Donor Options -- Serena Chen, MD -- 09/25/02
WebMD Live Events Transcript
The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Third-party infertility treatments -- egg (oocyte) donation, embryo donation, and artificial insemination using donor semen -- may be successful options for couples facing infertility. As part of National Infertility Awareness Week, WebMD joined with RESOLVE: The National Infertility Association to bring you the Trying to Conceive Cyber Conference. Serena Chen, MD, joined us to discuss donor options.
Moderator: Welcome, Dr. Chen. Thanks for being our guest this hour.
Chen: Thanks for having me.
Member: I am single and TTC via DI. I have had nine IUIs, including three with Clomid and three with injectables. My RE says it is hard to get pregnant with frozen sperm. Should I try more IUIs or go straight to IVF? I am running out of money and emotional reserve.
Chen: It sounds like you've had a lot of treatment already and moving on to IVF is certainly a reasonable option at this point. Try sitting down with your RE to review your whole history and discuss the pros and cons of staying with your current treatment as opposed to IVF including pregnancy rates per cycle. One other thing to consider when embarking upon an aggressive treatment like IVF is to consider a second opinion.
Member: When seemingly healthy embryos have been placed into a healthy uterus, what are the chances of retaining that pregnancy, and what are some of the reasons that pregnancy does not take?
Chen: The chances vary considerably depending on the woman's age or the egg donor's age. The number of eggs that were produced in the first place, the quality of the embryos, and the lab the embryos were grown in. So there are numerous variables.
Member: What is your view on the success of IUI? It seems like everyone I've spoken to has tried IUI several times only to give up on it and go on to IVF. Is it worth skipping IUI altogether?
Chen: It depends on what you're trying to treat. For couples with only male factor infertility, IUI may be great treatment if you need donor sperm. IUI for unexplained infertility using the husband's sperm is much less effective but when combined with donor sperm it can be very effective for some couples. On the other hand, some people need to move straight to IVF. An RE should be able to detail the pros and cons and the success rates in your individual case for all your treatment options.
Member: If someone has not gotten pregnant after two donor egg cycles from a proven donor, what other factors do you think should be investigated?
Chen: The uterine cavity should be reevaluated. Another donor should be considered and perhaps consideration should be put into seeking another opinion or program.
Member: I have PCOS. What should I expect when I use donor sperm in the way of success rate?
Chen: If PCOS is your only problem and you are now ovulating regularly on fertility drugs, donor sperm success rates, on the average, are around 25% per cycle. This, of course, varies with age and if other fertility factors are present that may also affect success rates.
Member: What is the success rate of using frozen sperm to conceive? My husband wants me to freeze his sperm if he dies before we have children.
Chen: Frozen sperm has about 50% of the fertility rate of fresh sperm. If there's very little frozen sperm available, as in after death or chemo, then someone might want to consider IVF in order to get the maximum potential. Using sperm after someone's death can be quite tricky, from a legal point of view, and if that is your wish and your husband's wish you should make it clear in his will and get advice from a reproductive lawyer.
Member: What's the best way to make a decision about how many embryos to transfer during an IVF cycle?
Chen: The number one criterion is age: your age or the egg donor's age. So women over 35 should have two eggs replaced. Age 35-39, three embryos replaced. Age 39-40, four eggs is reasonable. And over 40, five embryos are reasonable. But there are other criteria such as your own fertility history, the quality of your embryos, your feelings about multiple births, and the program's success rates. So this needs to be a very individualized decision.
Member: When using an anonymous egg donor, what is the most important factor to increase your chances of a successful IVF? Low FSH or age? Or is a proven donor the very best chance?
Chen: Age is probably the most important criteria, but that doesn't necessarily mean the younger the better. For an egg donor, anywhere between 21 and 32 years should give equal pregnancy rates. It is nice to know that a donor has donated successfully before but those types of donors may be difficult to come by. And all of them were first-time donors when they started out. FSH should always be normal, but as long as it's normal, whether it's high normal or low normal should not make a difference. The most important thing is to be at a program that does a lot of cycles per year, has experience, and has good pregnancy rates. Then you will know that they know how to evaluate your donor.
Member: I have heard of "assisted hatching," for IVF. Can you explain what this means?
Chen: Assisted hatching is a procedure that is performed on the embryo itself. It's a type of microsurgery that creates an opening in the shell around the embryo called the zona. This has been show in certain groups of patients to increase the chance of pregnancy.
Member: When do you expect the CDC to publish the 2000 success rates?
Chen: They have told us that by the end of this year the results should be out.
Member: What motivates young women to donate their eggs? I understand they have to go through the same procedures as with IVF -- all the shots, etc.
Chen: Yes, they do. They have to go through a full IVF cycle, minus the transfer. Most anonymous donors are paid compensation for their time, effort, and the discomfort that they experience. Many donors I've encountered want to do something to help others. They've had friends with infertility. They want to help somebody else, do some good, and make some money.
Member: For patients considering using donor eggs, how do programs find a donor?
Chen: Most programs recruit in their local area through advertising and word of mouth. Some programs such as St. Barnabus also make use of donor registries or agencies; this is a third party whose only job is to recruit possible donors.
Member: I'm having a tough time finding a donor who's 100% Chinese. Any suggestions?
Chen: When you're looking for a donor of a particular ethnic background, you often have to cast the net very wide. Many of the agencies are based in California and would be good place to start. You should use an agency your doctor has worked with before and has experience with good cycles. I think it's important when working with a donor from an agency to have your doctor evaluate the donor since that doctor is the one running the IVF cycle.
Member: If the donor is known, what issues are there for future rights to the child?
Chen: If the donor is known, the risk to your parental rights is thought to be higher than if the donor is anonymous. So I would recommend you have a good reproductive lawyer to draw a contract and that the donor has separate legal representation. This will ensure that everyone has a very good idea of what his or her rights and responsibilities are and will ensure a very open dialogue about everyone's expectations. Some donor arrangements end up being very closely knit and some do not. Both types of arrangements can work out fine but everyone who is involved has to be comfortable and agree ahead of time.
Member: How many couples share the donor's eggs?
Chen: This depends upon the program. Many programs just have a one to one arrangement -- one donor per couple. The programs that share eggs, it's one donor per two couples. Anything more, I think, would compromise the pregnancy rate.
Member: What is considered high FSH? Is this number based on a medical standard, or does each clinic decide its own limits? I am 36 and my FSH is 14. My doctor does not want to even try using my own eggs.
Chen: That's a very good question. Every clinic has its own ranges of what's considered to be normal. In general, less than 10 is normal, 10-14 is borderline, above 14 is abnormal. At St. Barnabus, we might consider cycling someone with an elevated FSH depending upon other factors that affect her prognosis. With a borderline FSH the decision has to be very individualized. And the final decision would be up to the patient if she wants to go forward knowing that the pregnancy rates are likely to be much lower than if her levels were normal. If your clinic does not have any pregnancies with women at this level, it is reasonable to tell you that they will not cycle you. So these decisions have to be based on what we think your chances of pregnancy are.
Member: What are some important criteria in selecting a sperm donor?
Chen: No. 1 is to use a good sperm bank -- one that follows the ASRM guidelines for sperm donation. One that your physician has had experience with and that has a good reputation. I like to use banks that have New York state licensing, because then you are assured that they follow some very stringent standards. Beyond that, most people are looking for a sperm donor that will match the characteristics of the father.
Member: We are doing our first donor egg cycle next month. We were not able to see a photo of our donor. Can you advise if there is anything pertinent that we should know about our donor? We have her medical and psychological information already.
Chen: The most important thing is that your donor has been screened by a physician experienced in screening donors and that the program has a good track record with donor eggs. I really think the biggest thing is you have to trust the doctor to screen the donor well.
Member: We are going to use an anonymous egg donor and my husband's sperm in an IVF attempt. I've told my mother and my sister, but don't want to tell my husband's side of the family. I also want to be open with any children that may be born. My husband says he will let me decide since the donor is for eggs. Do you think I'm asking for trouble not to be honest with them? They know we are doing IVF.
Chen: This is a tough one. In general, the thinking these days is that it is best to include the child in any disclosure decision and so you should be open with the child about his or her origins at an age-appropriate level, and not create a situation where everyone around the child knows, but the child doesn't. Children can sense when other people think that they're different somehow and if this issue isn't dealt with openly, they often interpret it in a negative manner, when actually using a donor and going to such great lengths to have child is a positive thing. So perhaps you and your husband should discuss this in terms of your plans of how to tell your future child, and make decisions based on how it will affect him or her.
Member: For residents in N.J. who have IVF insurance coverage due to the legislation passed last year, are donor services covered; specifically IVF with donor eggs?
Chen: That's a very good question. At this time it is uncertain whether or not this will be covered. I would contact New Jersey RESOLVE because they've been very active in getting the legislation passed in trying to ensure that things like donor eggs are covered, but I don't think that this has been worked out yet.
Member: Where do we go to judge whether or not that program has a good track record with donor eggs?
Chen: The CDC web site (www.cdc.gov) is probably the easiest way to look at pregnancy rates for donor eggs at a large number of programs. The web site has pregnancy rates from 1996 to the end of 1999. And by the end of the year we will have the 2000 results as well. On the homepage, you should look for ART success rates.
Member: I am 44 and stopped menstruating one year ago. Since then my hormone levels have been very low and I was having very bad menopausal symptoms -- hot flashes every couple of hours with anxiety attacks, night sweats, insomnia. I started taking an herbal formula with phytoestrogens, which helped. I had a failed donor attempt in August (my donor didn't respond to the drugs). All the estrogen I had to take made me feel wonderful. Should I take natural hormone replacement while waiting to be placed with a new donor? My clinic usually puts recipients on birth control, but I'd rather not take animal hormones.
Chen: I think it is a good idea to take some hormone replacement similar to what you would take during a donor egg cycle, but perhaps at a lower dose. This will ensure that the uterus has good blood flow and is primed for another cycle. When you're not on hormones, the uterus tends to atrophy and shrink and blood flow decreases. Birth control pills are a reasonable option but people often feel better, as you did, on hormone replacement similar to what is taken during a donor egg cycle.
Member: I'm interested in looking at track records from donor agencies, being able to judge their effectiveness, not from the IVF clinics themselves.
Chen: The donor agencies really do not have an effect on the pregnancy rates but can play a very important role on cycle, which is why you need an agency that is experienced and has a good track record. Unfortunately there are no objective ways to directly compare agencies. The experience that your doctor has had with particular agencies is probably the most important criterion to use when selecting an agency.
Moderator: Dr. Chen, we are just about out of time. Do you have any final comments for us?
Chen: Good luck to everyone in their efforts to conceive! Thank you for having me.
Moderator: Thanks to Serena Chen, MD, for joining us this hour. For more information about fertility issues, be sure to explore all the TTC info here at WebMD, including our message boards and regular live chats with Amos Grunebaum, MD.
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