As a clinician based in the UK, one cannot fail to be aware that some patients seek fertility treatments abroad. Until now we only had newspaper headlines or anecdotal evidence, but having presented the results of the first European study in Amsterdam at the annual European Society for Human Reproduction and Embryology (ESHRE) conference (1), we may now base our reflections on some facts, even if selected by the voluntary nature of participating colleagues and centres abroad.

So we know the phenomenon is present and unlikely to disappear, and we may well ask, is it a problem per se? The answer is no, not in the climate of a priori autonomy of our patients in the post modern world, and the fact that the term cross-border care is preferred to 'fertility tourism' is one aspect of the respect we owe our patients who certainly do not travel for fun as a tourist, but out of necessity (2), as most people would much prefer to receive appropriate care on their doorstep. The ethics of cross-border reproductive care have already been discussed by many (3), including our ESHRE Taskforce for ethics and law (4). This is of concern to patients and practitioners alike, let alone regulatory authorities. Knowing the lack of hard facts we decided to start a 'cross-border reproductive care' study in October 2008, thanks to the collaboration of colleagues in six European countries. Patients may feel the need to cross national borders because of their age, marital status (French single women or lesbian couples will seek donor insemination in Belgium, for example) as well as bans on the technique they need to use (for example PGD (preimplantation genetic diagnosis) in Germany, gamete donation in Italy). The EU has estimated that one per cent of healthcare spending in any European country is given to citizens from another EU country, and there are plans for 'consumers' to be able to access some care across borders and be reimbursed in their own state, although it may take a long time before this applies to fertility treatments.

But why our patients feel the need to seek care abroad had not been studied systematically. Thus, we started this prospective study, of all foreign women coming from abroad to attend the participating centres for assisted conception: IVF (in vitro fertilisation)/ICSI (intracytoplasmic sperm injection), with or without sperm donor; oocyte donation transfer cycles; PGD or PGS (preimplantation genetic screening); embryo donation cycle; insemination with partner's sperm or with donor sperm, for one month, in the six collaborating countries (Belgium, Czech Republic, Denmark, Slovenia, Spain, and Switzerland).

We had two main objectives: to estimate the number of couples who cross borders to obtain infertility treatment and their reasons for doing so and to compare the age distribution of cross-border patients with this of local national patients treated by the same centres.

Furthermore, what can be learnt from the facts is firstly whether what has merely been surmised until now is in fact evidence-based. Indeed, many Italians escape legal restrictions at hpme by going to Spain for oocyte donation, and to Switzerland for sperm donation. So do French lesbians who go to Belgium for the latter. Legal restrictions are also the cause of the flux of Germans to the Czech Republic, but the British quote access problems as the main reason for their travels. Although aware that the evidence is still partial because of the voluntary nature of the study, it provides a picture of trends, which may inform future policy and gives the cross-border phenomenon 'visibility'.

With my ESHRE hat on, I wish to promote the role of our professional society in informing the law makers, media and the public of the benefits of assisted reproduction technologies for infertile people, point to possibly negative consequences of restrictive legislations and access policies, ensure safety for all concerned (patients and gametes donors), whilst also considering the welfare of the future child. In this respect, the prevention of multiple pregnancy is still an important matter internationally, as indeed this is one of the complications our patients return to us from abroad with.

This very matter was the subject of a study, now published on line for the BJOG (5). This showed that we have seen at University College London Hospital an increase in the numbers of high order multiple pregnancies (triplets, quadruplets and above) in women who have received fertility treatment overseas. The added comment on the website that 'we need international protocols on this urgently, to be agreed by the professionals performing the fertility treatment and those caring for the women' is certainly one ESHRE is in agreement with, and which we will endeavour to put in place for the sake of our patients.

Refs:

1. Bionews report on the cross-border study presented at ESHRE

2. Pennings G G. Pennings (2004) Legal harmonization and reproductive tourism in Europe. Hum Reprod 12:2689- 2694

3. G.Pennings (2006) International parenthood via procreative tourism. In : F.Shenfield and C. Sureau (Eds) Contemporary Ethical Dilemmas in Assisted Reproduction Informa Healthcare, pp 43-56

4. ESHRE taskforce in Law and Ethics 15, Ethics of Cross- border reproductive care, Human Rep, 2008 23(10):2182-2184

5. McKelvey A, David A, Shenfield F, Jauniaux E. The impact of cross-border reproductive care or ‘fertility tourism' on NHS maternity services. BJOG 2009