Racial and ethnic disparities among donor oocyte banks in the United States

Abstract

Objective:

To determine whether racial and ethnic distributions of oocyte donors contributing to United States (US) oocyte banks differ from demographics of US women and donor oocyte recipients.

Design:

Cross-sectional study.

Setting:

United States donor oocyte banks, US Census, and fertility clinics reporting to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System.

Patients:

Oocyte donors from 12 banks, women aged 18–44 based on the 2019 Census, and US recipients of cryopreserved donor oocytes from 2012–2015.

Intervention:

None.

Main Outcome Measure:

Proportions of donors identifying as each racial and ethnic group.

Results:

Of the 1,574 oocyte donors, 678 (43.1%) identified as white, compared with 54.8% of US women and 69.1% of donor oocyte recipients. Proportions of donors identifying as Hispanic or two or more races were larger than those of US women and donor oocyte recipients (Hispanic: 24.1% vs. 20.8% and 24.1% vs. 8.8%; two or more races: 16.1% vs. 2.3% and 16.1% vs. 0.5%). African American donors were underrepresented compared to US women (8.9% vs. 14.0%) and oocyte recipients (8.9% vs. 10.8%). While the proportion of Asian donors was similar to that of US women (7.7% vs. 7.1%), Asian donors were underrepresented when compared to donor oocyte recipients (7.7% vs. 10.6%).

Conclusion:

Racial and ethnic distribution of oocyte donors differs significantly from demographics of US women and cryopreserved donor oocyte recipients. These data suggest a need for targeted recruitment of African American and Asian oocyte donors.

INTRODUCTION

Oocyte donation is an important reproductive option for women with diminished ovarian reserve or recurrent failed in vitro fertilization (IVF), as well as for same-sex male couples or single men (1,2). With the development of ultra-rapid cooling, cryopreservation by vitrification dramatically improved success rates of cryopreserved oocyte IVF (3–6) and subsequently led to the creation of donor oocyte banks (1). These banks provide a searchable database of donor profiles for couples or individuals seeking donor oocytes. Compared to fresh donor oocytes, donor oocyte banks allow for improved access to donor oocytes, reduced wait times and cost, and the ability to quarantine donor oocytes for infectious disease testing (1). Although donor oocyte banks have expanded the potential pool of oocyte donors for recipients across the United States, minorities often face challenges with finding donor oocytes concordant with their identified race (7).

Racial disparities in the utilization of assisted reproductive technology (ART) are apparent and widely studied (8–15). Asians and non-Hispanic black women present for infertility care at an older age than non-Hispanic white women (13–15). In accessing infertility care, non-Hispanic white and Asian women are over-represented compared to non-Hispanic black and Hispanic women, who remain relatively under-represented (9,11,12). The disparities also extend to IVF success rates: black, Asian, and Hispanic populations have reduced live birth rates with IVF compared to white women (13,14,16,17).

It is currently unknown whether there are racial and ethnic disparities among women who donate to cryopreserved donor oocyte banks. Race is a particularly salient feature for donor oocytes as it represents a construct for matching phenotypes, and couples and individuals looking for donors typically seek physical attributes (eye color, hair color, height) similar to their own (7). Our primary objective was to determine whether the racial and ethnic distribution of oocyte donors contributing to United States oocyte banks is representative of the demographics of reproductive aged women in the United States. Our secondary objective was to compare racial and ethnic distributions between oocyte bank donors and donor oocyte recipients.

MATERIALS AND METHODS

This study was determined exempt by the Duke Institutional Review Board. “Donor egg bank” and “donor oocyte” were used as Google search terms to identify donor oocyte banks in the United States. Publicly available demographic data on donors were entered into a Research Electronic Data Capture (REDCap) database (18,19) between December 3, 2019 and February 7, 2020. REDCap is a secure, web-based software platform designed to support data capture for research studies. Only cryopreserved donor oocyte profiles were included. The characteristics of oocyte donors were summarized with median and interquartile range (IQR) for continuous variables or proportions for categorical variables, as appropriate.

Information about the population of women aged 18–44 years was retrieved from the United States Census Bureau (20). On the date of access (September 1, 2021), the most recently available population estimates were from the 2019 United States Census through July 1, 2019.

Information about the racial and ethnic distributions of women undergoing IVF with cryopreserved donor oocytes from 2012–2015 was obtained from the Society for Assisted Reproductive Technology (SART) Clinic Outcome Reporting System (CORS). The SART CORS database contains comprehensive data from over 90% of all clinics performing ART in the United States. The data were collected through voluntary submission, verified by SART, and then reported to the Centers for Disease Control and Prevention (CDC) in compliance with the Fertility Clinic Success Rate and Certification Act of 1992 (Public Law 102–493). SART maintains HIPAA-compliant business associates agreements with reporting clinics. In 2004, following a contract change with CDC, SART gained access to the SART CORS data system for the purposes of conducting research. The data in the SART CORS are validated annually with select clinics having on-site visits for chart review based on an algorithm for clinic selection (21,22). During each visit, data reported by the clinic were verified with information recorded in patients’ charts. In 2012, records for 2,045 cycles at 35 clinics were randomly selected for full validation, along with 238 egg or embryo banking cycles (21,22). The full validation included review of 1,318 cycles for which a pregnancy was reported. Among the non-donor cycles, 331 were multiple-fetus pregnancies. Ten out of 11 data fields selected for validation were found to have discrepancy rates of ≤5%. The exception was the diagnosis field, which, depending on the diagnosis, had a discrepancy rate between 2.1% and 9.2% (21,22). For the present study, cycles in which the recipient race was labeled as unknown, refused, or not asked were excluded from the analysis.

All race and ethnicity categories were grouped to align with the categories reported by the United States Census Bureau and were as follows: white, black or African American, American Indian or Alaska Native, Asian, Hawaiian or Pacific Islander, two or more races, and Hispanic. “White” indicated a person having origins in Europe, Middle East, or North Africa. “Black” or “African American” indicated a person having origins in any of the black racial groups of Africa. “American Indian” or “Alaska Native” indicated a person having origins in the original people of North and South America. “Asian” indicated a person having origins in the Far East, Southeast Asia, or the Indian subcontinent. “Native Hawaiian” or “Pacific Islander” indicated a person having origins in Hawaii, Guam, Samoa, or other Pacific Islands. “Hispanic” indicated a person having origins in Cuba, Mexico, Puerto Rico, or other Spanish/Latino groups.

The primary outcome was the proportion of women in each race and ethnicity category compared between oocyte donors and United States women aged 18–44, as well as between oocyte donors and the population of United States women undergoing IVF with cryopreserved donor oocytes as reported to SART CORS. A sensitivity analysis was also performed to exclude one bank (Bank #6) that recruits only Asian oocyte donors. Chi-square or Fisher’s exact tests were used for these analyses. Given the lack of overlap between the years of data collection from the donor oocyte banks and from SART CORS, a linear trend test was performed to assess for changes in the distribution of race and ethnicity of donor oocyte recipients. This confirmed that there was no statistically significant trend over time (P=.764, Supplemental Table 1). All analyses were performed in SAS 9.4 (SAS Institute Inc., Cary, NC).

RESULTS

Twelve donor oocyte banks with a total of 1,575 donors were identified. One donor reported “Other” for race and was therefore excluded from further analysis, leaving a total of 1,574 donors available for analysis. The contribution of each bank to the overall oocyte donor population for this study ranged from 2 (0.1%) to 527 (33.5%) (Table 1). Data from the United States Census included 58,215,490 women between 18 and 44 years of age. Data from SART CORS included 6,941 cryopreserved donor oocyte recipients. Among these recipients, 3,272 (47.1%) did not have information on race and were therefore excluded from the analysis. The remaining 3,669 cryopreserved donor oocyte recipients with race and ethnicity data were included in the analysis.

Table 1:

Distribution of donors to each oocyte bank

Oocyte bank	Number of oocyte donors (N=1,574)
Bank #1	527 (33.5%)
Bank #2	358 (22.7%)
Bank #3	216 (13.7%)
Bank #4	135 (8.6%)
Bank #5	113 (7.2%)
Bank #6	83 (5.3%)
Bank #7	80 (5.1%)
Bank #8	29 (1.8%)
Bank #9	12 (0.8%)
Bank #10	10 (0.6%)
Bank #11	9 (0.6%)
Bank #12	2 (0.1%)

The majority of the publicly available information on oocyte donors concerned physical appearance: hair color (99.9%), eye color (99.9%), skin tone (86.8%), height (99.3%), and weight (92.2%) (Table 2). Education was also frequently reported (99.7%). A smaller proportion of profiles contained medical information, such as personal medical history (83.6%), family medical history (78.6%), and performance of genetic carrier screening (76.9%).

Table 2:

Availability of data on donor characteristics in donor oocyte banks

Characteristics	Number of oocyte donors (N=1,574)
Age	1307 (83.0%)
Hair color	1573 (99.9%)
Eye color	1573 (99.9%)
Skin tone	1367 (86.8%)
Height	1563 (99.3%)
Weight	1452 (92.2%)
Blood type	984 (62.5%)
Education	1569 (99.7%)
Occupation	1269 (80.6%)
Religion	492 (31.3%)
Prior donor	847 (53.8%)
Age at first retrieval	266 (16.9%)
Childhood photo	1,008 (64.0%)
Adult photo	1,278 (81.2%)
Genetic carrier screening performed	1,211 (76.9%)
Prior pregnancy	803 (51.0%)
Medical history	1,316 (83.6%)
Family medical history	1,237 (78.6%)
Family physical characteristics	1,081 (68.7%)
Handedness	571 (36.3%)

The median donor age was 26 years (IQR 23–29) and the median body mass index was 23.2 kg/m² (IQR 21.4–25.1) (Table 3). The majority of donors self-reported brown hair color (58.9%) and black or brown eyes (57.9%). Nearly all donors reported light or medium skin color (92.3%). All oocyte donors reported their education as at or above the level of a high school graduate. The most common occupation was student (27.4%). When describing their motivation for oocyte donation, the most common reason was to help others (80.5%), followed by having a close family or friend with infertility (15.4%), and feeling that being a parent was rewarding (11.6%). Only 5.4% reported financial reasons as a motivator for oocyte donation.

Table 3:

Oocyte donor demographics and characteristics.

Characteristics	Total (N=1,574)
Age [Median (Q1, Q3)]	26.0 (23.0, 29.0)
Body mass index (BMI), [Median (Q1, Q3)]	23.2 (21.4, 25.1)
Hair color
Black	311 (19.8%)
Brown	926 (58.9%)
Blonde	301 (19.1%)
Red or Auburn	35 (2.2%)
Eye color
Black or Brown	911 (57.9%)
Blue	272 (17.3%)
Green	156 (9.9%)
Grey or Hazel	234 (14.9%)
Skin tone
Light or Fair	682 (49.9%)
Medium or Olive	580 (42.4%)
Dark	105 (7.7%)
Education
High School Graduate or GED	227 (14.5%)
Some College/Associate’s Program/Vocational School	775 (49.4%)
College Graduate/Associate’s Degree/Vocational School Graduate	437 (27.9%)
Some Graduate School	52 (3.3%)
Completed Graduate School	78 (5.0%)
Reason for donating
Help others	1,267 (80.5%)
High personal fertility	34 (2.2%)
Rewarding being a parent	182 (11.6%)
Close family/friend with infertility	243 (15.4%)
Financial reasons	85 (5.4%)
Other	56 (3.6%)

Compared to United States women and cryopreserved donor oocyte recipients, a significantly higher proportion of donors identified as Hispanic (24.1% vs. 20.8%, P<.001; 24.1% vs. 8.8%, P<.001) or as two or more races (16.1% vs. 2.3%, P<.001; 16.1% vs. 0.5%, P<.001) (Table 4). While the absolute number of oocyte donors identifying as white was considerably higher than any other racial groups, the relative proportion was lower than that of United States women (43.1% vs. 54.8%, P<.001) and that of donor oocyte recipients (43.1% vs. 69.1%, P<.001). In contrast, black or African American donors were significantly underrepresented compared to United States women (8.9% vs. 14.0%, P<.001) and compared to recipients of cryopreserved donor oocytes (8.9% vs. 10.8%, P=.038). While Asian donors were similarly represented when compared to United States women (7.7% vs. 7.1%, P=.342), they were underrepresented when compared to donor oocyte recipients (7.7% vs. 10.6%, P=.001). A sensitivity analysis was then performed to exclude Bank #6, which recruits internationally and specifically recruits Asian oocyte donors. This analysis demonstrated an underrepresentation of Asian donors compared to both United States women (2.8% vs. 7.1%, P<.001) and recipients of cryopreserved donor oocytes (2.8% vs. 10.6%, P<.001) (Supplemental Table 2).

Table 4:

Distributions of race and ethnicity among oocyte donors, United States women aged 18–44 years (July 1, 2019), and donor oocyte recipients.

Race/Ethnicity	Oocyte Donors	US Population		Donor Oocyte Recipients
	N=1,574	N=58,215,490	P a	N=3,669	P a
White	678 (43.1%)	31,891,339 (54.8%)	<.001	2,535 (69.1%)	<.001
Black/African American	140 (8.9%)	8,170,464 (14.0%)	<.001	396 (10.8%)	.038
American Indian/Alaska Native	1 (0.1%)	462,279 (0.8%)	<.001	3 (0.1%)	1.000
Asian	121 (7.7%)	4,117,937 (7.1%)	.342	387 (10.6%)	.001
Hawaiian/Pacific Islander	1 (0.1%)	123,158 (0.2%)	.275	7 (0.2%)	.449
Two or more races	253 (16.1%)	1,363,445 (2.3%)	<.001	17 (0.5%)	<.001
Hispanic	380 (24.1%)	12,086,868 (20.8%)	<.001	324 (8.8%)	<.001

^aCompared to the oocyte donor group using Chi-square or Fisher’s exact tests.

DISCUSSION

This study demonstrated significant differences between the race and ethnicity of oocyte bank donors compared to the demographics of United States women aged 18–44 and of the recipients of cryopreserved donor oocytes. All racial categories, except for women identifying as Hispanic or two or more races, were underrepresented in the population of oocyte donors.

Although donor oocyte banks have expanded the availability of donor oocytes, our study demonstrated substantial racial and ethnic disparities. For example, only 8.9% of oocyte donors in the present study identified as black or African American, compared with 10.8% of oocyte recipients and 14.0% of United States women. Interestingly, the proportion of donor oocyte recipients identifying as Asian was almost 50% greater than that of United States women (10.6% compared with 7.1%). One bank specifically recruits Asians both domestically and internationally and supplied the majority of Asian oocyte donors. After excluding this bank from the analysis, the proportion of Asian oocyte donors decreased drastically from 7.7% to 2.8%. Further studies through focused surveys and qualitative interviews are needed to identify motivators and barriers to oocyte donation among minority groups. In the meantime, our findings demonstrate a need for targeted recruitment of donors identifying as black, African American, or Asian.

We also found an underrepresentation of oocyte donors identifying as white and overrepresentation of donors identifying as Hispanic or two or more races as compared to both United States women and donor oocyte recipients. These findings were surprising, and like the above disparities, may be a result of cultural differences, recruitment strategies, and financial incentives that would warrant further exploration in future studies. An additional consideration is whether certain racial and ethnic disparities exist among the population of oocyte donors that are not reflected in the general population. Another contributing factor may be a discrepancy between a patient’s self-reported race and ethnicity as compared with those reported by the clinic to SART CORS and those reported by the United States Census. Furthermore, missing data for race and ethnicity is a known limitation of SART CORS, with almost half of the women in our SART CORS dataset excluded for this reason. Among donor oocyte banks, reporting of race and ethnicity data is variable and could also have contributed to an overestimation of donors identifying as two or more races and a subsequent underestimation of white donors.

The present study provides an important update on the overall landscape of donor oocyte banks. In 2012, a cross-sectional survey of donor oocyte banks in the United States identified only 294 donors from 7 banks that had been in existence for a median of 2 years (23). In comparison, our study identified 1,575 donors from 12 donor oocyte banks. Despite the expansion of donor oocyte banks, donor characteristics have not substantially changed over time. The mean donor age has remained consistent at 25–27 years (24–26). As demonstrated in previous studies, a large proportion of donors identify as white and report some college education(24–26). In contrast, the motivation for donation may have changed over time. Prior studies found altruism and financial reward were both common reasons for oocyte donation (24,25). For example, in a retrospective survey study, 49.7% of oocyte donors identified altruism and 42.6% identified financial gain as the main motivator (25). In contrast, the present study demonstrated that women were much more likely to identify altruism rather than financial gain as the motivator behind oocyte donation (80.5% vs. 5.4%). The discrepancy may be explained by the publicly available nature of information displayed by institutions that may be incentivized to selectively omit financial motivations. Alternatively, oocyte donors submitting applications to donor oocyte banks may omit financial motivations to increase the attractiveness of their oocytes to the banks and potential recipients. Finally, surveys of oocyte donors that occur after the donation process has already occurred may be viewed by participants as more confidential, increasing the likelihood of honest disclosure of incentives. If there have indeed been changes in motivating factors with emphasis on altruism, it would be interesting to investigate whether these motivations vary by race and ethnicity and whether this could assist with improved targeted recruitment of minorities.

Another developing concern with regard to oocyte donation is the loss of oocyte donor anonymity. Privacy and disclosure topics surrounding donor eggs are addressed with oocyte donors and recipients through initial psychological counseling. With the development of direct-to-consumer genetic testing, however, anonymity of oocyte donors can no longer be guaranteed. Further studies are needed to also examine how anonymity affects oocyte donation decisions of women of different races and ethnicity. In addition, a vast amount of personal and medical information is publicly available on donor egg bank websites. With displays of physical appearance, race, ethnicity, education, occupation, as well as medical information including medical history, family history, and genetic carrier screening, it would be prudent to reevaluate the way institutions display information about oocyte donors even prior to conception.

The present study is strengthened by comparisons to both the population of United States reproductive-aged women and the population of oocyte recipients. Doing so allows a fuller characterization of disparities. Comparison of the demographics of the oocyte donors to oocyte recipients illustrates a classic supply and demand paradigm. Comparison of the demographics of the oocyte donors to the United States population provides a portrayal of actual and potential supply, possibly identifying prospective room for additional recruitment. For example, black and African American oocyte donors represent 8.9% of supply of donor oocytes, which may not meet the demand of African American oocyte donor recipients (10.8%) and is lower than the relative potential supply of African Americans in the United States (14.0%). This is in contrast to Asian oocyte donors (7.7%), the proportion of which slightly exceeds the correlated proportion of Asians in the general United States population (7.1%) but still may not necessarily meet the demand from Asian donor oocyte recipients (10.6%).

A major limitation of our study was the dependence on publicly available information from donor oocyte banks, which may not accurately represent the true supply of available donor oocytes at a given time point. As discussed earlier, our study was also limited by lack of standardization of reporting of race and ethnicity as well as missing data in SART CORS. In addition, the time periods for evaluation of each group did not perfectly align due to the limitations of available datasets from SART CORS and the United States Census. Lastly, the race and ethnicity categorizations encompass a diverse group of individuals. Patients who are searching for donor oocytes concordant with their own phenotype, culture, and background, may desire more specific ancestral identities or communities than those identified by race and ethnicity. For example, an individual who identifies as “Lebanese” may not necessarily seek nor desire an “Italian” donor even though both would be classified under the “white” race category, and similarly an individual who identifies as “Chinese” may not seek nor desire a “Japanese” donor even though both would be classified under the “Asian” race category. Accurate documentation of cultural and ancestral identity especially for patients seeking donor gametes is essential for more precise characterization of disparities.

CONCLUSION

This study demonstrated that the race and ethnicity distribution of oocyte donors differs significantly from the demographics of United States women aged 18–44 and from that of cryopreserved donor oocyte recipients. These data suggest a need for targeted recruitment of African American and Asian oocyte donors. Future investigations through qualitative interviews or surveys are needed to identify motivators and barriers to oocyte donations in minority groups.