Portfolio at NYU

Posted 03.30.03
Eggs: an investigative report into the murky world of the egg donation industry.

By Caroline Binham

The advertisements are enticing: pastel backgrounds replete with teddy bears and smiling faces of chubby babies offer: "Egg donor program - $5,000 compensation for time and effort" or "Seeking special women - egg donation... the most loving gift you can give." Often, there are several of these advertisements on any one of the back pages of a glossy magazine, a magazine normally read by women in their twenties (the advertisements quoted were taken from Fall 2001 Time Out New York Student Guide). The ads, however, are all offering the same thing: money in exchange for eggs. A great deal of money.

Go onto the Internet and this process is often reversed. Egg donation is listed under the "Shopping" category rather than under a medical subheading. One website, www.surrogacy.com, posts an interactive bulletin board where women offer their own eggs - always at a price. One anonymous 21 year-old woman, "of Swedish extraction, 5 feet 9 inches tall, with long blonde hair and skin that tans easily" is asking $10,000, double the amount of the market price of $5,000. "I realize my fee seems high," she writes, "but if you have been waiting for perfection, then you will appreciate its asking price. This is an investment, it is not the same as buying a new car."

The ethics of in vitro fertilization have been debated since it became a readily available procedure in 1983. The recruitment of egg donors, the young women who donate their own eggs for "recipient" infertile couples, remains a murky, little-discussed, and varied marketplace, where genes are commodities to be bought and sold.

However, buying eggs, or oocytes, as is their medical term, is illegal in New York State. The United States is an anomaly in developed countries in that it permits anonymous paid donors. The payment is, in fact, compensation for the donor's time and trouble rather than payment for her eggs. A report by the ethics committee of the American Society for Reproductive Medicine (ASRM) that appeared in volume 356 of The Lancet in 2000, concluded that payment to U.S donors "should reflect the time, inconvenience, and physical and emotional demands" of the egg donation and "minimize the possibility of undue inducement of donors and the suggestion that payment is for the oocytes themselves." There is little evidence that this premise is followed. The reading material for a national Florida-based egg donation agency, Loving Donation Inc., promises: "The minimum compensation is $3,000 but if you believe you have exceptional physical traits, superior intellect or extraordinary athletic ability, you may qualify for our premier program." This would suggest that women are paid on a basis of good genes rather than purely on their inconvenience.

Advertisements seeking to recruit egg donors appear in magazines or publications read by students. This is not solely because egg donors should ideally be aged between 18 and 30 for biological reasons (oocytes degenerate in quality after that age). It is also the result of market research: students are often in need of money; infertile couples would prefer that the provider of their potential baby' genes were intelligent. Both Columbia University and New York University have egg donation centers, together with a never-ending supply of potential candidates.

This situation may not seem any different to sperm donation; indeed, many advertisements recruiting egg donors are placed next to those recruiting sperm donors. A brief anatomy lesson would suffice to realize that egg donation could in no way be as simplistic as sperm donation. In this commercialized marketplace, this biological fact is reflected in the "compensation": males can only hope to gain around $50 for their efforts, while females can seek one hundred-times more compensation. More importantly, while sperm donation is a fairly quick and easy procedure, the same cannot be said of egg donation. Of the five advertisements studied, not one mentioned any detail of the medical procedure involved, or the associated risks.

The procedure for donating eggs is invasive. Amid the serenity of the I.V.F. Center at the N.Y.U. Medical Center, where couples sit in a beige reception room, flicking through magazines - some are the same that carry egg donation ads - the digitally rendered, bearded face of Dr. Fred Licciardi speaks from a computer video for egg donors, discreetly partitioned from the pan-pipe music of the reception area. Licciardi calmly describes the procedure: "You will be given a course of ovulation induction medications (gonadotropins). Then a week before your period, you will have an injection of Lupron. You will get your period as expected. Then, you must inject yourself every day to stimulate the egg follicles. You will produce around 20 eggs instead of just the normal one or two. You must come to the center every other day for monitoring of the amount and size of your eggs. Another injection of hormones called hCG (human chorionic gonadotropin) starts ovulation. Two days later, the operation will be performed. You will go under anesthetic and the procedure will take about 15 minutes." The "procedure" involves a needle and probe being inserted into the vagina. The needle is guided across the cervix to the ovary to "vacuum" the eggs from each follicle. The needle is then transferred to the other ovary.

Like any invasive medical procedure, egg donation comes with an extensive list of possible associated risks. Dr. Satwant Dhamoon's practice is sandwiched between two other private I.V.F. clinics on Central Park South. In her office, she proudly gestures to certificates from the Royal College of Obstetricians and Gynecologists in London that hang on the wall as sufficient proof of her authority. "As with any hormonal procedure, there can be any number of complications or allergies," says the diminutive Sikh doctor, her scraped-back hair accentuating her unsmiling, stern face, "Ovarian hyperstimulation is a risk that could be fatal. During the actual retrieval, there is risk of bleeding, organ trauma, infection, chronic pelvic inflammation and scar inflammation. There might also be an increased risk of ovarian cancer. These are things that no one talks about." Dhamoon's practice differs from the agencies that place advertisements because she accepts only known donors of the recipient couple. "I'm very conscious of these things when girls come to us," she says. "We know at the back of our mind that it's because of money. All that caring stuff is superficial. I've personally dissuaded young girls. My conscience does not allow it." Dhamoon's smiling receptionists, potted plants and Indian music are left behind for a staircase leading up to the I.V.F. facility. There, the walls are a sterile white. A familiar clinical smell of disinfectant lingers in the air. Behind a curtain, the doorway to the small operating theater reveals an eerie scene of stillness: machines with screens protrude white rubber tubes; a small cart is at the side, available to carry instruments which are for the moment stored away. The operating table, with one stirrup attached, lies in the middle of the room with two huge lights ready to beam down upon it. "I'm not speaking as a doctor now - well, maybe I am - but these young girls have no idea of what women's problems are: what backache is, what chronic pelvic pain is." Dhamoon does not mince her words: "I am upset by these agencies that entrap the girls by the lure of money. It is not right."

Entrapment is a strong word to use. The New York State Health Department's Task Force on Life and Law completed an executive summary in which it states: "Information about the potential risks associated with all phases of egg donation should be given to prospective donors before screening tests have been performed and before the donor has been matched to a recipient. Egg donors should be permitted to withdraw their consent to donation at any time until their eggs have been retrieved." The situation is complicated by the fact that many of the advertisements that recruit egg donors are often placed by agencies, rather than medical facilities, and there is a distinct medical and legal difference between the two: agencies are similar to brokers. They recruit donors, perform preliminary screenings and match them to a suitable recipient couple. They do not, however, perform any medical operation. Their donors are referred to a medical facility for this. Facilities may also carry out their own recruitment programs and also place advertisements. Claire Pospisil, of public affairs at the New York State Health Department in Albany explains: "Agencies are licensed for oocyte solicitation and education. They then must refer the donor to a licensed clinic. The I.V.F. clinic must inform the donor of associated risk." By this tenet, simple broker agencies are not obliged to explain the medical risk to potential donors, yet are able to perform basic screening of the donor. Screening involves a complete medical background, including second-degree relatives, psychological testing and a battery of blood tests. The discrepancy is that the health department's Task Force concluded the donor should be informed of risk prior to any screening process.

The differences in medical and legal obligation to the donor from various egg donor programs mean a donor may receive varying information at different stages of the procedure depending where she goes. At the N.Y.U. infertility center, which is also a licensed clinic, Dr. Licciardi was frank about the risk involved: "At N.Y.U., we have performed over 4,000 egg retrievals in seven years. Only two patients have had to be admitted for ovarian hyperstimulation. There is a one per 1000 chance of getting serious side effects, but you will probably only get minor ones. We have about one case a year of torsion, or twisting of the ovary due to its enlarged size. This causes damage to the ovary through lack of blood. You may have to have a laparoscopy to rectify this." Licciardi even mentioned the potential risk of ovarian cancer, although qualified this: "There is no good data on this subject." Each stage of the procedure, from the injection of hormones to the actual operation, was explained, together with the associated risk of each step.

Representing herself as a potential donor, this reporter telephoned three agencies to discover if associated medical risk was explained. Reproductive Resources Inc.'s answering service, after announcing, "we are an agency, not a medical facility" (how many young women would know the nuances between the two is debatable) asks that all first-time callers listen to an automated message before speaking to an employee. However, there is no way that the caller is forced to listen, or that an employee can make sure that the caller has listened: the onus is on the caller herself. The message details the procedure and listed some, but not all of the risks. The minor side effects of the hormones were listed, such as nausea and cramping. "Two weeks before and two weeks after the operation, you must refrain from having sex or any aerobic activity." The message did not explain why; that exercise may induce torsion, and why this is dangerous. "You will be especially fertile immediately before and after the operation," the message stated. It did not continue that a multiple birth that might occur because of increased fertility might, in and of itself, be dangerous.

A personable woman named Wendy answers the agency's direct line. She spends twenty minutes of thorough questioning, asking every conceivable detail from the height and weight of the potential donor to whether the caller's great aunt suffered from any hereditary disease. "Yes, it's a safe operation," she says. Jackie McKay, a 34-year old mother of two, used Reproductive Resources Inc. as her egg donor agency. Asked whether all the medical procedure was sufficiently explained to her, she said: "The clinic was not too forthcoming. They sort of did the tests and that was that. But the agency would find out the answer to any question I had." This is a reversal of what the official situation is meant to be. Reproductive Resources Inc., if not bound by law to explain the risks to McKay, was perhaps bound by ethics to do so. The onus of gathering knowledge, however, was still burdened onto McKay: "I did some extensive research. The only risk I'd heard of was over-stimulation but that happens only if you're not monitored properly."

Discrepancies appear as to how committed the donor is once she is recruited onto a database. Initially, all the agencies spoken to said: "You are free to withdraw at any time." This was in compliance with the advice given from the New York State Health Department's Task Force. When questioned indirectly on the topic, Lavana, an employee and former donor from Loving Donation Inc., said: "Once you're selected by a recipient family and you sign a contract, you have to do it. You're legally bound." Despite the Task Force's suggestion being that the donor may withdraw at any time prior to her eggs actually being retrieved, it appears discrepancy as to the exact point in the procedure where the donor is legally committed does not lie solely with donation agencies. In the New York State Health Department's own regulations on I.V.F. clinics, it is written in Subpart 52-8.8: "the reproductive tissue donor has the right to withdraw her consent to donation up until such time that a specific recipient has begun an assisted reproduction cycle in reliance on the availability of tissue from that donor."

The application pack to Loving Donation Inc. states: "Egg donation is a safe procedure. Thousands of women donate eggs each year." The application form is five pages long, requiring a complete breakdown of physical characteristics, such as race and complexion, progressing to questions such as: "What are your goals in life?" The five-page form also includes a legal notice with the disclaimer: "Applicant understands and acknowledges that laws concerning assisted reproductive techniques vary from state to state. Applicant understands and accepts responsibility for researching these laws and regulations." As well as her own medical research, the potential egg donor would be well advised to undertake her own legal research rather than depending on Loving Donation Inc.

The point that is raised by the disclaimer remains pertinent. The laws concerning egg donation and payment differ across the country. There is an incentive for the donor to travel to other states, however: more money. The travel expenses are covered by the recipient couple. "You are treated very nicely. You'll get a limo and a chaperone to assist you," coos Christy, an employee at Loving Donation Inc. The line between compensation and coercion is a particularly thin one.

Putting a price on such an invasive procedure is almost impossible. Is $5,000 enough money for putting one's body at potentially fatal risk? Lavana, who would not give her surname, a 20 year-old donor who also works at Loving Donation Inc., donated her eggs last July, and is being matched up with another recipient couple for her second donation. "I received $4,000, which is less then some because I didn't travel. This time, I'm going to ask for more because I know the drugs don't agree with me. Besides, if you're a previous donor, you get more." Jackie McKay, asked whether her $5,000 was sufficient compensation for her time and trouble, said: "I guess it's relative. I have two kids but I know friends with none. So I did it for other reasons than money. If I had it as a job or something, I'd want $100,000!" The eggs that McKay donated have resulted in two sets of twin boys. "I read the letters the recipients wrote me and I cry each time," she said.

Any bottle of aspirin, any packet of diet pills, any advertisement extolling the virtues of a new-fangled wonder drug will enumerate a list of possible medical risks, no matter how rare they might be. It is the drug company's responsibility to inform their customers even in simple advertisements. There is no such responsibility on egg donation programs, either clinics or agencies. Pospisil of the New York Health Department said: "There is no requirement that I am aware of for these agencies to mention anything on their ads." The responsibility of gathering what is often complex and contradictory information lies with the donor herself, responding to an advertisement where the figure of $5,000 looms large and there is not any small print to read. The ethics of I.V.F in general have long been debated. It would seem that the process of egg donation, if not beguiling, could be drastically improved by a more candid donor recruitment policy.