SART Fertility Experts - Donor Eggs: Fresh or frozen?

The information and opinions expressed in this podcast do not necessarily reflect those of ASRM and SART. These podcasts are provided as a source of general information and are not a substitute for consultation with a physician. Welcome to SART Fertility Experts, a podcast that brings you discussions on important topics for people trying to build a family.

Our experts are members of SART, the Society for Assisted Reproductive Technology, an organization dedicated to ensuring you receive quality fertility care. Hi everybody, welcome to the SART podcast. I'm your host Dr. Mark Trolice and it's my pleasure to have as a guest today Dr. Jennifer Kawwass .

Jennifer is the Medical Director at Emory Reproductive Center. She's Associate Professor there, Division of Reproductive Endocrinology. She did a residency at Emory, a fellowship, and is at Emory now and has contributed greatly to our knowledge in reproductive medicine.

Her interests are tubal factor and fertility and vitreofertilization. Today we're going to talk about egg donation and the difference between fresh and frozen. For years, since the 1980s when we started egg donation, it was always fresh egg donation.

We would stimulate patients and synchronize them with the recipient. But since around 2012, freezing eggs and then using them for egg donation started to gain popularity and has dramatically changed the landscaping of how we do egg donation. So we're going to talk today with Jennifer about this process.

So welcome to the podcast, Jennifer. Thank you, Mark. It's a pleasure to be here.

Well, it's mine as well. So Jennifer, take us back to 2012. That's when the American Society for Reproductive Medicine removed its experimental label on egg freezing and allowed clinics to be able to start offering this as standard of care.

And initially, it was used for egg freezing and anticipation for fertility preservation. But tell us why this sort of segued into egg donation. That's a great question, Mark.

So, and I think it was about October of 2013, ASRM put out a practice bulletin that suggested that oocyte cryopreservation, which is the freezing of eggs, was no longer considered experimental and that we had enough data to suggest that outcomes were similar between eggs that had been frozen previously versus eggs that were used fresh. This practice bulletin focused mostly on women that were freezing eggs for fertility preservation. So women undergoing treatment for cancer or some other therapy that might impact their future fertility.

But as a downstream impact of that publication and sort of the realization that fresh and frozen eggs could be used somewhat interchangeably, the field of egg donation and egg freezing for the purpose of donation has also sort of changed course and transitioned over the last nine, five years. Yeah, so what do you think is the advantage? For a while, we thought that fresh eggs were better, and I think it really had showed that. But over the last few years, we're seeing increasing success with frozen eggs comparable to fresh, essentially.

What do you think is the advantage? If a couple comes to you and says, we want to use an egg donor, I don't know what to do. Should I use fresh or frozen? How do you tell? What do you counsel them with? Well, I think you have to think about it on a case-to-case basis, as is true with a lot of things in the field of reproductive endocrinology. It depends on the center where you are having treatment and what they offer as services and also on what your family plans are.

Some of the advantages of using a fresh donor, for example, is that you might get a larger cohort of eggs and might have the opportunity to generate more embryos that may be able to allow you to build a larger family if you anticipate wanting more than one or two children. There also, in some situations, may be more diversity in the donor pool if you're selecting from a fresh donor. The limitations of using a fresh donor are that all donors go through FDA donor eligibility screening, and it can take a pretty significant amount of time to find a donor with whom you feel comfortable and also for that donor to go through all the screening that is required to make them eligible to donate their eggs anonymously.

In contrast, when you use frozen eggs, the donor has already gone through all of that screening and the eggs have already been retrieved and are frozen at an egg bank, so the time period from your decision to move forward with donor eggs until your ability to have a transfer is often shorter. Additionally, you can often buy sort of a cohort of eggs, so eggs are often sold in batches of six, seven, or eight. The limitation of this is that you might end up with one, maybe two embryos from each cohort.

We tend to think, whether it's for donor egg or autologous eggs, that from every six to eight eggs, on average, you may result with one embryo at the end. So if you buy a cohort of frozen eggs and only end up with one embryo, you may have to start from the beginning in order to generate more embryos. I think that's one of the key points.

When a couple ask me, or a patient asks me, which I use, fresh versus frozen, I often ask them, how many children do you want? Because if you're using fresh, you can end up with a lot of extra embryos. I mean, five, seven, ten. Frozen, probably one to three blastocysts, day five embryos, and not always a guarantee to go to blastocysts.

So that's definitely a concern. But if they only want to have one child, they may want to lean more towards frozen. That's true.

To not have to be concerned about, now what do we do with all these extra embryos? We have our family, what do we do? Do we donate them? You know, difficult decisions. Another thing, though, is the cost. It's true.

Yeah. Fresh seems to be, roughly, from talking to different programs, you could be talking about $10,000 more than frozen. Is that your understanding? That's true.

And I think another differentiating factor is whether the clinic at which you're seeking care has an egg bank in-house. There are some clinics that ship eggs from a central egg bank to their clinic, and some clinics that have an egg bank within their facility. And some of the flexibility in terms of the number of eggs you can get, or the ability to unfreeze additional eggs if the eggs don't thaw well, can vary depending on whether the eggs are coming from an external facility that has shipped a limited number, compared to a clinic that has the eggs available and can unfreeze eggs on an as-needed basis.

Is there a specific circumstance, Jennifer, that you would recommend fresh versus frozen for a patient? For a directed donor, so if you have someone whom you would specifically like to donate eggs, that's probably one of the most common indications. Like sister, cousin, niece. Correct.

Yeah. Yeah. Interesting.

What did you learn from your article in the Journal of the American Medical Association JAMA? You talked about donor egg trends, predictors of good outcomes. What did you gain from that? And what can you tell our audience? So in 2013, using national data that's collected by a CDC surveillance system, we looked at all donor egg recipient cycles that had been performed in the United States over a 10-year period. And we noticed that an increasing number of women are using donor eggs in the United States.

But we also learned that the percentage of those pregnancies that end in a term baby of normal birth weight has been increasing over time. And this is largely a reflection of the fact that practices are trending toward what's called elective single embryo transfer, which is when you put in one embryo at a time, even if you have extra embryos available. I often see couples, particularly from other countries, talk about doing chromosome testing on these donor eggs that contributed to embryos.

I think that that's a situation is very individualized, but it's probably not as cost effective, given that these are the best egg qualities that we can have. How do you counsel patients about that when they ask, should I test these embryos? I agree completely. It is a little bit of a controversial topic, potentially, worthy of a podcast of its own.

When to do and when not to do pre-implantation genetic testing. I would say, again, that nothing in REI is black and white. But generally speaking, when you're using donor eggs and the oocyte source is someone who's relatively young, the benefit gained from doing genetic testing is probably pretty limited.

What we didn't talk about yet is the process of freezing these eggs. Years ago, when they started to try to freeze the eggs, there was a slow freeze method. For our audience, this was risky for the eggs, because the egg has a high water content, and the slow freezing actually caused some crystal formation within the eggs that caused damage.

But then vitrification, which is a rapid freeze, came about and really allowed us to be able to do this kind of freezing and enhance the ability to keep the egg quality when it was frozen and then thawed. Do you have an idea of what percentage of survival of these now vitrified eggs are and fertilization of these eggs? What do you counsel patients about that? If they purchased six to eight eggs, how many eggs would you say would survive and then fertilize? I think the anticipated survival is well over 90 percent, maybe even 95 percent. A lot of the data, very interestingly, comes out of Italy, where freezing embryos was not legal for a long time, and so they gained a lot of experience in freezing eggs.

And a lot of what we know now and sort of the turning point in egg freezing, going from experimental to standard of care, stems from many studies that were done in Italy. In terms of fertilization, as far as I know, I actually think the fertilization rates are thought to be comparable, probably somewhere around 75 percent. And the recommendation usually is to do ICSI, or intracytoplasmic sperm injection, where a particular sperm is selected and injected into the egg.

For all frozen eggs? At the moment, that's the recommendation, yeah. We hope you're finding this episode of SART Fertility Experts helpful. Remember, for more information on this and related topics, visit www.sart.org and click on the tab labeled Patients.

And now, back to SART Fertility Experts. So we talked a little bit about the FDA screening of donors, sexually transmitted infections, the donors undergo drug testing, genetic screening, psychological screening. What type of screening for the recipient do you do for your patients? For recipients that are planning to use an egg donor, some of the screening is very similar to anyone who would be aiming to get pregnant.

So you want to make sure that the female partner is as healthy as possible. So you would do sort of standard prenatal screening. You would screen both partners for sexually transmitted infections.

And then both individuals in the relationship that are using the donor oocytes would see a psychologist for a psychoeducational appointment. It's an appointment where anyone using donor gametes, whether it's sperm, egg, or embryos, meets with a psychologist who specializes in third-party reproduction to sort of learn about studies that exist to date regarding use of donor gametes and to think about topics or issues that may come up in the future that warrant some forethought. For example, disclosure, you know, when might you tell the child that they are the result of a donor gamete? Are you planning to tell your friends and family? And making sure that everyone sort of feels comfortable and confident moving forward.

I found, excellent points, I found that the recipients are always worried about their age and how that impacts their fertility. And you try to educate about that to say that, you know, the uterus is not going to age reproductively like the eggs do. Probably only into the late 40s and early 50s do you start seeing a decline.

But what age do you recommend not proceeding with egg donation? That's it. There's lots of opportunities. I mean, we're seeing some sensationalized reports of women much, much older and menopause that are doing this.

Do you have a cutoff about the recipients? The American Society of Reproductive Medicine came out with the guideline of 55 as a cutoff. But what are you advising your patients? That's a great question. And not an easy one.

But our recommendation is sort of the natural age of menopause, which is 52 in the United States. So at our clinic, we use 50 as the cutoff for someone who doesn't have any frozen gametes and 52 if they do. This isn't meant to be discriminatory by any means.

But there are a lot of factors to take into account. The risk of pregnancy itself, the outcome of the pregnancy, and then the well-being of the resultant child. There are lots of ethical considerations both for the patient, the couple, and the resulting child or children.

What we do in our clinic is that we, it's arbitrary, of course, but we know that as a woman gets older and she carries a pregnancy, the risks during that pregnancy are higher. Hypertension, diabetes. So we've used 45 as a cutoff to do a complete health screen.

And we do an EKG, a treadmill stress test, a glucose tolerance test. We have them see a high-risk obstetrician. Because it's something that is, as much as it can be done with ease to do a transfer, the resulting pregnancy, we want to try to ensure that it's as healthy as possible.

That makes a lot of sense. Yeah. So we talked about screening for the recipient.

But bring us up to date, Jennifer, as to the standard of care right now, as to how we screen an egg donor. And what qualifies them to be an egg donor? That's a great question, Mark. So egg donors sort of fall into two groups, either known or anonymous.

And among the anonymous donors, the donation can be fresh or frozen. Among all egg donors, there is screening that is mandated by the FDA. This screening focuses mostly on risk of infectious disease and transmission of any type of infection from one individual to another.

So the same rules that apply to any kind of organ transplant apply to an egg donor. And this screening is termed donor eligibility testing. It involves a physical exam, an extended questionnaire that includes risk factors, such as areas of travel that might incur risk, and a physical exam, as well as a long panel of infectious disease blood tests.

To be an anonymous donor, all of that screening has to be deemed eligible or found to be negative. In the setting of a directed donation, that screening is still required. However, if someone is found to have a risk factor that the recipient is willing to consider or incur, the donation is allowed to proceed.

In addition to the FDA screening, donors are highly recommended and essentially required to go through additional screening that is guided by ASRM. This screening includes a meeting with a psychologist and a psychological evaluation, a meeting with a geneticist, and again, is focused primarily on looking at family history risk factors, as well as making sure that the donor herself is comfortable with moving forward and appreciates and understands what she is doing by donating her gametes. And there's also recommendations to not exceed, I think, five or six numbers of cycles for an egg donor to avoid the theoretical risk of consanguinity, which is the potential for the donor's eggs to be inseminated with some potential similar genetics from a relation.

Now that the world is a smaller place, it's hard to really put a number on how many times someone can cycle to go through that. We talked a lot about the different ways to screen, but what we didn't touch upon is when would a patient choose to pursue egg donation? The biological desire is to always have that connection to the baby, right? Eggs and sperm. But there reaches a point where the prognosis is so poor, and I'm going to talk, you know, obviously ovarian failure, menopause, I mean, those are obvious situations.

But when do you think a patient should really start considering egg donation, even though she's having cycles and hasn't reached the point of menopause? So how would you counsel a patient to that? Well, I'd say that the indications for egg donation are more varied than one might think. The classic indication, as you suggested, is someone who has significantly advanced maternal age, which somewhat remarkably can be in the early to mid-40s from a reproductive perspective. Additionally, someone who has significant diminished ovarian reserve or premature ovarian insufficiency even at a young age is likely to be a candidate for donor oocytes.

Same-sex male couples who desire to conceive using fertility services often use donor oocytes. And often even women with certain genetic diseases might opt to use donor eggs rather than their own. Now, if it's a heterosexual couple, I have found that there's a challenge initially by at least one of them to pursue egg donation.

And sometimes it's the man and sometimes it's the woman. What do you see as the stumbling block to pursue egg donation? What are the challenges psychologically for the intended parents? I agree completely in that it's often a very difficult decision to make and that it's something that evolves. So I'd say it's very rare that someone walks into my office and says, hi, I'm here to do egg donation.

But over time and with some sort of time to think through their options and think through what their goal in terms of parenthood is, the realization that building a family is not always the way that we initially envisioned it. It can be involving donor gametes. It can be adoption.

There's so many ways to build a family and to be a parent. And that I think over time, sometimes a couple's attitudes or priorities may shift. And there are many women for whom donor egg is the right choice.

And there are some women for whom it doesn't feel right. And I would argue that if it doesn't feel right, it's probably not a good idea. I'll never forget a patient.

We had just done a transfer. It was a Saturday morning. And wishing her well and ready to leave.

And she goes, can you make sure that my OB-GYN doesn't know this was egg donation? And I says, well, it's certainly going to be your prerogative. But given your age, he or she is going to think that you're going to be at risk of a baby with chromosomal issues like Down syndrome. And he's going to want to do that kind of testing.

I says, can I just ask why you would want me to withhold that? She says, well, I don't want my OB-GYN to know the baby isn't mine. And that was a paralyzing sentence to me. I remember it vividly.

So I literally had to sit down with her in the transfer room. And I says, can we talk a little bit? And I think when someone chooses this route, the baby that comes from that is only going to know the mother or if it's a heterosexual couple, the mother and the father as their parents. And I think when you choose this option, it needs to be chosen proactively where they are embracing that child as theirs.

Same as adoption. I adopted five children. And it's not in any way second best.

It's a way that you have decided now to choose your family. And I think it has to be looked upon in that type of encouraging way. And it's a much more healthy way to do that.

When we started to look into adoption and we adopted our first child, I shared with my wife, I did not want to have any more attempts at biologic children because I didn't want our children to ever think they were temporary or just a second best, as I said. So it's a it's a very our field is full of psychological challenges. But it's it's very rewarding nonetheless.

So, Jennifer, thank you so much for your insights, your years of valuable contributions to the literature. I learned a lot from you and I know our audience did as well. So until next time, this is Dr. Mark Trolice.

And we thank Dr. Jennifer Kawwass during the SART podcast. Thanks so much for having me. Thank you for listening to SART Fertility Experts, your resource for information on IVF.

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