The International Council on Infertility Information Dissemination, Inc

Maryland: A Friendly State for Surrogacy

 

Maryland is a great state for surrogacy. In Maryland, both gestational (a surrogate who is not biologically related to the child) and traditional surrogacy (a surrogate who agrees to be artificially inseminated with the intended father’s sperm and to carry the pregnancy to term), is possible for married, unmarried, and gay individuals.

There are no statutes or administrative regulations governing surrogacy arrangements in Maryland.  However, there have been two significant cases, both involving traditional surrogacy.

In both cases, the surrogate relinquished custody of the child when it was born and consented to the second-parent adoption by the intended mother.  In one of the cases, the court ruled that despite the fact that the second-parent adoption should be granted, surrogacy arrangements should be considered void and against public policy. In the second case, the court again ruled that the second-parent adoption should be granted and that surrogacy is not against public policy and does not violate Maryland law.  The judge in the latter case stated that the legislature should determine the legality of surrogacy agreements, not the courts.

The Maryland legislature tried to pass bills in 1992 and 1994 that would have made surrogacy agreements void against public policy.  However, the Governor vetoed these bills.  

In 2000, the Maryland Attorney General’s Office issued an opinion on surrogacy as well.  It’s a statement said that surrogacy agreements that pay fees to a birth mother are illegal and unenforceable. 

There has also been one appellate decision regarding surrogacy. In this case, the court ruled that if a single father is pursuing surrogacy, a surrogate mother, who has no genetic connection to the baby, does not have to be listed as the child’s mother on the birth certificate. The court also noted in this case that the payment of money for a child in a surrogacy agreement is illegal.

From the above cases and opinions, it can be deduced that it is important to have a surrogacy agreement that clearly states the intent of the parties, their rights, and responsibilities and that payments to the surrogate are not compensation for payment of a child.

In Maryland, intended parents can also get a pre-birth order, so that their names go directly on the birth certificate. In traditional surrogacy cases, the biological father’s name can go directly on the birth certificate. However, the biological father’s partner or wife would have to file for second-parent adoption in order to become the second legal parent.

Because Maryland is one of the friendlier surrogacy states, many couples wish to pursue surrogacy in Maryland.  However, in order to have Maryland laws apply, either the intended parents or the surrogate needs to reside in Maryland.

 

 

Legal Representation During Surrogacy Process: Don't Cut Corners

Legal Representation During Your Surrogacy Process: Don’t Cut Corners

The cost for undergoing a surrogacy process is significant, over  $100,000 for gestational surrogacy (using the intended mother’s ovum or donor ovum). Often times, to try to reduce costs, parents will cut corners. One avenue where parents have tried to reduce their fees is to try and do the legal aspects of the surrogacy process themselves. While this method might work for some, in general, it’s a better idea to have legal representation throughout your surrogacy process, both for your own protection and the surrogate’s protection.

A carefully and properly drafted contract is necessary, both so that all parties understand their rights and responsibilities, and also for any parental rights/adoption proceedings. A surrogacy contract should detail each parties’ duties, and all the critical issues involved in the surrogacy process, such as confidentiality, abortion/selective reduction issues, medical/psychological screening, parental rights, contact, compensation, and expectations. Both the parents and the surrogate need to feel comfortable with the contract before moving ahead.

Sometimes, parents will attempt to draft their own contract or use a contract they found on the internet. These contracts are often incomplete and leave out important elements. Further, they do not ensure that all the necessary safeguards have been met. This can be extremely detrimental to the parties if any issues arise. For example, in Munoz v. Haro, intended parents and their traditional surrogate, who was non-English speaking, entered into a surrogacy contract. (1) However, the surrogate did not have her own attorney and did not understand the contract. In fact, the surrogate thought she would be able to keep the child upon its birth. The court ruled that although surrogacy contracts are lawful, and the contract would have been valid had there been proper safeguards (such as legal counsel), in this case, those protections were not met and the contract was therefore unenforceable.

 

Finally, courts often want to see certain language in the contract in order to grant parental rights to the parents. This is necessary if the parents want to obtain a pre-birth order or their names on the birth certificate. It is also necessary to protect the intended parents if they separate or divorce during the surrogacy process. In Buzzanca v. Buzzanca, the intended parents used both donor ovum and donor sperm. (2) The parents filed for divorce before the child was born. The intended father claimed that he was not the father of the child, since it was not his sperm, and should not have to pay child support. The court ruled that the intended father had to pay child support since he was responsible for bringing the child into the world. The consent that the intended father gave in his surrogacy agreement, gave him the legal responsibilities of fatherhood, which include child support. Had there not been a carefully drafted surrogacy agreement, the court might not have held that the intended father had parental rights and responsibilities.

While there haven’t been very many court cases involving third party reproduction, in those cases that are contested, courts turn to the surrogacy contract to determine rights. It is therefore important that parties take proper legal measures to protect themselves during their surrogacy process, and have an appropriate contract written by an attorney with experience in surrogacy.

 

 

Footnotes:

1. Munoz v. Haro No. 572834 (San Diego Super. Ct. 1983)

2. Buzzanca v. Buzzanca 61 Cal. App. 4th 1410

 

Testing Anti-Mullerian Hormone to Determine Egg Reserves by Scott Roseff, MD

Golden egg sitting amoung ordinary white eggs

Golden egg sitting amoung ordinary white eggsEGG QUALITY starts declining when a woman is in her mid-20's!

There is a slow decline in quality from about age 24 to age 30, followed by a fairly quick decline between age 30 and age 35, with a rapid decrease between ages 35 and 40. And, over age 40, egg quality is generally quite poor. All of this may make it difficult to get pregnant...

OVARIAN RESERVE describes a woman's capacity to produce a reasonable quantity of good quality eggs. Of course, measuring a woman's ovarian reserve is very important in determining why someone may not be getting pregnant, as well as in finding out the ease (if she has good eggs) or difficulty (if she has poor eggs) with which a pregnancy may be realized.

Women with normal ovarian reserve (good eggs) may conceive via simple therapies (such as timed intrauterine insemination), while women with abnormal ovarian reserve (poor eggs) may require in-vitro fertilization (IVF) or even IVF with donor eggs. Until now, we have only been able to INDIRECTLY measure a woman's ovarian reserve via a cycle day 3 FSH/estradiol blood test, or through a "Clomiphene Citrate (Clomid) Challenge Test", or CCCT. These tests measured the brain's hormones which were INDIRECTLY affected by the ovary's egg quality. While these tests were the best we had, we now have a more modern and sensitive blood test which DIRECTLY measures a woman's ovarian reserve!

The human egg is "housed" inside a structure called the follicle. The follicle is comprised of specialized cells called granulosa cells. The granulosa cells produce a specific hormone directly and predictably linked to egg quality, and that hormone is called AMH. While other means of examining ovarian reserve may offer indirect, and possibly less accurate, less specific, and less predictive tests of egg quality (such as cycle day 3 FSH/estradiol levels and the CCCT), many reproductive endocrinologists believe women are better served by examining their AMH level -- a more direct, more accurate, more specific, and more predictive test of egg quality.

The AMH test has been found particularly useful in the following clinical situations: Women who either need a Clomiphene Citrate Challenge Test (CCCT) or previously had a CCCT and want to confirm/refute the results; Women of advanced reproductive age (35 years or older); Any women with a diagnosis of "unexplained infertility"; Women who have shown a poor response to ovulation induction with either Clomid/Serophene or injectable fertility drugs; Women who have been told they need IVF with donor eggs -- a normal AMH level may permit them to do IVF with their own eggs, while an abnormal AMH level may confirm the need for IVF with donor eggs. If you have individual questions about this article, please feel free to ask them on the General Infertility Medical forum: moderated by Dr. Scott Roseff.

Egg freezing, is it right for you?

Egg Freezing: Is it Right for You?

By Carlene W. Elsner, M.D., Z. Peter Nagy, M.D., Ph.D., and Amy E. Jones M.S.

         

Cryopreservation or freezing of human eggs is a technique intended to preserve a woman’s eggs for later use by herself or a designated recipient to create embryos and subsequent pregnancies. There are several groups of women who may be potential candidates for cryopreservation of eggs.

 

  1. Young unmarried women facing chemotherapy or irradiation for treatment of life-threatening disease, i.e. cancer, may be rendered sterile by the treatment of their disease. For these women the option to freeze some eggs, making it possible for them to have children later when their disease is cured, may be very important.
  2. Women who, because of impaired ovarian reserve or poor egg quality, require donor egg to conceive may consider the use of cryopreserved donor eggs in an egg bank because it would substantially lower the cost of treatment. Stimulation of one donor may produce enough eggs to supply several recipients, potentially lowering the cost of this technology to an individual.
  3. Women undergoing IVF in countries that prohibit the freezing of embryos may choose to have excess eggs cryopreserved for additional attempts to conceive without another stimulation cycle, effectively lowering the cost of additional treatment cycles.
  4. Women who for professional or family reasons desire to extend their ability to conceive past their normal reproductive lifetime may be interested in having some eggs frozen for later use. Most commonly women requesting these services are older and frequently already have impaired ovarian reserve, making them suboptimal candidates for this technology.

 

Ideally, all women should create their own egg bank before the age of 30 for 2 possible reasons. First, even if they have children, they may want additional children later in life (divorce and remarriage or death of child). Secondly, one’s own oocytes may be useful to assist in treating some disease that may develop in oneself anytime later in life (through stem cell therapy).

 

BACKGROUND

           

Frozen banked human sperm has been in use for many years for the treatment of male factor infertility. However, the human egg is much more sensitive to the freeze thaw process than is sperm.  The egg, because of its very nature, is definitely different from the sperm. It contains not only the genetic material necessary for the development of a new individual, but also a myriad of intracellular organelles and the meiotic spindle all of which may be damaged by the freeze thaw process. Damage to these structures may result in uneven separation of chromosome pairs leading to aneuploidy (an abnormal number of chromosomes within the cell), disruption of metabolic pathways, and even cell death. Early work proceeded slowly because of concerns about efficacy and potential risk of aneuploidy.

           

It was not until 1986 that Chen reported the first child born from an egg that had been frozen and thawed prior to fertilization. Since that time, a number of groups around the world have reported pregnancies and births of normal children using cryopreserved eggs and yet this technology has still not become commonplace. Initially, many eggs did not survive the freeze thaw process; fertilization rates were low because the zona pellucida (the coating around the egg) hardens from the freeze thaw process resulting in decreased sperm penetration; subsequent embryo development and implantation rates were poor; and pregnancy loss rates were high. However, there have been no reports of abnormalities in the children born following oocyte cryopreservation,       

 

In the past several years, significant progress has been made in the field of cryopreservation of eggs. Outcomes are improving, making this technology a realistic option for some women.

 

 

THE STATE OF THE ART

 

Currently most eggs are frozen as MII oocytes using one of two methods. The slow freeze rapid thaw method has been favored by European investigators, while their Asian counterparts favor a rapid freeze and rapid thaw technique called vitrification. Both procedures have resulted in acceptable pregnancy rates in small numbers of patients.  Freezing and thawing of eggs results in hardening of the zona pellucida making sperm penetration of the egg more difficult. For this reason, ICSI (intracytoplasmic sperm injection) is required with both techniques to achieve optimal fertilization rates. In order to achieve a live birth with egg cryopreservation, 1) the egg must survive the freeze and thaw, 2) fertilize normally 3) implant, 4) and the resultant pregnancy must continue until a live birth occurs. Using eggs from 7 young donors (age 18-25),  Fosas et al. reported 90% oocyte survival, 73% fertilization rate, and 57% (4/7) pregnancy rate with the slow freeze rapid thaw method plus ICSI. Five normal children were born to 4 recipients.

 

Quintans et al. used a slow freeze rapid thaw process with ICSI in 12 women (average age 33). He reported 63% oocyte survival, 59% fertilization rate, and 50% pregnancy rate per transfer. From the 6 pregnancies established, 2 children were born to women aged 29& 30 respectively.

 

Yoon et al. used virtification plus ICSI in 34 patients (average age 32.4) to produce 69% oocyte survival, 72% fertilization rate, and 21% (6/28) pregnancy rate. Seven normal children were born to 6 women.

 

The common thread here is that if eggs of young women are frozen, outcomes are acceptable. Therefore, cryopreservation of eggs for young women who need chemotherapy or irradiation makes sense provided the outcome of therapy is not adversely affected by the gonadotropins used and the necessary time delay to recover mature eggs. Cryopreservation of eggs is already available in countries where embryo cryopreservation is prohibited by law. The technology of egg cryopreservation has now progressed to the point that we will soon see the development of egg banks for storage of donor eggs which recipients can then order as needed.

           

 

OOCYTE CRYOPRESERVATION FOR WOMEN OVER 35

 

The age of the egg is the single most important determinant of the outcome of an IVF cycle. Women have all the eggs they will ever have when they are born and are most fertile in their late teens and early 20’s. With advancing age of the egg, per cycle pregnancy rates decline and miscarriage rates rise. Both of these occur because of meiotic spindle abnormalities common in aging eggs. These spindle abnormalities lead to aneuploidy (extra or absent chromosomes).  Battaglia et al. studied the aneuploidy rate in eggs of women of various ages and found in women 25 years of age or younger, 17% of eggs were aneuploid. However in women over 40, 79% of eggs were aneuploid. Aneuploid embryos usually either fail to implant or they are lost in early miscarriage, thus, aneuploidy explains both the fall in the pregnancy rate and the rise in the miscarriage rate that occurs with advancing age.  Aneuploidy causes most of the first trimester losses in older women. (see article on PGD)

 

As a woman ages, ovarian reserve diminishes. Therefore, fewer and poorer quality eggs are produced in each stimulation cycle. One stimulation cycle may produce 15 or more mature eggs in a woman under 35 while a woman over the age of 40 may produce fewer than 5. Over 50% of all embryos produced by women 40 and older are chromosomally abnormal. The results reported by Porcu et al. of 112 cycles of oocyte cryopreservation and ICSI are as follows: 1502 eggs were thawed; 16 pregnancies were established; and 9 women delivered 11 children (2 sets of twins). More than 100 eggs were required to produce 1 child in this large series. The sheer numbers of eggs required to give an older woman a reasonable chance to have a child from cryopreservation of her own eggs makes this technology impractical for women over the age of 35 at the present time. Further research may lead to improved outcomes in the future.

 

 

SUMMARY

 

Oocyte cryopreservation is a rapidly advancing technology that deserves ongoing attention. Over 100 babies have been born to date worldwide. As far as we know all the children are normal. Not all articles reporting live births from this technology report the age of the eggs in successful patients. When they do, the eggs used to successfully create babies were almost always from women under the age of 32.  For women over 35, oocyte cryopreservation does not yet provide the answer to advancing maternal age and impaired ovarian reserve.

 

Carlene W. Elsner, M.D. is a reproductive endocrinologist  at Reproductive Biology  Associates in Atlanta Georgia.
Phone: 404-843-3064 or Toll Free 1-888-RBA-4IVF

Email: rba-online@rba-online.com

Website: http://www.rba-online.com 

 

Z. Peter Nagy, M.D., Ph.D. is the scientific and laboratory director and Amy E. Jones M.S. is the laboratory supervisor at Reproductive Biology Associates.

 

 

 

REFERENCES

 

Battaglia, D. E., Goodwin, P., Klein , N.A., and Soules, M. R.. Influence of maternal age on meiotic spindle assembly in oocytes from naturally cycling women. Hum. Reprod., 11, 2217-2222. 1996.

Chen, C..  Pregnancy after human oocyte cryopreservation. Lancet 1, 884-886. 1986.

 

Fosas, N., Marina, F., Torres,  P., Jove, I., Martin, P., Perez,N., Arnedo, N., and Marina, S.. The births of five Spanish babies from cryopreserved donated oocytes. Hum. Reprod. 18[7], 1417-1421. 2003.

 

Quintans, C., Donaldson, M., Bertolino, M., and  Pasqualini, R..Birth of two babies using oocytes that were cryopreserved in a choline-based freezing medium. Hum. Reprod. 17[12], 3149-3152. 2002.

 

Yoon, T., Kim, T., Park, S., Hong, S., Ko, J., Chung, H., Cha, K.. Live births after vitrification of oocytes in a stimulated in vitro fertilization-embryo transfer program. Fertil. Steril. 79[6], 1323-1326. 2003.

 

Embryo Options

Embryo Options – The Case for Donation and Adoption

Advances in assisted reproductive technologies (ART) over the last several years has led to better cyropreservation techniques and the wider use of frozen embryos.  It is actually estimated that there are over 100,000 frozen embryos in storage in the United States alone.  With the advent of this technology, the concept of embryo donation has become another viable option for those individuals and couples who have been desperately wishing for a child.  In fact, it is often the only remaining viable alternative for those who have already been on the rollercoaster of infertility for many years, and who have already invested significant amounts of time and money into their journey.   

Certainly, the number of available embryos may seem high, but the actual number of embryos available to couples and individuals is really much lower due to the fact that the decision to donate leftover embryos to someone else is often a difficult one for many.  Many couples choose to destroy their remaining embryos or maintain them in the frozen state indefinitely since they are not willing to be contacted by any resulting child.  On the other hand, the major motivations for the donation of one’s embryos are usually to give the embryo a chance at life or to allow other infertile couples to have a child.  To be sure, the donors must certainly consider the following: a.) Whether they will want the embryos for future siblings for any of their existing children; b.) How they feel about the real possibility that there may be other children alive who are the result of their own genetic material or that of their partner and a donor; and, c.) The pain of not knowing the result of their donation

 

On the other hand, the options that are available to recipient couples and individuals are very few and far between once they have determined that they need to move onto donor embryos.  For example, they can sign up with a doctor’s office that has a lengthy waiting list for available embryos, or they can contact an adoption agency such as the SnowFlakes Embryo Adoption Program, whereby the participants are required to follow the same requirements that exist for traditional adoption.  The other options are to locate embryos independently online (which is absolutely not recommended without some guidance from a physician, lawyer or psychologist) or to sign up with a non-profit agency, such as Embryo Options, which provides the parties the option to tailor their arrangement to their own needs and desires, such as whether to have a relationship with the other party that is open, semi-anonymous or totally anonymous.  Each of these programs are different in many aspects, and it is really a personal choice of any recipient couple or individual to choose the program that best fits their needs, whether religious, financial or otherwise.         

 

Once a couple or individual has reviewed the available programs, they need to be certain of a number of things before making a decision:  1.) Be aware of all financial requirements that are involved with these embryos, including but not limited to medications and clinic fees, if any; 2.) Ask questions about the program’s own guidelines and protocol; 3.) Ask the program how donor parents and recipient parents are selected and matched.  Discover if the parties have the option to turn down embryos that have been offered to them or not; 4.) Ensure that the recipients and their doctor are entitled to the embryo quality reports, the (redacted) medical records of the donors and the results of any successful pregnancies.   

Most importantly, each program must have both donors and recipients sign legal agreements providing consent, undergo infectious disease screening, and meet for a counseling session with either a psychologist or social worker.  The real purpose of the counseling is to discuss such issues as disclosure to the child and the rest of the family.  

           

From a legal standpoint, the legal system nor the states’ legislatures have clarified the actual donation of embryos from one couple to another.  However, the case of Davis v. Davis (Tenn. 1992), as well as several others, have essentially given embryos the status of property when a dispute over the embryos arises out of a marital dissolution action.  The courts chose to decide against “forced procreation,” instead of providing the embryos with a higher (protected) status due to their ability to become life.  In an effort to clarify the status of the embryos from the standpoint of donation, attorneys in this field have chosen to use this same argument to treat the embryos as the donation of genetic material, or property in a sense, from one couple to another much like egg donation.             

Once a couple has decided to donate their embryos, there is one additional legal issue that cannot be disregarded; this issue revolves around the agreement between the donor parents of the embryos and any egg or sperm donor that was involved in the creation of these embryos.  Specifically, if an egg donor or sperm donor agreement is in place that spells out the donor parents cannot donate these embryos to another couple without his or her consent, then this must absolutely be followed in order to protect the rights of the recipient parents.  It would be a tragedy to the recipient parents to have to deal with any litigation that may result if an egg donor discovered that the embryos from her donation were donated to another couple without her consent.  Although the rights of the egg donor have already been terminated, this sort of dispute can be a very scary discovery for a recipient couple that has already given birth to their resulting child.   

           

 Furthermore, the reimbursement of costs that may be requested by a donating couple must be considered very carefully before agreed upon by a recipient couple.  Certainly, any additional medical testing required by the recipients’ clinic, as well as any outstanding storage fees, are acceptable fees to be paid; however, anything additional can make the donation itself questionable.  To be sure, the donation of embryos does not involve the same sort of pain and suffering associated with the donation of eggs; therefore, it is best to stay away any additional reimbursements that can be construed as the purchase and/or sale of embryos.         

Finally, the success rates from the transfer of frozen embryos is certainly lower than that of a fresh embryo transfer, as is reported by the American Society for Reproductive Medicine (ASRM); however, the availability of this option of donor embryos is certainly one that should be considered by everyone, donors and recipients alike.  To donors, it is the chance to help others and provide life to their frozen embryos; while, to recipients, it is a viable alternative in their journey to creating their families. 

 

 

 

Egg Donation: What We Have Learned From A Decade of Experience by Helane S. rosenberg, Ph.D. and Yakov M. Epstein, Ph.D.

Egg Donation: What We Have Learned From A Decade Of Experience
by Helane S. Rosenberg, Ph.D and Yakov M. Epstein, Ph.D.

 

On February 3, 2003, Nathaniel and Allegra Epstein, our twins, born with the help of an egg donor, will celebrate their 10th birthday. From the moment they were able to understand human speech, we told them that a kind lady, an egg donor, helped to make their birth possible. As they have grown older and have come to understand a bit more ofwhat an egg donor is and what having an egg donor as part of their conception means, we have experienced first hand, a personal and unique perspective on egg donation. We know what it is like to parent children conceived this way. We also know, to the extent that they share with us, our children's perspective on their unique status. We will share these insights with you in this article.

During that same decade that we were parenting our kids, we were working professionally with women and men who were considering embarking on the path we took. We have talked with more than 800 couples and single women, about 75% of whom ultimately decided to do a recipient procedure at IVF New Jersey in Somerset New Jersey. Also, during that decade, we met with almost 3,000 women who expressed an interest in becoming egg donors. We'll also share some of what we've learned from that experience.

 

Why Egg Donation?

After having worked with potential recipients for several years, we observed recurring patterns in the life circumstances leading to this parenting option. We found it helpful to think of archetypes of egg recipients. Over the past decade, we have found at least a dozen instances (and usually considerably more instances) of each of these archetypes. We described many of these archetypes in our book, Getting Pregnant When You Thought You Couldn't. We began to ask couples to write their "stories" - the paths that led them to try egg donation as their parenting option. Here are some sample stories that exemplify these archetypes.

 

Secondary Infertility

The most frequent archetype we have met are couples experiencing secondary infertility. Both the woman and her partner are in their early 40's. They have a child but would like another. Here is one such couple's story:

"We are the proud parents of a happy and healthy 3 1/2 year old boy. Our love for our child and each other leaves us with a strong desire to have an additional child (or children). We have several reasons for wanting a larger family. The most important one is that we love being parents to our son so much that we want to experience the joy of parenthood again. Also, we feel siblings add to the richness of life, particularly as children grow older. We are fortunate enough to have the wherewithal to provide for our family and wish to share our blessings and love with another child, whom we very much desire. Unfortunately, we met as older adults, and our ability to have a 2nd child has been compromised by repeated (3) miscarriages. due to our advancing age, modern assisted fertility techniques have been unsuccessful. Therefore, we very much desire donated eggs as a generous gift to allow completion of our family. This would provide all three of us with the opportunity to add a cherished member to our loving family."

Members of the secondary archetype are generally not depressed because they are happy that they have a child. But as this couple stated, they would like to have a second child to enlarge their family and to provide a sibling for their child. People in this group have a difficult time deciding to do the procedure because they are concerned about the differences between the child who has a biological connection to both of them and a donor baby who will not be genetically linked to the mother. They worry about how that child might feel. Should they tell the child that they used a donor? If they do, will s/he feel like a second-class citizen? If they don't tell, they have to be very selective about a donor who will produce a child that looks as if it could have been the wife's own biological child. So members of this archetype often take a long time to decide upon their choice of donor. Indeed, it took this couple 442 days - much more than the average (median) time for all recipients which is about 120 days.

 

The Two Career Couple

The second most frequent archetype is the "two career couple." Like those experiencing secondary infertility, they too are usually in their early 40's. Listen to one of their stories.

"My husband and I only met a few years ago and married at 40. This was a first marriage for both of us. We began to try to conceive not long after we were married. Apparently, due to my age, I have been unable to produce eggs of sufficient quality to get pregnant. My husband and I have a very strong, very loving marriage. Because we married late (relatively speaking) in life, I think we were both more sure of the type of person with whom we could have a happy lifelong relationship. I think we were also more appreciative and grateful for having each other. While we both led relatively satisfying lives before we were married, and more so since we married, there is a definite void that grows more apparent every day. The desire to raise a child overcomes the emotional and logistical difficulties of using an egg donor. We both have careers which have been important to us. Having a satisfying career, for many years, however, I am now acutely aware of the satisfactions it does not bring. It cannot replace having a family. We are at a stage in our life when the priority of raising a child is above the demands of our careers.

" This couple is typical of members of this archetype. They have been highly successful in their careers and find the setbacks of infertility a sharp contrast to the success they have been used to in all other areas of their lives. This couple selected their donor and began their cycle rather quickly - 109 days.

 

Young But Feels Old

The next most frequent archetype is one we call "young but feels old." We selected that title because it characterizes the view that these women express in their conversations with us. In many ways, they are very similar to the women in the "two career" archetype except that they tend to be about 4 years younger. What this means is that they are in the age group where it is still possible for women to have a baby with their own eggs. Since they are in their late thirties, the idea that dominates their thinking is the rapidly ticking biological clock. Here is how one recipient described her situation:

"My husband and I married in our mid-thirties at a time when we felt fairly well established and settled and hoped to begin a family. We stopped using contraceptives and tried to conceive. After 6 months we had no success. We sought my doctor's advice and tried more constructively to conceive-again with no success. We then chose to seek out a local fertility expert. We then underwent several test procedures to evaluate a potential problem but nothing was found. We then tried several months with mild chemical stimulation but this did not prove successful either. 'Time' becomes a very precious thing to couples like ourselves. You look at the months passing and the years passing and you try and use your time most effectively. You really do not think in terms of "wasted time" but rather how much more constructively you could have used your time on a more positive note. You never lose hope, you just restore it as we are doing with IVF-NJ."

This couple highlights a critical issue for this archetype - the passage of time. They are acutely aware of their age. In this case, both the recipient and her partner were 39 years old. They were in the gray area where it is still possible to get pregnant with their own eggs but it is not happening for them. This makes them feel old. A large proportion of the members of this group decide not to do the procedure at this time - instead, trying one more time to get pregnant using their own eggs. This couple, on the other hand, did do the procedure, taking 174 days to choose their donor and get started.

 

Trendsetters

As we met more and more couples who were thinking about doing a recipient procedure we noticed an interesting phenomenon. Many of the couples had wives who were 4 or more years older than their husbands. In fact, when we compared the frequency of this age difference in our sample with the frequency with which it appeared in a sample surveyed by the U.S. census bureau, we found that our sample contained 3 times as many couples of this type as there are in the general United States population. One group for whom this was the case is an archetype we called "To Mother Again." That group consisted of a woman who had children from a previous marriage married to a man who never had children of his own. We'll describe that group in more detail later.

But we noticed a second cluster of couples - ones in which neither the husband nor the wife ever had children and in which the wife was at least 4 years older than her husband. We called this group the "Trendsetters" and they were the 4th most frequently seen archetype. Here is a statement typical of this group:

"My husband and I met each other a few years ago. Prior to that we had not been in what we considered a permanent relationship. At that time I was 43 and he was 29. Eight months after we met, we wanted to spend our lives together and wanted to have a family. Our attempts were not fruitful over a two year period, and we began to seek medical evaluations to see if there was a problem.

It was discovered that my husband had some male factor problems. After some improvement over a several month period, we still were not successful. I had two tube tests, the first showing a blockage and the second no problem. We proceeded with artificial insemination to improve the odds, including fertility drugs. We continued to be unsuccessful. We were told that my ovaries were not responding very well to the medications, and this seemed to indicate that it was actually an egg-production problem. Our doctor believes it is due to my age, and seems to feel our chances of having a child naturally are very minimal. We are loving, compassionate and sensible people with a lot to give a child, or more than one if we are blessed with more. We are conscientious about using appropriate child-rearing techniques to raise a child to have high self-esteem and to be successful at accomplishing what their dreams are in life, and equally important is to have a child have a happy, love-filled life."

This couple typifies the archetype of a couple in which the wife is considerably older than her partner. We have found that in many of these cases the woman is more eager to have the procedure begin than the man because she feels great time pressure. The husband, on the other hand, is relatively young and feels there is plenty of time. As a result, we frequently find that the couple has difficulty making the decision about which donor to use. In the case of this couple, it took them 282 days to make their selection and begin their cycle.

 

Young Infertiles

An archetype we have seen almost as frequently as the trendsetters is a group we have termed the "Young Infertiles." The statement below is typical of such couples.

"My husband and I have been married for 4 1/2 years and have been trying to become parents for 3 1/2 years. After various testing, it's been determined that I produce a poor quality and low quantity of eggs. This seems to be fairly unusual, as I'm only 33 years old. Because I have a very poor chance of getting pregnant with my own eggs, my doctors recommended that we attempt an egg donation program. It would be such a wonderful gift to have a chance to become pregnant this way.

Both my husband and I are very family oriented. Our social life revolves around our family and neighbors. We enjoy having our nieces sleep over and the children of our friends and family are a big part of our lives. There is much room on our home and hearts for children."

This couple had a clear need to do the procedure. She was very young as was her husband.

She knew her egg quality was poor and she was not going to get pregnant on her own. She was part of a social network of friends who were having babies and she wanted to be like them. For couples in her situation, the decision to do the procedure is clear. The difficulty they have is in deciding which donor is the right one to take the wife's place. Indeed, this group and the group that we call "Young But Feels Old" are the most depressed women of all the archetypes. In the end, this couple did the recipient procedure. But they took a relatively long time (perhaps because of their heightened depression) to decide on which donor to use: 291 days

 

To Mother Again

Women in the "To Mother Again" group have experienced mothering and would like to do it again. Like the Trendsetter archetype, many of them tend to be 4 or more years older than their husbands. Perhaps, one aspect of the attraction between husband and wife in this group was the motherly qualities of the woman. We can only speculate that perhaps the husband enjoyed being mothered by his wife and would also like to see her mother a child that they can create together. Here is the story of one such couple:

"I was in an abusive marriage where my now ex-husband saw abortion as a means of birth control. After two healthy children and two abortions, I saw tubal ligation as the only hope of ending the abuse. I was wrong. The abuse continued and eventually I was strong enough to leave the marriage. I am now remarried very happily. My husband and I would like to have a child together - one who grows up in a loving non-abusive home. However, my previous surgery prevents us from having a child normally. We have been through six tries at IVF and all have failed."

This woman loved having children but had an unhappy first marriage. Now, she would like to mother again but this time with a partner who can be the co-parent she always wanted. Like most members of this archetype, the couple decided to do an egg recipient procedure and made a quick decision about their donor which enabled them to start their procedure 97 days after their initial interview.

 

The Modern Classic

The next most common archetype is the one we know first-hand. It is the group we belong to. It consists of a woman, typically in her early 40's who was never before married who marries a man who has children from a previous marriage. Here is a typical story (not ours but not very different from ours).

"To have a family, that is to be married and have children, has been a quest for me since my mid-twenties. At that time, I began to feel I was old enough and mature enough to settle down with a husband and have kids. Although, I was working, enjoying and valuing my chosen profession, I felt deep inside me that the most important thing for me would be to become a wife and mother. My feelings and convictions stemmed from my upbringing. I thought it was a matter of time before I would get married.

As hard as I tried the right man didn't come along until I was 38. I met my husband, a loving, caring, and intelligent man, on a blind date. We fell in love, dated for a year and a half, and then got married. He had been married before and had two lovely boys, now grown adults, 26 and 22 years respectively. Judging from the way the boys both turned out, I can say he was a great father. He was deeply involved in their education, read to them, got them to participate in sports, encouraged them to make friends and be interested in the world and the people around them. Above all, he gave them affection.

We have been married for seven years. It is a good marriage, a solid partnership. We consider each other a blessing. We have felt we could share our bond with children. So we have been trying to get pregnant for five years. It's been difficult, discouraging, and at times heartbreaking."

For this couple the decision to do an egg donor procedure was also quite clear. The wife knew that she could not use her own eggs since she was 45 years old. She very much wanted to experience a pregnancy because she never had an opportunity to do so. Her husband already had children who had his genetic makeup. He was not stuck on which woman's genes would replace those of his wife and neither was she. The couple did the procedure and made their choice of donor fairly quickly (109 days).

 

Long Marriage Trying For A Very Long Time

A less common archetype consists of a couple who have been married for a very long time and trying unsuccessfully, for most of the time they've been married, to have children. The story below is typical.

"We have been married for 14 years and have always wanted a family. We started trying to have a baby about 10 years ago. It took several years before we sought help, as it was difficult to admit we had a problem. Although the doctors never really were able to diagnose with certainty the cause of our infertility, they basically concluded that it was an ovarian dysfunction, which seems to be confirmed several years ago by the onset of premature menopause. I underwent exploratory surgery, surgery to remove a fibroid tumor and more than several years of treatment with all types of infertility drugs, including IVF; we never achieved a pregnancy.

Although we are happily married, we both feel our lives would be more meaningful and fulfilled by raising a child or children. We are both close to our families and feel we would offer a wonderful home and upbringing to our children. We have considered adoption, but have many reservations about it, and now it would be very difficult at our ages to be approved for adoption. Although neither of us feel our ages to be a negative we both hoped to have a family much sooner."

This couple is typical of those in this archetype. They have tried to get pregnant for a very long time and have not succeeded. They have also considered adoption but not pursued it. They display a certain hesitancy to take action - either through egg donation or adoption - to have a baby. In some sense, even though they may not be aware of it, they may have become resigned to living without children. This couple ultimately did not do a recipient procedure. Moreover, others who we also characterized as fitting this archetype were one of the least likely groups to do a recipient procedure. As a group, members of this archetype are some of the most depressed women we have met.

 

Long Marriage Trying For A Brief Time

Another archetype bears some striking similarities to the previous group. Like the previous group, this group has also been married for a long time. In contrast, however, they have only recently begun trying to get pregnant. So they do not have the long history of failure that members of the previous group experienced. Consequently, they are less depressed and more likely to do a recipient procedure. Here is a statement of a couple that we classified as a member of this archetype.

"Sometimes you find the 'right' person a little later in life. I was in my mid thirties, my husband was just turning forty. We wanted a family but we weren't ready right away. Then my best friend had a little girl. We became very attached to this child and she spent a great deal of time with us. It was then that we realized how much we wanted our own child, and we were secure in our feelings that both individually and together we'd make great parents! We wanted to nurture a child emotionally, spiritually and physically. We wanted to protect its happiness and innocence and to love and guide it to adulthood."

This couple is typical of this archetype. The woman is 46 and her husband is 48. They had been married for 8 years but only started trying to get pregnant two years earlier when the woman was 44. Like most people in this group they tend to be low risk takers who want everything to be right before they make a decision. They ultimately did do a procedure but took 282 days to decide on a donor.

 

Single Women

At IVF New Jersey we have seen quite a few single women. Some have been married previously, then divorced, and now, as single women, have decided to have a child without a partner. Other women have never married, have no partner, and want to be a parent. Finally, we have also met with a handful of lesbian couples who have done recipient procedures. Here are two stories.

"I have always wanted children but I waited too long. I felt I had to be married first. I was married for 5 years and I did get pregnant during that time. I was 28 years old. But the baby was stillborn. Soon afterwards I separated from my husband, as he really did not want children. To this day, he has no children and does not intend to have any. Frankly, after my baby was born dead, I was afraid to get pregnant again and so the years passed. Also, I was still unmarried. My father was old-fashioned and I loved him so much that I could not even contemplate having a child our of wedlock. When he died I was 43 years old and alone. That was when I decided to try to get pregnant but with no success."

This single woman is one who is presently single but had been married previously. Other single women have never been married. Here is an example:

"I have wanted children for many years, but waited until I could provide a good life for a child before I started trying to get pregnant. Being single, I had to save for many years to be able to buy a house. I took in roommates to bring in extra money to have a "baby fund". Finally, when I was 39, I began trying. Perhaps because I am missing a Fallopian tube, it was 8 months until I conceived. I was overjoyed and greatly relieved that I hadn't waited too long after all. At 5 weeks, the baby appeared fine, and had a heartbeat. But at six weeks I miscarried, and felt an enormous loss. I became depressed, but resumed trying after two months. After six more cycles on fertility drugs and IUI's, I tried a GIFT procedure. After four Clomid cycles failed, I lost hope that my own eggs would ever fertilize. I am 41 now. My periods have gotten very light, and I don't respond well to Pergonal anymore. I am remorseful that I didn't start trying sooner, but I didn't know it would be so difficult, or take so long. I want to be a parent because I am a nurturer. I feel the most relaxed and content when caring for someone. I always took care of the younger children in my neighborhood, and dreamed for years of the games I would play with my own children and how I would raise them. I dreamed of the things we would do together, and the things I would teach them. I am not able to put these dreams aside."

The decision to use an egg donor is somewhat easier for women in this group than for women in some other groups since they are already using a sperm donor. Some medical practices do not want to work with this population - viewing the procedure which we term "double donor" as an instance of embryo creation (bringing together two donors neither of whom has an connection to the parents of the baby that will result.). The first single woman (who had once been married) eventually decided to do the procedure and took 174 days to make her decision. The second single woman also decided to do the procedure and decided fairly quickly - taking only 105 days to do the procedure.

 

Adopted Kids

We have also met more than a dozen couple who have an adopted child and would like to have a second child. Although they adopted their first child, they would like to try to use an egg donor to have a second child. To understand their motive, consider the following story.

"We have been trying to have a baby for 8 1/2 years. After 3 surgeries and numerous IVF and IUI cycles, my ovaries do not respond to the medications. I have endometriosis and one blocked tube which has made it difficult to conceive on my own. We have one son whom we adopted and he would have a little brother or sister. We would love to have our own biological child and I would love to know how it feels to be pregnant and bring a life into the world."

As this woman noted, a strong motive to do an egg donation procedure rather than a second adoption procedure is the desire to experience "how it feels to be pregnant and bring a life into the world." Unlike members of the secondary infertility archetype who also have a child, members of the adoption archetype have an easier decision about using a donor. They already have a child that is not biologically connected to them. This couple took 156 days to decide on a donor and begin their cycle.

 

Medically Infertile

The final archetype that we have constructed is one consisting of medically infertile women. There are many reasons why a medical problem may lead to the decision to do an egg donation procedure. Consider the following story.

"When I was going into 10th grade, I was diagnosed with an ovarian dermoid cyst. Apparently it had been growing for over one year. My symptoms were minor, but after surgery we realized the extent of the damage. I lost 1 ½ ovaries and one of my fallopian tubes. Fortunately, the doctor felt that pregnancy could still be achieved so we decided not to worry. After all, I was only 15! Several years later and after 4 ½ years of marriage, my husband and I decided to try to have a child. We were devastated to find that upon examination and without symptoms I had another ovarian tumor. After this one was removed I was told that I had ½ of an ovary and a tube that was damaged beyond repair due to the scar tissue. Subsequently fertility specialists and tests have determined that the donor program is our only chance to conceive and carry a child."

Like other members of this archetype, this potential recipient is clear that she cannot use her own eggs. For her the choice is between doing a donor egg procedure or adopting if she wants to have a child. This couple weighed these two choices carefully:

"Since our diagnosis, we have concentrated on exploring both the donor option and adoption.

We know other couples who are experiencing trouble with infertility who are also experiencing martial problems because of it. We have worked hard to be supportive of each other through this very difficult time and feel that our marriage has been strengthened through the crisis, not weakened. After seven years of marriage, we are very fortunate to still feel like we did when we were newly weds but with a more mature outlook on life." Because they spent a great deal of time trying to choose between adoption and egg donation, it took them 383 days to begin an egg donor procedure."

Other medically infertile women have needed to use an egg donor for reasons such as being born without ovaries, having radiation treatment that destroyed their ovaries, or being carriers of a genetic disease that they did not want to pass on to their baby.

 

None Of The Above

Over the years, many infertile couples heard about our various archetypes. We received letters and emails from numerous people telling us that although they found our descriptions interesting, when they tried to see where they fit in, none of these descriptions were characteristic of their situation. And they are correct. When we looked at the more than 800 couples and single women that we met over the past decade, we found that some of them, less than 10% of the sample, could not be classified as fitting in to any of these archetypes. Some had features of one particular archetype but were different in one or more important ways. As an example, we met several couples who were similar to our "Modern Classic" archetype. The woman was around 40, had a successful career, never had any children, and was married to a man who was previously married and had children. But the woman in this instance had been married previously and had tried unsuccessfully to have children in her first marriage. We could not classify this woman as a "Modern Classic" because her "story" was not that of a woman who had put off having children until she established a successful career.

 

So Why Do We Care About The Concept Of Archetypes?

So, is the classification that we did just an interesting academic exercise or is it important for recipients, physicians, and mental health professionals to consider this concept?

 

We believe that the archetype concept is important. All recipients are not alike and the struggles that they have deciding whether to do an egg donor procedure and whether to choose a particular donor are likewise different. So while a "To Mother Again" couple has an easy time deciding on a donor, a "Young Infertile" or a "Young But Feels Old" couple has a much harder time. All of these women need a donor to conceive. But the "Mother Again" woman has had a child or children, has passed on her genes to a child, knows what it is like to be pregnant, and has the support of her husband to do an egg donor procedure. In contrast, the "Young Infertile" or the "Young But Feels Old" woman has not passed on her genes, and is not completely convinced that she doesn't still have an opportunity to do so. After all, other women her age are still having babies using their own eggs.

Mental health professionals can use this information to help their clients understand the issues surrounding their response to the procedure. If they are also helping couples select a donor, mental health professionals can point out to these couples why they are experiencing such turmoil about the procedure. As IVF New Jersey Donor Coordinator, Helane often shares information (anonymously) about other of the same archetype coped with their concerns about the matching process.

Physicians sometimes wonder why a recipient keeps passing up wonderful donor candidates who are presented to her. Knowing about the archetypes can help the physician understand why it is difficult for a particular woman to select a donor when other women can do so easily. The same is true for the recipients themselves. They may participate in face-to-face or internet support group and hear other women discuss their ability to select a donor easily and be thrilled with their decision. They may wonder why the other person had an easy time and they find themselves struggling. We believe that thinking about these archetypes can help them make better sense of their own situation.

 

And What About The Donors?

In the past decade we've also learned a great deal about egg donors. At IVF New Jersey, recipients can choose from the anonymous pool of donors that we have met, oriented, and interviewed, or they can choose to select a donor they have obtained by working with a "donor broker." In practice, more than 98% of the recipients at IVF New Jersey have worked with IVF New Jersey's own donors. Since none of the recipients we have worked with have done "split cycles" (sharing the eggs of one donor with two different recipients), we have had to meet with many potential egg donors in order to have a sufficiently large pool of donors for all the women who want to be recipients.

So how does IVF New Jersey find donors? It's not easy! The donors come from two different populations: young mothers and college students. All of IVF New Jersey's donors are between the ages of 21 and 30. They all attend an informational seminar designed to familiarize them with important aspects of egg donation. The seminars are conducted jointly by one of the IVF

New Jersey physicians and by Helane Rosenberg, the IVF New Jersey egg donor coordinator. At the seminar the potential candidates learn about the medical and logistical aspects of egg donation. They are apprised of the risks involved and encouraged not to do a procedure if they feel uncomfortable with these risks or if doing a procedure would cause them conflicts with significant others (spouse, boyfriend, or parent). Further, they are encouraged to consult their own physician to get a second opinion about the medical advisability of doing an egg donor procedure. They receive an informational packet that contains literature about research on the relation between infertility medical procedures and the risks of ovarian cancer. At the seminar, they ask questions and fill out forms with demographic and contact information. They are told that they will be contacted after the seminar to discuss their interest further and to be interviewed in depth if they would like to continue to consider being a donor. Finally, they are told that if they go home and think about whether they are comfortable deciding to donate and if they are not, to please tell the person calling that they do not want to donate. Many candidates indeed decide they are not willing to donate and are thanked for coming to find out about the procedure. No candidate is ever pressured to reconsider.

Interested candidates have a skilled clinical interview about their comfort and motivation to become a donor. Any candidate who shows evidence of psychological instability or any of the other features that the ASRM task force on egg donation has indicated as risk factors that should disqualify a candidate is eliminated from the pool of potential candidates. In contrast to other practices that administer the MMPI (Minnesota Multiphasic Psychological Inventory), we do not use this instrument as a screening device. The decision to do so is one of the things we learned over the decade of working with donors. When we began working with donors we did use the MMPI. But we did not find it useful in discriminating between good and poor donor candidates. Rather, we found that a skillful clinical interview was the best way to choose appropriate candidates.

We conducted a follow-up study of our donors and found that none of them had suffered any adverse effects from their decision to donate. The one instance of a negative reaction was one of the first donors we worked with who had previously had an abortion and, while in a "twilight sleep" from the IV sedation, had flashbacks of the abortion and felt badly about that.

Subsequently that donor felt Okay but we learned a lesson that we incorporated in our subsequent donor screenings. Almost all of the women who we interviewed subsequent to their donation felt proud of what they did and considered it one of the most important acts they had ever done. What concern the women had were not about their connection to a baby or any ambivalence about their genetic material being "out there." Rather, the few concerns that we heard were about the possible effects of the medications. Even though they had heard about risks ahead of time and had concluded that they were not concerned, a few women, after having donated, began to worry about long term negative effects that had not emerged as of now.

Not all women are suitable to become donors. Of the nearly 3,000 women that we interviewed, only about 450 actually donated. A little more than half of these women donated more than one time. Of all the cycles that were initiated, very few had to be cancelled because of donor problems. IVF New Jersey carefully screens donors for drug use. A few cycles had to be cancelled because donors were found to exhibit traces of marijuana in their drug screenings. (Such drug use is quite rampant on college campuses and it is not surprising to find a handful of women who succumbed to this temptation despite their promise to refrain from doing so.)

 

So What's Involved In Doing An Egg Donor Procedure?

Once you have decided that you are comfortable with the idea of having a baby using someone else' eggs, your chances of giving birth to a healthy baby are quite good. Over the decade that we have been involved with egg donation, the success rate for this procedure has climbed dramatically. When we got pregnant with our twins, we were members of the subset of successful recipient couples that constituted only about 30% of those trying to get pregnant with this procedure. Today, the national averages for live births from egg donation are nearly double what they were when we used this procedure. At IVF New Jersey, nearly 70% of the recipients are giving birth to healthy babies.

The biggest obstacle is the cost. Adding up all the components of an egg donation procedure can yield a cost approaching $30,000. In some states, for example, in or own state of New Jersey, medical insurance can cover a large fraction of these costs. But some costs will never be covered by any insurance. These include the fee paid to a donor and the costs for the non-medical management of the donor-recipient cycle.

The other major obstacle to doing a procedure is the wait for a donor. Some clinics have long waiting lists of a year or more to do a procedure. Fortunately, at IVF New Jersey we have been able to keep the wait to a reasonable period of time. In fact, if we compare the wait for a donor at IVF New Jersey during the first 5 years they did this procedure with the last 5 years, we find that the average time between coming to the practice for the initial interview and the date on which the donor selected began taking her medications to begin her cycle decreased from about 7 months to about 4 months.

The good news then is that it is now possible to do an egg donation procedure without having to wait very long at a reasonable cost with high odds of taking home a baby. The only remaining question is: "will I be happy parenting a baby born through egg donation?"

 

What Are The Experiences Of Parents Of Egg Donor Babies?

Here we have less data to use to provide answers. Certainly we have our own experience to discuss and that has been extremely positive. We also have talked informally with many of the recipients who we worked with at IVF New Jersey. Their reports to us have likewise been uniformly positive. Indeed, many of the recipients have returned to try to achieve a second pregnancy with egg donation. Some have asked us to try to locate their original donor for a second procedure. Sometimes we advised against doing this because now, several years after doing the first procedure, the age of their original donor was too old to offer them the best odds of success. But often, the donor was still of an age where she could be a good donor candidate.

The only problem was locating her after all the time that elapsed. We have had some success tracking down former donors and a number of them have agreed to donate again so that these recipients could have a baby with the same gene pool as their first baby.

But we would love to have more systematic information to offer potential recipients. With the help of INCIID we are planning to conduct a survey of recipients about their experiences parenting children born using this procedure. If you are a parent of a baby born through egg donation, you can contact us at yepstein@rci.rutgers.edu to find out how you can participate in an interview about your experiences. We will collate all the information we obtain and publish a follow-up to this article discussing parenting experiences and anecdotes in detail.

 

And Finally, The Voices Of The Children

We could not write an article about being an egg recipient without sharing the experiences of our children. We believe that it is very important to tell our children that they were conceived via egg donation. First, we believe that it is their right to know. Second, we don't like to keep secrets. We believe that keeping this matter a secret would change the atmosphere in our family in a way that we find unacceptable. For us, there was an additional reason to disclose. We want to inform people who are contemplating this procedure about our experiences so that they can act in a more informed way. If we tell others, we of course need to tell our children.

We had no trailblazers preceding us to let us know about their experiences. We had to act based on our hunches. We decided that it was best to start talking about egg donation from the time our children were very young. We starting including this term in our discussions even before our children were able to understand what it meant. We just wanted them to hear the words "egg donation" and "egg donor." At first, they had no idea what we were talking about. As they grew older they began to understand a little more. Now that they are about to turn ten years old, they understand that mommy needed a third party to help her become pregnant.

They do not understand the genetic implications of this yet, but will understand it when they get older.

In preparing this article we talked to them. We said that people reading this article might want to hear their thoughts about being an "egg donor child." Nathaniel said: "tell them I like Yugio and I love my family." We asked him "Do you ever talk to other kids about being a donor baby?" He said "No, why should I?"

We also asked Allegra what she had to say. She said, "It's a special thing." We said "what's life like for you?" She said:, "Life is pretty much like it is for anyone else." We said, "Do you talk to your friends about being an egg donor baby?" She said, "Sometimes." We said, "And what do they say" She said, "They don't understand what I'm talking about." Then we asked, "So what do you say?" She said: "I tell them someone had to help my mom get me born."

But sometimes there are painful moments. Last summer Nathaniel was playing with our dog, Yankee, and being a bit too rough. Helane told him to stop and he got angry. He said, "You can't tell me what to do, you're not even related to me." Helane told him that what he said made her feel really bad. She said, "Would you like it if I said you (Nathaniel) were not related to me?"

He thought for a minute and said, "No." Helane said, "Would you like it if I said to you that you're not really my son?" He said, "No." Helane said, "You can be angry with me, but you cannot say mean things to me because you hurt my feelings." Nathaniel apologized.

 

Allegra said a similar thing to Helane once when she wanted to stay up late and Helane would not allow her to do so. We have learned to expect that some time the kids may say things like this and we can deal with it. Sometimes they are saying it because they are angry. Sometimes they say it as a way to manipulate us. They know they can upset us and that gives them some power.

Allegra has also expressed an interest in meeting the donor to see what she looks like. She is primarily interested in looking at the donor's hair because Allegra has such unusually beautiful blonde hair, a characteristic that people mention when meeting her. Although Helane has dark hair, Yakov has blonde hair this. Interestingly, Allegra compares herself with her mother, Helane, not her father. Allegra also ponders whether the donor has had children. We believe that her interest at this time is in knowing if those children look like her. We have explained that Allegra's meeting the donor is not possible because of the agreement we made with her. We explain that we must honor our agreement. In fact, in our daily lives, both of us (Yakov and Helane) try to model a life in which we honor our commitments as a way to show that we will indeed honor our agreement not to look for the donor.

Our children are open to communicating with potential recipients if they have questions for them. If you email Allegra, she will respond to your questions (just be aware that she is only 10 years old and is not a fast typist.)

 

We hope this article has been helpful to you. Please contact us with your feedback and any questions you may have.

 

Egg Donation: Why and how women decide to donate. By Mark Bush, M.D.

Scope of the Issue

Egg donation has become a mainstay of infertility therapy in the United States. According to the most recent CDC statistics1, slightly more than 11% of all IVF cycles in this country involved donor eggs or embryos. With women delaying childbearing for professional, financial, educational, or personal reasons - or a combination of all of these - many women who are ready to start a family find out that their eggs have a poor prognosis in establishing a pregnancy. The miscarriage rate goes up and the ability to deliver a live birth goes down with age, most notably after 35. In addition to population statistics that depict an age-related decline in fecundity for women, a particular woman might also suffer from decreased ovarian reserve regardless of her age. Typically assayed with the clomiphene citrate challenge test, there are values on this test above which a woman has very little chance of delivering a live birth with her own eggs. For both of these groups of women, a donor egg cycle is a highly efficacious way of starting or continuing their families. Recent CDC statistics1 demonstrate a national average of 47% live birth rate per fresh embryo transfer for donor egg. Further, the concept of aggregate pregnancy rate is relevant. With donors providing adequate numbers of high quality eggs, good programs take advantage of this by culturing suitable embryos to the blastocyst stage and freezing those embryos not transferred. These frozen blastocysts are then transferred to the recipient woman in a subsequent cycle, either if the fresh attempt was unsuccessful or at a later date in an attempt for an additional child, but this time without the cost and procedures associated with stimulation and retrieval of a donor.

 

Comparison with Adoption

While adoption clearly has a valued role in our society, for the infertile woman who cannot use her own eggs, there are a number of distinct advantages of using donor egg over adoption.

First, it is completely anonymous. The woman donating her eggs does not know the identity of the recipient couple, and the recipient couple does not know the identity of the donor. And while there have been instances of the birth mother coming back at a later date and seeking custody of the child she has given up for adoption, there has not been a case to date where a similar situation has occurred with donor egg. This is attributable to the high level of anonymity preserved throughout the entire process, the fact that gametes are being donated as opposed to an infant being given up for adoption, and the fact that informed consent is signed by both parties at the outset. Non-anonymous egg donation can also be accomplished, and this commonly involves a fertile sister or cousin donating her eggs to her infertile sister or cousin.

Finally, while adopting children that are not infants or toddlers is both appropriate and preferable for many couples, many women desire the value and benefit of gestating with their baby and delivering their newborn. And if the gamete of the male partner is used, then the child has a 50% genetic linkage to the couple.

 

Why and how do women become donors?

Top IVF programs employ clinical psychologists who meet with prospective egg donors to determine their motivation, ability to handle the process, and appropriateness for egg donation. When properly screened and selected, the number one reason women become egg donors is that they sense an altruistic purpose in helping infertile women achieve pregnancy.

 

Compensation to the donor, which is part of the recipient couples’ fees, averages $5000 for a completed cycle. The donor will undergo a complete medical and genetic history, physical and infectious disease screening.

Programs with an adequate donor pool of women will allow the recipient couple to pick their donor. They are able to review physical, social and psychological characteristics of the donor all while keeping the actual identity of the donor anonymous. The recipient woman undergoes a history and physical, and an assessment of her uterine cavity via either a hysteroscopy or saline sonography to rule out polyps, myomas, scar tissue or malformation that might interfere with implantation and the ability to carry a live birth. The recipient will then undergo a mock cycle where the adequacy of her response to estrogen and progesterone is assayed and optimized. The donor and the recipient are then synchronized so that the recipient woman’s endometrium is ready to receive the fresh embryos resultant from stimulation and retrieval of the donor’s eggs fertilized with the sperm of the recipient’s partner or the sperm of a donor.

 

What are the risks to the donor?

There are two main considerations for the donor with regard to risks. The first is do the drugs used to stimulate her ovaries make her more likely to have ovarian cancer in the future, and second, what is ovarian hyperstimulation syndrome and is she likely to get it. With regard to ovarian cancer, recent studies suggest that the drugs we use to stimulate the ovaries are safe. In a meta-analysis of 7 case control and 3 cohort studies, cases of ovarian cancer were compared with infertile controls for exposure to fertility medications, and the odds ratio was not elevated (0.99; 95% CI 0.67, 1.45) . Comparing outcome in treated infertile patients with untreated infertile patients suggests treated patients may actually have a lower incidence of ovarian cancer (odds ratio 0.67; 95% CI 0.32, 1.41)2.

Ovarian hyperstimulation syndrome is a condition associated with the use of fertility medications and can lead to severe medical complications, notably fluid in the abdomen and lungs, blood clots and kidney impairment. There are two characteristics of the donor that help us avoid the severe form of this process. First, donors normally ovulate (those patients that do not normally ovulate are predisposed to the syndrome), and second, the donor uses contraception after retrieval of her eggs thus avoiding pregnancy and preventing the second phase of the syndrome. It should also be noted that good programs have a track record of avoiding this syndrome in their donors and are experts in treating it should it develop. The overall incidence for moderate and severe ovarian hyperstimulation is 3.1- 6% and 0.25 – 1.8%, respectively3.

 

References

Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA, 30333, 2001 Assisted Reproductive Technology Success Rates, www.cdc.gov
Kashyap, et al, Obstet Gynecol, Vol. 103, No. 4, April 2004, pgs.785-94.
Lunenfeld, et al, Diagnosis and treatment of functional infertility, 3rd ed, Blackwell Wissenschaft, Berlin, 1993, p 98.

Mark Bush, M.D. is a reproductive endocrinologist with Conceptions Reproductive Associates
In Littleton, Boulder, and Denver, Colorado.
Phone: 303-449-1084
Website: http://www.conceptionsrepro.com
 

 

 

Finding Your Assisted Reproduction Attorney by Diane Michelsen, J.D., M.S.W.

Once you have decided to make use of assisted reproductive technology to create your family, we suggest that you contact an assisted reproduction attorney. Assisted reproduction is still a new field and laws concerning assisted reproduction are constantly evolving. Whether utilizing a donor for genetic material or a surrogate (gestational or traditional), yesterday’s information may well be out of date. Please don’t rely on legal information provided by the internet or by friends who are well meaning but not well versed. The ramifications are too significant to not have accurate information. In this field, more than most others, you can preclude very serious problems by utilizing the services of a knowledgeable attorney.

 

Additionally, like adoption, laws and practices vary drastically state by state. Your attorney will be able to give you a comprehensive overview of what is allowable in your state, as well as what conflicts may need to be resolved. If commercial gestational surrogacy, for example, is not allowed in your state, your attorney may recommend that you use a program in a state where it is recognized.

 

The American Academy of Adoption Attorneys, http://www.AdoptionAttorneys.org , unlike the other paid listings, has qualified its members on the basis of ethics and expertise. At press time, it is in the process of developing an easily accessed listing of assisted reproduction attorneys.

Do feel free to contact more than one attorney to inquire as to services, expertise, philosophy, and costs. You need not feel limited to attorneys in your own immediate area, since the majority of work is done in writing and by telephone. The following questions may be helpful in obtaining useful information:

 

1. Philosophy: What is the attorney's philosophy about assisted reproduction? Is the attorney comfortable with the concept of assisted

reproduction? What are the attorney's feelings about ovum donation and/or surrogacy? Does he or she have strong beliefs about anonymity or disclosure of identities? How will this play out in the future? What about future access for sharing of medical information or for the child? Do the attorney's attitudes match yours, and/or is the attorney willing to adjust to your desires and needs? If the attorney seems uncomfortable in this area, do seek a different legal counselor.

 

2. Expertise: What is the attorney's familiarity with assisted reproduction, both legal and otherwise? Is the attorney experienced, knowledgeable and competent? How many assisted reproduction matters does the attorney work with each year? How long has the attorney been in this field? If he or she handles litigation, ask about their track record. You can also look up the attorney on the internet to get more information. (just type them in as the inquiry in Google.) Do ask for references, if desired.

 

3. Billing: How does the attorney bill, and what is the average cost for the services you wish. Some attorneys bill on an hourly basis, while others charge flat fees for their services. Remember not to just compare hourly rates as price alone should not guide your decision. An attorney who is an expert in his field can often work far more efficiently than someone who is unfamiliar with the area. The specialist knows the key issues as well as the details to preclude problems later!

 

4. Accessibility: Does the attorney return phone calls, and if so, when? Does the office keep you up-to-date and involved in your case? Are copies of relevant correspondence or documents regularly sent to you? If contracts are being drafted, find what the anticipated turn around time will be. When your attorney is away from the office, is another knowledgeable attorney on hand to answer your specific questions and concerns?

 

5. Personalities: Are the attorneys and the support staff pleasant people who help you to feel at ease? Your attorney-client relationship may well extend over several months' time, both before and during the pregnancy. It should be clear that the attorney is interested in providing you with competent, thoughtful and caring service, and that he or she is committed to working diligently on your behalf.

 

 

Diane Michelsen, J.D., M.S.W. is an INCIID professional member and California based Adoption and Surrogacy Attorney who has been in practice since 1980.

Phone: (925) 945-1880

Email: diane@lodm.com

Website: http://www.familyformation.com

INCIID Member Page

 

Embryo Donation: Where are we now?

 It is actually estimated that there are well over 100,000 frozen embryos in storage in the United States alone.  And, with the recent advances in Assisted Reproductive Technologies (ART) and improved cryopreservation techniques, this technology has led to the wider use of frozen embryos for both donation and research.  With that in mind, embryo donation still remains a comparatively new possibility that is just gaining ground as another viable option for those individuals and couples who have been desperately wishing for a child.  In fact, it is often the only remaining viable alternative for those who have already been on the rollercoaster of infertility for many years and who have already invested significant amounts of time and money into their journey.   

 

Although the number of available embryos may seem high, the actual number of embryos available to couples and individuals is really much lower since it is often a difficult decision to donate leftover embryos to someone else.  In fact, many couples choose to destroy their remaining embryos or maintain them in the frozen state indefinitely since they are not willing to be contacted by any resulting child.  On the other hand, the major motivations for the donation of one’s embryos are usually to give the embryo a chance at life or to allow other infertile couples to have a child. 

 

What the ideal solution for any person is, whether to thaw and destroy, donate to stem cell research or donate to another person, may be the biggest decision faced by those with embryos in storage – in fact, it is a decision that is highly ethical, morally, and emotionally charged.  For example, full siblings may never know one another, and there is the issue of contacting genetic siblings and parents in the event of health and medical issues. 

 

Legally, it is also often confusing since one school of thought believes it to be an adoption while others a donation – with those choosing adoption seeing the embryos as children awaiting their destiny.  Whatever way you choose to view this possibility – every donor must certainly consider the following possibilities when making your decision: a.) whether you will want the embryos for future siblings for any of your  existing children; b.) how you feel about the real possibility that there may be other children alive who are the result of your own genetic material or that of your partner and a donor; and, c.) the pain of not knowing the result of your donation. 

 

Once a couple has decided to donate their embryos, there is one additional legal issue that cannot be disregarded; this issue revolves around the agreement between the donor parents of the embryos and any egg or sperm donor that was involved in the creation of these embryos.  Specifically, if an egg donor or sperm donor agreement is in place that spells out the donor parents cannot donate these embryos to another couple without his or her consent, then this must absolutely be followed in order to protect the rights of the recipient parents.  It would be a tragedy to the recipient parents to have to deal with any litigation that may result if an egg donor discovered that the embryos from her donation were donated to another couple without her consent.  Although the rights of the egg donor have already been terminated, this sort of dispute can be a very scary discovery for a recipient couple that has already given birth to their resulting child.   

 

On the other hand, the options that are available to recipient couples and individuals are very few and far between once it has been determined that they need to move onto donor embryos.  For example, you can sign up with a doctor’s office that has a lengthy waiting list for available embryos, or you can contact an adoption agency such as the SnowFlakes Embryo Adoption Program, whereby the participants are required to follow the same requirements that exist for traditional adoption.  The other options are to locate embryos independently online (which is absolutely not recommended without some guidance from a physician, lawyer or psychologist) or to sign up with a non-profit agency, such as Embryo Options, which provides the parties the option to tailor their arrangement to their own needs and desires, such as whether to have a relationship with the other party that is open, semi-anonymous or totally anonymous.  Each of these programs are different in many aspects, and it is really a personal choice of any recipient couple or individual to choose the program that best fits their needs, whether religious, financial or otherwise. 

          

In fact, once a couple or individual has reviewed the available programs, they need to be certain of a number of things before making a decision:  1.) Be aware of all financial requirements that are involved with these embryos, including but not limited to medications and clinic fees, if any, and whether the donors are requesting any fees in return; 2.) Ask questions about the program’s own guidelines and protocol; 3.) Ask the program how donor parents and recipient parents are selected and matched.  Discover if the parties have the option to turn down embryos that have been offered to them or not; 4.) Ensure that the recipients and their doctor are entitled to the embryo quality reports, the (redacted) medical records of the donors and the results of any successful pregnancies.   

 

Yet, no matter if you are a donor or a recipient, the parties must follow a protocol that protects everyone, to include any resulting children.  In fact, the parties must sign legal consents, have a counseling session with a psychologist or social worker, and undergo infectious disease screening.  The purpose of counseling is to discuss issues such as disclosure to the child at an appropriate age – both for medical and social reasons.

  

From a legal standpoint, the legal system, nor the states’ legislatures, have clarified the actual donation of embryos from one couple to another.  However, the case of Davis v. Davis (Tenn. 1992), as well as several others, have essentially given embryos the status of property when a dispute over the embryos arises out of a marital dissolution action.  The courts chose to decide against “forced procreation,” instead of providing the embryos with a higher (protected) status due to their ability to become life.  In an effort to clarify the status of the embryos from the standpoint of donation, attorneys in this field have chosen to use this same argument to treat the embryos as the donation of genetic material, or property in a sense, from one couple to another much like egg donation.   

 

Essentially, the lessons learned over the last decade have shown those attorneys practicing in this field that precise contract drafting is absolutely essential – your attorney must carefully scrutinize the contract terms since there is strong dicta favoring enforceability.  Furthermore, the reimbursement of costs that may be requested by a donating couple must be considered very carefully before agreed upon by a recipient couple.  Certainly, any additional medical testing required by the recipients’ clinic, as well as any outstanding storage fees, are acceptable fees to be paid; however, anything additional can make the donation itself questionable.  To be sure, the donation of embryos does not involve the same sort of pain and suffering associated with the donation of eggs; therefore, it is best to stay away any additional reimbursements that can be construed as the purchase and/or sale of embryos. 

 

Finally, the success rates from the transfer of frozen embryos is certainly lower than that of a fresh embryo transfer, as is reported by the American Society for Reproductive Medicine (ASRM); however, the availability of this option of donor embryos is certainly one that should be considered by everyone, donors and recipients alike.  To donors, it is the chance to help others and provide life to their frozen embryos; while, to recipients, it is a viable alternative in their journey to creating their families – just remember to ensure that all parties, to include the resulting children, are protected. 

 

*The information in this article is not, nor is it intended to be, legal advice. You should consult an attorney for individual advice regarding your own situation.

 

 

 

Forum: Third (3rd) Party Reproduction (Donors and Surrogacy)

If you have questions about High Tech procedures such as IVF, Egg Donation, or Surogacy, Please visit the Dr. John Gordon on the INCIID IVF & High Tech Procedures Bulletin Board
If you have questions , please contact us.

The INCIID Interactive Forums are divided into two categories. The first category Ask a Professional consists of forums moderated by experts answering your questions. The section below includes non-moderated peer support forums by section:

 

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