Vangelis Stathopoulos, who is in Greece’s Larissa prison, is one of more than half a million people incarcerated in Europe amid the COVID-19 pandemic. And, like so many others, the prison where he is being held is an ideal breeding ground for viruses: it’s overcrowded, with cramped living arrangements, and often poor hygiene conditions.

“When I got COVID last December, around half of the prisoners in here were sick at the same time,” Stathopoulos says. “We were put into a ward with 60 people, in a space of around 110 square meters (1,200 square feet). It was a roll of the dice whether you were going to be severely or just mildly ill.”

Korydallos prison in Greece

During the pandemic, we have become accustomed to meticulously updated COVID-19 dashboards and kept a close public eye on settings vulnerable to outbreaks, such as care homes. Yet little data has been made public about the spread of the coronavirus in carceral facilities.

Together with 11 newsrooms in the European Data Journalism Network, DW has collected data from 32 countries that show how many cases and deaths were reported in prisons, how vaccinations progressed, and what measures were taken to curb the spread of the virus.

“Many prisons are overcrowded, with no possibility for physical distancing,” says Filipa Alves da Costa, a public health consultant for the World Health Organization’s Health in Prisons Program. “So, when the virus gets carried in, it gets transmitted much more easily.”

Incarcerated people vulnerable

Da Costa says the risk in prisons is similar to that faced by people living in congregate residential facilities such as care homes and shelters.

Many incarcerated people have multiple factors that put them at increased risk of severe COVID-19, including conditions such as HIV and histories of smoking or other drug use. Marginalization, poverty and poor access to health care often take their tolls on such populations even before incarceration, and prison conditions frequently have an exacerbating effect, the WHO has found. “We actually consider people in their 50s as elderly already in prisons, even though in the community they wouldn’t be,” da Costa says.

COVID outbreaks in prisons affect everyone

Outbreaks in prisons affect not only the people who are confined or working there, but also the surrounding communities. “It’s not a totally closed environment,” da Costa says. “People come in and out every day. Not only staff, but also service providers, lawyers, and prisoners themselves. So, if you’re not protecting prisons, you’re not protecting the community.”

In the US, where the coronavirus quickly swept through prisons in 2020, multiple case studies show how outbreaks in prisons spread to surrounding communities. A nationwide comparison found that COVID-19 cases grew more quickly in counties with more incarcerated people, and linked mass incarceration to more than half a million additional COVID-19 cases inside and outside prisons.

The most recent Europe-wide data collection, by the University of Lausanne, reported case numbers in prisons through September 2020. More than a year has passed since, with multiple waves, new variants and a global vaccination campaign.

First responses shut down all activity

A study by researchers in Barcelona shows that most countries locked down prisons hard and fast at the start of the pandemic.

Visits were immediately stopped or severely limited in virtually all countries. In many prisons, sports, recreational activities and work were also suspended and prison leave schemes were put on hold.

“Even our letters were quarantined,” recalls Csaba Vass, who is in prison in Hungary. Countries such as Germany, Belgium and Hungary quarantined new arrivals and prisoners who showed symptoms.

Prison infection rates follow the general population

Data collected for this investigation now show that, at first glance, these measures seem to have helped avoid the worst: Prisons have, overall, not become runaway COVID hot spots. According to the data available, infection rates in prisons in many countries seem to roughly parallel those of the population in general. 

Where infection rates were high in the general population, they also tended to be high in prisons. This is true, for example, in countries such as Slovenia, Estonia and Belgium, where more than one in 10 people have tested positive already.

In countries such as Croatia and Greece, prisoners are infected at a much higher rate than in the general population. But, in many countries, reported cases in prisons remained below the level of the general population, according to the latest available data — even in Hungary and France, countries with notoriously overcrowded prisons.

Even in countries with lower infection rates, individual prisons can still be the sites of serious outbreaks. Just recently, more than 50 people tested positive at Béziers prison in France, which currently confines 638 people to a space built for 389. 

Cases and deaths may be underreported

Official numbers may not always tell the whole story. Most prison administrations don’t collect data systematically, says Adriano Martufi, who researches prison conditions in Europe at Leiden University. “My feeling is that there is certainly a problem of underreporting,” Martufi says.

The Larissa prison in Greece, for example, had reported only 200 cases officially through July 2021. Stathopoulos says he has counted far more. “Just between December 2020 and now, I believe we’ve had more than 500 cases,” he says.

Underreporting might not necessarily be deliberate — it could also be the result of organizational challenges. “Health services in prisons are understaffed, underequipped,” Martufi says. “I’m not even sure whether they have the technical capability to collect and handle such data.”

Low case numbers come at an exorbitant price

Even if infection numbers are taken at face value, the restrictions imposed to curb the spread of the coronavirus often have side effects of their own. “The tragedy that we feared did not happen, but only with enormous sacrifices for the prison population: no more activities; an end to teaching; an end to what little work exists in prison, and so on,” Dominique Simonnot, who heads France’s independent public body for overseeing conditions at places where people are deprived of liberty. “In social terms the price is exorbitant.”

For the past 18 months, many prisons have established lockdown measures that put inmates in especially harsh conditions.

One prison in Malta kept new arrivals in a cell with just a floor mattress and an open floor toilet 23 hours a day for two weeks, in conditions that the European Committee for the Prevention of Torture had already condemned in 2013. 

Quarantine confinements pose serious health risks

The UN’s Nelson Mandela Rules, or Standard Minimum Rules for the Treatment of Prisoners, state that solitary confinement should only be used as a last resort, for as short a time as possible, and never for more than 15 days. But, during the pandemic, isolating prisoners has become a standard measure in many countries.

In Ireland, where incarcerated people 70 and older or with chronic illnesses were automatically placed in solitary confinement between April and June 2020, detainees in such isolation reported feeling depressed and even suicidal.

In some facilities in Germany, pretrial detainees were isolated for 14 days after each court hearing. 

In France, two-week isolation was mandatory after any leave of absence, family visit or outpatient medical treatment, says Dominique Simonnot, the country’s chief prisons inspector. “As a result, some are refusing these trips, with all the risks that this implies for their health.” 

And even people who weren’t under quarantine were often restricted to their cells for large parts of the day and left with very little to do to pass the time.

‘Lifeline’ for prisoners cut as visits stopped

Prohibitions on visitors were also especially difficult for many incarcerated people.

“Visits are an immensely important lifeline for prisoners,” says Catherine Heard, director of the World Prison Research Programme. “It’s hard to overstate just how much of a difference it makes to them, being able to stay in touch with families and loved ones.”

Prisoners have a right to family life, according to the European Court of Human Rights.

In October 2020, people incarcerated at the Rec prison in Albania launched a hunger strike to protest the suspension of visits when the pandemic was declared. They had only been able to contact families by phone since that March.

In Hungary, Vass says, “We had two and a half hours of physical contact twice a month before the pandemic — the lack of that caused very serious mental problems.” The prison eventually set up video-calling options to at least permit virtual visits. “That made it easier,” he says. 

Most countries introduced measures for virtual visits, although low connection speeds and usage restrictions still pose problems. “There’s been a huge leap forward in many prisons across Europe to develop videoconferencing systems,” Martufi says. “That was absolutely unthinkable in many member states before the pandemic. So that was a positive development.” 

Martufi says one possible risk of this is that prisons could attempt to use video calls as a replacement for in-person visits in the long term. “We have indication that some prison administrations said: ‘Well, now you have Skype, you can live with that — there’s no real need for you to be allowed to meet your family or your lawyers anymore,’” Martufi says.

“We don’t know yet how systemic this change is, but the risk is that this might stay with us even after the pandemic is gone.”

Apart from video calls, Catherine Heard does not see much effort being made to mitigate the effects of restrictions. “I cannot off the top of my head think of anything really meaningful that was done,” she says.

“There was a huge missed opportunity, for example, to provide reading material, recorded information or access to online courses. There were a lot of things that could have been done, should have been done, but weren’t done.”

The Netherlands was one of the countries that managed to restart prison activities relatively quickly through measures such as rotational schemes or smaller, fixed groups, Heard says. But most countries didn’t implement such measures.

Structural problems exacerbate situation

As in so many other areas of society, the situation has been exacerbated by structural problems that existed long before the pandemic.

“Some of the most severe and prolonged restrictions were seen in the countries with the worst prison overcrowding,” Heard says. A lack of space makes distancing measures impossible to implement, and alternative measures are hindered by staff shortages. “If there aren’t staff to move people around the prison,” she says, “there is no option but to keep them locked up in their cells for most of the day and night.”

Researchers, NGOs and incarcerated people alike repeatedly mention overcrowding as key to the problem. One in three European countries operate their prisons above official capacity. 

In many individual prisons, the situation is much worse than the country average suggests. “I am in a cell that is intended for five people — now there are eight of us. It is impossible to maintain distance,” a person on hunger strike told a Croatian news outlet at the start of the pandemic in March 2020. “We are unable to see our wives and children, and, God forbid, maybe some of us never see them again. We practically feel like death row inmates, waiting for the coronavirus to break into prison.”

French chief prisons inspector Dominique Simonnot: “Imagine three people crammed 10 hours a day into a 9-square-meter cell, which is only 4.5 square meters with the bunk bed, the table and the toilet area.”

During the first wave, many countries throughout Europe released people in unprecedented numbers in order to ease the pressure on prisons. “It’s what the experts have been telling them to do for years, but it was too politically scary,” Heard says. “I think COVID gave many countries an excuse to quietly reduce their prisoner numbers.”

Heard calculated that the incarcerated population may have been reduced by as much as half a million people globally between March 2020 and June 2021. Countries such as Slovenia, Belgium, France and Italy, all of which had been operating over capacity to begin with, reduced their incarcerated populations by up to 25%, bringing them down to at or below official capacity.

“One lesson countries will have learned is that they’ve reduced their incarceration numbers without the sky falling in,” Heard says. With the pandemic offering a public health reason for reducing prison populations, she says it is vital that countries now sustain the trend.

Prison populations are rising again

But many countries seem to be reversing the progress made since spring 2020. After the initial drop, incarcerated populations are now rising again in about half of the European countries studied — in some cases even surpassing their original levels. 

French and Slovenian prisons, for example, are now back to being overcrowded at the national level, with individual prisons worse off still.

Vaccinations delayed

With these structural problems exacerbating an already complicated situation, a “return to normal” in prisons hinges on the same thing it does for the rest of society: vaccination.

“When it was announced that there would be a vaccine, people became much calmer,” Vass says. “To the best of my knowledge, almost all inmates here took it. I received my first dose in May, the second in June, and, like many, I took the third in September.”

But not everyone has gotten their jab yet. One big reason for the delay is the fact that, even with the high risk to inmates, staff and the general population, most European countries did not include incarcerated people as a priority group in their vaccination plans. Many didn’t mention them at all. 

In Germany, for example, people in communal living arrangements such as elderly care homes were prioritized explicitly, but prisoners were still vaccinated in parallel with the rest of the population.

“There has been consistent indication from independent supranational organizations that prisoners should be prioritized,” Martufi says. “It’s a good example of the absolute discrepancy between the policy indications on the one hand and the reality on the ground.”

Many attribute this to a lack of political will. In some cases, Martufi says, politics even actively hindered early access to vaccination. “In Belgium, prisoners’ being prioritized became a political discussion,” he says, “and, as a result, prisoners just stayed out of the vaccination campaign until the very end.” In Italy on the other end, he says, the decision to give incarcerated people priority access to vaccinations was an administrative decision, made without much public discussion.

This has meant that the start of vaccinations in prisons was significantly delayed, with some countries not distributing a single shot in prisons before June, while others reported starting as early as the end of March.

Facing the second pandemic winter

With vaccination rates in European prisons finally reaching the level of the general population in many countries and with infections low during the summer, incarcerated people caught a breath of fresh air as visits and activities resumed under hygiene requirements.

But, with winter and the next wave arriving in most European countries, the pandemic isn’t over for anyone — and certainly not for people in prisons. “We will not get our old life, our benefits, back soon,” Csaba Vass in Hungary says. In Italy, weekly data show active cases among staff and inmates rising. And Croatia’s Justice Ministry recently confirmed that more than 20% of incarcerated people have by now been infected with the coronavirus — that is roughly 1.5 times the rate of the population in general.

Lessons for the future

Experts say countries need to reduce their prison populations drastically in order to better prepare for such situations in the future. “We cannot face another health crisis with these numbers of people incarcerated throughout Europe,” Martufi says. “That needs to go down.” 

But observers also see reason for optimism. “COVID should have been a wake-up call to invest in better prison conditions and to reduce the use of incarceration,” Catherine Heard says. 

For that wake-up call to be heard, public interest and political will are crucial. “It’s time to rethink our perception of prisoners as second-class citizens,” Martufi says. “We cannot allow anyone to be left behind. It will be worse for everyone.”

The project is a collaboration within the European Data Journalism Network

Project lead: Deutsche Welle

Collaborators: Alternatives Economiques, Civio, El Confidencial, EUrologus, Il Sole24Ore, iMEdD, MIIR, OBC Transeuropa, Openpolis, Pod črto, VoxEurop

This piece was edited by DW’s Milan Gagnon, Gianna-Carina Grün and Peter Hille.

Of the 43 countries analysed for this investigation, 12 do not allow single women to access in vitro fertilisation. Even more countries, 16, also prevent single women from getting assisted insemination. The list of countries that prevent single women from getting a donated egg is even longer.

The situation is worse for female couples: 24 countries ban their access to ART outright. For the LGTBIQ+ community, having children via ART is not an easy path in Europe. “The places where it’s most difficult for LGTBIQ+ people to get a job or to be out or to get married or to undergo legal gender recognition are also the places where it’s most difficult to have access to assisted reproductive technologies,” says Cianan Russell, from ILGA Europe, a federation of European lesbian, gay, bisexual, trans and intersex rights groups. They say Hungary and Poland are the countries where the situation is the worst, but the problem is widespread in Europe. Even where people can obtain reproductive assistance legally on paper, reality sometimes brings “discrimination, harassment or even violence” to the process, Russell says. Those who are suffering the most problems are trans and intersex people, they add.

People facing these forms of discrimination grapple with difficult alternatives. In the case of the LGTBIQ+ collective, says Russell, there are three. The first is misrepresenting one’s identity, such as female couples who lie by saying that just one of them is seeking treatment as a single woman, if that is allowed, or non-binary people or trans men who say they are women. The second alternative is crossing borders to seek access in another country. The third is conceiving with friends or trusted people even if they are not attracted to them.

Although this is not common, it is a path that many people who want to have children may take if the barriers seem otherwise insurmountable. In the case of single women, Izaskun Gamen, spokesperson for the association Single Mothers By Choice (MSPE), says that, during her years-long process to try to have children, some people suggested that she get pregnant by a stranger after a one-night stand and not tell the father. That seems unthinkable to her, she says: “How do you explain that to your child later? How do you explain that he or she was born of a deception?”

Older and older mothers

The only legal barrier for heterosexual couples, in most cases, is age. The women seeking ART are getting older. In the last decade, the average age of mothers at the birth of their first child , whether natural or assisted, has increased in most of Europe. In Spain and Ireland the average age was over 32 years old in 2019.

That’s average, which means that many women access ART later, when, because of their age, conceiving naturally becomes more difficult. Most countries put the legal ceiling for assisted reproduction around 50 years. This is the maximum age in Greece, for example, but in response to COVID-19 pandemic-related treatment delays the government extended the age to 52 years until June 30, 2023.

Juana Crespo, director of an eponymous fertility clinic in Spain specialised in difficult cases, says the main problem for her patients is old age: “We get old and, when our reproductive system becomes old, the whole orchestra is old.” She calls this a “new disease”: “The history of delayed motherhood is unwritten.”

Although women’s ages are a common source of reproductive difficulties, Carlos Calhaz-Jorge, a fertility doctor and researcher at the Universidade de Lisboa in Portugal and president of the European Society of Human Reproduction and Embryology (ESHRE), says that half of the problems of couples who seek ART are from the male partner.

Yet age is not a factor of legal exclusion for men and, in general, there are no limits in European countries. Only three of the 43 countries have maximums: France, 59 years; Finland, 60 years; and Switzerland, 56 years, although in these last two cases they are recommendations, not legal prohibitions. In fact, in Switzerland the recommendation is that the father can be alive until the child turns 18, a more sociological than medical recommendation.

The most common obstacle: lack of financial resources

Once the legal obstacles are overcome, the economic ones rear their heads. According to Calhaz-Jorge, “the problem for most of the population is the lack of public funding. Even in countries where heterosexual couples are allowed to have ART it depends a lot on the public financial support.” Another discrimination, to add to the previous ones, is the economic one: not all countries cover these techniques (six do not cover it at all), and those who do sometimes only pay part of it, or the waiting lists are years-long, in a matter in which every delay works against you.

For example, in Switzerland and Poland, only insemination is funded, not in vitro fertilisation, which is much more expensive. In Greece, the public healthcare system only covers very specific cases, such as people living in faraway islands.

In fact, there are gaping differences between European countries. There are even differences between regions of the same country, such as in the United Kingdom, Italy and Spain. In Spain, for example, single women can access artificial insemination in Navarra, but not in vitro fertilisation, even if they have medical problems that prevent them from becoming pregnant through insemination. Spain’s other regions do permit that. Germany, meanwhile, does not cover in vitro fertilisation for lesbians and single women.

Age limits, already an important legal barrier for those seeking private ART access, are lower for people seeking ART through national health services. Once again, in the case of heterosexual couples, very few countries put a ceiling on the age of men. Portugal sets it at 60 years and Austria, 49. For women there are limits: from 38 in Latvia to 46 in Italy or 48 in Malta, to the most common figure in Europe, 40.

In other countries, publicly funded assisted reproduction has additional barriers, such as not exceeding a certain weight (in Serbia, Romania and some Spanish regions) or not having previous children, as in Denmark, Malta, Portugal, Romania, Spain, Sweden and Turkey.

Another of the most common limits is to cover only a maximum number of attempts. Few countries are clear on insemination, or do not establish limits, although if they do, it is usually six or three cycles. Countries are clearer about in vitro fertilisation: almost all limit the number of funded attempts. Belgium, Slovenia and Italy fund six attempts. 15 other countries fund three attempts. Romania, Moldova, and Kazakhstan fund only one. There, either you get pregnant the first time, or if you want to keep trying you have to pay for it out of pocket.

Irene Cuevas, director of the embryology laboratory of the public General Hospital of Valencia (Spain), says that after a certain number of attempts the probability of success drops a lot. “We have very limited resources and we have to try to optimise them in some way. It is a very logical number,” she argues.

Then there are the copays, which mean that access is not free in practice. The most common are those for medicines, and they are significant. Each round of hormonal treatment for in vitro fertilisation in Spain, for example, can cost more than a thousand euros.

There are also the long waiting lists. Cuevas calls them, “the fundamental problem.” Long waits are also common, for example, in Hungary. At one point Hungary did not permit sperm donors that were not Hungarian. Even after they removed that obstacle, things did not improve, Sandor says. Last summer, Hungary nationalised all fertility clinics. “Everyone knows that this means that they’re going to be five- to 10-years-long waiting lists for those who don’t have any money,” Sándor says.

Calhaz-Jorge says this is not only a problem of rights: “I’d like to have more support in my country, Portugal, because there are too-long waiting lists and as in the rest of Europe. Our fertility is declining. More support could help slow the decline. We have an intention of providing reproductive assistance to up to 5% of all babies born in Portugal. This is realistic but for that we need more money.”

Spain is the country in Europe, together with Greece, in which more children are born thanks to assisted reproduction procedures, reaching 7.9% of the total number of children born in 2017 (last year with comparable data, but in 2019 this number grown to 9,5%). In Italy, the UK, and Portugal, the rate is around 3%.

Faced with all these difficulties, is a common European regulation possible that guarantees equal access for all? Russell, the LGBTIQ+ spokesperson, says that would be difficult. European countries, not the EU, have jurisdiction over this matter, so the only alternative when it comes to defending LGTBIQ+ rights are the courts.

Calhaz-Jorge, chairman of the ESHRE, says: “I’m convinced that it is not possible to have similar rules. If in one country it is not legal to treat single women, which kind of regulation will they have if going abroad? The political views and the cultural sensitivities are very different.” Indeed.

The working week was a grind but the weekends back then made it seem worthwhile. On Friday nights, between waitressing or whatever job she had taken to pay the bills, Lina would hit the dancefloor. She was in her early twenties and sucking the marrow out of the nightlife – or as she says, “eating it up with a spoon”. The Greek economy was on its knees and even waitresses were struggling, but if you worked through the tourist season, the money from tips could help you through the lean months. On the dancefloor, Lina learnt to get by on a single bottle of alcopops, staying out so late that it was practically early and she could take the morning metro home.

She had come to Athens in her teens and found a scene to suit her tastes in scruffy-but-trendy Gazi district. She styled herself as a punk and, with her cropped hair and soft features, could have passed for a beautiful boy playing at being a girl, or vice versa. As a kid, growing up in Bulgaria, she had a thing for toy soldiers. She was less fond of the pink lace dress that she was forced to wear for Christmas and special occasions.

It was always the same bars in Gazi that she went to, and the same crowd too. They all knew each other and they were looking for the same things – to flirt, have fun, forget. The vibe was intimate, uninhibited. Still, the approach from the barwoman came as a surprise. Ever fancied donating your eggs, she asked Lina – it’s easy money and I know the right people.

While not quite the sort of overture one expected in a lesbian bar, it was not the first time that Lina had heard of the practice – girls she knew had done it. Soon enough, she was wondering if she should do it too. It’s either that, said a friend who knew a thing or two about making money on the side, or go work as a call-girl – take your pick.

Lina first donated her ova at a fertility clinic at the age of 23. Over the next seven years, she would donate a further four times. Each cycle of donation involved ten days of hormone therapy, administered by daily injection to stimulate her ovaries to produce eggs that would be retrieved at the clinic under general anaesthetic. A selection of those ova would be fertilised to make embryos that would be assigned to one of the many thousands of clients from Europe and beyond that seek out Greece’s fertility clinics every year, hoping for a baby. “It doesn’t feel like giving birth,” Lina told the Balkan Investigative Reporting Network, BIRN. “You don’t feel anything, except that your ovaries are about to burst.”

Lina’s friend, Violeta, did not have such an easy ride. She too chose to donate her ova for money, but after the second cycle of hormone therapy, fluid filled her stomach and her lung cavity – a rare and potentially life-threatening complication linked to the over-stimulation of the ovaries. “I could no longer breathe,” she told BIRN. “I had to sleep standing up. I was coughing like I smoked ten packets a day.”

Lina and Violeta are not their real names – both women spoke on condition of anonymity. Their motives for donating their ova were explicitly financial, defying the ethos of the Greek fertility sector, where donations are meant to be altruistic. Their appointments were arranged by a scout, or “dealer”, who received a payment from both clinics and donors for bringing them together.

The use of paid scouts also defies the ethos of the Greek fertility sector. Although technically illegal, it is nonetheless widespread: the product of a market where the demand for donated ova far outstrips supply. BIRN interviewed one such scout in her apartment in a working-class neighbourhood of Athens. The meeting proceeded on the assumption that the journalist was a prospective donor. The scout introduced herself as a “representative of doctors”.

A husky-voiced woman in her fifties, she had a guarded, streetwise manner that softened as she spoke of the young women whom she had recruited for the fertility sector. “I love my girls,” she said. “All of them.” Her living room, furnished with a leopard-skin motif, was adorned with portraits of babies. The scout explained that fertility clinics had a tendency to exploit donors by making them donate more than was healthy. But the women who went through her had nothing to fear, she added, because the clinics dared not mess with someone of her standing. “The doctors fear me because they know I can take away their license. If one of my girls isn’t well, I’ll tear them apart,” she said. “After twenty years of working in the night, I can eat them for breakfast.”

The pool of ova donors in Greece includes many young women in financial need, tempted by the offer of money. Illustration: Sanja Pantic/BIRN

In the 42 years since the birth of the first IVF baby in Britain, advances in the science of assisted reproduction have made parenthood a reality for millions who might otherwise have missed out. A global market has emerged for fertility treatments and Greece has become a major player within it, thanks to its world-class doctors, cutting-edge clinics, competitive prices and a liberal legal framework.

Websites promoting the country’s clinics, illustrated with tourist-brochure images of the Mediterranean coast, offer the chance to combine IVF with a holiday. For more than a decade, Greece has closely followed Spain in the rankings of Europe’s top destinations for assisted reproduction procedures.

Throughout that period however, Greek fertility clinics have been operating without meaningful oversight. The state-backed agency tasked with regulating them has been chronically under-resourced since its creation in 2005, and for six years – between 2008-14 – it was effectively out of action. Last October, it was abruptly dissolved, and its successor agency was only launched in spring this year.

“The clinics are well versed in anarchy,” said Katerina Fountedaki, the deputy president of the disbanded regulator, the National Authority for Assisted Reproduction, from 2018-20. The regulator’s first board resigned in 2008, complaining that the state did not support them. For the ensuing six years, Fountedaki said, “the landscape of assisted reproduction was in chaos, without any controls.”

This investigation reveals how Greek fertility clinics became a law unto themselves, operating unsupervised at the frontiers of assisted reproduction. Drawing on accounts of ova donors, clinic employees and experts, it offers a glimpse of what an unregulated market in human fertility could look like: a place where ethics are trampled under the pursuit of profit, and exploitation thrives under the guise of altruism.

The market for donated ova, driven by huge demand, inhabits the margins of the fertility industry. To meet the demand, the market offers women on low incomes a financial incentive to engage in what is meant to be an altruistic process. It also incentivises some clinics to treat the women donating their ova in a manner that is often unethical, bordering on exploitative. Many have used ova from the same donors more often that is healthy or ethical. Some clinics have, on occasion, failed to secure informed consent from donors for invasive procedures that are not entirely risk-free. Others have performed procedures off-the-books – without keeping records – and others still have sourced genetic material from organised crime gangs involved in human trafficking.

BIRN has uncovered evidence of these breaches at individual clinics, but it is hard to gauge precisely how widespread they are across the sector. While some Greek clinics are guided by laws and ethics, others evidently are not. Exactly how many is unknown because the sector has been operating in a regulatory vacuum, with no mechanism for collecting essential data. A centralised register of donors – the bare minimum for monitoring ethical compliance – was only created in 2019, despite having been a legal requirement since 2005.

“The clinics may be at fault where they violate existing provisions,” said Vassilis Tarlatzis, a pioneer of IVF in Greece who served as the first vice president of the regulator, from 2006-8. However, he said, it was the state that was ultimately to blame: successive governments had failed to create a regulator and a central register that were fit for purpose. “These things show the amateurism of the state,” he told BIRN. “Because if you really take the issues around assisted reproduction seriously, you have to invest in them and get them right.”

BIRN contacted the press office at the Greek Ministry of Health by e-mail and phone four times over a three-week period before the publication of this story, asking it to comment on the regulation of the fertility sector. The press office said it could not find anyone to respond to the questions. BIRN also contacted the new regulatory body three times by e-mail and phone during the same period, asking for comment. An official said there was no one available to respond to the questions.

No universal guidelines

The science of assisted reproduction is still in its infancy – we are a long way from solving the riddle of infertility – but it is already generating scenarios that used to be the preserve of science fiction. The accompanying ethical debate tends to involve variations of the same question: should a certain procedure be performed just because it can be performed, and because there is a demand for it? And if not, where to draw the line? How far should parents be allowed to “edit” their child’s genes by screening the embryo? Does everyone have the right to make a baby? And should we try to meet the demand for babies by paying for the ova or the wombs that are required to create them?

Regional differences in the response to these questions have created an international market for fertility treatments. Websites promoting Greece as an IVF destination boast of procedures including surrogacy, and ovum and embryo donation for single women and couples. Many of the procedures are prohibited – or prohibitively expensive – in much of Europe but are facilitated in Greece by liberal laws.

International demand for these procedures have helped Greece’s fertility sector, dominated by private clinics, become the driving force within a medical tourism industry worth hundreds of millions of euros. The sector’s demand for donated ova is met by the ranks of anonymous donors such as Lina and Violeta, a number of them motivated by financial need.

Like blood as well as kidneys and other organs, ova are not meant to be traded. Greek law says ova may only be given for altruistic reasons, in keeping with ethical guidelines observed more or less worldwide. In practice however, women often donate for monetary reasons, tempted by the only form of payment that clinics are allowed to make – a “compensation” for lost earnings and the stress of the procedure. The payment is capped at 1,500 euros, which can amount to some two months’ wages for women on low incomes.

Every time Lina gave her ova, she received 1,200 euros from the clinic. She kept 1,000 euros for herself, and diligently handed over 200 euros as commission to the scout who had arranged the donation. While the scout had explained the procedure to her beforehand, Lina claims she received no information from the clinic about potential health risks and side-effects. She went ahead anyway, “sweetened by the 1,000 euros”.

Lina’s friend, Violeta, said she would not donate again, even though she still needed the money. “I didn’t have that great an experience the second time round,” she said. “I thought I was going to die.” For Lina too, what had seemed like a great idea in her twenties seems less so now. “I am done with that thing,” she said. “I blew the money anyway.”

The risk of severe health complications for women undergoing fertility treatment has generally been low, and is getting progressively lower. Hormone therapies are increasingly sophisticated, and regimes will often be tailored to individuals. Clinics also perform regular tests to make sure that the ovaries are not at risk of over-stimulation – the likely cause of Violeta’s condition. But while fertility treatment is undoubtedly becoming safer, much still remains unknown about its long-term effects.

“There is some concern that each time a donor undergoes another cycle, she exposes herself to medical risk,” said Diane Tober, a medical anthropologist and assistant professor at the University of California in San Francisco who has researched the fertility industry. “Without long-term studies, no one knows to what degree donors may experience long-term complications.”

There are also questions about the extent to which artificially stimulating the production of ova might lead, over time, to a reduction in their quality, which could influence a woman’s chances of conceiving later in life. Any procedure about which so much is unknown requires informed consent. But as Lina’s experience suggests, it is not always sought.

The uncertainty about the long-term impact of fertility treatment on a woman’s health, and on the quality of her genetic material, underpins one of the main arguments for tighter regulation of ova donation. The benefits of donation will outweigh the potential costs, the argument goes, as long as clear limits are set on how many times a woman undergoes the procedure to donate, and on how many ova are harvested from each cycle of donation.

Another argument for tighter regulation stems from concerns for the long-term health of the broader population. As the donation of genetic material tends to be done anonymously, it creates a risk of inadvertent in-breeding among adult half-siblings who share a biological parent. To minimise this risk, many countries set limits on how many children are born from an individual’s donated genetic material.

According to the European Society of Human Reproduction and Embryology, ESHRE, a Brussels-based NGO that advocates for reproductive medicine, there are “no universal guidelines”. Each country sets its own limits, an ESHRE spokesperson said in an email to BIRN, with some choosing to restrict how many times a woman may “undergo the procedure of donation” while others “only care about the number of babies born”.

Greek law does not set limits on how many times a woman undergoes fertility treatment to donate her ova, nor on how many donated ova are retrieved and fertilised from each round of treatment. These decisions are left to the discretion of individual clinics. Greek law only stipulates that no more than 10 babies should be born from a single donor – a somewhat arbitrary figure believed to minimise the risk of in-breeding within the population.

In practice however, compliance with the ten-baby limit – the only limit required by law – is also left to the discretion of individual clinics. It cannot be checked because there is no mechanism for monitoring the clinics. The regulator has been unable to function effectively, while the central register of donors – the only way of tracking how many babies are born from a person’s genetic material – was only created two years ago.

With no one monitoring their books, unscrupulous clinics have been free to push ethical boundaries, ignoring legal limits in pursuit of profits. “Many donors gave way too many ova without any oversight,” said Katerina Fountedaki, the former deputy president of the Greek National Authority for Assisted Reproduction, the regulator that was meant to have maintained the register. In relatively unpopulous regions of Greece, she added, there were “serious concerns that many children would be born with the same [biological] mother, with whatever risk of incest that entails.”

In the absence of a central registry, a fertility clinic faces an unenviable task if it wishes to comply with the law limiting the number of babies per donor. In theory, the conscientious clinic employee will ask a prospective donor if she has undergone ova retrieval at any other clinics. The donor, who will not be aware of how many babies have been born from her ova, will provide a list of the other clinics. The employee will then contact these clinics to compile a tally of how many children have been born from that donor, thus ensuring that any more embryos created with her ova remain within the limit.

In practice however, a clinic facing a huge demand for ova may simply not make too many inquiries about the donor’s past. If it does, the donor may, for a variety of reasons, not disclose all previous procedures. And if the donor does provide an accurate disclosure, the previous clinics may not have kept a record of the number of babies born or – if the law had already been broken – may choose not to share that record.

“We cannot know if the donor has gone elsewhere too,” said Christina, a senior employee at a reputable clinic who spoke on condition that her real name was withheld. “And there might not be any record of it because not everyone keeps a record. That does not have to be because they necessarily want to hide something. It could also be because of a lack of time, organisation etc. The truth is,” she said, inquiring into other clinics’ records is “a huge hassle and will place you in conflict with many people.”

Christina describes an instance where her clinic found out that a woman who had just donated her ova had already exceeded the permitted number of births. Doctors and clients were furious that valuable genetic material had to be destroyed because of an ethical lapse. “We threw away tens of eggs,” she told BIRN. “It was a mess, you can’t picture what happened. If you had seen it, you would cry.”

Lina has no idea how many ova were retrieved from her body over five cycles of treatment, nor how many formed viable embryos and, eventually, babies. She has been assured only that her ovaries were productive. Experts say productive ovaries may yield anything between 10 and 40 eggs per cycle, depending on factors such as the hormone regime administered and the biology of the donor. If an average of 10 ova were fertilised per cycle, a generous estimate, Lina could have had as many as 50 biological children by now – a possibility that she had not considered until her conversation with BIRN. “Do you really mean that?” she said, smiling. “Fine, I’ve made four football teams then, plus substitutes.”

International fertility hub

Some 200,000 babies are thought to be delivered every year in Europe using procedures such as IVF. As population growth rates decline across the wealthier swathes of the world, with more and more people choosing to start families later in life if at all, assisted reproduction has been hailed as a technological solution to a socio-economic conundrum. But the technology is far from perfect, and many causes of reproductive difficulty among men and women remain a mystery. Embryos created via IVF tend to have a high rate of failure, placing an enormous financial and emotional burden on those seeking treatment.

The high failure rate contributes to the demand for healthy ova, which many Greek clinics try to meet by using the same donors more often than is recommended. “Even though I cannot condone it,” said Christina, the senior manager at the reputable IVF clinic, “the demand is so intense that I can understand why various clinics do not even pretend to follow the rules and keep recycling the same people.”

Scouts are paid by fertility clinics to help meet the demand for ova donors. Illustration: Sanja Pantic/BIRN

Greece has one of the fastest rates of demographic decline in the world. In 2005, the state passed a set of laws seeking to broaden access to assisted reproduction. Additional laws would seek to encourage medical tourism as a source of revenue for the fertility sector. The influential Orthodox Church, known for its conservative stance on family life, offered some resistance, but was apparently swayed by the argument that IVF would help Greeks have bigger families. In the years to come, the country would be buffeted by economic crises and waves of migration, enlarging the pool of women willing to donate their genetic material for money. These anonymous donors and the clients of the fertility clinics may have little in common – yet they are linked by the pathways carved by breathtaking advances in reproductive medicine.

In September 2019, Greek law enforcement agencies, backed by the European Union’s police agency, Europol, took down a human trafficking ring with a difference: it was trading not just in human beings but in the raw materials of life itself. The gang are accused of making at least half-a-million euros in profit over a three-year period through a range of activities that aimed to meet the demand for babies in Greece. According to prosecutors, part of its business model involved paying for vulnerable, pregnant women from Bulgaria to travel to private clinics in Greece, where their newborns would be offered up for adoption. The gang are also accused of making its money by recruiting surrogate mothers to carry babies conceived by IVF, and by enlisting young women from Bulgaria, Georgia and Russia to undergo fertility treatment so that they could donate their ova in Greece. Nearly 70 people were charged in the case, including a lawyer, an obstretrician-gynaecologist and the employees of private clinics in Athens and Thessaloniki. The mass trial has yet to deliver any verdicts.

While the case remains an anomaly for now, it is unlikely that this gang were alone in spotting an opportunity within Greece’s fertility sector. The presence of organised crime in assisted reproduction may not be the norm, but it demonstrates the cold logic of the market. Wherever demand for a product far exceeds the lawful supply, the poorly regulated market generates opportunities for people with relevant experience in breaking the law. Where that demand is for babies, or for the elements needed to conceive them in a clinical setting, criminals associated with the trafficking and exploitation of women become involved in the supply.

In the absence of an effective regulator or register of donors, it is left to individual clinics to operate their own system of checks, if they so choose, to ensure that ova donors are not being coerced or exploited. Accounts from within the fertility sector suggest there are reasonable of grounds for suspicion: the pool of ova donors includes many women involved in sex work.

Christina has interviewed hundreds of young women to screen their suitability as ova donors, because a major part of her job involves matching donors with the clinic’s clients. She relies on her own network of donors, as well as on referrals from doctors known to the clinic. She told BIRN that her clinic paid a premium for ova that were secured through reputable doctors who worked with women that did not appear to have been exploited.

“There is a doctor who has decent donors, regular girls next door. I pay this doctor more than the others… because only half this job is medical work. The other half is shitty work,” she said, referring to the soul-destroying aspect of looking for ova donors. By contrast, another doctor “only has Georgian women,” she added. “I’m not being racist but these women are victims of prostitution, so I will not deal with him.”

There are few incentives for other clinics to be as scrupulous about the source of their genetic material. In fact, as the Greek fertility sector has begun serving a Europe-wide demand for ova, its clinics are being pushed to widen the net for donors. In the process, Greece has become an international hub where clients for fertility treatment, usually from the wealthier economies of western Europe, are accessing genetic material provided by women from an ever-expanding region encompassing the poorer economies of the east.

Women from Bulgaria and Georgia – both countries with high levels of poverty – feature prominently in the ranks of donors to Greek clinics. According to Diane Tober, from the University of California in San Francisco, women on low incomes often donate for financial reasons – they are more likely to “do things they might not otherwise do”. While conducting her research on Spain, Tober found that the post-2008 economic crisis had sparked a huge increase in ova donors. “The same thing is happening now with the coronavirus,” she told BIRN.

Christina says the vast majority of her international clients expect to use donated ova, and foreign donors are a major source. Demand can be shaped by the clients’ preference for attributes such as skin tone and ethnicity, or by the IVF success rate associated with ova from different regions. Polish ova are regarded as “very strong, reproduction-wise, just like Romanians,” Christina told BIRN.

Multiple cycles

The conditions in the market for ova not only determine what sort of women become donors – they can also determine how their bodies are treated during donation. The market is barely regulated, driven by huge international demand, and dominated by private clinics that compete with each other for financial gain. A certain portion of the supply of ova comes from women on low incomes who are also pursuing financial gain, albeit far smaller sums than the profits earnt by clinics. Thus money becomes the main incentive for both donors and clinics to participate in the market. Without checks and balances, these powerful incentives converge in the woman’s body on the system responsible for producing the ova: namely, the reproductive system.

There are two ways of maximising the amount of ova yielded by an individual donor. The clinic can aim to increase the number of ova produced within each cycle of donation, by adjusting the hormones administered to stimulate the ovaries. And it can keep using the same donors for repeated cycles of donation. Both practices are used in Greek fertility clinics, according to industry insiders and experts.

There are no legal limits on how many ova are harvested or fertilised from each donation procedure, nor on how many times a woman undergoes these procedures. And even if these limits were set out within Greek law, the absence of an effective regulator or register would mean there was no way of enforcing them. Profit-hungry clinics and cash-strapped donors would be in the same position as they are now: choosing how best to balance powerful financial incentives with hazy ethical concerns and uncertainty about the long-term health repercussions of repeated, intensive cycles of fertility treatment.

The absence of a central register makes it very hard to keep tabs on how many babies have been born to each donor. Illustration: Sanja Pantic/BIRN

The regulatory failure moreover makes it harder for clinics to follow their own ethical standards, even where they wish to do so. Christina recommends that a donor should not undergo more than three cycles of fertility treatment in her lifetime. However, she said, many of the new donors at her clinic openly admitted to having donated “at least eight times”. By contrast, regulators in the US say donors should not undergo the procedure more than six times.

If Christina wants to check how many times a prospective donor has given her ova, there is usually only one way of doing so – by asking the donor. As there is no central register, it is difficult for Christina to corroborate what the donor tells her. She has to decide whether or not to take the donor at her word.

There is nothing to stop a woman from undergoing donation cycles at multiple clinics more often than may be healthy. But while doing so will maximise her earnings, it may also be counter-productive from the clinic’s point of view. “If you have a donor undergo stimulation five times a year when she should be doing only two,” Christina said, “the eggs in between will be bad and won’t make for a good embryos” – meaning they were less likely to be successfully implanted.

Christina said the tendency to donate excessively often went hand in hand with an unhealthy lifestyle, which could further affect the quality of the ova. “Ideally, when things were more innocent, ova would be donated by women 20 to 30 years old, and there would be a better chance of getting embryos with good prospects,” she said. “This is no longer the case. The donors are still young but the material is defective because of repeated efforts… and because the eggs often come from substance abusers.”

As a rule of thumb, Christina said, her clinic distributes the ova retrieved from a donation cycle between no more than two clients. Within the sector however, there is a strong financial incentive for distributing the ova from each donation cycle among as many clients as possible. For each cycle, the clinic will pay out a more or less fixed sum: the cost of the doctors’ labour, the price of the medication, and the “compensation” to the donor, capped at 1,500 euros. However, the clinic’s earnings can vary widely, depending on how many clients it can serve from each donation cycle. The number of clients it serves is linked to the number of ova it harvests: the more ova are retrieved from each cycle, the more there are to go around. This in turn incentivises clinics to favour hormone regimes that will stimulate the ovaries to release large amounts of ova. The clinics try to get more eggs, said Diane Tober of the University of California in San Francisco, “because more eggs increase the profit.”

The current medical consensus states that the optimal, safe number of ova needed for achieving an ongoing pregnancy through IVF is between six and 15. However, even in a heavily regulated fertility sector such as the UK’s, it is not uncommon for clinics to administer hormone regimes that deliver far higher numbers of ova. Data presented at an ESHRE conference in June revealed that, in the period between 2015-18, some “16% of cycles” in the UK had led to the retrieval of between 16-49 ova. Nearly 60 women had “over 50 eggs” collected in a single procedure, the paper said. The data was from procedures involving women who wished to conceive with their own eggs, and the excess ova were expected to be frozen rather than donated. Nonetheless, the paper argued that these numbers were “too high” and called for a rethink of “egg retrieval practices” to take account of emotional, financial as well as potential health costs.

While Christina’s clinic tries to serve no more than two clients per donation cycle, this is not a hard and fast rule. Donors with polycystic ovaries, a common and usually symptom-less condition thought to affect one in 10 women, are prized by the clinic because they naturally produce more ova, which can be distributed among more clients. Provided the additional ova are of a high quality and result in good embryos, they will be called on to donate more. “The donors that make us happy, the star donors, are the ones with polycystic ovaries,” Christina said.

Back in her Athens apartment, the scout presented herself as a custodian of donors’ welfare – a bulwark between unsuspecting young women and unscrupulous clinics. “A girl came to me and asked, ‘can I give every month?’ If you allow them, the doctors will make you do it 15 times. But for your own sake, I say five at most.”

The scout also made a case for egg donation on the grounds of altruism. “You have 500 active ova in a lifespan,” she said. “Tell me how many kids you’ll have by the time you’re 38. Let us say you have as many as nine – you’ll be wasting the rest of your ova. Whereas you could donate them and help people.”

‘Single’ for official purposes

The welfare of ova donors may not be the only casualty of Greece’s regulatory paralysis. The future welfare of the many children conceived with donated genetic material may also be at risk if they are unable to trace their biological parents.

Donor anonymity has until now been the default within the fertility industry, the preferred option for donors as well as the parents who bring up the children. However, this is changing. As the ranks of children born from donated genetic material enter adulthood, questions about their rights have also come to play. Many experts argue that everyone has a right to their genetic information, particularly given its value in understanding hereditary health conditions. As a result, some countries have introduced provisions for donors to be partially or fully de-anonymised where there is mutual consent or a compelling reason. In Greece however, the prolonged absence of regulatory oversight and a functioning register of donors mean that any move towards de-anonymisation is likely to prove difficult and in some cases, impossible.

Eleni Rethimiotaki, a law professor at the University of Athens and former president of Greece’s bio-ethics committee, said the problem was particularly acute in the case of clinics that had gone out of business over the years. “These data are completely lost,” she told BIRN. “The files are completely destroyed. It is impossible to find out where [these children] came from.”

The Greek fertility industry has been adapting to the demands of an international client base. Illustration: Sanja Pantic/BIRN

Maria regards herself as a beneficiary of the Greek fertility sector and is not particularly troubled by its lack of transparency around donor identity. The former artist gave birth to triplets and has been raising them by herself in her apartment in an affluent central Athens neighbourhood. Her real name has been withheld to protect the identity of her children. At bedtimes, Maria tells the children a fairy story from the future: the tale of how they came into being, nurtured in their mother’s belly after being conceived in a laboratory with ova and sperm from donors.

“My children are so beautiful and I’m not saying this because I’m their mother – after all, they couldn’t have taken after me,” she said. “Was I tricked, was I lied to? Who gives a fuck, I have the most beautiful thing there is on the planet. “

Maria is nonetheless curious about who provided the genetic material for her triplets. “My first thought was to meet the donors and see who it is that can make such beautiful children,” she said. On Mother’s Day and Father’s Day, she added, it is now the anonymous donors that she thinks of – rather than her own parents.

Liberal bordering on laissez-faire in its attitude to assisted reproduction, the Greek state is yet to come on board with the idea of same-sex families. People in same-sex relationships cannot officially adopt or start families of their own – a stance influenced by the Orthodox Church. Nonetheless, in Greece as elsewhere, assisted reproduction is quietly bringing parenthood within reach of more and more gay and lesbian couples. Lesbian women are free to seek IVF, provided they gloss over their sexuality by declaring themselves “single” for official purposes.

Lina is still plagued by money worries and has been trying to get her finances in order. Years ago, she was offered the option of becoming a scout herself, enlisting donors from her social circle, but she did not like the idea. She believes the fertility sector has a particular interest in people like her. Young women living from paycheque to paycheque are an obvious source of genetic material – even more so if their sexual orientation means they have not considered starting families of their own.

If Lina were ever to start a family, it would have to be via IVF. But she cannot dream of putting together 5,000 euros for a round of treatment, let alone supporting a child on her wages. Moreover, she said, with no legal recognition of same-sex families, there was no way to ensure that her partner would share her parental duties if the relationship ended. “A straight girl will always know that there is a father to support the child, even if they break up. In our case, how will we be supported?”

And so the prospect of motherhood remains a distant fantasy. “Of course I am thinking that at 30, I have another 10 years maximum,” she said. “These thoughts are very nice but what is happening in my life right now? Is there a base for a family? I can’t think of the future when I haven’t even sorted out the present…. I have endless love to give, but love doesn’t feed you and clothe you.”

The Greek fertility sector continues adapting to the needs of its broadening international client base. Sources familiar with the market described consistently high demand for ova donated by black women. However, the black population of Greece is small and transient: a handful of expatriates and their descendants, or migrants making their way to western Europe. After exhausting their network of donors to meet client demands, the fertility clinics start ringing around the African embassies, asking for leads.

Late last year, the clinic where Lina gave her ova got lucky. A specialist employed there, speaking on condition of anonymity, told BIRN that the team had retrieved an extraordinary 60 ova from a donor of African descent, a 19-year-old woman. Her bountiful ovaries became the talk of the clinic. Just as remarkable, it seemed, was the fact that she had never had sexual intercourse.

In the laboratory, her healthiest eggs would be selected for a modern miracle – a clinically assisted virgin birth. Like Lina before her, the Black Madonna of Athens is a child of the revolution in reproductive medicine. And thanks to Greece’s regulatory vacuum, the exact number of children born of her genes shall always remain something of a mystery.

Elvira Krithari is a journalist based in Athens with the Greek public broadcaster, ERT, and a founding member of the MIIR collective. This article was edited by Neil Arun. It was produced as part of the Fellowship for Journalistic Excellence, supported by the ERSTE Foundation, in cooperation with the Balkan Investigative Reporting Network.