Oocyte donation accounts for approximately 10% of ART treatment cycles globally; meaning about 10 out of every 100 IVF cycles involve donor oocytes. This estimate was based on reported data from regions like the US and parts of Europe, reflecting the routine scale of donation within ART [8].

In 2020, the global total number of ART cycles exceeded 2.84 million, resulting in the birth of approximately 630,000 infants. Applying the estimated 10% proportion of egg donation to total ART cycles, the global number of oocyte donation cycles in 2020 is estimated at around 284,000, corresponding to an estimated 63,000 infants born from such donations [8].

Asia accounts for nearly 50% of global ART cycles, with China reporting approximately 1 million ART cycles annually and Japan around 500,000. Europe reported 1,103,633 ART treatment cycles in 2021, including techniques like ICSI, frozen ET, and preimplantation genetic testing (PGT). While donor sperm insemination accounted for 48,583 cycles, data on oocyte donation specifically were not separately detailed. The UK, a pioneer in mitochondrial donation (which involves oocyte manipulation), reported only 5 children born via this technique at the Newcastle Fertility Centre by the end of 2023 [8]. By 2025, the center had performed 19 mitochondrial donation procedures, resulting in the successful delivery of 8 healthy infants, including one set of twins.

Overall, ART delivery rates were 22.3% for fresh ETs, 31.3% for frozen-thawed ETs, and reached 49.9% for cycles involving PGT. The success rate for egg donation cycles is typically similar to that of frozen-thawed cycles (approximately 30%–40%) [9].

The proportion of single ETs has increased (rising to 57.9% in fresh cycles and 76.3% in frozen cycles), leading to a reduction in the multifetal rate to 16.5%. This optimization trend has also contributed to declines in preterm birth and neonatal mortality rates [9]. The number of donor egg cycles has been gradually increasing in recent years, particularly with the promotion of technologies like PGT.

ESHRE emphasizes the offspring’s right to know their genetic origins and the psychological well-being of donors, requiring dedicated counselors—reflecting Europe’s focus on balancing individual rights. American Society for Reproductive Medicine (ASRM) prioritizes patient autonomy through flexible compensation models, aligning with market-informed regulatory approaches [10]. In contrast, China adopts strict medical oversight, integrating oocyte donation into public health services to avoid commodification risks.

ESHRE highlights maternal-fetal immunological risks in heterologous pregnancies, advocating enhanced monitoring. ASRM targets the prevention of obstetric complications (e.g., cardiovascular issues) in advanced-age recipients [10]. China’s core focus is on preventing oocyte commodification and multi-fetal pregnancies, using mandatory SET to reduce iatrogenic risks.

ESHRE supports expanded preimplantation genetic testing (PGT-A) for donor oocytes to enhance embryo quality. ASRM restricts PGT-A to high-risk groups. China excludes routine PGT from donation protocols, reflecting conservative technical application. This comparison reveals divergent interpretations of “reproductive justice”: Europe balances individual rights, the US employs market-informed regulation, while China emphasizes public welfare. Further research should examine practical impacts using the International Federation of Fertility Societies (IFFS) global survey data [10].

Donation Restrictions: Influenced by Islamic doctrine, oocyte donation must be proven as a “therapeutic necessity” rather than a proactive fertility intervention, and commercial transactions are prohibited.

Procedural Differences: Oocyte retrieval must be performed exclusively by female medical staff, with strict donor anonymity to comply with Sharia law on bloodline purity [11].

Ethical Review: Religious leaders must participate in ethics committees, prioritizing the evaluation of embryo-handling compliance with the “sanctity of life” principle.

Psychological Intervention: Pre-donation Buddhist meditation therapy is required to alleviate hormone-injection anxiety, with some clinics mandating monk blessings.

Legal Exceptions: Foreign donors may meet recipients, as Buddhism’s “karmic connection” philosophy prioritizes transparency over anonymity [11].

Controversial Focus: Catholic institutions prohibit embryo freezing, necessitating immediate use of donated oocytes and increasing medical risks.

Special Clauses: Same-sex couples using donor oocytes require notarized documentation, with some states demanding proof of adherence to “traditional family values” [11].

Policy Orientation: Commercialization is strictly banned while altruistic donation is encouraged, with 100% clinical follow-ups replacing religious ethics oversight.

Cultural Adaptation: Donation advocacy emphasizes “bloodline continuation” traditions, downplaying technological intervention.

These variations directly impact donor recruitment approaches, medical protocol design, and legal safeguard intensity.

In China’s “oocyte-sharing” model, the willingness to donate oocytes to help others is an altruistic behavior. Therefore, when considering the conditions for oocyte donors, their rights should be prioritized, while also considering the rights of the recipients and offspring. The conditions for oocyte donation mainly include the donor’s age, health status, whether they have indications for IVF/ICSI, and whether they fulfill informed consent [17]. According to China’s “Notice of the Ministry of Health on the Issuance of the Implementation Rules for the Verification of Human ART and Human Sperm Banks” (hereinafter referred to as the “Implementation Rules”) and the recommendations of the “Expert Consensus”, oocyte donors should have IVF/ICSI indications, be aged between 20 and 35 years, and have obtained more than 15 oocytes, retaining 15 oocytes for themselves and donating the rest of oocytes [18]. In addition to routine pre-operative examinations for IVF/ICSI, donors also need to undergo screening for genetic diseases, chromosomal abnormalities, and infectious diseases. Only donors in good health and without genetic diseases or infectious diseases can donate oocytes. Moreover, donors and recipients must remain anonymous; each donor’s oocytes can only result in pregnancies in up to 5 women, and donors must be re-examined for human immunodeficiency virus (HIV) antibodies after 6 months, implementing the ethical principles of respect, benefiting both donors and recipients, protecting privacy, and safeguarding offspring. China’s requirements for donors’ age and health status are similar to those of other countries but are relatively strict regarding the number of oocytes obtained and retained. With the development of ART technology, a relatively stable cumulative live birth rate can be achieved with 10–15 oocytes, and the incidence of ovarian hyperstimulation syndrome (OHSS) is low. However, when more than 15 oocytes are obtained, the cumulative pregnancy rate does not increase significantly, but the incidence of OHSS increases markedly [19]. A study has shown that 8 oocytes are sufficient for a successful pregnancy in patients under 35 years old [9]. Therefore, it is necessary to re-examine the thresholds set in the “Implementation Rules” for the number of oocytes obtained and retained by donors, making it easier for benevolent patients to meet the conditions for oocyte donation. This approach not only reduces the incidence of OHSS in donors but also decreases the proportion of patients with polycystic ovarian syndrome (who typically produce more than 15 oocytes and may carry a genetic tendency), serving as oocyte donors. Consequently, it helps alleviate the imbalance between oocyte supply and demand while adhering to ethical principles that benefit both donors and recipients and protect offspring. Before donating oocytes, genetic and infectious diseases must be ruled out. Specific examples of genetic diseases that should be screened currently include: chromosomal disorders (Down syndrome (Trisomy 21), Turner syndrome); monogenic diseases (autosomal recessive, cystic fibrosis, thalassemia); autosomal dominant (Huntington disease: Marfan syndrome; X-Linked: Duchenne muscular dystrophy, hemophilia; mitochondrial disorders: Leigh syndrome); cancer predisposition syndromes: BRCA1/2 mutations (hereditary breast/ovarian cancer); screening methods: preimplantation genetic diagnosis (PGD); PGS/NGS; copy number variation (CNV) analysis.

China’s “Expert Consensus” recommends that recipients receive 3–5 donated oocytes and does not set an upper or lower limit on the number of oocytes that donors can donate. This can lead to the following issues: ① If a patient is only willing to donate 1 oocyte, is it acceptable to retain the rest for personal use? Although increasing the number of donated oocytes can improve pregnancy rates, in China’s oocyte-sharing model, donors cannot obtain significant financial returns from donations. In such cases, oocyte donation is considered a morally uplifting altruistic act. Therefore, regardless of the number of oocytes donated, it can to some extent increase the sources and quantity of oocytes, giving recipients a chance of pregnancy [20]. Hence, donors’ wishes should be respected. Most countries and regions do not set a minimum limit on the number of oocytes donated [21].

However, studies have shown that the fertilization rate of oocyte donation IVF/ICSI cycles in China is approximately 54.9%, the implantation rate is 52.05%, and the clinical pregnancy rate is 69.23% [22]. According to the “Notice of the Ministry of Health on the Revision of Relevant Technical Specifications, Basic Standards, and Ethical Principles for Human ART and Human Sperm Banks” (hereinafter referred to as the “Ethical Principles”), medical institutions are prohibited from performing “mixed semen fertilization” in ART involving sperm donation [23]. Similarly, oocyte donation IVF/ICSI procedures also prohibits “mixed oocyte fertilization”, in which oocytes from multiple donors are fertilized with the recipient’s husband’s semen [24]. Therefore, if a recipient receives only 1 donated oocyte, it will necessitate initiating an IVF/ICSI cycle, which may carry a higher risk of pregnancy failure, undoubtedly increasing their financial and emotional burdens. Furthermore, if recipients hope to have multiple children through oocyte donation, the ethical issues involved in inconsistent biological mothers for the children should also be considered. Therefore, donating too few oocytes can lower recipients’ pregnancy rates, thereby violating the principle of optimization. ② China does not set an upper limit on the number of oocytes that a donor can donate. If a donor obtains a large number of oocytes (e.g., more than 20) and is unwilling to have multiple children but also hopes to reduce the probability of incestuous marriages between their children and the recipients’ offspring, is it acceptable for them to donate a large number of oocytes (e.g., more than 10) to only one recipient? Although this approach can increase the recipient’s chances of pregnancy, it may result in waste. For instance, if the recipient only wishes to have one child, donating excessive oocytes will provide no additional benefit to the recipient and reduce the chances of other recipients obtaining oocytes, violating the principle of optimization. Currently, only India’s “ART Regulation Act, 2021” stipulates that females can donate a maximum of 7 oocytes per cycle to prevent potential overmedication by fertility clinics [25]. From the above analysis, donating 3–5 oocytes appears to be relatively reasonable, balancing the aforementioned considerations. From an ethical perspective, medical personnel do not have the right to control the number of oocytes donated by donors but can provide appropriate advice [26]. When discussing the number of donated oocytes with donors and other ethical principles conflict with the principle of respect, priority should be given to respecting the wishes of donors, including their choice to donate and the number of oocytes donated.

Regulatory authorities should strengthen supervision of the oocyte donation process [27]. Laws and regulations should be continually improved to prevent illegal and unethical activities in this field, such as the black-market trade of oocytes. By ensuring strict compliance with ethical and legal standards, we can safeguard the rights and interests of oocyte donors and maintain the integrity of the medical field. Most allocation policies range from a minimum of 4 oocytes to more oocytes, such as 8 or 10 oocytes per recipient. There was little information about the best way to allocate donated oocytes. Obviously, this decision was very important in terms of cost-effectiveness. In addition, vitrification of frozen oocytes after retrieval can reduce their survival rate of oocytes and increase the time cost for embryologists [28]. Limiting donation to only 3 oocytes may also significantly reduce the likelihood of achieving pregnancy.

Within the policy framework of China’s oocyte-sharing mode, donors are eligible for partial fee reduction for treatment, aiming to compensate for lost wages, transportation, and medical expenses incurred due to donation [36, 37]. At the same time, it is worth considering whether the recipient should also pay for additional physical examinations that donors need to undergo six months later due to their extra donation. In summary, economic compensation not only provides psychological comfort to donors but also supports their altruistic acts, promoting oocyte donation to some extent and helping alleviate the imbalance between oocyte supply and demand. This has been widely recognized and practiced globally. However, determining a reasonable level of economic compensation is a complex and controversial issue. Economic compensation in the oocyte-sharing model differs from non-compensated social or related oocyte donation and is distinct from commercial oocyte donation motivated by financial gain [38].

Therefore, different countries have adopted varying compensation standards: the Human Fertilization and Embryology Authority in the UK has provided a compensation of 750 pounds per treatment cycle for each donor since 2012, while in Spain, donors can receive approximately 1000 euros per ovarian stimulation cycle. In Russia, the maximum compensation is 600 euros, and in Ukraine, it ranges from 400 to 650 euros. French donors need to provide expense receipts before reimbursement [39]. However, with the adjustment of China’s fertility policy and the lack of specific standards for economic compensation for oocyte donation, the amount of compensation varies among reproductive centers, and the proportion of patients willing to donate oocytes among those undergoing IVF/ICSI treatment is relatively low [40]. Although most patients who donate oocytes do so out of altruism, without appropriate economic compensation, the sources of oocyte donation may further decrease [41]. Therefore, it is recommended to appropriately increase the amount of economic compensation and set an upper limit based on local average wages and price levels, which will help alleviate the imbalance between oocyte supply and demand while avoiding suspicions of commercialization.

Considering social harmony, family happiness, and the protection of the recipients’ and offspring’s rights, recipients should meet the following conditions: ① They have indications for oocyte donation, such as the inability to produce oocytes, severe genetic disease carriers or patients, and obvious factors affecting oocyte quantity and quality. ② Professionals assess the recipient’s physical, psychological, and financial conditions to determine that the perinatal maternal and infant risks are low or controllable, and that they are able to raise and educate their children. ③ The recipient’s age at the time of ET should not be too high to ensure they have the energy and ability to raise their children to adulthood (18 years old). Therefore, most countries and regions primarily limit the age of recipients to under 55 years old [42]. China’s “Expert Consensus” clearly states that the recipient’s age should not exceed 52 years at the time of ET (Summary of risks in oocyte recipients over 52 years old: ① Maternal Risks: Hypertension: 3–5$\times$ higher risk of preeclampsia; Diabetes: 40% increased gestational diabetes risk; Placental issues: 2–3$\times$ higher rates of abruption/previa. ② Delivery Complications: 60% C-section rate due to uterine dysfunction; 15–20% postpartum hemorrhage risk. ③ Fetal/Neonatal Risks: 30% preterm birth rate (often iatrogenic); Higher low-birth-weight (2500 g) incidence. ④ Biological Barriers: Endometrial aging: 81.5%$\downarrow$ gene expression for implantation; Embryo aneuploidy: $>$80% chromosomal abnormalities at age 52. ⑤ Outcome Data: Live birth rate 10% at 52, dropping 5%/year after 45; Medical costs 3.2$\times$ higher vs. under-35 recipients.). ④ The oocyte recipient must commit to active cooperation in follow-up procedures, ensuring a 100% follow-up rate, which aligns with the requirements for follow-up in donor sperm ART [43]. In summary, reproductive centers offering oocyte donation IVF/ICSI must rigorously adhere to recipient eligibility criteria and implement ethical principles that prioritize beneficence, the protection of offspring, and social responsibility.

ICSI cycles for young patients under 35 years old are expected to result in live births. The more donated oocytes received, the higher the cumulative pregnancy rate for recipients [44]. However, requesting an excessive number of donated oocytes (per cycle) can increase the risk of OHSS in donors. Currently, other countries and regions usually do not impose clear limits on the number of donated oocytes received, but some scholars believe that receiving 8 oocytes is the upper limit [45, 46]. With the implementation of China’s three-child policy, some recipients hope to obtain more oocytes from the same donor to have multiple children, which can increase the probability of pregnancy and live birth, as well as ensure consistent genetic backgrounds for multiple children, aligning with the ethical principle of protecting offspring. However, when one recipient receives a large number of donated oocytes, it necessarily reduces the number and opportunities for other recipients to receive oocytes, thereby lowering the number of recipients that can be served by the same batch of donated oocytes. Therefore, China’s “Expert Consensus” recommends that recipients receive 3–5 donated oocytes, conforming to the ethical principles of double effect, optimization, and social welfare. It is worth mentioning that when recipients request an excessive number of donated oocytes to achieve a higher live birth rate (i.e., at least two transfer procedures will be performed, with two embryos transferred per procedure), their wishes should be respected only after prioritizing other ART ethical principles and the donor’s consent [47].

Given the extreme scarcity of oocyte donation resources, China’s “Expert Consensus” clearly stipulates that patients need to queue up for donated oocytes based on their conditions and registration time [23]. Most reproductive centers in China follow the order of recipients’ registration time, which aligns with the ethical principle of justice. However, for older recipients without children, the risk of being unable to have offspring if they do not obtain oocyte donations soon is significantly higher than that for younger recipients. Therefore, simply following the order of registration time is not fully in line with ethical principles, which warrants discussion and adjustment [48]. For childless recipient families, oocyte donation is undoubtedly a lifesaver; for families that already have children and wish to have more, oocyte donation is more of a bonus, which may also complicate genetic backgrounds and pose potential risks to children’s growth and family relationships.

Oocyte donors have the right to protect their personal identity, lives, and families from disruption. Anonymity was a key factor attracting many donors, who may not wish to establish a future relationship or assume any form of social or legal parental responsibility for offspring resulting from their donation. Anonymity protects donors from being sought out, contacted, or held accountable (emotionally, financially, or even legally) by offspring in the future, ensuring the donation remains a one-time act with clear boundaries. Anonymity serves as a significant incentive for a segment of potential donors. Mandatory disclosure of identity could lead to a decrease in donation willingness, reducing the accessibility of oocyte supplies [54].

When a donor’s right to anonymity conflicts with the offspring’s fundamental right to know their origins and their health rights, the latter should take precedence. Donors should recognize, upon deciding to donate that their action creates another human life with specific needs. With the proliferation of genetic testing technologies (e.g., 23 and Me, Ancestry DNA), absolute anonymity is becoming increasingly difficult to maintain [54]. Offspring were highly likely to discover the donor’s identity through alternative means, and the impact of such passive discovery may be more significant and disruptive.

Understanding one’s biological origins is a fundamental human need and is crucial for forming a complete sense of identity. Lack of knowledge about genetic heritage can lead to confusion, identity crises, and potential negative psychological impacts. Anonymous oocyte donation deprives offspring of access to a complete family medical history and knowledge of potential health risks. This information is vital for the prevention, diagnosis, and treatment of certain genetic disorders. Anonymity obstructs access to potentially life-impacting health information. Documents like the UN Convention on the Rights of the Child implicitly recognize a child’s right to know their biological origins. An increasing perspective holds that knowing one’s biological parents is a fundamental human right. The anonymity system requires parents to conceal the truth of conception from their children; if this information is later revealed (e.g., through genetic testing), it can severely undermine familial trust.

Concerns exist that the involvement of a donor could disrupt the core family bonds between the child and the rearing parents or create internal family confusion. Opponents argue that the quality of the nurturing environment is more impactful on a child’s psychological well-being than knowledge of biological origins. Some children thrive and develop healthily within an anonymous donation framework.

Intended (recipient) parents typically have the right to choose the donation model (anonymous or open). They believe they have the right to determine the composition of family information and when/how to inform the child of their origins. Some intended parents prefer anonymous donation to avoid donor involvement in family life, minimize potential future relational complexities, or due to concerns that open donation could decrease the available pool of donor oocytes. Ethically, it was emphasized that intended parents have a moral obligation to be truthful with their child about the method of conception, regardless of whether the donation was anonymous. Anonymity should not serve as a justification for secrecy [55].

Anonymity impedes the timely updating and sharing of health information between the donor and offspring (e.g., if the donor later discovers a new serious genetic condition). Even within anonymous donation systems, it is critically important to establish secure, bidirectional mechanisms for updating essential medical information (non-identifying) through clinics or intermediaries. Anonymity may render the donation process more “commercialized”, diminishing the human dimension inherent in creating a life. Conversely, others argue anonymity protects donors from emotional coercion or inappropriate contact. Differing cultural views on family and kinship significantly impacts the acceptance of anonymous donations. Legal frameworks governing donation vary considerably across different countries and regions. Donors, often young at the time of donation, may be unable to fully foresee future changes in their perspective on being contacted (e.g., after starting their own families) [55]. Similarly, an offspring’s desire to uncover their origins in adulthood is difficult to predict at the time of donation.

There is a move towards “identity-release” donation, where donors agree that their identifying information may be released to the offspring once the child reaches a certain age (typically 18), if the offspring actively requests it. Current legislation in many countries (e.g., UK, Sweden, Netherlands, Portugal, and certain Australian states) mandates that donor identity information be stored by a registry, granting offspring the right to access this information upon reaching adulthood.

The prevailing ethical trend increasingly favors restricting or abolishing mandatory anonymity systems, shifting support towards open-identity or traceable donation models. This prioritizes safeguarding the offspring’s right to access information about their biological origins and critical health data. Simultaneously, efforts were made to find a more ethically balanced approach that protects donors’ reasonable expectations of privacy while meeting the offspring’s fundamental needs. This was achieved through mechanisms such as setting contact thresholds (e.g., offspring reaching adulthood), providing counseling support, and establishing intermediary systems for information exchange. Regardless of the model adopted, the long-term well-being of all participants, especially the offspring, must remain the core consideration.

Primary motivations blend altruism (80% prioritize helping others) with financial needs, although excessive monetary focus risks anxiety. Psychological risks include hormonal depression (gonadotropin-releasing hormone [GnRH] agonists), genetic linkage fears (21% anonymous donors), and bodily autonomy concerns (12%), mitigated by open (instructional design) ID programs, virtual reality (VR) simulations, and strict screening (excludes borderline personality disorder [BPD]/high-financial-motivation cases). Post-donation narrative therapy strengthens altruistic identity.

Face infertility grief (6–18 months adjustment) and maternal legitimacy anxiety (37%), addressed through parenting rehearsals. High cortisol ($>$14 µg/dL) lowers IVF success by 26%, while symbolic rituals improve compliance (23%). Early disclosure (age 3–5) reduces child identity confusion by 58%, with “special helper” narratives easing family dynamics.

The landscape of oocyte donation and oocyte sharing is defined by a series of critical interactive dynamics that extend beyond mere medical transactions. These interactions are multifaceted, emotionally charged, and carry profound ethical weight, primarily unfolding between three core parties: the recipient(s), the donor, and the medical intervention (Table 2).

East Asian cohorts: 89% donor concealment vs. 21% in Western populations; open-identity donation reduces Nordic donor regret by 76%; religious approval (e.g., Fatwa) decreases psychological burden by 54% in Muslim-majority regions.

Digital twin consultation: virtual offspring modeling using donor phenotypes; epigenetic education: emphasizes uterine environment’s role in gene expression; neurofeedback: enhances prefrontal $\alpha$-waves during embryo implantation.