Why might someone use donor eggs?

Egg donation has been available since 1984, although it was not widely used until the past decade. There may be many reasons for its recent popularity: more individuals are delaying conception, the associated technology has improved, and the egg donation process has become more socially accepted.

Donor eggs are commonly used by females over 40 years old who are trying to conceive using in vitro fertilization (IVF), as egg donor success rates are much higher compared to IVF using their own eggs at that age. According to the National Center for Chronic Disease Prevention and Health Promotion, 65 percent of females over the age of 44 who use IVF also use donor eggs.ⁱ

Unlike males, who produce new sperm daily, females are born with their lifetime supply of eggs. Over time, both egg quality and quantity diminish. For example, the number of chromosomes can be affected as shown in a large 2014 study published in Fertility and Sterility. Using a sample of 15,169 comprehensive chromosomal screening results from 2,701 patients in 3,392 cycles, the study found that the rate of aneuploid embryos (embryos with an incorrect number of chromosomes) increases with age. When using a 43-year-old female’s eggs, over 83 percent of embryos that survived until the blastocyst stage were aneuploid.ⁱⁱ By comparison, only 23 percent of embryos from the eggs of a 30-year-old female were aneuploid.ⁱⁱⁱ

If an intended parent has concerns about their egg quality, donor eggs are a viable option for achieving successful pregnancy outcomes. Here are some common reasons for using donor eggs:^iv,v

• Diminished ovarian reserve (decreased quality or quantity of eggs)
• Advanced reproductive age, leading to an age-related decline in fertility
• Hypergonadotropic hypogonadism (a condition that prevents the ovaries from functioning properly, such as in Turner syndrome)
• Poor quality of embryos or eggs in attempted IVF cycles
• Genetic conditions in a female that may be passed down to offspring
• Same-sex couples or single parents by choice, in which all individuals do not have the ability to produce eggs

According to data collected by the Canadian Fertility and Andrology Society (2019), donor eggs were used in approximately 10.1 percent of assisted reproductive technology (ART) fertility treatment cycles in Canada.^vi In the United States, there are over 20,000 ART cycles per year using fresh and frozen donor eggs.^vii Approximately 90 percent of U.S. fertility clinics offer egg donation for fertility treatment.^viii,ix

What are egg donation success rates?

Success rates from over 20,000 donor egg ART cycles per year in the U.S. range from 45 to 55 percent, according to national data reported by the Centers for Disease Control and Prevention (CDC). The numbers vary whether fresh or frozen donor eggs and fresh or frozen embryo transfers were used:^x

Two recent studies evaluating live birth rates using fresh versus frozen donor eggs and embryos among patients included in a large U.S. database similarly reported higher live birth rates in fresh donor egg and embryo cycles. However, these studies were limited by the information available in the database and could not account for patient-specific variables, which may have impacted the live birth rates observed for the study groups.^xi,xii

In Canada in 2020, the rate of ongoing clinical pregnancy in frozen donor oocyte IVF was 42.9 percent, while the ongoing clinical pregnancy rate in fresh donor oocyte IVF was 46.5 percent.^xiii Deciding between fresh and frozen donor eggs must balance multiple logistical and financial considerations. Both options are commonly used and result in high live birth rates.

Age of the egg donor

Research suggests that live birth rates decrease as the age of the egg donor goes up. A 2019 study published in Fertility and Sterility found these success rates:

For this reason, the ASRM advocates for egg donors to be under age 35.^xiv

IVF with donor eggs after 40

Donor egg IVF is most common among females over the age of 40, with a success rate of approximately 50 percent per cycle in the U.S. That number is a significant increase compared to females who use their own eggs. In females aged 41 to 42, the IVF success rate is 11.8 percent when using their own eggs. At age 43, the success rate is 3.2 percent.^xv

How to find an egg donor?

There are multiple ways to select an egg donor, including databases, agencies, and personal relationships with a known donor.

Databases

Online databases feature detailed profiles of egg donors. Individuals and couples intending to use donor eggs can peruse these databases and select their donor based on information such as donor age, race, appearance, education level, and other personal qualities.

To be included in a database in the U.S., a donor must go through an extensive application and pre-screening process. Some fertility clinics that provide IVF are associated with a certain database and may require patients to select from that database only. Other IVF clinics may even have their own database of egg donors available for fresh egg retrieval.

In some countries, databases can provide only extremely limited information due to anonymity laws. Other countries permit databases to share more detailed information about potential egg donors, including photos and/or videos.

Agencies

Egg donor agencies are businesses that connect intended parents with egg donors or frozen donor eggs, based on client preferences. Agencies often work with donor egg recipients to help guide them through the process and may have access to multiple egg donor databases around the world. They may also have their own database of egg donors.

Agencies can help the egg donor with items such as travel and expenses and may assist them with the legal process. Selecting an egg donor through an agency tends to be more expensive than selecting an egg donor through a database.

Known donor

When the egg donor is a friend, relative, partner, or other person known to the individual or couple seeking donor eggs, the process is called “known donor” or “directed egg donation.” The clinic performing the IVF can facilitate the process.

Often, frozen donor egg banks, intended parents, and egg donors will all seek legal counsel during the egg donation process. It is also common for the parties involved to undergo one or more counseling sessions as there are complexities regarding both the immediate use of donor eggs and the long-term considerations, of which all involved parties should be aware.

In the U.S. and Canada, it is common for egg donors to be compensated. The American Society for Reproductive Medicine (ASRM) has made a statement that such compensation is ethically justified given the time required, as well as the discomfort and risks of egg donation to the donor.^xvi

What to look for in an egg donor?

When looking for an egg donor, intended parents should consider the results of the pre-screening process, which typically includes genetic screening, medical history, and psycho-educational testing of each potential donor. The identity of the egg donor may or may not be disclosed depending on local regulations and the wishes of the involved parties.

Genetic screening for egg donors

It is recommended that egg donors undergo genetic screening prior to egg donation to reduce the chance that offspring will be born with a genetic disorder. Even if a potential egg donor does not have any signs or symptoms of a genetic disorder, they may be a carrier of a condition. If the sperm provider is also a carrier of the genetic condition, the embryo is at increased risk of developing the disorder.

Genetic conditions screened for during the egg donation process may include cystic fibrosis, spinal muscular atrophy, thalassemia, hemoglobinopathy carrier status, and fragile X syndrome carrier status. Additional panethnic expanded carrier screening panels may also be performed.^xvii

The number of genetic variants (or mutations) for which an egg donor is screened varies by fertility clinic, egg bank, agency, and country. Most clinics include more than the minimum number of screens suggested and screen hundreds of variants in their genetic screening panel. Asking about details of the genetic screening panel used for egg donors is a useful question when choosing a donor.

Medical history

The egg donor’s personal medical history and current medical state are obtained prior to egg donation, including information about the donor’s risk of infectious diseases, genetic conditions, and other disorders. Information about the donor’s family will also be obtained in order to assess genetic conditions that could be inherited by the offspring.^xviii

Psychoeducational testing

The ASRM recommends that egg donors be evaluated by a qualified mental health professional that is trained in third-party reproduction. During the evaluation, the mental health professional will interview the egg donor and administer a standardized questionnaire to evaluate the donor’s mental and behavioral health. It is important that the donor fully understands the breadth of the donation process and psychological impact of donating eggs. This evaluation will also provide additional details of the donor’s life, including their education status, life stressors, relationships, coping skills, legal history, drug use history, and motivation to donate.^xix

Egg donor anonymity

There are various categories of egg donors:

• Closed ID: Anonymous
• Semi-anonymous/semi-open: Limited information about the egg donor is disclosed
• Open ID: Identity is released
• Known/directed: The donor is known to the intended parents

Some countries require all egg donations to be anonymous, while others require all donations to be open ID. Some countries offer both options.

In the case of open ID, the identity of the egg donor might only be released when a donor-conceived child turns 18. Known donors, who are sometimes a relative or friend of the recipient (e.g., a sister or cousin), often have more communication with the intended parents.^xx

With the rise of publicly available genetic/ancestry testing, children conceived from an anonymous egg donor are likely to be able to identify their donor and any biologically related relatives by submitting their DNA to available databases. Thus, donor anonymity is a moving target, and donors opting for this route should be counseled that there is a high likelihood that any children resulting from their donation may be able to find them in the future.

Age of egg donor

Women can typically donate eggs until age 30 and the ASRM recommends that egg donors be at least 21 years old.^xxi However, the maximum age is variable and can depend on the egg donor program. The age of the egg donor is associated with success rates.^xxii

What is the difference between fresh and frozen donor eggs?

Donor eggs are available in two formats: fresh or frozen.

Fresh donor eggs

Fresh egg donation involves retrieval from the egg donor followed by immediate IVF to create embryos that can either be transferred at that time or frozen for later use. Fresh embryo transfers to the intended parent are usually performed five days after the eggs are inseminated. Any additional unused embryos can be cryopreserved (frozen) for later use. Fresh donor eggs were the original method used in donor egg IVF.^xxiii

Frozen donor eggs

Frozen egg donation involves retrieval from the egg donor followed by cryopreservation. These eggs can be thawed later and fertilized using sperm. Once an embryo develops, it will be PGT-tested and frozen, frozen for later use, or transferred to the intended parent or gestational carrier.^xxiv

Sometimes the eggs from one donor retrieval are split into separate batches and frozen for use by more than one intended recipient. It is important that recipients understand whether they are receiving all the eggs from one donor cycle (which is more common with fresh eggs) or if they are sharing them.

In new guidelines released in 2021, the ASRM indicated no significant differences in pregnancy rates with the use of fresh versus frozen eggs.^xxv However, results from studies using fresh versus frozen donor eggs are variable, with some studies showing higher pregnancy rates for fresh eggs.

Who receives the embryo transfer?

Following donor egg retrieval and IVF, the embryo will be transferred into the intended parent or a gestational carrier.

Intended parent

If a female intended parent wants to carry the pregnancy, they will need to undergo pre-pregnancy investigations prior to embryo transfer. This process will include a detailed review of the intended parent’s medical, surgical, and psychiatric history, medication and substance use, and medical family history. The pre-pregnancy investigation also involves a physical exam, including blood work and ultrasound, to ensure the recipient is a good candidate for carrying a pregnancy. Ultrasound imaging of the uterus using a sonohysterogram is often performed to assess uterine conditions that may interfere with pregnancy. Blood tests assess for infectious diseases, hormone levels, vaccination status, and blood type.^xxvi

Gestational carrier

A gestational carrier is a female who has an embryo transferred to their uterus so that they can carry a pregnancy on someone else’s behalf. A gestational carrier may be used if the intended parent(s) are unable or unwilling to carry a pregnancy. There are various reasons for this, including medical conditions where pregnancy is contraindicated (e.g., poorly controlled high blood pressure), uterine conditions (e.g., absence of a uterus or a significant uterine abnormality), or logistical or personal reasons for not desiring a pregnancy.^xxvii

What is the maximum possible age of a donor egg recipient?

The maximum age of a donor egg recipient — either the intended parent or gestational carrier — varies by region, and some countries have laws regulating the maximum age while others do not. In the U.S., the ASRM recommends a maximum age of 55 years.^xxviii In Canada, most clinics have a cut-off age of 50 years for egg donor recipients.^xxix

What is the process for IVF using donor eggs?

Once the eggs are successfully retrieved from the donor, they can be fertilized with sperm to form an embryo. (Note: If the eggs were cryopreserved, they will need to be thawed first.) Fertilization will be attempted with or without intracytoplasmic sperm injection (ICSI). The sperm often comes from the partner of the female recipient or from one partner in a male same-sex couple, but may also come from a sperm donor (a scenario known as “double donor”).

• ‍Conventional IVF (IVF without ICSI): Conventional IVF without ICSI introduces many sperm cells to the donor egg in a laboratory dish and allows for fertilization of the egg to occur naturally. This option is only possible for fresh egg donor cycles because the egg cryopreservation process requires the removal of the surrounding cumulus cells from the egg. These cells are necessary for conventional IVF.^xxx
• ^‍IVF with ICSI: IVF with ICSI aims to achieve fertilization by injecting a pre-selected sperm cell directly into the donor egg. This technique is especially useful in male factor infertility because it overcomes the process of sperm cells having to swim to and penetrate the donor egg on their own.^xxxi

Fresh donor egg process

For the donor egg retrieval process, the donor takes certain medications as part of a process called controlled ovarian hyperstimulation (COH). Hormone medications called gonadotropins are administered via injection to help multiple follicles develop. (Follicles are fluid filled sacs containing eggs.) Ultrasounds of the ovaries are also completed to track the development of these maturing follicles in the donor.

The egg donor will also take medications to suppress ovulation. These medications are called gonadotropin-releasing hormone agonists and antagonists.  When the donor’s ovarian follicles reach a certain size, a medication is given to trigger ovulation and help with the final maturation of the eggs.^xxxii Egg retrieval occurs approximately 34 to 36 hours after the ovulatory trigger is administered.^xxxiii

Egg retrieval itself is completed through the vaginal wall under ultrasound guidance. With the ultrasound focused on an ovary, a needle is inserted through the wall of the vagina into the ovarian follicles. Gentle suction pulls the egg into the needle for removal. During this process, the egg donor is under sedation or general anesthesia.^xxxiv

Once the eggs are retrieved, fertilization of the mature eggs occurs via conventional IVF or IVF with ICSI. The resultant embryos will grow in the lab, and can be transferred fresh when ready, usually five days after fertilization.^xxxv

In fresh donor egg cycles, the recipient may sync their cycle with the donor. While the donor goes through the controlled ovarian stimulation process, the intended recipient will take hormonal medications, like estrogen and progesterone, to prepare their uterine lining for a fresh embryo transfer. Cycle syncing can be logistically difficult, so some people choose to use frozen eggs or freeze the embryos created from fresh donor eggs for later use.^xxxvi

Frozen donor egg process

Frozen donor eggs are produced through the same process outlined above, with the key difference being that the fresh eggs are frozen (cryopreserved) directly after retrieval instead of being immediately fertilized with sperm. Note: Freezing eggs and freezing embryos are two different things.

To freeze donor eggs, substances called cryoprotective additives are added to the eggs, which help prevent damage during the vitrification process.^{xxxvii,xxxviii} Vitrification involves ultra-rapid freezing to preserve eggs in a glass-like state and helps prevent ice crystals from forming, which can damage eggs.^xxxix,xl Eggs used to be cryopreserved through slow freezing, but this technique has become rare in recent years because fewer eggs survive the thawing process after slow freezing compared to vitrification.^xli

In frozen donor egg cycles, the donor egg recipient may take medications to prepare their uterine lining for embryo transfer in what is called a medicated transfer or hormone replacement cycle. They may also choose to do a natural or modified natural transfer, where no or minimal medication is used. From a logistical standpoint, frozen donor eggs are easier to use, as the recipient does not need to sync their menstrual cycle with the donor stimulation cycle. Vitrified donor eggs will be thawed and undergo ICSI in the same manner as fresh eggs. Following fertilization, the embryos are grown in the lab and can be transferred fresh or frozen for later use.

Transfer process

Once donor eggs are fertilized successfully and an embryo forms, it is left to develop in the lab for three to 5five days. Donor egg embryos are most often transferred at the blastocyst stage (which usually develops on Day 5). Sometimes they can be transferred after three days of development (at the cleavage stage), after four days of development (at the morula stage), or after six to seven days of development if the embryo takes longer to reach the blastocyst stage.^xlii

The embryo is transferred into the uterus of either the intended parent or a gestational carrier. As mentioned above, the person who intends to carry the embryo will often take medications prior to the transfer, including estrogen and progesterone, to prepare the lining of the uterus to receive an embryo.^xliii,xliv The recipient will also undergo blood tests and at least one transvaginal ultrasound to check the uterine lining and ensure it has the appropriate thickness and structure prior to receiving the embryo.

On the day of embryo transfer, the recipient of the embryo will have a catheter inserted through the opening of the cervix into the uterus, often under ultrasound guidance, and the embryo will be expelled into the uterine cavity via the catheter to allow for implantation.^xlv

Conclusion

Many fertility clinics offer egg donation as an option for individuals and couples seeking assisted reproductive treatment. Success rates of egg donation vary and depend on several factors related to the specific donation method used, as well as the characteristics of the egg donor and intended parents. Individuals and couples considering egg donation should discuss their options with their medical providers.