Patients, instead of medical professionals, should directly reimburse egg donors for their time, inconvenience and potential loss of earnings

Recently, there has been much debate on the reimbursement of egg donors [1–3]. Proponents of financial remuneration for oocyte donation often point to the fact that volunteers for clinical trials are justly compensated for their time, inconvenience and potential loss of earnings. By the same line of argument, compensation of egg donors for their time, travel and childcare expenses seems ethically justifiable and reasonable enough, provided that a well-informed decision is made through proper counseling [2,3]. Additionally, it is often argued that the amount of financial reimbursement should not be so great as to entice women to donate solely for the sake of money, without regard for their own health and safety.

In many countries where substantial remuneration for oocyte donation is permitted (e.g., the USA) [4,5], fertility doctors and clinical embryologists often act as a ‘middleman’ or broker to facilitate the transaction of oocytes between donor and recipient. Very often, the practice is for fertility clinics to pay donors from their own funds and subsequently bill the recipient a higher price for the donated oocytes, thereby earning a commission for sourcing egg donors. This is an additional profit on top of substantial medical fees that would be earned from the provision of fertility treatment to the same patient.

Nevertheless, it is suggested that allowing patients to pay the egg donor directly will make the entire reimbursement process more transparent, by excluding medical professionals from acting as middlemen or brokers in the transaction of donated human material. The role of medical professionals should be strictly limited to providing fertility treatment and they should take no part in donor reimbursement and counseling, owing to potential conflict of interests. To ensure donor anonymity, it may not even be necessary for patients to meet the egg donor face-to-face in order to hand over payment. Instead, a government-controlled agency can perform this task, in addition to providing professional counseling for both donor and recipient. All these would involve additional costs, so an appropriate administration fee could be imposed by the government-controlled agency. There should be absolute transparency for patients, donors and the entire public.

Hence, the underlying principle is the separation of the procurement of donated oocytes and the provision of fertility treatment. This is somewhat analogous to the mandated separation of religion and politics (i.e., church and state) in many countries so as to ensure proper and efficient functioning of both. In fact, this principle of separation is already being practised in some countries with respect to organ donation, whereby transplantation surgeons play no part in the procurement and allocation of donated organs for their patients [6,7]. Their role is strictly limited to providing medical services; in this case, transplantation surgery.

The need for greater transparency in oocyte donation is further exacerbated by the increasing trend for fertility clinics in richer countries to source egg donors from poorer developing countries. There is a grave risk of medical professionals exploiting economically underprivileged women. In particular, cash-strapped college students who need to pay tuition fees and living expenses might be coerced into donating their oocytes in return for money, while risking their health through exposure to high dosages of superovulatory drugs [8].

The pertinent concern here is the inadequate compensation of egg donors and disproportionate gains on the part of medical professionals and fertility clinics. For example, egg donors in Romania were reportedly paid only GB£150 or approximately US$300 [101], a paltry sum compared with the hefty medical fees billed to oocyte recipients, which are usually in the order of US$10,000 per treatment cycle.

Hence, it is evident that the direct reimbursement of egg donors by patients would solve many ethical issues and make the entire process of oocyte donation much more transparent. More importantly, separating the procurement of donated oocytes and the provision of fertility treatment would encourage a higher degree of medical professionalism because fertility clinics and doctors would have to compete for patients solely based on the cost and quality of the fertility treatment that they can provide, rather than on their business and networking skills in procuring egg donors for patients.