Cross-border infertility care: socio

cultural and ethical aspects

Françoise Shenfield,
RMU, UCLH, London, UK,
past Coordinator GSCAIF SIG,
Webinar May 2022
Disclosures

I have no conflict of interest to declare

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Learning Objectives
• Be able to analyse the ethical and socio cultural pros
and cons of CBRC for the patients, future ofspring
and collaborators (?freedom v burden/dangers)

• Be aware of evidence and flows of patients (original

definition) in Europe, USA , and between North/South
where specific concerns exist

• Appraise the recent evolution and socio cultural

consequences of CBRC: from travel of patients to travel
of collaborators and transport of cells : extension/
(semantic) distortion/progress?

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CBRC, a growing phenomenon for >15y

• Definition: movements by candidate health care

recipients from one country or jurisdiction where
treatment is unavailable for them to another country or
jurisdiction where it can be obtained
• What is in a word? : “Tourism” , “exile”; better
‘transnational reproduction’, ‘reproductive travel’ ; CBRC:
more neutral and patient centred (“forced necessity”)
• Avoid the derogatory terms ‘reproductive’ or
‘procreative tourism’ because of their negative
connotations Ethics and law TF 2008

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Why CBRC: legal restrictions, availability

• type of treatment forbidden by law (i.e. oocyte

donation, surrogacy)
• categories of patients not eligible for ART(i.e. lesbian
couples, single, “aged”)
• waiting lists are too long in home country (OD)
• out-of-pocket costs for the patients are too high (i.e. no
state funding or insurance)
• technique not available because of lack of expertise or
equipment (PGD), or not considered safe enough
(ICSI/test sperm; egg freezing)
• personal wishes (i.e. privacy considerations)

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Evidence/extent: who, why , where?

• Europe: full extent of CBRC not precisely known as

many national treatment registries do not record the
patient's country of origin: estimation around 4 to 5%
• USA: 1.2% in 2006 to 2.8% in 2013 (estimated at 4% by
ASRM ethics committee 2016, Fert and Ster, 106, 1627-
1633)
• ESHRE CBRC TF study 2010, mean age= 37.3 years (21– 51 y)
> home national data (EIM data)
• “Older” women>= 40: 34.9%, 51.1% for DE (new case law
OD, next slide), 63.5% UK women (32.2% It, 30.2% Fr)

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From awareness to evidence in EU(data)
• Cross border reproductive care in six EU countries (Be,
Cz, Dk, Sz Sl, Sp)
• 1230 questionnaires in 1 month, or 12 000–15 000 cycles
• Thus yearly minimum 24 000–30 000 cycles (73% ART,
22% IUI, 5% both) assuming 2 ART cycles and 3 IUI
or..…11000–14 000 patients/y (ESHRE CBRC TF, Shenfield
et al, 2010, Hum Rep)
• Opportunity to cross borders as near as possible (Fr to Be
and Sp, De to Cz)
• Opportunity of choice: through www., Drs or friends ,
agencies

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 General reasons for travelling according to the CBRC patients’
country of residence

Patients’ Illegal Access Better Past Anonymous

residence difficulty quality failure Donation
Italy 70.6 2.6 46.3 26.1 14.1
Germany 80.2 6.8 63.8 43.5 25.4
Netherlands 32.2 7.4 53.0 25.5 10.7
France 64.5 12.2 20.6 18.7 42.1
Norway 71.6 0.0 22.4 16.4 16.4
UK 9.4 34.0 28.3 37.7 26.4
Sweden 56.6 13.2 24.5 5.7 18.9
Total n 674 86 531 358 220
% 54.8 7.0 23.2 29.1 17.9
 Treatment sought
according to the recipient country

Infertility treatment Donation

(total=100%)
Country Files (n) ART only IUI only ART/IUI Semen Oocyte Embryo
Belgium 359 66.6 28.1 5.3 20.5 6.8 0.3
Czech Rep 251 98.4 1.6 0.0 9.5 52.9 11.9
Denmark 154 43.5 53.2 3.3 40.9 1.3 0.6
Slovenia 64 100.0 0.0 0.0 0.0 0.0 0.0
Spain 190 94.2 1.6 4.2 4.1 62.2 4.7
Switzerland 196 45.9 40.3 13.8 27.1 1.0 0.5
Total n 1214 886 269 59 225 281 42
% --- 73.0 22.2 4.9 18.3 22.8 3.4
 Legal changes since 2010
• Same sex couples from FR, SW and NO(* 1987law
changed 2009); FR (53.3%** access single and same
sex 2021)
• OD Germany
• PGD Germany
CBRC surrogacy : recent FR events
• The Menesson saga:nationality
• ECHR decision
Surrogacy: a controversial exemple

• Surrogacy: Why the world needs rules for selling

babies, Claire Fenton-Glynn University of Cambridge,
BBC news website 26/4/2019

• Le Monde (2018)

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Indian surrogates: who were they?

• Sociodemographic characteristics of 96 Indian

surrogates: Are they disadvantaged compared with
the general population? Virginie Rozee, Sayeed
Unisa and Elise de La Rochebrochard , PLOS ONE |
https://doi.org/10.1371/journal.pone.0214097 March 25, 2019

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Non residents in CBRC to USA

• Older than U.S. residents (39.3 vs 36.1 years,)

• Lesser success rate IVF 38-40 years (30.4% vs. 27.9%)
and 41-42 years (19.1% vs. 16.3)
• higher utilization of PGS (19.1% vs. 5.3%), OD* (42.6% vs
10.6%), and **gestational carriers (12.4% vs 1.6%)

*OD= 60% of ART cycles by patients from 5 countries

(Japan, Australia, France, Israel, and New Zealand)
**Surrogacy >40% of cycles by patients from 6 countries
(France, Germany, Spain, Israel, Sweden, and Norway).

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Legal complications: do they reflect (societal)
acceptability?
• Intended parents may face legal problems both at
exit of treatment country and returning home
• Spain: 2006 twins born in California to a married male Spanish
couple with pre-birth judgment issued by local court (Freedom); no
visas till 2011 when… Spanish Ministry of Justice weighed the
interests of the children v the interests of the Spanish government
in prohibition of surrogacy (acceptable to the State v
couple/children)
• Known travel of Belgian surrogates delivering “sous X”
in France father pre delivery “recognition”, mother
adopts (no records) unacceptable to French state and
intended mother

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 Low/middle resources countries
India
Thailand
Nepal
Mexico
Kenya
Cambodia
Opportunity for international patients v drain
resources for locals?
Egg donation and surrogacy: many raised concerns about
women’s exploitation
 Acceptability in low income countries?
• FIGO Ethics committee report, Cross-border reproductive
services (2010) Int J of Gyn and Obs111:190–191
• Cross border referrals to reproductive care in low resource
countries should avoid ….
,….shifting resources (unacceptable )to wealthier individuals at
the cost of other essential local treatment provision
• Outcries: (too many) same sex couples, children abandoned
(Thailand);change of Indian law;UN CEDAW call to stop
criminalisation of surrogates in Cambodia ( outlawed 2016)
2018, 30 pregnant surrogates were imprisoned for 'cross-border human
trafficking' because they were carrying children for Chinese, intended
parents; since been released on the condition that they raise the children
themselves.
 Cambodia (bionews)
• CEDAW considers the women victims, as current legislation
does not 'take into account the unequal relations between the
parties to a surrogacy arrangement,' and forms part of more
general discrimination against women in Cambodia.
• At present, there are no legal or financial consequences for
the Chinese clients, highlighting the need for international
regulations.
• 'Surrogate women in Cambodia are likely to be at the sharp
end of various economic and political hardships that caused
them to make the decision to become a surrogate,' Chak
Sopheap, Executive Director of the Cambodian Centre for
Human Rights
 Consequences: less opportunity
surrogacy
Thailand: ban
commercial
India: no more gay
or foreign couples
Nepal: stopped in the
aftermath of earth
Quake
UK: legal, increasing,
Acceptable (no incoming
surrogacy CBRC)
More acceptable « solutions » ?

1. Man caught smuggling human embryo into India

March 2019, Bionews: Man from Malaysia....admitted to smuggling
embryos to IVF clinic in Mumbai X times in 18/12, detained at the
airport by India's Directorate of Revenue Intelligence (DRI)...
participated in a sting operation ...delivered the canister under DRI
surveillance to the clinic Is this (ethically/legally)) acceptable?
2. The case of migrant egg donors: “Egg provision can be a way
for migrant women to gain temporary financial benefit”, from
ethnographic study in Barcelona in 2016–2017 12 women with 14
interviews (Migrant extractability: Centring the voices of egg
providers in cross-border reproduction, Nahman, RBM and Society
Online (2018) 7, 82–90) Is this (ethically) acceptable?
Gametes, collaborators also X borders:
more acceptable?
• Gametes or E in OD: SP/Italy, transnational fresh OD (TOD)
between SP and It: « women treated with elective vitrified-
thawed embryo shipping »: 2016 E for 630 patients
cumulative LBR 39.3%
? a solution for « distance and inter countries OD programs »,
La Marca et al, Feb 2019, Hum Reprod
• Egg donors (OD study, Pennings et al and M Nahman)
• Sperm (import) for donation: proportion of newly-registered
sperm donors ..from outside the UK was 39% in 2016, v 27%
5 y ago (HFEA)? Not acceptable in France

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Conclusions: freedom (whose) or burden and
acceptability (society, state, patients)
• More patients access • relinquishing « home
treatment + support » -

• Escape restrictive law • legal/societal burden at

individual +, legal - return -

• More autonomy for the • exploitation of gametes

patient (ethical providers , surrogate -
acceptability) • shifting of needed local
• Macro level: a question of resources to wealthier
equity? population from abroad in
low income countries -
-
Why is the 2014 OD study relevant?

• Freedom X border from DE to CZ V burden to

go against the national “social contract”
• Freedom to go from UK to Ukraine v “ethical”
burden of disproportionate compensation (with
PPP adjustment)
Socio-demographic and fertility-related characteristics and
motivations of oocyte donors in eleven European countries,
Pennings, de Mouzon, Shenfield, Ferraretti, Mardesic, Ruiz, and
Goossens, Hum Reprod, 29, No.5 pp. 1076–1089, 2014

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 Results
• 1423 questionnaires in 11 European countries
(60 centres) between late 2011 and mid 2012
• Consecutive egg donors, including egg sharers

ESHRE 29th Annual Meeting, London, 7-10 July 2013

Who/what else X borders?: another type
of Reproductive Travel (less burden)
• Gametes or E in OD: SP/Italy, transnational fresh
OD (TOD) between SP and It: « women treated with
elective vitrified-thawed embryo shipping »: 2016 E
for 630 patients cumulative LBR 39.3%
? A solution for « distance and inter countries OD
programs », La Marca et al, Feb 2019, Hum Reprod
• Egg donors (OD study, Pennings et al and M
Nahman)
• Sperm for donation: proportion of newly-registered
sperm donors ..from outside the UK was 39% in
2016, v 27% five years ago (HFEA) ?

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The impact of Covid-19 on gamete shipping
by Australian & New Zealand patients
Everingham S & Whittaker, A.
• 31 Australian and New Zealand IVF provided data of
gamete export applications from two 12/12 periods pre
and post lockdown: 1 Mar 2019 - 28 Feb 2020; 1 June
2020 – 31 May 2021
• Increased international sperm shipping: 58 to 72 %
• Of the 21 destination countries reported for
international shipments, the US was the commonest
(39%), followed by Ukraine (21%) and Canada (9%).

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The rest of the world: more
evidence needed
Stop press : ART, CBRC and the war

• Headlines of intended parents trying to get to the

Ukraine
• Surrogates X borders to countries where legislation
is different both if egg donation and at delivery
• It is estimated that more than 2 million children
younger than 5 years and pregnant and
breastfeeding women in Ukraine are in need of
nutrition assistance (Lancet leader last week)

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Milano ESHRE annual meeting 2022

• Wed July 6th 14.00-15.15

• 1. Ayden Birol*; 2: FS: from Insult to Injury; 3 debate
(Sam Everington)

A WAR IN EUROPE?: UKRAINIAN SCIENTISTS'

STRUGGLE FOR LIFE AND FUTURE,
RELOCATION
AND SECURING OF FROZEN BIOMATERIALS

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References
• Pennings G, De Wert G, Shenfield F et al. (2008) ESHRE task
force on ethics and law 15: cross-border reproductive care
Hum Reprod 23(10): 2182-4
• FIGO Ethics Committee. (2009). Cross border reproductive
services. International Journal of Obstetrics and
Gynaecology, 111, 190-191
• Shenfield et al on behalf of the ESHRE TF CBRC(2010)
Cross border reproductive care in six European countries,
Hum Reprod 25 (6): 1361–1368
• ESHRE’s good practice guide for cross-border reproductive
care for centers and practitioners (2011), Shenfield et al on
behalf of the ESHRE TF CBRC, Hum Reprod, 26 (7):1625–
1627

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Refs
• Hudson et al (2011):CBRC, a review of the literature, RBM online
(22):673-685
• Rozee V and La Rochebrochard E (2013), CBRC among FR
patients: experience in GR, SP and BE, Hum Reprod 28
• La Marca et al (2019), A novel transnational fresh oocyte donation
(TOD) program based on transport of frozen sperm and embryos,
Hum Reprod 34 (2): 285-290
• Andrea Whittaker, Marcia C. Inhorn & Francoise Shenfield (2019):
Globalised quests for assisted conception: Reproductive travel for
infertility and involuntary childlessness, Global Public Health, DOI:
10.1080/17441692.2019.1627479

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