Assisted Reproduction in Greece in the Context of Medical Tourism: A Review of Legal, Medical, Economic, and Social Dimensions

Abstract

Assisted reproduction is a rapidly expanding pillar of medical tourism. Greece combines a liberal legal framework, internationally accredited clinics, and comparatively competitive costs, attracting cross-border patients seeking ART services. Following the 2022 amendment (Law 4958/2022) which amends the original law n.3305/2005, treatment is permitted up to age 54 under specific authorization, while court-approved surrogacy, anonymous gamete donation, and the adoption of decision-support technologies (e.g., AI-assisted embryo assessment, PGT-A) underpin the sector’s growth. This review synthesizes legal, medical, economic, and social dimensions, drawing on Q1 literature and official datasets (WHO, OECD, ESHRE/ICMART), and compares Greece with Spain, the USA, the Czech Republic, and Ukraine. Quantitative indicators include age-stratified success rates and indicative treatment costs. We discuss benefits and risks for patients and the health system, highlighting policy options for sustainable, ethically robust reproductive tourism in Greece.

1. Introduction

The medical tourism sector is constantly evolving [1] and is of global importance, as it combines the desire for access to specialized medical services with the pursuit of quality experiences for travelers [2].

Assisted reproduction, with in vitro fertilization as the main method, has established itself as one of the most important sectors of medical tourism. Its growth rates are impressive, and the global market is constantly expanding [3,4]. According to the National Authority for Medically Assisted Reproduction [5], more than 9 million children have been born using assisted reproduction techniques since 1978. The increasing flow of people seeking access to fertility treatments outside their national borders, known as “reproductive tourism” or “cross-border reproductive care”, is due to several different reasons. Restrictive laws in the countries of origin, increased medical costs, limited access to technologies and even ethical and cultural barriers [6,7]. Greece, thanks to its liberal legal regime, modern infrastructure in the health sector and competitive cost of services, has become the preferred choice for thousands of couples every year [8].

The Greek National Authority for Assisted Reproduction has observed a continuous increase in the number of foreign visitors choosing Greece for fertility treatments. This increase is particularly evident among people from countries with strict laws, such as Germany, Switzerland and Italy. The increasing age at which women become mothers in Western societies [9], the increase in infertility cases and the demand for modern technologies, such as preimplantation genetic diagnosis and the use of artificial intelligence in embryo selection, have developed and are strengthening people’s interest in solutions beyond national borders [10]. The World Health Organization [11] recognizes infertility as a public health issue affecting more than 15% of couples of childbearing age worldwide [12]. The Organization for Economic Cooperation and Development [13] emphasizes that assisted reproduction is a sector of great strategic importance, which requires policies based on sustainability, transparency and international cooperation. At the same time, organizations such as the United Nations Educational, Scientific and Cultural Organization (UNESCO) and the World Tourism Organization (UNWTO) focus on the need to uphold ethical standards and respect human rights [14,15].

Greece has multiple prerequisites for the development of a strong fertility tourism sector. It has highly educated medical and paramedical staff, as well as clinics that carry international certifications such as: ISO, TEMOS and GCR, a legal framework that facilitates practices such as anonymous egg donation and surrogacy, while at the same time exploiting digital technologies in assisted reproduction [16].

Fertility tourism is considered not only a medical issue, but also a socio-economic dynamic. According to Eurostat [17], the decline in birth rates in Europe makes it imperative to support reproductive health care. Assisted reproduction tourism also contributes to employment growth [18], in local communities and to the creation of new professional sectors such as patient coordinators, legal advisors and fertility consultants. Christoforidis and Anastasiadou [19] point out that human resource management in assisted reproduction facilities is directly related to the quality of services offered, as well as the ability to attract international patients [20].

Within this field, the aim of this study is to conduct a systematic analysis of assisted reproduction in Greece as a form of health tourism. The legal regulations, medical methods and technologies, as well as economic data are analyzed. The methodological approach is based on high-level international sources (Q1), includes quantitative and qualitative data, as well as a comparative analysis with other countries.

The aim is to promote Greece as a leading global destination for quality and safety in the field of reproductive tourism. Health tourism, and more specifically reproductive tourism, is a rapidly developing area internationally [3,21]. Assisted reproduction includes techniques such as in vitro fertilization, egg or sperm donation, gamete cryopreservation and surrogacy. In Greece, these treatments are offered in modern clinics with international accreditation, attracting couples from Europe, the United States and the Middle East [5]. The role of health travel agencies is crucial, as they facilitate the direct connection of international patients with fertility centers. The World Tourism Organization [15] recognizes the continuous growth of medical tourism, mainly in the field of assisted reproduction. It is important to mention that, globally, by 2020 [11] almost 9 million children have been born with the help of assisted reproduction, which demonstrates the spread of this technology.

Legal Framework

Greek Law 3305/2005 [22] establishes the core framework for medically assisted reproduction. According to its recent amendment in 2022, it allows treatment for women up to 54 years of age and introduces the possibility of surrogacy [23]. The new legislative intervention (Law 4958/2022) [24] increased the age limit for women interested in undergoing assisted reproduction medical procedures from 50 to 54 years. This is subject to obtaining a special permit from the Greek National Authority for Medically Assisted Reproduction earlier [16,25,26]. Greece offers protection to couples of all family forms, making it attractive to citizens of countries with stricter laws [6,7]. Greece also offers the possibility of anonymous egg donation, which is another important advantage compared to countries such as Germany and Italy, where restrictions are more stringent. Furthermore, it stands out for its transparency in consent procedures, mandatory psychological screening and clear certification procedures for assisted reproduction units by the Greek National Authority for Assisted Reproduction. Although there are positive elements, steps are proposed for the continued upgrading of legislation, such as the incorporation of international agreements on the rights of children born through surrogacy [27].

2. Method

This study adopts a multidimensional methodology, combining quantitative and qualitative analytical tools to examine in depth the phenomenon of fertility tourism in Greece. The research uses information from reliable international and national sources.

Stages of the methodological approach. Indicators include age-specific success rates, indicative cost ranges, and cross-country comparisons (Greece, Spain, USA, Czech Republic, Ukraine). Ethics & validity: triangulation, stratification, thematic analysis; data basis: from open data and official registries (

Table 1. Stages of Methodological Approach.

Stage	Description
Selection of thematic axes	Legal, medical, economic, social and political level
Data collection	WHO, OECD, ESHRE, EHRE, scientific literature, national registries, Online references
Quantitative analysis	IVF rates, age-specific success rates, costs
Comparative evaluation	Greece vs. Spain, USA, Czech Republic, Ukraine
Ethics and validity	Triangulation, stratification, thematic analysis, based on open data

).

This research uses a combination of qualitative methods, utilizing information from international and national organizations, high-level literature (Q1) and comparative analysis based on open data.

The references include the World Health Organization (WHO), the Organization for Economic Co-operation and Development (OECD), as well as the European Society for Human Reproduction and Embryology (ESHRE) and official data from Greek clinics, as well as from the National Authority for Medically Assisted Reproduction of Greece.

The analysis focuses on five main dimensions of the phenomenon: (a) the legal dimension, (b) health infrastructure, (c) economic factors, (d) the element of moral and social discourse and e) the corresponding political strategies.

The data collection was implemented, with a source of secondary data and official reports, during the years 2022–2024. Greece was also analyzed for the purpose of comparison with four other countries, the USA, Spain, Ukraine and the Czech Republic, in order to identify the relative strengths and weaknesses of the Greek model.

Quantitative data were collected using indicators such as IVF success rates by age group, average treatment cost, number of international assisted reproduction cycles per year and social acceptance indicators [28,29]. The literature review was conducted using reliable databases such as Scopus, Web of Science and PubMed. The selection criteria included publication in Q1 journals and thematic relevance to the subject under consideration.

The analysis also includes qualitative data derived from interviews with managers of assisted reproduction clinics in the cities of Athens, Thessaloniki and Crete, as well as with experts in the field of medical tourism. The interviews were conducted in a semi-structured manner, with the aim of collecting critical information on patient flow management, adherence to quality standards and cross-cultural adaptation of services.

The case study focuses on health policy and techno-economic evaluation.

In addition, special attention was paid to maintaining research ethics, including complete anonymity and participant consent.

The analysis included categorization with thematic analysis, while the quantitative data were analyzed with SPSS v27. The data layout revealed significant developments and patterns in the assisted reproduction markets around the world, as well as in Greece.

2.1. Financial Data and Comparisons

Greece offers comparatively lower-cost ART without compromising service quality. Indicative list prices place a standard IVF cycle at €5000–8000 in Greece, versus €5900–8500 in Spain and >€15,000 in the United States. Egg-donation programs average about €4500 in Greece, while comparable programs in the United States are typically around €20,000 [5,30] (

Table 2. Comparison of IVF and donor egg IVF costs (€) in selected countries.

Country	Cost of In Vitro Fertilization with Donor Eggs (€)	Reference
Greece	5000–8000	[31]
Spain	5900–8500	[32]
USA *	16,000–34,000	[33]
Czech Republic	3800–5500	[34]
Ukraine	4000–7000	[35]

* Notes: (i) Amounts are indicative list prices compiled from openly accessible clinic/portal sources; (ii) inclusions vary (e.g., ICSI, medications, freezing, PGT-A) and may affect totals; (iii) USD figures were converted to EUR at the rate used in the manuscript timeline; (iv) references [31,33].

).

The total cost cycle for each international patient includes accommodation, transportation, medication, translation and legal support services. The economic impact also boosts Gross Domestic Product (GDP) through linkages with other sectors (tourism, catering, retail) [36]. According to the Organisation for Economic Co-operation and Development [13], medical tourism in reproductive treatments can boost growth through technological innovation and human resource expertise. In addition, attracting assisted reproduction patients can lead to investment in local communities, boosting infrastructure and employment.

2.2. Social and Ethical Factors

Greek society shows a high acceptance of assisted reproduction, especially compared to countries with a strong Catholic or Muslim religious background [29]. Although the Orthodox Church maintains a conservative position, it does not intervene institutionally. However, there is intense public debate on the ethics of surrogacy, the protection of donors, and the child’s right to the truth about his or her origin [37]. Legislative provisions on donor anonymity conflict with the international trend towards open ID donation [38]. The need to continuously improve information and support for participating couples remains [39]. UNESCO [14] points out that any reproductive care policy must take into account the dignity and autonomy of all those involved, as well as the social inequalities that are likely to be exacerbated by international reproductive tourism.

3. Results

In the comparative assessment between Greece, Spain, the USA, the Czech Republic and Ukraine, Greece holds a competitive position, especially in terms of cost, legal flexibility and availability of methods. Spain, despite offering advanced technology, prohibits surrogacy, limiting demand from patients with such needs. In the USA, the cost is many times higher, but patients have access to commercial surrogacy and highly personalized services. The Czech Republic offers affordable packages but is limited by legislation for same-sex parents. Ukraine, despite low prices and legal acceptance of commercial surrogacy, faces obstacles due to political instability and deficiencies in quality controls [5,11,15] (Table 2).

Greece, on the other hand, has a combination of advantages: recognized legality of surrogacy, strong quality certifications (TEMOS, GCR), relatively low costs, political stability and high social acceptance. These factors make the country a top choice in the context of reproductive tourism. Greek society shows a high acceptance of assisted reproduction, especially compared to countries with a strong Catholic or Muslim religious background [29]. Although the Orthodox Church maintains a conservative position, it does not intervene institutionally. However, there is intense public debate on the ethics of surrogacy, the protection of donors, as well as the child’s right to the truth about his or her origin [37]. Legislative provisions on donor anonymity conflict with the international trend for open ID donation [38]. The need for continuous improvement in information [39] and support for participating couples remains. UNESCO [14] points out that any reproductive care policy must take into account the dignity and autonomy of all those involved, as well as the social inequalities that are likely to be exacerbated through international reproductive tourism.

3.1. Discrete Comparative Presentation: The Case of Canada

Canada is a steadily growing destination in the global assisted reproduction market, with a particular regulatory and ethical-political background. The country allows surrogacy and gamete donation only on a non-commercial basis, prohibiting any kind of financial compensation other than covering expenses [40]. While this promotes ethical transparency, it limits the availability of donors and surrogates.

At the provincial level, the public health system (Medicare) provides partial coverage for IVF (e.g., Ontario Fertility Program), but most treatments are performed in the private sector, with costs per cycle exceeding CAD 12,000 on average. Waiting lists at public clinics exceed 12–18 months, leading many couples to choose fertility tourism to Greece and other European countries [11].

IVF success rates in Canada are high (36–42% per embryo transfer), with an emphasis on the use of advanced PGT-A techniques and time-lapse monitoring. At the same time, the country is actively investing in fertility research, with university centers such as Mount Sinai Fertility and McGill Reproductive Centre to collaborate closely with state agencies [11].

However, the prohibition of monetary compensation, combined with limited public coverage and an orientation towards ethical acceptance, differentiate the Canadian model from the Greek one. Greece offers combined advantages: technological adequacy, a more flexible legislative framework, lower costs and immediate availability, making it attractive for Canadian couples seeking alternative IVF solutions abroad.

3.2. IVF Outcomes by Age Group (Pregnancy and Live-Birth Rates)

Age-stratified ART/IVF outcomes are presented in

Table 3. Data-IVF Success Rates by country and age group.

Country	Age Group	Pregnancy Rates (%)	Delivery Rates (%)	Reference
Greece	<34	53.2	30.6	[41]
	35–39	44.8	26.6	[41]
	≥40	33.2	15.7	[41]
Spain	<34	41.8	31.4	[41]
	35–39	34.9	24.3	[41]
	≥40	23.6	14.0	[41]
Ukraine	<34	51.2	42.1	[41]
	35–39	48.6	37.5	[41]
	≥40	40.4	26.5	[41]
U.S.A.	<35	65.3		[42]
	35–37	35.7		[42]
	≥37	56.3		[42]

. For European countries (Greece, Spain, Ukraine), data refer to FER/FET (frozen embryo replacement/transfer), presenting pregnancy rate and delivery/live-birth rate by age bins <34, 35–39, ≥40 (data source from references [31,32,33,34]; no data were available Czech Republic). For the USA, data originate from the Morbidity and Mortality Weekly Report (MMWR) of the Center for Disease Control and Prevention (CDC), Assisted Reproductive Technology Surveillance-United States [33] and present the percentage of ART cycles resulting in a live-birth by age group <34, 35–39, >40.

The legal status of surrogacy in the reference countries (Greece, Spain, USA, Czech Republic, Ukraine) is summarized in

Table 4. Legal Status of Surrogacy in Selected Countries.

Country	Legal Status of Surrogacy	Reference
Greece	Allowed under conditions	[24]
Spain	Not provided for by law	[43]
USA	Allowed on a case-by-case basis per State	[44]
Czech Republic	Not provided for by law	[45]
Ukraine	Allowed in commercial form	[46]

, where the key parameters that determine access and legal recognition are presented, namely: type of permissibility (prohibited/permitted-altruistic/permitted-commercial), prerequisites (e.g., prior court authorization, contractual requirements), and recognition of parentage (pre-birth or post-birth orders).

4. Discussion

Assisted reproduction in Greece presents a multifactorial and multifaceted profile that deserves special analysis. This discussion examines the main components emerging from this study: the comparative evaluation of the Greek assisted reproduction model, the challenges arising from the transnational dimension of health tourism, social acceptance, medical and ethical implications, and the country’s potential as an international center of reproductive care.

Strategic Advantages: Greece brings together advantages that make it an attractive destination for reproductive tourism: institutional framework that allows services such as surrogacy, donor anonymity and a maximum age of 54 years, technological innovation, such as the use of AI, PGT and culture new generation media and its geographical location that makes it easily accessible from Europe, the Middle East and North Africa. International organizations such as WHO and UNWTO recognize Greece as a rising pole on the global fertility map.

Risks and Challenges of Medical Tourism: Medical tourism comes with inherent challenges: potential inequality in access for domestic patients; need for harmonization with European and international regulations (e.g., GDPR, WHO Assisted Reproduction Guidelines) and the risk of commercialization of medical practice. Also, the lack of regulation of intermediary services may lead to misinformation of patients.

Cross-Border Rights and Legal Conflicts: Greece faces legal challenges due to the different legislations per country. Couples who proceed with surrogacy in Greece may not be recognized as parents in their home country [6]. The European Court of Human Rights and the principles of the Hague Convention create regulatory challenges. Cooperation with the European Union on a single regulatory framework is crucial.

Ethical Issues and Social Dialogue: Reproductive medicine raises profound ethical dilemmas: from donor anonymity to “characteristic selection” of embryos. UNESCO recommends a regulatory framework that respects human dignity [47], while ESHRE encourages transparency and psychological support. Society must take an active role in the dialogue on the future of assisted reproduction through public consultations and institutional education.

Data, Technology and Security: Artificial Intelligence, blockchain for traceability [48] of genetic material and big data analytics for treatment cycle success are transforming assisted reproduction. However, these developments raise issues of bioethics and personal data security. The WHO and OECD recommend strict security standards and national oversight of the analysis and storage of such data.

Connecting fertility tourism with smart technologies tourism and the digital reputation of medical destinations is a rapidly developing field. As analyzed by Anastasiadou, Masouras and Papademetriou [49], the use of technologies such as interactive experience platforms [50], digital service systems and the reputation of the destination in cyberspace play a key role in shaping a positive intention to revisit. Especially in the field of assisted reproduction, patients’ trust in Greek centers is enhanced by the transparency and digital visibility of services. These findings confirm that the strategic integration of smart tourism technologies can further enhance Greece’s competitiveness on the global map of reproductive care.

Health Policy and Sustainability: The sustainable development of the assisted reproduction sector requires supportive policies: creation of public Assisted Reproduction Units for domestic citizens, subsidized packages for low-income patients and systematic evaluation through a national registry. Policy proposals include the definition of a “National Assisted Reproduction Roadmap” in collaboration with the European Union, support for the research ecosystem and transnational quality certification of Assisted Reproduction services.

Furthermore, human resource management in assisted reproduction units is a critical factor in maintaining the overall quality of services. As highlighted by Christoforidis and Anastasiadou [19], strategic human resource management is not only supportive, but also crucial for the success of any Total Quality Management (TQM) effort. Appropriate personnel management practices, continuous training, adherence to health and safety procedures, and a patient-oriented approach enhance the competitiveness and sustainability of any assisted reproduction organization. Therefore, the integration of TQM and HRM principles can act as a pillar of development for reproductive care in Greece. Furthermore, according to the recent study by Christoforidis et al., [50], the internal culture of quality in health structures cannot be achieved without the active participation of human resources, which is the main agent of transformation towards health excellence systems. Strategic alignment of HR practices with quality indicators and change management through participatory leadership mechanisms fundamentally enhance the operational sustainability of assisted reproduction units.

Future Directions: Strengthening Greece’s international position in fertility tourism depends on a balance between technological innovation, legal adaptability, social acceptance and cultural sensitivity. Given global demand and declining fertility [13] (OECD, 2021), Greece can lead in terms of quality, safety and human respect.

The Greek model benefits from clear judicial pathways for surrogacy, donor anonymity, and extended age eligibility under authorization, complemented by internationally accredited clinics and the adoption of decision-support technologies. Risks relate to equitable access for domestic patients, registry completeness, and harmonization with European and international norms (e.g., data protection, donor–offspring rights). Policy options include strengthening the national ART registry, external quality audits, integrated psychosocial counselling, and transparent cost reporting.

4.1. Weaknesses and Challenges: Weaknesses of the Greek Assisted Reproduction System

4.1.1. Insufficient State Supervision and Control

Notably, the National Authority for Assisted Reproduction (NAAR) has limited human resources and infrastructure for the effective control of all units. On the other hand, in many cases, compliance with ISO standards and reporting of success are not systematically checked [24,26].

4.1.2. Lack of National Registry and Data Interoperability

A key structural weakness in Greece concerns the absence of a unified national registry and interoperable data systems. At present, there is no fully functional mechanism for recording the number of treatment cycles, their outcomes, the types of interventions applied, or donor information. This lack of digitalization not only undermines transparency but also hinders evidence-based policy design and long-term strategic planning [24,26].

4.1.3. Insufficient Government Support and Subsidy

Another persistent challenge is the limited governmental support and subsidy for assisted reproduction. The sector remains largely privatized, with only a few public facilities providing restricted access to services. While the National Organization for Health Care Services Provision (EOPYY) partially reimburses a limited number of treatment cycles, several advanced techniques—including preimplantation genetic testing for aneuploidies (PGT-A), vitrification, and embryo glue—are excluded [22,24,26].

4.1.4. Different Levels of Quality and Infrastructure Between Centers

Considerable disparities also exist in terms of quality standards and infrastructure among assisted reproduction centers. Some units are internationally accredited and equipped with state-of-the-art technology, while others continue to operate without adequate external quality control mechanisms or sufficient laboratory capacity. Although many embryologists and gynecologists are highly skilled, there is no national mechanism for professional development and lifelong learning, and staff retraining programs are not systematically implemented [24,26].

4.1.5. Gaps in Mental Health Support and Counseling

Equally pressing are the deficiencies in mental health support and counseling. Despite the well-documented psychological burden of assisted reproduction, most clinics in Greece do not provide structured counseling or integrate mental health services into routine patient care [22,24].

4.1.6. Ambiguities and Ethical Challenges in Legislation

From a regulatory perspective, the legal framework presents ambiguities and unresolved ethical challenges. While Greek legislation is more liberal than that of many European countries—permitting, for example, surrogacy—uncertainties persist regarding the citizenship of children born through assisted reproduction, the procedures for consent, and the rights of donors. Furthermore, the anonymity of donors remains a subject of consultation at the international level [26].

4.1.7. Insufficient Interconnection with Research Institutions and Universities

Finally, there is a notable lack of institutionalized collaboration between assisted reproduction units and academic or research institutions. Although Greece has a strong research community with expertise in reproductive medicine, these connections are not institutionally strengthened, limiting the potential for systematic knowledge transfer and innovation [26].

5. Conclusions

Greece has established itself as an attractive destination on the global map of assisted reproduction tourism, leveraging its favorable legislative framework, high level of medical services, relatively low costs and social acceptance. Greek assisted reproduction units are attracting more and more international patients, especially from countries with restrictive or costly reproductive care policies.

Comparative analysis with countries such as Spain, the USA, the Czech Republic and Ukraine demonstrated that Greece effectively combines institutional stability, affordable prices, technological innovation and a human approach. The existence of certified centers, accessibility to specialized techniques (e.g., PGT-A, AI embryo selection), anonymity in donation and the possibility of legal surrogacy create a competitive advantage.

However, challenges remain: the need for transnational harmonization of legal frameworks, ensuring ethical practice, protecting personal data and preventing the commercialization of reproduction. Furthermore, continued investment in human resources, infrastructure and cutting-edge technologies is essential for the sustainable development of the sector.

Overall, Greece can emerge as a model country in fertility tourism, provided it maintains the strategic balance between quality, accessibility, social sensitivity and international cooperation.