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Pauwels, B. Perrad, C. Pirard, F. Cross-border reproductive care indicates the cross-border movements made by patients to obtain infertility treatment they cannot obtain at home. The problem at present is that empirical data on the extent of the phenomenon are lacking. This article presents the data on infertility patients going to Belgium for treatment. A survey was conducted among the centres for reproductive medicine that are allowed to handle oocytes and create embryos B-centres.
Data were collected on the nationality of patients and the type of treatment for which they attended during the period — Sixteen of 18 centres responded to the questionnaire. The flow of foreign patients has stabilized since at approximately patients per year. The majority of foreign nationals seeking treatment in Belgium were French women for sperm donation.
The next highest group was patients entering the country to obtain ICSI with ejaculated sperm. There are clear indications that numerous movements are motivated by the wish to evade legal restrictions in one's home country, either because the technology is prohibited or because the patients have characteristics, which exclude them from treatment in their own countries. In the last decade, there has been a steady rise in cross-border reproductive care. Reproductive tourism, as it has been disparagingly called, attracts more and more interest because of its increasing visibility.
The media eagerly present the spectacular cases; elderly women conceiving abroad, a British woman transporting her dead husband's sperm to Belgium for insemination, gay men looking for a surrogate mother in India. The anecdotal evidence available through clinics and patients suggests several reasons why people travel to another country to obtain treatment; a certain type of treatment is not allowed in their home country, they are excluded from treatment because of specific characteristics for example age or sexual orientation , the technology is not available [such as preimplantation genetic diagnosis PGD ], the waiting lists are too long for treatments such as oocyte donation or the out-of-pocket costs for the patients are too high Pennings, The phenomenon raises a whole set of ethical problems going from law evasion and equity of access to professional responsibilities and safety issues ESHRE Task Force on Ethics and Law, Reliable data to evaluate cross-border reproductive care is required.
At the moment, data on the extent of this phenomenon is mostly lacking. European data are available for certain specific treatments, like PGD Corveleyn et al. In Italy, for instance, as part of the campaign against Law 40 on Assisted Reproduction, information was collected about the number of patients looking for a solution abroad.
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The number of Italians leaving Italy increased from before the law to 1 year after the law based on information from a selected number of foreign centres Fornasiero, However, for most other treatments and countries, hard data are scarce. Belgium is located centrally in Europe; it is composed of three regions: flanders Flemish speaking , Brussels officially bilingual but in reality French speaking and Wallonia French speaking.
All clinics have an official language depending on the region where they are located. The clinics in the Brussels region are supposed to be bilingual but they have a clear majority of either French or Dutch speaking personnel. Health care is organized at the federal level. Belgium's first in vitro fertilization IVF baby was born in Its centres contribute to the development of new techniques in the field of medically assisted reproduction, play a major role in the European and world organizations and participate in many scientific studies in the field.
Belgium has, compared with many other European countries, an advantageous insurance system that guarantees equitable access to reproductive health care. This point can be shown by comparing the uptake of assisted reproduction in Belgium to the theoretical estimate.
The uptake of ART in Belgium is , only slightly below the optimal uptake although the number of cycles used to calculate the uptake includes the cycles offered to foreign patients Collins, Reimbursement was linked to restrictions on the number of embryos to be transferred depending on the cycle rank and the age of the woman.
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Only partial data were available for infertility treatment for foreign patients in Belgium prior to this study. In , the proportion of foreigners among the oocyte donation cycles had risen to After that year, the information on the distribution of foreign and national patients for oocyte donation was no longer included in these reports. A report of the College of Physicians for Assisted Reproduction Therapy , comparing the data of two periods from 1 January till 31 December and from 1 July till 30 June , showed a substantial increase of Belgian patients.
This can be explained by the new regulation on the reimbursement of IVF cycles which entered into practice on 1 July In the second period, This increase was caused by the increase in Belgian patients due to the reimbursement rule since the absolute number of foreign patients also increased in the second period. Age and rank number of cycles provided to patients with and without social security from to The number of embryos transferred differs amongst patients with and without social security.
Number of embryos transferred in cycles provided to patients with and without social security from to This trend can be explained at least partially by the difference in patients' age and by the cycle rank, since a larger proportion of foreign patients have already performed more than one treatment cycle before coming to Belgium. However, other factors might also play a role. It has been argued that patients who have to pay for treatment themselves are more likely to accept transfer of more embryos. For the older patients, the time pressure linked to the increase in success rate may underlie the wish to have several embryos replaced.
However, this does not correlate perfectly with the patient's residence. The goal of the present study was to obtain detailed data on the inflow of foreign patients for infertility treatment.
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We collected data on the nationality of the patients and the type of treatment. In addition, we also investigated how the flow changed over time. A questionnaire was send to all B-centres for reproductive medicine in May Belgium counts 13 A-centres for reproductive medicine 1 per inhabitants and 18 B-centres. The main difference between these two types is that only B-centres have permission by royal decree 15 February to handle oocytes and create embryos in vitro.
The questionnaire started with six general questions regarding the attitude to and the relationship with foreign patients. These questions were subdivided in two sets.
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For the first subset, the centres were asked only to mark which of the listed items applied. The questions were: i Do special rules apply to foreign patients that do not apply to national patients? For the second subset, the clinics were asked to score different options from 1 to 6, with 1 being most important and 6 not important at all. Question 4 asked what problems they experience most with foreign patients?
The following options were presented: problems with making and keeping arrangements; language and general communication problems; administrative problems registration etc. Question 5 was what problems do foreign patients according to you experience most? The options offered were: problems with making and keeping arrangements; language and general communication problems; administrative problems registration etc.
Finally, question 6 asked for which reasons foreign patients according to you come to a Belgian centre? The options to be scored were: the treatment is forbidden in their country; they are not eligible for treatment because they do not fulfil certain criteria such as being too old or homosexual, etc. This set of questions was followed by questions regarding the number of foreign patients. The centres were asked how many patients they treated from different countries per year for the period —, subdivided per type of treatment.
The information reported by the centres was per treatment cycle since this is how the data were stored in their databases. To diminish the burden of the data collection, centres were asked to provide detailed data only for those countries from which they treated more than five patients per year. Centres were asked to simply list different countries from which they saw less than five patients. Finally, the centres reported the total number of treatments per year and per type of treatment for all patients foreign and national together and an estimate of the mean number of treatments per patient per type of treatment.
Five clinics indicated that they expected foreign patients to bring their own oocyte donor. No clinic mentioned this condition for sperm donation. Three clinics had a limitation on the number of foreign patients. Finally, 10 clinics ask foreign patients to pay in advance. A large number of clinics 14 of 16 had interpreters available on demand. However, only 12 centres indicated that the informed consent forms were translated in several languages. Fourteen centres collaborated with a doctor in the country of origin of the patient.
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Thirteen clinics combined the appointments to the gynaecologist and the psychologist for instance on one day and adapted the treatment where possible to reduce the number of visits and trips to the clinic. Finally, six centres had members of foreign origin in their medical staff who provided support to patients who speak the same language. Number of centres that made special efforts to facilitate or improve the treatment of foreign patients. Ten centres had a website in English or another foreign language.
Three centres also provided practical support beside the medical treatment, i. Since this organization strives to promote Belgian clinics abroad, it can be counted as a positive answer. The second subset of questions probed into the problems of patients and clinics. The original task for the clinics was to rank the different options from 1 to 6 with 1 being most important and 6 not important at all. However, some respondents misunderstood the scoring system and only coded the options as 1 important and 2 less important.
We recoded the answers 2 and higher to 2. Question 4 asked whether the centres themselves experienced difficulties with foreign patients. Evaluation of the problems infertility centres experience with foreign patients. Keeping appointments and language and communication problems were mentioned most frequently.
However, most clinics that answered this question 13 in total reported these sorts of problems as being of lesser importance. Evaluation of problems foreign patients experience according to the infertility centres. The most important reasons were a legal prohibition in their home country and the failure to fulfil certain conditions for access. Less important reasons were the treatment cost and the lack of expertise in their home country.
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In some countries, the law imposes criteria for eligibility. In France, for instance, couples have to be heterosexual, part of a stable relationship and of reproductive age to have access to assisted reproduction. In these cases, a legal prohibition coincides with the failure to fulfil certain criteria.
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Evaluation of reasons for foreign patients to travel to Belgium according to the infertility centres. The questionnaire asked for the numbers of foreign patients from onwards. However, only eight centres were able to provide data from that year. One centre reported data from , another one from , five from and an additional one only from For the analysis by nationality and treatment type, only the data from till were used because these data are complete and bias due to missing centres is avoided.
The centres merely listed the countries from which they treated less than five patients per year. This resulted in an impressive list of 86 nationalities. The number of patients was obtained by dividing the number of treatment cycles per type of treatment by the mean number of cycles for each type of treatment per patient. The total number of foreign patients increased from in to in Hereafter, we will only present the data for these countries. It is above all a sauna!