The Egg Donation Medical Process: For Egg Donors
Upfront, you should know: which drugs you will be taking during stimulation, what trigger shot the doctor plans on using, and how many eggs they aim to retrieve.
Becoming an egg donor can feel overwhelming and scary—especially the first time! Once you’ve been selected, the process can move pretty fast. Here is what you can expect from the medical process of providing eggs.
Every month, in a natural menstrual cycle, women produce multiple egg follicles (sacs in the ovaries that hold the developing eggs), but only one follicle will become a mature egg and be released from the ovary during ovulation. The remainder of the other developing follicles do not receive enough hormones from the body to develop into mature eggs, so they pass from the body during menstruation. Some women naturally have more developing follicles than others—what’s known as your resting antral follicle count—and the number of eggs your body produces may change from month to month, and reduces over time.
In an egg donation cycle, a physician prescribes medications, or fertility drugs, to stimulate the ovaries to get more follicles to develop into mature eggs than the usual one per month. There are many different medication protocols that can be used to create a higher number of mature eggs than usual, a process known as superovulation.
Your egg donor medication protocol may vary depending upon which doctor you go to, your resting antral follicle count and other fertility tests, and how many follicles are developing mature eggs in a single cycle. If you’re a repeat donor and have your protocol information that worked well for you (or didn’t) from a prior cycle you can share that information with the doctor, and they may use the protocol that already worked for you. Others will prefer to stick to a protocol they’re comfortable with.
It is important that you understand which drugs you will be taking upfront, what trigger shot the doctor plans on using, and how many eggs they aim to retrieve.
The first stop in the medical process is any pre-screening that is initially done.
When you sign up to become an egg donor, after being selected by recipients, you will be required to undergo a series of medical tests. Some clinics or egg banks may conduct these tests before you are chosen by intended parents (IPs), but most conduct the medical screening after you have been matched with recipients. Not all clinics do genetic testing or counseling, and there is some variation from clinic to clinic in the tests you may undergo.
Usually, the initial medical screening includes:
- Blood draw on the third day of your menstrual cycle to check your hormone levels, anti-mullerian hormone (AMH) to make sure you have a good ovarian reserve and how your ovaries might respond to hormone injections
- Blood tests to check for sexually transmitted infections, HIV, Hepatitis, Zika, and other afflictions
- Urine drug screening tests
- Transvaginal ultrasound to check your ovaries
After you have completed the above medical screenings, and are selected by IPs to be their egg donor, you will be ready to start your “egg donation cycle.” If you’re providing eggs to an egg bank, you will not need to wait to be matched with recipients.
There are four different phases to the medical process of an egg donation cycle:
- Regulating your cycle with the recipient
- The stimulation phase to make the ovaries produce more eggs
- The trigger shot to release the eggs from the follicles so they can be retrieved
- Retrieval surgery to remove the mature eggs and the fluid from the follicles
1.Regulating Your Cycle
If you are doing a fresh egg donation cycle when you first get “matched” with a recipient your doctor or nurse coordinator will want to coordinate your cycle with the cycle of the person receiving your eggs. The clinic will provide you with a calendar, so you can track your monthly cycle and keep track of the different prescriptions and dosages throughout. In most cases, you will start taking the birth control pill on the first day of your menstrual cycle and continue taking the pill for the next three weeks, or so.
The recipient of your eggs could be either an intended mother who plans to carry the pregnancy herself or a gestational surrogate, someone who plans to carry a pregnancy for someone else. In either case—unless all of your eggs are being frozen—your monthly cycle will need to be timed, so that your eggs are ready to be retrieved around the same time the recipient’s uterus is ready for the fertilized eggs (or embryos) to be transferred.
To coordinate donor and recipient cycles, different drug protocols can be used. Some use what’s called a “long Lupron” cycle--also known as a "long GnRH agonist" protocol. Lupron is a drug that was initially used to treat men with prostate cancer and is used “off-label” for fertility treatment—meaning it was not approved specifically for this purpose.
Lupron is used to shut down the ovaries, which some refer to as a medically induced menopause. A long Lupron protocol means you will be taking Lupron injections for many weeks throughout the cycle. Long Lupron cycles require that hCG be used as a trigger shot to release the eggs before retrieval surgery. HCG triggers are associated with a higher risk for ovarian hyperstimulation syndrome (OHSS), to be discussed below. On a long Lupron protocol, donors start on both Lupron and birth control pills simultaneously to suppress and control when ovulation occurs.
Most physicians no longer use this method—especially for egg donors—because it is more costly, it requires more injections over a longer period of time, and because it may increase donors’ risks for complications. If the doctor in charge of your egg donation cycle wants to use this protocol, you might consider talking to your own doctor to find out if this is the best option for you. Young women, and women who produce large numbers of eggs (high responders), are usually not good candidates for this protocol.
2. The Stimulation Phase
After several weeks, once your cycle is regulated with the recipient’s, you will stop taking the birth control pill and start other hormone injections to stimulate your ovaries to create mature eggs. This part of the egg donation cycle lasts about 10-to-14 days, depending upon how your ovaries respond, how many follicles you produce and how quickly the largest follicle develops.
Throughout the stimulation phase, you will need to go to the clinic regularly so they can monitor you and your egg production through blood tests and transvaginal ultrasounds. The clinic will also measure the number and size of your developing follicles, and how your body responds to the drugs, so they know when to have you administer the trigger shot.
Most fertility doctors now prefer to have egg donors on shorter medication protocols, rather than the long Lupron cycle described above. There are two other basic types of shorter protocols: a “short GnRH agonist” and what is called a “GnRH antagonist.”
Short Lupron (Short GnRH Agonist)
On this protocol, you will still be injecting Lupron, but start the injections at a later date, after you have been told to stop taking the birth control pills, and for a shorter period of time. The Lupron is used to keep your ovaries from ovulating and releasing the eggs.
During this phase, along with the Lupron, you will also be injecting follicle-stimulating hormone (FSH). FSH essentially sends more hormones to your ovaries so that more follicles produce mature eggs. Follicle-stimulating hormones are also known as gonadotropins. Different types of drugs in this class include Pergonal, Gonal-F, Follistim, Ganirelix, Fertinax, among others.
Some of the main benefits of this type of stimulation protocol are that it is shorter (about 10-12 days), involves fewer injections, and reduces the risk for ovarian hyperstimulation syndrome.
With a GnRH antagonist protocol, at the end of the cycle, the doctor has the flexibility to choose either an hCG trigger shot or a Lupron trigger. Lupron cannot be used as a trigger if it was used earlier in the cycle (on "GnRH agonist" cycles) because the ovaries won't respond properly to release the eggs for retrieval. Many physicians now prefer the GnRH antagonist protocol--especially for donors who are “high responders,” and produce a lot of eggs.
In the medical literature, though, there is some debate as to whether egg quality is just as good on this protocol as with agonist protocols. Typical drugs in this class include Ganirelix and Cetrotide.
Different people react differently to the various medications and protocols used. Some women immediately respond to the medications and produce a lot of eggs. The target number, according to most physicians, is 15 to 20. Some women produce dramatically higher numbers, however, if your body responds by producing a lot of developing follicles--on any protocol--the doctor should reduce your dosages so that you do not produce too many eggs. Donors who produce high quantities of eggs are at higher risk for a common complication known as ovarian hyperstimulation syndrome (OHSS).
3. The Trigger Shot
After the stimulation phase, once your leading follicle is about 2/3 of an inch in size, you will stop using the other medications and administer the trigger shot. You will probably be told to take the trigger shot about 36-48 hours before your retrieval surgery. The trigger shot basically tells your ovaries it is time to release the mature eggs from the follicle walls so they can be surgically retrieved.
There are three basic types of trigger shots: hCG, Lupron, or a “mixed” trigger that includes both. Again, the type of trigger used is up to the physician’s discretion and may depend upon the type of protocol used earlier in your cycle. That said, it is important to know that if you have a high egg count (e.g., over 20 or so), or if you have had OHSS before, you are much less likely to hyperstimulate with a Lupron trigger, than an hCG or mixed trigger. hCG is associated with a higher risk for OHSS.
4. Retrieval Procedure
The egg retrieval surgery will be scheduled for about 36 hours after you administer the trigger shot. Your clinic will advise you not to eat any solid foods within a certain number of hours before surgery.
The clinic should have an anesthesiologist on hand to administer anesthesia before retrieval surgery. The type of anesthesia you receive will depend upon your clinic, but basically, there are three different types:
- General anesthesia—in which the patient will be unconscious throughout the procedure
- Semi-conscious—where the patient is in a “twilight” state but is aware of what is happening
- Local anesthetic—where the patient is given an injection of a local anesthetic to block pain
During the retrieval itself, the physician passes an ultrasound-guided needle up through the vaginal wall to reach the ovary and the individual follicles contained in the ovary. The needle enters each follicle and sucks the fluid out of the follicle along with the mature egg. The needle will then repeat the process on each follicle on one ovary and then the process will be repeated on the other ovary.
The eggs and their fluid will then be taken to the lab, where they will be fertilized with sperm to create embryos. In about five days, a healthy embryo will be implanted into the recipient, and any remaining healthy embryos will be frozen and banked, in case the recipient wants to have a child in the future. If you’re donating through an egg bank, they will be flash-frozen until someone decides to purchase them.
You will likely be sent home within an hour or two after your retrieval surgery. It is important you have someone who can drive you home, as you may be in pain or still not able to drive due to the anesthesia. Even if you feel fine after your procedure, it is important to go home and rest for at least the remainder of the day.
After egg retrieval surgery, some donors recover quickly. Yet others have a longer recovery time. It is important that you not return to regular activities until your ovaries return to their normal size. If you start to notice rapid weight gain or bloating after your retrieval, you should contact the clinic or your donor coordinator right away. You may be at risk for OHSS. If you are unable to reach them, and if you continue to experience pain or excessive bloating, you may need to go to the emergency room for care. If so, it is important to tell anyone providing you with the care that you just donated eggs and may be experiencing side effects.
For more on recovery and risks see - Egg Donation Risk and Recovery: What We Know and What We Don’t