Infertility: Female Factor Infertility and Donor Eggs
Guest: Dr. John Schnorr – Obstetrics-Gynecology
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. John Schnorr who is division director of Reproductive Endocrinology here at the Medical University of South Carolina. Dr. Schnorr, we have done a couple of podcasts now about male infertility, female infertility. What about the situation where a woman for whatever reason, and maybe you can talk about some of those reasons, just is not able to provide a viable egg?
Dr. John Schnorr: Right. We know that, actually it is a term that we call decreased ovarian reserve which is a term that says the number of eggs and/or the quality of eggs in the ovary is lower than we would like them to be for a couple. We know that that affects about 20 percent of all cases of infertility. A lot of times that is because maybe a woman got busy with her career and when she looked around, it was time to reproduce and she was now in her early 40s, which could be a time when we start having problems with egg quality and egg number. It can also be that maybe she, unfortunately, had cancer. Fortunately, now, she is a survivor. She got treated with chemotherapy but that was harmful to her eggs and her ovary. Other things can be harmful, like tobacco use and surgery to the ovary. A variety of things can be harmful.
One of our most challenging diagnoses is that of decreased ovarian reserve, a decreased number, and a decreased quality, of eggs in the ovary. That is an early part of assessment in an infertility evaluation. To do that evaluation, you first can look at a woman’s age and have an idea of what her ovarian reserve is. The second thing we do to measure ovarian reserve is an ultrasound. We put an ultrasound probe in the vagina and we can look at the size of the ovaries and actually the number of early antral follicles, those small eggs in the ovary, to assess the egg and ovarian quality and number. The third thing we do is actually measure the hormones of the menstrual cycle. We know that the body uses a very elegant kind of feedback loop in which it kind of knows the quality of eggs and produces a certain amount of a hormone called FSH that is in proportion to the number of eggs that are in the ovary. As the number of eggs in the ovary gets smaller, a woman’s FSH level gets higher. An extreme example would be menopause. If you are in menopause, you have a very high FSH. A young healthy woman with plenty of eggs will have a low FSH.
On the third day of your menstrual cycle, with day number one being your first day of normal menstrual flow, if that FSH level is above nine, we think it is abnormal. If it is above 14, we think pregnancy rates are extremely rare with almost all forms of infertility treatment, including trying on your own. So, if the evaluation shows decreased ovarian reserve, elevated FSH, increased age, low number of follicles, whatever the combination is, the job of the physician is to try to interpret all of those pieces of data and then help the woman estimate her chances of getting pregnant on her own.
It is humbling as a male to know that the embryo is truly 90 percent egg quality and 10 percent sperm quality. The egg is the largest human cell in the body and it is there because it has all the metabolic machinery for an embryo to grow. The sperm is nothing more than a small missile with DNA in the tip of it that is there just to provide the male contribution. So, when we have decreased egg quality, we have decreased pregnancy rates with treatment.
Dr. Linda Austin: So, what do you do then, in that situation?
Dr. John Schnorr: So, you start to look at options. You fall back to counseling the patient as to her options. You say, trying on your own is going to give you, for example, a one to two percent chance of pregnancy per month with infertility treatment. Trying with ovulation induction, giving her medications to make more than one egg and putting the husband’s sperm in the uterus may also be a one to two percent chance of pregnancy per month with treatment. Then, you say, what is the next aggressive form of treatment? Well, that would be in vitro fertilization. We take the woman’s eggs out. We fertilize them with the husband’s sperm. Then, later, we put the embryos back into the uterus. Again, egg quality problems result in embryo quality problems and pregnancy rates typically less than five percent per try. So, generally that is not so rewarding in regards to your chance of having a child.
The next option is actually doing in vitro fertilization, but using an adopted egg, where we as reproductive endocrinologists help to find women who are younger that are willing to help couples with infertility. They would then go through infertility medications in the form of injections to help them make multiple eggs. We take the eggs out of the younger woman. We fertilize them with the husband’s sperm and then put the embryos back into the uterus of the infertile woman. That shows us pregnancy rates of a remarkable 70 to 80 percent chance of pregnancy per try. Again, this is going back to the quality of the eggs and its importance in embryo quality. So, that is, conventionally, called donor egg technologies. I like to think of it as egg adoption.
If you talk to couples about that, often the first thing they say is that they are just dismayed that we would even mention such a thing. They cannot even begin to think about such a thing. There is a grieving process associated with this, the loss of the ability to reproduce with your own genes. But, generally after a couple thinks about it a little bit, they step back and they think, well, do I love my dog or not, do I love my cat or not? And they do, of course! It is not of their genes. There is no relationship between the two, but they love their dog, or their cat. Could they ever love a baby that did not come from her egg? Eventually, they figure out that the ability to get pregnant, to carry the baby, to deliver the baby, sometimes the delivery is not so wonderful at the time but when you look back at it, it is fairly wonderful, and to be able to breastfeed the baby, the baby is on your birth certificate and it is your child, you start to realize, that is what parenting really is. So, there is a significant grieving process associated with it. But after reflection and a little bit of time, and a little bit of thought, donor eggs are acceptable to a fair number of patients. It is a common way that couples of increased age can conceive.
Dr. Linda Austin: I think most people have heard of sperm banks. I doubt that most people, though, know about how one gets donor eggs. Could you, for example, if the genetic issue were so important, ask a relative, a sister, to donate eggs?
Dr. John Schnorr: Sure. The reason you do not hear about egg banks is because we can freeze sperm successfully without harm to the sperm, but we cannot freeze eggs without harm to the eggs. That is a technology we are working on. We do not have “banks” of eggs. We try to do this in a fresh cycle, where we actually have a woman who is donating eggs at the same time the infertile couple is getting ready to accept the eggs. So, they are never frozen in the process.
You can use a family member for this. It is actually the very first decision, typically, that an infertile couple makes. They say, okay, well, if I cannot get pregnant with my own eggs, I want it to be my sister. So, that is generally the first line of thinking. Then, it is our job as reproductive endocrinologists, and psychiatrists, we use psychiatrists and psychologists a lot with this, to say, what if. What if you are at the Thanksgiving table and you have had a baby with your sister’s eggs and your sister is mad at you for feeding too many mashed potatoes to the baby, having too much candy? What if the baby is born abnormal? How would the sister feel about all of that? What if the sister had infertility and you took her last egg? There are a lot of what if scenarios that you have to think through. Most couples, after they think through the what if scenarios decide that maybe using an anonymous donor, who you do not know but you know all of their characteristics, is a better relationship for an adopted egg.
It turns out that the American Society for Reproductive Medicine, which is our guiding body, recommends anonymous embryo and egg donation. So, most are done anonymously. We do use family members and we are happy to do it, as long as we have gone through the appropriate counseling with the donor and the infertile couple. As long as they are all comfortable with it at the end of the day, we will do it. But, that is an area of caution that we tread lightly on and work through before we move through with those treatment cycles.
Dr. Linda Austin: So, who are the women who donate eggs? How do you find them, as a reproductive endocrinologist?
Dr. John Schnorr: Great question. As reproductive endocrinologists, we actually do it through recruiting egg donors. We have offices in Myrtle Beach, Savannah (GA), Wilmington (NC) and Columbia, SC. We advertise in all of the local newspapers with, basically, the ad being, we need women to help women with infertility, and that is what the ad says. Women who are interested, then, apply via regular application process. We read the application and look to see if we think this would be a good candidate for egg donation. Is she healthy? What is her age group? Does she smoke? Does she use drugs? If she appears to be a good candidate, she comes in and sees one of our reproductive endocrinologists to make sure that she is healthy, her heart is normal, her lungs are good. We do an ultrasound to count how many eggs are in the ovary. We would do blood measurements to see how many eggs are in the ovary by measuring her Day 3 levels. We would do drug screens to make sure that she does not use drugs. We also would ask her to see a genetic counselor here at MUSC who would go over her genetic history, make sure that she does not have any history of cystic fibrosis, sickle cell disease, or anything we need to know about, so we do not transmit that to an intended parent who is experiencing infertility.
And, we, then, have them see a psychiatrist, or a psychologist, to make sure that they are well adjusted with the concept of donating their eggs. Are they doing it for the right reason? Are they doing it solely for the money? Are they doing it because they want to help? Is this a woman who has who has any psychiatric illnesses? Does she have any psychiatric disorders in her family we may want to know about? And, they actually take a personality inventory test, which helps us understand how this potential donor functions. Is she likely to be compliant with her medications? Will she follow through with the process? There is nothing worse than a donor almost at the end of the process who decides to go to Hawaii and take a vacation, and skip out on the whole process. So, we want to make sure that that is all together. Once they are done with all of that screening, they are then available to that couple with infertility. To look at the information that we have, it is truly anonymous. The infertile couple will never know the name of or see the egg donor. Likewise, the egg donor will never see or know the name of the infertile couple. So, it is really kept separate. If the infertile couple likes the hair color, eye color, the basic phenotypic appearance of this donor, then we would move forward in a treatment cycle.
Dr. Linda Austin: You know, I think it is so important for people to remember that all human beings share, what, 99 point whatever percent of DNA anyway. We place so much emphasis on being related, so called, by blood when, in fact, we are all kind of cousins to each other anyway.
Dr. John Schnorr: No doubt about it. Just look at people who have their own children. Very frequently, they are very different from each other.
Dr. Linda Austin: I am here to attest to that.
Dr. John Schnorr: So am I.
Dr. Linda Austin: I have one child who is 5’ 2” and one who is 6’ 4” and it goes on from there.
Dr. John Schnorr: Totally different, yeah.
Dr. Linda Austin: Well, thank you so much for talking with us today.
Dr. John Schnorr: Thank you.
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