The following pages contains information regarding procedures important to egg donors.

This section has been written in the expected order of various steps in treatment. You may find helpful to refer to this section regularly during treatment.

  1. First clinic appointment where diagnosis is known. A full discussion of the relevant aspects of your treatment takes place in the clinic. We aim to minimise your visits and do not repeat investigations unless deemed essential for the conduct of your treatment.
  2. Screening tests. These tests are arranged as explained above at your first appointment in the clinic.
  3. New Patient’s Seminar. We very strongly recommend that you attend this open seminar by the team. Dates are available on request from the unit.
  4. Follow up clinic visit. You will attend the clinic for discussion of screening tests and you have this opportunity to clarify any outstanding issues that have arisen in your mind with respect to your treatment. At this visit, you will receive a prescription and also be advised to see the nurse co-ordinator on your way out so that the NHS funded patients can be given a start date for your treatment within the government target of 18 weeks. The NHS self funded patients will be added to the waiting list and the nurse co-ordinator will provide an estimate of the month in which you may receive treatment.
  5. Appointment with the Finance officer. The Unit’s finance officer will provide the invoice for the NHS fee paying patients, receipt payment and book a nurse consultation appointment in the weeks prior to your treatment start date.
  6. Consultation with the Nurse Specialist. Both Partners must attend this appointment (see details) because you both will be required to sign consents, receive instruction for self administration of injections and a cycle plan.
  7. Suppression of your natural hormones. When the ‘long protocol’ is used, your naturally produced hormones are suppressed from the 1st or the 21st day of the menstrual cycle using a nasal spray, a daily injection or a single depot preparation. This is maintained until you are ready to receive hCG and can in total last for approximately 5 to 7 weeks. When the ‘short protocol’ is used, we prescribe a second injection in parallel with the stimulation drugs from an appropriate stage. A baseline scan is performed, usually prior to starting this phase, unless you have had another recent scan within the preceding 3 months.
  8. Ovarian Stimulation. Hormones are administered in this period to help your ovaries produce multiple eggs. This treatment can lasts for approximately 9-14 days. In women receiving the ‘long protocol’ a pre-stimulation / down regulation scan will be performed before to confirm that natural hormones have been suppressed. You will receive further scans to monitor growth of the follicles.
  9. HCG injection. This injection prepares the eggs for ovulation and is given late in the night (usually between 10 p.m. and 2.00 a.m.).
  10. Egg Collection. The eggs are collected approximately 35 to 38 hours after the hCG injection.
  11. Insemination or ICSI. Male partner gives a sperm sample for preparation and insemination of the eggs by the direct method or by the ICSI procedure.
  12. Checking Fertilisation. You will receive a telephone call with necessary information on the day after egg collection.
  13. Embryo Transfer and Hormonal Support. The embryos are replaced in the womb and you will receive further medication afterwards to provide hormonal support in this phase of the cycle.
  14. Luteal phase monitoring. This is provided to all those women who we feel could be at risk of developing ovarian hyperstimulation syndrome.
  15. Pregnancy test. You are given a date for the pregnancy test at the time of embryo transfer.
  16. Pregnancy scan or Follow-up consultation. This is arranged after the pregnancy test and the outcome of treatment is known.

Downregulation phase

As explained above, during your IVF cycle the response from other glands (the pituitary) may interfere and affect the maturation of eggs. As this can lead to a lessening of your success rate, when using the Long Protocol we choose to inactivate this gland before stimulating your ovaries.

Baseline scan

A vaginal scan is performed before starting any medication unless the scan performed as part of Pre-assessments was done within the last 3 months. This is to ensure that there are no new developments that we should be aware of before starting the drugs.

Pre-stimulation or Down regulation scan

The scan is repeated at the appropriate time after starting the suppression phase. This should show inactive ovaries and a thin lining of the womb. The usual time taken for this phase is 10 days to 2 weeks.

Drugs used

A number of methods can be employed for the same ultimate effect. These, in our programme include the following:

  1. Nafarelin Nasal Spray: This is taken as one sniff in one nostril three times per 24 hours at 8 hourly intervals for first 2 weeks and then twice daily thereafter until the day of HCG. This medication is not suitable for those suffering from hay fever, chronic nasal discharge or who may not remember to use the spray regularly.
  2. The Buserelin Injection: This injection is taken once a day sub-cutaneously with a very fine needle-injection just under the skin. It is given daily at approximately the same time but an absolute and accurate precision is not essential (give or take 30 minutes).
  3. Prostap Depot Injection: This is a once only injection and works for 4-5 weeks in total. This is very convenient for many patients except those with reduced ovarian reserve. If the suppression phase is prolonged because of the agonistic/stimulatory response from the ovary, a ‘top-up’ with Buserelin/Nafarelin in the later stages of the cycle may be needed.

Side effects

  1. Hot flushes, night sweats, headaches, vaginal bleeding, temperamental behaviour. These are due to a fall in your oestrogen level, usually last for a short time and will disappear once we start stimulating your ovaries.
  2. Agonistic/ stimulatory response: In the initial stages all of the 3 preparations above can stimulate the ovary. This means that a follicle or cyst develops that has to resolve before we can proceed with treatment. It can naturally take up extra 2-3 weeks. If the cyst is aspirated the resolution may be slightly earlier and this requires an extra scan to see it disappear and for the endometrium to become thin. If you are prone to develop agonistic response seen in the form of cysts after starting this medication, we can use the oral contraceptive pill for a few days before starting the downregulation and this usually avoids such problems recurring.

Time to start

This treatment can be started on the first or the second day of your cycle especially when your cycle length is variable. It can also be started on the 21st day of the preceding cycle if your cycle is very regular.

Choices

We can prescribe any one of the above preparations and methods dependent on your preference and knowledge of past response. They are equally effective and are self administered. There is a relatively small difference in their costs with Buserelin being the cheapest.

Important notice:

The Nafarelin nasal spray and/or the Buserelin treatment is continued in the stimulation phase. We will specifically advise in writing when to discontinue which is the day you are advised to take hCG. Those with Prostap normally do not have to take additional medication during the stimulation phase.

Stimulation phase

There are large variations between donors in the number of eggs recruited and developed in response to the same dose of the stimulating hormones (see below). This response is mainly dependent on the donor’s age, her body weight and past treatments or ovarian surgery. There are other genetic determinants also. Having preformed the pre-treatment assessments, we judge the starting dose bearing in mind all clinical circumstances. When uncertain we may perform additional early scans to use the option of ‘stepping-up’ or ‘stepping down’ during the stimulation phase for a better response.

What does it involve?

The hormones (Merional / Fostimon / Menopur/Gonal-F/ Puregon) will be started when your ovaries have been adequately suppressed as judged by your pre-stimulation or the downregulation scan (see previous section).

My choices?

The difference in drugs is mainly in the way they are prepared, their purity, in the way they are administered and their costs. They are equal in terms of their success rate. We often choose them in combination or separately to suit.

How to inject?

Merional,  Fostimon, Menopur, Gonal-F and Puregon are usually given by a subcutaneous injection (very fine needle-injection in the fat layer under the skin).

How are they prepared?

Gonal-F and Puregon are synthetic compounds and produced in a laboratory, are very pure and with an identical structure to one form of PURE FSH only. Menopur and Merional are extracted and purified from menopausal women’s urine and are a combination of two naturally produced hormones. Fostimon is also extracted and purified from menopausal women’s urine and contains all forms of naturally produced FSH.

Side effects

As stated above, to date the only additional side effect with urinary preparations has been that of an occasional rash on the injection site and rarely a more generalised allergy has been reported. Other risks with protein impurities are purely theoretical and there have been no cases reported to cause concern.

Undesirable effects

This can happen with any of the preparations available. Sometimes the ovaries will recruit a large number of eggs especially in young women and those with polycystic ovaries. This can put you at risk of developing an illness called The Ovarian Hyper-stimulation Syndrome (see later for further details). We use ‘step-up and/or step-down’ method to adjust and protect you from this risk during the stimulation phase.

How effective are they?

We have used the Pure and Urinary preparations quite extensively and are happy with them all.

Who should give the injections?

The injections can be administered yourself or by your partner. We strongly advise you to consider learning self-administration. Independence will save you time, effort and stress of professionals not being available when needed. However, if you are extremely anxious then you may seek the help of your doctor’s nurse.

When to take the injections?

The injection is taken once a day at approximately the same time but an absolute and accurate precision is not essential. We will be able to estimate the day of your egg collection once the growth rate of follicles is established. It will also help in deciding the time of abstinence in preparation for the semen sample to be given on the day of egg collection.

The hCG (Gonasi or Pregnyl or Ovitrelle) Injection

When your follicles have reached an appropriate size, as assessed by scan, you are ready to be prepared for the egg collection. The hCG injection is essential to bring the eggs to the correct stage of maturation for this stage.

This injection is usually given late in the night normally between 10.00 p.m. and 2.30 a.m. It is specifically timed to be between 35-37 hours before the time of your egg collection.

Important notice: We will give you precise instructions as regards the time and day this injection has to be administered. It is essential that the hCG injection is given as close to the prescribed time as is possible. Please read the instructions before you leave the unit so that you can ask a member of The Centre if you do not understand any of the instructions.

Egg Collection

Approximately 35-38 hours after the time of your hCG injection the egg recovery will be performed. This is performed in the Procedure rooms with the help of an Ultrasound machine. It is very similar to vaginal scanning except that we take sterile precautions to protect you and the eggs.

Preparation

An egg collection procedure

An egg collection procedure

It is important to be as relaxed as possible for the egg recovery. Familiarity with your team will allow you to dispel some of the anxiety and fear. Your ovaries are considerably larger than their normal size which can lead to a dull ache and tenderness in the lower part of your abdomen before, during and after the egg collection. You will be advised to take an analgesic suppository on arrival and a further intravenous sedation and analgesia just before the procedure. We intend to relieve your discomfort as far as is possible. This is a short procedure and you should still be prepared for some discomfort as the needle enters the ovary. This procedure is outpatient based, you should be able to return home a few hours after the procedure.

A mature egg

A mature egg

It is necessary for your husband/partner/or a relative to drive you home and stay with you for the remaining part of the day. As you have received sedatives you should refrain from operating machinery, driving and should retire to bed after your return home.

We will tell you the number of eggs collected during and at the end of the egg collection. Very occasionally the eggs can be difficult to identify and we will need to have another look in the laboratory. So your final egg number may be slightly less than that quoted to you immediately after the egg collection.

Hormonal Support after the Egg collection

Donors at risk of ovarian hyperstimulation are given depot Prostap injection which would inactivate the pituitary glad and reduce the risks.

Follow-up after donation:

Donors at risk of ovarian hyperstimulation are routinely followed up until the period of risk has passed. Donors at not a specifically high risk are able to access us for help and advice at anytime via the unit direct line telephone numbers during the week and via the emergency number out of hours and on weekends. Our nurse co-ordinator will call you for a nurse follow-up approximately 2 weeks after your donation and we will ask you for feedback on our service so that we can make improvements where necessary. You may wish to return to see the doctors in which case upon request an appointment will be made. You can find out the results /outcome of your donation by contacting our nurse co-ordinator/s. If you wish to donate again, please do contact our nurse co-ordinator.

The day after the hCG injection, you may feel some heaviness or discomfort in the lower part of your abdomen. On this day, do not forget to take your bedtime Lorazepam tablet – this is given to reduce understandable anxiety and so that you can have a good night sleep before you arrive for your egg collection. Please remember that you are advised to refrain from driving or operating any machinery after you have taken the tranquilisers and not doing so could be hazardous for you and others. Please also remember to read the instruction sheet carefully.

Risks with an egg donation cycle

There are no treatments that are completely free of risk. As you would have undergone an IVF cycle your risks include the following:

Ovarian hyperstimulation syndrome

If your ovaries have shown an excessive response then you are at risk of Ovarian Hyperstimulation Syndrome. Everybody receiving drugs for ovarian stimulation in order to produce multiple eggs is at risk. However the risk is not the same in everybody and we have developed clinical tools with which we assess your individual risk. This can vary between mild, moderate, severe and very severe. Young and overweight women with polycystic ovaries are especially ‘at risk’.

General advice: You are advised to drink normally and check that you are regularly passing normal amounts of urine. Although mild symptoms are common, severe ovarian hyperstimulation is rare and occurs in only 1-2 % cases. If in doubt, please do not hesitate to contact the IVF team or the on call doctor (as per the instructions in the front) at any time. The switchboard at St James’s University hospital will be able to put you in touch with the on call gynaecological registrar at all times.

Management of this risk: We will assess your risk before deciding to give HCG, when we do an egg collection and afterwards until we do an embryo transfer. All women in categories a, b and c below receive monitoring within the unit for early detection of changes and as per our written protocols and those with symptoms will be treated as appropriate. This may include hospitalisation, administration of intravenous fluids and other treatment such as drainage of fluid from body cavities.

  • When in the category of very severe risk, we would not give HCG, advice abandoning the cycle and starting again with a modified regimen.
  • When the risk is severe, we may try to curtail the cycle prematurely with medication, will not do an embryo transfer and will freeze all developing embryos.
  • When the risk is moderately severe we may adopt an expectant individualised approach where we observe your progress carefully whilst we maintain at least some embryos in culture to day 5. If by then you develop signs or symptoms we may freeze all developing embryos still and take other precautions. If you remain well we may perform an elective single embryo transfer.
  • When in this category, you do not require monitoring or specific treatment but we advise you to contact the unit as and when you have problems and as per the contact address and details on the front of this booklet.

Recognised complications:

Fortunately with appropriate risk assessment, prophylactic monitoring, early detection and timely intervention most women will have no problems. Your co-operation is therefore essential in ensuring your safety. It is a self limiting disorder and there are no problems after the cycle is complete. In women who become pregnant the risk period extends into the first trimester of pregnancy and complications up to 12 weeks of gestation have been recorded.

Complications occur either as a result of thrombosis in large veins because of thickening of the blood and its sluggish flow or because of collection of fluid in body cavities such as the abdomen or the chest. Strokes, ascitis, pleural effusions, pericardial effusion, cardiac tamponade and deaths have been reported in the literature. The risk of death is less than 0.01%.

Risk of an unwanted normal or ectopic pregnancy:

We may not collect all eggs and therefore there is always some risk of an embryo forming naturally and leading to a pregnancy. You are advised to abstain in this cycle or use barrier forms of contraception at all times until you menstruate.

Risks of the Egg Collection Procedure:

At the time of an egg collection a needle is carefully passed through the wall of your vagina into the ovary under ultrasound vision. The risks include those of an infection, bleeding and damage to an internal organ requiring surgery and repair.

Infection:

  1. The needle can transfer germs from your vagina into the pelvis and lead to an infection. The risk of this is greater:
    • if you have chronically infected tubes, an active vaginal or pelvic infection, your tubes are swollen or distended with fluid that may still contain bacteria.
    • if you have endometriosis and especially if you have Endometriomas that have to be entered during the egg collection.
    • If you have extensive adhesions incorporating the bowel the risk of bowel injury is increased also.
  2. We advise that all donors undergo screening for genito-urinary infections before they undergo a treatment cycle at least once but it could be prudent that you have screening done before each cycle. It can easily be done via your GP and requires the nurse to take a swab and check your early morning urine samples for NAAT analysis for chlamydia in particular.
  3. We provide vaginal Clindamycin cream during the treatment cycle for you to use from the day of HCG administration (2 nights before egg collection) and maintain this at least until we do your embryo transfer.
  4. We also take further precaution of thoroughly cleaning your vagina before an egg collection and use fluids that contain strong antibiotics. Further we may give additional antibiotics by mouth in special at risk circumstances.
  5. You are advised to let us know if you are suffering from vaginal infections or an offensive discharge.

Bleeding or internal injury:

Potentially the needle can also enter a blood vessel leading to internal bleeding or perforate a loop of the small or the large bowel leading to internal infection, need for major surgery and further treatment as appropriate. The risk of this complication is quite remote and less than 0.001%.

Risk of equipment failure:

The trust maintains service contracts for all equipment that is regularly serviced. There are also many standard operating procedures in the laboratory that help us have an early warning for problems. Despite all our efforts and very uncommonly equipment failure may sometimes lead to loss of eggs or embryos. This is a ‘Category A’ incident that will be immediately notified to HFEA, the trust and you. There would usually be a thorough investigation and steps taken to prevent a recurrence of similar problems. The HFEA also operates an Alert system which we use to learn from incidents elsewhere.

Risk of an unwanted normal or ectopic pregnancy:

We may not collect all eggs and therefore there is always some risk of an embryo forming naturally and leading to a pregnancy. You are advised to abstain in this cycle or use barrier forms of contraception at all times until you menstruate.

Other risks

  1. Although some have raised alarm over the risk of ovarian cancer with the use of hormones, these preparations have been used in treatment since early 1960’s without any notified cases that can be directly liked to the use of these hormones. The available evidence suggests that there is no increase in your risk over and above that exists naturally. Infertility per se, delay in first pregnancy, and failure to breast feed, family history, obesity and smoking are known risk factors for the cancer of the ovary and the breast.
  2. There have been no cases of complications with protein impurities in the urinary preparations. Theoretically some have worried those external proteins when injected could transfer viruses or prions that could lead to an illness like CJD at a later date.

This section is there for your information and to reassure you that as far as we know none of the publicised risks have been scientifically confirmed.