Introduction

Egg donation refers to a form of assisted conception treatment whereby another person’s eggs are used. The woman who donates the eggs is the donor; the woman who receives the embryos (fertilized eggs) is the recipient. Both the donor and the recipient should have counselling to discuss the psychological, moral, ethical and legal implications of egg donation.

Who will benefit from egg donation?

• Women born without functioning ovaries (e.g. Turner syndrome)
• Women who have their ovaries removed for cancer, ovarian tumour, or endometriosis.
• Women whose ovaries were damaged by previous chemotherapy or radiotherapy.
• Women who have recurrent IVF failures.
• Women who have inheritable conditions: sex linked diseases such ashaemophilia, Duchene’s muscular dystrophy and Huntington’s chorea. There could be other chromosomal or genetic abnormalities which could be passed on to the children.

Issues pertaining to egg donation

The most difficult task is the recruitment of donors. There is a huge shortage of donors. Historically, donor eggs were obtained from women undergoing IVF treatment with excess eggs. They were not ideal donors. With improved technique of embryo freezing, excess eggs became scarce.

Donors can be known or anonymous. A family member (sister or niece) or a close friend can act as an egg donor. The other option is to advertise and recruit anonymous donor.

The long-standing debate is whether it is morally correct to pay the donors. It is equivalent to selling body parts and it may attract the wrong people to do it for the financial benefits. In view of this, some countries like France, Germany, Norway and Sweden ban egg donation completely. In some countries like USA, there is no regulation and payment to donors is allowed. In the UK, new legislation from the HFEA allows clinics to compensate donors (up to £750) for their travel and expenses.

The other controversial point is anonymity. Some donors would like to meet the recipient and to know what sort of person is going to receive her eggs. But this can lead to other social problems. Some donors do not wish to know or meet the recipient. They would like to know only the basic information about the recipient. Along the same lines, many recipients do not like to know or meet the donors. But, some would like to meet and know the donor before proceeding with the treatment.

Egg donors

Who can be an egg donor?

Any healthy woman between the age of 18 and 35 years can be a donor. It is preferable for the donor to have had a healthy child (or children) of her own. There should be no family history of genetic or inherited diseases. There should be no history of mental illness.

Screening of donors

Egg donors initially have a consultation with a doctor who will take a detailed medical history and perform a physical examination. A vaginal ultrasound scan will be performed to check the uterus and the ovaries. The doctor will explain the procedure involved in egg donation treatment. The donor will be offered counselling to discuss the social and psychological issues. Donors will be screened for the following:

• Full blood count
• Blood group and Rhesus type
• HIV and HTLV
• Hepatitis B and C
• Syphilis (VDRL)
• Cytomegalovirus virus (CMV) antibodies screening
• Chromosomal analysis
• Cystic fibrosis screening
• High vaginal swab
• Cervical swab for gonorrhoea and chlamydia
• In non-Caucasian donors, other screening tests are carried out in suitable cases
• Sickle cell tests for Africans
• Thalassaemia screening for Asians and Mediterraneans
• Taysach’s disease screening for Jews

Though the list seems to be a long one, all these can be done in a single blood test, except the two swabs

Egg recipients

Criteria for recipients

• Any woman up to the age of 51 years
• No history of serious medical illnesses
• No contra indication to pregnancy
• No history of mental illnesses
• Body mass index less than 35

Screening for recipients

• Full blood count
• HIV
• Hepatitis B and C
• Chlamydia
• Rubella immunity

Matching of donor and recipient

Usually the donors and recipients are matched for ethnicity, and physical characteristics such as eye-colour, hair-colour, skin-colour, height and build.

In the UK, according to the Human Fertilisation and Embryology Authority (HFEA) guidelines, the donor’s cytomegalovirus virus (CMV) status should be matched with that of the recipient. If the recipient is CMV (IgG) positive, she can use a CMV (IgG) positive or negative donor. If a recipient is CMV negative she can be matched with a CMV negative donor only.

What is the involvement of the donor?

The first step is the suppression of the hormone by a spray or daily injections. This is followed by a series of daily hormonal injections to stimulate the ovaries to produce many follicles (containing eggs). During the two week period of injections, the donor will be scanned three to four times to monitor the ovarian response. Blood tests to monitor the progress closely. Usually there are no side effects to these injections apart from the discomfort and bruising at the site of injections. However, some women may experience tiredness, tummy bloating, head ache, mood changes, hot flushes and weight gain. These are only temporary and all the symptoms will usually disappear once the egg collection is done.

When the follicles reach a mature size, the donor will be given the trigger injection to start the maturation process of the eggs. This will usually be a late evening injection and the egg collection will be performed 36 hours later. This is usually carried out under a mild intra-venous sedation. The follicles are aspirated trans-vaginally under ultrasound guidance. The donor will be allowed home after a couple of hours.

On average, donors produce eight to fifteen eggs. Occasionally, (5% of the cases), the treatment can be cancelled due to poor response or over response which can lead to ovarian hyperstimulation syndrome.

The donor is advised not to have unprotected intercourse following the egg collection until the next period to avoid the risk of unplanned pregnancy.

Risks and complications of treatment

• Ovarian Hyper-Stimulation Syndrome (OHSS). When the donor responds too well to the stimulation and produces a lot of follicles (and eggs), she runs the risk of developing OHSS. This can be mild, moderate or severe. Here the woman feels unwell, has nausea, sometimes vomiting, abdominal bloating, difficulty in lying flat, difficulty in breathing and passing small quantities of urine. Donors are carefully monitored with frequent scans and blood tests. If there are a lot of follicles, the dosage of the drugs may be reduced. They are advised to drink a lot of fluids which includes water, fruit juice and milk. If the OHSS is severe, the treatment may be abandoned.
• Pelvic infection. As the egg collection is performed trans-vaginally, the needle passes through the vagina and this can introduce infection into the pelvis. It is important to do swab tests before commencing the treatment. If there is any evidence of infection in these tests, it can be treated appropriately first. Antibiotics are given as a preventative meausure at the time of egg collection.
• Ovarian cancer. There have been a lot of studies to see if these hormonal injections cause an increased risk of ovarian cancer. So far, they have not been able to prove any link.
• Unplanned pregnancy. If the donor is not careful, and has unprotected intercourse during the treatment period, particularly the two weeks following egg collection, she can become pregnant. This can come as a surprise if the donor is not planning for a pregnancy.

Treatment synchronisation

Women who still menstruate will have hormonal suppression. This can be carried out in the form of daily injections or daily nasal spray or a single depot injection. Once the hormonal suppression has been confirmed by scan and/or blood test, they will be started on oestrogen tablets/patches to prepare the lining of the womb. Women who have stopped menstruating can straight away start with oestrogen tablets/patches without hormonal suppression. This is done as soon as the donor is started on the injections for ovarian stimulation to ensure that the recipient is ready for the implantation when the donor undergoes egg collection.

When the donor has egg collection, the recipient will be started on progesterone supplementation in the form of pessaries. The embryo transfer will be performed 3-5 days after egg collection. Surplus embryos will be frozen for future use. Pregnancy tests are usually performed in two weeks time. During this period Oestrogen and progesterone will be continued for the recipient. In the happy event of the test being positive, they should be continued for another two months (until 12 weeks of gestation).