All that has gone wrong with the process of egg donation in the U.S.
This article about third-party egg donation is presented as an Editorial because it represents the institutional opinion of The Reproductive Times (TRT). Witnessing rather substantial changes in how third-party egg donation has been offered to the public over the last 20 years, TRT has become increasingly concerned about the excessive commercialization of the process, best characterized by two key events: (i) the 2016 settlement by the ASRM of a class-action lawsuit brought by several egg donors (or should we say their attorneys) in which the ASRM agreed to remove recommended pricing caps for egg donors from its ethics guidelines1 and, (ii) the establishment of a plethora of commercial frozen egg banks. Both of these developments for the first time led to the definition of oocytes as marketable “products” of specific value and fostered a new coalition of economic interests among IVF clinics (especially in parallel rapidly growing clinic networks), frozen donor-egg banks, and egg-donor agencies, in the process significantly contributing to the de-privatization and commercialization of infertility practice.
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December 13, 2024
Too much egg donation!
The first IVF pregnancy and delivery from use of third-party donor eggs occurred in Australia in 1983; the U.S. saw the first American offspring from use of donated oocytes the following year. Ever since, third-party egg donation has been an integral part of IVF in the U.S. and in most countries (though in some countries egg donation is to this day is not permitted). We have over the years repeatedly criticized egg donation for one principal reason best demonstrated by the very small number of U.S. IVF cycles in women above age 42: A large majority of U.S. IVF clinics (as well as elsewhere) in our opinion are often much too quick in referring infertile women to egg donation.
The argument is usually that above age 42, pregnancy chances with autologous oocytes are too low to make IVF worthwhile, an opinion which we for several reasons categorically reject: the first reason is that, at least up to age 45, pregnancy and live birth rates – while of course declining with age – are still objectively reasonable for many, or even most, people. A more important point, however, is that what is “reasonable” for one person is not necessarily also “reasonable” for the next patient. And this dichotomy is also obviously applicable to physicians and their patients: what a physician considers to be reasonable may not coincide with the definition of her patient and some patients will be more and others less in line with the physician’s obviously very personal opinion of what is and is not “worth it.”
After age 45, pregnancy and live birth rates reach levels where an argument of universal unreasonableness makes increasingly sense; but even at those ages many women – having a right of self-determination – should, after receiving correct informed consent, have the right to choose much lower outcome chances with own over much better outcomes with third-party donor eggs. Yet, while the right to self-determination of patients is universally cited as a basic ethical law for all of medical practice, infertile women are almost routinely denied choosing autologous IVF cycles after age 42.
That after age 42 most women are still automatically strongly “encouraged” to use donor rather than autologous eggs must, therefore, have other motivations. Likely not accidentally, donor egg – recipient cycles are also the most profitable IVF cycles in IVF clinics.
The myth of equal outcomes between fresh and frozen donor eggs
Though repeatedly refuted by several studies over the years, the frozen egg-banking industry still maintains that live birth rates are “comparable” between fresh and cryopreserved donor eggs. That this was not the case was, indeed, first demonstrated in 2015,2 and has since been repeatedly confirmed. 2021 CDC data, for example, reported a national fresh donor-egg live birth rate of 53.35 vs. frozen donor-egg rate of 45.8% (-7.7%). The overall difference between various published studies was between ca. 7% to ca.12% in favor of fresh donor eggs.2,3
But frozen donor eggs do not only offer disadvantages. They indeed also offer many advantages to patients as well as IVF clinics, starting with the fact that they have basically eliminated long waiting periods for donor eggs. The rapidly increasing number of donor-egg banks also has substantially expanded donor choice, as individual egg donor pools in IVF clinics used to be small and limited numbers of donors almost always resulted in long waiting periods for patients. Clinics, moreover, hated the administration of their own donor pools which, in addition, was expensive and, therefore, adversely affected the bottom-line of what otherwise is the most profitable IVF cycle in IVF clinics.
No wonder then that frozen donor eggs nowadays are used in a large majority of donor-egg cycles in the U.S. and fresh donor egg cycles have become a rarity. But this is not where the story ends because with steadily increasing demand for donor eggs and increasing numbers of commercial frozen donor-egg banks opening – it seems almost daily – a real donor-egg industry has arisen ,characterized by features 20 years ago would have been unthinkable. So we were not surprised when The Free Press, likely the most impressive recently established “new-world” news outlet founded by Bari Weiss, published an article by Rina Raphael, titled “The ‘Wild, Wild West’ of the American Egg Donor Industry.”4 And, boy, was she on point and should be read by everybody thinking about becoming an egg-donor or thinking about purchasing donor eggs from wherever!
What has gone wrong with egg donation?
In attempting to answer this question, one is almost tempted to answer with only one word: everything! Though such an answer would, of course, be an exaggeration, it unfortunately is not far from the truth. Let us, therefore, answer this question in some detail, starting with how we now, here in the U.S., obtain eggs for donation.
The egg donor
As already noted above, egg donation changed radically with the legal settlement of a class action suit the ASRM reached in 2016 with a group of egg donors which led the Society to withdraw recommended payment caps to egg donors which it, previously, had published in regular time intervals as part of its clinical guidance program for clinical practice, basically accepting the plaintiffs’ argument that those priced caps restricted trade. This step – largely unmentioned then and to this day – instantly and radically changed the definition of egg donation from up to that point representing a selfless voluntary act for which donors were “reimbursed” for time and effort only (with the ASRM’s guidance representing a formal assessment of what this “reimbursement” should be in various markets), to a formal business agreement under which egg donors are free to sell their eggs, like in any other business transaction, to the highest bidder.
In other words, the ASRM’s decision to settle the class action suit for the first time defined eggs as a legal property of egg donors that could be freely bought and sold, an idea which up to that point was considered unethical, even though men had been “selling” their semen for decades (of, course at a tiny fraction of the price donor eggs demanded, considering the much larger effort women had to undergo in making a gamete donation). That the concept of human eggs being for sale raises major ethical concerns is also demonstrated by the fact that – to the best our knowledge – no other country has followed this U.S. example. Very much to the contrary, most countries to this day restrict egg donor “reimbursements” to even significantly lower amounts than ASRM caps had been prior to 2016.
The consequences are two-fold: (i) Practically everywhere else where permitted, third-party egg donation, because of lower donor payments, ends up being much cheaper than in the U.S. (leading to large numbers of U.S. patients traveling outside the U.S. for egg donation); (ii) Some U.S. clinics and – yes – allegedly also frozen donor egg banks, have started to “import” frozen donor eggs, or even “egg donors” themselves, from abroad who fly in for donations, both questionable practices for several clinical as well as legal reasons. However, what makes both of these practices even more repulsive is the fact that clinics (and frozen egg-banks) often are not transparent to patients about the “importing” of eggs and donors and, usually, also do not pass on the cost-savings to patients.
The frozen donor-egg bank
As also already noted above, frozen donor banks have greatly proliferated and, today, must be described as an industry with considerable power to influence practice policies in the infertility field. And this power derives from several facts, the most important one being that most fertility clinics – as noted earlier – have stopped maintaining their own egg donor pools and exclusively rely on cryopreserved donor eggs for their patients. As a consequence, the market these banks are serving has greatly expanded and service quality – according to observations in at least one clinic we talked to – has at multiple levels unfortunately decreased, while costs for oocytes are at times reaching obscene levels.
Why do we believe that egg quality has decreased? Because, based on what we hear from clinics not only has quality based on oocyte morphology decreased, but also based on thaw and fertilization rates. And we have also heard about deliveries of empty straws and incorrect egg numbers, all signs of decreasing quality control at frozen egg banks. In parallel, we have come to question egg-donor selection by some of these egg banks, as at least one clinic found donors refused by its donor selection process, later in lists of frozen egg banks.
And then there are the purchase contracts for eggs, with often have become so complicated that one must wonder whether that reflects purpose. The complications arise from all kind of outcome guarantees which patient can purchase and which, in most cases, means that the egg bank promises additional eggs in replacement if a given number of purchased eggs does not produce – for example – at least one transferrable (blastocyst-stage) embryo. And these contracts are complicated because they, often, become “negotiable” and, probably not surprisingly, egg banks frequently “must be convinced” to really come forward with replacement oocytes when these minimal goals are missed.
In other words, under most of these purchase agreements as they have evolved, patients in principle purchase a certain number of eggs (usually a minimum of 5-6) at an average cost per egg of $3,500 approximately without any outcome guarantee. If they do want a minimal outcome guarantee as described before, there are significant additional charges, raising the cost per egg even beyond $3,500.
Consider what this means: Assume an egg donor produces 10 freezable eggs (a very small number; most donors can be expected to produce over twice that number) these eggs will produce $35,000 in revenue
to the egg bank (and even more with insurance payments), with average payments to egg-donors in NYC currently at $8,000 (in other locations they frequently are lower). Moreover, clinics “importing” eggs and/or donors, usually have even significantly lower donor costs.
Current egg pricing by egg donor banks can, therefore, only be called abusive. That this judgment is well-earned is further demonstrated by the fact that the egg-freezing industry – as a major argument why patients should choose frozen over fresh eggs, from the beginning has been promoting frozen eggs as “significantly less costly.” So much then for this argument. Only a small group of IVF clinics still maintain their own egg donor pools. One reason is that they, often, trust their own egg donor selection. Some clinics also do not consider themselves to be in the business of “selling eggs” and, therefore, do not consider the production of donor eggs as a profit center. Such clinics then, often, price eggs obtained from inhouse egg-donors at cost. Some clinics with in-house produced eggs, therefore, offer lower per oocyte charges than most egg banks, even if freshly retrieved.
The excesses
But this is not where our criticism of the current egg-donation industry ends. The excesses go far beyond that and are, indeed, starting to attract the attention of several media outlets, as two very detailed recent articles in the general press well demonstrated. One is previously noted article by Rina Raphael in The Free Press4 and the other is an article by Jackie Davalos and Sophie Alexander in Bloomberg Businessweek, which tells an almost unbelievable story.
The first article – among other subjects – offer insights into what it takes to be an egg donor and rightly criticized the absence of research on the long-term effects of being an egg donor, often many times over. Addressing this issue, she quotes one donor as saying, “it’s [being an egg donor] sold as an easy way to make money and help others. Nobody mentions the long-term risks. I never saw this coming” (referring to infertility she experienced later in life, allegedly attributed to her egg donations).
Another issue the article addresses is the psychological effects of knowing that – somewhere there, likely, are children running around who are the product of the donors’ eggs. A donor whose experiences enliven almost the whole article now experiences “psychological distress” because she has started wondering whether those children might be curious about her, as she, is now very curious about them. The accusation, in short, is that egg donors do not receive proper informed consent before committing to being a donor.
Considering that most U.S. IVF clinics now use an extra-long ASRM-designed consent (or at least work off it), this cannot be considered a valid accusation for as long as donors are really encouraged to read the whole consent before signing and to ask questions. The article, however, does have a point when describing the egg-freezing industry in the U.S. as largely unregulated and, often, exploitative and even unethical. It cites misleading advertisements in recruiting financially vulnerable candidates on TikTok, and how some egg donor payments have really reached a stratospheric amount. The article claims that donors of Asian ancestry, because in increasing demand (egg donation in China is forbidden), can charge up to $50,000 for a single donation. But even that is nothing in comparison to one recent patient at a NYC clinic who, through an agency, paid $120,000 for a donor (who, as a side note, the clinic recommended against, but the patient insisted on), and who ended up producing only one single embryo.
And when things get really weird
And, if that is not already crazy enough, the same couple recruited right afterwards another donor from the same agency, and for roughly the same money; except this time, she turned out to be a very good donor.
The second article appeared in a business magazine because it involved a (legally) disgraced business tycoon billionaire who literally “built a network of egg donors and gestational carriers” (by some also incorrectly called surrogates). Many were young fashion models. One of them in the article given the name Anya because she was a native of Kazakhstan, was promised $1.5 million for posing at a Chicago IVF clinic as an acquaintance of his who she wanted to donate her eggs to for the standard fee of $10,000. In 2019, one year later, a gestational carrier gave birth to a boy conceived from one out of 20 of Anya’s eggs that had been retrieved. Five years later (now 33 years old), she hasn’t seen her biological son even once because her “ex-boyfriend” had her sign papers that cut her out of the boy’s life (and, as she never received the $1.5 million, she likely did not have the means to fight for him in court).
The exclusive father, according to the article, is a disgraced insurance tycoon who once had a net worth exceeding $1 billion but, now after two convictions in federal court for bribery is facing up to 30 years in jail (he already spent two years in jail and was released upon appeal). By now he has at least (nobody knows for sure) 12 children, with nine among them born over the last five years form arrangements as the one described for Anya. He is the sole parent for eight, and he lives with them near Tampa in Florida; another 4 live with his ex-wife and a business associate, possibly also his fiancée. According to the article at least six of his children were born through a network of egg donors and surrogates including at least 25 women.
What makes this story so remarkable is that all of these activities were, at least at the medical practice level, perfectly legal. Though one clinic apparently turned him away (see below), most did not! Interestingly, he initially was very supportive of the planned article and collaborated with the two writers for hours in telephone and sit-down interviews. Shortly before publication, however, he cut off all contact and actually filed a lawsuit against them, alleging defamation, slander, and interference in his relationship with one of the gestational carriers.
Coming back to his model girlfriends, another one – this time from Los Angeles – ended up with him at the Duke University IVF program. The Duke staff, this time, was, however, told the truth about the promised $1.5 million and this time the potential model-donor got cold feet and Duke also said no.
But pretty much every other IVF clinic he approached said yes, and he had donors go through egg donation cycles in California, Illinois, and Nevada, as well as outside of the U.S. at the single IVF clinic in Barbados. The large majority of cycles were, however, performed at HRC Fertility in Los Angeles and Kindbody in Chicago, two of the largest private equity IVF clinic chains in the country.
Does this mean that chain clinic networks financed by private equity are more unscrupulous than physician and academically owned IVF clinics? We cannot say this with certainty but there is, of course, reason to believe so; these commercial entities work on an on average 5-7- year schedule, in which they have to turn over an asset with significant profit. That can only happen if they massively grow revenue over this time and, of, course profit follows. A just recently, so-far only electronically published study of U.S. investigators in JARG which demonstrated that – based on nationally reported data – private equity-owned clinic networks utilize significantly more PGT-A than physician and academically-owned clinics.6 The literature is also full of reports of increasing pressure on physicians to maximize utilization of all kinds of treatments once private equity assumes ownership of a medical enterprise. The heavy involvement of the Kindbody network with the above-described billionaire, therefore, does not bode well for this company’s image in community as well as public, which recently has already been damaged by missed announcements of public listings, unmet other forecasts, and a major management shake-up.
Conclusions
This Editorial – as by now should be obvious – very clearly is meant to reflect dissatisfaction and even a degree of embarrassment about the current status of egg-donation in the U.S. This sentiment, moreover, also extends from frozen donor-egg banks to agencies which supply patients with “fresh” egg-donors (i.e., donors who go through a fresh stimulation cycle) which, therefore, makes it possible for donor-egg recipients to have a fresh-fresh cycle (fresh eggs and fresh embryos), and with gestational carriers (by many also falsely called surrogates because surrogates also contribute their own eggs). Among gestational carriers we have since the COVID-19 pandemic also noticed a rather steep decline in their clinical quality, finding ourselves much more frequently than in older times, recommending against use of proposed carriers. Moreover, the pricing of agencies for fresh donors and/or gestational carriers has, at times, reached truly absurd levels, especially when it comes to certain ethnicities.
In short, the state of the union is not great when it comes to egg donation (or a gestational carrier pregnancies). Recognizing this fact is an important first step; doing something about it is a very different – and more difficult – issue, and not the least because egg-donation has become such big business.
What we have been witnessing with egg-donation is, therefore, just one more symptom of a more general malaise in infertility practice which is caused by the “industrialization” of everything, from the practice of medicine itself, now increasingly owned by Private Equity and Wall Street, and a support- industry around this practice including testing, pharma, and supply services, as well as frozen gamete banks and various service agencies, all united in one common goal: to increase utilization of fertility-related respective services.
Because the overwhelming goal for all of these interest groups is more revenue and bigger profits, the primary traditional goal of good medical practice – outcome improvements in practice – have fallen by the wayside and are just receiving lip service and, even that, only rarely and then generally only in attempts to safe costs. No wonder IVF has, based on outcomes, actually made no significant progress in over a decade and, to a degree, has even regressed.
References
1. International Fertility Law Group. February 11, 2016. https://www.google.com/search?q=ASRM+settels+class+action+lawsuit&rlz=1C5CHFA_enUS1083US1083&oq=ASRM+settels+class+action+lawsuit&gs_lcrp=EgZjaHJvbWUyBggAEEUYOdIBCjE0MDQxajBqMTWoAgiwAgE&sourceid=chrome&ie=UTF-8
2. Kushnir et al., JAMA 2015;314(6):623-624
3. Souza Setti et al., Fertil Steril 2029;112(3):e120-e121 (abstract)
4. Raphael R. The Free Press, Wednesday, December 4, 2024. https://www.thefp.com/p/fertility-industry-preys-on-female-egg-donors
5. Davalos J, Alexander S. Bloomberg Businessweek. December 2, 2024. https://www.bloomberg.com/news/features/2024-12-02/us-fertility-clinics-helped-a-disgraced-billionaire-deceive-women
6. Patrizio et al., J Assiste Reprod Genet 2025; Ihttps://link.springer.com/article/10.1007/s10815-024-03340- In press.