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Past Article of the Month Originally Published 01/03/2008
Oocyte Donation: The Importance of Medical and Psychological Preparation of Potential Donors

By Steven R Lindheim, M.D. , M.M.M., Scientific Director, Fertility Specialists Medical Group, San Diego, CA

The demand for oocyte donors has increased exponentially in the past ten years. According to the most recently reported data collected by the CDC in 2004 (Centers for Disease Control and Prevention, 2004), 13,722 fresh and frozen egg donation embryo transfer cycles were performed representing 13% of ART cycles in the United States. The American Society for Reproductive Medicine (ASRM) Guidelines for screening oocyte donation candidates include adequate informed consent, thorough medical evaluation, testing for sexually transmitted infections, genetic screening, and a comprehensive psychological assessment. The latter is to ensure that the donor is adequately informed of all relevant aspects of the process, is evaluated for evidence of coercion, and that she has been able to think through the possible future implications of the donation decision. As part of the informed consent process, potential donor candidates should also be aware of all aspects of oocyte disposition and embryo management by the IVF Programs. Despite these recommendations, reports suggests that potential oocyte donor candidates may be misinformed or there may be a tendency to minimize risks of the donation process in order to recruit larger donor pools to accommodate waiting recipient couples. As a result, donors who do not know about the risks or do not ask about them will remain ignorant and may decide to donate, when perhaps they would have decided not to proceed if given more complete information about the process. ASRM practice guidelines recommend that prospective donors should be aware of all aspects of potential oocyte-embryo management and disposition applicable to that practice. Informal polls reveals that ART programs are often vague or give incomplete disclosure of where and who oocytes are given to with potential donor candidates. Donor candidates are typically told, eggs are anonymously given to an infertile woman or couple. But what about clinical scenarios such as single women; women >50 years of age; cross cultural-ethnic donation; lesbian couples; male homosexual couple using donor oocyte and gestational surrogate; posthumous reproduction; a recipient using a family members (father, brother) donated sperm; recipient who is physically handicapped; recipient who is HIV (+); and donated eggs split among 2 or 3 couples in order to pay for the cycle. Given it is well known that there is a negative association between post-donation satisfaction with pre-donation ambivalence, would these possible scenarios change the potential donors willingness to participate at all or participate with reservations? In our program, donor candidates who appear suitable are invited for a face to face interview to further detail the principles of oocyte donation including indications, legal and ethical issues, medications, time commitment, risks related to the process, and required screening tests for both the donor and recipient. After explanation, if the prospective candidate conveys further interest, a thorough review of the donors background and medical history is then performed. In our previously published report, following discussion of the principles of oocyte donation, most donors convey an understanding and want to proceed with the screening and testing process. After review of the donor candidates medical history, family history and completed questionnaire, discussion of oocyte disposition and embryo management is performed. In our published study of 122 donor candidates, twenty-nine percent (n=35) did not have any concerns regarding the hypothetical scenarios (Group A); 65% (n=79) stated they would donate and trusted the programs judgment in the allocation of their donation but would prefer that their oocytes not be given to recipients in scenarios they had reservations about (Group B); while 6% (n=8) stated they had significant enough reservations that they would not participate if they knew that their oocytes would be used in situations about which they had reservations, most notably for women of advanced reproductive age (Group C). No differences were noted with respect to age, marital status, or ethnicity among these three groups. All candidates from Groups A and B re-contacted the program to proceed with the screening and testing process, while only 1 of 8 in Group C re-contacted the program. The data from this study suggests that disclosure of possible destinations for donated oocytes uncovers ambivalence among a significant number of prospective oocyte donors. As the need for oocyte donation has increased, professionals in the field have highlighted the importance of assessing the motivations of the donors and psychological impact of participating in oocyte donation. Altruism and monetary compensation are reported as the primary motivations for donation, while others have suggested that some donors may be motivated to donate in order to compensate for a history of abortion. Studies examining the psychological impact of oocyte donation have found that most donors express feelings of satisfaction and altruism at having helped the clinic or an infertile couple. Other studies suggest that donors become emotionally invested in the process and are very disappointed for the recipient women who do not conceive following the donation. Disclosure is a key element in the informed consent process. Research suggests that low-balling research candidates (ie. not providing all information at the outset) or anchoring research candidates on initial information, resulting in failure to adjust sufficiently to information disclosed later (under-adjustment), may induce a candidate to make an initial commitment that he or she may regret later. Furthermore, research candidates subsequently given less desirable information about the target action, are less likely to withdraw from the decision to complete the target action because of the psychological commitment or physical investment made. With respect to oocyte donation, it has been suggested that potential donor candidates who make the initial commitment, once fully informed of the process, may be less likely to back out of the decision to donate because they may be reluctant to disappoint the program or recipient once an initial investment has been made. It is paramount for IVF programs to make the donation process a gratifying and fulfilling experience. Suggestions by oocyte donors to improve the donor experience include minimizing the number of trips to the clinic, limiting the number of injections, providing follow-up care, treating donor with respect and appreciation, and offering a post-donation support group. In addition to these suggestions, we place enormous emphasis on identifying any pre-donation ambivalence. Thus our questioning of oocyte embryo disposition has become a routine line of questioning as it appears to be a useful tool to identify ambivalence in women who may not be ideal candidates to undergo oocyte donation thus improving post-donation satisfaction. References 1. The American Society for Reproductive Medicine. Psychological assessment of gamete donors and recipients. Fertil Steril 2002;77 (6 Suppl 5):11-12. <i>STEVEN R. LINDHEIM, MD, FACOG is the Scientific Director of Fertility Specialists Medical Group in San Diego, CA and is Board Certified in Reproductive Endocrinology. Dr Lindheim comes from the University of Wisconsin School of Medicine and Public Health, where he served as the division chief and medical director for the division of Reproductive Endocrine & Infertility. He graduated from the Temple School of Medicine and was a resident at Pennsylvania Hospital in Philadelphia. Dr. Lindheim completed a fellowship in Reproductive Endocrinology and Infertility at USC, and is currently Board Certified in both Ob/Gyn and Reproductive Endocrinology and Infertility. Dr. Lindheim's areas of interest and research are in-vitro fertilization, egg donation, and gestational surrogacy.</i> <a [email protected]>[email protected]</a> <a href=http://www.ivfspecialists.com>Fertility Specialists Medical Group</a>

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