Reproductive agency and projects: Germans searching for egg donation in Spain and the Czech Republic

Mapping Ethical, Legal, and Social Implications (ELSI) of gamete donation

RESEARCH QUESTION

This scoping review investigates the Ethical, Legal, and Social Implications (ELSI) of gamete donation, a critical facet of Assisted Reproductive Technologies, by analyzing the evolving research scope, methodological approaches, and the geographical skew in the literature. Despite the increased global uptake of donor gametes, current scholarship predominantly emanates from Western contexts and focuses on majoritized groups. This bias constrains the universality of research findings and limits their applicability across varied legal, cultural, and social contexts, underscoring a need for broader inclusivity.

DESIGN

We addressed 867 pivotal articles published between 1999 and 2019.

RESULTS

Our analysis reveals a discernible escalation in research volume, with 62% based on empirical research. The intellectual landscape unfolds into four dominant clusters: Regulatory Frameworks, Incentives, and Access; Family Dynamics and Genetic Linkages; Identity and Privacy in Donor Conception; and Cultural and Societal Attitudes towards GD. Each cluster highlights nuanced dimensions of gamete donation, from regulatory intricacies and psychological welfare to identity ethics and cultural perceptions.

CONCLUSION

Our findings advocate for a shift towards more globally representative and methodologically inclusive research. By integrating diverse cultural narratives and expanding geographical breadth, future research can offer holistic understandings of gamete donation, fostering equitable and culturally resonant practices and policies worldwide.

The reproductive journeys of French women over 40 seeking assisted reproductive technology treatments in Spain

Fertility decline is a complex phenomenon resulting from converging social and cultural changes that are governed through politics. As it has been discussed in many studies, the European's low fertility rate goes hand in hand with the trend of maternity postponement. Although in many European countries over the last decades reproduction is envisaged as an individual choice that can be made at older ages, having a child after a certain age can be impossible -either "naturally" or using assisted reproductive technology-depending on the medical and legislative possibilities and limits of the country in which people live. In the extremely diverse European reproscape, reproductive legislations have forced but also allowed many people to seek reproductive treatments outside their home countries. Spain is a leading destination in Europe for cross border reproductive travel and, of the foreigners it receives, the French are the largest group. Despite having a history of strong pro-natalist policies, France has been one of the strictest European countries regarding access to medically assisted procreation. Until 2022, only heterosexual couples in which women were under 43 years of age could access treatments. Despite the recent opening of access to "all women", including single women and same-sex female couples, women over 43 years of age were once again excluded from the new legal framework and therefore remain condemned to travel abroad to access reproductive treatments. In this article, we analyze the experience of French women over 40 who cross the Spanish border to access reproductive treatments in order to fulfill their desire to have children. Through ethnographic data emerging from six years of participant observation and in-depth interviews with 15 women, we explore why they remain excluded from the French system of reproductive governance and the obstacles they face during their reproductive journey.

Eggonomics: Vitrification and bioeconomies of egg donation in the United States and Spain

Regulations governing assisted reproduction control the degree to which gamete donation is legal and how people providing genetic material are selected and compensated. The United States and Spain are both global leaders in fertility treatment with donor oocytes. Yet both countries take different approaches to how egg donation is regulated. The US model reveals a hierarchically organized form of gendered eugenics. In Spain, the eugenic aspects of donor selection are more subtle. Drawing upon fieldwork in the United States and Spain, this article examines (1) how compensated egg donation operates under two regulatory settings, (2) the implications for egg donors as providers of bioproducts, and (3) how advances in oocyte vitrification enhances the commodity quality of human eggs. By comparing these two reproductive bioeconomies we gain insight into how different cultural, medical, and ethical frameworks intersect with egg donor embodied experiences.

Patient and clinician experiences with cross-border reproductive care: A systematic review

OBJECTIVES

This review analyzes the experiences of patients and clinicians with regards to international cross-border reproductive care (CBRC) for the purpose of conception.

METHODS

Electronic databases PubMed, Embase, Web of Science, and Scopus were searched using 'medical tourism' AND 'assisted reproductive technology' from 1978 to 2020.

RESULTS

Predominant patient motivators for CBRC were cost and legality of assisted reproduction technology (ART) in one's home country, followed by cultural factors like shared language, religion, and cultural familiarity. Clinicians suggested global laws for CBRC would reduce the potential for exploitation of vulnerable populations but believed the enactment of international regulations unlikely and, even if enacted, difficult to enforce.

CONCLUSIONS

While patient and clinician experiences with CBRC varied, patients frequently cited financial and legal reasons for pursuing CBRC, while many providers had concern for the patient's safety.

CLINICAL PRACTICE IMPLICATIONS

This review recommends clinicians involved in family planning counsel patients seeking treatment abroad by: (i) informing patients of the risks and benefits of treatment abroad, (ii) establishing guidelines and standards for clinicians on resuming patient care post-CBRC, and (iii) creating a directory of reputable CBRC clinicians and experts.

Reproductive travel to, from and within sub-Saharan Africa: A scoping review

Scholarly interest in reproductive travel has increased in recent years, but travel within, to and from the African continent has received much less attention. We reviewed the literature on cross-border reproductive travel to and from countries of sub-Saharan Africa in order to understand the local forms of this trade. Access to fertility care remains deeply stratified, which is an ongoing concern in a region with some of the highest rates of infertility. We found a wide variety of reasons for reproductive travel, including a lack of trusted local clinics. Destinations were chosen for reasons including historical movements for medical treatment broadly, diasporic circulations, pragmatic language reasons, and ties of former colonial relations. We describe the unique tempos of treatment in the region, ranging from some intended parents staying in receiving countries for some years to the short-term contingent support networks that reprotravellers develop during their treatment and travel. Unique to the region is the movement of medical professionals, such as the 'fly-in, fly-out' clinic staff to deliver fertility care. Future research should include practices and movements to presently neglected 'reprohubs', particularly Kenya and Nigeria; the impact of pandemic-related lockdowns and border closures on the movements of intended parents, reproductive assistors and reproductive material; and the impact of low-cost protocols on treatment access within the region. This scoping review provides insight into the relevant work on cross-border reproductive care in sub-Saharan Africa, where a unique combination of access factors, affordability, and sociocultural and geopolitical issues fashion individuals' and couples' cross-border reproductive travel within, to and from Africa.

A Systematic Review of Qualitative Studies Investigating Motives and Experiences of Recipients of Anonymous Gamete Donation

The decision to use an anonymous gamete donation in fertility treatment could have significant long-term psychological and social effects for all stakeholders involved. In light of the growing recognition of donor-conceived children's right to know their genetic parentage, this entails profound ethical implications. This review aims to carve out the full spectrum of recipients' motives and experiences related to donor anonymity which could serve as an analytical framework for future ethical and sociological research on issues of donor anonymity. This review was conducted following a seven-step approach for systematic reviews of empirical bioethics literature. The characteristics and quality of the studies included in this review were reported. Data analysis was conducted using qualitative content analysis and was informed by sociological functionalist theorizations of ignorance. The 53 studies selected showed a diverse spectrum of characteristics concerning date and country of study, methodology, family type of participants, sample size, and the timing of data collection in relation to the stage of treatment. A total of 22 categories of motives and experiences of recipients concerning donor anonymity were identified inductively and grouped into five main categories. Donor anonymity was identified as a eufunctional form of ignorance, by which the recipients experienced or intended to control, regulate, or protect inter-stakeholder relations. Interpreting recipients' motives and experiences concerning donor anonymity as a form of ignorance directed toward particular stakeholders helps reframe the discourse on donor anonymity. It is a fruitful approach that can be refined further and applied in future research. This review identified possible directions for future investigations on motives for donor anonymity: the need for more thorough inquiries into the change in recipients' preferences over time, such as in the form of longitudinal studies and research on the perspective of non-biological parents.

Reprowebs: a conceptual approach to elasticity and change in the global assisted reproduction industry

In the last few decades, assisted reproductive technologies (ARTs) have become increasingly transregional and transnational, often involving travel within or between countries or even continents. Until recently, the global ART industry was marked by so-called 'reprohubs'-places (such as southern California, Dubai, Anand, and Mumbai) specializing in the provision of reproductive services. While reprohubs continue to exist, in the last few years, many have splayed out, transforming into something more akin to webs that encompass, but go beyond these hubs. These webs show a unique dynamic capability to tighten, entangle, or extend in reaction to local and global changes, a characteristic which became particularly obvious during the global Covid-19 pandemic. In this paper, we propose conceptualizing this new dynamic capability as 'reprowebs'-an approach that adds a new dimension to the existing conceptualization of reproductive travel and helps us to better understand current developments in the global ART industry.

'Nothing will stop me from giving the gift of life': a qualitative analysis of egg donor forum posts

Online spaces are increasingly important for our collective consciousness and provide an opportunity to document changing ideas, subjectivities and experiences surrounding new reproductive technologies. This paper reports on the first study of egg donation and online discussion boards in UK-based forums. Using thematic analysis, we investigated how donors use online forums and explored how they present themselves as possible donors in online spaces. Three major themes were identified: 'using online forums to exchange knowledge and experiences', 'egg donation as a gift' and 'having a drive to donate'. Findings from the study reveal how donors enter online spaces looking for advice, presenting themselves as available and weaving themselves into an online community. There exist multiple ways in which donors construct and narrate their own participation in the process of egg donation. Presenting a donor identity in these online forums is not a straightforward matter of helping by giving but also involves a specific drive. While more research is needed on the range of possible motivations, this study gives a better understanding of the available online information and the co-construction of donor identities on discussions boards.

"Mix or Match?": Transnational Fertility Industry and White Desirability

Does the transnational process of gamete selection challenge ways of mobilizing race and whiteness? Based on a mobile ethnography of the transnational fertility industry, I argue that fertility experts and intended parents (IP) co-produce the desirability of whiteness through "racial matching" for white, heterosexual IP, and "strategic hybridization", or strategic mixing of gametes, for some same-sex IP who do not identify as white. Although disruptive of notions of racial purity of whiteness and the heteronormative focus on resemblance match, the transnational legitimizing of such desires as intimate and innocuous choices depoliticizes conversations around race, racialization and whiteness as privilege.

Regulatory responses to assisted reproductive technology: a comparative analysis of Spain and Israel

PURPOSE

The market of assisted reproductive technologies (ARTs) is rapidly evolving, raising growing ethical and social dilemmas. This paper compares the regulatory responses to technological and market developments in Israel and Spain, both intensive users of ART. We identify strengths and deficiencies in the regulation of ART in these two countries.

METHODS

We developed a conceptual framework to classify the factors affecting regulations and priority setting, and applied it using a Delphi survey combined with in-depth interviews. We selected two panels of experts from various fields, trying to simulate the bioethics committees of Israel and Spain.

RESULTS

ART is often wrongfully perceived as a solution to age-related infertility. Both panels embraced alternative solutions. The impact of private commercial interest on regulations is resulting in excessive practices such as the repeat of ineffective cycles and the push of sometimes unnecessary treatment add-ons. Our findings show experts dissatisfaction with the regulations of donor-eggs concerning reimbursement and registries in both countries.

CONCLUSIONS

The adequacy of ART to solve age-related infertility should be confronted with alternative approaches, with emphasis on the distribution of accurate information. The magnitude of ART markets, particularly the use of donor-eggs, should raise the need for additional societal debate and the reform of regulations. The impact factors analysis leads us to question the current regulatory framework, which could be improved by nominating a non-governmental statutory central regulatory agency in Israel and by reforming the Spanish agency.

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.

Gendered bio-responsibilities and travelling egg providers from South Africa

'Unsuspecting young South African women are heading overseas to donate their eggs to infertile couples and earn a free international holiday in the process. But, at what cost?' This was the voice-over during a news show in South Africa in 2016 that described the phenomenon of young white South African women going abroad to 'donate' their eggs. Through the media, medical professionals sought to warn 'naïve girls' about 'unscrupulous agencies' taking advantage of them, and in doing so putting them at grave medical risks in 'Third World' clinics. Yet owners of agencies and egg providers themselves countered this imagery; here, the egg provider becomes a far more complex biocitizen who finds an opportunity to combine an act of altruism with an opportunity to earn money and travel. Through interviews with travelling egg providers, doctors and egg agencies, and analysis of public and social media, we analyse these competing discourses critically by situating them within the specific context of egg provision in South Africa. We argue that travelling egg providers' defence of their involvement may challenge some gendered assumptions made by the media and medical staff, but at the same time reaffirm what we call 'gendered bio-responsibilities', or the gendered nature of the emphasis on (individual) responsibilization of biological citizens. By focusing on a relatively understudied aspect of the burgeoning literature on biocitizenship, we argue that the project of biocitizenship assists the expansion and normalization of new biomedical technologies, often without proper emphasis on the disproportionate obligations on the women involved.

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.

Reproductive Travel to Ghana: Testimonies, Transnational Relationships, and Stratified Reproduction

In this article, I address reproductive travel to Ghana, based on research conducted in two private fertility clinics. Both clinics attract clients from West African countries as well as Ghanaian people living in the US and Europe. Their motivations to visit these clinics include positive "testimonies" about treatment results, "bioavailability" of matching donor material and surrogates, lower treatment costs and the circumvention of restricting regulations in the country of residence. Communication technologies are central in facilitating reproductive travel. Finally, I argue that the "international choreographies" of reproductive travel are co-shaped by the unique biographies and transnational relationships of the people involved.

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.

Reproductive Tourism: Through the Anthropological “Reproscope”

This review analyzes the emerging literature on reproductive tourism through a metaphorical “reproscope,” focusing largely on cross-border egg donation and surrogacy as the prime areas of contemporary anthropological investigation. While acknowledging that reproductive travel is not new, this article recognizes that there has been an increased volume of such travel over the past couple of decades. It provides an overview of the major areas of anthropological investigation into these transnational phenomena, globalization, stratification, exploitation, race, nationalism, religion, biopower, and bioethics. I propose that these areas of investigation may provide key indications about the preoccupations of anthropology today. Namely, what kind of discipline does anthropology imagine itself to be?

Cross-border-assisted reproduction: a qualitative account of UK travellers' experiences

Surveys on patients' experiences of cross-border fertility treatment have reported a range of positive and challenging features. However, the number of such studies is limited, and there is no detailed qualitative account of the experiences of UK patients who travel overseas for fertility treatment. The present study used a cross-sectional, qualitative design and in-depth interviews. Fifty-one participants (41 women and 10 men, representing 41 treatment 'cases') participated in semi-structured interviews. The experiences reported were broadly positive with a large proportion of participants (39 cases, 95%) citing a favourable overall experience with only two cases (5%) reporting a more negative experience. Thematic analysis revealed 6 major categories and 20 sub-categories, which described the positive and challenging aspects of cross-border fertility travel. The positive aspects were represented by the categories: 'access', 'control' and 'care and respect'. The more challenging aspects were categorized as 'logistics and coordination of care', 'uncertainty' and 'cultural dissonance'. The study confirms findings from others that despite some challenges, there is a relatively high level of patient satisfaction with cross-border treatment with participants able to extend the boundaries of their fertility-seeking trajectories and in some cases, regain a sense of control over their treatment.

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.

Ovules vieillissants, mères sans âge? Infertilité féminine et recours au don d’ovocytes en Suisse

Cette contribution1 examine l’impact des possibilités d’extension de la fertilité féminine ouvertes par le don d’ovocytes sur les significations de l’« âge limite de la maternité », dans le contexte suisse où cette technique est interdite. En me focalisant sur les expériences de femmes recourant au don d’ovocytes en cas d’infertilité liée à l’âge, je montrerai comment cette technique ouvre un espace de contestation et de négociation des limites biologiques de la fertilité. La première partie examine l’utilisation des normes biologiques et statistiques du déclin de la fertilité dans le cadre du diagnostic; la deuxième montre comment les significations des limites d’âge se transforment au fil du parcours de procréation médicalement assistée (PMA); la troisième met en lumière quelques stratégies utilisées pour reconfigurer l’« horloge biologique ».

Genre, parenté et techniques de reproduction assistée : bilan et perspectives après 30 ans de recherche

Ce numéro d’Enfances Familles Générations propose de se pencher sur les problématiques actuelles soulevées par les techniques de reproduction assistée (TRA) au regard des questions de parenté et de genre. Si, dans un monde globalisé, diverses possibilités reproductives sont désormais accessibles, celles-ci soulèvent de nombreuses questions socioanthropologiques du point de vue des rapports de pouvoir qu’elles engendrent, des pratiques et des régulations parfois très différentes dont elles font l’objet, ainsi que des significations individuelles et culturelles qui leur sont attribuées. Ces questions ont donné lieu à une littérature riche et abondante au cours des trente dernières années, en particulier dans le monde anglo-saxon. Cet article introductif est ainsi l’occasion de faire dialoguer davantage, en soulignant leurs apports respectifs, des travaux relevant de traditions différentes, en particulier dans les mondes francophones et anglophones. À partir de ce bilan des questionnements majeurs qu’a suscités l’étude des TRA dans les domaines du genre et de la parenté, nous soulignons les enjeux qui restent en suspens et qui mériteraient selon nous de faire l’objet de plus amples investigations. Le fil conducteur de notre propos, sur la base de la littérature disponible et des enquêtes menées jusqu’ici en sciences sociales, est d’insister sur la dimension du genre comme inextricable de l’expérience et de l’étude des techniques de reproduction assistée.

The Quiet Migration Redux: International Adoption, Race, and Difference

Demographers frame international adoption primarily as an unusual kind of migration. This insight offers anthropologists new ways to think about kinship. Drawing on demographic scholarship and anthropological kinship and migration studies, this article develops a new and hybrid approach to international adoption as a complex social process that is both migratory and productive of kinship. Viewing international adoption as a form of migration reveals how the stated "push factors" and actual "pull factors" of international adoption do not align perfectly. Using an anthropological life course perspective, the article then explores how the experiences of these "migrants" and those close to them, over time, are better understood as racialization than solely the product of migration. Looking at adoptees' lives through a migration lens reveals some of the persistent discomforts that prevent open conversations about racial difference and minority status in an adoptive context, that is, one where children have been caused to migrate, recruited into families. This article draws on data from ethnographic fieldwork with Spanish parents who have adopted Peruvian children to argue that international adoption is a unique form of immigration that produces a minority category within a majority population.

West is best: Affective assemblages and Spanish oöcytes

This article employs the concept of affective assemblage to discuss how fertility travelers make sense of their decision to travel to Spain for oöcyte donation. Motherhood is brought into being through racialized and gendered discourses on ova exchange; idealized and feminized (fertile and gift-giving) Spanish donor bodies. In their accounts, fertility travelers employ a narrative in which oöcytes become necessary spare parts, yet also, exotic substances with temperament and racialized nationality as well as collective bodies – shaped by the recipient woman’s body, intent, and desire. In this manner, kinship is created through shared blood and space, desire and intent while differences between recipients and donors are minimized. The directionality of desire, hope, and imagination has the effect of naturalizing transnational egg donation and transforming it into a shared western European femininity of sorts.

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.

Cross-border reproductive care: a clinician's perspective

Cross-border reproductive care (CBRC) is a means to an end. Nearly all patients' reproductive journeys are designed to deliver them a child, which, for the multitude of reasons discussed in the last issue of this journal, has not been proven possible for them in their home country. Their journey pathways look like the route maps in airline in-flight magazines, but at the end of their flight a medical procedure awaits, often involving a third-party donor or surrogate. Clinicians therefore are tightly involved in the delivery of CBRC, whether as service providers or service facilitators, and have a unique ethical responsibility to ensure that appropriate standards of care are provided to all those receiving treatment, be they patients or third-party providers. Several authors in the symposium issue are rightly critical of exploitation of third parties, particularly in the global south, although some are critical of the use of third-party fertility treatment in principle. However, CBRC and the subsequent fragmentation of fertility treatment is likely to increase and doctors must be drivers for improvement of standards of reproductive medical care in the developing world, and elsewhere, as more countries and clinics seek to benefit economically from the expanding market in medical consumerism.