In this session, Dr Elias Tsakos, FRCOG, Medical Director at EmbryoClinic, Thessaloniki, Greece, talked about IVF/egg donation regulations, such as age limit, surrogacy, cryopreservation in Greece.
Dr Tsakos also explains post-mortem fertilization is possible under the following rules and circumstances.
Surrogacy has been legal in Greece for many years since 2005. However, international surrogacy has been made possible only in the last seven or eight years. This has attracted many couples and many single women from all over the world to come to Greece for surrogacy. The doctor explains it is legal and regulated and it has some advantages over other countries. According to Dr Tsakos’ opinion, the most important advantage is the fact that the court order and the parental order are issued before the IVF process. This takes away all the stress of the parents regarding the parental order, which is issued beforehand, and it’s a security measure for the surrogate carrier herself that the parents, the commissioning parents, would be the parents of the child.
Dr Tsakos explains there are a lot of issues associated with surrogacy, mentioning a special event to cover all surrogacy issues should be held. He says it is very complex and complicated sometimes since it is a process that involves many people, commissioning parents, surrogates, and sometimes egg donors or sperm donors, among others. It is one of the most complex fertility treatment clinics offer. However, for many couples, this is the only way to childhood, and they need to understand that this is legally regulated and available.
With regards to the carrier, she has to be between 25 and 35 years old. She has to have at least one child of her own and she’s not allowed by law to use her own genetic material.
In Greece, cryopreservation is legal. It is a common place within the European Union. All the genetic material has to be kept in a licensed cryobank. All IVF units have their cryobanks and there’s a special license in Greece for a cryobank on top of the IVF unit license, to ensure quality and safety.
Dr Tsakos mentions this is a very important advancement of technology and science which has made possible the elimination of some diseases before implantation. Furthermore, over the last 10 or 15 years it has also been used for screening for standard common genetic anomalies that may be associated with age, for instance down syndrome; and it has also been used to exclude anomalies that are inheritable.
However, PGT-A in Greece is legal and regulated, it’s been recently implemented that, although all units are licensed, units require a special license to perform PGT-A and to follow certain criteria for that.
Moving on, Dr Elias compares Greece’s and other countries’ systems. Firstly, in Italy, there’s limited availability of egg donation. Although it is legal, it is not available, which is an oxymoron according to the doctor. It was illegal until 2014, but not available at the moment. That is the reason why Italian patients at the moment either have the option of using frozen eggs shipped to Italy by other European countries or they would still need to travel physically to Greece or other countries, like Spain, Praga and Belgium, maybe to receive egg and sperm donation.
In Germany and Turkey, egg donation is illegal. In France, there’s limited availability of egg donors and that’s why French people travel to Greece.
According to Dr Tsakos, fertility tourism is here to stay. It’s been happening for more than a decade now and it seems to be on the increase. Mainly because of various reasons, but legal barriers is one of those important reasons. There are legal barriers preventing patients from receiving treatment within their own country and therefore traveling to another destination in order to receive a treatment.
You may be interested in reading: IVF in Greece – costs, availability and legal aspects
Fertility clinics in Greece are all licensed by the Greek National Authority of Assisted Reproduction. There’s quite a good level of science and technology, regulation and quality assurance. He comments that up until a few months ago, there was no waiting list, but unfortunately due to the COVID situation, some waiting lists are being built up because with all this close and opening uh people are queuing for the opening times. Sometimes clinics cannot cope with the demand. The cost is still affordable. The doctor hopes it can be kept this way, despite the demand for more regulated standards, the demand for COVID compliance, and the demand for quality assurance in terms of ISO standards.
Greece is amongst the very few countries in the world where fertility clinics are not only required to have high quality standards, but they also need to be ISO certified by regulators from both quality and management but also on laboratory safety. ISO standards is a procedure that not only guarantees quality and success, but also it increases costs. There are excellent reviews about Greece. It is one of the emerging fertility destinations.
The authority that regulates the units is responsible for the accreditation, designation and licensing, and keeping the register of activities. They refer to the European Society of Human Reproduction and Embryology, where they publish results there. All professionals receive all the guidance and updates on science and technology.
The doctor mentions some of the future challenges in the legal framework of Greece. One of them is the age limit, which the doctor mentions the possibility that in the next few weeks, the announcement of the increase of the legal age limit for females to 52 may appear. That’s in light of the COVID pandemic that has prevented many women from going forward and having their IVF, especially those very near the 50-year-old mark. Moreover, about same-sex couples, there are a lot of talks at the moment between different authorities about whether that should be ethically or legally allowed.
Other future challenges mentioned by the doctor are treating single men, cryopreservation duration and the transportation of genetic material. The last one seems that because of the COVID jurisdictions, physical travelling seems to be becoming more and more complex. On the other hand, this has been proven to be safe, effective and regulated and therefore it is probably going to provide some extra options for patients all over the world who rightfully wish to become parents.
This is an endless discussion. We’re all aiming for single pregnancies and single deliveries. However, as you know, as an embryologist, it’s not just a number, it’s the quality that can be variable. Sometimes, we cannot always guarantee a top-quality blastocyst for all our patients, and even if we do, for a 40-year-old or a 42-year-old, a top-called blastocyst doesn’t mean that this blastocyst is euploid is chromosomally normal.
So, double lambda transfer will always be an option, and also apart from the scientific, clinical and ethical point of view and apart from our agreement that we wish to go for single embryo transfers of a normal euploid embryo, there is the human factor as well. If our patients request for their own reasons that they wish for a double embryo transfer, I don’t think we can refuse or deny them that option. So, of course, whether that increases the chance of a single pregnancy, depends on the quality, of the patient’s characteristics. Again, I think it’s an endless discussion. All I mentioned in my talk was the legal regulation and I think it’s very important that in Greece, it is legally not allowed to transfer more than two embryos as a general rule, which is a very good step forward as we know that in many countries, even within Europe, they can transfer up to three or four embryos with disastrous outcomes.
To be honest, I don’t know. This is not up to me. I’m a medical director and clinical doctor. However, all I can say is that it’s expensive. It’s a very complex and expensive type of fertility treatment. It’s the end of the road for some couples. Thankfully not many couples, but for some couples this is the only way to parenthood. The only way to achieve parenthood. It is an expensive, stressful and complex procedure that takes a long time to be accomplished. A minimum of maybe one and a half to two years. It’s very costly. However, if you’re particularly interested drop us an email at info@embryoclinic.eu, and I’m sure that my coordinators should be able to answer you specifically.
We do the standard genetic tests that most people do which include a karyotype and the full cystic fibrosis gene testing, not just the df508, which is the commonest cystic fibrosis gene. We do the entire range of gene testing, which covers 99.9% of possible mutations. On top of that, we test for fragile X. These are genetic tests. Also, we’ll do more testing apart from genetics, which includes all the viral testing. I would do a formal psychological assessment and so forth.
I still don’t know exactly the figures, so please drop us an email at info@embryoclinic.eu, and we should be able to answer that. Egg donation is also a complex procedure, not as complex as surrogacy. However, it involves a lot of work, a lot of counselling, and screening of the donors. In my clinic, we only accept probably about one in five donors who come forward. As I mentioned, we only accept donors under the age of 30, so a good proportion of the potential donors are excluded by age alone. So, if they’re over 30, although legally it is allowed up to 35 years old, they’re rejected.
We run various tests, including the genetic tests I mentioned, plus all the viral testing. We do microbiology testing. Of course, the psychological assessment and so forth. So only one in five donors are accepted in our program. And as you realize the added cost of that is, apart from the screening costs, it’s the cost of donor drugs, the stimulation drugs, the monitoring procedure, and the compensation which is legal and acceptable both ethically and legally in Greece. That increases the overall prices; however, egg donation is reasonably priced. It is roughly about half the price compared to the UK. It’s maybe 30 % cheaper than in Spain, and it’s the same as in the Czech Republic, just to give you a rough idea of the exact figures.
IVF in Greece is between three and three and a half thousand euros. Depending on whether, for example, there’s freezing or whether there are some adults in the lab. So, a rough figure is three to three point five thousand euros now. Unfortunately, there is a possibility that prices may increase because of the covid. Most of the products have started to increase, most of the technological equipment is increasing for some reason that perhaps some of us don’t understand and so forth, but at the moment the prices have remained the same, and it’s more or less at that level.
Yes, we do. As I said, in my clinic we have a very low threshold in rejecting donors and so any abnormality, either in the history or in psychological assessment, or in the genetic testing any minor abnormality would be a reason for rejection.
We do the standard testing that I mentioned and as I said in my clinic on top of the standard we do some extra tests, for example, the XY microdeletion, and also, of course, we test for thalassemia because in Greece thalassemia is a genetic disease fairly common. On top of this, of course, if the couple wishes, we can test for 301 genetic diseases, we also have a package for 500 genetic diseases and all that.
In request, we can test for anything that any couple would wish to test. Of course, in the US, as you probably know egg donation is probably seven to ten times more expensive than it is in Greece and this is one of the reasons why we have a lot of US patients flying out to Greece for the donation. We have one from Detroit coming next week for the second baby, having delivered the first one successfully. So, there’s no end to genetic testing and on request, anything could be done. There are costs of course but on top of that the cost-effectiveness of treatment increases is very favourable and that’s why Greece is so popular.
We do the standard testing that I mentioned and as I said in my clinic on top of the standard we do some extra tests, for example, the XY microdeletion, and also, of course, we test for thalassemia because in Greece thalassemia is a genetic disease fairly common. On top of this, of course, if the couple wishes, we can test for 301 genetic diseases, we also have a package for 500 genetic diseases and all that.
In request, we can test for anything that any couple would wish to test. Of course, in the US, as you probably know egg donation is probably seven to ten times more expensive than it is in Greece and this is one of the reasons why we have a lot of US patients flying out to Greece for the donation. We have one from Detroit coming next week for the second baby, having delivered the first one successfully. So, there’s no end to genetic testing and on request, anything could be done. There are costs of course but on top of that the cost-effectiveness of treatment increases is very favourable and that’s why Greece is so popular.
Yes, we can. I mean technically we can test for anything under the sun and of course that requires a medical indication.
Surrogacy is not legal because to my knowledge Greece is the only country within the European Union at the moment, not even Spain which is the mecca of IVF as we all know is offering legal services. So, within the European Union, Greece is the only option at the moment. Of course, in continental Europe, there are other options like Georgia, Ukraine, and Russia for surrogacy and I think that’s about it in Europe. Then it’s the United States. Regarding egg donation, I’m not exactly familiar what is the situation in Ireland, to be honest.
I don’t know, I’m sorry. Now it’s anonymous. I think it’s going to stay anonymous for quite a while because, as you probably know in continental Europe including Greece, it’s not very easy to change the laws and my feeling is that it’s going to stay anonymous for a long time. However in selecting donors, although it’s a wonderful marketing tool to show photographs, trust me I don’t look anything like what I used to when I was a child. So, I think it’s nice and happy for many people to see what the donors look like, but I don’t think it has so much to do with reality when it comes to the actual child.
As far as I’m concerned, as a clinician and a doctor with more than 30 years of experience now, the most important is not perhaps the looks or the baby’s looks or the young adult’s looks, what’s most important is the general characteristics, the genetic characteristics, the age of the donor of course and some other factors that perhaps are not very good for marketing, but they’re good for the substance of the whole of the egg donation process and in Greece, in Europe, in my clinic, it’s the medical team that guarantee them the matching, the selection of the perfect donor for every single woman and every couple that we treat. This is a huge responsibility but believe me, thankfully it is possible, and it is creating beautiful families all over the world.
Endometriosis is one of my passions, and it’s a disease that affects a lot of women. It’s a disease that is causing a lot of problems in the everyday life of those women. Not just infertility but also other problems and, of course, we have to address that it’s the silent epidemic in my opinion. So, whether I use Lupron or not depends on the endometriosis is the answer. It depends on the stage of the endometriosis, on the previous history of that woman and so forth. It’s not a very easy answer to give.
I try to individualize and, to be honest, I’m a great believer in the surgical management of endometriosis. I feel that endometriosis is best treated surgically on many occasions, especially when it’s creating symptoms. So, I prefer not to have endometriosis at all. I prefer to have successful surgery, either laparoscopic surgery or robotic surgery for endometriosis, before attempting fertility treatment.
However, if there is endometriosis, they are either visible on a scan or an MRI or clinically palpable or clinically suspicious endometriotic lesions, then yes, I would consider using Lupron. I must admit that I am a big fan of Lupron overall for frozen embryo transfers anyway. And maybe one of the reasons is that always in the back of my mind that there may be a possibility of undiagnosed endometriosis. Although I don’t like to think or to see endometriosis when I want to do embryo transfers or just before the end of the transfer, however, yes, I’m usually tempted to use Lupron how many months depends on the answer maybe six to eight weeks.
Male fertility has been neglected. Sperm quality is not only a fertility marker but also an indicator of overall male health.
A man with low sperm count at 35 may not only be subfertile but may also have underlying health issues. Semen analysis should be viewed as a general health assessment.
In our practice, we diagnose approximately one case of testicular cancer per month during fertility investigations. Early detection can be lifesaving.
