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Donor Egg Program
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
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.
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.
STEPS IN Donor Egg IVF
1. First visit with Dr. Brandeis.
2. Testing for all recipients
3. Egg donor requirements.
4. Selecting your donor
5. Coordinating The Donor Cycle with the recipient cycle
6. Egg retrieval
7. Insemination, Fertilization and embryo development
8. Embryo transfer
9. The important two weeks after the transfer, until your first pregnancy test. (HOPEFULLY POSITIVE!)
10. Pregnancy: the first few weeks
Step 1 – Your First Visit
All patients see Dr Brandeis personally:
• Dr. Brandeis reviews your history with you to determine if donor egg IVF is advisable and feasible for you.
• Dr Brandeis discusses the process with you and answer all of your questions.
• The fee for this first consultation is $200. It will include a transvaginal sonogram.
Step 2 – Required Testing for All Recipients
• Semen analysis
• Vaginal ultrasound
- Dr. Brandeis checks the lining of your uterus (must be thin, no polyps), and Evaluates any significant ovarian cysts or fibroids.
• Sonohysterosonogram (SHG)
- SHG is done by a radiologist to determine if there are any masses or lesions inside your uterus could interfere with implantation.
- Pelvic MRI if you have fibroids or had myomectomy (surgery to remove fibroids) in the past.
• Mammogram and Sonogram for patients over 38
• Pap smear (it screens for cervical pre-cancer and cancer).
• Medical clearance for patients over 40.
EKG, chest x-ray, or even exercise tolerance tests.
• Infectious-disease screening for both partners
- rubella (German measles),
- toxoplasmosis
- cytomegalovirus
- herpes.
- Hepatitis testing for B and C
- RPR (screen for syphilis)
- HIV-1 and HLTV-1/2
EVALUATING THE UTERUS
It is important that the condition of the uterus be optimal – in order to receive the donor embryos successfully.
Dr. Brandeis may advise corrective surgery if:
• 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
• Mulitple fibroids are present
This necessary attention to the condition of your uterus may delay your donor egg cycle at most by one month.
Step 3 – Selecting your donor
When we meet potential egg donors, we provide them with detailed information about medications – the procedure to remove the egg cells, the appointments required and compensation.
All donors are required to complete a demographic information form which includes information about:
Age
Height
Body build
Skin color
Eye color
Hair Color/Texture
Previous Pregnancies
Education
Interest in Hobbies
Medical and Surgical History
Mother’s and Father’s Ethnic Background
Dr Brandeis and the egg donor coordinator review the demographic information and the completed application forms to help match egg donors to egg recipients.
Egg donor recipients will soon be able to go online see pictures of available donors
Egg Donor Requirement
Applicants to become egg donors must satisfy the following requirements:
1. A healthy woman, between the ages of 21 and 28.
2. Must have regular cycles
3. Urine screening for drug use
4. Genetic screening
5. Physical examination
6. vaginal sonogram
7. Infectious disease screening:
- Chlamydia, gonorrhea and Mycoplasma
- rubella (German measles),
- toxoplasmosis
- cytomegalovirus
- herpes.
- Hepatitis B and C
- RPR (screen for syphilis)
- HIV-1 and HLTV-1/2
Step 4: Coordinating Donor and Recipient Cycles
The trick is for the donor and he recipient to be approximately
on day 1 at the same time.
In the month before the Donor Egg Cycle.
The donor and recipient both start Lupron on day 21 of each of their cycles.
If the donor is ahead of the recipient,
When the donor’s period starts, the donor stays on Lupron
and waits until the recipient gets her period.
When the recipient starts her period,
the donor starts her stimulation
If the recipient is ahead of the donor,
When the recipient’s period starts – the recipient stays on Lupron
and waits until the donor gets her period.
When the donor starts her period,
the recipient starts her Estrogen therapy for 14 days.
Step 5: the Egg Donor Cycle
A. The month before the Egg Donor Cycle
Both donor and recipient start Lupron on Day 21 of their own cycle
B. The Cycle during which the donor egg are transfered.
Both the recipient and the donor continue with your daily Lupron injections.
Days 1-12
Donor – Daily stimulation with fertility drugs (Bravelle & Repronex)
for approximately 10 days with frequent office visits
Recipient starts Estrogen therapy for 14 days
in increasing doses
Day 12
Donor Egg Retrieval
Recipient’s Partner produces sperm sample
Day 15, 16, or 17
Embryo transfer – The ultimate goal is that the day the donate embryos are transferred – that the uterus will be ready to recieve them.
In most cases, the uterine lining is most receptive to the embryos about days 15 to 17 which is 3 to 5 days after ovulation has occured.
Donor Recipient
Egg Donor Day 1-15
Estrace 2mg tablets twice a day
Fertility Injections
Every other day Blood + Sonogram
Day 5-10
Estrace 2mg tablets three a day
Fertility Injections
Every other day
Blood + Sonogram
Day 11-14
Estrace 2mg tablets four a day
Day 12
Husband produces sperm sample for insemination
Retrieval
Obtain the eggs
Day 15-17
Estrace 2mg tablets four a day
Progesterone 200mg vaginal suppository
Day 17 or 18
Embryo Transfer
Day 17-28
Estrace 2mg tablets four a day
Progesterone 200mg vaginal suppository
Day 28
First Pregnancy Test
Step 6: Egg Retrieval
On the day of egg retrieval, your the recipient’s husband must come to our office to produce a sperm sample. This will be processed and used to inseminate the donated eggs.
If donor sperm or frozen sperm is used:
• 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
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).
There are two ways to fertilize the eggs
Conventional IVF insemination – consists of 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.
ICSI – one sperm is directly injected into each mature egg that is retrieved.
This results in much better fertilization than conventional IVF.
Most couples doing Donor Egg IVF will use ICSI for most or all of the eggs.
There is no extra charge for ICSI with donor egg insemination
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.
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.
Before the transfer, Dr. Brandeis will discuss with you and your husband the number and quality of the embryos available for transfer.
• 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, – you will stay on the table for an appropriate period of time.
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.
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 (see below)
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.
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 recipient’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?
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.
When to do assisted hatching
Assisted hatching is advisable with donor egg patients when
• The zona pellucida (protein shell enclosing the embryo) is thick.
• 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.
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.
The 2 weeks after embryo transfer
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.
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.
Seven days after Embryo Transfer -
Dr. Brandeis may see you to check the lining of the uterus and your progesterone level.
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.
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.
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.
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.
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