Bioethics Forum Essay
Bartering Your Eggs: A Rotten Deal
The technology associated with assisted reproduction has grown exponentially in the last two decades. Planned oocyte and sperm freezing, posthumous reproductive genetic testing, and egg and donor sperm brokering are expanding infertility services. Demand has grown, as well. Estimates suggest there are now over one million donor-conceived children, about 10,000 per year. The use of donor gametes has allowed people with infertility or other medical conditions to achieve their parenthood goals.
The settings in which services are delivered are rapidly evolving, too. What was once only offered by academic and private medical facilities has become a burgeoning platform for start-ups, private equity firms, and international entrepreneurs. Corporations are offering insurance coverage for egg freezing for their young female employees. Around the country, egg freezing and egg shower parties market services to women. There are approximately 1,500 sperm banks and around 1,900 egg banks across the world with profits for sperm banks estimated at over $4 million in 2019 and for egg banks $487 million in the U.S. alone.
However, there is significant reproductive injustice and lack of access to fertility treatments by diverse populations. Nowhere is this more obvious than with egg freezing.
Consider a hypothetical case: Josie is a 32-year-old medical intern with at least seven more years of training. She wants to be a parent someday but recognizes that now is not the time. She also knows her chances of having a baby will be significantly lower by the time she finishes her training, at age 39. Josie wants to freeze her eggs, but the cost is high ($4,000 to $8,000) and not covered by her student insurance. A local clinic is offering a new program–free egg freezing–for patients willing to donate half of their oocytes to a donor bank and keep the remaining half for their use. In other words, barter your eggs to be able to afford to freeze some of your own.
Josie pursues information on this option. She learns that, in some cases, she can put stipulations on who can use her donated eggs–she can require the future recipients to be a certain religion, race, or partner status. Josie received significant counseling on the risks and benefits of participation, including the need to consider how she may feel if there are children biologically related to her but raised by other people.
At first glance, what could be wrong with this scenario? It offers Josie a practical and financial solution to her problem, and she has been counseled on the risks. Josie is free to make an autonomous decision about engaging in shared egg banking. But how autonomous is it? The counseling came from the for-profit egg bank that works with the clinic that advertised free egg freezing. (Most counseling of prospective donors comes from egg clinics, although donors can make the effort to seek external counseling.) Is the transaction she is being offered fair?
Josie is getting a service valued at around $8,000, and the egg bank will make around $11,000 per donated egg. Assuming Josie produces 20 eggs, she will have 10 saved for herself and will donate 10. This means the egg bank will make around $100,000 on this exchange (minus the cost of the retrieval and freezing process). There is no guarantee that any of the frozen eggs will produce a baby, however the egg bank profits no matter the outcome.
The huge profit going to the egg bank creates a tremendous conflict of interest by having their employees counsel Josie on her options. The for-profit bank has everything to gain and nothing to lose if Josie says yes.
Josie, on the other hand, has a lot to lose. What if she completes her training, moves to a new city to start her job, and attempts to use her stored eggs, but the fertility center where she now lives won’t accept these eggs? Or none of her eggs survive the freezing process? Or none result in a live birth? Meanwhile there could be children in the world with half her genes. Psychological and emotional support may be required no matter what she consented to years earlier.
During the egg freezing process Josie would have had genetic testing for every genetic risk that was known at the time, but seven years later, there would be new genetic risks discovered. What if Josie is a carrier of a gene for a newly discovered genetic disease? Is she liable for transmitting it? Some egg donor contracts cover this kind of contingency by assigning all fiscal responsibilities to the egg recipients, but there is no regulation or law mandating that they do. Can those who used her eggs go to court to require that she help pay for the care of an affected child?
What if the parents of children born from Josie’s eggs die in a car accident and the children find out who their maternal donor is (perhaps through 23andMeor by suing the egg bank)? Does Josie have any responsibility for those children? Josie may choose to ignore requests to connect with those children, in which case they may resort to media campaigns or social media harassment to locate and connect with her.
When the costs of donor eggs are high, only the wealthy are likely to be able to use egg donation services. So, donations are heading mainly to the rich. If egg donors can select who prospective users will be, as many new egg donor programs are promising as a means of recruiting donors–say, Christians only, no mixed-race or same-sex couples, Indian Americans only, or only those of a particular political orientation–what happens to respect for diversity and social equity? Is there potential societal discrimination when only specific people with certain characteristics can use donor gametes, especially when the donor is relying on racial or ethnic classifications with no firm basis in biological or medical science?
When only financially strapped women participate in egg-sharing programs; when they do so without independent counseling; when they don’t understand their liabilities, responsibilities, and duties to any children created from their eggs; when they are made promises that may not be kept; and when likely only wealthy people can use the gametes, we are robbing these young women of authentic autonomy, leaving them to be exploited by parties with obvious conflicts of interest, reinforcing bigotry, and creating or exacerbating health and social disparities. If infertility treatment is an important human right, it ought to be part of health insurance rather than subject to bartering.
Arthur Caplan, PhD, is the founding head of the Division of Medical Ethics at NYU Grossman School of Medicine. He is a Hastings Center fellow and a member of The Hastings Center’s advisory council. @ArthurCaplan
Gwendolyn P. Quinn, PhD, is the Livia Wan Endowed Chair and Professor in the Department of Obstetrics and Gynecology at NYU Grossman School of Medicine.