IVF & Egg Donor /3rd Party Reproduction Considerations to Maximize your Success

Cristin C. Slater, MDIdaho Center for Reproductive MedicineBoise, IdahoCristin.Slater@integramed.com

A Healthy Pregnancy is our Success

´ There are good clinics on every continent

´ Success rates depend on the patient and the clinic (lab conditions, physician, and clinical staff)

´ Success rates should be interpreted critically

Potential reasons US has slight increased LB rate via IVF compared to Europe.

´ Competition-most US patients are cash paying with high expectations´ More Aggressive Stimulation— US stimulates more aggressively. On average: have more

eggs and thus more embryos to choose from.´ Higher % Day 5 Embryo Transfers (2017-86% of thawed donor embryos were blast)(95% <

35 yoa FET) ´ Higher use PGT-A: This is a way to expedite the time to pregnancy. 2017: 60% of thawed

donor embryos w GC were s/p PGT.´ Higher % of Frozen Embryo Transfers (FET) with improved embryo vitrification protocols.

Patients > 35 benefit most from vitrification´ For egg donors: US has larger egg donor pool & highly screened donors (we require OD to

have AMH>3 and AFC>15). Often clinics with internal egg donors are medically screened more critically

´ For Gestational Carriers: Intensive screening options for Gestational Carriers

Society for Assisted Reproductive Technology (SART)

SART Preliminary Data 2017 USA

2017 Preliminary SART data USA

Medical Screening Tests in ART preparation´ Evaluation of Egg Reserve: Antimullarian Hormone (AMH) and Antral follicle

count (AFC)´ Semen Analysis look at sperm concentration (nl > 20 M/mL) and motility

(nl> 50%). With IVF and ICSI: only need as many sperm as there are eggs retrieved

´ Evaluation of uterus (Saline sonogram, Hysterosalpingogram, or Hysteroscopy)

´ Other Tests:´ Endometrial Receptivity Assay (ERA)-To determine window of implantation

timing.´ PGT-A-To improve efficiency of time to live born and decrease miscarriage

rates.

Ovum Donation

Image from donoreggbankusa.com

Ovum Donation

´ Initial Non-disclosed Egg Donor Application

1. Age: 21-32 yo (ideally up to 34 yo for known sibling project)

2. BMI < 30

3. Complete extensive 50 page online questionnaire´ No significant family medical or mental health history

Ø Drug/substance abuse, depression, bipolar disorder etc.

Ø Family cancer

Ø Essentially looking for possible heritable medical problems

´ Provides additional information about personality, education, prior employment.

4. Submit childhood and adult photos´ Only release adult photos with donor’s authorization. Will not release for local egg recipients.

Extensive profile consisting of above information becomes available for IP’s review

Ovum Donation

´ Initial Non-disclosed Egg Donor Intake Screening

1. Baseline ultrasound and ovarian reserve testing´ Want reassurance that donor will have good response to IVF

´ Desire to have > 15 antral follicles on ovaries

´ AMH, d3 FSH/LH/E2

´ Desire AMH > 3

2. Genetic screening and hemoglobinopathy testing´ High level genetic screening for 283 genetic disorders-done before they are added to pool

´ CBC and hemoglobin electrophoresis

´ ABO Rh (blood typing)

3. Health Maintenance must be up to date and FDA infection screening occurs (physical exam, questionnaire for high risk behaviors and infection screening (hepatitis B, hepatitis C, HIV, syphilis, chlamydia, gonorrhea)

Ovum Donation

´ Donor Sibling Registry

1. ICRM clinic default is for non-disclosed egg donation

2. HOWEVER- if intended parents and egg donor are interested in establishing contact, this is possible through the Donor Sibling Registry

3. Donor Sibling Registry (DSR)´ 3rd party program for establishing contact between intended parents and their children with egg, sperm, or embryo

donors.

´ Initial process w/ intended parents and donor is anonymous, but once guidelines for contact are established between all parties, contacted is facilitated through DSR. Degree of contact is dictated by both parties-

Ø Examples- Child can contact donor at a specified age, completely open process from beginning, and all ranges between. Can potentially facilitate contact between biologic siblings from a donor.

Currently 88 donor/parent relationships have been established through DSR for ICRM patients. Majority of our donors are open to contact, as long as intended parents are also comfortable.

Medical Screening/Clearance for a Gestational Surrogate

´ Review of potential surrogate’s obstetric/medical history

1. Number of pregnancies and mode of delivery2. h/o obstetric complications3. Review of PMHx and meds with focus on problems that could impact pregnancy4. Review of PSHx with focus on problems that could impact pregnancy5. Most recent pap smear6. BMI7. Prior IUD use

´ Psychiatric Screening w/ reproductive psychologist

Medical Screening/Clearance for a Gestational Surrogate

´ Medical Clearance Exam

1. Complete history and physical2. Saline infusion sonogram3. Lab testing for both surrogate and spouse/partner

I. Infectious disease testing (HBSAg, Hep C Ab, HIV, RPR/TPA, CMV IgG+IgM, HSV 2)

II. Urine drug screen, nicotine screen

III. ABO Rh + antibody screen, blood count, thyroid function

IV. Rubella/varicella IgG

Medical Screening/Clearance for a Gestational Surrogate

´ Legal Contract

1. Protects parentage rights of intended parents for resulting pregnancy.2. Establishes clear milestones for surrogate compensation.

§ An escrow account is established by the intended parents and payments are dispersed automatically once particular milestone has been met.

3. The surrogate should have separate legal representation (from the legal team preparing the contract) review the proposed agreement.

4. Establishes responsibility of each party (surrogate/intended parents) for entire duration of process, as well as if there are complications that arise during the pregnancy to either the surrogate or the child.

PGT: Pros

• Shortens time to pregnancy and livebirth(s)• Reduce multiple pregnancies by encouraging ESET• Reduces miscarriages and terminations associated with

chromosomal abnormalities• Detection and elimination of genetic disorders• May reduce medical expenses associated with genetic

disease• Sex selection for family balancing• Have more confidence that excess embryos that are

cryopreserved have potential

PGT: Cons

• Requires IVF with FET (and associated risks)• Additional cost for testing• Potential for embryo damage as a result of

biopsy and freezing/warming (very small risk)• Extra work for the lab and clinic• Risk of false negative• Cannot test for all genetic diseases• Playing God

Embryo Shipping

´ Written consent must be given to shipping clinic and shipping company in order to ship goods (eggs, sperm, embryos).

´ FDA/SART data needs to be received by receiving clinic in order for receiving clinic to authorize ability to accept biologic material (eggs/sperm/embryos). This information includes:´ FDA Eligibility status of tissue to be sent

´ Information regarding IVF stimulation and Egg Retrieval

´ Information regarding Cryopreservation Devices and Media used

´ Chain of Compliance must be upheld by Clinics and Shipping Companies´ Examples of International Shipping Companies: Cryoport, IVF Couriers, Kynisi, Cryozoom

Single vs Double Embryo Transfer´ Trend in US is to transfer 1 high quality embryo.

´ 2017 SART reported 72.5% elective single embryo transfer (ESET) in <35 yoa´ With ovum donors, approximately 50% of transfers Nation wide were ESET

´ After 2 single embryo transfers, the cumulative pregnancy rate will be equivalent to a double embryo transfer without the risk of multiple gestation.

´ Double embryo transfer (DET) with high quality PGT proven embryos only increases pregnancy rate on average of 5-15% compared to single embryo transfer but results on average with 30-40% twin rate and 1% triplet gestation

´ 36% of twins were born prematurely in 2017 SART data analysis

´ Multiple gestation pregnancy has more complications for carrier and for babies.´ Increased risk of pre-term labor and pre-term delivery´ Increased risk of Pregnancy induced hypertension and Preeclampsia ´ Increased risk of Gestational Diabetes

http://www.inviafertility.com/blog

Embryo Transfer

Why use egg donors and/or gestational carriers in the United States?

´High success rates´Extensive screening for egg donors ´Extensive screening for gestational carrier´Legal protection for intended parents and parentage rights

Transparent process: All information provided and regular contact with clinic as proceed through medical treatment.

Why get treatment through the Idaho Center for Reproductive Medicine?

• High success rates• Extensive experience with both egg donation and

gestational carriers. 1/3 of our cycles are third party cycles. We have an in house egg donor program

• Substantially lower costs for egg donation and surrogacy than majority of the U.S., while still providing legal/medical safeguards

• Unparalleled customer service

Idaho Center for Reproductive MedicineCristin.Slater@integramed.com

Only in Idaho……

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