When gametes and the ability to gestate a pregnancy are compromised through circumstances or disease, other reproductive options can be considered. These include use of donor sperm (discussed in “Male Factor”), donor oocytes, donor embryos, a gestational carrier, or a combination of these approaches. In contrast to donor gametes (sperm or oocytes), the decision to donate embryos is typically made after the embryos have been generated and there is a known surplus. A gestational carrier receives and gestates birth embryos created from the intended mother’s oocytes. Patients who choose to utilize a gestational carrier may have irreparable uterine factor infertility or suffer from medical conditions that contraindicate pregnancy. In true surrogacy, the birth mother is the genetic mother but not the intended mother. Legal and psychosocial counseling are suggested for all parties embarking on any form of third party reproduction.
Donor Oocyte Patients with ovarian failure, poor oocyte quality, poor ovarian response to stimulation, or failed fertilization or implantation after multiple ART cycles may be candidates to receive donated oocytes. A female same-sex couple may choose to have one partner undergo IVF and place the resulting oocytes fertilized with donor sperm into the other partner (383). At present, donor oocytes must be used to create embryos during the retrieval cycle, because oocyte freezing is considered experimental (384). With carefully selected donors, live birth rates per cycle of donor oocyte IVF are 50% to 60% regardless of the recipient’s age (Table 32.10). However, recipients must be aware that advanced recipient age is associated with higher risk for preeclampsia, diabetes, and cesarean section (385–387). Oocyte donors must endure all the interventions and risks of the ART process described herein except for embryo transfer and luteal support. Because of the intensity of therapy and the potential infectious disease and genetic risks for donor, recipient, and the resulting offspring, oocyte donors must be screened for infectious and heritable disorders similar to those performed for sperm donors (see “Male Factor”) and undergo meticulous informed consent and a comprehensive psychosocial evaluation. Oocyte donors may be anonymous or known to the recipient (96). Oocyte recipients undergo endometrial preparation (as described in the “Process of Assisted Reproductive Technologies” section), but GnRH analogues are not required if there is no endogenous ovarian function. Recipients may initiate progesterone one day prior, on the same day, or one day after the donor’s oocyte retrieval, but a randomized trial found lower pregnancy rates when progesterone was initiated prior to the retrieval (377). Other topics, such as methods for donor recruitment and financial compensation for the donor, are much more challenging issues (388).
Complications of Assisted Reproductive Technology
Cycle Cancellation Cycle cancellation in normal responders occurs in up to 6% of cycles because of inadequate stimulation response and in 1.5% of cycles because of excessive response (111). In 0.2% to 7% of retrievals, no ooctyes will be obtained. Two proposed explanations include human error during the administration of hCG and early oocyte atresia despite normal follicular response (346).
Oocyte Retrieval The risks of oocyte retrieval include bleeding requiring transfusion, injury to adjacent structures requiring laparotomy, formation of a pelvic abscess leading to loss of reproductive function despite prophylaxis, and risks related to anesthesia (389).