The final session of the Progress Education Trust's 'Passport to Parenthood' conference debated whether the facility to receive treatment outside of a patient's home country presents a genuine solution to meeting the growing demand for fertility care - or whether it generates new problems of its own.
Chairing the session, Sheffield University's Dr Allan Pacey began by asking for a show of hands from delegates in response to the motion of whether cross-border reproductive care is a solution, a problem, or is better represented as a solution with some problems.
Illustrative of the ethical complexity of the day's presentations, there was overwhelming agreement with the last proposition. Questions from the delegates to the panel of speakers reflected this majority position. The session began with queries on the possibility of young women suffering as yet undefined long-term health consequences as a result of egg removal and about future social and ethical problems that may arise for children conceived using foreign gametes.
Panellists replied that the first successful egg donation procedure was performed in 1984, and since that time, long-term studies carried out over a 20-year period showed no independent increase of breast or ovarian cancers as a result of egg removal, nor any evidence of earlier menopause in egg donors. In terms of the future of cross-border donor gamete-conceived children, Natalie Gamble, a UK fertility lawyer, responded that the most important issue was to ensure the parents who raise them have legal status as their parents, and the children do not end up stateless because of non-alignment of cross-border laws.
While there are bases for debating their legal status, the emotional impact on children born through cross-border fertility care is still unknown territory. Janet Radcliffe-Richards, Professor of Practical Philosophy at the Oxford Uehiro Centre questioned the notion, asking why there should be an emphasis on harms when these children are discussed. Her rationale was that there are difficulties in attempting to compare as yet non-existent problems, and that all children will have issues to deal with, however they were conceived. It may even be the case that these children will have more favourable life experiences than many naturally conceived children.
Mr Stuart Lavery, a specialist in reproductive medicine and Director of IVF Hammersmith, explained this was an issue that was less worrying to him. Mr Lavery's experience had been that children conceived through fertility treatment 'do great - they are really wanted kids because their parents really wanted to have a family'. However, Lorraine Culley, Professor of Social Science proposed a caveat: 'The evidence says that the outcome (for donor-conceived children) is positive - although we have no evidence about the cross border situation. This is too new'.
Research has shown mixed responses to disclosure. Some parents reported that they were probably not going to tell their children the nature of their conception, and chose instead to deal with potential consequences of their decisions in the future. Professor Culley made the point that people who undergo treatments abroad are not undertaking cross-border fertility treatment lightly. 'People work through how they will live with the consequences of this. It is not a spur of the moment, irrational decision', she said.
Another intriguing question visited the idea that the focus widely placed on the harms of certain facets of cross-border fertility treatments - especially egg harvesting - may be an over-hyped concern. Is there evidence that these harms are already occurring, or is the worry that they are likely to happen in the future? Are egg donors really in danger?
Mr Lavery answered by describing the incidence of ovarian hyper-stimulation syndrome (OHSS), known to be the most serious consequence of induction of ovulation as part of assisted conception techniques. 'It is not risk-free, but the risks are low - 0.2 percent for OHSS', Mr Lavery said. But apart from the documented medical risks, Allan Pacey added there may also be broader social risks. It is difficult to evaluate, because 'the voice of the donors is not what we are hearing'.
Zeynep Gurtin-Broadbent, a research fellow currently examining the bioethical and psychosocial implications of egg sharing, said that practice varies between countries and clinics. A large number of eggs are donated from Romanian women to clinics in Israel, and from Gurtin-Broadbent's native Turkey to Cyprus. She has documented cases of bad practice, including one in which a 17-year old donor died.
How can such harms be minimised? Professor Culley described a survey in which recipients of donated eggs reported being very concerned about the ethics surrounding how these eggs were acquired. Some 'fertility tourists' admitted that donor anonymity was a major factor in their decision to use international donors. Whether this was the case or not, most did not want to think of themselves as consumers.
However, Professor Culley suggested recipients should be asked to pay more, not less, and that no woman should donate eggs without recompense. 'It's not black and white - it's much messier and complicated', she said. 'Harm could be minimised by having an international code of practice, but there will be issues of implementation', she added, suggesting that more mediation and involvement of clinics in the UK could help to guide this process.
The lack of ethical codes was also described by Professor Naomi Pfeffer, who researches how human tissue is collected for medical purposes, as helping give rise to a 'rotten trade'. She explained that it is insufficient to think of just the women (donors) and consumers involved, but the social and political structures in place in countries which provide the international market with a supply of human eggs. These countries may be characterised by some as having weak governments and where women face severe inequality. Such conditions are easily exploited by a rotten trade. Professor Pfeffer suggested the trade is encouraged by a 'pick and mix' approach to regulation - if consumers don't like the situation in their own country, then rather than trying to change it, they instead take the option of being treated elsewhere.
Education could also play an important part in tackling age-related fertility issues and reduce at least some of demand for fertility treatment from older patients. Dr Françoise Shenfield suggested that teenagers should be advised to have kids as close to age 30 as they are able to. 'Perhaps the next generation won't be flabbergasted that at 39 they only have one year to get NHS treatment, and that after 40, I can't help them', she said.