With claims of better success rates, pioneering treatments and cheaper IVF, foreign fertility clinics are cleaning up. So are ‘fertility tourists’ really getting a better deal? Anna Magee investigates
Fertility tourism to clinics in Spain is on the rise
Two circles appear on a computer screen as a doctor in scrubs sits with her head curled over a microscope. Beside her a woman peers over from an operating bed, her feet in stirrups. A thick tear rolls down her face. Those two dots are five-day-old embryos. We are at the IVI fertility clinic in Madrid, watching as the embryos are brought out of an incubator, checked under the microscope, sucked into a catheter and then placed inside the woman’s uterus.
For the one in seven couples who need fertility treatment, an embryo transfer is one of the most emotionally fraught moments of their lives. Having injected herself daily with hormones to prepare her body for a pregnancy, and spent nearly £5,000 including travel and accommodation, the woman on the operating bed can only wait. Over the next 10 days the embryos may or may not implant and become a pregnancy.
Fertility treatment is big business. IVI, which runs 17 fertility clinics across Spain and another seven in Latin America, turned over €142 million (£101 million) in 2013. In the clinic that I visited in a genteel suburb, the shiny surfaces, minimalist design and pretty staff in high heels made it feel more like a conglomerate than a medical facility. In reception there were two types of people: well-dressed couples evidently there for treatment, and lone women in skinny jeans, parkas and worn leather boots, evidently there to donate their eggs. Only the occasional person in scrubs indicated that this was in fact a hospital.
This is where I met Sophie, 48, a teacher from south London who was waiting for her own embryo transfer. As we spoke she began to cry. “I’m taking so many hormones, I feel like an adolescent,” she said. She is evangelical about the treatment she has received at IVI, especially in comparison with her experience in the UK with a private clinic. “At home nobody would get back to me – and they were constantly up selling. When I finally did get an appointment the cost of the IVF was going to be around £6,000, but every extra test and extra treatment I needed was another £95 or £150.”
Some 300 patients from the UK are treated annually in IVI’s Spanish clinics, up 60 per cent in the past decade. Why? For Sophie it was simple. Given her age, she has a less than two per cent chance of having a baby using her own eggs. With donated eggs her chances are roughly one in four, but as there is a shortage of donors in the UK she faced a six-month wait. Sophie also wanted to use an anonymous donor. “It was an emotional decision but Tom [Sophie’s husband] and I wanted this to be our baby only,” she said. IVI confirms this is a key reason many British couples travel there for treatment. On 1 April it will be 10 years since a UK law was passed allowing children to discover the identity of their sperm and egg donors once they turn 18, and since then the numbers volunteering to donate have fallen. In Spain donors can remain anonymous and there is no shortage. “IVI was able to find a donor with my own blond hair and blue eyes, something never offered to us in the UK,” Sophie said.
In the UK the odds of having a live birth from IVF average about 25 per cent, depending on age and other factors, and in 2013 nearly 50,000 British women had fertility treatment in both private and NHS clinics, the resulting children accounting for two per cent of all births. The National Institute of Clinical Excellence (Nice) recommends that couples in which the woman is under 40 should get three free cycles of IVF. But a post code lottery for fertility treatment on the NHS forces many UK couples down the private route. Susan Seenan, the chief executive of the charity Infertility Network (IN), said, “If you live in one area you might get one cycle of IVF only, and if you picked yourself up and moved post code by only 10 miles, you might get three full cycles on the NHS.” The price of private fertility treatment in the UK is high, she explained, so UK couples are often forced to go abroad, where it can be more affordable.
Indeed, an online survey by the IN found that the reasons couples travel abroad for fertility treatment are many and varied, but for 70 per cent money was a key factor. Although there are no official figures for the average costs in the UK, IVI claims its treatments are 20-25 per cent cheaper than in the UK, charging roughly €5,000 (£3,600) for IVF and €6,795 (£4,850) for a cycle using donated eggs (excluding the cost of a week’s travel and accommodation). “The number of couples going abroad is increasing rapidly, and whereas once that was to access donor treatment, it’s now because it’s often cheaper,” Seenan said.
In 2012 the fertility pioneer Prof Robert Winston, a Labour peer and the former head of the NHS IVF clinic at London’s Hammersmith Hospital, launched an attack on the fertility industry in the UK, claiming a reasonable-sized clinic could offer a cycle of IVF for only £1,300. Last June he claimed the fertility industry has become “more and more private and more and more commercial”, despite success rates not having really improved by that much, leaving vulnerable couples open to exploitation. According to Dr Gillian Lockwood, the medical director of Midland Fertility Services, some clinics inflate their prices simply because of their location. “Our clinic is more down the Lidl end, and a full package of treatment including the usual drugs package would be about £4,000. But Harley Street clinics could charge up to £8,000. A lot of the things we include in our price, such as freezing, storing of embryos and culturing a blastocyst [a slightly more mature embryo], they charge as add-ons.”
Higher success rates were also a major draw, the IN study found. But whereas in the UK you can access data for any fertility clinic in the country via the website of the national fertility watchdog, the Human Fertilisation and Embryology Authority (HFEA), across Europe the only easily accessible data are those cited by the clinics themselves.
What it’s like to freeze your eggs
IVI’s website, for example, states, “Nine out of 10 couples that consult IVI due to problems with infertility and put their trust in us achieve their goal of becoming parents.” For a couple coming from the UK, who have been told of average success rates of less than half that number, that is astoundingly attractive. But it isn’t quite the whole picture.
“This is the cumulative pregnancy rate after four attempts,” Dr Juan Antonio García Velasco, the medical director of IVI Madrid, explained. In other words, after four cycles – and about £16,000 – nine in 10 couples are likely to become pregnant. But this doesn’t necessarily mean they will have a baby, as a proportion will miscarry. (IVI was unable to supply figures.) When asked about this, IVI’s press office replied, “IVI’s statement on its website that 9/10 couples become parents is based on pregnancy success, as they believe from the moment you are pregnant you are a parent.” Certainly after one cycle, 54 per cent of women treated at IVI’s clinics in 2014 did get pregnant, quite a bit higher than the average UK IVF pregnancy rate of 35.5 per cent. Still, it is easy to see how those unused to the nuances of probability and statistics could become confused.
“People have to know what questions to ask,” Seenan said. “There are ways clinics can present their statistics that will encourage people to go abroad, but a nine in 10 cumulative pregnancy success rate after four IVF attempts can’t be compared with a three in 10 live birth success rate after one cycle – that’s comparing apples and oranges.”
But it isn’t only clinics abroad that couples need to be prepared to question
When Christina, 36, went with her husband, James, to a leading private fertility clinic in central London, she remembered, “The gynecologist we saw was like a used-car salesman. He told us that we had a 65 per cent chance of having a baby after three cycles. James and I questioned him about that – it just didn’t sound right – but he was insistent. We had just come through a failed cycle on the NHS. We’d been told by the NHS that we should wait a couple of months before trying again to give my body a rest as it’s so grueling, but the gynecologist told me I could start a cycle that very day.”
The cycle failed, and in its wake Christina was “a wreck, physically and emotionally, far worse than the first time. I really regret rushing into it. But you will do and pay anything, and in hindsight I was naive. I’d only ever used the NHS. I was shocked by how mercenary the private system can be. I am not even sure why, but I decided to try again for one more cycle. This time we went back to the previous clinic we’d attended for NHS treatment, but as paying clients. The clinic wasn’t glitzy and the doctors were far more serious – nowhere near as pushy. They didn’t have the same level of staff so it was less convenient to make our appointments, but it did cost £700 less than the other clinic and I didn’t feel any less cared for.”
So has IVF technology really changed that much since Louise Brown, the world’s first “test-tube baby”, was born, in 1978? The main development was the arrival of intra cytoplasmic sperm injection (ICSI) in the 1990s, in which an embryologist picks out a single sperm from a sample and using a catheter injects it into the egg, rather than leaving the process to nature. ICSI is used in cases of male infertility, where eggs have been frozen (freezing toughens the outside of the egg, making it harder for a sperm to fertilize it naturally) or a couple with unexplained infertility who haven’t had success with IVF. More babies in the UK are now born from ICSI than from straightforward IVF.
A single sperm enters an egg via intra-cytoplasmic injection, or ICSI
“When I started in IVF in 1991 the national success rate for a live birth was about 14 per cent per cycle,” Dr Lockwood said. “Now it’s quoted at 25 per cent, and for a ‘good prognosis’ couple where the woman is under 37 that can be as high as 50 per cent.” Other developments mean your chances of success with frozen embryos are almost as good as with fresh, and doctors also know more about diagnosing infertility, which allows them to tailor treatment programes to increase the chances of success. But fertility treatment is still a game of chance, Dr Lockwood said.
“A doctor can get the diagnostics right, make sure the couple get the right tests, that their nutrition is in place and the recipe for treatment is exactly right for them, but the actual bits of IVF – the scanning, egg collections, embryo transfers and so on – haven’t really changed much.” Even a couple with the best prognosis has only a fifty-fifty chance of success, she explained. “Part of the source of stress and frustration couples feel is that even if everybody has done everything right and they have taken up all the new technology available to them, the outcome is still no better than the toss of a coin.”
In IVI’s embryology lab one wall is lined with incubators filled with embryos, and another huge room is filled with nitrogen tanks where eggs are frozen and stored in thin coloured straws.
IVI claims that its clinics are at the forefront of pioneering treatments.“In Spain the legislation is quite different from the UK,” Dr Velasco said. “We have a progressive liberal legislation that has created a positive environment for the development of therapies that can increase the chances of a couple getting pregnant.” These include the development of an incubation system that uses an embryo scope – a time-lapse camera that photographs a developing fertilized egg every 10 minutes.
“With conventional incubators you need to take the embryo out once a day and check it, which exposes it to the elements. With the embryo scope you can check the embryo every 10 minutes without removing it,” Dr Erik Hauzman, a specialist in reproductive medicine at IVI in Madrid, said. “We have found its use increased our pregnancy outcomes by 10 per cent.” The technology was pioneered at IVI, and is now available in some UK clinics.
Other treatments pioneered at IVI include endometrial receptivity array (ERA), which can determine the perfect time for an embryo to implant in the womb. “There are four days in a month when the endometrium is like velcro for a pregnancy,” Dr Velasco said. “With ERA we can look at a woman whose previous embryos failed to implant, and by taking a small biopsy of her womb, work out the exact time in the month that is perfect for implantation, and time her treatment around that.” Although still in its early stages, an IVI trial of the process on 85 women, who had each had an average of five rounds of failed IVF, found that 33 per cent of them got pregnant. “This is significantly higher than would typically be seen in such a group,” Dr Velasco added. IVI is now doing a pilot study of ERA involving 2,500 women across 10 countries. “My hope is that the ERA test will eventually help us work out how to avoid repeated IVF failure.”
The IVI fertility clinic in Madrid (IVI)
In 2007 IVI scientists in Spain were also the first to introduce a groundbreaking method of flash-freezing eggs called vitrification, which maintains their far better than previous methods. “In the past only about 60 per cent of frozen eggs survived the freezing process,” Dr Velasco said. “With vitrification, that has increased to 95 per cent.” It is now the most commonly used method for freezing eggs (for women who have had cancer treatment or those who want to delay having a baby) in fertility clinics.
But there are downsides to traveling for treatment. A 2010 study by the European Society of Human Reproduction and Embryology (ESHRE) found that in a third of countries across the world fertility treatment is largely unregulated. European fertility medicine is covered by the European Tissue Directive, which sets standards of quality control, infection management and equipment that clinics must abide by. But unlike the HFEA, the ESHRE is not a regulatory body.
“It only makes recommendations. Highly regarded clinics – like IVI – will follow its guidance,” Dr Lockwood said. “But it doesn’t do inspections in the same way the HFEA does.” Spanish fertility clinics are regulated by the country’s Human Assisted Reproduction Technique Act of 2006, and a National Assisted Reproduction Commission acts as a regulator. Still, no independent body I could find in Spain publishes every clinic’s success rates in English in the same way the HFEA does, leaving those patients who want to compare success rates adrift. Despite this, Dr Lockwood recommends IVI clinics in Spain when her patients need donor eggs that she can’t provide, “because I know the clinicians and the quality of their work”.
The biggest risks of fertility tourism come from multiple pregnancies after treatment in the former Eastern Bloc, Dr Lockwood said. In the UK Nice recommends only one or two embryos are put into a woman to lower the chance of multiple pregnancies, which carry increased risks of miscarriage, prematurity and birth complications, although paperwork I have seen from some clinics state they may put back three in a woman aged over 45. In Spain, where twins currently account for 30 per cent of pregnancies achieved through assisted reproduction, the limit is three embryos. But in some countries it is more. “In the Czech Republic, Bulgaria and Russia clinics are not only offering cut-price IVF, they’re putting back four or five embryos into women as old as 50,” Dr Lockwood said. “Women come back to the UK with a multiple pregnancy and the poor old NHS has to pick up the costs of the neonatal intensive care.”
Dr Gillian Lockwood, the medical director of Midland Fertility Services
So how can couples seeking fertility treatment make sure they are getting the best deal, whether they are traveling or staying in the UK? “Instead of taking success rates on a clinic’s website at face value, call and ask how they arrived at that number,” Seenan said. “They can’t make claims they can’t substantiate. And you should ask for a costed treatment plan upfront.”
Couples also need to know the right questions to ask, Dr Lockwood said. The most important one? Find out if the clinic has a good track record with their particular type of fertility problem. “There’s no point knowing a clinic has a 55 per cent success rate for women under 35 with polycystic ovary syndrome if you’re 39 with low ovarian reserve. You need to know its track record with women – or men – with your kind of problem. Think of the care a couple might put into choosing a car or washing machine, yet for something as monumental as where they are going to have their IVF treatment they don’t ask the clinic any questions. They just go where a friend went.”
Christina is still waiting to find out whether her latest treatment was successful. Three weeks after Sophie’s embryo transfer I received news from IVI: she is not pregnant and is now preparing for another cycle. But the woman who was lying on the operating bed has had an ultrasound and is showing a fetal heartbeat – she is pregnant. Despite the huge costs, the painful and potentially dangerous side-effects of hormone treatments and frequent disappointments, the fact that scientific advances can give a woman the one thing she wants more than anything – that her body can’t give her naturally – is as emotionally compelling as it gets.