us who have been through the process of IVF with donor eggs, and who have had both successful and unsuccessful cycles?
24. Will you arrange for our donor, if desired, to talk to other donors who have been through your program?
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Recruiting Donors
Attitudes about donors, accessibility of information about the donor, etc. vary widely from clinic to clinic. The following are some questions to consider when choosing a clinic. See also "Questions for Recruited Donors who are willing to meet with the Recipient Couple," as sample questions to ask a clinic about a recruited donor (whether known or anonymous) in order to elicit more specific information about the donor and her history.
1. Does your clinic have a pool of recruited donors?
2. If you don't have a pool of donors, do you work with a third party broker to recruit donors? Are they patients undergoing IVF with extra eggs who are willing to share them, or are they other women recruited through word of mouth or the media?
3. Do you offer several third party broker sources or do you have a contract with one third party broker?
4. Will you assist us in recruiting our own donor?
5. What is the age range of your recruited donors?
6. Will your donors be anonymous, or will they be known to us? What is your rationale for this policy?
7. If your general policy is to recruit only anonymous donors, are you open to recruiting a donor we can meet?
8. How accessible is the donor's pertinent medical history to the recipient couple? How long do you keep the records?
9. If your donors are known, do you accept relatives and friends of the recipient couple into the program?
10. Do you accept donors recruited by a third party broker?
11. Do you allow the donor and recipient to remain anonymous if they desire?
12. What is your screening process for recruited donors? Is the screening similar or different with relatives, friends or third-party recruited donors?
13. What does the screening process entail? Does it include medical, social, and psychological history, as well as lab tests and physical examinations?
14. Who performs the screening?
15. How do you know a new donor will stimulate adequately?
16. How long do we have to wait for a recruited donor?
17. What kind of flexibility do we have in selecting a recruited donor? Can we choose from a file of donors? Can we see pictures, or read a short history about each prospective donor?
18. Do you have recruited donors who have proven successful in being stimulated to provide follicles and resulting ongoing pregnancies?
19. Are your recruited donors required to carry and be covered by their own health insurance to cover any unforeseen medical problems that result from ovarian stimulation and/or retrieval?
20. Do you work with sperm banks or have sperm donors recruited to provide donor sperm if there is a male factor?
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Costs:
What are the costs for the:
1. Initial consultation
2. Donor recruitment and screening
3. Donor reimbursement
4. My and my partner's screening
5. Prescription drugs for the donor
6. Prescription drugs for myself
7. Ultrasounds and blood tests for the donor
8. Retrieval of the oocytes
9. Gamete lab
10. Transfer
11. What are the costs for freezing and storing embryos? If the embryos are frozen on different days, do we pay for each time the embryos are frozen?
12. What is the charge for embryo thawing and the subsequent transfer?
13. How do you bill my insurance company? In my name for all procedures for both the donor and myself, or in both the donor's name and my name?
14. If needed, will you bill my insurance separately for the different procedures?
15. How much of the payment is required before the procedure? How much is refunded if the donor stimulation cycle is canceled before the oocytes retrieval or before the embryo transfer?
16. Will you help us work with our insurance company?
17. Are there any other costs associated with this procedure that we have not discussed?
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This information taken from:
RESOLVE National Office
RESOLVE of Northern California
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Infertility Resources
Developed and maintained by Internet Health Resources
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Authors: the Howlands and D. Pettee and his wife
First posted 1/1/96
Updated 1/1/96
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Copyright 1996 RESOLVE, Inc.
Back to Top of Questions
Finding an Egg Donor
This area, like much of egg donation, is largely uncharted territory and preferred methods vary from one person to another. Using one's judgment and comfort level are the best guides. There are a variety of ways to identify egg donors.
a) Through your fertility clinic or RE's office. Programs offering DE usually have their own lists of donors. Waiting lists vary significantly from 0 to many months. Donors are either anonymous or "known" meaning you're using your own. Clinics vary in their rules about their donors remaining anonymous. Some allow pictures, some baby pictures, and other require total anonymity.
b) Donor egg brokers. These are independent persons, usually with a nursing, law, and/or counseling background who screen applicants, advertise, and set up fee structures for people seeking donors. The information provided varies, but usually includes a detailed medical/social history including family background and picture.
c) Family member or friends. People sometimes seek the assistance of a sister, cousin, aunt or other family member, or even a friend.
d) Personal advertisements in local newspaper, entertainment weekly, or college newspaper.
The following information provides some tips for finding donors and things to consider during and after your search. The information is directly from the RESOLVE of Northern California web site, www.ihr.com/resolve/nchome.html.
How To Choose a Third Party Donor Provider
Article provided by RESOLVE of Northern California
The doctor you have chosen may not provide donors, or you may have very specific requirements in a donor. You can use the services of a third party donor broker or provider. This is a very new service and there are no licenses or degrees required and there are no legal guidelines to determine what a donor broker should or shouldn't be required to do when matching donors and recipients. Here are some common guidelines and questions to ask that may make your search more effective:
1. What is the fee structure for the provider's services? Do you have to pay a fee up front? Is the fee refundable if you change your mind about a donor or don't want to work with any of the donors currently on file? What do all the fees cover? Do you have to pay a separate fee if you don't want to work with any of the donors currently on file and the broker needs to advertise? How long and how much effort will the broker put into finding a donor with specific characteristics? Does the broker charge differently if you pay cash, check or credit card?
2. What is the fee for the donor herself? Can she set her reimbursement herself? If she has provided eggs before has her price remained the same or gone up? If the recipient pays the donor's expenses, does the broker provide an itemized list of expenses?
3. What kind of screening does the donor need to have? What is the psychological screening and who performs it, the broker or a third party? Is there an extra charge for psychological testing (i.e. MMPI)? Can you see the results of the testing? Can you have the donor tested by a third party of your own choosing?
4. What kind of medical screening has the donor had? Who will do it if you choose a donor? Is the medical screening included in the cost or is it separate? Has the donor has a 3rd day FSH level blood test done? The FSH level gives an indication of how well a donor will stimulate with fertility drugs.
5. Does the broker facilitate a meeting between you and the donor if you wish to meet? Does the broker provide anonymous, known donors or both?
6. Does the broker work with the donor during the actual cycle and in what capacity? For example, the broker can get the donor's daily estradiol level from the doctor's office and then pass the information on to you.
7. What kinds of records and information are kept on anonymous donors, where and for how long? There may be some reason in the future to contact an anonymous donor.
8. What does the broker do to ensure that a donor hasn't donated too many times before in terms of resultant offspring? If the broker has screened someone out as a donor, does the broker provide this information to broker colleagues and/or recipient clients if they ask about this potential donor?
9. What is the legal contract the broker requires the recipient(s) to sign? Does the broker require that the recipient work only with him/her?
10. What is the legal contract the broker requires the donor to sign? Is the donor required to work only with that broker for any specific period of time? Has the donor worked with other brokers?
11. How long has the broker been in business under the current name or a different name? How many donors has the broker matched with recipients in a year? Out of the number of donors matched how many stimulation cycles, how many retrievals, how many pregnancies and live births have resulted (multiple fetuses/births count as one)?
12. Does the broker have recipient references? Is the broker on RESOLVE of Northern California's referral list, for how long? If not, why not? You can call the TAP network to find out more information too.
13. Does the broker keep a medical record of each stimulation the donor has done? Can you see her protocols? If not will the donor release her medical records? Specifically, how many ampules of Pergonal and/or Metrodin did the donor need, did she stimulate easily, how many mature and immature follicles were produced at the time of retrieval, how many eggs were retrieved, how many eggs fertilized and was there a male factor, what were the number and quality of embryos?
14. If successful pregnancies have resulted, in what general geographic area do the recipients currently live?
15. Does the donor broker help the uninsured donor find medical coverage?
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RESOLVE National Office
RESOLVE of Northern California
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Infertility Resources
Developed and maintained by Internet Health Resources
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Author: L. Howland
First posted: 4/30/95
Updated: 11/30/95
Copyright 1995 RESOLVE, Inc.
Back to Top of Questions
Questions to Egg Donors
This article is divided into several sections:
- General Questions for A Known Donor Whether Recruited, Friend or Family Member
- Specific Questions When the Donor is a Friend or Relative
- Specific Questions For a Recruited Donor
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General Questions for Either a Relative or a Recruited Donor:
Depending on whether the donor is a relative or friend, or a known recruited donor, there are a number of general questions that might be considered by a recipient couple.
1. Why do you want to participate in egg donation?
2. Why did you choose to be a known donor?
3. What are your feelings about being available in the future for the baby?
4. What are your expectations about how a child born would be raised?
5. Does it matter if the prospective parents are married?
6. Does it matter if I (as the recipient) am single or a lesbian?
7. What do you imagine how you will feel if the procedure does not succeed?
8. Are you aware excess eggs may be fertilized and may be frozen as embryos?
9. Do you expect any legal relationship with the baby?
10. What are your expectations, if any, around receiving a fee for your participation?
11. Are you willing to participate a second time if we desire siblings for our child, or if a pregnancy didn't result from the first transfer?
12. How do you feel about our decision to give embryos to another couple or make them available for scientific research?
13. Do you have any children of your own? How many do you have, and what are their ages?
14. Are you willing to participate in a counseling session with us to discuss relevant concerns? Are you willing to continue counseling indefinitely if the need arises?
15. Are you aware that you will need to sign a legal agreement detailing your willingness to sacrifice all parental claim or responsibility?
16. Do you have health insurance in the unlikely event of post-surgical complications?
17. Have you had the opportunity to thoroughly discuss the risks associated with the procedure and the medication?
18. If you have a husband/partner, how does he feel about your interest in donating eggs?
19. What is your understanding of the medical procedure that will be involved to stimulate your ovaries with medication and retrieve eggs?
20. Who will be your support person during the intensive weeks leading to the egg retrieval? Who will give you your injections?
21. Are you aware that we may have multiple pregnancies? How do you feel about this possibility?
22. Are there people with whom you have shared your interest to be an egg donor? If there were any, what were their reactions?
23. What are examples of intensive, complicated projects you have chosen to be involved in? What did you learn about yourself?
24. Why do you think you would be a good egg donor?
25. What do you believe your strengths and weaknesses are?
26. Do you have any ethical or religious viewpoints which might affect your decision to be an egg donor?
27. Can you accept the unlikely prospect that we might choose or need to abort a fetus?
28. Do you know anyone who has donated her eggs? Or who was a sperm donor? What was her or his experience?
29. Do you consider yourself to be a responsible person?
30. Where did you learn about this opportunity?
31. How do you feel about the possibility that embryos may be frozen for a long time, perhaps for years?
32. What are your feelings about selective termination or selective reduction?
33. Are you aware that the legal issues surrounding egg donor IVF and parental rights have never been established or challenged in court?
34. Are you aware that there is a possibility that a successful pregnancy from your donated eggs might be referenced in an article in the medical literature?
35. Do you want publicity about your decision to donate eggs if the possibility arises?
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Specific Questions When the Donor is a Relative or a Close Friend:
It is presumed that any donor who is a relative or a close friend will not be a real stranger to the recipient couple. Consequently, the questions do not need to be as expansive as with a recruited donor.
1. Is there anything significant about your relationship with your relative that contributed to your decision to donate eggs?
2. What do you imagine are the concerns associated with donating eggs to a relative?
3. How do you imagine your relationship will change by donating eggs?
4. How does your family feel about your decision to donate eggs to a relative?
5. Who will know about this decision and who will not?
6. If you have decided to keep this private, how do you expect to handle an unplanned disclosure?
7. If you have a husband or partner, how does he feel about the possibility of a baby born of this procedure? Will he participate in counseling if requested?
8. Have you discussed with your partner the risks associated with this procedure and with the medication you must take?
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Specific Questions for Recruited Donor Who is Willing to Meet with the Recipient Couple:
1. Does your family have a tendency towards any particular illnesses, i.e., allergies, intestinal problem, cancer, heart disease or psychological problems? Who had one or more of these illnesses, and at what age did the onset occur?
2. Are your blood relatives living, i.e., parents, siblings, grandparents, aunts and uncles? If not, how old were they when they died, and what did they die of?
3. Have you or any member of your immediate family ever smoked, drank or used illegal substances? To what extent are any of these, or have any of these ever been, a problem?
4. Have you ever been pregnant? What was the outcome?
5. Have you ever donated eggs before? If you have, how many follicles developed? How many eggs were retrieved? How many successfully fertilized? Was there a resulting pregnancy, multiple pregnancy, and live birth(s)?
6. What can you tell us about your family of origin? Who are they and what are their ages? What are their vocational and avocational interests, hobbies, talents and dispositions? What are their physical characteristics such as coloring, size, weight and height?
7. Do you have any children? If yes, how old are they now? When did they learn to sit up, walk and talk? Were there and are there any significant health issues we should know about? What are their sleeping and eating habits? What are their special abilities and interests? What was their birth weight and length?
8. If you don't have children, why do you want to help us have a baby using your egg(s)? Have you considered the unlikely circumstance where at a later date you might be unable to conceive?
9. What is your family's genealogical heritage or history? What country(s) did your ancestors come from, where did they settle here, and when?
10. Why do you want to be a donor? What do you think you will get out of it? If you have already donated, what did you get out of it?
11. If we get pregnant, will you tell your family members including your children? If so, how will you tell them, and when? Would you want your children to know that our child would share half of their genetic heritage? How will you handle their questions?
12. May we see or have pictures of your family, siblings and children? If we desire, may we meet with your immediate family, including your children?
13. Have you thought about how you'd feel if, after all this interaction and sharing, we don't get pregnant?
14. Have you thought about whether you would like any ongoing contact such as pictures, phone calls or meeting the child?
15. Is your job or school situation flexible enough to do this procedure? Do you have child care available, if you have children?
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Refer to: "Minimal Genetic Screen for Gamete Donors," Fertility and Sterility, Supplement 2, Appendix B, Vol. 53, No. 6, June 1990, pp. 885-895.
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RESOLVE National Office
RESOLVE of Northern California
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Infertility Resources
Developed and maintained by Internet Health Resources
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Authored by: the Howlands and D. Pettee and his wife
First posted 1/1/96
Last Updated 1/1/96
Copyright 1996 RESOLVE, Inc.
Back to Top of Questions
Known Donor vs. Anonymous Donor
Many of the decisions we face when doing IVF with donor eggs can be based on numbers: hormone levels, sperm counts, success rates, number of follicles, classification of embryos, etc. When we come to the question of whether to use a known or anonymous donor, however, things are not so quantifiable. It is an extremely personal, individual choice. For example, some people feel that knowing a donor intimately gives them a sense of control over the procedure; others get a sense of control by having as little contact as possible with the donor. Some people find the choice immediately obvious one way or the other; for others, choosing can be a difficult process. The following list of questions may help you focus your thinking when trying to decide which type of donor is right for you.
For the purposes of this list, donors are defined as follows:
"Familiar donor" is someone you know already such as a relative or friend who has agreed to be your donor.
"Known donor" is one you've chosen from a list, and you have agreed to at least one meeting. This option is not available at all clinics or in some countries. It's more common in the western USA.
"Anonymous donor" is one you've chosen according to her listed characteristics, or that the clinic has chosen for you based on their assessment. You may have access to a picture of her, but you are in agreement that you will not meet.
* Choosing a relative to be your donor provides you with the ability to contribute some of your family genes to the child. Usually you know the details of such a donor's family health history and genetic makeup. You and/or your child may see this person frequently and some type of relationship between the child and the donor will have to be forged. The closeness of that relationship will vary from situation to situation, but it is something that will need to be dealt with.
* With a friend as a donor, although you have given up the genetic link, you are able to choose someone whose characteristics are well known and appealing to you. You may already know or be able to learn her detailed family history and ethnic background. The same is true to some degree with a "known" donor. Again, in both cases, the donor's future relationship with you and your baby is an issue to be addressed.
* An anonymous donor appeals to those who do not wish to have any relationship with the donor once they become pregnant. For some, this is a way to avoid a constant reminder that the baby has a connection to someone else. Choosing this option usually means you will have less information about the donor and her family history, or perhaps no information. You will have to decide how important such information is to you.
QUESTIONS TO CONSIDER:
Do you want ongoing contact with a donor? To what extent? Birthday cards? Structured, occasional visits? Call or drop by any time? "Part of the family?"
Do you want a loving, mutually supportive relationship with a donor?
Do you want the donor to be someone your child can rely on in the future?
Do you want a warm, friendly initial meeting(s) with a donor before transfer, and little or no contact afterwards?
Do you prefer to think of contact with a donor as a one-time transaction, rather than any kind of relationship?
If you choose a relationship, yet with a limited degree of contact, can you maintain the "boundaries?" Are you willing to be flexible if, over time, the donor wants to be closer, or becomes more distant?
Does your clinic have a long waiting list for donors? Would a Familiar donor eliminate the wait? Are you willing to travel to another city for a shorter wait for a Known or Anonymous donor? Note: Sometimes a clinic with a long waiting list (i.e. a donor shortage) will put you on the top of their list for an anonymous donor if you bring a donor (commonly a Familiar donor) to their program.
Do you want the donor to be with you for the transfer? Birth? What about baby showers, baptism, bris, first birthday, and the like?
Will your donor be available in the future for another cycle? What if this one fails, or you have no embryos to freeze? Will you want genetic siblings for your child in the future?
Familiar: How will your current relationship be affected by the donor relationship?
Familiar: Will she undergo psychological testing/counseling before the procedure? Will you? (Note: clinics/brokers usually provide psychological screening of their donors as a mutually beneficial requirement of their program. They may advise the same for a Familiar donor, even though you already know something of her personality.)
Familiar: How will it affect your relationship if her commitment falls through, or if her ovaries don't produce? (Note: sometimes doctors are not able initially to select the best stimulation protocol for a first-time donor. Would you both be able and willing to try again?)
Familiar: There may be future gatherings of mutual friends or family where you, your child, and your donor would be present. Would you be uncomfortable with that?
Familiar: Can you, the donor, and your partners agree about whether/when to tell other family members, friends, the child?
Familiar: Are there existing family jealousies that may come into play?
Familiar: Would your costs be different than if you choose from a list of donors?
Known/Familiar: What happens if you feel you must terminate a pregnancy, for example in the case of chromosomal abnormalities?
Known/Familiar: If you have older children, in what way will they be affected by this new relationship?
Known/Familiar: Do you/will you have a comfortable relationship with the donor's partner and children, if any?
Anonymous/Known: Will you want and have access to the donor's continuing health history?
Anonymous/Known: How would you feel about your child's physical resemblance to the donor, if any? Would your feelings be different with a Familiar donor?
Anonymous: Are you comfortable allowing your doctor/nurse coordinator/broker to choose a donor who is a "perfect match" for you? How much detailed knowledge of a donor's characteristics do you require? Would you prefer to "be surprised" by your child's unique talents and traits?
Anonymous: Would you want to correspond with the donor, with your clinic or broker as intermediary? More than once? After the transfer?
Anonymous: Do you want to see a photo of the donor?
Anonymous: If you don't see a photo of your donor, will you ever wonder what she looked like? If you do see a picture of her, will she be less anonymous to you, more of a presence?
AND REMEMBER: While this decision looms large once you've decided to go ahead with DE, the identity of your donor is likely to be less of a presence in your thinking as your pregnancy progresses and after the child is born. Many women with anonymous or known donors have said they thought of their donors rarely as time went on after a successful embryo transfer.
Back to Top of Questions
Giving Up Your Genetic Link
For some women, one of the most painful experiences in moving to the DE process is giving up your genetic link. Some Dear Husbands (DH) find sadness in giving up the genetic link to the wonderful women they married. This is an accumulation of responses from MVED members on how they moved through this difficult emotional issue. Some women offered processes they used to move through their grief and others offered realizations that led them to accept, then rejoice in DE. We sincerely hope that you find something here that speaks to you.
* When we went into the DE process, our clinic had us visit with a therapist who specialized in infertility issues. This was just after having our last failed IUI with my eggs. It was emotionally wrenching and stressful. Some days I wanted to scream at the injustice of having to move on to DE. The counselor suggested that I keep a journal of my thoughts and feelings on the subject. In addition, she suggested that I allow myself one hour or some specified amount of time every day (you pick the time) to focus on the infertility issue...what it meant to lose the genetic link and the other related issues. She felt that rather than obsess about it all day it was better to allow myself time to focus on my thoughts about the situation-to give myself permission to actually grieve. In the meantime, I also found MVED. The combination did wonderful things for me. I was finally able to move out of my "mourning" period and put my energies into the DE process.
* I focused on the downsides of a pregnancy with a mature-aged egg. The rates of so many conditions in pregnancy go way down as the egg age goes down. Reduced egg age is something I could never offer our baby, but DE could. I focused on that thought. My RE felt VERY strongly about egg age and the integrity of a pregnancy. It really helped me.
* For me it never mattered. It does, however, matter to my husband. He wants a genetic child. I've been thinking about this and I think the reason it never mattered is that in our family we didn't think genetic. If you married into the family, you were a member. Even if your spouse died, you were a member. Even if you divorced, you were often still a member.
* I'm fortunate to live in a high population area (Northern California) and was able to get into a Resolve support group specifically for DE. We had a counselor lead the first 8 meetings with 5 couples. After the 8 counselor led sessions, we decided to continue meeting. It's been tremendously helpful to have others to lean on and learn from. By listening to the other couples' sadness and concerns, my DH and I were able to give words to our own feelings, and really open up and talk about what this meant to us, and how we felt. With the help of this group and counselor, I got to suppress my embarrassment about my inner fears, and express my concerns that my husband and his family would have more rights with a DE baby than I would. And once I got that out, I was able to deal with my fears and discard those thoughts. The fears sound silly to me now, but they were very real at the beginning of this journey.
* A counselor suggested this one and it really worked for me. Grieve the loss of your "dream baby" by getting out your baby and toddler pictures. Put them around your family room and every time you look at them grieve for the loss of your genetic connection...of that "dream baby" that will never be. Sometimes just look longingly at those pictures, and sometimes just cry. I did this for I don't know how long, but I'm finished grieving and they are back in the drawer. You can add your DH's baby and toddler pictures to the process.
* I am a VERY optimistic person - I have two children from a previous marriage (I was 20 and 23 when I delivered them!), and my face and body do not give my age away, so I was very confident that I would get pregnant. But the more I read, and the more I talked to different doctors, and the longer we tried without becoming pregnant, I began to realize that my optimism could keep me from ever having a baby with my new husband (who has no children). So I asked myself, "Are you that optimistic that you are willing to give up ever having a child again?" I decided no, and jumped into DE full speed ahead (my husband and I continued trying on our own as everything is still working). I am very excited as we continue on our DE cycle.
* Giving up my genetic link has been a struggle for me too. It helps to remind myself of that beautiful saying that our children come "through" us, not "from" us - that is, they are separate people whom we parents spend 18 years letting go of anyway. (As the parent of a teenager conceived naturally, I am well aware that the child becomes very separate indeed!) Also, it helps me to remember that we are all interconnected in the universe, so any woman who chooses to donate eggs is really not all that different from me and my family. The gifts she provides through her eggs may be different from what I would provide through my own eggs, but they are valuable nevertheless.
* As an adoptee, I have learned that there does not need to be a genetic link to pass on "parts" of one's parents or grandparents. I am my mother and father's daughter in so many ways that it is eerie sometimes. So much of what we are as humans is NOT genetic, yet we often focus on that connection because society has conditioned us to think in terms of "having Dad's nose." I have my mother's knack for managing finances well and her love of family and tradition. I have my father's old-fashioned work ethic as well as his kindness and compassion for others. My sister and I are not genetically related but we use the same gestures and share so many mannerisms that people can tell we are sisters despite the fact that we do not look like we are related. The point here is that we are all products of the people that raised us and they are products of the people that raised them. As the parent of an adopted son and a DE son, I am passing on a little bit of my parents to them. What made my parents the incredible people they were is not lost just because there is no genetic link.
* DE is a very, very wonderful option and I thank God that it's available because it is my only hope in having a child. I just can't help but feel sad because my Father passed away unexpectedly this past May and I would have loved to have had a child with a little part of Dad mixed in. He was an incredibly caring and wonderful man. If he were still here, he would have encouraged me and would have loved the child just as much, genetic link or not. I know in my heart that if I am lucky enough to succeed in having a baby that I will still look for any similarities. Who knows, maybe my baby will be "heaven sent."
* How did I come to terms with the loss of my genetic link? I suppose, in part, it is a matter of looking at options: Adoption was one option we were seriously looking at last spring before we decided to try DE "one last time." In fact, we were looking at Chinese adoption and had begun the process. However, once the process was under way, I found I was having trouble visualizing the outcome. I hate to admit it, but I just could not "see" myself with a Chinese daughter. That was losing too much of the genetic link, for me. Something inside of me "snapped" around that time and I decided I had to try DE again. My husband had been supportive of the adoption but he "lit up" when I told him I was thinking of trying again. I knew he wanted a genetic child and I also knew I wanted to try to give birth to a child that was automatically ours. I wanted a process that did not require 6-12 months of paperwork, FBI fingerprints and home visits to qualify. (It was frustrating for us when we realized what a happily married, educated, middle class couple has to go through before they can qualify t o adopt a child. It doesn't seem "fair".) Of course, I looked for a donor that resembled me, both from a physical standpoint and a personality standpoint. I feel very lucky that I found such a donor. I learned that when we choose donors who look like us and have similar ethnic backgrounds (or in some cases are actually related to us) we have to be honest with ourselves. We need to realize that we are holding onto something like a genetic link - we are not really giving it up entirely. However, this argument can be made for anyone who decides to have "biological" children (however the biology comes about). The urge to further your own heritage/line is stronger in some than in others, I suppose. After years of infertility treatment, I think the urge for some of us just gets stronger. DE is as close as we will ever come to NOT losing the genetic link. Therefore, can we say that we have given it up if we are pursuing DE? I don't think we can say so honestly. As mothers, we have certainly given up our own, personal, genetic link. But we are still furthering the link that is represented by the donor who has our coloring, has our ethnic background and, in many cases, shares our values...and, of course, if the DH is the sperm donor as well, his genetic link remains "intact." I have this sneaking feeling that, once I give birth, I will learn that this "genetic link" stuff I have been grappling with is much less important that I once thought. Those of you out there who have adopted already have said it very well. It just doesn't matter - once the child is in front of you and you see that this child is an individual. From a logical standpoint, I know that had we gone through with the Chinese adoption, we would have been happy with the outcome. However, in the meantime I am happy that I am getting the chance to go through a pregnancy, that my husband will be the genetic father, and that I will have a daughter (yes, we know the sex already) that resembles me (at least somewhat). But most importantly, I am happy that, after all these years, it appears we are actually going to be parents!
* We have a 3-year-old through adoption and are pursuing DE with a cousin donor. Building a family despite infertility is a very personal thing and choices should never be dictated by society or social workers as "socially responsible." We did not adopt to be socially responsible - we adopted to be parents and that situation felt right for us personally. We had pursued adoption in China at the same time as we pursued adoption in Canada. We were presented with a possible adoption scenario about 2 months before our actual adoption and it was a situation (not based on race) that made us quite uncomfortable. The social worker flipped out on us and told us that we were possibly not candidates for adoption. That is not how we felt at all. When our son was born and presented to us - nothing could have felt more right in the whole world. Now our DE situation also feels very " right" for us. Infertility takes many things from us - but it also asks many things of us. I think feeling that we are making the choices that are right for "US AND OUR FAMILY" is so important because that means we are listening to the voice of our soul and thus the voice of God and what he ultimately WANTS for us.
* I have struggled with the loss of the genetic link, but the following rationalization has helped me:
1) If ED succeeds, I will get 2.5 out of 3 - 1 is the desire to parent, 2 is experiencing pregnancy, and 3 is passing on your genes. With ED you get 1 and 2, and half of 3 (at least in my case), since the husband still throws in his genes. In terms of the other half of 3, I feel my donor resembles me quite nicely. My background is German and Swedish, hers is Scottish, Dutch and Italian. Well, Scotland and Holland are Northern Europe, so that covers Sweden. My father is Bavarian, which is in the South of Germany, so Italy covers that part!
2) One of my closest friends said to me once, that "passing on your heritage" is not just about your genes, but the way you raise your children. It's the stories you tell them, how you keep them connected with their ancestors, etc. (telling them about Sweden and Germany, teaching them those languages etc.). I am less and less unhappy about ED. I am so comfortable with my donor that she almost feels like relative, although I have never met her (and most likely won't, our choice and hers). I think once you have that baby you almost start forgetting where he/she came from, because they could not have come into this world without you!
* My mother, a genealogist, without knowing that I'm even considering DE, sent some e-mail to me this past week informing me that she and dad are 9th cousins once removed. This occurred by virtue of the fact that they are both direct descendants of some very famous Mayflower pilgrims. This makes my siblings and I cousins; we are our parents' cousins and our own children's cousins. Family trees are amazing. We are all related somehow. Direct genetic link or not. It's there! Even if it is 10 generations or more.
* I was thinking again about the genetic connection issue and decided that despite the lack of genetic connection, we MVEDs are more mothers of the child that anyone else could be. After all, we are the ones who decided to create the child! We paid for its complicated conception, we suffered all kinds of agonies over months and years with IVF, we drained our savings, we mortgaged our homes, and we soldiered on in the face of numerous obstacles to create the child and give it life. The child's very existence on earth is due to us, to our wills, to our efforts and desire (okay, some doctors helped and so did a donor, but they wouldn't do it without us needling them and paying them!). Surely that makes us just as much the 'real mother' as any normally fertile young woman who found herself pregnant and decided to keep the child. And of course it makes us far more the 'real mother' than the wonderful women who agreed to be either a gestational surrogate or an ovum donor for us. And none of that is to speak about the raising of the child after its birth. Hence, I no longer have the slightest doubt or anxiety, when the child arrives (knock on wood I reach that point), it's mine and DHs and just let the nay sayers and puritan wackos and ethical crazies try and tell me different!
Back to Top of Questions
How Long Does it Take To Find a Donor?
Recipients find donors in one of several ways:
- a. through friends, siblings, other relatives (known donor)
- b. through the clinic (often an anonymous donor)
- c. through an agency
- d. over the Internet
- e. by advertising for their own donor
See "Finding a Donor" for more information.
Known Donor
Often people who use a known donor can find one right away, though there can be some wait while a sister or friend educates herself and decides if she is willing to be an egg donor.
Donor Recruited by Clinic
Using a donor recruited by a clinic can be the easier method to find a donor, but often takes the longest. Many clinics have waiting lists of 6 - 12 months, and sometimes longer. There are clinics that have immediate access to donors, but they tend to be more expensive. If time is of the essence, it is recommended that you call several clinics to determine what their current waiting periods are.
Some clinics do not recruit egg donors and do only shared cycles between IVF patients desiring reduced cost IVF and egg recipients. These clinics often have a smaller selection and a longer wait than the clinics with a specific program for recruiting egg donors. In countries where donors cannot be compensated, there is a donor shortage, which results in even longer waits.
Donor Recruited by an Agency
There are a number of agencies that specialize in locating and matching donors. These agencies generally have immediately available donors, although if a recipient is interested in a particular donor, there could be a several month wait.
Donor Recruited Over the Internet
Recruiting your own donor over the Internet can be a quick process, or it can take a number of months. This will depend on the quality of the donors who are currently advertising on the Internet and whether these donors meet your criteria for selecting a donor.
Advertising For Your Own Donor
Some people place advertisements for a donor in college newspapers or other publications that young women may read. This could involve several personal interviews and the time period for finding a donor could range from very quickly to not at all.
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Is There an Optimal Number of Times a Young Women Should Donate Eggs?
The answer may be three cycles, according to a group of New York researchers who presented their data at the recent annual meeting of the American Society for Reproductive Medicine in Cincinnati, Ohio, 1997.
In a study conducted at the egg donation program at the Mount Sinai Medical Center in New York, women who underwent a fourth stimulation cycle showed a significantly poorer ovarian response than they had during the first three cycles, according to Alan B. Copperman, M.D., director of infertility at the Mount Sinai Medical Center in New York. "The donors' ovaries responded equally well in each of the first three cycles," he said. "But the response was significantly worse when the young women were stimulated a fourth time." In four women who donated eggs four times, peak E2 was significantly lower in the fourth cycle (2,198 pg/ml Ò 687) compared with the first three cycles (3,070 pg/ml Ò 584). The incidence of ovarian hyperstimulation dropped to zero during the fourth cycle, as compared to a baseline incidence of almost 30%.
Infertility clinics often use the same donors over and over again because it is hard to find egg donors, and it is cost-effective to use the same ones repeatedly, according to Dr. Copperman. "You don't have to rescreen them genetically, psychologically or hormonally," he said. The absence of guidelines regarding the optimum number of times an egg donor should donate has led to a situation in which some clinics limit it to two cycles, while others allow an egg donor to donate as many as 10 times, according to Dr. Copperman.
The study results indicate that IVF centers using donors multiple times should analyze their data so that they can inform infertile couples using donor eggs of any potential decreased response of the donors, according to Dr. Copperman. "Until we analyze what's out there, we should be limiting the donors to three attempts," he said. In addition, there may be an association between the decreased ovarian response seen in the New York study and donors' future reproductive potential, the New York researcher added. "It's important that we make sure this is safe," he said.
G. David Adamson, M.D., director of the Fertility and Reproductive Health Institute in San Jose Calif., agreed with Dr. Copperman. "Because egg donation is still relatively new, it behooves us to be conservative and cautious in the protocols that we follow," he said. "I would support the recommendation for all programs pursuing egg donation to look at their own data to see if it supports the conclusion of this small study. It may be a consideration for collecting data on a national basis." --S.F.
Egg Donors Show Reduced Ovarian Response After Three Cycles [Medical Tribune: Obstetrician & Gynecologist Edition 4(12): 1997. (c) 1997 Jobson Healthcare Group]
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How Do Age and Prior Pregnancy Status Affect the Choice of an Egg Donor?
The American Society for Reproductive Medicine issued guidelines in 1997 that egg donors should be less than 34 years old. However, a recent extensive study suggests that this age should perhaps be lowered. Faber et al. (1997) (Jones Institute for Reproductive Medicine, Eastern Virginia Medical School, Norfolk) examined 568 DE cycles. They found that the previous birth record of the donor did not make a difference. The pregnancy rates and delivery rates with donated eggs were the same whether or not the donors had given birth previously or not. The age of the donor, however, did make a difference. They began to see a decrease in successful pregnancies beginning when the donor hit 33-34 years old. If the donor was less than 33 years old, the pregnancy rates in this study were around 45% and the delivery rates were 35%. If the donor was 33 or older, then the pregnancy rates dropped to 27% and the delivery rates dropped to 22%. So they recommended a cut-off age of between 32 and 33 years old. Note however, those of you might be considering older donors, the rates did not drop to zero. The top age of donors examined was 38 years old.
Reference:
Faber et al., "The impact of an egg donor's age and her prior fertility on recipient pregnancy outcome" Fertility and Sterility, 1997 68:370-372.
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Sample Egg Donor Contract:
This is a sample contract only. It is not endorsed by MVED and has not been approved by a lawyer. Your situation may be different in particular areas, but this contract should serve as a useful guideline for information that should be included in any such document. Many clinics have a contract of their own (which has been reviewed by their lawyers) for your use. It is always a wise idea to have your own attorney review any contract which you develop yourself. Oocyte Donor/Recipient Contract
Statement of the Parties' Intention:
I ____________________ (egg donor) and __________________ (husband/none)
desire to donate oocytes (eggs) to the prospective parents (names withheld to protect
anonymity). I hereby do voluntarily consent and authorize (name of physician) and the
(name of clinic or hospital), their officers, doctors, agents, employees, successors,
assigns, and the in vitro program personnel and associates to perform ovulation
induction and oocyte retrieval.
I (we) warrant that all written representations and information provided to
(name of clinic or hospital) and to any professional physician, physician's
assistant, nurse or embryologist or to the prospective parents are true, accurate,
and complete.
I (we) do not desire to have a parental relationship with any child born
pursuant to this agreement. Further, we believe the child to be morally and
legally the issue of the prospective parents.
______________________________________________________
Purpose of the Procedure:
The purpose of this procedure is to provide a means for the prospective
parents to achieve pregnancy.
______________________________________________________
Requirements of the Procedure:
I (we) represent that the following requirements for participation in this
procedure have been met:
* the oocyte donor is between age 18 and 35.
* the oocyte donor has some form of medical insurance, or
provisions for medical care via the prospective
parents and their health insurer.
I (we) acknowledge and agree that my ( our) acceptance into the program and
our continuing participation is at the discretion of (physician name).
The egg donor agrees to abstain from any unprotected sex and agrees to use
condoms at all times.
The egg donor agrees to adhere to all medical advice given related to this
procedure.
The egg donor agrees not to use any alcoholic beverages, not to use any
illegal drugs, not to use any prescription or non-prescription drugs, without
the knowledge and consent of (clinic or hospital name), commencing 28 days
prior to donating eggs.
______________________________________________________
Description of the Procedures:
I (we) understand that egg donation involves hormone injections to stimulate
the egg donor's ovaries and the removal of eggs from the donor's ovaries by
a needle and the fertilization of those eggs with the husband's/donor's sperm
in the laboratory. If fertilization occurs, the pre-embryos may be placed into
the prospective mother's uterus and/or cryopreserved. Subsequently, at the
discretion of the prospective parents, the resultant cryopreserved pre-embryos
may be later transferred to the prospective parents' uterus and may be
disposed of as the recipient mother sees fit.
I (we) consent to the following medical/surgical/diagnostic procedures:
Pre-IVF screening: determination by medical history and physical
examination that I am a good candidate for this procedure. Screening includes
a workup to rule out any venereal diseases or STD's including the AIDs virus;
Ovulation induction: the use of fertility drugs (usually pergonal, metrodin,
follistim, gonal f, lupron, humegon, and human chorionic gonadotropin (HcG),
to stimulate the growth and maturation of ovarian follicles (eggs) in the ovaries;
Laboratory tests: frequently, blood samples may be taken to monitor hormone
secretions from the ovary and the pituitary gland;
Ultrasound: this is a diagnostic procedure using sound waves to provide a
picture of the ovaries and the follicles to monitor the development of the
eggs and uterine lining;
Egg retrieval: the introduction of a needle into the ovary to obtain eggs.
This is performed with ultrasound guidance. A local anesthetic and/or
painkiller is used to minimize discomfort;
Fertilization: placing the eggs and sperm together in a suitable medium to
allow fertilization. If there is no fertilization after 72 hours of
incubation, the oocytes and sperm will be disposed of in an ethically
acceptable manner;
Embryo culture: development of the fertilized eggs and pre-embryo formation;
Embryo transfer: placement of the embryos into the recipient mother's uterus
by means of a plastic catheter inserted through the cervix into the uterus;
Cryopreservation: if there are more embryos than can be safely transferred,
the excess embryos are frozen for future use by the prospective parents.
______________________________________________________
Success Rate:
I (we) understand that no guarantees have been made regarding the success
of ovarian stimulation and the ability to perform egg retrieval.
I (we) understand that I (we) may not be informed of the ultimate outcome,
i.e., whether pregnancy and/or viable birth was achieved as a result of this
procedure, or any subsequent transfers.
______________________________________________________
Financial Consideration:
The prospective parents and their insurer will be responsible for any and
all medical costs related to complications which may arise as a result of
this procedure.
The egg donor will receive a total financial consideration of (insert amount)
for her expenses associated with participation in this procedure.
Payment will be dispersed as follows:
(Insert amount) to be paid upon the prospective parents receipt of this
signed/notarized document.
The balance of (insert amount) to be paid after egg retrieval, on the date of
retrieval.
In the event of the donor's voluntary withdrawal from the procedure, prior
to egg retrieval, the egg donor will be deemed responsible for all of her
medical expenses. A voluntary withdrawal by the donor, prior to retrieval will
also result in a forfeiture of all financial consideration.
______________________________________________________
Possible Risks and Hazards Associated With IVF/Egg Retrieval:
Potential fertility drug side effects: along with their intended benefits,
fertility drugs have a potential to cause side effects. The most common side
effect is hyperstimulation of the ovaries. Occasionally, abdominal
enlargement with symptoms of abdominal discomfort can occur.
Mild to moderate uncomplicated ovarian enlargement, sometimes accompanied
by abdominal distention, and/ or abdominal pain occurs in about 20% of those
treated with pergonal, metrodin, and HcG.
This is generally reversed without treatment within approximately 2 to 3
Weeks.
Severe ovarian enlargement, known as ovarian hyperstimulation syndrome, is
also a potential adverse side effect of therapy. This syndrome is characterized
by sudden enlargement of the ovary and an accumulation of fluid in the abdomen.
This fluid can also accumulate around the lungs and may cause breathing
difficulties. If the ovary ruptures, blood can accumulate in the abdominal
cavity. Complications of ovarian hyperstimulation syndrome can also include
a blood clotting disorder which can be life threatening. Fortunately, this
syndrome only occurs in about 1.3% of all patients. Treatment consists of bedrest,
correction of fluid imbalances, and the prevention and/or correction of blood
clotting disorders.
Other adverse reactions that have been reported with the use of pergonal,
metrodin, lupron, humegon, and HcG are: allergic sensitivity, pain, rash,
and swelling at the injection site, and ectopic pregnancy. Adverse reactions
with HcG have also been reported to include headache, irritability, restlessness,
depression, and fatigue. Patients taking lupron may experience hot flashes. I(we)
understand that we must report these symptoms immediately.
Blood tests may cause discomfort and a risk of developing a bruise or
infection at the injection site.
Discomfort may also be caused by ultrasound procedures.
During egg retrieval, there is also the possibility of bleeding, infection,
and/or injury to the bladder and/or abdominal organs. These complications can
require surgery and or other interventions. Infection
may impair future fertility of result in a loss of fertility potential.
If I (we) should fail to avoid intercourse during the period preceding egg
retrieval and for at least one week after, I may become pregnant.
______________________________________________________
Treatment Decisions:
I (we) understand that all treatment decisions regarding each step of the
procedure involved will be made by (insert physician name) based on his
independent medical judgment.
I (we) understand that the physician may decide not to proceed with the
procedures and I (we) agree to abide by his decision in this regard.
______________________________________________________
Legal Status Of Children:
I (we) understand that many legal issues surrounding the procedure have not
been resolved and the legal status of children born as a result of this
procedure has been widely debated. It is my (our) intent and understanding
that any children resulting from this procedure will be the legitimate
children of the prospective parents , and that neither I _____________ nor
my husband ever attempt to form a parent-child Relationship with any child or
children born as a result of this procedure.
I (we) accept egg donation as my (our) own act and acknowledge the
child(ren) so produced to be the legitimate child(ren) of the prospective
parents. I (we) waive forever any rights I (we) may have to claim such
child(ren) as mine (ours).
This agreement contains the entire agreement between the parties with respect
to the subject matter hereof. All agreements, covenants, representations, and
warranties, express or implied, oral or written, made by any party with respect
to the subject matter of this agreement are embodied herein. All prior agreements
and representations, of whatever nature, which relate to this agreement are
waived, merged, and superseded. This is a fully integrated agreement and the
terms and conditions of this agreement are to be governed by (insert state) law.
______________________________________________________
Medical Expenses In The Event Of Complications:
I (we) have been informed that if I should suffer any physical injury as a
result of this procedure, that all of the necessary treatment facilities will
be made available. We understand, however, that all of the payment for
medical care as a result of complications related this procedure will be the
responsibility of the prospective parents and their health insurer.
I (we) have also been informed that the prospective parents and their health
insurer, (insert name of insurance company) has agreed to cover the
reasonable and customary charges as well as all medically necessary
expenses related to this procedure.
______________________________________________________
Confidentiality:
We understand that unless otherwise compelled by law, the physician and his
associates will make reasonable efforts to keep information obtained about me
(us) during the course of treatment confidential.
I (we) agree that specific medical details may be revealed in professional
medical publications so long as confidentiality is maintained.
I (we) also agree not to disclose the identity or any other identifying
information about the prospective parents without their consent.
______________________________________________________
Indemnification:
I (we) do hereby agree to indemnify and hold harmless, (physician name)
And the (name of clinic or hospital) and all of their respective employees
and agents, from and against any and all such actions, claims, costs, and
liabilities, including but not limited to attorney's fees, court costs,
damages, settlements, compromises, judgments, and any other losses or
expenses they incur or for which they may be responsible with respect to
any claim or legal action arising out of egg donation.
______________________________________________________
Arbitration:
Any and all disputes arising under or relating to this agreement, shall be
first submitted to the prospective parents' health insurer for resolution
and mediation.
If the parties are unable to resolve their dispute, then the parties may
submit their claims to binding arbitration. The arbitrator shall be an
independent third party as agreed to by the parties or shall be appointed by
the laws in accordance with the state of (insert state name).
Said arbitrator, in his or her discretion, shall be authorized to award costs,
including attorney fees to the prevailing party.
______________________________________________________
I (we) acknowledge by the signatures below that I (we) have read this
instrument and that all questions I (we) have been answered to my (our)
satisfaction. I (we) understand the answers to my (our) questions and
acknowledge that I (we) have received a copy of this informed consent document.
_______________________________________________________________________________
Donor signature Donor husband's signature/none.
Date:_______________ Date:__________________
______________________________________________________________________________
Witness Witness
Date:_______________ Date:__________________
Notary Seal:
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Should I Give My Donor a Gift?
Many of our MVED members did decide to give their donor a gift. They felt that donors like to be recognized as the compassionate women they are, donating to help an infertile couple achieve a pregnancy that they could not otherwise achieve. The donors take a number of medications, then go through a surgical procedure to have the eggs retrieved. This requires a sacrifice of their time and a small risk to their health. While it is true that they are compensated for their time, we all like a "thank you" and a pat on the back for a job well done. Typical gifts might be flowers in the recovery room, a card or letter telling you how important her contribution is to you, a charm for a necklace, or something else special. It doesn't have to be expensive, just a token of appreciation.
Some MVED members chose not to give their donor a gift, preferring not to establish any emotional connection with their anonymous donor.
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Money-back Guarantee Programs
In an effort to expand the options for infertility patients, some clinics offer a money-back package. These are called such things as Warranty, Shared Risk, and Refund Programs. The idea is that a couple can undergo a Donor Egg cycle at a fixed rate, with a guarantee that part or all of the fee will be refunded if the cycle is unsuccessful. In most cases, couples are eligible to use the Program for up to 3 attempts. The Programs are usually not available to people with insurance coverage. The bill is not itemized, and cannot be submitted for reimbursement.
The fee for a complete cycle with these Programs is significantly higher than a standard single IVF cycle. They range in price from $13,000 to $20,000, with the refund being anywhere from 80% to 100% of that fee. The refund is given if no pregnancy occurs, a pregnancy is not sustained for more than 12 weeks, or there is no live birth - depending on each Program's guidelines. A complete cycle is considered to be a fresh cycle and however many frozen cycles are needed to use all embryos created from a single egg aspiration. A complete cycle is limited to a time frame of 12-18 months.
In order to participate in these Programs, both the Donor and the Recipient Couple must meet certain criteria. Usually, there is an age restriction for the donor. Most programs limit the donor age to 34 or 35, but some will go up to 45. Also, she must have normal Day 3 FSH and E2 levels. The Recipient Mother must have a healthy and normal uterus. The male must have adequate sperm production, or be willing to undergo PESA (Percutaneous Epididymal Sperm Aspiration) or TESA (Testicular Sperm Aspiration). Or, the couple can use Donor Sperm. Some Programs have you sign a contract agreeing to their terms, and some insist that you go through their screening process first.
A cycle fee usually includes the following: all IVF in-cycle medical monitoring, including ultrasounds and lab work (blood tests) for both donor and recipient; egg retrieval from donor, fertilization of eggs, and embryo transfer to recipient mother. Some Programs include an initial pregnancy test, and some cover cryopreservation and short-term storage of unused embryos (12-18 months). Also, these services must be given at the clinic offering the Program. If an outside Provider is needed to perform a service, e.g. IVIG or anesthesia for the donor, it most likely would be an additional charge.
In general, the fee does not cover: pre-cycle medical exams and lab tests, including hysteroscopy to examine the health of the uterus; fertility drugs; and ICSI or Assisted Hatching. However most programs will refund the cost of ICSI, and sometimes Assisted Hatching, at the same percentage as the flat fee refund. Also not included in the fee are the costs of Donor Agency screening and fees, and any egg donor and/or sperm donor fees. Any pregnancy-related treatments or genetic testing is not covered.
The money-back programs give couples the opportunity to participate in multiple IVF cycles at a lower combined price than that of numerous single IVF cycles. The "risk" to the couple is that if they become pregnant on the first attempt, they do not get any refund, and have thus paid a significantly higher fee than if they had done a "normal" cycle plan. Also there has been criticism of these Programs, suggesting that there might be more incentive for the clinic to devise a separate protocol for participants in order to raise their success rates. An example would be to transfer a greater numbers of embryos, which would also most likely increase the number of multiple births. In addition, by offering these Programs, the clinic is playing the role of both medical provider and insurer, which could be construed as a conflict of interest. It is important that you carefully research the Program you are interested in, and feel comfortable about the services you will receive. Also, fully explore in detail which services are included in the fee, and which are not, as well as what limitations or additional charges are added.
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Shared-Cycle Programs
A shared program allows a couple to share eggs, and share expenses, with another couple. Different clinics offer different options, but, generally the programs work like this.
There is usually a primary couple and a secondary couple. The primary couple is the first couple to choose a particular donor (or have that donor selected for them). They, then, must wait until another couple chooses the same donor (or is matched with that donor). The second couple then becomes the secondary couple. The resulting eggs will be split evenly between the couples. Usually, if there is an uneven number of eggs, the extra one goes to the primary couple. If the number of eggs retrieved is below a pre-set number, then all the eggs go to the primary couple. In this case, the primary couple usually becomes responsible for most, or all, of the donor expenses.
In some clinics, you are automatically a secondary couple if this is your first attempt, and become a primary couple on subsequent attempts.
There are also clinics that offer a flat 50/50 split on the number of eggs retrieved, no matter how many or how few are produced. In this case, all expenses are also split evenly.
There are some clinics now offering shared cycles with people undergoing IVF themselves who wish to share expenses. This is primarily women who cannot get pregnant for some other reason than because of their eggs. In these cases, the primary couple would be the couple undergoing IVF and you would be the secondary couple, receiving eggs only if there were a pre-set number produced.
Clinics differ in expenses, but most require a flat fee up front. (This fee seems to currently be around $10,000 at several of the clinics MVED'ers have used.) You would be responsible for your own medications. Rather than a flat fee, some clinics simply divide up all the donor's expenses between the two couples including donor fee, meds, monitoring and retrieval fees.
The advantage of using a shared program is that you can save considerably on expenses. The disadvantage is that, now there are three people to coordinate, rather than the usual two, and this leads to a greater chance that the cycle may be canceled for some reason.
Since this is a relatively new opportunity, some clinics are "learning as they go" and don't really provide any protection to you as a consumer. Therefore, it's important to ask questions and get their policies in writing. Try to anticipate things that could go wrong and ask what the outcome would be if that happened. Some questions you will need answers to...
1) Expenses: who pays for what and what are you still responsible for if you don't receive any eggs? What exactly is included in the flat fee you pay up front? The donor fee? Donor's meds? Your's and donor's monitoring?
2. Distribution of eggs: what is the minimum number that must be produced in order for a split to occur? Who gets the extra egg if there is an uneven number? How will the eggs be split up quality-wise?
3. What happens if you must pull out of a cycle?
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Cytoplasmic Transfer
This is an exciting new procedure which uses cytoplasm from a donated egg to improve the quality of the recipient's own eggs...thus allowing the recipient to retain her own DNA within the egg. The idea behind this process is to make your vintage eggs behave like a younger woman's egg and increase the chance of pregnancy/implantation.
A woman is a candidate for this procedure if she can be stimulated successfully. The recipient mom and donor are stimulated simultaneously and retrieval is performed on the same day, or within one day of each other. All eggs are prepared for ICSI. A sperm is drawn up into a needle, which then pierces the donor egg. A small amount of cytoplasm is taken into the needle, and then the donor cytoplasm and sperm are injected into the recipient egg as in an ICSI cycle. One donor egg can supply cytoplasm for two recipient eggs, usually, so there will be leftover donor eggs that can be fertilized and cultured as well.
The recipient mom can choose to have only her own genetic embryos transferred, or a combo of donor embryos and genetic embryos. The donor embryos can be frozen for later use.
With this procedure, the DNA of the donor is usually gone from the embryo by the 16th week according to the research done. Also, this procedure transfers mitochondria (which produce the energy for a cell to do all its activities) from the younger woman's egg to the older woman's eggs which have "tired " mitochondria. This is why women with old eggs either can get pregnant but miscarry early as their embryo doesn't have enough energy to keep growing, don't get pregnant at all as again their embryo doesn't have enough energy to implant in the uterine wall, or the eggs fertilize poorly.
The thinking is that for women with elevated FSH, a history of poor response or poor embryo development, there is a problem with the eggs that is probably related to the mechanical function of the cell. Since cytoplasm contains the equipment that makes the cell work, a "boost" from a younger woman's cytoplasm may help the flawed egg to divide properly. Although the nuclear DNA isn't transferred, there is DNA in the cytoplasm associated with mitochondria, and some RE's (including Jacques Cohen) are a little anxious about the implications of this procedure. The one live baby he reported about in his study was the genetic offspring of his patient, not the donor. There is a good essay about this topic at INCIID's fact sheets.
A few tidbits of info from MVED members:
(1) It is still in the experimental stages, so a clinic that is doing it is probably a good one
(2) It does not use the donor's DNA/genetic material, your embryos retain all your own DNA.
3) It can cost mucho bucks; it's an extra $5,000 at the Jones Institute in Norfolk.
(4) At Jones, you need at least to put out eight mature eggs to participate...reasoning behind this is that just as with ICSI, they can actually LOSE some eggs in the process (mistake, rupturing the egg, etc.) so they want a minimum of EIGHT to work with.
(5) It's generally offered to women over 35 or 40, using their own eggs, because younger women generally don't need that type of help.
This Cytoplasm injection is being done at quite a few clinics on the East Coast, Jones, St. Barnabas in NJ, Cornell in NY, GIVF in Fairfax, VA... It might be worth asking your clinic about.
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If I am over 45 years old, what problems can I expect with a pregnancy achieved through egg donation?
A recent article by Sauer et al., (1996) (Columbia-Presbyterian Medical Center and Univ. of Southern Cal), provides some answers to this question. All information in quotes ("text") is from their article. Items in square brackets are remarks by the author.
Sauer et al., (1996) transferred up to five pre-embryos per IVF-ET (egg transfer) patient into carefully selected women between 45 and 59 years old. They eliminated women with gross distortion of the endometrial cavity, abnormal treadmill stress (ECG) tests, diabetes, cancers, psychological instability and multiple sclerosis. The 162 women that passed the tests underwent 212 cycles where there was successful fertilization of donor eggs and 48.6% established pregnancies. Of the 212 cycles, there were 74 deliveries (34.9%). The rest were various types of spontaneous and clinical abortions. Out of the 74 deliveries, 45 were singletons, 24 were twins and 5 were triplets. The age of mothers who delivered infants was not different from those who failed to conceive. Of those who delivered, 38% had antenatal complications (28 out of 74 deliveries). These complications included preterm labor, hypertension, diabetes, pre-eclampsia, HELLP syndrome (haemolysis, elevated liver enzymes, low platelets), carpal tunnel syndrome, premature rupture of membranes, placenta previa, placenta acccreta. Only 5% (5/108 infants) of the delivered children had problems (growth retardation (2/108), Downs (1/108), ventricular septal defect (1), small bowel obstruction (1). There were no maternal or neonatal deaths.
According to the authors of this study, "Fertility potential decreases with advancing maternal age, and it is expected that most older women will be unsuccessful in their efforts to reproduce. Numerous reports document that advanced maternal age does not diminish pregnancy rates in women undergoing oocyte donation (Navot et al., 1991, 1994; Lydic et al., 1996). In fact, as noted by our present study, the implantation and pregnancy rates are the same in perimenopausal women as those rates experienced by younger women undergoing oocyte donation (Sauer et al., 1994). With proper hormone preparation, the endometrium retains its receptivity to embryo implantation, suggesting that the decreasing fecundity normally seen in older women is primarily due to ovarian rather than uterine factors."
"Medical and obstetrical complications occur with increased frequency in pregnant women of advanced reproductive age, whether the conception is spontaneous or assisted (Cnattingius et al., 1992). It is often difficult to determine if the observed increase is due to age alone or to other confounding variables such as pre-existing disease, obesity, parity and socioeconomic factors. Glucose intolerance clearly increases with age and may present as pregestational or gestational diabetes. This risk is further influenced by obesity. In a review comparing pregnancy in women over the age of 40 years with women under 30, Spellacy described a 4-fold increase in diabetes, complicating up to 7% of the pregnancies in the older age group (Spellacy et al., 1986). Similarly, hypertension also occurs with increased frequency, and advanced maternal age is associated with an increased incidence of pregnancy-induced hypertension (PIH). However, a significant proportion of this risk is based upon the presence of pre-existing disease or obesity."
Sauer discusses the fact that older maternal age has been reported to impact perinatal morbidity and mortality. However, other studies dismiss the association of age and complications when the pre-existing diseases and prenatal care are considered. Sauer says, "Information from oocyte recipients has not indicated an increase in neonatal morbidity or mortality. This may be attributable to the excellent health of women prescreened to receive donor oocytes, and the high risk obstetrical care with which they are provided."
"Recipients of donor oocytes experience a high rate of operative delivery [Cesarean section]. Many patients undergo elective induction of labour which is not always successful."
1. The high frequency of Cnattingius, et al., Delayed childbearing and risk of adverse perinatal outcome. 1992. JAMA, 268:886-890.
2. Lydic et al., Success of donor oocyte in in vitro fertilization-embryo transfer in recipients with and without premature ovarian failure. 1996. Fertility and Sterility 65:98-102.
3. Navot et al., Poor oocyte quality rather than implantation failure as a cause of age related decline in female fertility. 1991. Lancet 337:1375-1377.
4. Navot et al., Age related decline in female fertility is not due to diminished capacity of the uterus to sustain embryo implantation. 1991. Journal of Reproductive Medicine 36:839-845.
5. Sauer et al., Extending reproductive potential in the older woman. 1994. In: Lobo, RQ (ed), "Treatment of the Postmenopausal Woman: Basic and Clinical Aspects." Raven Press, NY, NY pp. 35-46.
6. Sauer MV, Paulson RJ, Lobo RA. Oocyte donation to women of advanced reproductive age: pregnancy results and obstetrical outcomes in patients 45 years and older. 1996. Human Reproduction, 11:2540-2543.
7. Spellacy et al., Pregnancy after 40 years of age. 1986. Obstetrics and Gynecology 68:452-454.
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Tests You May Be Required to Take
DONOR AND RECIPIENT:
Blood Studies
- Blood Type-RH (blood type and RH factor)
- CBC (complete blood count)
- Chlamydia Ab - tests for antibodies against Chlamydia trachomatis, a sexually transmitted disease.
- Cytomegalovirus (CMV) - is an infection is caused by a common virus. It is harmless to most people. CMV is a member of the herpes group of viruses. Most people catch CMV at some time in their lives. Most adults and children who catch CMV have no symptoms and are not harmed by the virus. The danger is if you get this virus in your 1st trimester it can severely deform the fetus. This is only a concern if you are negative for the virus, and your donor is positive. Currently, there is no research that shows a donor's egg can/has infected the recipient.
- Ranges in Elisa Units (for the Elisa diagnostic test)
IgG < 15 test is negative for IgG antibody
IgM <= .9 test is negative for IgM antibody
IgM .91 - .99 test is inconclusive, should be repeated
IgM >= 1.0 test is positive for IgM
- Hepatitis B (HBV, HbsAG, HcAb) - Hepatitis B is a highly infectious virus that attacks the liver. HBV is found in blood and certain body fluids of people infected with HBV, fluids such as serum (blood), semen, vaginal secretions, and saliva. It can be transmitted by contact with these fluids. The blood is tested for the presence of antibodies and antigens to the hepatitis B virus.
- Hepatitis C - Hepatitis C is a viral infection, which causes inflammation in the liver. Hepatitis C is transmitted by exposure to the blood of a person with hepatitis C or by sexual contact. The blood is tested for the presence of antibodies to the hepatitis C virus.
- HIV - serology test for the auto-immune deficiency syndrome (AIDS) virus.
- RPR - Rapid Plasma Reagent test used to test for Syphilis
- Rubella (Checks for antibody to German Measles)
Cervical Cultures
- Urea/Mycoplasma Urealyticum.
These are micro-organisms which are commonly missed because they cause no symptoms and are difficult to culture. The culture requires the use of a specialized transport medium. The organisms do not ordinarily cause infertility and are hardly, if ever, found within the uterine cavity. When present, they grows in the glands of the cervix (the opening to the uterus).
When a women gets pregnant without using IVF the embryo "drops in" from the fallopian tube into a sterile uterine environment. However, when IVF or procedures such as intrauterine insemination are done, a catheter is introduced via the cervix into the uterus, dislodging Ureaplasma (and other organisms), and propelling it into the uterine cavity at exactly the time that the embryos(s) or the sperm sample is discharged. Under such circumstances, the uterine cavity can become infected, and the embryo is confronted with an organism that compromises implantation by attacking rapidly dividing cells.
Testing for Urea/Mycoplasma requires access to the woman's cervical mucus, and an ejaculate from the husband's sperm. If Ureaplasma is present, it is recommended that both partners be treated appropriately with antibiotics and re-tested thereafter to confirm that the organism has been eradicated. The semen and cervical mucus are accordingly cultured well in advance of initiating a cycle.
- Gonorrhea and Chlamydia are bacteria in the cervix and uterus usually put there through sexual transmission. While neither of these organisms causes vaginal infection, once they enter the cervix and uterus and pass through the fallopian tubes, they cause pelvic inflammatory disease. Both chlamydia and gonorrhea are readily identified through cultures routinely performed by most IVF programs.
DONOR PARTNER/HUSBAND AND RECIPIENT PARTNER
Blood Studies
- Chlamydia Ab - tests for antibodies against Chlamydia trachomatis, a sexually transmitted disease.
- Hepatitis B (HBV, HbsAG, HcAb) - Hepatitis B is a highly infectious virus that attacks the liver. HBV is found in blood and certain body fluids of people infected with HBV, fluids such as serum (blood), semen, vaginal secretions, and saliva. It can be transmitted by contact with these fluids. The blood is tested for the presence of antibodies and antigens to the hepatitis B virus.
- Hepatitis C - Hepatitis C is a viral infection, which causes inflammation in the liver. Hepatitis C is transmitted by exposure to the blood of a person with hepatitis C or by sexual contact. The blood is tested for the presence of antibodies to the hepatitis C virus.
- HIV - serology test used to detect the auto-immune deficiency symdrome (AIDS) virus
- RPR - Rapid Plasma Reagent test used to test for Syphilis
Male Semen Cultures
- Urea/Mycoplasma
Urealyticum are micro-organisms which are commonly missed because they cause no symptoms and are difficult to culture. The culture requires the use of a specialized transport medium. The organisms do not ordinarily cause infertility and hardly, if ever, found within the uterine cavity. When present, they grows in the glands of the cervix (the opening to the uterus).
When a women gets pregnant without using IVF the embryo "drops in" from the fallopian tube into a sterile uterine environment. However, when IVF or procedures such as intrauterine insemination are done, a catheter is introduced via the cervix into the uterus, dislodging Ureaplasma (and other organisms), and propelling them into the uterine cavity at exactly the time that the embryos(s) or the sperm sample is discharged. Under such circumstances, the uterine cavity can become infected, and the embryo is confronted with an organism that compromises implantation by attacking rapidly dividing cells.
Testing for Urea/Mycoplasma requires access to the woman's cervical mucus, and an ejaculate from the husband's sperm. If Ureaplasma is present, it is recommended that both partners be treated appropriately with antibiotics and re-tested thereafter to confirm that the organism has been eradicated. The semen and cervical mucus are accordingly cultured well in advance of initiating a cycle.
- Gonorrhea and Chlamydia are bacteria in the cervix and uterus usually put there through sexual transmission. While neither of these organisms causes vaginal infection, once they enter the cervix and uterus and pass through the fallopian tubes, they cause pelvic inflammatory disease. Both chlamydia and gonorrhea are readily identified through cultures routinely performed by most IVF programs.
RECIPIENT:
Blood Studies
- Antiphospholipid Antibodies (APA) - an autoimmune response that may launch an immune assault on the early root system of new embryos and is also found in association with a variety of disease states where antibodies are formed to the body's own tissues. Examples include Rheumatoid Arthritis, Hashimoto's Thyroiditis, Lupus Erythematosus, Myasthenia Gravis, endometriosis, pelvic adhesions or pelvic inflammatory disease.
Ranges in International Units (GPL,MPL)
IgG Units (Termed "GPL")
* Negative <8 GPL Units
* Low Pos 8-19 GPL Units
* Mod Pos 20-49 GPL Units
* Positive 50-79 GPL Units
* High Pos >80 GPL Units
* IgM Units (Termed "MPL")
* Negative <= 14 MPL Units
* Low Pos 15-19 MPL Units
* Mod Pos 20-29 MPL Units
* Positive 30-59 MPL Units
* High Pos >60 MPL Units
- Antisperm Antibodies (ASA), Some women's blood develops an allergic-like reaction to sperm and forms antibodies against sperm. Sperm antibodies reduce fertility, but do not usually prevent conception altogether. Rather, the effects are graduated (the larger the immunologic response, the less likely it is that a pregnancy will occur).
- APTT: clotting test that might indicate a need for heparin and baby aspirin.
Reference ranges:
APPT 32-48 SECS is normal
Corrective APPT 32-48 SECS is normal
Hormone Tests:
- Follicular Phase (day two or three): * Luteinizing Hormone (LH) - Less than 7mIU/ml
* Follicle Stimulating Hormone (FSH) - Less than 13mIU/ml
- Day of LH Surge (ovulation): * Luteinizing Hormone (LH) - Greater than 15mIU/ml
* Follicle Stimulating Hormone (FSH) - Greater than 15mIU/ml
* Estradiol - Greater than 100 pg/ml
* Progesterone - Less than 1.5 ng/ml
- Mid Luteal Phase (seven days after Ovulation) * Estradiol - Greater than 60 pg/ml
* Progesterone - Greater than 15 ng/ml
KEY:
mIU= milli International Units
ml=milliliter
pg=picograms
ng=nanograms
Other
- Hysterosalpingogram:
This test is used to examine a woman's uterus and fallopian tubes. It is essentially an x-ray procedure in which a radio-opaque dye is injected through the cervix into the uterus and fallopian tubes. This "dye" appears white on the x-ray and allows the radiologist and your doctor to see if there are any abnormalities, such as an unusually shaped uterus, tumors, scar tissue or blockages in the fallopian tubes. If you are trying to get pregnant in the same cycle of an HSG, make sure to schedule the test PRIOR to ovulation so that there is no danger of "flushing out" a released egg or developing embryo. Although most women report only minor cramping and short-term discomfort during this procedure, some women, especially those who DO have blockages, report intense pain. Speak to your doctor about taking a pain medication 30 minutes prior to the actual procedure. While this is a helpful procedure, it tends to be too inexact for IVF purposes, because it often misses small lesions that would otherwise be detected. The hysteroscopy provides a more accurate diagnosis.
- Hysteroscopy:
If a uterine abnormality is suspected after the HSG, your doctor may opt for this procedure, performed with a thin telescope mounted with a fiber optic light, called a hysteroscopy. A thin telescope-like instrument is passed via the vagina through the cervix into the uterine cavity. It permits direct visualization of the cervical canal, the uterine lining, and the openings to the fallopian tubes. The procedure may be accompanied by a laparoscopy. "Photos" are taken for future reference.
Diagnostic hysteroscopy will permit a through evaluation of your uterine cavity in order to exclude and/or diagnose the presence of conditions that might interfere with implantation of the embryo and normal development of the pregnancy.
This procedure may or may not require general anesthesia; if it does not you may choose to have an anesthesiologist present to provide intravenous sedation or anesthesia. In many instances, this procedure is well tolerated using local anesthesia.
You might anticipate a small amount of discomfort associated with the performance of diagnostic hysteroscopy under local anesthesia. In fact, the discomfort largely relates to the injection of the local anesthetic around the cervix and to some cramping that results from the purposeful inflation of carbon dioxide gas into the uterus (which is necessary to distend the uterine cavity in order to allow visualization). Some women experience mild to moderate cramping for a short period of time after hysteroscopy, while other may experience some shoulder pain and minor discomfort with breathing. The latter occurs in a case where the tubes are open and gas that is insufflated into the uterus passes via the tubes into the abdominal cavity, irritating the nerve endings under the diaphragm.
This procedure is usually performed in the early half of a woman's cycle so that the build-up of the endometrium does not obscure the doctor's view. However, if the doctor is planning to do an endometrial biopsy at the same time, it is done near the end of the cycle.
- Sonohysterography
Sonohysterography ("SHG") is an ultrasound-monitored procedure similar to a hysterosalpingogram ("HSG"), and is used to detect abnormalities of the uterus and fallopian tubes or tubal blockage. The indications for its use overlap with those for an HSG. Under these circumstances, it no doubt offers a safer alternative to the conventional HSG because it has the added advantages of no radiation exposure, no iodinated contrast injection (which can be associated with increased discomfort and allergic reactions), the potential for fewer complications.
- Laproscopy
During this procedure, a narrow fiber optic telescope is passed via the belly button into the abdomen to look at the uterus, fallopian tubes and ovaries and to discern endometriosis or pelvic adhesions. This is the best diagnostic tool for evaluating the ovaries. It is also used in the performance of certain surgical procedures. This test is usually done two or three days before menstruation is expected and only after an HCG beta blood test ensures the woman is not pregnant.
- Endometrial Biopsy
This procedure involves a scraping of a small amount of tissue from the endometrium shortly before menstruation is due-between 11-13 days from LH surge. It should ONLY be done after an HCG blood test shows the woman is not pregnant. This test is used to determine if a woman has a luteal phase defect-a hormonal imbalance that prevents a woman from sustaining a pregnancy because not enough progesterone is produced.
- Mock Transfer
A mock transfer may be done on a non-IVF cycle, days 3-11 of your cycle. For the mock transfer, the physician inserts a tiny plastic catheter into the uterus. This allows the physician to measure the depth and direction of your uterus. You may experience some cramping during the procedure. It is recommended that you take ibuprofen (approximately 600 mg) 30 minutes prior to the procedure to reduce the cramping. If you can not take ibuprofen, take 2 Extra-Strength Tylenol tablets instead. You may schedule to have this performed at the time of your IVF consults or along with having cervical cultures, depending on your doctor's protocol.
Post Transfer Tests
- Beta HCG human chorionic gonadotrophin (pregnancy test)
3 week(s) since LMP 5 - 50 mIU/ml
4 3 - 426 mIU/ml
5 19 - 7,340 mIU/ml
6 1,080 - 56,500 mIU/ml
7 - 8 7,650 - 229,000 mIU/ml
9 - 12 25,700 - 288,000 mIU/ml
13 - 16 13,300 - 254,000 mIU/ml
17 - 24 4,060 - 165,400 mIU/ml
25 - 40 3,640 - 117,000 mIU/ml
- Progesterone levels. These bloods will be drawn 10, 12 or 14 days post-transfer depending on your doctor's protocol. A progesterone level of at least 30 is desired to maintain a pregnancy. Again, check with your doctor or nurse as lab values differ.
DONOR TESTS:
- Follicle Stimulating Hormone (FSH) Measurement of blood concentrations of follicle stimulating hormone (FSH) levels during the first three days of the natural menstrual cycle provides a rough estimation of ovarian reserve and helps predict the potential of an individual to respond to fertility medications. If on repeated occasions the FSH levels are greater than 7.5 mIU/ml by EIA during the first three days of the menstrual cycle, the women might anticipate a poor response to ovarian stimulating medications, which may ultimately translate into producing few, if any, embryos.
RECIPIENT PARTNER/HUSBAND
- Semen Freezing
In some practices, it is necessary to freeze semen once before the first IVF cycle, unless it is used to inseminate your eggs and you choose to do another cycle. This sample is used as an emergency backup for the day of retrieval. It is preferred that the eggs are inseminated with fresh sperm, if possible.
- Blood Studies
Antisperm Antibodies (ASA). Some infertile men have an allergic-like reaction to their own sperm and form antibodies against their sperm. Sperm antibodies reduce fertility, but do not usually prevent conception altogether. Rather, the effects are graduated (the larger the immunologic response, the less likely it is that a pregnancy will occur). Treatments for this problem include IUI, prednisone therapy, IVF and ICSI.
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Medications You and Your Donor Will Be Taking
Stimulation Drugs Used by the Egg Donor
Stimulation drugs are used to hyperstimulate the ovaries to produce more than one egg. These drugs will be taken by the egg donor (not the egg recipient), usually for 8 to 14 days. All drugs are given by either intramuscular (in the buttocks) or subcutaneous (in the thigh, arm, or stomach) injection. There are basically two types of stimulation drugs: follicle stimulating hormone (FSH) drugs, and drugs containing both FSH and luteinizing hormone (LH). Although both drugs types generally effect similar results, many physicians rely on combinations of either type to produce the desired response.
Because they are human hormones, the side effects of stimulation drugs are minimal. Most complaints involve the injection site, as bleeding, bruising, pain, swelling, and redness may occur. Severe itching may indicate an allergic reaction and should be reported to the physician. The most serious adverse event involving the stimulation drugs is hyperstimulation of the ovaries. Excessive weight gain (2-3 pounds per day) is an indication of hyperstimulation and should be reported immediately to the physician.
FSH + LH drugs (Human Menopausal Gonadotropins)
Pergonal, Humegon, and Repronex are FSH + LH combination drugs given intramuscularly. They are derived from human menopausal urine and thus may contain some impurities that may result in some variation in response. Other brand names available throughout the world include Pertisol, Menogen, Merinal, and Lepori.
FSH drugs (Urofollitropin and Follitropin drugs)
Metrodin and Fertinex are FSH drugs also derived from menopausal urine. Metrodin is given intramuscularly, whereas Fertinex, because it is highly purified, has the advantage of being administered subcutaneously. Other international brands include Fertinorm. Gonal-f and Follistim are also FSH drugs, but are genetically engineered. Thus, they are truly pure FSH analogs and are expected to provide consistent follicular response. AN international brand name is Puregon.
Human Chorionic Gonadotropin
Human Chorionic Gonadotropin (HCG) (Trade names include Profasi and Pregnyl) is used to cause the eggs to release from the follicles. It also further matures the follicles. HCG is taken by the donor as an intramuscular injection approximately 36 hours prior to egg retrieval. The side effects of HCG are similar to those of the stimulation drugs, with bloating and cramping the primary adverse reactions.
Drugs Used to Prepare the Recipient for Embryo Transfer
Oral contraceptives and progesterone are both frequently prescribed to the egg/embryo recipient in order to synchronize her body with that of the egg/embryo donor. In particular, estrogen-containing drugs, such as Estrace, Estraderm, Cyclacur, and estradiol, are prescribed to the recipient to prepare the uterine lining for the embryo. Estrogen drugs are most frequently prescribed as tablets or as patches. Side effects of estrogen and oral contraceptives include moodiness, depression, bloating, increased hunger, loss of hunger, and headache. Calf pain should be reported to the physician, as it may indicate thrombosis or other cardiovascular conditions.
Progesterone is also used to prevent miscarriage. For this indication, progesterone may be taken up to 12 weeks after embryo transfer. Progesterone used in conjunction with assisted reproductive techniques should always be the natural, rather than the synthetic, form. The synthetic form of progesterone has been associated with birth defects and thus, should never be taken while pregnant. Natural progesterone is available in many forms, including: capsules, lozenges, vaginal suppositories, rectal suppositories, vaginal gel (Crinone), and intramuscular injection. Other than the gel and injection formulations, all other progesterone formulations are not routinely manufactured and therefore require compounding by the pharmacist. The side effects of progesterone include: spotting, edema, changes in weight (increase or decrease), breast tenderness, breast enlargement, bloating, nausea, dizziness, headache, and depression. Indeed, many of the side effects of progesterone mimic those of pregnancy and the patient should be aware of this.
Leuprolide (Lupron) is also used to synchronize the recipient's uterine lining with that of the donor. In addition, Lupron is also used by the egg donor to prevent ovulation prior to egg retrieval. Lupron is a gonadotropic releasing hormone agonist; that is, it moderates the release of FSH, which stimulates the follicles to mature, and LH, which stimulates the follicle to release the egg. Because Lupron prevents the pituitary from releasing LH, premature ovulation is avoided.
Lupron is provided by subcutaneous injection. The egg donor may use one of two primary protocols (although there are many variations on these also used throughout the world!): 1) the regular, or "long", protocol; and 2) the flare, or "short", protocol. In the long protocol, lupron is administered for approximately 10 to 12 days, beginning three days after menses begins. The stimulation drugs are then begun and the lupron is given with the stimulation drugs, often at a lowered dose, until the hcg trigger is administered. The short protocol is given several days after menses begins and is provided for just a few days. Stimulation drugs are then begun and the lupron is usually discontinued (even though some variations have the lupron provided at a very low "micro" dose). The short protocol is thought to provide a burst of FSH just as the body itself begins to release FSH. This protocol is thought to be helpful for older women and for those women who have demonstrated relatively poor response to stimulation drugs. The short protocol is also frequently administered as a low or dilute dose of lupron.
Side effects of lupron include: headache, menopausal-like hot flashes, mood swings, insomnia, and mild joint pain. Pain, redness, swelling, and irritation at the injection site are also frequently reported. Other names for lupron include Suprefact and Daronden.
Synarel (Buserelin) is similar to lupron in both action and utility. It is administered as a nasal spray, and is often used by women who are overly suppressed by lupron.
Miscellaneous Drugs
Other drugs which may be used by the egg donor include antibiotics, such as Doxycyline to preclude infection during egg retrieval and to prevent the transmission of sexually transmitted disease during egg retrieval. The egg recipient may also be prescribed antibiotics shortly after transfer, as well as methylprednisone, in order to improve the odds of implantation. Other drugs used in egg retrieval and sometimes transfer include intravenous sedatives, pain relievers (narcotics), anxiolytics (e.g., Valium) and anesthesia.
Some women also receive baby aspirin to improve the blood flow to the uterus, as well as steroids, IVIG, and heparin for immune disorders.
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What Are Other Options For Getting Meds?
Many people buy their medicines and those required for the donor through their local drugstore, which is generally the most expensive option. In many countries other than the US, fertility medications are available much more cheaply that in the US. Therefore, this section is written to assist US residents with alternative and less expensive approaches to obtaining medications:
- a. Buy through a mail order pharmacy in the United States
- b. Buy though a pharmacy in Europe or in Mexico
- c. Buy unused medications from others who have completed cycles
- d. Have donor's prescriptions written in recipient's name, if recipient has insurance which covers medications
Internet Link
A list of discount pharmacies both in the US and outside the US is provided at http://www.fertilethoughts.net/faq/drugs.html.
Mail Order - US
Most of the mail-order pharmacies are able to ship by overnight mail, so the medications are not subject to extreme heat in the summer or cold in the winter. There are no legal issues with respect to mail-ordering medicines within the US. The following pharmacies have been recommended by MVED members.
- Park Ave Pharmacy (NYC) 1-800-842-6600
- IVP Pharmaceutical Care 1-800-424-9002 (different prices for people without insurance)
- Schraft's Pharmacy 1-800-876-4545 Fax: (973) 373-2664; manz@net-lynx.com
Pharmacies Outside US
Be aware when mail-ordering from abroad or traveling to Mexico to buy medications that there may be laws which restrict these transactions. Generally, if the recipient travels to out of the country with a prescription in her own name, she may buy up to a limited personal supply without a problem and bring it with her into the US. Prescriptions written in the donor's name could potentially cause problems; as a precaution, carry a letter from your RE that states that the medications are for a donor egg cycle and indicates the donor's and recipient's name.
Although a person can save substantially on certain drugs by buying them from outside the US, mail order packages containing drugs can be subject to confiscation or search, so be sure you understand the latest laws on transporting drugs across country lines. The pharmacies that sell these drugs will not necessarily be able (or willing) to provide you with correct information on the US laws of out-of-country mail order shipments. Before ordering medications from other countries by mail-order, please read the restrictions at http://www.ceri.com/import.html. This notice allows medications that are not currently approved or available in the US to be shipped in from outside the country for personal use. It does not specifically allow shipments of medications which ARE currently available in the US.
The following pharmacies were recommended by MVED members.
London:
International Pharmacy Organisation
E-mail: ipo@aapi.co.uk
Howard Turner, pharmacist
Tel 01144 181 381-1911
Fax 01144 181 952-2063
Pharmamed
E-mail: pmed.com
Ralph, pharmacist
Feldman Pharmacies aka British American Pharmacy,
in Paris
Fax: 01133142 65 29 42
Phone: 47424940
Buying Left-Over Medications from Others' Cycles
There are several sites on the Internet where people post sales of unused medications, and the prices tend to be approximately 50% or less than the pharmacy prices. This practice is illegal, and it is in fact even illegal to give medications to another person. To comply with the laws, all medications are to be purchased from a pharmacist. There are also several other risks: the person may not actually have the medications and might request payment in advance, leaving the purchaser with no medications; or the seller may send phony medications.
Requesting Doctors to Write Prescriptions in Recipient's Name
Often a recipient will have insurance coverage that will pay for her medications, but not those of a donor. Therefore, the recipient would request that the doctor write the prescription in her name, rather than in the donor's name. This practice used to be more common than it is today. It is illegal for a doctor to write a prescription in the name of anyone other than the person who is to take the medication, and the practice could lose its license by writing prescriptions in the recipient's name. There has been stricter enforcement of this law in recent years, leading many clinics to tighten their practices.
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Progesterone and DE
Progesterone and estrogen supplementation are required for Donor egg procedures. In a natural pregnancy, your ovaries produce the egg that is fertilized. Then, the tissues in the ovary that surrounded the egg form into a structure called a corpora lutea. The cells in the corpora lutea produce the estrogen and progesterone that stimulate uterine growth and maintain the embryo for the first 12 weeks of pregnancy. When you use a donor egg, or when you use any other method that does not take advantage of your own ovaries, you do not have a corpora lutea. Thus, you have to be supplemented with progesterone and estrogen for about the first 12 weeks of pregnancy (10 weeks after transfer of a donor embryo). Supplementation will also usually begin before the embryo transfer. Estrogen replacement can be in the form of pills or patches that usually go on the lower body (hips, thighs and rear end). These cause minimal discomfort usually and are not discussed here. The progesterone, however, is another story.
Progesterone supplementation can now be taken in several forms:
- 1. Progesterone intramuscular (IM) injections (usually into rear-end muscles).
Pros: This has been the tried and true method for many years in this country and most REs trust this method.
Cons: The injections can be painful and will always bring a slight risk of infection. Also, some people can develop allergies to the peanut oil or sesame oil that is used to dissolve the progesterone.
- 2. Crinone gel:
This is the newest form of progesterone. It is given vaginally in a base that is more solid than traditional suppositories, which prevents leaking. It is important to know that, with Crinone 8%, progesterone gets absorbed more directly into the uterus. Therefore, blood levels of progesterone tend to be lower, even though the amount of progesterone is effective at the level of the uterus.
Pros: No pain! This is a relatively novel method that has only been used in the US since around 1997. It has been used for many more years in Europe and all of the studies to date suggest that pregnancy rates are the same as with IM injections.
Cons: This method is still considered by some to be experimental. So some REs will not trust it. This can cause some very minor bleeding because the cervix and vagina are more fragile during pregnancy. The act of putting in the plastic syringe/holder and injecting the gel can cause a small amount of trauma to the area and very small, probably unnoticeable bleeding. It is also somewhat messy. The cream makes a gel-like plug in the vagina that can come out as whitish blobs. Your regular physician will not be able to diagnose a yeast infection while you are using this cream. Can be expensive if your insurance does not cover. Some insurance companies will cover expenses once you become pregnant.
- 3. Rectal suppositories or a "troche" - a waxy pill that is held between the cheek and gum until it dissolves. Recommended by someone going to Dr. Perloe in Atlanta (www.ivf.com). This RE found a "compounding" pharmacy that would prepare the progesterone in this format. That pharmacy, in Atlanta, is Miller Compounding Pharmacy at 1-800-547-1399. A 20-day supply was $55. According to one MVED member, "Dr. Perloe recommended a suppository in both am and pm and a 200 mg troche in both am and pm. With this protocol, he has been getting blood progesterone levels of 50-100, even higher than my current level on 2 cc IM progesterone and certainly better than the minimum acceptable level (10 mg)." Statistics on this method are not yet available.
Note: it's not clear how to compare dosages from one of these methods to another. When taking suppositories or vaginal gels, the hormone is delivered locally, giving adequately high local levels, although there is no increase in blood progesterone.
In general, intramuscular and vaginal administration of progesterone work well. The particular type of progesterone treatment used will depend on the type of cycle and the patient's history.
One further note: the natural progesterone used during fertility therapy is the same as that produced by the body and is safe in pregnancy. Synthetic progesterones, such as those found in menopausal hormone treatment (Provera) or in birth control pills, should be avoided once someone is pregnant.
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Methods of Easing the Pain of IM Progesterone injections
A. Warm the progesterone first to thin it. Warm it to either a comfortable room temperature or body temperature. Methods to warm it vary:
1. Fill hot water bottle, but keep the water bottle "thin" (easier to manipulate). Fold bottle over syringe containing progesterone and heat for at least one minute; check temperature.
2. After you draw up the progesterone in the shot, recap it and put it somewhere warm for about a minute. You can hold it in your hand on sit with it between your thighs.
3. Place the vial in hot water to warm.
4. Wrap shot in wet hot face cloth for a few minutes.
B. Preparing the site of the injection:
1. Some people prefer to ice down the injection site for 2-10 minutes. Others avoid icing.
2. Another alternative was to use a lidocaine (local anesthetic) cream, the EMLA cream, which requires a prescription from your RE.
EMLA cream: Remember "when all else fails, read the directions!".........
a. How much cream should be applied? You just need a "blob" about the size of the end of your thumb applied to the area where you will be injecting.
b. How big of an area should the cream cover? You shouldn't need more than about 1 square inch - you don't rub this stuff in - just put it on there.
c. How long should the cream be on before the injection? 30 minutes to one hour, check the label.
d. Should a bandage or something be used to cover up the area that the cream was applied to? Yes, but not a gauze bandage. You need something to keep the air out. They may supply this type of air occlusive dressing when you buy the EMLA, but if not, just plain old plastic wrap will do just fine.
e. Can it be used prior to any other injections, such as, delestrogen? EMLA can be used for any injection, or before having blood drawn or having an intravenous started.
f. I assume the area that the cream is applied to should be cleaned before the injection? Yes, the cream needs to be wiped off and the injection site cleaned with alcohol or peroxide.
C. Relax the muscles:
1. The recommended spots are the large muscles of the rear end (back of hip) (the gluteus maximus muscle).
2. If you have help, lie flat on your stomach, with toes inward - pigeon-toed (relaxes gluteal muscles). Another method is to stand up against a table or other support, with your leg bent, relaxing the muscle, while someone else gives you the injection.
3. Relax the muscles as much as possible.
4. If getting help for the injection, have a newspaper or magazine to be looking at while the whole thing is going on.
D. The injection:
1. Wait for the alcohol to dry completely (it causes some of the sting). Don't let anyone blow on it to dry or you'll get germs all over your nice clean site.
2. Keep the dry skin tight and smooth; don't pull up a pinch of skin.
3. Insert the needle into the skin quickly to minimize pain. One clinic recommended having DH put the syringe in like you would throw a dart.
4. Aspirate quickly before injecting.
5. Most people recommend injecting fast and steady. If you feel pain while the injection is in progress, try injecting slower.
E. After the injection:
1. Withdraw needle quickly and immediately massage injection site.
2. After about 30-60 seconds apply hot water bottle and massage area vigorously with the flattened bottle as an "in between" layer for at least two minutes. (Heat and massage will break up progesterone and decrease pain).
3. Keep warm compress on for some time.
4. The night after the injection, have partner massage the spot injected the day before.
Some Possible Side Effects of Progesterone Treatment:
The side effects of progesterone may include (but are not limited to): sore breasts; delayed menses; nausea; vaginal irritation (for vaginal administration techniques); abdominal distention (bloat); weight gain; depression. Note that many of these are the same symptoms as with pregnancy. Because the progesterone supplementation for an IVF-DE starts a few days before DE transfer, you are just beginning to feel the effects of the progesterone after the transfer. This can mislead you into thinking, prematurely, that you are pregnant. You will (in most cases) probably not feel any symptoms of a pregnancy until at least one, if not two to three, weeks after the transfer.
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What is Coasting?
Coasting was developed and is described as "a way to avoid the occurrence of what can become a life threatening condition, without having to stop the IVF cycle and without compromising success rates.
In some cases, when fertility drugs are taken, women develop more than 29 ovarian follicles and develop blood levels of estrogen that are extremely high (greater than 6,000 pg/ml). These levels of hormone can cause life-threatening complications. This condition is called "severe ovarian hyperstimulation syndrome (OHSS)".
In women that show these symptoms, it is possible to begin a "coasting" routine. This means that the RE stops the menotrophins and does not give the stimulating hormone (human chorionic gonadotrophin, HCG) right away. Instead, the RE waits for a number of days, while continuing the gonadotrophin-releasing hormone agonist (GnRH analogue), until the blood levels of estrogen fall down to below 3,000 pg/ml. Then, the HCG is given. This protocol, with the waiting, is called "coasting", or "prolonged coasting."
The advantage of using coasting is that the whole cycle does not have to be canceled to save the life of the women. One disadvantage is that coasting, especially if it takes too long, can reduce the number of eggs retrieved. However, when eggs are retrieved, there is NO difference in the success rates, i.e. in fertilization rates of the eggs or delivery rates.
References:
1. Benadiva CA, et al., 1997. Withholding gonadotropin administration is an effective alternative for the prevention of ovarian hyperstimulation syndrome. Fertil Steril Apr;67(4):724-727.
2. Sher G, et al., 1993. Eliminating the risk of life-endangering complications following overstimulation with menotropin fertility agents: a report on women undergoing in vitro fertilization and embryo transfer. Obstet Gynecol Jun;81(6):1009-1011.
3. Sher G, et al., 1995. 'Prolonged coasting': an effective method for preventing severe ovarian hyperstimulation syndrome in patients undergoing in-vitro fertilization. Hum Reprod Dec;10(12):3107-3109.
4. Tortoriello DV, et al., 1998. "Coasting" does not adversely affect cycle outcome in a subset of highly responsive in vitro fertilization patients. Fertil Steril Mar;69(3):454-460.
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What are Some Methods That I Can Use to Help Increase the Thickness of the Uterine Lining in Preparation for Egg Donation?
1. nitroglycerine patches
Someone wrote: "I used the nitroglycerin patches on my last cycle attempting to use my own eggs. My lining is usually around 7 by retrieval time and when I used the patch it was 9mm on day 6. I did run into a couple of problems. The nitroglycerin patches can cause very severe headaches (migrane level) so I only kept the patch on for 7 hours before having to remove it. I only used it 1 day before my cycle was canceled due to poor ovarian response, but the nitro patch really seemed to work. I am planning on using it again with my next cycle."
2. Injectable estrogen
3. EString: (estrogen ring) that gets inserted inside and releases estrogen directly to the uterus.
4. Acupuncture: Schoolcraft's clinic in Denver refers patients to see an accupuncturist for a special 5 week (2 times a week) electro-accupuncture treatment to increase blood flow to the uterus. You can contact Schoolcraft to get a copy of the medical journal article done by Swedish docs about this successful protocol. They measure using a dopplar u/s before and after and say that it really works and increases pg rates quite a bit.
5. Rectal suppositories
6. A "troche" - a waxy pill that is held between the cheek and gum until it dissolves.
6. Oral projesterone (good old-fashioned pills)
7. Vaginal suppositories
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What is Blastocyst Transfer and How Does That Differ From 2-3 Day Embryo Transfer Techniques?
Taken from the Advanced Fertility Center of Chicago: http://www.advancedfertility.com/blastocy.htm.
A blastocyst is an embryo that has developed for five days after fertilization. At this point the embryo has two different cell types and a central cavity. The surface cells, called the trophectoderm, will become the placenta, and the inner cells, called the inner cell mass, will become the fetus. A healthy blastocyst should hatch from its outer shell, called the zona pellucida by the end of the sixth day. Within about 24 hours after hatching, it should begin to implant into the lining of the mother's uterus.
The ultimate goal of in vitro fertilization (IVF) and embryo culture is to provide high quality embryos which are capable of continued normal development and result in live births. However, under standard IVF culture conditions, only about 20-40% of human embryos will progress to the blastocyst stage after 5 days of culture. This low rate of embryo development is the result of a less than optimal culture environment for the embryos. For this reason, embryos are usually transferred into the uterus after only 2-3 days of culture.
One problem with this is that 2 to 3-day-old embryos are normally found in the fallopian tubes, not in the uterus. The embryo first moves into the uterus at about 80 hours after ovulation. The implantation process begins about 3 days later - after blastocyst formation and hatching have occurred. Therefore, if in vitro culture conditions could be improved so that blastocysts formed at a higher rate, then embryos could be placed into the uterus at the blastocyst stage - at a more "natural" time, and shortly before implantation should occur. Transferring blastocysts following IVF also provides another benefit - reduction of the possibility of multiple pregnancy. Some 2 or 3-day-old embryos do not have the capacity to become high quality blastocysts and a viable pregnancy. However, on day two or three of culture we do not have reliable methods to determine which embryos will be viable long-term. By culturing embryos to the blastocyst stage we have more opportunity to choose the most competent ones for transfer. We may then be able to transfer fewer embryos and obtain an equivalent pregnancy rate with less risk for multiple pregnancy.
It is generally very difficult to get good numbers of high quality blastocysts with current culture conditions. New culture media are currently being developed and tested that might allow higher blastocyst formation rates. This could make blastocyst transfer a viable option for all IVF programs in the future.
One option to improve blastocyst formation rates that is currently available is coculture. The basic concept involves growing embryos on top of a layer of cells rather than directly on the bottom of a plastic culture dish. Various types of cells have been used, such as fallopian tube cells or cells from the lining of the uterus (endometrial cells). IVF with coculture has been utilized in animal in vitro embryo culture systems for over 30 years. More recently it has also been used in some human IVF laboratories. The concept behind coculture is that these cells, which are sometimes referred to as "feeder" cells or "helper" cells, help to stimulate the development of the embryos.
Several published studies have demonstrated improved pregnancy rates and delivery rates with utilization of coculture for human IVF. Coculture has also been shown to produce a higher proportion of embryos that develop to the blastocyst stage. One study showed that coculture resulted in a 68% blastocyst formation rate and a 50% pregnancy rate per transfer in patients with several previous IVF failures (R. Schillaci, et al., Human Reproduction, Volume 9, p. 1131-1135, 1994). Also, transfer of "leftover" cocultured blastocysts that had been cryopreserved (frozen) resulted in very good delivery rates. In one program with 563 thawed blastocyst transfer cycles, the pregnancy rate was 26% per transfer for hormonally controlled cycles, and 13% per transfer for "natural" cycles (R. Kaufmann, et al., Fertility and Sterility, Volume 64, p. 1125-1129, 1995). In another study, 101 cycles of coculture with blastocyst transfer for couples with multiple previous IVF failures resulted in a pregnancy rate of 29% per retrieval and 37% per transfer. This was accomplished with a maximum of 3 blastocysts transferred per cycle (F. Olivennes, et al., Human Reproduction, Volume 9, p. 2367-2373, 1994).
Coculture is labor-intensive and, unless the cells are obtained from the woman having IVF, there is at least a theoretical concern regarding transmission of infectious disease (viruses, etc.) from the cells to the embryos or to the patient. New culture media are currently being developed and tested that might allow higher blastocyst formation rates.
A recently published study reported a 63% pregnancy rate using a new media with day 5 blastocyst transfers without the use of coculture (D. Gardner, et al., Fertility and Sterility, Volume 69, p. 84-88, 1998). These results are promising; however, they need to be confirmed - only 8 patients in this study had blastocyst transfers.
Unresolved issues of critical importance are:
1. Will blastocyst transfer improve pregnancy rates for a few couples, for many couples, or for almost all couples undergoing IVF?
2. Which patients are the ones that will benefit the most? How do we select the most appropriate candidates?
3. How many blastocysts should we transfer - 2 or 3? Would 3 give too high a triplet rate? Would 2 give too low a pregnancy rate? The best answer is probably 2 in most cases and 3 in others. If so, how do we decide the cases that are better off with 2 or 3 transferred?
4. How many couples will have no blastocysts for transfer if we culture to day 5? How will this figure vary according to the selection criteria used by the program for selecting patients for blastocyst transfer?
Our IVF program and some others are currently doing blastocyst transfers in selected cases and these important issues should be resolved over the next 1-2 years. Stay tuned... Hopefully, these improvements in culture media will make blastocyst transfer a viable option for all IVF patients in the near future.
Ten years ago, GIFT (egg and sperm transfer to the tubes) and ZIFT (one-day-old embryo transfer to the tubes) were popular because IVF laboratories were not able to attain high pregnancy rates with longer periods of in vitro culture. Today, most programs have abandoned these much more expensive and invasive tubal procedures and are routinely doing day 3 uterine transfers with much improved pregnancy rates. As we continue to learn more about human embryonic needs and improve our culture systems, we will move toward more routine use of blastocyst transfer in order to give our patients the highest possible pregnancy rates while reducing their risk for multiple pregnancy.
NOTE added to this info: Since the coculture and blastocyst growth techniques are still experimental, it requires a very experienced and competent laboratory. If your RE is hesitant about doing blastocyst transfer, do not force them to continue. They have a very good idea of what their lab is capable of doing. If you are truly set on doing blastocyst transfer, change to an RE and lab that has more experience with this very technically complicated procedure.
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What Is the Number of Eggs I Can Expect to Get at Retrieval?
Most clinics tell their patients that individual response to medications is very hard to predict. Some clinics have told patients that a good cycle should yield approximately 12 eggs; others have stated an average of 8-12 eggs. The number of eggs can vary from zero (unlikely) to 40 or more (also unlikely). Generally with a higher number of eggs, the fertilization rate is lower and the number of immature eggs is higher; so more isn't always better.
Also, an experienced donor may have significant variations in the number of eggs produced from cycle to cycle, even on the same doses of medications.
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What Percentage of Eggs Can I Expect to Fertilize?
Generally, fertilization is considered successful if 60-70% of the eggs fertilize. If an extremely high number of eggs is retrieved, a rate of 50% may be more normal. One study showed that implantation rates per embryo were also lower the higher the number of eggs retrieved.
If male factor infertility is present, ICSI may be indicated. ICSI will increase the fertilization rate, but may result in fewer of the fertilized eggs dividing to become embryos. (Studies conflict on this.) In some cases, a clinic will recommend dividing the eggs and doing ICSI on half, while allowing the other half to attempt to fertilize without ICSI.
In rare cases (approximately 15% incidence in several studies), "fertilization failure" may occur, meaning that no eggs fertilize. If this occurs, it is possible to do "rescue ICSI" the following day, but studies have shown that the fertilization rate from this procedure is only approximately 10%, so it may not be cost-justified.
Several studies have concluded that there is no correlation between fertilization rates in IVF cycles and successful "Sperm Penetration Analysis" (SPA), a test of whether the sperm can penetrate a hamster egg.
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Bedrest After Transfer. Is It Necessary?
Each clinic seems to have a different philosophy regarding bedrest after egg transfer. Many women choose to remain on bedrest for a couple of days after transfer even though their RE says it is not necessary. Following are three articles which support the philosophy that, after an initial 20-minute rest period after transfer, further bedrest does not increase chances of pregnancy.
Probably the best advice, as usual, is to follow your RE's instructions.
Is bed rest following embryo transfer necessary?.
Authors: Sharif K. Afnan M. Lashen H. Elgendy M. Morgan C. Sinclair L.
Abstract
OBJECTIVE: To evaluate the effect of no bed rest following ET on the results of an IVF program. DESIGN: Historical cohort-control study. SETTING: A University-based assisted conception unit. PATIENT(S): One thousand and nineteen (1019) IVF cycles were performed at our unit from June 1994 to August 1996. The historical control consisted of all the 19,697 IVF cycles reported in the United Kingdom national database from April 1994 to March 1995. INTERVENTION: No bed rest following ET in our patients. MAIN OUTCOME MEASURE(S): Pregnancy rate (PR) and clinical PR per cycles started and per ET procedure. RESULT(S): The clinical PR per ET was significantly higher in our patients than in the national data (30% versus 22.9%), as was the clinical PR per cycle (23.5% versus 18.6%). The implantation rate in our patients was 17.2%. CONCLUSION(S): The favorable PR in our patients despite no bed rest following ET suggests the bed rest is not necessary.
Source: Fertility & Sterility. 69(3):478-81, 1998 Mar.
Is a prolonged bed rest following embryo transfer useful?
Authors: Botta G. Grudzinskas G.
Abstract
A total of 182 infertile patients undergoing in-vitro fertilization (IVF)-embryo transfer were randomly assigned into two groups. Eighty-seven patients (group A) underwent 97 treatment cycles and had 87 embryo transfer procedures followed by a 24 h period of bed rest. Ninety-five patients (group B) underwent 102 treatment cycles and had 93 embryo transfer followed by a 20 min period of bed rest. There were no statistically significant differences seen between the groups with respect to age, duration and causes of infertility and number of previous fertility treatments. The clinical and biological procedures were identical in both groups, the only difference being the length of bed rest. There were 21 pregnancies in group A (pregnancy rate per embryo transfer: 24.1%) while in group B there were 22 (pregnancy rate per embryo transfer: 23.6%). There were four spontaneous miscarriages (19%) and three twin pregnancies (14.2%) in group A, while in group B there were four spontaneous miscarriages (18.1%) and three twin pregnancies (13.6%). None of these values was statistically significant (P > 0.05). This study shows that a 24 h period of bed rest following embryo transfer is not associated with a better outcome of the IVF-embryo transfer when compared with a 20 min rest period. Prolonged bed rest does not appear to influence the implantation rate after IVF-embryo transfer.
Source: Human Reproduction. 12(11):2489-92, 1997 Nov.
Do patients need to remain in bed following embryo transfer?
The Birmingham experience of 103 in-vitro fertilization cycles with no bed rest following embryo transfer.
Authors: Sharif K. Afnan M. Lenton W. Khalaf Y. Ebbiary N. Bilalis D. Morgan C.
Abstract
Since the early days of human in-vitro fertilization and embryo transfer, rest in bed for hours immediately following the transfer has been advocated and widely practiced. However, there is no scientific validation for this practice which is both time-consuming for the patient and increases space occupancy in the hospital or clinic. We report here on a study of 103 in-vitro fertilization cycles with no bed rest in hospital following the embryo transfer. The mean number of embryos transferred was 2.7 (range 1-3) and the clinical pregnancy rate per embryo transfer procedure was 40%. These results suggest that bed rest is not necessary following embryo transfer.
Source: Human Reproduction. 10(6):1427-9, 1995 Jun.
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What Does It Mean if I Have Antiphospholipid Antibodies? What Are the Problems, the Treatments and What are the Dangers of the Treatments?
The bulk of this information, and any numbers not otherwise referenced come from a recent article by Kutteh (1997).
If you are going through IVF and you have been diagnosed as having higher levels of anti-phospholipid antibodies (APA), you may NOT experience any greater problems with getting pregnant and keeping a pregnancy. However, there is sufficient data to suggest that if you are having troubles with miscarriages, this is an area that should be tested and considered. It is an area in which significant controversy exists and there are still debates in the research and clinical literature.
If you are diagnosed as having the anti-phospholipid SYNDROME (APS), not just the antibodies, you may have 1) higher than normal problems in getting pregnant and 2) have more risk of significant problems during the pregnancy when you compare yourself to all women. If you are at the point of considering IVF, you may have a sufficiently complicated medical history that you are at risk for this syndrome.
There are several treatments possible for APS that can be given during pregnancy, and all have been reported by at least one or two studies to be effective at increasing the rates of live births in the general population of women. Whether or not all women with AP antibodies that are undergoing IVF-ET require or will be helped by treatment is not clear.
See below for detailed information on APA.
Antiphospholipid Antibodies (APA):
Having APA is one of several types of "autoimmune" problems. Antiphospholipid Antibodies are antibodies that are not normally produced by your body. They bind to the lipids (fats) so they can bind to just about any cell you have in your body. When antibodies bind to cells, they can destroy those cells.
There are many types of phospholipids in the body and the clinics will differ in what they term APA. Of the many phospholipids that they could test for, the most common one is a phospholipid called cardiolipin. Anti-cardiolipin antibody tests are the ones for which the standards have been developed, and the most common tests done are for these antibodies. However, there are at least five other common phospholipids and therefore, at least five other tests that perhaps should be done to completely rule out a problem with APA. Some of these tests are: assays for immunoglobulin G (IgG), IgA, and IgM, antibodies for antiphosphatidyl serine, antiphosphatidyl ethanolamine, antiphosphatidyl choline, antiphosphatidyl inositol, antiphosphatidyl glycerol, and antiphosphatidic acid. Finally, as will be discussed later, included in this APA category are the antibodies found in patients with Lupus.
Dr. Beer in Chicago has added considerably to this list of tests. See the INCIID web site (http://www.inciid.org) for some of his theories. Note that his work is considered suspect by many REs because his success rates have not been duplicated; but on the other hand, not enough work has been done to totally rule his theories out, either.
If you have higher than normal APA, you may be at risk for having several different types of problems. One of these problems might include getting and keeping a pregnancy, but there could also be problems with other parts of the body. Because the immune system is so complicated, it is not possible to predict what clinical signs a person will exhibit, when they will occur, or even if they will occur. You could be completely without any clinical symptoms. In other words, APA could cause one type of problem in one person, other ones in another person and no symptoms in a third person.
The presence of APA is associated with problems with pregnancy. In Kutteh (1997), the following statistics are given: 1) Of women with normal obstetrical history, an average of 5.3% have high APA. 2) Of women with recurrent pregnancy loss, 20% have APA. 3) Of women with Lupus, 37% have APA. 4) Of women undergoing IVF, 24 % have APA.
Lupus Erythematosus (Lupus)
This is another "autoimmune" disorder, meaning that this is another case in which a person makes antibodies that can recognize and possibly damage cells in their own bodies. The antibodies in Lupus, which are collectively called the Lupus anticoagulant (LA), bind to a phospholipid. Therefore, the Lupus anticoagulant is a form of APA. So when they test for APA, they may also tell you they are testing for Lupus. Testing for LA is a common blood test in most labs.
Tests for APA:
Tests to determine if you have higher than normal APA are not simple. There have been efforts to standardize the tests, but additional information is still needed. A recent study suggested that the number of people at risk, (i.e., the number that really have higher than normal APA) may be greater than previously suspected, because the labs are currently only testing for one type of phospholipid, usually cardiolipin. Because the tests are not simple, and the results may vary from lab to lab, and from time to time, it is recommended that two tests be taken, more than 6 weeks apart, before you are definitively diagnosed as having higher APA levels. Also, pregnancy can change the levels of different types of APA, or provide interference in the tests. So the RE and the lab should be experienced in order to correctly interpret these tests.
Antiphospholipid Antibody Syndrome (APS)
Just having the antibodies does not mean that you have the "anti-phospholipid syndrome" or APS. To be defined with that, you have to have BOTH the APA antibodies AND other clinical signs. The clinical signs are very diverse. They can include one or more of the following: recurrent pregnancy loss (not all types of losses indicate APS), unexplained second or third trimester loss, fetal demise, early onset, severe pre-eclampsia, pg-related thrombosis (blood clots), intrauterine growth retardation, autoimmune or connective tissue disease, false-positive for syphilis. Note that, if you have one of these symptoms, you do not automatically have APS. Only a careful work up with the RE can define this syndrome.
Risks with APS
If you have been diagnosed as having APS, you do have a reduced chance of having a normal pregnancy. This is where more research is needed. As noted above, there are problems with the APA tests, and with the definition of APA. A recent review (Kutteh, 1997) compared several studies in the literature. These studies looked at women with high APA and more than two or three failed fetal losses (these qualify as having APS). Among these women, the live births varied in four different studies from 7 to 30%. One study had an unusually high rate of 54%. The average was around 20-30% live birth rates in women with APS. Note that women with APS frequently have multiple problems during pregnancy, as seen by the list above, not just problems getting pregnant.
Treatments
There are four proposed treatments for APS. 1) A single low-dose aspirin per day (usually 81 mg, which is the amount in one baby aspirin), 2) low dose aspirin and low or high dose of prednisone (a corticosteroid, also called a steroid), 3) low dose aspirin and subcutaneous heparin and 4) intravenous gammaglobulin (IVIg) (gammaglobulins = immunoglobulins = antibodies). With IVIgs, the idea is to boost your own antibodies by giving you antibodies from other people. This product is derived by taking blood from many people and doing a process to take out just the antibodies. To quote a recent review (Kutteh, 1997) : "All treatments appear to improve the live birth rate; however, the combination of heparin and aspirin, and prednisone and aspirin seem to provide the highest success rates."
Following is a summary of some recent studies on this topic. All of the studies used women who had two or more fetal losses and two positive APA tests. Only one of the studies involved women going through IVF-ET. All others had normal conception. These averages do not take into account differences in the numbers of patients in each study, or the slight differences in amounts of drugs used. None of these studies directly compared all treatments. Most studies compared just two treatments.
Controls: The percent of live births per women in the study was 31% (control means no treatment, placebo, or injections of albumen as controls for the Immunoglobulin studies) (9 studies).
Aspirin alone gave average live birth rates of 53% (4 studies).
Aspirin and heparin gave live birth rates averaging 76% (6 studies).
Prednisone and aspirin gave average live birth rates of 63% (6 studies).
Injection of immunoglobulins gave average live birth rates of 60% (4 studies).
In six out of the nine studies that used a no treatment control, there were differences between no treatment and treatment. However, 3/9 studies showed no difference with treatment. These average numbers suggest that 1) most, but not all, of the treatments had some impact compared to control treatments. 2) The four treatments are roughly equally effective.
So, although much more testing needs to be done, the studies suggest that the proposed treatments recommended for APS can increase the rate of successful live births.
Risks with Treatments:
The cautionary notes are as follows (and see below). (Kutteh, 1997) said "In general, heparin has been associated with fewer side effects than prednisone." Use of heparin and prednisone together is not recommended because it increases the risk of bone fractures. Not enough studies have compared heparin plus aspirin to prednisone plus aspirin. But prednisone is associated with increased neonatal morbidity (problems with both the baby and mother) (Kutteh, 1997) and it increases the risk of prematurity (Laskin).
Heparin use must be monitored carefully because of the potential for problems with excess bleeding (see note below on warning about heparin).
Aspirin alone is the most benign of the treatments. However, it does reduce blood clotting ability to some degree. Some reports describe no incidence of maternal or fetal problems with low dose aspirin use alone. However, as shown below, there can be some increased risks. Several studies have investigated the use of aspirin to prevent pre-eclampsia, which is a common and serious complication of pregnancy. The use of aspirin has been extensively explored for treating that condition. For pre-eclampsia, aspirin is started in the second trimester. The results from several studies suggest that aspirin is not effective. More studies have looked at the effects of aspirin on maternal problems such as eclampsia and high blood pressure, than have looked at the effects of aspirin on getting pregnant. In terms of maternal problems, I quote from CLASP (1994): In a large study, they found some benefits of aspirin. "Low-dose aspirin may be justified in women judged to be especially liable to early-onset pre-eclampsia severe enough to need very preterm delivery. In such women it seems appropriate to start low-dose aspirin prophylactically early in the second trimester."
In terms of the hazards of aspirin treatment: (CLASP) "Aspirin was not associated with a significant increase in placental hemorrhages or in bleeding during preparation for epidural anesthesia, but there was a slight increase in use of blood transfusion after delivery. Low-dose aspirin was generally safe for the fetus and newborn infant, with no evidence of an increased likelihood of bleeding. Our findings do not support routine prophylactic or therapeutic administration of antiplatelet therapy (aspirin) in pregnancy to all women at increased risk of pre-eclampsia or IUGR.
The use of IVIg is still the most controversial and expensive treatment. This is the technique that is championed and frequently recommended by Dr. Beer in Chicago. However, the majority of other researchers using IVIg have shown no increase in pg rates.
IVIg is hard to get, very expensive and has some serious risks (the major risk is contracting diseases from other humans, such as mad cow disease or AIDs, although there are good screens for AIDs now).
APA and IVF
What about APA and IVF? This the unusual part. Among women that are going through IVF, over 45% will have APA (the antibodies) (Kutteh, 1997). This is higher than the rate for the general population and for those women that had recurrent pregnancy losses (see above). HOWEVER, when the women are divided into those with APA and those without APA, there were NO DIFFERENCES in the percent that get pregnant (48% vs. 47%) or the percent that have ongoing pregnancies (82% vs. 77%) (Kutteh 1998, Denis, 1997). This is unusual given the information above. No explanations are given and one of the studies (Denis, 1997) is being hotly debated in the literature (see Fertility and Sterility, 1998, 69:164-168 for a lively discussion of this paper).
This area needs more study!
References:
1. CLASP (Collaborative Low-dose Aspirin Study in Pregnancy) Collaborative Group. CLASP: a randomized trial of low-dose aspirin for the prevention and treatment of pre-eclampsia among 9364 pregnant women. 1994. Lancet, Mar 12;343(8898):619-629.
2. Balasch J, Montserrat C, Fabregues F, Reverter JC, Carmona F, Tassies D, Font J, and Vanrell JA. Antiphospholipid antibodies and human reproductive failure. 1996. Human Reproduction, 11:2310-2315.
3. Denis AM, Guido R, Adler P, Bergh C, Brenner R, Scott Jr. Antiphospholipid antibodies and pregnancy rates and outcome in vitro fertilization patients. 1997. Fertility and Sterility, 67:1084-1090.
4. Geva E, Amit A, Lerner-Geva L, Lessing JB. Prevention of early pregnancy loss in autoantibody seropositive women. 1998. The Lancet, 351:34-35.
5. Kutteh WH. Antiphospholipid antibodies and reproduction. 1997. J. Reprod. Immunol., 35:151-171.
6. Laskin CA, Bombardier C, Hannah ME, Mandel FPK, Ritchie JW, Farewell V, Farine D, Spitzer K, Fielding L, Soloninka CA, Yeung M. Prednisone and aspirin in women with autoantibodies and unexplained recurrent fetal loss. 1997. The New England J. of Med., 337:148-53.
6/24/98
Just in from RESOLVE:
CDC - Alert on Heparin and Aspirin Treatment for Pregnant Women - The Centers for Disease Control and Prevention (CDC) issued a fact sheet on May 16, 1998 on a pregnancy-related death associated with heparin and aspirin treatment. The 38-year-old woman, pregnant through IVF with triplets, died of cerebral hemorrhage; she was on heparin and aspirin treatment. This treatment is usually reserved for women who test positive for antiphospholipid antibodies and/or have a history of multiple miscarriage. This anticoagulant treatment protocol using aspirin and/or heparin is used to modify a blood clotting mechanism at the placenta, which, if uncorrected, could case clotting and trigger pregnancy loss. The woman who died did not have a history of multiple miscarriage or positive antibodies. Some clinics are also using this treatment protocol for women undergoing IVF, but who have no history of miscarriage or a positive antibody test. Neither aspirin nor heparin, alone or in combination, is approved by the Food and Drug Administration for use as an anticoagulation therapy for IVF patients.
The CDC has made the following recommendation:
- - Anticoagulant therapy with aspirin and heparin for IVF should be subject to vigorous investigation before becoming standard practice.
- - Women seeking infertility treatment, including anticoagulant therapy with heparin and aspirin, should discuss risks and benefits with their doctors.
- - A telephone line has been established by the CDC, 770-488-5372, for individuals to report on any severe complications or deaths from this treatment.
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In Regard to RH Factor, Whose Blood Type Do I Have to Consider During an IVF-DE Pregnancy? Mine, My Husband's, the Egg Donor's or the Child's?
The DE/ET baby receives its blood type from the genetic combination of its genetic mother (egg donor) and genetic father (sperm donor). The fetus develops it own blood system from its developing organs. The biology of the system is designed so that (under ideal conditions) the mother carrying the baby does not exchange any blood at all with the developing baby. Instead, the mother's blood provides nutrients (oxygen etc.) that diffuse through her blood vessel walls, which lie next to the placenta, and into the placenta. Once in the placenta, these materials diffuse into the blood vessels that go to the child.
HOWEVER, the reality is that there are frequent opportunities for exchange of blood from the mother (the one carrying the child) to the fetus. This can occur during situations like amniocentesis, tears in the placenta and at delivery. This is a well documented phenomenon in medical literature. This exchange of blood is only a concern if the mother carrying the child is Rh-negative and the fetus is Rh-positive. You, your donor and your husband should be screened before your pregnancy to determine if you are Rh-negative, and if there is a possibility that the child will be Rh-positive. If this occurs, it can be treated with the drug RhoGAM. "RhoGAM is an anti-Rh gamma-globulin given after delivery to an Rh-negative mother of an Rh-positive fetus or child. This prevents the development of permanent active immunity to the Rh antigen." The source for this information is "Maternal Newborn Nursing" by Sally Olds, Marcia London, and Patricia Ladewig, Third edition.
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Pregnancy Tests After DE
HCG (human chorionic gonadotrophin) Test:
HCG is the hormone that increases in the blood after an embryo implants and begins to grow. The normal levels in men and in non-pregnant women average around 4 mIU/ml (milli-International Units per milliliter). If you are pregnant, your levels start increasing shortly after the implantation of the embryo. A level of above 10 mIU/ml is considered possible pregnancy. After the levels appear in your bloodstream, they also start appearing in your urine. The urine levels will be a little lower than the blood levels, but for all practical purposes (like the comparisons we do below) they are approximately the same.
Values of HCG After IVF-ET:
The values of HCG in pregnant women after IVF-ET are extremely variable. This could be in part because of natural differences, or because more than one egg is transferred. After the transfer, there could be times when you are losing one or more embryos. During these times, the HCG levels could be lower. After the embryo is lost, the levels will then start to increase again.
However, despite the fact that HCG values can vary, several studies have shown that they can be used to give some idea of whether or not the pregnancy will go well. The table below gives some very conservative blood level values of HCG in women after IVF-ET. In other words, these are the LOWEST values of HCG that you would expect to see on each day after the IVF-ET. They are also the values that would be seen with one single embryo. If you are carrying multiple embryos, the values should be much higher (see below).
REMEMBER: The HCG values can be very different from one person to another. This is only a GUIDELINE! For an amazing story that shows that these guidelines are sometimes bunk, see below. Day after Serum HCG for
Transfer successful pg:
greater than or equal to:
Day 9 18 mIU/ml
10 25
11 36
12 50
13 72
14 100
15 100
16 100
This is from, first, a study where they found that if blood HCG values after IVF-ET were greater than 18 mIU/ml on Day 9, there was a 95% probability of a viable pregnancy (Mol et al., 1997). The day 14-16 values came from a study out of UCLA and Cedars Sinai Medical Center in Los Angeles (Heiner et al., 1992) where they examined a total of 102 IVF and GIFT pregnancies. If the day 14, 15 or 16 blood HCG values were greater then 100 mIU/ml, then 82% of patients successfully had a live birth. There were no statistical differences between days, so any value greater than 100 on either day 14, 15 or 16 gave the same prediction. To get the values for the other days, it was assumed that the HCG values in the blood double every 2 days. This is another conservative estimate because the increase can occur much quicker according to other studies (for example, doubling every 1.5 days).
MULTIPLE EMBRYOS: The levels will be much higher with multiple embryos. The UCLA study also found that if the 14-16 day HCG values were greater than 500, there was a 50% chance of multiple births and the possibility of a nonviable pregnancy was essentially zero.
What the Reading Means
A beta HcG test that is positive needs to be followed by another test to be sure that it is an ongoing pregnancy and not just a chemical pregnancy. Chemical pregnancies means that at the time the first pregnancy test is performed the level of HcG is less than about 100 but does not double every day and eventually drops back down to 0.
One reading for a pregnancy test less than 100-indicates one of two reasons- the test was taken too early or an embryo or embryo is just starting to implant. However, if the level does not double every two days, the embryo may be ectopic-in an area outside the uterus such as the oviduct or one of two or three embryos has started to implant but is either rejected by the uterus or dies because of an inherent trouble such as genetic problem. The chemical pregnancy is often called a blighted ovum or an early miscarriage.
It is the developing placenta that produces HcG-the more embryos implanted-the higher the HcG. In fact the commercially available HcG (e.g. Profasi or Pregnyl) is purified from pregnant women and is pooled, purified and sold as a drug to induce ovulation. If a woman is undergoing an IVF cycle which requires a shot of HcG, especially 10,000 units-the HcG from the shot may still be present in the woman's blood even a week after the egg retrieval. Therefore, a pregnancy test which detects HcG (but cannot distinguish between an embryo's HcG in the patient and the shot of HcG) performed too soon may register as a false positive. Sometimes a pregnancy test taken too soon may not detect a pregnancy, or the level might be low, because of an embryo that has had a delayed implantation. Embryos normally implant between 7 and 10 days after ovulation and the placenta needs time to develop before it can produce enough HcG to be detected by a pregnancy test. Later, if the HcG levels continue to go up, the pregnancy should be confirmed by an ultrasound to determine the numbers of sacs and if there are heartbeats. The presence of a heartbeat is recorded as a clinical pregnancy.
The blood test is far more powerful and sensitive-it is quantitative-giving the exact level of HcG-the hormone produced by the embryo-present in the blood. Urine tests only are qualitative-positive or negative-fraught with misdiagnosis problems due to possible contamination-it is a quick and dirty method. All pregnancy tests after IVF and IUI should be repeated by a blood test two days after the first blood test. The doctor needs to know how pregnant you are-twins? ectopic? biochemical-early miscarriage? All can be determined by a subsequent blood test but not the urine test.
Back to Top of Questions
Home Pregnancy Tests
The urine values of HcG are lower than blood levels, but can be considered, for our purposes here, approximately the same as the blood levels. Therefore, use the table above for comparing over-the-counter Home urine Pregnancy Tests (HPTs).
According to the literature on a website about the kits (http://www.pinelandpress.com/support/hpt.html), the most sensitive over-the-counter HPT tests can detect levels of 25 mIU/ml HcG in urine. Most readily available kits are less sensitive; detecting 50 or 100 mIU/ml.
When Can You First Expect To see a Positive HPT?
Given the most sensitive HPT tests, and the table above, you are asking for trauma if you try before day 10. If we assume that the tests really can only detect levels of 25, then you cannot expect to see a positive before day 12, or perhaps even day 14 through 16. However, if you are still negative by those days, take heart in the story given below.
An Unusual Case of Low HcG and Successful Pregnancy: As many of us are highly sensitive to the type of information, this story might be of interest: A group in Denmark (Grinsted and Avery, 1996) reported a single case of suspected delayed implantation after IVF-ET. The woman had an HCG level of <10 mIU/ml on day 15 after transfer of 3 eggs by IVF-ET. The doctors assumed that she was not pregnant and had her stop all medications. The couple had intercourse one time between the transfer and day 15, but not again after that because of her depression and nausea. At seven (7) weeks after the transfer, the serum HCG was 329 mIU/ml. The ultrasound showed an early pregnancy and this woman gave birth to a healthy normal boy!
So, remember, this whole process is very complicated - do not give up too early or get depressed!
Will the HPT Kits Help Me Monitor My Progress in the Pregnancy After I See a Positive?
This is not a good idea. First, your levels may not climb continually. They may dip because of loss of one of the multiples, or for reasons we do not understand. Also, the sensitivity of the HPT kits can vary drastically from one brand to another and even from one box to another, even if they are the same brand. Finally, these tests are not meant to let you compare one day to another. If you have a band, no matter how dark, all you can say is that you are pregnant. It is impossible to say that slightly darker means the same level of HCG, or 2, 3 or even 10 times more HCG. They just aren't designed like that. So, leave this up to your RE (reproductive endocrinologist).
How Will My HCG Keep Changing?
In general, the rule is that HcG doubles every 2 days. However, this is very variable. It is likely to climb much faster after day 14-16, but if one of a multiple is lost, it could decrease. One study looked at day 15 and day 22 values and found that if the day 15 value was over 150 and the day 22 value divided by the day 15 value (day22/day15) was 15 or greater, there was a very good chance of a live birth. Because of the extreme variablity of the HcG levels, the better measure of success of an ongoing pregnancy is the vaginal ultrasound (US) at week 5 (3 weeks after transfer) when you should be able to see the fetal sac but no heartbeat. Even better is the vaginal US at week 6, when it should be possible to see a heartbeat.
References:
1. Glatstein IZ, Hornstein MD, Kahana MJ, Jackson KV, Friedman AJ. The predictive value of discriminatory human chorionic gonadotropin levels in the diagnosis of implantation outcome in in vitro fertilization cycles. 1995. Fertility and Sterility, 63:350-356.
2. Grinsted J, Avery B. A sporadic case of delayed implantation after in-vitro fertilization in the human? 1996. Human Reproduction, 11:651-654.
3. Heiner JS, Kerin JF, Schmidt LL, Wu T-CJ. Can a single, early quantitative human chorionic gonadotropin measurement in an in vitro fertilization-gamete intrafallopian transfer program predict pregnancy outcome? 1992. Fertility and Sterility, 58:373-377.
4. Mol BWJ, van der Veen F, Hajenius PJ, Engelsbel S, Ankum WM, Hogerzeil HV, Hemrika DJ, Bossuyt PMM. Diagnosis of ectopic pregnancy after in vitro fertilization and embryo transfer. 1997. Fertility and Sterility, 68:1027-1032. A Comparison of Home Pregnancy Tests
Copyright (c) 1996, 1997, 1998 by Rebecca Smith Waddell
25 mIUs
Equate (Wal-Mart)
* detects as low as 20 mIU
(The other companies are providing a guaranteed
level, which would obviously be higher than the as low as
number provided here.)
NOTE: I have been contacted several times regarding
false positives with this brand of test. Most of these false
positives were in overweight women who may have polycystic
ovaries (PCO). It is possible that these tests are detecting
elevated levels of LH (luteinizing hormone).
If your test line is very faint, please test again with a
different brand.
Also manufactures a number of store-brand tests.
Manufactured by Perrigo
Allegan MI 49010
1-616-673-8451
Advance
* detects 25 mIUs of HcG -- square test (2 steps)
* detects 50 mIUs of HcG -- 1-step
Manufactured by Ortho Pharmaceutical Corp.
Raritan NJ 08869
1-800-526-3979
Confirm 1-Step
* detects 25 mIUs of HcG
by mail since no phone number.
Distributed by Durex Consumer Products, Inc.
A division of London International Group, Inc.
3858 Engineering Drive NW
Norcross, Georgia 30092
1-770-582-2222
Consumer affairs 1-334-792-3775
Customer service 1-888-387-3927
Fact Plus square test
* detects 25 mIUs of HcG -- square test (2 steps)
* detects 50 mIUs of HcG -- 1-step
Manufactured by Ortho Pharmaceutical Corp.
Raritan NJ 08869
1-800-526-3979
LifeSign 1 Midstream Pregnancy Test
* detects 25 mIUs of HcG
Available by mail order only from Geodesic Meditech
1155 Camino Del Mar, #517
Del Mar, CA 92014 USA
1-888-357-9399, 1-619-792-1100
fax: 1-619-793-1824
jlolson@connectnet.com
http://www.geodesicmeditech.com
One Step Be Sure Pregnancy Test
* detects 25 mIUs of HcG
Manufactured by Syntron Bioresearch, Inc.
Carlsbad CA 92008
1-800-854-6226
Selfcare
* detects as low as 25 mIUs, "guaranteed" at 50.
Distributed by Selfcare, Inc.
200 Prospect Street
Waltham MA 02154
1-800-899-SELF (7353), 1-617-647-3900
50 mIUs
Advance One-Step
* detects 50 mIUs of HcG
Contact information
Clearblue Easy
* detects 50 mIUs of HcG
This for both 1-minute and 3-minute tests.
Manufactured by Whitehall Laboratories
Madison NJ 07940
1-800-883-EASY (3279)
E.P.T. Park-Davis
* detects 50 mIUs of HcG
Manufactured by Warner Wellcome Consumer Health
Morris Plains NJ 07950
1-800-EPT-1STEP or 1-800-337-7266
Fact Plus One-Step
* detects 50 mIUs of HcG
Contact information
First Response
* detects 50 mIUs of HcG (this is the *new* test with 1
window,
older test with 2 windows detects 100 mIUs)
Carter Products
Division of Carter Wallace, Inc.
New York, NY 10105
1-800-367-6022
100 mIUs
Answer
* detects 100 mIUs of HcG
Distributed by Carter Products
Division of Carter-Wallace, Inc.
1345 Avenue of the Americas
New York NY 10105
1-212-339-5000
1-800-833-9532 (customer service, *not* a help line)
Conceive
* detects 100 mIUs of HcG
Quidel Corporation
San Diego CA 92121
1-800-CONCEIVE (266-2348)
Precise
* detects 100 mIUs of HcG
Becton-Dickinson
1 Becton Lane
Franklin Lakes NJ 07417-1883
1-800-238-1000
QTest
*detects 100 mIUs of HcG
Manufactured by Quidel Corporation
San Diego CA 92121
for Ansell Incorporated
Dothan AL 36502
1-800-266-2348
Rite-Aid, Target & Hannaford
*detects 100 mIUs of HcG
Selfcare, Inc.
200 Prospect Street
Waltham MA 02154
1-800-899-7353
Walgreens
* detects 100 mIUs
Manufactured by Quidel Corporation for
Walgreens Co.
Deerfield IL 60015-4681
1-800-225-0730
Consumer Reports did its own ranking of pregnancy tests. Check the
October 1996 issue, or if you're on America Online you can check the
text in the Consumer Reports area. It is also posted on the
ONNA website at http://www.directiondesigns.com/onna/.
All rights reserved. The text from this page may be distributed
as long as copyright is attached and the use is not for profit.
http://www.fertilethoughts.net/faq/hpt.html
Last revision: June 24, 1998
Comments are welcome at hpt@pinelandpress.com, but please
note that medical questions cannot be answered. These pages are
patient FAQs written by patients, for patients.
Back to Top of Questions
To Tell or Not To Tell?
For anyone considering donor egg, "telling" can be an important question to resolve. This includes telling family and friends, and telling the child.
Obviously, there is no right or wrong, or clear-cut answer. Each couple will have to develop their own philosophy about how to handle this. What this information reflects is simply a summary of opinions of MVED members. Reading these opinions might help you develop your own answers to this difficult question.
As donor egg becomes more prevalent, there will be words of advice to rely on from parents with DE children who have gone through this. But, for now, we simply can ask for advice from others.
An informal poll taken of MVED list members resulted in the following information:
29% said that the child should know, but it is no one else's business.
21% were open about this DE issue with family, friends and the child.
50% felt that they would not tell.
In other words, it is basically a 50:50 situation.
There were very good arguments both for telling and not telling. One major issue that came out, was that if you decide not to tell, then you tell absolutely NO ONE. (As one person said, a story tends to spread like wildfire).
Most of the women also felt that our parents (us being in the 30s & 40s) would not understand (them being in their 50s - 70s). Also, people who have not been through infertility will have a hard time to understanding.
Telling the Child
The big argument for people saying a child should know, is that he/she might find out later and will feel betrayed. This is the most important issue to many. Also, bone marrow transplants & kidney problems needed later on, might cause a problem. They feel, that if a child hears it, it should be from the parents & not someone else.
Some felt that it should only be told to the child and s/he should be told it is a private matter. Should s/he want to tell this to anyone, it would be his/her choice. A child should not be put into a situation where he has to justify his origin. "Judgmental" was a word that came up a lot when speaking about other (clueless, ignorant) people.
Some arguments from the other camp (not telling) were: It puts too much burden on a child (emotional baggage). Children should be protected against the ignorant masses. And we, as DE parents don't want to "educate everyone" every time this issue is brought up. The most important thing is that a child needs to know how much he is wanted & loved. Who will, (without understanding what path brought you both to that decision) understand sufficiently your decision on DE? Children will never understand why you have done what you have done, or why you have made the decisions you have made. And you should not ever have to defend that decision.
Others were worried that the child might be treated differently by others who know and they do not want their child to feel any different, insecure or inferior to other children.
Some women worried about rejection from the child when they found out. Ask the question - Will my child be happier & healthier day-to-day if he knows, and will there be more love? Probably not.
Questions about the origin of the sperm & egg need not ever be a topic of conversation.
Conclusion:
What is right for one person is not necessarily right for someone else (all our circumstances are different). Please let us respect each other's views, because we can learn from each view.
Once it is "told", it can never be "untold".
If you cannot decide, consider then not telling anyone. You can take each day at a time and examine the situation as it develops (as one said: "sleep on it for a year or two"), and then make a decision when the time is right and the child is at an age when he can understand.
Telling Friends and Family
Personal crises have a different impact on every person. Some people do not wish to share their problems with anybody, and might even become very reclusive, or do a very good job of acting and pretending that everything is wonderful as usual. Some want to pour their hearts out, sometimes even to people that they don't really know that well or are close to. One reason to pour your heart out is that you hope the person will be supportive. On occasion, you hope that people will cut you some slack, be it friends, family or co-workers.
But, before you get into too much detail regarding your situation with anybody, you should ask yourself what you are trying to accomplish. This sounds like a very rational approach in times of high emotional distress, but it will ultimately serve you well.
Usually women going through infertility/egg donation have a husband/partner, and his/her wishes also need to be respected - it is vital that both people involved have the same attitudes in terms of disclosure, otherwise one person will only end up boycotting another.
Let's get back to what you are trying to accomplish - if you are seeking support, you have to carefully pick whom to talk to. Even the nicest people can be insensitive when it comes to infertility, especially when it involves egg donation. If you expect people to cut you some slack, you will be disappointed - most people are only understanding for a limited period of time, especially co-workers who don't really want to have to work harder while you are going through elective medical procedures (sounds harsh, but this is what people who are not going through this themselves often feel).
So far, what we have discussed only covers the circumstance when you feel the need to tell. The other circumstance is that friends and family may ask you very personal questions regarding your plans for children. The bottom-line is that these questions are as personal as inquiries into your sex-life or salary, and nobody is entitled to an answer. So don't feel guilty if somebody acts put-off when you decline to comment. Resolve has printed a very helpful brochure "When you're wishing for a baby - Managing family and friends". Many RE offices have these brochures; otherwise you can order it by calling 617 - 623 - 0744.
In terms of what you actually tell friends and family, you should decide whether you are pro-privacy or pro-disclosure. You need to realize, once again, that telling is always easier than untelling - once you have told people that you plan to do egg donation, it is usually difficult to convince them that magically you became pregnant with your own eggs. On the other hand, if you say that you had to do IVF (and certainly, you wouldn't even be obliged to get into that kind of detail), you can always add more information later.
One sentence that might be helpful is "We are trying some high-tech stuff, but talking about it makes us nervous and depressed" - only a cruel person would persevere. And once you have your little bundle(s) of joy, you could always say something like: "It was a lot of work getting there. We want to just enjoy our child/ren, and not revisit those anxiety-ridden and depressing times."
Dealing with the outside world when you are going through infertility is a challenging task. If you focus on what will be best for the child ("what would I like other people to know in terms of how I came to be?") and your relationship, things will fall into place more easily.
Back to Top of Questions
How Do the Chances of Success Differ Between a Fresh or Frozen Transfer?
As with all success rates, this varies from clinic to clinic. The most successful donor egg clinics these days are experiencing success rates of 50% and up (as measured by live birth rate per cycle initiated) on fresh cycles. Frozen transfers have lower success rates, possibly explained by a number of factors:
1. The number of embryos transferred on the average frozen embryo transfer (FET) is lower than the number of embryos transferred on a fresh cycle;
2. The best embryos are often transferred at the fresh cycle, so the frozen embryos may be of slightly worse quality;
3. The freeze/thaw process can thicken the "shell", making implantation more difficult.
Clinics are attempting to improve the statistics on FETs by doing assisted hatching on the embryos before transfer. In addition, a clinic may recommend that a recipient have more embryos transferred on a FET cycle than on a fresh cycle, although the patient is limited by the number of embryos available and the number that survive the thawing process.
The CDC publishes success rates overall and by clinic:
http://www.cdc.gov/nccdphp/drh/arts/index.htm
These statistics are prepared by each clinic and filed with the Society for Assisted Reproductive Technology (SART). Because successful cycles are often measured by live births, statistics are not available for at least 9 months following the end of a calendar year. Then they are compiled, resulting in further delays. The CDC's website currently has only 1995 data, though SART has published the 1996 results. A summary of the 1995 results is given below:
Fresh transfer live birth rate per transfer:
25.1% (excludes donor egg cycles)
Frozen transfer live birth rate per transfer:
15.1% (excludes donor egg cycles)
DE fresh & frozen live birth rate per transfer:
35.5% (data not split between fresh and frozen)
Often statistics on fresh cycles are provided on a "per cycle initiated" basis, so that anyone who begins medications and is subsequently canceled is counted as a failed cycle. The CDC web-site includes these statistics as well, but we have included here only the results per transfer, to provide statistics on fresh cycles that are comparable to those on frozen cycles.
The success rates shown above are outdated and the current rates are much better. However, this chart provides a comparison which indicates that FET cycles experience lower success rates than fresh transfers, in this year by approximately 10% (25.1% - 15.1%). The DE success rates were significantly higher than success rates on non-donor cycles, although no summary data was provided to compare fresh versus frozen transfer success rates on donor egg cycles.
Back to Top of Questions
When to Cancel a Donor Egg IVF Cycle
Provided by RESOLVE of Northern California
This is a controversial subject. In general the same rules that apply to canceling a regular (non-donor) IVF cycle should apply to a donor IVF cycle. You will need to discuss these issues with your doctor up front before starting the cycle. Many doctors are reluctant to cancel unless all indications are terrible. Because of the emotional and financial cost of any IVF cycle, you may want to cancel a cycle before retrieval, but be aware that you may meet with resistance from your doctor. You may still choose to continue with a cycle that doesn't look promising, but be sure it is an informed decision. You also need to remember that the donor is also a patient of your doctor and your doctor is obliged ethically and legally to provide the best care for her as well as for you. Here are some guidelines to help you through the process:
1. You will need to call the office every afternoon to get the results of your donor's estradiol; you should arrange this before the cycle starts. The estradiol should increase steadily over the course of her pergonal/metrodin. Short-term periods (3 or less days) of modest or no increase may be all right if the donor had lupron as part of her protocol. There may be a problem if the estradiol level stays low or plateaus for more than 3-4 days, and there is definitely a problem if the estradiol level drops. Most of the follicles should grow in size at about the same rate. Near the time of retrieval the estradiol level should equal approximately 200 times the number of mature follicles. Mature follicles are determined by their diameter; usually a follicle measuring 16 mm or greater is considered mature.
2. There have been successful transfers and pregnancies with few retrieved eggs and/or resulting embryos; your doctor will probably tell you this. The belief is that younger women will make great eggs and resultant embryos even if their number isn't high. However there are some things you should know.
First, not all follicles contain eggs, and not all eggs are mature at the time of retrieval. It's not enough to know that your donor has 10 follicles; you need to know the number of mature-looking follicles.
Second, not all eggs will successfully fertilize (even if there is no male factor) and some will be over-fertilized (with more than one sperm). A normal fertilization rate is about 60-70%.
Third, not all embryos will be of high enough rating (at least a 3 or C) to give a good chance of pregnancy. Embryos rated at 4 or 5 do not usually result in pregnancy.
Fourth, if your program has a good embryo freezing program, it would be nice to have enough to freeze for another try or a second child. Most clinics do not freeze embryos rated below a 3 or C.
It will assist you greatly if you ask ahead of time about the embryo lab's percentages with regard to these areas: fertilization rate, information about quality of embryos, and follicle to egg relationship.
3. If you or your doctor cancel a cycle, you need to know how much money you will be refunded from your initial payment. Most people will have paid the entire amount up front. Establish this ahead of time before the cycle starts. If you worked with a donor broker, you will need to discuss this ahead of time with him or her as well.
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RESOLVE National Office
RESOLVE of Northern California
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Infertility Resources
Developed and maintained by Internet Health Resources
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First posted: 4/30/95
Copyright 1995 RESOLVE, Inc.
Back to Top of Questions
What Can I Do After a Failed DE Cycle to Enhance Chances of Success in a Subsequent Cycle?
First, take heart because there CAN be success afterward! In the meantime, realize that not only are you going through tough times mentally, your body is going through a lot, recovering. Don't be shy about seeking help for your emotional pain. This can be in the form of using this MVED list, talking to friends, getting into massage and/or exercise, getting therapy, getting help from your religious group, etc. Most people simply want to try something different on the next cycle so that they feel they have a better chance of success. Below is a kind of checklist of things that might help you formulate a plan for your next cycle or give you an idea of some things to discuss with your RE.
Review your medical history and write down the major "events" in your reproductive life, the dates and all the details involved such as treatments and medications. Write down all the underlying medical problems you have and their treatments. Write down ALL the tests you have had and the results. Organize it well so it is relatively easy to read.
Bring this list in and give a copy to your RE. Get them to really look over your medical history to date. Despite the fact that the RE has your medical records, they are only human and they see a lot of patients. Sometimes bringing in this list and going over it in detail with her/him will help them see some area that still needs testing. Make sure that they have paid close attention to any underlying medical conditions. Then, tell him/her you want to get every possible test done (or re-done) that could relate to your reproductive problems. Then, if they have really ruled out any possible problem, you might want to consider one or some of these....
1. Assisted hatching (AH): AH is where the lab technician puts a small hole in the zona pellucida (the gelatinous layer around the embryo). This theoretically should make it easier for the embryo to "hatch" through that layer and implant in the uterus. The eggs from older women sometimes have a thicker zona. You don't want this done by a lab with little experience at it. If it is done wrong it could damage the embryo. The techniques involved are very similar to ICSI, so if your RE's lab does a lot of ICSI and AH, and has good success rates with those, then that is good. If not, consider another alternative.
2. Blastocyst transfer. This means that they keep the embryo for 5 days after transfer instead of the usual 3. They may use co-culture techniques to do this. (Co-culture means they put the blastocysts with another cell type to aid growth.) There is some evidence that this aids implantation. Again, your RE's lab has to be good to do this. The techniques to get blastocysts to grow are still experimental.
3. Use some technique to prevent your body's immune system from rejecting the embryo. Most REs will approve of you taking one baby aspirin per day, beginning before the transfer and continuing throughout the pregnancy. Many studies have shown that this can increase the success rates for IVF in women that have had multiple miscarriages. It interferes to a small extent in clotting, and clotting is part of the immune rejection process.
The next more complicated steps in fighting autoimmune problems are to combine this with either heparin injections or steroids (prednisone). These medications have been used with some success to fight autoimmune problems. Heparin greatly decreases blood clotting, so excess bleeding can be a problem. Prednisone has some risks involved too, so your RE needs to be familiar with your medical history.
Finally, the most drastic (and expensive) technique at present is giving intravenous immunoglobulins (IVIg). This is the technique that is championed by Dr. Beer in Chicago. It is also the most controversial. Dr. Beer quotes very high success rates, but there is controversy among many other REs about his program. Most of the studies that are thought to be reputable have shown no increase in pg rates with this. Ask your RE how he/she feels about the effectiveness and risks of this method.
4.. Some clinics do a mock cycle, to see how your body reacts to the medications. This ensures that your body reacts properly to estrogen and progesterone, and all the other drugs. If you have a problem with developing a poor uterine lining, this can pinpoint that problem and they can start doing something about it.
5. Find out all you can and don't be shy about asking questions of your RE. If ever there was a time to learn to be aggressive with a doctor, this is the time. It is your life, money and baby you are fighting for.
6. And last but not least, keep trying! There are so many unknowns that it really is a matter of the odds and persistence. And on the side, keep encouraging your RE to do research, keep pushing the insurance companies to pay for assisted reproduction and keep encouraging congress to pay more for medical research!
Back to Top of Questions
When To Move On
The knowledge of when to move to on, either onto another path or to embracing child-free living, is very individual and a very difficult one to make. When is enough? When is it time to move on to the next step, whatever that means in your individual situation? Some things to consider include:
1) Finances. What are the financial impacts of what you're experiencing? Are you going into debt? Are you comfortable with the level of debt incurred? Are you sacrificing future security and is that OK?
2) Your relationship with your significant other. How is your relationship withstanding the rigors and stress of infertility and decision making? Is your communication sound? Are you able to discuss what's happening? Are you in agreement or supportive of one another? Are you in sync with future plans? Or, is it time to unburden yourselves of the demands being made?
3) Your physical and emotional health. Are you physically able to continue or have you had enough? Are you able to maintain a semblance of emotional equilibrium or are you constantly depressed and overwhelmed? Is your overall well being (family, work, relationships, finances, etc.) suffering? Is worth it to continue down that road?
4) The desire for something tangible vs. unknown. The move toward adoption is often made because the need to parent is greater than the need to experience pregnancy and/or a genetic link.
5) Time pressures and markers Sometimes people use their birthdays or significant dates as milestone markers - to begin or end something.
6) Overall vision - major life plan. Some people have a pre-arranged time limit on their quest for children based on their overall view of the scheduling of things and their budget.
7) There may be family or work pressures that influence people to change course. There may be an illness in the family that facilitates a decision to change, or work demands which may help you make decisions.
8) Decisions may be facilitated by reading, exchange with others undergoing similar experiences (Internet newsgroups, therapy groups, adoption groups, etc.) seminars, RESOLVE meetings, psychotherapeutic counseling, religious searching and counseling, etc.
9) There is a burning desire to either continue or begin a significant journey in your life unrelated to childrearing.
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DE Outside of the US
Following is a summary of DE laws and procedures in several different countries.
Australia
There are two ways of receiving egg donation in Australia: by finding your own donor or by waiting on a clinic list for anonymous donation. There are long waiting lists for egg donation at the clinics with generally a minimum waiting period of at least 2 years. However, there are also many clinics where there is an indefinite period of waiting. It is worth phoning around the clinics to find the up-to-date situation as this can change quickly. You could find yourself at the top of the list if they are just starting a program or reorganizing.
You can also find an egg donor who is a friend or relative, or by advertising in parents' or women's magazines. Some people have even found more than one willing donor this way!
The shortage of donors at the clinics is in part due to legislation which in most states prevents donors from being paid for donating eggs except for traveling or medical expenses. Another reason for the shortage of donors is as well is, of course, the risks and time involved, plus the fact that legislation may be enacted in the future which allows identifying information on donors to be given to the children. (This already exists in Victoria).
Some potential egg donors, however, would strongly prefer to meet the egg recipients and to know their eggs are going to a good home, so they prefer known to anonymous donation. Some clinics reimburse known donors for expenses; on other occasions this is left up to the recipient's judgement. Many clinics also only allow egg donation from their own limited supply of donors to recipients who are less than 40 years of age. So if you above this age you will need to bring your own eggdonor. Recipients may generally be up to about 50 but it is something that you need to ask first before deciding on your choice of clinic.
Known donation, which some clinics will allow, allows the possibility of fresh egg transfer which gives a higher success rate. Shop around, as there are many clinics which won't allow fresh transfers.With anonymous donation, there is a generally a 6-month quarantine on using the embryos after donation.There may also be a waiting period of 3 months at some clinics after seeing the specialist, a "cooling off period," for the donor/recipient before donation to give them time to change their mind. There is also a month before you can get an appointment to see the specialist.This can, therefore, make the waiting period to receive embryos up to 12 months, if a six month quarantine period is also necessary, and 2 monthly cycles are involved in the donation. It is worth finding out clinic policies on each of these matters before you decide on a clinic. If you find a donor in a particular area, it is also possible to have the monitoring carried out by one clinic and the final pickup at another. This helps to get around these limitations and do a fresh egg transfer.
Egg donation, in fact, has a higher success rate than normal IVF, with around a 15 - 16% take home baby rate per transfer. Of course you will hopefully have enough embryos for several transfers. An egg donor, like all Australian residents, has six subsidized cycles of IVF/GIFT for donation through Medicare which helps with costs for medication and monitoring. Some out-of-pocket costs however will remain. These will be generally considerably higher if you choose anonymous donation through a clinic (eg $Au750 - $5000 at 1998 depending on variables and clinic). However overall egg donation in Australia is very affordable compared to many overseas countries.
Amazing as it seems, there are some wonderful women out there who will donate totally altruistically, and without receiving payment, who will respond to advertising requests from other women or clinics looking for egg donors. Despite the challenges of the system, it is possible to be successful and find an egg donor with advertising in parents' or women's magazines in particular. In fact, sometimes you may find more than one potential donor, in which case you can line both donors up at the clinic and increase your chance of success.
(c) Anne Ozscot, 1998
Denmark
Danish laws allow only egg donation from women undergoing IVF themselves. No money can be involved (that is considered selling reproductive material/children, which is strictly prohibited). Obviously there are not a lot of donors around. Also, the doctors do a lot when putting together the stimulating protocol to avoid the risk of hyperstimulation, so very few produce a lot of eggs, further deepening the existing shortage of eggs. Because of these factors, few people in Denmark actually get the opportunity to try DE.
Egg (and sperm) donation is strictly anonymous. You get no information about your donor at all. Basically, you are offered the eggs that are available, but the Danish doctors would not match very different types (i.e. a common blond, blue eyed Dane and black or Asian donor). Who is matched with who is only registered at the clinic and a DE/DI child can't have information about its genetic parents at a later date. The child is automatically registered as yours and the fact that it came from DE/DI is only known by the people you tell it to.
Infertility treatment (including in principle DE) is offered for free under the public health service, if you are not too old (generally the public clinics only allow women on their long waiting lists until the age of 35-36). Usually, you get 3 IVF tries; then you must go to a private clinic like those too old or too impatient for public treatment. No clinic - be it public or private - is allowed to treat women over 46. In the case of DE/DI, one of the parents must be genetically present, so embryos made from donor eggs and donor sperm are not allowed and consequently embryo adoption is prohibited too. Embryos can be frozen for 3 years, then they are destroyed. Scientific use of embryos is prohibited.
Greece
In Greece, DE issues are very obscure. There is no law forbidding or allowing the DE procedure, so everything depends on the relationship between the doctor and the patient. Following is a quote from a MVED member from Greece, "I had many DE procedures in Greece, I never knew how many eggs I would get and I did not dare to ask. I could be waiting on estrogen for 17 days to 1.5 month."
The DE recipient does not know if the donor consented, what kind of problem the donor has, who she is, if the donor pays less, if the recipient pays more. All recipients have so many questions they will never ask, and will always be grateful to the doctor even if they know that their chances are minimal.
Things are easier if you bring the donor because then it is considered as a standard IVF procedure.
Canada
In Canada, socialized medicine is a factor in invertility treatment. IVF is not covered unless your tubes are blocked, then only a limited number of cycles are covered. DE is never covered, although medications may be covered by many people's drug plans from their place of employment.
The cost of your cycle is directly related to how long you want to wait for a donor. It's cheapest at regular hospitals but waiting periods are so long (3-6 years), that most people go to private clinics. Some mid-priced clinics have waiting lists that are as little as 9 months to a year long, and one clinic that has access to American donors has no waiting time but the cost is $17,000 (American).
Canadians have most of the same options open to them that US citizens to. They can wait for the clinic to find a donor for them or find their own. They can also share cycles with other couples or with someone undergoing an IVF cycle.
Whether or not you meet the donor or not is sometimes up to you and sometimes up to your clinic's policy. Usually, people take the first donor that is offered to them because the wait has been so long to get one.
There are no age restrictions at most private clinics.
Israel
In Israel, the law allows egg donation to come only from women undergoing IVF for their own needs. Fertility drugs and treatments are given only to women who want themselves to have a child and need assistance. These women can donate some of their eggs to another woman who need a donation. No other arrangements are allowed, though there are now motions to change these regulations. Naturally, in this situation only physicians can be egg recruiters - and you need to find a doctor who is a good recruiter to have ready donations. Some doctors do not recruit at all, so patients who want eggs must go elsewhere.
Since almost everybody can get coverage in Israel for IVF for a first or second child, there are no money incentives for young women to donate. Rather, women donate to cover the treatment in a private establishment, with a specialist doing the procedure and not the physician on duty, as happens in most public (covered) IVF units. Occasionally there may be a woman who will donate because she prefers "fresh" cycles over FET.
In Israel, all donation is anonymous - and that means strict anonymity. You get no info about your donor at all. The matching is done either by the doctor or by the DE coordinator - if more then one physician shares a pool of donors.
DE cycles can sometimes occur in public hospitals - but that's rare, and you can expect to wait 1-3 years for donation. On private practice you have a lot more activity, and waiting can vary from none at all to 7 months.
Japan
Egg donation is illegal in Japan. IVF with your own eggs is OK, and sperm donation is legal, but not DE. If Japanese women want to try DE they have to go to another country.
UK
In the UK the main thing is that it is forbidden by law to pay a donor for her services. (only her expenses, e.g. travel, babysitters, etc and obviously all her clinic and meds costs). So therefore it has to be altruistic. There are long waiting lists for donors at all the clinics, both private (pay for everything) or NHS (free but restricted and long waits). A few clinics (eg the Cromwell) do egg sharing. So one can either bring ones own donor or advertise. They then categorize the donor as 'known' or 'unknown' to the recipient. If known, then the donor & recipients have to do physchological tests and it has to be approved by a committee. Not too hard but a bit of a pain and time consuming.
What is quite common is for someone to bring a friend or relative as a donor, for that donor to give to someone else, i.e. a stranger, which means the person who brought her in goes to the top of the list. Re: insurance, they do not cover infertility at all unless you have the very top of the range executive coverage.
The usual total cost would be about ú3000 - ú6000.
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Other Web Sites That Might Be Helpful
1. Infertility Treatments (and Related Procedures), from Internet Health Resources: http://www.ihr.com/infertility/treatmnt.html
INCIID: InterNational Council on Infertility Information Dissemination: http://www.inciid.org
PUBMed: You can search the original medical literature yourself, read abstracts on line and then register to have the articles sent to you. http://www.ncbi.nlm.nih.gov/PubMed/
http://www.eggdonation.com Shelley Smith (Egg Broker)
http://www.ivf.com AHRC(Atlanta Medical Group)
http://www.hannah.org Christian support
http://www.asrm.org
http://www.resolve.org Infertility Support Group
http://www.mostonline.org Multiples
http://www.obgyn.net
http://www.surrogacy.com/fortility/weblinks.htm
http://www.debsdomicile.com/wgen.htm
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