Dr Elias Tsakos, Medical Director at Embryoclinic, is explaining IVF and egg donation treatment options in Greece – availability, quality, success rates, costs and legal framework.
Up until now, I had six reasons why so I can go through that list with you, but now we have a seventh reason which is related to the world that we see nowadays.
So quality is the number one reason. In our opinion and quality, includes safety and safety means medicals safety in terms of having the facilities to look after patients and fertility safety which means that fertility clinics are quite well equipped to manage all cases and of course a country’s safety. Quality also reflects success and overall experience. Number two accesses, number three is the legal situation framework, which in Greece is allowing seven types of treatment and which are legal and regulated and of course, costs are also an important factor that makes Greece. Egg donation is a separate reason why Greece is attractive to many patients from all over the world, and I will elaborate on this a little bit later.
Surrogacy also is a factor because our patients from all over the world find Greece as the only destination embraced in that in Europe which is legal and regulated. Number seven is the COVID situation which makes also Greece attractive, and this is simply because Greece has proven to be a very safe destination when it comes to COVID situation. We managed to keep the virus at bay, there were less than 180 deaths overall, and we’ve only had less than 5,000 cases reported until now this is mainly because of the early lockdown and Greece has been out of lockdown for nearly one month.
I will elaborate a little more on quality, which includes several factors and this is safety, I mean quality consists of three factors, one is safety, number two is a success, and number three is experience. We are focusing a lot on safety, and we are looking into safeguarding our facility, our practices, we do practice very safe medicine in terms of avoiding unnecessary risks. I am aware that in many European countries and even in the US and North America, some egg collections are being performed without the presence of anaesthetist. They are either done with local anaesthesia or no anaesthesia even a little bit of sedation provided by gynaecologist or nursing staff. Here we do have a consultant who is present at any given time. The other factors that increase in order to be performing fertility care, IVF treatment, you have to be consulted, so we do not have research fellows or clinical fellows or social specialists, and so forth, with those ranks of medical practitioners, I think the addition with proven experience infertility, we are allowed to treat IVF patients, which is another added safety measure.
There are minimum safety members of Staff that have to be involved in any given time. All IVF units in Greece have to be ISO standardized and have an ISO certificate up until two years ago, we were required to have one ISO certificate, which includes the overall performance of our services. Two years ago health authorities instituted the requirement that we need to have a laboratory standards certificate as well provided by an ISO company, and this is the laboratory standards quality and safety ISO. All of the IVF centres, by law, are required to have two ISO certifications which ensure minimum status for the safety.
Quality has to do with success, and in Greece it’s high, there’s a lot of reason why. I’m not going to go through all of them individually but what I have to say is that, of course, the success of one of the factors that would bring more patients in, most of us and including Embryoclinic, we do fight very hard to increase the success rates. How do we manage that, of course by doing a little bit more investigations than the standard ones, and so f. e. we do have the karyotype testing as a standard before we will proceed to IVF for anyone using genetic material. The chance of having a karyotype anomaly is not very high in the general population but please remember that we’re dealing with a selected population because most of our patients coming into Greece from abroad had tried locally. We’re talking about the high-risk population to be suffering from an unknown or non diagnosed paragon effect.
We do investigate thyroid disorders something I do know that the overall incidence of asymptomatic thyroid disease is very low however again in the select group of patients who have failed a number of times the overall incidence of thyroid disease even asymptomatic could be as high as 10 or 15%, so by treating simply the thyroid increases the chance of pregnancy. This is only an example, there are a lot more examples of how we do insist on some standard investigation. We don’t go very far, and we don’t go very deep into investigating however eliminating any uterine factors or any basic hormonal defects may make a difference, and we are trying to optimize. The point I would like to make here is in the individualization. I think this is the way forward for medicine overall. I absolutely believe that there’s no one-size-fits-all, so a 37-year-old woman undergoing IVF was probably 60 kilos in weight, is not the same with the one sitting next to her in the waiting area, so we are trying to individualize as much as we can, and in my opinion, this is the future of medicine, trying to identify individually, what is the right optimum management and care for each one of our patients. The last factor is perhaps the experience factor.
Most of the medical directors here in Greece like myself, we do wear our blues in a theatre all day, we do a lot of managerial work, we do some scientific work, we are involved in the overall administration of the unit, but we also see patients and treat them. We have our differences, and ultimately it’s our responsibility that our patients receive the best care. I think that having the most experienced person in the unit, performing some procedures and especially in those difficult, complex international patient’s that are visiting us, I think it’s of great importance in order to achieve the goal of safety and quality.
Lastly, here in Greece and definitely at Embryoclinic, I devote a lot of time on the experience of our patients, for us successful outcome is not just achieving the goal of a single healthy pregnancy, hopefully, the first time around but also to have a very positive experience, I mean I can just mention that we had the accepting patients since the middle of March however the national team was very busy communicating, connecting, supporting and advising numerous international patients all over the world in order to have been ready, alert and prepared for the next step, for the time when it’s right for them to travel.
Access is a big issue. Access has to do with how far or near the country is, to the origin of our patients. I mean we are in Europe, almost everybody has travelled to Greece, especially from the UK many times, so we all know that access has to do with geography, location. So access within Europe and the Middle East is very easy, very simple, it’s a flight maximum of saying 1,2 hours, sometimes 4 hours, so this is easy access, but even for patients from further away like from the US, Australia access is not difficult because by flying into Central Europe like London or Germany, there’s another fight straight into Greece, so we don’t have very easy access I mean most of the clinics, like Embryoclini, which is only 20 minutes from the airport, so that means patients can visit us even for a weekend, so if you’re flying into Greece on a Friday afternoon by taking one day off, we can do a consultation on Friday evening and then the consultation on Saturday and then fly out on a Sunday. This is part of the access and the easiness by which this could be reduced.
Easy access to treatment has to do with waiting lists, I mean most of us, we don’t have huge waiting lists, so if somebody books an online consultation, they can book the first consultations within the next two to three weeks, we can treat patient straight away after online consultations if they’re having own eggs IVF, and we can treat them within the next 2-3 weeks after the initial consultations and when we are happy that full optimization has occurred with regards to pre-event consultation and so forth.
In regards to egg donation again the waiting list is never longer than six weeks provided that, there’s no particular request for rare phenotypes. I will talk about egg donation information later on but as you all know our egg donation waiting list could be as long as six months to a year in the UK and of course this is due to the lack of unavailability of potential donors. Because of an anonymous egg donation and because of the fact that most of the units have agreements with universities and there’s a lot of donors coming forward, egg donors for donation and of course this is reducing the waiting list for any treatment. Even in the COVID situation, our waiting list for treatment is no longer than four weeks.
I mean Greece has always been a little bit liberal and a little bit pro-patient. I mean we have managed to agree between ourselves, the scientists, societies, universities, authorities and the church to address the importance of fertility treatment for the patients. In Greece, single women can be treated, there’s no age limit for getting treatment up until the age of 50, there’s a lot of discussions to push that limit over to 53, health authorities responded very swiftly to the pandemic, so now there’s a small increase in the age limit, so we are allowed to treat patients who turn 50 during the epidemic, during the early days of March, they could be treated throughout the year 2020 even if they’re just over 50, however, there’s a lot of discussions, and we hope that before the end of the year, the age limit would be 53.
Egg donation is legal, regulated and anonymous, the anonymity of the donors is allowing a lot of young women wishing to donate for their own reasons to come forward and the local patients and from all over the world patients, do have the opportunity to be treated with this means of fertility care quite regularly. What I have to say about the egg donation is that although the age limit for donors is 35, at Embryoclinic we have the upper age limit of 30 and so we don’t accept donors over the age of 30 although it is legal. By having egg donors in their 20s we have a very important success factor in our hands, and we’re giving our patients the best possible solution by providing them with much younger eggs than the average other clinics provide.
I mean costs are in general about 30 to 50% cheaper comparing to the UK. A lot cheaper compared to the US, Australia, we do have a lot of patients coming from the Americas and Australia because, given the huge difference in costs in Australia and the US, the cost is about 3 to 5 times more than it is in Europe. Even if people take into account flights, accommodation and all that, they’re still receiving a very good deal. 50% decrease in cost is very important for couples who are on the budget, and not all of our couples are on a budget. Not all, doesn’t mean that they do not save money, but they also have more opportunity to have more treatments for the budget, so the cost factor overall if it’s reduced, it increases the overall success rate because patients do have the opportunity to repeat the cycle if they are not successful. The cost-effectiveness is quite an important factor, and this is something that is very attractive. On top of that, there is the overall cost of living, so most of our UK couples although they do have the opportunity and the option to have some of the treatment or some of the investigation performer locally, I would say the majority of our UK couples prefer to fly to Greece for the initial investigation because they can check everything within one or two days and again this can be very cost-effective. By doing this, they familiarize themselves with travelling, the city, the clinic and so forth. And that takes away a lot of stress for the first official treatment visit.
I did mention a few reasons why. One is anonymous egg donation and anonymity makes it more available because more egg donors potentially come forward, so with a particular issue in recruiting egg donors although we’re not allowed to advertise or look out for the donors, and we do have the luxury of choosing and picking the best ones, and as I’ve mentioned before, at Embryoclinic we won’t accept donors who are over 30. This is one of the reasons that make the whole egg donation attractive. Anonymity is another reason that makes a lot of difference. There’s a lot of concern with information as to whether the donors are distributed amongst a small area. By having a selection of donors and availability of a bigger range of donors, we do have the luxury of allocating one particular donor to the UK, and they’re successful and the same donor to another country to Greece and so forth. By allocating donors to different countries, we are also minimizing the risk or the potential risk of children or siblings meeting each other by distributing them into a huge geographical area, this is one of the reasons why international patients do prefer to come to Greece for egg donation. We do offer 2 packages for the donation, which is also very important, by having two packages either a full donation or mini donation our couples do have the opportunity to choose a suitable package for the situation. I mean f. e. if a lady is in her late 40s and will have only one or two attempts, then there’s no reason for a full package at all. This is giving availability for cost-effective, individualized selection of egg donation packages which is another attractive option.
Surrogacy law changed a few years ago and allows international surrogacy. Now, Greece is the only European Union country in which surrogacy is legal and regulated, which means that it can be performed under a very very strict legal and regulatory framework. Surrogacy involves very complex and complicated procedures which include those legal procedures, court orders and delivery of the child locally and so forth, so, within the European Union. I think it’s quite important for patients and the intended parents to realize that it is important not only to be successful with the IVF but also to have a very successful regulated and controlled pregnancy and delivery and smooth return into their home country with a baby. This within the European Union is quite streamlined, even with Brexit, we don’t expect any issues as you probably know Greece and the UK are very well connected, so we’re hoping that no major issues would be raised even after Brexit. Another important factor that surrogacy is quite attractive for the UK or international couples is that the court order is issued before we do the IVF procedure, so this is taking away all of the stress associated with the court order issued after the delivery of the child. Even before we embark on IVF plan through gestational surrogacy, the parents are reassured that they are the legal parents of the child that hasn’t been conceived yet. This is making a whole procedure much less stressful, and it’s taking away legal issues even before we embark on the surrogacy process.
I do have to mention that Greece has been quite fortunate to have dealt with the pandemic in a manner that worked. I mean as we all know responsible politicians and doctors, they made some calculations in every country, and we were very fortunate that the calculations made in Greece worked, evidently people had the very low impact of the epidemic. In the north of Greece, it’s been even better, I understand we had like 150 cases in a population of around 3.5 million. Overall cases in Greece have been around 3000 in 10 million population, and we’ve had about 170 deaths and if I remember well, more than 90% of them were high-risk population. I mean today we have a daily announcement from the Department of Health and with 2 to 3 cases are increasing every day. Even since the lockdown was red-phased, the Health Ministry officials today declared that they will stop giving us daily updates and that they were hoping that they would not need to give us their daily updates anymore. Based on that, the whole country has opened now, we’re back to normal, and we do have our masks, I am alone in my office, but I do put my mask on when anyone enters my office and so forth, we take a lot of measures. IVF clinics have the extreme measures to ensure that they remain healthy and safe we have instituted the PCR obligatory testing on anyone on-premises of IVF, and in the IVF cycle 3 tests are performed, and this is on top of the questionnaires and all the other measures that would have been taking, so any couple before they start embarking on the IVF treatment, so before they even start injections, they have the first PCR test and of course before the egg collection or to the sperm production we do check the women and the men as well. By doing this we’ll ensure that the genetic material is COVID-free.
For many people this is over the top, I understand that in many countries this cannot be performed for logistic, financial and other reasons but in Greece it is possible, it is not hugely expensive. We have negotiated amazing prices for a PCR testing, and we’re even seriously considering into integrating at least covering some of the costs between the clinics and patients and so forth. Bottom line is that no patient will undergo IVF without official testing for PCR genetic testing, which seems to be the most reliable at the moment and this is because we want to ensure that our patients have this extra confidence but not only are they healthy before they embarked on IVF or before they have implantation but also that the fellow patients next to them are also safe as well.
With regards to egg donors, we do a standard test, any female undergoing fertility care herself, on top of that we do a psychological assessment, official psychological assessment signed by a psychologist and also in terms of genetic testing we do karyotype testing, fibrosis tests as you probably know cystic fibrosis genes involve quite a big number of genes, and there are quite a few tests covering anything between 50 to 99% of potential mutations so in our egg donors will do the 99% cystic fibrosis mutations test, and on top of that, we’ll do the fragile X genetic testing as well. All the standard testing, which include pap smears. We need to ensure the health of the egg donor firstly and of course secondly the overall quality of ovaries, hormonal profile, AMH, blood groups, we perform thalassemia, electrophoresis, which is absolutely necessary for all our patients, and I may stress here that we also do that on any single recipient as well.
Implantation failure is a very huge subject, it’s one of my favourite subjects because most of our patients do suffer from implantation failure and our international patients even more. I would be very happy if you wish to just drop us a line, and I can give you complimentary consultation on the subject.
Absolutely, yes. One of the factors of implantation failure is related to the endometrium, which is the part of the uterus in which we implant the embryo, so one of the tests that we would need to do to exclude any pathology is a high-resolution scan, but we also do an evaluation of the uterus and if in doubt, we perform hysteroscopy. If there is submucous myoma, then, in my opinion, that has to be removed in the way that ensures that the endometrium remains normal. We do need a normal endometrium and a normal lining of the uterus before we do any embryo transfer, whether it is with our own eggs or donor eggs.
It depends on the clinic, that is the answer. Legally we can treat anyone with their own eggs up until the age of 50 or up until the age limit of each country. In my opinion, I don’t think it’s a matter of age, as it is a matter of individualized history, so f. e.xample I do have 35-year-olds who had multiple own eggs failures, who went into egg donation in order to become mothers, so in my opinion, it has to be individualized. It depends on the situation, or other factors, history, depending on whether they had tried before failure or not. In general, I can give you a very important piece of data. I think 45 to 46 is possibly the upper age limit, over that it is very unlikely for anyone using their own eggs to be successful. However, I don’t think we can refuse treatment. Unless there is another risk factor, another adverse factor, there are other confounding factors etc. If we do proper counselling and if we counsel our patients correctly if we quote the right number if we share our worries, our anxieties not only with regards to the success or not but also with regards to the outcome of that pregnancy. I don’t think we can refuse treatment. I mean you know even the 46-year-old could deliver with her own eggs.
I think we do have to look after patients more than we look after results and of course, you know we’re thriving for results, and of course, I do know that some clinics refuse or reject patients because having a failure is not looking very good on paper. In my opinion, we should not be refused unless there’s a risk and we should be just consulting, suggesting, advising and definitely supporting our patients, and it’s not a matter of age, but it’s a matter of individual circumstances and understanding.
I mean the mid-thirty could be someone who would produce 15 eggs and someone who produces 2 eggs. Mid-thirty could be someone who may have a fibroid in the uterus, who’s never going to get pregnant or someone with the hydrosalpinx, not get pregnant or who might get pregnant and miscarry. I think it’s very important again to individualize, we need to ensure those standard factors. I had a 32-year-old yesterday with the DNA anomaly who had 2 biochemical natural pregnancies, they came for IVF, and we did karyotype, most people would not do it before an IVF, and they had a DNA abnormality that would reduce the chance of pregnancy. I think we all have to agree, and agreement with the patients is easier than agreement with between ourselves. I’ve been around for about 30 years, and I’ve been fortunate to meet representatives of two schools. One school doesn’t investigate much, if at all, so you know standard investigation file, one scan and off you go with IVF. The other school is heavily investigating, you have a standard couple at 35 years old, male infertility and you will do every test, paying thousands of pounds before you even started using the first injection later. In my opinion, both approaches are probably incorrect, and I think we should be individualized depending on who is the patient that we’re dealing with. In the mid-thirties, in a standard, well-investigated or essentially investigated with a mild infertility count, I would expect a pregnancy chance of pregnancy between 40 or 50% minimum.
The question is how do we define success? Is it success per embryo transfer or is it success per exhaustion of all the embryos per embryo transfer. This depends on whether we plant one or two embryos, so in mid-thirties, I would definitely transfer one ember at a time, and I would hope from a mid-thirties would hope to get a minimum of maybe 3 to 4 maybe 5 top embryos, now 4 million sperm count for an ICSI technique and provided there are no associated factors in the male, provided that there are no DNA anomalies or there is no other adverse factors would give us very good fertilization of maybe over 80-90% of fertilization rate.
The answer is yes. Thank you for suggesting the embryos opposed to oocytes. At 41 with 0.7 AMH, those are a good number, if everything else is optimized. I would suggest to go ahead and freeze embryos. The number is depending on the quality and this is a question to be addressed and answered after the first round of IVF, as it depends. If you’re lucky enough to produce 2,3 top-quality embryos, I would suggest maybe repeating this once more, would give you a higher chance but even one top-quality embryo at 41 is better than one top-quality embryo at 42. My suggestion would be to carry on a with IVF, freeze the embryos, see what they are, how many and of what quality and then discuss it and decide if it’s worth repeating the procedure.
At the moment, the age limit is 50, and 50 plus a few months if somebody just turned 50, we can treat them with a new regulation that came out. There might be some brown colour donors, but again if you wish to know the exact possibility, you would have to send us some sample pictures to be able to double-check. In regards to prices, I prefer not to provide prices online, however, bear in mind that it is about 50% less compared to the UK and if you wish individualized price list, please send us an email, and our coordinators will answer that.
We do not require to have any declaration from your home country. There’s a very standard legal procedure, you have to declare yourself that you are single and then for the benefit of the child, there is a notary document signed by yourself in front of a notary. All of this can be organized by the clinic and it’s quite simple and quite inexpensive. By declaring before a notary that you’re single and you take full responsibility for the unborn child, then that should suffice. In terms of costs, this is fairly inexpensive, I think it’s around 150 pounds, and it takes about an hour in terms of time.
I confirm that the clinic was right, this is exactly our situation, so you cannot use a sperm sample for someone who is legally married and not legally divorced. I confirm that this is the case in Greece.
I mean the chance of success with your own eggs even with the surrogate is I would say zero. As you’ve tried so many times and you’re going with the surrogate, I would definitely suggest egg donor. I’m not sure in which European country it would be accepted at this age so if you were I would suggest that you move on to egg donation now. In regards to rejuvenation, we could dedicate a whole seminar, we don’t practice rejuvenation although my department is quite well-trained in those sorts of interventions and endoscopic surgery and so forth. Rejuvenation, in my opinion, has not proven itself yet, I do know that a lot of people perform it, but I don’t think the evidence until now is enough that is allowing us to use it in everyday clinical practice. If used, it should be used in the context of clinical trials and of course if those clinical trials are proved to be safe and effective, I promise to be among the first ones in the world to use it as well.
It has been performed in Greece, in Athens. I happen to know the scientists who performed that, and there are some amazing people, however, it’s still in the context of clinical trials. In my opinion, we should be guarded about anything that is not currently available yet and is under trials. I think in your case, I think it probably matters of changing the odds by using a method that could be more successful and definitely more safe for the offspring.
I don’t know, and if I were to guess, I would say that it’s unlikely. Neither patients nor doctors are keen on non-anonymous donation. One of the issues associated with a non-anonymous donation as you know in the UK is that the availability of donors may drop overnight. Very few donors would go forward with this if their anonymity could be lifted. Most of European Union countries rely on anonymous information for the egg donation programs.
Well, definitely one is the answer. With egg donation definitely, one is the answer. With own eggs IVF, it depends. By law, we can only transfer up to two after the age of 40, however, if somebody is between 35 and 40 and if they’ve had more than two unsuccessful transfer we can transfer two or more. In my practice, we tend to transfer one embryo in the egg donation program unless it’s specifically requested and after we evaluate the couple’s case and we are trying to find a different solution which is to transfer maximum 2 embryos.
The answer is yes, although we have to stress that the transportation of embryos can happen within European Union freely, so f. e. in Bulgaria, I do know that they have an age limit at 52-53, and it is within the European Union, and so it is possible there. However, transporting outside the European Union could be very complex, it requires a special license by our health authorities, this may take a very long time, so we discourage people from transporting embryos outside the European Union. This is something that has to be discussed individually. Bear in mind that transporting genetic material within the European Union, it does not require a license at all, so it’s a straight forward and is quite common.
In general, we like Vitamin D, I’m not sure about the liability of the tests, so, in my opinion, I think you have to discuss it with your GP, and personally, if I were to judge, 63 I would probably repeat that because it looks a little bit too high.
You would need at least 1 or 2 visits, depending on your wishes and individual situation. We can do the whole treatment within one visit provided that we identify some providers locally and we do have collaborations throughout the UK, so that could be done. Then in terms of the IVF treatment itself. If its own eggs anything between seven and fourteen, eighteen days.
I’m very fortunate to have been working with David Gibbon who is an embryologist and a friend of mine for the last 13 years, so he would be the best person to answer. I leave this up to the embryologist. I mean some indications are depending on the history, the quality of the embryos, patient wishes and all that.