"Patients must be aware that laws and regulations from other countries will likely be different from home"
Author: Raquel Pillado
WHAT IS “CROSS BORDER REPRODUCTIVE CARE”?
Accessibility of patients suffering from infertility to appropriate treatments may greatly vary depending on which country or region they reside in. The availability of appropriate care, its quality, cost or regulatory restrictions may push patients into seeking treatment abroad (2). Furthermore, these limitations may also include privacy issues, involving the social stigma that may be associated with certain treatments (surrogacy, sex selection, preimplantation genetic diagnosis…) in certain cultures. Such situation is known as Cross Border Reproductive Care (CBRC), and it is defined as the practice of travelling to another region or to a different country to receive fertility treatments (3). CBRC is also commonly known as reproductive, procreative or fertility tourism because many patients take the chance to combine their fertility treatments with regular tourist activities. Also, some authors refer to this phenomenon as “reproductive exile”, because they see it as the patient being pushed to this alternative in order to achieve their desire to become parents (4).
PREFERRED DESTINATIONS FOR CBRC
The destination choice often represents an arduous task for patients due the travel logistics, including the geographical and cultural proximity and the specificities of treatments required (5). As a result, some companies have appeared to offer assistance for patients interested in CBRC. These companies help their clients to organize their trip, from accommodation booking to arranging all medical meetings. Moreover, some clinics directly advertise specific programs for international clients, and they even include sections on their websites specifically dedicated to provide information on every step of the process and tourist attractions.
Nowadays, the main global markets or hubs for CBRC industry are Denmark for sperm donation, Belgium for in vitro fertilization (IVF) or Spain and Czech Republic for egg and embryo donation. Likewise, the most popular destinations for fertility preservation seem to be Denmark and Belgium in Europe and the United States in the American continent. This country is also a preferred choice for cryopreservation of gametes, embryos and ovarian and testicular tissues. Furthermore, and along with Russia and India, it is a popular destination for preimplantation genetic diagnosis (PGD) and sex selection procedures (3).
The selected country depends on where patients are originally from and the treatment they seek (Table 1). For example, North Americans visit countries with comparative lower prices, Britons travel to other European countries looking for sperm, eggs and embryo donors and some Arab couples engage in “return reproductive tourism”* (6) to the Middle East (5).
FACTORS TO CONSIDER BEFORE TRAVELLING ABROAD FOR CBRC
Patients must be aware that laws and regulations from other countries will likely be different from home. There are two main ways of regulating the practice and the access to ART. First, proper regulation can be achieved through sets of rules or guidelines followed by the practitioners on a voluntary basis. Usually these guidelines are developed by professional organizations related to the field. Secondly, governmental legislation, which implies specific rules in the shape of laws ruling the use of ART and legal penalties for those who violate them (7).
It is important to study the specific ART legislation and/or guidelines of both the origin and chosen destination countries. In order to find information about these regulations the first step is to find out whether there is a national independent regulator overseeing ART practice. For example, in the United States, United Kingdom and India these are the American Society of Reproductive Medicine (ASRM) (8), the Human Fertilisation and Embryology Authority (9), and the National Registry of Assisted Reproductive Technology (ART) Clinics and Banks (10), respectively. These organizations usually provide information concerning national legislation and/or guidelines, and some of them even offer data of officially approved clinics. In the case of the US and UK there are legislation and guidelines, while in India there are only guidelines (6). Regarding this country, the National Registry is still in the process of verifying whether clinics follow these guidelines and awarding them with official certificates accordingly (10).
The information obtained from guidelines/legislation will provide a general idea about the standards required for ART in those countries. When looking for a gestational carrier or sperm, eggs or embryos donors, it is important to specifically look into the requirements asked to potential donors and gestational carriers (genetic tests, STD reports, etc.). Additionally, in the case of surrogacy it is also advisable to double check any law related to legal rights over the offspring, both in the surrogate mother and the couple´s respective countries of origin (for more information about surrogacy, read one of our previous posts here).
Lastly, the language barrier must not be forgotten. Before travelling, one should verify with the fertility centre the availability of interpreters and the ability of the staff to speak the required language. Also, it will be necessary to ask the centre to provide copies of every document in that language (certificates, bills, informed consents, etc.).
THE FUTURE OF CBRC
Travelling between countries and easy access to information is nowadays part of our routine life due to globalization and internet. As a result, it is very attractive for assisted reproduction clinics to offer their services to international clients. However this market has quickly developed without any international regulation ruling over it. As a future objective to improve CBRC, governs and health organizations should work on an international regulation in order to protect both patients and professionals (2). Ideally, the creation of an international joint database and standardization of data collection would help to improve ART efficiency (11). In addition, special attention should be given to writing up laws in order to:  prevent exploitation of gamete donors and/or gestational carriers in destination countries; and  avoid the price rise that would make it more difficult for local patients to access ART treatments.
Even though CBRC seems to provide a solution for most patients to access to certain treatments, this option needs a much clearer international regulation. Such improvement should help to collect data to increase the current knowledge on ART field, which will enable professionals to offer a better care in the future. Furthermore, governments should probably implement specific measurements to prevent misinformation to international patients. Simultaneously, this would help defending local citizens from exploitation in specific cases; for instance, those in which a third party is involved such as gestational carriers or donors.
Finally, the decision of signing on CBRC should be made after extensive research about the treatment one wishes to undergo and the regulations in the destination country.
*Situation in which a couple or an individual who lives abroad returns home specifically for ART treatments due to a variety of cultural, moral and psychological reasons (6).
1. https://www.babygest.es/turismo-reproductivo/que-es-el-turismo-reproductivo-o-de-fertilidad/ (10-03-2018)
2. Storrow RF (2011) Assisted reproduction on treacherous terrain: the legal hazards of cross-border reproductive travel. Reproductive BioMedicine Online (2011) 23, 538– 545.
3. Salama M (2014) Cross Border Reproductive Care (CBRC): A Global Perspective. Obstet Gynecol Int J 1(2): 00008. DOI: 10.15406/ ogij.2014.01.00008.
4. Inhorn and Patrizio (2009) Rethinking reproductive ‘‘tourism’’ as reproductive ‘‘exile’’, American Society for Reproductive Medicine, Fert and Steril, 92 (3): 904-906.
5. Gürtin ZB et al (2011) Introduction: travelling for conception and the global assisted reproduction market. Reprod Biomed Online, 23(5): 535-537.
6. Inhorn MC (2011) Diasporic dreaming: return reproductive tourism to the Middle East. Reprod Biomed Online, 23(5): 582 - 91.
7. Präg P and Mills MC (2017) Assisted Reproductive Technology in Europe: Usage and Regulation in the Context of Cross-Border Reproductive Care. In: Kreyenfeld M, Konietzka D (eds) Childlessness in Europe: Contexts, Causes, and Consequences. Demographic Research Monographs (A series of the Max Planck Institute for Demographic Research). Springer, Cham.
8. American Society For Reproductive Medicine. Montgomery Highway Birmingham, Alabama. Availability: http://www.asrm.org/arm/
9. Human Fertilization and Embryology Authority. 10 Spring Gardens London Availability: https://www.hfea.gov.uk/treatments/eexplor-all-treatments/fertility-treatment-abroad/
10. National Registry of Assisted Reproductive Technology (ART) Clinics and Banks in India. ICMR. Ansari Nagar, New Delhi Availability: http://www.icmr.nic.in/icmrnews/art/art.htm
11. Shenfield F (2011) Implementing a good practice guide for CBRC: perspectives from the ESHRE Cross-Border Reproductive Care Taskforce. Reprod BioMed Online 23: 657– 664.