By fertility experts from Spain.
Due to enormous interest in fertility treatment options in Europe, we have decided to organise an event focused around the topic of IVF with egg donation at one of the European clinics. Watch the webinar recording above and learn everything you need to know about the process of IVF using donor eggs abroad.
We have invited IVF Spain to talk about this topic. The subject presented was called “The process of egg donation treatment abroad. How to prepare, the number of visits & milestones” – the webinar was given by a fertility expert, Dr Natalia Szlarb.
Deciding to use an egg donor can be an overwhelming and daunting prospect, feelings which could be compounded if that treatment is to be given abroad. In this webinar, Dr Natalia Szlarb, Medical Director of IVF Spain in Alicante, explains the individual steps, the unique process of seeking treatment with donated oocytes (eggs), overseas.
In modern times, parenting is being delayed. There are many sociocultural reasons for this, including financial stability, education and career, alongside those who have, sadly, been struggling for years to conceive.
However, these, valid, reasons aside, the problems arise with the fact that whilst societal preferences might be changing, our fertility isn’t, and our bodies are not always in sync with modern lifestyles; oocyte quality and quantity is known to diminish, with age.
Becoming pregnant and creating a family is an emotional journey and, for many of us, can lead to disappointment and heartbreak. With improvements in medical science and procedures, egg donation now offers a pragmatic solution for those experiencing repeated failure to conceive, due to female factor infertility.
From research, at IVF Spain, Dr Szlarb describes how the percentage of “normal” blastocysts (five-day old embryos), created by IVF, is seen to decrease with the maternal age. However, she goes on to explain how, when donor eggs are used, the pregnancy rates appear to be unaffected by the age of the mother.
How then do potential patients decide whether egg donation, with an overseas clinic, is the best option for them, how does it work and what is the process?
Before continuing to outline the donor egg procedure, used by their clinic, Dr Szlarb advises it’s important to note that the legalities, she mentions, are specific to Spain; differing legislations could apply, depending on where treatment is sought. Spanish law, currently, allows for the anonymity of donor eggs, sperm and embryos, and there is an age limit, of 35 years, for women who donate their eggs. The procedure listed here may also differ, from clinic to clinic.
Dr Szlarb is keen to stress that each fertility journey is unique. She is aware that travelling may feel intimidating and explains how clinics need to consider the individual needs, of each person, who contacts them.
IVF Spain, for instance, offers Skype calls, as an initial consultation, however, if there is a preference for clients, to visit the facility for this meeting, then that is also an option. The timescale, for physically being in Alicante for an IVF cycle, using donated oocytes, would typically be between seven to ten days, allowing time for the collection of eggs, from the donor, fertilisation, embryo monitoring and cultivating to blastocyst (day-five) stage, ending with the embryo transfer.
Following the agreement between patients and clinic to proceed, various medical protocols are, firstly, undertaken, on both clients, including sperm analysis and a “mock embryo transfer”, for the female. Dr Szlarb also advises that if fertility problems persist, even when using donated eggs/oocytes, then endometrium immunology testing might be advised to help the medical team find the best protocol for continuing. Ultimately, the clinic wants the outcome to be a pregnancy, to term, for each patient.
As with any cycle of IVF, whether using donor or own oocytes, the objective is to transfer a healthy embryo for implantation.
Clinics, therefore, monitor embryos and look for those which appear to, scientifically, offer higher odds of progressing and developing into pregnancy and live birth. Embryos are monitored by looking at many things, including cell division, appearance and whether there are signs of fragmentation or any anomalies. It’s expected, that after fertilisation has taken place, within 24 hours the impregnated oocyte should begin its first cleavage division, of becoming two cells, and then continue doubling to reach between 100-200 cells, on day five (blastocyst stage).
Obviously, any medical treatment takes place after the donor has been chosen and, in the webinar, Dr Szlarb outlines her clinic’s four steps in choosing the right donor for each individual.
IVF Spain has a donor pool of around 500 women who make up their database. Donors are all screened, physically and psychologically, and are limited to a maximum of six live births, resulting from fertility treatments.
Once patients have decided to venture along the IVF egg donation path, the first step, in selecting a donor, is to look at the basics and legalities; the donor and mother-to-be should have similar phenotypes (observable physical properties), such as eye and hair colour, body shape and ethnicity.
An initial search, of the database, will then take place, using basic phenotype grouping, and will usually result in around 100 options, for consideration.
Clients are also asked to fill in a, more specific, phenotype questionnaire, detailing which characteristics are the most important to them, for example, height/body type/education level. The 100 options, from the first search, are then whittled down to around 20 candidates, who match the clients’ individual preferences.
After the in-depth database searches have been completed, the medical team, at IVF Spain, discuss each case, selecting the best two to four donors to present to the patients. Finally, scheduling and arranging can begin. The selected donors are contacted, one is linked to the parents and treatment starts.
Choosing whether to use a donor and then seek treatment with a clinic abroad, is an incredibly personal and unique experience. Dr Szlarb believes it is an extremely individual patient journey and one which should be undertaken with professionalism and compassion from the chosen clinic.
That’s a very good question. It has to do with the number of eggs you are given and the technology implemented in the embryo development process. If the clinic focuses only on day-three embryos, giving you three or four eggs, the price is going to be cheap because, basically, the clinic focuses only on one transfer. If the clinic focuses on certain quality and a cumulative pregnancy rate, the price will be higher because in order to guarantee quality we need to have 12 or 16 donor eggs for you, basically giving you exclusively all, or almost all, the eggs from one donation. That’s why the price of egg donation is higher. If the clinic gives you a guarantee of a certain number of embryos or blastocysts then we have to give you even more than 12 or 16 eggs, because usually out of those eggs we have 3 blastocysts. We have programs that guarantee 5 blastocysts, so sometimes I have to repeat the process with the same or a different donor. We repeat only with donors who have had a successful pregnancy with us.
It depends on the program you choose. I would prefer you to have a transfer with day 5 embryos with blastocysts, because the embryos are well-developed and have a lot more cells than day-three embryos and the statistics for day-five embryos is a lot better than for day 3. So we highly recommend day-five embryos; either the 3-blastocyst or 5-blastocyst program.
In Spain, egg donation is anonymous and altruistic. The law allows us to compensate the donor about 700 Euros for one cycle. By the way, it is important to notice that Spain is number 1 in organ donation in general. At IVF Spain we have developed a special program where we offer donors a top-class treatment included fertility check, genetic check, fertility preservation options. Furthermore, they have free gynaecological check-ups for the rest of their lives.
We have to differentiate two things. The biochemical pregnancy rate means a positive pregnancy test, and then there is a clinical pregnancy and live birth. If you see the biochemical pregnancy rate, you have to subtract 10-15 %, which is the miscarriage rate, to give you the live birth rate. If I say that we have a biochemical pregnancy rate of 70%, automatically, I say that we have a 60% live birth rate per transfer. That’s why we are interested in having at least three embryos out of the egg donation cycle. The first transfer is always fresh, except if you do PGS, the second and third transfers are frozen. If you have a miscarriage after the first transfer, we do the second one, then we try to improve your endometrium. Then we try to work on your immunology. After two transfers over 70 % of all the patients have children at home. If we do three consecutive transfers, your accumulated pregnancy rate live birth rate at IVF Spain last year was over 80%. After four transfers it is over 90%.
In our clinic we are allowed to transfer one or two embryos – two is the maximum – on day 5. We see that the twin rate with two embryos is over 35% and we do not want to over-do our job. A good IVF centre should have a lower than 10% twin rate so our goal is always to transfer one embryo, the best one. If you want, we counsel you for the possibility of twins and then we have to decide whether you are ready for this in your life because a twins pregnancy is always high-risk. You have to go to the doctor more often, you are not seen by a midwife anymore, there is always the risk of preterm delivery, and when the twins are born life gets quite challenging. We would transfer no more than two definitely.
No. Egg donation in Spain is anonymous under Spanish law. You have to trust that the medical team will find you a donor, but you will never be able to meet her.
American laws and the processes in the United States with egg donation it’s a lot longer than in Spain: there are many agencies and many people involved. The law in Spain allows only for anonymous egg donation. There are different countries in Europe which allow for donors with open ID, like the UK. The problem is that, if you allow for the open ID of a donor, you can meet the donor, but nobody wants to donate. So different countries in Europe have different legislation but when working in Spain we have to follow Spanish law.
It’s an extra cost, but this is not something that we do upfront. We do NK cells testing if you failed the first egg donation cycle or the first transfer, or if you have a history of recurrent implantation failure. Then we would test your NK cells right away. It’s not obligatory, not something that we demand upfront.
At the age of 44, we have to realize that the number of genetically normal embryos is quite low. Two years ago, the ASRN (American Society of Reproductive Medicine) showed that out of forty-six blastocysts at the age of over 44 years, only 10 are genetically normal. We would first focus first on finding genetically normal embryos for you. The NK cell of 24 does not scare me at all and at IVF Spain, before the transfer, we would put you on a low dose of prednisone after the transfer, and then raise the dose. In some cases we put patients on an intralipid protocol at the beginning of the transfer cycle, then another IV infusion on the transfer day or two or three days before the transfer, and then three-six weeks after. This is our NK cells protocol. 24 is not ideal, but what we could do is, after the treatment with intralipid and prednisone, we could check the levels.
We can diagnose them in blood or in the uterus lining. I don’t like blood examinations because they are not sensitive enough. The endometrium test has a much higher sensitivity, as NK cells, like every cell, have certain HLAs. There is a way to test the cells according to which HLA they carry. We know that the bad NK cells, which express CD56 are uterine, in the womb, and not in the blood, and are best are diagnosed through biopsy.
A fresh egg donation cycle with three blastocysts costs 9,700 euros. The first transfer is always included and, if we need to repeat transfers, the frozen embryo transfer is 1 800 euros. Medication is paid on top, but this shouldn’t scare you. Oral estrogens and vaginal progesterone, the same kind of medication used in substitute cycles of women who are menopausal, is very cheap, about 200 euro up to the twelfth week of pregnancy. The donor’s medication on us, so you just pay for the certain number of embryos that we guarantee you depending on the program you chose.
In reproductive medicine, you can organize your cycles in a very simple way. When you come to us, we do an ultrasound transvaginal scan and if the lining is thin, if there are no dominating follicles we can start a cycle straight away. If we see that there are dominating follicles, we let you ovulate and put you on birth control pills for 7-10 days. We then get rid of dominating follicles, you have your period and when you want to you can start a cycle. We can start with a period or after an ultrasound evaluation and then we can plan how we start a cycle. You have to come to the centre, we have to examine you and then we make a medication plan and so you can know when everything is going to happen.
Yes, we do PGS but we do not do CGH (Comparative Genomic Hybridization) anymore. Genetics has made huge progress in the last couple of years. We do PGS, which is a lot more thorough and a lot more sensitive than CGH. We know that, even though donors are young, 60-70% of the embryos that they generate are good, genetically normal but some of them only look good and may be genetically abnormal. Also, the embryo quality depends on sperm quality, too. So if we suspect that the sperm quality is too low and might affect the genetics of the embryo, we can indicate PGS with egg donation. This is the reason why we perform them in selected cases. We are aware that PGS cycles are quite expensive but in specific cases, it is the guarantee of a better outcome.
I had a patient today and her BMI was high. I cannot and I will never allow any of my doctors discriminate you because of your age, because of your a skin colour or because of your BMI, but we have to be realistic – with a lower BMI, you have a higher probability of getting pregnant. We can have a first appointment with the BMI that you have, and we can talk about it and what we can do about your BMI, so that, when we transfer, that your BMI will be good enough to achieve pregnancy.
Not at all. We will put you on hormone replacement therapy. The hardest job in egg donation is done by the donor because she is generating the eggs and embryos. The ‘easier’ job is done by the patient where, with artificial estrogens, we mimic your natural cycle. We give you 14 days of estrogen and five days estrogen and progesterone. This is something that your doctor does with HRT but in HRT you are on two to four milligrams of Progynova daily, and in egg donation, you’re on Progynova, six to eight milligrams daily. We want your lining to be thick enough, between 7 and 8 millimetres when we transfer. In HRT, doctors are not interested in the lining growth, they want the lining to be thin, they just want to get rid of the side effects of the menopause. Basically, we will design something like an HRT cycle but with a little higher dose of hormones to have a proper lining for implantation.
With three blastocysts, it is 9,700 euros, with the first transfer included. Medication is euro 200 on top. For Exclusive Plus, it’s 10,700 euros, with medication at 200 Euros extra. There are no other hidden costs.
We are not allowed – egg donation has to be anonymous. You can only find out the age and blood group of a donor and nothing else.
I know countries where you pay $400 for an ultrasound. The average dose that patients respond well to is Progynova six milligrams and what you can do, if you do not have access to your to your scans in your country, is that you can come to IVF Spain on day 14 of a cycle and we will scan you. If the lining is good, we transfer the embryo. If the lining is too thin, we will keep you on Progynova for a couple of days more for the lining to grow. You will have to be ready to extend your stay in Alicante. When you come to Alicante for the transfer, you are already synchronized with the donor. Two weeks before you have a period, the donor starts injections and you start Progynova. I can only synchronise you through your periods. When you come, I can scan you and if the lining is too thin, you will have to extend your stay in Alicante. It will not be possible to transfer them in the synchronised cycle. We will have to freeze the embryos and then when your lining is a ready, transfer one or two embryos. The post-thawing survival is 99% so this should not be a problem.
Unfortunately, we don’t have any partners in Canada.
For double donations, it depends on how much you want to pay. If your budget is very limited and you just want one blastocyst, it will cost you not more than 4,000 euro. If you want to have 3 or 5 blastocysts guaranteed, the price is the same as Exclusive or Exclusive Plus egg donation and you have to add the price of sperm on top. If the sperm is from Spain it costs 750 euro extra if the sperm is from a European sperm bank then the price is euro 1,000 extra. We then guarantee you, depending on which agreement we sign, 3 or 5 blastocysts.
There are centres in Spain that work only with frozen eggs: we do not. We see that sometimes there are some donors, and this is how the embryology lab puts it, who thaw very well, that the thawing of the eggs is very good, the post-thawing survival is very good. There are other donors where it goes badly, even though they are young and healthy. Not all the eggs that I freeze survive thawing and nobody knows why. We are a clinic where, for us, it is very important to work with you on a certain quality and not repeat cycles. We want to do our best from the very beginning, we want to work with fresh eggs because we do not have to worry post-thawing survival and so generate you more good embryos at once, from fresh eggs.
No. IVF and ICSI are both included in the price we discussed.
No. The program that you pay for, let’s say five blastocysts, is 10,700 euros with the first transfer included. If we see that it’s not working, my obligation is to have four more frozen embryos for you. The second transfer, the frozen embryo transfer, costs 1,800 euros.
Not at all. We have people come here, where the lining is thin or they have just had a period, and we start a test cycle right away
Well, we do not have a sperm bank at the clinic; we just have our own donor bank. This is because we have in Spain and in Europe, very professional sperm banks, dedicated to this activity, which provide us good sperm quality of any kind of phenotype, including African sperm donor. You know, coming from Detroit originally, I had to differentiate between different skin tones. When speaking about egg donation, girls from Ethiopia, who have a very special phenotype, have features like Caucasian Europeans but a different skin tone. We have donors from Nigeria, who have a different shape of nose or mouth. We match different donors according to your needs, according to the phenotype of our patient. It is the same for sperm donors, whether the sperm donor is from one part or another of Africa. When you describe yourselves, you also put down what your donor sperm donor should look and that your sperm donor should be from one part of Africa. My obligation as a medical professional is to follow your needs and if I see that what you would like is not available, we can meet to discuss it further.
No, the medication is not included. The medication of the donor is included, but your medication, which in Europe is cheap, 200 euro per cycle, is not included. You have to pay extra.
I do, a lot, you know. My life changed completely five years ago when I delivered my daughter and I was diagnosed with an autoimmune disease and I had to come to Spain. My daughter is a blessing to me. She’s seven years old now and believe it or not, when I was pregnant, I used to listen to Tchaikovsky, and my daughter now, when she falls asleep, listens to the same concerto. Even though she’s seven years old, she wants this concerto to fall asleep to. And then, you know, when you are pregnant you have crazy levels of progesterone in your body and you eat pickles with marmalade. I used to crave salmon, and now, the only fish that my kid eats is salmon, she doesn’t touch any other fish. When I see this kind of behavior in her, I strongly believe in epigenetics.
It depends on your budget. It can be from one to five.
No. Our Spanish colleagues at the clinic want to have their summer vacation in August. All doctors have to present their vacation calendar for the entire year in January, so of course, we already have the calendar for this year. I will be not at work for the first week of July and then the last week of August. In the meantime, Dr. Álvarez will be on vacation at the same time as me. In August, Dr. Rogel will be working but he only speaks Spanish. The international team works over the summer.
No. This is not allowed in this country. I can only transfer embryos that are genetically the same, either from your own eggs or from donor eggs. If you would like to work with us, we have to take it one step at a time. We will try with your own eggs and if we see that it’s not working and you are here in Europe, in Spain, what we have developed is a program called Switch. This is for when you do the IVF cycle and egg collection but there are no eggs or we obtain poor quality eggs are bad, your follicles are producing estrogens to let the uterus lining grow, but I have nothing to transfer. Once again, this is a case by case situation in terms of medical and economic possibilities, but we will analyse the option of undergoing an egg donation during the same cycle.
We only generate all the blastocysts of your chosen guarantee if you choose the family planning. Otherwise, we will try to generate 1 or 2 blastocysts at once for the first transfer. This way, if the donor is not right for you for immunology reasons for instance, we have the option to change the donor for the rest of the guarantee. In any case, our obligation is to stimulate a new donor for you, without any extra cost, to fulfil our guarantee.
You can go with your local doctor without any problem. If you don’t have your own GP or you are not comfortable to undergo a fertility treatment with him or her, we can give you names of GP that we know that are OK to do this follow-up from all over Europe.
The time-lapse, where we put the embryo into an incubator and get a memory stick, is about 600 euros. We do not routinely use embryo glue because we believe that if you have a good lining, embryo glue is not needed but it costs about 200 euros. Assisted hatching, I don’t remember the cost exactly, but it’s not more than 250 euros. Assisted hatching, costs €80.
With many of them. We have partner clinics in London, Bristol, Manchester, Belfast and Glasgow. On a regular basis, we hold patient meetings in the UK.
This not a problem. Adenomyosis is endometrium in the wall of the uterus. What can we do is that we can down-regulate you. This means we can, before we start treatment, put you artificially into menopause. We can give you hormones that stop production of all the female hormones in your body. You will hate me for this; no one likes to have hot flashes, so we only do it when it’s really needed. Adenomyosis is an immunological phenomenon. We know that in adenomyosis there are inflammatory cells which can negatively influence implantation. But there are a lot of things we can do about this. We can down-regulate you; we can give you Prednisone to immune-modulate you. I cannot shut down the immunological process completely, but at least we can prevent the immune cells from producing the inflammatory factors which contribute to adenomyosis. When you work with adenomyosis patients, implantation rates are no worse than for patients without adenomyosis.
Biochemical, a positive pregnancy test, is 70% per transfer; 60% live birth rate per transfer. Per cycle, it is cumulatively a lot more.
We, doctors, do not decide this. We have a lot of different things to decide, but we have brilliant colleagues from the embryology lab for this, two of whom are senior embryologist. In order to gain this title, you have to go to the European Society of Human Reproduction, show that you have been working at least four years as a biologist, pass a very hard test and then allow you to be independent in an embryology lab. We have two senior embryologists and they decide how to proceed.
The Indian recipient has to be aware that I do not have a lot of Indian donors. If you look online, you’ll see that I have blonde hair and blue eyes, so I do not look Spanish at all. With an Indian background, you look, with all due respect, a lot more Spanish than I do. If you agree to have a donor with your features, with your colouring, but from a Spanish or South American region I’ll be more than happy to help you.
Unfortunately, not. This is a step in infertility treatment that will be allowed in Spain in two or three years. There is a big lobby working on it, but for now, surrogacy is not allowed in Spain.
It depends on how you feel and it depends on how the womb looks but, basically, no longer than a month. The treatment of endometriosis is complex. Usually, you have surgery to get rid of the big islands of endometriosis in your belly, and then you have to be down-regulated, or you have to be on long cycles of birth control pills. So, if after laparoscopy and endometriosis removal you are down-regulated, in a month you can start treatment. Not a problem.
It depends where the cysts are. If they are in the wall and are due to adenomyosis, this does not bother me at all; you can live with this, you can be pregnant with this, you can enjoy your life with this. If they are cysts in the uterus lining, we have to postpone the transfer; the lining has to be perfect; cysts in the uterus lining will not transfer. With cysts in the ovaries, it depends on how big they are and whether they are hormonally active. We cannot do anything here; we have to wait for the second cycle. If they are not hormonally active and small, less than two centimeters, we can transfer. If they are bigger than 2 centimeters and not hormonally active, you would be wise to remove them. But this has to be decided on a case-by-case basis. You could come over to the clinic, we could scan you see where we are and then decide, so there are no surprises in the transfer cycle.
You know, we have considered this. We do not repeat donors from the same countries as the recipients. The same donor can be repeated, but we perform only one egg donation cycle for Germany, one for Switzerland one for the United States, etc. This is how we try to avoid the issue that you talked about.
My obligation is that the child looks like the recipient. Because according to Spanish law, the child that we are going to generate has to look like a combination of you and your husband, so we have a program in the egg donation database that shows the shape of your eyes, the shape of your nose, the shape of your mouth and this is how I match the egg donor to you. It’s quite systematic work, so the children not only mimic our behavior, and this is epigenetics, when they are in the womb we do something and then we have a feeling when they are born like déjà vu, but also our obligation here, as doctors, is to make the matching of a donor to you as if it were you, 20 years ago. So when the child is born, it has to resemble you.
Yes it is. Mammography and pap-smear dated from less than a year the day of the transfer are mandatory at the clinic for women over 40. Another option is that they can also sign a refusal form.
We do not have this ethnicity here. If you want to have a child from egg donation in IVF Spain, it’s very difficult to find an Indian donor in Alicante. You would have to agree to a donor from Spain or South America, having your features. When you look at me, I have blonde hair blue eyes and when I open my mouth everybody thinks that I’m German, but I have very strong Russian roots. If you were to choose a donor for me from Poland Ukraine or Germany, these girls would look very similar to me. This is what we would do for somebody with blond hair and blue eyes. We would not be able to find an Indian donor for you but when I see the girls with your ethnic background that I remember from my childhood, in Detroit, in the neighbourhood of Dearborn, with the highest population of Arabic and Indian people living in the same city, I hope that, visually, you would be happy with South American or Spanish donor. The question is if you will feel psychologically comfortable with this. But, feel free to contact us to discuss it. Drop us an email and let us verify whether we have a Middle-Eastern donor in the databank or somebody of your colour, but with a different ethnic background.
Of course, but, from London, you have an amazing connection to us. Take the Gatwick Express from London Victoria and you’ve got five flights every day by easyJet. You can catch a flight at, I think, 6 o’clock in the morning from Gatwick, and take the latest flight back at 5 in the evening, basically, you can do it in one day. But I understand we are all busy people.
The ethnic diversity is quite amazing here in Alicante. Europe does not really have borders anymore. Erasmus student exchange programs mean that people study two years in Berlin and then two years in Alicante so the majority of our donors are from Europe. Talking about different phenotypes, we have Polish and Ukrainian donors for girls with blonde hair blue eyes, for girls with darker complexions, the typical Spanish beauties, we have a lot of Spanish donors, and we have girls from Asia and Africa. The majority of them either study here or they have they have a Spanish passport.
In the classification of a uterus septum, if we see that the septum goes down more than two-thirds of the uterus, it has to be removed. It is an easy procedure to remove the septum with a hysteroscopy. It is not a big deal if the septum is more than one-third, we can perform the transfer without any problems.
It depends on sperm quality. If we have a patient where everything is okay then it doesn’t matter if I use fresh or frozen sperm. If we see that the sperm quality is low, if there is a problem with motility, we would recommend treatment and fertilization with fresh sperm.
No. We have our own donors from here from Alicante.
No. EggDonationFriends donor database is increasing all the time but it’s not our database and is much broader and also includes the egg donors from other clinics. EggDonationFriends is an institution where a lot of clinics compete but we have our own donor database where the key is anonymity. I cannot show my donors on the Internet or on any webpage because then I would be breaking Spanish law. I cannot share our database with anybody. It belongs to the clinic.
I already have children in Australia, twins even. The only problem is the European border. Basically, our patients ship the sperm of their husband to Europe, the sperm arrives at the European border and then the problems start, because it’s arriving from outside of the European Union. Our embryology lab has to write documents to the border control that everything is legal, that we ordered the sample. This process takes about two months before the sperm is physically in Alicante. Once we know that the sperm is at the border, we can plan the entire preparation while this paperwork is ongoing. Six weeks to two months later, after we confirm that the sperm is here in the clinic, you can come for the transfer. If we were to start work on today in March, realistically in June or July we could do the transfer.*