Cross-border reproductive care, also called reproductive tourism, refers to the travelling of citizens from their country of residence to another country in order to receive fertility treatment through assisted reproductive technology. Several reasons account for cross-border reproductive care: (i) a certain kind of treatment is forbidden by law in the couple’s own country or is inaccessible to the couple because of their demographic or social characteristics; (ii) foreign centres report higher success rates compared with those of the centres in the country of residence; (iii) a specific treatment may be locally unavailable because of a lack of expertise or because the treatment is considered experimental or insufficiently safe; and (iv) limited access to the treatment in the couple’s home country because of long waiting lists, excessive distance from a centre or high costs. Although cross-border reproductive care can be viewed as a safety valve, the phenomenon is often associated with a high risk of health dangers, frustration and disparities. Solutions to these problematic effects need to be considered in the light of the fact that cross-border reproductive care is a growing phenomenon.
Introduction
Cross-border reproductive care refers to the travelling of citizens from their country of residence to another country in order to receive a specific treatment to exercise their personal reproductive choice. The phenomenon can be considered a part of the more general ‘medical tourism’, in turn a part of the wider phenomenon of globalization. Nonetheless, the phenomenon and its causes are locally specific because of the different ethical, religious and legal attitudes surrounding the patient’s right to reproductive health.
Historically, the presence of different national rules regarding the termination of pregnancy (TOP) was the first cause of migration in the field of reproduction. Whereas in Europe this type of travelling had steadily decreased due to the legalization of abortion in several countries, a new migration trend, related to nationally different accessibility to assisted reproductive techniques increased in the 1990s. A similar phenomenon occurred in Australia and in the United States.
The trend was reported by mass media for the first time due to extreme cases such as egg donation, pregnancy in 60-year-old women, and insemination with cryopreserved spermatozoa from a deceased husband. However, cross-border reproductive care is not limited to these atypical requests, but it is a more complex phenomenon expressing the controversial aspects of reproductive technologies (Pennings, 2004, Pennings, 2006).
The necessity of travelling to another country for assisted reproduction purposes arises from limitations to the rights granted in the country of residence, but it can also be considered a safety valve. Lacking an international legal harmonization on assisted reproduction, patient migration reduces moral conflicts and contributes to the peaceful coexistence of different ethical and religious views.
However, this phenomenon is often associated with a high risk of health hazards, frustration and disparities that have to be taken into great consideration, especially because cross-border reproductive care is increasing.
An approach to solve and clarify these problems should include discussion, estimation of the extent of the phenomenon, an analysis of the causes and the sharing of experiences. National and international efforts should be promoted to solve the existing problems.
Currently, no clear information is available on the topic. For this reason, the European Society of Human Reproduction and Embryology (ESHRE) established a scientific research project named ‘Cross-border reproductive care’, in order to collect quantitative and qualitative information on the trend. A specific task force was set-up within the Society to conduct the study.
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Definition
Knoppers (Knoppers and Lebris, 1991) was the first to name the phenomenon ‘procreative tourism’ in 1991 (later changed to ‘reproductive tourism’). ‘Health tourism’ has emerged as a specific aspect of globalization (Wilson, 2004), and was originally used to refer to people going on vacation primarily for pleasure, adding the advantage of obtaining medical services. Nowadays the primary reason (often the ‘only’ reason) for medical tourism is the medical treatment itself. Therefore the term
Main causes of cross-border reproductive care
Several factors, often inter-related, promote patient migration. The main causes can be summarized as follows.
Estimation of the phenomenon
The topic is often an object of discussion but, still, a clear idea of the extent of the migratory fluxes entity is not available. It is not easy to study patient flow from one country to another for reproductive reasons. The idea of law evasion and its negative connotation, as well as the personal and emotional issues related to infertility, may hide the problem. In addition, a country may not disclose national immigration or emigration registries regarding medical care, due to political
Problems and risks
Cross-border reproductive care is a clear consequence of two main issues: post-modern society, characterized by a multitude of moral and religious point of views which, in the matter of reproduction, produce a mosaic of different laws even among countries with similar cultures and values (like Europe); and limited public infertility care, which promotes a private-based reproductive medicine.
Ethically, the need to cross the border for assisted reproduction (due to legal restrictions or financial
Possible solutions?
Given that European citizens are free to travel voluntarily in Europe in search of medical treatments (including assisted reproduction), the best solution to avoid the non-voluntary need to travel abroad due to restrictive laws would be a legal harmonization of assisted reproduction (no national restrictive laws) and/or strong policies to guarantee public funding or insurance coverage of infertility treatments. However, one must realize that this goal is distant; any proposal for future
Conclusions
Cross-border reproductive care is a complex phenomenon expressing several controversial aspects of reproductive technology. Monitoring the phenomenon is crucial to promote public discussion and to analyse the underlying causes. Despite the difficulties, efforts should be made at all levels to reduce the involuntary need to travel, to find solutions to prevent dangers, to guarantee the safety and the quality of the treatments wherever provided, and to balance disparities among patients (Pennings
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Anna Pia Ferraretti is Scientific Director of the Reproductive Medicine Unit at SISMER, Bologna, Italy. She obtained her MD degree in 1979 at the University of Bologna, her specialism in Obstetrics and Gynaecology in 1982 and her PhD degree in Endocrinology and Metabolism in 1990. She was the first Fellow at the IVF unit set up at the Eastern Virginia Medical School, Norfolk, USA (1981–1982). Since then, she has been working in the field of human reproduction as the leader of the IVF Program at the University of Bologna (1983–1989), the Clinical Director of the Reproductive Medicine Unit at Villa Regina (1989–1995) and the Clinical Director of the Reproductive Medicine Unit at SISMER (1995–2005).
