During this live Q&A session, 3 Top Fertility Experts discussed the egg donation process in Greece, Czechia and Spain. The session also covered various aspects of choosing an egg donor and possible outcomes.
Featuring Experts:
Dr Konstantinos Pantos – Medical Director of Genesis Athens, Greece
Dr Katharina Spies – Medical Director of Vida Fertility Institute, Spain
Dr Hana Visnova – Medical Director of IVF Cube, Czech Republic
The event was hosted by: Professor Alan Thornhill, Fertility Expert & Coach, Founder of The Fertility Guy.
Dr Konstantinos Pantos, Genesis Athens: We have 4 clinics here in Greece—1 in Athens, another in Crete, one in Larisa, Central Greece, and another in Northern Greece, in Thessaloniki. Each clinic has its own doctors, and I oversee them with their own embryologists. We offer egg donation as one of our primary services, and we conduct over 6,000 cycles a year. We are also contemplating opening another unit in Santorini, one of the Greek islands, to combine this with medical tourism.
Dr Katharina Spies, Vida Fertility Institute: I’m Dr Katarina, and you might recognize my accent as German, though I live in Spain. I’m the Medical Director of VIDA Fertility Institute in Madrid. VIDA Fertility is a medium-sized clinic with 2 locations—one in Madrid and another in Alicante. We aim to offer very personalized treatments. We’re not looking to grow into a huge clinic but instead, focus on getting to know our patients and providing personal treatment. For the treatments we offer, we provide everything that is allowed in Spain, including IVF with preimplantation genetic diagnosis and egg donation. We also offer ROPA treatment, which is for 2 women.
Dr Hana Visnova, IVF Cube: My name is Hana Visnova, and I’m the Medical Director of IVF Cube Clinic in Prague. Our clinic is very similar to the ones my colleagues introduced earlier. We offer a wide range of IVF treatments, including egg donation and genetic testing. However, in comparison, we can only treat heterosexual couples in our country. Egg donation is a significant proportion of our treatments.
Dr Hana Visnova, IVF Cube: First, they need to decide because this is a very difficult decision to go down the egg donation path. Once they and their partner agree that this is their method of choice, they need to get in touch with us. We have a short consultation to summarize their medical history and make sure they can undergo this type of treatment. Then, we ask them to submit various hormonal results and ultrasound pictures. From the beginning, we also ask the male partner to come to Prague to give his sperm sample. After that, we start choosing the donor for them. We provide a donor questionnaire to match an appropriate donor. Once we find a suitable donor, we issue the treatment plan for the recipient.
Dr Konstantinos Pantos, Genesis Athens: Yes, she has to be under 35 years of age. We take a medical history from her, including a family history. We prefer donors who have had a pregnancy in the past and who have no health issues. She must also consent, of course. In Greece, the law allows up to 12 children per donor, which does not include overseas patients.
Dr Katharina Spies, Vida Fertility Institute: In Spain, egg donation treatment is anonymous, so the patient cannot choose the donor. We select the donor based on the physical characteristics of the patient and the couple. We ask the patients to send us some pictures to complete a phenotype characteristics form. Furthermore, we hold a meeting every week between the doctors, biologists, and nurses to choose the best donor from our pool of donors who are available at that moment. We also consider the blood group. For patients with immunological issues or repeated miscarriages, we may select a donor based on immunologist recommendations. However, we cannot provide pictures of the donor. We only disclose basic information such as age and blood group.
We cannot provide information on whether the donor has produced children before, but we can include proven fertility in our selection criteria. If requested, we can choose a donor who has already had children or who has produced embryos in other treatments with ongoing pregnancies or euploid embryos. However, we cannot disclose the donor’s identity.
Dr Hana Visnova, IVF Cube: In the Czech Republic, egg donation is also anonymous, and patients must trust the clinic. The patient submits a questionnaire, including a donor matching form, and can request specific characteristics such as proven fertility or blood type. Our clinic conducts mandatory genetic testing of all donors. We also offer additional genetic compatibility tests between the male partner of the recipient and the donor to eliminate common genetic conditions. We do not show pictures of the donors but can disclose basic characteristics such as age and blood type. Furthermore, we also follow phenotype criteria, and I recommend submitting childhood pictures around the same age as the donor’s. However, as I tell my patients, even with natural conception, we never know how a child will look. There are many combinations, and sometimes children resemble extended family members more than their parents. I believe children raised in a family environment often develop similarities in behaviour and appearance with their social parents, not necessarily the genetic ones.
Dr Konstantinos Pantos, Genesis Athens: We have recipients from over 67 countries. In Greece, egg donation is anonymous, but we now have a category of known donors for relatives of the recipient, though this is expected to change soon. We conduct Skype consultations, and patients can choose from profiles provided by the clinic. The profiles do not include pictures but contain relevant information. In anonymous donations, recipients select a profile based on their comfort. The recipient’s age limit for donation is up to 54. Amazingly, the vast majority of children from egg donation tend to look like the mother, which gives the impression that the children inherit some characteristics from the recipient.
Dr Hana Visnova, IVF Cube: I have not heard of any correlation between egg donation and autism. There are theories suggesting that male age may contribute to psychiatric disorders, and since egg donation recipients may have older male partners, this could contribute to risks. From a safety point of view, egg donation can be better than using eggs from older recipients. The younger donors are typically much younger than the recipient, which decreases the risk of genetic abnormalities like Down syndrome. Additionally, as I mentioned earlier, all donors undergo genetic testing, so they are more thoroughly investigated than the general population before donation.
In the Czech Republic, we have a strict age limit of 49. After the 49th birthday, they cannot approach treatment here anymore.
Dr Katharina Spies, Vida Fertility Institute: This is something new that has been rising in the last 4 or 5 years. The KIR and HLA testing is a test we do for patients who do IVF treatment with their own eggs or if we include egg donors, sperm donors, etc. We normally use it if we suspect implantation failure or if the patients have repeated miscarriages. We test the KIR and the HLA for the male partner or sperm donor. Then we check if there is a high risk of rejection or possible rejection of the embryo. There are three types of KIR: KIR AA, KIR AB, and KIR BB. In KIR AA patients, we need to be careful and check if we might need a donor with a low C2 chart. We look for a donor with HLA C1 C1 C1, which is very specific. This is done in cooperation with immunologists, and we consult with them and the patients online. We add this test before looking for a donor because it helps us find a donor who might reduce the rejection of the embryo, improving the clinical outcome.
In Spain, there is no legal age limit for undergoing IVF treatment, but most clinics set an age limit of around 50 or 51 years. In our clinic, we accept new patients up until their 51st birthday. If a woman has just turned 52, had a baby, and wants to go for a second child with frozen embryos, we accept them under specific conditions until their 53rd birthday.
Dr Katharina Spies, Vida Fertility Institute: We do not use DQ Alpha testing. Instead, we perform KIR testing along with other tests, such as thrombophilia studies, lymphocyte tests, antiphospholipid syndrome screening, and other immunological tests.
Dr Konstantinos Pantos, Genesis Athens: In Greece, we know that as a woman ages, so do the mutations, and pregnancy rates go down. The consensus is 44–45 years, but we believe women still have the right to try with their own eggs as long as they understand that the pregnancy rate is low. We have had women as old as 49 give birth with their own eggs, but the pregnancy rate is lower than 5% in those cases. We generally advise women over 45–46 years to consider donor eggs as the best option, though many women try with their own eggs first before turning to egg donation. The success rate with donor eggs is about 65% for pregnancy and about 50% for live birth. We are legally allowed to transfer 2 embryos, though many women choose one.
The success rate for donor eggs is about 65% for pregnancy and 50% for live birth. Many women in Greece opt for two embryos to be transferred, which is allowed by law.
Dr Hana Visnova, IVF Cube: Our standard approach is not to include PGT-A for egg donation. However, if there is a medical history or concern about genetic conditions on the male side, PGT-A can be done. We do not think it makes a major difference because the donors are screened for genetic conditions and come from an age group where there is no higher risk of genetic abnormalities.
In our country, donors must be at least 18 years old. There have been theoretical studies that show a higher risk of genetic abnormalities in very young donors, particularly teenagers. However, egg donation is not allowed in our country for anyone under 18, and we rarely see donors younger than 23–25 years.
Yes, I always prefer a donor who is a mother herself because the experience, the cooperation, and the emotional aspect make a big difference compared to a donor who is childless or has never intended to have a family.
Dr Katharina Spies, Vida Fertility Institute: Yes, I confirm that you can choose the blood type. In the end, the blood type doesn’t change the pregnancy rate; it does not change the success rate, but it’s something that we offer to patients in order to avoid family or friends, or whoever, knowing because of the blood group of the baby that the treatment has been with egg donation.
In Spain, it’s also allowed to transfer several embryos. Legally, it’s allowed up to 3 embryos. I have to say that I have never transferred 3 embryos, nor have my colleagues, but we let patients decide between 1 or 2 embryos.
Our recommendation generally for everybody is to transfer 1 embryo to avoid twin pregnancies. The pregnancy chances are quite high with egg donation, it’s similar to what Dr Pantos said—about 60-65%. The success rate doesn’t increase much if you transfer 2 embryos; it raises about 10-15%, but it increases the risk for twin pregnancies. I say risk because, in the end, the pregnancies are much more risky for the patients and the babies. So, normally, up to 45, we allow the patients to transfer 2 embryos.
If a woman is older than 45 or if there are contraindications like former C-section or fibroid operations, obesity, high blood pressure, diabetes, or anything like this, we recommend a one-embryo transfer.
Regarding genetic testing in egg donation treatments, normally, as the donors are young, there’s no medical indication for genetic testing in egg donation treatment, but we can do it when we recommend it. As my colleague said, if there is a male factor, if there are alterations in the sperm, if they had trisomy in the past, if they had several miscarriages, or if the patients are interested in doing it. More and more, we also do it in patients who have had many treatments already to ensure that we only transfer genetically healthy embryos and also raise the chances of a healthy child.
Dr Konstantinos Pantos, Genesis Athens: No, it’s up to 12 children in Greece. There’s no maximum number of children outside of Greece, and of course, this does not include babies within the same family. So, it’s actually for 12 families.
I think this is quite liberal within the framework of our medical practice. As I said, here in Greece, we do have an embryo transfer of up to 2 embryos for egg donation. If a woman uses her own eggs, and she’s over 40, legally it’s allowed to transfer up to 4 embryos. We usually do not transfer 4; we transfer 2 or 3 if she’s over 40 unless she is 40 or over.
Regarding pre-implantation genetic screening in Greece, we have to have approval from the health authority to proceed with genetic screening. They usually provide this service for women over 40 with their own eggs. However, when we use donor eggs, they will not approve because they don’t think this is warranted for women under 40. They will approve only if there are lots of miscarriages or if there’s a genetic problem with one of the partners.
Dr Hana Visnova, IVF Cube: Carrier Screening is something different from a karyotype. Sometimes patients, as the wording is similar, don’t distinguish between a karyotype and carrier screening. A karyotype means that we check the number of chromosomal copies for each individual, which is a mandatory test for any egg donation donor or sperm donor as well. But carrier screening means that we can investigate the donor and the male partner for the most frequent genetic mutations, which any healthy person can carry without having any relevant family or personal history.
We want to avoid that the sperm is carrying the identical mutation as the egg has. We can offer testing, and I believe that those people who follow our discussion today can find out in their home country, multiple laboratories offering so-called carrier screening or sometimes the couples have done it as part of their previous genetic investigations because of infertility issues.
If we are aware that the male partner of the egg donor recipient is a carrier of some mutation, we run a similar investigation for the donor. There are different laboratories; some of them offer screening for the 50 most frequent genetic conditions, and some offer a panel for the most frequent 230, 400, or 600. I know that there are also genetic companies offering screening for 2,000 mutations, so it just depends on the country and the options for each patient.
We run carrier screening for the most frequent 430 genetic conditions, because it may differ in different countries. I don’t know what is the situation in Spain, but it’s different in different laboratories.
Dr Katharina Spies, Vida Fertility Institute: We don’t have it. Why do we not have it? Because we are much smaller than IVI. This is the reason. So, as I mentioned in the beginning, we are a much smaller clinic, and this means that we know personally our donors, and we know our patients, and we do this matching on our own. So, it’s personal; it’s not a computer, it’s not artificial intelligence. It’s us who do the matching, so we look at the face form, we look at the eyes, the nose, the ears—whatever the patients demand of us—and like this, we look for the donors.
I think this kind of matching is quite useful, but I think there’s no difference whether you do it personally or whether it’s a program. Probably, it’s just the difference in clinic size. If you have 800 donors, it’s impossible to know them. If you have 100, you can know them. So, this is the reason why we decided not to use this kind of program.
If it’s an open donation, there is a risk that fewer women will donate, so we have fewer donors. It’s also something that you don’t know. This donor, you can see maybe pictures, you can see the description, but you don’t know her. You will never meet her, and you will not know her.
Also, if you meet her or if they give you an idea about something, that she says something, or you listen to her voice, you will not know her. And it doesn’t matter because the baby is going to be your baby. It’s going to be from you and your partner, in case you have a partner. As we mentioned before, once the baby is born, a lot of things are going to happen because of imitation, the mimics, how we look, how we smile, how we love, and what we do in our day-to-day lives. Also, if there are brothers and sisters, it’s imitation. It’s a lot about epigenetics as well. Because it’s not one baby you transfer to one patient—it’s going to be a different baby. Epigenetics are important, imitation is important, and then, of course, it’s important to choose a good donor with the main physical characteristics. I’m sure that all the clinics do this.
Dr Konstantinos Pantos, Genesis Athens: To my opinion, no, the birth rates are more or less the same up to the age of 54, which is allowed in Greece. As far as the health concerns for older patients, if a woman here in Greece is over 50, the recipient needs to have health authority approval up to 54. So, we do not put all women into this process. We get health approval, which means that they do have to have a certificate from a cardiologist, a pathologist, and a gynaecologist.
If a woman is healthy, we do not look at her age; we look at biological health, which is more important and has the required prerequisites. So, we do proceed very much, and the pregnancy rate is more or less the same. We’ve had even a woman having 2 or 3 children after 50 years of age and their attempt to increase their family up to 54. So, we haven’t had any complications from women other than what we know that with increasing age, we have to be more careful, of course.
Dr Hana Visnova, IVF Cube: We would recommend the DNA fragmentation test for those where the previous fertilization attempts have failed, or they have been facing very low fertilization rates or if have repeated treatment failures using donor eggs. Of course, if there is any personal medical history of the male partner, like any oncology treatment, such as chemotherapy, or working in a dangerous environment, they can consider DNA testing. But I don’t think it is necessary for everyone, though some people are interested.
Dr Katharina Spies, Vida Fertility Institute: Concerning DHEA, it’s true that there are some studies about this. I don’t want to call it vitamins for this medication. I think it can help, but I’m not sure that it will help, but it doesn’t do any harm. So, what can we expect from this? We know that to raise the quality and the number we can get of eggs in treatment, we need to take adequate doses of DHEA. Normally, we tell the patients to take about 75 milligrams per day, and they need to take it for several weeks or even months. So, the idea would be to take it for two to three months and then do a stimulation. It does not do any harm. I can’t promise you that it helps.
The same for preparing for treatment, for egg transfer, or embryo transfer with your own eggs or with egg donation. One of the most important things for a woman is to have good general health. It’s very important to have good control of the thyroid function, have good control of vitamin D levels, of course, the endometrium. It’s very, very important to try to have no overweight or to try to lose weight if you’re overweight or obese. This is very important. This doesn’t exclude that we need a good endometrium, so sometimes we need to check with hysteroscopy before to see if there is chronic endometritis or not. We need to check embryo quality. So, in case of doubt, we recommend genetic testing.
In summary, it’s very important to have good general health with all the hormone levels at good levels, and then, of course, the genetics of the embryo and the uterus as well.
Dr Konstantinos Pantos, Genesis Athens: There is a unit here, an IVF unit, which offers mitochondrial transfer. I do not believe that it will increase the quality of the eggs. It is done for mitochondrial diseases, as you know. However, many women, in their attempt to have their own eggs and their own DNA, do seek this service. We do not offer this at our clinic, but I can assure you that not all of these women, but the majority, will eventually go for egg donation. They just need to be satisfied that they’ve tried their best. To my understanding, this is a good marketing tool for some to try to persuade women to go to that clinic. However, because of this, we do not offer it to women of increased age, as we see a lot of women in recent years coming for the first time to have a baby over 40, thinking that they can get pregnant any time because there’s not much information about how infertility comes into play after the age of 35.
Most women here in Greece think that as long as a woman has menstruation, she is fertile. So, when they get to see the dilemmas and problems they face over 40, they will do anything to try to achieve pregnancy with their own eggs. Finally, most will end up with egg donation. So, answering this question, we should be very careful about how we handle these women because psychology has to play a huge role, not only in convincing but in providing the right medical service for all this.
Dr Hana Visnova, IVF Cube: Yes, you can apply for a different phenotype, but this will have an influence on the waiting time for the treatment, as most of our donors are of European origin, so they have pale skin type. However, we do have some small numbers of donors coming from different parts of the world. So, it might not be so easy to find someone directly from Japan or India, but if they prefer someone with an Asian phenotype, we can offer them donors originally coming from Asia. But they are sometimes not from the same region, such as India or Pakistan. These donors’ phenotypes might look different from the general population in the Czech Republic.
In such cases, we don’t have a huge group of donors to choose from, so the couple must be much more flexible when requesting the treatment. For example, they should not request a specific blood type, because there might be a problem finding someone with an Asian phenotype who also has the same blood type. Similarly, if they want the donor to be the same body size or body weight, it might be quite difficult, because we’re talking about small groups of donors who are not of European phenotype.
Dr Katharina Spies, Vida Fertility Institute: I think what we recommend in Spain is, to be open with this, if patients ask us, “Should I tell my baby or not?” we normally answer, “Yes, tell, but tell from the beginning.” Tell it like something very natural, that the donor made a gift for you that allowed you to have the baby with you. We also see it from the point of view that it’s a donation. So, if you have a donation of an organ or a blood donation, you don’t know the donor. I know this is very personal because it implicates a lot of things, but in the end, it’s a donation. You accept this donation, and the family for this child is going to be you and the rest of the family.
If you deal with it like this, normally the children and the family accept it and see it as something natural. It’s also very similar to adoption. You also tell, or the recommendation is to tell as soon as possible and to see it as something positive, which allowed you to have this child with you. So, of course, it’s difficult. I know a lot of German people, in my case also, struggle with it because in Germany that’s why egg donation is not allowed. But from my experience in Spain, and with the different nationalities we deal with, with patients from many countries, normally the acceptance is very good in the end.
Dr Konstantinos Pantos, Genesis Athens: Now, the Greeks do not talk about it. I mean, they do a lot of donations, they do have children, they can have children up to 54, but they do not talk about it. Even though we stress that they should talk about it, they should be more open, they should be more sincere about it, because when a young woman, let’s say 38 or 40 years old, sees a 50-year-old woman getting pregnant, she thinks, “Oh, there’s no problem. I can wait,” and so she delays her own fertility without understanding that these women have gotten pregnant with donated eggs. Even though she might get pregnant with donated eggs, again, she will not talk about it. So, this is in general for Greece.
For anonymous donation in Greece, the law is that the donor cannot be known to the recipient or the baby. However, the second category, which is now coming from Greece, is the known donor. At the moment, it’s a relative donor, but the known donor is going to come into effect also very soon. Then they can find out. They will know from the beginning who the donor is, and the baby can know the donor too. So, yes, it’s all about society and the way people think and act on this, and we have to try and slowly change their point of view, I think, with time.
Dr Hana Visnova, IVF Cube: I remember when I finished my medical studies, even doing IVF treatment using donated sperm was a big taboo, and the patients were reluctant to disclose the IVF treatment using donated sperm within the family. Nowadays, we are facing a completely different situation. The patients who use donated eggs and donated sperm, talk to everyone, at work, with friends, in the family that they underwent IVF treatment, and such a taboo is gone.
It’s not a shame to go through IVF, and my expectation or opinion is that, as fertility is declining and people are postponing having families, the request to use donated eggs or even donated sperm is increasing. Maybe it will become more common to use donor eggs and donor sperm, and the taboo would not be such a big secret, not to disclose to anyone, because it would be better accepted that this is a medical way of donation if someone wants to have a child outside of the biological borders.
Dr Konstantinos Pantos, Genesis Athens: Yes, we have to understand the Greek culture. Greeks want, or they do not demand, but they would like and most want donors from Greece. So most of our donors are donors from Greece. However, we do cooperate with egg banks, especially from Spain, where we have a multiple sort of phenotypes, and other phenotypes, that they might like to cover the need.
Dr Hana Visnova, IVF Cube: Yes, we ask them. Each donor must undergo a psychological interview, and we ask about their motivations. Usually, the reason is a combination of wanting to help someone (altruism) along with other reasons such as having a friend who is childless, having a friend who was a donor, or being curious if they could produce good eggs. But at least half of their motivation is to help someone have a child.
Dr Konstantinos Pantos, Genesis Athens: Yes, I agree that the male contribution is important. Many women over 40 have older husbands, and if the husband is over 50, they might have genetic issues. If allowed, I would recommend PGT-A to screen embryos, although it is not currently allowed in Greece. However, with the new health authority, there will be recommendations to allow PGT-A for donors when the husband’s age is a concern or when there are genetic issues.
If the male is over 45 or 50, I would recommend genetic testing. However, we need approval from the health authority, which is currently not provided for this reason.
Dr Katharina Spies, Vida Fertility Institute: Yes, we recommend genetic testing for men over 45 or 50, as the genetic alteration rate is similar to women over 39-40. For this age range, we offer and recommend embryo genetic testing before transfer.
Dr Hana Visnova, IVF Cube: We can do genetic testing based on male age, particularly if there are issues like low sperm count or other health problems. However, if the male has fathered healthy children from previous relationships, it’s an individual decision. It’s not commonly requested, but we do offer it. We explain to patients that PGT-A is a screening for the most common abnormalities and does not screen for conditions like autism.
Dr Hana Visnova, IVF Cube: If AMH is measured in nanograms per millilitre and the result is 2.3, then despite being over 40, the ovarian response should be good. In this case, PGT-A can be performed on embryos. If AMH is measured in pmol per litre, there will likely be fewer eggs retrieved, making it harder to find a genetically healthy embryo. Regarding PRP, there is controversial data and most studies are based on small sample sizes, so we need to wait a few years for clearer answers on its effectiveness.
Dr Konstantinos Pantos, Genesis Athens: No, we avoid splitting donor eggs. We try to provide eggs to a single recipient to give them more embryos to freeze, allowing the chance for more children with the same donor or more transfer opportunities if the first attempt fails.
Dr Katharina Spies, Vida Fertility Institute: Normally, we try to use one donor for one patient. In Spain, we typically don’t use egg guarantees, but we use guarantees for blastocysts. If we guarantee a certain number of blastocysts, we cannot share eggs. We usually work with fresh eggs to maintain guarantees.
Dr Hana Visnova, IVF Cube: We prefer to use fresh donor eggs for a single recipient. We don’t offer frozen donor eggs, and we don’t split them between recipients. We synchronize the treatment and use fresh eggs for the intended recipient. Depending on the donor’s response, we generally aim to retrieve around 11–12 eggs for the recipient.
