html xmlns=”http://www.w3.org/1999/xhtml” xmlns:mml=”http://www.w3.org/1998/Math/MathML” xmlns:epub=”http://www.idpf.org/2007/ops”>
Simon (42) and Sally (40) have had several failed treatment cycles with donor sperm. They had always assumed that Simon’s diagnosis of a low sperm count was the only factor limiting their fertility. As a result of treatment taking several years, Sally has also been diagnosed with infertility due to poor ovarian response. She was advised that it has become very unlikely that she will conceive using her own oocytes. The couple is now considering oocyte donation in combination with ICSI. As oocyte donation is prohibited in their home country, they have to travel abroad. In addition, they only find very limited information and are uncertain which country and which clinic to travel to. They feel confused by the infinite amount of information they find online and have the impression that much of this information is unreliable. At the same time, they feel time is pressing, and they want to continue treatment as soon as possible and hopefully finally conceive.
Traveling to another country for medical and for fertility treatment is not a new phenomenon. For centuries, couples have traveled to places considered conducive to infertility, such as spas, fertility shrines and specific landmarks in the hope that these will have a positive impact on their fertility. The development of in vitro fertilization (IVF) has brought hope to many experiencing infertility and, together with quick and affordable international travel, has provided the momentum for cross-border reproductive services (CBRS). Those experiencing fertility problems who faced limited access to, or availability of, appropriate services in their own countries started to consider travel abroad to access services that they hoped would realize their family building aspirations. Although IVF and related procedures have become available quickly in many developed and developing countries, various factors have contributed to individuals and couples traveling for treatment. Key amongst these are:
law evasion in jurisdictions with restrictive legislation (e.g., prohibition of oocyte donation in Italy and Germany; prohibition of sperm donation in jurisdictions subject to Sharia law; prohibition of either commercial or altruistic surrogacy in many jurisdictions);
lengthy waiting lists for, or unavailability of, specific services (e.g., oocyte donation in the United Kingdom, sperm donation for couples in a same-sex relationship or single women in several jurisdictions);
the wish to undergo fertility treatment without the knowledge of family or friends;
the wish to undergo treatment in the individual’s or couple’s country of origin; and
beliefs that treatment in another country may be more successful and/or less costly.
As a consequence, although accurate and robust data are not available, the number of individuals and couples engaging in CBRS is believed to have risen significantly over the last 20 years [1–3]. According to a pilot study carried out by ESHRE (European Society of Human Reproduction and Embryology), 24 000 to 30 000 treatment cycles alone were provided annually to foreign patients in the following six destination countries: Belgium, the Czech Republic, Denmark, Slovenia, Spain and Switzerland [4]. Patients had travelled from 49 different “home” countries, with approximately two-thirds of patients coming from Italy (31.8%), Germany (14.4%), the Netherlands (12.1%) and France (8.7%). It is not surprising that country-specific associations were observed. The majority of Italians traveled to Switzerland and Spain, most Germans to the Czech Republic, most Dutch and French patients traveled to Belgium and – to a lesser extent – Spain. The nature of these flows can be explained largely by the relatively easy access provided by shared national borders. French, Norwegian and Swedish patients were the most likely to travel for sperm donation, while Denmark, Belgium and Switzerland were the most popular destinations for sperm donation. Patients from Germany and the UK were the most likely to travel for oocyte donation, and Spain and the Czech Republic were the most popular destination countries for both oocyte and embryo donation. Extrapolating the data relevant for Germany, we can assume that approximately 2000 German couples travel annually mainly for egg donation. (See Table 22.1 for a listing of patient’s home countries and the destination country for treatment.) Survey data from the United States indicate that 4% of all fertility treatments (around 6000 cycles p.a.) is provided for non-US domiciliaries [12,13]. The largest groups of incoming patients are from Latin America (39%) – as with the European findings, geographical proximity contributing to a significant extent – and Europe (25%). By contrast, the incidence of patients from the US traveling abroad for care is estimated to be far lower than the rate of incoming patients [6,12].
CBRS: Home and destination countries (compiled by the authors based on data from recent studies [3–11]).
| Home Country | Destination Country | Service |
|---|---|---|
| Australia | Thailand | Sex selection |
| Canada | USA | Donor oocytes |
| Denmark | Baltic States, Czech Republic, Greece, Russia, Span | Donor oocytes |
| Egypt | Spain, other European countries | Donor oocytes |
| France | Belgium | Donor sperm |
| Germany | Spain, Czech Republic | Donor oocytes |
| Hungary | USA | Surrogacy |
| India | Europe, USA, United Arab Emirates | Standard IVF |
| India | Thailand, USA | Sex selection |
| Israel | Romania | Donor oocytes |
| Italy | Austria, Belgium, Czech Republic, Greece, Slovenia, Spain, Switzerland, UK | Donor oocytes, donor sperm, embryo cryopreservation, PGD |
| Japan | USA | All services |
| Macedonia | Belgium | ICSI-TESE |
| Macedonia | Czech Republic | Donor oocytes |
| Middle East | Jordan | Sex selection |
| Netherlands | Belgium | Donor sperm |
| Norway | Denmark | Donor sperm |
| Portugal | Russia, Spain | Donor oocytes |
| Sweden | Denmark | Donor sperm |
| Sweden | Baltic States, Finland, Russia | Donor oocytes |
| Switzerland | Austria | Standard IVF |
| Switzerland | Eastern Europe, Spain | Donor oocytes |
| UK | Czech Republic, Spain | Donor oocytes |
| USA | India | Surrogacy |
On an international level, Blyth et al. [14] have shown that:
patients travel from more or less anywhere to everywhere, although not all destination countries have a reputation for high-quality service provision;
a number of countries are both home and destination countries; and
although, in general, patients report a relatively high level of satisfaction with the services they have received, clinical experience also suggests that some clinics leave questions unanswered. For example, there can be little transparency regarding recruitment strategies and financial compensation for donors and surrogates, and counseling is seldom available. In addition, treatment contracts may be minimal and only cover issues relevant for the clinic.
While not all CBRS arrangements give major cause for concern, those that are potentially most problematic remain under-researched. There is emerging evidence of potentially serious risks to patients, donors, surrogates and children, such as high numbers of multiples, unknown quality of medical services for donors and surrogates, and offsprings’ lack of access to their gamete or embryo donor or surrogate (see, for example, [3,15]). Furthermore, there has been criticism regarding the dearth of available information. Despite the growth of the CBRS industry, there is only minimal international monitoring and little is known of the services provided by, and remuneration of, intermediary agencies. These organizations symbolize the interface of medicine and business in this field and the Internet has become a “virtual site” of CBRS activities. Utilizing CBRS to evade domestic restrictions and/or to restrict other people’s knowledge of recourse to assistance with family building in turn promotes secrecy. This ensures that many of the practices relating to CBRS remain “hidden,” with significant potential psychosocial, ethical and legal consequences [16]. However, the secrecy has also impacted on the uptake of counseling. CBRS is only beginning to emerge as a theme for infertility counseling and little has been published by experts in this field, with the German Society for Fertility Counselling being the only organization that has developed CBRS guidelines for counselors [17].
Lack of a framework for CBRS
Due to different and sometimes contradictory cultural and ethical values, the harmonization of legislation between different jurisdictions is unlikely to occur. It has also been argued that harmonization may not be desirable as it denies ethical, cultural and religious pluralism. Thus, “harmonization” may actually result in “uniformization” and CBRS could be considered a “safety valve” that helps to avoid conflicts [18]. On the other hand, the current situation lends itself to the exploitation of vulnerable parties, above all, the donors, surrogates and children born from these services. Their voices so far have not been heard to any significant degree. Furthermore, with the exception of a small British study relating to the impact of overseas multiple-embryo transfer during single IVF cycles [15] no research has been conducted on or with children born as a result of CBRS, especially on the psychosocial impact of their mixed cultural/ethnic background. Last but not least, worries have been expressed that CBRS could create demands and burdens on both the home and the destination countries [15].
These concerns have led to the development of practice guidelines by two professional bodies, ESHRE and ASRM, respectively. ESHRE’s “Good practice guide for cross border reproductive care for centers and practitioners” [19] and the ASRM Ethics Committee’s “opinion” [20] are both welcomed for making a start in acknowledging the challenges as well as the opportunities presented by CBRS. However, the scope of both documents as regards infertility counseling practice is modest. The ESHRE guidelines identify the need of foreign patients to receive the same level of medical care, information, counseling and psychosocial support as are provided for domestic patients; the need to minimize health risks for donors and surrogates; and the possibility of professional collaboration in those countries where this does not pose a legal problem. However, it fails to acknowledge the problematic areas: the interests of donors or surrogates, or the possibility for children born as a result of treatment to be able to access information about themselves.
The committee opinion of the Ethics Committee of the American Society for Reproductive Medicine [20] summarises what is currently known about the incidence of, and the key reasons for, utilizing CBRS. It describes the potential benefits of travel to access fertility services and acknowledges the potential harms of CBRS. It focuses only on the responsibilities of physicians; there is no mention of the roles of counselors. Physicians in departure countries are not considered to have any duty to be informed about or disclose risks and benefits of treatment elsewhere and physicians in destination countries are seen to have a duty to deliver the same quality of care required for all domestic patients. The ASRM does not consider that the physician is obliged “to discuss the patient’s circumvention tourism.”
In order to expand on these existing practice guides, minimum standards of care have been proposed [21] that could be implemented on a voluntary basis by clinics, professionals and research institutions, and thus provide a degree of transparency to other professionals as well as to potential patients, donors and surrogates. Most importantly, they could contribute to national and pan-national discussion of the challenges in CBRS. These minimum standards cover the following issues:
1. Voluntary commitment to the standards to be followed as well as voluntary oversight by a national or supra-national body. This is especially pertinent for those countries that have not yet established legislation.
2. A commitment to altruistic donation and surrogacy and a ban on commercial procedures. It is difficult to say the least to determine a just price for services such as donation or surrogacy. There should be national and pan-national discussions regarding financial compensation in order to agree on a “just” price.
3. Gamete donors and surrogates should receive the same level of care as recipients. They should be provided with full healthcare coverage to enable them to access free medical treatment required after potential complications and they should be insured for any (long-term) health impairment resulting from the donation or surrogate service.
4. Since donors and surrogates undergo health risks for the benefit of others, a high level of informed consent should be ensured. They should receive comprehensive and accurate information regarding the medical procedure and the psychosocial implications in an unbiased manner. This should also include legal information such as the status of the donor/surrogate, her husband (in the case of a married surrogate or female donor) and the recipients/intended parents. An independent ombudsman or a donor/surrogate advocate can be established to represent the interests of these parties.
5. All parties involved should have access to psychosocial counseling prior to, during and post treatment. Psychological assessment may be necessary in some cases, but this should neither be confused with, nor substituted for, counseling.
6. In complex cases, prior to new and/or innovative treatment, multi-disciplinary ethics committees installed in the clinic providing treatment should be involved.
7. In order to avoid conflicts of interest, the recruitment of donors and surrogates should be carried out independently from those institutions that are responsible for the informed consent procedure, the psychosocial counseling and the legal advice.
8. There has been a lot of controversy regarding the anonymity and ability to identify donors and surrogates. From a moral perspective, offspring should be granted as much autonomy as possible, including the possibility of accessing full information about their biological and genetic origins, if they wish to do so. Therefore, clinics should document records for a minimum of 80 years and offspring should be entitled to access this information. As a complementary requirement, donors should be able to learn about the outcome of their donation and the number of offspring conceived with their gametes, if they wish. Registers should also enable contact between half-siblings, if mutually agreed upon.
9. All countries should strive towards self-sufficiency as regards ART services so as to reduce the need for patients to travel. Donors and surrogates do not need to provide their service to recipients from abroad (usually with a higher living standard) in order to generate income. In accordance with national cultural and ethical principles, ARTs should be regulated so that this aim is achieved.
10. There are a number of international regulations and conventions on human rights such as the Convention of Human Rights and Biomedicine of the Council of Europe [22], the Convention for the Protection of Human Rights and Fundamental Freedoms [23], the Ethical Issues in Obstetrics and Gynecology [24] or the International Alliance of Patients’ Organisations (IAPO) – Declaration on Patient-Centered Healthcare [25] that can serve as a framework for CBRS.
While adherence to such minimum standards can contribute towards more ethical and respectful treatment, considerable challenges lie in the way of their acceptance. However, they can form the basis of discussion and collaboration between different professional groups, and between professionals in different countries, to ensure that patients, donors, surrogates and the children born as a result of CBRS are not exposed to unnecessary risks.
Counseling in cross-border reproductive services
The provision of appropriate counseling as an integral part of fertility services has been well documented (for an overview see [26–28]) and qualification guidelines have been issued by several organizations [29]. There is agreement that professionals offering fertility counseling should:
1. hold a graduate-level qualification in a psychosocial profession;
2. hold a relevant professional license to practice;
3. demonstrate relevant training in the medical and psychosocial aspects of infertility;
4. demonstrate a minimum level of relevant clinical experience; and,
5. demonstrate engagement in continuing professional education.
When counseling in CBRS, additional requirements arise for professionals. These include: knowledge and information regarding the legislation of typical destination countries; awareness of societal attitudes and their impact on patients; attentiveness for ethical issues, such as commodification, and the potential of exploitation of donors and surrogates, and its effect on patients; as well as being able to raise these issues with patients.
Given that counseling is non-directive, supports the decision-making process of patients, and explores the implications of family building options rather than recommends specific treatments, counseling does not direct patients towards treatments that may not be allowed in their home country. Whether counseling in this area may entail punitive consequences, however, is dependent upon national legislation and/or case law. Fertility counselors, therefore, need to be informed about the implications of relevant legislation and proceed with care, even though supra-national bodies such as ESHRE [30] endorse evasion of domestic law by a medical professional as in the interest of patient autonomy by providing information on treatment options abroad.
Fertility counselors also need to explore their personal and professional attitude regarding CBRS, especially regarding treatment options that are controversial in their country and that raise moral dilemmas. There is a risk of exploiting donors and surrogates, especially when CBRS takes place between countries with very different living standards and customs (e.g., North America and Europe on the one hand, and Eastern Europe and South East Asia on the other). Counselors need to explore their professional attitude towards such challenging issues, beware of transference issues and make use of professional supervision to clarify these. Patients deserve understanding and respect for their family building plans. This does not imply that counselors should refrain from raising controversial issues. In fact, it is often a relief for patients to be able to explore these in a supportive and empathetic environment, and counseling often affords the only possibility to provide time and space for this. The counseling process, however, should not be influenced by the attitude of the fertility counselor.
The case of Simon and Sally presented at the beginning illustrates many common matters presented in CBRS counseling: patients pursuing treatment that is not available in their home country, dealing with limited information, resources and a sense of time. The following section will further examine these clinical issues and provide case vignettes when working with (a) patients, (b) donors and surrogates and (c) the resulting children [17]. Given that CBRS is a relatively new phenomenon, there is little research on which these issues can be based. Therefore, counseling interventions are based on existing knowledge in the area of fertility counseling, especially third party reproduction, although the focus will be on issues that are relevant where treatment takes place outside the patients’ country of residence. For specific counseling in third party reproduction, reference should be made to the relevant chapters in this book.
Preparing for CBRS
Fertility counselors should respect the reproductive autonomy of all parties involved, including the interest of offspring created, resulting in a well-considered and measured use of reproductive medicine. Counseling should be accessible prior to, during and after fertility treatment in a language that patients can use to explore emotional issues; counseling in the country of residence is most likely to fulfill these conditions. Providing counseling prior to treatment may mitigate the risk of accepting treatment that could entail physical or psychological risks for patients or the future child. However, clinical experience indicates that many patients take up counseling after failed treatment cycles, and, in the area of CBRS, after having decided on a clinic and thus the country of treatment.
Susan and Richard sought counseling after they had signed a contract with a clinic and had already made payments towards their first treatment cycle. During the counseling sessions, they raised their frustration regarding the lack of communication by the clinic. Their emails remained unanswered, the responsible staff could not be reached by telephone and they were unable to clarify several issues in the treatment protocol they did not understand. This could not be rectified by counseling. We focused one session on this frustrating situation and this helped the couple develop a greater understanding of the gullibility their emotional situation had resulted in when signing the contract. They developed more confidence and were able to proceed with much more assertiveness during medical treatment.
From a counseling perspective, this is frustrating from several perspectives. This situation is indicative of the importance of pre-treatment counseling. Although fertility counselors are not in a position to recommend specific clinics, even though there may be no adverse legal consequences for doing so where the treatment planned is possible in the “home” country, we firmly believe that patients who have considered their needs prior to medical treatment and have developed their personal “check-list” for the clinics they consult, are more likely to choose a clinic that fulfills their needs. In the case of CBRS, this “check-list” includes issues such as reliable communication via email or telephone and the possibility of contacting staff in emergency situations. This is one of the tasks of counseling before treatment: preparing patients for what lies ahead of them and supporting them to make informed choices.
Exploring infertility always includes a critical appraisal of limits in life, limits of medical treatment and limits of emotional suffering. It therefore may also result in patients deciding against pursuing treatment abroad, in which case counseling focuses on developing strategies for a life without children.
As many patients who intend to undertake treatment abroad have already experienced treatment failure in their home country, fertility counselors should explore whether they have sufficient psychological, emotional and financial resources to continue treatment, and whether this is feasible given their physical, psychological and emotional health. Furthermore, treatment abroad can be associated with moral qualms, especially if the treatment intended is prohibited in the patients’ home country. Careful exploration is necessary in order to assess whether the patients are sufficiently confident to proceed. Moral doubts can also result in keeping the treatment a secret from family members and friends, and thus vital emotional and practical support may be absent during treatment. In some cases, time off treatment may be indicated to work through and resolve some of these issues; in others, patients may decide not to proceed with treatment altogether. For those who proceed, fertility counseling should include the exploration of general issues, issues related to the use of their own gametes and issues related to third party reproduction.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
