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The donation review: a chance to end the elaborate subterfuge?

4 April 2011
By Professor Brian Lieberman
Medical Director of Manchester Fertility Services, and Consultant Gynaecologist at St Mary's Hospital for Women and Children
Appeared in BioNews 602
Human eggs are in short supply. Whilst the first reaction to the concept of payment for eggs may evoke the 'yuk' response, is this response rational? However, significant differences of opinion, ethical conduct and attitudes prevail. Yet, it can be argued that payment in one form or another is justified not only to try to meet this need, but also to reduce exploitation of the women who require donated eggs and those who have specifically been recruited into the egg trading market from outside the UK, given the risks associated with the provision of eggs.

It is not good enough to hide our heads in the sand and ignore the thriving European egg tourism market frequented by UK women. It is a UK problem and to my mind unethical to meet this need by using eggs obtained from impoverished and impecunious women elsewhere in Europe. These schemes with businessmen and traders all taking their cut is to say the least undignified. Therefore we need to right the system at home.

Before discussing this subject it is worth defining the categories of egg providers in the UK. Altruistic egg donors receive neither payment nor payment in kind for their eggs - they are few and far between and invariably involve family members or close friends. Egg share providers usually trade half their eggs in return for fertility treatment services and egg vendors just receive payment for their eggs.

Many women in the UK need eggs and if payment was allowed many providers are likely to come forward as in the United States and Spain. Such a system would not only go a long way to meet this need, but also permit such services to be monitored and provided in a controlled and safe manner, and in a HFEA (Human Fertilisation and Embryology Authority) licensed centre.

Egg donation is associated with a degree of risk and this maybe heightened by over zealous stimulation regimes designed to recover as many eggs as possible. The major danger is ovarian hyperstimulation. About three percent of women report a degree of pain and discomfort, but around one percent develop severe ovarian hyperstimulation (OHSS) with ovarian enlargement, significant abdominal swelling and shortness of breath. In addition, the risk of venous thrombosis is also increased significantly and deaths have been reported.

Severe OHSS is a medical emergency and requires prompt admission to hospital. Treatment includes intravenous fluids and anti-coagulation, but drainage of excess fluid gives prompt symptomatic relief. In the event of pregnancy the symptoms will continue and treatment with intravenous fluids and heparin for anti-coagulation is necessary until the abdominal swelling abates.

Egg recovery also carries a small but recognised risk to the provider. These include pelvic infection, and damage to the intestines and pelvic blood vessels. An intra-ovarian abscess is a rare but dangerous consequence to egg recovery. Given the risks and the inconvenience, payment for eggs in one form or another is therefore a daily reality in IVF centres throughout the world.

The payment may take a number of guises. Direct payment to a woman for her eggs is not allowed in the UK, although is common practice in the USA, Spain (€900) and Czech Republic (€600). However in the UK, payment in lieu of treatment is allowed in egg sharing (trading) schemes. Half of the eggs harvested from the provider are given to another woman (the recipient). The recipient is generally responsible for all the fees but this varies from centre to centre. This scheme works to the satisfaction of most participants and ovarian stimulation of a woman not requiring treatment is thus avoided.

In addition, extensive counselling is required prior to egg sharing. The pre-treatment agreements should cover details such as an unexpectedly poor response to stimulation, the number of eggs to be allocated to the provider and recipient and who gets the odd numbered egg.

In the UK, are we therefore not partaking in an elaborate subterfuge? The HFEA conceded the principle of payment in kind by allowing egg sharing. The argument on that occasion being that the egg share provider had to be stimulated in any event.

Therefore, why should we not be open and transparent with respect to the purchase of eggs? The risks to the egg vendor are recognised and the judicious use of stimulation hormones such as gonadotrophins, has reduced the incidence of serious side effects.

Why not agree to a payment to the egg providers over and above their verifiable expenses and loss of earnings? And of course, the egg provider must be fully counselled and informed about the risks associated with ovarian stimulation and egg recovery.

Finally the welfare of the children is vitally important, as successful treatment will create half siblings, and donor conceived persons have the right to seek identifying information about their genetic parents from the age of 18 or earlier if they intend to marry.

Counselling of both the egg provider and the recipient couples is therefore essential. The counselling must ensure that all participants are fully informed as to the implications of their decisions, and the legal and ethical ramifications of using donated human gametes to overcome their infertility.

Finally, treatments using donated gametes should always be open and transparent. Parents of donor conceived people should be prepared from the outset to answer their children's queries truthfully. This is far more preferable to the inadvertent disclosure by a third party or worse, mockery in the playground.

When parents of donor conceived children are asked 'Where did I come from?' they have the ideal opportunity to gently introduce the concept of medical involvement in the process. Instead of the usual reply the couple could inform the child why donated gametes were needed and that they may well have half siblings. This provides the donor conceived persons with the opportunity to confirm with the HFEA when they are 18-years-old or intend to marry that they are unrelated to their partners.

The purchase of eggs is highly unlikely to expose the egg providers/vendors/sharers to unacceptable risks and it is of paramount importance that a new human life is initiated with eggs that have been appropriately acquired.

I hope the HFEA, as part of its donation review, will lift its head from the sand and closely scrutinise the ethical dilemmas relating to the purchase of eggs. It is more than 30 years since the birth of Louise Brown and more women are delaying starting their families. The needs of the infertile population need to be reassessed.

SOURCES & REFERENCES
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