Unpacking Cross-Border Reproductive Care

The Progress Educational Trust's conference next week will tackle the subject of Cross-border Reproductive Care (CBRC), as a range of UK experts come together to present the evidence and argue over the ethical conundrums. Also referred to variously as 'reproductive tourism' or 'reproductive exile' (1), CBRC refers to the movements of people across national borders in search of fertility treatments in other jurisdictions.

Although the contested term 'reproductive tourism' has firmly entered public vernacular through the popular media, as yet little is known about this rapidly growing phenomenon. Indeed, CBRC is now recognised by many as an area in urgent need of policy engagement and rigorous enquiry. Although the empirical evidence on CBRC is patchy and fragmented for the moment, several studies have begun to provide important information. For example, a recent six-country study by European Society of Human Reproduction and Embryology (ESHRE) coordinated by Francoise Shenfield estimates that there are between 11,000 and 14,000 CBRC patients in Europe per year, with expectations of better quality and legal restrictions acting as the main reasons for travel (2). 

A study by Professor Guido Pennings corroborated the importance of legal restrictions by showing the treatments sought by patients coming to Belgium from France, the Netherlands, Italy and Germany differed in direct correlation with prohibitions in their own jurisdictions (3). However, unlike these studies, Professor Lorraine Culley and colleagues are finding that UK residents seeking Assisted Reproductive Technologies (ARTs) abroad are motivated primarily by donor gamete shortages, and not by regulatory factors (4). These studies show that it is important to note both emerging trends and the degree of diversity that exists in CBRC movements.

The many potential reasons for CBRC include the desire to access treatments that are prohibited, unavailable due to a lack of expertise or not practiced due to safety concerns in the home country. Some treatments, although generally available, may be inaccessible by certain groups (such as single women or gay couples) who travel to bypass access restrictions. Intending parents may also travel to avoid resource shortages and long waiting lists, to access treatments at cheaper prices, or to preserve their confidentiality. 

The reasons why a person or couple are travelling will depend on the regulatory and economic conditions in their home country and will influence their choice of destination. Indeed, global disparities in economic conditions, reproductive resources and regulatory structures have created a complex and heterogeneous set of CBRC trajectories. These include US citizens contracting Indian surrogates, Germans travelling to Belgium for PGD (preimplantation genetic diagnosis), and couples from the Middle East heading to Iran for sperm donation.

Closer to home, the foreign clinics exhibiting at the recent Fertility Show in London were a stark illustration of the growth and significance of CBRC in the global ARTs market. Glossy leaflets and friendly staff from clinics in Spain, India, Cyprus, the United States and the Caribbean, among others, presented an enticing alternatives to UK-based fertility treatment. While some clinics offered attractive prices and packages in sunny locations, others boasted high success rates, innovative techno-science, and readily available donors or surrogates. There were also a few clinics that provided services (such as sex selection or 'family balancing') which are illegal in the UK, although it must be said that these did not seem to be the main attractions.

Besides clinics, there were also several international brokerage agencies, promising to link intending parents with providers and clinics in streamlined international arrangements. One company offered their customers an 'East Plan' and a 'West Plan' with treatments in India and the United States respectively. A third alternative - the 'East-West Plan' - combined both by offering IVF treatment and donor eggs in the United States, followed by the importing of frozen embryos to India for surrogacy.

These arrangements represent unprecedented relationships between globalisation, consumerism and the quest for conception, posing new dilemmas and begging novel questions. While international travel remains relatively easy and major regulatory differences continue to exist between jurisdictions, there is every reason to assume markets in cross-border reproductive medicine will flourish and continue to challenge practitioners, regulators, ethicists, and potential patients.

Regulators in each jurisdiction must decide whether CBRC has legislative implications, and - if so - how best to respond to these. While potential patients may demand better information on success rates, safety standards and satisfaction levels in foreign clinics, clinicians will need to decide whether - and where - they will refer patients wishing to go overseas.

Moreover, clinics treating large numbers of 'foreign' patients will need to be aware of the specific needs of such patients - whether deriving from cultural or linguistic differences, or simply from the discomforts of 'being away from home' during their treatment - and work to adequately address these.

It is significant that the horizon scanning meeting of the UK's Human Fertilisation and Embryology Authority in 2010 defined 'reproductive tourism' as the most pressing and challenging new development in ARTs. Moreover, patient organisations, such as Infertility Network UK, Resolve in the United States, and International Consumer Support for Infertility, have developed leaflets to inform their members about the pros and cons of travelling for ARTs.

In December this year, an international academic workshop at the University of Cambridge will bring together leading researchers from a range of disciplines (including sociology, anthropology, ethics, law, psychology, counselling, economics, and clinical medicine) to discuss emerging insights and to develop and agenda for further analysis. Needless to say, the 'Passport to Parenthood' conference organised by the Progress Educational Trust will provide a timely opportunity to broaden the parameters of the UK debate on CBRC and promises to be as thought-proving as it will be informative.