EGG DONATION IN GREECE: ALL YOU NEED TO KNOW


Assisted reproduction techniques help thousands of couples with infertility to circumvent their problem and become parents. Nevertheless, when it is not possible for a woman to conceive due to poor egg quality or from having no eggs at all, she may still become pregnant by using eggs from a donor.

The first pregnancy with egg donation was reported in 1983, and ever since, more and more women are choosing this procedure to achieve their dream of having children. The main reason for this trend is that women are increasingly postponing childbearing until later on in life, when their fertility is often reduced; another reason is that over the years, the process has become highly successful due to recent technologies advances and improved freezing techniques.

What is egg donation?

Egg donation is a form of assisted reproduction by which a woman donates her ova to enable another woman to conceive. These oocytes are fertilized by the recipient’s husband sperm, or alternatively by a donor sperm.

The resulting embryos are transferred into the recipient uterus, which has been adequately prepared to receive them. The difference with routine in vitro fertilization (IVF) is that the egg donor is not the recipient; that is, they are two different women.

If pregnancy occurs, the recipient will have a biological but not a genetic relationship to the child, and her partner (if he provided the sperm) will be both biologically and genetically related.

What are the indications for egg donation?

Egg donation may be considered in the following situations:

  • Premature ovarian insufficiency: a condition in which menopause begins earlier than usual, usually before the age of 40 years old. In most cases the cause is unknown, but it may be the result of certain diseases, chemotherapy, radiotherapy or surgical removal of the ovaries. Egg donation is also suitable for women who were born without ovaries.
  • Low ovarian reserve: when there is a decrease in the number of eggs, resulting in reduced chances of pregnancy. Generally, this is due to advanced reproductive age, as the number of oocytes -and therefore fertility- decreases rapidly after the age of 35-40 years old.
  • Genetically transmitted diseases: women affected by, or carriers of a significant genetic disease who would prefer not to pass this disease on to their child.
  • Previous history of failure with IVF: especially when egg quality seems to be the problem.

Who are the egg donors?

1) Anonymous, voluntary donors: According to the Greek law, candidate egg donors are covered by anonymity and are required to sign a specific consent for the donation of their genetic material. In order to accept a woman into an egg donation program she should meet the following requirements:

  • Age between 18 and 35 years old.
  • She should be healthy, non-smoker, with no personal or family history of genetic diseases.

By law, the donor receives financial compensation only for the loss of working days, travel and other expenses incurred during the treatment cycle in which she participates. In any case, egg donation is an altruistic, anonymous and voluntary act.

2) Egg sharing: Women undergoing IVF may agree to donate their surplus oocytes to other women with infertility.

3) Known donor: a person who is known to the recipient, usually a close relative of friend. According to the Greek law, oocyte donation is an anonymous procedure, that is, the donor has no access to the child born, nor the recipient to the donor. Therefore, in Greece the donation of ova to known persons is forbidden by law.

Evaluation of the egg donor


Each candidate donor, after being fully informed about the egg donation program, completes a thorough questionnaire on her family, medical and psychological history. In addition, she is the subject of a series of exams to determine whether her health is in good condition and she can respond properly to the hormonal therapy.

The evaluation involves a comprehensive physical and gynecological examination, as well as the assessment of her psychological and mental status, her genetic material and reproductive system.

In addition, donors undergo the following laboratory testing:

  • Blood type and Rhesus
  • Hepatitis B & C
  • HIV 1 & 2
  • Syphilis
  • Hemoglobin electrophoresis
  • Sickle cell trait testing
  • Cystic fibrosis (CF) mutation
  • Fragile X testing
  • Conventional karyotype. It is also possible to a perform a molecular karyotype, upon request of the recipient couple.

A donor is ineligible if either the questionnaire or the screening tests indicate the presence of risk factors, or clinical evidence of an infectious or genetic disease.

Evaluation of the recipient couple 


Adequate screening and preparation of the recipient couple are essential for the success of an egg donation program.

According to the Greek law, a woman is considered suitable to receive oocytes when her uterus has normal morphology and functionality and has not exceeded the age of 50 years.

The evaluation of the recipient couple is similar to that of couples undergoing routine IVF. First, the physician obtains a thorough medical history from both partners.

The assessment of the woman includes an in-depth physical and gynecological examination, a detailed pelvic ultrasound and laboratory testing. Briefly, the ovarian function, her blood group, and exposure to certain infections are examined. In addition, a Pap smear test and cultures for certain microbes (Neisseria gonorrhoeae, Chlamydia trachomatis, etc) are obtained.

In some cases, the uterine cavity is evaluated with hysterosalpingography (HSG), sonohysterography or hysteroscopy. If the woman is over 45 years old, a more thorough assessment of her cardiac function, pregnancy-induced hypertension and gestational diabetes risk are recommended. The effect of advanced maternal age on pregnancy will be discussed extensively, as well as any medical conditions that may affect pregnancy.

An embryo transfer trial before the actual procedure (“mock” embryo transfer) is strongly recommended. It allows to determine the best way to place the embryos into the uterus, and ensures that there are no unexpected obstacles along the way. Sometimes the cervix is very narrow and hinders the transfer of the embryos into the uterus; this may result in significantly reduced chances of pregnancy. In case of a narrow or distorted cervical canal, a cervical dilation may be recommended.

A treatment trial in a previous cycle with the same medications used for the endometrial preparations is proposed when possible, in order to assess the uterine response to hormone therapy.

The male assessment includes a semen analysis, blood group and genetic testing, among other exams.

According to the Greek law, the recipient couple should be tested for syphilis, hepatitis B and C, HIV-1 and HIV-2 within the six months preceding the treatment cycle.

The procedure

Preparation of the donor for egg retrieval 

The donor follows the procedure of a standard IVF. Initially, she undergoes ovarian stimulation, that is, she receives a combination of hormonal medications in order to achieve the development of a sufficient number of oocytes within the ovaries; egg development is monitored by ultrasound and blood exams at regular intervals. When the oocytes are at the appropriate size, ovulation is triggered by an injection of human chorionic gonadotropin (hCG). Oocyte retrieval, scheduled approximately 34-36 hours after hCG administration, entails the use of a needle which is inserted through the vagina into the ovaries, whereby the eggs are aspirated under ultrasound guidance. The procedure is carried out under a mild sedation.

The ova obtained are evaluated for their maturity and then fertilized with the partner’s sperm, which has been processed in the laboratory. Donor sperm may be also utilized when indicated.

The male partner should provide the semen sample the day of the donor’s egg retrieval. Alternatively, if the presence of the partner is not possible on that day, the semen can be cryopreserved (frozen) at an earlier time.

Preparation of the recipient for embryo transfer

In order for the embryos to implant into the recipient’s uterus, the endometrium (uterine lining) must be prepared and synchronized with the donor cycle.

There are numerous protocols for endometrial preparation. Briefly, women who still have menstrual period may receive an injectable medication for temporary suppression of the ovarian function. When the donor starts ovarian stimulation, the recipient receives a hormone called estradiol to achieve endometrial growth. Estradiol can be administered orally or through a transdermal patch. Ultrasound assessment of endometrial thickness -and occasionally blood tests- are performed during this period. On the day after the donor receives hCG, the recipient begins treatment with progesterone. Progesterone causes endometrial maturational changes that allow the embryo to implant. Progesterone can be administered by intramuscular injection, vaginally or orally. Besides estradiol and progesterone, other medications may be prescribed if required.

The embryos are transferred into the recipient’s uterus, usually within three to five days after fertilization of the eggs in the laboratory. Embryo transfer is done using a thin catheter inserted through the cervix into the uterus. If the recipient couple has extra embryos, they will be cryopreserved (frozen). Thus, it is possible to transfer these embryos at a later time without the need for another egg donation.

Hormonal therapy with estradiol and progesterone continues until the recipient takes a blood pregnancy test (β hCG). If the test is positive, the hormones are continued during the first trimester of pregnancy.

Success rates with egg donation

Since egg donors are young and healthy women, success rates are higher than those obtained with conventional IVF. The age of the recipient does not seem to affect the success of the procedure. According to data from the National Agency of Medically Assisted Reproduction, the pregnancy rate with egg donation in Greece is 54%.

Nevertheless, the greater the number of attempts with donor-egg IVF, the higher the odds of success. Thus, it is estimated that the success rates after the third attempt reach almost 90% in most cases.

Many factors play an important role in the success of the procedure: adequate evaluation and preparation of both donors and recipients, optimal synchronization between them, high laboratory standards and well-trained scientific staff, will all have a positive impact on pregnancy rates in an egg donation program.

Risks of egg donation 

1) For the donor:

Egg donation is a very safe procedure. Nevertheless, it is not entirely risk-free. Medicines taken to stimulate the ovaries, oocyte retrieval and the anesthesia required are all possible sources of complications. Briefly, the side effects of medications are usually mild, as one of the most feared complications in assisted reproduction, ovarian hyperstimulation syndrome is very rare in these cases. The remaining risks are estimated as follows: anesthesia risks: 1 / 10,000; risk of severe bleeding from oocyte retrieval: 1 / 2,500; risk of infection: less than 1/500.

It should be noted that the fertility of women who become egg donors is in no way affected. In fact, the eggs donated would have been otherwise discarded by their bodies.

2) For the recipient:

The possibility a donor transmits an infectious disease to the recipient is virtually non-existent, provided that proper evaluation of the egg donor has been performed, as dictated by the Greek law.

The most common risk for the recipient is the occurrence of a multiple pregnancy (twins) if more than one embryo is transferred. In any case, in egg donation cycles, the transfer of more than two embryos is strictly forbidden by the Greek law. If the couple is opposed to the possibility of a twin pregnancy, then only one embryo may be transferred (single embryo transfer, SET).

Pregnancy complication risk in recipiens with advanced age should be assessed individually for each case.

3) For the child:

To date, thousands of children have been born with this procedure, and the available data is reassuring, and equivalent to that of conventional IVF: the rate of birth defects is the same as the general population.

THE LEGISLATION IN GREECE 

On Egg Donation

  • Egg donation is an altruistic act, voluntary and with no financial benefit. Donors are compensated only for the working days they lose as part of the donation process and their travel expenses.
  • Donation of ova and sperm is allowed in Greece provided donor anonymity is ensured.
  • Egg donation is not allowed to women over 50 years old.
  • Donors must sign an oocyte concession consent.
  • Recipients sign a document stating that they are married and accept to undergo in vitro fertilization with egg donation. If they are not married, they should sign a notary act stating that they wish to undego IVF using the egg donation method.

On Assisted Reproduction

On January 27 2005, the law 3305/2005 on the application of assisted reproduction techniques was reported.

The Greek law on medically assisted reproduction is one of Europe’s most flexible. It safeguards the couple who wants to have a child based on medical, biological and bioethical principles. Its main purpose is, ultimately, the protection of the child to be born.

Basic principles of the current legislation

Some of the key points of the in-force law are the following:

1) Assisted reproduction methods are legal and allowed for women up to the age of 50 years, as this is considered the limit for natural conception.

2) The donation of ova and sperm is permitted, but the consent of the spouse or partner is also required.

3) Pre-implantation genetic diagnosis is allowed with the purpose of diagnosing whether the resulting embryos are carriers of genetic diseases. Consent of the concerned individuals is required.

4) Sex selection is prohibited unless a serious sex-related hereditary disease is avoided.

5) Cloning for reproductive purposes is prohibited.

6) Cryopreservation of genetic material or fertilized eggs is permitted.

7) The use of a gestational carrier (surrogacy) is allowed. A surrogate is a woman who carries a pregnancy for another couple or woman, who wishes to have a child but is unable to get pregnant for medical reasons. The surrogate woman must undergo medical and psychological examination. There should be no financial transaction other than the costs resulting from pregnancy exams, loss of work, etc. The procedure requires a special permit from a judge.

8) Assisted Reproduction Units are established and operate with the permission of the competent Authority, which shall give its agreement and verify that the legal requirements are met. For any violation, it sets administrative and criminal penalties.

9) The law sets age limits for sperm donors (younger than 40 years old) and egg donors (younger than 35 years).

10) Single women are allowed to conceive with assisted reproduction.

11) Donors must undergo clinical and laboratory testing and are not admitted to donation programs if they suffer from hereditary, genetic or infectious diseases. The use of fresh semen from donor is not permitted; only frozen semen may be used.

 

More info at gofertile.eu

PHTHALATES LINKED TO PREGNANCY LOSS -AND OTHER HEALTH PROBLEMS

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A recent study came -again- to incriminate certain environmental toxins known as phthalates as being responsible for pregnancy losses. Women undergoing assisted reproduction techniques (in-vitro fertilization or intra-uterine insemination) had urine exams to assess the presence of certain phthalates; it became evident that women with high levels of phthalates had up to three times increased risk of pregnancy loss. The study was recently presented at the Annual Meeting of American Society for Reproductive Medicine (ASRM).

For several years now we have been hearing about the toxic effects of phthalates, but what are they exactly? Where do we find them? Are they really harmful? Check out this article to learn more about these enigmatic toxins…

What are Phthalates?

Phthalates are chemicals used to soften plastics and make them more flexible (they are also known as plasticizers). These substances do not bound to plastics, therefore they are continuously released into the air, foods or liquids. Certain phthalates are used as dissolving agents for other materials.

Where do we find them?

Phthalates are used in an astounding array of products. They are most commonly found in:

  • Plastic bottles.Phthalates plastic bottles
  • Plastic containers and plastic wraps.
  • Cosmetics: in creams and lotions (to help them penetrate and soften the skin), in perfumes (to help them last longer), in hair sprays (to reduce stiffness), in nail polish (to prevent chipping), in deodorants, soaps, shampoos and almost every cosmetic with fragrance, including baby products.
  • Household products: air fresheners, paints, plastic flooring.
  • Plastic toys and other baby products such as teethers.
  • Certain medical devices, e.g., blood bags, intubation tubes, intravenous catheters.
  • Objects made of vinyl or PVC.
  • Phthalates are present even in seemingly unexpected sources. One example is milk: even in glass bottles, high levels of phthalates have been found, presumedly due to the plastic tubing used in milking machines.

We get exposed to phthalates by:

  • Ingestion: eating food contaminated from food packaging; drinking beverages from plastic bottles that leach the chemical; sucking plastic objects (e.g., baby toys, teethers).
  • Absortion: using cosmetics products. According to the CDC, women of childbearing age have the highest levels of phthalates, possibly due to the use of cosmetics.
  • Inhalation: breathing dust or fumes from products containing vinyl (vinyl floors, the interior of cars, shower curtains, etc).

Which are the most commonly used phthalates?

Phthalates perfumeThese chemicals have very difficult names, but there are a few you may want to keep in mind (see the studies below):

-In cosmetics: the primary phthalates used in cosmetic products have been dibutylphthalate (DBP), used in nail polishes; dimethylphthalate (DMP), used in hair sprays; and diethylphthalate (DEP), used as a solvent and fixative in fragrances. According to latest survey of cosmetics conducted by the Food and Drug Administration (FDA) in 2010, DBP and DMP are being used rarely, while DEP is the most commonly used phthalate. The use of DBP and DEHP is banned in the European Union  but they are still found in cosmetic products.

-In food packaging: the most commonly used is Di-(2-ethylhexyl) phthalate (DEHP). Bisphenol-A (BPA) is not a phthalate, but is also being used as plasticizer in food packaging and plastic bottles.

-In paints, plastic and PVC objects, solvents and adhesives: DEHP, Diisobutyl phthalate (DIBP) and DBP (also called DnBP).

-In children toys and child care products: In the USA, phthalates used in these products have been divided in three categories:Phthalates toy ducks

  1. permanent ban (permanently prohibits the sale of any “children’s toy or child care article” individually containing concentrations of more than 0.1% of DBP, BBP or DEHP);
  2. interim ban (prohibits on an interim basis the sale of “any children’s toy that can be placed in a child’s mouth” or “child care article” containing concentrations of more than 0.1% of DNOP, DINP, or DIDP); and
  3. currently unrestricted under Section 108 of the Consumer Product Safety Improvement Act of 2008 (DMP, DEP, DIBP, DCHP, DIHEPP, DIOP, DPHP).

Similar recommendations apply in Europe, where the six above-mentioned products are banned.

What is the evidence linking phthalates to pregnancy losses?

In addition to the recent American study (where they measured metabolites of DEHP), two previous studies had found a relationship between phthalates and miscarriages:

In 2012, a Danish study  found an increased risk of early pregnancy loss in women with high urine levels of DEHP‘s breakdown products. More recently, a Chinese study, comparing urine samples of women who had miscarriages and healthy women found that pregnancy loss was associated with higher levels or three phthalates: DEP, DBP, and di-isobutyl phthalate (DiBP).

Another American study also found and increased risk of miscarriages in women with high levels of BPA.

Eliminating phthalates and BPA from our lives is virtually impossible, but you can take some measures to minimize exposure, especially if you are trying to conceive, are pregnant or have young children”

Are there any other health risks?

Phthalates are widely known as endocrine disruptors: they mimic hormones, interfering with their function. Some possible consequences of this are:

Effect on male fertility: phthalate exposure in men was associated with reduced fecundity.

Birth defects in baby boys: several studies have found abnormalities in baby boys’ genitals when pregnant women were exposed to high levels of certain phthalates; another study found increased risk of hypospadias (the opening of the urethra is on the underside of the penis) in occupational exposure of pregnant women.

Neurological problems in newborns, infants and children: such as attention deficit hyperactivity disorder (ADHD), reduced IQ, behaviour problems.

Obesity: both in children and adults.

Asthma: in children when pregnant women were exposed to high level of phthalates.

Interference with puberty in girls: the evidence is inconsistent on this subject; while some studies found that phthalates may be related with precocious puberty, others reported delayed puberty.

Breast cancer: a small study showed increased breast cancer risk, but the evidence is not conclusive; there is a large study being conducted in the USA, which will provide more clear answers on this matter.

What can I do to reduce exposure to phthalates?

Phthalates glass food containersEliminating phthalates and BPA from our lives is virtually impossible -they seem to be everywhere- but you can take some measures to minimize exposure, especially if you are trying to conceive, are pregnant or have young children:

  1. Read labels on personal care products. Unfortunately, manufacturers are not forced to list phthalates, and  they can be added as a part of the “fragrance.” Many companies have voluntarily removed phthalates from their products, so you may search for products labelled as “phthalate-free”.
  2. Limit the use of baby care products in babies and young children.
  3. Don’t microwave food in plastic, or use only “microwave safe” and phthalate-free containers to microwave food or drinks. Phthalates can leach from containers (or plastic wrap) into foods on contact and when heated, particularly oily foods or with a high fat content. Don’t put plastic containers in the dishwasher (heat will increase phthalates leaching).
  4. Replace plastic bottles, cups, dishes and food containers with those made of glass, porcelain or stainless steel, especially for hot food and beverages.
  5. Check labels on plastic bottles and containers: choose only those with recycle codes 1, 2, 4, or 5. Plastics made of polyethylene terephthalate (PET) or high-density polyethylene (HDPE) are safer than those made of PVC (“PET” or “HDPE” may be printed on the label or the bottom of the bottle).
  6. Use only toys and toothbrushes labeled “phthalate- free”. There are strict regulations banning the most dangerous phthalates in toys and baby products, both in the USA and in Europe.
  7. Reduce your use of canned foods, as they are often lined with material that contains BPA. Prefer fresh products or those in glass containers. Avoid canned milk (including canned formula for babies).
  8. Phthalates baby bottlesChoose only bottles and cups that are BPA-free. In fact, BPA was banned in all baby products in 2011 in Europe, and since 2012 in the USA.
  9. When using paints or solvents, keeps the area well ventilated. Prefer natural paints, phthalate-free (DBP is the phthalate usually used in these products).
  10. Choose non-vinyl products, such as shower curtains, raincoats or furniture, as the chemical off-gassing from these products introduces phthalates to your environment.
  11. Keep your house clean, as phthalates can remain in dust.
  12. Avoid air fresheners; prefer essential oils instead.

Is anything being done?

Phthalates safe cosmeticsAs people are becoming more aware of the harmful effects of phthalates, increasing information is being available to consumers; websites such as the Campaign for Safe Cosmetics have actively advocated the elimination of dangerous chemicals from cosmetics and personal care products. As a result, certain companies and retailers have been taking measures to reduce toxic substances in their products.

Initiatives are also being taken at governmental level. European authorities have restricted the use of phthalates in some baby products, cosmetics, and plastics designed to come into contact with food; more phthalates will be soon banned from medical equipment, electrical and electronic devices. Recently, a very extensive Report to the U.S. Consumer Product Safety Commission by the Chronic Hazard Advisory Panel on Phthalates and Phthalates alternatives (CHAP) analyzed the available data on each phthalate and phthalates alternative and provided recommendations, which will hopefully lead to banning certain phthalates that proved to be toxic.

 

Photo credits

Getty Images; Reciclado creativo, Flickr.com; Etienne, Flickr.com; Pixabay.com; Target.com; Alicia Voorhies, Flickr.comjillsamter.com

SMOKING IN PREGNANCY: MORE DANGEROUS THAN WE THOUGHT

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We knew for many years that smoking during pregnancy was harmful for the baby, as it has been linked to increased risk of miscarriage, preterm labor and low birthweight. But a recent study came to incriminate cigarette smoking for something we were not sure yet: birth defects.

British scientists examined the literature published on the subject the last 50 years, and after putting all the information together in what is called a meta-analysis, they came up with the conclusion that smoking is indeed responsible for certain birth defects.

The higher risk was for a malformation called gastroschisis, in which the baby is born with the intestine or stomach protruding outside the body through a hole in the abdominal wall; for this anomaly, babies of women who smoked during pregnancy had 50% increased risk.

In addition, they found that babies born from mothers that smoked while expecting had higher risk for the following:

  • Musculoskeletal defects, that is, missing or shortened arms and legs, cleft lips, cleft palate, craniosynostosis (abnormally shaped head): 26% higher risk;
  • Gastrointestinal malformations: 27% more chances.
  • Undescended testis in baby boys: 13% higher chances.
  • Heart problems: 9% excess risk.

That cigarette is toxic for a developing baby does not seen illogical: cigarettes contain more than 7000!! chemicals, most of which can easily cross the placenta. And we know very well that cigarette is highly toxic for adults and children.

The mechanism by which cigarettes may cause all these defects is not clearly understood, but the key seems to be reduced oxygen supply to the baby. Nicotine (the addictive component of cigarettes) causes blood vessels to constrict, this may lead to reduced blood flow to the placenta or to the baby’s tissues; another component, carbon monoxide, binds to hemoglobin (the molecule that carries oxygen in the blood) stronger than oxygen, thus lowering the amount of oxygen in the blood circulation. Maybe, some of the chemicals contained in cigarette have a direct toxic effect on the baby’s tissues.

In light of this information, if you are a smoker you should make every possible effort to quit smoking as soon as you learn you are pregnant, or even better, before conceiving.

Cigarette is addictive, so it may not be easy, but your baby can give you a great motivation to quit….

 

Reference
Allan Hackshaw, Charles Rodeck, and Sadie Boniface: Maternal smoking in pregnancy and birth defects: a systematic review based on 173 687 malformed cases and 11.7 million controls. Hum. Reprod. Update (2011) doi: 10.1093/humupd/dmr022. First published online: July 11, 2011