Donor Motivations, Associated Risks and Ethical Considerations of Oocyte Donation Amy L. BouteLLe

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In 1983, researchers at Harbor-UCLA Medical Center and Monash University in Australia nearly simultaneously reported the first human pregnancies and births from oocyte and embryo donation. This remarkable advance in assisted reproductive technology (ART) revitalized the possibility of pregnancy in a subset of women for whom carrying a child was previously considered impossible. Despite criticism and controversy, over the last 30 years, this technique has evolved and grown in its application and popularity and has achieved widespread acceptance for its use as a treatment for infertility. Abstract: Three decades after the first reported successful cases, oocyte donation continues to grow in popularity and regard as an established method to aid women in achieving their reproductive goals. As a result of the increased demand for donated oocytes, many young women in the U.S. volunteer to undergo complex medical procedures to donate their oocytes in return for financial compensation. To best care for these women before, during and after donation, it is important to explore donor characteristics and motivations, discuss the safety of the donation procedure and examine the ethical issues related to this process. DOI: 10.1111/1751-486X.12107 Keywords: assisted reproductive technology | egg donation | infertility | informed consent | oocyte donation

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Background While oocyte donation was initially only used for women younger than 40 years with premature ovarian failure, once success was demonstrated in women of advanced maternal age, interest among women and providers working in reproductive health shifted dramatically. “The introduction of egg donation to address age-related infertility was most influential on the rapid increase in popularity of the method. There was a substantial rise in the number of cycles performed in the United States and in the number of clinics providing egg donation services following the publication of successful births in women in their 40s and 50s” (Sauer & Kavic, 2006, p. 154). Oocyte donation provided a new, promising option for women in their 40s for whom traditional infertility therapy often fails. As women age, in vitro fertilization (IVF) becomes increasingly more successful using a donor egg when compared with traditional IVF using an embryo produced from a woman’s own egg. Population data from the CDC indicate that “the percentage of transfers resulting in live births for cycles using embryos from women’s own eggs declines as women get older. In contrast, since egg donors are typically in their 20s or early 30s, the percentage of transfers that resulted in live births for cycles using embryos from donor eggs remained consistently high at above 50 percent among most women of different ages”(CDC, American Society for Reproductive Medicine, & Society for Assisted Reproductive Technology, 2012, p. 48). As a result of these findings, the demand for oocytes donated from young, healthy women has increased, creating a complex dynamic between donors and recipients. “Historically, donor eggs were obtained by utilizing the ‘excess’ oocytes retrieved from women undergoing IVF” (Sauer & Kavic, 2006, p. 156). However, most women undergoing IVF in the United States choose to keep all of their retrieved oocytes, so as to increase the likelihood of having a sufficient number of their own embryos to cryopreserve for future use (Sauer & Kavic, 2006). Therefore, in the United States, supply from excess IVF oocytes does not meet the demand of interested recipients. Amy L. Boutelle, WHNP-BC, is a recent graduate of the Columbia University School of Nursing in New York, NY. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected]

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As a result, recipients most frequently use anonymous donors solicited by the ART clinic through advertisements that typically associate donors’ remuneration with their critical role in helping an infertile couple conceive (Kenney & McGowan, 2010). Anonymous donors are matched to recipients by physical characteristics and various other preferences of the recipient, and known donors, such as close friends, siblings, parents or same-sex female partners, are used significantly less frequently (Sauer & Kavic, 2006). The recruitment of donors, the process of donor screening, donor compensation and the egg donation process itself are only loosely regulated by the U.S. government, and oversight is primarily conducted through statistical tracking by the CDC and the issuance of professional guidelines by the American Society of Reproductive Medicine (ASRM), which rely primarily on self-regulation of ART providers (Keehn et al., 2012; Kenney & McGowan, 2010). However, no particular overarching body is responsible for enforcing these guidelines, and there are no repercussions for refusing to follow them. Because egg donation is such an ethically, legally and medically nuanced issue, this lack of oversight opens the door for the compromise of best medical practices. For example, the issue of donor compensation generates an enormous amount of ethical debate. In the United States, the ASRM guidelines set a reasonable rate of compensation, which is intended as “reimbursement for the donor’s time and effort related to the egg donation procedures and for the medical risks she undertakes by participating in the procedure” (Kenney &McGowan, 2010, p. 455). The most recent ASRM report on financial compensation of oocyte donors states that payments in excess of $5,000 require particular justification and that payment of more than $10,000 is inappropriate, although reports exist of private individuals advertising compensation as high as $50,000 or more (Ethics Committee of the American Society for Reproductive Medicine, 2007). The guidelines also emphasize that compensation is not technically payment for the egg itself as a commodity. However, each agency sets its own rates, and it’s not uncommon to find that donors with particular traits are compensated at higher rates, despite guidelines urging against this practice. By contrast, the regulation of egg donation in most Western European countries and Canada closely mirrors that of organ donation. In these countries, “eggs can neither be bought or sold; they can only be given freely” (Kenney & McGowan, 2010, p. 455), most frequently by other couples undergoing IVF that donate a portion of the retrieved embryos.

Characteristics and Motivations of Donors In light of the controversy surrounding egg donation compensation and the potential for coercion, researchers have begun to investigate donor characteristics and motivations. According

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With the current reproductive trend toward postponed childbearing (Matthews & Hamilton, 2009), the demand for ART has grown rapidly, accompanied by a dramatic increase in the role of oocyte donation. According to the Centers for Disease Control and Prevention (CDC), donor eggs or embryos were used in approximately 12 percent of all ART cycles performed in 2010, the most current year for which data are available (CDC, American Society for Reproductive Medicine, & Society for Assisted Reproductive Technology, 2012).

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OOCytE DOnAtiOn pROviDED A nEw, pROMising OptiOn fOR wOMEn in thEiR 40s fOR whOM tRADitiOnAl infERtility thERApy OftEn fAils to demographic data from several studies, donor age typically ranges from 20 to 37, with an average age of 27 (Jordan, Belar, & Williams, 2004; Kenney & McGowan 2010; Maxwell, Cholst, & Rosenwaks, 2008). The vast majority of donors self-identify as white, Caucasian or European American. These women are often students (45 percent) when they first donate, and most (80 percent) are employed at the time of donation (Kenney & McGowan, 2010). Many have had children of their own prior to donation (43 percent), and some donate while in the process of trying to conceive children of their own through IVF (Kramer, Schneider, & Schultz, 2009). But the question remains: What drives women to donate their eggs? Kenney and McGowan (2010) surveyed 80 women across the country, who first donated eggs between 1989 and 2002, regarding their motivations, expectations and experiences. The researchers found that nearly all women were primarily motivated by two factors: altruism and financial gain. While 41.2 percent cited a combination of both factors as motivators, 32.2 percent reported that they donated purely with the goal of helping others and 18.8 percent stated that their motives were strictly financial. The authors also suggest the possibility that motivations are fluid over the course of the process—a woman might initiate donation for the money, but become increasingly aware of her service to helping someone conceive a child as time goes on. Even when financial gain is the primary incentive, it

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appears that many women may feel more positive toward this effort to earn money because of the underlying altruistic nature of the act, even if they don’t cite it as their reason for initiating the process at the outset. Interestingly, Jordan et al. (2004) found that the primary reasons motivating donation influenced donor satisfaction with their experience of donating. In their survey of 24 past donors, all respondents reported undergoing the procedure with the expectation of helping another woman, but many also cited their expectation for financial reward. Overall, 79 percent of donors were “satisfied” or “extremely satisfied” with having been an egg donor, with 37.5 percent reporting that their sense of satisfaction had exceeded expectations. In response to their expectation of altruism, all but one respondent said that their opportunity to help another woman was met, with half reporting it had been exceeded. For those women citing financial motivations, the expectation of financial reward was met in 70.8 percent of respondents, and in 12.5 percent, the expectation was exceeded. However, in examining long-term attitudes, Kenney and McGowan (2010) found that while the majority of donors reported long-term postdonation satisfaction, this satisfaction was less common in those women that donated for financial reasons relative to those women who had altruistic motives.

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Despite relatively high satisfaction rates reported by donors, data have emerged to indicate that many donors are illinformed about the health risks and potential adverse effects of donation prior to initiating the process (Gurmankin, 2001; Kenney & McGowan, 2010). In this unique situation in which healthy women are undergoing complex medical procedures from which they do not receive any direct health benefit, the risks need to be well-delineated. Nevertheless, due in part to the relatively recent technology and the early reliance on data from women undergoing IVF with their own embryos, statistics on rates of complication specifically in the donor population have been slow to emerge. However, Maxwell et al. (2008) published a large-scale retrospective study of all attempts at oocyte donation at the New York Presbyterian Hospital-Weill Cornell Medical School from 1991 through 2007, providing information on risks and adverse events exclusive to egg donation. The authors investigated the incidence of both serious and minor complications experienced by women undergoing controlled ovarian hyperstimulation and oocyte retrieval for donation in an effort to accurately document risks of the procedure and to aid in reducing their occurrence. Regarding oocyte donation, the discussion of risks can be generally categorized into two groups: (1) short-term risks that occur during or immediately after donation, and (2) long-term risks that occur in the months or years following donation.

short-term Risks Through retrospective chart review, Maxwell et al. (2008) found serious complications occurred in only 0.7 percent of retrievals over the course of the 973 total cycles reviewed. They defined the following conditions as serious: severe ovarian hyperstimulation syndrome (OHSS), moderate OHSS requiring hospitalization, infection requiring IV antibiotics, intraperitoneal bleeding, ovarian torsion or any other complication necessitating hospitalization. While the incidence of these complications was rare, it’s clear that the egg donation process is not without serious health risks and should be portrayed as such to interested patients.

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Also of note, when compared to infertile women undergoing IVF, donors in this study actually experienced serious complications at a lower rate. Interestingly, however, when Kramer et al. (2009) questioned women regarding serious complications using an online survey on the Donor Sibling Registry, 11.6 percent of respondents reported that they required hospitalization or paracentesis. This difference in rates of adverse events could reflect discrepancies in the oocyte donation protocol followed by different facilities. All of the cycles reported by Maxwell et al. (2008) were per-

formed at a highly regarded, academic institution with strict adherence to the ASRM guidelines, while Kramer et al. (2009) surveyed women from an array of IVF clinics across the United States, where the ASRM guidelines and recommended protocol may be adhered to less rigorously. When looking at minor complications, defined as “mild/moderate OHSS necessitating one or more office visits or any other symptoms resulting in and office visit” Maxwell and colleagues (2008, p. 2166) found their occurrence in 8.5 percent of cycles. Examples of the reasons for office visits included ovarian cysts, hematomas, urinary tract infections and yeast infections. Symptom-related phone calls that did not result in an office visit occurred in 4.2 percent of cycles. Additionally, Maxwell et al. (2008) reported a 9 percent rate of cycle cancellation, typically a result of poor ovarian

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Risks of Oocyte Donation

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response (3.9 percent), but also for high risk of developing OHSS (1.6 percent), and positive drug screens (0.8 percent). For potential donors who go through all of the screening, medication and initial procedures, cancellation of the cycle could be considered a risk with considerable physical and psychological significance.

long-term Risks Despite its strength in delineating immediate risks related to oocyte donation, the research by Maxwell et al. (2008) did not specifically investigate long-term risks, and the authors acknowledge the need for additional research beyond the scope of their own study. Pearson (2006) suggests that it may take decades to fully ascertain the true risks of egg donation and that informed decision-making by donors should emphasize the possibility of unknown risks. Evaluation of long-term risks has often drawn data from the entire pool of women who have undergone ovarian stimulation, either for their own infertility or as a donor. There are many more years of data for IVF in

survey. And while this provides anecdotal information, it cannot provide donors with comprehensive risk/benefit information to make the most informed choices. Using a retrospective questionnaire, Kramer et al. (2009) found that 9.6 percent of women reported new infertility after donation. However, only 2.6 percent of respondents reported that their clinic had followup contact with them to update their medical information. This lack of follow-up represents a missed opportunity to confirm patient-reported medical complications and gather meaningful data on the long-term effects of donation. The inconsistencies in this pool of data are highlighted by the significantly different results yielded by a telephone survey of 205 donors in Belgium that evaluated fecundity before and after donation (Stoop et al., 2012). Investigators found a very low incidence (5.0 percent) for the need of fertility treatment in past oocyte donors, and despite fertility struggles, all women conceived within a year. While these data may provide some reassurance to patients and providers, they are insufficient to make a definitive statement or recommendation regarding fertility after donation. Due to

DEspitE RElAtivEly high sAtisfACtiOn RAtEs REpORtED By DOnORs, DAtA hAvE EMERgED tO inDiCAtE thAt MAny DOnORs ARE ill-infORMED ABOut thE hEAlth Risks AnD pOtEntiAl ADvERsE EffECts Of DOnAtiOn pRiOR tO initiAting thE pROCEss general, compared with only a few decades for oocyte donation specifically, which limits the generalizability of these data, comprised mostly of research on infertile women, to young and healthy egg donors (Pearson, 2006). Long-term effects of oocyte donation are thought to potentially include breast, ovarian and endometrial cancer or decreased fertility (Black, 2010; Sauer & Kavic, 2006). However, the increased risk of these cancers is currently theoretical and remains empirically unproven. Overall, the data suggest that the incidence of breast or ovarian cancer is actually not significantly increased in women who have received ovulation inducing drugs, but uterine cancer was found to be 1.8 times more likely in this population (Pearson, 2006). Again, these data were not specific to egg donors. Some experts even propose that infertility itself may predispose women to disease, rather than fertility drugs. This theory suggests that donors may actually be at lower risk of cancer than the combined data, which includes both IVF recipients and donors, may indicate (Pearson, 2006). The possibility for infertility associated with egg donation is an area of particular interest for potential and former donors as well as clinicians. Unfortunately, most data on long-term risk are available only in the form of patient self-report via follow-up

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the uncertainty of the long-term effects of oocyte donation on the donor’s future fertility, it has been suggested that it is safer and more ethical to require that donors have already completed their own families (Black, 2010). The consistent message across all present research is the great need for additional long-term research to evaluate the effects of oocyte donation on donor’s future fertility. As with data on long-term physical risks of oocyte donation, data on psychological sequelae are also lacking (Practice Committee of the American Society for Reproductive Medicine & Practice Committee of the Society for Assisted Reproductive Technology, 2006). Black (2010) found that many donors feel a sense of letdown after the process ends, and many programs do not provide follow-up care for donors. This finding suggests that patients may lack routine access to appropriate counseling. Similarly, Jordan et al. (2004) found that more than half of donors have lingering worries about the medical risks of donation after the fact. However, 83.3 percent of survey respondents indicated that they had no regrets about having participated. Although reassuring to see that patients do not typically regret their decision to donate entirely, it is clear that the possibility exists for patients to have persistent anxieties about the

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risks they incurred by donating. Given that these worries are common and expected, establishing an avenue to seek care for potential lingering fears seems warranted, and the extension of the support period provided may be beneficial. Once donors are medically cleared for release from care, it would be in the donor’s best interest to assess her psychological well-being prior to discharge and to provide the option for continued contact, support and reassurance afterward.

Despite the numerous potential risks of oocyte donation, in a survey of 80 former egg donors, Kenney and McGowan (2010) found that before donation most women viewed risks as minor or very minor, and 20 percent reported that they didn’t recall being aware of any physical risks associated with the egg donation process. These results raise the question of whether these women truly never understood the risks prior to donating or they simply forgot, in the time since donating, that they did know the risks at the time. However, if in fact they never understood the risks at all, was it because they were not fully informed? A possible contributor to this miscommunication of potential adverse effects may be the distortion of the typical doctor/patient relationship and the inherent conflict of interest that exists within the egg donation process as it currently exists in the United States. As noted by Kalfoglou and Geller (2000), typically the patient is also the consumer, but in the case of oocyte donation, “the donor is not the consumer because someone else is ultimately responsible for the professional’s fee” (p. 226). This creates an ethically complicated scenario in which the provider is indebted to the oocyte recipient, the one who is paying the fees, while the best interest of the donor and recipient may be at odds. Cholst (2013) further contends that the “oocyte donor’s relationship to her physician is more akin to a subject/researcher relationship than to a patient/doctor relationship” (p. 1561) because donors take medical risks without direct medical benefit, financial incentives may interfere with donors’ ability to assess risks objectively, and interest in the donor’s well-being may at times be in direct conflict with provider interest in the success of the recipient. Ultimately, Cholst argues that this subject/researcher dynamic may cause oocyte donors and their providers to fall victim to therapeutic misconception, the “failure of (research) subjects to appreciate the difference between goals of clinical care and goals of research” (p. 1561),

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which may contribute to the failure of providers to fully describe, or donors to adequately process, risks. Much effort has recently been put into improving the oocyte donor informed decision-making process in order to ensure that providers disclose all potential risks and that women truly understand them. However, current research demonstrates that individuals make risk-benefit decisions based on their first impressions, which in the case of oocyte donation, often occur while viewing agency recruitment websites (Keehn et al., 2012). When Keehn et al. (2012) examined 102 online egg donor recruitment websites, researchers found that all websites indicated financial benefits of donation, but most did not describe short-term risks (56 percent), long-term risks (92 percent) or psychological/emotional risks (77 percent). These results highlight the failure of most donor recruitment websites to comply with ASRM guidelines, which advise that donor advertisements acknowledge the existence of risks and burdens where financial incentives are publicized. Despite the diligence of clinicians in discussing risks throughout the informed decision-making process prior to donation, potential

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Ethical Considerations and the informed Consent process

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donors may have already made up their mind based on an incomplete, biased website advertisement. Concerned about the potential for generous financial compensation to reduce donor incentive to research potential negative consequences of egg donation and impair decision-making, Skillern, Cedars, and Huddleston (2013) developed and vali-

Informed Consent Document. It uses a “written teach-back” method and a test of prospective donors’ understanding of the risks, which forces donors to actually demonstrate understanding rather than merely voicing it (see Box 1). However, in response to the publication of EDICT, Cholst (2013) argues for an even more direct line of true/false questioning to prove donor

As wOMEn’s hEAlth CARE pROviDERs, whAt shOulD wE tEll A wOMAn COnsiDERing Egg DOnAtiOn? with OOCytE DOnAtiOn, thE issuEs ARE tOO nuAnCED fOR A siMplE, DEfinitivE AnswER thAt is fully AppliCABlE tO All wOMEn dated the Egg Donor Informed Consent Tool (EDICT) in an attempt to standardize provider disclosure of risks and assessment of patient understanding. Citing ethical concerns regarding the lack of a tool to assess disclosure of risks or oocyte donor capacity to understand these risks, authors constructed EDICT based on informed consent guidelines from U.S. Department of Health and Human Services, the ASRM/SART Joint Practice Committee Bulletin and the New York Model Oocyte Donor

Box 1

Aspects of the teAch-BAck method The teach-back method is a method of confirming patient understanding by asking the patient to explain in her own words the information that was just taught by the clinician. It allows the clinician to assess patient recall and comprehension. If the patient has difficulty explaining back the information, the care provider must repeat, clarify or modify teaching to ensure patient understanding and then ask the patient to teach it back again. Repeat the process as necessary until adequate understanding is demonstrated. Not intended to be a test of the woman, but rather a test of how well the clinician explained the material to the woman.

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comprehension. For example, “the goal of my safety and the goal of the recipient becoming pregnant will never be in conflict” (p. 1562). With the interest of protecting the health and safety of the donor in mind, the most seemingly ethical and obvious answer to this query would be “true.” But in reality, the interest of the donor and the interest of the recipient’s success are often dueling forces that must be delicately balanced by the clinician. While “false” presents a much less appealing answer, it would be the response provided by a donor that truly understands the complexity of the dynamic into which she is entering. Cholst acknowledges that most clinicians would never accept her suggested questioning, which so bluntly highlights the conflicting interests at play. Still, Cholst (2013) does acknowledge the progress made by Skillern et al. (2013) in developing a tool “that can improve consistency, rigor, and depth in the informed consent of oocyte donors” (p. 1562).

Recommendations for providers As women’s health care providers, what should we tell a woman considering egg donation? With oocyte donation, the issues are too nuanced for a simple, definitive answer that is fully applicable to all women. While egg donation is generally considered safe by the medical community, there are very real associated risks, and it’s also possible that the procedure carries as yet unknown long-term consequences. Providers can advise patients to become thoroughly informed about the donation process and weigh all of the known risks and benefits, critical for a truly informed consent. Potential donors should be urged to consider both potential physical and psychological consequences and the potential gains, either financial or emotional. Nurses and other providers should recommend that women who wish to donate do so through a reputable institution that

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REsEARChERs Must COntinuE tO DiligEntly stuDy DOnOR OutCOMEs tO pROviDE pOtEntiAl DOnORs with A COMplEtE AnD ACCuRAtE Risk pROfilE As ADDitiOnAl DAtA EMERgE follows guidelines of the ASRM. Providers can also refer women considering donation to reliable online resources (see Get the Facts) and encourage potential donors to seek individual legal representation and establish their rights before commencement of the cycle (Black, 2010). If you’re a general women’s health practitioners, you can assure women that while this may not be your specialty, you’re there if they should need help before, during or after the oocyte donation procedure.

Conclusion The increasingly widespread availability of oocyte donation to treat infertility has created a promising option for pregnancy in women for whom childbearing was once impossible. With this advancement in ART has come a complex set of unique ethical issues surrounding donor recruitment, compensation and informed consent, complicated by the lack of one particular body responsible for regulating the industry and enforcing ethical guidelines. Despite these concerns, data indicate that most women are satisfied with their decision to donate and are motivated

Box 2

suGGested topIcs f oR futuRe ReseARch Continued investigation of the long-term side effects of oocyte donation, both physical and psychological.

References Black, J. J. (2010). Egg donation: Issues & concerns. MCN, American Journal Maternal/Child Nursing, 35(3), 132–137. doi:10.1097/ NMC.0b013e3181d763b9 Centers for Disease Control and Prevention (CDC), American Society for Reproductive Medicine, & Society for Assisted Reproductive Technology. (2012). 2010 Assisted reproductive technology national summary report. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved from www.cdc.gov/ art/ART2010/PDFs/ART_2010_National_Summary_Report. pdf Cholst, I. N. (2013). Oocyte donation and the therapeutic misconception. Fertility and Sterility, 99(6), 1561–1562. doi:10.1016/j. fertnstert.2013.03.025

Development of oocyte donor informed consent validation tools to aid in ensuring the integrity of each donor consent.

Ethics Committee of the American Society for Reproductive Medicine. (2007). Financial compensation of oocyte donors. Fertility and Sterility, 88(2), 305–309. doi:10.1016/j.fertnstert.2007.01.104

Adherence to ASRM guidelines by donor agencies and its effect on donor outcomes and satisfaction.

Gurmankin, A. D. (2001). Risk information provided to prospective oocyte donors in a preliminary phone call. American Journal of Bioethics, 1(4), 3–13. doi:10.1162/152651601317139207

The influence of advertisement and compensation practices on potential donor decisionmaking. Postdonation counseling and its value in assisting donors with lingering or newly arising worries after the donation process concludes.

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mostly by a combination of altruism and financial incentive. Still, these women are assuming potential health risks by undergoing procedures for which they do not medically benefit; therefore, the obligation lies with ART providers to present an accurate description of the associated risks to ensure donors are fully informed in their decision-making. Tools to ensure the integrity and completeness of the informed consent process, such as EDICT, may become essential to providers and patients to confirm mutual understanding. Although data are limited to only a few decades, clearly both serious and minor risks do exist, and the possibility remains that long-term sequelae may be revealed with prolonged study in the future (see Box 2). Researchers must continue to diligently study donor outcomes to provide potential donors with a complete and accurate risk profile as additional data emerge. NWH

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Jordan, C. B., Belar, C. D., & Williams, R. S. (2004). Anonymous oocyte donation: A follow-up analysis of donors’ experiences. Journal of Psychosomatic Obstetrics & Gynaecology, 25(2), 145– 151. Kalfoglou, A. L., & Geller, G. (2000). Navigating conflict of interest in oocyte donation: An analysis of donors’ experiences. Women’s Health Issues, 10(5), 226–239. Keehn, J., Holwell, E., Abdul-Karim, R., Chin, L. J., Leu, C. S., Sauer, M. V., & Klitzman, R. (2012). Recruiting egg donors online:

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Get the Facts New York State Department of Health

www.health.ny.gov/publications/1127/ ReproductiveFacts.org From the American Society for Reproductive Medicine

www.reproductivefacts.org Society for Assisted Reproductive Technology

www.sart.org

An analysis of in vitro fertilization clinic and agency websites’ adherence to American Society for Reproductive Medicine guidelines. Fertility and Sterility, 98(4), 995–1000. doi:10.1016/j. fertnstert.2012.06.052 Kenney, N. J., & McGowan, M. L. (2010). Looking back: Egg donors’ retrospective evaluations of their motivations, expectations, and experiences during their first donation cycle. Fertility and Sterility, 93(2), 455–466. doi:10.1016/j.fertnstert.2008.09.081 Kramer, W., Schneider, J., & Schultz, N. (2009). US oocyte donors: A retrospective study of medical and psychosocial issues. Human Reproduction, 24(12), 3144–3149. doi:10.1093/humrep/dep309 Matthews, T. J., & Hamilton, B. E. (2009). Delayed childbearing: More women are having their first child later in life. NCHS Data Brief, (21), 1–8. Retrieved from www.cdc.gov/nchs/data/databriefs/db21.htm Maxwell, K. N., Cholst, I. N., & Rosenwaks, Z. (2008). The incidence of both serious and minor complications in young women undergoing oocyte donation. Fertility and Sterility, 90(6), 2165– 2171. doi:10.1016/j.fertnstert.2007.10.065 Pearson, H. (2006). Health effects of egg donation may take decades to emerge. Nature, 442(7103), 607–608. doi:10.1038/442607a Practice Committee of the American Society for Reproductive Medicine, & Practice Committee of the Society for Assisted Reproductive Technology. (2006). 2006 Guidelines for gamete and embryo donation. Fertility and Sterility, 86(5 Suppl. 1), S38–S50. doi:10.1016/j.fertnstert.2006.06.001 Sauer, M. V., & Kavic, S. M. (2006). Oocyte and embryo donation 2006: Reviewing two decades of innovation and controversy. Reproductive Biomedicine Online, 12(2), 153–162. Skillern, A., Cedars, M., & Huddleston, H. (2013). Egg Donor Informed Consent Tool (EDICT): Development and validation of a new informed consent tool for oocyte donors. Fertility and Sterility, 99(6), 1733–1738. doi:10.1016/j.fertnstert.2013.01.096 Stoop, D., Vercammen, L., Polyzos, N. P., de Vos, M., Nekkebroeck, J., & Devroey, P. (2012). Effect of ovarian stimulation and oocyte retrieval on reproductive outcome in oocyte donors. Fertility and Sterility, 97(6), 1328–1330. doi:10.1016/j.fertnstert.2012.03.012

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Donor motivations, associated risks and ethical considerations of oocyte donation.

Three decades after the first reported successful cases, oocyte donation continues to grow in popularity and regard as an established method to aid wo...
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