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ASRM ETHICS COMMITTEE REPORT Financial compensation…
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ASRM ETHICS COMMITTEE REPORT
Financial compensation of oocyte donors
The Ethics Committee of the American Society for Reproductive Medicine
American Society for Reproductive Medicine, Birmingham, Alabama
developments suggest that oocyte donation may become an
1. Financial compensation of women donating oocytes for in- important process in the field of stem cell research.
fertility therapy or for research is justified on ethical The use of financial compensation raises two ethical ques-
grounds.
tions: [1] do recruitment practices incorporating remunera-
2. Compensation should be structured to acknowledge the
time, inconvenience, and discomfort associated with
tion sufficiently protect the interests of oocyte donors, and
screening, ovarian stimulation, and oocyte retrieval. Com- [2] does financial compensation devalue human life by treat-
pensation should not vary according to the planned use of ing oocytes as property or commodities?
the oocytes, the number or quality of oocytes retrieved, When oocyte donation first became clinically available,
the number or outcome of prior donation cycles, or the do-
three sources of donor oocytes were envisioned: [1] women
nor's ethnic or other personal characteristics.
3. Total payments to donors in excess of $5,000 require
undergoing IVF who produced more oocytes than could be
justification and sums above $10,000 are not appropriate. reasonably employed for their own use, [2] women undergo-
4. To discourage inappropriate decisions to donate oocytes, ing an unrelated surgical procedure who undertook controlled
programs should adopt effective information disclosure ovarian stimulation (COS) so oocytes could be retrieved
and counseling processes. Donors independently recruited during surgery, and [3] women who agreed to undergo
by prospective oocyte recipients or agencies should COS and oocyte retrieval specifically to provide oocytes to
undergo the same disclosure and counseling process as do- others.
nors recruited by the program.
5. Oocyte-sharing programs should formulate and disclose However, the clinical success of embryo cryopreservation
clear policies on the eligibility criteria for participants led most women in the first group to choose to have all their
and on how oocytes will be allocated, especially if a low oocytes fertilized and embryos stored for their own future
number of oocytes or oocytes of varying quality are use. Most women in the second group were unwilling to
produced. accept the burdens associated with COS or were excluded
6. Treating physicians owe the same duties to oocyte donors from donating for medical reasons. In the face of a growing
as to any other patients. Programs should ensure equitable medical need for donor oocytes, financial compensation of
and fair provision of services to donors. oocyte donors in the first and third groups has become
7. Programs should adopt and disclose policies regarding cov-
routine.
erage of an oocyte donor's medical costs should she expe-
rience complications from the procedure.
TYPES OF REMUNERATION
In recognition of the significant time, inconvenience, and dis-
comfort associated with oocyte donation, two types of remu-
During the last 2 decades, oocyte donation increasingly has neration are common. One is monetary compensation to
been accepted as a method of assisting women without women who undergo COS and oocyte retrieval for the sole
healthy oocytes to have children. In addition to coordinating purpose of providing donor oocytes. Another form of finan-
the voluntary and usually unpaid donation of oocytes from cial compensation involves an arrangement known as oocyte
friends and relatives, a number of programs offer financial sharing. In this arrangement, a woman may undergo IVF at
compensation to oocyte donors. These remunerations take a reduced cost in exchange for providing some of her oocytes
the form of monetary payment to donors or reduced fees to to another patient.
IVF patients who agree to provide oocytes to others. Pro-
grams also provide services to couples who have obtained oo- A survey published in 1993 found that approximately 60%
cyte donors through their own offers of payment or through of responding programs offered payment to women undergo-
agencies that recruit oocyte donors. Finally, recent scientific ing oocyte retrieval solely to provide oocytes to others (1). In
2004, 94% of the 411 assisted reproduction programs report-
Received January 17, 2007; revised and accepted January 22, 2007. ing to the Centers for Disease Control (CDC) stated that they
Reprint requests: No reprints will be available. offered oocyte donation services (2).
0015-0282/07/$32.00 Fertility and Sterilityâ Vol. 88, No. 2, August 2007 305
doi:10.1016/j.fertnstert.2007.01.104 Copyright ª2007 American Society for Reproductive Medicine, Published by Elsevier Inc.
Although there is some variation in compensation arrange- consequences of their agreement to forgo parental rights
ments, they have certain features in common. Programs, in- and future contact with children born to oocyte recipients.
fertile couples, and independent agencies recruit women for
Another ethical concern is that payment for oocytes im-
oocyte donation through advertising, often through notices
plies that they are property or commodities, and thus devalues
in college or other local newspapers. By early 2005, some
human life. Many people believe that payment to individuals
IVF programs offered as much as $8,000 for one retrieval, al-
for reproductive and other tissues is inconsistent with main-
though smaller sums appeared to be more common. Regional
taining important values related to respect for human life
influences seem to account for these differences. Although
and dignity. This view is reflected in state and federal laws
such payments have generally not been verified, much higher
prohibiting direct payment to individuals providing organs
sums--$50,000 or more--have been offered in print and
and tissues for transplantation. Yet such laws generally per-
Internet advertisements placed by couples or entrepreneurs
mit organ and tissue donors to receive reimbursement for
seeking oocytes from women with specific physical, cultural,
expenses and other costs associated with the donation
or other characteristics and intellectual or other abilities.
procedure. In the analogous circumstance of biomedical re-
Few detailed descriptions of US oocyte-sharing programs search, human subjects exposed to physical and psychologic
have been published. It seems that IVF patients in these shar- risks are often reimbursed for expenses. Moreover, they may
ing arrangements generally donate up to half the oocytes re- receive additional payments to compensate for the time and
trieved in a single cycle to another patient, in return for inconvenience associated with study participation. These
a 50%60% reduction in the total costs of the IVF cycle facts support the compensation of oocyte donors regardless
(3). Oocyte-sharing programs reportedly exist in a number of the ultimate use of the oocytes (e.g., fertility therapy or
of other countries, including the United Kingdom, Israel, research).
Denmark, Australia, Spain, and Greece (4).
Compensation based on a reasonable assessment of the
time, inconvenience, and discomfort associated with oocyte
ETHICAL CONCERNS RAISED BY REMUNERATION retrieval can and should be distinguished from payment for
the oocytes themselves. Payment based on such an assess-
Both monetary compensation and oocyte sharing create the
ment is also consistent with employment and other situations
possibility of undue inducement and exploitation in the oo-
in which individuals are compensated for activities demand-
cyte donation process. Women may agree to provide oocytes
ing time, stress, physical effort, and risk.
in response to financial need. High payments could lead some
prospective donors to conceal medical information relevant As payments to women providing oocytes increase in
to their own health or that of their biologic offspring. Patients amount, the ethical concerns increase as well. The higher
undergoing IVF who cannot afford the procedure may, be- the payment, the greater the possibility that women will dis-
cause of the intensity of their desire to have children, consent count risks. High payments, particularly for women with spe-
to share oocytes without careful consideration of risks and cific characteristics, also convey the idea that oocytes are
burdens. With both types of compensation, there is a possibil- commercial property. Moreover, high payments are disturb-
ity that women will discount the physical and emotional risks ing because they could be used to promote the birth of per-
of oocyte donation out of eagerness to address their financial sons with traits deemed socially desirable, which is a form
situations or their infertility problems. Financial compensa- of positive eugenics. Such efforts to enhance offspring are
tion also could be challenged on grounds that it conflicts morally troubling because they objectify children rather
with the prevailing belief that gametes should not become than assign them intrinsic dignity and worth. Finally, high
products bought and sold in the marketplace. payments could make donor oocytes available only to the
very wealthy.
Concerns Raised by Payment
Women undergoing retrieval purely to provide oocytes to Concerns Raised by Oocyte Sharing
others are exposed to physical and psychologic burdens
Women participating in oocyte-sharing programs undergo
they would not otherwise face. There is some risk of uninten-
COS and oocyte retrieval for their own benefit and to assist
tional pregnancy, because hormonal contraceptives must be
the oocyte recipient. Yet oocyte sharing presents the possibil-
discontinued for donation to occur. Donors also are exposed
ity of added burdens to such women. In some cases, few
to risks of morbidity and a remote risk of mortality from COS
oocytes may be produced. Donors with few oocytes available
and oocyte retrieval. Although the data are unclear at this
for the initial IVF cycle may have their chances of pregnancy
time, it is possible that fertility drugs and procedures involved
reduced. All donors will have fewer oocytes to create em-
in oocyte donation could increase a woman's future health
bryos for their own possible later use; thus, some may need
risks, including the risk of impaired fertility (5). Young
to undergo additional COS and retrieval procedures.
women may be prone to dismiss the potential psychologic
consequences of donation, particularly those that could arise Donors in oocyte-sharing programs also may be required
if they later experience infertility problems themselves. In ad- to undergo the additional medical and psychologic screening
dition, they may underestimate the psychologic and legal required of oocyte donors. They also may experience extra
306 Ethics Committee Financial compensation of oocyte donors Vol. 88, No. 2, August 2007
psychologic burdens. A donor who remains childless may financial incentives do not necessarily exceed and may be
feel added distress based on her knowledge that another cou- less than those experienced by women asked to make altruis-
ple may become the parents of a child genetically related to tic donations to relatives or friends.
her. In a 1997 British survey, 8% of 79 donors who failed
Although the physical and psychologic risks entailed in
to become pregnant reported experiencing such distress (4).
oocyte donation are real, they are not so severe as to justify
Oocyte sharing also raises concerns related to commodifi- intervention to limit the decision-making authority of adult
cation of human life. Women undergoing IVF with the hope women. Programs offering financial incentives should take
of having their own children receive a financial benefit in ex- steps to minimize the possibility of undue influence and ex-
change for providing oocytes to others. Critics of oocyte ploitation by incorporating certain safeguards into the disclo-
sharing argue that it involves ``an indirect form of egg-- sure and counseling processes. Programs can also structure
and ultimately child--buying'' (6). the provision of incentives in ways that reduce the likelihood
that women will be improperly influenced to donate. Such
Women undergoing IVF who agree to share oocytes accept
steps would reflect good ethical practice and reduce the like-
the added time, inconvenience, and discomfort associated
lihood of later legal action by dissatisfied donors.
with the enhanced medical and psychologic screening ac-
companying oocyte donation. It could be argued that the re-
duction in their IVF costs is payment for these and other
added burdens entailed in sharing oocytes, rather than for DISCLOSURE AND COUNSELING
the oocytes themselves. This characterization is somewhat To discourage improper decisions to donate oocytes, pro-
strained, however. The preferable approach is to acknowl- grams should adopt effective information disclosure and
edge the potential for commercialization inherent in such ar- counseling processes. Regardless of how prospective donors
rangements and to consider whether the benefit of expanded are recruited, programs should ensure that they receive accu-
access to IVF is sufficient to override this moral concern. rate and meaningful information on the potential physical,
psychologic, and legal effects of oocyte retrieval and dona-
tion. The potential negative health and psychologic conse-
JUSTIFICATIONS FOR PERMITTING REMUNERATION quences should be openly acknowledged. In the case of
oocyte sharing, it is important that the unique implications
Although potential harm must be acknowledged and ad-
for prognosis and participant burden be addressed in the
dressed, financial compensation may be defended on ethical
counseling and informed consent processes. Prospective do-
grounds. First, providing financial incentives increases the
nors should understand the measures they must take to avoid
number of oocyte donors, which in turn, allows more infertile
unwanted pregnancy during a stimulation cycle. They also
persons to have children. Second, the provision of financial or
should understand that they could later develop desires to es-
in-kind benefits does not necessarily discourage altruistic
tablish contact with genetically related children, desires that
motivations; indeed, in surveys of women receiving such
may be difficult or impossible to satisfy because of legal or
benefits, most reported that helping childless persons re-
other barriers.
mained a significant factor in their decisions to donate
(4, 79). In a recent survey of donors who had been compen- Donor candidates should be encouraged to explore their
sated up to $5,000, 88% of subjects reported that the best possible emotional responses, particularly those that could
thing about the donation experience was ``being able to develop if they have infertility problems themselves. To re-
help someone'' (8). duce the incidence of subsequent psychologic problems, it
would be prudent to limit donors to those who are 21 or older
Third, financial compensation may be defended on
and have the emotional maturity to make such decisions (11).
grounds that it advances the ethical goal of fairness to donors.
There is no doubt that egg donors bear burdens on behalf of To enhance the likelihood that information relevant to do-
recipients and society, and compensation for bearing those nation will be fully explored, programs are encouraged to
burdens are justified morally. Because the burdens of dona- designate an individual with psychologic training and exper-
tion are similar regardless of the ultimate use of the oocytes, tise to counsel prospective donors (12). This individual's pri-
compensating egg donors for fertility therapy differently mary responsibilities are to ensure that the prospective oocyte
from donors for research cannot be justified. Thus, we dis- donor understands and appreciates the relevant information
agree with the recommendation of the National Academy and feels free to decide against donation if doubts arise at
of Sciences with respect to compensation for oocyte donation any point before completion of the procedure. The pros-
for stem cell research (10). pective donor's motivation should be explored during the
session, with the goal of ascertaining whether she fails to ap-
The failure to provide financial or in-kind benefits to oo-
preciate the full consequences of her donation or is improp-
cyte donors would arguably demean their significant contri-
erly discounting the risks because of her economic status or
bution. Such an approach also would treat female gamete
infertility problems.
donors differently from sperm donors, who typically receive
a financial benefit (albeit a modest one) for a much less risky Some empiric data show that egg donors may want to know
and intrusive procedure. Fourth, the pressures created by whether children are born as a result of their donations.
Fertility and Sterilityâ 307
Others may have preferences about how their donated eggs who withdraws for medical or other reasons should be paid
are used (13). For example, they may not want eggs to be pro- a portion of the fee appropriate to the time and effort she con-
vided to unmarried persons or unused embryos produced with tributed. To protect the donor's right to withdraw, oocyte re-
their eggs to be destroyed. Program staff should discuss with cipients must accept the risk that a donor will change her
prospective donors the amount of information they will be mind. In no circumstances should payment be conditioned
given about whether a birth occurs and any control they on successful retrieval of oocytes or number of oocytes
will have over oocyte disposition. retrieved. Likewise, donors should never be required to cover
the costs of the interrupted cycle. To avoid putting a price on
human gametes or selectively valuing particular human traits,
THE INCENTIVE STRUCTURE compensation should not vary according to the planned use
Payment of the oocytes (e.g., research or clinical care), the number
Payments to women providing oocytes should be fair and not or quality of oocytes retrieved (11), the outcome of
so substantial that they become undue inducements that will prior donation cycles, or the donor's ethnic or other personal
lead donors to discount risks. Monetary compensation should characteristics.
reflect the time, inconvenience, and physical and emotional
demands associated with the oocyte donation process.
Oocyte Sharing
A 1993 analysis estimated that oocyte donors spend
Designing a fair oocyte-sharing program requires attention to
56 hours in the medical setting, undergoing interviews, coun-
a number of issues. As noted above, the general approach is to
seling, and medical procedures related to the process. Ac-
reduce the donor's total IVF costs by about half, in exchange
cording to this analysis, if men receive $25 for sperm
for a donation of half the oocytes retrieved. This appears to be
donation, which this analysis estimated as taking 1 hour,
a reasonable allocation of benefits and costs. Because donors
oocyte donors should receive at least $1,400 for the hours
are still responsible for the remaining IVF costs, the differ-
they spend in the donation process (14). In 2000, the average
ence in fees seems not so extreme as to induce women to ac-
payment to sperm donors was $60$75, which this analysis
cept risks they would ordinarily reject. In contrast, a program
suggests would justify a payment of $3,360$4,200 to oocyte
that charged no IVF fee to oocyte donors would raise serious
donors.
concerns about undue inducement.
The above analysis fails to consider the time spent by
The discussion above illustrates that oocyte sharing in-
sperm donors undergoing interviewing and screening. Even
volves unique issues of counseling and informed consent.
if this additional time is taken into account, however, the
Programs have an obligation to use their best medical judg-
lengthier time commitment of women providing oocytes sup-
ment to identify good prognosis candidates eligible for oo-
ports substantially higher payments to them than to sperm
cyte sharing so that any negative impact on the donor's
donors. Moreover, because oocyte donation entails more
prognosis is minimized and cases resulting in a low number
discomfort, risk, and physical intrusion than sperm donation,
of oocytes of acceptable quality are avoided. At a minimum,
sperm donor reimbursement rates are reasonably considered
oocyte-sharing programs should formulate and disclose clear
to underestimate the amount that is appropriate for women
policies on the eligibility criteria for oocyte-sharing partici-
providing oocytes.
pants and on how oocytes will be allocated, with particular
It has been suggested that compensation for oocyte donors attention to the case in which a low number of oocytes or oo-
should be given for the hours spent on medication and on cytes of varying quality are produced. Because of the dispro-
clinic visits, with the hourly rate based on the mean hourly portion in knowledge and expertise between egg-sharing
wage of persons with demographic characteristics similar programs and potential donors, and because of the medical
to those of the donor (15). This method of establishing pay- risks that donors bear, the program should commit to provid-
ment rates presents practical difficulties and arguably would ing some minimal number of oocytes that is clearly compat-
be unfair to women from lower income groups. ible with a good prognosis for conception to the donor before
additional oocytes are shared. If a donor is accepted into an
Although there is no consensus on the precise payment that
oocyte-sharing program, the reduction in fees should not be
oocyte donors should receive, at this time sums of $5,000 or
conditioned on retrieval of a particular number of oocytes
more require justification and sums above $10,000 are not ap-
or quality of oocytes retrieved (11).
propriate. Programs recruiting oocyte donors and those as-
sisting couples who have recruited their own donors should
establish a level of compensation that minimizes the possibil- ADDITIONAL ETHICAL CONSIDERATIONS
ity of undue inducement of donors and the suggestion that
Once the donation process begins, oocyte donors become
payment is for the oocytes themselves. A recent survey indi-
patients owed the same duties present in the ordinary
cates that these sums are in line with the practice of most
physicianpatient relationship. Programs should ensure that
SART member clinics (16).
every donor has a physician whose primary responsibility is
Payment also should reflect the amount of time expended caring for the donor. Oocyte donor program staff should rec-
and the burdens of the procedures performed. Thus, a woman ognize that physicians providing services to both donors and
308 Ethics Committee Financial compensation of oocyte donors Vol. 88, No. 2, August 2007
recipients could encounter conflicts in promoting the best in- Robert Brzyski, M.D., Ph.D., has nothing to disclose.
terests of both parties and should create mechanisms ensuring Jeffrey Ecker, M.D., has nothing to disclose.
equitable and fair provision of services.
Ruth Farrell, M.D., has nothing to disclose.
Programs offering either type of financial incentive should Leslie Francis, J.D., Ph.D., owns stock in Schering-Plough.
adopt and disclose policies regarding coverage of an oocyte
donor's medical costs should she experience health complica- Mark Gibson, M.D., has nothing to disclose.
tions from the procedure (11). Ideally, programs should ensure Anne Lyerly, M.D., has nothing to disclose.
that donors will be covered for any health care costs resulting R. Dale McClure, M.D., has nothing to disclose.
from the procedure. Programs also should consider whether to
make psychologic services available to oocyte donors who ex- Robert Rebar, M.D., has nothing to disclose.
perience subsequent distress related to the procedure. John Robertson, J.D., has nothing to disclose.
Programs offering financial incentives should ensure that Bonnie Steinbock, Ph.D., has nothing to disclose.
advertisements for donors are accurate and responsible. If fi- Sean Tipton, M.A., has nothing to disclose.
nancial or other benefits are noted in advertisements, the ex-
istence of risks and burdens also should be acknowledged. REFERENCES
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1993;59:121620.
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2. http://apps.nccd.cdc.gov/ART2004/nation04.asp (Accessed 13 March
ascertain whether excessive or improper incentives were of- 2007).
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Fertility and Sterilityâ 309