What Are the Costs?
For infertile couples, a once inconceivable notion has become a possibility through egg donation. But now they're bidding up to six figures for blue-ribbon donors, and candidate-rich campuses make fertile breeding grounds for picky parents-to-be. The question is: what are the costs?
Photo: Mark Estes
By Joan O'C. Hamilton
For eight agonizing weeks last fall, Calla Papademas, a 22-year-old Stanford graduate, slipped in and out of a coma in the intensive care unit at Stanford Hospital while her mother, Nancy, kept vigil. One day, seeking a distraction, Nancy began flipping through a copy of the Stanford Daily she had spied on a hospital lounge table. What she saw stopped her cold. The paper was peppered with advertisements from agencies representing infertile couples seeking egg donors, some promising $25,000 or more for candidates with the right combination of intelligence, good looks and athletic prowess.
Seeing the ads seemed a cruel irony to Nancy, whose daughter fit the advertised profile for an egg donor all too well. Months earlier, Calla had answered just such an ad, eventually agreeing to donate her eggs for a fee of $15,000. Now she was lying in a hospital bed, fighting for her life.
Calla had an extraordinarily rare reaction to Lupron, a synthetic hormone administered to prepare her body for egg donation. A few days after Calla began the drug regimen, a benign, undetected tumor on her pituitary gland--which Calla's doctors believe was stimulated by the Lupron--grew at a furious rate and ultimately ruptured, causing a massive stroke. Calla suffered brain damage and lasting weakness on her left side. Her academic and career plans were derailed, and she and her family incurred $100,000 in uninsured medical bills.
Calla's ordeal, while unusual, casts a shadow on the emotionally charged, unregulated world of egg donation, where an influx of big money is exacerbating the ethical, religious and legal dilemmas associated with the practice. For years, the traditional donor fee range has been $1,500 to $5,000, and the clinics involved have been careful to characterize the money paid by recipients as "compensation" for the donor's time and discomfort. But as the pursuit of genetically select offspring has exploded, so have the fees--and concern that human eggs have become just another commodity in a market-driven economy. In the past year, couples have offered as much as $100,000 for eggs from bright, attractive donors like Calla--eggs that statistics say will result in a live birth less than 40 percent of the time and that may not convey the characteristics would-be parents desire.
RESOLVE, a national association and support group for infertile couples, has called for a fee ceiling of $5,000 and a national body to oversee egg donation. And some ethicists are exasperated that the fertility industry continues to gallop ahead as fast as technology will take it. "When people want to [provide an egg] for altruistic reasons, it's a wonderful gift," says Ernlé Young, director of the Center for Biomedical Ethics at Stanford. "When donation becomes commercialized, it raises all sorts of deep, philosophical questions about using humans as a means to an end."
Young and others note that paying big bucks for über eggs goes well beyond injecting supply-and-demand dynamics into the intensely personal realm of fertility. The trend also complicates some of the most elemental aspects of life and human relations, such as parents' expectations of their children and the ethics of putting healthy, young women at risk as commodity purveyors. And advances in unraveling the human genome promise to increase debate about the issue of manufacturing humans.
"Making babies" once was merely a euphemism for intercourse. But in the late 1970s, fertility specialists discovered that they could create a viable embryo by injecting sperm into an egg in the laboratory, a process commonly known as in vitro fertilization. Suddenly, couples with specific medical problems that prevented natural conception, such as a low sperm count or Fallopian tube damage, could hope to have a child. By the mid-1980s, doctors found a way to harvest eggs from one woman, fertilize them, and implant an embryo in a woman who could not conceive with her own eggs, but who could carry a child and give birth. There are now more than 6,000 egg-donation procedures each year in the United States, and several hundred babies at least are delivered to couples who could not have children any other way.
For women who've successfully borne children via egg donation, the procedure's stickier issues are easily overshadowed by their own joy. "It's hard for many women to give up on their own ovaries, but my happiest patients now are those who've had egg donations," says fertility specialist Lynn Westphal, MD '87, who was recruited to set up the Oocyte Donation Program at Stanford Medical Center in 1998. One of Westphal's patients said that when she finally got pregnant and had a child thanks to egg donation, "it was a wonderful, humbling moment of healing. I had been so beaten up by miscarriages and treatments."
Egg donation works like this: The donor begins 10 days of daily injections of a drug such as Lupron to suppress her own ovarian function and synchronize her menstrual cycle with the recipient's. Later, the donor is given another hormone to stimulate her egg production, which can result in 10 or more eggs during one ovulation cycle.
The donor's eggs are extracted using a large needle inserted into the vagina while the patient is under light anesthesia. The eggs are then inseminated immediately, and within a couple of days, a doctor implants several embryos in a recipient to improve the chances of one embryo becoming viable. Recent statistics from 300 U.S. clinics that perform advanced reproductive-technology procedures indicate that live births result from about 39 percent of these procedures. Payment to the donor is made after the eggs are retrieved, however, and is not contingent on either a pregnancy or a live birth.
How safe is this procedure for donors? As Calla Papademas's case shows, powerful medications, anesthesia and surgical procedures always carry some risk. However, Westphal--who did not work with Papademas, and whose patients give her high marks--says most doctors monitor donors closely throughout the process and she has "never seen any serious complications." She does warn donors that researchers are still studying the long-term safety of the procedure and that, in the short term, donors can expect discomforts ranging from mood swings and abdominal swelling to a very painful condition called "hyperstimulation" in which ovaries produce an unusually large number of eggs. This can force hospitalization of a donor to drain large amounts of fluid.
But from the earliest days of in vitro fertilization, debate about the procedure has focused less on patient safety than on the implications of tinkering with life at so elemental a level. The Roman Catholic Church has long condemned all reproductive technologies that manipulate human embryos. It holds that life begins at conception and therefore the risks to any one engineered embryo--some are discarded, frozen or even ultimately aborted if multiple implantations occur--outweigh any benefits to an infertile couple.
And then there is the specter of eugenics, about which the Stanford community has some first-hand knowledge. The University's controversial Nobel laureate, the late William Shockley, generated massive criticism in the early 1980s when he publicly supported--and donated to--a "genius" sperm bank in Southern California. Although Shockley's view that intelligence and other important characteristics were both inherited and race-linked was furiously condemned, there has been little public outcry about egg donor programs unabashedly seeking women with specific physical and intellectual characteristics.
Moreover, medical and ethical experts are quick to point out that medicine cannot assure that any given trait will manifest itself in a baby. "[Eggs from] athletic supermodels with high sat scores . . . may produce dumpy kids who can't do math," notes Henry Greely, '74, a Stanford law professor and co-director of Stanford's Program on Genomics, Ethics and Society. "Most of us who are parents know that the environment makes a difference, chance makes a difference, the other parent makes a difference."
Westphal agrees. Ordering up special characteristics and paying large sums to a select donor "creates unrealistic expectations for the couple," she says. "You never know what kind of child is going to develop from any egg or sperm. You can't guarantee that anyone will have any characteristic."
To what degree could parental hopes backfire on the child? What if the parents felt they "bought" specific characteristics that didn't play out? "It scares me, putting these kinds of expectations on a child before it's born," says Rabbi Michael Gold, author of And Hannah Wept: Infertility, Adoption, and the Jewish Couple. "It's my opinion that a child has intrinsic value and is not here to meet the needs of a parent."
Yet, several women who've borne children thanks to egg donation offer no apologies for searching out particular traits. "Mainly, I was looking for a good spirit," says Lillian, a San Francisco mother and eight-year veteran of infertility treatments. She recently had a baby girl, after paying a donor the "going rate" of $4,000. But she admits that she pored over donors' vital statistics in the binder her agency provided and interviewed the woman she eventually picked. "I may be the best mother in the world, but I'm still going to have some genetic code to deal with," she says, explaining why she looked for signs of an upbeat, appealing, generous nature in donor candidates. And she was eager to improve the odds that her child would share her own tall, blonde features, especially since she didn't tell everyone in her family about the egg donation. "It's just going to fly better at the mall than if my baby has a dark, Mediterranean look," she says of her fair-haired daughter.
'Give the Gift of Life & Love' read a full-page ad placed in the Stanford Daily and in student newspapers at Harvard, Yale, ucla and other schools last spring. It promised $100,000 to a Caucasian woman under age 30 with "proven college-level athletic ability" willing to donate eggs. Numerous other ads have offered between $10,000 and $80,000. Many list highly specific requirements, ranging from sat scores to religious orientation to eye color. Others are less businesslike in their approach: "Bright, creative egg donor wanted by loving, playful Boston couple," read one April ad in the Daily. "We recycle, floss our teeth and respect our elders. . . . Anal personality a plus."
Prospective parents occasionally take out their own ads, but the splashiest displays offering the biggest dollars often come from one of the hundreds of attorneys, agencies and fertility clinics that broker the transactions between donors and recipients. In some cases, those organizations amass profiles of donor candidates and post them on websites, which hopeful recipients can peruse like seed catalogs.
STANFORD was unable to connect with any individuals or couples who paid sums higher than the $15,000 offered to Papademas. Citing privacy concerns, agencies refuse to discuss details about specific ads or couples.
Some skeptics question the legitimacy of large payouts. "I'm a suspicious guy," says Greely. "But why would you pay those amounts when there are donors willing to do it for $3,000 or $4,000? If you're in the egg-donation business, what better way [than a sensational ad] to increase your rolls of donors?"
The Southern California law firm of Thomas M. Pinkerton had several ads in the Daily offering donors as much as $50,000. Darlene Pinkerton, who runs the donor-search program, insists that those offers were real, sponsored by actual clients, and that several Stanford students who were chosen received between $10,000 and $25,000 each. "After the media hype following our [$50,000] ad, we did have other families calling us saying they were looking for the same type of donor but were not able to pay the same $50,000 that we advertised for," she says. "I contacted some of the [prospective donors] who said they were still interested, and made them an offer of dollars that the family could pay. Some said yes; some said no."
There is no way of knowing exactly how many Stanford students are succumbing to the hard-sell pitch for eggs. Conversations with students and local physicians don't seem to indicate that undergrads are flocking to fertility clinics. However, it was not difficult to find a half-dozen students or recent grads who've donated within the past year (all for less than $5,000). Their experiences were mixed, but mostly positive.
Calla Papademas, '99, acknowledges that in the spring of her senior year, when she first answered an ad that offered $50,000 for a donation, she had tens of thousands of dollars in student loans piling up, grad school looming and a clunker automobile that kept conking out. Her mother, who'd gone through several in vitro cycles herself when she tried to conceive a baby after Calla, was supportive. Although Calla wasn't picked for the $50,000 donation, the agency called her back and said someone else was interested--a gay man seeking a donor egg to be inseminated with his sperm, then implanted in a surrogate mother. Calla met the man, and they ultimately agreed on a fee of $15,000; but by then, Calla says, her primary motivation was not the money. "He came from a big family and he loved kids, and this was the only way he could do it," she says.
"Michelle," a recent Stanford grad from Southern California, says she is thrilled with the $7,500 total she made from two egg donations, but she insists the money wasn't the only factor. "It's nice to have a little chunk of change in the bank from this, but it's not purely a capitalist venture," she says. "A friend of mine did it, and afterward she felt so good [about helping a couple have a child] that I decided to try it."
Lauren Russell, '00, had quite a different experience. A veteran of the varsity crew team, tall, intelligent and attractive enough to have done some professional modeling, she answered a $50,000 ad that ran in 1999. When the candidates had been narrowed down to Russell and a Harvard student, Russell was flown to Boston, asked to take an iq test, interviewed and put right back on a plane home. After speaking at length with the donation agent during that visit, she began having second thoughts about participating. The agency focused on Russell's looks, her high iq and her experience on the crew team, she recalls. "That was all that was important to them and all they really wanted to know about," Russell says. "I told them I was curious about why they were looking for these specific qualities and they quickly changed the subject."
Although the money was tempting, "my desire to help a family have a baby became darkened with the realization that the child would be brought into a world full of unfair expectations," says Russell. When the agency notified her that she'd not been chosen, they asked if she'd be willing to donate for a different family for $35,000. She declined: "I've developed negative feelings about the whole idea of paying for specific genes, and no amount of money could convince me to do it at this point," she now says.
Berkeley artist Lisah Horner, one of Westphal's patients, has donated four times, explicitly for the money. She says she's never wanted children and feels no bond to the babies her eggs helped produce--even to the one she actually met. Yet Horner was startled at how empowering she found the process, and how she came away from it with much more empathy toward mothers who desperately wanted children. During her 10 days of hormone injections, she kept a journal that she has incorporated into a collage series. Reads one entry: "An interesting contrast. . . . This procedure--methodical, intimidating, empowering, and physically uncomfortable for myself as well as the other woman. My conception--New Year's Eve 1964--manhattans, champagne, and a little carelessness."
These donors' feelings about the high fees are also mixed. Horner would have happily taken the higher amount had it been offered several years ago when she began donating. Michelle adamantly opposes exorbitant payment. "I know there's something wrong with those ads offering $50,000 or that kind of money. It smells bad to me. I wouldn't trust the kind of doctors in it for that kind of money," she says.
Egg donation "is a classic example of how explicitly market-oriented we are, even though we deny it," notes Linda Hogle, an anthropologist and senior research scholar at the Center for Biomedical Ethics. Despite attempts by the fertility industry to describe money paid for eggs as "compensation" for the donor's inconvenience, says Hogle, many Americans express a "yuck response" to the idea of selling human ova. The fact is, says Hogle, "it's a sale if you get $5,000 or $50,000 or $5."
Many European and South American countries prohibit paying for human eggs and outlaw any kind of commerce in organs or blood. In the United States, blood, plasma and sperm have been harvested and sold for decades. However, the more invasive, more intimate nature of egg donation raises a fundamental moral issue that Young says is at the crux of why prostitution is prohibited--namely, that one should not be able to contract to "use" another person's body, devaluing that person's own humanity.
Stanford law professor Margaret Jane Radin, '63, who studies commodification and the limits of the market, says the issues are extraordinarily complex. Some feminists say, "Let's not degrade ourselves by allowing parts of ourselves to be sold. On the other hand, some feminists say, 'I should be able to sell anything I want to. I don't want the state to tell me what I can sell or not.'" If one takes that reasoning a step or two further, Radin says, the implications escalate in entirely new directions. "Imagine, for example, a student being told, 'Well, you don't need housing assistance because you could just sell your eggs.'" Radin adds: "My parents scrimped and saved to put me through Stanford years ago. Well, what if I'm sitting on a $50,000 entitlement? Does that mean I should just sell my eggs?"
And in a report issued in August, an ethics committee of the American Society for Reproductive Medicine said that while donors should receive some compensation--just as men receive money for donated sperm--the amounts should not be so high that "women will discount the physical and emotional risks of oocyte donation out of eagerness to address their financial situations or their infertility problems." The panel suggested a ceiling of $5,000 for one "donation."
Donors aren't the only ones with financial incentives to consider. Increasingly, physicians whose incomes have been reduced by changes in managed health care are gravitating toward the lucrative practice of fertility treatment. "It's a cash business with affluent patients who pay up front," shrugs one Menlo Park doctor. But Palo Alto obstetrician/gynecologist Andrea Hutchinson cautions that although there are many top-notch fertility practitioners in the Stanford area, "some clinics have become factories, performing these treatments over and over on patients who medically should not even be trying to get pregnant."
It's not immediately obvious upon meeting Calla Papademas, poised, attractive and articulate, that she suffered brain damage. She has made what her mother calls a "miraculous recovery," but she is still impaired. She has memory lapses. She had to leave school, at least temporarily. And doctors have warned that she will probably have difficulty conceiving her own children.
Although Calla says she is angry at the egg-donation agency and about the quality of her medical care at the fertility clinic--(despite severe symptoms that included a high fever and raging headaches, she was advised to continue taking the Lupron, she says)--she is not sour on the procedure. "I wouldn't want this option taken away from someone. . . . I wish I had been better warned," she says.
Shelley Smith of the Egg Donor Program, a respected Los Angeles agency, is concerned that "some of these doctors are treating donors like commodities who are only there to help them get their real patients pregnant." Smith says she has clients who've reported unsettling experiences in egg harvesting, for example. "There are about 20 offices doing this in Southern California, and I only work with two of them," she says, citing concerns about "shoddy" practices at the others.
Ernlé Young believes the time has come for formal regulation of egg-donation procedures. Right now practitioners cannot even agree on basic standards, such as how many times a woman might safely donate eggs. He says even the risk disclaimers donors sign are suspect because of the inherent lure of big dollars. "One of the fundamental elements of 'informed consent' that people [sign in waivers] before a procedure is not only that it is fully informed, but also that it is voluntary," says Young. "You could argue that offering a college kid a sum of money that is excessive is really coercive."
Clergy are grappling with how to advise people concerning egg donation. Rabbi Gold says that, while he would not oppose a couple's desire to use this method, the technology has created some important questions. To begin with, he says, rabbis have been debating just how to establish lineage. Conservative Judaism holds that one is Jewish only if one's mother is Jewish. So, what if an egg donor is not Jewish but the recipient--the birth mother--is? In Gold's opinion, it should be determined by the woman who gives birth to the child.
Meanwhile, according to Smith, futuristic scenarios of parents-in-waiting "constructing" a child already have arrived. Scouring a website where they can select donors, hopeful couples can quickly get caught up in comparison shopping, where physical features are the stock in trade. "Couples who would have been looking for someone with a lovely character before [the Internet] now say, 'Well, we like No. 98, but haven't you got someone with a bluer eye?'"
A bluer eye could be just the beginning. Soon genetic analysis may identify genes responsible for specific traits and make it possible to create embryos "loaded" with the desired genetic material. Step right up, folks. Here's an egg guaranteed to sidestep genetic illness, assure a foreign-language aptitude, produce red hair and freckles and that anal personality you requested.
Now, what am I bid?
Joan O'C. Hamilton, '83, a Stanford contributing writer, is a columnist on high technology for Business Week.
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Data is from the past two weeks.