Reproductive BioMedicine Online (2011) 23, 642– 651

www.sciencedirect.com
www.rbmonline.com

SYMPOSIUM: CROSS-BORDER REPRODUCTIVE CARE

ARTICLE

CBRC and psychosocial counselling: assessing

needs and developing an ethical framework
for practice
Eric Blyth *, Petra Thorn, Tewes Wischmann

University of Huddersfield, School of Human and Health Sciences, Queensgate, Huddersfield HD1 3DH, United Kingdom
* Corresponding author. E-mail address: e.d.blyth@hud.ac.uk (E Blyth).

Eric Blyth is professor of social work at the University of Huddersfield and visiting professor of social work at
Hong Kong Polytechnic University. Petra Thorn: Practice for Family Therapy, Moerfelden, Germany. Tewes
Wischmann: Institute for Medical Psychology, Heidelberg University, Heidelberg, Germany.

Abstract Encountering infertility and involuntary childlessness and undergoing infertility treatment are acknowledged as stressful
experiences that impact on individuals’ psychological and emotional health – and for which access to psychosocial counselling by a
skilled mental health professional may be beneficial. Evidence of patients’, gamete donors’ and surrogates’ experiences indicates
that utilization of infertility treatment in another country may not only exacerbate these psychosocial adversities, but may also pose
additional risks to the psychological or physical health of participants, thus further emphasizing the need for competent psychoso-
cial counselling services in cross-border reproductive care. However, this is a largely neglected topic in recent discussions of both
CBRC itself and of infertility counselling practice. This paper extends the previous work undertaken by two of the authors to begin to
map out practice issues within an ethical framework for counsellors when working with clients, donors, surrogates, individuals con-
ceived following infertility treatment and existing children in clients’, donor’s and surrogates’ families where cross-border repro-
ductive treatment is considered or undertaken. RBMOnline
ª 2011, Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.
KEYWORDS: assisted-conception offspring, cross-border reproductive treatment, donors, patients, psychosocial counselling, surrogates

Introduction In keeping with the focus of this Symposium issue, this

This paper highlights an important, but so far largely
neglected, component of cross-border reproductive care
(CBRC): the need for competent psychosocial counselling
services.
paper uses the term ‘cross-border reproductive care’. How-
ever our work – and that of others – suggests that the
benevolent image that ‘care’ conveys is not always present
in the experiences of patients seeking fertility services in a
country other than their own, donors, surrogates or the

1472-6483/$ - see front matter ª 2011, Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.rbmo.2011.07.009
CBRC and psychosocial counselling
children born as a result of the procedures undertaken. Our
preference is for the term ‘cross-border reproductive ser-
vices’ which we consider to be less value laden than
‘cross-border reproductive care’.
With the exception of Thorn and Wischmann (2010), who
specifically refer to work with German clients who have
undertaken or are seeking treatment in another country,
no publication has previously articulated specific issues that
need to be considered by infertility counsellors when work-
ing with clients who are contemplating or who have under-
taken reproductive services in another country (or in
another state in federated nations). This paper builds on
and extends these authors’ earlier work to outline the need
for such services and to begin to map out an ethical frame-
work for psychosocial counselling practice in CBRC for pro-
fessionals in both home (i.e. the country of residence
from which CBRC is sought, that may or may not, also be
the country of which the individual is a citizen) and destina-
tion countries.
It is widely accepted that undertaking infertility treat-
ment is often stressful, as it adds to existing pressures on
individuals and couples experiencing involuntary childless-
ness (Cousineau and Domar, 2007). This has generated an
acknowledgement of the value of psychosocial counselling
as an important adjunct to medical and technical services,
an importance that is reflected in mandatory infertility
counselling requirements in some jurisdictions and prescrip-
tions for the qualifications of professionals providing
counselling.
For example, New Zealand and most Australian states
have enacted legislation and regulations concerning infertil-
ity counselling. Although there are some variations between
different jurisdictions, a common factor to all is the remit
of the Fertility Society of Australia (FSA), which accredits
fertility clinics in both countries. Through its Reproductive
Technology Accreditation Committee, FSA requires accred-
ited clinics to ensure access to counselling and recipients of
donated gametes or embryos and their partner – and donors
and their partner (if any) – to meet with an infertility coun-
sellor prior to the commencement of any donation proce-
dure. All counsellors hired by clinics must be members of
the Australian and New Zealand Infertility Counsellors Asso-
ciation (ANZICA) and meet ANZICA’s eligibility require-
ments, i.e. to:
(i) possess a minimum 4 year tertiary academic qualifica-
tion from a recognized institution and:
(a) be registered to practise as a psychologist in a
state of Australia or in New Zealand; or
(b) be a member of (or be eligible for membership
of) the Australian Association of Social Workers
or the New Zealand Association of Social Work-
ers; or
(c) be registered to practise as a psychiatrist in a
state of Australia or in New Zealand; and
(ii) be counselling clients who are concerned about issues
related to infertility; and
(iii) possess at least 2 years full-time or equivalent super-
vised postgraduate counselling experience; and
(iv) demonstrate current knowledge of infertility and
infertility treatments.
643
In the UK, under provisions of the Human Fertilisation
and Embryology Act 1990, all individuals seeking a licensed
fertility treatment – and donors of gametes or embryos
used in such treatments, non-medical fertility services or
research – must be offered a ‘suitable opportunity’ to
receive ‘proper’ counselling (Schedule 3(3)(1)(a)). Guide-
lines issued by the UK’s statutory regulatory body, the
Human Fertilisation and Embryology Authority, specify that
counselling should be provided only by a qualified counsellor
who:
(i) possesses specialist competence in infertility counsel-
ling; and
(ii) holds a recognized counselling, clinical psychology,
counselling psychology or psychotherapy qualification
at least to the level of diploma of higher education;
and
(iii) is an accredited member of, or working towards
accredited membership of, a recognized professional
counselling body that has a complaints/disciplinary
procedure; and
(iv) agrees to abide by an appropriate code of conduct or
ethics (Human Fertilisation and Embryology Authority,
2009, 2.12–2.13).
In other jurisdictions where the concept of infertility
counselling is well developed, similar emphasis is placed
on ensuring high quality standards (Covington and Hammer
Burns, 2006). On the other hand, while guidelines for the
provision of infertility counselling as well as qualification
guidelines for infertility counsellors have been established
in several jurisdictions, most have minimal or no guidance
for infertility counselling (Blyth, 2011). Counselling is
referred to only tangentially (and incompletely) in the Inter-
national Federation of Fertility Societies’ triennial global
compendium of national rules and regulations for assisted
reproductive services. In the most recent report (Jones
et al., 2011), providing information for 105 countries, the
following references only are made to counselling: in Croa-
tia, Ireland and the Netherlands in respect of oocyte dona-
tion; a ‘few’ (unspecified) jurisdictions in regard to embryo
donation; Nepal as regards sperm donation; Belgium in
respect of ‘welfare of the child’ requirements; and general
references to counselling for IVF surrogacy.
As is elaborated upon below, undertaking fertility ser-
vices in another country or jurisdiction almost invariably
adds a further level of practical and emotional complexity
to the pressures already noted (Blyth, 2010; Infertility Net-
work UK, 2008; Thorn and Dill, 2010; Thorn and Wischmann,
2010). Psychosocial counselling, therefore, can play a key
role in raising awareness of the complexity of carrying out
infertility treatment abroad, providing basic knowledge
about infertility treatment in other countries to facilitate
informed consent and exploring psychological and social
implications, especially where an anonymous or identifiable
donor or a surrogate are used, as these also raise ethical and
legal challenges. At the present time, however, there has
been scarcely a reference to counselling in the existing lit-
erature and research. Where any such reference is made, it
is to highly idiosyncratic models of ‘counselling’. For exam-
ple, Pande (this volume) notes the role of the counsellor in
644
the surrogacy programme in Anand, India, who doubles up
as matron of the hostel in which the surrogates reside during
their confinement and who describes her task as one of pro-
viding surveillance of the surrogates, to ‘make sure that the
clients don’t get fooled’. Such a model sits no more easily
with the arrangements for counselling previously described
than the view of counselling promoted by the ESHRE Task
Force on Ethics and Law (discussed in more detail below).
For this reason, the present paper focuses on issues relating
to donor procedures and surrogacy undertaken in associa-
tion with CBRC.
Home and destination countries for CBRC
The reasons for which fertility patients seek CBRC have
been articulated elsewhere (Blyth, 2010; Inhorn and Patri-
zio, 2009; Thorn, 2008) and for reasons of space they will
not be repeated here. However, limited systematic data
are currently available concerning utilization of CBRC,
although some recently published studies and others in pro-
gress have begun to indicate from where patients are trav-
elling, their destinations and the services they are seeking
(Blyth, 2010; Haase, 2009; Hughes and DeJean, 2010; Infer-
tility Network UK, 2008; Inhorn and Patrizio, 2009; Nygren
et al., 2010; Pennings et al., 2009; Shenfield et al., 2010;
Smith et al., 2010; Whittaker, 2009). Fewer studies docu-
ment the experiences of donors or surrogates or outcomes
for children conceived as a result of CBRC (see McKelvey
et al., 2009; Pande, 2009 for rare exceptions). Collectively,
these studies illustrate that:
(i) patients travel from more or less anywhere to pretty
much anywhere else in the world for reproductive ser-
vices – although not all destination countries have
reputations for high-quality service provision, so more
sophisticated analysis of the reasons for patient travel
and their choice of destination and service is
warranted;
(ii) a number of countries are both home and destination
countries;
(iii) patients generally recount a relatively high level of
satisfaction with services they have received, includ-
ing the availability of donors, shorter waiting times,
lower costs, and the ability to receive treatment in
a country where they are familiar with the language
and culture. However, the clinical experience of the
authors (PT, TW), with German patients who have
experienced such services suggests that their ques-
tions regarding recruitment strategies for donors or
their financial compensation are often answered eva-
sively, and counselling, when requested, is seldom
available.
Currently available evidence regarding patients’ use of
CBRC indicates some potential trends (Table 1). Notably
(and hardly surprisingly), geographical proximity between
home and destination countries is strongly evident. How-
ever, the current knowledge base is insufficiently robust
to indicate whether these are anything more (or less) than
artefacts of the study design (e.g. reflecting the specific
services or origin/destination countries studied and/or
E Blyth et al.
highlighting practices developed by dominant service pro-
viders/entrepreneurs). At the same time, current data do
not reflect the cross-border movements of donors, surro-
gates, gametes or embryos.
In addition to the relatively piecemeal and serendipitous
way in which data are being built up, fundamental charac-
teristics of CBRC will continue to impact the ability to sys-
tematically generate knowledge. Recourse to CBRC may
be driven by evasion of restrictive laws in patients’ home
countries or other motives that may be perceived as ethi-
cally dubious, and some services that are obtained may be
either illegal or disapproved of in the countries in which
they are provided. It is unlikely, therefore, that individuals
participating in such practices will readily engage in
research studies and institutional review boards might well
baulk at approving research conducted surreptitiously. Such
constraints have limited the expeditious development of an
inclusive understanding and conceptualization of the CBRC
phenomenon and, until relatively recently, knowledge of
these particular facets of CBRC has been derived largely
from reports provided by investigative journalists – often
posing as fertility patients (e.g. Abrams, 2006; Barnett
and Smith, 2006; Foggo and Newell, 2006; Jeska, 2008;
McBeth, 2008; Schindele, 2009) – and anecdotal accounts
to be found on patient support websites and personal blogs.
However, as the reports by several anthropologists in this
volume show, some academic entrée into the less easily
accessible areas of reproductive services is now being
achieved.
Issues in CBRC provision for patients, donors,
surrogates and offspring
As indicated above, reports of patients’ experiences are
mixed. This must be borne in mind in setting the context
for the following discussion, which, necessarily, focuses
on actual or potential problems that need to be taken into
account in formulating a coherent and comprehensive coun-
selling and mental health strategy for the provision of CBRC.
Many of the issues that have been identified through
research, the media or anecdotal accounts relate specifi-
cally to the lack of regulation, oversight and safeguards
for patients, donors, surrogates and offspring, and lower
employment and donor/surrogate recruitment costs, which
enable services to be provided competitively and are char-
acteristic of several popular destination countries. Indeed,
these (together with a good tourist and travel infrastructure
and use of English as a common language) are often pre-
cisely what facilitate the availability of services.
Issues relating to patients’ experiences and patient
care
CBRC involves additional practicalities associated with
travel, in particular synchronizing timing of travel with
treatment cycles, especially where treatment plans may
change at short notice, for instance because of complica-
tions with visa applications (Blyth, 2010; Chung, 2006).
Patients sometimes encounter higher than expected costs
of services (Chung, 2006; Ferraretti et al., 2010; Infertility
CBRC and psychosocial counselling 645

Table 1 Cross-border reproductive care: home and destination countries and services.

Home Destination country Service(s)

country

Australia Thailand Sex selection

Canada USA Donor oocytes
Denmark Baltic States, Czech Republic, Greece, Russia, Spain Donor oocytes
Egypt Spain and other European countries Donor oocytes
France Belgium Donor spermatozoa
Germany Czech Republic, Spain Donor oocytes
Hungary USA Surrogacy
India Europe, USA, United Arab Emirates Standard IVF
Thailand, USA Sex selection
Israel Romania Donor oocytes
Italy Austria, Belgium, Czech Republic, Greece, Slovenia, Spain, Donor oocytes, donor spermatozoa, embryo
Switzerland, UK cryopreservation, PGD
Japan USA All services
Macedonia Belgium ICSI-TESE
Czech Republic Donor oocytes
Middle East Jordan Sex selection
Netherlands Belgium Donor spermatozoa
Norway Denmark Donor spermatozoa
Portugal Russia, Spain Donor oocytes
Sweden Denmark Donor spermatozoa
Baltic States, Finland, Russia Donor oocytes
Switzerland Austria Standard IVF
Eastern Europe, Spain Donor oocytes
UK Czech Republic, Spain Donor oocytes
USA India Surrogacy

Sources: Bergman (2010), Blyth (2010), Hughes and DeJean (2010), Infertility Network UK (2008), Inhorn and Shrivastav (2010), Kilani et al.
(2010), Nahman (2010), Shenfield et al. (2010), Smerdon (2008), Whittaker (2011). ICSI = intracytoplasmic sperm injection; PGD = preim-
plantation genetic diagnosis; TESE = testicular sperm extraction.

Network UK, 2008; Shenfield et al., 2010), although some
patients comment that services in their destination country
are cheaper than in their home country and this is one of the
key reasons why CBRC is contemplated in the first place.
Some clinics in destination countries apply inferior safety
and quality levels (Ferraretti et al., 2010; Hughes and
DeJean, 2010; Pennings, 2006a,b). Some clinics in destina-
tion countries show insufficient respect for patients’ rights
(Pennings, 2006a). Some clinics in destination countries
have either no counselling facilities or counselling services
that are inadequate (Blyth, 2010; Ferraretti et al., 2010;
Infertility Network UK, 2008; Pennings, 2006a; Thorn and
Dill, 2010). Success rates in some clinics in destination coun-
tries are lower than expected (Pennings, 2006b). Some des-
tination countries do not offer adequate access to
malpractice law (Ferraretti et al., 2010; Pennings, 2006b).
Patients have also been reported to experience difficulties
in accessing, absorbing and evaluating information about
services, in particular the volume of unfiltered information
on the internet (Blyth, 2010; Shenfield et al., 2010). Assis-
tance in making arrangements to receive services in desti-
nation countries is infrequently provided (Blyth, 2010;
Infertility Network UK, 2008; Shenfield et al., 2010).
Patients sometimes encounter language problems, in partic-
ular when either they or professionals do not share a com-
mon language sufficiently proficiently (Infertility Network
UK, 2008; Pennings et al., 2009).
An overwhelming impression from existing studies of
patients’ experiences of CBRC is that most make their own
arrangements with minimal support and liaison from clinics
in their home country (Blyth, 2010; Infertility Network UK,
2008), although the clinic-based study by Shenfield et al.
(2010) shows that home-country clinic involvement in
arrangements for CBRC varies between countries. What is
becoming apparent is that, in some countries at least, spe-
cific partnerships are being established between clinics in
different countries to facilitate the provision of CBRC. In a
survey conducted by the Human Fertilisation and Embryol-
ogy Authority (2010), of 30 UK clinics responding, 11
reported that they provided no support to patients consider-
ing treatment in another country, four provided information
about clinics in destination countries, two referred patients
to clinics in destination countries with which the clinic had
no association, six referred patients to clinics in destination
countries with which the clinic had an association and seven
clinics participated in a ‘joint care arrangement’ with a
clinic in a destination country.
Issues relating to donors’ and surrogates’
experiences and their care
Very little information regarding the experiences of donors
and surrogates engaged in CBRC is available as the result of
646
academic scholarship. Pande’s ethnographic studies of
Indian surrogates (2009 and this volume) provide a rare
example. Common characteristics shared by young women
who act as oocyte donors or surrogates for CBRC illustrate
their exposure to risk of exploitation in the absence of the
safeguards noted above: they are primarily poor, living in
economically disadvantaged countries and are either stu-
dents or poorly educated and in low-paying jobs if they
are in employment at all. Inter-related, specific issues that
stem from this are: (i) the levels of fees paid; (ii) the impli-
cations of these for informed consent given by donors and
surrogates; and (iii) the provision of care following donation
or – in the case of a surrogacy arrangement – delivery of a
child. On the one hand, fees offered to surrogates and
donors are low compared with fees payable in the recipi-
ents’ home country (in those countries where payment of
fees is permitted and not prohibited). On the other hand,
relative to income levels in the destination country, fees
offered may be at such a high level that they constitute
undue financial inducement and encourage prospective sur-
rogates or donors to discount the physical, emotional and
social risks, thus compromising their consent. Abrams
(2006) recounts the experience of Alina Ionescu, an
18-year-old Romanian mattress factory worker earning the
equivalent of £55 a month, who was saving to get married
and who agreed to ‘donate’ her oocytes for a foreign
recipient in return for the equivalent of 3 months’ wages.
However, the procedure left her infertile and the clinic
which had recruited her showed no interest in offering her
post-donation medical care. Her case was subsequently
taken up by a Romanian civil rights lawyer, prompting the
European Parliament to adopt a resolution to ban trade of
human cells and embryos (European Parliament, 2005).
Indian surrogates are paid US$3000–5000, the equivalent
to about 10 years’ family income for rural Indians (Pande,
2009). To put this in perspective, gross national income
per head of population in India was US$1180 in 2009, while
that for the USA was US$47,240 (World Bank, 2009). How-
ever, claims that Indian surrogates are exploited are con-
tested and Haworth (2011, p. 6) cites one Indian surrogate
as stating: ‘This [surrogacy] is not exploitation. Crushing
glass for 15 hours a day is exploitation’.
Issues relating to outcomes for, and experiences of,
offspring
Much as for donors and surrogates, there is hardly any
empirical evidence that relates to outcomes for – much less
the experiences of – offspring conceived as result of CBRC.
McKelvey et al. (2009), reporting a study that highlights the
cost to the UK’s National Health Service of CBRC that results
from transfer of a greater number of embryos than is per-
mitted in the UK, nevertheless draw attention to the
adverse health implications of higher-order multiple preg-
nancy and higher-order multiple birth both for mothers
and their infants. Problems regarding the child’s legal status
– including rights to nationality – have arisen in several
high-profile cases involving foreigners using Indian surro-
gates. In 2008, Manji Yamada was born following a surrogacy
arrangement involving a Japanese couple, who used the
husband’s spermtozoa and a donor oocyte to create an
E Blyth et al.
embryo that was carried to term by an Indian surrogate.
Before Manji’s birth, the Japanese couple separated and
divorced. The sole adult who wanted Manji was her father.
However, since Indian law neither recognized him as Manji’s
father, nor – as a single man following his divorce – permit-
ted him to adopt her, he was not allowed to take her back to
Japan. The Indian authorities also refused to issue Manji a
birth certificate because of her ambiguous parentage under
Indian law. This impasse was eventually resolved when Man-
ji’s paternal grandmother was permitted to take her to
Japan (The Hindu, 2008).
Similar cases were reported in 2010 and 2011. In one
instance, German parents had used the services of an Indian
surrogate using their own gametes. In the second case, a sin-
gle Norwegian woman had used oocytes from an Indian donor
and semen from a Scandinavian donor to create embryos that
were implanted into an Indian surrogate, who subsequently
bore twins. The incompatibility of German and Indian as well
as Norwegian and Indian legislation made it difficult to deter-
mine the children’s nationality in both cases and, thus, they
were refused to enter the home country of their parents.
After 2 years, the German children were granted permission
by the German embassy to travel home with their parents,
although they were not entitled to German citizenship (Spie-
wak, 2010). The Norwegian mother and her twins remain in
India (Roy, 2010; S. Roy, personal communication October
2010). In a third case, also involving a German couple using
an Indian surrogate to conceive a child with their own
gametes, a German court also ruled that the child was not
entitled to German citizenship (The Local, 2011).
Patient support groups have also reported anecdotally of
concerns of parents who have undergone a successful
oocyte donor procedure abroad, but where the child has
skin colouring suggesting that her or his donor was not of
the ethnic characteristics indicated or promised by the
clinic (Merricks, 2007).
Yet another group of offspring conceived as a result of
CBRC whose welfare might be considered compromised are
those whose parents reside in a jurisdiction that requires
gamete or embryo donors to agree to the disclosure of their
identity to their offspring, but who have undergone donor
conception in a jurisdiction where donor anonymity is pro-
tected and no provisions exist for offspring to learn the iden-
tity of their donor (or donors in the case of embryo donation).
Of course it is acknowledged that some philosophers would
argue that the child conceived using the gametes of an anon-
ymous donor is a different child to the one conceived using
the gametes of an identifiable donor, so such a comparison
is invalid (Bennett and Harris, 2001; Parfit, 1987). Neverthe-
less, the point here is that such practices result in the birth of
children whose welfare, as defined by some individuals, pro-
fessional groups and the legislation in some jurisdictions, is
necessarily compromised in this way.
A final issue to be highlighted is the cultural/ethnic her-
itage of children conceived following oocyte donation
undertaken through CBRC. In inter-country adoption, racial,
ethnic and cultural awareness have been found to be essen-
tial ingredients for individuals’ successful identity formation
(Triseliotis, 2000). There is little evidence either from for-
mal research studies or from clinical practice that this issue
is considered at all by those providing services for an inter-
national clientele, although it is highly likely that similar
CBRC and psychosocial counselling
issues may well apply to offspring conceived following repro-
ductive procedures whose genetic and social parents may be
of different races and or cultures and consideration of these
is essential to ensure individual and family wellbeing.
Counselling and CBRC
Little specific practice guidance exists for counsellors
regarding CBRC. Apart from recently published guidelines
from the German Society for Fertility Counselling (BKiD)
(Thorn and Wischmann, 2010), the only existing position
statement explicitly referring to counselling and CBRC is
that published by the ESHRE Task Force on Ethics and Law
(Pennings et al., 2008). As noted above, its reference is
brief and one that is unlikely to be considered adequate
by counsellors themselves: ‘When a physician refers
patients to centres abroad, he or she should also provide
counselling in order to make sure that they know what will
happen, what kind of questions they should ask, etc.’ (Pen-
nings et al., 2008: p. 2183).
However, the Task Force also mentions – although not in
any detail – the need for clinics to ensure the provision of
psychological counselling. Since, apart from this acknowl-
edgement of the involvement of other professionals, the
sole professional to which the ESHRE report refers is the
physician, it is not clear whether the Task Force intends
its endorsement of civil disobedience and evasion of the
law (as expounded further in its report) to extend to other
professionals working in reproductive services.
While one would laud any stand taken against unjust
laws, to do so only on the basis ‘of guarantee[ing] safe
and effective treatments’ to patients (Pennings et al., 2008:
p. 2184) and ‘tak[ing] into consideration’ the ‘safety, effi-
cacy and welfare of the patient and the future child’ (Pen-
nings et al., 2008: p. 2182) – whilst paying scant regard to
the potential exploitation of donors and surrogates – is
insufficiently grounded in notions of social justice and
human rights to recommend itself to a professional who is
committed to responsible and ethical practice.
ESHRE has built on this, through publication by its Task
Force on CBRC, comprising four fertility clinicians and one eth-
icist, of a Good practice guide for cross-border reproductive
care for centres and practitioners that provides guidance for
centres and physicians providing fertility treatment to foreign
patients (Shenfield et al., 2011). However, its specific refer-
ence to psychosocial counselling is again modest, identifying
the need for foreign patients to receive ‘the same information,
counselling and psychological support’ as is provided for
domestic patients and in a language that they understand. It
also states that foreign donors should receive similar care
to that provided for patients and domestic donors.
At the present time, national infertility counselling orga-
nizations are known to exist in Argentina, Australia and New
Zealand (a single association for both countries), Belgium,
Brazil, Canada, Germany, Japan, the Netherlands, the
Republic of Ireland, Spain, Switzerland, the UK and the USA.
These are at varying stages of development and of consider-
ably different sizes as regards membership although, given
the nature of the professional specialism, none are numer-
ically large organizations (Blyth, 2011). Given that there is
currently very limited specific guidance and comment on
647
CBRC for counsellors, this paper draws underlying state-
ments provided by a number of counselling organizations
and related professional bodies to help inform the develop-
ment of an ethical framework for counselling practice in
CBRC, which include (but are not restricted to) the follow-
ing organizations.
International Infertility Counseling Organization
(IICO)
Regarding CBRC, the IICO bylaws promote a comprehensive
and ethical approach to the care of people affected by fer-
tility issues, to define quality standards of communicative
and counselling interventions within the context of infertil-
ity care and to establish global professional standards and
practice guidelines for the provision of psychosocial care
in the area of infertility care (IICO, 2011: Article II).
International Federation of Social Workers/
International Association of Schools of Social Work
(IFSW/IASSW)
According to the IFSW/IASSW, ‘The social work profession
promotes social change, problem solving in human relation-
ships and the empowerment and liberation of people to
enhance well-being. Utilising theories of human behaviour
and social systems, social work intervenes at the points
where people interact with their environments. Principles
of human rights and social justice are fundamental to social
work’ (International Federation of Social Workers, 2004).
International Federation of Social Workers (IFSW)
In 2008, the International Federation of Social Workers
adopted a policy on CBRC that extended the application of
its ethical standards and of ethical codes of national profes-
sional associations ‘to reproductive health care, and to
CBRC in particular.’ The policy emphasized: (i) commitment
to protecting human rights; (ii) non-commercialization of
surrogacy and gamete and embryo procurement; (iii)
non-anonymous donation; (iv) protection from exploitation;
(iv) self-determination; (v) safety; (vi) ethical practice; and
(vii) equality of access (International Federation of Social
Workers, 2008).
American Psychological Association (APA)
The APA’s Ethical Principles of Psychologists and Code of
Conduct (American Psychological Association, 2010) pro-
mote principles ‘to guide and inspire psychologists toward
the very highest ethical ideals of the profession’, emphasiz-
ing: (i) beneficence and nonmaleficence; (ii) fidelity and
responsibility; (iii) integrity; (iv) justice; and (v) respect
for people’s rights and dignity.
British Association for Counselling and
Psychotherapy (BACP)
BACP emphasizes the practitioners’ values, principles and
personal moral characteristics. Specifically it also endorses
648
practitioners’ commitment to: (i) respecting human rights
and dignity; (ii) respecting clients’ autonomy; (iii) protect-
ing client safety; (iv) beneficence and nonmaleficence; (v)
fidelity and responsibility; (vi) integrity; and (vii) justice.
BACP also alerts practitioners to their ‘personal and
professional responsibility to challenge, where appropri-
ate, the incompetence or malpractice of others’ (BACP,
2010).
Drawing on these general principles, the following
issues regarding counselling in respect of CBRC have been
identified. These are based on guidelines issued for Ger-
man infertility counsellors (Thorn and Wischmann, 2010)
and are expanded to cover issues pertaining to post-treat-
ment counselling for patients as well as counselling for
donors (Thorn and Wischmann, 2009), offspring, surro-
gates and any existing children of patients, donors and
surrogates. Although counsellors have recourse to existing
knowledge and expertise, for example, in the area of
third-party reproduction, it has to be noted that counsel-
ling in relation to CBRC is an emerging area for which
there is currently limited knowledge or expertise (e.g.
children conceived using donor gametes from a different
cultural background than parents, sex selection, major
socioeconomic as well as cultural and ethnic difference
between recipients and donors/surrogates, counselling
for existing children of patients, donors and surrogates,
etc.) and for which counselling concepts remain to be
developed.
As part of such development with CBRC, different expec-
tations and obligations would apply to counsellors who are:
(i) involved in advance of treatment with patients mak-
ing their own arrangements for treatment in another
country where there is no formal assistance or
involvement from a clinic or counsellor in their home
country;
(ii) providing services for a clinic operating a ‘joint care
arrangement’ with a clinic in another country. There
will be particular implications for ethical practice if
the service sought in the destination country is illegal
in the home country. At the very least, the counsellor
will need to discuss with the patient their views and
feelings about law evasion and the potential implica-
tions of proceeding with their intended course of
action, especially including the possible impact on
any child(ren), including existing children. While the
ability of counsellors to exclude themselves from
any activities on the grounds of conscientious objec-
tion is noted, there may well be instances where the
counsellor also has a professional responsibility to
raise a clinic’s engagement in practices that are ille-
gal or that they consider to be compromised ethically
with their colleagues. This emphasizes the impor-
tance of counsellors having at least some measure
of independence from the clinic and the potential dif-
ficulties where such independence is absent;
(iii) providing counselling in the home country for
patients/clients who have received treatment
abroad;
(iv) providing counselling in the destination country for
clients who have travelled to that country for
treatment;
E Blyth et al.
(v) providing counselling to donors, surrogates, offspring
or existing children in patients’, donor’s or surro-
gates’ families.
Before undertaking treatment in another country,
patients need to be given the opportunity to:
(i) explore their motivation to seek services in another
country and their expectations of these;
(ii) be aware of potential language barriers and also cul-
tural differences, especially in providing informed
consent to treatment and when signing contracts,
and of the need to involve a translator;
(iii) be aware of the indications and contraindications for
specific treatments, and thus the potential need for
medical screening prior to treatment as well as of
realistic success rates;
(iv) explore the (legal) possibility of undertaking pretreat-
ment in their home country;
(v) be aware of the need for full medical documentation
of prior assisted reproductive procedures and of all
treatment cycles carried out in the destination coun-
try in case of medical complications;
(vi) be aware of financial reimbursement under the health
insurance system of their home country;
(vii) explore financial, emotional, psychological and other
(e.g. organizational) resources needed to carry out
(further) treatment in another country, especially in
those cases where they have undergone futile treat-
ment in their home country. This also includes the
option to decide against further treatment;
(viii) be informed comprehensively about the risks for
mothers and children associated with multiple-
embryo transfer.
Further, when undergoing infertility treatment using
their own gametes, patients need to:
(i) have basic understanding of treatment and costs so
that both success rates and costs indicated on the
internet can be judged realistically;
(ii) be aware of the current state of preimplantation
genetic diagnosis (PGD) to avoid unrealistic
expectations.
When using third party reproduction, patients need to:
(i) explore their attitudes towards any information they
may have regarding recruitment methods of, financial
compensation and medical service for oocyte and
sperm donors and surrogates;
(ii) have sufficient understanding of costs and compensa-
tion for donors and surrogates so that they can judge
whether these are reasonable and ethical;
(iii) be knowledgeable about the legal implications of
reproductive services in the destination country,
especially legal parenthood, any rights or obligations
exercised by the donor(s)/surrogate and the nation-
ality of the child following surrogacy, and be aware
of the need always to seek independent and compe-
tent legal advice in advance of undergoing
treatment;
CBRC and psychosocial counselling
(iv) be aware of emerging thinking among counsellors (and
others) and legislation concerning the right of individ-
uals conceived following a third-party reproductive
procedure to have access to information about her
or his biological origins – including knowledge of the
identity of the donor(s) or surrogate and other genetic
relatives – and any tensions with such rights gener-
ated by practices or legal systems in different juris-
dictions. Disclosure/concealment plans should also
take into account the possibility that any child may
be evidently of a different race or ethnicity to either
of her or his parents and the interests of any existing
children;
(v) be aware of the merits of early disclosure to the child
concerning the nature of her or his conception;
(vi) reflect on and understand the difference between bio-
logical and social parenthood, explore disclosure and
be educated how to talk to children about their con-
ception, including in those cases where the
donor(s)/surrogate remain(s) anonymous and where
the donor(s)/surrogate may be of a different race
than the parent(s);
(vii) be informed about the nature of any information pro-
vided about or by the donor(s)/surrogate and whether
offspring have access to this information.
Where patients are planning to engage in a reproductive
procedure that is considered ethically dubious or is illegal in
their home country, they need to consider the implications
of this for themselves as future parents and for their
intended children and for any existing children in their fam-
ily. This also includes the need to explore how they may
manage adverse or ambivalent feelings, such as shame
and regret, and how they will manage disclosure or conceal-
ment of their treatment.
Finally, patients should be aware that counselling can
provide support not only during, but also following,
treatment.
Counselling for donors and surrogates should:
(i) include comprehensive medical information, includ-
ing potential physical risks caused by hormonal stimu-
lation, oocyte retrieval, oocyte transfer as well as
pregnancy and birth;
(ii) include information on the limit on the number of off-
spring and financial compensation;
(iii) include relevant legal information, especially as
regards legal parentage in all cases of gamete dona-
tion and surrogacy;
(iv) explore their motivation and attitude towards dona-
tion/surrogacy as well as expectations of information
about potential offspring and contact; in the case of
egg-sharing, donors should also explore their attitudes
towards their own treatment being unsuccessful but
the recipient’s treatment being successful;
(v) explore long-term implications, such as the knowl-
edge of a child born with their assistance, manage-
ment strategies of their donation/surrogacy within
their social network, especially towards their current
or future partner and children;
(vi) be free of charge;
649
(vii) be available for patients and donors/surrogates at any
time before, during and after the treatment is fin-
ished and a child is born – or the treatment ended
without a child being born;
(viii) be available in the native language of the patient and
donor(s)/surrogate;
(ix) be easily accessible both in the home and the destina-
tion country;
(x) provide relevant and necessary information regarding
psychological, medical and legal issues and help
patients as well as donors/surrogates to reflect on
and explore all long- and short-term implications of
CBRC;
(xi) be carried out with respect and empathy for the inten-
tions of patients as well as donors/surrogates. This
does not imply that psychosocial professionals should
not ask critical questions, but the counselling process
should not impose values or the personal views of the
counsellor onto clients. If a counsellor cannot accept
what the client intends to do, (s)he may withdraw
from offering counselling but has an obligation to
explain to their client their reasons for withdrawing
from counselling, and endeavour to direct the client
to another colleague who is willing to help.
Counsellors should reflect on their own limits and be
transparent in what they offer to clients – for their own
sake as well as the client’s
Conclusion
CBRC has much potential. It can, and does, help patients to
fulfil their family-building aspirations that may have
otherwise remained unrealized. It also has the potential to
expose to exploitation and impair the welfare of patients,
gamete donors, surrogates and the individuals born as a
result of the treatment. This paper has highlighted some
of the problematic areas, draws attention to the role that
psychosocial counselling can – and must – play, and outline
issues to be raised by counsellors involved in CBRC. It is our
firm conviction that principles such as safety and quality,
rightly emphasized by others as well, must be accompanied
by attention to fundamental values such as fairness, auton-
omy and benevolence – for patients, third parties who
undergo psychologically stressful and physically invasive
procedures to facilitate patients’ family-building aspira-
tions and the individuals thus created. While further
research is necessary to enhance knowledge and improve
practice, counselling can make an essential contribution
to ensure reflective practice in CBRC.
References
Abrams, F., 2006. The misery behind the baby trade. Daily Mail 17
July. Available from: <http://www.dailymail.co.uk/pages/
live/femail/article.html?in_article_id = 396220 and in_page_id
= 1879 and in_a_source> (accessed 08.03.11).
American Psychological Association, 2010. Ethical Principles
of Psychologists and Code of Conduct 2010 Amendments.
Available from: <http://www.apa.org/ethics/code/index.
aspx> (accessed 08.03.11).
650
Barnett, A., Smith, H., 2006. Cruel cost of the human egg
trade. The Observer. 30 April. Available from: <http://www.
guardian.co.uk/medicine/story/0,1764687,00.htm> (accessed
08.03.11).
Bennett, R., Harris, J., 2001. The welfare of the child. J. Fertil.
Couns 8 (3), 24–29.
Bergman, S., 2010. Reproductive borders, agency, and imagination:
the experience of Germans seeking egg donation abroad.
Cambridge/RBMOnline.
Blyth, E., 2010. Fertility patients’ experiences of cross-border
reproductive care. Fertil. Steril. 94 (1), e11–15.
Blyth, E., 2011. International guidelines for infertility counselling –
is there an emerging trend? European Society of Human
Reproduction and Embryology (ESHRE). In: 27th Annual Meeting,
Stockholm 3–6 July.
British Association for Counselling and Psychotherapy, 2010.
Ethics for Counselling and Psychotherapy. Available from:
<http://www.bacp.co.uk/ethical_framework/> (accessed
08.03.11).
Chung, L.H., 2006. Free trade in human reproductive cells: a
solution to procreative tourism and the unrelated internet.
Minnesota J. Int. Law Online 15, 263–296.
Cousineau, T.M., Domar, A.D., 2007. Psychological impact of
infertility. Best Practice Res. Clin. Obstet. Gynaecol. 21 (2),
293–308.
Covington, S., Hammer Burns, L., 2006. Infertility Counseling. A
comprehensive handbook for clinicians. Cambridge University
Press, New York, 559.
European Parliament. 2005. Planned egg cell trade. 10 March 2005,
Available from: <http://www.europarl.europa.eu/sides/get-
Doc.do?pubRef = -//EP//NONSGML+TA+P6-TA-2005-0074+0+DOC+
PDF+V0//EN> (accessed 08.03.11).
Ferraretti, A.P., Pennings, G., Gianaroli, L., Natali, F., Maggli,
M.C., 2010. Cross border reproductive care: a phenomenon
focusing the controversial aspects of reproductive technologies.
Reprod. BioMed. Online 20, 261–266.
Foggo, D., Newell, C., 2006. Doctors offer illegal baby sexing:
Couples pay £12,000 to get child of choice, Sunday Times 5
November, 7pp.
Haase, J. 2009. Counseling Perspectives on Cross-Border Treat-
ment. Presentation at American society for Reproductive Med-
icine Annual Meeting Atlanta: GA. 17 October.
Haworth, A., n.d. Surrogate mothers: womb for rent, Marie Claire,
pp. 1–7. Available from: <http://www.marieclaire.com/
world/articles/surrogate-mothers-india> (accessed 08.03.11).
Hughes, E., DeJean, D., 2010. Cross-border fertility services in
North America: a survey of Canadian and American providers.
Fertil. Steril. 94 (1), e16–e19.
Human Fertilisation and Embryology Authority, 2009. Code of
Practice. eighth ed. Available from: <http://www.hfea.gov.uk/
docs/8th_Code_of_Practice(2).pdf> (accessed 08.03.11).
Human Fertilisation and Embryology Authority, 2010. Annex 1:
Clinic survey presented at HFEA meeting 7 July 2010. Available
from: <http://www.hfea.gov.uk/docs/2010–07–07_Author-
ity_papers_-_complete.pdf> (accessed 08.03.11).
Infertility Network UK, 2008. The Infertility Network UK fertility
tourism survey results. Unpublished survey results.
Inhorn, M.C., Patrizio, P., 2009. Rethinking reproductive ‘tourism’
as reproductive ‘exile’. Fertil. Steril. 92, 904–906.
Inhorn, M.C., Shrivastav, P., 2010. Globalization and reproductive
tourism in the United Arab Emirates. Asia-Pacific J. Pub. Health
22 (Suppl. 3), 68S–74S.
International Federation of Social Workers, 2008. International
policy on cross border reproductive services. International
Federation of Social Workers: Geneva. Available from:
<http://www.ifsw.org/p38001484.html> (accessed 08.03.11).
International Federation of Social Workers and International Asso-
ciation of Schools of Social Work, 2004. Ethics in social work:
E Blyth et al.
statement of principles. Bern: International Federation of Social
Workers and International Association of Schools of Social Work.
Available from: <http://www.ifsw.org/en/p38000324.html>
[accessed 08.03.11].
International Infertility Counseling Organization (IICO). Available
from: <http://www.iico-infertilitycounseling.org/. = 142>
[accessed 08.03.11].
Jeska, A., 2008. Mein Bauch, dein Kind. Brigitte, Dezember, S.
120–127.
Jones, H. W., Cooke, I., Kempers, R., Brinsden, P., and Saunders,
D., 2011. International Federation of Fertility Societies Surveil-
lance 2010. Available from: <http://www.iffsreproduc-
tion.org/documents/IFFS_Surveillance_2010.pdf> (accessed
08.03.11).
Kilani, Z., Shaban, M., Haj Hassan, L., 2010. Gender selection. In:
Hédon, B., Mettler, L., Tinneberg, H.-R. (Eds.), Proceedings of
the IFFS 20th World Congress on Fertility and Sterility. Lukon
Verlagsgesellschaft mbH, Munich (Germany), pp. 110–114.
McBeth C., 2008. Parents queue to select baby gender. BBC
NewsOnline 29 October. Available from: <http://news. bbc.
co. uk/go/em/fr/-/1/hi/uk/7696698. stm> (accessed 0.03.11).
McKelvey, A., David, A., Shenfield, F., Jauniaux, E., 2009. The
impact of cross-border reproductive care or ‘fertility tourism’
on NHS maternity services. BJOG 116, 1520–1523.
Merricks, W., 2007. Fertility tourism: too many choices, too little
support? Address to annual conference of the British Infertility
Counselling Association.
Nahman, M., 2010. Transnational reproduction: the case of Israel
and Romania (Cambridge/RBMOnline).
Nygren, K., Adamson, D., Zegers-Hochschild, F., De Mouzon, J.,
2010. Cross-border fertility care – International Committee
Monitoring Assisted Reproductive Technologies global survey:
2006 data and estimates. Fertil. Steril. 94, e4–e10.
Pande, A., 2009. It may be her eggs, but it’s my blood: surrogates
and everyday forms of kinship in India. Qual. Sociol. 32 (4),
379–397.
Parfit, D., 1987. Reasons and Persons. Clarendon Press, Oxford.
Pennings, G., 2006a. International parenthood via procreative
tourism. In: Shenfield, F., Sureau, C. (Eds.), Contemporary
Ethical Dilemmas in Assisted Reproduction. Informa Health Care,
Abingdon, pp. 43–56.
Pennings, G., 2006b. Reproductive tourism: a solution for the conflict
between ethics and politics. In: Kaiafa-Gbandi, M., Kounouge-
ri-Manoledaki, E., Symeonidou-Kastanidou, E. (Eds.) Biotechnology
Issues: Cloning. Sakkoulas, Thessaloniki, pp. 107–113.
Pennings, G., Autin, C., Decleer, W., Delbaere, A., Delbeke, L.,
Delvigne, A., De Neubourg, D., Devroey, P., Dhont, M., D’Hoo-
ghe, T., Gordts, S., Lejeune, B., Nijs, M., Pauwels, P., Perrad,
B., Pirard, C., Vandekerckhove, F., 2009. Cross-border repro-
ductive care in Belgium. Hum. Reprod. 24, 3108–3118.
Pennings, G., de Wert, G., Shenfield, F., Cohen, J., Tarlatzis, B.,
Devoey, P., 2008. ESHRE Task Force on Ethics and Law 15:
Cross-border reproductive care. Hum. Reprod. 23, 2182–2184.
Roy, S., 2010. Norwegian stuck in limbo with twins not genetically
her own. Times of India 21 July. Available from: <http://time-
sofindia.indiatimes.com/city/mumbai/Norwegian-stuck-in-lim-
bowith-twins-not-genetically-her-own/articleshow/6193640.
cms> (Accessed 08.03.11).
Schindele, E., 2009. Der Eierdeal – das globale Geschäft mit
menschlichen Eizellen www.dradion.de/dlf/sendungen/
wib/545060/ [accessed 12.02.09].
Shenfield, F., de Mouzon, J., Pennings, G., Ferraretti, A.P., Nyboe
Andersen, A., de Wert, G., Goossens, V.The ESHRE Taskforce on
Cross Border Reproductive Care, 2010. Cross border reproduc-
tive care in six European countries. Hum. Reprod. 25,
1361–1368.
Shenfield, F., Pennings, G., de Mouzon, J., Ferraretti, A.P.,
Goossens, V. on behalf of the ESHRE Taskforce on Cross Border
CBRC and psychosocial counselling
Reproductive Care, 2011. ESHRE’s good practice guide for cross
border reproductive care for centers and practitioners. Hum.
Reprod. Advance Access published April 19, 2011
doi:10.1093/humrep/der090.
Smerdon, U.R., 2008. Crossing bodies, crossing borders: interna-
tional surrogacy between the United States and India. Cumber-
land Law Rev. 39 (1), 15–85.
Smith, E., Behrmann, J., Martin, C., Williams-Jones, B., 2010.
Reproductive tourism in Argentina: clinic accreditation and its
implications for consumers, health professionals and policy
makers. Dev. World Bioethics 10, 59–69.
Spiewak, M., 2010. Verbotene Kinder. Die Zeit, 17, 2 April 2010.
The Hindu, 2008. Japanese baby gets birth certificate, The Hindu 11
August. Available from: <http://www.thehindu.com/2008/
08/11/stories/2008081160180300.htm> (accessed 08.03.11).
The Local, 2011. Surrogate children have no right to German
passport, court rules. The Local, 28 April. Available from:
<http://www.thelocal.de/society/20110428–34681.html>
(accessed 26.05.11).
Thorn, P., Wischmann, T., 2009. German guidelines for psychoso-
cial counselling in the area of gamete donation. Hum. Fertil. 12,
73–80.
Thorn, P., 2008. Reproduktives Reisen–eine Expertise für den pro
familia Bundesverband. Pro Familia Bundesverband, Frankfurt.
651
Thorn, P., Dill, S., 2010. The role of patients’ organisations in
cross-border reproductive care. Fertil. Steril. 94 (1), e23–24.
Thorn, P., Wischmann, T., 2010. Leitlinien des BKiD Psychosoziale
Beratung für Frauen und Männer, die eine Kinderwunschbehand-
lung im Ausland beabsichtigen. J. Reprod. Endokrinol. 7,
394–402.
Triseliotis, J., 2000. Identity-formation and the adopted person
revisited. In: Treacher, A., Katz, I. (Eds.), The Dynamics of
Adoption Social and personal Experiences. London, Jessica
Kingsley Publishes, pp. 81–98.
Whittaker, A., 2009. Global technologies and transnational repro-
duction in Thailand. Asian Stud. Rev. 33, 319–332.
Whittaker, A., 2011. The new sex trade: PGD and reproductive
travel. Cambridge/RBMOnline.
World Bank, 2009. GNI per capita. Available from:
<http://www.data.worldbank.org/indicator/NY.GNP.PCAP.CD>
(accessed 08.03.11).
Declaration: The author reports no financial or commercial
conflicts of interest.
Received 14 April 2011; refereed 27 May 2011; accepted 4 July
2011.