IVF Treatment in some form is needed for all kinds of fertility treatment, whether it is a donation cycle or own egg cycle.
Donation cycles involve egg donors being stimulated with hormone treatment in preparation for an egg collection. Once eggs are collected from a donor, the eggs are then injected with sperm from the couple. The fertilised embryos are then transferred to the recipient after she has been prepared in synchronisation with the donor. This method of IVF has been used widely for nearly 30 years.
Egg donation treatment was first introduced and used on cattle to increase the production of milk yield. This process to date has advanced further and has seen the transfer of only female embryos to increase the number of producing animals. Eggs are collected from healthy female cows and fertilised with sperm from healthy bulls. The females are selected from the embryos and then transferred, this is a process widely used in Turkey to improve the economy in agriculture.
The first Egg donation transfer was carried out by Dr. Jon Buster in America. This cycle resulted in a pregnancy and live birth on the 3rd of February 1984 in California.
Egg donation was a new way of women who have no eggs or poor quality eggs being able to fall pregnant via IVF treatment. Egg donation is used widely in many European countries and very few Muslim countries such as Iran, Lebanon and Egypt.
Egg Donation is forbidden in some European countries, however it is allowed in Greece, England, Spain and Belgium. North and South America, Africa, Australia and in many Asian countries the method is accepted. In Northern Cyprus Egg donation is allowed in certain circumstances and forbidden in specific cases due to the Turkish law.
How Egg Donation is Carried Out
There are two choices when a recipient is looking to choose an Egg Donor.
Where the donor and recipient are not known and not traceable and are only given limited information during the treatment process, i.e. Blood group, hair and eye colour, height, skin tone, country born etc..
This is where the identity of the donor is known or the donor can at some point be contacted by any child conceived from Egg Donation.
Egg Donation Procedure Outline
The egg donation procedure is when the donor goes through the stimulation process to increase the possibilities of the number of eggs produced. In turn the female recipient is then started on separate medication not to stimulate her eggs but to prepare her body for transfer and possible pregnancy. When women undergo Egg donation the main focus for development is the thickening of the endometrium lining in synchronisation with the donor while she undergoes egg stimulation. The same preparation method is used for women undergoing a frozen embryo cycle. The statistics at our clinic have showed that there is no difference in the percentage of women falling pregnant via a fresh or frozen donation cycle.
When a fresh donation cycle is carried out, the same day of the donor egg collection the sperm is also collected from the recipient’s partner and the Microinjection (ICSI) procedure is where good sperm is collected and directly injected into a healthy egg. The gamete (egg and sperm) is then left to fertilise. Once fertilisation takes place the embryo is left to develop for either 3 or 5 days before a transfer to the recipient is carried out, the embryo can also be frozen at these stages too as the quality of the embryo is better evaluated. If transfer is carried out, then pregnancy is determined at least two weeks after the transfer date.
Who is a candidate for Egg Donation?
Egg Donation is the most effective treatment for women who are of an age where they are unable to produce eggs or have poor egg quality.
The following situations are usually assessed before commencing treatment:
- Women who have a womb but have entered menopause early and are unable to produce eggs are candidates for Egg donation;
- Women with hereditary disorders e.g. Turners Syndrome, where a female can suffer from Premature Ovarian Failure;
- Women who have undergone chemotherapy or radiotherapy for treatment of cancer;
- Women whose ovaries are poorly stimulated or cannot be stimulated once hormone treatment has begun;
- Women with Hemophilia, Duchenne’s muscular dystrophy, Huntington’s chorea, in which the transporter gene maybe passed to the child from the mother also prefer Egg donation to prevent the risk of having children with inherited diseases;
- Continuous unsuccessful IVF cycles;
- Advanced age of women who have poor egg reserve or no eggs to conceive;
- Genetically inherited diseases passed by the mother;
Necessary Preparation and Procedure Outlines for Donors
When applying to become a donor, many elements such as:
Psychological assessments are carried out first, in which Preliminary tests assess the mental wellbeing of the donor candidate. General information, depression and anxiety tests are carried out, after detailed medical analyses are completed. Depressive personality disorder, psychosis and neurotic individuals are disqualified.
Serological Evaluation; Infectious diseases (HBsAg, HCV, HIV, syphilis, chlamydia, CMV) and thalassemia test which is legally mandatory is also done as well as Cystic Fibrosis. All mentioned tests are completed in a trusted laboratory that has all the necessary ISO certificates and all is accompanied with valid ID control.
The donor candidate are put through a Gynaecological Review in which her Egg reserve and antral follicle counts are assessed to see if she is suitable to become a donor.
Under no circumstances are blood tests such as LH, FSH, and AMH relied upon on check whether the candidate is fertile. Trans-vaginal scans are carried out to determine whether the donor candidate is suitable for the stimulation process.
Hematologic Tests; Due to risk of bleeding during the egg collection, the adequacy of the person’s blood cells and clotting potential are identified, this procedure is also completed for men who will have a surgical intervention for sperm collection.
Genetic tests; if the recipient`s partner is a genetic carrier of a specific gene that can affect any off springs health, the donor is then screened for this also to reduce the risk of a child being born with the same gene. The routine tests carried out on donors for Chromosome Analysis are, testing for Thalassemia and Cystic fibrosis. Screening up to 1800 genetic disorder tests can be completed in our clinic or can be negotiated with centres abroad in order to fulfil this request. There are still many new techniques that are being produced in order to thoroughly screen and test genetic disorders but the results are not 100% and any pregnancy is advised that further screening should be carried out.
Once all the additional tests are concluded a certificate is issued to the donor. This certificate includes all the physical details along with medical details and their psychological profile to sure they are successful in their application.
Couples who intend to have Egg donation treatment are offered a choice of the most suitable donors to them, which not only matches their blood group but also their characteristics. Once the selection has been made the donor is then informed to begin preparation. The egg stimulation begins on the 2nd or 3rd day of menstruation. Once the eggs are mature enough the HCG or GnRh analogue injection is administered which then gives a 35 – 36 hours window to collect the eggs under general anaesthesia. Once the eggs are collected they are then prepared and ready for ICSI to be performed on the mature eggs in the laboratory and they are left to fertilise and develop. The embryos that have developed are prepared then for transfer.
The donors and the recipient do not have interaction in any circumstances. All personal information that is kept is private and confidential and is not used or mishandled.
INFORMATION AND GUIDANCE FOR DONORS
Donors are given information about the points below and are obliged to agree to them without any pressure. The donors firstly sign a consent form at the beginning of the procedure, so that they are providing consent to begin treatment and that any child born with via donated eggs is not legally hers and that the woman receiving the eggs is the legal guardian. Families are entitled to get information about the donors as long as the donors name is not exposed or any other information that can reveal the identity of the donor. The information for both parties is confidential and kept between doctor and patient. The only way this may be exposed is if the information is required in legal circumstances. The donor has the right to cancel treatment at any time from the date egg development starts to the point of egg collection. Sometimes things might not go according to plan and the donor has to pull out of her commitment to the cycle. Treatment may need to be cancelled or if there is a reserve donor then treatment is completed with her.
The complications associated with treatment are explained in detail during and after the procedure. Details of all the risks are given in writing and the donor signs a consent form that they are aware of these. All information is provided and only then with the donors full awareness and consent do we proceed with stimulation.
PROCEDURE OUTLINES FOR EGG DONOR RECIPIENTS`
İt is imperative that the receiving families are prepared properly. They are informed about the stages of the procedure thoroughly. Below is necessary information about the procedures. For the mother to be, procedures begin with her having an ultrasound. Necessary blood tests are done. İt is very important that the man definitely has a sperm analysis. Afterwards couples have blood tests to rule out contagious illnesses such as Hbs AG, HIV AND HACV. Results are then filed. The key to success is that receiving couples are examined properly. The necessary procedures are listed below according to importance.
- HSG (Hysterosalpingogram – medicated screening of the uterus)
The medicated screening of the uterus is the most important as well as the easiest method to analyse the state of the fallopian tubes. This viewing method is conducted by fluid containing radiopaque being inserted via the entrance of the uterine cavity through to the fallopian tubes. To which an x-ray allows to see where the dye inserted into the uterine cavity and fallopian has travelled. Growths like myoma and polyps which take up space in the womb are also seen more clearly. Hydrosalpinxs where tubes are swollen due to liquid retention is also seen. These conditions can affect falling pregnant and can also cause an ectopic pregnancy. Hydrosalpinx can be treated by tying the fallopian tubes or by surgically removing them using open or closed surgery. Polyps and myoma`s once seen in the x-ray are deemed a problem and also need to be removed surgically before commencing treatment.
IMPORTANT NOTE – usually when patients hear that they need surgery for Hydrosalpinx (swelling in the tubes) panic is a natural reaction. The fallopian tubes are not only useless; at the same time they obstruct pregnancy from occurring and have to be removed.
- Endometrium (the lining of the womb) is easily observed with USI (ultrasound contrast imaging)
This is the easiest and most effective way to examine the tissue that lines the inside of the uterus, this layer is called the endometrium. The thickness of the endometrium is measured. Finding problems with this lining and treating it is very important for patients undergoing IVF treatment and with thorough examination; patient’s chances of pregnancy can be increased. The endometrium is sensitive to woman`s Oestrogen hormone. The hormone estradiol is secreted to the tissues that surround the egg during development. The progesterone hormone is also secreted from the same place. Towards the end of a period, the amount of this hormone decreases. Due to this a withdrawal bleed can occur. When women become pregnant, this hormone will continue to increase in the blood, the endometrium will not shed and throughout the pregnancy, the placenta will be secreting this hormone and a withdrawal bleeds will not occur.
For an endometrium to accept an embryo and for pregnancy to occur, it needs to produce enough estradiol for 10 days and only afterwards be exposed to the progesterone hormone. For the preparation of the endometrium, the points below are very important:
IN ORDER FOR PREGNANCY TO TAKE PLACE
- The endometrium should be exposed to estradiol hormone for at least 10 days and the receptors found in the endometrium should be saturated. Due to this, the endometrium should thicken by about 8mm-14mm. Studies carried out in the recent years, have shown that at least 7mm and above have been deemed suitable.
- Estradiol needs to continue to be found in the blood for about 24 days so that a withdrawal bleed does not take place. There is no agreed period of which estradiol should continue being used after embryo transfer.
- About 5 days after implantation, the placenta starts to secrete estradiol and progesterone.
- Estradiol and progesterone are given externally for egg donation, embryo donation and frozen embryo transfer cycles. It is hard to conduct the procedure when the patient is following their natural hormone cycle.
- The levels of progesterone and the following of natural cycles is very important. İf the endometrium is exposed to progesterone for more than 7 days and the transfer takes place, the patient will not fall pregnant. We accept that the cut off amount, in other words the limit of saturation of progesterone is 1.85. So, in order for the patient’s endometrium to be prepared, 10 days of estradiol then after looking at how many days old the embryo is for the amount of time it needs to be exposed to progesterone and the effects of this hormone need to continue for up to about 17 days after transfer.
PROBLEMS WITH THE ENDOMETRIUM
This subject needs to be looked at in 3 different sections.
- Factors that cause damage to the endometrium
Theoretically, Tuberculosis and Pre-cancerous pathologies (where tissues are seen to be different before the diagnosis of cancer is confirmed) are problems that are all passed to doctors to confirm diagnosis. When the endometrium sheds every month, it rarely catches microbial infections. Tuberculosis is the only microbial illness that causes damage to the endometrium. This illness can occur when droplet which is caught through the airway and then it sticks to the endometrium. I myself have seen this once in my professional life and the patient fell pregnant and gave birth. This patient of mine was told in one of the largest hospitals in Ankara that she would never become pregnant.
Patients that attend our clinic, have in one way or another seen damage to their endometrium. We see this in about 18% of patients but i feel that this rate is not as high in other clinics as we see this as a challenge. This is because when people come to us, they are in a critical state.
If we were to put the importance in order then;
- Hysteroscopy is the most common surgery that can cause endometrium damage. It has become very common procedure and is sometimes performed unnecessarily. It is not done for diagnosis but performed and treated like a routine check-up. This procedure has dramatically been accepted as easy and harmless by fellow doctors but although it is easily performed, it is time consuming and damage to surrounding tissue can occur. Again, without causing any damage, the septum inside the uterus is being cut out and then burnt. The same procedure is used for heart shaped uteruses also after polyps and myoma`s have been seen via ultrasound and that have been found using HSG, however taking out large myoma in one operation causes endometrium damage. The endometrium has been known not to thicken the same.
- Myoma operations come back to us as a second reason
- Women who have undergone abortions are not at risk of damage to the endometrium as long as the procedure has been carried out properly. It is not considered as an advantage to have an abortion with the vacuum method.
- The inside of the uterus can be damaged due to frequent injections to the uterus, frequent IVF treatments and usage of the coil.
- Polyps should be removed if they are under 0.5mm
- Myoma`s which grow towards the gap of the womb can be a reason why a pregnancy may not continue. Myoma`s which are on the wall of the womb or grow towards the empty part of the belly do not harm a fetus as long as they are not too big in size. There is no agreed number on the limit of size. In my personal experience it is best to proceed with treatment and see, with 15cm being the largest myoma, I have seen. I have witnessed many times women with large myoma`s have given birth with no problems.
- Hyperplasia and pre-cancerous conditions. In these situations, patients need to get their cancer or illnesses that lead to cancer cured first.
- Chronic endometriosis that goes away with thickenings reason is still unexplained.
İ. Endometrium cancer
- Uterine tuberculosis
Tamoxifene and femara like drugs can be used for the treatment of breast cancer and can cause thickening of the endometrium. There is no need to panic as they are harmless.
ANALYSING AND RECOGNISING ENDOMETRIUM DAMAGE
The best method to observe the endometrium is by vaginal ultrasound which is medically known as transvaginal USI.
The endometrium sheds and thins when the menstruation periods starts. On the first 6-7 days of this period, it is thin and then later, the endometrium thickens with the increase of the estradiol hormone which is produced when the egg cells begin development or it can be increased with the aid of medication. When the egg reaches 20 mm or when medication is taken for 10 days, the thickness of the endometrium should ideally be a minimum of 8mm. For women in their menopause, a longer medication process may be needed (about 20 days). If the endometrium does not reach 8mm despite the medication being taken correctly and the occurrence of ovulation, it will be deemed that there is a problem with the endometrium lining. The shape and layer of the endometrium is also assessed to make sure that there is no abmormalities.
DAMAGED AND THIN ENDOMETRIUM. PARTIALLY IRREGULAR ENDOMETRIUM. REGULAR TRIPLE LINED ENDOMETRIUM.