Progress Educational Trust conference: The evidence for cross-border reproductive care

Are European airlines bursting with 'fertility tourists' risking their health by travelling abroad? Do most people seeking fertility treatment overseas fit the media stereotype - white, middle-class career women over 50? Does cross-border reproductive care (CBRC) include eggs imported from abroad? Dr Françoise Shenfield and Professor Lorraine Culley tried to answer these questions during the first session of last Wednesday's Progress Educational Trust (PET) annual conference 'Passport to Parenthood: The Evidence and Ethics Behind Cross-Border Reproductive Care'.

We have limited evidence for how many people seek CBRC, why they go abroad and who they are, according to Dr Shenfield and Professor Culley. Professor Culley is principal investigator on the first empirical study of UK fertility travellers - the Trans-national Reproduction (Transrep) study. Dr Shenfield coordinates the European Society of Human Reproduction and Embryology's (ESHRE's) Cross-Border Reproductive Care Taskforce, which published the first European study into numbers of fertility travellers.

The ESHRE study found thousands of patients were travelling abroad for fertility treatment. Dr Shenfield thought ESHRE would struggle to get 500 responses when they gave questionnaires to patients travelling to European clinics, but they received 1230 questionnaires in one month from clinics in countries including Croatia, Spain and the Czech Republic. ESHRE's findings are published in the journal Human Reproduction.

Most (70 percent (%))  European fertility travellers surveyed by ESHRE sought treatment illegal in their own country, Dr Shenfield said. About 50% of travellers (674 questionnaires) came from Italy, which Dr Shenfield said passed restrictive laws on fertility treatment in 2005. She said Germans travelled to the nearby Czech Republic to receive legal egg donations. Single French women and lesbians travelled to Belgium where it's legal for them to be inseminated.

Travellers from the UK had different motivations than people from other European countries. Around 34% travelled because of problems accessing fertility treatment and 38% because they expected better quality care abroad. Dr Shenfield mentioned the 'disastrous' state of NHS fertility treatment, such as PCTs suspending funding. An IVF cycle in Belgium costs half what it does in London, she said.

Professor Culley also found some fertility travellers from the UK were dissatisfied with the cost and quality of UK treatment and believed success rates were better abroad. The interview-based Transrep study, which involved more than 65 fertility travellers and professionals, found people travelled for many reasons. Few had a single reason. This shows decision-making on fertility travel is 'complex', Professor Culley said.

Transrep interviewees were middle-class, mostly white, mainly heterosexual and usually married or cohabiting. Professor Culley said this lack of diversity shows the social inequalities in access to fertility care overseas. Contrary to media stereotypes of fertility tourists, the women travelling abroad were not significantly older than those having treatment in the UK. The average age was mid-30s. Some women had children already.

Choosing care abroad was not a spur-of-the moment decision, contrary to media stereotype. People were treated for up to 10 years in the UK before going abroad, Professor Culley said. Long waiting lists for donor gametes was a common problem: 70% of participants needed donor eggs. One woman went abroad after being put back on a three-year waiting list after waiting three years for unsuccessful treatment with a donor egg.

Dr Shenfield and Professor Culley disagreed about the risk to women of unscrupulous foreign clinics transferring multiple embryos. Dr Shenfield said: 'in some clinics, women have to argue hard against the autonomy of their body being violated by more than two embryos'. Creating triplets was tantamount to medical malpractice, she said. Triplet rates were high in the Ukraine, Greece, Russia and several other countries.

Professor Culley said the multiple pregnancy rate in the Transrep study was 19% - similar to the UK, although she had a small sample of patients. Many fertility travellers she interviewed felt the quality of care abroad was good or better than the UK, particularly the quality of communication with clinicians. Despite this, most people would have preferred treatment at home because it was less stressful and difficult.

Commercial pressures could encourage some clinics to implant multiple embryos but some people wanted a multiple birth, Professor Culley said. Despite knowing the risks, one person went to India and another to the Ukraine to receive multiple embryos. They had weighed up the medical risk of multiple births against the benefits of a ready-made family and the trauma of risking a failed treatment cycle.

Professor Sally Sheldon chaired a lively discussion about the phrase 'fertility tourism'. Professor Culley's interviewees felt 'fertility tourism' was a derogatory term since it trivialised the distress caused by infertility. But Abortion Review editor Jennie Bristow thought CBRC was 'tourism' for interviewees who wanted to escape everyday stresses at a pleasant clinic overseas. These people felt relaxing treatment abroad would boost their chance of a successful pregnancy.

An argument erupted over the definition of CBRC. Retired gynaecologist John Parsons thought Dr Shenfield wrong to include transporting vitrified (frozen) eggs from Russia to the UK in CBRC. Dr Shenfield said technological advances in vitrification would allow 'Russian and Ukranian eggs to conquer Europe' and was concerned about exploitation of foreign donors. Checking the treatment of donors in Barcelona is easier than in the Ukraine, she said.

Foreign eggs were discussed again during the second session of the conference. The audience quizzed Juliet Tizzard from the UK's fertility watchdog, the Human Fertilisation and Embryology Authority (HFEA), about inconsistent regulation of egg donor payment. A Russian egg donor would be paid £250 expenses if their eggs were frozen and shipped to the UK, but nothing to fly to the UK and donate fresh eggs.

A report on the second session of the conference will be published in next week's BioNews. PET is grateful to the conference's gold sponsors Merck Serono.