EGG DONATION:

Infertile Couples Turn to Egg Donation

By Nan Callender-Price, RN

0nly a generation ago, options were limited for couples who experienced infertility, defined as the inability to conceive after one year of unprotected intercourse. But for more than a decade now, egg donation has offered hope to couples for whom other treatments have failed.

The procedure of egg donation, which was simplified about five years ago, involves the surgical removal of eggs from a donor, in vitro fertilization (IVF) of a donated egg, and transfer of the resulting embryo to the recipient's uterus. The overall success rate can be about 50 percent, which is nearly double the success rate of many other hightech infertility treatments. Through 1993, 2,500 babies had been born from donated eggs; 1,000 of them were conceived in 1993 alone.

For some women, egg donation may be the last chance to become pregnant after years of unsuccessful treatment with a variety of low- and high-tech procedures,' known as assisted reproductive technologies (ARTs). Other women have medical or genetic conditions that keep them from conceiving. Such conditions include ovarian failure due to radiation or chemotherapy treatments for malignancies; a genetic defect; a history of surgical removal of the ovaries; or compromised ovulation function-commonly related to age.

"Egg donation is becoming a more promising option for infertile couples," said nurse practitioner Mary English, MSN, RN, director of clinical services since 1983 at the Pennsylvania Reproductive Associates, a private ART practice in Philadelphia. "There is a decline in ovarian function usually beginning at 35 years old and increasing with age, making the odds to conceive much less. A decline in ovarian function can be assessed through baseline hormonal levels, such as FSH [follicle-stimulating hormone] and estradiol, which increase with age. Because the average age of a woman seeking treatment at our center is 36 years old, some choose to attempt IVF with their own oocytes once or bypass it and try oocyte donation first if the prognosis for IVF using their own oocytes is poor."

Many insurance companies do not provide coverage for egg donation or other ARTs, and costs can run as high as $10,000 to $20,000 per procedure. "When counseling patients, we really have to evaluate the whole picture-not only their medical history, but also their emotional stamina and financial resources as well," English said. "All of these things must be considered in the decision-making process."

The center maintains anonymity between the donor and recipient, unless the donor is a friend or relative of the couple. A donor undergoes rigorous genetic, medical, and psychological screening and testing, and the resulting comprehensive profile is given to the couple with identifying information removed. This way prospective parents have access to the child's medical and genetic family history.

But this policy of anonymity may change; the center is considering allowing the donor and recipient to establish contact by telephone or shared photographs. Decisions about whether to maintain anonymity would be made case by case according to the wishes of donors and recipients. "Many recipient couples feel a tremendous sense of loss of control, and as a result, disconnected about the future child," English said. "For some, having such contact with the donor helps to restore control and makes them feel more connected to this parenting option."

Nurses play a key role in patient care management, according to English. "Ours is a nurse-managed program, which means nurses are responsible for the total case management of patients, based on clinical protocols and on-going consultation with primary physicians and the IVF team."

At present, no formal regulations cover IVF centers in the United States. Many centers use voluntary guidelines developed by the American Society for Reproductive Medicine (ASRM) as the framework for their standard of practice. Experts disagree about whether the specialty should be formally licensed or regulated.
Because nurses are on the front line of patient care in IVF centers, English said, they are in a position to ensure the ethical practice of ARTs. "Nurses should provide adequate and appropriate information so both donors and recipients can make an informed decision," she said. "They should maintain meticulous patient screening and medical records and protocols. They should also be knowledgeable about ASRM guidelines and feel comfortable about the ethical boundaries of the team they work with."
Linda Applegarth, EdD, clinical assistant professor of psychology in the department of ob/gyn and psychiatry at Cornell University Medical College in New York, works with the university's Center for Reproductive Medicine and Infertility at the New York Hospital-Cornell Medical Center. She sees infertile couples at every stage of their treatment with low- or hightech procedures. Applegarth interviews potential donors, evaluates their psychological profiles, and sets up a consultation meeting with the prospective parents. "It's part of my job to help them feel as comfortable and prepared as possible in choosing this parenting option," she said.

The center gives recipients comprehensive information about the potential donors without revealing the donors' identities. "Historically, in sperm donor situations not much information was divulged to families, and many families have done well," Applegarth said. "However, we now have data from adoption cases showing that the more information given about the genetic parents to the adoptive parents and children, the more beneficial it is to them. Still, du medical mentality often is that the less recipient parents and the child know, the better it is for them, even though there isn't any data to support this belief."
Although risks to the donor are usually minor, preparation for the procedure is time-consuming. First the donor undergoes hormone therapy to hyperstimulate the ovaries; she is then closely monitored with ultrasound and blood tests. Egg retrieval is done while the patient is sedated. A needle, inserted transvaginally and guided by ultrasound, aspirates the eggs from the ovarian follicles.

Surprisingly, most donors are motivated mainly by altruism-not financial incentives-to endure the discomfort and inconvenience of this process. Marilyn Butterfield, MS, RN, owner and director of the Family Fertility Center in Walnut Creek, said that although her center otters a $2,500 stipend, many donors contribute their eggs out of "the desire to help someone else,. particularly if they have had a friend or relative who experienced infertility." Butterfield thinks some donors who have had an abortion may unconsciously see egg donation as an act of restitution.

Only 10 percent of the candidates who respond to the center's advertisements make it through the screening process. Many decide not to proceed after hearing about what it involves, and others do not meet the stringent criteria to become a donor at the center.
Butterfield started the center after her own experience as the recipient of a donated egg. The center works closely with four IVF clinics in California, acting as the liaison between the clinics and the potential donors and recipients. The company recruits young women (the average age is 25) by advertising in university publications, parenting magazines, and other consumer periodicals young women may read.

"The majority of donors want to be reassured that they will not be responsible for the future child," Butterfield said. Conversely, the recipient couple wants a guarantee of their legal guardianship. Standardized contracts are provided.

The Family Fertility Center is unique in its philosophy about anonymity between participants: It requires that the donor be open to the possibility of a meeting if desired by the recipient couple. The potential donor and prospective parents meet in the center's office but do not exchange last names, addresses, or telephone numbers. The couple also can examine the comprehensive medical and psychosocial profile and photographs of the potential donor at the office. "I'm very concerned about the self-esteem of the future child," Butterfield said. "Often secrecy implies stigma or shame, whereas an open, matter-of-fact approach seems to be a better path for all."

Butterfield thinks businesses similar to hers should be run by licensed professionals. "As nurses or therapists, we are bound by inherent standards of practice that require expertise and an ethical framework required in egg donation," she said. "Nurses play a pivotal role in IVF coordination and case management and can help to ensure equity for all participants."

Should guidelines remain voluntary for IVF centers?

Last year, several prominent physicians affiliated with the University of California, Irvine were charged with misappropriating eggs and embryos from women without their consent and transferring the eggs and embryos to recipients. The scandal prompted experts to re-evaluate the need for formal oversight at in vitro fertilization (IVF) centers.

Just as the technology used in infertility treatment has become more corn= plea, so have the social and ethical issues related to assisted reproductive technology (ART). This high-tech approach to infertility includes a variety of procedures, such as gamete intrafallopian transfer, zygote intrafallopian transfer, in vitro fertilization, cryopreservation, egg donation, intrauterine insemination, and (ntracytoplasmic sperm injection. About 40,000 couples a year try ART in, the United States, according to a Newsweek report.

Currently, IVF centers across the country do not have mandatory licensing; voluntary guidelines recommended by the American Society for Reproductive Medicine (ASRM) are the standard of practice for many centers.

Founded in 1944, ASRM has, over 11,000 members and represents nurses, physicians, and other scientific and healthcare professionals in reproductive medicine.

Gladys B. White, PhD, MSN, RN, the executive director of the Washington-based National Advisory Board on Ethics in Reproduction (NABER), maintains that something more than voluntary guidelines is needed to win back public trust. "I think some sort of licensing would convey to