Cross-border reproductive care for law evasion: A qualitative study into the experiences and moral perspectives of French women who go to Belgium for treatment with donor sperm

Experiences in the delivery of preconception and pregnancy care for LGBTIQA+ people: A systematic review and thematic synthesis of patient and healthcare provider perspectives

BACKGROUND

The widespread availability of reproductive technology and family planning services has led to an increase in the number of available pathways to parenthood for LGBTIQA+ people. However, emerging research indicates that significant healthcare inequities have been documented among LGBTIQA+ people and attributed to the pervasiveness of structural and systemic discrimination that extends to preconception and pregnancy care.

AIM

The aim of this systematic review was to synthesise qualitative research that has explored the experiences of LGBTIQA+ people in navigating preconception and pregnancy care services to inform healthcare quality improvement.

METHOD

Six databases were searched for relevant research published between 2012 and 2023. The findings of all included studies underwent a secondary thematic synthesis, and methodological quality was assessed using the Joanna Briggs Institute Checklist for Qualitative Research.

FINDINGS

A total of 37 studies were eligible for inclusion. Four major themes were constructed through thematic synthesis: (1) unavailability of information, services, and support; (2) clinical competencies of healthcare staff; (3) hetero- and cis-sexist care experiences; and (4) discrimination and traumatisation.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The findings of this review indicate that LGBTIQA+ people experience significant challenges during the journey towards parenthood, marked predominantly by the pervasiveness of inequity, and defined by discriminatory healthcare processes. This review has led to several recommendations for future healthcare quality improvement through an investment in policies, procedures, and interactions that are sensitive to the needs of LGBTIQA+ people. Importantly, future research must be co-designed and led by LGBTIQA+ community input.

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.

Factors influencing pregnancy outcome with special attention to modified slow-release insemination and a patient-centred approach in a donor insemination programme: a prospective cohort study

Introduction: A higher pregnancy rate after slow-release insemination instead of bolus injection was described in previous studies. Besides an effective medical treatment most patients wish to receive a patient-centred approach with sufficient emotional support. Study question: Does a patient-friendly approach with slow-release insemination (SRI) increase the clinical pregnancy rate (CPR) after intrauterine insemination (IUI) with donor semen? Study design, size, duration: The data of an ongoing prospective cohort study were analysed investigating the results of 1995 donor inseminations in 606 women from July 2011 until December 2018. As from January 2016 the insemination procedure was performed by midwives instead of medical doctors. Instead of bolus injection of sperm a slow-release IUI was done together with a more patient-centred approach. Materials and Methods: The data of 1995 donor inseminations were analysed to study the importance of different covariates influencing IUI success. Generalized estimating equations (GEEs) were used for statistical analysis. Results of two periods (2011-2015 and 2016-2018) were examined and compared. Results: Clinical pregnancy rates (with foetal heartbeat) following donor inseminations increased from 16.6 % to 20.8 % per cycle, a non-significant increase (p=0.061). Conclusion: A more patient-friendly approach with slow-release of processed semen resulted in a non-significant higher clinical pregnancy rate of 4.2 % per cycle after donor insemination.

Fair allocation of cryopreserved donor oocytes: towards an accountable process

A growing number of people desire ART with cryopreserved donor oocytes. The allocation of these oocytes to couples and mothers to be is a 2-fold process. The first step is to select a pool of recipients. The second step is to decide who should be treated first. Prioritizing recipients is critical in settings where demand outstrips supply. So far, the issue of how to fairly allocate cryopreserved donor oocytes has been poorly addressed. Our ethical analysis aims to support clinics involved in allocation decisions by formulating criteria for recipient selection irrespective of supply (Part I) and recipient prioritization in case supply is limited (Part II). Relevant criteria for recipient selection are: a need for treatment to experience parenthood; a reasonable chance for successful treatment; the ability to safely undergo an oocyte donation pregnancy; and the ability to establish a stable and loving relationship with the child. Recipients eligible for priority include those who: have limited time left for treatment; have not yet experienced parenthood; did not undergo previous treatment with cryopreserved donor oocytes; and contributed to the supply of donor oocytes by bringing a donor to the bank. While selection criteria function as a threshold principle, we argue that the different prioritization criteria should be carefully balanced. Since specifying and balancing the allocation criteria undoubtedly raises a moral dispute, a fair and legitimate allocation process is warranted (Part III). We argue that allocation decisions should be made by a multidisciplinary committee, staffed by relevant experts with a variety of perspectives. Furthermore, the committees' reasoning behind decisions should be transparent and accessible to those affected: clinicians, donors, recipients and children born from treatment. Insight into the reasons that underpin allocation decisions allows these stakeholders to understand, review and challenge decisions, which is also known as accountability for reasonableness.

Lesbian Women Undergoing Assisted Reproduction: Diverse, But Not Different

The use of assisted reproduction among women in relationships with other women has increased in the United States over the past decade as a result of increased legal access and social acceptance. Despite this shift, limited studies currently exist to guide optimal fertility care for this growing patient population of women seeking assisted reproduction. In this Commentary, assisted reproduction will be meant to include ovulation induction, intrauterine insemination (IUI), and in vitro fertilization (IVF). Conflicting studies suggest that self-identified lesbian women may demonstrate an increased prevalence of polycystic ovarian syndrome. Most available studies find that a woman's sexual orientation does not affect the outcome of fertility treatment. Self-identified lesbian women undergoing donor sperm IUI and IVF have similar pregnancy and live-birth rates as heterosexual women. Better evidence regarding patient demographics and comorbidities, underlying etiologies of subfertility, and assisted reproductive outcomes among women building families with other women is needed to optimize care.

Doing and undoing nation through ART: a Franco-American comparison

This article explores a Franco-American comparison of assisted reproductive technology (ART), specifically as it relates to sex selection and cross-border reproduction. As a basis for comparison, the nation can materialize in the form of state structure just as much as in cultural-economic assemblages or ideologies that breach geopolitical boundaries. By juxtaposing many contrasts between the French and US contexts - departure versus destination country, highly regulated versus deregulated governance, medical versus social applications, and access (or lack thereof) via public versus private health insurance sectors - it may be difficult to imagine how these extremes occupy a common continuum of globalized market channels. I suggest that invisible or semi-visible reproductive practices along with ART governance provide an avenue to stake out or protect the 'French' way of being and doing ART just as much as they make the 'American' way simultaneously elusive and easy to appropriate. Ultimately, both the French and American approaches to ART collude in the institutionalization of globalized markets. Through the case of cross-border and (sex) selective ART, it is possible to see how both the French and the Americans are involved in the undoing and doing of nation via ART as global assemblage.

Ten years of fertility treatment experience and reproductive options in transgender men

BACKGROUND

Up to 2018, the Belgian law stated that transgender people who wanted to change their legal sex had to undergo physical gender affirming treatment. This included gonadectomy to a medically possible and justified extent, which entailed that they had to accept the fact that they could no longer reproduce. However, research has shown that many transgender people desire to have children.

AIMS

(1) to describe a cohort of transgender men and their respective cisgender female partners, to share our experiences with their request for donor conception, and to evaluate their disclosure intentions to the child, (2) to explore how the couples approach current and future reproductive options.

METHODS

This mixed method study presents data from a retrospective analysis of patient records and from a qualitative interview study. The couples were selected from the group of transgender men who - together with their respective cisgender female partners - applied for sperm donation at Ghent University Hospital between 2002 and 2012.

RESULTS

Forty-seven transgender men with a cisgender female partner requested treatment with anonymous donor sperm for a first child as a couple. Forty-one requests were accepted for treatment. We found that most couples requesting treatment intended to disclose the use of donor sperm to their future child (n = 34) while 24 couples were planning to inform the child about the parent's transgender identity. The six couples we interviewed saw donor conception as the preferred route to become parents. Adoption was seen as less obvious. The couples' attitudes toward stem cell-derived gametes reflected the significance of the genetic link with the child for both parents.

DISCUSSION

Not all participants in our study were aware of their reproductive options. To be able to make a well-informed decision, transgender people should be counseled about all options at the time of transition.

Accounting for the Moral Significance of Technology: Revisiting the Case of Non-Medical Sex Selection

This article explores the moral significance of technology, reviewing a microfluidic chip for sperm sorting and its use for non-medical sex selection. I explore how a specific material setting of this new iteration of pre-pregnancy sex selection technology-with a promised low cost, non-invasive nature and possibility to use at home-fosters new and exacerbates existing ethical concerns. I compare this new technology with the existing sex selection methods of sperm sorting and Prenatal Genetic Diagnosis. Current ethical and political debates on emerging technologies predominantly focus on the quantifiable risk-and-benefit logic that invites an unequivocal "either-or" decision on their future and misses the contextual ethical impact of technology. The article aims to deepen the discussion on sex selection and supplement it with the analysis of the new technology's ethical potential to alter human practices, perceptions and the evaluative concepts with which we approach it. I suggest that the technological mediation approach (Verbeek, 2005, 2011) can be useful to ethically contextualize technologies and highlight the value of such considerations for the informed deliberation regarding their use, design and governance.

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.

Providing quality family planning services to LGBTQIA individuals: a systematic review

OBJECTIVE

Lesbian, gay, bisexual, transgender, queer/questioning, intersex and asexual (LGBTQIA) individuals have unique sexual and reproductive health needs; however, facilitators and barriers to optimal care are largely understudied. The objective of this study was to synthesize findings from a systematic review of the literature regarding the provision of quality family planning services to LGBTQIA clients to inform clinical and research strategies.

STUDY DESIGN

Sixteen electronic bibliographic databases (e.g., PubMed, PSYCinfo) were searched to identify articles published from January 1985 to April 2016 relevant to the analytic framework.

RESULTS

The search parameters identified 7193 abstracts; 19 descriptive studies met inclusion criteria. No studies assessed the impact of an intervention serving LGBTQIA clients on client experience, behavior or health outcomes. Two included studies focused on the perspectives of health care providers towards LGBTQIA clients. Of the 17 studies that documented client perspectives, 12 elucidated factors facilitating a client's ability to enter into care, and 13 examined client experience during care. Facilitators to care included access to a welcoming environment, clinicians knowledgeable about LGBTQIA needs and medical confidentiality.

CONCLUSIONS

This systematic review found a paucity of evidence on provision of quality family planning services to LGBTQIA clients. However, multiple contextual facilitators and barriers to family planning service provision were identified. Further research is needed to assess interventions designed to assist LGBTQIA clients in clinical settings, and to gain a better understanding of effective education for providers, needs of specific subgroups (e.g., asexual individuals) and the role of the client's partner during receipt of care.

Cross-border reproductive care for law evasion: should physicians be allowed to help infertility patients evade the law of their own country?

There are fundamental differences between countries with regard to legislation on assisted reproduction. Many infertility patients are looking to evade the law of their own country and make use of reproductive services abroad. The role of the local physician in cross-border reproductive care for law evasion has been characterized as "channeling local patients to foreign medical establishments" and "against the spirit and essence of the law". The logical view is that by supporting CBRC for law evasion, physicians are essentially supporting immoral behavior. We will tackle this position on two levels. First, we will argue that governments should generally be tolerant toward people with different positions on assisted reproduction. Second, we will show that contributing to cross-border reproductive care for law evasion is not necessarily immoral, because the prima facie wrongness of complicity in law evasion can be outweighed by the fact that physicians should act in the best interest of the patient. Several countries have tried to prevent local physicians from helping patients to make use of reproductive services abroad, but they should rather leave it up to the individual physicians to decide whether or not to support a particular patient.