Review of Eggonomics

Diane M. Tober, Eggonomics: The Global Market in Human Eggs and the Donors Who Supply Them.
Routledge, 2024.
ISBN 978-1-0325-4991-0, Paperback, 326 Pages, $21.99.

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This monograph is a detailed report of a study exploring the experiences of human egg (oocyte) donors in the United States and Spain, tracing their journeys as suppliers of valuable commodities. It is a sobering read. Diane Tober is a medical anthropologist who has spent a decade investigating the world of egg donation. Regulatory differences between the two countries allowed Tober to compare the impact of greater regulation (in the Spanish system) with the relatively unregulated and more commercial context of the US. In Spain, doctors choose donors on behalf of the patients based solely on phenotypic resemblance, rather than intended parents choosing their own donors as occurs in the US. In Spain, a national donor registry is being developed to track donor cycles and live births so that limits to each can be enforced. Such measures increase the safety of egg donation and reduce the risk of consanguinity. Tober uses her investigations to explore whether the Spanish system might offer insights that could improve egg donation in the United States.

In the world of assisted reproductive medicine, donor eggs are recommended for women whose own ovaries no longer function, for women with hereditary genetic disorders, and for couples with unexplained infertility. Use of donor eggs in the treatment of infertility has dramatically increased since the first live birth from donated eggs in 1983. This is due to factors such as delayed childbearing, increased restrictions on international adoptions, and the rising numbers of single people and same-sex male couples accessing fertility treatments.

A significant change in the donor egg landscape occurred in 2013 when the ASRM (American Society for Reproductive Medicine) removed the “experimental” label from oocyte cryopreservation (egg freezing) after reviewing scientific evidence that showed it to be a safe and effective method for fertility preservation.

At the same time, the technology improved. Egg freezing in the early years had a low success rate, resulting in a preference for “fresh” eggs. Then in 1999, Japanese veterinarian Dr. Masahige Kuwayama pioneered his Cryotop^© vitrification method for human eggs and set up the first egg bank. The first live birth from a vitrified egg came in 2002, and his laboratory reported their improved success rates in the medical literature.

Egg vitrification removed the need for the donor and recipient to synchronize their cycles, and the need for the egg donors, the prospective mother, and the clinic personnel to be in the same place at the same time for egg retrieval, embryo creation, and embryo transfer. This single technological improvement revolutionized the fertility industry. With improved frozen egg survival rates, clinics could expand their own donor egg banks and, for the first time, standalone donor egg banks began to appear.

In the US, there was a rapid increase in the use of frozen eggs for in vitro fertilization (IVF) cycles, increasing by 44% within two years of the ASRM decision. It also had a profound impact on “oocyte bioeconomies” due to new global opportunities for egg procurement and distribution. Now eggs, like sperm, could travel through space and time, enhancing the profitability of the human egg market and the global fertility industry.

Tober quotes the price of frozen donor eggs in a range between US$14,000 and $22,000 for a batch of five. Therefore, if a single egg donor produces 30 mature eggs on a single donation cycle, the clinic could potentially receive up to $132,000, less their payment to the donor, which on average is around $7,500. According to this metric, the average price of an egg is around $4,150, so if the donor produces more eggs, profits will increase accordingly. For the clinic, that is: donors are paid per cycle, not per egg.

The heightened profit potential in this market has attracted private equity investors seeking new opportunities for increased revenue. But if the number of eggs produced by donors is directly linked to the extent of profit for the clinic, there emerges a potential ethical conflict. There is evidence that medical decisions can become less donor-focused, and medical professionals can be pressured to maximize profits.

Medical risks, about which donors are often poorly informed, can be substantial and increase according to the medication protocol used and the number of eggs the donor produces. Donation involves interventions that in no way benefit the physical health of the donor. The process is time-consuming, uncomfortable, can be emotionally draining, and recovery can take days to weeks. The future fertility of donors may be compromised. Suffering may be ongoing. To be fair, not all clinics are run by large conglomerates. But according to Tober, while motivation can be complex and include an altruistic desire to help others, in the end, few women would donate if financial compensation was not involved. The question of coercion cannot be avoided.

The author suggests that the highly lucrative commercial market for human eggs in the US is driven by several intersecting factors: (1) inconsistent and insufficient regulations surrounding gamete (egg and sperm) donation and surrogacy throughout the US, which makes it a primary international fertility treatment destination for those from countries with restrictive policies; (2) the high costs of higher education and accompanying student loan debt, compounded with consumer debt, creating a cohort of young women seeking financial relief; and (3) unrestricted egg donor compensation rates enhancing commercial competition for both donors and recipients. These factors combine to create an environment in which there is an enormous demand for local IVF with outsourced labor and an ample supply of young women to meet that demand.

Tober gives case history after case history of women who have suffered within this network. Stories of problems with informed consent, misleading enticements to donate, pressure to keep donating after complications have occurred and safety margins have been exceeded. Stories of health problems that lead to the donor ending up with increased, not decreased, financial burdens. Tober also documents problems for donor offspring, who often find their desire for knowledge of their biological origins ignored. A darker side to egg donation is revealed, with links to abuse and exploitation of poor women in developing countries, baby trafficking and illegal adoptions, and human eggs sold on the black market. Stark evidence that suggests that the industry is unable to regulate itself.

Human eggs are the primary raw materials that enable the fertility industry to thrive. Yet donors themselves are precariously placed on the spectrum of financial benefit and personal empowerment. While some women do not regret their donations, and some even report a positive experience, the take-home message for me was that, in this industry, the donors are viewed as a source of spare parts for others and treated as a means to an end.

In the world of egg donation, clinicians downplay the importance of the genetic link to dismantle the perception of the egg donor as parent. Instead, stress is given to the importance of the gestational and social role of (commissioning) mothers. Donors are often persuaded at the time of donation by the idea of altruistic donation of eggs that are “going to waste.” But feelings change over time, and Tober found that when donors had their own children or faced infertility, their genetic offspring often became more important to them, with most donors open to contact at some point. In fact, 56.7% of Tober’s sample had attempted to find their offspring. It is complex because the clinical reframing of motherhood gives potential donors permission to proceed and also to make sense of what they have done, and anyway they needed the money.

While Tober believes that egg donation can be a wonderful thing, she feels the lack of enforceable standards and contracts makes the industry ripe for abuse. The book ends with recommendations for how the practice of egg donation might be improved if rooted in the values of reproductive justice and human rights, aiming for equality of rights of donors, intended parents, and donor offspring.

Global fertility services are projected to grow to $68.32 billion by 2032. Egg donors tend to be poor, young, and often non-white. Long-term impacts of donation are unclear, but the donors are not followed up to investigate health outcomes. Instead, the focus is on the production of materials; the focus is on the eggs. Yet after all that, the majority of donors Tober interviewed found the process rewarding even in the face of regrets. She seeks a system where it is not achieved at so great a cost.

This is not a Christian book. The author self-identifies as pro-choice and promotes the idea of unrestrained individual liberty to pursue parenthood. She uses language that endorses fluid gender ideology. Ethical questions for Christians, such as the morality of assisted reproduction in general and gamete donation in particular, are not addressed. Nonetheless, I think this book is a valuable insight into what happens when we commodify human bodies.