The HFEA (the body responsible for regulation in the UK) have just recently announced that they are standing by the commitment to reduce the multiple birth rate to 10%
; however, this will not be part of the licence requirement for a clinic. There had been a legal challenge by two clinics about this condition for a licence. The HFEA has been very successful at bringing down the multiple birth rate from 24% in 2009 to 15%. They launched a campaign called One at a Time
to educate people about the risk of multiple pregnancy. But now, it would appear that the clinics will be free to make a decision for their patients on how many embryos to transfer without any restriction. I would assume that most clinics will not drastically change what they have been doing since pregnancy rates have remained stable with the policy in place.
In Europe, IVF clinics abroad usually have to abide by a law stipulating the maximum number of embryos allowed to be transferred. These laws vary from country to country:
· In Greece,
up until the age of 40, three embryos can be transferred. After the age of 40, up to four embryos can be transferred.
· In Bulgaria
, the law is more complicated and it depends on the age of the women, the number of unsuccessful attempts and on the stage of the embryo itself.
· In Spain
a maximum of three embryos are allowed to be transferred.
· In the Czech Republic
there is no law on the maximum number of embryos allowed to be transferred but most clinics will offer 1- 2 embryos at transfer.
With the advent of better techniques for selecting embryos prior to transfer (for example, time-lapse imaging
), it may be that the number of embryos being transferred can be reduced further. Furthermore, because the cost associated with these techniques is lower abroad, they may be accessible to many more people. This will hopefully mean that at embryo transfer, you will have much more information on which to base your decision on how many to transfer. Find out more information on:
By Caroline Phillips
Zdenek Dvorak, Managing Director at www.PragaMedica.com kindly gave a short interview about Gest IVF in Prague and also their about service to people travelling to Gest IVF clinic for IVF treatment.
1) Prague is a very popular place for IVF treatment for people from abroad. Why do you think that is?
Prague is a safe modern Central European city with a beautiful old town and rich history. Czech medical care is of the highest standards, making it a good place for the medical tourism in general. The Czech republic is well known in the world for quality IVF treatment and particularly for high success rates with anonymous egg and embryo donation.
There are IVF clinics all over the world, some cheaper than Prague clinics. However, Prague has many benefits that beat any other location: be it an ideal location in the heart of Europe, good public transport, modern facilities, high quality IVF treatment and UNESCO enlisted cultural heritage. Our clinic is just 20 min. drive from Prague International Airport and many UK patients say it is actually faster to get from their home to our clinic than to a clinic in central London. 2) Gest is a very established IVF clinic. Can you tell me a bit about what Gest offers people seeking IVF and egg donation? What makes it different from other IVF clinics?
Most of our patients (especially those from UK) appraise the friendly atmosphere and personal approach. The clinic is relatively small, but very efficiently run, so there are not the usual barriers between patients and doctors. Apart from the helpful doctors every international patient of PRAGA MEDICA has a personal assistant, adding a VIP feeling to his/her stay. As one of our patients said: “You always have enough information, you can always call someone and ask if necessary”. You are simply not treated as a number, but as a human being.
And, of course, we have reasonable prices, very good results and very short waiting times for egg and embryo donation. 3) What kind of support if offered to patients who travel from abroad?
GEST has an exclusive cooperation with a medical tourism facilitator PRAGA MEDICA. International patients can therefore enjoy extraordinary personal assistance, ranging from arranging their stay to psychological support during their treatment. We offer accommodation in our time-tested apartment houses and hotels, always close to the clinic and within walking distance from the beautiful city center. We are able to arrange your transportation in Prague as well as a wide range of tourist activities. Our drivers will pick you up at the airport day and night.4) Would you always respect a couple's wishes for a particular treatment, or would you suggest another treatment if it was more suitable in your opinion. For example a couple may want IVF using their own eggs but you may consider that egg quality may be too poor and that egg donation is best. How do you deal with this situation?
We respect patient’s wishes thus we usually agree with the treatment even in situations where the chances are lower. On the other hand patients are always explained what consequences their wishes may carry. We refuse patients who want illegal procedures such as PGD for gender selection or wishes that may result hazardous for the patient.
Your example with donor eggs is one of the more common cases. Some older patients simply do not want to hear that their chances can be as low as 1% using own eggs while they could have over 50% chance with donor eggs. 5) Which particular aspect of treatment do you consider to be the most important in order to have a successful outcome?
Patients should arrive relaxed as much as possible. We believe stress is a killer of success. For that reason we always spend a lot of time in advance preparing the patient for the arrival to our clinic. We advise patients to come over for 1 day personal consultation to meet the doctor, their personal assistant and to get familiar with the clinic and the city. Patients rest for 1 hour after the embryo transfer in our rest room and they are advised to relax in the hotel for 1 night before they fly back home. Although patients tend to shorten their stay as much as possible they should understand IVF cannot be done in a rush.6) Are there any preparations that a couple should do before travelling abroad for IVF?
A crucial part of any preparations is to choose the right clinic. Patients should check references of the clinic and their doctors. They should make their decision after they have been answered all their questions and they have spoken to the representative of the clinic. This will give them a good picture of who they are dealing with.
Another important detail is to have all the recommended tests and examinations, such as hormonal profile, STD tests etc. However, if patients split their treatment in 2 shorter visits, these tests can be done abroad on the 1st visit, usually at much lower cost than at home. 7) Finally, Prague is beautiful, Is there somewhere you would recommend visiting in Prague not to be missed?
There are probably 1000 things to see. You could spend 2 weeks in Prague and still be entertained. I would definitely recommend a night walk from the 14th century St Vitus catedral to the Old town square. The views over 100 towers of the old town are spectacular. You will see the baroque buildings of Lesser Town, walk over the famous Charles bridge with its 30 statues, enjoy a breath-taking view of impressively lit Prague Castle before entering narrow lanes of the Prague Old town. It is especially poetic at night.
Thank you Zdenek.Zdenek Dvorak is a director of PRAGA MEDICA and has been working as an international coordinator for fertility treatment at GEST clinic since 2010. He has been in daily touch with the GEST clinic, doctors and patients since then, making sure that every patient has a smooth and pleasant stay in Prague. He combines his excellent knowledge of fertility treatment with great customer care which is sometimes missing when you deal with a clinic directly.Further information on Gest IVF clinic is available on our website.by Caroline Phillips
Plan you IVF treatment abroad
Are you considering going abroad for IVF treatment? One of the reasons couples may consider going abroad for IVF is that it is perceived to be cheaper. But unless you actually sit down and total all the expenses you will incur, you will not be able to make an informed decision about whether you are indeed saving money.
Like everything, planning and having a budget makes sense, not only because you will be in control of your spending, but also because you may feel less stressed.
First of all, the actual treatment itself. Let’s consider egg donation treatment costs.
These may include:
· First Consultation
· Donor medication and monitoring
· Donor Egg Retrieval
· IVF (usually ICSI is performed)
· Culture to blastocyst stage
· Embryo Transfer
· Embryo freezing and storage of surplus embryos
· Recipient medication and scan
This list is not extensive and could also include other IVF procedures
such as assisted hatching, time-lapse embryo monitoring
, preimplantation genetic screening (PGS), IMSI to name a few. Many IVF clinics have an advertised price for egg donation but the packages are all so different so you cannot compare like-with-like based on the advertised price. A little bit of work and research is required to drill down to what you actually need to spend
. For example it is not always essential to have
embryo monitoring or PGS or assisted hatching. Finding out a bit more about them may help you make an informed decision about whether you should use them if they are discussed with you during your treatment.
Next there is the cost of travel and accommodation
. Budget airlines can usually be relied upon to get to most places in Spain, the Czech Republic and Greece. For egg donation treatment, usually only two trips will be required. The first will be to have a First Consultation where you will have certain tests carried out and sperm will be frozen. The doctor will also discuss the donation program and begin the process of matching you with a donor. This trip can usually be done in one day. The second trip is for the embryo transfer itself and usually a 2-night stay is all that is required. However, if your budget airline does not fly every day to your destination then you may have to hang around for longer. So you will need to budget for the number of nights you need to stay bearing in mind the airline schedule. Some clinics will help arrange hotels and may even have discounts at some so it is worth asking. They may also be able to arrange airport pickups too. Having known costs for accommodation and travel make it easier to budget.
Finally there is the day-to-day spending
when you are away from home. If you are being treated in Prague, Madrid or Athens, you may want to do a little sightseeing whilst there. You may also want to consider insurance for your trip abroad.
Arriving at an approximate total cost for the treatment including accommodation and travel will mean that you will be able to decide whether going abroad really will save you money. Focussing only on the advertised price of the treatment will not tell you the whole story. Thereis too much variation in price and in what is included.
We have detailed information on fertility clinics in Spain
and the Czech Republic
which may help with planning your IVF treatment costs abroad.
At the heart of IVF clinics at home and abroad is the IVF laboratory. And at the heart of the lab are the embryologists. These skilled personnel are sometimes invisible behind the closed door of the laboratory. Many medical directors of IVF clinics will admit that the IVF laboratory is where all the critical work of the clinic is undertaken. IVF embryologists have to be extremely skilled, patient and knowledgeable to perform their role well. It takes many months of training to be able to perform all the tasks which are required to be undertaken in an IVF laboratory.
The European Society of Human Reproduction and Embryology (ESHRE) implemented an accreditation scheme a few years ago in order to standardise the training undertaken by embryologists in IVF clinics in Europe. They recognised that embryologists may have come from different scientific backgrounds and that usually an “apprenticeship” or “training-on-the-job” was the training available to new recruits. They therefore implemented certification to demonstrate an individual’s level of expertise and knowledge in the field of embryology.
With the explosion of new technologies, and greater demand for embryologists, the ESHRE accreditation scheme now rightly recognises Embryology for the profession it is. The accreditation scheme is based on a submitted and verified logbook of procedures undertaken by the embryologist followed by a written exam. There are different requirements for the senior embryologist. A senior embryologist must hold specific postgraduate academic qualifications and have had at least 6 years hands-on lab experience.
Since the laboratory is so important to the success of the IVF clinic, it is right that there are measures in place to ensure that quality of procedures are maintained. In the UK and Ireland, the Association of Clinical Embryologists also has a defined training scheme in place. The ACE Certificate in Clinical Embryology ensures that entrants to the field of embryology are properly trained and qualified to perform their scientific duties.
There are many countries in Europe now with embryologists who are ESHRE accredited. For those IVF clinics which enable their embryologists to participate in the ESHRE accreditation, it can be another indication of the quality control procedures which are present within.
Read some interviews by staff at top IVF clinics in Europe.
By Caroline Phillips
Dr Giuliana Baccino PhD
In this interview, Dr Giuliana Baccino PhD discusses her role as a psychologist at FIV Madrid in Spain.Dr Baccino, thank you for your time. Could you explain what your role is within FIV Madrid.
Being responsible for the Psychology Department, I do specific research in reproduction, and I handle the patients’ emotional aspects, writing guidelines, holding support meetings, etc, as well as evaluating donors in the donation processes, and giving support to clinical staff. I am also a member of the International Department, and give specific support to foreign patients. I think that these patients, in particular, need a lot of emotional support. They are far from home, dealing with a different language, different procedures from those they are used to, different medical staff culture, etc. Support is essential to make these patients feel comfortable, and secure. FIV Madrid is a very established clinic as it has been open since 1993. Can you tell us a little about the clinic and what it means for patients who attend such an established clinic.
FivMadrid has being working in assisted reproduction for more than 20 years. 90% of the patients treated in our clinic achieve pregnancy. This means that patients who come to FivMadrid can be sure that all our staff knows exactly how to help each patient. All patients are different and need different types of treatments and approaches and we have the experience to be able to provide it. What can FIV Madrid offer that other clinics may not be able to? You mentioned before the support you can give to International patients?
Yes, emotional support is very important in assisted reproduction, and if we add the complexity of not being at home, emotional support is extremely necessary. Patients have doubts about the acceptance of their treatment in their country, about how and when they should tell their offspring about his/her origins, what to tell to their family and friends, how to cope with “bad days” at home and far away from the clinic that is treating them, etc. Which significant breakthroughs in fertility treatment have helped patients most at FIV Madrid?
Anonymous reproductive donation helps most of our patients. Nowadays, women want to be mothers later in life, or want to have a baby without a male partner. New types of family are growing, and in almost all of these cases, a reproductive donation process is needed. Some of the staff at FIV Madrid have been there a long time, do you think that helps improve patient management?
Of course, almost all of our staff has been here at FivMadrid for more than 10 years. This means that they are committed to this place, they like their job, and they have a high level of know-how, which makes the difference. A new beginner may be very excited about the new experience, but patients in reproduction need more than that. They need experience, research background, skill in working with infertile couples. Research appears to be very important in your clinic, can you tell us why you think it is important to be involved in research?
Reproductive Medicine without research is meaningless; procedures can be done without proving how they work, or their results for patients. All clinical aspects in FivMadrid (medical, psychological, and laboratory procedures) are evidence-based on scientific medicine or psychology. Are there any new developments on the horizon for FIV Madrid e.g. clinical or perhaps an expansion in size?
Yes, we are very close to the opening of our new Centre, in the Castilian area in northern Spain.Thank you Dr BaccinoFind out more about FIV MadridGiuliana Baccino, PhD. Responsible I+D Psychology Research Department in FivMadrid. Coordinator of the Psychology Interest Group of the Spanish Fertility Society. Coordinator of the Research Committee in the Latin-America Association of Reproductive Medicine. Lecturer in the Master: Reproducción Humana, Universidad Complutense de Madrid, lecturer in the Postgradute Experto en Enfermería de la Reproducción, Universidad Rey Juan Carlos, and in the Postgraduate Psicología de la Reproducción Humana Asistida, Universidad de Barcelona. Member of the Psychology and Counselling Group of the European Society of Human Reproduction and Embryology.
by Caroline Phillips
I have come across this question many times before. If you do research on fertility clinics abroad, you will see that the donor egg success rates advertised seem to hover around the 50-60% mark. This is usually the clinical success rate, but you should check to be sure because it could be the chemical success rate being reported (and this is usually higher). This success rate usually relates to the pregnancy rate following embryo transfer. You could further drill down and ask the pregnancy rate per embryo transferred. This will be lower because clinics often transfer more than one embryo. It is also prudent to ask about how many cycles got to embryo transfer because obviously the fewer cycles there are, the less predictive are the results.
Why not give live birth rates? I think that for IVF clinics which treat many people from abroad, this particular statistic may be more difficult to report. Contacting everyone after their due date may be logistically a bit difficult.
So it can be difficult to compare like-with-like when it comes to pregnancy rate.
But back to the question – why do pregnancy rates seem higher abroad. Well a perceived increase in pregnancy rate in clinics abroad can be explained by the following:
1) The number of embryos transferred may be greater abroad than in the UK. There is a real push to promote single embryo transfer in the UK. Abroad, the average number of embryos transferred would usually be about two embryos. The result of this may lead to an increased pregnancy rate.
2) Blastocysts are routinely used for embryo transfer abroad and are usually included in the price advertised (this can be called extended culture). At this stage, the embryo has passed all of its milestones and is progressing in development. So transferring at this stage means that preimplantation development has successfully completed. Transferring embryos at this stage should lead to better success.
3) The egg donors will on the whole be younger than donors in the UK. Having a younger egg donor may mean that egg quality is superior. Although many women do donate here in the UK, it can tend to be women who are a little older – friends, family members. Women going through treatment themselves for infertility also donate eggs. However, if the cause of the infertility is unknown, this may lower the chance of success for the recipients of these eggs.
4) IVF clinics abroad can use “proven” donors a few times (in Spain six children can be born from the same donor -including her own). So the chances of success with each cycle using a proven donor may be higher.
I hope this has partly answered the question about IVF success rates abroad. Do you have anything to add? Please do so in the comments box.
By Caroline Phillips
You may like to read more about IVF abroad in Spain and the Czech Republic.
Deciding to go abroad for IVF treatment abroad is quite a big deal. Not only do you have to deal with the treatment itself, but you have to do so in a foreign land where everything is unfamiliar. Choosing an IVF clinic abroad is one of the hardest choices. What should you look for?
Firstly, the clinic should be transparent about its success rates and costs. If you can’t find this information out or the clinic seems hesitant in giving you full facts then I would avoid it. It only takes an email to request the information. Their response will give you confidence in going forward.
Deciphering what all the results mean and costs can be tricky. We have provided an IVF Cost Calculator
which may help you with costs. With success rates, you need to focus on clinical pregnancy rates. This is when there is a heartbeat found on the scan at six weeks gestation. A chemical pregnancy rate is sometimes quoted by clinics and this reflects the fact that a blood test has indicated that hormone levels are rising indicating that an embryo has implanted. This rate is always higher than a clinical pregnancy rate because, unfortunately, many pregnancies will terminate before 6 weeks. It is also beneficial to find out how many embryos are routinely transferred at transfer. A clinic which puts many embryos back will almost certainly have a better pregnancy rate but at the risk of a multiple pregnancy.
The clinic should also have staff in place to help and assist people coming from abroad. Most of the clinics have an international team whose job it is to coordinate treatment. These teams usually have staff that is multilingual. They will help you plan your treatment and even accommodation.
The clinic should have excellent communication channels. When questions crop up, you want to be able to get in touch quickly with the staff. Find out about out-of-hours communication. Who will you speak to in an emergency?
Find out what other IVF travellers have to say about the clinic. There are lots of forums with boards which discuss individual fertility clinics abroad e.g. Fertility Friends
, Fertility Zone
. Comments on these boards may give you confidence but it is always good to go with your gut instinct. The best way to find out about a clinic is to visit it yourself but of course this isn’t always practical.
Choosing the right clinic is not easy. I am a great believer that if something doesn’t feel right then it isn’t. If this is you too then your gut instinct from your research will lead you to the right clinic.
By Caroline PhillipsFind out more:
I was recently reading an article on blastocyst appearance before embryo transfer and live birth outcome in a publication by the European Society of Human Reproduction and Embryology (ESHRE). The article discussed some research undertaken where the scientists looked at blastocyst appearance; in particular the appearance of the trophectoderm and inner cell mass (ICM) and the degree of blastocoele expansion. First let’s explain what this all means.
Blastocyst-stage embryos have reached the end of their preimplantation development. To get there they started off as fertilised 1-cell embryos which divided into 2 cells, then 4-cells etc. until eventually they reached approximately 100 cells. They passed through various stages during their development finally reaching a stage where there are two distinct cell types. One of the cell types is called the trophectoderm and that is found surrounding the outer part of the embryo. This will eventually develop into the placenta. The other cell type is called the inner cell mass. That is what will develop into the embryo proper (foetus). Inside the embryo there is a fluid –filled cavity called the blastocoele. Eventually the blastocyst will reach a point where it will escape from the protective “shell” called the zona pellucida and implant in the womb.
The researchers in the study looked at these three aspects of the blastocyst embryo and how each had an effect on pregnancy outcome. In particular they found that the appearance of the trophectoderm cells was the most important predictor of live birth. This was surprising as most people would predict that the state of the ICM was the most important cell type for successful outcome. Therefore, the embryologist may consider choosing an embryo which has a grade A trophectoderm and a grade B ICM in preference to prioritising embryos with a grade A ICM for transfer. Or at least not be afraid of transferring embryos with a lower grade ICM but a top notch trophectoderm.
The embryologist will use all their skill and knowledge to make the best decision about which embryo to choose for transfer. For those clinics without time-lapse imaging, this information may actually help the IVF team in their decision-making.
by Caroline Phillips
Find out which IVF clinics abroad use embryo monitoring:
The European Society of Human Reproduction and Embryology (ESHRE) have just published IVF results for Europe from 2009
. These results are summaries for each country who submit their results to ESHRE. In 2009, 34 countries (out of 47 in Europe) were included in this report.
Of the Spanish IVF clinics, 109/166 contributed and 100% of the Czech Republic IVF clinics contributed to this report. The report makes interesting reading.
Main points to take away:
1) The number of treatment cycles is increasing each year.
2) The overall pregnancy rate was the same as 2008.
3) The number of transfers with multiple embryos (3+) is declining.
Interestingly, the report points out that public access to individual clinic data were available only in nine countries: Hungary, Iceland, Ireland, Latvia, Moldova, Romania, Slovenia, Spain and UK. It would be good news if this number were to increase as it would allow members of the public to find out the information they need without having to email each IVF clinic. Some IVF clinics do publish their results on their websites which is very helpful; however, having all the information available instead of a subset would be even better.
In an earlier posting, I talked about embryo transfer
, and the number of embryos being transferred. In the report by ESHRE, the Czech Republic IVF clinics
on average carried out more 2-embryo transfers than single or triple embryo transfers. Out of approximately 10 000 IVF and ICSI embryo transfers in 2009, 72.8% were 2-embryo transfers (7.2% were 3-embryos). In Spain
, out of approximately 26 500 IVF and ICSI cycles, 68.2% were 2-embryo transfers and 16.1% were 3-embryo transfers. Since this data is 4 years old, and with more awareness of the problems associated with multiple embryo transfers, these numbers may have decreased in 2013. Certainly compared to 2008, the overall number of 3-embryo transfer has come down significantly.
I believe it is really helpful and beneficial to have this summary report as it gives us valuable information on trends within countries. It allows us to compare one country with another. It provides background information on the controls surrounding IVF in each country. The data is from 2009 which may not make it seem as relevant; however, the trends reported within the report are based on a huge amount of data. As a result, drastic swings will not usually occur over a short period of time, so we can be confident that the trends being reported for 2009 are relevant today in 2013.
By Caroline Phillips
Dr. Štěpán Machač
Dr. Štěpán Machač thank you for your time. Lots of people from the UK and Ireland consider the Czech Republic for IVF treatment. Why do you think the Czech Republic is so popular?
I think, that it is: affordable prices, high quality treatment, perfect service, short waiting time. There is a large choice of IVF clinics in the Czech Republic, in your opinion, how should people choose one clinic over another? They should choose depend on:
reference, success rate, prices, personal approach, number of foreign patients treated annually. Reprofit International is a popular choice for egg donation treatment. Can you tell me a little about the egg donation program? Where do you get your donors from? How long does a couple have to be in Brno etc?
Our clinic has a very sophisticated donor´s system. We have in our register more than 1500 donors ready to donate. Most of our donors are students, and the mothers on maternity leave. We do a lot of advertisements to get them. Our price is 4500 Euro for whole treatment, except the medication. The treatment takes about 1 week of staying in Brno. In your opinion, which particular aspect of the treatment is important for success?
In my opinion it is preparation of a patient for treatment and selecetion of young healthy good responding egg donor In the future, which IVF techniques do you think will offer best hope for infertile couples? Do you think embryo monitoring is a breakthrough? I think that genetic testing by cGH and transferring of single embryos in a natural cycle is a future. Embryo monitoring is just a small part of embryo selection process Finally, where is one place in Brno that you would recommend that people should see before they leave?
It is the heart of Brno - Freedom Square
Find out more about Reprofit International
or IVF in the Czech Republic.
Dr. Štěpán Machač, PhD. is the head physician of the Egg Donation Program at Reprofit International. Following his 10-year medical practice at the Obstetrics and Gynecology Clinic in Olomouc, he decide to devote himself fully to infertility treatment. In 2006 he became a co-founder of the Reprofit International clinic. He specialises in the treatment of patients with reduced ovarian reserve. He is a member of the SAR ČGPS and of ESHRE.
By Caroline Phillips