It is well-known that there are critical shortages of eggs available for assisted reproductive treatment in countries, such as Australia, that rely on altruistic donation. Less well recognised is the fact that these shortages extend to access to eggs for research purposes. With advances in fertility treatment, increased demand for eggs is bringing these shortages into sharp relief.
In Australia, the current process to implement mitochondrial donation is likely to increase demand for eggs, for both treatment and research purposes. Australia recently legalised mitochondrial donation for research and training purposes with the Mitochondrial Donation Law Reform (Maeve's Law) Act 2022. with the Federal Government providing funding for a five-year Mitochondrial Donation Pilot Program to determine the safety, efficacy and feasibility of implementing mitochondrial donation into clinical practice. Following outcomes of this trial, mitochondrial donation could be made available in the clinical practice setting.
The clinical trial and associated further research into mitochondrial donation techniques requires access to donated eggs. While Australian researchers are currently heavily reliant on animal eggs, the transition to clinical practice will require human eggs for research and training purposes, as well as for reproductive purposes.
Gamete donation in Australia must be altruistic. The donor can only be reimbursed for verifiable out-of-pocket expenses and cannot receive financial reward or inducement. For the most part, donors for reproductive purposes are recruited by the intended recipient themselves.
During 2020-2021 a report showed that in the Australian state of Victoria, 81 percent of egg donors were recipient recruited, 12 percent were obtained through an overseas egg bank, and seven percent were recruited through a clinic. Donation of gametes for research purposes is very limited: while in principle, eggs excess to reproductive treatment can be donated for research, in practice there are considerable barriers to this happening, research published over a decade ago in Sociology of Health and Illness has shown.
While various solutions to egg shortages have been discussed, both in Australia and internationally, these have often focused on increasing supply for reproductive purposes. Furthermore, they are for the most part focused on financial mechanisms to elicit increased donations, such as systems for increased compensation. As such, they blur the lines of altruism and commercialism; however, empirical research published in Human Fertility from New Zealand suggests that altruistic egg donors resist a commercial model. In the Australian context, such proposals are also likely to fall foul of regulation that prohibits mechanisms such as discounting of services to incentivise donation. Ultimately, they do little to address the question of how to meet the need for eggs for research purposes.
A new approach is required. We suggest that the solution lies not in changing compensation systems but in changing consent systems. Specifically, we argue that consent processes for elective egg freezing should change such that donation to research becomes the default option for eggs that remain unused at the end of the cryopreservation period.
In Australia as elsewhere, the popularity of egg freezing has increased dramatically in the past decade. In Victoria alone, the number of women in 2020-2021 who froze their eggs increased by 23 percent from the previous year. Overall, the number of egg freezing cycles by 311 percent in the 2010-2015 period in Australia and 880 percent in 2010-2016 in the USA, research published in Human Reproduction has shown. Even so, a recent international study published in Fertility and Sterility indicates that fewer than half of people freezing eggs for elective reasons return to use them.
Eggs that are unused at the end of cryopreservation periods are an untapped source for eggs for research purposes. While limits for cryopreservation periods vary, when those limits are approaching, Australian clinics must make reasonable efforts to contact the person whose gametes are frozen. Where contact is not achieved, and no other directive given as to the disposal of the frozen material, the gametes, including eggs, are to be discarded.
We propose that rather than discarding such eggs, they should instead be automatically directed to research. Essentially, this amounts to an 'opt-out' consent model for donation of eggs for research purposes. People should be appropriately counselled at the point of undertaking elective egg freezing, and opportunities to opt out – such as the current procedure at the end of the freezing period – should be maintained. But unless there is a specific request for another option, such as donation for reproductive purposes or discard – then eggs remaining at the end of cryopreservation periods should become available for research purposes.
While opt-out systems have been controversial in the context of organ transplantation, where they are adopted to increase supply of donated organs post-mortem, we believe that in the egg freezing context the controversial features can be avoided. In particular, no one is born into the opt-out system in this context; rather, in undertaking egg freezing, people are essentially 'opting in' to the opt-out system. Naturally, the ethics of this proposal rest somewhat on the details of implementation. But we believe that ethical implementation can be achieved with appropriate counselling and opt-out opportunities.
While we focus on the Australian context, this proposal has far wider implications. The shortage of eggs for both reproductive and research purposes is an international phenomenon, as is the increasing popularity of fertility preservation through elective egg freezing. Refining the practice and protocols for one of these – elective egg freezing – in order to resolve problems in the other – eggs for research purposes – is unlikely to cause harm and instead, will bring significant benefit. Boosting access to human eggs for researchers is critical to improving reproductive technologies such as mitochondrial donation and facilitating implementation in clinical practice.