Cross-Border Reproductive Care

by Pam Burton
Winter 2010

While most couples do not expect to be infertile, once diagnosed, they are usually treated within their own country. Some couples, however, will look for treatment beyond their country’s borders. People travel to another country for treatment, a practice frequently referred to as "fertility tourism" or "cross- border reproductive care," for several reasons:

•Services may be prohibited in their own country
•Services may be unavailable in their home country due to lack of technical expertise (particularly in countries with small populations and/or limited resources)
•More established/expert/successful treatments may be available in another country
•Services in their home country may be subject to lengthy waiting lists – a particularly salient issue given that female fertility, in particular, declines rapidly from the mid 30s
In the absence of – or limits to – publicly funded or otherwise affordable services in their home country – services may be cheaper and therefore more accessible in another country

Services in their home country may be denied to particular groups (e.g. single people; couples in same-sex relationships; individuals over a specific age).1www.icsi.ws ):http://www.ifsw.org/en/p38001484.html

In Canada, Assisted Human Reproduction Canada (AHRC), under the Assisted Human Reproduction Act (AHR Act), is the "federal regulatory agency responsible for protecting and promoting the health, safety, dignity and rights of Canadians who use or are born of assisted human reproduction technologies." 2 Sections of the AHR Act came into effect in 2004, including restrictions on payment for sperm, eggs and surrogacy, thus creating some of the background for fertility tourism in Canada.

The birth of premature twins to 60-year-old Calgary mother Ranjit Hayer earlier this year heightened public awareness of fertility tourism.3 Prior to the birth of the Hayer twins, the AHRC had recognised that the trend of fertility tourism was significant and hosted a First Invitational International Forum on Cross-Border Reproductive Care: Quality and Safety in January this year. In a personal interview with IAAC, Kate MacGregor of Assisted Human Reproduction Canada explained the forum’s objectives.

Forum goals were:

•to develop agreement on the information patients need to make informed decisions with respect to the quality and safety of care,
•to develop agreement on the information required for health professionals pre-, during, and post treatment;
•to create an international network of organizations and countries with a common commitment to safe, quality cross-border reproductive care;
•to gather or develop, and share data that describes the scope and impact of cross-border assisted human reproduction; and
•to provide a venue where individuals, organizations and countries could discuss common issues and learn from one another.
Forum findings have not yet been released.

While Canadian statistics related to fertility tourism are not available, Calgary doctor Cal Greene says that in his experience some couples travel to India, Spain and several eastern European countries for treatment, but the vast majority travel to clinics in the United States.3

Professor Eric Blyth from the University of Huddersfield, England, cautions,

two key and inter-related findings from patient accounts are that the internet is a significant source of information about reproductive services in other countries, and that in most instances patients make their own arrangements with service providers in destination countries. As is always the case, the quality of information on which decisions are made is all-important and, in the case of cross-border reproductive services, the sheer volume of information available on the internet, the pace at which this information changes, and the difficulty in verifying it, may serve to disempower rather than empower patients. For example, a ‘Yahoo’ search undertaken on 18 April 2009 for this piece identified 11,000,000 websites for ‘sperm donation,’ 5,400,000 for ‘IVF’ clinics, 4,090,000 for ‘surrogacy’, and 3,600,000 for ‘egg donors’.4

As well, Blyth noted three characteristics of many destination countries for cross-border reproductive services: (1) the lack of regulation affording protection for the parties most directly affected, i.e. donors, surrogates, patients and children; (2) the operation of a commercial market in human gametes – especially eggs – and women’s gestational services; and (3) a level of secrecy that helps to conceal unprofessional, unethical and illegal practices.

Clearly there is a need for caution when considering cross-border reproductive care. Our colleague and dear friend, Sandra Dill, who is Coordinator of the International Consumer Support for Infertility (iCSi) network has kindly agreed to our displaying here excerpts from a fact sheet entitled "Travelling abroad for assisted reproductive technology (ART) treatment" which is available in its entirety on the ICSI website (

The following issues and questions can become relevant if you consider seeking treatment abroad. In this list, you will not only find questions about the physical treatment, but also issues concerning financial, legal, emotional and long-term implications for the family you plan to build.

Medical issues:

• Is the type of treatment you are seeking abroad appropriate for your specific circumstances? If uncertain, can you consult a medical expert to clarify this?

• Is a clinic in your home country able to provide information on the treatment you are considering?

• Is it possible to have some of the initial investigations and early monitoring of treatment in your home country, i.e. ovulation induction, specific examinations, ultrasound scans, monitoring of ovarian stimulation, etc.?

• Do you know which medical examinations and tests will be performed on the donor? Is the donor in ongoing observation after egg retrieval to ensure that complications can be treated quickly?

• Is the person donating gametes (egg/sperm) or embryos a citizen of the said country or is the sperm/ egg/embryo imported or the donor recruited from another country?

• What follow-up and after care is provided for you – where and by whom?

Financial issues:

• Does your health insurance (or any other reimbursement provider) cover the total or partial cost for treatment abroad? This is not commonly the case, but may be the case if EU citizens seek treatment within the EU.

• Is a clinic in your home country willing to provide any follow-up treatment that may become necessary and are these costs reimbursed by your health insurance?

• Do you understand how much the various parts of the treatment cost? Are you aware of the payment/compensation given to the donor? Is this sum morally acceptable in your view?

• Are you reimbursed for any pre-treatment that may be carried out in your home country?

• Bear in mind that treatment abroad not only involves the direct cost for medical intervention, but travelling and accommodation. Furthermore, there are additional costs difficult to ascertain prior to treatment. These include travelling between hotel and clinic, meals in restaurants as well as all the extra expenses of being away from home.

Legal issues:

• If you are considering gamete donation, are you fully informed about the legal implications, i.e. legal paternity and/or maternity following gamete donation in your home country; the rights and responsibilities of donors in their home country or the recruiting country; the rights or possibilities for a donor conceived person to access information about his or her biological origins?

• Is it advisable and permitted to draw up a legal document in order to clarify the legal implications for all parties involved?

• In the case of surrogacy: what is the legislation regarding the maternal rights of the surrogate and the recipient mother and/or father in both your and the surrogate’s home country? Is it advisable and permitted to draw up a legal document?

• Seek independent legal advice before embarking on surrogacy arrangements in another country. Ensure you have the necessary documentation to bring your child back into your own country.

• Prior to commencing treatment, ensure that you have received complete medical and financial documentation. This may be vital for later reimbursement in your home country and/or for any future treatment you may consider.

Emotional issues:

• Considering a treatment abroad, whether legal or not in your home country, can be overwhelming. You may find it helpful to share your plans with a trusted friend or family member, with members of a patient organisation or with a counsellor. The latter is bound to professional discretion, so anything you may share with him or her, will be confidential.

• Not all clinics provide counselling prior to treatment and very few are likely to provide counselling in your native language. It can be helpful to explore emotional issues with a counsellor in your country, even if he or she is not familiar with infertility treatment in the country where you are intending to undergo treatment.

• If you are considering creating a child through gamete/embryo donation or surrogacy and intend to travel abroad for treatment, exploring all the short and long term implications of this with a specialist fertility counsellor before you make a final decision can be very beneficial. It is particularly important where the proposed treatment is either illegal in your home country and/or where access to donor information and potential contact with donors is different as this can raise complex emotions, as well as legal and social issues, for you which may in turn affect the strong and healthy family you are hoping to build.

• It is also helpful to think about the kind of support you may need alongside and after treatment, once you have returned home. If you have already established a relationship with a counsellor, he or she may be able to offer continuing support throughout your attempts to build a family of your own.

Future issues:

• How long are medical records kept? Do you know what is likely to happen to these records if your clinic closes down? In rare circumstances, medical information about the donor may become vital for a child conceived by gamete donation.

• Do you want to ensure that your child has access to information about his or her biological/genetic origins? How can you ensure this in those countries that do not have legal clarification in this respect?

• In the countries where anonymity of donor egg/sperm/embryo still remains what information does the clinic give regarding the donor conceived child’s biological background?

• How might you help your child reconcile the loss of cultural inheritance?

Fertility tourism, like ART generally, has emerged relatively quickly and it will take time for societal and legal understandings to adapt, embrace and protect those involved. Further research is needed and "should include the experiences of patients, the difficulties they experience, the impact of such movements on the national healthcare systems, the effects of, for instance, portability of insurance on the numbers, etc. It will only be possible to evaluate the phenomenon properly when a full picture can be patched together."5 Bioethicist Glenys Godlovitch at the University of Calgary states that "fertility tourism requires ‘an incredible amount of due diligence’ where couples research the risk, meet others who have gone through the process and formulate a plan about what to tell their child."3

References

1. Cross Border Reproductive Services – International Federation of Social Workers (IFSW)

2. Assisted Human Reproduction Canada. http://www.ahrc-pac.gc.ca

3. Lang, Michelle. (2009, February 16). Quest for baby crosses borders. Calgary Herald [online]. Retrieved October 16, 2009 from

http://www2.canada.com/calgaryherald/news/story.html?id=acc1bb50-bd19-44d5-8902-c7e55749bffa.\

4. Blyth, E. Tackling Issues in Cross-Border Reproductive Care. BioNews. Retrieved October 16, 2009 from http://www.bionews.org.uk/page_38069.asp

5. Pennings, G., Autin, C., Decleer, W., Delbaere, A., Delbeke, L., Delvigne, A., et al. (2009) Cross-border reproductive care in Belgium. Human Reproduction. Retrieved October 16, 2009, from http://humrep.oxfordjournals.org/cgi/content/abstract/dep300