Liberal Macedonian law lures foreigners for in-vitro fertilization

Out of about 2.500 cases of in-vitro fertilization, about 1.000 are residents of neighboring countries and further away, announced the Health Insurance Fund in North Macedonia. Legal restrictions on a woman's age, but also good experiences in hospitals, are reasons why foreigners do artificial insemination in this country.

“Doctor, just to let you know that as a result of your work I gave birth to twins, a boy and a girl, and I thank you for that. Greetings from Serbia", wrote the Serbian citizen, Dunja S., to a doctor from the 'Plodnost' hospital in Bitola, where they performed biomedically assisted fertilization - popularly known as in-vitro fertilization (IVF).

Through this procedure, egg cells and sperm are united in laboratory conditions and fertilized are returned to the woman's body to start a pregnancy.

At the end of November, a 61-year-old woman from Skopje gave birth to a healthy son, after 37 years of not being able to conceive. The mother had had ten unsuccessful in-vitro fertilizations, and as many miscarriages. She had previously performed three gynecological interventions, of which two in Belgrade, and one in the gynecological clinic in Skopje.

"We have patients from all countries of the former Yugoslavia, we also have patients from further afield, we attract patients from everywhere. Mostly, they come to us because of the possibility to use donated material, because of unsuccessful in-vitro fertilizations in the countries where they live, but also because of our success", he told Radio Free Europe. Tashe Tërpčevski, the founder of "Plodnost" hospital in Bitola.

Such stories are shared by all private hospitals that perform this procedure, since in the inability to have children naturally, the artificial insemination method is chosen.

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"Sophie is developing great so far, and this week she started to smile," wrote a patient from Spain to a doctor at the Newborn clinic in Skopje, where the baby was fertilized by the in-vitro method.

A similar message was sent by a patient from Kosovo, who had performed the same procedure in this hospital in Skopje, while she was born in Germany, where she currently lives.

The State Clinic of Gynecology and Obstetrics (IPSH) in Skopje had a three-and-a-half-year hiatus after the coronavirus pandemic, and did not perform any in-vitro interventions.

The work was restarted a month and a half ago, and there are already patients who have started the procedure, confirmed Irena Aleksioska Pepatiev, director of the IPSH.

Significant increase in infertility

"Looking in general, infertility in our country and in other countries is increasing significantly and is a very big problem in modern human reproduction. Every year, the number of patients in our department increases, not only from foreign citizens, but also from our country. We have patients from Kosovo, Serbia, Croatia, Albania, as well as from many European countries, England, the United States...", said doctor Mitko Ivanovski, head of the department for assisted reproduction at the "Acibadem Sistina" Clinical Hospital.

Among the factors of infertility, according to doctors, in addition to medical reasons, there are postponing births after the age of 30, stress, polluted air, and a significant increase in male infertility and unexplained infertility is observed.

In North Macedonia, there are no statistical data on how many couples or women cannot have children naturally, because no such evidence is kept.

However, the number of in-vitro procedures performed is known. Out of about 2.500 cases a year, about 1.000 are from neighboring countries and further afield, the Health Insurance Fund (FSHSM) announced, after a meeting in early October with representatives of all health institutions, with which the Fund has an agreement on this procedure.

With this number of patients from abroad, North Macedonia has become a regional center for assisted fertilization, according to gynecologists from hospitals that perform the procedure.

Fewer restrictions, more possibilities

Macedonian law on biomedical assisted fertilization is more liberal compared to the laws of countries in the region. He has no restrictions on the age of the woman who can initiate this procedure.

The state does not bank sperm or egg cells, but allows their import when necessary - something that is limited or impossible in countries in the region.

"We have no restrictions in this area, so women have more opportunities to become mothers in later years as well. We have had patients from Bulgaria, Kosovo, Albania... everyone seeks their own destiny, so if they are not successful in one country, they go to another. Maybe we are a small country, but we have several centers for in-vitro and we all follow the modern world trends in this field", said the doctor Verica Organxhiska from the hospital "Dr. Organxhiski" in Shtip.

The restrictions in Croatia, for example, are that the in-vitro procedure, with the support of the Health Insurance Fund there, is performed on women up to the age of 42. The law allows the donation of egg cells and sperm, but this must be a procedure, it must not be anonymous. The child conceived in this way, when he grows up, has the right to know the identity of the donors. Croatian media wrote that this significantly reduces the interest in donating reproductive material.

Croatia does not allow the import of egg cells and sperm. According to the data of the Health Insurance Fund of Croatia, every year, about 300 couples from this country go, mainly to North Macedonia and the Czech Republic, to receive donated egg cells or sperm cells.

In Serbia, the age limit for women is up to 45 years, while there is no age limit for the male partner. Serbia began importing donated reproductive material from 2022, with the support of the country's Health Insurance Fund. For women without a partner, or couples who meet the criteria, the cost is covered by the state. The procedure costs about 7.000 euros.

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Doctors have said that in the last two years, since Serbia allowed the import of reproductive material, the number of couples from there, who previously came to North Macedonia for this procedure, has decreased.

An age limit for women, up to 42, also exists in Bosnia and Herzegovina. Women over this age there, can get approval, but with the proposal of the professional council from the health institutions.

Kosovo has not yet adopted a law on reproductive health. There is a bill that has not been passed because it was opposed by some members of the ruling party, who do not want unmarried women and same-sex partners to have access to the in-vitro method.

In Kosovo, on December 24, the Medically Assisted Fertility service was inaugurated at the Gynecology Clinic of KKUK.

The Ministry of Health said that the Medically Assisted Insemination or Fertilization service "will be free for the first two times, while after the first two times it will cost 670 euros, significantly cheaper than the service in the private sector that has a price of around 3 thousand euros".

Until now, in-vitro has most often been done in private clinics based on an administrative instruction from 2013, which provides that individuals and couples have the right to access in-vitro, but does not provide for a bank of reproductive material.

According to the data of the Ministry of Health, the citizens of Kosovo, on average, spend 5 million euros per year for assisted medical procedures for reproduction in private clinics. According to a mother from Kosovo, who previously spoke to Radio Free Europe, the cost of this procedure is around 4.000 euros.

Greece and Bulgaria also allow egg and sperm donation. Women from North Macedonia often go to Greece, as this country also has a bank of reproductive material. Due to this regulation, the procedure is faster than in North Macedonia with import from foreign banks, and although it is more expensive than here, said doctor Tërpčevski.

High success and lower prices

Hospitals in North Macedonia that offer in-vitro fertilization have a high success rate and lower prices, compared to hospitals in European countries, which is one more reason for the interest of foreign patients, doctors have stated.

"We as North Macedonia rank very high on the list of ESHRE (European Society for Human Reproduction and Embryology) for in-vitro success, after Spain and Greece. Moreover, we are cheaper. People come on the recommendation of someone who has already been to us, read on forums, exchange experiences. The problem with us is that we do not have a National Donor Registry and this slows down the procedure a lot. It takes four to five months from the moment the Commission in the Ministry of Health approves it, until the donated biological material arrives," said Dr. Tatjana Gurzhanova from "Newborn Clinic".

The in-vitro procedure in private clinics costs around 2-3 thousand euros. With imported egg cells or sperm, the price is approximately twice as high. It is imported by banks from Spain, Ukraine and Denmark.

For Macedonian citizens who meet the conditions under the Law on Biomedical Assisted Fertilization, the cost is covered by the Health Insurance Fund.

The Commission for assisted biomedical fertilization in 2023 reviewed a total of 1.457 requests, the annual report of the Health Insurance Fund has shown.

Of these, 1.238 are requests for the first child, 205 for the second child, 11 requests for the third child and three requests for the fourth child. Moreover, last year the Fund approved 95.4 million denars (about 1.5 million euros) for in-vitro procedures performed in eight health institutions with which it has agreements.

For those who meet the conditions, in-vitro is covered by the Fund. Others who turn to private clinics, the procedure costs 2.000-3.000 euros. For those with donated material, the price is higher and the procedure is longer.

According to the interlocutors of Radio Free Europe, 4-5 months pass from the preparation of the documents, obtaining the import permit, to the pregnancy test.

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The in-vitro procedure as a right was made possible for the first time with the support of the Fund, in 2008. Patients have the right to in-vitro up to three attempts, for the first, second, third and fourth child. .

The insured are exempt from financial participation. Persons living in marriage, living outside marriage and women without a partner, who have exhausted their treatment options, are eligible and have the right to donated sperm.