Something Increasingly Doesn’t Smell Well in Third-Party Reproduction—Increasing Concerns About Egg Donation and Gestational Carrier Use in the US
The CHR has for some time been getting increasingly concerned about the use of egg donors and gestational carriers (also falsely called surrogates). This concern started brewing almost 10 years ago after the ASRM agreed to settle a class action suit filed by egg donors, ending the society’s practice of publishing guidelines for the egg donor fees that IVF clinics were paying egg donors.¹ Unsurprisingly, one of the consequences was the commercialization of “selling” eggs, and not only by egg donors.
Coincidentally, this court settlement also coincided with the establishment of increasing numbers of frozen commercial egg banks, with some IVF clinics in principle becoming “suppliers” of these egg banks. Almost overnight, a whole egg-freezing industry arose, not only including commercial frozen egg banks but also egg donor agencies, with some specializing in “special” egg donors and charging willing recipients in excess of $100,000 for a single donation cycle (yes, the CHR retrieved several among those, and some were not even good donors).
Yet at the same time, with ever greater choice in egg donors and steadily increasing egg costs (eggs are now were tradable commodity, while before the above-noted lawsuit settlement, donors were, at least conceptually, not paid for their eggs but for their time and efforts in being an egg donor.
There, of course, are ethical as well as philosophical dimensions of reimbursing a donor fairly for her time and efforts, and they differ from making human eggs into a tradable commodity almost akin to Bitcoin (who wouldn’t agree that an egg donation for over $100,000 is not as equally ridiculous as any other speculative financial transaction!).
With increasing offerings from the industry, most IVF clinics abandoned maintenance of their own egg donor pools, which up to that point had been a uniform practice at almost all IVF clinics. And with the disappearance of donor pools in clinics (the CHR is an exception and, still, maintains its own small donor pool), the option of fresh donor egg cycles mostly disappeared (i.e., fresh embryo transfers of embryos created with fresh rather than frozen eggs, as donor banks offered). Except for a small number of IVF clinics like the CHR, which still maintain their own donor pool, the only source for fresh donor eggs, therefore, became egg donor agencies, which, of course, work with considerable profit margins.
Many of these agencies not only offer egg donors but also gestational carriers (GCs). They, therefore, are at times also called surrogacy agencies, as already noted above, a semantically incorrect term because a surrogate is not only a woman who carries a pregnancy, but who also contributes the egg for the pregnancy. A GC, in contrast, does not contribute the egg and just carries an embryo produced by the two partners of a couple.
And just as costs for donor eggs have reached stratospheric heights, so have costs for gestational carriers. Fees in excess of $100,000 plus additional expense reimbursements are almost routine these days. Once again, profit margins for the agencies are substantial in these cases, and as demand has increased, especially after the end of the COVID pandemic. But not surprisingly, so has the quality of the GCs we are seeing at the CHR (we, consequently, recommend to CHR patients to allow a CHR physician to interview any GC before the patient makes a down payment for their GC. While before COVID we rarely rejected candidates, nowadays we recommend rejection of at least a third of the candidates.)
In short, the CHR is increasingly concerned about the quality of egg donors as well as gestational carriers.
And the concern is not only regarding their medical qualifications, but also regarding their honesty in disclosing their medical history, including, for example, prior egg donations. We just recently found ourselves forced to cancel an already scheduled egg donation cycle at its very beginning when the donor, by ultrasound, was found to demonstrate an atypical ovarian scanning pattern suggestive of a recent egg retrieval (obviously elsewhere), which she, of course, had not informed the CHR about, and she actually denied it when confronted.
If egg donors cannot be believed regarding their representations about prior egg donations, how can they be believed regarding all other information they provide and regarding following instructions during their IVF cycles? They really can’t, even using a complex and repeated interview process prior to acceptance as egg donors. And if we can’t trust our quite sophisticated interview process, how can we trust the interview process of egg banks and egg donors, and surrogacy agency processes, which we know are less rigid because we repeatedly have found donor candidates we rejected later in donor bank pools.
Even if told otherwise, we always knew that, with very few exceptions, egg donor candidates and/or being a GC was always mostly motivated by financial needs. But by now, it appears that being donors and/or GCs has seemingly, for many candidates, become at least temporary “professions.” And with it, and due to the fact that a large majority of donor egg cycles in the U.S. now use frozen donor bank eggs, that means that candidate selection now in most cases, has become the responsibility of commercial egg banks.
With the mostly use of frozen eggs, the IVF clinic no longer even has the opportunity to interview the egg donor. The donor selection now is in these cases exclusively the responsibility of the egg bank and/or of its agent’s IVF clinic doing the retrieval, which has absolutely no responsibility for the cycle outcome with these eggs. While we still believe that our multilayered interview process will likely catch most misrepresentations, we simply no longer have the same certainty when it comes to donor egg banks.
As egg donation has increasingly become a “profession” for some young women, it has also become more difficult to believe them about the number of prior IVF retrievals they underwent at other centers. The ASRM used to recommend not more than six such cycles over a donor’s lifetime. This recommendation remained in principle the same in an updated policy recommendation 2024,² but was improved with more explanation (see below).
It is difficult to provide a precise number of times that a given donor can be used because one must take into consideration the population base from which the donor is selected and the geographic area that a given donor may serve. It has been suggested that in a population of 800,000, limiting a single donor to no more than 25 births would avoid any significant increased risk of inadvertent consanguineous conception. This suggestion may require modification when the population using egg donors represents an isolated subgroup or when the specimens are distributed over a wide geographic area. Oocyte donors should be limited to six (6) treatment cycles per donor. The basis for this recommendation is rooted in concern over the cumulative risk for the donor after undergoing more than six ovarian stimulation and oocyte retrieval procedures. When splitting donor embryo batches, the potential risk of siblings in close geographic proximity should be considered. Additionally, donors should be informed about the potential future request for follow-up testing or receipt of follow-up medical information that stems from a medical diagnosis in a donor-conceived child.
Most commercial frozen egg banks, however, do not feel bound by the restriction to six treatment cycles
and, indeed, some do not even have announced limits (a similar problem, of course, also exists with frozen donor semen banks, where some banks still sell semen samples of donors who have fathered over 20 children. As we previously reported, a commercial European sperm bank was this year reported to have provided semen from a single sperm donor who fathered 67 (!) children and was unaware that he was a carrier for a cancer-promoting gene. Ten of those children now have cancer.³
The reason why we are now bringing this subject up is that the legacy media, as well as the medical literature, are starting to pay attention to what is going on with third-party gamete donation and surrogacy. So, for example, we now know what the presumed value of the current U.S. donor egg market is roughly a whopping $400 million)and by 2030 is expected to reach $520.5 million.⁴ The same article also recently listed standard average egg donor reimbursements in the U.S. (of course, excluding “special” donors) at a range of $10,000 to $12,000 per retrieval cycle.
And then there is also, of course, the question about risks for egg donors: while short-term risks of being an egg donor are in general relatively minor (long-term risks have to this day really not been properly investigated); but they most certainly are not nil and to a significant degree depend on the skills as well as professional integrity of the treating physician. Skill is especially important in choosing the right ovarian stimulation protocols and conducting egg retrievals, which mandate repeated insertion of a long needle under ultrasound control through the vagina into both ovaries. A short video of an egg retrieval is shown here.⁵
But professional integrity is probably even more important because every egg retrieval cycle represents an ethical conflict situation between the obvious desire of the operator to maximize profit (which means retrieving as many sellable eggs as possible) and safety of the egg donor because the more eggs a donor produces, the higher is her risk of developing OHSS (ovarian hyperstimulation syndrome) which may require hospitalization and in very rare cases can even lead to death.
Unfortunately, many egg donors are, therefore, overstimulated and OHSS, with proper conservative stimulation and current available medications, fortunately, a very rare occurrence, is, nevertheless, more common in egg donors. A 2023 paper reported severe OHSS in 10% of egg donor cycles,⁶ which we consider a really unacceptable incidence, strongly suggesting either incompetent clinical management or purposeful overstimulation to increase retrieved egg numbers. The current rate of OHSS in a responsible IVF clinic should be significantly below 1%.
The economic incentives for overstimulating egg donors are, however, quite significant: As the article by Faruqui noted,4 egg banks (theoretically this, of course, also applied to IVF clinics) selling 12 batches of frozen eggs for $20,000 per 5-egg batch from a high producing donor (this donor would have to produce 60 sellable—all mature eggs—even with significant hyperstimulation a difficult result to achieve and, certainly, very dangerous for the donor if achieved!), the egg bank would generate from this single retrieval $240,000, while in most clinics the average donor would still only receive a flat rate of $10,000 to $12,000 in payment. The incentive for treating physicians to overstimulate, therefore, will be obvious, especially if they are also personally incentivized by an egg bank based on the number of eggs they retrieve.
There, of course, are also other potential complications, the second most frequent one likely being intra-abdominal bleeding from the retrieval needle accidentally piercing a vessel. And every time a needle pierces skin or mucosa, there, of course, is a risk of infection. Fortunately, both of these risks are very rare.
And now let’s switch to GCs, where the recent literature has become quite worrisome. A Canadian group of investigators published three studies in three different medical journals, all involving the same patient population in the province of Ontario. The most recent study discovered a very disturbing link between being a GC and developing mental illnesses.
All study subjects were women without known mental diseases before pregnancy who gave birth after 20 weeks of gestation. Published in JAMA Network Open, the group reported that GCs during and after pregnancy were more frequently diagnosed with mental illnesses than autologous pregnant women after either spontaneous or IVF conceptions.
Though the paper listed several, fairly typical limitations of this study, the paper did not ask the, in our opinion, most important question: why were these GCs developing an increased incidence of psychiatric diseases?
There are really only two possible explanations:
(i) Women with a predilection toward mental disease are more often than women without such a predilection becoming GCs. Should that be the case, then GCs would have to undergo much more detailed psychiatric screening before selection than they currently undergo (usually just a single interview)
(ii) A second possible explanation is of a more biological nature but may, indeed, cross over into the first explanation: The pregnancy of a GC carrier is 100% allogeneic. This means that egg as well as sperm are genetically different from the GC genetic make-up, while in most pregnancies, only the genetic contribution from sperm is allogeneic (genetically) different and is, therefore, only 50% allogeneic.
Our immune systems in women and men are, however, built to prevent entry into our bodies by allogeneic invaders. A normal immune system is, indeed, ready to attack and destroy any such invader and, indeed, would, for example, in almost all cases instantly reject a kidney transplant from husband to wife (unless the wife receives appropriate immunosuppressive treatments). Yet a 50% allogeneic embryo under normal circumstances is not rejected because, after receiving messages from the embryo, the maternal immune system reprograms itself, making the embryo (and later the whole fetal-placental unit) immunologically “invisible” by inducing so-called tolerance pathways.
Women with abnormal function of their immune systems (hyperactivity because of autoimmunity, inflammation, and or excessive allergies) often demonstrate a reduced ability to induce these necessary tolerance pathways. The result can be early in pregnancy miscarriages and in the third trimester, and often carries over into the postpartum period, premature labor, and certain other pregnancy complications, like severe preeclampsia, all due to too early termination of immunological tolerance of the pregnancy by the maternal immune system.
In the latter case, in this paper reported data may support a notion presented in the literature by Norbert Gleicher, MD, the CHR’s Medical Director and Chief Scientist, already in 2010, in which he suggested that especially peripartum psychiatric diseases (what is now called peripartum depression and/or manic-depressive disease) may have an autoimmune etiology.⁸ A very recent report also raised such a possibility in a Mendelian randomization study that peripartum depression is a risk factor for other autoimmune diseases, including type 1 diabetes, Hashimoto’s thyroiditis, and encephalitis.⁹ An increased risk of other autoimmune diseases in the presence of a first autoimmune disease is very typical.
Another surprising finding—considering that GCs should be selected for being healthy—was reported by these Canadian investigators already roughly a year earlier in the BMJ. In this paper they reported that GCs demonstrated higher risks of developing pregnancy complications, including postpartum hemorrhage, severe preeclampsia and also premature delivery,¹⁰ all findings highly associated with autoimmunity, as Gleicher also already reported in 2010.¹¹ And, finally, the same Canadian group, researching the same patient population (they got 3 papers out of one study!) reported the Annals of Internal Medicine also increased neonatal morbidity in GCs.¹²
In short, all of these data offer significant food for thought regarding the current explosion we are witnessing in third-party pregnancies, at least partially likely induced by the increasing number of celebrities officially announcing their third-party pregnancies.
It appears high time to be more transparent to patients as well as GCs regarding all of these until recently unknown increased risks in a patient population that should be selected for especially good health, and to figure out what is really going on medically with GCs that makes them so complication-prone in association with pregnancy.
Whether they self-select as GCs, in itself a quite fascinating possibility, or whether everything is linked to the difference in percentage of allergenicity of the fetal placental unit, is at a scientific level of considerable interest; but it is, of course, of even bigger importance for GCs and infertile couples who end up with the offspring from GC-pregnancies.
References
Practice Committees of the ASRM & SART. Fertil Steril 2020; 113(6): 1152-1156
Idem. Fertil Steril 2024; 122(5):799-813
Harris C. New York Post. May 24, 2025. https://nypost.com/2025/05/24/world-news/sperm-from-donor-with-cancer-forming-gene-used-at-least-67-times/
Faruqui F. ThinkGlobalHealth. July 16, 2025. https://www.thinkglobalhealth.org/article/money-and-risks-behind-human-egg-donation
Advanced Fertility Center of Chicago. YouTube.
Tober DM, et al., J Assist Reprod Genet 2023;40(6):1291-1304
Velez et al., JAMA Network Open 2025;8(7):e2523428
Gleicher N. Autoimmune Reviews 2002; 6(8):572-576
Yu et al., Frontiers in Psych. 2024;15:1425623
Wise J. BMJ 2024;386:q2100
13. Gleicher N. Clin Rev Allergy Immunol 2010;39(3):194-206
14. Velez et al., Ann Intern Med 2024;177(1):1482-1488