1.
Cross Border Fertility Treatment ASSISTED REPRODUCTION- IVF Giles Palmer-Mitera IVF Unit www.kosmogonia.gr

2.
Assisted Reproduction <ul><li>1978 Natural cycle - in Vitro fertilization/ embryo transfer First child born </li></ul><ul><li>Success rate=25% </li></ul><ul><li>2009 >3.5 million children Born </li></ul><ul><li>1-3% children born through ART </li></ul>

3.
Initial consultation, Medical history, semen analysis, hormonal profile etc Fertility Treatment 1 2 3 4 5 6 Hormonal Stimulation E2 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

4.
Initial consultation, Medical history, semen analysis, hormonal profile etc Fertility Treatment 2 3 5 6 Minimum 2 visits Minimum Days 3 Implantation support Pregnancy test +14 days Down regulation 0-14 days 36 hours Embryo culture & Embryo transfer +2-6 days

5.
Assisted Reproduction <ul><li>Initially for treatment for Tubal damage </li></ul><ul><li>Ovarian Stimulation </li></ul><ul><li>Hormonal disorders, Endometriosis etc </li></ul><ul><li>Male factor, Donor Sperm </li></ul><ul><li>Embryo freezing, Egg donation, Surrogacy </li></ul><ul><li>Embryo selection against genetic inherited diseases </li></ul><ul><li>Intra-cytoplasmic sperm injection, Azospermia, Testicular Biopsy, Post Humous Fertilization </li></ul><ul><li>Genetic Screening, sex selection </li></ul><ul><li>In vitro maturation of oocytes </li></ul><ul><li>Oocyte Freezing, Ovarian Freezing, HLA Typing (Savior Sibling) </li></ul><ul><li>Egg banking, Same sex couples </li></ul>

6.
Assisted Reproduction <ul><li>Initially for treatment for Tubal damage </li></ul><ul><li>Ovarian Stimulation </li></ul><ul><li>Hormonal disorders, Endometriosis etc </li></ul><ul><li>Male factor, Donor Sperm </li></ul><ul><li>Embryo freezing, Egg donation, Surrogacy </li></ul><ul><li>Embryo selection against genetic inherited diseases </li></ul><ul><li>Intra-cytoplasmic sperm injection, Azospermia, Testicular Biopsy, Post Humous Fertilization </li></ul><ul><li>Genetic Screening, sex selection </li></ul><ul><li>In vitro maturation of oocytes </li></ul><ul><li>Oocyte Freezing, Ovarian Freezing, HLA Typing (Savior Sibling) </li></ul><ul><li>Egg banking, Same sex couples </li></ul>

7.
Assisted Reproduction <ul><li>Initially for treatment for Tubal damage </li></ul><ul><li>Ovarian Stimulation </li></ul><ul><li>Hormonal disorders, Endometriosis etc </li></ul><ul><li>Male factor, Donor Sperm </li></ul><ul><li>Embryo freezing, Egg donation, Surrogacy </li></ul><ul><li>Embryo selection against genetic inherited diseases </li></ul><ul><li>Intra-cytoplasmic sperm injection , Azospermia, Testicular Biopsy, Post Humous Fertilization </li></ul><ul><li>Genetic Screening, sex selection </li></ul><ul><li>In vitro maturation of oocytes </li></ul><ul><li>Oocyte Freezing, Ovarian Freezing, HLA Typing (“Savior Sibling”) </li></ul><ul><li>Egg banking, Same sex couples </li></ul>

8.
IVF Cost <ul><li>Is IVF Medically necessary ?…Mainly private health care </li></ul><ul><li>Great differences in cost </li></ul><ul><li>In Europe inequality of Funding: </li></ul><ul><li>Denmark -5 cycles fully reimbursed, Ireland, Ukraine non-existent </li></ul><ul><li>UK 3 / 4 pay for fertility treatment ~4500 €, Australia ~5000 €, USA 10,000+ </li></ul><ul><li>Total cost: treatment plus medication </li></ul>

9.
<ul><li>30 countries, reported 418 111 cycles (Cx) </li></ul><ul><li>Huge differences with success rates, no. embryos transferred, multiple pregnancy rate </li></ul><ul><li>pregnancy rate/transfer </li></ul><ul><li>UK 23.9%, Greece 30.5% </li></ul><ul><li>Only 16/49 units in Greece gave data 10 110 Cx </li></ul>European Figures <ul><li>Climate of reducing multiple pregnancy (SET)- Mainly N. European countries </li></ul>No. Embryos transferred % 0 0 30.6 69.4 Sweden 15 49.7 21.9 13.3 Greece 1.4 7.3 43.3 48 Belgium 4 3 2 1

10.
Push and Pull factors <ul><li>Shortage of resources: Techniques unavailable, long waiting lists, </li></ul><ul><li>“ Post code Lottery” </li></ul><ul><li>Legal restrictions </li></ul><ul><li>High cost- high compared to many European countries </li></ul><ul><li>Patient right and choice to seek medical treatment as a “consumer” </li></ul><ul><li>No legal/ religious restrictions, </li></ul><ul><li>availability of “prohibited” techniques </li></ul><ul><li>Low cost- </li></ul><ul><li>High success rate of treatment </li></ul><ul><li>“ Holiday package” ?? </li></ul>

11.
Europe’s Patchwork Legislation

12.
Europe’s Patchwork Legislation

13.
Europe’s Patchwork Legislation <ul><li>Oocyte donation-largest growing sector in assisted reproduction </li></ul><ul><li>One donor donates –several recipients </li></ul><ul><li>Little regulation in Eastern European countries </li></ul><ul><li>Spain leader in cross-border destination >3000 donors/year </li></ul><ul><li>Greece-allowed but anonymous </li></ul>

14.
Market Data <ul><li>ESHRE Task Force for Law & Ethics (2008 ) – Francoise Shenfield </li></ul><ul><li>Data from 6 countries, 1 month Study </li></ul><ul><li>1230 Cx (~25,000/ year ) </li></ul><ul><li>Italy (31.8% ), Germany (14.4%), Netherlands (12.1%), France (8.7%) </li></ul><ul><li>Main Reason-avoid legal restriction: Germans, Norwegians, Italians and French </li></ul><ul><li>British-Difficulty of access (34.%) </li></ul><ul><li>Partial reimbursement 13.4%, total reimbursement 3.8% </li></ul>

15.
Greece….medical destination <ul><li>Relatively Inexpensive treatment, </li></ul><ul><li>low flight costs </li></ul><ul><li>Liberal Legislation: N2002,N2005 </li></ul><ul><li>allowing gamete donation, Surrogacy, genetic testing etc </li></ul><ul><li>High Success rates: </li></ul><ul><li>Reputation, Experienced, trained abroad Health care-workers </li></ul><ul><li>49 IVF units operating in Greece </li></ul><ul><li>Location-adjacent countries </li></ul><ul><li>Unclear costs- but no as cheap reimbursement? </li></ul><ul><li>Units not inspected - to date </li></ul><ul><li>EU Directive on Human Tissue and Cells not in force- to date </li></ul><ul><li>No official figures </li></ul><ul><li>Lacking patient care and follow up </li></ul><ul><li>Many units operating outside Medical establishments </li></ul><ul><li>Lone/budget travelers </li></ul>

16.
Greece….medical destination <ul><li>Relatively Inexpensive treatment, </li></ul><ul><li>low flight costs </li></ul><ul><li>Liberal Legislation: N2002,N2005 </li></ul><ul><li>allowing gamete donation, Surrogacy, genetic testing etc </li></ul><ul><li>High Success rates: </li></ul><ul><li>Reputation, Experienced, trained abroad Health care-workers </li></ul><ul><li>49 IVF units operating in Greece </li></ul><ul><li>Location-adjacent countries </li></ul><ul><li>Unclear costs- cheap but not as cheap, reimbursement? </li></ul><ul><li>Units not inspected - to date </li></ul><ul><li>EU Directive on Human Tissue and Cells not in force- to date </li></ul><ul><li>No official figures </li></ul><ul><li>Lacking patient care and follow up </li></ul><ul><li>Many units operating outside Medical establishments </li></ul><ul><li>Lone/ Budget travelers </li></ul>

17.
Greece’s IVF Market <ul><li>Greece </li></ul><ul><li>~15000 cycles year </li></ul><ul><li>~1800-3000 € </li></ul><ul><li>Success rate 30.5% per Transfer </li></ul><ul><li>From Overseas: </li></ul><ul><li>Overseas patients ~2000 </li></ul><ul><li>Vast majority oocyte donation </li></ul><ul><li>Cost ~4000 € </li></ul><ul><li>Mainly from UK, Italy </li></ul><ul><li>3 Units- Crete, Athens, Thessaloniki </li></ul><ul><li>Mitera Assisted Conception Unit </li></ul><ul><li>1502 insemination,1088 IVF cycles 2008 </li></ul><ul><li>2500 € IVF </li></ul><ul><li>Pregnancy per transfer 42% </li></ul><ul><li>No Donor Oocyte policy </li></ul><ul><li>30 overseas couples </li></ul><ul><li>Greek expats, UK (donor sperm ), Switzerland, Germany </li></ul>

18.
Oocyte Donation in Greece <ul><li>N.389/2002, N.3305/2005 </li></ul><ul><li>Un-paid, Anonymous Donors, age limit <35 years old </li></ul><ul><li>Revised Legislation ΦΕΚ 1287/ 2008 Compensation 800 € plus 600 € travelling expenses No trafficking </li></ul><ul><li>Large number of foreign women donating oocytes </li></ul><ul><li>Source of infertile Patients internet / Doctor to Doctor relationship </li></ul>

19.
IVF & Internet <ul><li>Internet use </li></ul><ul><li>Fast and anonymous information resource </li></ul><ul><li>Readily available </li></ul><ul><li>Inexpensive mode of communication </li></ul><ul><li>Internet users are of reproductive age </li></ul><ul><li>Growing number of online private health care guides </li></ul><ul><li>Answering E-mails </li></ul><ul><li>Accuracy of medical advice </li></ul><ul><li>Legality </li></ul><ul><li>Time consuming </li></ul><ul><li>Internet patient are demanding </li></ul><ul><li>Worthy of recruiting patients? </li></ul><ul><li>Chat rooms/Forum/message </li></ul><ul><li>Ivf-connections, Fertility-friends </li></ul><ul><li>Exchange experiences </li></ul><ul><li>Information </li></ul><ul><li>Misleading ??? </li></ul>

20.
Kosmogonia.gr study <ul><li>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 </li></ul><ul><li>…… .established IVF information resource for Greeks, ……..expressing the wish to directly communicate online with their healthcare provider. </li></ul><ul><li>The frequency and nature of email use varied greatly depending upon the country of origin </li></ul><ul><li>Valued and established information resource to seek treatment overseas. </li></ul><ul><li>Donor oocytes 39%, Surrogacy 8%, Sex selection 5% </li></ul>

21.
“ IVF Tourism” <ul><li>“ Tricked into high expectations with no official figures” </li></ul><ul><li>“ Unsafe Clinics”-medical standards differ…. </li></ul><ul><li>“ Dangerous treatment” Suzi Leather chair HFEA 2006 </li></ul><ul><li>“ Bypass” laws </li></ul><ul><li>Anecdotal evidence of exploitation of women </li></ul><ul><li>No insurance , No patient follow up </li></ul>

22.
The Way Forward <ul><li>EU estimates 1% healthcare spending is given to foreign citizens </li></ul><ul><li>EU Directive proposes: </li></ul><ul><li>1. Legal framework reimbursement </li></ul><ul><li>2. Common Principals Healthcare/ safety </li></ul><ul><li>3. Establish transfer of patients information and records </li></ul><ul><li>EU “..to insure right of couples to universal access of infertility treatment” </li></ul><ul><li>ESHRE “Treatments of proven benefit should be easily available through-out Europe irrespective of patient’s income or place of residence” </li></ul><ul><li>Keith Pollard- Treatments abroad.com “…97% of patients willing to travel for treatment again” </li></ul><ul><li>Introduced ratings and reviews system </li></ul>

23.
The Way Forward <ul><li>EU of infertility treatment </li></ul><ul><li>In Greece: </li></ul><ul><li>Organized structure of Health care, dedicated staff </li></ul><ul><li>Organized handling of accommodation & travel </li></ul><ul><li>International Standards, Quality Assurance, Accreditation, Adoption of best practices </li></ul><ul><li>Safety for all concerned-Donors and Patients </li></ul><ul><li>Insurance, Follow up </li></ul><ul><li>Patients opinions !!! </li></ul>