By fertility experts from Spain.
Surrogacy is sometimes the only way for couples to fulfil the desire to have children of their own. However, in many countries there is still no legal framework to support it. Greece is one of the exceptions – surrogacy has been legal there since 2004. In this webinar, Dr. Danny Daphnis, Scientific Director at Mediterranean Fertility Institute (Chania), and Katerina Dimotaki (Director of the Surrogacy Programme) are talking about surrogacy options in Greece – legal framework, the process and outcomes.
Surrogacy is defined as “the practice by which a woman (called a surrogate mother) becomes pregnant and gives birth to a baby in order to give it to someone who cannot have children.” It is a part of the Assisted Reproduction Techniques (ART) – which means it cannot be performed without IVF.
There are two types of surrogacy: traditional surrogacy and gestational surrogacy. The former describes the situation when the surrogate’s eggs are inseminated, making her the biological mother of the child she carries. Therefore, she does not only carry the child but her DNA also constitutes half of the child’s DNA. Dr Daphnis stresses that traditional surrogacy is prohibited in Greece. Gestational surrogacy, on the other hand, is allowed by the Greek law and it refers to the procedure in which the oocytes of the intended mother or from an anonymous egg donor are fertilised by the sperm of the intended father (or an anonymous egg donor). The embryos that are created are then transferred into the uterus of the surrogate mother. In such a way, the surrogate has no genetic relation to the baby.
Dr Daphnis admits that the idea of a surrogate mother has changed and expanded over the last 10-15 years and more countries have been introducing it into the scope of the ART techniques they are using. However, a lot of countries have banned it as well, due to the abuse and misuse of surrogacy happening in some parts of the world. Fortunately, one can now observe growing awareness and acceptance of this technique by global societies. As there has been an increased demand for these programmes over the last years, neither religion nor laws become obstacles in accepting it anymore.
According to Dr Daphnis, the main clinical objective in gestational surrogacy is to acquire the right number of oocytes from the surrogate mother or an anonymous egg donor. Then, it is expected to transfer one or two embryos into the uterus of the surrogate mother and have the rest of the embryos frozen. In order to achieve the goals, IVF laboratories have to maintain high quality standards, which – combined with the best techniques and all the accreditations available – will help to achieve good embryos resulting in good pregnancy results.
It is important to mention that surrogacy only applies to women who cannot become pregnant due to medical problems. The latter include congenital absence or abnormalities of the uterus, medical conditions that make pregnancy dangerous for a woman’s life (such as e.g. congenital heart disease), cases of multiple miscarriages and selected cases of multiple failures in previous IVF efforts.
At the moment, the surrogate motherhood program in Greece is allowed only for married heterosexual couples, cohabiting couples and single women. Dr Daphnis goes on to explaining the steps of the program at his clinic. Everything starts with an email or a phone call from interested patients, which is followed by an initial consultation with a doctor (either in person or via Skype). If patients are able to show themselves at the clinic, some initial diagnostic examination is performed – however, if they are far away, they are asked to perform all the necessary tests back home. Gathering all patients’ medical issues and fertility problems together is necessary in order to understand the reason why the intended mother cannot carry a pregnancy to term. Once it is determined, doctors proceed with choosing the appropriate treatment plan based on patients’ personal needs. Dr Daphnis says that at that moment, they ask patients to come over to Chania to meet the team and see where everything is carried out – and to start the paperwork.
When the first medical part of the program is completed, the organisation of the legal process starts. According to Dr Danny Daphnis, the good thing about the Greek law is the fact that surrogacy is highly regulated. It means that there always has to be a court hearing and it is the judge who passes on the judgement, deciding whether the surrogacy program can go ahead or not. Once the court’s positive decision is out, the clinic starts the IVF treatment plan that was decided beforehand.
For the surrogate motherhood programme to be successful, there are two processes of the highest importance: the selection of the right egg donor and the right surrogate mother. In case of the former, the donors have to be between 18 and 30 years old. They have to be in overall good health – for that reason, they are tested for 27 genetic diseases, including karyotype, cystic fibrosis and fragile X syndrome. They have to have good ovarian reserve and undergo a thorough examination for infectious diseases, such as HIV, AIDS, Hepatitis, etc. Apart from the clear medical report, they also have to be aware of what they’re doing and conscious of all possible consequences of their actions.
Choosing the right surrogate is equally important. Dr Daphnis admits that it is a good solution when the intended parents have their own surrogate chosen beforehand. If not, the surrogate needs to be selected in medical terms first of all. It means she needs to have an anatomically normal uterus (with no significant polyps or fibroids) and she has to be healthy in both physical and emotional sense. In order to determine her psychological profile, she goes through a detailed evaluation that includes checking her stable character, moral values and a positive attitude towards the surrogacy program. It is also highly important that the chosen surrogate mother is willing to end the program successfully – regardless of the number of IVF attempts required to achieve the desired final result.
In Greece, all aspects of surrogacy are clearly defined by the law. First of all, the Greek legislation allows intended parents to be foreign – and this is surely important information for patients traveling for fertility treatment abroad. Secondly, the court decision is required to state clearly that the baby resulting from the surrogacy program is the intended parents’ – and not the surrogate’s. According to the Court Order, on the day of baby’s birth, the clinic registers him or her into the intended parents’ family names and on the basis of that, the Registration Office provides the baby’s birth certificate. The Court Order also says that the surrogate mother has no legal rights to the intended parents’ baby. Dr Daphnis thinks that knowing this fact may help many patients ease their anxiety regarding the relationship between the surrogate mother and their offspring. It clearly proves that the baby, which is born through the surrogate motherhood program, is the intended parents’ child – and nobody else’s.
Once the court decision is in the clinic’s possession, the medical procedure of the program may be initiated. If needed, an anonymous egg or sperm donor is selected and afterwards – depending on the treatment plan – either the mother’s or the donor’s eggs are collected. Afterwards, laboratory fertilisation of eggs with sperm (either partner’s or donor’s) takes place. Dr Daphnis says that, if required, the fertilised eggs (embryos) may undergo pre-implantation genetic diagnosis to exclude any potential chromosomal abnormalities. Finally, the process is completed by transferring one or two embryos to the uterus of the surrogate mother. If there is a positive result, the embryo transfer is followed by pregnancy and birth.
According to Dr Daphnis, the surrogate motherhood program at his clinic ensures that all surrogate mothers have the best possible conditions to achieve a successful birth of a healthy baby. During pregnancy, a surrogate mother is monitored every 2 weeks. She is tested via ultrasounds, hormone tests and general blood tests, with one or two gynaecologists being responsible for her. She also has a specialised fetal medicine gynaecologist monitoring her three times during her gestation (at 12, 20 and 32 weeks). According to Dr Daphnis, their clinic also performs non-invasive prenatal testing at 12 weeks of gestation (e.g. Harmony or NATIVA tests). Both the pregnancy and the delivery is supervised by a very experienced obstetrician in order to bring a fully term healthy baby into life and maintain the health of the surrogate mother. Once the baby is born, the intended parents can make their dream come true and take the desired child home with them.
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The first visit will be to meet the whole team and to speak with a lawyer. If patients agree with the whole program, they can sign all the papers and the documents that the court will need. Then, they are more than welcome to visit us as many times as they want: during the embryo transfer and during the pregnancy. Actually, we cannot say that they have to come to us like three or four times – it totally depends on them and how many times they want to visit us to follow the pregnancy. For us, it is important that they come at least once: to meet the lawyers and to sign all the documents that have to be signed.
A surrogate mother receives really good care from the clinic. There is a nurse who takes care of her and makes sure she has anything she wants, from transferring her to the clinic to going to the supermarket for her. So there is nothing to worry about. As it was mentioned in the slide regarding the clinical care that the surrogate receives, it is probably five to ten times bigger than what a normal patient would receive. I doubt if there is any other patient who is seen around twenty times for a scan and for tests during a pregnancy. All these tests and scans are all non-invasive and they are performed to assess that everything is going according to the plan.
Regarding the documents, there is a surrogacy agreement that needs to be signed between the intended parents and the surrogate mother. That’s the main document that has to be signed. Afterwards, they need to sign the birth certificate of the baby and – depending on the country that they are from – there are other different documents. So it’s different whether they are from the UK or Germany: there might be an emergency passport needed to go back home, in Australia or in the UK they need a parental order, etc. So it all depends on the country that they are from. We would love to answer questions like this one in details but as the whole service is a very intricate process, it’s best if we have a better and more detailed idea of each patient’s status. One of the most important aspects is where the patient is from and how to obtain citizenship for the baby. So always when we’re answering such questions – even before saying ‘Hello’ in an email – we have to take into consideration where home for the intended parents is.
Absolutely. In most of the countries, in order to give citizenship to the baby, they ask for a DNA test – and most of the times, it is from the father. In most of the countries there must be a genetic link to at least one of the intended parents. So the answer is yes. Of course, when it comes to the US, there are different laws of surrogacy depending on which part of the country you are from. So for example, it’s different in Canada and it’s different in New York. So I’ll need to know more details in order to answer this question right.
In Greece, surrogacy is allowed for married or unmarried heterosexual couples or single women. At the moment, it is not allowed for single men but they are willing to do that in the future. We’re waiting for the law to change so that adoption and surrogacy for single men will be possible. In the meantime, I am 99.9% sure that it is a legal procedure in the US – as far as I know from the conferences and webinars I’ve attended.
Firstly, there is the consultation. Then, there is the decision whether we’re able to accept the patient or not – we have to be able to prove that the patient cannot have or cannot carry a child to term. Then there is the court decision and the whole process of the legal proceedings. Later on, there is IVF followed by pregnancy and birth.
There is a consulate in every place in Greece so you don’t have to go straightaway to Athens. In order to get a passport to go back home to any country, you can either meet the consul in the place that you are staying in at the time or visit Athens and the embassy. Most of the couples do the latter because it’s easier for them to find the flight from Athens straight to their countries. But from my experience, there are also the ones who just go to the consulate in Chania and get the documents that are needed, such as an emergency passport or an original passport. So you can either do that or go to Athens and take the flight from there because there are obviously more flight options there.
First of all you, it’s very difficult to guarantee a program. It all depends on patients’ parameters. So to answer your question in simple terms: because there is IVF involved in the process – and as you mentioned, it can fail sometimes – it’s very important to be able to assess the parameters correctly in order to offer a guarantee program. For example, we had the case in which normal sperm from the intended father was used, it was tried in several donors and it never gave a pregnancy. Once it was changed for donor sperm, we got the pregnancy with the first IVF cycle and the first embryo transfer. Therefore, a guarantee program in our centre does not exist per se – but we do offer different types of guarantee programs based on patients’ parameters and requirements.
When the baby’s born, the clinic that the baby is born at will ask the intended parents to sign the documents. With these documents, their passports and the court decision, the intended parents will go to the registration office in order to get the birth certificate of the baby. Afterwards, you need to speak with the embassy – in this case the Spanish Embassy – and you ask for the passport of the baby. They can ask you to sign some more documents. When it comes to Spain, it has always recognised all our decisions so far. We have never had any issues with getting the passport and going back home with the baby – at least, until now. I’m saying ‘until now’ because things with surrogacy change day by day in Europe. Other countries are starting to be more aware of surrogacy nowadays and about what is going on. But as I said, there should not be any problems with getting the passport and going back home. I just want to add one more thing: we would never start a surrogacy motherhood program without being sure that the intended parents can take their babies home. Our clinical director, dr. Giakoumakis is very adamant about knowing as much as possible about any specific legal process that needs to be carried out following the birth of the baby. We always ask our patients to visit a lawyer back home, prior to getting into our program. It should be a lawyer who is specialised in family law or family planning and who can help them and guide them through the process of getting the baby back home. Unfortunately, laws do change quite often in many countries and we have to be up-to-date at all times. So in order for intended parents to have no problems in getting the baby back home, before we start anything, we always ask patients to have a lawyer back home – just to make things easier during the program.
Intended parents do not have not to be residents of Greece – so it doesn’t matter whether you’re coming from Australia or from Europe. The law is very clear about that. Our patients will get a positive court decision and the law will accept the decision. The only problem that might arise is when taking the baby back home – so before venturing on any kind of a surrogacy program, patients should get to know what happens in the process once the baby’s born.
Actually, the age limit for intended mothers is 50 years old now – but we’re expecting it to be changed to more than 50 years old. And it can happen any day now so I don’t think that you will have any problems. The birth certificate has nothing to do with the fact whether you’re using an egg donor or a sperm donor. As I said, in most countries, there has to be a genetic link to at least one of the parents. The fact that you’re a dual Greek/Australian citizen and a dual British Australian citizen won’t be problem either. When it comes to patient’s age, at the end of the day, it’s always a court decision. There are judges who see it more humanely – so they do not judge just by looking at the age. If you email us directly, Katerina can help you find out if you can go through the surrogacy program.
Actually, I spoke to the head of the Commission that governs IVFs yesterday. Because of the coronavirus lockdown, everything has been at a standstill so we cannot give the answer to this question right now. But as I said before in regards to the age limit, I would suggest you to email Katerina because these are the judges who – at the end of the day – decide if the program can go ahead or not.
That depends on each country. In our country, at the moment there is a protocol for all ladies who give birth – regardless of the fact if it is a birth from a surrogate or a normal delivery. The protocol is prepared in order to make sure that the baby is not infected in any way. So that’s the first part of the question answered. When it comes to the baby being together with the parents: on June, 15, all flights go back to normal so if you state that the procedure is a medical one, I’m sure they will allow you to come and undergo all the process for the baby.
Yes, we are aware of that. The most important thing to say is that by the Greek law, the Greek embassy does not have the right to issue an emergency passport for a newborn baby. The baby born from surrogacy does not have the Greek citizenship – it has citizenship of the intended parents. And no embassy can forbid these people to go back home with their baby. They can have an emergency passport issued for them to go back home . And then, if their country does not recognise surrogacy and the Greek court’s decision, they have to go through the adoption process. That’s why we always inform our patients about it before. And we always advise them to have a lawyer back home just in case. In France and other countries like Finland, Sweden and Norway, we have experienced that 99% of these cases end up through adoption. So remember that the baby will have the citizenship of the parents and the embassy – whether it’s in Finland, France or Norway – doesn’t have the right to say to this couple: “You have to stay in Greece.” At least, they can have an emergency passport, which is valid from 10 to 20 days, and they can go back home with their baby. And then, in their country, they may face all the problems that may emerge in such a situation.
I think the question is best answered according to patient’s parameters. There’s no specific cost and no cut-off line. The best thing is to email Katerina. We have to work on the clinical parameters and this is what happens in the initial consultation. We need to speak to the intended parents, we need to see what the requirements are, we need to see how we’re going to help them and work the cost accordingly. So it would be wrong to quote the amount at the moment because each patient has different requirements. It’s not fair to give a specific cost because each patient can have different aspects of their treatment. So if you want a specific answer to your specific needs, I would advise you to email Katerina, state your situation and your clinical parameters and then we’ll sit down and explain how it works. When it comes to the third part of your question: yes, the payments are definitely divided. Nobody gives all the money upfront. It is all worked out to help patients undergo the surrogacy motherhood program.
You can send us an email, we can speak about your medical problem, we can speak about all the issues and worst case scenarios. Every person and every patient is unique and it’s going to be different for a single person with a donor or for a couple undergoing IVF, etc. We want to give you the specific cost in order for you to know what’s going on. There is a range so it’s better if you speak to Katerina and she will help you accordingly.
Yes, you can. It always depends on the country you are from. In Greece, there is no problem: single women are allowed by law to undergo the surrogacy program. In Sweden, they need a proof of birth and it is usually solved through adoption. But as you are half Greek, that’s not a problem – the baby will have the Greek passport.