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Bill Klaproth (Host): So, how would you know when it's time to consider using donor eggs? And then how would you go about choosing an egg donor? Those are just a few of the questions when it comes to using donor eggs. So, let's learn more with Dr. Laura Eisman, a Physician and Macy Schoenthaler, Third Party Counselor and Donor Program Liaison at the Reproductive Science Center of San Francisco Bay Area. This is Fertile Edge, a podcast by Reproductive Science Center of the San Francisco Bay Area. I'm Bill Klaproth. Dr. Eisman and Macy, thank you so much for your time. We appreciate it. Dr. Eisman, let me start with you. So, when is it time? When should someone consider using donor eggs?

Laura Eisman, MD, RE (Guest): So, just to start with a little background, we, as women are born with all the eggs we'll ever have, we're born with about one to 2 million eggs. And over the course of our reproductive lifetime, the number of eggs declines, and the quality of the eggs also declines. The quality of the eggs means their ability to become a chromosomally normal embryo. By the time we're in menopause, very few eggs remain and they're essentially all poor quality. Because of egg quantity and quality issues as women age, we recommend using donor eggs in women, age 46 or over. And we also recommend using donor eggs in women who are under 46, but who've had testing that indicates that it would be unlikely they would be successful with IVF with their own eggs. We also consider egg donors when women have had failed IVF cycles using their own eggs.

Host: Right. So, success is what everyone is after on this. So, then what is the testing that helps predict success with IVF, with one's own eggs?

Dr. Eisman: The testing that helps predict response to fertility treatment is called ovarian reserve testing. Ovarian reserve refers to the quantity of eggs remaining. Two of the tests for ovarian reserve are hormone levels. One is anti mullerian hormone or AMH and the other follicle stimulating hormone or FSH. And the third test is one done with ultrasound called the antral follicle count.

It's a count of the small follicles or egg sacks that we see at the beginning of the cycle. These tests are not great at predicting reproductive potential in general, but they are helpful in predicting the likelihood of successful response to ovarian stimulation and IVF. And we use them to help us decide when it would be appropriate to try IVF with one's own eggs, versus when it would be a good idea to use donor eggs.

Host: So, it sounds like it's kind of a window into predictable success. It kind of gives you judgment of yes well, we can do this or no, we can't.

Dr. Eisman: Right. It gives us an idea.

Host: Got it. All right. Well, thank you for that. And Macy, let me bring you in now. You have an interesting title, third party counselor and donor program liaison. Could you tell us more of what you do at RSC?

Macy Schoenthaler, M.Arts (Guest): Absolutely. I am a licensed marriage and family therapist. I've been here for almost a decade and worked in multiple roles. But now I am the first point of contact for all of our patients who are thinking about using an egg donor and exploring that option. So, I really help them to think about the emotion, that search for a donor and anything beyond that with raising their child and beyond.

Host: Yeah, that is really interesting, your role there. So, trying to look at this from a patient's perspective, could you tell us what it's like for patients when deciding to use an egg donor?

Macy: Yes, there is a lot to consider when deciding to use an egg donor, such as costs, timeline, the success and what this means for you, what this means for your family and for your child. There's three main categories that I think of when it comes to decision-making. It would be the readiness to use an egg donor, that search for the candidate and donor screening.

I get a lot of questions about why donors do this and how we screen them. In terms of readiness, it's certainly an emotional rollercoaster and an emotional roller coaster just getting to this point, usually with the treatment leading up to this, and then hearing that you may need an egg donor or considering needing an egg donor can bring up a lot emotionally. You can feel grief and sadness, anger, there can even be sometimes a relief or excitement. And eventually, I do see an incredible amount of joy and gratitude that comes from this, but it is a journey as they say. And there's levels of readiness that folks feel from feeling like absolutely not. This is not an option I would ever consider too. Yes, I feel a lot of relief in knowing that there's success here and I want to do this. It changes over time. Some folks might not be ready and then eventually feel ready later on down the line. That's a big piece of it that I help guide folks through.

The other part is the search. There is certainly a lot to know and a lot of questions come up. Like how do I find a donor? What do I look for in finding a donor? Where do I even start with all of this? And that's also, my role is to help guide folks through that. But we will present to you a lot of different programs and ways to find donors, which I'll talk about a little bit later too, but, essentially you will look at different donor profiles and things like photographs and certain characteristics of donors. And you're really looking for, how could you imagine this person fitting even this child really, fitting within your family? And what does that mean for you? And what kinds of things are you being drawn towards. A majority of folks like to start with ethnicity or heritage, certain characteristics, eye color, hair color, height, or even, just the general sense of where is this connection? Is there's something about her personality? Is there something that you're drawn to on her education? So, we're really looking for a connection here, because this is about a connection with your child and how are you seeing that and how is that coming through?

And there's nothing in particular you actually have to do when looking for a donor, like you don't have to match up blood type. We will help you look at the genetic carrier status, but essentially you can pick whichever donor you feel is the best fit for you in your search. Another big thing to consider is openness to future contact. We're seeing a big move towards donors being more open to contact after a child turns 18. And a lot of families would prefer that. But you do also see donors that are preferring anonymity or not having disclosure as well. So, that can mean a lot to families and what they want when picking a donor and the success of that donor.

Has she donated before? Has it worked? When you're investing so much, it can feel a little bit better to pick a donor that has success. You certainly don't have to, but that can help in that selection. And that's something that I can help with too. And then the third main piece is the screening. How are we screening these donors and why are they doing this?

Why are they donating and helping other people? And so, there are national guidelines set forth by the American Society of Reproductive Medicine, guidelines are recommendations that we all follow, when screening an egg donor to make sure that she is appropriate and herself ready to donate. And there's also individual clinical standards.

The Reproductive Science Center, we have our own layer of standards that we're looking for in candidates as well. So, you have multiple layers there. And then the screening itself is another set of layers, from an application process, usually 40 or 50 pages, multiple interviews, interviews about personal and family health history.

She'll do fertility testing, her own AMH testing and antral follicle count, to make sure her fertility is looking good. We will do infectious disease screening and screening that's required by the FDA to make sure she's eligible for tissue donation. We will do genetic testing to make sure, to see if she was a carrier of anything so that we can look at the egg source and the sperm source to make sure they're not carriers of the same thing.

And she will do a psychological assessment with psychological testing to make sure she's in a stable place. And we're looking for young women who are really wanting genuinely to help someone else, have a good motive that are really altruistic. We understand that there is compensation that they do get paid for their time and their effort in donating, but we are looking for someone that has a good balance of the true desire to want to help someone else and understanding that there will be compensation. So, there are multiple layers in screening a donor to make sure that she herself is appropriate. And we're also thinking about her in the long-term too. We're thinking about our recipients and the longterm family building for them and for their child, but we're also thinking about the donor and her family in the future, thinking 20, 30, 40 years from now and what that might look like for her and her family.

Host: Right. Well, those are really important components to consider and understand. And basically the three things we really need to know about is readiness, search and then donor screening. Really good stuff Macy. So, thank you for that. And then if we boil all of this down, what are some of the top things patients should consider when starting their donor search?

Macy: The first question I pose to our patients is what are your longterm family building plans? Often I'll hear, well, I just one child is one or one more. But by long-term family building plans, I mean, how many kids idealy do you imagine wanting out of this? And that's to help guide them in thinking about how many eggs do we want to get? How many embryos we want to make? Because oftentimes food prefer that their children can share their full genetics if possible. That helps me to know, okay, we're looking to create one child here or two or more. And that helps me to know where to guide them in their search.

Another piece is insurance coverage. Do you have any coverage for this treatment? Cause that can certainly help alleviate some of the costs that you will see. Not everyone does, but some insurances do have coverage and that can certainly help to know what to guide you and where you're picking this donor from which program are you going to do PGT?

Are you going to biopsy embryos and do that chromosome testing? Because that will impact maybe how many eggs and essentially how many embryos you're hoping to get. If you are going to do that PGT and the timeline, how long are you looking for in terms of waiting? Oftentimes folks will say, well, yesterday, you know, they were already so ready, that the sooner is better for them, but, timeline is a big one when you're deciding between fresh or frozen eggs, which is the next big question, fresh or frozen.

A majority of our patients lean towards frozen eggs because it is incredibly convenient and affordable. But I do also encourage them to look at fresh egg donors, too. There's there's benefits and challenges either way. So, I encourage our patients to look for the donor they feel connected with first and foremost, and to look at fresh and frozen, and then we can continue to talk about this, but I do present to them some of the differences between fresh and frozen when they're starting that service.

So, the fresh versus frozen egg pregnancy rate is basically the same, 70 to 75% pregnancy rate with that fresh embryo transfer. The live birth rate is a little bit different with frozen eggs. It's 56 to 60%, with fresh eggs, it's closer to 68%. And so there are differences there. There's an incredible amount of convenience with the frozen and it's so affordable that so many folks go that route versus fresh.

So, with frozen, you could be looking at starting about 20,000 for six to eight eggs and with fresh, you're looking at starting at 35,000, but you could get 12 to 20 eggs. So, that's what you're looking at in terms of differences with costs. With frozen, the way it works is, and we have multiple external egg banks that we work with that, you can go to their databases and view to select those donors.

But the way they work is you get six to eight eggs in what they call a lot or a cohort, which is a batch. And it's designed to get you one blastocyst embryo. If you don't get that one blastocyst embryo, then you do get another batch of eggs at no additional cost. So, it's really designed to get you the way I see it, it's one child. If you're wanting multiple children or you want to do PGT, you might want to think about getting extra eggs and you can purchase more eggs rather than six to eight. You can get 12 to 16 so you can get more eggs. It is then going to take the cost up closer to if you would've gone fresh. So, if you're thinking about multiple children, if you're thinking about PGT, you can also look at fresh because what if there's a fresh donor that you really like and feel connected to that you passed up?

Just because you were thinking about cost, for example. And when you really put the numbers together, it's very similar. Oh, and timeline is a big one too. With frozen, once you pick that donor and you purchase those eggs, it's designed to be able to go thawed embryo transfer within the next one to two cycles.

So, it could be within about the next one to two months, maybe upwards of four to eight weeks with fresh eggs it's longer. You're coordinating more. We still have to get those eggs. So, while the cost is more, you do get more eggs, essentially more embryos to work with potentially, meaning more embryos, which is good for PGT, good for multiple children, but it is more expensive.

And it's going to be a longer timeline, but not much longer, necessarily. It depends on everyone's availability and how we can make that live cycle work. But that could be from the time of picking that donor, it could be anywhere from two to four months until we have those eggs and those embryos. So maybe just anywhere between a month or two, maybe three more than you would have seen with the frozen eggs.

Host: That is good stuff Macy a lot of information there. A lot of top considerations you said, number one, know what your long-term plans are? How many kids do you want to have? Number two, you need to consider insurance coverage. Number three, you need to consider the timeline and then fresh or frozen eggs and Macy you are there to help work through all of these considerations? Is that correct?

Macy: Yes. All of these pieces come together and involve your emotions in multiple ways. And I help our patients to navigate through all of that. And we start really by presenting our patients, there's hundreds of ways to find an egg donor. We start by giving our patients the choices that are the most successful, the most popular, affordable and convenient. And then if they're not finding a candidate there, then we can explore dozens if not hundreds of other ways. It's just that a majority of our patients will find a appropriate donor for them within the initial resources that we provide them, which is about four or five different programs.

If they're not finding the right candidate there, then we'll help them to search beyond that. There's so much to know. We just want to help them get started and not feel too overwhelmed.

Host: Well, we are happy you are there to help us not feel overwhelmed. So glad to know there's such a great team at RSC, including Dr. Eisman and yourself, and many others. Dr. Eisman and Macy, thank you so much for your time today. This has really been informative and helpful. Thank you again.

Dr. Eisman: Thank you so much for having us.

Macy: Thank you. It was great to be here.

Host: And that's Dr. Laura Eisman and Macy Schoenthaler and to get connected with Dr. Eisman or Macy, please visit rscbayarea.com that's rscbayarea.com. And if you found this podcast helpful, please share it on your social channels. And check out the full podcast library for topics of interest to you. This is Fertile Edge by Reproductive Science Center of the San Francisco Bay Area. I'm Bill Klaproth. Thanks for listening.