Shelby Tadaki is majoring in biology and public health and is a 2022-23 health care ethics intern at the Markkula Center for Applied Ethics. Views are her own.
Fertility is often a gift taken for granted. Almost one in every six people of reproductive age experience infertility worldwide. Treatment options such as in-vitro fertilization (IVF), gamete (egg/sperm) donation, and surrogacy grant couples/individuals in these positions the opportunity to have a child. However, various reasons have led to an influx of fertility tourism: a form of medical tourism in which patients travel abroad to receive fertility care. Also known as reproductive tourism or cross-border reproductive care, this trend has gained popularity in both America and abroad.
Reasons for Fertility Tourism
Cost is one of the main reasons patients opt for fertility tourism. The cost of a single IVF cycle in the U.S. can range from $15,000 to over $30,000 in 2023, depending on the kind of embryo used. In fact, the U.S. spends the most per capita on health care compared to its peer countries. Clinics in popular destinations like Mexico, on the other hand, advertise IVF costs of $8000 and lower.
Patients may also prefer to go abroad because their home country’s legislation prevents them from seeking reproductive care. Some countries have strict policies on surrogacy: France, Germany, Italy, Spain, and Taiwan ban all forms of surrogacy, while Canada and Britain allow altruistic surrogacy but ban for-profit (commercial) arrangements. The U.S. has no legislation regarding surrogacy at the federal level, so various states allow commercial surrogacy.
Other countries have restrictions on the kind of reproductive options available depending on patients’ age, sexual orientation, or marital status. For the well-being of the mother and child, the Ethics Committee of the American Society for Reproductive Medicine discourages egg/embryo donation to women over 50 with underlying issues and all women over 55. 16 European countries, such as Italy, prohibit single women from accessing artificial insemination and 25 European countries ban lesbian couples from accessing artificial insemination. In these cases, Belgium, Czechia, Denmark, and Spain are popular destinations due to their lenient fertility regulations and high success rates.
Fertility tourism allows patients, who otherwise could not in their home country, the opportunity to receive fertility treatment. While there is good reason for participating in fertility tourism both in the U.S. and abroad, patients should first examine the ethical considerations surrounding their treatment in regard to all stakeholders including themselves, the provider, and the destination country.
Patient Considerations
Fertility “tourism” implies that patients will be able to travel to a tropical destination and relax, while also seeking fertility care. In fact, island paradises like Barbados have become popular destinations due to their “peaceful and stress-free environment that couples need when undergoing IVF”. However, these procedures can be quite aggressive when done in a short period of time and patients are put at a higher risk of experiencing complications. Patients may also have to fly home during treatment for work or cost-related reasons, meaning they are not able to receive consistent or longer-term care from their provider. This additional stress on the patient puts them in unnecessary harm.
Patients must also consider why they are going abroad. Some couples/individuals may be seeking more affordable options or avoiding discriminatory legislation, while others are using fertility tourism for more questionable reasons like gender selection. In fact, a popular fertility center in the U.S. advertises this option to couples/individuals who want to “avoid gender-specific disorders or to better balance out their family.” It has been debated since the inception of genetic screening whether it is ethical to choose your child on the basis of gender. Using the ethical principle of fairness, one can argue that it is unethical to select one child over the other on the basis of gender. If gender selection becomes universally practiced and accepted, it could lead to the justification of other discriminatory practices regarding embryo selection.
Provider Considerations
People are often enticed by novel therapies without fully understanding the extent of the treatment and its potential risks. For patients that are in vulnerable or urgent situations, like those sometimes involved in fertility tourism, they may be more likely to go ahead with treatment without considering the risks because they are desperate for a solution.
From the provider’s perspective, it is important that they provide medical information to the patient in a way that they can accurately comprehend so that patients can provide informed consent. While the standard of medical care is improving throughout the world, patients should be aware of the potential risks that are associated with a treatment that may differ from their home country. The responsibility of providing information in layman's terms falls on the health care facility and provider. Language barriers, if any, should be addressed to ensure informed consent is granted throughout the treatment process. For lay people, medical terminology can already be difficult to comprehend in their native language so it is even more pertinent that the language barrier is addressed.
Destination Country Considerations
Due to the lack of federal regulation, the U.S. has become a popular destination for commercial surrogacy. This creates the possibility of exploitation of vulnerable women, mainly those of lower socioeconomic status. They may be pressured into serving as a surrogate or donating their eggs because of financial stress. Patient autonomy maintains the belief that the patient makes their own decisions, however coercion of any kind can undermine this ideal. As such, it stands to reason that the financial gain can potentially compromise the patients’ voluntariness and it is questionable as to whether they are acting autonomously. Women in this position may fail to consider the health consequences that are associated with surrogacy and egg donation such as ovarian hyperstimulation syndrome and postpartum hemorrhage.
Fertility tourism has also raised concerns about access to fertility treatment for citizens of the destination country. A report from the Institute for Health Information and Statistics in Czechia hints that prices of fertility treatments may increase with the influx of patients coming from outside of the country. This raises ethical concerns around the principle of justice: is this fair for citizens of the destination country? Should foreigners take precedence over citizens, if they have the financial means to do so? As this medical trend gains popularity, it is important for health care providers and policymakers to take these questions into consideration when setting the precedent for years to come.
While it does provide an alternative for couples and individuals that find themselves with no other options, fertility tourism is a complex medical trend. It raises health concerns for the patient, as well as ethical concerns for stakeholders involved. Rather than trying to work around discriminatory legislation and overpriced fertility treatment with fertility tourism, policymakers should target these root issues head on. In this way, patients can remain in their home country for treatment in a stable and familiar environment. This guarantees safer outcomes for patients, as well as more equitable access.