Portal de Periódicos da CAPES

Introduction: travelling for conception and the global assisted reproduction market

2011; Elsevier BV; Volume: 23; Issue: 5 Linguagem: Inglês

10.1016/j.rbmo.2011.08.001

1472-6491

Zeynep B. Gürtin, Marcia C. Inhorn,

Global Healthcare and Medical Tourism

Cross-border reproductive care (CBRC) is a fast-growing phenomenon at the intersection of medicine, law, business and travel. Often referred to as ‘reproductive tourism’, ‘procreative tourism’ or ‘fertility tourism’ (Blyth and Farrand, 2005Blyth E. Farrand A. Reproductive tourism – a price worth paying for reproductive autonomy?.Crit. Soc. Policy. 2005; 25: 91-114Crossref Scopus (103) Google Scholar, Cohen, 2006Cohen J. Procreative tourism and reproductive freedom.Reprod. Biomed. Online. 2006; 13: 145-146Abstract Full Text PDF PubMed Scopus (18) Google Scholar, Deech, 2003Deech R. Reproductive tourism in Europe: infertility and human rights.Global Govern. 2003; 9: 425-432Google Scholar, Martin, 2009Martin L.J. Reproductive tourism in the age of globalization.Globalizations. 2009; 6: 249-263Crossref Scopus (38) Google Scholar), ‘reproductive exile’ (Inhorn and Patrizio, 2009Inhorn M.C. Patrizio P. Rethinking reproductive “tourism” as reproductive “exile”.Fertil. Steril. 2009; 92: 904-906Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar, Matorras, 2005Matorras R. Reproductive exile versus reproductive tourism.Hum. Reprod. 2005; 20: 3571Crossref PubMed Scopus (31) Google Scholar), ‘transnational reproduction’ (Whittaker, 2009Whittaker A. Global technologies and transnational reproduction in Thailand.Asian Stud. Rev. 2009; 33: 319-332Crossref Scopus (46) Google Scholar) or ‘reproductive travel’ (Inhorn and Patrizio, 2009Inhorn M.C. Patrizio P. Rethinking reproductive “tourism” as reproductive “exile”.Fertil. Steril. 2009; 92: 904-906Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar), CBRC connotes the movement of persons from one jurisdiction to another in order to access or provide fertility treatments. A 21st-century permutation making its mark on the landscape of assisted reproductive technologies (Nygren et al., 2010Nygren K. Adamson D. Zegers-Hochschild F. de Mouzon J. International Committee Monitoring Assisted Reproductive TechnologiesCross-border fertility care – International Committee Monitoring Assisted Reproductive Technologies Global Survey: 2006 data and estimates.Fertil. Steril. 2010; 94: e4-e10Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar), CBRC is enabled, on the one hand, by globalization, which makes the transnational travel of persons, technologies and ideas ever easier (Appadurai, 1996Appadurai A. Modernity at Large: Cultural Dimensions of Globalization. University of Minnesota Press, Minnesota1996Google Scholar, Inhorn and Shrivastav, 2010Inhorn M.C. Shrivastav P. Globalization and reproductive tourism in the United Arab Emirates.Asia Pas. J. Public Health. 2010; 22: 68S-74SCrossref PubMed Scopus (56) Google Scholar), and on the other by the commercialization of the assisted reproduction industry (Jones and Keith, 2006Jones C.A. Keith L.G. Medical tourism and reproductive outsourcing: the dawning of a new paradigm for healthcare.Int. J. Fertil. Womens Med. 2006; 51: 251-255PubMed Google Scholar, Spar, 2006Spar D.L. The Baby Business: How Money Science and Politics Drive the Commerce of Conception. Harvard Business Press, Boston2006Google Scholar). Although CBRC may involve the movements of assisted reproduction professionals, egg and sperm donors and surrogates, as well as the importing and exporting of gametes, the main focus thus far has been on the movements of men and women pursuing conception (see Inhorn and Gürtin, 2011Inhorn M.C. Gürtin Z.B. Cross-border reproductive care: a future research agenda.Reprod. Biomed. Online. 2011; 23: 665-676Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar). CBRC responds to and exploits the heterogeneity of local conditions under which fertility treatments are made available. This heterogeneity can be observed in: the differing legal frameworks that govern assisted reproductive technologies, sometimes in neighbouring jurisdictions; variations between success rates in different countries and clinics; and the enormous global range in the cost of treatment. Thus, although there are multiple drivers behind CBRC, it is always the case that men and women cross borders in order to access fertility treatment under conditions that are different from what is available to them in their ‘home’ jurisdictions. So far, scholars have identified at least 10 different reasons why individuals may engage in CBRC (Blyth and Farrand, 2005Blyth E. Farrand A. Reproductive tourism – a price worth paying for reproductive autonomy?.Crit. Soc. Policy. 2005; 25: 91-114Crossref Scopus (103) Google Scholar, Culley et al., 2011Culley, L., Hudson, N., Rapport, F., Blyth, E., Norton, W., Pacey, A.A., 2011. Crossing borders for fertility treatment: motivations, destinations and outcomes of UK fertility travellers. Hum. Reprod. Available for online access from 29.06.11.Google Scholar, Deech, 2003Deech R. Reproductive tourism in Europe: infertility and human rights.Global Govern. 2003; 9: 425-432Google Scholar, Hudson et al., 2011Hudson N. Culley L. Blyth E. Norton W. Rapport F. Pacey A. Cross-border reproductive care: a review of the literature.Reprod. Biomed. Online. 2011; 22: 673-685Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar, Inhorn and Patrizio, 2009Inhorn M.C. Patrizio P. Rethinking reproductive “tourism” as reproductive “exile”.Fertil. Steril. 2009; 92: 904-906Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar, Inhorn and Shrivastav, 2010Inhorn M.C. Shrivastav P. Globalization and reproductive tourism in the United Arab Emirates.Asia Pas. J. Public Health. 2010; 22: 68S-74SCrossref PubMed Scopus (56) Google Scholar, Pennings, 2002Pennings G. Reproductive tourism as moral pluralism in motion.J. Med. Ethics. 2002; 28: 337-341Crossref PubMed Scopus (180) Google Scholar, Pennings, 2004Pennings G. Legal harmonization and reproductive tourism in Europe.Hum. Reprod. 2004; 19: 2689-2694Crossref PubMed Scopus (152) Google Scholar, Pennings, 2008Pennings G. International evolution of legislation and guidelines in medically assisted reproduction.Reprod. Biomed. Online. 2008; 18: 15-18Google Scholar, Pennings et al., 2008Pennings G. de Wert G. Shenfield F. Cohen J. Tarlatzis B. Devroey P. ESHRE Task Force on Ethics and Law 15: cross-border reproductive care.Hum. Reprod. 2008; 23: 2182-2184Crossref PubMed Scopus (125) Google Scholar, Shenfield et al., 2010Shenfield F. de Mouzon J. Pennings G. Ferraretti A.P. Nyboe Andersen A. de Wert G. Goossens V. The ESHRE Taskforce on Cross Border Reproductive CareCross border reproductive care in six European countries.Hum. Reprod. 2010; 23: 2182-2184Google Scholar). These are: (i) legal, religious or ethical prohibitions; (ii) denial of treatment to certain categories of persons (based on age, marital status or sexual orientation); (iii) high costs; (iv) absence of assisted reproductive technologies in resource-poor countries due to lack of expertise and equipment; (v) long waiting times due to resource shortages; (vi) safety concerns; (vii) low-quality care and/or success rates; (viii) desires for cultural understanding (e.g. language and religion); (ix) proximity to support networks and family members; and (x) privacy concerns. Although these reasons for travel are quite distinct, they may be grouped together into four broad categories: legal and religious prohibitions (i and ii above); resource considerations (iii, iv, and v); quality and safety concerns (vi and vii); and personal preferences (viii, ix and x). While these broad categories may summarize the majority of CBRC cases, the sheer variety of reasons for reproductive travel belies the accuracy of popular depictions of CBRC. Often represented in the media as frivolous fertility ‘tourism’ or IVF ‘holidays’ in regions of ‘fun and sun’, or as calculated attempts by wealthy Westerners to purchase legal exemption, the discussions around CBRC have suffered from overly simplistic and extreme caricatures. Far from being rich, selfish hedonists or single-minded law evaders, many men and women are motivated to partake in CBRC by a complex combination of factors, including their ardent desires for children and their perceived needs to end the social and physical suffering of infertility and its treatment. Furthermore, many reproductive travellers would prefer to stay at home if safe, accessible, affordable and effective services were available (Inhorn and Shrivastav, 2010Inhorn M.C. Shrivastav P. Globalization and reproductive tourism in the United Arab Emirates.Asia Pas. J. Public Health. 2010; 22: 68S-74SCrossref PubMed Scopus (56) Google Scholar). Similarly, although certain locations have become CBRC ‘hubs’ (e.g., Spain, India, Thailand) through the nationally endorsed promotion of a ‘reproductive tourism’ industry, the choice of destination often also represents an arduous negotiation for patients, involving the logistics of travel, geographical and cultural proximity, and the specificities of treatments required. Indeed, CBRC trajectories are so many and so varied that, even within this symposium issue, readers will find accounts of: Turkish men and women seeking third-party assisted reproduction in Cyprus; North Americans visiting the Czech Republic with the help of bicultural ‘brokers’; Britons and Italians trying to escape, respectively, the resource shortages and tight legal restrictions in their countries by travelling across Europe and further afield; Germans searching for donor eggs in Spain and the Czech Republic; diasporic Arab couples engaging in ‘return reproductive tourism’ to the Middle East; Australians travelling to Thailand for preimplantation genetic diagnosis and sex selection; and American couples heading to India for commercial surrogacy. Indeed, 22 nations and five continents are represented in this symposium issue on CBRC, with a diverse cast of characters including infertile couples, travel brokers, egg donors, gestational surrogates, physicians and embryologists, lawyers, psychological counsellors and health policy makers. Rather than referring to one homogenous entity then, the term ‘CBRC’ encapsulates a range of highly diverse trajectories, with different constituents, different origins and destinations, different desires and motivations, leading to different concerns and outcomes. The novel interactions, opportunities and challenges generated by the travel of increasing numbers of persons in their ‘quests for conception’ (Inhorn, 1994Inhorn M.C. Quest for Conception: Gender, Infertility, and Egyptian Medical Traditions. University of Pennsylvania Press, Philadephia1994Google Scholar) form multiple international choreographies, ranging considerably in detail and character. While some of these CBRC trajectories have been conceptualized by scholars as a ‘safety valve’ enabling the demonstration of ‘moral pluralism in motion’ (Pennings, 2002Pennings G. Reproductive tourism as moral pluralism in motion.J. Med. Ethics. 2002; 28: 337-341Crossref PubMed Scopus (180) Google Scholar, Pennings, 2004Pennings G. Legal harmonization and reproductive tourism in Europe.Hum. Reprod. 2004; 19: 2689-2694Crossref PubMed Scopus (152) Google Scholar), others have been criticized as exploitative of existing stratifications (Spar, 2006Spar D.L. The Baby Business: How Money Science and Politics Drive the Commerce of Conception. Harvard Business Press, Boston2006Google Scholar, Storrow, 2005Storrow R.F. The Handmaid’s Tale of fertility tourism: passports and third parties in the religious regulation of assisted conception.Texas Wesleyan Law Rev. 2005; 12: 189-213Google Scholar). It is possible that the practice of CBRC spans a wide spectrum, from excellent service at one end to neglect or abuse at the other. However, it is difficult to estimate the incidence of these practices or to detail the experiences of patients, providers and others involved in the world of CBRC. Although CBRC has entered the public vernacular over the past decade, the available empirical data still remain, for the most part, incomplete and fragmented (Gürtin-Broadbent, 2010Gürtin-Broadbent, Z., 2010. Unpacking cross-border reproductive care. Bionews 584.Google Scholar, Hudson et al., 2011Hudson N. Culley L. Blyth E. Norton W. Rapport F. Pacey A. Cross-border reproductive care: a review of the literature.Reprod. Biomed. Online. 2011; 22: 673-685Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar). This is due not only to the relatively recent emergence of this phenomenon, but also to the methodological complexities and challenges associated with researching it. Increasingly, CBRC is being recognized by professional organizations, patient support groups and regulators as an area in need of sustained and rigorous attention (Blyth and Auffrey, 2008Blyth, E., Auffrey M., 2008. International Policy on Cross Border Reproductive Services. International Federation of Social Workers Policy Statement, Geneva. Available from: .Google Scholar, Collins and Cook, 2010Collins J. Cook J. Cross-border reproductive care: now and into the future.Fertil. Steril. 2010; 94: e25-e26Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, Mainland and Wilson, 2010Mainland L. Wilson E. Principles of establishment of the First International Forum on Cross-Border Reproductive Care.Fertil. Streril. 2010; 94: e1-e3Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, Nygren et al., 2010Nygren K. Adamson D. Zegers-Hochschild F. de Mouzon J. International Committee Monitoring Assisted Reproductive TechnologiesCross-border fertility care – International Committee Monitoring Assisted Reproductive Technologies Global Survey: 2006 data and estimates.Fertil. Steril. 2010; 94: e4-e10Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar, Shenfield et al., 2011Shenfield, F., Pennings, G., de Mouzon, J., Ferraretti, A.P., Goossens, V., on behalf of the ESHRE Task Force ‘Cross Border Reproductive Care’, (CBRC), 2011. ESHRE’s good practice guide for cross-border reproductive care for centers and practitioners. Hum Reprod. Available online from 19.04.11.Google Scholar, Thorn and Dill, 2010Thorn P. Dill S. The role of patients’ organizations in cross-border reproductive care.Fertil. Steril. 2010; 29: e23-e24Abstract Full Text Full Text PDF Scopus (20) Google Scholar). It is thus the aim of this timely symposium issue to bring together the leading scholars of CBRC from around the world and from a wide range of disciplines (including anthropology, sociology, psychology, philosophy, ethics, law, gender studies, social work and clinical medicine) to discuss the legal, ethical, clinical, socio-cultural and gender considerations raised by CBRC. Through empirical research and critical analysis, this issue’s goal is to challenge the one-dimensional portrayals of CBRC and to foster more accurate representations. The symposium issue includes novel insights from a number of empirical studies (by Bergmann, Gürtin, Hudson and Culley, Inhorn, Nahman, Pande, Speier, Whittaker and Zanini), alongside critical debate and analysis (by Pfeffer, Storrow, Van Hoof and Pennings) and the perspectives of professionals engaged in the delivery of assisted reproductive technologies across borders (by Blyth et al., De Sutter and Shenfield). The symposium issue is divided into four sections, each of which takes account of a particular set of concerns and considerations around the practice of CBRC. In the first section, entitled ‘Legal concerns’, Storrow and Van Hoof and Pennings discuss legal considerations surrounding CBRC from jurisprudential and ethical perspectives, respectively. These normative discussions are followed by empirical anthropological investigations of the role of legal restrictions on infertile couples in Turkey (Gürtin) and Italy (Zanini). The second section, entitled ‘Patient concerns’, investigates and elucidates the attitudes and experiences of men and women who have travelled from one country to another in their quests for conception. While the narratives of patients from the UK (Hudson and Culley), Germany (Bergmann), North America (Speier) and the Middle East (Inhorn) reflect the diversities of CBRC, they also raise some cross-cutting themes, such as the individual agency and concerted effort required to coordinate such travel. In the third section, the focus shifts to ‘Gender concerns’, examining the consequences of CBRC for women and their reproductive bodies and relationships. Whittaker debates the issue of PGD and non-medical sex selection, while Pande explores the relationships between Indian gestational surrogates and their foreign commissioners. Nahman follows the ‘reverse traffic’ of donor eggs from Romania to Israel and Pfeffer offers a critical feminist analysis of such ‘eggs-ploitation’, comparing it with transplant tourism. In the final section on ‘Professional concerns’, the practice and provision of CBRC are addressed from the perspectives of psychological counsellors (Blyth et al.), clinicians involved in treating foreign patients (De Sutter) and the ESHRE Taskforce on CBRC (Shenfield). Finally, we, the editors, draw upon our own research, as well as discussions with the authors in this issue, to highlight some of the methodological challenges of studying CBRC and to outline an agenda for future research (Inhorn and Gürtin, 2011Inhorn M.C. Gürtin Z.B. Cross-border reproductive care: a future research agenda.Reprod. Biomed. Online. 2011; 23: 665-676Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar). As demonstrated by the articles in this symposium issue, CBRC is not just a passing trend, currently resting at the crossroads of travel, consumerism, law and reproductive medicine. Rather, it is a growing global phenomenon that can significantly affect physical health and mental wellbeing, gender and marital relations, family formation and ultimately population health. CBRC is already posing new dilemmas for regulatory bodies, clinicians and those seeking treatment. Thus, it is hoped that this symposium issue will have wide interdisciplinary and global appeal, as merited by its subject matter, and that it will ultimately foster a more informed debate on CBRC as an important 21st-century phenomenon. The articles in this symposium issue were discussed at a workshop held at the University of Cambridge in December 2010. The editors would like to thank the Centre for Research in the Arts, Social Sciences and Humanities (CRASSH), University of Cambridge; The Wellcome Trust (Grant Number WT093960MA); Council on Middle East Studies, Yale University; King’s College, Cambridge; Downing College, Cambridge; and the Cambridge Political Economy Society Trust (CPEST), who all supported this workshop. They are also grateful to Molly K Moran for her excellent copy-editing. Finally, the editors thank Reproductive Biomedicine Online, which is the perfect home for these articles, and especially thank Martin H Johnson and Caroline Blackwell for sharing their vision and for bringing this project to fruition with such speed and efficiency.