Donating frozen eggs: Why treatment costs cannot be reimbursed in Australia

With the increasing popularity of egg freezing and ongoing egg donor shortages, a new policy question has emerged: Should the costs associated with egg freezing be returned to patients if surplus frozen eggs are donated? Recently, Dr Alexis Heng Boon Chin argued that repaying these costs should be permitted in Australia, characterising it as reimbursement of reasonable expenses arising from the donation process (see BioNews 1318). However, this proposal is inconsistent with Australia's ethical and legal restrictions on payments for human tissues.

In Australia, gamete donation occurs under a long-standing gift paradigm. Eggs cannot be sold for financial gain; they must be gifted. It is an offence to intentionally provide or offer 'any inducement, discount or priority in the provision of a service' in exchange for human gametes. However, covering 'reasonable expenses incurred in connection with the supply' is permitted. This is to mitigate financial losses that may deter potential donors.

We argue that the costs of egg freezing do not qualify as reasonable donation-related expenses under current law, and that treating them as such risks undermining the gift paradigm.

Egg freezing costs are not reasonable expenses

Egg freezing is most commonly undertaken for personal fertility preservation. It involves medical examinations, hormonal stimulation, and surgical egg retrieval all at the patient's expense. If frozen eggs are no longer required, they can be donated to others.

'Egg-freezers' can be contrasted with a group we call 'de novo donors': individuals who undergo egg retrieval for the primary purpose of donating eggs to others.

While both groups undergo the same procedure and face similar burdens and risks, the purpose for which these are assumed is different. Egg-freezers incur them for personal reproductive goals, whereas de novo donors incur them to support another family's reproductive projects.

This difference matters as, under Australian law, the exchange of money is only permitted if the cost was incurred in connection with supply. For de novo donors, the costs associated with egg retrieval are directly linked to the supply of donor eggs and can therefore be treated as reasonable expenses. For egg-freezers, the costs of egg retrieval were incurred entirely for personal reasons and not as part of the donation process. Electing to donate eggs later does not change the purpose for which eggs were originally retrieved or make the costs donation-related.

This is consistent with how Australian law handles personal reproductive expenses in the context of embryo donation. Federal legislation specifies that costs associated with embryo donation 'do not include costs incurred before an embryo becomes an excess ART [assisted reproductive technology] embryo.' In effect, the costs of obtaining gametes, and of creating and storing embryos for personal use, are detached from the future act of donating surplus embryos. Failing to apply the same standard to frozen eggs would create a regulatory double standard without a principled justification.

Repaying egg freezing costs could undermine the gift paradigm

One reason that payments beyond responsible expenses are prohibited is to uphold the 'gift paradigm' that underpins organ and tissue donation in Australia. The paradigm exists is to avoid treating human bodies like market commodities.

Repaying egg freezing costs could undermine the gift paradigm by providing those who are uninterested in altruistic donation with a new reason to donate. Egg freezing is expensive, and most people never return to use their frozen eggs. For some, recovering several thousand dollars of past medical expenses may be seen as a way to recover money they now regard as wasted. For others, it may be a way to repurpose funds for other priorities. In both cases, the primary motive to donate is non-altruistic.

Further, allowing people to recover past treatment costs if they later donate would mean that fertility preservation could effectively be free. This could influence decision-making: people may be more willing to freeze eggs if they know they can later recoup the cost, and may feel a financial pull to donate rather than discard unused eggs at the end of the process. While these choices may still be voluntary, decisions regarding egg freezing and donation would become increasingly tied up with financial motives.

Evidence-based alternatives for increasing donor supply

Proposals to pay for egg freezing costs have a laudable aim: to increase the supply of donor eggs. Strategies involving the exchange of money are not our only option, though; non-financial strategies could also increase donor supply.

There is limited awareness of the need for donor eggs, the option to donate, and the procedural, legal, and moral aspects of egg donation. Improving public awareness and education could encourage more people who are altruistically motivated to consider donation.

Donor eligibility criteria are known to exclude a significant proportion of prospective donors and vary between clinics, leading to inconsistent access across the sector. These criteria should be reviewed to ensure they are evidence-based, proportionate, and just, while still promoting the wellbeing of donors, recipients, and donor-conceived people.

There is also the broader question of whether we should continue to prohibit payments that exceed reimbursement of expenses. Evidence from the USA indicates that payments do increase the availability of eggs. It is important to acknowledge that fixed payments don't always negate altruistic motivations. For example, the introduction of a fixed sum payment for egg donors in the UK seems not to have displaced altruistic motivations, despite donors being financially better off.

There are, of course, serious ethical issues associated with introducing such payments. Perhaps some of these could be mitigated via regulation, and perhaps some costs are worth bearing to help more people realise their reproductive goals. Nonetheless, changing the law to permit payment for gametes would mark a significant departure from the paradigm that underpins human tissue and organ donation in Australia. This change should not be undertaken lightly.

Conclusion

Repaying the costs of egg freezing if eggs are donated is inconsistent with both the ethical and legal standards that govern organ and tissue donation in Australia. Such payments would retroactively reclassify private reproductive expenses as donation-related and undermine the gift paradigm that underpins Australian gamete donation. If the aim is to increase the supply of eggs from altruistic donors, there are other ways to achieve it.