Trends in Egg Donation Vitaly A. Kushnir MD Center for Human Reproduction
Disclosures No relevant financial relationships to disclose CHR views the commercial trade in human oocytes with considerable ethical concerns. CHR does not derive profit from managing the process of egg donation, and offers donor matching services as an unreimbursed courtesy to the center s patients. CHR prices the anonymous exchange of eggs between donors and recipients in its program at cost, and without profit margin.
Women are delaying pregnancy
Age and Female Fertility
Aging and Ovarian Reserve Gleicher N, Kushnir VA, Barad DH. Endocrinology. 2013 Oct;154(10):3498-501
Oocyte Aneuploidy and Age
CHR Patients Age and Ovarian Reserve
Kawwass JF et al. JAMA. 2013
Live Born Infants after Third Party Reproduction 13,523, 12% 5,352, 5% 3,244, 3% 13,408, 11% 79,797, 69% Oocyte Donation Embryo Donation Multiple Third Party ART Sperm Donation Gestational Carrier Kushnir et al. AJOG, 2017
Kushnir et al. AJOG, 2017
Kushnir et al. AJOG, 2017
Demand for donors race Shapiro AJ, Darmon SK, Barad DH, Albertini DF, Gleicher N, Kushnir VA. Effect of Race and Ethnicity on Utilization and Outcomes of ART in the USA. Reprod Biol Endocrinol. 2017
Fertility rates are rapidly declining -Especially among Hispanic women Utilization of ART is inversely related to fertility rates and age at first birth in the general population Utilization of ART is high among Asian and Caucasian women and low among Black and Hispanic women Utilization of third party ART/egg donation is increasing more rapidly than autologous ART Shapiro AJ, Darmon SK, Barad DH, Albertini DF, Gleicher N, Kushnir VA. Effect of Race and Ethnicity on Utilization and Outcomes of ART in the USA. Reprod Biol Endocrinol. 2017
Patient race is correlated with ART live birth rates Black women have the lowest live birth rates with ART Shapiro AJ, Darmon SK, Barad DH, Albertini DF, Gleicher N, Kushnir VA. Effect of Race and Ethnicity on Utilization and Outcomes of ART in the USA. Reprod Biol Endocrinol. 2017
ART live birth rates are lower while spontaneous abortion rates are higher among Black women even with egg donation Shapiro AJ, Darmon SK, Barad DH, Albertini DF, Gleicher N, Kushnir VA. Effect of Race and Ethnicity on Utilization and Outcomes of ART in the USA. Reprod Biol Endocrinol. 2017
Cross-Border Reproductive Care Access to care Cost Privacy Regulation laws that restrict payment to donors require disclosure of the identity of donors sex selection gestational surrogacy
Cross-Border Reproductive Care Non-U.S. resident cycles were associated with a 3-fold higher utilization of PGD (19.1% vs. 5.3%), a 4-fold higher utilization of oocyte donation (42.6% vs 10.6%), and a 8-fold higher use of gestational carriers (12.4% vs 1.6%).
Effect of PGS on Live Birth Rates in U.S. Oocyte Donor Cycles 2005-2013 65.0% 60.0% 55.0% 50.0% 45.0% 40.0% Fresh Transfer FET 1 FET2 FET3 non-pgs PGS Barad DH, Darmon SK, Kushnir VA, Albertini DF, Gleicher N. Am J Obstet Gynecol. 2017
Fertil Steril. 2013 Jan;99(1):37-43.
Commodification of Human Eggs Ethnicity Education Employment Esthetics
Fresh and Cryopreserved Donor Oocyte cycles reported to SART, 2013-2015 Fresh Donor Oocytes Year(s) 2013 2014 2015^ Cryopreserved Donor Oocytes 2013 2014 2015^ Number of cycles 8921 6929 5982 2227 2886 3215 Embryos transferred 1.7 1.6 1.6 1.6 1.6 1.6 % Cancelled Cycles 11.7 7.0 9.1 8.5 12.4 15.0 Kushnir VA et al, J Ovarian Res. 2018 Jan 5;11(1):2.
Live Birth Rate per recipient cycle start (%) Live birth rates with fresh vs. cryopreserved donated oocytes, 2013-2015 60 50 40 30 20 10 0 2013 2014 2015^ Fresh Donor Oocytes Cryopreserved Donor Oocytes Kushnir VA et al, J Ovarian Res. 2018 Jan 5;11(1):2.
Adjusted for significant risk factors from the set of all possible cycle-level risk factors. -patient age, number of prior births and diagnoses of ovulatory dysfunction and tubal factor infertility. Donor cryopreserved oocyte cycles had decreased likelihood of live birth (arr 0.87, 95% CI 0.80 0.95) Crawford et al. Fertil Steril (2017)
Fresh Oocyte Donation Advantages Disadvantages Gold Standard Practiced since 1983 Documented safety and efficacy Highest Live Birth Rates Complicated logistics High cost Donor pool vs. agency Waiting periods Long distance travel Kushnir VA, Gleicher N. Curr Opin Endocrinol Diabetes Obes. 2016
Cryopreserved Oocyte Donation Advantages Disadvantages Simplified Logistics Improved selection of donors Long distance shipping Lower Cost per Treatment? Improved safety due to quarantine Limited number of eggs Lower Live Birth Rates Variability in Freeze/Thaw technique? Cost per Live Birth? Long Term Health Kushnir VA, Gleicher N. Curr Opin Endocrinol Diabetes Obes. 2016
Key Points Fertility rates are declining Utilization of ART is inversely related to age at first birth and fertility rates in the general population Utilization of egg donation is particularly high among Asian and Caucasian women and low among Black and Hispanic women ART live birth rates are lower while spontaneous abortion rates are higher among Black women even with egg donation Reliance on egg donation increases with maternal age, it accounts for the majority of ART live birth to women above age 40
Are frozen donor eggs in donor-recipient cycles really the equal of fresh oocytes? Vitaly A. Kushnir MD Center for Human Reproduction
Disclosures No relevant financial relationships to disclose CHR views the commercial trade in human oocytes with considerable ethical concerns. CHR does not derive profit from managing the process of egg donation, and offers donor matching services as an unreimbursed courtesy to the center s patients. CHR prices the anonymous exchange of eggs between donors and recipients in its program at cost, and without profit margin.
Oocyte Cryopreservation Cryopreservation Storage Thawing
Fertil Steril. 2013 Jan;99(1):37-43.
Commodification of Human Eggs Krawiec KD. Egg-donor price fixing and Kamakahi v. ASRM. Virtual Mentor. 2014 Jan 1;16(1):57-62. Klitzman RL, Sauer MV. Kamakahi vs ASRM and the future of compensation for human eggs. Am J Obstet Gynecol. 2015 Aug;213(2):186-187.e1.
Commodification of Human Eggs Ethnicity Education Employment Esthetics
Donor Oocyte Vitrification Program- SPAIN (IVI) 2007 2013 (n= 3,467 cycles) Oocyte survival rate was 90.4% Implantation 39% Delivery rate/donation cycle 39.1% CDR/donation cycle was 78.8% Cobo A, Fertil Steril. 2015 Dec;104(6):1426-34.e1-8.
Fresh vs. Cryopreserved Oocyte Donation Kushnir et al. JAMA 2015
Fresh vs. Cryopreserved Oocyte Donation Kushnir VA, Gleicher N. Curr Opin Endocrinol Diabetes Obes. 2016
Fresh and Cryopreserved Donor Oocyte cycles reported to SART, 2013-2015 Fresh Donor Oocytes Year(s) 2013 2014 2015^ Cryopreserved Donor Oocytes 2013 2014 2015^ Number of cycles 8921 6929 5982 2227 2886 3215 Embryos transferred 1.7 1.6 1.6 1.6 1.6 1.6 % Cancelled Cycles 11.7 7.0 9.1 8.5 12.4 15.0 Kushnir VA et al, J Ovarian Res. 2018 Jan 5;11(1):2.
Live Birth Rate per recipient cycle start (%) Live birth rates with fresh vs. cryopreserved donated oocytes, 2013-2015 60 50 40 30 20 10 0 2013 2014 2015^ Fresh Donor Oocytes Cryopreserved Donor Oocytes Kushnir VA et al, J Ovarian Res. 2018 Jan 5;11(1):2.
Adjusted for significant risk factors from the set of all possible cycle-level risk factors. -patient age, number of prior births and diagnoses of ovulatory dysfunction and tubal factor infertility. Donor cryopreserved oocyte cycles had decreased likelihood of live birth (arr 0.87, 95% CI 0.80 0.95) Crawford et al. Fertil Steril (2017)
Fresh Oocyte Donation Advantages Disadvantages Gold Standard Practiced since 1983 Documented safety and efficacy Highest Live Birth Rates Complicated logistics High cost Donor pool vs. agency Waiting periods Long distance travel Kushnir VA, Gleicher N. Curr Opin Endocrinol Diabetes Obes. 2016
Cryopreserved Oocyte Donation Advantages Disadvantages Simplified Logistics Improved selection of donors Long distance shipping Lower Cost per Treatment? Improved safety due to quarantine Limited number of eggs Lower Live Birth Rates Variability in Freeze/Thaw technique? Cost per Live Birth? Long Term Health Kushnir VA, Gleicher N. Curr Opin Endocrinol Diabetes Obes. 2016
Technical Considerations Vitrification vs. Slow Freezing Open vs. Closed Systems Automated Systems Embryo Selection Techniques -Routine Blastocyst Culture -PGS
Oocyte Cryopreservation Vitrification (Rapid) Slow-freeze Cil AP, Bang H, Oktay K. Fertil Steril. 2013 Aug;100(2):492-9.e3
Open vs. Closed System RCT of sibling donor oocytes to evaluate thaw survival Thaw survival rates (93.7 vs. 89.9%) Most embryology parameters were similar The clinical pregnancy rate per transfer was 36.5% De Munck N, et al. Open versus closed oocyte vitrification in an oocyte donation programme: a prospective randomized sibling oocyte study. Hum Reprod. 2016 Feb;31(2):377-84
Closed System Prospective, observational, cohort, noninferiority trial. Papatheodorou. Fertil Steril. 2016
Automated Vitrification
Key Points Fresh oocyte donation should be viewed as the "gold standard" against which newer procedures, such as cryopreserved donor oocytes, are compared. Acceptable but somewhat lower live birth rates have been achieved with use of cryopreserved donated oocytes in comparison to fresh donor oocytes. Use of cryopreserved donated oocytes may simplify logistics and lower the cost per treatment cycle but whether they lower cost per live birth is still unknown. Long term follow-up studies on the health of children conceived from cryopreserved oocytes are still lacking. Establishment of donor oocyte banks formalizes commodification of human oocytes