Why might someone use donor eggs? 

Egg donation has been available since 1984, although it was not widely used until the past decade. This is likely because more individuals are delaying conception, the associated technology has improved, and the egg donation process has become more accepted socially.  

Donor eggs are commonly used by women over 40 years old who are trying to conceive using in vitro fertilization (IVF), as the rates of successful pregnancy outcomes with donor eggs are much higher compared to IVF using their own eggs at that age. According to the National Center for Chronic Disease Prevention and Health Promotion, 65 percent of women over the age of 44 who use IVF use donor eggs.ⁱ

Unlike men, who produce new sperm daily, women are born with their lifetime supply of eggs. For this reason, both egg quantity and quality are age dependent. A large 2014 study published in Fertility and Sterility used a sample of 15 169 comprehensive chromosomal screening results from 2 701 patients in 3 392 cycles. The study found that over 83 percent of embryos that survived to the blastocyst stage created from a 43-year-old woman's eggs were aneuploid, meaning they had an incorrect number of chromosomes.ⁱⁱ By comparison, only 23 percent of embryos from the eggs of a 30-year-old woman were aneuploid.ⁱⁱⁱ

If an intended parent has concerns about her egg quality, donor eggs are a viable option for achieving successful pregnancy outcomes. Common reasons for using donor eggs include:^iv,v

• Diminished ovarian reserve (decreased quality or quantity of eggs)
• Advanced reproductive age, leading to an age-related decline in fertility
• Hypergonadotropic hypogonadism (a condition that prevents the ovaries from functioning properly, e.g., in Turner Syndrome)  
• Poor quality of embryos or eggs in attempted IVF cycles
• Genetic conditions in a woman that may be passed down to offspring
• Same-sex couples or single parents by choice, in which all individuals do not have the ability to produce eggs

According to data collected by the Canadian Fertility and Andrology Society (2019), donor eggs were used in approximately 10.1 percent of assisted reproductive technology (ART) fertility treatment cycles in Canada.^vi In the United States, there are over 20 000 ART cycles per year using fresh and frozen donor eggs.^vii Approximately 90 percent of U.S. fertility clinics offer egg donation for fertility treatment.^viii,ix

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How to find an egg donor?

There are multiple ways to select an egg donor, including databases, agencies, and personal relationships with a known donor.

• Databases: Online databases feature detailed profiles of egg donors. Individuals and couples intending to use donor eggs can peruse these databases and select their donor based on their personal preferences. Egg donor profiles include extensive information such as donor age, race, appearance, education level, and other personal qualities. To be included in a database in the U.S., a donor must go through an extensive application and pre-screening process. Some fertility clinics that provide IVF are associated with a certain database and may require patients to select from that database specifically. Additionally, some IVF clinics have their own database of egg donors available for fresh egg retrieval.  In some countries, databases can provide only extremely limited information due to anonymity laws, whereas other countries permit databases to share more detailed information about potential egg donors, including photos and/or videos.  ‍
• Agencies: Egg donor agencies are businesses that connect intended parents with egg donors or frozen donor eggs, based on client preferences. Agencies often work with donor egg recipients to help guide them through the process and may have access to multiple egg donor databases around the world. Additionally, they may have their own database of egg donors.  Agencies also help the egg donor with items such as travel and expenses and may assist them with the legal process. Selecting an egg donor through an agency tends to be more expensive than selecting an egg donor through a database.  ‍
• Known donor: When the egg donor is a friend, relative, partner, or other person known to the individual or couple seeking donor eggs, the process is called known donor or directed egg donation. The clinic performing the IVF can facilitate the process.

It is not uncommon for frozen donor egg banks, intended parents, and egg donors to all seek legal counsel during the egg donation process. Additionally, it is common for parties involved to undergo one or more counseling sessions as there are complexities regarding both the immediate use of donor eggs and the long-term considerations of which all involved parties should be aware. In the United States and Canada, it is common for egg donors to be compensated. The American Society for Reproductive Medicine (ASRM) has made a statement that such compensation is ethically justified given the time required and discomfort and risks of egg donation to the donor.^x

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What to look for in an egg donor?

When looking for an egg donor, intended parents should consider the results of the pre-screening process, which typically includes genetic screening, medical history, and psycho-educational testing of each potential donor. The identity of the egg donor may or may not be disclosed depending on local regulations and the wishes of the involved parties.  

Genetic screening for egg donors

It is recommended that egg donors undergo genetic screening prior to egg donation in order to reduce the chance that offspring will be born with a genetic disorder. Even if a potential egg donor does not have any signs or symptoms of a genetic disorder, they may be a carrier of a condition. If the sperm provider is also a carrier of the genetic condition, the embryo is at increased risk of developing the disorder. Genetic conditions screened for during the egg donation process may include cystic fibrosis, spinal muscular atrophy, thalassemia, hemoglobinopathy carrier status, and fragile X syndrome carrier status; additional panethnic expanded carrier screening panels may also be performed^xi  

The number of genetic variants (mutations) for which an egg donor is screened varies considerably by fertility clinic, egg bank, agency, and country. Most clinics include more than the minimum number of screens suggested and screen hundreds of genetic variants in their genetic screening panel. Asking about details of the genetic screening panel used for egg donors is a useful question for recipients to consider when choosing a donor.

Medical history

The egg donor’s personal medical history and current medical state are obtained prior to egg donation, including information about the donor’s risk of infectious diseases, genetic conditions, and other disorders. Information about the donor’s family will also be obtained in order to assess genetic conditions that could be inherited by the offspring.^xii

Psychoeducational testing

ASRM recommends that egg donors are evaluated by a qualified mental health professional that is trained in third-party reproduction. During the evaluation, the mental health professional will interview the egg donor and administer a standardized questionnaire to evaluate the donor’s mental and behavioral health. It is important that the donor fully understands the breadth of the donation process and psychological impact of donating eggs. This evaluation will also provide additional details of the donor’s life, including their education status, life stressors, relationships, coping skills, legal history, drug use history, and motivation to donate.^xiii

Egg donor anonymity

Egg donors may be anonymous (closed ID), semi-anonymous/semi-open (limited information about the egg donor is disclosed), open ID or identity release, or known/directed. Some countries require all egg donations to be anonymous, other countries require all donations to be open ID, while others offer both options. In the case of open ID, the identity of the egg donor might only be released when a donor-conceived child turns 18. Known donors, who are sometimes a relative or friend of the recipient (e.g., a sister or cousin), generally have more communication with the intended parents.^xiv With the rise of publicly available genetic/ancestry testing, children conceived from anonymous donors are likely to be able to identify their donor and any biologically related relatives by submitting their DNA to available databases. Thus, donor anonymity is a moving target, and donors opting for this route should be counseled that there is a high likelihood that any children resulting from their donation may be able to find them in the future.

Age of egg donor

Women can typically donate eggs until age 30 and the ASRM recommends that egg donors be at least 21 years old.^xv However, the maximum age is quite variable and can depend on the egg donor program. The age of the egg donor is associated with success rates, as discussed below.^xvi

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What is the difference between fresh and frozen donor eggs?

Donor eggs are available in two formats, fresh or frozen.

Fresh egg donation involves retrieval from the egg donor followed by immediate IVF to create embryos that can either be transferred at that time or frozen for later use. Fresh embryo transfers to the intended parent are usually performed 5 days after the eggs are inseminated. Any additional unused embryos can be cryopreserved (frozen) for later use. Fresh donor eggs were the original method used in donor egg IVF.^xvii

Frozen egg donation involves retrieval from the egg donor followed by cryopreservation. These eggs can be thawed later and fertilized using sperm. Once an embryo develops, it will be PGT-tested and frozen, frozen for later use, or transferred to the intended parent or gestational carrier.^xviii Sometimes the eggs from one donor retrieval are split into separate batches and frozen for use by more than one intended recipient. It is important that recipients understand whether they are receiving all the eggs from one donor cycle (which is more common with fresh eggs) or if they are sharing them.  

In new guidelines released in 2021, the ASRM indicated no significant differences in pregnancy rates with the use of fresh versus frozen eggs.^xix However, results from studies using fresh versus frozen donor eggs are variable, with some studies showing higher pregnancy rates for fresh eggs (see below).

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Who receives the embryo transfer?

Following donor egg retrieval and IVF, the embryo will be transferred into the intended parent or a gestational carrier.

Intended parent

If the intended parent wants to carry the pregnancy, she will need to undergo pre-pregnancy investigations prior to embryo transfer. This includes a detailed review of the intended parent’s medical, surgical, and psychiatric history, medication and substance use, and medical family history. The pre-pregnancy investigation also involves a physical exam, including blood work and ultrasound, to ensure the recipient is a good candidate for carrying a pregnancy. Ultrasound imaging of the uterus using a sonohysterogram is often performed to assess uterine conditions that may interfere with pregnancy. Blood tests assess for infectious diseases, hormone levels, vaccination status, and blood type.^xx

Gestational carrier

A gestational carrier is a woman who has an embryo transferred to her uterus so that she can carry a pregnancy on someone else’s behalf. A gestational carrier may be used if the intended parent(s) are unable or unwilling to carry a pregnancy. There are various reasons for this, including medical conditions where pregnancy is contraindicated (e.g., poorly controlled high blood pressure), uterine conditions (e.g., absence of a uterus or a significant uterine abnormality), or logistical or personal reasons for not desiring a pregnancy.^xxi

What is the maximum possible age of a donor egg recipient?

The maximum age of a donor egg recipient—either the intended parent or gestational carrier—varies by region, and some countries have laws regulating the maximum age while others do not. In the United States, ASRM recommends a maximum age of 55 years.^xxii In Canada, most clinics have a cut-off age of 50 years old for egg donor recipients.^xxiii

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What is the process for IVF using donor eggs?

Once eggs are retrieved from the donor, the next step is fertilization of an egg to form an embryo for transfer into the recipient. Once the eggs are successfully retrieved (or thawed if previously cryopreserved), fertilization is attempted with or without intracytoplasmic sperm injection (ICSI). The sperm often comes from the partner of the female recipient or from one partner in a male same sex couple but may also come from a sperm donor (double donor).

• Conventional IVF (IVF without ICSI): Conventional IVF without ICSI introduces many sperm cells to the donor egg in a laboratory dish and allows for fertilization of the egg to occur naturally.  
• ‍IVF with ICSI: IVF with ICSI aims to achieve fertilization by injecting a pre-selected sperm cell directly into the donor egg. This technique is especially useful in male factor infertility because it overcomes the process of sperm cells having to swim to and penetrate the donor egg on their own.^xxiv ICSI is also recommended when using cryopreserved eggs.^xx

Fresh donor egg process  

For the donor egg retrieval process, the donor takes certain medications as part of a process called controlled ovarian hyperstimulation (COH). Hormone medications called gonadotropins are administered via injection to help multiple follicles develop (follicles are fluid filled sacs containing eggs). Ultrasounds of the ovaries are also completed to track the development of these maturing follicles in the donor.

The egg donor will also take medications to suppress ovulation. These medications are called gonadotropin-releasing hormone agonists and antagonists.  When the donor’s ovarian follicles reach a certain size, a medication is given to trigger ovulation and help with the final maturation of the eggs.^xxvi Egg retrieval occurs approximately 34-36 hours after the ovulatory trigger is administered.^xxvii

Egg retrieval itself is completed through the vaginal wall under ultrasound guidance. With the ultrasound focused on an ovary, a needle is inserted through the wall of the vagina into the ovarian follicles. Gentle suction pulls the egg into the needle for removal. During this process, the egg donor is under sedation or general anesthesia.^xxviii

Once the eggs are retrieved, fertilization of the mature eggs occurs via conventional IVF or IVF with ICSI. The resultant embryos will grow in the lab, and once ready can be transferred fresh, usually five days after fertilization.^xxix In fresh donor egg cycles, the recipient often syncs their cycle using hormonal medications so that their uterine lining will be ready to receive a fresh embryo. This means that while the donor is going through the controlled ovarian stimulation process, the intended recipient takes hormonal medications, like estrogen and progesterone, to prepare their uterine lining for a fresh embryo transfer. Cycle syncing can be logistically difficult, so some people choose to use frozen eggs or freeze the embryos created from fresh donor eggs for later use.^xxx

Frozen donor egg process

Frozen donor eggs are produced through the same process outlined above, with the key difference being that the fresh eggs are frozen (cryopreserved) directly after retrieval instead of immediately fertilized with sperm. Note that this is different from freezing embryos.  

To freeze donor eggs, substances called cryoprotective additives are added to the eggs, which help prevent damage during the vitrification process.^xxxi,xxxii Vitrification involves ultra-rapid freezing to preserve eggs in a glass-like state and helps prevent ice crystals from forming, which can damage eggs.^xxxiii,xxxiv Eggs used to be cryopreserved through slow freezing, but this technique has become rare in recent years because fewer eggs survive the thawing process after slow freezing compared to vitrification.^xxxv

In the case of frozen donor eggs cycles, the donor egg recipient may take medications to prepare her uterine lining for embryo transfer in what is called a medicated transfer or hormone replacement cycle. She may also choose to do a natural or modified natural transfer, where no or minimal medication is used. From a logistical standpoint, frozen donor eggs are easier to use, as the recipient does not need to sync her menstrual cycle with the donor stimulation cycle. Vitrified donor eggs will be thawed and undergo ICSI in the same manner as fresh eggs. Following fertilization, the embryos are grown in the lab and can be transferred fresh or frozen for later use.

Transfer process

Once donor eggs are fertilized successfully and an embryo forms, it is left to develop in the lab for three to five days. Donor egg embryos are most often transferred at the blastocyst stage (which usually develops on day 5). Sometimes they can be transferred after 3 days of development (at the cleavage stage), after 4 days of development (at the morula stage), or after 6-7 days of development if the embryo took longer to reach the blastocyst stage.^xxxvi

The embryo is transferred into the uterus of either the intended parent or a gestational carrier. As mentioned, the person who intends to carry the embryo will often take medications prior to the transfer, including estrogen and progesterone, to prepare the lining of the uterus to receive an embryo.^{xxxvii,xxxviii} The recipient will also undergo blood work and at least one transvaginal ultrasound to check the uterine lining and ensure it has the appropriate thickness and structure prior to receiving the embryo.

On the day of embryo transfer, the recipient of the embryo will have a catheter inserted through the opening of the cervix into the uterus, often under ultrasound guidance, and the embryo is expelled into the uterine cavity via the catheter to allow for implantation.^xxxix

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What are the success rates for using donor eggs?

Success rates from over 20 000 donor egg ART cycles per year in the United States range from 45-55 percent, according to national data reported by the Centers for Disease Control and Prevention (CDC):^xl

• Fresh donor eggs and fresh embryo transfer: live birth rate 57.1 percent
• Frozen donor eggs and fresh embryo transfer: live birth rate 44.2 percent
• Fresh or frozen donor eggs and frozen embryo transfer: live birth rate 47.8 percent  

Two recent studies evaluating live birth rates using fresh versus frozen donor eggs and embryos among patients included in a large United States database similarly reported higher live birth rates when in fresh donor egg and embryo cycles. However, these studies were limited by important information that is not available in the database and thus they were not able to account for important patient-specific variables which could have impacted the live birth rates observed for the study groups.^xli,xlii

In Canada in 2020, the rate of ongoing clinical pregnancy in frozen donor oocyte IVF was 42.9 percent, while the ongoing clinical pregnancy rate in fresh donor oocyte IVF was 46.5 percent.^xliii Deciding between fresh and frozen donor eggs ultimately must balance multiple logistical and financial considerations and both options are commonly used and result in high live birth rates.  

Research suggests that live birth rates are inversely associated with the age of the egg donor. A 2019 study published in Fertility and Sterility found that live birth rate was 44.7 percent in donors younger than 30 years old, 43.4 percent in donors aged 30-34, 33.6 percent in donors aged 35-37, 22.6 percent in donors of age 38-40, and 5.1 percent in donors age ≥ 41 years. For this reason, egg donors under age 35 (or not greater than age 34 according to the ASRM) are usually advocated.^xliv

Use of donor egg IVF is most common among women over the age of 40. IVF success rates per cycle for women over 40 using donor eggs is approximately 50 percent in the U.S., compared to 11.8 percent at 41-42 years old and 3.2 percent at 43 years old when using their own eggs.^xlv

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Conclusion

Many fertility clinics offer egg donation as an option for individuals and couples seeking fertility treatment. Success rates of egg donation vary and depend on several factors related to the specific donation method used, as well as the characteristics of the egg donor and intended parents. Individuals and couples who are considering egg donation are encouraged to discuss their options with their medical providers.

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