Cross border donations – the IVI experience

Let me make a short introduction about cross-border relative care which involves the movements of patients across or outside the countries looking for reproductive treatment and services. That’s a phenomenon that has been increasing during the last two decades, probably because the legal diversity and free movements of people through different countries is a perfect background for this type of studies. Also, the delayed motherhood in many developed countries is a very important underlying factor for CBRC (cross-border reproductive care) and we already know that approximately 5% of all European fertility care involves cross border traveling. Egg donation is leading this type of treatment. If we talk about the USA , it is around 4% and surrogacy is one of the most popular treatment for cross border. One of the reasons for this type of traveling is the legal restrictions in the origin countries. This is the most popular one but also shorter waiting times, better outcomes, greater privacy and lower costs are other reasons for cross-border reproductive care. Spain meets them all. We are a very active country in Europe in fertility treatment with a long experience. In fact, in 2016 with the last data from ESHRE (the European Reproductive Society) 130,000 cycles were performed in Spain, ranking the top five in the world. Therefore, it is not surprising that patient travel to Spain because of our experience in this type of treatment, the results, of course, and mostly because our fertility law is one of the most open and safe in Europe. Treatment are possible for female couples, single women, older women. We also perform preimplantation genetic diagnosis for the embryos and regarding egg donation, donor anonymity is a very important factor. Also, very short waiting times are the principal reasons. ESHRE data has found that 50% of all the egg donation treatments performed in Europe is done in Spain so that’s a lot. Nearly 10% of the treatments performed in Spain were for foreign patients so as I have said we have a lot of experience with foreign people. Most of them were egg donation. Talking about IVI, 30 % of all our egg donation treatments are in foreign patients. 80% of them came from France, Italy, Germany, the UK and Switzerland. Probably because of their law in their countries. I think these are the basic reasons for Spain to be so popular for this type of tourists.

In an egg donation program, there are different factors that have an influence on success. We could divide them into patients, donors and the lab. Probably, the most important one is the embryo quality and normally it depends on the egg quality so the donor screening is essential. We have to be very selective with the donors. Also, we have to look for a balance between donor safety and results because having a good number of eggs is important for the final treatment result which is having a healthy baby at home. Regarding the IVF lab, the technical equipment such as those depending on the IVF lab as well upon embriologist’s experience are very important because they are going to allow us to transfer the embryo in blastocyst stage which is a very good quality parameter and raises pregnancy rates. The cryopreservation program is also another quality parameter. Talking about the patients, they also play an important part in the successful outcome because the sperm quality affects the embryo quality and the model characteristics or conditions can also increase or decrease the success. If the patient or the recipient is overweight, has any endometrial or uterus pathologies, high blood pressure or thyroid problems, it will affect the results but that’s why it’s very important for the recipient to be as healthy as she can.

I like this question very much because I am very much a defender of single embryo transfer. That’s a very important challenge that our group promoted in 2017 and achieved in 2018 – a 100% of blastocyst transfer and a 100% single embryo transfer in egg donation. We promoted that action because it’s very important for us, the safety of our patients but it is also very important to maintain the quality of our treatment and the success rate. Nowadays, the pregnancy rate doesn’t differ more than a 5-7% per attempt when transferring one or two embryos. The risk of twin or a single embryo pregnancy isn’t 5-7% more; it is much more, more than 50% the risk in a twin pregnancy compared with a single one. In fact, in nature, the rate of twin pregnancy naturally at home in a spontaneous mode is less than a 2%. We try to look to do our treatments as naturally as we can maintaining the pregnancy rates. The risk involved for the mother are preeclampsia which is high blood pressure produced by the pregnancy, diabetes, bleeding during the pregnancy, a placenta bundle abnormalities, higher risk of Cesarean section, and, for the babies, the most important risk is prematurity with all the consequences that is produced but, also, low birth weight, abnormal presentation, congenital malformation, risk of miscarriage. All those risks rise with maternal age and, nowadays, most of our patients are over 40 which is in itself a risk for all these complications. That’s why we think that we have to take care of our patients but also of their babies. We offer them safety and efficient treatment with minimal side effects and complications. That’s why we have bet for single embryo transfer. It’s very important.

In all our clinics we have specific international units with doctors, nurses, assistants who speak the patients’ language which is very important when you are traveling abroad for this type of treatment. We have all kinds of protocols and information for doctors abroad and patients. In some cases, there are local doctors who used to collaborate with us before so it’s easier. But if they haven’t, there is no problem because we will send them a treatment plan with all the scans required and also the prescription for the medication that they are going to use. We try to make it as easy as we can for our personal or for our colleagues so they feel as comfortable as possible. We know that this type of treatment has a very important psychological impact, because of the objective and the way to achieve it the objective which is having a baby and the way to achieve it which implies having to travel to a foreign country with a different language. As I’ve said before, Spain is a very popular destination for egg donation and we have very quality reproductive results. We follow all the European normative standards for the patient and for the donors and in our clinics we have a lot a long experience with foreign patients. You don’t have to be worried about coming to Spain for any type of treatment because we are going to give you the most excellent medical assistance and care and also make the best techniques available to the patients.

I know you have touched on this topic before during another webinar about donors and donor selection. We have plenty of donors in Spain because Spanish people are very supportive. We are the first country in the world in organ donation. We have a very large blood donor bank so it is not surprising that we have plenty of egg donors. Anonymity is a very important fact for this big number of donors. To ensure patient and donor safety we follow all the European safety guidelines and the national registry of gametes and embryos has been developed accordingly so that all the donors have to fulfill our inclusion criteria. We have many women who want to be donors and we can be very selective with them. The inclusion criteria are women with good physical and segmental health or psychological health under 35 years old, most of them are under 30, with regular menstrual cycles, no family history or chromosomal diseases, a normal karyotype, normal body mass index, no pathology in the ovaries such as polycystic ovaries or endometriosis or having more than two previous miscarriages or another with gynecological or medical disorders, they have to have a negative screening results for sexually transmitted diseases. We also have a genetic test, a special one that studies over 600 recessive diseases. This test doesn’t raise the pregnancy rate but gives you the knowledge that you are not going to have a baby with one of those recessive diseases which are very severe and don’t have any treatment. All the donors have to sign a written informed consent form and they are not legally compensated. We treat them with respect because we need them. We perform safe ovarian stimulation and egg retrieval with a very low-risk rate. They are all well-explained processes where we make follow-ups. We offer genetic counseling and psychological support. Talking about COVID-19, at the moment we are adapting to this new situation all over the world. We had to stop all the treatments in April and March and now we have opened all the clinics and all the labs following all the sanitary requirements and guidelines that we know it by the moment in order to prevent disease expansion. We have taken all the preventive measures in our clinics all the personnel has been tested for Coronavirus in order to protect our patients and our personnel. It seems that there is no risk of infection through oocytes but we test all donors with PCR tests just before the retrieval, before getting into the operating theatre. All the samples of vitrified eggs obtained between January to March 2020, have been tested for Coronavirus. Regarding the patients traveling, we depend on the government’s sanitary regulations for the opening of the borders. At the moment, it is supposed that in the next week of July, the borders are going to be open so patients can start traveling to Spain with security and with all the medical measures to prevent it.  At the moment, we are not going to ask them to be tested for Coronavirus just in case they have any contact or any symptoms, then we will. I think there is no reason to delay pregnancy. Coronavirus doesn’t affect the baby directly. Maybe indirectly it could because if you have if you are pregnant and get ill from Coronavirus depending on how it affects you, it could produce premature delivery or something like that. But I think I wouldn’t recommend delaying pregnancy desire. We don’t know what is going to happen at this moment. We are waiting for another wave of Coronavirus in October but we don’t know. At the moment, we are working normally with all the new measures. We are waiting for all the patients to be able to come to Spain.

Fortunately, in Spain is not the same. It is not very common but we have black donors. Maybe you are looking at a specific phenotype. Not all black people have the same characteristics but there is no problem with that and there is no waiting list for black donors here in Spain. The most difficult to find donors are the Asian ones but black donors if you need one,  you could find them here in Spain without a waiting list. Regarding Asian donors, we have them. They are very precious but donors are women who live here in Spain so Asian people are not used to donation so although they live here, it’s difficult to find them but we have them.

It depends on your country. There is a debate about that because if a country asks for two weeks’ isolation, the other country will ask for two weeks’ isolation, too. At the moment, I think we’re not going to ask for that if you’re coming here for an egg donation treatment. But I don’t know what your country’s government is going to say if you come from Spain. I don’t really know. If you’re going to be able to travel to Spain and everything goes fine, you are going to be able to come back and I think you shouldn’t be isolated for two weeks. But that’s dependent on your government regulation. We are not going to ask for that here in Spain at the moment.

Another difficult phenotype, too, but Indian people are more open-minded, I think. We don’t have Indian ethnicity but we have very dark-skinned, very similar to Indian phenotype donors. We have Indian donors but there are few of them. We can compensate for that with a very dark Spanish or half Indian donor but it’s another type of difficult donor to find. We have a very extensive egg donor bank so if you go to any IVI clinic and they don’t have a donor who matches with you, we can look for a donor in another IVI clinic. We can send the eggs to your clinic and have the treatment performed. There are many IVI clinics in Spain. We are the same a company. We are different clinics in different cities in Spain and we work together. We have a common egg donor bank so if you don’t have a donor, we can ask, for example, our Barcelona clinic to send the eggs. We have one of the largest donor banks.

That’s a question I cannot answer because we don’t talk about money in the surgery. We talk about all the medical issues but the all economical issues are treated outside with the specific assistant for that. If you check our page, I think, the prices are listed or if you want to send us an email, we will answer you. I can give you a price but I’m not going to be sure so I do prefer you ask directly to any IVI clinic and they will answer you directly.

Yes, here in Spain egg donation is totally anonymous. You are going to know just a few details about the donor: the age, the physical characteristic and the blood group. You are not going to be able to know anything more about the donor. And she’s not going to be able to know where her eggs are going to go. In Spain, we have totally anonymous donation and I think it is going to be like that for a long time.

You cannot travel at any time merely because your uterus has to be prepared and synchronized with the embryo for the embryo transfer. If I transfer the embryos at any time and it is not going to be synchronized, you’re not going to get pregnant. We have to prepare your uterus before coming for the embryo transfer but you can do all that preparation at home in your country and come for the embryo transfer. We will give you all the medication you’re going to use and information when you need to have the scans done. We can adapt to your travel timetable, e.g. if you want to have holidays in August, travel to Spain on specific dates, we will regulate your period and we will adapt to your schedule but it has to happen within an agreed time.

Yes, you’re going to know the age of the donor because it is important to calculate the risk of Down’s syndrome which depends not on your age but on the egg donor’s age. You’re going to know the donor’s age, the blood group and the physical characteristics if you want. That is what you are going to know. The age is very important to know when you get pregnant and start controlling your pregnancy because the risk of miscarriage or the Down’s syndrome depends on the age of the egg donor, not egg recipient.

That depends on sperm quality. For foreign patients, we normally use frozen sperm because it’s easier to arrange the treatment timetable. You will have to come to Spain one time for the first appointment and leaving the sperm sample. Then, you come for the second time for the embryo transfer. If the sperm is of good quality, we can use a frozen one, it doesn’t matter. But if it’s a very bad sample of sperm, then we will recommend you to come to Spain for a fresh sperm sample. When we use donor sperm, it is frozen so there is no difference between frozen or fresh if it has good quality. But if we have a very bad sperm sample, then we will ask for a fresh sample and, in that case, you should be here a week more or less for giving the sperm sample and five days later for the embryo transfer.

I’m sorry but we don’t ask our donors about their religion. If it is important for you, we can ask and tell you. Religion is not a hereditary or genetic issue so it’s not important for getting pregnant. I understand maybe that because of your religion it is important for you but normally we don’t ask our donors what religion do they follow. But if you are interested, if you want to know that detail, we’re able to ask the donor, we are in touch with them.

Once you decide to start, counting from your period, it takes around 2 months for the process. If you have your period in June, the embryo transfer could be at the end of August more or less. It depends on your period date because we have to prepare your uterus in a not natural way. That allows us to play with the dates so it takes around two months to have all the treatment finished.

The best day for the embryo transfer depends on what type of endometrial preparation you are doing. If you do it in a natural cycle, it has to be done a week after the ovulation but if you do in a not natural cycle like the one you have done with estrogen and progesterone, we can do it whenever we want. Once your uterine lining is ready, you start with progesterone which is the hormone that changes your lining your endometrium to be receptive to the embryo. Then if it’s a blastocyst we’re transferring, it’s five days on progesterone for you to be ready for the transfer. There is no best day for embryo transfer. It depends on the way we prepare your uterus.

In the case of the same blood group, you don’t have to give any explanation of whether your baby comes from egg donation or not. It doesn’t matter if you are A Rh+ and have a baby who is B Rh+. It’s not going to change your pregnancy rate. But when your child grows up and asks about your blood group and it is the same and you don’t want to explain that they come from a donor, you don’t have to. If you don’t care about the blood group, you will simply have more donor options to choose from. We try to find a compatible blood group with you and your partner or just with you. In case you have a negative blood group, we try to look for a negative donor because if you get pregnant and the baby is positive and also if the next pregnancies are positive, this creates problems for the baby. That’s the only advice we give regarding blood group. If you don’t care, there is no problem. But we try to look for a donor as much similar to you and that includes your blood group.

In egg donation programs, we do 5-day embryo transfer. Why? That’s the best way to select the embryo. One embryo can be perfectly morphologically OK when we look at it under the microscope. And on day 5 the development can stop. If it stops in the incubator, it would have stopped inside your uterus. Nowadays, transferring embryos on day 3, especially when it’s egg donation, it doesn’t make sense. You’re not going to gain anything. If you want to get higher success rates and you have the opportunity to choose the day, it’s better to transfer on day 5.

Sperm is affected by a lot of different factors. Coffee or caffeine affects the sperm quality but it depends on a person. It’s like smoking – it affects sperm motility but there are patients who smoke a lot and have perfect sperm. The best way to know is to have a sperm test done and see the results and perhaps try to reduce coffee intake. Coffee is not a healthy drink to be drinking all day for males and females. However, it isn’t the most important factor which affects sperm quality. Alcohol especially affects it much more. The only way to know is to have a sperm test.

Yes, of course, we accept the blood screening test results if they are less than a year old. We got the Spanish law that says that we have to have all those tests done within the last year. If you have done it in another clinic or in the UK, we can accept it.

I need to know what you mean by two failed egg donations. Two failed embryo transfers from the same donation or two different egg donations failed. Because this makes a difference. In case of two different egg donations, we should find out what’s happening that the transfer fails. It depends on the number of embryos you have you have had transferred and their quality. I’d need more information to answer your question fully. Perhaps you can write me an email and I will answer you personally. After two failed egg donation, I would do more tests for your endometrial receptivity. Also, we have to know the sperm quality, your uterus condition, etc. If you come to me for another egg donation, I’d ask you to have some tests done, blood coagulation, immunology if you haven’t done it, uterine receptivity test, etc.

I’d recommend vitamins for the pregnancy: folic acid and vitamin D, vitamin B,  the vitamin complex that women use.

Yes, it is but that’s better when you are going to use your own eggs. There have been studies on these supplements and they seem to be useful for getting better egg quality when you are using your own eggs. But when you’re having egg donation, they are not really necessary but they are good, too. The more healthy you are the better results you are going to have. There are supplements that can help you to be healthier. They are more recommended for improving egg quality when you are going to use your own eggs.

Yes, it can help. All the vitamins can help because you want to have all your mineral levels as much regulated as you can. So vitamin D, vitamin C or vitamin B12 can help you in the pregnancy. The folic acid is for the development of the central nervous system of the baby. However, vitamin C doesn’t really raise progesterone levels. It hasn’t been demonstrated that it raises the progesterone levels. Still you have to be a as much calibrated as you can. It doesn’t hurt, it can help, take it if you wish.

It has been already demonstrated that there is no difference between fresh or frozen eggs. I’d prefer fresh if I have a testicle biopsy, for example, which is a very bad sperm sample. In this case, I’d prefer the eggs to be fresh. But it is not the case, it doesn’t matter if it’s fresh or frozen. They have the same blastocyst reaching rate, they have the same pregnancy rates. The only difference between fresh or frozen is if in a fresh cycle, in egg retrieval you get 12 eggs, you’re going to have 12 mature eggs to be fertilized. But if you have 12 frozen eggs, sometimes not all of them are going to survive thawing. You could then have 10 eggs. Between 10 to 12, there is no big difference. To sum up, only with a testicle biopsy, I would prefer fresh eggs. Otherwise, it doesn’t matter.

Yes, it is. There is no problem with that.

If the sperm is normal, it doesn’t matter using fresh or frozen eggs. It matters only when it’s with frozen sperm biopsy. I prefer personally to use fresh eggs but if we have normal sperm, we can choose between fresh or frozen eggs.

Dexamethasone has become very popular because immunology is now broadly studied and is a quickly developing field in fertility. Some patients with a repeated implantation failure may have another underlying immune problem that can be treated with Dexamethasone. However, I wouldn’t recommend taking it just to help with the implantation. I would recommend it for patients who have an indication for it but not because it can help with implantation. It helps when you have an immunology problem. If you don’t have any immune issues, it’s not going to help you in any way. The question for the patient is if you were studied by an immunologist or prescribed it just because of the previous failures? The most common cause of miscarriage is a chromosomal abnormality in the embryo. Nature is clever and if the embryo is not healthy, the development stops. I see you have done all the tests for the implantation failure study. My recommendation is that you go ahead with treatment and try again but if because if you got pregnant once probably you will be successful again.