One of the biggest challenges we face as fertility medicine specialists is how to do more to help our least-likely-to-succeed patients. What I mean here is the 42-and-over age group, patients with high FSH levels (decreased ovarian reserve), patients with very low responses to fertility medications, or those with very poor quality eggs. Some patients have a combination of the above which leads to a really dim prospect of having a baby with their own eggs.

Some people get the impression that fertility clinics avoid these patients like they have a communicable disease. They get the impression that we try to cherry pick patients to keep success rates high and make the CDC stats look good.  My impression from talking to my colleagues across the country and certainly from our own practice is that we do not try to discourage patients with poor possibilities from making a consult appointment and discussing treatment options. We all have such patients. In fact, we have so many of them at PFC, I don’t think we would have many patients at all if we tried to pre-select our best prognosis patients for IVF. When it comes to treatment, although there are challenges and sometimes the rewards are few, we don’t just throw up our hands and give up. We try to come up with a strategy to achieve the goal, looking at the emotional reserves and financial resources we have to work with, and start by making a plan.

Sometimes that plan will be to try a couple of cycles of low-tech approach, like just intrauterine insemination or Clomid + insemination, or a mid-level approach, like injections of FSH along with  insemination. We would see how things go and play it by ear from there. Sometimes, the plan will be to blast ahead to the big guns, full steam ahead to IVF. Sometimes, it’s counseling with our marriage and family therapist to begin the discussion: are we ready to move on to donor eggs? Sometimes it’s a sequence of all of the above. There really is no one plan for any one person. It’s just too complex to say one size fits all.

A certain percentage, even of the-less-likely-to-succeed patients will get pregnant with their own eggs and go on to deliver a healthy baby. The remainder may be faced with a tough decision. Do we just stop here and live child-free?  There are certain perks to that plan (sleeping in on the weekends, eating in nicer restaurants, adult vacations to name just a couple) but most people want to have a family no matter what or how. So then there is the adoption vs. egg donation question. There is no right or wrong choice here, either: just choices.

For patient(s) who need to use an egg donor to create or expand their family, medical scrutiny is performed on the chosen egg donor before she can proceed with the IVF cycle.

The medical screening of egg donors is an important process. Here at the PFC Egg Donor Agency, we proceed with an extensive screening process PRIOR to allowing the egg donor to become eligible for choosing by the intended parent(s). This extensive screening is performed to help determine and identify any medical factors which may disqualify the donor, or to identify information which may require additional testing prior to determining donor eligibility. At PFC, our philosophy is that we want to identify any issues prior to intended parents choosing the donor, so that the risk of identifying medical issues with the donor after the start of the IVF cycle is minimized, and the risk of canceling the cycle is much reduced.

Medical screening for the donor includes an extensive review of her personal and family medical history, physical exam and pelvic ultrasound, psychological evaluation (in-person visit with our MFT Peggy Orlin),

standardized personality assessment (PAI), and blood testing including ethnic appropriate genetic testing.

The PFC Egg Donor Agency complies with current recommendations by the American College of Obstetrics and Gynecology (ACOG), and the American College of Medical Genetics (ACMG). The donor identifies her ethnic background, and based on this information, appropriate testing is performed (see article by Lauri Black, Genetic Counselor, outlining current recommendations). This testing is done and results reviewed prior to approving the egg donor as eligible to be in the donor database. If the donor is a carrier for a genetic mutation, this may disqualify her from being an egg donor; some genetic mutations may not be disqualifying, but the sperm source may need to be screened for that mutation, prior to deciding to choose that egg donor. These tested mutations are for recessive disorders, so an embryo would only be at risk of having the disorder if BOTH the egg and sperm source were carriers for the identified mutation (see above noted article).

It is important to understand that new genetic mutations are identified almost every day; so recommendations for ethnic-based testing do potentially change year by year. While many genetic mutations have been identified on the human genome, many of these are very rare, and only mutations that are more frequently seen within one’s ethnic group are those that are recommended to be tested for. It is not appropriate, nor feasible, to check for all known possible mutations. The PFC Egg Donor Agency is kept apprised of current recommendation by our affiliated genetic counselors, so that our list of genetic screening tests may change over time. Rest assured that we keep informed of these changes, and comply with up-to-date recommendations.

While all this testing may seem cumbersome, it is to help assure that once you choose your egg donor, we can proceed with the IVF cycle with minimal risk of a cancellation, and start you on your way to achieve your dream of a healthy family.

At Pacific Fertility Center, we consider very carefully the number of embryos we transfer to each patient. Our goal is to create a healthy singleton pregnancy. We do our best to avoid multiple gestations. Consequently, in many cycles where we think that the chance of pregnancy is extremely high, we transfer only a single embryo. Our outstanding and robust embryo cryopreservation program preserves all embryos that were not transferred in the fresh cycle. Patients who transfer only a single embryo can feel secure in knowing that there are frozen embryo(s) available should they be needed.

Recently, we completed our analysis of the cumulative pregnancy rates per cycle for 2007. This type of report represents the overall pregnancy chance from a single IVF treatment cycle. This data was not available previously as many patients delay their use of frozen embryos. This cumulative analysis looks at the chance of pregnancy from a single IVF cycle when using both fresh embryos and subsequent frozen embryos, if needed.

Table 1 shows the rates for patients that used their own eggs (oocytes).
Table 2 shows pregnancy rates for patients that were the recipients of donor oocytes.

Please note that these are not delivered pregnancy rates. Many of these pregnancies are ongoing. There are also some patients that have not yet achieved pregnancy, but have frozen embryos remaining.

Pacific Fertility Center launched it’s Educational Series on July 31 st with a presentation on the “Disclosure of Use of Sperm or Egg Donors.” The speaker was Dr. Bob Nachtigall, a local Reproductive Endocrinologist, who has done much research and published numerous papers on various fertility related issues. Dr. Nachtigall addressed the difficult decisions couples face, who attempt conception with donor sperm or donor eggs. These include when to abandon medical treatment using their own gametes, whether to conceive with donor gametes over other options such as adoption, and decisions related to the selection of a donor. Yet the final decision, whether to disclose to their children the circumstances of their conception, is one of the most challenging.

He and his team, conducted research which was based on interviews with 254 parents of children conceived with donor sperm or eggs, they found that 95% of study couples came to a united disclosure after discussions that reflected a wide range of contexts and influences that included: the sociopolitical environment of the community; the couples’ friendships and support network; counseling and professional opinion; religious and cultural background; extended and immediate family structure and relationships; the child’s appearance; and the couple’s individual personal and ethical beliefs. For those couples who decided to tell their young children about their use of a donor, no parent expressed regret or reported a negative outcome after having initiated disclosure.

Dr. Nachtigall will be returning to PFC, to present his findings from a research study he did on “Frozen Embryos.” The annual number of IVF procedures performed in the U.S. has increased from less than 2,500 in 1985 to over 120,000 today. Yet the rapid growth and availability of this advanced reproductive technology has had an unforeseen consequence – the accumulation of an estimated 500,000 frozen embryos that represent the unused “leftovers” of past IVF cycles.

His presentation will address the question of what to do with frozen embryos, which is complicated by the variety and disparity of their potential uses and fates: (1) they can be used by the couple in further attempts to conceive; (2) they can be “donated” to other infertile couples who wish to have a child; (3) they can be used in stem cell research; (4) they can be destroyed; (5) they can be stored indefinitely. Dr. Nachtigall and his team interviewed over 100 couples (many of whom were PFC patients) who had undergone IVF. The team found that ambivalence, uncertainty and most significantly, feelings of deep connection to a couple’s own embryos are several factors that cause difficulty in reaching a disposition decision.

The presentation on “Frozen Embryos” has not been scheduled at this time. However, please watch for dates and times in upcoming issues of Fertility Flash.

PFC Educational Series 2008

The PFC Educational Series are presentations held the last Thursday of each month from 4:00 till 5:30 p.m. in the PFC Education Center located at 55 Francisco Street, Suite 500. The presentations address various topics, which are open to PFC staff, as well as members of the medical community. The PFC physicians found offering programs of this nature would be an ideal way to increase knowledge regarding different topics. In addition, this is a great opportunity to “reach out” to other local physicians and their staff, by offering educational resources, that they otherwise may not have access. The presentations are offered at no charge and the topics will be published in the Fertility Flash, as well as on the website www.pacificfertilitycenter.com. If you are interested in attending this presentation, please contact our Development Department directly at 415-249-3656.

As a lesbian couple, we were aware that getting pregnant might be a challenge and might require medical intervention, but decided to try at home anyway.  Since Jean is older it made sense for her to carry first.  In 2002, we began the process of trying to conceive with our known donor.  We had a few challenges to overcome. Our donor was from out of state and we had to use a shipping kit designed by University of Chicago Andrology Lab to maintain the viability of the sperm.  We hired a midwife to come to our home, clean the semen sample and do the insemination.  In 2004, after two years of trying and many dollars spent, it became apparent that we were not going to be successful on our own.

We spoke to our OB/GYN who recommended that we work with a fertility specialist.  On a recommendation from a Pacific Fertility Center staff counselor, Peggy Orlin, we contacted Dr. Eldon Schriock at PFC.  Though the initial paperwork and set up seemed daunting, we were able to complete the required items quickly and were ready to start fertility treatment with Dr. Schriock in March 2005.  Jean was set to do the “Clomid challenge” test on our first attempt.  With new FDA regulations looming in May 2005, we felt we had limited time to get Jean pregnant with our current donor so the pressure was on.  Although the PFC staff was not initially familiar with our shipping kit, they were more than willing to work with it and help us with the logistics.  Jean had a fortunate experience with Clomid and on April 15, 2005 with 3 good follicles we completed our first IUI with PFC.  Two weeks and 3 positive pregnancy tests later, we confirmed that we were in fact going to have a baby.  It was hard to believe that after so many years and tries it was actually happening.  Now 3 years later we have a beautiful and fun two year old girl named Logan.

When Logan was 5 months old, there was an accident in my family that gave us pause.  We realized life is short and you never know what is in store for you around the next corner .We decided to begin the process of trying to get Marni pregnant. In May 2006 we made the decision that we would begin the process at home, but needless to say, we were unsuccessful. After 6 months we would again meet with Dr. Schriock and his fabulous team of nurses and doctors.    Because of our history with PFC, we were able to quickly begin the process and get started trying to achieve pregnancy at PFC.

With the new FDA regulations now in place we had a host of new hoops to jump through. Once we cleared the list of hurdles, we began our attempt to get Marni pregnant.  After many different fertility treatments (Clomid, Letrazole, and Follistim), three different PFC doctors (Dr. Schriock, Dr. Ryan and Dr. Givens) all suggested that if we were committed to our donor then we should seriously think about IVF as an option because of the quality of his frozen/thawed sperm.  In October 2007 we began the IVF process.  Though there was a lot to manage and keep track of (when to give shots, appointments, blood tests, etc.) we never felt alone.  The PFC doctors, nurses and staff were always available for a phone conference to answer any questions or concerns.  In late November 2007 we completed IVF – the egg retrieval and embryo transfer process.  Four embryos were implanted out of the seven that fertilized.  In December 2007, two weeks later, we received the positive blood test result and were ecstatic.  Unfortunately, within days of the positive pregnancy result it became clear that this was not going to be a viable pregnancy.  Marni had apparently been pregnant with twins. She miscarried the first embryo and had to undergo not only the abortion pill, but a subsequent D&C to remove the second gestational sac.  Dr. Schriock and all of the staff, nurses and other doctors were available for emotional support and medical guidance throughout the process.

We completed our second egg retrieval and awaited the fertilization results.  Our hopes were high but we were realistic and knew that anything could happen. As it turned out, Marni’s second round of IVF was unsuccessful. Though the quality of embryos was better than in the first cycle, she did not get pregnant.  We had a few conversations with Dr. Schriock and determined that if she were to continue trying to get pregnant, it would take an ovum donor and a lot of money.  We decided to have Jean try again, because we wanted to be pragmatic and realistic and keep the goal of adding to our family in mind.  Jean is currently under Dr. Schriock’s care and last week she completed a course of Clomid and an IUI.  We are now in the waiting period and are hopeful for a positive result.

Our experience with PFC, Dr. Schriock and all the other staff has been great.  We had a few bumps along the way but the doctors, nurses, office manager and staff responded quickly and effectively.  We always felt at ease to express concerns and ask questions.  Everyone we encountered at PFC has a good understanding of how emotional this process can be and has always been empathetic in their dealings with us.  We never felt uncomfortable as a lesbian couple.  We would absolutely recommend PFC for their cutting edge technology, knowledge and exceptional care during this highly emotional event.

Best Regards,
Marni & Jean

In the June 2008 issue of the Fertility Flash, Dr. Isabelle Ryan answered a question on how to choose an egg donor from a medical perspective. This month I’ll focus on the psychological aspects of choosing an agency egg donor. As the Marriage and Family Therapist at Pacific Fertility Center, this is a question I address regularly. All PFC patients considering ovum donation will have a complimentary meeting with me

Choosing an egg donor may seem like a daunting and foreign process. You are undertaking an unfamiliar task that you probably never planned on. But now that you are here, it may help to remember that the gene pool is huge. No matter whose gametes create your offspring; your children will be a magical and unique blend of nature and nurture. DNA is not destiny. Your love, your values, your womb, all have an impact on the person your child will become.

I find the following to be helpful reminders as you move forward with choosing a donor:

• The experience of attachment to a child, the feeling of being in love with him or her, happens regardless of whether one or both parents share the child’s DNA.
• Mothers and fathers are the ones that raise and love a child. Donors are the ones that donated or helped.
• Most donors donate for a complex blend of altruistic and monetary reasons.
• Each of our PFC agency donors has a psychological interview with me. In addition they take a psychological test (PAI); this test assists me in assessing not only their personality, but also their honesty and reliability.
• The more stringent your criteria for choosing a donor, the longer it will take to find her.

So, how in the world do you choose a donor?

I think there is a relatively simple answer to this seemingly complex question.

Choose the donor that jumps off the page at you. Choose the donor whom you like best, resonate with, feel a connection to, are impressed by.

That donor may or may not look exactly like you, but she will be someone you might have chosen as a friend or you could imagine as your daughter.

I believe the goal in choosing an egg donor is to be able to look at your child and either say or think to yourself, “we couldn’t use my DNA, but we chose someone we thought was lovely, interesting, attractive, smart, motivated (add the adjectives of your choice) to be our child’s donor. “

Practically speaking, if you have a partner, it may work best to look at donor profiles separately from him or her. After each of you note your favorites, you should then come together and choose from the selections that you both indicated. This process helps assure you both were able to choose without pressure from your partner.

Finally, please remember there is no “perfect donor,” but that does not mean you won’t be blessed with the “perfect child.”

1. A healthy woman in her late 30’s or even in her 40’s, will have the fertility of a younger woman.
   Although it is always better to be healthy, especially when it comes to carrying a pregnancy, the likelihood of conception is tied to the age of a woman’s eggs and is not closely related to her general health.
2. You should have sex every other day during the fertile window.
   For most men, sperm recovery is very rapid. Sometimes when an IVF cycle is done and there are many eggs to fertilize, we ask for a second semen sample. We are often amazed when the second sample, collected just 2 hours after the first sample, has even better numbers. So, rather than attempting to “save up good sperm” by having less frequent intercourse during the most fertile time period, we recommend more frequent intercourse. A home ovulation predictor kit is useful to time sex to ovulation. When using the ovulation predictor kit, we recommend sex on the first day of the LH surge and the next day too.
3. Fertility medications are associated with a higher risk of cancer.
   In the early 1990’s, some concerns were raised that taking fertility medications might be associated with a higher lifetime risk of ovarian cancer. Since then, several studies have been published that did not find this to be true. Because of this thorough and extensive research we feel comfortable using these medications not only on patients, but our egg donors as well.
4. Fertility medications (especially injectable fertility medications) cause women to be emotional wrecks.
   Although Clomid (clomiphene citrate) has well-known side effects related to its anti-estrogen effects, the injectable fertility medications do not tend to cause the same negative mood alterations. These drugs increase estrogen levels, a hormone which tends to have positive affects on mood.
5. Using fertility drugs and getting multiple eggs might use up my future eggs and cause me to go into menopause earlier than expected.
   Humans usually only ovulate one mature egg each month. This egg is contained in the dominant follicle and grows in one ovary or the other. For each dominant follicle that develops in any particular cycle, there are several other follicles/potential eggs available that are also trying to become that dominant follicle. The number of these other “antral” follicles varies from woman to woman and to lesser degree, from cycle to cycle. In general, the number of antral follicles declines with female age. Once the dominant follicle has been selected and the egg ovulated, the menstrual period or a pregnancy begin, and the other antral follicles, undergo programmed cell death, called atresia. The use of fertility medications rescues this group of antral follicles from atresia. For this reason creating multiple mature follicles and obtaining multiple eggs in any one cycle does not use up future eggs. We are simply rescuing eggs that would have otherwise died that month.
6. Having a miscarriage is a good sign that a woman is fertile.
   Approximately 70% of miscarriages are due to abnormal chromosomes (DNA) in the embryo. As a woman ages, more and more of her eggs become abnormal In fact, at age 40, only 1 in 10 eggs on average has normal chromosomes; so a woman at that age may only ovulate one normal egg per year. While a miscarriage may indicate that fertilization and implantation can occur, it doesn’t necessarily mean that overall egg quality is good. Egg quality is the best indicator of the ability to produce a viable pregnancy.
7. Stress is a major cause of infertility.
   There is enough circumstantial evidence to indict stress as a collaborator when it comes to fertility; however, there is very little evidence to convict stress as a major perpetrator. Usually there is some other underlying cause to the problem, even if it is just age-related sub-fertility (decline in fertility due to female age and therefore higher numbers of abnormal eggs). Stress, however, can compound the problem and possibly negatively impact egg quality and uterine lining quality. Look for a new addition to our website, the Domar Fertility Stress Questionnaire, to assess your stress levels.
8. In Vitro Fertilization can help women in their late 40’s and even 50’s to conceive with their own eggs.
   Despite the number of celebrities having babies in their mid-forties and beyond, these babies may not necessarily have been the result of an in vitro fertilization process using their own eggs. While we respect a woman’s right to privacy and their decision not to divulge this little detail, the perception left with the public is that fertility treatments can extend one’s reproductive life. Unfortunately, this simply is not true. There is a very, very low probability of improving one’s success of conceiving after age 43 by using assisted reproduction, unless the woman considers using donor eggs.
9. In Vitro Fertilization success rates are low.
   Across the United States, including patients of all ages, the delivered success rates for in vitro fertilization have risen from about 20% in the mid-1990s to about 35% in the mid-2000s. During this same period, fewer embryos were being transferred to the uterus per cycle and the triplet and higher-multiple pregnancy rates dropped dramatically. Though it may take more than one attempt to conceive, the majority of patients are successful.
10. Very few people ever experience infertility.
    Many fertility patients feel they are the only ones in their circle of friends and acquaintances suffering from infertility. At times, it seems as though everyone else is having a baby. Actually, one in six couples is having trouble with conception, they just may not talk about it. Since they are not pushing a stroller, there is no outward visible sign of their fertility status. When couples decide to share the story of their fertility quest, they often find there are many of their peers experiencing similar difficulties. They discover friends who can not only relate but also provide valuable support.

In late October of this year, our first patient who underwent embryo transfer with embryos created from vitrified and warmed donor oocytes has successfully delivered. The baby was born at term and appears to be perfectly healthy.

Three other pregnancies are ongoing and are expected to deliver in 2008. We congratulate our new parents and the parents-to-be who have participated in this ground breaking program.

PFC has ended enrollment of patients into this program, but expects to continue research efforts with respect to oocyte vitrification.

The American Society for Reproductive Medicine (ASRM) is the largest organization in the United States for medical professionals in the field of Reproductive Endocrinology and Infertility. In 2002, ASRM published medical and psychological guidelines for ovum donation. The psychological recommendations for donors are general guidelines for addressing moral, ethical and psychosocial issues that may confront ovum donors. Included are standards for what should be included in a psychosocial screening of donors and reasons to exclude donors. A few of the objective reasons for donor exclusion include known substance abuse, positive family history of heritable psychiatric disorders such as schizophrenia or bipolar disorder, or instability in donors’ lives. To determine “inclusion” I take a psychosocial history and administer a psychological test that informs me about the donor’s personality profile, including just how much they are trying to impress me – the “fake good” factor. I am also assessing motivation to donate and the donor’s “need” versus “desire for” the compensation. Stability, stress levels, and reproductive history are also part of an ASRM assessment of donors.

Although I would like to base my entire decision on objective information, much of my decision on donor acceptance must, in fact, be based on intuition. Throughout my 25 years as a therapist, I have found that my intuition is quite accurate, but it is not fool proof.

There is one major controversy in the field that may hinder a psychotherapist’s ability to screen donors. That is the hotly debated topic on compensation of donors. In August 2000, the Ethics Committee of The American Society for Reproductive Medicine concluded that there is no consensus on the precise payment that oocyte donors should receive. It was suggested, “sums of $5,000 or more require justification and sums above $10,000 go beyond what is appropriate.” Due to costs of living and the scarcity of available donors, there are significant regional variations that affect these rates.

The Society for Assisted Reproductive Technology (SART) has attempted to assist clinics and patients by creating a list of Egg Donor Agencies that have signed an agreement stating that they will abide by the Ethics Committee Guidelines governing the compensation of egg donors.

The debate centers on the fact that donors could feel undue inducement and exploitation in the process if the fee is so high as to be coercive. Part of the job of the mental health professional is to provide donors with informed consent. Might donors conceal pertinent medical information that could be important for themselves or offspring if the monetary incentive is so high? Will donors discount risks to themselves? How can the donor actually give informed consent about the medical procedure and pay attention to the risks if $$ signs are floating before their eyes?

Ethicists and some in the field of women’s health advocacy express concern “that lucrative payments are enticing young women with credit-card debt and steep tuition bills to sell eggs without seriously evaluating the risks.” Can the payment cloud someone’s judgment and can we assess that? How much is too much? Where is that line?

When I began working with PFC in 1998, we were paying first time egg donors $2,500. Nine years later, the compensation is $6,500 for a first time donor and $7,000 for any subsequent donations. Even adjusted for inflation, the payment is rising at a phenomenal rate. Competition, supply and demand govern these rises.

As part of my objective/intuitive approach to interviewing donors, I discuss money with them. What would she use the compensation for? How does she support herself? What kind and how much debt does she have? While $25,000 in student loans points to a person’s drive toward positive goals, the same amount in credit card debt speaks to me of impulsive behavior. How much have they educated themselves on ovum donation? Whom have they talked with about their desires? Do they have their own children? Are they science majors who may be more likely to view gametes as DNA and not their own children? Are their answers well thought out?

My goal is to provide the recipients of donated eggs with intelligent, healthy, and thoughtful young women who understand the implications of ovum donation both for themselves and for the recipients. Donors who are motivated by the “need” for money are more likely to provide inaccurate information on their applications, or leave out information that could be pertinent to the recipients or their offspring. It is my job and the job of the Egg Donor Agency to determine motivation.

Although impossible to attain, we would all like donors to be motivated altruistically. We may diminish altruism by making the donation about eggs for money. However, I believe we can increase altruism by helping the donors to have a greater understanding of who the recipients are and what their struggles have been.

Peggy Orlin, MFT

Ms. Orlin served as 2006-7 chair of ASRM’s Executive Committee of the Mental Health Professional Group, is a member of Resolve’s National Mental Health Advisory Board. She co-teaches PFC’s Mind/Body workshops.

To register for the September 8th Mind/Body@PFC Workshop, please phone 415-834-3095.

DonateYourEggs.com

Pacific Fertility Center provides an in–house egg donor agency as a convenient way for our patients to find carefully screened egg donors. Our Egg Donation Agency is always looking for new egg donors to add to our registry. Do you know a college graduate, a student, a young professional or an exceptional woman who might be willing to make a life-altering difference? She could be a young woman who has chosen to delay childbearing or has decided to be childless and wants to help others become parents, or she could be a mother who wants to share the joy of parenthood through the gift of egg donation.

Please send them to our agency’s Egg Donor website. The website has more information about becoming an egg donation and also has an online application.

Please note: Because age is a critical factor in the success of IVF with egg donation, egg donors must be healthy and between the ages of 21 and 29.

Click here: PFC Egg Donor Agency for information about the services we provide egg donor recipients.