Cross Border Fertility Treatment

ASSISTED REPRODUCTION- IVF

Giles Palmer-Mitera IVF Unitwww.kosmogonia.gr

Assisted Reproduction• 1978 Natural cycle - in Vitro

fertilization/ embryo transferFirst child born

• Success rate=25%

• 2009 >3.5 million children Born

• 1-3% children born through ART

Hormonal StimulationE2 Blood test, U/S scan Ovulation trigger ~12 days

Implantation support Pregnancy test +14 days

Down regulation 0-14 days

36 hours

Egg retrieval Sperm Preparation

Fertilization

Embryo culture & Embryo transfer +2-6 days

Initial consultation, Medical history, semen analysis, hormonal profile etc

Fertility Treatment

1

2

34

5

6

Implantation support Pregnancy test +14 days

Down regulation 0-14 days

36 hours

Embryo culture & Embryo transfer +2-6 days

Initial consultation, Medical history, semen analysis, hormonal profile etc

Fertility Treatment

2

3

5

6

Minimum2 visits

MinimumDays 3

Assisted Reproduction• Initially for treatment for Tubal damage

• Ovarian Stimulation

• Hormonal disorders, Endometriosis etc• Male factor, Donor Sperm• Embryo freezing, Egg donation, Surrogacy• Embryo selection against genetic inherited

diseases• Intra-cytoplasmic sperm injection,

Azospermia, Testicular Biopsy, Post Humous Fertilization

• Genetic Screening, sex selection• In vitro maturation of oocytes• Oocyte Freezing, Ovarian Freezing, HLA

Typing (Savior Sibling)• Egg banking, Same sex couples

Assisted Reproduction• Initially for treatment for Tubal damage

• Ovarian Stimulation

• Hormonal disorders, Endometriosis etc• Male factor, Donor Sperm• Embryo freezing, Egg donation, Surrogacy• Embryo selection against genetic inherited

diseases• Intra-cytoplasmic sperm injection,

Azospermia, Testicular Biopsy, Post Humous Fertilization

• Genetic Screening, sex selection• In vitro maturation of oocytes• Oocyte Freezing, Ovarian Freezing, HLA

Typing (Savior Sibling)• Egg banking, Same sex couples

Assisted Reproduction• Initially for treatment for Tubal damage

• Ovarian Stimulation

• Hormonal disorders, Endometriosis etc• Male factor, Donor Sperm• Embryo freezing, Egg donation, Surrogacy• Embryo selection against genetic inherited

diseases• Intra-cytoplasmic sperm injection,

Azospermia, Testicular Biopsy, Post Humous Fertilization

• Genetic Screening, sex selection• In vitro maturation of oocytes• Oocyte Freezing, Ovarian Freezing, HLA

Typing (“Savior Sibling”)• Egg banking, Same sex couples

IVF Cost• Is IVF Medically necessary ?…Mainly

private health care

• Great differences in cost

• In Europe inequality of Funding: Denmark -5 cycles fully reimbursed,

Ireland, Ukraine non-existent

• UK 3 / 4 pay for fertility treatment ~4500 €, Australia ~5000 €, USA 10,000+

• Total cost: treatment plus medication

• 30 countries, reported 418 111 cycles (Cx)

• Huge differences with success rates, no. embryos transferred, multiple pregnancy rate

pregnancy rate/transfer UK 23.9%, Greece 30.5%

• Only 16/49 units in Greece gave data 10 110 Cx

• Climate of reducing multiple pregnancy (SET)- Mainly N. European countries

No. Embryos transferred %

1 2 3 4Belgium 48 43.3 7.3 1.4

Greece 13.3 21.9 49.7 15

Sweden 69.4 30.6 0 0

European Figures

Push and Pull factors• Shortage of resources:

Techniques unavailable, long waiting lists,

• “Post code Lottery”

• Legal restrictions

• High cost- high compared to many European countries

• Patient right and choice to seek medical treatment as a “consumer”

• No legal/ religious restrictions, availability of “prohibited”

techniques

• Low cost-

• High success rate of treatment

• “Holiday package” ??

Europe’s Patchwork Legislation

Europe’s Patchwork Legislation

Europe’s Patchwork Legislation

• Oocyte donation-largest growing sector in assisted reproduction

• One donor donates –several recipients

• Little regulation in Eastern European countries

• Spain leader in cross-border destination >3000 donors/year

• Greece-allowed but anonymous

Market Data

ESHRE Task Force for Law & Ethics (2008) – Francoise Shenfield

• Data from 6 countries, 1 month Study• 1230 Cx (~25,000/ year)• Italy (31.8%), Germany (14.4%), Netherlands (12.1%), France

(8.7%)• Main Reason-avoid legal restriction: Germans, Norwegians, Italians

and French• British-Difficulty of access (34.%)

• Partial reimbursement 13.4%, total reimbursement 3.8%

Greece….medical destination

• Relatively Inexpensive treatment, low flight costs

• Liberal Legislation: N2002,N2005 allowing gamete donation,

Surrogacy, genetic testing etc

• High Success rates:

• Reputation, Experienced, trained abroad Health care-workers

• 49 IVF units operating in Greece

• Location-adjacent countries

• Unclear costs- but no as cheapreimbursement?

• Units not inspected - to date

• EU Directive on Human Tissue and Cells not in force- to date

• No official figures

• Lacking patient care and follow up

• Many units operating outside Medical establishments

• Lone/budget travelers

Greece….medical destination

• Relatively Inexpensive treatment, low flight costs

• Liberal Legislation: N2002,N2005 allowing gamete donation,

Surrogacy, genetic testing etc

• High Success rates:

• Reputation, Experienced, trained abroad Health care-workers

• 49 IVF units operating in Greece

• Location-adjacent countries

• Unclear costs- cheap but not as cheap, reimbursement?

• Units not inspected - to date

• EU Directive on Human Tissue and Cells not in force- to date

• No official figures

• Lacking patient care and follow up

• Many units operating outside Medical establishments

• Lone/ Budget travelers

Greece’s IVF Market Greece

• ~15000 cycles year• ~1800-3000 €• Success rate 30.5% per

Transfer

From Overseas:

Overseas patients ~2000 Vast majority oocyte donation Cost ~4000 €

• Mainly from UK, Italy• 3 Units- Crete, Athens,

Thessaloniki

Mitera Assisted ConceptionUnit

• 1502 insemination,1088 IVF cycles 2008

• 2500 € IVF• Pregnancy per transfer 42%

• No Donor Oocyte policy 30 overseas couples

Greek expats, UK (donor sperm), Switzerland, Germany

Oocyte Donation in Greece

• N.389/2002, N.3305/2005 Un-paid, Anonymous Donors, age limit <35 years old

• Revised Legislation ΦΕΚ 1287/2008Compensation 800 € plus 600 € travelling expensesNo trafficking

• Large number of foreign women donating oocytes

• Source of infertile Patientsinternet / Doctor to Doctor relationship

IVF & Internet

Internet use• Fast and anonymous

information resource• Readily available• Inexpensive mode of

communication• Internet users are of

reproductive age

• Growing number of online private health care guides

Answering E-mails• Accuracy of medical advice • Legality • Time consuming• Internet patient are demanding• Worthy of recruiting patients?

Chat rooms/Forum/message Ivf-connections, Fertility-friends• Exchange experiences• Information• Misleading ???

Kosmogonia.gr study• The use of the internet for IVF

information in Greece - trends and patients opinions –

Palmer. G.A, Triantafillou. T, Spiropoulou. I. and Walters R.J

• …….established IVF information resource for Greeks, ……..expressing the wish to directly communicate online with their healthcare provider.

• The frequency and nature of email use varied greatly depending upon the country of origin

• Valued and established information resource to seek treatment overseas. Donor oocytes 39%, Surrogacy 8%,

Sex selection 5%

“IVF Tourism” • “Tricked into high expectations with

no official figures”

• “Unsafe Clinics”-medical standards differ….

• “Dangerous treatment” Suzi Leather chair HFEA 2006

• “Bypass” laws

• Anecdotal evidence of exploitation of women

• No insurance, No patient follow up

The Way Forward• EU estimates 1% healthcare

spending is given to foreign citizens

• EU Directive proposes:

1. Legal framework reimbursement

2. Common Principals Healthcare/ safety

3. Establish transfer of patients information and records

• EU “..to insure right of couples to universal access of infertility treatment”

• ESHRE “Treatments of proven benefit should be easily available through-out Europe irrespective of patient’s income or place of residence”

• Keith Pollard- Treatments abroad.com “…97% of patients willing to travel for treatment again”

• Introduced ratings and reviews system

The Way Forward• EU of infertility treatment In Greece:

• Organized structure of Health care, dedicated staff

• Organized handling of accommodation & travel

• International Standards, Quality Assurance, Accreditation, Adoption of best practices

• Safety for all concerned-Donors and Patients

Insurance, Follow up

• Patients opinions !!!