- Why Greece is an established top-class fertility destination?
- What is the Greek law regarding gamete donation?
- Who are the egg donors, how are they selected and tested?
- What are the main advantages of gamete donation in Greece?
- What are the COVID-19 safety measures in Greece nowadays?
What are the fertility treatment options for international patients in Greece?
In this webinar, Elias Tsakos, FRCOG, Medical Director at Embryoclinic, is explaining fertility treatments in Greece – egg, embryo and sperm donation – legal aspects, cost and availability of donors.
Questions and Answers from the event
Does your clinic help intended parents to find a surrogate? If so, how long does the process take on average?
Surrogacy is a huge chapter. You can send us an email anytime and we can set up a video call. Our international service in Greece was established a few years ago. Although, we’ve had experience with treating local patients for surrogacy. The law changed only about 5-6 years ago. Over the last few years the experience has been built up so I’m very happy to say that, indeed, this is a service that is very well established. We’ve got a lot of experience now both in medical, legal, logistics and in patients from many countries from all over the world, including the UK, Australia and most of the European countries who have been treated successfully.
What about same-sex male couples and single males?
At the moment, in Greece, as far as I know, most, if not all clinics, cannot treat them. Although there are some legal cases which have been, the general feeling in Greece is that the society perhaps is not ready to embrace this kind of treatment. I can speak on behalf of my clinic and at the moment we’re not treating all male couples or single male infertility.
What is the cost of embryo donation?
I mentioned that in one of my slides. This treatment starts from GBP 3,500.
We are a Sri Lankan couple. Do you have any South Asian donors? What’s the matching process like at your clinic?
I’ve never treated a Sri Lankan couple, I have to be honest. Although I have treated a few Asian couples. Thessaloniki is becoming very popular with the Asian population so we have a lot of people moving here from Asia. My children have quite a few Asian classmates and there’s quite a big Asian community being built up. However, at the moment, we don’t seem to have any Asian donors. I don’t know what’s going to happen in the future in the next six months or a year. If this is what you’re after, an Asian donor, at the moment, the availability is very limited. However, please, don’t get disappointed; please stay in touch or drop us a line, and we can send you a personalized reply.
Can we use my husband’s sperm and donor egg to create an embryo?
Absolutely. This is a standard treatment for egg donation: husband’s sperm and donor egg.
What about screening for genetic mutations? For example, BRCA?
Absolutely, it can be done. Whether you mean donor screening or patient screening, we can definitely do both. In our department, we have a pretty big breast clinic as well, run by my wife. She is a senior consultant, breast Surgeon, and we do have specific provisions for counselling and supporting the BRCA potential or diagnosed patients. This is not a problem. Apart from the standard genetic screening of the egg donor our tests include thalassemia testing, fragile X testing, karyotype testing, cystic fibrosis 99% testing. This is standardly done to everyone. We also perform other multiple tests, microbiology, hematology, biochemistry, psychological and so forth. We can do specific added genetic testing on request.
Given your experience, is the fresh embryo or frozen embryo transfer better? Does the cryo embryo implantation rate decline the longer the embryo stays frozen?
We’ve been through phases with regard to what is best for patients in terms of stimulation. With the help of David Gibbon who is a senior biologist and a very good friend of mine based in the UK, we’ve been looking into the entire data for many years before we came to the following conclusion. Effectively, there are three ways of doing an egg donation. One is to use frozen eggs. You freeze the eggs from the donor and then, when the time is right, you thaw the eggs, fertilize them with the partner’s fresh or frozen sperm or donor sperm. Then you do a fresh embryo transfer.
The second way is to synchronize the egg donor with the recipient. We stimulate the donor and, at the same time, we prepare the recipient’s endometrium. Then synchronize the egg collection with the maturation and with the timing of the implantation of the embryo so you have fresh embryo created by fresh eggs implanted.
The third way is to use non synchronized cycles. The third option works best in our hands and in my experience in most clinics. Why? Because frozen eggs don’t seem to be behaving as well as we would have liked them to behave. Sometimes they can be a little bit unpredictable and also freezing embryos created by frozen, thawed fresh eggs aren’t always as predictable as we would have liked. Trying to synchronize the donor and recipient is not a brilliant idea, in my opinion. Firstly, because it doesn’t always work. Even the top quality egg donor still has a chance of 5-10% of self-cancellation which is pretty big, in my opinion. The chance of cancelling by the recipient is also 5-10% so if we add those chances then we’re faced with a chance of perhaps 10-15% of not getting the synchronization right. There are also logistics issues when we try to synchronize. We have a couple, we have their characteristics, we were looking for a donor and we find this perfect match, in our opinion. This perfect match is available now, at the time when the recipient is not available to travel. You have to remember that donors are human beings with their own lives, schedules, work, exams, the family sometimes. If they wish to donate, they may be available this month but they may not be available next month. They may not be available at all when the recipient is available and so forth. But even if they are available, even if they are willing, there’s a lot of stress involved trying to synchronize the donor and the recipient. When we audited our results, we found that although the success was 10% less in the synchronized cycles, the experience was terrible compared to the experience of using unsynchronized cycles.
Effectively, that’s what we use now. How do we work? We have the recipient couple or a single lady coming in. We do all the tests and we do all the preparation, the counseling, and so forth. In the case of a couple, the man’s sperm is kept frozen in our unit and then the couple can fly back home. Now we have some time. That’s why we keep a very short waiting list because by the time we’ll have the sperm here, once the suitable donor is available and the compliance is sorted, we proceed with creating embryos. Once we have the embryos in place, those embryos belong to the couple and the donor is effectively, physically, out of the equation. It’s much more applicable to proceed with the frozen embryo. In our experience, not only does that create the maximum possible chance of success which is in the region of 55% if we implant one embryo and 75% success rate if we implant two embryos. We discourage the latter but many couples do opt for a double embryo transfer which we have to offer. It’s legal and although it’s not our first choice, it’s not something we discourage, sometimes we do perform that.
The cryo time of embryos in our experience has never affected the quality. I wouldn’t worry too much about that because the conditions of preserving the embryos are perfect.
Does unexplained infertility really exist? Surely there has to be an issue with either the male and female? For IVF treatment with unexplained infertility, what additional testing, if any, should we have?
It depends on how hard we investigate. In terms of pre-IVF investigation, I have very clear views. In my opinion, at the moment we have to balance between doing very little of free IVF investigations and doing too much free IVF investigations. I think we need to individualize, we need to be a little bit balanced between doing the essential investigations and not going over the top. We need the patients to contribute to the final decision of what is an essential investigation in their case and what is not.
Unexplained infertility does exist, however, it’s not as common as we think it is because we’re not testing too much. I’m probably the third generation of IVF doctors. People who are now in training are probably the 5th-6th generation of IVF doctors. In my generation, which is fertility doctors trained in the 90s, we were a little bit more fortunate as we were also trained as general gynecologists and as endoscopists. We were trained as fertility surgeons, not only fertility reproductive endocrinologists as they call us in the US. I think the more hysteroscopy we do, the more laparoscopy we do (and I’m not saying that we should be doing it on everyone) the more we realize that there’s less unexplained infertility. The more tubal assessments we do the better. These are very clear examples of how little we do tubal assessments. A lot of IVF patients have been told that if you have an IVF, then you don’t need to check the [fallopian] tubes. But what if the patient has hydrosalpinx?
For example, tubal assessment is absolutely obligatory in order for patients to get compensation from the state. This is not because we’re a very rich country and we can offer free tube assessments for everyone. It’s because there is data showing that if someone has hydrosalpinx and IVF, the chance of success is limited, maybe 50% and the risk of ectopic pregnancy is increased by 3-10 times. The same applies to some standard testing like thyroid function. In Greece, we have 10% of patients with subclinical hypothyroidism so by performing TSA testing at the cost of £20 perhaps, we can improve the thyroid function before we embark on IVF. This may not only impact the IVF success but it may have a huge impact on the pregnancy success.
To sum up, unexplained infertility does exist but perhaps to a lesser extent than we think it does. We need to individualize. It’s different tests that we would do for the first time couple, compared to a couple who have had 5 miscarriages. Today I did an open surgery on someone who has had about 8 miscarriages before somebody suggested an HSG (Hysterosalpingography) and the lady had a few problems in her tubes and hydrosalpinx.
I do think we need to individualize and we need to take into account the fact that sometimes a little bit of extra investigation may save the woman and the couple a lot of hardship in the future either in terms of failed IVF or miscarriage.
I’m 45 and I’ve had 2 failed attempts (IVF and ICSI). I have NK cells and considering egg donation. Do you treat NK cells? Would you recommend having an egg donor? Do you have egg donors from the UK and Scandinavia?
NK cells are a huge discussion. There’s a big debate as to whether this exists as an entity. Definitely, the HFEA (Human Fertilisation and Embryology Authority) has got a red flag on it, so I’m not sure if this was or could be related to your IVF failure or not. However, if you wish to have some more information, I urge you to check the HFEA website in order to get some solid scientific evidence for that.
Would I recommend egg donation? The answer is possibly yes. Because at 45, the chance of own egg IVF success is extremely low. Even if there is a pregnancy, the chance of miscarriage due to chromosomal anomalies related to your age is very high. Yes, egg donation is perhaps the most valid option for a 45-year-old woman. Do we have any donors from the UK or Scandinavia? No, we don’t. We do have Scandinavians and Brits living in Greece now. Perhaps in the future, they may be willing to donate their eggs. But this is not very likely to happen.
Which clinic are you linked with in Manchester? Do you have many donors with blonde hair and blue eyes?
We do have a lot of associates in Manchester, either facilities providing preliminary testing and investigations or physicians and gynecologists. Depending on the situation, we would be able to support you, for example, in having some tests performed under supervision. I’m also licensed there in the UK to practice and am fully registered as well so I provide consultations either on-site or online. If you have any questions, please feel free to send us a private email on firstname.lastname@example.org. We don’t have many blonde hair and blue-eyed donors, however, we do have a cue. Interestingly, in the north of Greece, in Thessaloniki, you can see perhaps more blonde and blue-eyed females than you would see in Manchester or Newcastle. My wife is blonde and blue-eyed and Greek. We don’t have many but we do have some. This is what applies to the matching criteria. If somebody is looking for a particular phenotype, a particular type of hair and eyes, we make a note of that and we try to match you as closely as possible. However, there’s a lot of other characteristics that we look into as I mentioned in my talk. The number one limiting factor for selecting a donor is the age limit that is max. 30. This is to ensure the maximum safety and success, in our opinion. However, we do respect individual requests from our patients as long as they understand that this may make the matching process a bit longer.
What matching information can we receive about the egg donor? What kind of information do you disclose about egg donors? Only basic phenotype?
We’re talking about anonymous egg donation. We try to give as relevant information as possible. The donor ID contains the standard phenotype and standard information that may be relevant to the pregnancy which is the egg donor’s age, height, weight, phenotype, blood group, all the genetic data and the screening that we perform. We try not to get into the details in terms of education level or hobbies. Strictly speaking, we try to keep it very strict and anonymous, based on standard phenotype, standard genetic age, body size and weight.
Does the ethnicity of the donor egg recipient matter? Could an Indian woman have an embryo donated from Greek egg/sperm donors?
Absolutely, yes. We have treated Indian patients. Some phenotypes are very similar to the Indian phenotype. This particularly applies to the southern Greeks. A female patient’s phenotype has nothing to do with how well they receive the transfer. Patients state their requests and wishes and people’s logic is very different. We’ve had short females requesting a tall egg donor and vice versa. We’ve had a taller recipient who was nearly 6 ft tall and requested a shorter egg donor because she had a hard time at school – she was the tallest girl. We try to understand and we’re trying to work very closely with our recipients in order to identify the best match for them. The matching process is a very sensitive process. We are very happy to listen in to comply with your wishes to the extent that this is possible medically and ethically.
Do you treat hepatitis B positive patients?
In terms of treating infected patients, yes, we can treat hepatitis B positive patients. Part of the essential investigation we do and we are legally obliged to check for hepatitis stages, hepatitis B, hepatitis C, HIV, syphilis and VDRL. We have special protocols in place in order to ensure the safety and success for the recipient. We can treat hepatitis C patients. We do not treat HIV patients. None of the Greek clinics possess the license to treat HIV patients, unfortunately. There are a lot of discussions to create a public bank and that was one of our suggestions that we should not be discriminating against the HIV-positive patients and we should not be rejecting them. However, on the other hand, we have to ensure the safety first for them, for the staff and for the non-HIV patients. There’s a lot of talks about infectious screening. There’s very strict regulation with regard to screening in order to ensure that our patients are guaranteed that there will be no cross-contamination.
I am a single woman. Can I freeze my eggs at your clinic to use later on?
Yes, as long as you’re at a reasonable age. What is a reasonable age? The younger the better. On the other hand, even a woman in her early 40s, if the conditions are optimal, can freeze her eggs but there’s a lot of counseling involved. If you wish to go for that option, please get in touch and we should be able to do an assessment online, then do some testing on-site wherever you are based and depending on the outcome of the assessment then we can advise you whether it’s feasible, whether it’s suggested, what kind of success we would be expecting. Also, you need to understand that we can only treat you up until the age of 50 and a few months after that.
Do you transfer multiple embryos to a surrogate or a single blastocyst only?
By law, we can only transfer one or two. We heavily advise transferring one blastocyst. Eventually, the first and second time the cumulative success rate with transferring one blastocyst from an egg donor to a surrogate is extremely high. It is very rare to, either at the request which we cannot alter, to transfer two, but again there are multiple discussions involved in this subject. The general line and the general purpose is to transfer one top-quality blastocyst.
There’s about 55% success rate with transferring one top quality donor egg embryo – it’s fine. If we transfer one embryo twice, the cumulative success rate would be 75% which is pretty high.
Which charities/agencies are you linked to in the UK that could also support the intended parents in the surrogacy process?
We have taken the patient pledge with the Fertility Network UK so we’re supporting patients through them. They’re doing great work and we’re hoping to have individual sessions with them on various subjects like surrogacy, egg donation or online consultations which, in my opinion, are probably going to be the next big thing after the Covid-19 situation. There’s another big charity in Australia called Growing Families. If you are interested in their services, you can get some independent advice from them. They are helping patients from all over the world. We also support a wonderful Serbian charity which is the largest in Serbia. If anyone of you has any other suggestions, we are very open because we take huge pride in supporting charities and initiatives like MyIVFanswers in order to support IVF patients all over the world.
What is the cost of surrogacy using donor eggs?
It’s quite complex. It has to do with a lot of factors. Drop us a line at email@example.com. I would be very happy to answer your questions individually. Since there is some interest in surrogacy, you should know that, at the moment, Greece is the only country within the European Union providing surrogacy services to international patients. There are other countries in Europe but not within the EU that offer surrogacy. Greece is the only option within the EU. We have treated patients from a lot of European countries. They come from Spain, they are referred to us by my wonderful colleagues from the Spanish clinics. We’ve had successfully treated many Spanish patients but, of course, also UK patients and patients from Germany, Switzerland, France, Serbia and Australia.
If you’re looking into surrogacy, you should focus not just on the entry process but also on the exit process. As you have probably heard in the news that especially during the Covid-19 situation, there have been a lot of children born through surrogacy in some non-European Union countries stranded without being able to be collected. It’s quite a complex process. Now patients need a team to back them up and support them in a journey that can be as long as two years. However, patients are usually so determined that they support us instead of us supporting them and we have worked closely with some amazing patients. The legal side is very important, too. You need to have a lawyer in the UK in order to oversee the whole process. We, as a clinic, have an in-house legal department but also we suggest having an external lawyer in order to ensure the maximum levels of compliance and safety.
I’m a single woman. If I need donor eggs, would I then automatically move to embryo donation versus egg and sperm donation? Do you ever consider creating embryos from the patient’s eggs, examining them which are best if I’m on the edge of my eggs being in question?
Absolutely yes and it depends on some factors. If we have a patient in their early 40s who have never tried IVF before, then, of course, own egg IVF with donor sperm would be the first option, the first choice.
If someone is in their mid-40s, then we would have to advise them that the chances of a successful outcome (a healthy baby born), then the egg donation is probably the only valid option forward. However, we’ve had women who keep trying with their own eggs even at the age of 46 or 47. As you probably know, the oldest woman in the world who delivered a baby through IVF with her own eggs was 46. Before it happened, the oldest woman was probably 45 years old then perhaps she was advised that it couldn’t happen before but it did. I’m pretty sure that soon someone will publish that a 47-year-old lady would make it with her own eggs and then maybe a 48-year-old. In my opinion, there’s no right or wrong in general. There’s a lot of discussions, there’s a lot of counseling that has to be offered and there’s a lot of understanding that has to come from the patient of what the real chances are and from us to understand the needs of our individual patients. We would be happy to support anything that is scientifically based and ethical. We would be very happy to work with you even if you know you’re fighting against the chances. On the other hand, we would have to be very skeptical about offering treatments that are equivocal or unproven. We would need to be very careful in how we handle the hope and trust of our patients so it is not easy to make the hard decision. However, we’re very happy to work with individual patients in order to identify what’s best for them.
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