How Agencies Market Egg Donation on the Internet: A Qualitative Study

Introduction

Oocyte donation has been used to treat human infertility for nearly 30 years, and remains particularly popular in helping women of advanced reproductive age,¹ yet it also poses ethical concerns. Due to increasing demand and undersupply of available oocyte (or egg) donors, a niche business has developed in which “agencies” assist physician practices in advertising, recruiting, screening and even “matching” donors to recipients in need of such services. The advent of the Internet has increased the number and visibility of these services, creating a market in which programs bid for women perceived as having desired traits and superior pedigrees. A few questionable ethical aspects of these agencies have been examined by ourselves and others,² including patterns of monetary compensation that directly conflict with the American Society for Reproductive Medicine’s (ASRM) ethical guidelines,³ but many questions remain unexamined.

For-profit agencies that recruit and often match egg donors with intended parents exist alongside licensed, professional fertility clinics that actually perform the medical procedures. Our previous research focused on several readily quantifiable aspects of websites of both agencies and medical clinics that recruit and offer money to egg donors online.⁴ We assessed several simple dichotomous characteristics of these websites including: type (agency vs. clinic) and location of entity; whether they mention risks; SART or ASRM approval or guidelines; age or education minimums; and desired donor traits (e.g., ethnicity, prior donation success).⁵ These quantitative data, combining both agencies and clinics, suggested that many violated several of ASRM’s professional guidelines⁶ that prohibit varying compensation based on a donor’s traits (34%) and recommend an age of 21 years or older (41%) and presentation of risks alongside compensation (56%).⁷ We then examined how agencies and medical clinics differ, and found that the former were more likely to discuss short-term risks, but also to set their minimum >$5,000, offer a fee range, specify preferable traits, cap provider age at <31, require an education minimum, discuss short-term risks, not acknowledge possible cancer risks, and to be located in the West/Pacific.⁸ Hence, agencies raise several ethical concerns, as their practices may place undue influence on donors’ decision-making by offering large monetary gain, and may promote a mindset of “designing” offspring, and even discrimination through the promotion of certain desirable traits in donors.

These problems may exist, in part, due to the lack of regulation in the U.S. regarding third-party gamete donation, raising important questions as to whether more oversight is needed. Currently, the standard of practice regarding compensating, recruiting and communicating risks/benefits to egg donors exist as voluntary guidelines issued by ASRM, the largest and self-regulating professional society of reproductive medical care specialists.⁹

Agencies are even less influenced by the self-regulating model since they exist as third-party businesses outside of professional medicine, and are not subject to professional codes of conduct. To date, the only effort made to regulate agencies on these issues has been the Society of Assisted Reproductive Technologies (SART), asking agencies to agree voluntarily to ASRM’s guidelines in exchange for a listing on ASRM’s website as a professional endorsement.¹⁰ One study has already shown that this initiative only partially influenced the participating agencies to comply fully.¹¹

Buying and selling human eggs has, since its inception, been controversial, raising concerns about the possibility of commodification, exploitation of vulnerable populations of women (both egg donors and infertile recipients), and even eugenics. The term eugenics (from the Greek for “good heredity”) has often been used to refer to policies meant to shift the genetic make-up of a population towards a pre-conceived notion of what is good or better. However, the term has increasingly also been used to apply to situations where individuals seek select phenotypic traits for their descendants.

Research on these more qualitative issues has been relatively limited, with only a handful of other studies conducted. One study interviewed staff at two egg donation agencies, who encouraged “properly feminine profiles,” screening photos for any evidence of alcohol, cigarettes or revealing clothing, and encouraged donors to present themselves to recipients as altruistic.¹² Although anecdotal, these staff suggest a degree of intentional manipulation by these two agencies along with emphasis on themes of altruism and motherhood (compared to sperm banks, which see donation as being a “job”). Hobbs examined the use of metaphor in 36 ads recruiting egg donors in the Daily Bruin, the student newspaper of the University of California, Los Angeles during the 2000-2001 academic year¹³ and found that 34 ads used metaphors of love, presumably to attempt to de-commercialize the process by applying to ART the traditional myths of love and commitment that surround biological parenthood. Gezinski et al. analyzed the images and language of 19 egg donor agencies and clinics websites,¹⁴ and found that sites used largely emotional, rather than informative or medical images and language to describe egg donation (e.g., 9 sites described “the gift of life”).¹⁵ Increasingly, health care organizations in general are also using websites to attract consumers. The American Medical Association (AMA) has issued guidelines for presentation of health information on the Internet.¹⁶ Yet websites’ presentations of medical information in general have been shown often to be deficient in quality (e.g., in completeness, accuracy, currentness and comprehensibility).¹⁷

These prior studies have thus each examined relatively small samples, and did not report on other critical aspects of these ads — e.g., regarding details of compensation of specific donor traits or types of business entities (i.e., as agencies or clinics) or ways that websites may target egg recipients, or depict relationships between recipients, donors, and business entities.

Given the many controversies involved with the procurement of eggs from paid donors, and the fact that these transactions inherently differ from the sale and purchase of other commercial entities, we thus decided to examine several additional key qualitative characteristics of these websites in order to better assess whether common themes emerge, and if so, what they are, and how they may influence patients. These websites contain large amounts of qualitative information that we consequently systematically examined and coded. Specifically, we investigated, among a larger sample of websites than other investigators have examined, how egg donor agencies seek not only to recruit donors, but market to recipients, and portray the relationship between all involved parties. We decided to focus here on agencies rather than clinics, since our prior research suggested that agencies were more likely to raise several particular sets of ethical concerns. Clinics, but not agencies, necessarily include physicians, who are required to follow professional standards of conduct and patient care. The ASRM ethics committee has established numerous recommendations concerning the egg donation process. In contrast to clinics, agencies can be staffed by any individuals, without necessarily having any training or professional education, or thus necessarily any connection to professional organizations or guidelines.

Given that egg donation remains essentially self-regulated by the industry and has been controversial, these data can provide crucial insights that can inform discussions regarding current and possible future guidelines and policies concerning these domains. These issues are important, especially in light of ASRM’s September 2014 Ethics Committee Report, which calls for “reexamination of the consent process and new attention to the landscape of ethical responsibilities as well as the rights of involved parties to one another.”¹⁸

Materials and Methods

As we reported elsewhere,¹⁹ we systematically reviewed egg donor agencies involved in the recruitment of women by analyzing their websites. To simulate the steps that a prospective egg donor or recipient would take to find donation opportunities, we conducted an online search through Google™²⁰ entering the term “egg donation” in June 2010.

As shown in Table 1, we collected a list of 414 websites from within the first 300 results returned from Google. Within the first 20 results, a large health directory website²¹ appeared, as did the SART²² and ASRM websites. From these three sites, we included all links to websites recruiting egg donors, and then removed any duplicate site that appeared both on any of these three sites and within the first 300 hits of the initial Google search results. We eliminated sites that were not directly related to the recruitment of egg donors, such as news articles and informational websites.

Table 1.

MARKETING APPROACHES USED	NO. OF AGENCIES (N = 46)
Benefits Offered Toward Donors
Presentation of Lifestyle Benefits of Compensation
Covers bills/tuition	10.9%	5
Fast/easy money	6.5%	3
Summer job	2.2%	1
Total value of multiple donations	2.2%	1
Imagine/possibilities	13.0%	6
Not lifestyle specific	73.9%	34
Use of Non-Monetary Benefits to Attract Donors
Emotional fulfillment	71.7%	33
Free medical exam	4.3%	2
Vacation with friend	2.2%	1
No added benefits	28.3%	13
Presentation of Financial Benefits of Compensation
Experience based	56.5%	26
Donor sets the amount	34.8%	16
Means of Building Trust with Potential Recipients
Sources of Credibility
Family testimony	52.2%	24
Founder’s personal experience	47.8%	22
Business press	39.1%	18
Emotional Themes Driving Site’s Graphic Design and Tone
Intimacy/Commitment	17.4%	8
Angels/Heaven/Grace/Fantasy	13.0%	6
Tranquility/Peace/Wellness	8.7%	4
Intelligence/Excellence/Success	6.5%	3
Joy/Love/Happiness	6.5%	3
Empowerment/Camaraderie	6.5%	3
No strong theme	45.7%	21
Market Segments Targeted
International/tourists	28.3%	13
Ethnicity	10.9%	5
Gay/Lesbian	6.5%	3
Religious	6.5%	3
No specific targeting	63.0%	29
Promotion of Trait Selection
Types of Messaging About Selecting Traits
Promotes aspirational traits available among donors	34.8%	16
Affirms ability to find the right “match”/”fit”	56.5%	26
Affirms ability to suit recipients’ “preferences”/”desires”	19.6%	9
Suggests design/customization of a child	15.2%	7
Does not discuss traits	13.0%	6
Types of Subjective Traits Specified
Interests/Hobbies/Likes	63.0%	29
Aspirations	32.6%	15
Temperament	19.6%	9
Childhood behavior/memories	15.2%	7
No mention	34.8%	16
Positioning of Typical Donor
Caring/Generous	54.3%	25
Smart/Successful/Beautiful	39.1%	18
Healthy/Responsible	37.0%	17
Other (e.g., Sweet/Wholesome)	8.7%	4
No specific positioning	23.9%	11
Means of Portraying Typical Donor
Letters/Quotes in the donor’s voice	47.8%	22
Lifestyle photography	47.8%	22
Beauty photography	43.5%	20
No portrayal	17.4%	8

Every second website was selected from the master list, leaving a total of 207 sites. In addition to the quantitative data we have previously reported, we then returned to examine the 46 websites of egg donation agencies in July 2012 to collect further qualitative detail, which we coded. We removed 1 additional website that had since shut down. Two coders independently read this sample of websites to familiarize themselves with website content and develop a systematic coding manual. We examined 3 broad categories related to marketing techniques (language and visuals) that targeted donors and recipients:

• Benefits to donors: How financial compensation is determined and presented; types of non-monetary benefits mentioned.

• Communication used towards egg recipients regarding the donors’ traits: Types of traits mentioned as available to review; description of a typical donor; means of portraying the typical donor; and language used regarding trait selection

• Presentation of relationships: Communications toward niche market segments (e.g., international recipients); sources of credibility discussed; emotional themes in design and language.

Coders then examined the websites independently for qualitative data and compared results, discussing ambiguities in the coding to arrive at a consensus. Any available information on the sites was coded, including blank donor applications, if available without registration.

We assessed the frequencies of each of these qualitative codes. We did not obtain Institutional Review Board (IRB) approval, as we did not collect data concerning any human subjects and assessed only publicly available websites. We have no conflicts of interest.

Results

Overall, as seen in Table 1, websites present themes concerning benefits to donors, selections of donor traits, and relationships with past, present, and future donors and recipients.

Benefits to Donors

Of the 46 agency websites examined, 71.7% suggest the benefit of emotional fulfillment (ranging from “proud to help a family,” to “feel tremendous gratification,” “life-enriching and [an] incredibly beautiful experience for young women,” “the reasons are altruistic, such as a prior abortion they can’t forgive themselves for”).

In terms of non-monetary benefits, 56.5% mentioned compensation increasing with prior experience (e.g., “Couples assign extra value to…[donors] who have successfully donated in the past.”), 34.8% mentioned that donors can set their own compensation amount (e.g., “You will control the process in terms of…how much you will require as compensation.”), and 19.6% offered a flat fee to donors. Among agencies, 17.4% indicated higher compensation amounts for desirable traits (e.g., “Our Loving Couples will be willing to pay you $3,500, $5,000, $7,500 or more for your time, effort and inconvenience depending upon your special attributes or talents and the scarcity of your particular characteristics”; or line item payment bonuses for proof of higher college entrance exam scores, GPA above 3.7 or prior successful donation), and 6.5% did not list a compensation amount.

Regarding lifestyle benefits, of the 46, 10.9% mentioned the benefit to donors of paying off bills or tuition with the financial compensation, 6.5% gave the impression of immediate or easily earned money (e.g., a large headline about earning money, partial payment to get started, or “urgent demand” for certain types of donors), one website discussed egg donation as a “great summer job…must apply now,” 2.2% referred to the total sum of money attainable after six donations (e.g., “opportunity…to be compensated up to $48,000”), 13.0% used open-ended language referring to the possibilities that the financial compensation could offer (e.g., “to pursue future goals,” “financially benefit your family,” “new car…or down payment on a house”), and 73.9% did not mention lifestyle benefits.

Selection of Traits

In describing or showing the kinds of information that intended parents can review in their donor profiles, websites presented a range of traits: 63.0% websites include interests, hobbies, or likes in profiles; 32.6% include aspirations or goals; 19.6% include mood or temperament descriptions; 15.2% include childhood behavior or memories (e.g., “where they were raised”; “how would you describe your childhood?”; “favorite childhood memory”). In discussing the donor selection process, 34.8% promoted the positive or desirable traits among its donors (e.g., “only accepts the top 5%” of donor applications”; “the majority…are educated, married with children”; “offering our clients quality donors with numerous diverse characteristics”). 56.5% described finding the right “fit” or “match,” 19.6% described suiting the recipient’s “preferences” or “desires,” 15.2% implied the ability to design or customize a potential child (e.g., “donors represent a diverse collage of individuality”; “modeling agencies that help us find girls”; a headline “Extraordinary Women. Diverse Backgrounds. Limitless Possibilities.”), and 13.0% did not describe donor selection. In all, 87% mentioned trait selection in some regard.

Of agencies, 54.3% presented typical donors as caring or generous; 37.0% as healthy or responsible; 39.1% as smart, successful or beautiful. One website, e.g., included a “sample profile” on its home page describing a donor who, “plays the flute…loves her mother…always helps people in need…goes to the gym regularly to de-stress…humble,…[only has] 1 drink a week.” To portray the typical donor, 47.8% used letters or quotes in the donor’s voice; 43.5% used photography focused on beauty with noticeable makeup; and 47.8% used lifestyle imagery concerning donor’s personality, putting the donor in an environment suggesting her hobbies or interests (e.g., beside a riverbank, holding a book, socializing with friends, in front of The Capitol building, outdoors, at the gym), styling her with props to demonstrate success (i.e., books/notebook, glasses), or showing her in social moments bonding with friends. 28.3% had communications specifically targeting international egg recipients or tourists, 10.9% toward particular ethnic groups, 6.5% toward gay and lesbian recipients, 6.5% toward specific religions (e.g., targeting Jewish recipients), and 63.0% had no such targeted communications.

Presentation of Relationships

Websites all presented themes concerning relationships with past, present, and future donors and recipients. To better engage potential recipients, 52.2% displayed family testimonials (e.g., “I want to thank you from the bottom of my heart…”; “Your professionalism, support and love made us feel at ease.”), 47.8% shared the agency founder’s personal experience with infertility, and 39.1% used press coverage featuring their business (e.g., “featured in Oprah magazine”; “We specialize in celebrity and high profile clientele.”)

54.3% websites used one or more emotional themes through language and/or visual design, with 13.0% suggesting heaven, grace, or fantasy (e.g., “miracle,” imagery of clouds and white light, references to angels, fairies or storks); 8.7% suggesting tranquility, peace or wellness (e.g., images of serene nature or headlines about peace, references/services for mind/body wellness); 6.5% suggesting intelligence, excellence, or success (e.g., headlines about “extraordinary,” “excellent,” or “premium” donors); 6.5% suggesting joy or love (e.g., “loving couples,” “special someones,” use of heart symbols); 17.4% suggesting intimacy or commitment (e.g., “standing beside you,” “holding hands,” “being there for you”); and 6.5% suggesting empowerment (e.g., “strong arms,” “opening doors,” headlines about “supporting women”).

Discussion

These data, the first to examine several critical aspects of egg donation agencies, reveal characteristics of how these businesses communicate to prospective donors and recipients, raising several ethical concerns. These websites present several themes relating to benefits to donors, selection of donor traits, and relationships with past, present, and future donors and recipients. Many agencies engage in practices that may promulgate misunderstandings of the role of genetics, make emotional appeals that can distract participants from appropriate assessments of risks and benefits, and raise issues related to commodification, commercialization over professionalism, and eugenics.

Several of our findings are consistent with prior research on smaller numbers of websites or ads. We found that these websites portray egg donation to the donor as emotionally safe and fulfilling. Yet, we also found that agencies use such language to influence recipients as well and to describe potential relationships to donors. Thus, while previous research suggested that sites may try to influence potential donors to see donation as natural and fulfilling, we found that these sites thus also work to portray the egg donor in familiar ways to assuage recipients’ fears about using reproductive material from someone they do not know. Furthermore, sites present themselves as intimately committed to the process of finding the perfect egg donor and recipient match, and as vehicles through which “miracles can happen.”

Our data highlight how agencies attempt to influence potential donors through both monetary and non-monetary benefits that may inappropriately focus donors and recipients on personal gain, rather than on considerations of medical concerns. These data thus add further insight into the commercial character of egg donation agencies, which operate in an essentially unregulated grey area, posing questions of whether any enhanced guidelines or oversight may be needed, and if so, how, what and by whom.

These data also shed valuable light on key details agencies use regarding trait selection. Donor profiles aimed at intended parents include a range of donor personality characteristics, presumably reflecting perceived demand for such traits. Websites suggest egg recipients’ desires to understand donors’ physical or artistic talents and intellectual abilities, passion and sense of purpose in life, and general temperament or demeanor. Yet, these messages may foster questionable ideas about behavioral genetics, and inappropriately inject emotional cues into donors’ and recipients’ decisions.

Agencies reassure recipients of donors’ desirable traits, implying that recipients can aspire for the best genes available. Websites referred to intended parents’ “preferences” or “desires,” reflecting selective valuation of certain traits — expressly discouraged by ASRM’s guidelines²³ — and potential abilities to design or customize a potential child.

Websites underscored recipients’ desires to see “donation” as an act of kindness, not as a purely mercenary commercial transaction. Altruism has been suggested to be a motivator among egg donors²⁴ though one retrospective study of 80 egg donors found that financial compensation was a significant motivating factor for 73.8%, and very significant for 58.8%.²⁵

Donor qualities of intelligence, success, or beauty may reflect concern for ensuring that a donor has “good quality” genes, reflecting what might be considered positive eugenics (pursuing socially desirable) vs. avoiding negative, problematic traits. Descriptions of donors as “responsible” may reflect recipients’ desires to avoid “flakey” donors (who may fail to follow through with medical appointments), and valuing virtue and abstinence from substance use. Websites that implied “sweet” or “wholesome” qualities about donors suggest recipients’ desires to avoid certain socially stigmatized qualities that may be associated with women who provide oocytes (e.g., joblessness, needs for money, unmarried status and possible promiscuity), though scientific research has not indicated that these qualities are in fact primarily, if at all, genetic.

Agencies often appear to deliberately frame their messages to unduly influence prospective donors. Mentioning the benefit of paying off tuition or bills or the total sum of $48,000 after six donations may inappropriately target young women with financial hardship, and potentially compromise the autonomy of vulnerable women in greater financial need. Discussing donation as a “summer job” inappropriately promotes egg donation as employment, in contrast to ASRM’s characterization of the process as a “donation.”²⁶ Though altruism can be an important motivator for donors, agencies clearly use financial compensation as an important incentive.²⁷ Indeed, some agencies may lead and guide donors to present themselves in ways that recipients would find most appealing, including altruistic motivations.²⁸ However, when paired with the trait-based payments and often high sums (up to $10,000), the altruistic image that agencies try to have donors present may be misleading.

Many websites use photography, depicting donors with noticeable cosmetic makeup or set in a studio with professional lighting, and with the image framed close-up on her face using the “gloss” of celebrity and/or tabloid-driven marketing. Such enhancements may help intended parents feel more comfortable that they’re getting “good genes” from an unknown third party, which in turn facilitates business, though potentially at the risk of encouraging undue expectations of a child.

The 28% of websites targeting international recipients underscore the frequency of reproductive tourism in the U.S. Only three websites mentioned gay and lesbian intended parents, raising questions of whether agencies may be less welcoming to single or alternative parenting.

The fact that individuals who themselves had donated or received eggs founded 48% of the agencies may reflect a demand from egg recipients for a heightened sense of understanding in the services provided, but may also confer a false sense of professionalism, since a professional may best be able to counsel parents about these complex medical, ethical, psychological and legal issues, and uphold appropriate quality control standards. Reference to celebrities, and media coverage of their business highlight agencies’ perceived needs to be validated and trusted. Many sites refer to major media outlets, but these do not seem relevant to the medical issues that might more appropriately be communicated in other, more valid and objective forms of vetting (e.g., through ASRM).

Themes of angels, heaven, magic and fantasy may help distract women from the “yuck factor” that some individuals attribute to third-party reproduction.²⁹ Recipients may also feel frustration after failed attempts at pregnancy, fostering emphasis on donation as an act of grace, with donors as saviors.

These issues suggest how agencies craft messages to both egg providers (by emphasizing monetary as well as non-monetary benefits) and recipients (by highlighting the possibility of choosing various traits and good quality genes and achieving recipient preferences and desires altruistically — not commercially — by suggesting images of heaven and grace, and avoiding the “yuck” factor).

Questions arise of how egregious these practices are, and whether improved guidelines or oversight may be beneficial, and if so, how. Some observers may argue that in a free-market economy, these communications are all acceptable, given the notion of caveat emptor. Yet due to the sensitive nature of these interactions, the highest possible ethical standards are, arguably, important. Moreover, Kahneman and Tversky have described “anchoring heuristics” — through which initial presentations of information to an individual anchors how he or she then weighs that information and can shape his or her later decisions.³⁰ Initial information on a website can thus frame the potential oocyte providers’ preferences and willingness to provide eggs later in the process.

Concerns arise, too, as to whether websites that emphasize monetary and other rewards may unduly influence women of lower socioeconomic status. AMA guidelines have emphasized that care should be taken when addressing health information on the Internet. Websites should make sure that a clear distinction exists, for instance, between advertisements and editorial information, and that information is written in a clear and unbiased manner in order to assure facility and truthfulness. Individuals who procreate without assisted reproduction routinely choose partners based on physical or mental attributes. These are basic realities, and it would be unrealistic to criticize or change them. But whether medical professionals involved with in vitro fertilization (IVF) should endorse and assist all clients’ desires, and carry out medical procedures on egg providers who only gain via compensation, raises complex questions regarding these physicians’ professional roles and goals. While commercial markets operate based on caveat emptor, medical professionalism mandates principles of beneficence, respect for persons, and justice.

The practices described here cast a negative “shade” on the fertility industry, and can ultimately hurt all parties involved. A possible approach to address these problems is to establish clearer, more explicit guidelines or regulations concerning agency donation programs according to an established set of ethical standards.

These data also highlight several areas for future research. Further studies can probe donors’ and recipients’ perceptions and experiences, and public attitudes concerning these practices — how egg donors and recipients view these issues; whether recipients imagined certain donor personality traits would appear in their children, and how they felt when these traits did or did not appear. While several studies of health websites in other fields have focused on failures to provide certain accurate factual content,³¹ the present data highlight other potential problems — how websites may use marketing strategies that frame information in ways that may potentially bias consumers in certain ways, raising concerns.

This study has several limitations. A list of websites could alternatively have been compiled using searches for key words other than “egg donation” (e.g., “selling eggs”) or using online digital banner ads or classified ads. Information on agency websites may differ from actual practices. Future research can examine agencies’ actual practices, though doing so may be very difficult since many agencies decline to participate.

In sum, this study reveals several critical aspects of egg donor agencies that have not been described before, and that raise several concerns, suggesting needs for improvements in efforts to enhance adherence to ASRM guidelines,³² and policy and practice.

Given the many controversies involved with the procurement of eggs from paid donors, and the fact that these transactions inherently differ from the sale and purchase of other commercial entities, we thus decided to examine several additional key qualitative characteristics of these websites in order to better assess whether common themes emerge, and if so, what they are, and how they may influence patients. These websites contain large amounts of qualitative information that we consequently systematically examined and coded. Specifically, we investigated, among a larger sample of websites than other researchers have examined, how egg donor agencies seek not only to recruit donors, but market to recipients, and portray the relationship between all involved parties. We decided to focus here on agencies rather than clinics, since our prior research suggested that agencies were more likely to raise several particular sets of ethical concerns.

Overall, websites present themes concerning benefits to donors, selections of donor traits, and relationships with past, present, and future donors and recipients.

These issues suggest how agencies craft messages to both egg providers (by emphasizing monetary as well as non-monetary benefits) and recipients (by highlighting the possibility of choosing various traits and good quality genes and achieving recipient preferences and desires altruistically — not commercially — by suggesting images of heaven and grace, and avoiding the “yuck” factor).