Rare occurrence of ovarian hyperstimulation syndrome in oocyte donors

Oocyte donors' physical outcomes and psychosocial experiences: a mixed-methods study

OBJECTIVE

To expand knowledge on physical outcomes and psychosocial experiences of oocyte donors after donation across 3 age cohorts.

DESIGN

Cross-sectional mixed-methods survey.

PATIENTS

A total of 363 participants (ages: 22-71 years, M = 38.8) recruited from Donor Sibling Registry and Facebook groups donated an average of 3.3 times, with 77.1% using nonidentified donation. Most were White (92.8%) and over half (59%) were married at the time of survey. Average length of time from initial donation to study participation was 13.75 years.

EXPOSURE

Previous oocyte donation.

MAIN OUTCOME MEASURES

Self-reported physical outcomes and psychological experiences after donation.

RESULTS

Most donors (89.5%) completing the online survey (N = 363) reported a positive overall experience. Self-reported physical outcomes, including changes to menstrual cycles, ovulation, or fertility, were reported by 21% of participants after donation. Many (41.4%) reported procedural pain, and 10.5% reported ovarian hyperstimulation syndrome. Anxiety (25.8%) and depression (23.2%) were the most common self-reported diagnoses. Validated measures (Patient Reported Outcomes Measurement Information System Bank V1.0 Depression, Patient Reported Outcomes Measurement Information System Bank V1.0 Anxiety) were used to assess mild or greater anxiety and depression (25.1% and 17.6%, respectively; t-score ≥55). Participants screened clinically significant rates of alcohol/drug misuse (11.5%; ≥2 Cut down, Annoyed, Guilty, Eye opener-Adapted to Include Drugs), with 50% of those reporting depressive symptoms. Anonymity was the most common qualitative response for reported emotional distress (17%) and regret (20%). Most participants (94.3%) reported no contact by clinics for medical updates after donation, despite 25% reporting they had changes in their health to communicate. Participants' open-ended responses detailed the 3 most important concerns: improved communication with clinics; desire for less anonymity; and more information on long-term donor health outcomes.

CONCLUSION

Most participants felt their oocyte donation experience was positive despite reported pain, menstrual cycle changes, and emotional distress. Depression and anxiety were the most common self-reported diagnoses. Depression rated higher than the national prevalence. Elevated Cut down, Annoyed, Guilty, Eye opener-Adapted to Include Drugs was associated with depression, indicating the importance of screening oocyte donors for mental health and drug/alcohol misuse. Concerns included lack of communication after procedure and lack of information provided on long-term health outcomes. Clinicians can incorporate these findings when counseling this population.

Egg donor self-reports of ovarian hyperstimulation syndrome: severity by trigger type, oocytes retrieved, and prior history

PURPOSE

To evaluate self-reported survey data provided by US oocyte donors on their experiences with ovarian hyperstimulation syndrome and possible correlations between OHSS severity and number of oocytes retrieved, trigger type, and prior OHSS history.

METHODS

An 85-question retrospective survey was administered online. Survey questions included demographic information, reasons for donating, immediate per-cycle experiences and outcomes, perceptions of informed consent, and perceived impact of donation on long-term health. Quantitative Data for this study was collected between February 2019 and September 2020 via Qualtrics^XM (January 2019), an online survey platform. Follow-up interviews were also conducted. Participants were recruited via fertility clinics, egg donation agencies, and online forum. The research was approved by the University of California, San Francisco Institutional Review Board (#14-14765).

RESULTS

Of 420 initiated US oocyte donor online surveys, 289 (68%) respondents provided detailed information on per cycle experiences with ovarian hyperstimulation syndrome, number of oocytes retrieved, and trigger type over a total of 801 cycles. On cycles where donors reported receiving GnRH agonist triggers (n = 337), they reported milder OHSS compared to cycles with hCG or dual triggers. Among donors undergoing multiple retrieval cycles, the severity of OHSS in second cycles was strongly associated with OHSS severity in first cycles.

CONCLUSION

Self-reported OHSS in oocyte donors is lower in GnRH antagonist stimulation protocols combined with GnRHa trigger and in cycles where donors reported fewer than 30 oocytes retrieved. Donors who reported severe OHSS on a prior cycle were significantly more likely to experience severe OHSS on a subsequent cycle.

Overview of hospitalizations in women undergoing oocyte retrieval for ART in the French national health data system

STUDY QUESTION

What is the incidence rate of complications in women undergoing ART procedures compared to the period prior to their first oocyte retrieval?

SUMMARY ANSWER

The study shows a significant increase in the post-ART incidence rate of some complications but a low overall rate of occurrence relative to the total number of oocyte retrievals.

WHAT IS KNOWN ALREADY

ART, widely used in Europe, accounts for 3.3% of births in France. The various studies of ART complications are fairly reassuring, showing relatively low overall complication rates but only few studies have used exhaustive national registers.

STUDY DESIGN, SIZE, DURATION

The cohort for this study was identified from the comprehensive French national hospital-discharge database and includes women under 50 years with a first oocyte retrieval (T0) in 2012-2017, classified in three population subgroups according to the indication for oocyte retrieval: infertility (IF), oocyte donation (OD), and fertility preservation (FP). This study includes 156 916 women whose first oocyte retrieval occurred in 2012-2017 and 542 775 hospitalizations in 2010-2019 (excluding first retrieval).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Hospitalizations for complications or others events (oocyte retrieval, delivery, pregnancy loss, and death in the hospital) during the 2 years before (control period) and after their first oocyte retrieval (post-oocyte retrieval period) were compared and expressed per 10 000 person-months (pm).

MAIN RESULTS AND THE ROLE OF CHANCE

In the IF subgroup, incidence rates were significantly higher after (vs before) retrieval for hospitalized ovarian hyperstimulation syndrome (OHSS) (162 vs 6/10 000 pm), adnexal torsion (14 vs 3), venous thrombosis (8 vs 1), arterial thrombosis (3 vs 1), trauma (2 vs 1), and significantly lower for infections (61 vs 87). The higher incidences of OHSS, adnexal torsion and venous thrombosis could only partially be explained by the occurrence of pregnancy.In the FP subgroup, incidence increased significantly after (vs before) retrieval for hospitalized OHSS (55 vs 0), venous thrombosis (59 vs 4), and infections (176 vs 56). For the OD subgroup, hospitalized OHSS (116 vs 0) and bleeding (24 vs 0) were significantly higher after (vs before) retrieval.

LIMITATIONS, REASONS FOR CAUTION

The French national health data system, despite all its advantages, present some limitations such as the risk of coding errors. The unavailability of some personal information and the absence of consideration of risk factors prevented us from adjusting the risk. Finally, only complications resulting in hospitalization were analyzed which probably leads to their underestimation.

WIDER IMPLICATIONS OF THE FINDINGS

The use of medico-administrative bases will be a valuable tool in public health and will furnish a better overview of the complications. Further studies are needed to complete this analysis. Adding information on drugs would help to better define T0 and less severe complications.

STUDY FUNDING/COMPETING INTEREST(S)

N/A.

TRIAL REGISTRATION NUMBER

N/A.

Alignment between expectations and experiences of egg donors: what does it mean to be informed?

This study evaluated the retrospective perceptions of egg donors regarding information communicated about immediate and long-term risks during the process of becoming an egg donor, and the alignment of that perception with their experiences and expectations of egg donation. Data were collected using an anonymous online survey. Egg donors' demographics, perceptions of being informed about immediate complications and long-term risks, and alignment between their expectations and experiences were analysed. In total, 375 current and former egg donors participated in an online survey about their decisions and experiences. Participants ranged in age from 18 to 57 years, with a median age of 24 years at first donation for compensated donors. The majority of the participants (81%) provided eggs in the USA, and 86.1% reported being compensated beyond direct reimbursement. Overall, 66% of egg donors surveyed reported feeling that their experiences matched their expectations based upon what they had been told during the informed consent process. While most participants (64.8%) felt well informed about potential short-term risks, 55.2% did not feel well informed about potential long-term risks. The findings indicate that while the majority of egg donors felt informed about immediate complications, there are gaps in knowledge about potential long-term risks. Results from this research provide insight into how egg donors understand risks and benefits, and can be used to improve counselling and informed consent forms and processes. The findings also indicate that longitudinal research on the health and well-being of egg donors is needed in order to improve informed consent.

Fatal ovarian hyperstimulation syndrome in an anonymous egg donor

Ovarian hyperstimulation syndrome is a rare, but potentially life-threatening iatrogenic disorder arising from ovulation induction or ovarian hyperstimulation for assisted reproduction techniques. We report a case of a 26-year-old multiparous woman, an anonymous egg donor, who died a few hours after undergoing a procedure to donate eggs at an in vitro fertilization clinic. Her husband alleged that medical negligence had led to her death. The autopsy confirmed death due to ovarian hyperstimulation syndrome. We know of no previous descriptions of fatal ovarian hyperstimulation syndrome in an anonymous egg donor in medico-legal literature.

Third party reproduction and the aging couple

The average age of childbearing has been increasing in industrialized nations, including the United States. As a result, more women in their late 30s to early 40s are seeking their first pregnancy than ever before. Unfortunately, fertility declines with increasing female age. In addition, success of infertility treatments including those using assisted reproductive technologies (ART) decreases as the age of the female partner advances. Third party reproduction involves using gametes or the uterus of a third person to achieve pregnancy. Oocyte donation is a common form of third party reproduction, associated with significant success rates, which gives aging couples an opportunity to bear children. For safety and success, all the participants must be extensively screened medically and psychologically. In addition, a detailed understanding of the process by all parties involved should be achieved. While third party reproduction through oocyte donation is a long and labor intensive process with a significant amount of emotional, financial, and physical involvement from all parties, it is quite often a gratifying experience for everyone involved which include, oocyte donors, recipients, social workers, nurses and physicians.

Repetitive oocyte donation

This Committee Opinion concludes that donors be advised on the number of cycles/donations that a given oocyte donor may undergo. Although existing data cannot permit conclusive recommendations, a concern for the issues of safety and well-being of oocyte donors warrants consideration.

Complications related to ovarian stimulation and oocyte retrieval in 4052 oocyte donor cycles

A retrospective study was conducted in a private infertility centre to evaluate the rate of complications in a large oocyte donation programme. A total of 4052 oocyte retrievals were performed between January 2001 and October 2007. Altogether, 1238 cycles (30.6%) were stimulated with the use of gonadotrophin-releasing hormone (GnRH) agonists and in 2814 cycles (69.4%) the GnRH antagonist protocol was used. The GnRH antagonist treated cycles were triggered with human chorionic gonadotrophin (HCG) or a GnRH agonist in 1295 and 1519 cycles, respectively. Complications related to oocyte retrieval occurred in 17 patients (0.42%) (intra-abdominal bleeding: n = 14, severe pain: n = 2, ovarian torsion: n = 1). Fourteen of these were hospitalized (0.35%) and six donors (0.15%) required surgical intervention. Pelvic infections, injury to pelvic structures or anaesthesiological complications were not observed in this series. Moderate/severe ovarian hyperstimulation syndrome (OHSS) occurred in 22 donors; 11 required hospital admission and 11 were managed on an outpatient basis. All cases were related to HCG triggering (0.87%). Serious complications related to oocyte retrieval occurred at a low rate in healthy young donors. The risk of OHSS can be substantially reduced by specific stimulation protocols, which include GnRH agonist triggering. Prospective oocyte donors should be adequately counselled about the risks related to egg donation.

In vitro maturation of oocytes collected from unstimulated ovaries for oocyte donation

OBJECTIVE

To assess the role of immature oocyte collection from unstimulated ovaries as a potential source of oocyte donation.

DESIGN

Prospective cohort study.

SETTING

A tertiary, university-based, in vitro fertilization center.

PATIENT(S)

Twelve oocyte donors with ultrasound-only polycystic ovaries or polycystic ovary syndrome matched with 12 oocyte recipients.

INTERVENTION(S)

Immature oocyte collection without any ovarian stimulation. In vitro maturation of the oocytes. Embryo transfer of the embryos.

MAIN OUTCOME MEASURE(S)

Immature oocyte collection, maturation, fertilization, and cleavage rates. Implantation, pregnancy, and live birth rates.

RESULT(S)

A mean of 12.8 +/- 5.1 Germinal-vesicle oocytes were aspirated per collection. The in vitro maturation rate was 68.3% +/- 18.4% with a mean of 8.7 +/- 3.6 mature oocytes per collection. The mean fertilization rate was 73.3% +/- 19.4%. Two to five embryos (median four) were transferred. Six recipients conceived, giving a 50% clinical pregnancy rate per cycle. The mean implantation rate per embryo was 18.2%. The live birth rate per cycle started was 30%.

CONCLUSION(S)

Collecting immature oocytes from unstimulated ovaries for the purpose of oocyte donation is a simple procedure that totally avoids ovarian stimulation. With appropriate selection of women with ultrasound-only polycystic ovaries or women with the polycystic ovary syndrome, the pregnancy rates of the recipients are comparable with those achieved through conventional IVF oocyte donor cycles.

Oocyte donation for stem cell research

The future success of stem cell research by means of somatic cell nuclear transfer (SCNT) depends on a sufficient supply of human oocytes. However, oocyte donation presents certain risks for the donor, and concerns for women's welfare are rightly vocalized. At the same time, these risks are comparable with the risks faced by other healthy research subjects. Thus, research donation can withstand ethical scrutiny if it fulfils the same conditions as other research involving healthy human subjects. Specifically, this means that the benefits of the research project need to outweigh the harms, that risks must be minimized, that informed consent has to be guaranteed by averting undue inducement and the recruitment of vulnerable women and that donors can and should be reimbursed for their research participation.

Oocyte and embryo donation 2006: reviewing two decades of innovation and controversy

For over 21 years, oocyte and embryo donation have been used to treat infertility caused by a variety of conditions affecting the ovary. Many disorders, including premature ovarian failure, advanced reproductive age, unexplained recurrent implantation failure and inherited conditions, are amenable to gamete donation, with high pregnancy rates and good obstetrical outcomes observed in recipients. Protocols for the medical screening of recipients and donors, as well as infectious disease and genetic testing, have become relatively uniform and well accepted. Established guidelines allow synchronization of the menstrual cycles of both women to ensure that embryos are transferred to a receptive endometrium. The high demand for donor services has led to escalating costs and long waiting lists. American programmes bid against each other to secure the participation of young women often motivated as much by financial reward as altruism. In the United States, where the majority of oocyte donation is practised, more than 100,000 treatment cycles have occurred. However, to date no meaningful longitudinal studies detailing the long term effects of treatment on donors, recipients, children born, or families created have been published. Throughout its history, oocyte and embryo donation has proven to be both efficacious and clinically innovative, yet remains highly controversial.

GnRH agonist versus GnRH antagonist in oocyte donation cycles: a prospective randomized study

BACKGROUND

The specific role of LH in folliculogenesis and oocyte maturation is unclear. GnRH antagonists, when administered in the late follicular phase, induce a sharp decrease in serum LH which may be detrimental for IVF outcome. This study was performed to evaluate whether the replacement of GnRH agonist (triptorelin) by a GnRH antagonist (ganirelix; NV Organon) in oocyte donation cycles has any impact on pregnancy and implantation rates.

METHODS

A total of 148 donor IVF cycles was randomly assigned to use either a GnRH antagonist daily administered from the 8th day of stimulation (group I) or a GnRH agonist long protocol (group II) for the ovarian stimulation of their donors. The primary endpoints were the pregnancy and the implantation rates.

RESULTS

The clinical pregnancy rate per transfer (39.72%, 29/73 versus 41.33%, 31/75) based on transvaginal scan findings at 7 weeks of gestation, the implantation rate (23.9 versus 25.4%) and the first trimester abortion rate (10.34 versus 12.90%) were similar in the two groups.

CONCLUSION

In oocyte donation cycles the replacement of GnRH agonist by a GnRH antagonist appears to have no impact on the pregnancy and implantation rates when its administration starts on day 8 of stimulation.

Oocyte and embryo quality after coasting: the experience from oocyte donation

BACKGROUND

Oocyte donation provides us with an opportunity to study the clinical outcome of oocytes, retrieved from women undergoing coasting, in recipients in whom endometrial receptivity is unaltered by the coasting procedure. Thus, our aim was to describe oocyte donation outcome in donors undergoing coasting, the oocyte and embryo quality obtained from these cycles, and to determine the influence of coasting duration in the cycle outcome.

METHODS

Matched-paired analysis included 15 oocyte donors with high response to ovarian stimulation and submitted to coasting and 15 oocyte donors with normal response to ovarian stimulation and not undergoing coasting. There were 38 oocyte recipients who shared oocytes from the donors under coasting and 37 from donors not undergoing coasting.

RESULTS

Both groups of donors were comparable in terms of days and dose of ovarian stimulation, oocytes retrieved, metaphase II oocytes obtained, and in the appearance of ovarian hyperstimulation syndrome. Both groups of oocyte recipients were comparable in male-associated factor, pregnancy and implantation rates, as well as in embryo quality. Recipients from donors with coasting for >4 days had significantly lower implantation and pregnancy rates.

CONCLUSIONS

the outcome of oocyte donation from donors undergoing coasting is not impaired, as good implantation and pregnancy rates are achieved. Embryo quality, according to our current standards, does not seem to be compromised by coasting itself. However, if coasting in oocyte donors is prolonged for >4 days there is a significant decrease in both implantation and pregnancy rates.

Oocyte donation

Oocyte donation affords women with ovarian failure, advanced reproductive age, heritable conditions or recurrent implantation failure the ability to conceive. Recipients must be medically screened carefully prior to attempting pregnancy. Egg donors should also be healthy and pose no infectious or genetic risk to the recipient or offspring. Donor and recipient menstrual cycles are synchronized so that embryos are transferred to a receptive endometrium. Donors are prescribed injectible gonadotrophins to achieve multifollicular growth. Recipient endometrial priming begins with 2 weeks (or more) of oestradiol, with progesterone added to the regimen 3-4 days prior to the transfer of embryos. Pregnancy rates following egg donation are among the highest observed following assisted reproduction. Despite advanced reproductive age, perinatal and obstetric outcomes are generally good. Techniques (i.e. germinal vesicle transfer, donor ooplasm, and ovarian cryopreservation and transplantation techniques) may permit the recipient to provide some genetic contribution to offspring and are currently under investigation.

Defining the incidence of serious complications experienced by oocyte donors: a review of 1000 cases

A review of 1000 aspirations of oocyte donors was performed. Only witnessed events necessitating hospitalization or emergent intervention were considered significant. Seven (0.7% incidence) cases were noted, including severe ovarian hyperstimulation syndrome (n = 3), adverse reaction to intravenous anesthesia (n = 2), intra-abdominal bleeding after aspiration (n = 1), and bladder atony with hematuria after aspiration (n = 1).