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Cross-Border Reproductive Care: an Ethics Committee Opinion

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Cross-Border Reproductive Care: an Ethics Committee Opinion Cross-border reproductive care: an Ethics Committee opinion Ethics Committee of the American Society for Reproductive Medicine American Society for Reproductive Medicine, Birmingham, Alabama Cross-border reproductive care (CBRC) is a growing worldwide phenomenon, raising questions about why assisted reproductive tech- nology (ART) patients travel abroad, what harms and benefits may result, and what duties health-care providers may have in advising and treating patients who travel for reproductive services. Cross-border care offers benefits and poses harms to ART stakeholders, including patients, offspring, providers, gamete donors, gestational carriers, and local populations in destination countries. This document replaces the previous document of the same name, last published in 2013 (Fertil Steril 2013;100:645–50). (Fertil SterilÒ 2016;106:1627–33. Ó2016 by American Society for Reproductive Medicine.) Discuss: You can discuss this article with its authors and with other ASRM members at https://www.fertstertdialog.com/users/ 16110-fertility-and-sterility/posts/12456-22950 KEY POINTS Cross-border care offers benefits Referral to other qualified experts, and poses potential harms to ART including mental health profes- Cross-border reproductive care stakeholders, including patients, sionals, should be considered and is (CBRC) refers to the activity sur- offspring, providers, gamete donors, encouraged when appropriate. rounding patients who travel outside gestational carriers, and local popu- Infertility knows no political bound- their country of domicile to seek as- lations in destination countries. aries, but prevailing policies, costs, and sisted reproductive services and Physicians in departure countries laws within an individual's country of treatment. CBRC affects both the de- have no independent duty to inform domicile can hamper access to treatment. parture and destination countries patients about opportunities for These formal and informal country-based from and to which patients travel. CBRC but must not misinform pa- restrictions on access to ART do little to CBRC is a growing worldwide phe- tients when responding to questions temper their citizens' desire for biologic nomenon, raising questions about about ART options abroad. parenthood. Increasingly, prospective why assisted reproductive technol- Physicians in destination countries parents from around the globe who face ogy (ART) patients travel to another have a duty to uphold local standards reduced access to fertility care at home country, what benefits and harms of care, legal requirements, and are traveling across national borders may result, and what duties physi- informed consent but have no duty to to seek ART treatment. This practice, cians may have in advising and learn about or disclose the legal, prac- commonly referred to as CBRC, has sig- treating these patients. tical, and other nonmedical barriers a nificant implications for stakeholders in The main reasons cited by patients patient might face in accessing CBRC. both departure and destination countries. for CBRC are a desire to access Patients considering CBRC should What follows is a discussion of the inci- broader and higher quality care, a seek out advice from qualified legal dence and reasons for CBRC, its potential need to reduce the cost of care, an experts who can provide guidance benefits and harms, and the ethical con- effort to circumvent legal restrictions on legal aspects of such activity, siderations that arise in treating or in a departure country, and a desire both in the destination country and advising patients who leave home to ac- for privacy or cultural comfort in a upon their return to the departure cess assisted reproductive care. destination country. country. THE INCIDENCE OF CBRC Comprehensive data on the worldwide incidence of CBRC are emerging as re- Received August 18, 2016; accepted August 18, 2016; published online September 24, 2016. searchers, professional organizations, Reprint requests: Ethics Committee, American Society for Reproductive Medicine, 1209 Montgomery Hwy, Birmingham, Alabama 35216 (E-mail: [email protected]). and patient groups delve into the ques- tion of who travels to access reproduc- Fertility and Sterility® Vol. 106, No. 7, December 2016 0015-0282/$36.00 Copyright ©2016 American Society for Reproductive Medicine, Published by Elsevier Inc. tive care and why. In a 2010 survey of http://dx.doi.org/10.1016/j.fertnstert.2016.08.038 CBRC in Europe, researchers counted VOL. 106 NO. 7 / DECEMBER 2016 1627 Downloaded for Anonymous User (n/a) at University of Alabama at Birmingham NAAL from ClinicalKey.com by Elsevier on April 07, 2017. For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved. ASRM PAGES 24,000–30,000 cycles of cross-border treatment annually, personnel, utilize more up-to-date equipment, and offer involving 11,000–14,000 patients (1, 2). Based on a total of more specialized services, incentivize experienced ART 525,640 treatment cycles during the same period, this means patients to seek treatment abroad (7–9). Finally, patients that approximately 5% of all European fertility care involves travel to avoid long wait times—a reality in countries that cross-border travel (3). include infertility care as part of their national health Survey data from the United States indicate that 4% of service (9, 10). all fertility treatment provided in the country, or approxi- mately 6,000 cycles, is delivered to non-US domiciliaries (2, 4). The largest groups of incoming patients are from Travel to Reduce the Cost of Fertility Care Latin America (39%) and Europe (25%). The incidence of The high cost of ART is a well-described barrier to its use. US patients traveling abroad for care is estimated to be Because fertility treatment can be prohibitively expensive, it far lower than the rate of patients coming into the United is utilized by only a fraction of those in need of care (11). States (2, 5). Even patients who can afford care often incur financial hard- Researchers caution that the volume of CBRC activity is ship in their quest for parenthood (12). Global price variations difficult to estimate accurately given the lack of a robust in- are published, with the average price of an in vitro fertiliza- ternational reporting system (6). Logically, it is easier to tion (IVF) cycle highest in the United States (13) and signifi- collect data in destination countries and regions that main- cantly lower in countries such as India (14, 15). The fiscal tain ART databases in which a patient's country of origin is impact of ART on patients varies across the globe; patients included as a variable. Identifying those who leave home to in countries that fund care as part of a national health access care requires either high patient response rates to service are impacted the least while those in non- posted surveys or elaborate tracing through multiple foreign reimbursement countries are impacted the most, sometimes ART databases. To date, a precise accounting of global ART incurring lasting financial harm (11, 16). travel remains a goal rather than a reality. Disparities in the fees paid to gamete donors and gesta- tional carriers also incentivize travel. Media reports indicate THE REASONS FOR CBRC that India has been a popular destination country for access- fi The factors that motivate patients to travel abroad for fertility ing gestational surrogacy services due to signi cantly lower care are varied, complex, and often interrelated. The reasons compensation amounts (17). Fees to oocyte donors also for CBRC fall into four basic categories: 1) access; 2) cost; 3) vary considerably from country to country (1). Surveys of pa- regulation; and 4) privacy. Each is described briefly below. tients who travel to access third-party reproductive services indicate that cost is a significant factor in their decision to leave home (1, 2). Travel to Access Broader and Higher Quality Care A patient's ability to access fertility care in his or her country of domicile depends upon the supply of ART services, the Travel to Circumvent ART Law quality of care offered, the array of treatment options avail- Legal regulation of ART worldwide occurs on a country-by- able, and the wait time associated with obtaining care. Survey country basis, with no overarching international treaties or data suggest that each of these factors plays a role in moti- formal laws in place. Logically and empirically, jurisdictions vating cross-border fertility travel, particularly in the Middle with restrictive laws are more likely to serve as departure East, Southeast Asia, and Latin America where ART clinics are countries, while nations with few or no legal restrictions are sparse (6). patronized as destination countries. The act of seeking Travel is also more prevalent from departure countries fertility care outside of one's country of residence to avoid where the supply of donor gametes and gestational services application of prevailing law is sometimes referred to as is low (compared with demand), owing primarily to regula- ‘‘circumvention tourism’’ (18, 19). tory, compensatory, and/or anonymity policies. Countries ART regulation that motivates CBRC falls into two broad that restrict payments to gamete donors and gestational car- categories: 1) restrictions on who can access fertility care and riers see the majority of their fertility travelers leaving to ac- 2) restrictions on what fertility care can be accessed. Laws ad- cess these services across borders (5, 7). National policies that dressing ‘‘who’’ typically restrict access based on patient de- require disclosure of donor identity also impact the mographics. Restrictions on patient age, marital status, and availability of donor gametes, and hence factor into fertility sexual orientation are embedded in law in some countries, travel. Patients in Sweden, the United Kingdom, and sending older, single, and gay and lesbian patients across na- Norway, for example, report the desire for access to tional borders. By contrast, in some US states, strict nondis- anonymous gamete donors as a factor in their decision to crimination laws prohibit ART clinics from denying care on seek care abroad (1, 8).
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