DONOR EGG IVF

Women in their late 30s and early 40s will generally find it much more difficult to conceive than women 35 years or younger.

An older woman may be in the best of health and look 10 years younger than her actual age, but she must face the unfortunate fact that egg aging corresponds to chronological age.
• Beyond age 35, a woman will have ovulated her best eggs.
• Compared to her earlier reproductive years, her ovaries will have far fewer eggs    to choose from.
A quarter century of experience with IVF has shown that egg quality is the most critical factor for success. Poor egg quality is not a problem limited to older women. Some women in their early 20s, for a variety of reasons, also have infertility and miscarriage problems that are mainly due to poor eggs.

When donor eggs are utilized, success rates are dramatically improved and match those of the age group to which the donor belongs.

When is egg donation recommended as a fertility treatment?

Egg donation should be considered by women who:
• Have never had a menstrual period spontaneously
• Stopped menstruating at an early age
   - Premature ovarian failure (POF) may be due to genetic factors, auto-immune      disease, radiation or chemotherapy, or surgical removal of both ovaries.
• Show few follicles or have elevated FSH and/or estradiol (E2) at the start of a    natural cycle (poor ovarian reserve)
• Do not respond well to fertility drugs
• Have had multiple failed cycles of IVF
• Have had multiple miscarriages

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How does egg donation work?

Eggs are donated by a healthy young donor during an IVF cycle, requiring the participation of both the recipient and the donor.

The donated eggs are inseminated with the recipient husband’s sperm, and the resulting embryos are then deposited in the recipient’s uterus.

In the United States, egg donation has been used successfully since 1983. It was originally developed for women who have lost their ovarian function - either through surgical removal of the ovaries, premature ovarian failure or radiation/chemotherapy.

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Donor Egg IVF Success Rates

The use of donor eggs in IVF assisted reproduction is now widespread. In the United States alone, the 1997 ASRM/SART registry reported:

• 6,643 cycles of egg donation (9% of all ART cycles).
• Live birth rate of approximately 40% per transfer.

Currently, the national success rate of egg donor programs is about 50% per egg donation cycle. This success rate is obviously higher than that for women over the age of 38 using their own eggs.

Most candidates who choose to proceed with donor egg IVF appreciate the following advantages:
• The child will carry her husband’s chromosomes as half of its genetic make-up
• The recipient mother has total control over the pre-natal environment
• The recipient mother will have the full maternal experience of childbearing,    childbirth and breast feeding.

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What causes poor egg quality?

Regardless of the woman’s age, poor egg quality – and consequently, poor embryos - is generally associated with chromosome abnormalities that develop when an egg cell is activated for ovulation.

At birth, all the egg cells that a woman has are in a state of suspended development. These eggs do not get activated for further development unless they are ‘selected’ in a given cycle for potential ovulation. As a woman grows older, her egg cells are more likely to develop chromosome abnormalities upon activation.

Before the start of each menstrual cycle, the body naturally selects several egg-bearing ovarian follicles that will develop during the first half of the cycle. One of these follicles will dominate and produce the activated egg that is ovulated.

Chromosome abnormalities in the mature egg can affect fertility in several ways, whether it is a natural cycle or a stimulated cycle as in IVF:

• The most severe effect is failure to fertilize.
• Even if it fertilizes, the fertilized egg may fail to divide.
• Even if it divides, the resulting embryo may not develop normally.
• Even if the embryo develops normally, it may not implant.
• Even if the embryo implants and pregnancy occurs, it may result in miscarriage.

The majority of early miscarriages are due to chromosome abnormalities. In such cases, miscarriage is a process of natural selection – nature itself prevents an abnormal embryo or fetus from developing further.

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Applying to our Program

The first step in becoming a parent through egg donation at the Brandeis Fertility Center is to print out the Donor Egg Recipient Application/Questionnaire form. Fill it out as completely as you can and mail it to:

Dr. Vincent Brandeis
Medical Office Suite
110-15 71st Rd.
Forest Hills, NY 11375

Once this application has been received and reviewed by Dr. Brandeis, we will call to; Notify you if you are eligible and instruct you about your next step.

If you do not hear from us one week after you mailed your application,
please call us.

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SUMMARY OF STEPS IN donor egg IVF

The donor egg process is not complicated - but there are several steps.

Basically, it involves the IVF process but with extra preliminary steps that involve choosing and preparing your egg donor for the procedure.

It will be helpful, if you have not done IVF before, to read our section on In Vitro Fertilization (IVF) first.

1. Starting out – your first visit with Dr. Brandeis.
2. Required testing for all recipients – necessary before you begin treatment.
3. Selecting your donor – how we screen, test and choose our donors.
4. Synchronizing your period with the donor’s for the IVF cycle
5. Starting the IVF cycle – what you do, what the donor does
6. Egg retrieval and insemination
7. Fertilization and embryo development
8. Embryo transfer
9. Luteal support – the important two weeks after the transfer, and your first     pregnancy test.
10. Pregnancy: the first few weeks

Dr. Brandeis and our egg-donor program coordinator are available to answer any questions. Each recipient couple requires individualized attention to provide them with the best possible outcome at the least possible cost.

Donor egg IVF is usually not covered by health insurance plans.

• If you are covered for IVF, some plans may pay for your part of the IVF cycle,    provided you are not older than 45.
• Therefore, it is realistic to consider yourself a self-pay patient for donor egg IVF.

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Step 1 – Starting out

You will meet with Dr. Brandeis and during your first visit:

• Dr. Brandeis will review your history with you to determine if indeed, donor egg    IVF is advisable and feasible for you.
• He will review the egg donor IVF process with you and answer all of your    questions.
• In addition, you will be provided with additional printed information about donor    egg IVF.
• The fee for this first consultation is $200. It will include a transvaginal sonogram.

Once you have decided to proceed with us

• Our program coordinator will meet with you to answer your specific questions    about your potential donor.
• She will schedule you and your husband/partner for all the necessary preliminary    tests.
• Fees and manner of payment will be discussed with our financial coordinator.

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Step 2 – Required Testing for All Recipients

You and your husband must undergo the following tests and procedures:
• Semen analysis
If you require donor sperm, Dr. Brandeis will discuss this further with you. Generally, this is required only if a testicular biopsy shows that no viable sperm is produced in the testes.

• Pelvic ultrasound
   - Baseline study – In the first few days of your menstrual cycle, Dr. Brandeis       checks the lining of your uterus (must be thin, no polyps), and whether you       have any significant ovarian cysts or fibroids.
   - Post-ovulation – This shows Dr. Brandeis the thickness of your uterine lining.

• Sonohysterosonogram (SHG) and/or hysteroscopy – Both are performed within    one week after your period ends. Dr. Brandeis recommends
   - SHG is done by a radiologist to determine if there are any masses or lesions      inside your uterus could interfere with implantation.
   - Hysteroscopy done in a hospital setting is indicated if SHG shows the presence       of a polyp, fibroid or scar tissue inside the uterus. Through a hysteroscope (thin       telescope)
      inserted into your cervix, micro-instruments will be used to remove these       lesions.
   - Pelvic MRI may be indicated if you have fibroids of significant size or had       myomectomy (surgery to remove fibroids) in the past.

• Mammogram
   - If you are between 35-40, or there is a history of breast cancer in your family,       Dr. Brandeis advises a baseline mammogram (unless you had a mammogram       within the last five years).
   - If you are between 40-50, a mammogram is recommended every one to two      years.
   - You must provide us with the report if you have had a prior mammogram within       the time limits stated above.
• Pap smear (it screens for cervical pre-cancer and cancer), if one has not been    done within the past 12 months. You must do this with your gynecologist.
• Medical clearance from your primary doctor or internist, especially if you are over    40. He/she may recommend appropriate tests such as EKG, chest x-ray, or even    exercise tolerance tests.
• Infectious-disease screening for both partners
   - TORCH tests for your exposure or immunity to several viral diseases that can      affect a pregnancy, including rubella (German measles), toxoplasmosis,      cytomegalovirus and herpes.
   - Hepatitis testing for types A, B and C
   - VDRL/RPR (screen for syphilis)
   - HIV-1 and HLTV-1/2
• Genetic screening is also recommended, depending on your ethnic background.

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ABOUT EVALUATING THE UTERUS

It is important that the condition of the uterus be optimal - in order to receive the donor embryos successfully.

Ultrasound, SHG/hysteroscopy, or even a pelvic MRI, if necessary, will

• Verify that the cavity of the uterus is healthy and not adversely affected by    fibroids.
• Adequately document any abnormality that must be treated first before    proceeding to IVF.

Dr. Brandeis would advise corrective surgery, usually by operative hysteroscopy, prior to starting a donor egg cycle if the imaging studies show:

• A polyp larger than 1 cm
• A fibroid that protrudes into the lining of the uterus
• Scar tissue in the form of fibrous bands within the uterine cavity

At hysteroscopy, Dr. Brandeis will also be able to check if your cervix

• Has no obstruction (scar tissue) and
• Is wide enough to accommodate a thin catheter (plastic tube) that will be used to    introduce embryos into your uterus during the IVF cycle.

This necessary attention to the condition of your uterus will delay your donor egg cycle at most by one month.

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Step 3 – Selecting your donor

Choosing your donor is obviously one of the most important decisions you will ever make.

Potential egg donors can be:
• Anonymous Donors – The donor will not know who her eggs are used for, and the   recipient will not receive any information about the donor that will allow her   identity to be traced. Our program works mainly with anonymous donors, but we   can also work with-
• Known Donors – Relatives or friends who are known to recipient and wish to   donate their eggs. They will be subject to the same screening and preliminary   testing requirements as anonymous donors.

At the time you see us, you would have informed Dr. Brandeis if you wish to use a family member or friend as a donor, or whether you prefer an anonymous donor.

If you prefer using a known donor, especially because you already have someone who is willing to be your donor

• She must meet all the requirements for egg donor candidates (especially about    age, general health and regular cycles) and she must undergo exactly the same    screening tests as an anonymous donor.
• While using a family member assures you that your family characteristics will be    represented in your child’s genetic make-up, the major risk in such cases is    confidentiality – other members of the family are likely to hear about it.
• Also, you must make legal arrangements to insure that there will be no future    dispute with your donor (even if she is your sister or daughter) over parenthood    rights and/or appropriate compensation. You must provide us with a copy of    these documents before we can proceed with treatment.

If you have no potential known donor

• Please be sure to indicate on the questionnaire your preferences as to the    physical characteristics that you would like your donor to have.
• It will be the responsibility of Dr. Brandeis to choose and screen a suitable    anonymous donor for you.
• Our program coordinator will carefully review our available donors to pick out the    best match for you.
• She will also provide you with non-identifying information about your potential   donor.

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Who can donate eggs and how are egg donors chosen?

Here, we will describe briefly what is involved in our selection of egg donors. [This is described in greater detail in the section BECOMING AN EGG DONOR

Recognizing the multi-ethnic and cultural backgrounds of our patients, we are constantly looking for donors who come from various ethnic groups.

Our guidelines for donor selection follow strict regulations imposed by the Department of Health of New York State, which grants and supervises licensing of donor egg programs.

A careful review of the detailed application form submitted by women who wish to be considered as egg donors will generally rule out most unsuitable candidates right away. For example, women with endometriosis, inflamed tubes or polycystic ovaries would not be suitable candidates.

Applicants to become egg donors must satisfy the following requirements:

1. A healthy woman, married or unmarried, between the ages of 21 and 35.
    a. A married applicant must have the written consent of her husband.
    b. Psychologically, it is best if the couple do not plan to have any more children         themselves.
2. Must have regular cycles, documented evidence of normal ovarian reserve    (determined by blood tests), and no indication of impaired fertility.
3. Must undergo testing for
    • communicable infectious diseases (e.g., hepatitis, HIV, syphilis)
    • drug use
    • genetic screening, done through
       - a detailed family history taken by a genetic counselor, and
       - specific blood tests according to her ethnic/racial background
         (e.g., for cystic fibrosis, Tay Sachs disease, sickle cell disease, thalassemia).
4. Pass a formal psychological evaluation.

Baseline assessment of donor applicants

Of the egg-donor applicants who can be considered for screening, the first step is for them to meet Dr. Brandeis for

• a physical examination and
• baseline assessment to verify normal baseline hormone levels and ovarian    function.

This is scheduled in the first few days of the applicant’s menstrual cycle and consists of

• blood tests to determine her baseline reproductive hormone levels (FSH, LH,    estradiol and prolactin) ; and
• trans vaginal sonogram to determine a) number of antral follicles and b) that her    ovaries accessible for trans vaginal aspiration.

Although regular cycles are a reasonable indicator of proper ovulatory function, baseline hormones may indicate subtle ovulation dysfunction that requires further investigation.

Ultrasound shows Dr. Brandeis if both ovaries are “accessible”: Are they positioned properly so that the thin needle used for egg retrieval can easily reach both ovaries?

• Sometimes one ovary or both may positioned behind the uterus and difficult to    reach.
• This can happen because of scar tissue from previous pelvic surgery or pelvic    inflammatory disease.
• Such a candidate would not be a suitable egg donor.

The baseline sonogram also shows the number of antral follicles that the candidate has at the start of her cycle.

• These are follicles at least 5mm in size that can be seen on ultrasound.
• The ideal egg donor will have many antral follicles.
• In women who do not have polycystic ovaries, the number of antral follicles is an    indication of healthy ovarian reserve, which helps to assure that they are likely to    respond well to stimulation.
[Please refer to our IVF section for more information about follicles and stimulation.]

A donor applicant who has a successful baseline assessment profile will then be listed among our potential donors.

Because many preliminary tests required for donors have a time limit imposed by federal and state law, further testing of the potential donor will be deferred until she is chosen for an actual cycle.

• All deferred tests can usually be completed within a month.
• Specimens needed for all necessary lab tests can be taken at one time.
• Genetic test results generally require 2-3 weeks to come back.
• Meanwhile the potential donor will see an internist and a psychologist for her    medical and psychological clearances.

Thorough evaluation or screening of each potential egg donor is of critical importance, whether the donor is known to the recipient (e.g., a sister) or is anonymous.

• This screening serves to protect all parties involved (the donor, the recipient and    the resulting offspring).

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What are the required elements for donor screening?

If the potential donor’s baseline assessment is normal, then the following tests and procedures will be done:

• Medical clearance from an internist
• Infectious disease screening – the same tests done for the recipient, plus the ff:
    - Urine screening for drug use
    - Chlamydia, gonorrhea and Mycoplasma

• Genetic screening
   - Karyotype and Fragile-X (to rule out any chromosome abnormalities)
   - Cystic fibrosis
   - Diseases associated with donor’s ethnic group (Ex: Tay-Sachs, thalassemia,       sickle-cell)
• Psychological evaluation with a qualified psychologist

The psychological evaluation is just as important as the physical and medical screening to make sure she is psychologically appropriate to be a donor (i.e., she is mature, responsible and has no underlying psychopathology) and that she fully understands what she is proposing to undertake.

Particular attention is given to:

• Stress factors and potential scheduling conflicts
• History of psychological counseling/treatment
• History of substance abuse
• Emotional state and determination about donating her eggs
• Personal motivation;
• Commitment to completing the program requirements.

Once your chosen donor has satisfactorily completed the above preliminaries, you will be informed by our program coordinator so that you can plan a treatment timetable.

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Step 4: Synchronizing Donor and Recipient Cycles

This means preparing you and your donor so that you will both get your period on about the same day for the treatment cycle. The goal is for your uterine lining to be ready for embryo transfer about two weeks after your period starts.

Sometimes, both donor and recipient may have cycles that coincide.
If not, Dr. Brandeis will place you on the pill for a few weeks to delay your natural cycle.

• Continue on the pill until the donor is several days away from her next period.
• Seven days after the donor ovulates in her pre-IVF cycle,
   you will both begin daily Lupron injections.
   - Your first four days of Lupron will overlap your last four days on the pill.
• You should get your period at about the same time as the donor, around 7 days    after you started Lupron.
   - A difference of 1-3 days between you and your donor in getting your period for       the IVF cycle is not significant, since you are both on Lupron, which suppresses       ovarian activity.

You will both continue on Lupron, even after you get your period, until Dr. Brandeis instructs you to stop it.

During this time, your husband may be asked to produce a sperm sample that can be frozen as a back-up in case he is not available or is unable to make a sperm sample on the day that the donor eggs are retrieved.

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Step 5: Starting the IVF Cycle

Both you and your donor will continue with your daily Lupron injections.

In the first half of the cycle
• The donor will undergo ovarian stimulation to develop her follicles.
• You will start taking estrogen tablets to prepare your uterine lining.

Here is an illustration of what will take place during the cycle for both of you:

• Your estrogen dose will increase as you approach embryo transfer.
• Several days before embryo transfer, you will also start taking progesterone by    vaginal suppository or by injection.

During this first half of the IVF cycle, you and your donor will be monitored by Dr. Brandeis. Obviously, we will take all steps to make sure that you and your donor will NOT be in our office at the same time.

Most recipients require 3-4 visits before embryo transfer for

• Blood test to measure your estrogen level, and
• Ultrasound to evaluate the thickness of your uterine lining.

During one of these visits, Dr. Brandeis will perform a trial transfer by inserting a catheter (thin plastic tube) through your cervix to make sure that it can get through easily.

Dr. Brandeis or the program coordinator will let you know when your donor is ready for egg retrieval and when you may expect to have the embryo transfer.

• Usually the transfer will take place 15-17 days from the time the donor started    her fertility medications.
• You will continue to take Lupron till the day of egg retrieval from the donor.

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Step 6: Egg Retrieval and Insemination

On the day of egg retrieval, your husband must come to our office to produce a sperm sample. This will be processed appropriately and used to inseminate the donated eggs.

If donor sperm is used – be sure that:

• The sample is delivered to you the day before the retrieval. Do not open the    transporter tank.
• Make arrangements to have the sealed tank delivered to our office on the day of    egg retrieval, along with the paperwork sent with the sample by the lab.

Once the eggs are retrieved, your donor’s participation ends.

We will let you know –

• After egg retrieval, how many mature eggs were retrieved, and
• The day after egg retrieval, how many have fertilized.

From this point on, everything will be done as in a regular IVF cycle.

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Step 7 – Insemination and Fertilization

In the laboratory, the mature eggs that have been aspirated are isolated.

• The embryologist removes the cells that normally surround an aspirated egg, then
• The ‘cleaned’ eggs are placed into a laboratory dish containing culture medium,    until they are ready for insemination (the process of bringing the egg and sperm    together).

In conventional IVF, insemination consists in putting each egg into a droplet of medium containing 100,000-500,000 sperm cells, in the hope that at least one sperm will penetrate and fertilize the egg.

However, insemination is done through ICSI (intra-cytoplasmic sperm injection) in case of -

• a known male factor
• history of previous fertilization failures
• history of multiple IVF failures
• a patient older than 37
• a patient who has not conceived for more than 3 years despite open tubes and   normal semen analysis

In ICSI, one sperm is directly injected into each mature egg that is retrieved. This results in much better fertilization than conventional IVF, especially in the above-cited cases.

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Step 8 – Embryo Transfer

Three to five days after egg retrieval, you will be seen again for the embryo transfer. Because the procedure does not require anesthesia, you may eat anything beforehand.

However, you are advised to start drinking water about half an hour before your scheduled procedure. This is necessary because the embryo transfer will be guided by abdominal ultrasound which requires a full bladder for best visualization of the uterus.

Just before the transfer, Dr. Brandeis will discuss with you and your husband the number and quality of the embryos available for transfer.

Unless you have a tight or scarred cervix (from prior procedures such as colposcopy), embryo transfer is done without anesthesia.

• The procedure is very much like an insemination, except that embryos, instead of    sperm, are being introduced into your uterus.
• The embryos in a small amount of culture medium are loaded into a thin catheter    (plastic tube) attached to a syringe.
• Dr. Brandeis introduces the catheter into the cervix under ultrasound guidance, so    that its tip is about 1 cm from the top of the uterus - at the level where the    fallopian tubes enter the uterus. He injects the embryos into the uterus at that    point.

• Once the embryos have been released, the catheter is held in place for about 30    seconds, then gently withdrawn.
• It is taken back to the laboratory by the embryologist who inspects it under the    microscope to make sure all the embryos have been released.
• If there is any retained embryo or embryos, these are re-loaded into a fresh    catheter and a second transfer is done immediately. This should have no effect    on your chances for pregnancy.
• Once all of the embryos have been deposited in the uterus, Dr. Brandeis will    remove all instruments and you will stay on the table for an appropriate period of    time.
• If you need to urinate right away, you will be given a bedpan so you do not have    to get up.

Normally, you will be able to go home after about half an hour. You will be given instructions on what to do in the next two weeks. The instructions are also contained in a written sheet which you will take home with you.

We advise all our IVF patients to rest at home in bed or in a comfortable chair for at least 3 days after embryo transfer. You should also avoid stress and physical exertion for the next two weeks.

If your job requires lifting, walking up and down stairs or other strenuous activity, then Dr. Brandeis may recommend that you stay home for two weeks.

Dr. Brandeis will provide you with an excuse note for the appropriate time that you may need to stay home. The note will not indicate what procedures you underwent that require staying home afterwards.

OTHER IMPORTANT CONSIDERATIONS REGARDING EMBRYO TRANSFER

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When to transfer

Day-3? Day-4? Day-5?

The decision on when to do the embryo transfer is based on several considerations discussed by Dr. Brandeis with the couple.

With the present state of ART, embryo 'quality' is usually assessed on the basis of

• Whether the cells develop and divide on schedule (8 cells by Day-3 after retrieval)
• How the embryos look under the microscope
   - Are the individual cells more or less uniform in size?
   - Is there any fragmentation; and if so, is the degree within acceptable limits?

Pre-implantation genetic diagnosis (PGD), which looks at the chromosomes in the embryo, will show chromosome abnormalities, but this is not routinely indicated to check embryo quality.

Please note, however, that some IVF patients do get pregnant even with embryos that failed to show appropriate development or uniform cell size and/or had some degree of fragmentation.

For some patients, embryo transfer may be done on Day 4 or Day 5, when the embryos are farther advanced in development.

Morula stage

Healthy embryos reach the compacted morula stage on Day 4 post-retrieval.

• The cells have now become so numerous that the embryo looks like a blackberry    (morula is the Latin word for blackberry) with at least 64 cells.

Blastocyst stage

By Day 5, a healthy embryo will be at the blastocyst stage, with at least 128 cells.

• In natural conception, the embryo normally reaches the uterus from the fallopian    tube about 5 days after fertilization - when the embryo is at the blastocyst stage.
• Therefore, theoretically, embryo transfer at the blastocyst stage may result in a    higher IVF success rate.

In general

• Good embryos which develop according to schedule and appear normal in    appearance under the microscope, may be allowed to become blastocysts before    transfer.
• If the embryos are of lesser quality, one must consider the advantage and the    disadvantage of aiming for a blastocyst transfer anyway.
   - Plus: It is a good sign of embryo quality if the embryo reaches blastocyst stage      by Day 5.
   - Minus: Embryos that do not progress to blastocyst or even to morula stage by      Day 5 may have benefited from a Day-3 transfer. The uterus is still the best      incubator for embryos
     because it produces natural nutrients for the embryo.

In donor egg IVF, embryo transfer is generally done on Day-5, because a young donor with healthy eggs is likely to produce good-quality embryos that will benefit from being transferred at the blastocyst stage.

Two other decisions must be made with the couple about embryo transfers:

• How many embryos to place into the uterus?
• Whether to do assisted hatching?

Both depend on embryo quality primarily.

These considerations will be discussed with the couple by Dr. Brandeis before proceeding to the transfer.

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How many embryos to transfer?

This is very patient-dependent. Theoretically, more embryos transferred at one time means greater chances for at least one of them to implant. However, this can also lead to multiple gestation (conceiving more than one child in the same cycle).

Besides embryo quality, one must consider

• The patient's age and reproductive history
• The couple's wishes
   - Will you take a chance on a multiple gestation by transferring more embryos to       increase the chances for pregnancy?
   - Will you want to avoid a multiple gestation at all?

In 2004, the American Society of Reproductive Medicine and the Society for Assisted Reproductive Technology issued guidelines suggesting how many embryos to transfer in order to avoid multiple gestation (conceiving more than one child in one IVF cycle).

However, these guidelines do not

• Distinguish between Day-3 embryos and Day-5 blastocysts
• Account for the generally non-uniform characteristics of embryos from the same    patient in the same cycle.

However, in donor egg IVF, if the embryos develop into excellent-appearing blastocysts by Day 5, Dr. Brandeis will recommend transferring no more than 2 blastocysts. Any other remaining embryos suitable for freezing can be frozen for your future use, without having to go through the entire process again - you would simply undergo a frozen-embryo transfer (FET) cycle just like a regular patient whose embryos come from her own eggs.

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When to do assisted hatching

Assisted hatching is advisable when

• The zona pellucida (protein shell enclosing the embryo) is thick.
• The patient is older than 37 and/or has a history of high FSH.
• The patient has had previous IVF failures.
• Frozen embryos are thawed for transfer (freezing hardens the zona).

If assisted hatching (AH) is necessary or advisable, it is done just before the embryos are loaded into the transfer catheter.

• Hatching involves creating a tiny hole in the protective covering of the embryo -    this will make it easier for it to hatch from this shell at the time of implantation    into the lining of the uterus.
• The 'hole' is created by micro-injecting a tiny amount of an acidic substance that    dissolves the shell only at the point where it is injected.
• Hatching can now be done with laser. At the Brandeis Center, we are considering    a study to determine whether there is an advantage to laser-assisted hatching.

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When to freeze embryos

Couples using donated eggs have this option if there are extra good embryos left after the couple has decided how many embryos to transfer.

• If pregnancy does not occur in the cycle using 'fresh' embryos, freezing extra    embryos will enable you to have an embryo transfer at a later date without    having to undergo the whole process again, except for the embryo transfer.
• If you do get pregnant, the frozen embryos are available if want to have another    child.

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Luteal Support

In the two weeks following embryo transfer, the embryo continues to develop and implant itself in the lining of the uterus. This corresponds to the period following ovulation (and possible conception) in a natural cycle, and is called the Luteal phase.

• During this time, you will be taking progesterone and estrogen preparations to    thicken the uterine lining so it is more receptive and better able to support    embryo implantation.
• The lining produces special nutrients and cell adhesion molecules that will allow an    embryo to continue developing and implant itself in the uterus.

Implantation is when the embryo attaches itself to the lining of the uterus, and some of its cells penetrate into it. Interaction between the embryonic cells and the uterine cells will give rise to the placenta, the structure through which the mother's system interacts with the fetus during the pregnancy.

The placenta

• Allows fetal blood to absorb nutrients from the mother's blood
• Produces the pregnancy-supporting hormone progesterone starting 8 weeks after    conception.
• Produces human chorionic gonadotropin (HCG), whose level is a measure of the    progress of pregnancy in the first 12 weeks.

Whether one or more of your embryos will implant depends upon

• Embryo health and quality
• Appropriateness of the uterine lining
• Immunologic factors, such as the presence and quantity of natural-killer cells (NK    cells) that are naturally found in the blood
• Cell adhesion factors that have not yet been fully characterized.

Progesterone, a natural hormone, helps the lining of the uterus develop and support the pregnancy.

• Supplemental progesterone is given by vaginal suppository and by injection.
• Most patients will develop a thicker lining if, in addition to progesterone,    supplemental estrogen is taken in the form of tablets (Estrace 2mg or generic    equivalent) taken twice a day.
• Progesterone and estrogen are taken daily after egg retrieval and continued at    least until the first pregnancy test (14 days after embryo transfer).

Please note: Although the FDA requires the drug manufacturer to include warnings about adverse effects of progesterone in early pregnancy - long experience with IVF shows that progesterone has proven beneficial effects on pregnancy.

Progesterone has been universally prescribed for Luteal support after fertility treatments, even for patients who only use fertility drugs, with or without insemination.

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What happens after embryo transfer?

Except for the anxiety of waiting for the outcome of the IVF process, most patients will have an unremarkable two weeks until the first pregnancy test.

However
• Patients who are susceptible to OHSS will usually manifest some signs and    symptoms in the week following embryo transfer.
• Even patients not likely to develop OHSS may continue to feel heaviness or    cramping in the pelvis for several days after egg retrieval, usually because the    ovaries are still enlarged from stimulation.

Call us if
• The discomfort is significant
• You feel nauseated or bloated
• You gain more than 10 pounds in 3 days
• You develop a fever
• You have any questions

Seven days after Embryo Transfer -

Dr. Brandeis may see you to check the lining of the uterus and your progesterone level.

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Step 10 - Pregnancy testing

Fourteen days after embryo transfer, you may see us or go to a laboratory near you for your first pregnancy test.

Your blood will tested for:

• HCG, the hormone made by the trophoblast cells of the embryo (a value of >50 at    this time indicates that the embryo has implanted)and
• Progesterone (a level of >20 is desirable, but women on luteal medications will    usually show an even higher level, especially if they have conceived.

If your pregnancy test is negative, you may

• Stop all medications
• Expect to get your period in 2 to 5 days.
   •If you do not get your period within 5 days of discontinuing the medication,
     call us.
Schedule a re-consultation with Dr. Brandeis the following Saturday or Sunday.
He will
• Review the cycle with you
• Discuss what the possible problems could have been
• Discuss future alternatives.

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PREGNANCY: THE FIRST FEW WEEKS

If the first blood test 14 days after embryo transfer shows you are pregnant, Dr. Brandeis will advise you to repeat the test within 2-3 days, depending on the initial value.
• Generally, if more than one embryo has implanted, this first level is >100.
• If your level is <50, Dr. Brandeis may recommend that you repeat it the following    day to make sure it is rising.
• If your HCG level rises appropriately, then you are most likely pregnant.
   • Dr. Brandeis advises blood tests every 3 days the first two weeks, then at least      once a week until your 12th week of pregnancy.

If your HCG level continues to rise appropriately, Dr. Brandeis will advise you to schedule a visit with the obstetrician of your choice. Let us know who you will be seeing - so Dr. Brandeis can speak directly with the OB and urge that you must be

• Seen as soon as possible
• Treated like a high-risk patient because of your infertility history
• Monitored with blood tests and ultrasound more frequently and regularly than    normal patients.

If your pregnancy is going well - your ovaries will be able to make the progesterone you need to support the pregnancy in its first 8 weeks.

Your obstetrician will be able to tell based on serial progesterone values.

If you continue to make progesterone appropriately, then you may stop progesterone supplementation, but Dr. Brandeis would still advise regular monitoring.

You will be considered clinically pregnant only after ultrasound shows the presence of a gestational sac or sacs inside the uterus. This can usually be seen during the third week after embryo transfer, at which time we will know how many embryos have implanted.

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Is an ectopic pregnancy possible with IVF?

Occasionally, some IVF patients may have an ectopic pregnancy - when the conceptus implants in one of the fallopian tubes instead of within the uterus.

This is more likely if one or both of your fallopian tubes are not blocked at the point where they join the uterus.

An ectopic pregnancy is suspected if ultrasound in the third week after embryo transfer does not show a gestational sac, although your HCG level has been rising.

Dr. Brandeis will advise serial ultrasound with a radiologist over a period of 1-2 weeks will be advised to see whether the embryo has in fact implanted in the tube.

If an ectopic pregnancy is confirmed, Dr. Brandeis will discuss treatment with you.

• At this early stage, it will generally involve a medication called Methotrexate    (MTX) injected once or twice. MTX results in 'dissolving' the ectopic pregnancy.
• An ectopic pregnancy that is discovered late, when the pregnancy mass has    grown or when the pregnancy value is already high, may require surgical    removal.

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A heartbeat is your best confirmation

By the 4th week after embryo transfer, ultrasound will be able to detect a heartbeat in the gestational sac.

• For purposes of IVF data reporting, it is this ultrasound that dates your clinical    pregnancy.
• Subsequent ultrasounds through your obstetrician will continue to monitor the    development of the fetus.

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POSSIBLE CONCERNS IN EARLY PREGNANCY

You may experience spotting, minor bleeding and even some mild cramping in these first few weeks.

This is quite common. But as long as the cramping is not severe and/or bleeding is not heavy or accompanied by blood clots, it is usually not a cause for alarm.

If the bleeding becomes heavy, similar to menstrual bleeding or heavier, or if the cramping or pelvic pain is significant, call your obstetrician right away.

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Risks To The Recipient

As a recipient, you do not undergo ovarian stimulation or egg retrieval, therefore you are not exposed to the potential risks of these procedures, as, for example, ovarian hyper-stimulation syndrome, or anesthesia-related risks.

Your principal risk is multiple pregnancy, because egg donors are young.

• The age of the recipient, even if over 40, does not affect pregnancy rates.
• Therefore, it is generally advisable to limit the number of embryos transferred: no    more than three embryos for a Day 3 transfer, or 2 blastocysts for a Day-5    transfer.

Other theoretical risks to the recipient include transmission of infectious diseases such as HIV.

• It is unknown whether eggs can transmit the AIDS virus, and, to date, no cases of    HIV transmission through egg donation have been reported.
• However, meticulous screening of potential egg donors makes infectious-disease    transmission highly unlikely.

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Cost of a donor egg IVF Cycle

The fee of $15,000 - payable by certified check or cash at the time you choose your donor - covers the following:

• Donor screening
• Monitoring of recipient and donor cycles
• Donor medications for IVF
• Fee paid to anonymous donor
• IVF procedures on the donor and the recipient (egg retrieval, anesthesia, oocyte    insemination, laboratory culture, embryo transfer)

The above fee does not cover:

• Recipient consultation fees and office visits before the treatment cycle
• Diagnostic and other preliminary tests/procedures for recipient and husband
• Recipient medication
• Cost of donor sperm if used
• Intracytoplasmic sperm injection (ICSI)
• Assisted hatching
• Embryo cryopreservation
• Monthly storage fee for frozen embryos
• Frozen embryo thawing and transfer

THE PREMISE FOR EGG DONATION

The past two decades of clinical experience in assisted reproduction have conclusively demonstrated that a successful outcome is closely linked to optimal egg quality.
• Using donated eggs has proven to be a very successful option for women with    poor egg quality
• Recipients are usually older women who have not conceived despite repeated    attempts in assisted reproduction, or whose attempts have ended in miscarriage.

Egg donation makes it possible for previously infertile women to bear and deliver their own child, conceived from the laboratory union of their husband's sperm with the eggs of an appropriately selected younger woman.

In anonymous egg donation, the donor and the recipient remain anonymous to each other.

Donors must first undergo a thorough physical, medical, genetic and psychological evaluation through our center to ensure their suitability as donors.

Prospective egg recipients choose a donor recommended by Dr. Brandeis from a list of available screened donors, depending on the donor characteristics desired by the recipient.

If you are chosen by a couple, your personal profile (not including identifying information) will be made available to them. It would be helpful if you provide us with a recent photograph.

When you are matched with a couple, you will be notified and asked to come in for further instructions.

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Egg donation is performed in an IVF cycle

Egg donation is currently done with "fresh" eggs. This means that the donated eggs are fertilized with the sperm of the recipient's husband (or sometimes, with donated sperm) right after the eggs are retrieved from the donor’s ovaries.

The process of assisted reproduction in which donated eggs are used is called in-vitro fertilization or IVF. [You will understand the whole IVF process better if you read the IVF section on this site].

The egg donor is involved in the first three phases only - ovarian suppression, ovarian stimulation and egg retrieval.

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Steps in a donor egg IVF cycle

First, the donor’s menstrual cycle is synchronized with the recipient’s cycle by means of hormonal medication (the pill and/or the ovarian-suppressing medication, Lupron), so that both will get their period about the same day for the cycle during which the egg donation is done.
When the egg-donation cycle begins, the donor is given hormonal medications to stimulate her ovaries to produce about 8-10 mature eggs.
When the eggs are mature, usually after 10 days of hormonal injections, they are retrieved from the donor's ovaries.
This is done as an outpatient procedure under anesthesia, using a specially designed aspiration needle passed through the vaginal wall in order to puncture the ovaries.
The donor's part ends with the retrieval.
The donated eggs are inseminated with sperm from the recipient's husband, and any resulting embryos are transferred 3-5 days later to the recipient's uterus.

       

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EGG DONOR REQUIREMENTS

To qualify as an egg donor, you must be

• 21-34 years of age
• In good health, with regular periods and no menstrual problems
• If married with children, the initial requirements are -
    a. You had no difficulty conceiving
    b. You did not have 2 or more miscarriages
    c. You do not wish to have any more children of your own
    d. You have your husband's full consent
• If single – you must have had
    a. Not more than one sexual partner in the last 12 months
• Willing to take on the obligations of an egg donor as described in the next section
• Willing to waive any and all rights to any information that would enable the donor    or her representatives to identify or locate the recipient parents and any resulting    offspring.

It is important that you understand the principle behind anonymous egg donation. Once you have donated your eggs:

• you surrender all rights to them, and to any resulting embryos or offspring    thereof; and
• you entrust the fertility center with the task of using these eggs to enable an    infertile couple to bear a child.
     - Any child or children resulting from your donated eggs are legally the offspring        of the recipient couple, and you have no right to learn anything about them.
     - Anonymous donation avoids the possibility of an egg donor later trying to        claim any offspring
       resulting from her donated eggs.

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YOUR RESPONSIBILITY AS AN EGG DONOR

As a prospective egg donor, you must be prepared to commit yourself to devoting the necessary time and effort to do the following:

• Answer the d