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.

At the junctures of healthcare: a qualitative study of primary and specialist service use by Polish migrants in England

Background:

Polish people are the biggest migrant group in the UK and the scholarship shows that they are attentive to their healthcare needs and seek to fulfil them by using various services both within and outside the British public healthcare system. This article explores the role of junctures within healthcare systems in the connections migrants realize between healthcare systems and sectors. The article argues that in a transnational context, migrants enact these junctures by joining different levels of care within the same sector, between sectors and across national borders. In particular, the article explores how Polish migrants’ healthcare seeking practices within and beyond national borders are enacted given the features, availability and relationship between primary and specialist care for how they are articulated between private and public sectors.

Methods:

This article is based on the second phase of a mixed-methods study on how Polish people in the UK manage their health transnationally. The participants were purposefully sampled from survey respondents (first phase) who identified as having a long-term health condition or caring in a non-professional capacity for someone who is chronically ill. Thirty-two semi-structured audio-call interviews were conducted with Polish migrants living in England between June and August 2020. Transcripts were analysed by applying thematic coding.

Results:

Key findings include a mix of dissatisfaction and satisfaction with primary care and general satisfaction with specialist care. Coping strategies consisting in reaching specialist private healthcare provided a way to access specialist care at all or additionally, or to partially complement primary care. When Polish private specialists are preferred, this is due to participants’ availability of time and financial resources, and to the specialists’ capacity to fulfil needs unmet within the public healthcare sector in the UK.

Conclusion

Polish migrants join with their practices systems which are not integrated, and their access is limited by the constraints implied in accessing paid services in Poland. This shapes transnational healthcare practices as relating mostly to routine and ad-hoc access to healthcare. These practices impact not only the wellbeing of migrants and the development of the private market but also the public health provision of services.

Attracting a geographically diverse patient base: who is willing to travel for hospital care?

Purpose

Medical tourism, characterized by patients leaving their home community to seek health-care services elsewhere, is on the rise globally. In New York state, approximately 5% of the 35,661,559 hospital visits in 2018 were non-residents. Although some are visiting New York for other reasons, and unintentionally wind up hospitalized – a percentage of this population come to New York intentionally to seek care. Understanding the make-up, needs and patterns of this population allows hospitals to tailor investments in marketing, technological resources and culturally responsive initiatives to prepare for broadening their patient population and remain competitive globally.

Design/methodology/approach

Using a rich all-hospital discharge data set, the authors identify patterns in diagnoses, treatment and hospital choice of patients who intentionally travel across borders for health care. The authors model the characteristics associated with “elective” admit patients with a multivariate logistic regression approach.

Findings

The authors find that among non-resident patients in New York, domestic travelers, those using insurance plans for payment and women are positively associated with seeking elective inpatient care across border. There are clear patterns of type of treatment that is more likely to be sought, with care for musculoskeletal concerns accounting for more than one-third of all non-resident elective admissions. Proximity also matters, both in terms of patients being more likely to live in a travel zone adjacent to the state, as well as being more likely to seek care from hospitals in counties closest to the borders.

Originality/value

To the best of the authors’ knowledge, this is the first study, using a large set of claims data, that is able to empirically differentiate between patients who travel to NY for the primary purpose of obtaining health care versus those who emergently must access care while traveling for other reasons. This approach can inform future studies seeking to better understand patient migration patterns and strategic educational and marketing initiatives to motivate consumers to cross borders to seek care.

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.

About gladiators and a sacred disease

In this special edition of the Biomedical Journal the reader gains an insight into drug-resistant epilepsy and according treatment approaches involving deep brain stimulation, the ketogenic diet and fecal microbiota transplant. Another emphasis is put on personalized medicine strategies, and covered in articles about the use of natriuretic peptides against cancer, along with an article about companion diagnostics involving extracellular vesicles. Recurrent infection with Clostridium difficile, associated risk factors and therapeutic options are discussed. We learn about a mechanism that helps Leishmania evade a host control mechanism, receive an update about human adenovirus and are presented with characteristic magnetic resonance neuroimaging in COVID-19 pediatric patients. An advanced assessment in pediatric septic shock and an improved model for a pediatric early warning system are proposed. Some of the genetic causes of renal hypomagnesemia are explored, the impact of air pollution on children is examined, and an antisiphon device is described for surgical treatment of hydrocephalus. The relation between energy metabolism, circadian rhythm and its influence on the ATPase in the SCN are investigated, and among others some of the genetics influencing smoking duration and lung cancer. Finally it is discussed how embryo quality can be improved in in vitro fertilization, and what impact high estradiol has on blastocyst implantation. The outcome of surgery to correct mandibular deficiency is assessed, and in two letters the inclusion of observational studies in the evaluation of clinical trials related to COVID-19 is elaborated.

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.

Who can take advantage of medically assisted reproduction in Germany?

Compared with other European societies, access to medically assisted reproduction (MAR) in Germany is rather restrictive. Surprisingly little is known about the actual utilization of MAR in Germany and its social selectivity, primarily due to a lack of appropriate data. This article studies the use of MAR by drawing on 11 waves of the German Family Panel (pairfam), an annual survey that collects data on partnership and family dynamics in Germany. In estimating pooled logistic regression models that take into account whether or not MAR has been used, the following treatments were included: (i) in-vitro fertilization or micro-fertilization; (ii) intrauterine insemination; and (iii) any type of surgery performed to treat infertility. The highest odds of seeking medical help for infertility were found among married, childless couples who had a higher income, a strong desire to have children, a poor self-assessed health status, and who reported having problems conceiving a child prior to the year of the interview. Among these married couples, those with an above-average income were particularly likely to use MAR. These findings indicate that social selectivity in the uptake of MAR is based on economic resources and on the importance of marriage as the cultural ideal for a 'normal family'.

Changing Fertility Landscapes: Exploring the Reproductive Routes and Choices of Fertility Patients from China for Assisted Reproduction in Russia

Global reproductive landscapes and with them cross-border routes are rapidly changing. This paper examines the reproductive routes and choices of fertility travellers from China to Russia as reported by medical professionals and fertility service providers. Providing new empirical data, it raises new ethical questions on the facilitation of cross-border reproductive travel and the commercialisation of reproductive treatment. The relaxation of the one-child policy in 2014 in China, the increasing demand for ART exceeding the capacity of national fertility clinics and the difficulty of accessing treatment with donor eggs concomitant with a growing economic power of the upper–middle class are shaping the ART industry in Asia in new ways. A new development is Chinese citizens increasingly seeking ART treatment in Russia, which has a long-standing practice of ART governed by a liberal legislation. Furthermore, as China prohibits the export of gametes, Chinese fertility travellers rely on acquiring donor gametes once starting treatment abroad. Clinicians in Russia report three strategies amongst their Chinese patients: One group is using donor eggs of women of Asian appearance living in Russia or is hiring women of resembling appearance from third-party countries to donate their eggs in Russia to create resemblance in their offspring. Another group is buying white donor gametes to create Eurasian mixed children and thus ‘enhance’ their offspring. Providing novel empirical data, this article informs ethical deliberation and raises imminent questions for further research in this understudied geographic region and on cross-border reproductive treatment.

Viapolitics and the emancipatory possibilities of abortion mobilities

Scholarship on abortion travel has examined the places women travel between and why such journeys are necessary. However, there has been scant attention paid to the journeys themselves and how these journeys are undertaken. This paper uses William Walters' notion of 'viapolitics' to better attend to how people travel by focussing on the role of vehicles in abortion politics. This takes three parts: an exploration of the emotional and embodied journeys that women have to take to access abortions; the role of the vehicle as a site of political activism around abortion rights; and the transportation of abortion medication. Viapolitics has to date only been used within migration politics but as this paper shows, it has utility beyond this field to interrogate abortion travels and highlight the role of vehicles in abortion access as well as to explore how abortion transport can be emancipatory for women. This paper furthers viapolitics by arguing that we need to consider the journeys of 'things' and not just people. In the case of abortion access, it is the transportation of abortion medication rather than the travel of women that is the most socially just solution to discriminatory laws and extra-legal barriers.

Abortion exile: navigating Mexico's fractured abortion landscape

This paper develops the concept of 'abortion exile' to understand the situation of women who are forced to travel for abortion services because the procedure is outlawed, stigmatized, unaffordable or otherwise inaccessible in their place of residence. A number of legislative, economic, and moral mechanisms conspire to deny women abortion rights at home such that they must journey within and across national borders in pursuit of needed abortion care. While anthropologists have examined the movement of women and men in search of fertility care that is unavailable at home, attention to the situation of women forced to relocate to terminate an untenable pregnancy is surprisingly scarce. Taking Mexico's fractured abortion landscape as an ethnographic starting place, this paper examines the experiences of women made to venture to the capital for legal abortion services because the procedure is criminalised and difficult to access elsewhere in the country. The concept of 'abortion exile' can helpfully explain the forced movement, political status and subjective experiences of women in different world regions where abortion rights are limited, absent, or under threat, and for whom reproductive citizenship remains elusive.

Papering the Origins: Place-Making, Privacy, and Kinship in Spanish International Adoption

This article examines place and privacy as two key resources for producing kinship through an analysis of exceptional legal practices in Spain that overdetermine international adoptees’ Spanishness. Per Spanish law, minors internationally adopted by a Spanish parent are “Spanish by origin” (españoles de origen). Over and above this, however, Spain’s Civil Registry Law was modified in 2005 to allow internationally adoptive parents to officially change their child’s place of birth in the formal record. I draw on legal material about this change, as well as online posts by adoptive parents discussing it, to make two claims. First, I identify the significance of place as a key resource for the production of kinship—belonging to a Spanish family and nation. Second, I note the persistence of an ideology of secrecy or privacy surrounding the family that is linked to a history of illicit child circulations during the Franco era. I further show that documents are a key nexus mediating the place–kinship and privacy–kinship relations, requiring further attention to both legal documentation and the proliferation of public personal narratives, such as blog posts, as evidence of family dynamics.

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.

Troublesome reproduction: surrogacy under scrutiny

In recent years, the emergence of transnational commercial surrogacy arrangements has prompted consideration of how and whether it is possible to bridge claims for reproductive rights from involuntarily childless couples and singles, many of whom historically have been excluded from reproduction, with the rights and well-being of the reproductive assisters. In this article, I suggest that a fruitful starting point for a conversation on how to tackle such a challenge is to examine the way in which surrogacy is conceptualized. Thus, I examine how scholars have queried surrogacy, asking how different conceptualizations of who this reproductive phenomenon concerns have led to the formulations of different types of 'troubles' of surrogacy. I delineate three different conceptualizations of surrogacy. Firstly, how surrogacy as a way to make parents has troubled scholars because of the conflation of reproduction with consumption, thereby making reproduction a matter of financial resource. Secondly, the trouble emerging when surrogacy is conceptualized as baby-making relates to how surrogacy turns babies and bodies into commodities. Thirdly, surrogacy understood as a phenomenon that concerns the women gestating and birthing the children has brought attention to issues of exploitation. These different formulations of trouble point towards tensions in the literature, while also offering reminders that surrogacy is not one thing alone; a finding that provides an opening for new forms of reproductive justice. This brings me to propose a rethinking of the notion of 'reproductive assistance', arguing in favour of moving away from substitution and transaction towards a relational being-together.

Reproductive Desires and Disappointments

In this introduction we consider how people who have difficulties achieving "natural" parenthood seek to form families, and their experiences of reproductive negotiations and losses in this pursuit. We highlight gaps in the literature on infertility and loss globally, and identify how the special edition addresses the dearth of research in this field with men, with non-elites and on loss. We consider the key insights drawn from studies conducted in divergent geographical, cultural, socioeconomic and political contexts, including perspectives from Ghana, Indonesia, Romania, Spain, the United Kingdom, and the United States. In these contexts we explore both high tech and no tech reproductive strategies, encompassing assisted reproductive technologies, third party donation, surrogacy, as well as intra-family and transnational adoption. We illuminate how people attribute meaning to their lived experiences of reproductive disappointments ranging from failed conception (primary and secondary infertility), miscarriage, stillbirths, neonatal death, and failed adoption. We reflect on both local and transnational practices embedded in family making, highlighting the complexity and dynamism of reproductive opportunities, and how these opportunities are embedded in multifarious power relations. We articulate a range of important themes for the anthropology of reproduction, including: the sociality of reproductive desires and disappointments; gender sexuality and emergent masculinities; migration, practices of belonging, and kinship; reproductive stratification and leveling; and reproduction and relationality.

"I didn't have to prove to anybody that I was a good candidate": a case study framing international bariatric tourism by Canadians as circumvention tourism

Background

Medical tourism is a practice where patients travel internationally to purchase medical services. Medical tourists travel abroad for reasons including costly care, long wait times for care, and limited availability of desired procedures stemming from legal and/or regulatory restrictions. This paper examines bariatric (weight loss) surgery obtained abroad by Canadians through the lens of ‘circumvention tourism’ – typically applied to cases of circumvention of legal barriers but here applied to regulatory circumvention. Despite bariatric surgery being available domestically through public funding, many Canadians travel abroad to obtain these surgeries in order to circumvent barriers restricting access to this care. Little, however, is known about why these barriers push some patients to obtain these surgeries abroad and the effects of this circumvention.

Methods

Semi-structured phone interviews were conducted with 20 former Canadian bariatric tourists between February and May of 2016. Interview questions probed patients’ motivations for seeking care abroad, as well as experiences with attempting to obtain care domestically and internationally. Interviews were digitally recorded, transcribed verbatim, and then thematically analyzed.

Results

Three key barriers to access were identified: (1) structural barriers resulting in limited locally available options; (2) strict body mass index cut-off points to qualify for publicly-funded surgery; and (3) the extended wait-time and level of commitment required of the mandatory pre-operative program in Canada. It was not uncommon for participants to experience a combination, if not all, of these barriers.

Conclusions

Collectively, these barriers restricting domestic access to bariatric care in Canada may leave Canadian patients with a sense that their health care system is not adequately addressing their specific health care needs. In circumventing these barriers, patients may feel empowered in their health care opportunities; however, significant concerns are raised when patients bypass protections built into the health system. Given the practical limitations of a publicly funded health care system, these barriers to care are likely to persist. Health professionals and policy makers in Canada should consider these barriers in the future when examining the implications medical tourism for bariatric surgery holds for Canadians.

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.

Mitochondrial Replacement Techniques: Divergence in Global Policy

In 2015, the UK became the first country permitting the clinical application of mitochondrial replacement techniques (MRT). Here, we explore how MRT have led to diverging international policy. In response, we recommend focused regulatory efforts coupled with United Nations (UN) leadership to build international consensus on the future of MRT.

Obstetric and neonatal complications in pregnancies conceived after oocyte donation: a systematic review and meta-analysis

BACKGROUND

Approximately 50 000 oocyte donation (OD) treatment cycles are now performed annually in Europe and the US.

OBJECTIVES

To ascertain whether the risk of adverse obstetric and perinatal/neonatal outcomes is higher in pregnancies conceived by OD than in pregnancies conceived by conventional in-vitro fertilisation (IVF)/intracytoplasmic sperm injection (ICSI) or spontaneously.

SEARCH STRATEGY

A systematic search was performed in the PubMed, Cochrane and Embase databases from 1982-2016. Primary outcomes were hypertensive disorders of pregnancy, pre-eclampsia (PE), gestational diabetes mellitus, postpartum haemorrhage, caesarean section, preterm birth, low birthweight and small for gestational age.

SELECTION CRITERIA

Inclusion criteria were original studies including at least five OD pregnancies with a control group of pregnancies conceived by conventional IVF/ICSI or spontaneous conception, and case series with >500 cases reporting one or more of the selected complications. Studies not adjusting for plurality were excluded.

DATA COLLECTION AND ANALYSIS

Thirty-five studies met the inclusion criteria. A random-effects model was used for the meta-analyses.

MAIN RESULTS

For OD pregnancies versus conventional IVF/ICSI pregnancies the risk of PE was adjusted odds ratio (AOR) 2.11 (95% CI, 1.42-3.15) in singleton and AOR 3.31 (95% CI, 1.61-6.80) in multiple pregnancies. The risks of preterm birth and low birthweight in singletons were AOR 1.75 (95% CI, 1.39-2.20) and 1.53 (95% CI, 1.16-2.01), respectively.

CONCLUSIONS

OD conceptions are associated with adverse obstetric and neonatal outcomes. To avoid the additional increase in risk from multiplicity, single-embryo transfer should be the choice of option in OD cycles.

TWEETABLE ABSTRACT

Oocyte donation pregnancies have increased risk of a range of obstetric and neonatal complications.

Romanian IVF: a brief history through the 'lens' of labour, migration and global egg donation markets

This paper centres on a history of Romanian IVF, including the achievement of significant milestones and the establishment of key clinics. In addition to examining some of the legal and ethical aspects of IVF in Romania, the paper also details some important elements of IVF in neighbouring countries, providing a perspective on regional similarities and differences. Romania's neighbours with similar economies and national-religious contexts have very different IVF pasts and presents. This highlights the importance of migration and cross-border egg donation in understanding IVF in Romania. After providing an analysis of Romania's economy and migration, the paper examines Romania's egg donation history, arguing that it has a so-called 'extractive reproductive economy'.

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.

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.

Merit and money: The situated ethics of transnational commercial surrogacy in Thailand

Specific studies of the “situated ethics” of international surrogacy that address the structural conditions and local moral economies that sustain the trade are needed. In this essay, I describe the intimate industry of surrogacy in Thailand, exploring the local moral economy in which surrogacy is described as a form of Buddhist merit making and an opportunity to provide for one’s own children. This offers a further example of how other ethical values beyond the strictly economic are negotiated in commercial surrogacy relationships. Situated ethics allow us to locate and understand the tensions, competing logics, and contradictions within ethical practices.

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 ».

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.

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.