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Now What Do I Tell Her? All The Things to Do to Use Donor Egg

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Title: Now What Do I Tell Her? All The Things to Do to Use Donor Egg


1
Now What Do I Tell Her? All The Things to
Do to Use Donor Egg
  • Maria M Jackson MA, RN

2
Learning Objectives
  • Understand the emotional impact of infertility
    and the transition to using donor gametes
  • Discuss potential gender differences and societal
    influences on each partner
  • Identify concerns and obstacles that impede the
    transition
  • Explore strategies to help patients become more
    comfortable with this reproductive option

3
What is the nurses role in the donor egg process?
  • Role of the nurse in DE is multi-faceted
  • Liaison
  • Educator
  • Sounding board
  • Coordinator
  • Counselor
  • 50 of SART member clinics have MHP on staff
  • Grief counseling integral part of role
  • Failed cycles
  • Miscarriages

4
Steps in the Process
  • Acknowledge their emotions
  • Normalize their feelings
  • Identify their concerns/ obstacles
  • Give them resources
  • Give them time

5
Case Study
  • Dr. Jones comes to your door with Mr. Mrs.
    Smith in tow. They have done 3 IVF cycles and
    have been unsuccessful. Todays consultation was
    to discuss next steps.
  • She is visibly upset and trying unsuccessfully to
    keep her emotions in check. He is looking at his
    watch and appears to be in a hurry to leave. Dr.
    Jones tells the couple hes going to put them in
    your capable hands and youre going to tell them
    everything they need to know about using donor
    eggs.
  • He has already given them a brief overview of the
    process and
  • discussed other options including adoption and
    living childfree.
  • So how do you begin the conversation???

6
How do you begin the conversation?
  • Mary, I see youre upset. This process is
    difficult and challenging. It can feel like an
    emotional punch in the gut
  • Raw emotions can be uncomfortable to witness
  • Crying is an appropriate response
  • Using donor eggs is not a cure for her infertility

7
Acknowledge the emotions
  • Mary, I see youre upset
  • A diagnosis of infertility has been likened to
    Kubler-Ross stages of death and dying because it
    involves multiple losses on multiple levels
  • The emotional response to loss is mourning and
    grieving
  • Couples may not recognize it as such
  • They may need permission to jump off the
    treatment treadmill for a while and just
    experience the emotions

8
Unlike traditional mourning and grieving the
child was never bornso how do you mourn and
grieve a dream?
Dream
Reality
9
Case Study Continued
  • The couple is seated in your office. Mary, an
    attorney is crying and her husband John, a bond
    trader is busy texting. She and John have been
    married for about 10 years.
  • Mary got pregnant in law school before meeting
    John and terminated the pregnancy. They decided
    as a couple to delay childbearing until they were
    established in their careers despite pressure
    from their parents to give them a grandchild.
  • Mary admits she never expected to be infertile
    she has planned her life out with great care and
    was shocked when she didnt conceive. She shares
    that the IVF process is having a negative impact
    on all aspects of her life and now Dr. Jones is
    recommending egg donation. Shes just not sure
    she can use someone elses eggs.

10
Acknowledge the emotions
  • Common emotional responses to infertility
  • Depression
  • Anger
  • Guilt
  • Confusion
  • Loss of control
  • Questioning the meaning of your relationship
  • Failure

11
Normalize Their Feelings
  • Its normal to have fears, concerns, doubts when
    using a third party to conceive
  • This is a nontraditional form of family building
  • No one expects to give over control of their
    reproduction to strangers
  • It may take some time to get comfortable with the
    idea of using another persons eggs
  • Using donor eggs is not a cure for infertility

12
Lots of folks are using the donor egg option
  • SART Clinic Summary Report 2012
  • Donor Oocytes (all ages)
  • Fresh Embryos Thawed Embryos
  • Transfers 9250 7608
  • LBR/ET 56.6 37.2
  • Avg embryos/ET 1.8 1.8

https//www.sartcorsonline.com
13
Gender differences
14
Case Study Continued
  • John has finally put down his phone at Marys
    urging. He reminds her this process is expensive
    so his job is important. Mary asks him how he
    feels about using donor eggs and he replies,
  • Im willing to do whatever it takes to have a
    child. We can choose the donor and you carry
    the pregnancy. Its not what I expected but it
    seems like the best option. Well have a much
    better chance of conceiving.
  • Mary continues to cry and tells John she feels as
    if shes let him down that this is all her fault.
    He reminds her his sperm count wasnt the best
    so he shares some of the responsibility.

15
Gender Differences
  • Mary
  • Role failure
  • Pregnancy is played out in a womans body
  • Impacts self-image
  • Women practice playing Mommy from childhood
  • Experience more stress
  • May need to talk (too much) about infertility to
    cope with the diagnosis
  • Social support is important

Peterson et al Hum Reprod 2006 21 2443-2449
16
Gender Differences
  • John
  • Distancing more often used by men to cope
  • Not comfortable exposing themselves emotionally
  • May work longer hours
  • May consume more alcohol
  • Self-control and problem solving typical
  • He wants to fix this for his partner
  • His coping style does not mean hes less invested

17
Identify Obstacles
18
Common Obstacles
  • Unresolved issues surrounding the couples
    infertility
  • Societal attitudes
  • Religious restrictions
  • Age
  • Fears about the donor
  • Honesty
  • Reliability
  • Can I see a picture?
  • Concept of multiple parents
  • Concerns about bonding with the baby
  • Is it going to work????

19
Unresolved issues surrounding the couples
infertility
  • Grief work is an integral part of the process
  • Many losses
  • Closeness as a couple
  • Confidence in their ability to accomplish an
    important life task
  • Both must mourn the loss of the womans genetic
    contribution
  • Unsure how to help each other cope with the
    complex personal medical issues
  • Unexpressed anger, fears or concerns about using
    donor gametes

Mahlstedt Greenfeld Fertil Steril 1989 52
908-914
20
Strategies
  • Mandatory pyscho-educational meeting with MHP
    before they can cycle
  • They dont know what they dont know
  • In person or online support groups
  • Resolve http//www.resolve.org/support-and-servic
    es/
  • The American Fertility Association
  • http//www.theafa.org/advice-support/

21
Societal Attitudes
  • Her horrifying personal story about using a host
    of assisted reproductive technologies (ART),
    including in vitro fertilization (IVF) and egg
    donation, in an effort to have a child is part
    memoir and part exposé of an unscrupulous,
    high-profit industry. Its a compelling read.
  • Book describes a 6 year struggle with infertility
    that ended with the couple adopting

22
Societal Attitudes
  • Blood is thicker than water
  • Does society favor biological ties?
  • At least one of us will be biologically
    connected
  • Are we as a society ambivalent about
    non-traditional family building?
  • Will the grandparents love this child the same?
  • Will this child be accepted or treated
    differently?
  • My religion doesnt condone the use of donor
    gametes under any circumstances
  • If God wanted me to be pregnant it would have
    happened

23
Strategies
  • In 2014 families are created in many ways
  • We assume a biological and genetic connection
    that may not be present
  • A grandparents ability to love their grandchild
    is not dependent on a biological connection
  • Fear of parents rejection may be related to
    life-long issues (rejection/criticism) rather
    than the childs means of conception
  • Religious sanction for ART may never happen
  • If God didnt want people to have children these
    technologies would never have been developed

Mahlstedt Greenfeld Fertil Steril 1989 52
908-914
24
Is this the new normal? New technologies and
cultural shifts have created a booming cohort of
wrinkled moms and dads with newborn babies. So
why do older parents make so many people uneasy?
By Lisa Miller
25
Is She Too Old For This?
  • Old parents face a version of the judgment
    implicit here They have no idea what theyre in
    for. More than that This is just not right. A
    new child may be a blessed event, but when a
    50-year-old decides to strap on the Baby Björn,
    that choice is seen as selfish and overwhelmingly
    prompts something like a moral gag reflex.

26
How old is too old?
  • Concerns for the mothers health
  • Careful screening required
  • Adequate counseling re risks of complications
  • SET strongly recommended
  • Discouraged/denied in women 50 and over with
    underlying medical conditions gt55 regardless of
    health

ASRM Ethics Committee Report Oocyte or embryo
donation to women of advanced age Fertil Steril
2013 100 337-340.
27
How old is too old?
  • Ethical concerns for the donor conceived
    offspring
  • Possibility that one or both parents could die
    before the child reaches adulthood
  • Stresses of parenting as an older parent
  • Difficulties of meeting the emotional and
    physical demands of parenting

ASRM Ethics Committee Report Oocyte or embryo
donation to women of advanced age Fertil Steril
2013 100 337-340.
28
Strategies
  • Ageism still an acceptable bias in 2014
  • Hypocritical given how many US grandparents are
    primary care givers to young children today
  • 3 mil (2011) Pew Research Center
  • Older parents often have more resources
  • Age alone does not make one a good parent
  • Less parental stress reported by older moms
  • ART children outperformed peers on standardized
    test scores in a comparison study
  • Older the mom the better the better they did

http//www.pewsocialtrends.org/2013/09/04/at-grand
mothers-house-we-stay/ Van Voorhis et al Hum
Reprod 2010 25 2605. Paulson Fertil Steril
2007 87 1327- 1332
29
Fears about the donor
30
Fears about the donors
  • Who are they?
  • Why do they do it?
  • What are the options?
  • How are they screened?
  • What characteristics should I consider?

31
Donors Who are they?
  • 21-31/32yo
  • Motivation is a combination of altruism and
    financial compensation
  • Compensation amounts vary regionally
  • They often know someone whos experienced
    infertility and want to help

32
Donors Source options
  • Clinic recruited (Fresh)
  • Couple is screened and matched by the clinic
    staff
  • Agency recruited (Fresh)
  • Couple selects donor to be screened
  • Egg bank
  • Screened and stimulated

33
Source options Clinic recruited
  • Advantages
  • Passed screening
  • Donor is known to staff
  • Disadvantages
  • Couple is matched to the donor
  • Identity release option not available
  • May or may not see photos

34
Source options Agency recruited
  • Advantages
  • Couple selects donor
  • Can see photos
  • May choose identity release
  • Disadvantages
  • May not pass screening process
  • Emotional let down
  • Compensation may be higher
  • Travel expenses additional cost

35
Source options Egg Banks
  • Advantages
  • Convenient
  • Affordable
  • Timing is not an issue
  • PR are comparable
  • Disadvantages
  • Fewer frozen embryos
  • Inventory ebbs and flows
  • Some still consider this experimental

36
Source options Egg Banks
  • In 2013 ASRM Practice Committee published a paper
    entitled, Mature oocyte cryopreservation a
    guideline
  • Removed the experimental status
  • Impacted insurance coverage
  • Made egg banks more accessible to patients in
    states with mandated coverage for infertility

Fertil Steril 2013 99 37-43
37
Donors How are they screened?
  • ASRM Guidelines
  • FDA
  • Genetic
  • Ovarian Reserve
  • General health
  • Psychological
  • Fertil Steril 2013 99 47-62.

38
Donors How are they screened?
  • Psychological screening is as important as
    physical screening
  • MMPI/PAI
  • Clinical interview
  • Ovarian reserve screening may be of particular
    importance to young recipients
  • Discuss the significance of blood type

39
Donors Can I see a picture?
  • Policy varies from clinic to clinic
  • Adult/childhood/both
  • Egg banks policies may also vary
  • Some recipients find a picture comforting others
    a reminder of the donor

She has to be young and pretty just like me
40
Strategies
  • Reassure them Donors are nice people
  • In person forums very helpful
  • Give them a list of all the testing done
  • Provide a genetics report
  • Emphasize the thoroughness of the psych
    evaluation
  • Info re ovarian reserve testing
  • Significance of multiple measures D3, AFC, AMH
  • Discuss the significance of blood type

41
Concept of Multiple Parents
  • Whether the couple discloses the use of donor
    eggs to the outside world or not they know there
    is a third person involved
  • Genetic and biological relatedness not required
    to create a family
  • Framing the use of donor gametes in the context
    of society as a whole may be helpful
  • Divorce
  • Adoption

42
Concept of family is changing
43
Concept of Multiple Parents
  • Donor presence recedes over time but never really
    goes away
  • Focus changes over time from donor and recipient
    to the offspring
  • Offspring are often the forgotten ones
  • Who is the real mother?

44
Strategies
  • There is one mother
  • Introduce the concept of mDNA
  • Empowering and restores a sense of control
  • Anonymity infers no identity
  • Donor is real and will always be a part of their
    lives
  • She can be a helper or a threat
  • Prepare them for resemblance talk
  • Innocent remarks can be a painful reminder of the
    donors presence

45
Concerns About Bonding
http//www.nurture.co.za/wp-content/uploads/post-s
ecret.jpg
46
Concerns About Bonding
  • I fell in love with my son the moment I saw him
    for the first time on the ultrasound. I will
    never forget how it felt to see his tiny
    heartbeat flashing on the screen before we could
    even hear it.
  • I know that he is not genetically related to me.
    But he still is, and always will be, MY SON. I'm
    the one he snuggles next to when he's hungry and
    wants to nurse. I'm the one he cries for when he
    wakes up in the middle of the night and can't
    sleep. I'm the one he crawls to with a big smile
    on his face when I come home after a long day at
    work. He is MY SON and I am HIS MOTHER. I love
    him so much it makes my heart ache. I have never
    felt disconnected from him and I don't ever
    really think about the fact that we don't share
    DNA.

http//anonymousus.org/stories
47
Concerns About Bonding
  • I am pregnant with a donor baby and basically
    have butterflies in my stomach the whole time
    time. I don't feel like I am bonding with it al
    all. I wish it would miscarry and go away because
    it just doesn't feel right. The clinics don't go
    through this do they when they take your payment
    of 8,000 None of this is discussed. The whole
    thing just feels wrong to me. I did this for my
    husband. He so wants to be a dad. People do have
    a right to know where they come from. It's a
    natural human instinct to want to know. But it's
    also a natural human instinct to want to pass on
    your jeans and have children. But if this cannot
    happen for couples, then that should be it. IVF
    fine, but using other people's eggs and sperm is
    wrong and a step too far. I feel what we have
    done is wrong. My husband has no idea how I feel.
    I feel very alone and isolated with no to talk
    to. Everyone expects me to be happy but I am
    putting on a brave face. I have been off work for
    weeks with terrible morning sickness and just
    want this baby to go away so that we can live a
    clean life.

http//anonymousus.org/stories
48
Strategies
  • Concerns are real and appropriate
  • It is normal to have concerns
  • Not everyone will embrace the DE option and we
    shouldnt talk them into it
  • 23 chromosomes exert a lot of influence
  • Child will never have Dads ____ or Moms ____
  • Maternal DNA is also being passed to the child
    during pregnancy
  • Responsible for far reaching epigenetic
    modifications

49
Is It Going to Work?
  • Investment of time money and emotions are worth
    it if
  • Some are not prepared for negative outcomes no
    matter how much theyre counseled
  • 40-60 of embryos are euploid
  • Realistic expectations
  • SART data 56.5 THBR

50
Strategies
  • Manage their expectations
  • Give them SART Summary Report for your clinic
  • Discuss inherent loss rate in pregnancy
    regardless of age
  • Review normal reproductive physiology and rate of
    attrition from follicle ?egg?embryo?baby
  • Be honest there is a leap of faith required
  • Increasing number of IRMS patients choosing aCGH
    to maximize their chances

Patrizio P, Sakkas D. Fertil Steril 2009
911061-1066.
51
Resources
52
Resources Bibliography
  • Give them all the information they need to make
    an educated decision
  • MHPG Bibliographyhttp//www.asrm.org/uploadedFiles
    /ASRM_Content/About_Us/Specialty_Societies/Profess
    ional_Groups/MHPG/MHPG_Childrens_Bibliography.pdf
  • Translated into many languages
  • http//booksfordonoroffspring.blogspot.ca/
  • Selective reduction

53
Resources Donor Selection
  • Health and family health hx most important
  • Blood type disclosure decision impacts donor
    choice
  • Education often confused with intelligence
  • Open identity option?
  • Influence of staff on donor choice
  • They trust you and your opinion matters

Braverman et al Fertil Steril 2011 96 S10
Braverman et al Fertil Steril 2010 94 S67.
54
Resources Disclosure
  • Parents may be conflicted
  • Fear the child will want to find the donor
  • Some make legitimate reasons for non-disclosure
  • Fear stigmatization if DE goes against cultural
    norms
  • Timing is important
  • Research comparing DE, DI to adopted and
    naturally conceived positive

Golombok et al Hum Reprod 2002 17 830-840
55
Case Study
  • Mary and John have opted to use a fresh donor
    from our program. They had looked at multiple
    profiles and asked for input from the DE team re
    the best donor. They are not sure if they are
    going to disclose the use of donor egg to their
    children. It has taken Mary a few months to get
    comfortable with the idea of using donor eggs.
    She asked if she could talk with another
    recipient who has already cycled and seemed more
    at peace after doing so.

56
Give Them Time
  • Reproducing with someone elses eggs is not the
    same as using ones own
  • Waiting list can offer the gift of time when the
    couple is on the treatment treadmill and cant
    get off
  • This is a process that requires assimilating a
    lot of information

57
Final Thoughts
  • Be aware of your personal feelings re third
    party reproduction
  • Your opinions matter
  • We communicate both verbally and non-verbally and
    may be influencing patients
  • My personal philosophy is to be as unbiased as
    possible
  • Give them the resources and let them make the
    decision

58
Summary
  • DE is not a cure for infertility
  • Patients often have many concerns and obstacles
    transitioning to DE
  • The nurses role is multi-dimensional and
    significant
  • There are many resources available to patients to
    help them make informed choices

59
IRMS at St. Barnabas
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