Egg donation has been a routine procedure at most fertility centers for decades. CHR, indeed, believes that the procedure has become too routine; that is, patients are often prematurely “pushed” toward the use of donor eggs.
How do we know that this is happening? There, indeed, are quite a number of pieces of evidence that support the above statement. Likely, the most convincing is that over half of all new patients at CHR received such a recommendation before consulting with CHR (we, of course, wished they had consulted a CHR physician earlier) and, once evaluated and advised of their options and pregnancy/live birth chances, only a small minority chose egg donation as their next treatment step.
A very strong piece of further evidence lies in the fact that approximately one-third of patients who previously elsewhere were advised that egg donation was their best and/or only chance of conception, at CHR still end up conceiving with use of their own eggs. CHR patients' testimonials point this out constantly.
Finally, unrelated to CHR, comparative national U.S. data on IVF cycles are telling: using autologous (own) or donor eggs, it is remarkable, indeed, especially over the last decade, how much quicker donor cycles have been increasing than autologous cycles.
There are no studies available in the literature to answer this question, but a number of potential explanations sound plausible: First, many IVF centers compete in the marketplace based on their claimed pregnancy/live birth rates. Such centers, of course, have no incentive in treating patients with poor outcome chances.
Second, donor egg cycles are psychologically and financially rewarding for IVF centers: They have the highest pregnancy/delivery rates among all IVF cycle types and require relatively little work since IVF centers have mostly given up on maintaining their own egg donor pools and, instead, work preferentially with donor agencies and, more recently, with frozen donor egg banks to secure donor eggs.
Donor egg cycles are also more profitable than autologous cycles. Autologous cycles are increasingly covered by patients’ insurances (under relatively poor reimbursement rates), while insurances do not usually cover donor egg cycles. Therefore, IVF centers with many insurance-covered patients especially benefit from egg donation cycles. For those, even insured patient must pay out of pocket at much higher fees than insurance companies reimburse IVF centers for in autologous cycles.
But a third reason may be the most important one: Most IVF centers simply no longer know how to treat poorer prognosis patients because they haven’t done it for so long. A good example are older patients who, judging from the national reporting data, only rarely, and by only very few IVF centers, are given a chance with own eggs after ages 42-43 years. The centers’ argument in those cases (CHR physician hear this from patients all the time) are that pregnancy chances above age 42 are equal to those of spontaneous pregnancy attempts and that live birth rates are only 1-2%.
Those claims are, of course, nonsense! They are the consequence of using long-outdated experiences, when outcomes, likely, indeed, were at those ranges. Things have changed, however, dramatically since. In the 1980s, IVF pregnancy rates were in single digits. Because nobody could help them conceive, practically all IVF centers (in those days, likely, fewer than 100 in the whole U.S.) refused treatments to women above age 38. Had the field at that point stopped, IVF centers still would not know how to treat women above age 38. Why ca. 10 years ago, age 42 years, suddenly, became the ultimate barrier for autologous IVF is, therefore, puzzling.
For a number of reasons, there is no simple answer to this question, but one fact is definite: Average pregnancy and live birth chances are a multiple of the above-quoted rates many of our patients heard at IVF centers before coming to CHR. Since CHR, proportionally, treats more patients at age 43 and above than any other IVF center in the U.S. (and, likely, the world), we can offer some pretty accurate further statistical information: First, in contrast to younger ages, where outcomes can be quite accurately predicted because they remain within quite a narrow range, once a woman passes ages 42-43, the range of possible outcomes widens and, increasingly includes zero.
If a woman produces no eggs or no embryos in a cycle, she a priori will have a zero pregnancy chance. Moreover, because chances per transferred embryo decline with advancing age, and are in single digits in this age group, a patient will need multiple embryos for transfer to reach double-digit pregnancy and live birth chances. Only a fraction of women at that age will, however, produce large enough numbers of embryos, clearly allowing for differentiation between women with better and poorer outcome chances. Differences in outcome chances at identical ages in this very advanced age group of patients are, therefore, much more profound than at younger ages and must be appropriately explained to patients when giving them full informed consent. The more embryos they produce, the better their chances!
Similar conclusions were also reached in a large recently published study from our colleagues at the Cornell program, one of the few centers besides CHR that still do treat older women.
Which brings us back to age because age 44 is very different from age 45 and age 45 is very different from age 46, etc. In these women of very advanced age, every year counts to significant degrees. Our Cornell colleagues so far reported their oldest autologous pregnancy at age 46. Our oldest two pregnancies so far were 47 years old, and just weeks short of their 48th birthday. Pregnancies and live births in this group of women of very advanced age, even at experienced centers, are, therefore, a clear exception. However, if patients are properly selected and counseled, and if they know that their chances with donor eggs would be much better, yet, still wish to proceed with use of their own eggs, why would anybody refuse them the request?
Indeed, donor eggs can be a wonderful option for infertile women, as long as they really want this option. Most women very clearly prefer conception with use of their own eggs and, often require for psychological reasons the experience of having a failed IVF cycle with use of their own eggs before egg donation even becomes an option for them. Only once a patient reaches the point where her head and her heart are telling her that egg donation is her only chance of biological motherhood, does CHR consider her an appropriate candidate. In other words, in CHR’s opinion egg donation should always be a last-resort procedure!
As already noted before, because of its relative simplicity and excellent outcomes, the procedure of egg donation requires much less special expertise than treatment of older women with use of their own eggs. Practically speaking, almost every IVF center nowadays will produce good pregnancy and live birth chances, maybe a few percentage points up or down, but such relatively minor differences are usually not reason to travel long distances. Seeking out treatment with own eggs, however, very frequently is reason for such travel.
Recently quickly expanding use of frozen, in place of fresh, eggs, as we will demonstrate in this section, may upset the relative congruity of outcomes in donor-recipient cycles between IVF centers. Here are the reasons:
As also already noted before, most IVF centers over the last decade stopped recruitment of their own egg donors. The reasons were practice convenience and cost concerns. Selecting egg donors is a difficult, lengthy and costly process. CHR accepts on average only 3-4% of applicants into the center’s donor pool. Screening out the other 96-97% takes time and effort and, even among accepted donors, many are never selected by a recipient. Screening costs for them, therefore, are basically wasted.
For fresh egg donation cycles, most IVF centers, therefore, nowadays work with donor agencies which, usually for an additional fee of thousands of dollars, assume the donor selection process (CHR does not charge for the donor selection process). The few centers that still maintain their own donor pools, usually have lengthy waiting periods and limited donor choices. Donor matches in these centers, therefore, can take up to 12-18 moths.
As IVF centers increasingly prefer the use of frozen (cryopreserved) eggs, the use of fresh eggs (i.e. freshly obtained eggs from a donor that allows fresh fertilization of eggs and transfer of fresh embryos) is, not surprisingly, quickly declining. This trend has been exacerbated by establishment of commercial frozen egg banks, which, in analogy to sperm banks that have existed for decades, can deliver frozen donor eggs to IVF centers overnight.
The VOICE has previously addressed advantages and disadvantages of fresh vs. frozen egg use in detail, coming to the conclusion that both have advantages and disadvantages. CHR, therefore, offers both options, a fresh egg donation program we call the Standard Donor Egg Program (SDEP), and a frozen donor egg program, we call the Eco(nomical) Donor Egg Program (EcoDEP).
CHR’s opinions about these two options have not changed since we last addressed the issue in the VOICE. If anything, recently by CHR researchers published national U.S. data, with Vitaly A. Kushnir, MD as lead author [J Ovarian Res 2018;11(1):2], even strengthened our previously voiced opinion that, in principle, a fresh egg donor cycle will always offer significantly higher pregnancy and live birth rates than a cycle that uses frozen eggs. Since CHR’s first report in the literature [Kushnir et al, Outcomes of fresh and cryopreserved oocyte donation, JAMA 2015;314(6):623-624], the par between fresh and frozen eggs in the national data set, indeed, even grew from ca. 7 to approximately 10 percentage points.
CHR’s initial publication in the prestigious medical journal JAMA was harshly attacked by some colleagues with the argument that, as the field developed more expertise in using frozen eggs, the gap would shrink. CHR, however, already then concluded that the opposite was much more likely to happen: as use of frozen eggs expanded, the gap would grow for two distinct reasons:
We here at CHR have mixed feelings about having been proven correct on yet another controversial subject in the IVF arena. To a degree, we, indeed, would not have minded at all, had our opponents been correct because the utilization of frozen eggs is so much less cumbersome for IVF centers and patients. We, however, strongly feel that patients and their IVF centers should decide on the treatments they, respectively, wish to dispense and receive based on evidence, and not based on inaccurate information distributed through ever-growing marketing budgets of commercial enterprises with considerable commercial self-interests.
To say it bluntly, the frequently heard argument from colleagues and frozen egg banks that IVF outcomes from fresh and frozen cycles are the same, is INCORRECT!
That such commercially-driven dynamics never are in the best interest of patients has in recent years, unfortunately, been repeatedly demonstrated. CHR made this point in the VOICE (and in the medical literature) early in the discussion of preimplantation genetic screening (PGS), now called preimplantation genetic testing for aneuploidy (PGT-A) and ever since. We are pleased to report that our arguments against utilization of PGS/PGT-A are, finally, resonating. We made this point when industry announced a revolution in the practice of embryology with introduction of closed incubation systems with real-time imaging, which since, indeed, has fizzled with the disappearance of most of the companies that initially entered this market, and we advised caution regarding many other add-ons to IVF, at times heavily, and not always transparently, promoted by commercial interests.
Likely the single most important principle behind CHR’s decades of clinical success has been the center’s ironclad rule of not introducing new treatments to IVF without validated assurances from prior testing that they will not adversely affect IVF cycle outcomes.
Above noted study of national IVF outcomes in donor cycles that used fresh or frozen eggs, clearly demonstrated that the outcome par between these two options has been growing year by year. We, indeed, are concerned that this trend will continue, as more and more IVF centers switch from fresh to frozen donor egg utilization. Should our concerns about a further expanding outcome par also turn out to be correct, the U.S. will in coming years see declines in the country’s stellar pregnancy rates in donor-recipient cycles. This will then mimic the decline in live birth rates observed in the U.S. over the last few years in autologous IVF cycles, which brought us back to live birth rates lower than those achieved in 2004 because of changes in IVF practice introduced without proper prior validation studies, such as routine blastocyst-stage embryo culture, closed incubation systems, PGS/PGT-A and others.
As in all of these other “fashions of the moment,” CHR will in the best interest of our patients not participate. This, of course, does not mean that CHR opposes the use of frozen eggs. We don’t and would not offer such a program if we did. Patients are, however, entitled to make their own choices based on correct information, and that mandates that they be told that frozen eggs significantly reduce pregnancy chances in comparison to fresh eggs, yet may also offer advantages, like relative simplicity of process and potentially lower cost.
Where egg donation cycles are done, therefore, matters after all. We wanted you to know! (Egg donors: get answers to frequently asked questions about donating eggs here.)
This is a part of the March 2018 issue of the CHR VOICE.
Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.
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