* Author Topic: Agate's serum file-if you've got a question look on here first! thanks  (Read 54574 times)

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Offline agate

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Agate’s Serum Notes
These are my personal opinion - have not been checked or endorsed by Serum and only record my experience of treatment there - other ladies will need to get their own advice!


This thread contains multiple links/information. This information is not confirmed/checked by Fertility Friends and readers are reminded that FertilityFriends.co.uk or its owners are not responsible for the content or accuracy of external internet sites, or of the accuracy of medical information shared by members other than those in our "Ask A Professional" section.
Please note that Pobby has previously written some very helpful information about her experience too - so read her excellent notes as well!

Index
1.   Why do I think Serum is really good clinic to go to
2. Are there any bad points?
3.   What is Serum like?

4.   Egg or Sperm donation
4.1 Who are the egg donors?
4.2 Who are the sperm donors?
4.3 Can I use egg and sperm donation (or embryo donation)?
4.4 Do Serum treat single ladies?
4.5 What is the matching process?
4.6 What information is available about the donors?
4.8 Can I do IUI/DIUI with Serum?
4.9 Can I do a tandem OE and DE cycle with Serum?
4.10 Is there an age limit


5  How much does it cost?
5.2 Does ICSI/IMSI cost extra?
5.3 Do they do PICSI?

6.1   How to arrange a consult
6.2.   How to do the infection tests on menstrual blood?

7.   How long does it take to get started?

8.1   Having hysteroscopy in Athens
8.2   If I have an aquascan and its abnormal can I have a hysteroscopy the same day?
8.3   Can I have hysteroscopy at any time of the month?
8.4   Why am I being advised to try naturally after hysteroscopy?


9.   How to get to the clinic from the airport

10.1   Where to stay
10.2   How to get to Athens from the UK

11.   Buying medication in Greece and in the UK

12 Protocols
12.1 Donor egg protocols
12.2 Own egg protocols

12.3 What is natural cycle OE IVF?
12.4 What immune/adjunctive treatments are available with Serum?
12.5 The importance of sperm quality
12.6 Extended down regulation pre-treatment

13.   Paying for your treatment


14.1   When will I need to be in Athens? When will I be able to book my flights?

14.1.1 Fresh cycle own egg IVF
14.1.2 Natural cycle own egg IVF
14.1.3 Natural cycle donor egg
14.1.4 Medicated donor egg
14.1.5 Natural cycle frozen embryo transfer
14.1.6 Medicated cycle frozen embryo transfer

14.2   Checklist for booking your trip

15.   Packing for your trip

16.   Checklist for going home after embryo transfer

17.   Cycle monitoring for an own egg IVF

18.   Having your egg collection – own egg cycles

19.   Having embryo transfer – own egg and donor egg cycles

20.   Other practical information

21.   Eating out

22.   Self catering

23.   Internet access

24.   TV and radio

25.  Going to Athens with a baby or toddler

26.   With love from Agate


1.   Why do I think Serum is really good clinic to go to

•   Because Penny and all the other staff are lovely and really care about you having a happy, healthy baby.  Having spent a lot of time there, and talking to other ladies on FF over a long time, I have seen that Penny does what she does out of purely altruistic reasons - everything she does is motivated by trying to get the best for everyone - the patients, the donors and their babies.
•   Because you can get rapid access to tests and consults e.g., most blood tests can be done on the spot with results the same day or the next day -  if an abnormal scan suggests a problem you can normally be scheduled for a hysteroscopy at the local private hospital the next day – you can have sperm DNA fragmentation tests done within 4 hours (which means you can test the sperm and make decisions about whether to use it on the day) – Penny can arrange for you to see other specialists as needed e.g. an immunologist.
•   Because you can access both own egg and donor egg (and donor sperm) treatments quickly and easily without waiting lists
•   Because Penny takes a lot of care with own egg protocols to maximise your chances whatever your age and your fertility problems
•   Because Penny can often pick up on problems that other doctors have missed e.g., infections, undiagnosed issues with the sperm, undiagnosed adenomyosis, fibroids etc
•   Because the egg donors available tend to be younger than UK donors and a good match for UK ladies (e.g, Blonde and brunette polish and ukrainian ladies as well as greek nationals) and are treated well, stimulated gently and not pressured into donation.  She prefers donors in their 20s with kids already so she knows they have the proven ability to have a healthy baby and they aren't likely to regret their decision to donate later because they have a family of their own.  She treats the donors like her own family which helps because you know she won't accept a donor she doesn't trust and you can be certain that the donor is well treated.
•   Because although egg and sperm donation is anonymous under Greek law, you get to find out detailed information about your donor because Penny knows the donors personally - and if you had an important question about the donor she can usually find out the answer for you because she knows them.
•   Because you can access ‘niche’ treatments like intralipids, LIT, GCSF and antibiotic therapy more cheaply and easily than in the UK - and can access some treatments that aren't available in the UK yet, like PBMC
•   Because you don’t feel like you are just another number and another statistic - its not a production line factory like my understanding of some the big clinics in Spain or Czech - and it has a long, carefully built reputation under the same long term management, rather than some less reputable clinics.
•   Because the costs of treatment are economical compared to clinics in Spain, US and UK
•   Because private medical care in Greece seems a bit better quality than medical care in some UK NHS hospitals - cleaner, more innovative, more organised.
•   Because Penny is an instinctive practitioner who tailors her treatment to you, monitors you as closely as she feels you needs, follows her hunches, tries new approaches, works collaboratively with you and any other practitioners involved in your care, won’t give up on you, won't patronise you and will try really hard to get you your baby.
•   Because cycling at Serum is cosy, friendly and relaxed - and its nice to cycle with someone who is so warm and positive and always looking for solutions to your infertility issues.   
•   Because if you are cycling with a baby or toddler in tow, the staff will help you out and you won't feel unwelcome - you won't find any notices on the walls at Serum asking you not to bring children like in some UK clinics!
•   Because, for couples who can't face another own egg/own sperm failure, double donor embryos (made with donor eggs and donor sperm) are available quickly to give a very high chance of finally bringing a baby home.


2. Are there any bad points?

-   Travelling to Athens can sometimes be a hassle because of strikes, flight cancellations etc.  In the last few years we’ve had the British Airways strikes, the Icelandic ash cloud and several strikes by Athens airport workers or air traffic controllers - as well as demos and street protests in the centre of Athens (not near the clinic) to avoid.
-   Donor sperm and egg treatment is completely anonymous under Greek law (the same as Spain, Czech republic etc) so if you choose to have egg or sperm donation treatment you have to accept that your child will never be able to contact their donors and you will need to sign an agreement stating you consent to receive treatment from anonymous donors.

3.   What is Serum like?
Serum is quite a small clinic compared to the large NHS hospitals I was used to.  The street it is situated on looks unimpressive.  It is arranged over 5 floors with reception on the ground floor, a laboratory in the basement, consulting rooms on two other floors and the embryology lab and a small operating room (for egg collections, scans and embryo transfers) with two recovery cubicles on the third floor.  Appointment times are a bit vague, but very flexible (Penny stays until she has seen everyone who needs to be seen) and the atmosphere is relaxed and casual. There are sofas in reception where its nice to chat with other ladies going through treatment.  There is a water dispenser but no coffee etc but there are plenty of places nearby to pick up a coffee or a snack (there is a yummy bakery in the street behind the clinic for an economical snack, but there are also lots of cafes nearby).  There is a room next to reception where blood is drawn when you need it.

Penny who runs the clinic (her official title is Clinic Director) has a very hands-on approach and works most days – she tries so hard to help as many ladies as possible that she barely gets any sleep - and is in the clinic 7 days a week if she has to be in to do an egg collection or an embryo transfer on a Sunday (Penny gets most of her time off in August as the clinic is closed for the whole month of August every year).  In the mornings she is usually very busy dealing with egg collections, then scans and other appointments but if you need to see her she will usually fit you in – often in the early afternoon when it’s a bit quieter.   The desk is manned from 8am to 8pm most days but if you have queries, they are best dealt with before 2 or 3pm (Greek time) – if she is not too busy, Penny will go home in the afternoon.  Thimmios (Penny’s husband) is the embryologist.  Dr Georgiou Konstantinos attends the clinic most mornings to do the egg collections and to cannulate for intralipids.  He also does the surgeries like laproscopy and hysteroscopy.  Dr Pannegiotis is the anaethestist (and the acupuncturist). Dr Pannos also sees Serum patients at the nearby private hospitals for hysteroscopy.  Nurse Ewelina assists Penny and the doctors upstairs in the operating room for egg collections and embryo transfers.  Dimitra the midwife also gives hands on help with your injections, medications etc.

On the reception desk, Vasso, Maria, Georgia and Andriana help to co-ordinate appointments etc.   Christa and Vasso also take blood, give injections etc.   Katie helps with email queries and initial enquiries from home.   

Dr Evangelos Kontorousis has recently joined the clinic to assist and train up with Penny and also Dr Meridis who is an experienced Gynaecologist who used to work in London.

In the embryology and other labs, Thimmios and several other technicians deal with the technical side of the work.

Penny is not a medical doctor but has degrees in biochemistry and human biology and has been working in the fertility field for many years.   She performs scans and embryo transfers herself (although Dr Meridis will be doing more of these) and is on hand during the egg collections which are done by Dr Georgiou, and the anaesthetist, Dr Pannegiotis.  She is extremely warm, glowingly positive and caring.   You leave the clinic feeling there is nothing more that anyone else could have done to help you.  She handles all queries and questions personally, and is very dedicated to getting ladies pregnant so, please be kind to her by being organised with your queries, thinking them through and trying to batch your questions all together rather than bombarding her with many separate, small queries.

All the staff speak some English, and Vasso and Maria in particular will try very hard to help you, but Penny’s English tends to be better than some of the reception staff.  Andriana and Dimitra both speak good English.

Most ladies deal direct with Penny (and her assistant Katie), and Dr Meridis.  Penny's English is good and it means you deal directly with the owner of the clinic.  I have always dealt direct with Penny and would highly recommend it. 

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Offline agate

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Re: Agate's file of serum stuff - part 2.
« Reply #1 on: 26/10/11, 10:57 »
4.   Egg or Sperm donation
4.1 Who are the egg donors?
For matching UK recipients, the egg donors chosen seem to be mainly blonde or brown haired eastern European ladies, usually from Poland or Ukraine who are economic migrants to Athens working in, for example, healthcare, hotels etc.   They are often in their twenties and most of them have young children of their own and choose to donate to get extra cash for their own families and because it makes them feel good to something for someone else.  Egg donation is altruistic, so the donors aren't paid, but the Greek law allows them to ask for expenses of up to €800+€600.  There are also greek egg donors who are often university students and who tend to be more suitable for dark haired/brown eyed recipients.    Red haired donors may be more difficult to find as they are unusual in Athens and Penny's preference is not work with red haired donors due to the increased risks of clotting etc that are sometimes associated with red hair.   There are a few african origin donors on Serum's books.  All donors are screened for infection, karyotype, cystic fibrosis , sickle cell etc and their family medical history is reviewed by Penny before they are accepted.  When matching a donor for a couple, a knowledge of which physical traits are dominant is also relevant - for example, if your eyes are blue but your husband has brown eyes, if you had a natural child, the brown eye trait could dominate so your own eye colour might be irrelevant.  Even if you wanted to match your blood group so the baby wouldn't know he was from egg donation, if your husband has a dominant blood group, your blood group would be irrelevant.

Donors are recruited only by word of mouth (advertising for donors is not legal in Greece), so donors tend to be friends of previous donors who become familiar with the process whilst their friend is donating.   Penny is careful about which donors she can accept on to her programme, but donors who join the programme tend to have a long term relationship with the clinic and Penny gets very attached to the donors who do join the programme.   She only accepts donors who have a clean family medical history (no early age cancers, heart problems, mental illness, serious allergies etc), are normal weight and who she is satisfied are mentally stable and have a good character.  As economic migrants from Poland and Ukraine, the egg donors are often well educated and over-qualified for the work that they do in Athens but also tend to be motivated,  'self-starters' who have chosen to move to a new country for better prospects.  The resulting babies from treatment are very important to Penny and she believes that beautiful and intelligent people tend to have better lives and that beautiful children will tend to fit better into families, so she does only accept donors who she judges to be beautiful.

4.2 Who are the sperm donors?
Sperm donors are often young Greek men (not all Greek man are dark!) and are personally known to Penny (again, donors are recruited by word of mouth, so by recommendations of friends), but if a different ethnic match is required, Penny can buy sperm from a commercial cryobank.  For sperm that is already in Serum’s bank, there is no extra charge if you are doing a donor egg cycle.  All donors are screened for infection and family medical history and the information that is recorded about them is similar to the information recorded for egg donors.  Donor sperm is quarantined for at least 6 months by law.

If you want to choose your own anonymous donor sperm you can arrange to import it from one of the large international cryobanks like Cryos, Xytex or ESB (serum seem to prefer Cryos), but you have the cost of the sperm and the shipping to arrange.

4.3 Can I use both an egg and a sperm donor?
Yes.

4.4 Do Serum treat single ladies, or work with surrogates?
Yes.

4.5 What is the matching process?
When you consult with the clinic you will fill out forms with your medical history etc and giving your basic information ready for an initial discussion.   As donation is strictly anonymous in Greece, the clinics have to use their best judgement as to which donors are a suitable match for you. You will also need to send photographs of yourself, your partner, and any children you already have so that Penny has these in front of her when she is picking your match.  When you ask Penny to find you a donor, you might want to write down a list of the characteristics that are most important to you, so that she can try to match as much as she can.   Penny will never compromise on the basic physical characteristics needed for a match - hair colour, eye colour etc but the more additional criteria that need to met, the lower the number of potential donors who can be considered for you.  If you are doing a full donor egg cycle, Penny may be able to tell you which of your criteria she has matched in the proposed donor at the start of your cycle and will be able to answer any (reasonable) questions you have about the donor to the best of her own knowledge about them, but at the moment, there are so many donors, that at the start of the cycle, Penny may well have more than one possible donor in mind and will prefer to wait until egg collection day before deciding which donor she feels is going to be the best choice for you.   Accordingly, it makes more sense to wait until at least egg collection day before having a detailed discussion about the donor.  On embryo transfer day, you will always have the opportunity to discuss the donor in detail before the transfer and she won't ever match you with a donor who doesn't meet a requirement that you told her was essential.

Penny seems to have a strong belief that matching a donor is more than just physical characteristics - she seems to try very hard to match on her instincts too of what donor child might 'fit' into your family because she believes the baby will be happier.  My feeling is that although the donor will always be anonymous to you and to your child, you probably end up with more (non-identifying) information about the donors that you would receive from a UK donor clinic.

It has never happened with Serum, but in the even that the baby born from egg or sperm donation had a medical condition that meant that knowing their genetic parents might help their health e.g., they were trying to trace genetic family for an organ transplant, there is a provision under Greek law for their Court to overturn the anonymity of the donors. 

In common with all Greek fertility clinics, Penny keeps detailed records on all the donors.  Under Greek law, if a clinic were to close down, these records have to be transferred to another clinic to ensure that they are always preserved.   As an extra precaution, in case there is ever a need for it in future, Penny keeps a DNA sample from each donor on file, which can be made available to the recipient.  So, for example, if later on you needed/wanted to know more about the donor's genetics, you could have the sample analysed (but of course, still not know the donor's name).  This does provide a little extra security for the future in case there is was a medical need to know the donor's genetics but he/she had died or could not be traced.

4.6 What information is available about the donors?
Donation is strictly anonymous and you will be asked to sign a form agreeing that you will never know the donor’s identity.  However, Penny screens all prospective donors personally, looks after scans, stimulation, and holds their hands for egg collections and therefore gets to know the donors well and she also keeps a file on each lady with basic information – height, weight, nationality, hair colour, eye colour, blood group, profession, family medical history, other children.  She can also give you her own impression of the donor from knowing her.  If you are doing a full donor egg cycle, Penny will be able to tell you basic information about your donor at the start of the cycle - but, unless you have more unusual criteria, there will often be more than one possible egg donor at the start of the cycle, and, if that is the case, Penny will usually prefer to delay making the decision on which donor fits you best in terms of matching criteria and timings until the donor reaches her trigger shot day (two days before egg collection).

Most couples have a sit down consult with Penny to discuss the donor either on egg collection day if the male partner is providing fresh sperm or otherwise on embryo transfer day. If you prefer, you can choose not to ask about the donor until you know if your cycle has been successful, but that is your choice.  Ladies/couples who aren't lucky on their first cycle often find that they want to know everything possible about the donor on the first cycle, but by the second cycle, they are so comfortable with Penny they would rather just leave it all up to her and then wait until there is a confirmed pregnancy before asking for information about the donor. 
 
Obviously, to preserve the donor's right to anonimity - you must not post any identifying information about your donor on the net - and if you did decide to leave a card or a gift for the donor (which is a nice thing to do!), you must not include information that identifies you.

4.7 How are the egg donors treated?
From what I've seen during my trips to the clinic, they appear to be looked after well and Penny gets very emotionally attached to the donors (and their kids) and would never want to compromise their health and wellbeing.  Penny feels that egg quality is compromised anyway by being overly aggressive with stimulation drugs, so her approach is always to give the minimum level of drugs to aim for about 8-10 eggs for the recipient, but not more than this.  The donors are treated in the in the same building and given a similar level of care to that of the recipients and the own egg patients.   Most of the donors are comfortable with their first treatment so are happy to return to be egg donors again (but Penny does not like the donors to do more than 4 or 5 cycles in a 2 year period) - and there is a limit under Greek law of 10 babies per country per donor (I don't think siblings count).

Because egg donation is anonymous, you will be unlikely to be in the building at the same time as the donor.   If your partner is arriving at Serum on the donor's egg collection day to give his sperm sample, the clinic will try to ensure a different time so you/he will not bump into the donor, and if you are arriving at Serum just for embryo transfer, the donor will have finished her part of the cycle 2-5 days before your visit.

My understanding is that the donors receive their maximum entitlement under the Greek law - this is compensation for their expenses/lost earnings/travel etc.   The cost of medication for the donor (included in the cost of a donor cycle) is about 1000Eu.  On top of that, the clinic has to pay for staffing etc - and all those costs are covered in the fee that you pay.

4.8 Can I do IUI/DIUI with Serum?
Yes, my understanding is that its possible to do either IUI with your partner's sperm, DIUI with donor sperm or even to combine treatments in the same cycle, e.g, DIUI and Donor egg/Donor sperm or DIUI and donor embryo.   This would mean having an insemination just before ovulation and then having an embryo transfer a few days later and would give you the possibility of becoming pregnant with your own egg (and the inseminated sperm) or with the donor egg/embryo.   You wouldn't be sure until baby is born who is the genetic mother of the baby - and by the time baby arrives you may feel it is not something you need to ever want to know - but if you felt you wanted to be sure, it is very simple and not expensive to test baby using a cheek swab genetic test to compare with your dna and you can do this privately if you want keep the situation confidential.

4.9 Can I do a tandem OE and DE cycle with Serum?
I think doing this might end up being a bit of a compromise in that trying to tie in the exact length of your OE stim with a specific donor's stim could be difficult and could mean that one of you ends up with a less than ideal length of stimulation, or missing the implantation window (the time when your lining is capable of accepting an embryo) - but they do offer tandem.  Also, if you do an own egg cycle and things do not progress well by egg collection day/embryo transfer day, there may well be an unbooked back up donor who is a suitable match for you (depending on your characteristics), so it may be possible to switch to a donor egg cycle at the last minute.  If not, you would hopefully be able to do a donor cycle starting on your next period and that might even work out better as some ladies have a better implantation window if their hormone levels aren't raised as much as can happen during an OE cycle.

4.10 Is there an age limit?
I think its age 50 in Greece (i.e,. you can't have fertility treatment after the female partner is past her 51st birthday).  There isn't an upper limit for own egg treatment (apart from age 50), but Penny will be honest about your chances, so if you have a very low chance of it working due to your age, you will be clear on that before you decide to try.

5  How much does it cost?
For a full egg donation cycle it currently costs 5000E (excluding medication for the recipient (you)).     Because of the extra travel costs to get to Greece it makes sense to try to maximise the chance of success first time.   Penny therefore only uses proven egg donors (ladies who have donated successfully before) for a full egg donation cycle (donors who are not proven are usually cycled first only as backup donors).  This reduces the chance of a cycle needing to be abandoned at the last minute and gives a better pregnancy rate because Penny has experience of the donor's response to stimulation so is better able to use an optimal dose of stimulation meds for that particular donor.

Where there is no immediate recipient for eggs from a backup donor, it is Serum's policy to fertilise the eggs with sperm from their donor bank and freeze the fertlised embryos.  Although, Penny would prefer that the fresh embryos were used immediately rather than frozen as this gives slightly better success rates.  The best quality batches of frozen donor embryos are then made available to recipients who want to use the 'frozen donor embryo adoption programme' and are a suitable physical match to the donors.  Frozen donor embryos (created from backup donor eggs and donor sperm - not surplus embryos from own egg or own sperm cycles) are occasionally available for 2000E for 3 grade 1 blastocysts (the 'frozen donor embryo adoption programme'). 

The lower grade frozen embryos are not wasted, but are made available to couples living locally who can accept the reduced chance of pregnancy per cycle as they don't face the travel costs incurred by international patients.   Due to the economic crisis in Greece, many couples can no longer afford any kind of fertility treatment, so Serum provides a lot of significantly subsidised treatment by way of frozen embryos.  This is very important to Penny personally as she wants to help as many ladies/couples as she can.

The cost for a fresh own egg IVF cycle (including ICSI if required) is 3000Eu (excluding your medication).  Currently, Serum are still doing a 2 cycle package for 4000Eu (with a discount of 1000Eu from a DE cycle if you decide to switch your 2nd cycle to DE).

If you want to freeze any spare embryos, the cost is 1000E (but this includes the follow up frozen transfers - so its effectively a freezing+FET cost of 1000Eu).

If you are using your partner’s sperm it may be more convenient to freeze a sample and leave it at the clinic so that he doesn’t have to be in Athens on egg collection day, particularly if you are doing an egg donor cycle – in which case, neither of you will need to be in Athens until embryo transfer day (usually 5 days after egg collection day). The cost for sperm freezing is 60Eu per vial per year (one ejaculation can give several vials and you need at least 1 per each IVF you do).  If you want to have the DNA fragmentation level of the sperm sample tested its 100Eu.  There is no extra charge for ICSI IMSI, PICSI or assisted hatching (although I don't think Thimmios is a big believer in PICSI).

Intralipid infusions (a treatment for excessive NK activity - see http://www.fertilityfriends.co.uk/forum/index.php?topic=242395.msg3904724#msg3904724) given at the clinic are 100Eu.

LIT is €245 (a treatment for repeat miscarriage, or rare cases of implantation failure - see under LIT here: http://www.fertilityfriends.co.uk/forum/index.php?topic=242395.msg3904727#msg3904727) is 245Eu.

PBMC/white cell uterine infusion is 500Eu (a new, experimental treatment for implantation failure - see http://www.fertilityfriends.co.uk/forum/index.php?topic=242395.msg3904733#msg3904733) - but I don't think they suggest it often because other treatments seem to make more difference.

Mandatory infection screening tests for Syphilis, HIV, Hep B and Hep C are about 110Eu (per partner), but you can often get these free in the UK from your local GUM clinic although there may be a small charge to issue a hard copy of the results.

Penny normally doesn’t charge for consultations with her patients, although if you need tests and procedures, obviously she has to charge for those.

An aquascan with Penny is 200Eu.

A hysteroscopy with one of the surgeons that the clinic recommend at the local private hospital is about 1550Eu.

If you need additional blood tests there will usually be a charge of 30Eu or more depending on the type of test. 

The locus medicus chlamydia menstrual blood test is 100Eu.  Penny is now using a new combination test for Mycoplasma Genitalium, Mycoplasma Hominis, Ureaplasma, Garnerella Vaginalis, Atopobium Vaginae and Chlamydia by a lab called Life Code in Athens.  This lab can test for all 6 bugs by PCR on a menstrual blood sample for only 170Eu, but Penny still prefers to run the separate Chlamydia test at Locus Medicus because they use a different method which appears to detect some positive results that the standard chlamydia test included in Life Code's panel seems to miss.   The Life Code test also measures the total bacterial load of lactobacillae by PCR.  Lactobacillae are normal vaginal bugs ('good bugs') and if the test finds a reduced level of lactobacillae it suggests there is another (undetected) infection like E coli or Proteus which is changing the pH of the vagina and making it more hostile to 'good bugs' like lactobacillae and therefore more vulnerable to 'bad bugs' that cause bacterial vaginosis.

I have put a lot more info about the Locus Medicus test and about chlamydia, mycoplasma and ureaplasma in my immunes FAQ on FF - the link is in my signature.

If you do test positive and want to have the antibiotics posted to you from Greece apparently its about 90Eu if sent by ordinary post (about 6 days) or 170Eu using a courier 2 day service for enough antibiotics to treat you and your partner.   Otherwise, you can arrange to have a prescription sent from Athens which you can use to buy the antibiotics in the UK.

I've done a budgetting spreadsheet which you might like to look at if you want to get an idea of the overall costs including the medication you might need - you can get an idea of what your cycle might cost by just updating the current exchange rate (at the top) and then using the column called 'how many' to include or leave out any costs you think you might have for your treatment.

https://docs.google.com/spreadsheet/ccc?key=0Ah3l-_AvvCXydE5NallOZEhFeWVzSTB6YzhfUnU0dWc

I've just tried to make the spreadsheet easier to use - so if it didn't work before, please try it again now - it should open the spreadsheet fully so that you can use the File menu to find 'download As' so you can download an excel or an open office version.... unfortunately if you use it on the web, it might get broken for whoever wants to use it next, so I'd prefer if you downloaded your own copy to take away.  If you can't download it, please pm me.

5.2 Does ICSI/IMSI/PICSI cost extra?
No, if Thimmios feels you have you a better chance with it, its included.  He will try to use his (vast) experience to select the best sperm for ICSI using IMSI and or PICSI if appropriate and if he thinks some of the eggs have a better chance of being fertilised with IVF, he may want to fertilise part of a batch with ICSI and part with IVF.

5.3 Do they do PICSI, IMSI or assisted hatching?
Yes.  There is no extra charge for this.

5.4 Do they do PGD?
Yes, but usually only for proven, serious, genetic medical conditions. Not for sex selection - that is illegal in Greece.  It costs €350 per embryo and is done on day 2-3 for ET on day 5.

6.1   How to arrange a consult
Its easy to have an initial consultation by phone with Serum after sending your medical history questionnaire by email.  You arrange a time and Penny emails you her phone number and you call her at home (or in the clinic) when arranged. You can use a telephone consult to decide whether you need to travel to Athens for a consult/tests before you cycle or whether you can just book your cycle.  Penny doesn’t charge for initial consultations.

http://www.serum-ivf.com/ (info about consults including an initial information form for you to fill in and email back)

Serum are trying out a snazzy new website www.ivfserum.com

serum@otenet.gr (serum reception - Maria normally deals with prescriptions, Vassou deals with LIT, both of them deal with most other admin or billing queries)

info@serum-ivf.com; (all initial queries - info@ivfserum.com goes to the same place!)

If you travel to Athens for a consult, Penny will always take the opportunity to have a look at your uterus using an ultrasound scan.  If she needs a more detailed look, she will use saline contrast (aquascan – usually 200E).  If the aquascan suggests a problem (or if your medical history suggests it), she will recommend a hysteroscopy to be carried out by one of the surgeons at the local private hospitals.   Hysteroscopy can normally be arranged at short notice (e.g., next day) and for a fixed price because they are doing them every day except sunday with Serum's surgeons over at the Yaia hospital.

6.2.   How to do the infection tests on menstrual blood?
Penny has seen many cases where treatment with antibiotics has resulted in pregnancy very quickly despite many years of infertility, miscarriages or IVF failures.   Most doctors seem to regard  infections of the male or female genital tract only as a problem if it causes blockage of the fallopian tubes or overt symptoms (fever, pain, discharge etc), but there is growing evidence that inflammation caused by infections can cause damage to sperm as well as a uterine lining that is not hospitable for an embryo.

She started using a novel test for chlamydia in menstrual fluid (the blood, mucus and tissue that is shed during a period), run by Locus Medicus lab in Athens and had a lot of success in improving pregnancy rates after giving antibiotics where a positive test result was detected.   She has recently added a panel of tests run by Life Code lab in Athens costing 170Eu.  This panel includes ureaplasmas, 2 species of mycoplasmas, and two other bacterial vaginosis species (Gardnerella vaginalis and Atopobium vaginae as well as an 'ordinary' test for Chlamydia and a test of total bacterial load which measures whether there is a normal population level of 'good bugs' (lactobacillae).   She feels that this extra panel of tests is very good value for money as it seems to detect other problematic infections, rather than just Chlamydia (and it is cheaper than having just the 2 tests for mycoplasma and ureaplasmas done by Locus Medicus (100eu each).

The tests can easily be done by sending a sample of menstrual fluid collected at home to Athens.   You need a small, sterile urine bottle (available from most pharmacies) and a few drops of sterile saline (e.g., contact lens saline - also available from pharmacies).   Its easiest to collect the sample when your period is in full flow e.g, day 2. If there is plenty of flow, then its probably easiest to wait until you've been lying down for a while, then hold the sample bottle up to the vagina when you get up.   Otherwise, some ladies find using a boiled teaspoon to collect the blood is easier.   If the flow is very skimpy, then wearing a boiled mooncup (from Boots) overnight can help to collect a sample - or even wearing a light flow tampon overnight and then squeezing a sample out into the bottle the next morning is possible.   

Only a small amount of blood is needed - enough that you can shake it down to the bottom of the bottle to mix with the saline and turn the saline pink/red.   The purpose of the saline is just to keep the sample liquid until the lab receive it. 

Screw the cap on tightly, ensure your name and date of birth is labelled on the bottle, wrap  in tinfoil, then bubble wrap.  Ensure you add a covering letter giving your contact details, email, name, date of birth etc and specify which tests you need to do (e.g., the Locus Medicus Chlamydia test and the Life Code test for Chlamydia, Ureaplasma, Mycoplasmas and total bacterial load) and then post it back to Serum.   If you are doing both tests, you only need to send one sample as the staff at serum will split the sample for you providing you make it clear in your letter that you want both tests.  Some ladies do prefer to prepare 2 samples and keep one in the fridge back home just in case the first one gets lost in the post. 

Its fairly cheap to use the Royal Mail tracked post - but if you prefer to use a courier service, several ladies have recommended City Sprint who are happy to deal with blood samples but they are much more expensive for pick up outside of London/South East.   

You need to contact the Serum reception staff by email to arrange payment, preferably by bank transfer or by paypal.  Once the results have been received, Serum will send you a copy by email and then you need to contact Penny if the results are positive to find out what antibiotics she recommends.  Then if you need a prescription, Maria can arrange it once you know what you need.

If you are going to be travelling to Athens for hysteroscopy, a blood sample can easily be obtained for the test as you will have some bleeding after the hysteroscopy.

If you do not have natural periods, you should be able to generate a bleed by taking 21 days of cyclacur (cyclo-progynova in the UK).   You should start to bleed 3-5 days after the last pill in the packet.  You may be able to get a prescription for cyclo-progynova from your GP, or otherwise Serum can post you the pills or a prescription to use in the UK.

7.   How long does it take to get started?
Its often very quick.  If you are ready to get started and Penny can squeeze you in for a telephone consult that week, you’d be ready to book your hysteroscopy or aquascan (if needed) for just after your next period – hysteroscopy is best done after your period finishes but before ovulation.  If you don’t need a hysteroscopy, you might be ready to start on your next cycle, depending on whether you are doing own egg, or donor and whether a matching donor is already waiting to start.   Depending on your donor requirements, a donor may well be available for you for your next period. 

Penny has a very positive approach and she has had a lot of success treating ladies who have failed IVF treatments elsewhere, by treating more gently and monitoring more closely, so unless you are already settled on donor egg treatment, she may recommend having one more try with OE to see if she can help you with that before deciding whether to continue with OE or move on to donor - I've seen many ladies report that their Serum OE cycle was much better in terms of egg quality/response etc than they'd managed at other clinics, but as a lot of us do come to Serum quite late in our IVF journeys sometimes even a much better cycle than before still isn't quite good enough - but Penny will work with you whatever you decide.   Obviously, for most infertility patients over 35, the chance of pregnancy with donor eggs is always higher than with own eggs so if you are sure you want to move on to donor egg, even though Penny thinks you still have a chance with your own eggs, you need to make that clear and she will try to accommodate you.   Sometimes, having one last, careful try with OE makes it easier to accept moving on to donor eggs.   If you feel that donor eggs are not for you, then Penny will keep trying with you, for as many cycles as you want to, as long as there is at least some activity in your ovaries.

8.1   Having hysteroscopy in Athens
Hysteroscopies are normally scheduled either at the Mitera hospital http://www.mitera.gr/Default.asp?langID=2 6 Erythrou Stavrou Street,Marousi GR-151 23,Athens,  Leto hospital (http://www.leto.gr/default.aspx, 7-13 Mouson Str., Athens), the REA (PEA) http://en.reamaternity.gr/ 383, Siggrou Ave. & 17, Pentelis 17564 Palaio Faliro, Athens, Greece (or the Yaia maternity department of the Iatriko Kentro Athena (Central Hospital of Athens) on Distomou 5-7 , Marousi.  http://www.iatriko.gr/en/gaia)

please note that the Yaia relocated in 2013 to the Iatriko Kentro Athena (Central Athens Medical centre) which is on Distomo street near the Kifsias bus stop (a taxi ride or a bus ride (route 550 from the stop called Ippokrateio near Serum on Leoforos Kifisias to the stop Vlastou)- Its too far to walk from Serum and not particularly near to a convenient metro station unless you catch the metro to Neratziotissa (but that means going all the way into the centre of Athens to Monastakiri and then changing onto the green line 1 because the metro station for serum (Ambelokipoi or Megarro Mousikkis) is on the blue line 3 and you have to go into the centre of Athens to change lines.  Please note that that not all the taxi drivers know the location of the new hospital so make very sure that they know they are going to the Iatriko Kentro Athena in Marousi - its actually very easy to find from Ambelokipoi, just straight up North on Leoforas Kiffisias, but for some reason, the new location is confusing the taxi drivers and they keep going to locations in the South of the city rather than the North

If you are going to any of the hospitals straight from the airport - taxi is the easiest option, although the Leto is just about walkable from the metro/X95 bus route.

(My google map: http://maps.google.com/maps/ms?ie=UTF&msa=0&msid=216291340940802168436.0004bfd72e971a5fd1675)

You can walk to the Leto from the vicinity of Serum but its a a relatively long walk - so you might want to get a taxi.  Most ladies do get a taxi back to Serum afterwards because they are tired.   Walking from the new Yaia at the Iatriko Kento Athinon is just too far!

Hysteroscopies are normally scheduled for just after your period has finished so that the lining is thin and there isn’t too much debris from your period - its not possible to do hysteroscopy if you have your period (because the view is obscured) or if you might be pregnant (because the baby might be harmed).  If your cycles are irregular or fall at an inconvenient time, you may want use the pill (e.g., microgynon 30, marvelon, yasmin - started on about day 3 of your cycle) to keep your lining thin until the hysteroscopy, or to fix the timing of your period. But, bear in mind if you want to check your ovarian activity on a scan whilst you are at serum, the pill can give you a false result by partially suppressing your ovaries and it doesn't let Penny see your natural lining. You can get the pill for free from your GP (for contraception purposes) or can get it fairly cheaply from a UK pharmacy using a private prescription posted from Serum or emailed to Rigcharm pharmacy - if you are paying for the pill, bear in mind that something like microgynon 30 is much cheaper (about £3 for 3 x 21 pills) than yasmin.  You will need a medical review at the hospital before the surgery which means filling in some forms, some blood and urine tests and an ECG (heart monitoring).  This takes at least an hour so is often done at the hospital the day before, particularly if your hysteroscopy is scheduled to be done at the Yaia.  You need to show your passport when you fill out the forms. Serum can sometimes send one of their staff to the hospital with you to help you with filling out the forms etc.   You may have to wait for the blood tests to be cleared by phone before you can leave in case they need to draw any more blood so you will want to take a book to read.

You will be asked to fast (no food or drink or water) from midnight the night before your hysteroscopy. You need to remove contact lenses, make up, jewellery and nail polish and to bring some sanitary towels with you.  Its best to leave your valuables at the hotel but you will need your passport to confirm your identity.  You will want to bring a snack to eat afterwards and if you are staying at a hotel, you might want to ask if they can make you a packed breakfast if you have paid for breakfast included.   The surgery will normally take less than 30 minutes but there can be quite a bit of waiting around (emergency surgeries may need to be carried out first) and recovery time.

When you come round in the recovery room, you will be asked to stay lying down until the nurses are happy for you to get up.   If you are thirsty, they may let you initially have only tiny squirts or sips of water until they are sure you are safe to have a proper drink.

The hospital staff are very efficient and it can feel a bit brusque e.g., as soon as you get to the operating theatre, one nurse will quickly put your feet up in stirrups at the same time as someone else is giving you the anaesthetic and someone else is taping down your eyelids.    When you are recovering, if they want to check you are not bleeding heavily, they will lift up your gown to check without much preamble and not explain what they doing- and they don't seem to be that concerned with making sure you are covered up e.g., for listening to your heart.   It seemed to me to be more a culture where visitors are excluded so that the surgical areas only had patients and staff and therefore, covering you up, wasn't seen as important.     Your partner or anyone else accompanying you will have to wait in the waiting area until you are ready to go back to the waiting area.

You have to pay the hospital fee (about 550E) by card/cash to the hospital before you leave.   The surgeon’s fee (about 1000E) needs to be paid to serum in cash because this fee gets paid to the surgeon and cannot go through the clinic's books - Serum do not get any fee themselves for arranging the hysteroscopy.  If you are not comfortable with carrying cash from the UK, you can arrange to draw it out from the ATM machines near the clinic (e.g, near the Athens Tower), or if you really don't want to pay cash, you could talk to Serum about making a bank transfer to Serum but I understand this would have to be at least 1 week in advance of your visit and would cost an extra 50Eu on top because of the added complexity for Serum.

After you have recovered you will normally get a taxi back to Serum – its easy to hail a taxi from the main street just outside the hospital – so you can have a chat with Penny about the findings from the hysteroscopy.  The surgeon will normally provide a short video of the hysteroscopy on a DVD which you can view on Penny’s TV. If you haven’t had the locus medicus menstrual blood test for Chlamydia or the Life Code test for 6 'bugs', Penny can take a cervical blood sample when you get there as you will have some bleeding following the hysteroscopy.   The results of the locus test are normally back within 1 or 2 days and will be emailed to you.

Penny will usually prescribe some cyclacur (HRT) and antibiotics after the hysteroscopy and will discuss with you whether you need to take just the white tablets or the white tablets and then the brown tablets (usually you take the white tablets then the brown tablets but stop the tablets if your period arrives whilst you are taking the brown ones.  If your period arrives when you are taking the white tablets, you normally stop the tablets for 4 days and then resume them) and whether you need any ‘resting’ cycles on cyclacur before you can do your next fertility treatment (depending on the findings from hysteroscopy).   Whether your period will arrive at about the normal time or will be late will depend where you were in your cycle when you had your hysteroscopy and started the cyclacur.   If you start cyclacur at the beginning of your cycle, it normally stops your ovulation, so you will get your period 3-7 days after finishing the packet.  If you start cyclacur after ovulation your period should arrive at its normal time.  Sometimes if you start cyclacur a few days before ovulation it will delay your period by up to 2 weeks. Penny will usually also prescribe some antibiotics or suggest you buy some antibiotics to take back with you to the UK just in case the locus test suggests you need them.    If you are intending to cycle soon, you might want to take the opportunity to buy the medication you will need for your fertility treatment to take it back with you - especially if you need avekap 0.1mg for an OE cycle because you can't buy that in the UK.

8.2   If I have an aquascan and its abnormal can I have a hysteroscopy the same day?
Probably not because you do need to fast (no food or water) before the general anaesthetic and you do need serum to be able to get you a surgical slot and a doc and they keep morning slots at the hospital.

8.3   Can I have hysteroscopy at any time of the month?
The ideal time to go is just after your period finishes - so the lining is thin but you don't have any bleeding obscuring the 'view'.   A thin lining makes the surgery easier especially if you end up needing to have something complex done like fibroid removal.  So although technically it may be possible to have hysteroscopy at any time of the month (provided they are sure they can't possibly be pregnant), it is best to go when your lining is thin, just in case you unexpectedly need a more complex surgery (but its usually not essential). You can't have hysteroscopy after ovulation if there is a chance you might be pregnant.     If you need to book flights etc and your periods are not predictable, you can ask Penny if you can use the pill to fix the timing of a bleed, or to prevent the lining thickening up (and hold off a bleed).  You normally need to start the pill (a low dose combined pill like marvelon or microgynon) on about day 3 of your natural period, but can then take it for between 3-6 weeks (usually) if that helps your timing - a bleed will normally start on day 3-5 after stopping the pill. In the UK you can get the pill for free from your GP - although technically its only available free on the NHS if its for contraception.   You can get a private prescription from Serum and use that to buy it from any pharmacy.

8.4   Why am I being advised to try naturally after hysteroscopy?
Where the hysteroscopy or infection testing reveals a problem that can be addressed (e.g., adhesions in the uterus that are cut away), Penny often advises couples to try naturally for at least 2 cycles - just in case the main barrier to infertility has just been fixed.   This may seem like an unnecessary delay, especially if you have been trying to conceive for many years, but she very often does see spontaneous pregnancies after hysterscopy/antibiotics.   Its likely that if hysteroscopy has dealt with a problem, pregnancy will result quickly, so its worth just trying for 2 or 3 cycles just in case you no longer need IVF.  Experience shows that, in these circumstances, natural conception is likely to happen quickly or not at all, so only 2 or 3 months is justified before continuing with IVF.

9.   How to get to the clinic from Athens airport

TIP: before you leave the airport visit the information stand and pick up a free map of Athens.

You have several choices:

- a few ladies have recommended taxi drivers called Stavros on (0030) 6970 414771 or Michael Sterianos, Taxi Tours Athens (+30) 210.93. 42 222 • Mobile (+30) 6937 221 142
www.athenstaxitour.com, michael@greecetaxitravel.com

- You can arrange a pre-booked airport transfer with one of many firms who advertise on the internet

- You can pick up a taxi from the taxi stand at the airport.  This costs about 35Eu during the day but more at night.  Ask for an electronic taxi receipt to avoid being ripped off.  The official fare is fixed by the government and is set out on the airport's official website.

-   You can catch the metro from the airport to either Megaro Moussikis or Ambelokipoi and walk from there (this is currently 8Eu each way – but if you are travelling with someone else, its cheaper to buy a group ticket).   When you arrive at the airport, you go through passport control, pickup any luggage, go out through customs and then follow the signs for ‘trains’.  That takes you outside, across the road and then you need to go up lift/escalator/stairs to the floor above, then keep following the signs to the trains along a moving walkway.  After the end of the moving walkway you get to a sort of atrium which has a shop, cafe, ticket booths and ticket machines.  You can buy tickets from the machines if you have change/small notes or buy from the ticket booths if you only have large notes.  After you have bought your ticket, you need to punch it (datestamp) in the machines in front of the stairs down to the trains.   Then you go down the stairs (or use the lift) down to the trains.  The airport is the last station on the line, so all the metro trains leaving the airport are heading back to Athens - you just need to board the train that has its doors open.   There are luggage racks, but the security officers on the trains and stations prefer you to keep bags and suitcases right next to you at all times. The train runs overground initially and then goes underground when it gets nearer to Athens.   The journey takes about 35 minutes and there are usually two trains every hour – trains don’t run at night though.   You can find the timetables on www.amel.gr.  The trains have bilingual maps inside and bilingual announcements so you will easily be able to navigate.  The same metro line runs down past Ambelokipoi and Megaro Moussikis (the clinic is in between those stations), through to Syntagma (the centre of Athens).   Be very wary of distraction pickpockets on the metro and in the metro stations.

-   You can catch the X95 bus from the bus stop at the airport.   Follow the signs for buses and then you will find the ticket booth near the bus stop.  Buses run 24 hours a day but during the night the ticket booth will be closed until just before the bus is due to leave so you need to queue at the closed booth and wait for someone to come to sell the tickets just before the bus leaves. The price is about 5Eu each way. The Athens Tower or Ippokrates hospital is a good landmark for where you need to get off if you are going straight to the clinic.  The X95 runs down Mesogeion and onto Vassilas Sofias - so ask for the stop called 061040. PL.AMPELOKIPON. (Platia Ambelokipon: ΠΛ.ΑΜΠΕΛΟΚΗΠΩΝ‎) on the Street: LEOF.VAS.SOFIAS on your journey to Serum or the next stop: 060673 PL.MAVILI (ΠΛ.ΜΑΒΙΛΗ‎. platia Mavili, Mavili Square - in front of the Athinais Hotel) on the Street: LEOF.VAS.SOFIAS.

Do not be afraid to ask the driver or other passengers to let you know when its your stop - you can print off the names of stop in Greek if that helps.  After Platia Mavili the bus continues into central Athens (Syntagma square).  You can find bus timetables on www.oasa.gr - look for the union jack icon to see the page in English and then use the search function to show the x95 timetable.  The bus runs more frequently than the metro and I like it because the stop is nearer to the clinic than the metro station.

For the return journey to the airport by bus X95, the stops on the opposite side of the road are Stop Code: 061025, Stop Name:PL.MAVILI (ΠΛ.ΜΑΒΙΛΗ‎, platia Mavili, Mavili square - opposite the Athinais hotel) on the Street: LEOF.VAS.SOFIAS.  Or Stop Code: 060677. Stop Name:GALAXIAS (ΓΑΛΑΞΙΑΣ‎) on the Street: MESOGEION (go out of the clinic, turn right and walk to the top of Evinou, turn left onto Sinopis, past New York Sandwiches, at the end of Sinopsis, turn right onto Mesogeion and the stop is almost opposite National Bank near to the pharmacy.)  For the return trip, you can buy tickets on the bus.

(once you have reached central athens and are travelling by metro or bus, bear in mind that, metro, bus and tram tickets are interchangeable and you can buy them in advance (you can also buy airport metro tickets in advance too but they cost more).  You can buy tickets from booths and machines in metro stations and at the airport, and from machines at tram stops.   Some kiosks of the kind that sell drinks/snacks/newspapers etc also sell tickets (but they don't seem to be reliable in always having tickets, so if you know you will need a ticket later, its best to buy one in advance).  Once you have bought tickets you just need to validate them using the punch machines just before you hop on a metro train/tram or just inside the the bus).

The clinic is at number 8, Evinou, 11527 Athens  (11527 is the greek postal district).  The road is parallel to Evrou.  At the Southern end (which has the new cafe on the other corner called Expressaki), there is no road sign to tell you that you have found the right road, but there is a road sign at the Northern end of Evinou (which has the Epoca café on one corner and To Sagura (a souvlaki restaurant with big glass windows) on the other corner.  (see my map on google: http://maps.google.com/maps/ms?ie=UTF&msa=0&msid=216291340940802168436.0004afd491cb0e8b6162d)

Whilst you are in Athens, if you have a smartphone (android/iphone) with data roaming and GPS switched on you may want to use an app called taxibeat (www.taxibeat.com) to help you call a taxi - it doesn't cost any extra, it should protect you from being overcharged and help with your safety as the trip is centrally logged and you can choose a taxi driver who speaks english and has had good reviews.  You can see the location of nearby registered available taxis on a map and you won't risk hailing an unregistered driver.

10.1   Where to stay

The main 3 hotels nearest the clinic are: the President (http://www.president.gr/default.asp?langid=2) - which has an outdoor pool, The Athinais (http://www.athinaishotel.gr/en/athinais/default.htm) and The Airotel Alexandros (http://www.airotel.gr/index.asp?a_id=176]http://www.airotel.gr/index.asp?a_id=176]http://www.airotel.gr/index.asp?a_id=176).  Of those three, I like the Alex best because it has kettles in the rooms (the Athinais and President don’t have kettles- but apparently you can get a kettle at the President on request and a thermos flask at the Athinais).  I liked the breakfast at the Alex slightly more than the breakfast at the Athinais and some ladies have said that they don’t like the breakfast at the President but I haven’t stayed there myself.  Prices start from about 60Eu in winter but go up a lot in spring and summer.    Other ladies have recommended Holiday Suites (with a pool).  The Statos Vasilikos is the sister hotel to the Alexandros and can be more expensive during the summer months because its a 5 star rather than a 4 star but Serum reception can usually book it for you for €60-70 (winter vs summer).

Hotels fairly near the clinic (still within walking distance) include the Elizabeth
(http://www.hotel-elizabeth.gr/index.php?language=en&sess=43gi7gdgtjcoqkobn7p4e1esr3), The Golden Age (http://www.goldenage.gr/index.php?lang=en), The Art Suites (http://www.artsuitesathens.gr/default.asp), the Airotel Stratos Vasilikos (http://www.airotel.gr/index.asp?a_id=175 - this is the sister hotel to the Alexandros and is very similar to the Alexandros), the Best Western Embassy Hotel (http://www.embassyhotel.gr/ - another lady stayed there in November 2011 and liked it) and Family Inn (www.familyinn.gr) but I haven't tried them.     All hotels provide towels, bedding etc - most provide small in room safes for your passport etc. 

I have used expedia.co.uk, britishairways.com , lastminute.com and booking.com for hotel bookings - I tend to use booking.com but apparently trivago.co.uk is good for price comparisons.

The Athinais seemed to be cheaper if you booked direct by email than using the online engines and they had availability even when none was showing on the internet. 

(see my map on google: http://maps.google.com/maps/ms?ie=UTF&msa=0&msid=216291340940802168436.0004afd491cb0e8b6162d)

A little further from the clinic there are some very smart hotels in the Kolonaki area (Evangelismos metro station) e.g., the Hilton.  Sometimes these hotels do come up at bargain prices on Expedia, last minute.com etc, sometimes with a hotel/flight combination.

One patient recommended the hotel Proteas to me as being clean, cheap and in a safe area - a bit further than Athinais etc, but still walk-able, cheaper than the 4star hotels and with reasonable wife (no fridge or kettle in room though) http://www.proteashotel.com/location.php.  Nearby to hotel Protea, there is also the Zafolia - about 15mins walk from Serum with an outdoor pool - which was recommended by another FF. http://www.zafoliahotel.gr/

If you are staying for more than a couple of nights, you might want to look for a cheaper option.  Hotels near Ommonia or the area north of there, e.g., around Larissa train station, Metaxorgio, Exarchea can be very cheap (even 28Eu per night) but the area isn’t nice especially at night (think hookers, druggies etc) - there are even backpacker hostels for 15Eu per night or room stays for 7Eu per night.   

There are some nice hotels in Plaka and near Syntagma which is a good base to stay if you want to do sightseeing (and about 3 or 4 metro stops from the clinic) but if there is any likelihood of civil disruption its nicer to stay nearer to the clinic as trouble always centres on Syntagma because of its proximity to the Parliament building.

Apartments are a good option if you are staying for more than a couple of nights.   Penny has a 2 very nice and well equipped 1 bedroom apartments right next door to the clinic which she lets out for 70Eu per night, and her son has another one above the Expressaki cafe at the end of Evinou. The apartments have everything you might need - washer/dryer, shower, microwave, hob, toastie maker etc and a separate bedroom - with tvs in both rooms and a dvd player and dvds. Websites like www.wimdu.com and www.only-apartments.com, www.athensstudios.com have a good selection starting from about 40Eu per night for studios or 7Eu upwards for rosoms.   Look for apartments (or even just rooms) in Ambelokipoi, Megaro Moussikis, or Kolonaki if you want to be near the clinic.

I've stayed in the studio listed as Artemi's nest on only-apartments - it is on Kerasountos Street near to Megara Moussikis metro station.  It's a basic studio apartment in a quiet building on a quiet street with poor wifi, but the owner is helpful and reliable and she has several (large) apartments available in the same building.  If you want to book with her - you might want to contact Vasileia direct on lilikapapag@gmail.com to see if she will let you book direct - that way, you wouldn't incur the booking charge levied by only-apartments.

I also stayed in the studio listed as Luxious studio (not my typo!)only-apartments - it is on Arkadias Street near to the President hotel.  The furniture and decor were a bit nicer than Artemi's nest, the wifi a bit better (got very slow in the evenings though) and the owner was extremely helpful.  He also has several larger apartments in the same building - "loveable experience apartments" http://athensfurnishedapartments.gr/Contact-Information.php. If you want to book direct to avoid the booking charge, he is happy to do that.  Contact George (manos) on yourhomeaway@windowslive.com.

I would say that all 3 apartments I've stayed in are suitable for a toddler.   Penny's apartments are the most luxurious (although they contain more breakable objects!)

One lady has recommended a nice looking 2 bed apartment with balconies on Av Tsoha (easy walk to serum) http://www.fertilityfriends.co.uk/forum/index.php?topic=153595.msg5095446#msg5095446  contact John and Thalia on th.vassiliou@hotmail.com - but they don't let to families.

If you want to stay by the seaside, try the Glyfada (or maybe Voula) area (but bear in mind it’d be quite a long journey (taxi or tram/metro/bus) to the clinic so you probably wouldn't want to stay that far away if you need to be in the clinic most days.

When deciding whether to splash out on a hotel with a pool during the summer months, bear in mind that after you've done hysteroscopy, egg collection or embryo transfer, swimming will probably be off-limits, and sunbathing will be off-limits if you are taking doxycycline or prixina antibiotics.  If you want to use the pool for the day, the President allow non-residents to use the pool for €20 and the Hilton for €30.  Otherwise, Athenians tend to get a tram or taxi to the beach to go swimming.

If you want to tag on a few days holiday to your trip, you could think about staying on one of the nearby islands.  Agistiri Island is very quiet and only a short ferry ride from Athens.   You take the metro to Piraeus (the port) and then a ferry (www.hellenicseaways.gr/index.asp?a_id=209)  (or flying dolphin www.aegeanflyingdolphins.gr/index.php?lang=en) over to Agistiri.  There are at least 2 or 3 sailings every day and the sailing takes between 40-90 minutes.   There are lots of places to stay, but Rosies Little Village (http://www.rosyslittlevillage.com/) is nice.

10.2   How to get to Athens from the UK

From the UK, most ladies fly Easyjet direct from Manchester or Gatwick, or BA, BMI (if available) or Aegean from Heathrow. 

From Aberdeen, Edinburgh or Glasgow, I think you'd probably choose Easyjet from Edinburgh or KLM with a stopover in Amsterdam, BA with a stopover at Gatwick, Olympic with a stopover in Amsterdam or Air France with a stopover at Charles De Gaulle.  From Newcastle there are KLM flights via Amsterdam and BA flights via Heathrow.  But there are other options, e.g., Swissair flights via Amsterdam from Manchester, or seats on summer charter flights run by the package tour operators (although these rarely go to Athens).   

For Easyjet, its easiest to go direct to the easyjet.co.uk website.  For other airlines, skyscanner.net, travelsupermarket.com (which includes seats on package charters) or kayak.com can help find the best prices (and track down what flights are available) and may undercut the airlines' own sites - but be aware when looking at these sites that the final price can be very different to the price initially quoted, you need to click all the way through as you are going to actually book to check the real price.

Its impossible for me to quote typical prices as all the airlines use dynamic pricing models - they price based on actual and forecast demand, the number of seats left and how long before flying.   Seat prices can go up as it gets closer to the flight day but then come down again if demand is not as high as the airline forecast or if they have a lot of cancellations.   In general, prices are highest during peak holiday season - May-September - but also reach peaks for christmas and UK - because of competition, prices flying from Gatwick or Heathrow are often cheaper than flying from other airports. 

In the unlikely event that flights to Athens are impossible on the day you need to travel, it may be possible to fly to another Greek airport and then get a connecting flight or a ferry (although any ferry journey would probably be a long one) - but its usually possible to find indirect flights via somewhere like Amsterdam if you have to.

If you do not know which day your treatment will be finished e.g, because you are doing an OE cycle and expecting to be in Athens for more than a week, you will probably want to book a one way ticket and then sort out your return flight when you know when your ET will be - buying a flexible return ticket is also a possibility but this costs extra, and if you want to change the return flight, if the seat is more expensive you will still usually have to pay.   There are so many hotel options in Athens that you will be able to find accommodation for an extra night or two if you need to - so don't worry about accommodation too much.

In the (hopefully) unlikely event that your prebooked flight home is cancelled e.g., due to a strike - your airline has a legal responsibility to provide vouchers for meals/accommodation and to let you rebook on the soonest flight that has availability. 

http://www.moneysavingexpert.com/travel/flight-delays has more information on your rights.

Booking your flights (and accommodation) by visa debit or by credit card has slightly more protection in the event that the airline or booking agency goes bust, but most airlines charge an extra fee for paying by credit card.   In the UK, fees for booking by credit/debit card are supposed to be being abolished, but not until the end of 2012.   

This post contains an unconfirmed link/information and readers are reminded that FertilityFriends.co.uk or its owners are not responsible for the content of external internet sites

Offline agate

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Re: Agate's file of serum stuff - part 3
« Reply #2 on: 26/10/11, 14:25 »
11.   Buying medication in Greece and in the UK

In the UK, pharmacies can add whatever mark up they want to the manufacturer’s cost price, but Superdrug have advertised that they will not charge any mark up on private prescriptions, and Asda have advertised that they will not charge any mark up on private fertility prescriptions.     

Home supply pharmacies like Central Homecare can still sometimes undercut Superdrug and Asda because prescriptions delivered mail order are not VAT-able, whereas VAT has to be charged on prescriptions bought from a physical pharmacy like Superdrug or Asda.   Accordingly, to find out the cost of meds from a UK pharmacy, you will need to phone around and check.   

Sometimes there are shortages of medication in the UK and in Greece, particularly of OE stimulation drugs like puregon and menopur, but also of drugs like gestone.   Therefore, when shopping around for drugs, its worth double checking that a pharmacy can actually supply the drugs they are quoting for as sometimes they quote a price but then only realise a few days later that they can’t actually source a drug which can be frustrating.

In Greece, apparently, the costs of drugs used to be set centrally every month so the price charged would be exactly the same whether you walk in to any pharmacy or buy from Serum - but the medication situation in Greece is in flux so the prices of meds are very volatile and can change significantly over just a few days.  You don’t need a prescription to buy medication from a Greek pharmacy – you just buy what you need – although you do need to know what names the medication is sold under as the same drugs have different names in different countries - I've tried to put the names used in Greece in green, below.   If the pharmacy doesn't have enough packets of whatever drug you need - they can normally get it the next day, or you can walk to the next pharmacy.  The prices of some of the drugs (the expensive ones like puregon) have varied in Greece by more than 25% from one month to another, so Penny suggested that ladies doing OE might want to check the price with a Greek pharmacy before they decide where to buy that month.  Serum keep a stock of the commonly used meds from a local pharmacy to make it easier for ladies, but they don't make a mark up on meds - they just pass the payment on to the pharmacy, so you will normally need to pay cash for meds from serum as these need to go through the pharmacy's books and not through serum.

At the moment, shortages of all medicines is possible in both Greece and the UK, so you may want to buy medications wherever they are available, in case you cannot get hold of them later

Your options for getting the medication you need are:

-   buy your drugs from Serum or from any Greek pharmacy whilst you are in Athens
-   have drugs posted to you from a Greek pharmacy (or via Serum)
-   ask for an email prescription which you can send to Rigcharm in London (Yasser Latif at Rigcharm pharmacy yasserlatif4@hotmail.com  alischemist@yahoo.co.uk 0207 790 9150)
or Fazeley/fertiilty2u in Derbyshire http://www.fertility2u.com/ 0182 781 8321 or 01827 262488 or Central Homecare 01420 543400 for postal delivery (you will need to email the script to them and then follow up with a phone call to pay for your medication by credit card.   Serum will follow up by posting the original scripts a few days later.)
-   ask for a hard copy prescription to bring back or to post back to you from Serum - some pharmacies may agree to accept an email prescription in an emergency provided you can satisfy them that you will get the hard copy forwarded to them quickly.   UK pharmacies are required under EU law to accept scripts from anywhere in the EU provided it properly identifies you (full name, address, DOB), it properly identifies and gives the contact details of the doctor and their registration (so that the pharmacist can be satisfied they are a doctor), it properly identifies the drug, the dose and how it needs to be taken. They are not required to accept email or fax prescriptions though.  In practice, some pharmacies may be difficult and may insist on speaking to someone from Serum the first time they get a script from Serum - but I've used a couple of branches of ASDA and they've been helpful.
-   Your GP might agree to dispense the drugs to you either on a UK private prescription or possibly an NHS prescription – particularly once you are pregnant (in which case they are free once you have got your NHS maternity exemption certificate).

If you are an on own egg programme that includes avekap/decapeptyl/triptorelin 0.1mg (not the 3.75mg or 11.25mg doses for donor egg protocols) buy enough of it in Greece because it is not available in the UK at that dose and it is expensive to have it couriered from Greece.

The drugs commonly used are:

valtrex/valaciclovir (an anti-viral drug) 500mg 112E for 42 tabs (ladies who use this tend to take it twice a day from the start of stimulation/estrogen until OTD - or more often just for 10 days - not all ladies take this, but a lot do) - UK COST ex VAT price £86.30.  In the UK, Valaciclovir tends to be slightly cheaper than branded valtrex so ask for a prescription for valaciclovir (the generic drug) rather than valtrex.

doxycycline/vibramycin, miraclin (an antibiotic) 100mg 2E for 8 capsules (again tends to be twice a day the start of stimulation/estrogen until OTD) - not all ladies take this, but those needing antibiotics for previous chlamydia infection do) - UK COST  ex VAT price £1.30.  This can upset your stomach and gut if you are sensitive - some ladies need to take omeprazole 20mg (you may want to get a prescription for this too in case you are affected) half an hour before this in the morning to avoid feeling sick.   To buy the 20mg dose of omeprazole in the UK, you will need a prescription.  In an emergency, any over the counter proton pump inhibitor will do e.g., panteprazole, ranitidine, zantac, omeprazole 5mg.  Taking doxy with milk can reduce heartburn but it also reduces how much of the active drug you can absorb so its best if you can try to avoid milk/yoghurt/cheese and also calcium/aluminium/magnesium based ant-acids and try to take your multivits and folic acid at lunch time.  To reduce the chance of feeling sick - take with a big glass of water after a substantial meal e.g., for your morning dose you probably want to have a bowl of porridge (made with water, ideally) or 2 pieces of toast (its ok to have butter) before you take your doxy.   For your evening dose, take it just after supper. Don't lie down for at least 30 minutes because it can result in very unpleasant heartburn. Many women get very sun sensitive on doxycycline and burn very easily even when using suncream.

Azithromycin/zithromax (an antibiotic) 250mg 15E for 6 tabs - (not all ladies take these - but those needing antibiotics for previous chlamydia infection do) tend to take 4 tabs (all together) on 2 separate days during your treatment plan, then when you get your bfp you take 2 tabs a day for 5 days, then break for 5 days and repeat until 8 weeks pg (so 3 sets of 5 days) - UK COST price  ex VAT £14.46 - this is another med that can upset your stomach.   Take on an empty stomach with a glass of water and consider taking omeprazole 10mg first especially if you are planning to take it in the daytime.   Some ladies find its easiest an hour before bedtime so you can sleep through the nausea - especially if you are not used to taking it, but do expect to get some diarrhoea/nausea.   Sometimes taking some high dose probiotics (from health food stores) or live yoghurt for a few days after azithromycin will help calm your gut.

estradiol/white cyclacur/progynova (estrogen – to build and retain your lining) 2Eu for 11 tabs (tend to start on 2 a day but end up on 4 day a day until week 8 of pg, then half the dose, then stop) - not all ladies take this, but all DE ladies do, and a lot of OE ladies. UK COST price  ex VAT £7.30 for 84 tabs (fertility2u.com £10.80).

prednisolone/medrol/methylprednisolone (an immune suppressant – to try and make your body more hospitable to an embryo - not all ladies take these but ladies with autoimmune issues do) 4mg 3E for 50 tabs or 16mg 3Eu for 14 tabs (tend to start at start of stimulation/estrogen until week 10 of pg (but need to gradually taper down the dose). Doses vary from (not at all to) 4mg to 32mg depending on issues/history etc. UK COST price  ex VAT £1.28 for 28 tabs of 5mg.  Always take with breakfast as it will keep you awake.  Sometimes you feel a bit jittery when you take it initially but it usually settles down after a few days.  It tastes bitter (unless you get the red coated gastric resist pills) so take with a big glass of water.  Its important to minimise your salt and sugar intake when taking this because it makes you retain salt so you can look bloated and puffy and it hikes your blood sugar levels which isn't very healthy for you and baby so you need to try and eat low GI and avoid sugar and salt.

clexane (a blood thinner) (this is pronounced 'clexan' in greece) 0.4mls/40mg 4.5E per shot. clexane 0.6mls/60mg 7.5E per shot (tend to have daily shots from start of stims/estrogen until week 12 of pg - but some ladies will need it for longer or not at all - not all ladies take these but ladies with a thrombophilia diagnosis will definitely take these e.g., elevated APLAs/anticardiolipin antibodies, Factor V Leiden, MTHFR, PAI-1, Prothrombin II, Protein C and Protein S resistance etc). Doses vary from 40mg to possibly 2 x 40mg per day. UK COST price  ex VAT £4.04 for 40mg (fertility2u.com price £6.50), £4.57 for 60mg (fertility2u.com £7.15).  You take this as a daily subcutaneous injection into the belly flab.  Expect to bruise quite a bit whilst you are taking this - see my tips for minimising bruises etc in my immune faq in the clexane section.  Remember to get hold of a sharps bin - easy to buy in the UK from any online medical supply shop - but probably cheaper from ebay if you only want to buy 1 at a time.  The disposal arrangements vary between different counties in the UK - so check with the receptionist at your GP.

Progesterone/utrogestan (matures and maintains your lining) 200mg 7E for 15 capsules (dose is usually 2 capsules, twice a day starting from day after EC until week 12 of pg, then half the dose, then stop) - in the UK, its often easier to get cyclogest 400mg pessaries (2 per day) - almost all ladies OE/DE will take this or cyclogest and/or gestone shots. UK COST  ex VAT price utrogestan 200mg £5.13 for 15 capsules (fertility2u.com price £7.20), cyclogest 400mg £10.18 for 15 pessaries (fertility2u.com price £12), crinone gel 90mg 15 applicators £30.83, gestone 50mg £4.50 (Not many ladies need it, but gestone and its italian equivalent, prontogest, can be hard to source in both the UK and in Greece - if you get stuck, its sometimes worth trying Rigcharm pharmacy in London- otherwise, you can buy Agolutin from Czech republic (with an email prescription e.g., from serum) which is 3Eu for 5 ampoules of 60mg - from www.pharmawell.eu).  Occasionally, ladies may get instructions from Penny to take utrogestan (not cyclogest) orally (usually its vaginally) to boost their blood levels but this can make you feel dizzy and sick so its easier to take it before bed/nap this way.    Some ladies may be recommended to take gestone/prontogest/agolutin shots on top of their pessaries- often 50mg every day or every other day - see the gestone section of my immune FAQ.  All types of progesterone can upset your stomach and give you constipation.   Drink lots of water, try eating more fruit e.g., prunes/prune juice and if that fails to relieve discomfort, you should be able to take a half dose of lactulose (over the counter from the chemist) but try to avoid harsh laxatives like senna.

folic acid/filicine (needed by the developing baby and can help protect some ladies from blood clots - all ladies take this) 5mg 2Eu for 30 tabs (all through ttc and pg, 1 tab per day) - UK COST  ex VAT price £0.89 for 28 tabs.  It is ok to take this on top of prenatal vitamins that contain 400mcg of folic acid.

low dose aspirin/salospir 100mg (a blood thinner) 1Eu for 20 tabs (from start of stims or estrogen all through pg - almost all ladies take this) - in the UK it tends to be only available in 75mg tabs for about £0.75 for 100 tabs - always take aspirin with food, never on an empty stomach.

Arvekap/triptorelin/decapeptyl 0.1mg (a down regulation drug) 40Eu for a packet of 10 shots (e.g., on an OE cycle, daily shots from start of period, or maybe from day 21 of cycle until trigger shot day) - not available in the UK at this dose - if this is on your protocol, make sure you buy it in Greece - the nearest equivalent is to use busererlin/suprecur 1 mg/mL but its much easier to use triptorelin/decapeptyl 0.1 if you can get it. Buserelin ex VAT COST price for a 5.5-mL vial = £13.76 -and discuss with penny how much to inject each day (because you only need a tiny amount (0.1mls - 1/10th of a ml) to equate to the arvekap 0.1mg its very fiddly to get this right - and very easy to get it wrong! so its probably safer to get arvekap 0.1 couriered from greece. The courier cost is expensive so its much better to buy arvekap 0.1mg when you are in Greece. Penny often suggests using a half dose of arvekap 0.1 - which means you could theoretically use only 1 vial of arvekap 0.1 every 2 days - but I found it really hard to get 2 half doses from 1 vial (you lose a lot in the needle etc), so it was easier to take 1 half dose from the first vial, then use the rest of the first vial plus a bit from a second vial on day 2, then take a half dose from the second vial on day 3, then start again with a new vial on day 4 - that way you get 3 days doses from 2 vials.  Although, according to penny as long as you get at least 1/3rd of a dose each time, it will be ok.  Can be transported/stored at room temp.

Arvekap/triptorelin 3.75mg (a down regulation drug) 156Eu for a shot (e.g., on a DE cycle with a full down reg - just 1 shot, or if you are doing a prolonged down reg 1 shot a month for 2-3 month). The UK equivalent is gonapeptyl depot/triptorelin 3.57mg UK COST  ex VAT price £81.69 or prostrap SR/leuprorelin acetate 3.75mg UK COST price £75.24 (Fertility2u.com price £85.24).  If you are down regging for 3 months or more, you might be prescribed a shot of 11.25mg (called Prostap 3 in the UK - (fertility2u price £255)) which lasts for 3 months.   All these long down reg drugs can make you feel tired and headachy and give you other menopausal symptoms like hot flushes and hair loss.  Some ladies take them with no problem, others find the side effects hard going.  Accordingly, although penny seems to find that taking a long down reg for donor egg cycles gives higher success rates, she doesn't usually make this the first choice because of the side effects.    Can be stored/transported at room temp.

Puregon 900U (FSH used for stimulation for OE IVF) 432E (e.g., 150U per day on an OE cycle from start of stims until day before trigger shot... maybe 7-10 days) UK COST  ex VAT price £292.23, Fertility2u.com price £298.50 (but bear in mind that refrigerated courier is expensive).  Needs to be refrigerated.

Puregon 600U (FSH used for stimulation for OE IVF) 287E (e.g., 150U per day on an OE cycle from start of stims until day before trigger shot... maybe 7-10 days) UK COST  ex VAT price £194.82. Fertility2u.com price £195.  Needs to be refrigerated. 

Puregon 300U (FSH used for stimulation for OE IVF) 146E (e.g., 150U per day on an OE cycle from start of stims until day before trigger shot... maybe 7-10 days) UK COST  ex VAT price £97.41. Fertility2u.com price £108.50.  Needs to be refrigerated.

Menopur 124E (FSH and LH used for stimulation for OE IVF) for a packet of 75U - 10 ampoules (e.g., 2 ampoules per day on an OE cycle from start stims until day before trigger shot... maybe 7-10 days) UK COST  ex VAT price £163.80. Fertility2u.com price £175.   Needs to be kept at room temp below 25deg.  Generally, if you buy more menopur than you end up using, serum will take the extra vials back from you because they are stable at room temp - they usually can't take back extra cartridges of puregon because they can't be guaranteed once they've been out of the fridge.

Intralipids 100mls 20% (an IV infusion used to try to make your immune system more hospitable to an embryo - ladies with immune problems tend to use this - usually 1-3 infusions before embryo transfer, 1 infusion on BFP and probably 1 more 4 weeks later - after than Penny is very cautious about continuing intralipids any longer than that) - per bag with cannula etc - just the meds, not administering it - (I THINK) about 40Eu. UK COST  ex VAT price £7.05 (but not including the cannula etc).   Needs to be kept below 25deg (room temp).   You can easily buy the cannulas etc in the UK from boundtree medical.

Prixina/Prulifloxacin (an antibiotic) - 30 Eu for 5 pills - often taken by both partners for 10-15 days - we don't have this antibiotic in the UK - I GUESS the closest UK equivalent would be either moxifloxacin or ciprofloxacin.  don't take milk/yoghurt/cheese/calcium, magnesium or aluminium based ant-acids/supplements for 2 hours before and 4 hours after as it reduces the absorption of this antibiotic - and avoid sun. For the patient info leaflet: http://www.faran.gr/en/node/295.  All antibiotics from the moxifloxacin/prulifloxacin group have a very broad spectrum effect, so they are reserved to be used for the 'last resort' i.e., they aren't appropriate to use unless you've already used other antibiotics for the same issue/ unsuccessfully.

Pregnyl (HCG, used for trigger shot and sometimes for luteal support/lining preparation).  For trigger shot a dose of 10,000 IU or 5,000 IU is often used.   For luteal support, a dose of 1500 IU is used. I don't have the up to date prices but it is not expensive - about £3 per vial - pharmacies in Athens often have it in stock (unless there are shortages), but in the UK its normally ordered in specially.  It needs to be kept refrigerated unless it is going to be used within a few hours.   When buying pregnyl, you need to be aware the packet usually does not include the syringe and the needles that you will need (a 2 ml syringe and a 1" blue needle (ideally 2 needles, so you can use one for drawing up and one for jabbing - if the drawing up needle is at least 1&1/2" that makes it easier).  Penny prefers you to do the pregnyl shots intramuscularly (upper outer quadrant of the buttock).

Femara/Letrozole (an aromatase inhibitor)  This is mainly used to trying to improve the implantation environment e.g., for ladies with possible mild/moderate endometriosis or hydrosalpinges, but it can be used to help with ovarian stimulation.   For lining preparation, its normally given as a 5 day course of 2 x 2.5mg tablets.   In most UK pharmacies its a special order item and sold in packets of 28 tablets - the lowest price available is about £102 (asda). Fertility2u.com sell individual tablets for £3.47 each which is a good price, especially if you only need 10 tablets, but there is a shipping charge of £10 minimum.  The price in Greece is about €112 for 30 x 2.5mg.

Vaginal viagra cream - this is about 100Eu for a complete course including applicators and 40Eu for shipping (50Eu if you ship 2 packs, maximum number of packs per shipment is 3).   You need to order it direct from the distributor in Malaysia not from serum and need to allow at least 20 days for it to arrive.  Contact johnbowen12@gmail.comwww.herbalassistance.com

John Bowen also supplies cordyceps sinensis capsules 400mg at 0.5Eu per capsule - He seems to suggests 30 days of cordyceps 2g per day prior to ET and 30 days post ET cordyceps 1.2g for implantation failure.   For egg quality problems he seems to suggest the same programme but with 30 days of 'vitality herbs' prior to egg collection (1 capsule per day for 12 days and then 18 days of 1 capsule every other day).  The vitality herbs contain:
Radix Panax Ginseng 50mg
Herba Cynomorium 130mg
Herba Epimedium Sagittatum 120mg
Fructus Cnidium Monniem 100mg

The cordyceps provided by John is high grade wild grown cordyceps from China and Tibet.  The cordyceps available in the UK from mushroomnutrition.com (purehealthonline) is farmed in the US by Aloha medicals who are a very reputable supplier and the brand used (myco-nutri) is the same brand used by Trevor Wing's people in the UK so it should be reliable.

For male sperm problems he suggests about 60 days of cordyceps 2g per day and 1 capsule of 'vitality herbs'. 
John currently charges 0.5Eu per 0.4g capsule of cordyceps and 1.5Eu per 0.4g capsule of vitality herbs, but there is also the cost of shipping to the UK.   I think that if you just want cordyceps, it should be cheaper and easier to order it from the UK e.g., 300 0.4g capsules from mushroomnutrition.com are about £40 plus postage), but if you want to buy the vitality herbs as well, it may be easier to order everything together from Malaysia. Although, I haven't ordered from purehealthonline myself because I have bought the mushrooms from one of Wings associates (who gets them from purehealthonline).

As explained in the section about paying your bill at serum, its often very expensive to make payments overseas (e.g., to John in Malaysia) using your own bank, but there are many services to do the same thing more economically e.g., travelex, fairfx etc

My understanding is that Penny made contact with John Bowen for providing chinese herbs/cordyceps after being very impressed with the results some of her patients had after getting similar treatment from Trevor Wing in the UK.   My understanding is that Trevor uses a similar regime but its not identical.  He seems to favour 1.5g of 3 mushrooms (cordyceps sinensis, reishi and coriolus - myco nutri brand from mushroomnutrition.com or purehealthonline.co.uk) often used together with 2 herbs (Qin Jiao (gentiana macrophylla)1.5g and Huang Qi 1.5g (astralagus e.g. http://www.chineseherb.co.uk/index.php?main_page=product_info&cPath=61_135&products_id=1331).   The mushrooms and herbs are easy to buy from purehealthonline (and this programme is a bit cheaper than John Bowen's one).  There is a little more info in my immunes FAQ under M for mycology.

Offline agate

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Re: Agate's file of serum stuff - part 4
« Reply #3 on: 28/10/11, 22:01 »
12.   Protocols

12.1 Donor egg protocols
For a donor egg protocol, there are normally 3 possible options depending on the timing of your cycle and the donor, and Penny’s judgement of what will suit your body best:

1) you use your natural cycle and aim so that your ovulation and your donor’s egg collection coincide so you don’t need to take estrogen (progynova/cyclacur white), and might add progesterone (utrogestan/cyclogest/crinone gel etc) if your blood tests show you need it after ovulation, or if Penny guesses you might need it without blood tests; or

2) you use a semi-medicated cycle and start estrogen (progynova/cyclacur white) near to the start of your cycle and then add progesterone usually the day after the donor has had her egg collection (Egg collection is usually about 11-16 days after you start your estrogen and she starts her stimulation);

3) you do a fully down regulated cycle where you take a drug like arvekap/prostap (usually monthly shots of 3.75mg or 3 monthly shots of 11.25mg) to down-regulate your body for 2 weeks to 3 months before you start your estrogen.     The down reg shots are started on day 21 of a normal cycle, or if you are still on IVF meds (e.g., progynova/cyclacur and utrogestan) you can usually start immediately provided you continue to take the IVF meds for about 7 days overlap to prevent your body restarting your cycles before the down regulator takes effect.  Otherwise, you can start a down reg on about day 3 of your cycle, but you won't be fully down regulated until your own cycle has ended as your body may continue to ovulate that cycle and make its own hormones.  All down reg drugs produce an initial surge in hormones (LH and FSH), but after about 1 week, the hormones will start to drop and within about 2 weeks (longer if you start DR on day 3), you will have a bleed and then your lining will stay thin as your cycles will be shut down (for as long as the down reg drug lasts).   You can stay in this state indefinitely (if necessary having extra monthly or 3 monthly shots), and you will start your estrogen medication to build up your lining again whenever the donor (and you) are ready.  After the bleed, you should have some (menopausal) signs that you are down regulated to give you some reassurance e.g., hot flushes (particularly at night) and your cervical mucus should remain thin, fairly dry and white-ish (not profuse, clear and egg white like).   

On a long down regulated cycle, penny may recommend a scan just before you are due to start estrogen to check that you have stayed down regulated - i.e., your ovaries are still quiet and your lining is still thin to make sure you are ok to start your estrogen that week.  If you have obvious menopausal signs, the scan may not be needed.

On all donor egg cycles, Penny may recommend you have an ultrasound scan on about day 10 of your estrogen/natural cycle just to see whether your lining is thickening up properly.

In London there are many places to get a scan e.g. the Birth Company on Harley St.   In Bristol, some ladies use Dr Valentin Arkande's clinic.  In Leeds, some ladies use thisismy.  In other areas, you might want to start with your local private pregnancy ultrasound clinics and see if they can do a transvaginal ultrasound (some clinics only have the equipment to do an abnormal ultrasound (the type used in pregnancy) which isn't good enough to see the lining), otherwise, you can try your local BMI or Spire private hospital gynae department.   Its worth finding out where you can get a scan in advance in case you need one.  There is a thread I started on the board where we've listed lots of places to get scans in the UK.

For immune issues you may be advised to take prednisolone/methylprednisolone/medrol in doses from 4mg to 32mg

For clotting issues you may be advised to take clexane shots (40mg, 60mg or 2 x 40mg) from the start of estrogen or stimulation (with a pause for egg collection if you are doing an OE cycle)

All ladies are advised to take 5mg folic acid/fillicine throughout the time they are planning to conceive or pregnant.

Some ladies will be advised to take 500mg valtrex/valaciclovir twice a day from the start of estrogen or stimulation until pregnancy test day (or possibly a short 5 day course).

Some ladies will be advised to take 100mg doxycycline/vibramycin twice a day from the start of estrogen or stimulation until  ET.

Some ladies will be advised to take vaginal Viagra twice a day from part way through estrogen administration until embryo transfer – Penny arranged with John Bowen in Malaysia to formulate a special vaginal Viagra preparation which is much more convenient than mushing up oral tablets with vaginal jelly etc.  So far, the ladies who have used the new vaginal 'cream' have shown good lining results according to Penny. To order this, you need to contact John Bowen's by email (see above) and arrange payment and delivery so that it can be shipped direct to you in advance of your cycle.  The cost is about $100 (for 1 cycle's worth) with a shipping to the UK about $40.  Bear in mind that it can take at least 20 days to arrive from Malaysia.

On most donor egg cycles and some own egg cycles progynova 2mg is taken (often 4 tablets per day but starting on 2 tablets).  The greek equivalent of progynova is cyclacur, but only the 11 white tablets from the cyclacur packet (you throw the brown progesterone tablets away if you just need the white tablets).

On most donor egg and own egg cycles you will need some progesterone support after egg collection day with utrogestan (pellets which are normally taken vaginally but can be used orally if Penny thinks they will help better that way), cyclogest pessaries or crinone gel, sometimes with additional support from gestone or prontogest shots (particularly after embryo transfer).  You might like to think about ordering Agolutin from the Czech republic in advance if you are likely to need progesterone shots because gestone hasn't been available for several months and prontogest imported from Italy is very expensive and not available at many UK pharmacies.  If you do need progesterone shots, remember to buy antiseptic wipes, needles and syringes - see the tips in my immune FAQ under Gestone

Example natural cycle donor egg protocol:
day 1 of your bleed (or before) start folic acid 5mg
day 7 start using LH urine sticks
day 13 - see positive LH test - and let Serum know - donor should be having her EC at approximately the same time as you ovulate - so your partner may need to be there if he is giving a fresh sperm sample.
day 16 start progesterone
day 18 have embryo transfer

Example semi medicated cycle donor egg protocol:

Day 3 of your bleed: start white cyclacure/progynova per day (one in the morning and one in the evening)
Start Fillicine/folic acid 5mg
Start prednisolone 25mg (avoid salt and sugar)
Start Salospir/aspirin 100mg
Start Clexane 40 (injection)
Start 100 mg doxycline with breakfast 100mg doxycline with supper
Start 500 mg Valtrex in the morning and 500mg Valtrex at night

Day 6 increase white cyclacur/progynova to one in the morning, one in the evening and 1 at night)
Start viagra 100mg vaginally in the morning and at night

Have intralipids (if needed), ideally on about day 7 (otherwise, have them as soon as you get to Athens)

Day 9 increase white cyclacur/progynova to one in the morning, one in the evening and 2 at night)

Day 12 take 1g (4 x 250mg) of azithromycin/zithromax and do not take doxycycline that day

Day 13 have an ultrasound scan (if needed)


Egg collection day (approx day 13-17) – partner needs to be in athens to provide sperm sample if needed

Day after egg collection: (approx day 14-18) start utrogestan 2 x 400mg or cyclogest 1 x 400mg at night, then twice a day

3 days or 5 days after egg collection – - recipient needs to be in Athens for embryo transfer – stop Viagra, continue all other meds (possibly start prontogest/agolutin/gestone shots)

Pregnancy test day (usually 9-12 days after a day 5 transfer, or 12-14 days after a day 3 transfer - if you test at the earlier end of the ranges, and its negative you need to stay on meds and test again 3 days later - you need to be absolutely sure its negative before you stop your meds)– if negative stop all meds (taper predisolone/medrol if necessary).  If positive, stop doxycycline and stop valtrex, but start 500mg azithromycin for 5 days, then break for 5 days, then 500mg azithromycin for 5 days, then break for 5 days, then 500mg azithromycin for 5 days – this should take you until about week 8 of pregnancy (6 weeks after egg collection).

Repeat the intralipids on positive pregnancy test and once more 3 or 4 weeks later.

Week 8 of pregnancy (6 weeks after egg collection) – halve the progynova/cyclacur white

Week 9 of pregnancy stop the progynova/cyclacur white

Week 10 of pregnancy halve the prednisolone/medrol for 5 days, then halve again for 5 days until you are down to 5mg then stop

Week 12 of pregnancy stop the clexane but only after checking with your obstetrician in case you need to continue it.

Week 12 of pregnancy halve the dose of utrogestan/cyclogest/gestone for 1 week then stop

(Folic acid can be continued.  Aspirin can be continued unless you have red bleeding (not just spotting) in which case you may need to stop or pause it).

Example of a different (experimental) donor egg protocol using an extended down regulation and PBMC

day 21 of a natural cycle or on BFN from IVF : 3.75mg prostap injection (overlapped for 7 days with progynova and utrogestan if continued from a previous failed IVF cycle)
wait 1-3 months
then
day 0 zithromax 1g

day 1-3:
2 white cyclacur per day
1 Fillicine
prednisolone 10mg
1 Salospir 100mg
1 Clexan 4,0 (injection)
100 mg doxycline in the morning 100mg doxycline in evening
500 mg Valtrex in the morning and 500mg Valtrex at night for 5 days only

day 4-6
3 white cyclacure per day
1 Fillicine
prednisolone 10mg
1 Salospir 100mg
1 Clexan 4,0 (injection)
100 mg doxycline in the morning 100mg doxycline in evening
viagra vaginally twice a day

day 7 onwards
4 white cyclacur per day (one in the morning one in the evening and 2 at night)
prednisolone 10mg
1 Salospir 100mg
1 Clexan 4,0 (injection)
100 mg doxycline in the morning 100mg doxycline in evening
vaginal viagra twice a day

approximately day 7 - have intralipids

day 11 replace the doxycycline with 1000mg zithromax ( 4 pills of 250mg all together)

donor's trigger shot day - 5000 IU pregnyl shot
donor's EC day (need to be in Athens) take blood for PBMC white cell treatment, then take 1500 IU pregnyl and have LIT
day after EC - start utrogestan 400mg evening
2 days after EC - (need to be in Athens) take more blood for PBMC and do PBMC white cell intrauterine infusion
2 days after EC 400mg utrogestan morning and evening
start gestone 50mg or agolutin 60mg 4 days after EC
ET day (usually 5 days after EC but sometimes 3 days after if own sperm is being used, or if there is a reason to assume the implantation window maybe short e.g,. high progesterone levels) - 1500 IU pregnyl injection

12. 2 Own egg protocols

Ladies doing an on own egg cycle will often use a mixture of menopur and puregon (or gonal F) with arvekap 0.1 (a down regulation drug) for their stimulation.  For some ladies Penny will recommend starting down regulation medication on day 21 of your cycle (long protocol), then waiting for a bleed and having a scan after bleeding has started.    Or, pretreatment with a month or more on the pill to try and 'rest' your ovaries.

Otherwise, you will start your stimulation drugs just after your AF starts without down regulating first (a short protocol).  Ideally you will make a 1 day trip to Athens to have this baseline scan on day 1 or 2 of your period, but it may be possible to have the scan locally and email the scan report and images to Penny (she will need to know your lining thickness and the number of follicles on each ovary together with their sizes).  This is a final check to make sure you have no troublesome cysts/dominant follicles, and that your lining is shedding properly and to help her confirm which dose of stimulation drugs is appropriate for you that month.   After your baseline scan, you wouldn’t normally need be seen in Athens until day 7 of your stimulation drugs (day 6 if there is any risk of you overstimulating), by which time you’ll need to be in Athens until your egg collection (see cycle monitoring for OE IVF).

Example long protocol own egg (with extra immune medication):

day 21 - start down regulation
day 2 of period  (or any time in the 2 weeks after the bleed starts)- have baseline scan and speak to Penny on the phone
day 4 of period  (or any time in the 2 weeks after the bleed starts)- start puregon, menopur and take 1g of azithromycin, 40mg clexane, 5mg folic acid/fillicine and 25mg prednisolone (and valtrex if needed)
day 5 of period - start doxycycline 100mg morning and evening
day 9 - start having daily scans in Athens
day 10 - have intralipids
day 13 - take HCG trigger shot
day 14 - swap 1g azithromcyin instead of the doxycycline for the day
day 15 - egg collection
day after egg collection - start utrogestan 2 x 200mg morning and night, start progynova 2 x 2mg (if needed)
day 17 - have LIT
3 days after egg collection - embryo transfer - possibly start gestone/prontogest/agolutin if needed

The post ET (and pregnancy) protocol would be similar to the donor egg protocol

Example natural cycle OE

day 1 (or before) start folic acid 5mg
4 days before ovulation is predicted - have scan
3 days before ovulation is predicted - take HCG trigger shot
3 days after trigger shot - have egg collection
day after egg collection - start utrogestan 2 x 200mg morning and night
2 days after egg collection - embryo transfer

The post ET (and pregnancy) protocol would be similar to the donor egg protocol

12.3 What is natural cycle OE IVF?

For older ladies/poor responders/poor egg quality, and ladies who have estrogen mediated problems like endometriosis/adenomyosis I understand Penny prefers natural cycle IVFs  - as she feels that there is no advantage in taking high doses of stims to try to produce more eggs at the expense of reduced quality.

This means not taking down-regulation or stimulation drugs and instead, tracking your developing follicles with ultrasound (so you will need to be in Athens 3 days before ovulation - or at least be able to have scans in the UK starting 4 days before ovulation). 

Before the natural LH surge occurs, she will prescribe an HCG trigger shot to ready the follicles (unless blood tests show that the natural LH surge is happening), then egg collection is performed as for a conventional IVF. The intention with natural cycle IVF is only to yield 1-3 eggs but to aim for the highest possible quality (without any damage from high doses of estrogen and FSH), and potentially, to do 2 or more cycles back to back cycles if the first is not successful. 

However, because of the low egg numbers, it is less attractive if there is a significant male factor problem requiring ICSI.   According to the studies done so far about natural cycle IVF, the average success rate for good prognosis patients (e.g,. less than age 35) is quite a lot lower than the average success rate using conventional stimulation (e.g, about 1/3rd), but it does cost less per cycle because stimulation drugs are not used.  For older ladies/poor responders etc, she feels that the success rates are at least as high as for conventional IVF and that it may achieve pregnancy for some ladies that don't get pregnant using conventional stimulation because of either egg quality damage or a short implantation window due to the high doses used.  Natural cycle IVF may be a good option for ladies who can commit to trying, maybe, at least 3 back to back cycles of it (especially if they might have estrogen mediated implantation issues e.g, endometriosis/adenomyosis), but its probably unrealistic to expect it to be a 'magic bullet' for achieving pregnancy in a single cycle - and if pregnancy does not happen within 2 or 3 cycles, it is probably better to investigate donor egg.

12.4 What immune/adjunctive treatments are available with Serum?

You can easily have paternal LIT at Serum (see the LIT section of my immune FAQ) for more info on LIT.

Serum will prescribe steroids and clexane for those ladies who are likely to need it (see the Corticosteroids and the Clexane section of my immune FAQ)

Serum will administer intralipids for those who are likely to need it (info in the intralipids section of my immune FAQ) - but Penny is very cautious about administering intralipids in pregnancy so once you are pregnant Penny is currently recommending having a drip on BFP, then possibly one more 3-4 weeks later but no more after that.  If you need intralipids before or after you get to Athens you can either arrange to buy the medication there and bring it back and find someone to administer it to you in the UK (not always easy - but in London you can try Verona Hall in Dulwich, otherwise your GP might help or you may be able to find a friend who is a nurse or doctor?), get a prescription for it posted to you and have Healthcare at Home administer it to you or get a prescription posted to you and find someone else to administer it to you.  In Wiltshire, you can try Prestige Nursing 01666 503020. If you do want to get your intralipids administered by Healthcare at Home, they have a form that Serum have to complete by email for you. UK pharmacies are required by law to accept EU prescriptions provided they are satisfied that the prescription is valid and the doctor is properly registered. Mums in Solihull are another possibility for intralipids (£160 exc the cost of the intralipids), and Independent Nursing in London will administer on intralipids on a prescription.

Penny often recommends antiviral treatment with valtrex/valaciclovir for ladies with a history of relevant viral infections.    She often recommends antibiotic treatment for ladies who have a history of chlamydia or who test positive on the locus medicus menstrual blood test (see Chlamydia in my immune FAQ).

Penny often recommends vaginal viagra to ladies with thin lining but she prefers a special vaginal viagra formulation so you will need to order it and have it shipped to your home from Malaysia before your cycle (see above under Medication).

I think Penny is reluctant to treat using humira due to lack of safety data.

I think Penny is reluctant to treat with IVIG due to perceived cost vs benefit but it can be arranged at a local hospital in Athens if necessary.

I think Penny is supportive of ladies who try resveratrol (see my immune FAQ under Supplements) for inflammatory immune issues like elevated TNFa

Penny has started to use GCSF/neupogen for some patients (mainly those with repeat implantation failure or early m/c)  - see G-CSF in my immunes FAQ. She is trialling using G-CSF daily injections for repeat implantation failure and (more rarely) intrauterine washes as a treatment for thin lining.

Penny tried PBMC (white cell uterine infusion) therapy (December 2011) and was trying it for ladies who have experienced multiple IVF failures or lining thickness problems -  see PBMC in my immunes FAQ - but she was finding that a wash with HCG produced similar results more cheaply so she was tending to use the HCG wash instead.

Penny has recently started using letrozole/femara for ladies with repeat implantation failure (see the endometriosis section of my immunes FAQ.)

Penny started to try a uterine infusion of HCG prior to embryo transfer for some patients after a recent Turkish study showed promising results (see HCG in my immunes FAQ).  She also supports using injections of HCG (1500 IU pregnyl) during the luteal phase and early pregnancy for patients who have a history of repeat implantation failure or early miscarriage.

Serum can arrange for you to be seen for immune tests e.g., NK assay (170Eu immunophenotype - CD56 bright/dim and CD4/8 but not the cytotoxicity - Dr Economou feels that the CD4/CD8 ratio and the CD56bright/dim ratio is sufficient to indicate whether there would be an elevated cytotoxicity - this can be done by post on a sample of chilled blood), cytokines (120Eu TNFa:IL10, IFNg:IL10, IL4:IL10, IL17F:IL10 - these are done on the free cytokines in the serum (like RIC UK) rather than the intracellular cytoplasmic cytokines in CD4 cells like RFU - this allows the test to be done by post), HLA- DQa (80Eu per partner - easily done by post), thrombophilia panel 260Eu (including MTHFR, PAI-1, Prothrombin II, Factor V Leiden and antiphospholipid antibodies, KIR activator gene test €200 (package price NKa, TH1:TH2 and KIR €490, or same including LAD and DQas €580)- all can be done by post - although sending frozen/refrigerated samples can be very expensive (see my immune FAQ for more info on those tests). The KIR blood sample is easy to send by post (2 – 5 ml whole blood in a EDTA containing tube (lavender/purple top), NO CENTRIFUGATION, no specific storage conditions) by post.  Their local immunologist is:
Dr Emanuel Economou
Assistant Professor of Pharmacogenetics
Medical School
University of Athens
Dimitriou Soutsou 41,
Ampelokipi 115 21
Athens
eveconom@pharmagenetix.net

http://www.pharmagenetix.net/greece/pharmagenetix/contact  (use google translate because the page is in greek)

and then provide treatment on his recommendation.  The antipaternal antibody test/LAD test (see LAD test in my immune FAQ) can be run at Serum quickly - I think it was about 100Eu. 

Penny has been impressed with the successes that ladies treated with Chinese medicine in the UK under Trevor Wing have had recently (particularly those with inflammation or thin lining problems) and Serum can provide an email contact in Malaysia can supply reputable chinese herbal/mushroom medicines direct to patients based on questionnaires/medical history.   Ladies who have contacted him (and their partners) are trying therapy with cordyceps (a chinese mushroom) and chinese 'vitality' herbs (see above or see Mycology in my immunes FAQ).

Serum can arrange acupuncture pre and post ET.  In Greece, this can only be done by a qualified doctor and Serum can arrange for a doctor to come to the clinic to do this for €100 - email Maria on serum@otenet.gr to book this with Serum's anaesthetist.

Apparently Penny is prepared to offer interval double transfer (sometimes also called sequential transfer - transferring embryo(s) from the same batch on day 3 and then further embryo(s) on day day 5) to patients who request it.    Some studies suggest that this method might give a slightly better chance of implantation in case the implantation window is short (favouring day 3 transfer) but still giving the chance of a blastocyst (day 5) transfer in case that gives a better chance of pregnancy.   It may also benefit those patients who really want to try for blast but don't want to risk having nothing to transfer (as they can have a day 3 transfer as 'backup in advance'). Obviously interval double transfer requires an extra ET, so it does incur an extra cost of €300, but some patients may want to ask Penny to do this for them.

12.5 The importance of sperm quality
I feel that UK clinics tend to underestimate the importance of sperm quality.  UK clinics tend to do relatively few donor egg cycles compared to Serum and UK donors tend to be older and have infertility problems of their own as most UK donors are either known family members/friends or on an egg share programme.  Serum work with top quality eggs from healthy young donors every day, so they have a vast experience of seeing the difference in fertilisation and success rates when they use these eggs with top quality sperm from sperm donors vs partners own sperm of lower quality.   I feel Serum therefore recognise the impact that sperm quality has much more than most UK clinics.   They try to address this by ensuring your partner does a semen analysis before your cycle and ensuring that quality problems in your partners sperm that may be due to infections like chlamydia are addressed in advance of your cycle using antibiotics and antioxidants like vitamin E, and they do sperm DNA fragmentation tests for a much lower cost with a very fast turnaround compared to in the UK.  This means that, if you and your partner want to, you can have a sperm DNA check run on your partner's sperm immediately prior to it being used for your cycle.   If you are unsuccessful with poor sperm fragmentation despite good looking eggs at least you have some possible idea of why.  Alternatively, if you and your partner want to fertilise some or all of the eggs from your cycle with donor sperm at the last minute, and then choose which batch of embryos to transfer based on their quality, or 'test' some of the eggs with donor sperm with no intention of actually using them just to see if they fertilise and divide better, Serum will usually be able to let you do that on egg collection day.  This is a much greater level of flexibilty than we have available at UK clinics. 

However, if it helps, Serum offer IMSI and PICSI for no extra charge.

12.6 Extended down regulation pre-treatment
Where implantation appears to be dysrupted by endometriosis or adenomyosis, Penny sometimes recommends an extended down regulation.   This takes the form of 1 or more months of down regulation shots.   Arvekap or Prostap 3.75mg injections are taken monthly (or once every 3 months using Prostap 3 11.25mg) starting either on day 21 of your cycle, or at the start of your cycle.  Within about 2 weeks of the first injection, you will normally have a bleed (triggered by the fall in your estrogen and progesterone levels). Whilst you are down regulated, your estrogen and progesterone levels will remain low so your lining will not start to thicken until you start your stimulation drugs for OE or your estrogen for DE.  Whilst you are down regulated you will be in a temporary menopause so you may experience menopausal symptoms e.g, hot flushes, tiredness, headaches, insomnia.

12.7 Treatment options for implantation failure
Where a patient has repeatedly failed to get pregnant with IVF despite apparently good looking embryos, Penny will tend to consider the following options:
antibiotics and or antivirals if there is a suspicion of bacterial or viral infections (to try to treat the infection and reduce inflammation)
steroids and/or intralipids where there is suspicion of autoimmune problems (to try to suppress any elevated NK activity)
hysteroscopy where there is a suspicion of polyps/scarring/fibroids/septa in the uterus (to try to improve the quality of the lining and to provide a deep implantation 'scratch' to aid implantation by kickstarting the inflammation/healing response in the uterus)
natural cycle IVF or extended down regulation where there is a possibility of undetected endometriosis/adenomyosis/tiny fibroids (to try to reduce the endometriosis/adenomyosis/fibroids by reducing the level of estrogen)
PBMC or aquascan carried out 2 or 3 days before embryo transfer to improve the hospitability of the uterine lining/generate a helpful local inflammatory response
Letrozole preparation protocol (to try to improve uterine lining levels of beta3 integrin)
HCG 'wash' into the uterus just before embryo transfer to try to improve implantation rates
Penny is also seeing some good results where patients have used the herbal remedy - cordyceps sinensis - prior to treatment.
GCSF/neupogen daily injections (usually done after testing KIR)

12.7 Treatment options for improving embryo quality

For older ladies/ladies with reduced ovarian reserve/quality, Penny feels that natural cycle IVF may give at least the same chance of pregnancy if not better than using high doses of stims.  She seems to feel this is a better approach, because it results in a less abnormal hormonal environment and uses a lot less medication.    Penny's general approach is that very high doses of stimms e.g, 450IU etc or very long courses of stimms are often counter-productive, so even on conventional IVF, she prefers to use lower doses for shorter lengths of time and aim to collect fewer but better eggs rather than slightly higher numbers of eggs where the quality is compromised by high doses.

13.   Paying for your treatment
For surgeon’s fees and medication, Serum like payment in cash rather than credit card because they have to pay the surgeon/pharmacy immediately and (I don't understand Greek tax law, but payments to the pharmacy and surgeons cannot go through Serum's accounts), but they can sometimes take part payment for cycle fees by credit card if this is agreed in advance.   ALL donor treatments need to be be paid 50% on start of your period/the donor's period (i.e., when you start your meds) to enable donors meds to be purchased and the remaining 50% at ET.   The initial 50% needs to be paid by bank transfer to the Serum Account (please email the clinic for the correct bank details to use) and the last 50% can be paid in cash ideally or with prior agreement by credit card at the Serum Clinic no later than embryo transfer day.   Ladies having OE treatment need to complete payment on ET day.

When making any electronic payment, please send an email to the clinic to let them know so that they can look out for it and match it up with your account.

However, I think it can work out quite a bit cheaper if you pay your whole bill by electronic transfer at least a week before you travel (subject to having to pay the 50% earlier than that if its DE - as above)– The transfer can take several days to go through, so doing it advance means you know there will be no last minute problems (e.g., with a credit card that refuses to accept a payment in Greece) and you will know the UK sterling cost before you travel so you know how much you have left in your budget for food etc.  Please double check the bank details to use with serum before you make the remaining payment.

Doing an advance bank transfer means you can also shop around for the best exchange rate.   High street banks usually give poor exchange rates and may also charge fees on top, but currency brokers can offer much better rates.   Your credit card company may also give poor exchange rates and charge fees, so its worth checking this before you plan on using your credit card.

Fairfx.com are very easy to use and have good rates but there are many other similar services e.g., travelex.   Please note that your bank may have a per transaction limit e.g., £999 which means you might have to split your transfer and some brokers have a minimum transaction limit which means that if you only have a small payment to make, you will need to choose a service which has a low minimum.

Fairfx has a minimum payment of around £500, so for small transfers e.g., to John Bowen, there are other services available like Tranzfers.com - the rates aren't quite as good as for larger transfer, but unless you bank with an exceptionally good bank, they are probably still cheaper than using your bank - especially if your bank charges a flat fee e.g., £25 on top of the poor exchange rates that they usually give.

You will also need some currency for taxis, food, etc, and a prepaid currency card can give you a much better exchange rate than, for example, buying Euros at the airport.    You transfer money onto your card over the internet before you travel (you need to order your card at least a week before you travel) and then you just use any ATM in Athens to draw out Euros overseas when you need them or pay with your card like an ordinary debit card.   

Travelmoneymaximiser (travelmoney.moneysavingexpert.com/) will show you the best exchange rates for the amount of Euros you want to buy.

14.1   When will I need to be in Athens? When will I be able to book my flights?

14.1.1 Fresh cycle own egg IVF
If you are doing a short protocol, you will normally need to have a scan on day 1 or 2 of your period.  If you are doing a long protocol (with down regulation first), then the scan can be any time in the 2 weeks after your period starts.  Ideally, you would make a day trip to Athens for this baseline scan so that Penny can determine the mix/dose of drugs for you to start on day 2 that day and you can buy them at Serum.  Alternatively, you can have the baseline scan locally, and email the scan images to Penny - but in that case, you need to have obtained a few days supply of puregon and menopur already so you are ready to start.

Penny likes to start daily scans and bloods on day 7 of stimulation, so you would need to arrange to be in Athens from day 7 onwards (unless you are at higher risk of over-responding, in which case you may need to start scans on day 6).

Egg collection is typically on day 12 after starting stimulation - but it can be a couple of days earlier or a couple of days later - although, Penny tends to avoid giving very long courses of stimulation as she feels its not usually helpful. 

Embryo transfer will usually be on day 2, 3 or 5 after egg collection.

Ideally, then, you will book a daytrip to Athens for your baseline scan, and make sure your baseline scan is ok before you book your flight out to Athens for cycle monitoring (day 7 of stimulation).  Its probably not sensible to book your return flight until after egg collection.   Bearing in mind that there are many places to stay in Athens, it makes sense to book accommodation for about 1 week initially, as you will always be able to find somewhere else if you need it.

14.1.2 Natural cycle own egg IVF
You will need to be monitored from at least 3 days before ovulation so that you can take a trigger shot at least 3 days before ovulation.  Ovulation usually takes place about 1 day after you see a positive result on an LH urine stick test, so you will need to estimate when your ovulation is likely to be based on previous cycles.   Ovulation normally takes place about 14 days before your period, so, say your cycle is usually 28 days, you would expect to ovulate on day 14 - and need to be ready to take a trigger shot on day 11.  Therefore, you would either need to get a scan locally on about day 10, or plan to be in Athens at around day 10.  If your cycle is normally 30 days, then you'd be expecting to need your scan on day 12 etc.

Egg collection will be 3 days after the trigger shot, with embryo transfer being usually 2 days after egg collection.

14.1.3 Natural cycle donor egg/embryo
This requires that there is at least one matching donor cycling who is expected to have egg collection at around the time of your ovulation - so you need to be in touch with the clinic on the day that your period starts to see if there is at least 1 possible matching donor for you.   In Penny's experience, even donors who normally have very regular periods often experience an unexpected delayed period when they are due to be starting their donor cycle due to anticipatory stress of cycling so its not uncommon for donors to be delayed in starting or substituted.  For ladies with common physical characteristics, there will often be several possible donors due to start within a few days of each other and Penny's view about the best possible choice for you (taking into account characteristics and timing, may well change between the start of your cycle and the donor's egg collection).  Serum will estimate your ovulation based on your previous cycles - either by assuming that its about 14 days before your period, or because you've previously been monitoring your cycles using LH urine sticks (ovulation normally takes place about 24-48 hours after a positive stick test).

You will need to monitor your cycle with LH urine sticks and will be aiming to have embryo transfer about 4-5 days after you see a positive result.

If your partner is providing fresh sperm, he will need to be in Athens on egg collection day - so he will get about 3 days notice of when he needs to be in Athens.

14.1.4 Medicated donor egg/embryo
You will either be starting estrogen medication on about day 2 or 3 of your natural period or at the clinic's convenience if you have down regulated.   The donor will start her stimulation drugs at the same as you start your estrogen.  Egg collection is typically on day 12 of the stimulation drugs/estrogen but it can be a couple of days earlier or later than that.   Additionally, if there is more than one possible donor matching your criteria due to be cycling within a couple of days, Penny may decide to delay the decision on which is the best donor to choose for you until egg collection so she can see how the response to stimulation has been.   In Penny's experience, even donors who normally have very regular periods often experience an unexpected delayed period when they are due to be starting their donor cycle due to anticipatory stress of cycling, so its not uncommon for to be delayed or substituted.  For ladies with common physical characteristics, there will often be several possible donors due to start within a few days of each other and Penny's view about the best possible choice for you (taking into account characteristics and timing, may well change between the start of your cycle and the donor's egg collection). 

If your partner is giving a fresh sperm sample, he will need to be in Athens on egg collection day, but there will only be absolute certainty about the date 3 days beforehand - when the donor is given her trigger shot.   If he can wait until 3 days before EC before booking his flights then he can have certainty.  Otherwise, he will need to be available possibly from day 10-14 from when you start estrogen.   

Embryo transfer will usually be on day 3 or 5 after the egg collection.

14.1.5 Natural cycle frozen embryo transfer
You would expect to be in Athens to have a transfer 4-5 days after seeing a positive LH pee stick test (assuming blastocysts).

14.1.6 Medicated cycle frozen embryo transfer
You would expect to start estrogen (e.g., cyclacur) on about day 2-3 of your period (or at your convenience after you have down regulated) and then have a transfer on about day 16-17 of your estrogen (assuming blastocysts).  Progesterone needs to be started about 4 days before transfer.  A scan may be needed on day 11 of your estrogen.


14.2   Checklist for booking your trip

(you will need a valid passport, E111 (which covers you for emergency greek 'nhs' treatment) card and you should consider medical tourism insurance especially if you are having OE IVF - you might want to look at
www.ivftravelshield.com
http://medicaltravelshield.com/
https://www.sevencorners.com/insurance/bordercross/HW32D3N - remember your existing travel insurance policy will probably not be valid if you are travelling specifically for medical tourism)

-   Try not to stress too much about booking your trip for DE or OE.  Penny won’t want to confirm the dates until your donor has been prescribed her trigger shot (or for OE until you have started your period and had your baseline scan), as until then, she can’t be sure how long your donor will take to stimulate (or exactly how long it will be until you can start stims if its OE).   For DE, once the donor's follicles reach the right size, Penny will prescribe the shot and then let you know to book your flights - its stressful and pointless staring at flight prices and hotel bookings until you know your dates and hassling Penny before she can give you a confirmed date is also pointless as she will ALWAYS tell you as soon as she knows because she will be seeing your donor every day waiting for trigger day.  Egg collection will usually be around day 12 of your estrogen/your donor's stimulation.  Trigger day will always be 3 days before egg collection.  Your donor will take the shot the same night its prescribed, then have a drug free day, then have her egg collection the following morning.   If your partner needs to provide a fresh sperm sample, he will need to be in Athens on egg collection morning, but if he has provided a frozen sample, he should not need to travel at all (unless he wants to, or if Penny thinks there might be a benefit in having the choice of a fresh sample as well as the frozen sample), and you will normally only need to be in Athens for embryo transfer on day 3 or 5 after egg collection (usually somewhere between day 14 and 19 after you start your estrogen/your donor starts her stims).   There isn’t much point in staring at flights and hotel bookings until you have a confirmed date – unless you are travelling from so far away that it makes sense for you to stay in Athens for the whole possible time (e.g,. probably day 14-19 for just embryo transfer, or probably day 11-19 for egg collection to embryo transfer).  From the UK there is always some way to get to Athens and there are always many hotel options.
-   Once you get the email confirming when you need to be Athens - check for any strikes or industrial disruption – try to avoid flying if the air traffic controllers or the airport staff are intending to be on strike – bear in mind that strikes are often cancelled at the last minute but its not something good to gamble on.  This blog is really good for up to date information on the Athens situation http://livingingreece.gr/strikes/.  If there are strikes, ash clouds etc affecting the UK end of your trip you’ll need to check the websites for the UK airports.
-   Book your flights – most ladies fly Easyjet from Manchester or Gatwick, or BA, BMI or Aegean from Heathrow.  I’ve enjoyed Aegean flights the most and Easyjet flights the least. But there are other options, e.g., Swissair flights via Amsterdam or summer charter flights (although these rarely go to Athens).   For Easyjet, its easiest to go direct to the easyjet.co.uk website.  For other airlines, skyscanner.net, travelsupermarket.com or kayak.com can help find the best prices.  In the unlikely event that flights to Athens are impossible, it may be possible to fly to another Greek airport and then get a ferry or a connecting flight.
-   If you fly Easyjet you can print off your boarding card as soon as you have booked and added your passport info – then you can use the ‘bag drop only’ queue at the airport
-   If you fly on the other airlines, you can usually check in and choose your seat 24-48 hours before your flight – and again, you can print off your boarding card before you fly.
-       Sometimes its cheaper to buy a package including flights and accommodate e.g., on britishairways.com (or expedia.com etc), but bear in mind Athens has MANY hotels but not that many which are really convenient for Serum so if you definitely want a hotel near the clinic then try to skim through the package offerings to find one of the hotels listed here.
-   Check you have enough medication to last you until you get to Athens and at least 1 extra day just in case.
-   Email Serum and confirm when you are arriving and ask them to email you a letter to take with you if you need to carry any needles in your hand luggage (you can carry drugs in your hold luggage easily, but for hand luggage, a letter is needed in the unlikely event that you need to prove that you need needles).
-   Book your accommodation – see Where to stay
-   Work out how you are going to get to the UK airport and book parking if needed (prebooked parking is always cheaper than turning up and parking at the airport) e.g., holidayextras.co.uk
-   Work out how you are going to get from Athens airport to serum/your hotel
-   Make sure your Serum bill is paid and arrange some currency (e.g., a prepaid currency card).
-             Print off your booking confirmations and make sure you have the address of the clinic and their phone number in your hand luggage.
-             Book travel insurance.  If you want to arrange specific insurance for your IVF - some ladies use IVFtravelshield
-             Make a note of your passport numbers, credit card numbers and the card company's phone numbers just in case you lose them
-             phone your mobile phone company to check whether you need to give advance permission to use your phone abroad
-             phone your bank and credit card companies to check whether you need to give advance permission to use your cards abroad

15.   Packing for your trip
Checked in bags do occasionally get lost, so its best to make sure you carry enough medication in your hand luggage to tide you over if your bag was lost e.g., until you get to Serum where you could buy more.   If you are taking clexane, gestone, or stims drugs you will have to carry needles – airport security normally aren’t bothered if the needles are small but can get more difficult if you are carrying large needles e.g., for gestone.   Its best to ask the clinic to email you a letter saying why you need the needles so you can carry it with you and show it if you get any problems, but in practice you will probably not need the letter.    Pack your needles (and any drugs that are in liquid form) in a clear plastic bag so you can show them separately to security if you are going to carry them as hand luggage.    Liquids/pastes in hand luggage are still limited - so remember you can't carry drinks/bottles of water through security (but can buy them afterwards - and you can carry an empty bottle/flask through security and then fill it with water after security) and can only carry them in up to 100ml volumes with a total limit of 1L in a single clear plastic bag no bigger than 20cm x 20cm.

Check the weather forecast – obviously its extremely hot in summer but also very cold in winter.

http://www.bbc.co.uk/weather/264371

http://www.weather.com/weather/tenday/Athens+Greece+GRXX0004

There can be a fierce wind in Athens which can carry a lot of grit, so you might want sunglasses whatever the weather.



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Offline agate

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Re: Agate's file of serum stuff-part 5
« Reply #4 on: 31/01/12, 16:18 »
16.   Checklist for going home after embryo transfer
Serum have helpful leaflets telling you when to test, when to stop your medication and other useful info - take a moment to sit down and read it before you leave so you can be sure you have everything you need to:


-   know when you are supposed to do a pregnancy test
-   understand what medication you are supposed to be taking and how long for
-   calculate how much medication you need to have to tide you until your pregnancy test and, maybe a week after that, just in case.   
-   In the rare case where you get a positive pregnancy test but only a slow rising betaHCG, Penny sometimes likes to try 3 ‘rescue’ shots of pregnyl 1500IU given on alternate days, in case it helps to rescue the pregnancy.   Pregnyl is cheap (about £2 per shot), but difficult to get in the UK at short notice, so you might want to ask about buying 3 shots to take home with you or ask for a prescription for 3 shots to take away and buy it from a UK pharmacy to keep just in case, although you are unlikely to need it (it does need to be kept in the fridge though).  Each shot of pregynl should raise your HCG level by about 45-60 IU/ml after 24 hours which drops to 15-30 IU/ml after 48 hours - so it will need to be taken into account if you are having a betaHCG blood test within 48 hours.
-   Buy whatever medication you need
-   Make sure you carry enough medication in your hand luggage to tide you over for a few days in case your checked bag gets lost.
-   Make sure you allow enough time to get to the airport and get through security – remember that there are only 2 metro trains per hour (and none at night) and sometimes there are long queues to clear security at the airport

At the airport:  if you have time, there is a free mini museum upstairs and a spectacular view of the planes from the gallery in Macdonalds.   If you want to buy food, the choice is better before passport control.  After passport control there is a much more limited selection.  After security there are only slot machines.   As with UK airports, the amount of liquids/pastes you are allowed to take through security is limited (and needs to be displayed in a small clear plastic bag when you go through security), but you can buy bottled water from the slot machines (50Eu) after security.  If you are travelling Easyjet, it is worth buying a sandwich before you fly as sometimes they run out and it’s a long flight if you are hungry.

17.   Cycle monitoring for an own egg IVF
Penny prefers to see you for a scan before you start your stimulation.  This would normally be a few days after your bleed if you are using a day 21 down regulated protocol, or during your bleed if you are using a natural cycle start.   However, it may be possible to arrange a scan locally and then either email her the results or phone her to discuss them.   You will need to know your lining thickness and the number of antral follicles on each ovary and their sizes.   This is basically a final check to determine whether there are any problematic cysts or dominant follicles and to check that the dose of stims drugs she has in mind is appropriate for the antral follicles that you are carrying this month.   If you have your baseline scan with Penny you can buy the drugs you need in Athens and bring them home with you, otherwise you will need to arrange to have bought the likely drugs already (e.g., using a prescription posted to you from Serum).

Once you start your stimulation drugs you probably won’t need to be seen until day 6 or 7, by which time you will need to be in Athens and will see Penny almost every day for a scan and bloods as needed.  If it is very difficult for you to be in Athens by day 6/7 it may be possible to have scans in the UK and email them to Penny but you would need to discuss whether this would be practical/appropriate in your case.

Once Penny is happy that the lead follicles are large enough, she will tell you to stop your stimulation (and any down regulation) drugs and give you the packet containing the HCG trigger shot.   If you are on clexane you will normally be told to pause it before the trigger shot until after egg collection day. HCG is taken 36 hours before egg collection, so usually that means it is taken at night so that egg collection can be scheduled in the morning.   The HCG packet contains a glass ampoule of powder and another of dilutant.  You will be given a syringe and needles (TIP: ask for an extra long needle to draw up the dilutant – its easier with a long needle and you don’t want to spill any!).   You will normally be told to give the shot into the upper outer quadrant of your buttock muscle (not in the belly like in some UK clinics)- you will need to use a mirror to make sure you jab the right place if you are travelling solo.   Some ladies will be given a double dose of the HCG, so you will need to draw up both doses into the same syringes (so you don’t have to jab twice).  Try to keep your HCG in the fridge until you need it.   (Tip: Before you leave the clinic with your HCG try to be absolutely sure you understand the timings and the instructions and have everything you need.   In an emergency, you will be able to contact Penny if you have a problem with your shot but it will probably be quite late at night so its best to try and be sure you have everything and understand what to do).

The day after your trigger shot is often called a ‘drug free’ day because you won’t be taking any stims or down regulation drugs (and you will been asked to stop clexane), but you will probably still be taking valtrex, doxycycline, filicine etc.

18.   Having your egg collection – own egg cycles
Egg collection is done at the clinic on the third floor in the morning - 7 days a week if necessary.  Serum tend to use a general anaesthetic for egg collection so you will normally be fasting (no food, drink or water) from midnight the night before - and will need to remove nail varnish and make up so that the anaesthetist can see your skin and nail colour at all times - I think you need to take off jewellery too. You will be shown up to one of the third floor recovery cubicles where you will need to undress fully and put on a disposal theatre gown and plastic bootees.    A surgeon and anaesthetist come to the clinic to perform the procedure but Penny is also with you during egg collection.  When the staff are ready you will go next door to the operating room and the doctor will put in a cannula and you will go to sleep for your egg collection.  If your partner is with you, he can wait in the recovery cubicle which is just a few feet away from the operating room.   If your partner is giving a fresh sperm sample, he will be asked to produce his sample in the room downstairs or if you are staying nearby he can take a sample pot back to the hotel if that he prefers that.    If he has trouble giving the sample, there is several hours degree of flexibility if he needs to wait and try again later. If you have concerns about sperm quality, you can ask to have a DNA fragmentation test run on the sample before it is used, particularly if you are considering whether to use donor sperm for some or all of your eggs.

When you wake up, you will be back next door in the recovery cubicle.  You will rest for as long as you need to, maybe about an hour, and will be free to go as soon as you feel ready to.  If you have had egg collection done elsewhere you may appreciate Penny's gentle approach.   She aims for quality rather than quantity and wants your body in good shape for embryo transfer in a few days time so she is very gentle.  She doesn't try to recover eggs from follicles that are obviously too small. So typically, you won’t feel too sore but will be advised to take it easy for the rest of the day and to try and eat some extra protein (milk, eggs etc) and drink plenty of fluids (especially if you have had a lot of eggs collected).    You will probably want to arrange to phone up or to pop back to the clinic on the following day to find out about fertilisation rates and to get an idea of whether you are likely to be aiming for a day 5 ET or a day 2 or 3.

After egg collection you will be given painkillers to take away and told when to start your progesterone (utrogestan/crinone gel/cyclogest/gestone etc).  Penny doesn’t like your progesterone levels to rise too quickly as it may shorten the implantation window so she may want to monitor your progesterone levels by blood tests.  In which case, you’ll go back to the clinic when requested to have blood drawn and then phone back later in the day to check whether you need to change how much progesterone (or estrogen) you are taking.

19.   Having embryo transfer – own egg and donor egg cycles

After you or the donor has had egg collection you will need to keep in touch with Penny to decide whether you are going to do a day 2, 3 or 5 transfer.   If there are many good looking embryos to choose from, a day 5 transfer will often be the preferred option, but an earlier transfer may make more sense if there are fewer embryos or if, for example, from your bloodwork (your progesterone level), Penny thinks your implantation window may be shortening.   Waiting until day 5 helps the embryologist weed out the least good embryos from a large batch but if there are only a few embryos then there may be no point in waiting until day 5.

For embryo transfer you will be given a (flexible) appointment time.  When the staff are ready, you will go up to the third floor and get fully undressed in one of the recovery cubicles and put on a disposable gown and plastic bootees.    If your partner is with you, he can normally gown up and come into the operating room with you.   If you are travelling with a baby they can also come in with you or wait with the reception staff. Before the embryo transfer you will probably want to discuss how many embryos to transfer with Penny.  Her advice will tend to depend on your fertility history, Thimmios' opinion on the quality of the embryos and whether you would be happy or unhappy to find you were having twins.   You will be able to talk to Thimmios directly - but his English is not as good as Penny and he can be hard to understand.   My impression of Thimmios is that he sees embryology as an 'art' and himself as an 'artist' just as much as a scientist.

If all your prognostic indicators (your lining thickness, your fertility history, the embryo quality look good), then typically your chance of getting pregnant might be around 60% but if you have more than 2 embryos put back the chance of twins will be quite high (maybe 30%), although live birth rates are a bit lower than pregnancy rates.  If you decide to have 2 embryo's put back the chance of twins should reduce (to under 25%), but the overall chance of getting pregnant will drop a little too.   If you have more than 2 embryos put back there is a small chance of becoming pregnant with triplets, but, according to serum, in this situation, it is rare for all 3 embryos to progress.  In the rare cases where ladies have become pregnant with 3 strong, continuing embryos, some ladies on the serum thread have opted to have a selective reduction procedure and have carried twins. 

When everyone is ready for your ET, you will be shown next door into the operating room and climb up onto the bench and put your legs into the stirrups.   Penny (or Dr Meridis) will insert the catheter and check its position using ultrasound.  Penny may take several minutes to decide where is the best position in your lining for the embryos to be placed.  If you have had difficult embryo transfers before, you might be pleasantly surprised how comfortable it is as Penny is very gentle and takes as much time as she needs to get everything right.  You should have no pain or discomfort (anaesthetics, painkillers etc are not normally required for ET). The nurse, Evalina usually assists Penny for embryo transfer.  Thimmios then brings the embryos from the laboratory next door which are ‘injected’ up through the catheter by Penny using ultrasound guidance.    After placing the embryos, Thimmios takes the catheter back into the lab and checks that the embryos have not been retained. Penny likes you to rest afterwards for at least half an hour or more.  If the room is needed immediately, you will be wheeled back out into the recovery room to rest there before you dress and leave the clinic.

Serum don’t have facilities to show you an image or give you a picture of your embryos.  Thimmios says that doing this is a waste of time because it won’t help you to get pregnant.    However, you will see the little white 'flash' on the ultrasound screen which is the bubble of fluid containing the embryos and Penny will give you a print out of the ultrasound screen showing the 'flash'.

After the embryo transfer, if there are any remaining embryos you will need to decide if you want to have them frozen.   Thimmios should be able to give you some guidance on their quality, but in general Penny seems to prefer fresh transfers as the success rate is higher.  However, particularly if its an OE cycle and the embryos look good, I would guess that most ladies would choose to freeze them.   Freezing costs 1000Eu so its not cheap, but that does include the cost of the follow up FETs (excluding medication).

Before you leave the clinic, you will need to make sure you have paid any remaining balance of your bill and will be given instructions on when to take a pregnancy test, how long to continue your medications, not to take baths or go swimming and to try and take it easy and not do any heavy lifting.   

Take some time before you leave the clinic to double check you understand the instructions and either have all the medication you need or have any prescriptions you need to buy it on your return to the UK.

You might want to save any bits and pieces from Athens to make a scrapbook for when you little one is old enough to understand the whole process.

20.   Other practical information

For the time now in Athens:  http://www.timeanddate.com/worldclock/city.html?n=26

Shops and many offices open in the morning from about 8am until about 1pm then close and reopen about 6pm-9pm.  Supermarkets tend to be open all day (not sunday as almost all shops except the many street kiosks, cafes, restaurants are closed on sundays).

There is no need to worry about travelling alone to Athens.  Its easy to get a free map from the airport information stand and to use the metros, buses and trams to get around as most signs are bilingual (greek and english).  Athens is safe and its safe for women to walk around at night - although, personally, I wouldn't go to the areas around Ommonia square, or the areas north of there e.g., around Larissa railway station or Metaxorgio, or Exarcheia after dark, and I wouldn't go near Syntagma if there are political demos, but the area near Serum (Kolonaki, Ambelokipoi, Megaro Moussikis is very safe.

Its worth posting your travel days on the Serum threads on fertility friends and keeping in touch on the internet whilst you are away - its very likely you will find other FF ladies who are at Serum overlapping with your trip who you can meet to chat with and maybe have coffee or lunch or a wander round.

Pickpockets are prevalent in some of the touristy places and on the metro – so it’s a bit worrying carrying cash.   As a general precaution, try to keep valuables out of site etc and make sure your pockets, bag etc are zipped up – and ideally, carry your handbag inside your coat etc and keep an eye on your phone and other valuables whilst you are in cafes etc.

Try to work out whether its cheaper to buy your drugs in Athens or in the UK (prices for drugs in Greece are regulated so in theory you can walk into any pharmacy and get the same prices as you would at Serum – pharmacies don’t use prescriptions – you just ask for what you need).   

Typical prices for a coffee to take away are about 2-2.5Eu (more like 3-4 Eu to sit in a nice café), but the discount chains like Goodys (a bit like Macdonalds) often have discounted snacks and coffee for 1Eu which are often advertised on boards outside the shops.

In the airport and on ferries, there are state regulated prices for bottles of water, coffee, cheese toasties and ham and cheese toasties which are quite a bit cheaper than open market prices e.g., 1.50Eu for a toastie vs 2.5Eu.

There are street kiosks everywhere selling water, snacks, milk, drinks etc which are convenient because they are open all the time, but the supermarket prices are cheaper (e.g., 1 Eu for a bottle of water vs 0.22Eu).

In some restaurants and cafes you have to pay for what you want at the till and then take the receipt to the server.

In 'proper' sit down restaurants expect to pay an automatic cover charge person which covers a basket of bread and sometimes (but not always) bottled water.

You can take a (very slow) tram to the seaside (Voula) from the stop at Syntagma – if you want a day doing nothing much but looking out of the window of the tram.

You can walk from the clinic to the Plata at Dimitriou Gouliamou and Mikras Asias if you want a nice plaza to hang out in (with cafes, benches, souvlaki, pizza etc) which isn’t very busy.

You can go and visit one of the nearby Islands like Agistiri but its probably not something you want to try and cram in as a day trip.

You can get lots of sightseeing info here: http://www.athensguide.com/

Several ladies liked the red bus tour of Athens.  http://www.city-sightseeing.com/?command=search&clear-search=true&destinations=Athens

The public bus company oasa did their own circular 'tour' bus the 400 round central Athens which was a lot cheaper (but had no headphones and no commentary) but its not running anymore.

Why not print off the greek alphabet (capitals and small letters) before you go so you can learn it on the plane.

http://www.greek-language.com/Alphabet.html

Just being able to read the letters means you can more easily choose your supper – as you will recognise simple words like pita and pizza.

Its worth investing in a pocket sized greek phrasebook if you are going to be in athens more than a couple of days - it makes it easier to find more budget (and tasty) choices to eat - so you won't end up at just the posh restaurants (with bilingual menus) or the Macdonaldsy hamburger chains like Goody's - but can easily pick something nice from the more modest local restaurants on the side streets. 

If you know there are going to be any demos, protests etc – stay away from Syntagma (the centre of the metro network) – all the trouble centres around the Parliament buildings there.

If you travel with someone else, you can buy a double or group ticket on the metro which is cheaper.

The tap water is perfectly safe to drink and brush your teeth with but it can taste quite chlorinated so its common to drink bottled water, or in some establishments, filtered water from a water dispenser.

If you try to dial someone in the UK on your mobile from Athens, if you have used their number before you left the UK, most mobile phones will automatically add the +44 prefix to the number for you, but if you are dialling a new UK mobile number, you will need to add +44 and remove the first 0.  Most UK mobile phones will automatically register on vodafone or wind telecom as soon as you switch your mobile on when you land in Greece - but you might want to double check your phone will allow you to call from abroad by phoning your mobile operator before you leave the UK.  To dial a number in Greece from your UK mobile its easier to dial the full international code 00 30 etc.

Some credit and debit cards may reject (large) payments from abroad.  If you haven't used your card abroad before, you might want to double check its approved before you travel - and be on the look out for texts on your phone from your credit card company asking you to phone them to approve an overseas charge.

There are ATMs at the airport, several on the main streets near Serum (e.g., near the Athens Tower) and dotted in all the main shopping streets in Athens.

If you need a urine pregnancy test whilst you are in Greece the brand to ask for (in pharmacies only) is Self Clear - obviously if you are near Serum, its probably easier to have a blood test.

Supermarkets don't sell any kind of pharmaceuticals - not even aspirin (and I don't think even plasters!)- you need to go to a pharmacy for all medication, but there are pharmacies dotted everywhere - identifiable with signs carrying a green cross.

If you want to try learning some greek before your trip, there is a free online greek course here: http://www.xanthi.ilsp.gr/filog/

21.   Eating out
My favourite thing to eat is a Yiro (γύρος - a rolled cone of flatbread (pita), filled with tomatoes (domates), salad (maruli), onions (kremethia), tsatsiki (yoghurt sauce) and either grilled chicken (kotopoulo) or pork (Hirno) and a handful of French fries (patatas).   Takeaway shops selling really nice Yiros or Souvlaki (σουβλάκι - similar to Yiros but the chicken or pork is grilled on a skewer and is a bit drier) are everywhere in Athens – they make a good budget meal for about 2-2.20Eu – and are much more delicious than anything we get in the UK – and I tend to buy a banana and a peach or an apple from a greengrocer to complete my meal.   If you want a budget vegetarian meal, you can ask for a vegetarian pita (or have it with tyri (cheese).  If you want a budget low carb meal, you can ask for chicken or pork souvlaki (skewers) without the pita (Horis pita).   The staff in To Saguri (the Souvlaki restaurant on the same street as Serum) are friendly and there is an English (Aglika) menu, but there are similar Souvlaki shops dotted everywhere.  If you want a place to have a snack, a drink and to hang out for a long chat near the clinic, To Saguri is a good place to start.

Common greek dishes are moussakka (aubergine, potato and mince baked with a cheese sauce) and Pastitsio (mince, cheese and pasta bake).   There are many baked vegetable dishes – e.g, baked cauliflower, or baked mixed vegetables (Briam), peppers and tomatoes stuffed with rice (gemista), dolamades (vine leaves stuffed with rice)  and also Gigantes (butter beans in tomato sauce) and Horta (cooked spinach and other greens in lemon and olive oil).  If you wander round the side streets you will find many small neighbourhood restaurants where you can eat in or take dishes away – if it looks busy, the food will be good!   Greek salad with cucumber, tomatoes and feta (horiatiki) is available everywhere but some other ‘salads’ are more like dips e.g., melitzanosalata is an aubergine dip, and tyrisalata is a spicy cheese spread that you normally have with bread.   Dishes with minced meat tend to be more often beef than lamb.

Το Αρχοντικό on Evrou (the street behind the clinic) or the Agora (Αγορά) (near Ambelokipoi metro station on the opposite corner to Applebees) are both nice restaurants for a smart dinner with your DH but not budget options.  There is noodle bar on Dimitriou Soutsou (the same road as the Agora) which is ok (see my map on google: http://maps.google.com/maps/ms?ie=UTF&msa=0&msid=216291340940802168436.0004afd491cb0e8b6162d)

In case you are eating a special diet (no milk, no gluten, vegetarian etc), I have made a handy list in greek and english - so you can cut and paste what applies to you and either print yourself off a card with your requirements on it to show to restaurant staff or you can do a tick and cross list of the foods you can and cannot eat.

https://docs.google.com/spreadsheet/pub?hl=en_GB&hl=en_GB&key=0Ah3l-_AvvCXydEE3VXhqTlJUT3YzOU5TYkVtSThTT2c&output=html

22.   Self catering
There are small supermarkets dotted everywhere. 

The greeks don’t seem to use as much convenience food as we do.  So  there aren’t as many ready meals but what is is very good quality (although not cheap) – so in most of the supermarkets you’ll find moussakka, pastitsio, horta (cooked greens in olive oil and lemon juice), peppers and tomatoes stuffed with rice, and even fresh ‘gourmet’ dinners like octopus salad or amazing stuffed squid.   You will also find frozen pizzas (but again, they are the more up market kind).    There is usually pesto if you want to make a quick pasta supper.   The range of tinned foods tends to be limited but you will find Gigantes (butter beans in tomato sauce), dolmades (vine leaves stuffed with rice) and meatballs as well as tinned tuna.

As you might expect, the range of fruit and vegetables is very good.

The large supermarkets like Carrefour (on Kiffisias near the President hotel) have a health food section so you might be able to find tofa, soya milk etc if you need them, but the selection is a lot less than in the UK, and you won’t find many health food shops.  I found one on Papadiamantopoulo street (see my map on google:http://maps.google.com/maps/ms?ie=UTF&msa=0&msid=216291340940802168436.0004afd491cb0e8b6162d)

Almost all shops are closed on Sundays (even supermarkets) and a lot of shops close in the afternoons and reopen in the evenings at about 6pm.  However, you can always find street kiosks selling milk, drinks, snacks, water day and night.   

If you need a snack, bakeries (usually the logo contains a sheaf of wheat somewhere) sell a selection of pies (tyropita – cheese, spanokopita (cheese and spinach) or cheese and ham.   Cafes also sell pies (pita), tost (toasties) and sandwiches (although sandwiches do tend to be ham, cheese or chicken – and cheese is usually feta or edam).  Coffee shops and bakeries are open long hours and the cake shops and bakeries sell an enormous range of cakes, biscuits, patisserie and ice creams.

If you buy fruit or vegetables at the supermarkets, usually there is a system where you have to get the stuff weighed and ticketed before you go to the checkout.

There are usually counters in the supermarkets where you can buy cheese (e.g., sliced edam, or feta) and ham/chicken/turkey etc) by the kilo which is easier than buying a whole packet if you are only trying to make one meal.   Some cheese, some salad and some bread is an easy meal to pick up.

Lots of the supermarkets have more than one floor, so if you can’t find what you are looking for, you may need to look for the stairs.

23.   Internet access
In an emergency (e.g., to print off a lost boarding card) the staff at Serum will let you use their computer.
Most hotels have internet (wireless in the rooms if you bring your laptop and sometimes a terminal in reception).   

Many cafes have free wireless internet if you have your laptop with you.

Some hotels will let you pay to use their reception terminal.  Otherwise, try Global on Mikras Assias near the corner with Faranton or Blaster.net on Padiamantopoulo also near the corner with Faranton which is cheaper.  At Blaster.net you can buy a 3 Eu membership which seems to last for ages.  At Global its about 2Eu per hour. (see my map on google:http://maps.google.com/maps/ms?ie=UTF&msa=0&msid=216291340940802168436.0004afd491cb0e8b6162d)

24.   TV and radio
In hotels there is often a small selection of english TV channels (e.g., BBC news 24 and CNN global).  Some of the greek channels e.g,. Star/Alta show a lot of american/UK shows in the evenings and on weekends which are in english but with greek subtitles.

Its hard to find english radio in Athens because most broadcasts including the BBC world service have switched to internet radio.

Its easy to go to the cinema if you want to, because most films are shown in English with Greek subtitles.

25.   Going to Athens with a baby or toddler

-   For the plane, I packed one Ziploc bag with 3 nappies, a small pack of baby wipes and 3 nappy sacks and another Ziploc with tissues, another small pack of baby wipes, mini Ziplocs of measured portions of baby formula, 2 clean bottles and toddler snacks.  I then packed both Ziplocs into a carrier bag with my snacks, bottled water and empty thermos and kept the bag under foot.   Then I have everything within reach and when baby needs a change I just grab the nappy Ziploc and leave the rest.  My baby is fussy about only having hot milk hence the thermos which I ask the cabin crew to fill with boiling water as soon as I get on board.   Then she can have a bottle as soon as we take off which gets her settled and helps her ears pop and another one whilst we are descending.  Aegean are probably the most helpful airline for travelling with a baby and give free toys and books.
-   You can easily buy nappies so you only need to take a few with you for your journey as there are many supermarkets but its hard to get anything on a Sunday as everything is closed.
-   Supermarkets don’t sell much baby formula – but pharmacies have a big selection – and greek versions of stuff you will recognise like Aptamil.
-   The greeks don’t use a lot of baby food so the choice is limited to 1 or 2 flavours of pureed fruit even in big supermarkets.   I think greek babies eat a lot of yoghurt with honey.
-   The staff at serum are always very happy to help mind your baby or toddler while you have your treatment – but its worth checking in advance that it will be ok.
-   There is a nice children’s playground on Mikras Assias near the corner with Faranton (see my map on google:http://maps.google.com/maps/ms?ie=UTF&msa=0&msid=216291340940802168436.0004afd491cb0e8b6162d) (and others in other areas) but I never understood the opening hours.
-   The pavements are narrow, obstructed by doorsteps and signs and the kerbs are high – if you take a stroller, consider buying a small, cheap umbrella stroller that you might have to throw away after its trip to Athens or a ultralightweight umbrella stroller.
-   Babies and toddlers often travel without car seats in Athens especially in Taxis but if you are worried about this, you might want to stick to the metro.
-   Almost all the metro stations have a lift if you look for it – although its usually only on one side of the road e.g,. at Megarro Moussakis, you might need to cross the road.
-   Supermarkets are often on 2 floors and there is no lift – so you might have to try another shop if what you want is on another floor.
-   The big Carrefour supermarket)on Kiffisias near the President hotel) has its food section in the basement so its difficult to get downstairs to it with a baby buggy.
-   Most restaurants don’t have highchairs but most hotels do – a Totseat or similar cloth highchair can be useful if your toddler will use one.
-   Greek restaurants and cafes tend to be baby-tolerant, and its generally a really nice experience to go out and about with baby in Athens - the taxi rank supervisors at the airport will often bring travellers with baby to the front of the queue, security has a fast track route for travellers with babies and in general, other travellers on the metro etc are helpful for ladies struggling with a stroller and a suitcase (but keep your handbag (cash, mobile phone etc) out of sight and under you coat just in case).
- Greek babies tend to wear shoes, even tiny babies, and are swaddled up in very warm clothes even when it feels hot compared to back home - expect lots of strangers to stop you in the street and tuck your baby in, do their jacket up, or even be shocked that your tot is 'underdressed' - even when you think they are close to suffocating with the heat!
- Greek baby clothes assume that reusable nappies don't exist so are too small to accommodate a tot in a proper nappy!
- Sometimes the wind in Athens can be quite fierce and dusty - you might want to think about rigging up some sort of screen across your stroller to stop sharp grit blowing into baby's eyes, if baby will let you - you and older children will probably want sunglasses because of the grit.

26.   With love from Agate

If you've read this far and found this post useful... and you end up deciding to go to serum - best of luck and don't forget to give my love to Penny and the other staff at Serum!

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