How professional discretion shapes participation in egg donation: a mixed-methods comparative study

Abstract Study Question: How are access-related decisions in egg donation, including donor and recipient eligibility, matching and allocation, regulated and operationalised in practice? Summary Answer: Formal regulations set only broad parameters with the substance of access-related decisions determined at clinic level through provider discretion that was variable and often opaque. What is Known Already: Clinic-recruited egg donation, in which people donate eggs to clinics or egg banks for allocation to recipients unknown to them, requires decisions about who can participate and under what conditions. These decisions can carry significant consequences for the reproductive opportunities of donors and recipients, yet little is known about how they are made in practice. Previous work has documented differences in the formal rules governing access to egg donation across jurisdictions. How these rules are applied in practice, and how clinics approach access-related decisions where formal regulation is absent or limited, remains poorly understood. Study Design, Size, Duration: A mixed-methods qualitative design comprising an analysis of policy and governance documents and semi-structured interviews with key informants experienced in egg donation policy or practice. Analysis spanned eight jurisdictions: Australia, the Czech Republic, Denmark, Israel, Spain, New Zealand, the United Kingdom, and the United States. Interviews were conducted between September 2025 - April 2026. Participants/Materials, Setting, Methods: Document analysis mapped the formal regulatory landscape in each jurisdiction, drawing on legislation, professional guidelines, grey literature, and publicly available clinic materials. Interviews explored how formal regulation is interpreted and applied, how decisions about eligibility, access, and allocation are made, and the ethical tensions and practical challenges these involve. The two data sources were integrated through a thematic comparative framework organised around four domains: donor eligibility, recipient access, matching and allocation, and underpinning rationales. Main Results and the Role of Chance: Across all eight jurisdictions, formal regulation set broad parameters but left many access-related decisions unspecified, leaving these to be operationalised at clinic level through provider discretion. Donor eligibility was shaped less by legislation than by clinic-level interpretation, with providers applying additional screening and assessment criteria alongside formal requirements. Recipient access was similarly variable, shaped by clinic policy, donor availability, and financial capacity, with participants describing inequities between public and private systems and disparities in donor diversity across providers. Approaches to donor-recipient matching also varied from recipient-led selection to clinic-mediated approaches, with clinics in some jurisdictions directed by regulation to match on physical, cultural, or religious resemblance, and clinic discretion extending in some settings to overriding the preferences of both donors and recipients. Providers framed access-related decisions in terms of professional obligations to protect donors, ensure recipient suitability, and safeguard the welfare of future children, but described some discomfort and uncertainty in making these decisions. Limitations, Reasons for Caution: The regulatory analysis may have been limited by the accessibility and availability of key regulatory documents, particularly in non-English-speaking jurisdictions. Participants varied in professional background, which likely influenced their accounts and assessments of practice. Findings may not capture all variation in the global provision of egg donation. Wider Implications of the Findings: Access-related decisions varied significantly between and within jurisdictions. These decisions carry real implications for fairness, equity, and the welfare of donors, recipients, and donor-conceived people. Future work should examine the limits of provider discretion and the principles needed to support transparent, accountable and consistent decision-making.