Cross-border reproductive care: a phenomenon expressing the controversial aspects of reproductive technologies

Gendering the beginning of life: Taiwanese gay fathers' navigation of preimplantation genetic diagnosis-assisted sex selection in transnational third-party reproduction

Preimplantation genetic diagnosis (PGD) has been used not only to avoid genetic diseases and increase conception success rates but also to perform non-medical sex selection, particularly in the surging cross-border reproductive care (CBRC). In the context of commercialised biomedicine, assisted reproductive technologies, such as lifestyle sex selection, have been tailored to meet intended parents' preferences. However, there is a lack of analysis on how individuals' reproductive decisions on PGD-assisted sex selection were shaped within the sociocultural norms and CBRC. This article explores Taiwanese gay fathers' navigations on sex selection while seeking third-party reproduction overseas because of local legal constraints. Drawing on in-depth interviews with 53 gay fathers (to-be), I analysed how 'individual preferences' were dynamically shaped by local sociocultural norms and embedded within transnational settings of routinising PGD in chosen repro-destinations. The findings showed that gay fathers mobilised strategic discourses on non-medical sex selection from both the local and the global to negotiate their decisions in coherence with their LGBTQ+ identity and their role as sons carrying familial responsibility to procreate male heirs. This article proposed a nuanced understanding of gay fathers' reproductive practices of 'gendering the beginning of life' through PGD-assisted sex selection.

Ready for polygenic risk scores? An analysis of regulation of preimplantation genetic testing in European countries

STUDY QUESTION

Would the different regulatory approaches for preimplantation genetic testing (PGT) in Europe permit the implementation of preimplantation genetic testing using polygenic risk scores (PGT-P)?

SUMMARY ANSWER

While the regulatory approaches for PGT differ between countries, the space provided for potential implementation of PGT-P seems limited in all three regulatory models.

WHAT IS KNOWN ALREADY

PGT is a reproductive genetic technology that allows the testing for hereditary genetic disorders and chromosome abnormalities in embryos before implantation. Throughout its history, PGT has largely been regarded as an ethically sensitive technology. For example, ethical questions have been raised regarding the use of PGT for adult-onset conditions, non-medical sex selection, and human leukocyte antigen typing for the benefit of existing siblings. Countries in which PGT is offered each have their own approach of regulating the clinical application of PGT, and a clear overview of legal and practical regulation of PGT in Europe is lacking. An emerging development within the field of PGT, namely PGT-P, is currently bringing new ethical tensions to the forefront. It is unclear whether PGT-P may be applied within the current regulatory frameworks in Europe. Therefore, it is important to investigate current regulatory frameworks in Europe and determine whether PGT-P fits within these frameworks.

STUDY DESIGN, SIZE, DURATION

The aim of this study was to provide an overview of the legal and practical regulation of the use of PGT in seven selected European countries (Belgium, France, Germany, Italy, the Netherlands, Spain, and the UK) and critically analyse the different approaches with regards to regulatory possibilities for PGT-P. Between July and September 2023, we performed a thorough and extensive search of websites of governments and governmental agencies, websites of scientific and professional organizations, and academic articles in which laws and regulations are described.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We investigated the legal and regulatory aspects of PGT by analysing legal documents, regulatory frameworks, scientific articles, and guidelines from scientific organizations and regulatory bodies to gather relevant information about each included country. The main sources of information were national laws relating to PGT.

MAIN RESULTS AND THE ROLE OF CHANCE

We divided the PGT regulation approaches into three models. The regulation of PGT differs per country, with some countries requiring central approval of PGT for each new indication (the medical indication model: the UK, the Netherlands), other countries evaluating each individual PGT request at the local level (the individual requests model: France, Germany), and countries largely leaving decision-making about clinical application of PGT to healthcare professionals (the clinical assessment model: Belgium, Italy, Spain). In the countries surveyed that use the medical indication model and the individual requests model, current legal frameworks and PGT criteria seem to exclude PGT-P. In countries using the clinical assessment model, the fact that healthcare professionals and scientific organizations in Europe are generally negative about implementation of PGT-P due to scientific and socio-ethical concerns, implies that, even if it were legally possible, the chance that PGT-P would be offered in the near future might be low.

LIMITATIONS, REASONS FOR CAUTION

The results are based on our interpretation of publicly available written information and documents, therefore not all potential discrepancies between law and practice might have been identified. In addition, our analysis focuses on seven-and not all-European countries. However, since these countries are relevant players within PGT in Europe and since they have distinct PGT regulations, the insights gathered give relevant insights into diverse ways of PGT regulation.

WIDER IMPLICATIONS OF THE FINDINGS

To the best of our knowledge, this is the first paper that provides a thorough overview of the legal and practical regulation of PGT in Europe. Our analysis of how PGT-P fits within current regulation models provides guidance for healthcare professionals and policymakers in navigating the possible future implementation of PGT-P within Europe.

STUDY FUNDING/COMPETING INTEREST(S)

This project has received funding from the European Union's Horizon 2020 research and innovation program under the Marie Skłodowska-Curie grant agreement no. 813707. The authors declare no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Underground Gamete Donation in Sunni Muslim Patients

This qualitative study focuses on the "underground" practices of Sunni Muslim physicians and patients who are performing and undergoing religiously prohibited third-party gamete donation. It is based on face-to-face interviews with two Sunni Muslim gynecologists and 25 Sunni Muslim women who underwent third-party gamete donation treatments and gave birth to a baby. The analysis of the interviews sheds light on patients' experiences regarding donation and explores the experiences of the gynecologists. The patients shared with us their inner conflict regarding childbearing using either donated sperm or a donated egg. They expressed a subversive attitude toward the religious authorities and the Islamic fatwa (religious ruling) that prohibits third-party gamete donation. The gynecologists provide fertility care involving third-party gamete donation despite Islamic religious prohibitions; in consequence, they suffer feelings of guilt for their actions. The study participants challenge accepted binary conceptions regarding the boundaries between religious laws and the desire to produce offspring, between what is allowed and what is forbidden, between guilt and happiness, and between the desire to maintain a marital relationship and the desire to comply with cultural-religious rules. Based on Gloria Anzaldua's theory of the borderlands, and the context-informed approach, this study underscores the importance of giving voice to Sunni Muslim patients who underwent third-party gamete donation treatments and contributes to a deeper understanding of their dilemma of finding a reproductive solution that does not run counter to religious values.

Cross-border reproductive care: an Ethics Committee opinion

Cross-border reproductive care is a growing worldwide phenomenon, raising questions about why assisted reproductive technology patients travel for care, what harms and benefits may result, and what duties health care providers may have in advising and treating the patients who travel for reproductive services. Cross-border care may benefit or harm assisted reproductive technology stakeholders, including patients, offspring, providers, gamete donors, gestational carriers, and local populations in destination countries. This document replaces the previous document of the same name, last published in 2016.

Social egg freezing and donation: waste not, want not

The trend towards postponement of childbearing has seen increasing numbers of women turning towards oocyte banking for anticipated gamete exhaustion (AGE banking), which offers a realistic chance of achieving genetically connected offspring. However, there are concerns around the use of this technology, including social/ethical implications, low rate of utilisation and its cost-effectiveness. The same societal trends have also resulted in an increased demand and unmet need for donor oocytes, with many women choosing to travel overseas for treatment. This has its own inherent social, medical, financial and psychological sequelae. We propose a possible pathway to address these dual realities. The donation of oocytes originally stored in the context of AGE banking, with appropriate compensatory mechanisms, would ameliorate AGE banking concerns, while simultaneously improving the supply of donor oocytes. This proposed arrangement will result in tangible benefits for prospective donors, recipients and society at large.

Bioethical issues and legal frameworks of surrogacy: A global perspective about the right to health and dignity

Modern advances in assisted reproduction technology (ART) have disrupted the traditional concept of parenthood. Every year, thousands of people travel abroad from their home countries in order to circumvent restrictive legislation or to benefit from lower fees. In a similar context, surrogacy raises many bioethical and legal issues. The present paper will address the main questions arising from the debate prompted by surrogacy, focusing on international legislation, and looking critically at the different legislative models. As a result of worldwide heterogeneity in policies, legal approaches, and access to ART throughout the world, a growing number of would-be parents are seeking treatment abroad. The lack of regulation on cross-border surrogacy in low income countries can undermine the dignity and rights of women as even modest economic compensation determines a significant purchasing power. The international effort should be aimed at creating an international regulatory framework from which guidelines useful to national governments derive. An international agreement would provide a solid legal basis for the protection of surrogate women. In order to limit the economic interests linked to procreative tourism, so as to truly protect global health and women's rights, legislative uniformity is therefore necessary between the various states.

Latest-Late Fertility? Decline and Resurgence of Late Parenthood Across the Low-Fertility Countries

After decades of fertility postponement, we investigate recent changes in late parenthood across low-fertility countries in the light of observations from the past. We use long series of age-specific fertility rates from the Human Fertility Database (1950-2016) for women, and new data covering the period 1990-2016 for men. In 1950, the contribution of births at age 40 and over to female fertility rates ranged from 2.5 to 9 percent, but then fell sharply until the 1980s. From the 1990s, however, the prevalence of late first births increased rapidly, especially so in countries where it was initially lowest. This has produced a late fertility rebound in the last two decades, occurring much faster for women than for men. Comparisons between recent and past extremely late (age 48+) fertility levels confirm that people are now challenging the natural fertility barriers, particularly for a first child.

Legal and ethical issues in cross-border gestational surrogacy

This article aims to identify the main legal and ethical issues around international surrogacy. Owing to the legal diversity and ethical background of such a globalized practice, a review of the key existing literature on these two matters has been identified and analyzed. The article also identifies and analyzes the most significant legal solutions provided by supranational jurisdictions when dealing with cases of international surrogacy. The scope of the article includes the efforts to reach a minimum legal framework at the international level, with the aim not to standardize but to provide common legal solutions to those travelling abroad to have a child by means of surrogacy.

Incidence of surrogacy in the USA and Israel and implications on women's health: a quantitative comparison

PURPOSE

Gestational surrogacy (GS) has been researched in multiple qualitative studies. In contrast, quantitative aspects of the practice are conspicuously understudied. The present article assesses and compares the incidence of GS in the USA and Israel, two industrialized countries that have maintained active commercial surrogacy practice, for over two decades.

METHOD

The article is a secondary analysis of GS figures published by the Israeli Parliament's Centre for Research and Information (2018) and by the USA's Centers for Disease Control (2016) and related professional publications. Each dataset is analyzed in reference to the respective country, so as to devise local incidence scores that are then juxtaposed in inter-country comparison.

RESULTS

The incidence of GS rises steeply in both countries. Though US surrogates are contracted by local and international, heterosexual and gay, and partnered and single intended parents, the relative incidence of GS is lower in the USA than in Israel, where only local heterosexual couples could contract a gestational surrogate. An exceptionally high rate of multiple births was observed in both settings, suggesting some overlooking of professional recommendations for elective single-embryo transfer.

CONCLUSION

GS incidence appears to resemble the ratio between the countries' respective fertility rates. The paper underscores two main risks facing gestational surrogates: the risk of not conceiving and not being paid and the risk of carrying a multiple pregnancy, which is extremely prevalent in GS pregnancies, and sustaining the short- and long-term health complications that are more prevalent in such pregnancies.

Oocyte provision as a (quasi) social market: Insights from Spain

The provision of oocytes plays an important role in human fertility treatments. Spain alone performs half of oocyte provision cycles in the European Union whilst all other European countries face an oocyte shortage. How do Spanish fertility clinics manage to match the increasing domestic and foreign demand for female oocytes? Adopting a weak performativity approach and drawing insights from interviews carried out with 20 fertility clinic representatives, this study suggests that Spanish clinics are successful thanks to an egg provision system designed as a (quasi) social market. In the absence of traditional market mechanisms based on price fluctuations, the combination of fixed monetary compensation for providers and altruistic framing of oocyte provision as an act of donation, are used to mobilize relatively high numbers of women. Fertility clinics optimize this supply through a set of supplementary strategies to ensure oocyte supply always meets oocyte demand. Though successful, this market design reinforces gender stereotypes and relies on manipulative notions of altruism. A clear but unacknowledged appropriation of women's bodies and reproductive labour are also operated, which reinforces and reproduces racial and social stratifications. Therefore, we ask whether alternative mechanisms to promote female solidarity across different generations, to raise awareness of the risks of advanced maternal age, and to explore alternative market designs should be considered.

Globalised quests for assisted conception: Reproductive travel for infertility and involuntary childlessness

The global movement of people across international borders to undergo assisted reproductive treatment is common, although there is little accurate data. In this article, we synthesise findings from our own empirical research on reproductive travel in addition to a review of clinical, ethical, legal, and regulatory complexities from studies on reproductive travel since 2010. Motivations for travel include legal and religious prohibitions; resource considerations; lack of access to gametes and reproductive assistors; quality and safety concerns; and personal preferences. Higher risks to mothers and children are associated with multiple embryo transfer and subsequent multiple and higher order pregnancies and the average older age of women undertaking reproductive travel. The potential exploitation of other women as providers of oocytes or surrogacy services, the lack of equity in access to assisted reproduction and the ambiguous legal status of children conceived from international reproductive travel are important ethical considerations. A range of significant legal issues remain given variable and limited international regulation. Scholarship on this trade necessarily engages with issues of power and gender, social inequities, global capitalism and the private decision-making of individuals seeking to form families. Research gaps remain given recent changes in the organisation, demands and destinations of the trade.

Heritable Genome Editing in a Global Context: National and International Policy Challenges

A central problem for the international governance of heritable germline gene editing is that there are important differences in attitudes and values as well as ethical and health care considerations around the world. These differences are reflected in a complicated and diverse regulatory landscape. Several publications have discussed whether reproductive uses would be legally permissible in individual countries and whether clinical applications could emerge in the context of regulatory gaps and gray areas. Systematic comparative studies that explore issues related to the governance of this technology from different national and international perspectives are needed to address the lack of knowledge in this area. In this research report, we contribute to filling this gap by presenting views of stakeholders in the United Kingdom on challenges to the governance of heritable genome editing. We present findings from a multistakeholder study conducted in the United Kingdom between October 2016 and January 2018 and funded by the Wellcome Trust. This research included interviews, literature analysis, and a workshop. We involved leading U.K. scientists, in vitro fertilization clinicians, and representatives from regulatory bodies, patient organizations, and other civil societal organizations, as well as fertility companies. Part one of this article explores stakeholder perceptions of possible global developments in heritable genome editing and associated risks and governance challenges. Part two presents a range of policy options that were generated during the workshop in relation to the challenges discussed in part one.

Regulating surrogacy in Europe: Common problems, diverse national laws

Despite the diverse legal approaches towards surrogacy in Europe, there are common socio-legal arguments attempting to legitimise it amongst the European Union member states. Regardless of the prevailing regulation in each country, surrogacy in general is confronted with common criticisms and faces similar obstacles. For instance, the operative definition of altruism is put under question in countries where altruistic surrogacy is permitted. Surrogacy is also considered an attack on a woman’s dignity and a risk to children’s welfare. Behind such claims, however, rests the common yet unsubstantiated belief in a natural maternal instinct. Furthermore, a clear misunderstanding about the bonding theory still persists. Common debates around surrogacy in Europe show us that, beyond the national margin of appreciation, surrogacy challenges basic definitions of motherhood, filiation and family. These challenges are deeply permeated by gender stereotypes which partially explain the national similarities among the legal diversities.

Cross-border and domestic surrogacy in the UK context: an exploration of practical and legal decision-making

This study aimed to explore UK intending parent's reasons for cross-border and domestic surrogacy, their preparations for the birth and the practical and legal challenges faced after the birth. An online survey was completed by 203 participants, of which 132 had a child born through surrogacy, 33 were in the process of surrogacy and 38 were planning a surrogacy arrangement. The most common reason for pursuing surrogacy in the UK was wanting a relationship with the surrogate (43%; n = 17) and for conducting surrogacy in the USA was because of a better legal framework (97%; n = 60). Parents returning to the UK from countries other than USA experienced greater delay and difficulties in obtaining the necessary documents for their return. This study highlights the disparities in parents' experiences of undergoing surrogacy in different countries, the frustrations some face in obtaining legal parenthood and the feelings of stress and anxiety this may cause. Whilst this is the first study comparing the experiences of people from the UK having surrogacy in different countries, the representativeness of the sample is unknown. The findings are important in identifying future directions for research, including assessing the impact of these early decisions and experiences for later parental wellbeing and children's welfare.

Cross border reproductive care (CBRC): a growing global phenomenon with multidimensional implications (a systematic and critical review)

PURPOSE

Many people travel abroad to access fertility treatments. This growing phenomenon is known as cross border reproductive care (CBRC) or fertility tourism. Due to its complex nature and implications worldwide, CBRC has become an emerging dilemma deserving more attention on the global healthcare agenda.

METHODS

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review of the literature was performed for all relevant full-text articles published in PubMed in English during the past 18 years to explore CBRC phenomenon in the new millennium.

RESULTS

Little is known about the accurate magnitude and scope of CBRC around the globe. In this systematic and critical review, we identify three major dimensions of CBRC: legal, economic, and ethical. We analyze each of these dimensions from clinical and practical perspectives.

CONCLUSION

CBRC is a growing reality worldwide with potential benefits and risks. Therefore, it is very crucial to regulate the global market of CBRC on legal, economic, and ethical bases in order to increase harmonization and reduce any forms of exploitation. Establishment of accurate international statistics and a global registry will help diminish the current information gap surrounding the CBRC phenomenon.

Quality of life, anxiety and depression of German, Italian and French couples undergoing cross-border oocyte donation in Spain

STUDY QUESTION

What is the quality of life (QoL) and mental health of infertile heterosexual couples from different nations (Italy, Germany and France) undergoing cross-border oocyte donation (OD) in Spain?

SUMMARY ANSWER

Women have lower QoL and more anxiety than their male partners; overall French couples have lower QoL than their Italian and German counterparts.

WHAT IS KNOWN ALREADY

In Europe, thousands of couples move across national borders annually to seek ARTs, primarily OD, driven mainly by legal restrictions in their countries of origin. Most research shows that infertility and ARTs affect patients' mental health and QoL. The decision to undergo reproductive care abroad might add further emotional and practical complexity. Reliable information on how this experience affects the mental health and QoL of cross-border reproductive care (CBRC) patients is lacking. Moreover, most research has focused on women, and further research on male partners and intercultural differences is needed.

STUDY DESIGN, SIZE, DURATION

Cross-sectional study including 548 heterosexual individuals (347 women, 201 men) from Italy, Germany and France seeking IVF with donated oocytes in Barcelona, Spain between March and November 2013.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 432 couples were invited to participate and handed a questionnaire set. Questionnaires were answered separately and anonymously by each member of the couple on the day of embryo transfer. The questionnaire set included the Fertility Quality of Life (FertiQoL) instrument, the generic Hospital Anxiety and Depression Scale (HADS) instrument and three close-ended questions assessing perceived usefulness, desire, and use of psychological support. The overall response rate was 63.4%.

MAIN RESULTS AND THE ROLE OF CHANCE

Men reported significantly higher scores than women in the emotional (+13.74; P < 0.001), mind-body (+13.39; P < 0.001) and social (+4.11; P < 0.01) FertiQoL domains, at multilevel analysis controlled for confounder factors. Intercultural differences in QoL of couples were seen. French individuals had significantly lower emotional (-6.44; P < 0.01), mind-body (-7.41; P < 0.001) and relational scores (-6.41; P < 0.001) compared to Italians. Germans showed higher social scores (+6.41; P < 0.001) but lower relational scores (-8.94; P < 0.002) than Italians. Men reported significantly lower anxiety scores for the HADS than their partners (-1.38; P < 0.001), and German couples reported lower anxiety (-1.70; P = 0.003) and depression than their Italian counterparts (-1.56; P < 0.001). French patients were more likely to have required support by a mental health professional due to fertility problems in the past (+0.19; P < 0.001).

LIMITATIONS, REASONS FOR CAUTION

The scope of this study is limited to heterosexual couples undergoing cross-border OD. Caution on the interpretation of the results in men is advised, mainly because only three men for every five women completed the questionnaire.

WIDER IMPLICATIONS OF THE FINDINGS

These findings call for further work to identify the true nature of the differences in QoL and mental health observed.

STUDY FUNDING/COMPETING INTEREST(S)

None.

The market for reproductive tourism: an analysis with special reference to Greece

Background

For many people, the need for parenthood remains unfulfilled due to biological reasons and a remedy for these individuals is assisted reproduction (AR). Because of widely differing and sometimes incompatible legislations around the world related to AR, there is considerable confusion across national borders. Within Europe, Greece seems to be in a comparatively favorable position because of lower restrictions and the availability of decent quality specialized medical facilities. This research is a market study with a business perspective and explores the emerging landscape of reproductive tourism (RT) in Greece.

Methods

The research adopted mixed methods. First, open-ended questions were used to interview foreign medical tourists and staff in various AR clinics. Based on the insights from these interviews and guided by the extent literature, a survey instrument was prepared and administered among 130 patients.

Results

Findings indicate that Greece still lack policies that nurture transparency and dynamic response to technological changes in AR. Also, the travel industry lack specialists who can effectively liaison with clinics, who understand the availability of AR technologies, regulations, and the unique needs of AR tourists.

Conclusions

Globally, the need for assisted reproduction has tremendously increased; yet, the supply of facilities is lagging far behind. There is a unique advantage for clinics located in touristic locations in countries that offer cheaper treatment options. Given the shape of its debt-ridden economy, Greece needs foreign exchange inflows and gaining first mover advantage in reproductive tourism is probably an important way to achieve this. This research draws up a reproductive tourism strategy for Greece.

Comparative preimplantation genetic diagnosis policy in Europe and the USA and its implications for reproductive tourism

Unlike many European nations, the USA has no regulations concerning the use of preimplantation genetic diagnosis (PGD), a technique employed during some fertility treatments to select embryos based on their genes. As such, PGD can and is used for a variety of controversial purposes, including sex selection, selection for children with disabilities such as deafness, and selection for 'saviour siblings' who can serve as tissue donors for sick relatives. The lack of regulation, which is due to particular features of the US political and economic landscape, has ethical and practical implications for patients seeking PGD around the world. This paper contrasts the absence of PGD oversight in the USA with existing PGD policies in Switzerland, Italy, France and the UK. The primary reasons why PGD is not regulated in the USA are addressed, with consideration of factors such as funding for assisted reproductive technology treatmemt and the proximity of PGD to the contentious abortion debate. The obstacles that would need to be overcome in the USA for PGD to be regulated in the future are outlined. Then, the significance of the current divergence in PGD policy for patients around the world are discussed. Regulatory differences create opportunities for reproductive tourism, which result in legal, health and moral challenges. The paper concludes with comments on the need for policymakers around the world to balance respect for the characters and constitutions of their individual countries with appreciation of the needs of infertile patients across the globe.

Unravelling orders in a borderless Europe? Cross-border reproductive care and the paradoxes of assisted reproductive technology policy in Germany and Poland

This article examines assisted reproduction policy and practices in Germany and Poland. Germany is among the most restrictive countries in the European Union (EU) with respect to assisted reproductive technologies. In contrast, Poland only recently passed legislation regulating assisted reproductive technologies. Before this, most practices were unregulated, despite vocal opposition to all forms of IVF from conservative Roman Catholic activists. Germany and Poland differ significantly regarding the cultural narratives and historical experience that impact attitudes toward reproduction. In Germany, discussions on assisted reproduction often invoke concerns about medical intervention in ethically complex matters, due - in part - to the country's National Socialist past. My objectives in this article centre on examining assisted reproduction contexts in each of these two countries, with attention to the framing of debates on reproduction, the anxieties that inform them, and the resulting paradoxes. I consider the unintended consequences of domestic policy and their importance regarding cross-border reproductive care (CBRC). Within the borderless EU, the widespread practice of CBRC demonstrates the ineffectiveness of national policies. Moreover, this shift in location can impact practices and trends found in other accessible, but less restrictive countries. Of particular concern are the relocation of risk to 'bioavailable' populations in less affluent countries and the reification of cultural and socio-economic hierarchies.

Cross-border reproductive care: an Ethics Committee opinion

Cross-border reproductive care (CBRC) is a growing worldwide phenomenon, raising questions about why assisted reproductive technology (ART) patients travel abroad, what harms and benefits may result, and what duties health-care providers may have in advising and treating patients who travel for reproductive services. Cross-border care offers benefits and poses harms to ART stakeholders, including patients, offspring, providers, gamete donors, gestational carriers, and local populations in destination countries. This document replaces the previous document of the same name, last published in 2013 (Fertil Steril 2013;100:645-50).

Italian law on medically assisted reproduction: do women's autonomy and health matter?

Background

In Italy in 2004, a very restrictive law was passed on medically assisted reproduction (MAR) (Law 40/2004) that placed Italy at the most conservative end of the European spectrum. The law was widely criticized and many couples seeking MAR brought their cases before the Italian Civil Courts with regard to pre-implantation genetic diagnosis (PGD), donor insemination and the issue of consent. Ten years on, having suffered the blows of the Italian Constitutional Court, little remains of law 40/2004.

Discussion

In 2009, the Constitutional Court declared the maximum limit of the number of embryos to be produced and transferred for each cycle (i.e. three), as stated in the original version of the law, to be constitutionally illegitimate. In 2014, the same Court declared as unconstitutional the ban on donor insemination, thus opening the way to heterologous assisted reproduction. Heterologous MAR is therefore perfectly legitimate in Italy. Finally, in 2015 a further ruling by the Constitutional Court granted the right to access MAR to couples who are fertile but carriers of genetic diseases. However, there is still much room for criticism. Many couples and groups are still, in fact, excluded from MAR. Same-sex couples, single women and those of advanced reproductive age are, at the present time, discriminated against in that Italian law denies these subjects access to MAR.

Summary

The history of Law 40/2004 has been a particularly troubled one. Numerous rulings have, over the years, dismantled much of a law constructed in violation of the rights and autonomy of women and couples. However, a number of troubling issues still exist from what is left of the law and the debate is still open at national and transnational level regarding some of the contradictions and gaps in the law highlighted in this article. Only by abolishing the final prohibitions and adopting more liberal views on these controversial yet crucial issues will Law 40/2004 become what it should have been from the start, i.e. a law which outlines the ‘rules of use’ of MAR and not, as it has been until now, a law of bans which sets limits to the freedom to reproduce.

Indian egg donors' characteristics, motivations and feelings towards the recipient and resultant child

This is the first study to examine characteristics, motivations and experiences of Indian egg donors. In-depth interviews were conducted with 25 egg donors who had donated during the previous 8 months at a fertility clinic in Mumbai. The semi-structured interviews were conducted in Hindi and English. In addition to demographic information, data were collected on donors' motivations for donating, with whom they had discussed donation, and feelings towards the recipients. The response rate was 66%. All participants were literate and had attended school. Twenty (80%) egg donors had children and five (20%) did not. The most common motivation (19, 76%) for donating was financial need. Egg donors had discussed their donation with their husband or with close family/friends, with almost all mentioning that wider society would disapprove. The majority (20, 80%) had no information about the recipients and 11 (44%) preferred not to. The findings highlight the similarities and differences between egg donors from India and those from other countries and that egg donors are of a more varied demographic background than surrogates in India. Given that India has been a popular destination for fertility treatment, the findings have important implications for regulation and practice within India and internationally.

Views of Swedish commissioning parents relating to the exploitation discourse in using transnational surrogacy

Transnational surrogacy, when people travel abroad for reproduction with the help of a surrogate mother, is a heavily debated phenomenon. One of the most salient discourses on surrogacy is the one affirming that Westerners, in their quest for having a child, exploit poor women in countries such as India. As surrogacy within the Swedish health care system is not permitted, Swedish commissioning parents have used transnational surrogacy, and the majority has turned to India. This interview study aimed to explore how commissioning parents negotiate the present discourses on surrogacy. Findings from the study suggest that the commissioning parents' views on using surrogacy are influenced by competing discourses on surrogacy represented by media and surrogacy agencies. The use of this reproductive method resulted, then, in some ambiguity. Although commissioning parents defy the exploitation discourse by referring to what they have learnt about the surrogate mother's life situation and by pointing at the significant benefits for her, they still had a request for regulation of surrogacy in Sweden, to better protect all parties involved. This study, then, gives a complex view on surrogacy, where the commissioning parents simultaneously argue against the exploitation discourse but at the same time are uncertain if the surrogate mothers are well protected in the surrogacy arrangements. Their responses to the situation endorse the need for regulation both in Sweden and India.

Evolving minimum standards in responsible international sperm donor offspring quota

An international working group was established with the aim of making recommendations on the number of offspring for a sperm donor that should be allowable in cases of international use of his sperm. Considerations from genetic, psychosocial, operational and ethical points of view were debated. For these considerations, it was assumed that current developments in genetic testing and Internet possibilities mean that, now, all donors are potentially identifiable by their offspring, so no distinction was made between anonymous and non-anonymous donation. Genetic considerations did not lead to restrictive limits (indicating that up to 200 offspring or more per donor may be acceptable except in isolated social-minority situations). Psychosocial considerations on the other hand led to proposals of rather restrictive limits (10 families per donor or less). Operational and ethical considerations did not lead to more or less concrete limits per donor, but seemed to lie in-between those resulting from the aforementioned ways of viewing the issue. In the end, no unifying agreed figure could be reached; however the consensus was that the number should never exceed 100 families. The conclusions of the group are summarized in three recommendations.

What do we know about medical tourism? A review of the literature with discussion of its implications for the UK National Health Service as an example of a public health care system

BACKGROUND

Medical tourism is a growing phenomenon. This review of the literature maps current knowledge and discusses findings with reference to the UK National Health Service (NHS).

METHODS

Databases were systematically searched between September 2011 and March 2012 and 100 papers were selected for review.

RESULTS

The literature shows specific types of tourism depending on treatment, eg, dentistry, cosmetic, or fertility. Patient motivation is complex and while further research is needed, factors beyond cost, including availability and distance, are clearly important. The provision of medical tourism varies. Volume of patient travel, economic cost and benefit were established for 13 countries. It highlights contributions not only to recipient countries' economies but also to a possible growth in health systems' inequities. Evidence suggests that UK patients travel abroad to receive treatment, complications arise and are treated by the NHS, indicating costs from medical travel for originating health systems.

CONCLUSION

It demonstrates the importance of quality standards and holds lessons as the UK and other EU countries implement the EU Directive on cross-border care. Lifting the private-patient-cap for NHS hospitals increases potential for growth in inbound medical tourism; yet no research exists on this. Research is required on volume, cost, patient motivation, industry, and on long-term health outcomes in medical tourists.

Motivations and experiences of patients seeking cross-border reproductive care: the Australian and New Zealand context

OBJECTIVE

To explore the motivations, clinical care, counseling, and support experiences of Australian and New Zealand participants considering or having participated in cross-border reproductive care (CBRC).

DESIGN

Questionnaire-based study.

SETTING

Not applicable.

PATIENT(S)

One hundred thirty-seven Australian and New Zealand participants aged 23-53 years.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURES(S)

Quantitative and qualitative responses to an anonymously completed online questionnaire.

RESULT(S)

Quantitative responses from participants indicated that motivations for engaging in CBRC included limited availability of gamete donors in their home state, difficulty in meeting treatment eligibility criteria, and treatment being legally prohibited. Experiences of CBRC were generally rated positively in terms of medical needs (91.2%), safety (89.4%), and costs (85.7%), although rated more conservatively to emotional needs being met (57.9%). Less than half the sample (47.5%) had accessed some form of CBRC-related counseling. Themes identified in qualitative analysis reflected gamete supply and demand issues, the importance of donor information and disclosure, the personal impact of legislation, and ongoing support needs after CBRC treatment.

CONCLUSION(S)

A greater percentage of participants agreed that their CBRC clinic satisfied their overall medical needs and treatment expectations in comparison with overall emotional needs. Participants indicated access to post-treatment support counseling particularly with regard to their emotional well-being and disclosure issues to donor-conceived children would be useful. The implications of our findings for the provision of best-practice psychosocial counseling support and development of counseling guidelines are highlighted.

Cross-border reprogenetic services

The purpose of this review is to synthesize the current knowledge on the international movement of patients and biopsied embryo cells for pre-implantation genetic diagnosis and its different applications. Thus far, few attempts have been made to identify the specific nature of this phenomenon called 'cross-border reprogenetic services'. There is scattered evidence, both empirical and speculative, suggesting that these services raise major issues in terms of service provision, risks for patients and the children-to-come, the legal liabilities of physicians, as well as social justice. To compile this evidence, this review uses the narrative overview protocol combined with thematic analysis. Five major themes have emerged from the literature at the conjunction of cross-border treatments and reprogenetics: 'scope', 'scale', 'motivations', 'concerns', and 'governance'. Similar themes have already been observed in the case of other medical tourism activities, but this review highlights their singularity with reprogenetic services. It emphasizes the diagnostic and autologous feature of reprogenetics, the constant risk of misdiagnosis, the restriction on certain tests for medically controversial conditions, and the uncertain accessibility of genetic counseling in cross-border settings.

Impact of egg donation deliveries from domestic and overseas sources on maternal care: a questionnaire survey of Japanese perinatal physicians

OBJECTIVES

Recent demographic changes, such as marriage at later ages and delayed childbearing, have contributed to the increased demand for ovum donation. The purpose of the present study was to evaluate the frequency and impact of egg donation deliveries on maternal care using a questionnaire survey of Japanese perinatal care providers.

METHODS

A quantitative survey was conducted from October to November 2012 using self-administered anonymous questionnaires. We asked 2,693 obstetrics clinics/hospitals throughout Japan to complete the survey: 679 questionnaires were returned (response rate, 25.2 %).

RESULTS

Of the respondents, 15.8 % answered that they had handled egg donation deliveries in the past. With regards to the country in which patients received egg donation services, the most frequent was the United States, including Hawaii. Asian countries, such as Thailand, Korea, and Singapore, were also reported; only two cases in Japan were reported. "Advanced age/menopause" was the most frequent reason for egg donation, and the mean age at egg donation delivery, because of advanced age/menopause, was 48.3 years.

CONCLUSIONS

Our findings will increase public awareness of the legal issues related to assisted reproductive technology and cross-border reproductive care, as well as care of the mother and child in pregnancies resulting from reproductive technologies such as egg donation overseas. People should be aware of the issues involved in egg donation abroad and the resulting deliveries, and should implement specific care for women bearing children at later ages.

Implications for the NHS of inward and outward medical tourism: a policy and economic analysis using literature review and mixed-methods approaches

Background

The study examined the implications of inward and outward flows of private patients for the NHS across a range of specialties and services.

Objectives

To generate a comprehensive documentary review; to better understand information, marketing and advertising practices; examine the magnitude and economic and health-related consequences of travel; understand decision-making frames and assessments of risk; understand treatment experience; elicit the perspectives of key stakeholder groups; and map out medical tourism development within the UK.

Design and participants

The study integrated policy analysis, desk-based work, economic analysis to estimate preliminary costs, savings and NHS revenue, and treatment case studies. The case studies involved synthesising data sources around bariatric, fertility, cosmetic, dental and diaspora examples. Overall, we drew on a mixed-methods approach of qualitative and quantitative data collection. The study was underpinned by a systematic overview and a legal and policy review. In-depth interviews were carried out with those representing professional associations, those with clinical interests and representative bodies (n = 16); businesses and employees within medical tourism (n = 18); NHS managers (n = 23); and overseas providers. We spoke to outward medical travellers (46 people across four treatment case studies: bariatric, fertility, dental and cosmetic) and also 31 individuals from UK-resident Somali and Gujarati populations.

Results

The study found that the past decade has seen an increase in both inward and outward medical travel. Europe is both a key source of travellers to the UK and a destination for UK residents who travel for medical treatment. Inward travel often involves either expatriates or people from nations with historic ties to the UK. The economic implications of medical tourism for the NHS are not uniform. The medical tourism industry is almost entirely unregulated and this has potential risks for those travelling out of the UK. Existing information regarding medical tourism is variable and there is no authoritative and trustworthy single source of information. Those who travel for treatment are a heterogeneous group, with people of all ages spread across a range of sociodemographic groups. Medical tourists do not appear to inform their decision-making with hard information and consequently often do not consider all risks. They make use of extensive informal networks such as treatment-based or cultural groups. Motivations to travel are in line with the findings of other studies. Notably, cost is never a sole motivator and often not the primary motivation for seeking treatment abroad.

Limitations

One major limitation of the study was the abandonment of a survey of medical tourists. We sought to avoid an extremely small survey, which offers no real insight. Instead we redirected our resources to a deeper analysis of qualitative interviews, which proved remarkably fruitful. In a similar vein, the economic analysis proved more difficult and time consuming than anticipated. Data were incomplete and this inhibited the modelling of some important elements.

Conclusions

In 2010 at least 63,000 residents of the UK travelled abroad for medical treatment and at least 52,000 residents of foreign countries travelled to the UK for treatment. Inward referral and flows of international patients are shaped by clinical networks and longstanding relationships that are fostered between clinicians within sender countries and their NHS counterparts. Our research demonstrated a range of different models that providers market and by which patients travel to receive treatment. There are clearly legal uncertainties at the interface of these and clinical provision. Patients are now travelling to further or ‘new’ markets in medical tourism. Future research should: seek to better understand the medium- and long-term health and social outcomes of treatment for those who travel from the UK for medical treatment; generate more robust data that better capture the size and flows of medical travel; seek to better understand inward flows of medical travellers; gather a greater level of information on patients, including their origins, procedures and outcomes, to allow for the development of better economic costing; explore further the issues of clinical relationships and networks; and consider the importance of the NHS brand.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Reiterative changes in the Italian regulation on IVF: the effect on PGD patients' reproductive decisions

National legislations represent one of the main factors influencing access to assisted reproduction treatment. The Italian situation in the last decade is an example of how the treatment of patients for preimplantation genetic diagnosis (PGD) was more dependent on regulators than on medical choices. This report analysed how the changes in Italian regulation affected the number of PGD referrals to this study centre, as well as their decision to opt for cross-border reproductive care (CBRC). The analysis showed that during the period in which PGD was actually not performed because of the restriction imposed by the Italian law on IVF (from 24 February 2004 to 7 May 2009) there was a significant decrease in the number of referrals asking for PGD (2.5% of total referrals) compared with the previous years (3.3%; P < 0.025) and following years when PGD was legalized (5.1%; P < 0.001). The number of couples opting for CBRC had an opposite trend, reaching a maximum when PGD was banned from Italian centres (55 couples), whereas after the readmission of PGD, only eight couples went abroad for treatment. Concomitantly, since May 2009, the proportion of couples performing a PGD cycle in this centre has constantly increased.

Cross-border reproductive care among French patients: experiences in Greece, Spain and Belgium

STUDY QUESTION

What are the characteristics, motivation and experience of French patients seeking cross-border reproductive care (CBRC)?

SUMMARY ANSWER

French patients seeking CBRC are same-sex couples, single women who are not eligible for assisted reproduction technologies (ARTs) in France and heterosexual couples seeking oocyte donation due to extremely limited access to this technique in France, while their choice of Greece as a destination is influenced by financial issues.

WHAT IS KNOWN ALREADY

CBRC is a new, increasing, complex and poorly understood phenomenon. A few studies have investigated UK, German or Italian CBRC patients, but none have specifically investigated French patients although France is one of the top four countries of origin of CBRC patients in Europe.

STUDY DESIGN, SIZE, DURATION

A cross-sectional study was carried out in 2010-2012 in three ART centres in Greece, Belgium and Spain in order to investigate French patients treated in these centres. Recruitment was prospective in Greece and Belgium and retrospective in Spain. The overall response rate was 68%, with 128 French patients participating.

PARTICIPANTS/MATERIALS, SETTING, METHODS

French patients filled in a questionnaire. Information was collected on their socio-economic characteristics and their search for ART treatment in France and in other countries.

MAIN RESULTS AND THE ROLE OF CHANCE

In the Belgian centre, 89% of French patients used sperm donation whereas oocyte donation was used by 100% of patients in the Greek centre and 74% of patients in the Spanish centre. The majority (94%) of French patients using sperm donation in Belgium were not legally eligible for access to ART in France as they were same-sex couples or single women, and the main criterion of choice of centre was its geographical proximity (71%). Most of the French patients using oocyte donation in Greece and Spain fulfilled criteria for fully reimbursed oocyte donation treatment in France as they were heterosexual couples (99%) with the woman aged <43 years (65%). For these couples, CBRC was motivated by the extremely limited access to oocyte donation in France. Half of French CBRC patients using oocyte donation in Spain had a low/intermediate occupational level (such as primary school teachers, nurses, administrative officers or sales agents, workers and employees) and this proportion was much higher in Greece (82%, P < 0.01).

LIMITATIONS, REASONS FOR CAUTION

Larger and more wide-ranging studies are needed as this study included only 128 patients who may not be representative of all French CBRC patients, especially because the study was carried out only in three ART centres and these too may not be representative.

WIDER IMPLICATIONS OF THE FINDINGS

CBRC among French patients had been thought to reflect mainly law evasion. This study showed that the reality is much more complex and that CBRC among French patients reflects both law evasion and limited access to oocyte donation in France. It also brings new insight into the characteristics of the patients by suggesting a certain degree of 'democratization' in access to such care. However, the choice of centre seemed related to socio-economic characteristics, in that the Greek centre treated a less advantaged population than the Spanish centre.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by French public research funds, the Institute Emilie du Châtelet from the Ile-de-France Region, the Biomedicine Agency and the Research Institute of Public Health (IReSP). There are no conflicts of interest.

TRIAL REGISTRATION NUMBER

Not applicable.

Attitudes towards cross-border reproductive care among infertile Japanese patients

OBJECTIVES

The attitudes towards cross-border reproductive care (CBRC) held by infertile Japanese patients have not been explored. The objective of the present study was to examine interest levels, preferred destinations, motivations, and sources of information related to CBRC. Our findings provide a general outline of CBRC and the future of reproduction and assisted reproductive technology (ART) in Japan.

METHODS

The study used a cross-sectional design. Data were collected from 2,007 infertile Japanese patients from 65 accredited ART clinics in Japan (response rate, 27.4 %) via anonymous questionnaires.

RESULTS

Most of the infertile Japanese patients who responded denied using CBRC. However, by group, 171 (8.5 %) patients in non-donor in vitro fertilization, 150 (7.5 %) in egg donation, 145 (7.2 %) in pre-implantation genetic diagnosis, and 129 (6.4 %) in surrogacy said that, depending on the situation, they might travel abroad in the future. Older respondents were more likely to express an intention to travel overseas for egg donation in the future. The most popular destination for CBRC was the United States. Popular reasons for interest in CBRC among those considering or planning using this approach to third-party reproduction were that egg donation or surrogacy was unavailable or that obtaining ethical approval takes too long in Japan, whereas these processes are legal and affordable overseas. However, high cost was the most common reason for hesitancy regarding CBRC. Among the participants who were considering or planning to travel abroad for this purpose, TV, medical agencies, print media, and message boards on websites were popular sources of information, whereas doctors, friends, and patient self-help groups were not.

CONCLUSIONS

Although CBRC among infertile Japanese patients is not at present common, the demand for and use of this approach may increase in the future in the context of the increasingly aging population. Lack of regulation and unavailability of third-party reproduction is a major cause of CBRC among Japanese patients. Health care provider faces an urgent need for giving useful information for patients regarding CBRC.

Cross border treatment for infertility: the counselling perspective in the UK

There is increasing evidence that people with infertility problems are seeking treatment in a wide range of countries. While many make an independent choice about their destination clinic, others are referred under shared-care arrangements based in the UK. In response to cross border reproductive care, concerns have been raised and recommendations for best practice have begun to emerge. The involvement of counsellors appears to be limited. This paper considers the issues raised by cross-border reproductive care with a particular focus on those who travel abroad for treatment for gamete/embryo donation or surrogacy. It describes the part that counselling can play in both supporting patients and providing a service that will enable them to prepare for the additional challenges that may arise in the future. It concludes with a recommendation for further research, for UK clinics routinely to refer patients to a counsellor prior to travel arrangements being made and for collaboration between countries in developing and implementing best practice guidelines.

Cross-border reproductive care: a committee opinion

Cross-border reproductive care (CBRC) is a growing worldwide phenomenon, raising questions about why assisted reproductive technology (ART) patients travel abroad, what harms and benefits may result, and what duties health care providers may have in advising and treating patients who travel for reproductive services. Cross-border care offers benefits and poses harms to ART stakeholders, including patients, offspring, providers, gamete donors, gestational carriers, and local populations in destination countries.

Patterns of globalized reproduction: Egg cells regulation in Israel and Austria

Since the successful introduction of in vitro fertilization in 1978, medically assisted reproduction (MAR) has proliferated in multiple clinical innovations. Consequently, egg cells have become an object of demand for both infertility treatment and stem cell research, and this raises complex legal, ethical, social and economic issues.In this paper we compare how the procurement and use of human egg cells is regulated in two countries: Israel and Austria. Israel is known for its scientific leadership, generous public funding, high utilization and liberal regulation of assisted reproductive technology (ART). Austria lies at the other extreme of the regulatory spectrum in terms of restrictions on reproductive interventions.In both countries, however, there is a constant increase in the use of the technology, and recent legal developments make egg cells more accessible. Also, in both countries the scarcity of egg cells in concert with the rising demand for donations has led to the emergence of cross-border markets and global 'reproductive tourism' practices. In Israel, in particular, a scandal known as the 'eggs affair' was followed by regulation that allowed egg cell donations from outside the country under certain conditions.Cross-border markets are developed by medical entrepreneurs, driven by global economic gaps, made possible by trans-national regulatory lacunae and find expression as consumer demand. The transnational practice of egg cell donations indicates the emergence of a global public health issue, but there is a general lack of medical and epidemiological data on its efficacy and safety. We conclude that there is need for harmonisation of domestic laws and formulation of new instruments for international governance.

The ethical, legal, and social issues impacted by modern assisted reproductive technologies

Background. While assisted reproductive technology (ART), including in vitro fertilization has given hope to millions of couples suffering from infertility, it has also introduced countless ethical, legal, and social challenges. The objective of this paper is to identify the aspects of ART that are most relevant to present-day society and discuss the multiple ethical, legal, and social challenges inherent to this technology. Scope of Review. This paper evaluates some of the most visible and challenging topics in the field of ART and outlines the ethical, legal, and social challenges they introduce. Major Conclusions. ART has resulted in a tectonic shift in the way physicians and the general population perceive infertility and ethics. In the coming years, advancing technology is likely to exacerbate ethical, legal, and social concerns associated with ART. ART is directly challenging society to reevaluate the way in which human life, social justice and equality, and claims to genetic offspring are viewed. Furthermore, these issues will force legal systems to modify existing laws to accommodate the unique challenges created by ART. Society has a responsibility to ensure that the advances achieved through ART are implemented in a socially responsible manner.

CBRC and psychosocial counselling: assessing needs and developing an ethical framework for practice

Encountering infertility and involuntary childlessness and undergoing infertility treatment are acknowledged as stressful experiences that impact on individuals' psychological and emotional health – and for which access to psychosocial counselling by a skilled mental health professional may be beneficial. Evidence of patients', gamete donors' and surrogates' experiences indicates that utilization of infertility treatment in another country may not only exacerbate these psychosocial adversities, but may also pose additional risks to the psychological or physical health of participants, thus further emphasizing the need for competent psychosocial counselling services in cross-border reproductive care. However, this is a largely neglected topic in recent discussions of both CBRC itself and of infertility counselling practice. This paper extends the previous work undertaken by two of the authors to begin to map out practice issues within an ethical framework for counsellors when working with clients, donors, surrogates, individuals conceived following infertility treatment and existing children in clients', donor's and surrogates' families where cross-border reproductive treatment is considered or undertaken.

Cross-border reproductive care: a review of the literature

Cross-border reproductive care (CBRC) has attracted considerable attention in media and professional publications. The aim of this review is to present a critical narrative overview of the published evidence on CBRC. A systematic search of key academic databases was undertaken with no time restrictions set for publication. This was supplemented by additional searches of key websites, reference chaining and enquiries to people working in the field. A total of 54 items are included in the review, including both empirical research studies (18) and debate papers (36). The key themes discussed are: terminology and definitions; incidence; experiences; explanations; implications; and policy responses. Significant methodological limitations and gaps in the literature are identified. Evidence on incidence is scant, though it suggests that CBRC is increasing. The literature suggests legal, social and political drivers, which vary in importance geographically and between individuals. Limited findings on patient perceptions suggest a broadly positive patient experience. Suggested policy responses include prohibition, regulatory harmonization and harm minimization. There is a need for better international data collection tools and both quantitative and qualitative work which encompasses views of patients, donors, surrogates and professionals and which explores the implications for healthcare services in sending countries.