What we currently know about cross-border reproductive services derives primarily from anecdotal patient accounts shared on the Internet and reports provided by journalists - often working 'undercover' and posing as patients. The nefarious character of some services under investigation, alleging illegal activities (1,2) and exploitation of young women as egg donors (3,4), mean that these are among the least likely to be amendable to systematic empirical research and verification.
More recently, in the UK at least, research has been undertaken to identify the cost to home country health services of providing care to mothers and babies when treatment provided elsewhere involves the transfer of more embryos than are permitted in the home country (5). Recent surveys of the experiences of patients who have undertaken cross-border reproductive care have also indicated that at least some consider they were exploited by unscrupulous service providers; although the majority of patient reports in these surveys indicate positive rather than negative experiences - especially when compared with previous encounters with services provided in their home country (6, 7). Two key and inter-related findings from patient accounts are that the Internet is a significant source of information about reproductive services in other countries and that in most instances patients make their own arrangements with service providers in destination countries. As is always the case, the quality of information on which decisions are made is all-important and, in the case of cross-border reproductive services, the sheer volume of information available on the Internet, the pace at which this information changes, and the difficulty in verifying it, may service to disempower rather than empower patients. For example, a 'Yahoo' search undertaken on 18 April 2009 for this piece identified 11,100,000 websites for 'sperm donation', 5,400,000 for 'IVF clinics', 4,090,000 for 'surrogacy', and 3,600,000 for 'egg donors'.
A further key group of individuals whose interests are also affected by cross-border reproductive care are the children conceived as a result of services provided. Currently nothing is known at all about these children, and so any concerns about their welfare must remain speculative, although we are aware anecdotally of concerns expressed by some parents who sought donor services in another country who are seeing in their growing children unanticipated physical characteristics suggesting, at the very least, that the ethnic origins of their child's donor might not be what they originally thought. As these children grow up, whatever their parents' initial intentions, it will be impossible to avoid talking to their children about their origins. And, as concerns are articulated about the possible exploitation of donors, donor-conceived people are quite likely to be troubled if they have reason to think their conception was potentially founded both on donor exploitation and donor misinformation.
Three key characteristics of many countries that have become popular destinations for cross border reproductive services are: first, the lack of regulation affording adequate protection for the parties most directly affected, i.e. donors, surrogates, patients and children; second, the operation of a commercial market in human gametes - especially eggs - and women's gestational services; and third a level of secrecy that helps to conceal unprofessional, unethical and illegal practices.
However, some efforts are now underway to develop trans-national responses to address a problem that cannot be resolved by jurisdictions or professional organisations working alone. In 2005, the European Parliament adopted a resolution banning trade in human cells and embryos (8). In 2008, the International Consumer Support for Infertility (iCSi) produced an information leaflet available online for anyone considering travel to another country for reproductive care (9). Also in 2008, ESHRE (European Society of Human Reproduction and Embryology)'s Task Force on Ethics and Law produced a statement on cross-border reproductive care (10), while ESHRE also began work to investigate and collate members' experiences of cross-border reproductive care. In 2008 the International Federation of Social Workers (IFSW) became the first world professional body to issue a global policy which, among several recommendations, calls for national regulation in all jurisdictions to safeguard the interests of patients, donors, surrogates and children conceived as a result of cross-border reproductive services (11). In January 2009 the first International Forum on Cross-Border Reproductive Care, hosted by the Canadian government, brought together, for the first time, national regulators, representatives of national and international professional bodies and consumer groups, the European Union and the World Health Organisation.
Tackling the 'unacceptable face' of cross border reproduction is no easy task. However, it is to be hoped that these initial steps will mark a distinct beginning to rise to the challenge.