Mount Sinai Hospital

 

1. Did you make egg donation in your clinic? yes
2. Did you make this procedure also for foreign people? yes
3. How does the procedure goes in your clinic (e.g. visits for the couples,
how long must they stay in your clinic, and so on, which medicaments must
the person take, which get the embryos)?  out patient visits only; see attachments
4. How much embryos and in which stadium did you transfer the embryos? depends on age and history of recipient - generally 3 embryos at 72 hours or 2 embryos at blastocyst stage
5. Did you make procedures like haching and so on  yes
6. How long is the waiting time?  for anonymous donation, wait is 5 - 7 years; but if person finds their own donor, we do it right away
7. How much does it cost?  anonymous is $2050.; known is $3900 plus drugs for donor
8. Did some one speak in your clinic german, or english?  all speak English, some speak also French

Website: www.baby-makers.com

Donor Ovum Recipient Program

Introduction

We have had the ability to donate gametes from the male through the mechanism of donor sperm for over 100 years. The first report of the use of donated oocytes/eggs in humans was in 1983. The potential to donate gametes from the female has only become possible with the knowledge we have gained through In Vitro Fertilization (IVF). In Vitro Fertilization (IVF) was initially intended as a mechanism to bypass the fallopian tubes, thereby allowing women with blocked tubes to conceive. It soon became apparent that most cases of infertility, regardless of the etiology benefited from  IVF. With the advent of IVF, the only absolute contraindication became a lack of eggs to retrieve, or the absence of a uterus in which to place the embryos. With the possibility of donated eggs, the former condition (lack of eggs) is no longer necessarily a barrier to conception.

Indications for Oocyte Donation
Women without ovarian function
This group includes those women without ovaries as well as those with non-functioning ovaries, (premature ovarian failure). Premature ovarian failure is defined as ovarian failure which results in secondary amenorrhea with elevated gonadotropin levels, occurring before the age of about 40 years. Premature ovarian failure occurs in 3.7% of all women. Premature ovarian failure may be due to premature menopause, the resistant ovary syndrome, auto immune disorders, or ovarian destruction following surgery, radiation or chemotherapy. The effect of the chemotherapy or radiotherapy is dependent on the type of drug, the location of the radiation, and to a certain extent the age of the patient at time of treatment. Most cancer therapies do not leave the patient with loss of ovarian function. Another group requiring donor eggs are those women with a chromosomal abnormality, such as Turner Syndrome, or its variants. Because of the absence of part or all of an X chromosome, the ovary may never have functioned, or may have functioned incompletely, or for a short period of time. The group of women with absent ovaries generally refer to women who have had surgical removal of their ovaries and the indications for removal vary. They include adnexal accident, or cysts that required oophorectomy (removal of the ovaries). Less commonly oophorectomy for ovarian malignancy is encountered.

Women with functioning ovaries
Those women who have had unsuccessful IVF cycles (likely due to poor egg quality), those who are not candidates for IVF or those who are carriers of a genetic disease may be candidates for ovum donation. The genetic abnormalities usually involve significant autosomal dominant or sex linked disorders. These women carry a genetic trait that would prove lethal to their offspring, and the likelihood of the offspring acquiring it is high. Duchenne's Muscular Dystrophy is an example of this. Occasionally there may be autosomal recessive traits where the couple is reluctant to have donor insemination. Women who are not IVF candidates may have anatomically inaccessible ovaries or have repetitive failure with IVF. There may be lack of fertilization of apparently normal oocytes and spermatozoa or lack of implantation. It is postulated that these women may have subtle defects in their eggs. We are unable to demonstrate this, other than the lack of success. Donation of eggs would serve as a diagnostic test, and potentially as treatment.

Selection of Donors

There are many potential sources for donated eggs. Any premenopausal women could be a potential donor of eggs. All potential donors require thorough medical histories, with attention to family history, psychiatric history and drug history. Donors may be anonymous or non anonymous (known to the potential recipient).

Non anonymous Donors

This group refers to women who are recruited by a specific recipient. Often these are sisters or relatives of the recipient. they may be friends or may have entered into a special arrangement for this purpose. The number of non anonymous donors, especially relatives, is of course, very limited. Using non anonymous donors gives the recipient the opportunity to involve herself in search for a donor. Furthermore, she will know about the donor's physical appearance and personality traits as well as the more clinical medical history. In the case of sisters, much genetic information is shared between the two women.

In Ontario at the present, the decision is made by individual hospital or clinic ethics committees. Our Ethics Committee has recently made the decision to support this concept. In all cases of non anonymous donation, the donor and recipient couple will undergo specific psychological assessments. In order to donate the donor will have to undergo IVF, with all its risks (e.g. medication side effects, complications of the procedure etc.) with no benefits to herself, only that of the recipient couple.  All donors have to accept the medical risks intrinsic in IVF, without any direct benefits. There is no payment for human tissue, and as such the donors are not paid for their work. They will be no out of pocket costs to the donor as these costs will be paid by the recipient couple.

Anonymous Donors

These women have no relationship with the recipient. Anonymous donors may be recruited from a group of women who are already undergoing IVF or a related procedure, or may be actively recruited specifically for this purpose.

Volunteer Donors

Many centres have begun to use volunteer donors in the place of, or in addition to IVF patients. Although all women who donate eggs are in a sense volunteer, we use this term to denote those who are specifically recruited, as opposed to those who are already involved in IVF for their own care. The number of IVF patients is always limited, and in centres with embryo freezing, even more so. In an attempt to increase the number of donations of eggs, some centres have begun to recruit volunteers. Often this takes the form of articles in local newspapers or through doctors offices. Volunteers may undergo IVF solely for the purpose of donating eggs, or may do it in conjunction with another procedure. Some centres ask women undergoing laparoscopic sterilization to donate eggs. These women are considered good candidates because they are not undergoing any increased surgical risk for the donation. They are less likely to regret the loss of eggs since they have already completed their family. In the United States patients have to pay for procedures such as sterilization. If they donate eggs, the payment for their time and inconvenience can subsidize the cost of the sterilization. This system is problematic. At one centre, close to 80% of the tubal ligation patients were ineligible. The vast majority (54%) because of age over 35. Of the eligible women 88% refused donation and 12% agreed to oocyte donation. Psychological testing and/or psychiatric evaluation is carried out. Although it would seem that similar analysis should be undertaken for potential donors of sperm, this is not the case. They are screened with respect to health problems, but not usually with respect to the psychological impact of donating gametes. The difference in approach is multifactorial. There is the practical consideration of the number of sperm donations compared to egg donations. There is the more recent emphasis on the psychological considerations of fertility and infertility, and the related subjects of adoption and loss. These have not been considered with sperm donors. There is also the assumption that donating sperm is "different" than donating eggs. Whether the attitudes of donor of gametes is dependent on the sex of the donor is not known.

IVF Patient Donors

Women who are undergoing IVF are excellent candidates for oocyte donation. One of the drawbacks of using volunteers, is that they are subjected to relative risk, for no personal gain. IVF patients, on the other hand, are already committed to undergoing IVF for their own needs and therefore, there is negligible additional risk to them as patients. Concerns about using IVF patients stem from the IVF patient's vulnerability. They are often in a very dependent relationship with their physician. As such they are also at risk of a type of coercion. A simple request of donation could be perceived by the patient as an obligation she has to her physician. She may then agree, even though she has reservations. Alternatively, an IVF patient, having had to deal with her infertility may be more likely to help another. The success rate in attracting potential donors varies greatly. The difference in attitudes and characteristics of a group of infertile women, who were in a position to donate excess eggs but declined, and those that chose to donate were studied by Leeton and Harmon. They found no significant differences with respect to religion, education, or socio-economic factors. The non donors were less likely to discuss their possible donation with others. The authors pointed out that in their clinical experience, those with children were more likely to donate. Once an IVF patient is considered acceptable from a medical and psychological perspective, she must also produce enough eggs to donate. Through the use of drugs such as human menopausal gonadotropin (HMG) multiple follicles are recruited and matured. This controlled hyperstimulation is an integral part of IVF. It is known that not all eggs fertilize, and that not all embryos implant. In order to ensure the best chances of conception, the goal is to have several mature follicles at the time of egg retrieval. At a certain number, the eggs become superfluous. As the success rates with IVF improve, the optimal number of eggs and embryos changes. The pregnancy rate does not seem to increase when more than three embryos are transferred. However, the rate of multiple gestations does. Since this is associated with complications for the mother and fetuses, it is to be avoided. One way is to limit the number of embryos transfers. The number of eggs necessary to achieve three embryos is variable. In most centres, the fertilization rate is approximately 60%. This varies, depending on such factors, such as sperm quality, previous experiences with the same patient, and quality of the eggs. Generally speaking, more than six eggs, will, on the average be excess. Some centres have the facilities to freeze embryos. The excess can be stored and used in subsequent cycles. If freezing is not available, the eggs can be donated to research, donated to women without eggs, or destroyed. (replaced in the vagina) It is imperative that the donation of eggs does not compromise the donor's own quest for pregnancy. In fact some studies have suggested that those women who donate eggs have a better pregnancy rate than those that do not. This is not because they donated eggs per se, but if they were able to donate eggs then they had a good stimulation cycle, and many eggs were retrieved. Today's trend to start a family later in life means many otherwise willing egg donors are disqualified too to being over the age of 35. The older the donor is over the age of 35, the greater the risk of a child born with congenital anomalies.

Most infertile women donate eggs to help another women conceive, as do the volunteers. There are differences in their attitudes toward the result of the action. In a British study, the attitudes of voluntary donors and infertile donors were compared. 85% of the volunteers wanted to know if a child was born of their eggs, compared to 40% of the infertile women. However, 80% in both groups felt they would have no connection with that child. The volunteers were more interested in meeting the recipient, than were the patients (40% vs. 13%). Overall, 76% said they would donate again.

The procedure of Anonymous Egg Donation:

for the Donors

In most centres IVF patients are the donors. For them egg donation involves all the same steps as a normal IVF cycle with a few additions. Prior to being accepted as donors, all women will have had to complete an extensive medical history form. This review family history, family psychiatric history, and drug history, among other more standard questions. The prospective egg donor proceeds through her IVF cycle then, once the procedure is complete, the decision on how to divide the eggs must be made. In the case of an IVF donor, there may not be an excess of eggs, in which case, there would be no donation. If the IVF patient has enough eggs to donate and is agreeable, the lab staff will set 4 aside for the recipient, and fertilize those eggs with the recipient male's sperm. A fair division of quality of eggs is assured.

for the Recipient couple

The goal for recipients is to develop an endometrium that is receptive to the embryos and will allow implantation. This is usually assessed during a mock cycle by an endometrial biopsy. This will document the histological development of the endometrium. If it is not adequate, the dosage can be changed. The advantage of the constant dosage is that it allows for flexibility in order to synchronize the donor cycle and the recipient cycle. Although the replacement protocol appears less "physiologic" the pregnancy rate is comparable. This approach has been extended by some, to include up to 35 days of Estradiol and 4 days of Progesterone prior to ovum pickup. The risks to the recipient are the risks of the medications, the risks of acquiring a transmissible disease from the donor, and the risks inherent in pregnancy, should one occur. The side effects are minimal, and are the same as with any estrogen. There is no known teratogenic risk of natural progesterone. There is a theoretical risk of acquiring a transmissible disease through donor eggs. However there have not been any reported cases of AIDS or Hepatitis through this program. Nonetheless, all donors are screened for HIV, Hepatitis B & C as well as syphilis.

Important addition information

Sickle cell anaemia

If you are of Mediterranean or African descent it is important for you to be screened for Sickle Cell anaemia. This is an inherited disease which can cause bouts of pain, damage to vital organs. For patients with sickle cell anaemia, the symptoms worsen during pregnancy so it is very important that these women have pre pregnancy counselling.

If you are at risk and have been screened for any of these tests please send a copy of the screening results with your male and female histories.

If you have not been screened please inform the IVF secretary (416-586-5217) who will then order this screen at the time that other blood tests are completed.

General Considerations

There are psychological and emotional consequences for all of the involved parties. There are unanswered questions about the potential effect on the families of the donor and of the recipient. Although the data are not directly applicable, studies of family relationships after pregnancies from sperm donation show no essential difference from relationships in other families. There are theoretical risks of unwitting consanguinity from the use of multiple eggs from an individual donor. This is much less than the risk from sperm donors who give repeated samples over years. The Canadian law recognizes the gestational mother as the legal mother, and supports anonymity of the donor. However, there is much flux at this time with respect to all aspects of assisted reproductive technology, and we cannot be sure that this will hold.

The finding of an improved pregnancy rate with donor oocytes is probably explained by the separation of follicular development and endometrial development. There is no difference on the pregnancy rate between those oocytes that had been donated by IVF patients and those that had been donated by volunteers.

The Donor Ovum Recipient Program

An Overview

The Donor Ovum Program was initiated by Dr. Carol Cowell and Dr. Heather Shapiro in 1991. The primary goal of the program was to offer cycles to women who otherwise would never have an opportunity of achieving pregnancy, such as women with Turners Syndrome or Premature Ovarian Failure. Women with genetic predisposition to fatal or debilitating diseases, previous treatment with radiation and/or chemotherapy or surgical menopause face a similar dilemma. Gradually the criteria for entrance to the program has been relaxed. We can now offer Donor Ovum also to those women who still have ovarian function, but the quality of eggs is inadequate to produce a pregnancy.

Occasionally Donor Sperm is required to fertilize Donor Ovum due to a previously known male factor. A selection of donors may be obtained from our Andrology Lab and can be purchased cycle by cycle or reserved for subsequent cycles. See Therapeutic Donor Insemination.   Another option for couples with male factor is Embryo Donation.
 
 

New Patient Referrals

We are unable to take any new referrals for the anonymous program due to the extremely long waiting list. At present, if a person was added to the waiting list today, she probably would receive eggs in seven years.

Donor Ovum Recipient Program Drug Regime

For patients that have normal, regular periods on their own a drug called Depot Lupron 3.75 mg will be given intramuscularly, once monthly. This may be given by your family doctor, your husband, a clinic, or you may come to the RBU on weekday afternoons before 4 PM (by appointment). First dose is on day 21 of your menstrual cycle. This produces a drug induced menopause that is necessary to manipulate your menstrual cycles to synchronize you with a donor. Synchronizing a natural cycle is virtually impossible to do.

Patients who are not menstruating regularly on their own may not need to take Depo Lupron. The determination will be made by the Donor Ovum Recipient physician upon review of the blood hormone levels.

On the second Day 1 start Estrace 2 mg daily. When a donor becomes available the Donor Ovum Recipient nurse will call you to advise you of a possible donor, get your approval, and advise you to increase your Estrace to 8 mg daily and start Baby ASA 80 mg daily, both which will help develop your endometrial lining. An endometrial lining thickness of 8 mm or more -triple line pattern will provide an optimal environment for implantation of an embryo. This will be determined at the time of your ultrasound that will be done just prior to selecting you for a particular donation.

On day of donation start Prometrium capsules 100 mg three times daily and Progesterone suppositories 100 mg three times daily. Continue for 2 weeks, until your pregnancy test. If pregnancy test is positive continue the Prometrium capsules 100 mg three times daily and Progesterone suppositories 100 mg three times daily until 10 weeks of pregnancy. The physician will discontinue Prometrium and Progesterone suppositories when the serum progesterone levels are therapeutic and placental function is established. Blood will also be taken from you on this day for serum (to be frozen), for genetic testing if applicable, and for Estradiol and serum Progesterone levels. This will give us a baseline as your drug therapy progresses through the first trimester of your pregnancy.

If the pregnancy test is negative stop Prometrium and Progesterone suppositories. Continue Estrace 2 mg daily. A withdrawal period should occur soon after. This will be your day one, and you will call this into the Donor Ovum Nurse. On day 10, and for about 10 days thereafter,  your body should be ready to receive a donation if one is available.

If no donor is available after 2 weeks of Estrace start Provera 10 mg daily for 10 days. Call next day one. Continue Estrace 2 mg daily while on Provera.

Discharging the Patient

A pregnancy ultrasound is done in the RBU 6 weeks post embryo transfer. This may need to be repeated if it is too early to detect the fetal heart activity.

Once the pregnancy is established by ultrasound you will be referred to their obstetrician of choice or we will help you to select one from our staff Obstetricians if you wish. Consent is required if they wish their records to be forwarded. The patient may or may not wish to share information regarding their ovum donation. There will be a charge of $25.00 for forwarding records to a doctor not affiliated with Mount Sinai Hospital.

In the ultrasound room the patient is given the IVF statistics sheet to fill in and return to us at the end of her pregnancy, hopefully with a baby picture for our "Brag" Board.

Her pregnancy ultrasound is recorded in the Pregnancy Ultrasound Statistics Book. This information includes the patients addressograph, number of sacs, number of fetal hearts seen, doctor of choice for obstetrical care and the ultrasound results. The nursing manager uses this book as a quick reference for pregnancy outcomes of all of the programs in the RBU.

Anonymous Donor and Recipient Charts

Donor charts

When an IVF patient wishes to be a Donor a record of this must be kept whether or not an actual Donation is made. All patients who are interviewed for donation have a Red File Folder chart created as a permanent record of this event. This chart is numbered sequentially and is kept in the locked filing cabinet. The recipient charts are kept locked and separate from the donor charts and are only cross-referenced by number. The keys to this
cabinet are kept by the Nursing Manager and the Donor Ovum Recipient nurse. There is a record kept of each
donation made in the donor’s chart and of each donation received in the recipient’s chart.
If an IVF patient wishes to donate again in a subsequent cycle she requires another consent interview and update of her questionnaire and history, but keep the same ovum donor number.

Donor Ovum Recipient charts

This chart is a permanent record of the Donor Ovum Recipient. It contains the recipient's and her spouse's Registration forms, referral letter, blood results, past medical history, Donor Ovum Recipient Characteristic profile and any other pertinent information. On the front inside cover of the chart each donation cycle is recorded as is the Donor’s number and the outcome of the recipient’s cycle.

The Donor Ovum number is the only identifying link between the recipient and Donor if any future reference is required.

Donor Ovum Statistics Book

This book is a permanent record of all Donor Ovum Recipient cycles started, completed and cancelled. It must be kept in mind that the nature of the program is anonymous and confidential.

This record includes cycle number, patients age, number eggs donated, number embryos transferred and endometrial thickness and pattern on day of donation or prior to, Estrogen and progesterone levels on day of donation or embryo transfer, number of days on Estrace 8 mg, Embryo Transfer Date, patient’s diagnosis and outcome of the cycle. Her pregnancy ultrasound is recorded in the Pregnancy Ultrasound Statistics Book. This information includes the patients addressograph, number of gestational sacs, number of fetal hearts seen beating, Obstetrician of patient's choice for referral and the ultrasound findings i.e. - single , twins, triplets, or missed pregnancies. The Nurse Manager uses this book as a quick reference for pregnancy outcomes of all of the programs in the RBU.

Statistical information of the donors is keep in a similar fashion. In the book are the names of all patients from the IVF Program who have been interviewed for donation, (whether or not a donation takes place) and the number of the red Ovum Donor folder. Here the date of the interview and donor questionnaire, the date of retrieval, number of eggs donated and the date consent was obtained are recorded. These numbers reflect the number of interviews done versus the number of recipient cycles completed.

Costs For Anonymous Donation (For Known Donation Add $1075.)

The Donor Ovum Recipient Program is not a service completely funded by OHIP

TO PREPARE FOR YOUR FIRST DONOR OVUM RECIPIENT APPOINTMENT

*Please come as a couple for your first appointment if possible.*

Please bring with you on your first appointment, or have sent to the unit ahead of time, your complete infertility history from your family physician, gynaecologist or other clinic for the appointment. This history could include the following information:

1) Hormone (LH, FSH, TSH, Prolactin) results
2) Sperm Analysis Report
3) Pelvic Ultrasound Report
4) Operative Note and Pathology Report for Pelvic or Abdominal Surgery

Take this list to your physician so he/she will know what to send for your appointment.

NB: It is not necessary to have the above tests done before you are seen in the unit.

Finally, we look forward to seeing you in the near future. Please check in at the Patient Management Centre in the Eaton Wing, at the front foyer, upon your arrival at Mount Sinai Hospital, and present your Health Card to facilitate the making of your Blue Hospital Cards. Please have 2 copies made os each card. One copy is for you to keep and the other copy will be presented to the secretary on arrival at the IVF/RBU Unit of the 6th floor of the Eaton North Wing for this and every appointment in the future. It is important that the information is kept up to date on this card and on your chart i.e. name, address, home and business numbers, and any changes in your Health Card information. If any of your personal information changes between appointments, inform the Patient Management Centre on your next appointment so a new card can made. Your Health and Hospital Card must have your current Ontario Health Card Number and Version Code. Also inform the RBU staff of changes in your personal information so your chart can be updated. This is most important.

Confidentiality

Please remember that the Anonymous Donor Ovum Program is  Confidential. We therefore request that you not discuss your cycle in the waiting room in case anonymity be jeopardized.
 

Costs

These costs must be paid when the donation cycle commences. You will be entitled to a refund for any services paid for and not used. This refund will be mailed and reach you within a month.

Anonymous Donor Egg Costs for Ontario Residents with Ontario Health coverage

1 Laboratory Expense @ $2050.00 each (Donor Ovum Program)
 

DRUGS

Estrace 2 mg X 60 tablets - $37.00

Prometrium 100 mg three times daily - $28.00 for 2 week supply

Progesterone suppositories - $210 for 2  week supply

Subtotal -$275.00 (for 2 weeks supply)

These drug costs are approximate and can be subject to change.

ALL AMOUNTS HAVE BEEN ROUNDED TO THE NEAREST DOLLAR

Total - $2050.00 + $275.00 = $2325.00
 

Known Donor Egg Costs for Ontario Residents with Ontario Health coverage

1 Laboratory Expense @ $2050.00 each (Donor Ovum Program) - $2050
Cost of donor's IVF cycle and synchrony to recipient - $1075
 

DRUGS

Estrace 2 mg X 60 tablets - $37.00

Prometrium 100 mg three times daily - $28.00 for 2 week supply

Progesterone suppositories - $210 for 2  week supply

Subtotal -$275.00 (for 2 weeks supply)

These drug costs are approximate and can be subject to change.

ALL AMOUNTS HAVE BEEN ROUNDED TO THE NEAREST DOLLAR

Total - $2050.00 + $1075 + $275.00 = $3400.00
***please note the above quotes do not include the costs of the donor's IVF drugs (add $1500. to $3500.)***

For Non-OHIP "out of province" or "out of country" patients please refer to the detailed fee schedules by pressing the appropriate highlighted phrase. These fees must be paid when the donation commences, and before the recipient male's sperm is used in the fertilization procedure. A refund will not be given if there is no fertilization.. All costs are approximate and are subject to change.

Financial Assistance


We are now able to offer financial assistance through the Bank Of Montreal. A standard credit application must be completed. A Line of Credit will be set up (up to $30,000) or an unsecured loan. Preferred rates are given to our patients from the Bank of Montreal.