controversial issues in clinical practice. Oocyte donation: controversial issues in clinical practice. Results in a program of reciprocal donation. Henk Ruis MD, Obst & Gyn, PhD, CEO Stg Geertgen Behandelcentum Stg Geertgen, Elsendorp Upcoming challenges, Leiderdorp, 04.10.2013

Conflict of interest: none Upcoming challenges, Leiderdorp, 04.10.2013

Framework for gamete donation EU Tissue Directive 2004/23/EC Technical directives Upcoming challenges, Leiderdorp, 04.10.2013

Framework for gamete donation EU Tissue Directive Landelijke richtlijn Embryo Act Dutch Donor Registration Act Upcoming challenges, Leiderdorp, 04.10.2013

Framework for gamete donation EU Tissue Directive Landelijke richtlijn Embryo Act Dutch Donor Registration Act Upcoming challenges, Leiderdorp, 04.10.2013

Types of gamete donation Altruistic donation Donation with payment to donor Sharing Reciprocal donation – ‘wederkerigheid’ Upcoming challenges, Leiderdorp, 04.10.2013

Reciprocity – wederkerigheid Reciprocity refers to responding to a positive action with another positive action, rewarding kind actions Wederkerigheid is de onderlinge verplichting binnen een relatie om een gift te beantwoorden met een tegengift Cooperative reciprocal tendencies i.e. inclinations to give back in a cooperative manner, are called positive reciprocity. Upcoming challenges, Leiderdorp, 04.10.2013

Upcoming challenges, Leiderdorp, 04.10.2013 Solidarity Vertical Health Insurance system in Netherlands State controled mandatory health insurance ‘General Law on Exceptional Healthcare Costs’ Premiums may not be related to health status or age Risk equalisation with a common risk pool. Upcoming challenges, Leiderdorp, 04.10.2013

Reciprocity A form of horizontal solidarity Local Exchange Trading System – LETS Is a locally initiated, democratically organised, not-for-profit community enterprise that provides a community information service and record transactions of members exchanging goods and services by using the currency of locally created LETS Credits. For instance, a member may earn credit by doing childcare for one person and spend it later on carpentry with another person in the same network. Upcoming challenges, Leiderdorp, 04.10.2013

Upcoming challenges, Leiderdorp, 04.10.2013 Donation of gametes No provisions for donation of gametes by government Historicaly shortage of donors and donor material At time of change from A to B donors: Minister of Health promised to facilitate the recruitment of donors Limited to production of 2 information flyers : one for donors and one for recipients Upcoming challenges, Leiderdorp, 04.10.2013

Upcoming challenges, Leiderdorp, 04.10.2013 Donation of gametes Donor recruitment private initiative is necessary Upcoming challenges, Leiderdorp, 04.10.2013

Donation of gametes Reciprocity system One patient is in need of donor sperm Other patient is in need of donor oocytes Reciprocity system - ‘wederkerigheid’ Bank Upcoming challenges, Leiderdorp, 04.10.2013

Donation of gametes: Is there a need? The primary recipients of donor sperm are heterosexual couples suffering from severe male infertility lesbian couples single women Upcoming challenges, Leiderdorp, 04.10.2013

Donation of gametes: Is there a need? The primary recipients of donor sperm at Stg Geertgen are heterosexual couples suffering from severe male infertility - 1/3 lesbian couples - 1/3 single women - 1/3 For use in IUI or IVF/ICSI Upcoming challenges, Leiderdorp, 04.10.2013

Donation of gametes Sperm donation at Stg Geertgen 30% of patients bring own sperm donor 30% of patients use sperm from Stg Geertgen altruistic sperm donor bank 20% of patients use sperm from external donor bank 20% participate in reciprocity system Upcoming challenges, Leiderdorp, 04.10.2013

Donation of gametes: Is there a need? The primary recipients of oocyte donation at Stg Geertgen are Patients suffering from severe female infertility eg. POF, genetic indication Intra-relational donation - lesbian couples For use in IVF/ICSI Upcoming challenges, Leiderdorp, 04.10.2013

Donation of gametes Oocyte donation at Stg Geertgen 50% of patients bring own oocyte donor 50% by reciprocity system Upcoming challenges, Leiderdorp, 04.10.2013

Donation of gametes: Sperm - oocytes Stg Geertgen in 2012 Only 30% of need for donor semen is fullfilled by reciprocity Sperm donor from bank is a realistic option More requests for oocytes through reciprocity than offered Donor oocytes from bank is currently not a real option Upcoming challenges, Leiderdorp, 04.10.2013

Upcoming challenges, Leiderdorp, 04.10.2013 Donation of gametes Free choice to become a donor Counseling by fertility specialist risks of treatment Counseling by fertility psychologist implications of donation – B donor – psychosocial stability Donor participating in reciprocity: extra counseling Sign inform consent Upcoming challenges, Leiderdorp, 04.10.2013

Upcoming challenges, Leiderdorp, 04.10.2013 Donation of gametes Maximum age = 37 years ±50 years Psychosocial stable person Serological tests ok Genetics ok Healthy life style ok Upcoming challenges, Leiderdorp, 04.10.2013

Upcoming challenges, Leiderdorp, 04.10.2013 Donation of gametes: is there a need? Results with natural cycle Donor IUI Stg Geertgen in 2012 Donor IUI 2012 Donor IUI 2013 (1-5) Number of cycles 2257 785 Pregnant per cycle 227 10,1% 82 10,3% Ongoing pregnancy rate per cycle 157 6,9% 65/695 9,4% Upcoming challenges, Leiderdorp, 04.10.2013

Donation of gametes: is there a need Donation of gametes: is there a need? Results with Donor oocytes - freeze/thaw of embryos Stg Geertgen in 2012 Number of cycles Number of patients Number of embryos thawed % Survival Mean numebr of embryos per thawing Number of transfers Mean number of embryos per ET % Clinical pregnancy rate per transfer Miscarriage rate Stg Geertgen 238 123 301 78,1% 1,1 (1-4) 209 1,1 (1-2) 25 11,9% 30,6% Landelijke registratie 7513 1124 15% 32,6% Upcoming challenges, Leiderdorp, 04.10.2013

Upcoming challenges, Leiderdorp, 04.10.2013 Reciprocity Not a free system. Voluntary and informed choice All information concerning reciprocity is published on website and in brochure Stg Geertgen is open and clear about the reciprocity system Upcoming challenges, Leiderdorp, 04.10.2013

Upcoming challenges, Leiderdorp, 04.10.2013 Reciprocity Reciprocity is undermining national (vertical) solidarity system of health care. “Het systeem van ‘faire wederkerigheid’ ….. . Als het echter gaat om het doneren van geslachtscellen lijkt de rol van de overheid eerder beperkend dan stimulerend.” Minister van Volksgezondheid, Welzijn en Sport, mw. drs. E.I. Schippers 11.07.2013 Upcoming challenges, Leiderdorp, 04.10.2013

Upcoming challenges, Leiderdorp, 04.10.2013 Reciprocity Recipient is pregnant, but donor is not. This is of course possible, this issue is discussed in detail during cousneling sessions with psychologist and fertility specialist. If issue is not accepted by patient, treatment will not commence. Stg Geertgen 2012 - 2013 10 donors are not pregnant but are still undergoing treatment 2 stopped treatment 1 couple received oocytes resulting in pregnancy but partner semen was never donated to bank Upcoming challenges, Leiderdorp, 04.10.2013

Upcoming challenges, Leiderdorp, 04.10.2013 Reciprocity No need for fertility tourism Reduce time ‘start to treat’ (<3 months) ‘Matching’ of donor and recipient is possible Outcomes are good Patient is in charge of treatment Accepted by society Acceptance by professional body is growing Upcoming challenges, Leiderdorp, 04.10.2013

Upcoming challenges, Leiderdorp, 04.10.2013 Reciprocity Number of patients that will enrole in reciprocity donation system is limited Banking of donor oocytes by vitrification will change strategy Use of vitrified oocytes from ‘donor oocyte bank’ will result in less oocytes necessary per recipient Cost reduction through ‘donor oocyte bank’ Follow up of children and families in reciprocal donation program is mandatory Upcoming challenges, Leiderdorp, 04.10.2013

Upcoming challenges, Leiderdorp, 04.10.2013 Teamwork Behandelcentrum Stg Geertgen Pater Rossaertstraat 3 - 5424 TG Elsendorp Directie - Henk Ruis - algemeen directeur - Han Michgelsen - medisch directeur - Erik Unterhorst - directeur laboratorium - Bas Ruis - directeur beheer Gynaecologen - Carola Backx - Eric Mendels - Han Michgelsen - Henk Ruis Fertiliteitsartsen - Daniëlle Bax - Marieke van den Broek - Frank van Heerebeek - Mathilde Kuijpers - Dolf Wissmann Psychologen - Martje Ubbens - Marloes Verhulst - Judith Zegers Gespecialiseerd verpleegkundigen - Corine Aldenzee - Veronique de Brouwer - Judith Dongelmans - Kristel van Lieverloo - Marie-Louise van de Loo - Dorien Philipsen - Jeanne van Santvoort - Simone Verboven - Tiny Wagemaker - Brigitte van den Woldenberg - Brigitte Zimmerman Secretariaat - Ad de Beer - Anky Buijs - Anja Hezemans - Susan Hoevenaars - Lia Scheltenaar - Gerda Schrauwen Medisch receptionistes - Karin van Dommelen - Judith Drouen - Hilke van Duijnhoven - Hilde van Heck - Rodette Janssen - Karin Leenders - Astrid Michiels - Marianne Peeters - Stefanie Sam - Ine Schepers - Judith de Visser Sr Klinisch embryologen - Erik Unterhorst - Martine Nijs Andrologie Analisten - Marianne Huijbers - Linsey van Lieverloo - Rita Martens - Roger van de Wetering - Peter Wiering IVF-analisten - Dorien van der Heijden - Corlinda Martens - Marleen Sevenster Donorenbegeleiding - Dirk van Bragt - Bauke Geeris Doktersassistentes - Suzan Klomp - Monica van Os Apotheker - Pieter Weerts Apothekersassistentes - Petra Coopmans - Thea Muijsers - Annette Roelands - Antonie van de Ven - Heidi Vereijken Facilitair medewerksters - Joke Bekx - Tini van Berlo - Thea van der Cruijsen - Karin Sterken - Stella van Tilborg - Ingrid Verwegen Kwaliteitsmedewerkers - Sharon de Bruin - Anneke van Dommelen - Frenk Habraken - concierge - Martine Nijs - wetenschappelijk adviseur - Janine Ruis - juridisch medewerker - Marcel Ruis- human resources manager - Tina Ruis – patientenbegeleiding - donatie Upcoming challenges, Leiderdorp, 04.10.2013

Upcoming challenges, Leiderdorp, 04.10.2013 Thank you! Upcoming challenges, Leiderdorp, 04.10.2013