Fertility tourism

Fertility tourism or reproductive tourism^[1] is the practice of traveling to another country or jurisdiction for fertility treatment,^[2] and may be regarded as a form of medical tourism. The main reasons for fertility tourism are legal prohibitions or regulation of the sought procedure in the home country, the non-availability of a procedure in the home country, as well as lower costs in the destination country. The main procedures sought are In-vitro fertilization (IVF) and donor insemination, but also surrogacy.

It has been proposed to be termed reproductive exile to emphasise the difficulties and constraints faced by infertile patients, who are "forced" to travel globally for reproductive procedures.^[3]

IVF destinations

About 20,000 to 25,000 women (often accompanied by their partners) annually seek cross-border assisted reproductive technology (ART) services.^[4]

Destinations

Israel is the leading fertility tourism destination for In-vitro fertilization (IVF) procedures, having the highest number of fertility clinics per capita in the world.^[5] The United States is the destination of many Europeans because of the higher success rates and liberal regulations. In turn, India and other Asian countries are the main destinations for U.S. women seeking fertility treatment, being the destinations for 40% of U.S. women seeking IVF and 52% seeking IVF with donor eggs.^[6] Many travel from countries like Germany and Italy, which are very restrictive of the number of eggs that may be fertilized and how many embryos can be used for implantation or cryopreservation. In recent years, Mexico has become a popular destination for cross border IVF treatment due to its liberal ART policies and egg donation. Even small countries such as Barbados provide JCI-accredited IVF treatment aimed at women from abroad.

Cost factors

Women from countries such as the United States and the United Kingdom may travel for IVF treatment and medications to save money. The cost for 1 IVF cycle in the United States averages US$15,000, while comparable treatment in Mexico is about $7,800, Thailand $6,500, and India $3,300.^[7][8]

Egg donation

Egg donation is illegal in a number of European countries including Germany, Austria and Italy. Many women then will seek treatment in places where the procedure is allowed such as Spain and the United States where donors can be paid for their donation.^[4] Almost half of all IVF treatments with donor eggs in Europe are performed in Spain.^[4] IVF with anonymous egg donation is also the main ART sought by Canadians traveling to the U.S, and is the sought procedure for 80% of cross-border treatments by Canadians.^[6]

Sex selection

Sex selection is prohibited in many countries, including the United Kingdom,^[9] Australia^[10] and Canada,^[11] except when it is used to screen for genetic diseases. Some women wishing to be sure of a child's sex may travel to countries where it is legal to perform a preimplantation genetic diagnosis (PGD, a potential expansion of IVF), which can be used for sex selection, such as the United States.^[12]

Risks

Many countries have no restriction on how many embryos may be transferred into the uterus at the same time, increasing the risk of multiple pregnancy and resultant potential complications.^[13] The burden of multiple births generated by placing too many embryos is carried by the patients and the home country.

Donor insemination

A woman may go to another country to obtain artificial insemination by donor. The practice is influenced by the attitudes and sperm donation laws in the host country.

There is generally a demand for sperm donors who have no genetic problems in their family, 20/20 eyesight, with excellent visual acuity, a college degree, and sometimes a value on a certain height, age, eye colour, hair texture, blood type and ethnicity .^[14][15][16] Anecdotal evidence suggests that the inventory of taller men who are blonde and blue eyed is most popular.^[17]

Destinations

Denmark has a well-developed system of sperm export. This success mainly comes from the reputation of Danish sperm donors for being of high quality^[18] and, in contrast with the law in the other Nordic countries, gives donors the choice of being either anonymous or non-anonymous to the receiving couple.^[18] Furthermore, Nordic sperm donors tend to be tall, with rarer features like blond hair or different color eyes and a light complexion, and highly educated^[19] and have altruistic motives for their donations,^[19] partly due to the relatively low monetary compensation in Nordic countries. More than 50 countries worldwide are importers of Danish sperm, including Paraguay, Canada, Kenya, and Hong Kong.^[18] Another emerging destination for fertility tourism is Barbados.^[20] More and more Caribbean couples and couples of African origin are in need medical help to conceive, and often want eggs and sperm that match their genetic composition. For a long time, their only option was the United States; however for over 11 years Barbados ^[21] has been providing couples with the latest in cutting edge technology and has introduced new techniques.

Origins

Some countries such as United Kingdom and Sweden, have a shortage of sperm donors.^[22][23] Sweden now has an 18-month-long waiting list for donor sperm.^[24]

As a consequence of the shortage of donor sperm in UK in the late 1990s and the early years of the 21st century, British women travelled to Belgium and Spain for donor insemination,^[25] until those two countries changed their laws and imposed a maximum number of children one donor may produce. Prior to the change in the law, the limit in the number of children born to each donor depended upon practitioners at fertility clinics, and Belgian and Spanish clinics were purchasing donor sperm from abroad to satisfy demand for treatments. Anonymous donation was permitted in Belgium and is a legal requirement in Spain. These two countries also allowed single heterosexual and single and coupled lesbians to undergo fertility treatment. Ironically, at the time, many Belgian and Spanish clinics were buying sperm from British clinics donated by British donors whose local limit of ten families in the UK had not been reached, and they were able to use that sperm according to local laws and limits. In addition, lesbian women from France and eastern Europe travelled to these countries in order to achieve a pregnancy by an anonymous donor since this treatment was not available to them in their own countries. British fertility tourists must therefore now travel to other countries particularly those that do not include children born to foreigners in their national totals of children produced by each donor. Britain also imports donor sperm from Scandinavia but can only limit the use of that donor's sperm to ten families in the UK itself, so that more children may be produced elsewhere from the same donor.^[26]

At least 250^[24] Swedish sperm recipients travel to Denmark annually for insemination. Some of this is also due to that Denmark also allows single women to be inseminated.

It is illegal to pay donors for eggs or sperm in Canada. Women can still import commercial U.S. sperm, but that's not true for eggs, resulting in many Canadian women leaving the country for such procedures.^[27]

Surrogacy destinations

Surrogacy destinations are those countries and jurisdictions which permit commercial surrogacy, where the cost is relatively low, and which give the intended parents legal rights over the newborn child, whether by streamlined adoption procedures or direct parental rights.

India

India is a main destination for surrogacy because of the relatively low cost. Indian clinics are at the same time becoming more competitive, not just in pricing, but in the hiring and retention of Indian females as surrogates. Clinics charge patients between $10,000 and $28,000 for the complete package, including fertilization, the surrogate's fee, and delivery of the baby at a hospital. Including the costs of flight tickets, medical procedures and hotels, it comes to roughly a third of the price compared with going through the procedure in the UK.^[28]

In 2008, the Supreme Court of India in the Manji's case (Japanese Baby) has held that commercial surrogacy is permitted in India.

There is an upcoming Assisted Reproductive Technology Bill, aiming to regulate the surrogacy. However, it is expected to increase the confidence in clinics by sorting out dubious practitioners, and in this way stimulate the practice.^[28]

Russian Federation

Liberal legislation makes Russia attractive for “reproductive tourists” looking for techniques not available in their countries. Intended parents come there for oocyte donation, because of advanced age or marital status (single women and single men) and when surrogacy is considered. Gestational surrogacy, even commercial is absolutely legal in Russia, being available for practically all adults willing to be parents.^[29] Foreigners have the same rights as for assisted reproduction as Russian citizens. Within 3 days after the birth the commissioning parents obtain a Russian birth certificate with both their names on it. Genetic relation to the child (in case of donation) doesn’t matter.^[30] On 4 August 2010, a Moscow court ruled that a single man who applied for gestational surrogacy (using donor eggs) could be registered as the only parent of his son, becoming the first man in Russia to defend his right to become a father through a court procedure.^[31] The surrogate mother’s name was not listed on the birth certificate; the father was listed as the only parent.

Ukraine

Surrogacy is completely legal in Ukraine. However, only healthy mothers who have had children before can become surrogates. Surrogates in Ukraine have zero parental rights over the child, as stated on Article 123 of the Family Code of Ukraine. Thus, a surrogate cannot refuse to hand the baby over in case she changes her mind after birth. Only married couples can legally go through gestational surrogacy in Ukraine. Gay couples and single parents are prohibited to use gestational surrogates.

United States

The United States is sought as a location for surrogate mothers by couples seeking Green Card in that country, since the resulting child can get birthright citizenship in the United States, and can thereby apply for Green Cards for the parents when turning 21 years of age.^[32] However, there are many other reasons people come to the US for surrogacy procedures, including to enjoy a better quality of medical technology and care, as well as the high level of legal protections afforded through some US state courts to surrogacy contracts as compared to other countries. Increasingly, same sex couples who face restrictions using IVF and surrogacy procedures in their home countries travel to US states where it is legal.

Citizenship

The citizenship and legal status of a child resulting from surrogacy can be problematic. The Hague Conference Permanent Bureau identified the question of citizenship of these children as a "pressing problem" in the Permanent Bureau 2014 Study (Hague Conference Permanent Bureau, 2014a: 84-94).^[33][34] According to U.S. Department of State, Bureau of Consular Affairs, for the child to be a U.S. citizen one or both of the child's genetic parents must be a U.S. citizen. In other words, the only way for the child to acquire U.S. citizenship automatically at birth is if he/she is biologically related to a U.S. citizen. Further, in some countries, the child will not be a citizen of the country in which he/she is born because the surrogate mother is not legally the parent of the child. This could result in a child being born without citizenship.^[35]

References

External links

• IVF Treatment Abroad: Issues and Risks