Human Reproduction, Vol.26, No.9 pp. 2373– 2381, 2011
Advanced Access publication on June 29, 2011 doi:10.1093/humrep/der191
ORIGINAL ARTICLE Infertility
Crossing borders for fertility
treatment: motivations, destinations
and outcomes of UK fertility travellers
L. Culley 1,*, N. Hudson 1, F. Rapport 2, E. Blyth 3,4, W. Norton 5,
and A.A. Pacey6
1
School of Applied Social Sciences, De Montfort University, Hawthorn Building, The Gateway, Leicester LE1 9BH, UK 2College of Medicine,
Swansea University, Swansea, Wales SA2 8PP, UK 3School of Human and Health Sciences, University of Huddersfield, Queensgate,
Huddersfield, HD1 3DH, UK 4Visiting Professor: Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong 5School of Nursing
and Midwifery, De Montfort University, London Road, Leicester, LE2 1RQ, UK 6Academic Unit of Reproductive and Developmental
Medicine, Department of Human Metabolism, University of Sheffield, Level 4, The Jessop, Wing, Tree Root Walk, Sheffield S10 2SF, UK
*Correspondence address. Tel: +44-116-2577753; E-mail: [email protected]
Submitted on March 22, 2011; resubmitted on May 6, 2011; accepted on May 19, 2011
background: There are few systematic studies of the incidence of cross-border fertility care and even fewer reports of qualitative
research with those undertaking treatment outside their country of origin. This paper reports findings from a qualitative study of UK residents
with experience of cross-border care: the socio-demographic characteristics of UK travellers; their reasons for seeking treatment abroad; the
treatments they sought; the destinations they chose and the outcomes of their treatment.
methods: Data regarding cross-border fertility treatment were collected from a purposive sample of 51 people by means of in-depth,
semi-structured interviews between May 2009 and June 2010. Data were analysed using a systematic thematic coding method and also subjected to quantitative translation.
results: Patient motivations for travelling abroad are complex. A desire for timely and affordable treatment with donor gametes was
evident in a high number of cases (71%). However, most people gave several reasons, including: the cost of UK treatment; higher
success rates abroad; treatment in a less stressful environment and dissatisfaction with UK treatment. People travelled to 13 different
countries, the most popular being Spain and the Czech Republic. Most organized their own treatment and travel. The mean age of
women seeking treatment was 38.8 years (range 29–46 years) and the multiple pregnancy rate was 19%.
conclusions: UK residents have diverse reasons for, and approaches to, seeking overseas treatment and do not conform to media
stereotypes. Further research is needed to explore implications of cross-border treatment for donors, offspring and healthcare systems.
Key words: cross-border reproductive care / fertility tourism / reproductive tourism / treatment abroad / medical tourism
Introduction
Cross-border reproductive travel, part of a more general globalization
of healthcare (Culley and Hudson, 2009), has attracted considerable
interest from international media, and from academic commentators.
However, there has been little systematic study of this apparently
growing phenomenon (Hudson et al., 2011). Therefore, while there
is evidence of cross-border fertility treatment occurring in many
countries across the globe (Nygren et al., 2010), there are few
robust data on incidence. Recent papers have documented patient
travel between Canada and the USA (Blyth, 2010; Hughes and
DeJean, 2010), from the USA and Australia to Europe and Asia (Whittaker and Speier, 2010) and extensive movements to and from the
United Arab Emirates (Inhorn and Shrivastav, 2010).
In the European context, the survey carried out by the European
Society of Human Reproduction and Embryology’s (ESHRE) Task
Force on Cross-Border Reproductive Care (Shenfield et al., 2010)
provides the most comprehensive study of cross-border travel to
date, with data from 46 clinics in Belgium, the Czech Republic,
Denmark, Switzerland, Slovenia and Spain, collected for a period of
1 month between October 2008 and March 2009. While suggesting
caution in extrapolating from these data to the rest of Europe, the
authors estimate that there could be 24 –30 000 cycles of crossborder treatment, involving 11 –14 000 patients in Europe annually.
Patients from Italy and Germany were the most dominant travellers
in this survey, which included 53 patients travelling from the UK. Pennings et al. (2009) also show a steady growth in foreign nationals
treated in Belgian clinics between 2003 and 2007, particularly from
& The Author 2011. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved.
For Permissions, please email: [email protected]
2374
France, the Netherlands, Italy and Germany. Studies of Italian patients
have reported a growth in overseas travel from Italy since legislative
changes in 2004 (Bartolucci, 2008; Ferraretti et al., 2010).
Commentators have suggested a range of possible motivations for
cross-border travel, including legal restrictions on access to certain
forms of treatment (e.g. third-party-assisted conception); restrictions
on the availability of treatment for certain categories of people (e.g.
single women or same-sex couples); high cost of treatment in the
home country; a desire for donor anonymity; a desire for identifiable
donors; sex or trait selection; a desire for treatments considered too
experimental to be provided in the home country; a lack of expertise
in the home country; shortage of gamete (especially oocyte) donors;
long waiting times; a desire for culturally sensitive care; perceived
higher success rates or higher quality of care abroad; the pull of
active marketing in the global medical tourism sector (Pennings,
2004; Blyth and Farrand, 2005; Ferraretti et al., 2010; Inhorn and
Shrivastav, 2010; Pennings and Mertes, 2010).
To investigate these issues in the UK context, this paper reports
findings from a study designed to explore, in depth, the motivations
and experiences of UK residents who travel overseas for fertility treatment. It discusses the socio-demographic characteristics of UK travellers, their reasons for seeking treatment abroad, the treatments they
sought, the destinations they chose and the outcomes of their
treatment.
Materials and Methods
The data reported here are derived from a cross-sectional qualitative
study of cross-border fertility treatment. A purposive, non-probability
sample of UK residents who had been or were planning to go overseas
in the near future for fertility treatment were recruited from online fora
and websites (44%); patient support group newsletters and mailings
(22%); media coverage of the project (17%); word of mouth (7%); overseas clinics (7%) and UK clinics (2%). Semi-structured interviews, lasting
an average of one and a half hours, were carried out by experienced interviewers between May 2009 and June 2010. The interviews were wide
ranging and included explorations of participants’ motivations for going
abroad for treatment, the destinations visited and their experiences of fertility treatment in the UK and abroad. Interviews were digitally recorded
and transcribed in full. Demographic data were collected from participants
via a short questionnaire.
The qualitative interview data were analysed using a systematic thematic
coding method in which a framework of emergent codes was developed,
elaborated into analytic categories and applied to the transcripts in the
qualitative software package Nvivo 8 (Silverman, 2001). In order to
enhance the validity and interpretive authenticity of the findings, all team
members were involved in coding a sample of interviews. In addition to
the thematic analysis, and in order to ensure descriptive validity on key
findings (Maxwell, 1992), aspects of the interview data were also subjected
to ‘quantitative translation’, involving simple counts (Boyatzis, 1998).
When conducted alongside a conventional qualitative analysis, this
process can assist with the identification of common typologies and categories and enhances the credibility and validity of qualitative research
(Seale, 1999). The data derived from this process were used in two
ways: they were counted and analysed independently in Excel and were
also subsequently used as additional comparators when performing crosscase analysis with the qualitative data. Ethical approval for the study was
obtained from De Montfort University Human Research Ethics Committee
(REF No. 459).
Culley et al.
Results
Demographic profile
The socio-demographic profile of participants is given in Table I.
Forty-one women and 10 men took part in the study, constituting a
total of 41 ‘cases’. A ‘case’ is defined as either an individual or a
couple seeking treatment together, even where only one partner
took part in the study. Cases therefore included: 24 heterosexual
women in a couple, but participating in the study alone; 10 heterosexual couples where both partners were interviewed; 6 single, heterosexual women; and 1 woman in a lesbian relationship but taking
part on her own. The majority of participants had already been
abroad at the time of the interview (83%, 34 out of 41 cases). In
the remaining seven cases, firm plans to travel had already been
made at the time of participation in the study, including for most,
Table I Demographic profile of participants in study of
UK residents having fertility treatment abroad.
Characteristic
n
%
........................................................................................
Gender
Female
41
80
Male
10
20
White British
46
90
British Asian
2
4
Ethnicity
White Irish
1
2
British Black
1
2
Mixed ethnicity (White and Asian)
1
2
Occupational statusa
Professional and managerial
37
72
Intermediate
9
18
Routine and manual
1
2
Full time parent
3
6
Student
1
2
Secondary level
16
31
Graduate
16
31
Post-graduate
19
38
50
98
1
2
Educational status
Sexual orientation
Heterosexual
Bisexual
Marital status
Married
a
36
70
Co-habiting
8
16
Single
6
12
Civil partnership
1
2
These data were collected by asking participants to record their occupation. The
resulting classes are devised from the ‘National Statistics Socio-economic
Classification’ (NS-SEC) (ONS, 2008): http://www.statistics.gov.uk/methods_
quality/ns_sec/class_collapse.asp.
2375
Study of UK residents having fertility treatment abroad
booking flights and initial consultations. The age of the female participants at first treatment abroad is given in Table II.
In 11 cases (27%), there were already children in the family when
treatment began, though not always living with the couple. In six
cases, these existing children were from a previous relationship. In
the remaining five cases, a couple already had a child together
(adopted or naturally conceived) and were seeking to add to their
family. The majority of participants had attempted one or more treatment cycles in the UK before considering travelling overseas (32 of 41
Table II Women’s age at first treatment abroad.
Mean
age
n < 35
years (%)
35 –39
(%)
40 –44
(%)
>45
(%)
Range
........................................................................................
38.8
8 (20%)
13 (32%) 17 (41%) 3 (7%)
29– 46
years
Figure 1 Reasons for travel: cases using donor gametes (n cases ¼ 29).
Figure 2 Reasons for travel: cases using own gametes (n cases ¼ 12).
cases, 78%), with an average of 3.1 years between identifying a potential need for fertility treatment and deciding to go abroad.
Motivations for travelling abroad
The lengthy interviews gave participants the opportunity to discuss
their fertility histories and reasons for travel in great detail and a
complex combination of often interrelated issues emerged. The categories described in Figs 1 and 2 are therefore the motivations for
travel as described by the participants themselves, and were not a
priori categories offered by the research team.
Across the whole sample, the four most commonly mentioned
reasons for travel were: donor shortages in the UK (27 cases), cost
(13 cases), perceived better success rates overseas (12 cases) and
previous unsatisfactory care in the UK (7 cases). Many of our participants had spent considerable sums of money in the UK (in some cases
in excess of £20 000) in their quest for a child.
Comparing those seeking treatment abroad for third-party-assisted
conception (n ¼ 29) with those having treatment with their own
2376
gametes (n ¼ 12) provides a somewhat different picture. Among the
29 cases that were seeking treatment with a donor (Fig. 1), 27
(93%) gave donor shortages in the UK as the predominant reason
to be seeking treatment outside the UK, illustrating the importance
of this issue for UK travellers. This group also described a range of
additional factors that contributed to the decision to actually travel
(Fig. 1). The precise combination of these reasons was complex and
varied between individual cases. A further 29% (12 cases) were
seeking treatment with their own gametes at the time of interview
and were therefore not taking into consideration the need for a
donor in their reasons to travel (Fig. 2). This group were more
likely to relate their travel to issues of ‘cost’ (n ¼ 6), a desire to
have treatment in a less stressful environment (n ¼ 6), or gave the
perceived higher rates of success overseas as a reason to cross
borders (n ¼ 5). However, this group also gave several additional
reasons and no one had a single reason for wanting to travel.
Contrary to the way this phenomenon has been reported in the
media, although some participants combined their treatment with a
holiday abroad, this was not a primary reason to go overseas.
Instead it was perceived as an opportunity to have treatment in a
relaxing environment, away from the stresses of everyday life and
this was given as a reason in a total of six cases. Some patients
found the logistics of travelling and organizing treatment gave rise to
additional difficulties, but a number of our participants felt that going
abroad (especially those who were able to be away from home for
longer periods of time) could reduce the stressful impact of trying
to combine treatment and work or family commitments. Furthermore,
disguising an absence from work for treatment abroad as a ‘holiday’
was helpful for those who did not wish to divulge treatment to
employers or family members. Those going longer distances were
most likely to be away for longer periods of time, while others had
most of their workup at home and flew out for just a few days, and
of course the precise timing was sometimes difficult to predict.
All our participants, however, actively resisted the ‘fertility tourist’
label and felt that the connotations of pleasure and leisure in no
way represented the process of organizing and undertaking fertility
treatment. They felt strongly that this was an unfair and inaccurate representation of their experiences.
Culley et al.
Figure 3 Destinations.
Table III Destinations and use of own/donor gametes,
all cases (n 5 41).
Use of
gametes
n cases
(%)
Destinations
........................................................................................
IVF donor oocyte
19 (46%)
Spain, Czech Republic, Ukraine,
Greece, South Africa, Cyprus, Russia,
USA
IVF own gametes
12 (29%)
USA, Barbados, Norway, Cyprus,
India, Russia, Spain, Czech Republic
IVF/IUI donor
sperm
5 (12%)
Hungary, Czech republic, Denmark,
USA, South Africa
IVF donor oocyte
and sperm
4 (10%)
Czech Republic, South Africa, Spain
Donor embryo
1 (3%)
Czech Republic
IUI, intrauterine insemination.
consideration, but were included in a more complex process of
decision-making.
Destinations
People travelled to a wide range of countries. Figure 3 shows actual
and planned destinations. The most popular destinations were Spain
and the Czech Republic. However, an additional 11 countries featured
in the participants’ accounts. In six cases, two different countries had
been visited and in a further three cases, plans to visit a second different country for treatment were being made at the time of interview.
Table III shows the destinations of different categories of travellers.
Various factors were taken into account in deciding on destinations:
shorter waiting times and greater availability of donors abroad; clinic
reputation and recommendations of other patients. For some patients,
an existing familiarity with a specific country was significant. For
example, one couple chose South Africa because they had relatives
there and had travelled there often; another couple chose the USA
since they were regularly in the country for work-related reasons.
Convenience, accessibility and cost of travel were usually taken into
Organizing overseas travel
Participants described a number of ways in which treatment overseas
was organized and these are given in Table IV. A substantial proportion (44%) of our sample had no involvement or assistance from
UK healthcare professionals when organizing their treatment.
Others were assisted by UK health personnel who provided ultrasound scans or raised and dispensed prescriptions. In most cases
(12) patients accessed these services on an ad hoc basis, while a
smaller number (6) received such help from clinics that had provided
their UK treatment. Many of our participants reported that they would
have appreciated recommendations on overseas clinics from UK clinicians and assistance with preparation and follow-up. Some patients
welcomed the choice and control that organizing their own treatment
offered and others found having to manage and co-ordinate their own
2377
Study of UK residents having fertility treatment abroad
Table IV How treatment was organized, all cases.
Organization of
treatment
n cases
(%)
Destinations
........................................................................................
No UK clinic
involvement
18 (44%)
Table VI Singleton and multiple pregnancies by
country.
USA, Barbados, South Africa,
Russia, India, Norway, Denmark,
Spain, Czech Republic, Greece,
Cyprus
Singleton
versus
multiple
Singletons
18 (44%)
Shared care with UK
clinic
4 (10%)
Spain
Twins
Medical travel agency
1 (2%)
Hungary
Total pregnancies
Countries
........................................................................................
1
4 (6%)
2
48 (70%)
Spain, Czech Republic
Spain, Czech Republic, Norway,
Barbados, USA, Greece, Russia
3
12 (17%)
Czech Republic, Russia,
Ukraine, USA, South Africa,
Barbados
4
4 (6%)
Ukraine, India, USA
5
1 (1%)
USA
treatment added to the stress of treatment, especially when they
encountered unwillingness on the part of UK providers to assist them.
For the majority of those managing their own treatment, the internet was a key source of both information and peer support. Websites
such as ‘Fertility Friends’ and ‘IVF World’ were frequently mentioned
as places to find out about specific clinics or to get information about
transport links and places to stay whilst abroad. Testimonies and recommendations from former patients were very important in choosing
clinics and countries to visit. Patients used overseas clinic websites, but
were often somewhat sceptical about the information provided,
especially in relation to success rates.
Embryo transfer and treatment outcomes
As Table V shows, for those who had reached the point of embryo
transfer, the majority of cycles involved the transfer of two
embryos. Few people reported a desire for more than three
embryos to be transferred, but several reported that they did not
wish to be restricted to single embryo transfer. Just one person
gave a desire for multiple embryo transfer (MET) as the dominant
reason for travelling abroad, but several others suggested that this
was one of the attractions of overseas treatment. Most participants
reported that they were aware of the risks of multiple pregnancies
but some judged MET as their best chance of success and were
willing to accept these risks.
Countries (n 5 number of
pregnancies)
26
81%
Spain (9), Czech Rep (3), USA (3),
Barbados (3), Norway (2),
Ukraine (2), Greece (1), India (1),
South Africa (1), Denmark (1)
6
19%
USA (2), Barbados (1), Spain (1),
Czech Rep (1), Ukraine (1)
32
100
Spain, Czech Republic, Greece,
Ukraine, Barbados
Table V Embryos per cycle and by country.
n cycles
(%)
%
........................................................................................
Monitoring and/or
prescriptions in UK
n embryos
transferred per
cycle
n
cases
There were 26 ‘successful’ cases in our sample (live births and
current pregnancies from cross-border treatment at the time of
taking part in the study; Table VI). In six cases, overseas treatment
had resulted in more than one pregnancy per woman, giving a total
of 32 pregnancies reported by our participants. Eighty-one percent
of the pregnancies were singletons and 19% were twins. No one in
the study had a high-order multiple pregnancy (triplets and above)
and no-one disclosed use of fetal reduction technologies to reduce
higher order pregnancies. Of those pregnant at the time of interview,
most were well established (into the third trimester) and all were at
least 7 weeks gestation with a fetal heart beat seen on ultrasound
scan. In three cases people had children as a result of treatment in
two different countries (two cases in Spain and the Czech Republic,
and one case in Spain and Greece).
Discussion
Socio-demographic characteristics
The travellers in this study were predominantly from professional or
managerial backgrounds, which may be a reflection of the economic
resources required to engage in cross-border fertility travel. All of
our participants were paying directly and personally for their overseas
treatment. In some other European countries (e.g. Netherlands,
France, Italy, Norway), patients report at least partial re-imbursement
in their countries of origin for cycles undertaken abroad (Shenfield
et al., 2010). While we have no way of knowing just how representative of UK fertility travellers our participants were, the profile suggests
that cross-border travel may be part of the broader process of ‘stratified reproduction’, whereby less wealthy and more marginalized
groups have reduced access to fertility treatment, both at home and
abroad (Culley et al., 2009).
In our study, the mean age of female participants at first treatment
abroad (38.8 years) was older than those having IVF treatment in the
UK in 2008 (35.2 years) (HFEA, 2010a), and younger than the mean
age (40.8 years) of the 53 UK patients surveyed in the clinics included
in the ESHRE Task Force survey (Shenfield et al., 2010). The oldest
person having treatment abroad in our study was aged 46 years and
just 7% were over 45 years of age. The age profile may reflect the
fact that many of our participants (78%) had already had treatment
in the UK prior to going overseas and that many were seeking
third-party-assisted conception with donated oocytes. Several had
2378
long and often complex fertility histories and had been trying to conceive for several years before travelling overseas.
Reasons for travelling abroad
Despite national variations in the most dominant reason for travel,
most studies identify a combination of factors leading patients to
seek treatment abroad (Inhorn and Shrivastav, 2010; Shenfield et al.,
2010). This study confirms this finding and is able to show in some
detail the complex forms of decision-making surrounding whether to
seek treatment overseas and where to go. The four most commonly
mentioned reasons for travel were: donor shortages in the UK
(especially donor oocytes), cost, success rates overseas and unsatisfactory care in the UK.
In the UK, demand for treatment with donated oocytes or sperm
continues to outstrip supply, resulting in long waiting times at some
clinics. There are currently 396 people registered as sperm donors
(HFEA, 2010b), and the British Fertility Society estimates that the
UK requires 500 donors a year to meet demand (Hamilton and
Pacey, 2008). The reasons for the donor shortage in the UK are
complex. While donor numbers have risen slightly in recent years,
there has been a decrease in patients receiving treatment with
donor gametes. It is unclear exactly why this is the case. It has been
proposed (Pacey, 2010) that this may be because following the
ending of donor anonymity in 2005, new donors are more likely to
be ‘known’ donors, though empirical data to support or refute this
suggestion are lacking. Human Fertilisation and Embryology Authority
(HFEA) data show that 16% of newly registered donors limit the use of
their donation to just one family (HFEA, 2011a). Furthermore, 20% of
new sperm donors are from overseas and their donation is more likely
to be used by one pre-specified patient (HFEA, 2011a). Many people
make initial enquiries about donation, but they do not go on to
become donors. The reasons for this are unclear. Donor and
patient organizations also suggest that donors are sometimes lost to
clinics because of inadequate communication and follow up. In
addition, and in contrast to some other European countries, the
number of families who can be created from one donor is limited
to 10. However, ,1% of donors create 10 families. On average
sperm donors create one or two families, with one or two children
in each family (HFEA, 2011a). The UK allows egg sharing whereby a
woman receives free or reduced cost treatment in exchange for the
donation of eggs to another woman for use in her treatment. This
is a significant source of donated oocytes used in treatment, but
again demand for oocytes outstrips supply (Simons and Ahuja,
2005). The shortage of donated gametes also means that recipients
have a limited choice of donor in the UK.
The cost of treatment in the UK was an important consideration for
many in our study and this may reflect a significant difference between
the UK and several other European countries in funding for IVF. Public
funding for treatment in the UK via the National Health Service (NHS)
has been described as a ‘postcode lottery’ in which entitlement varies
markedly from one locality to another (Kennedy et al., 2006). A range
of social criteria, such as age and presence of existing children, are also
commonly applied by local NHS funding bodies to exclude patients
from NHS treatment. While the National Institute for Clinical Excellence (NICE) Guideline for fertility treatment (NICE, 2004) recommended that three cycles of IVF should be available to those
Culley et al.
clinically suitable, relatively few local NHS commissioners have provided this level of treatment, and there is also an indication that in
the current economic climate, several areas are reducing the already
limited access to public funding for IVF (Guy, 2010). This is likely to
add further impetus to the search for cheaper options. Only around
12% of UK citizens have private health insurance (Coulter, 2006)
and fertility treatment is often excluded. Consequently, it has been
estimated that as many as 85% of IVF cycles are paid for directly by
patients (HFEA, 2008), at an average cost of around £5000 (HFEA,
2010c). Costs for assisted reproduction treatments (ARTs) vary considerably between countries (Connolly et al., 2010) and given the UK
funding context, it is perhaps not surprising that cost may be a significant factor in deciding where to have treatment.
An interesting finding from this study is that for those not requiring a
donor, the attraction of treatment overseas included the perception
that this would reduce the stress involved. Anecdotally, commentators
have suggested that one of the disadvantages of crossing borders is
that patients are away from normal sources of support. Our study
shows, however, that while the label ‘fertility tourist’ was criticized
by all participants, some felt that treatment away from the demands
of everyday activities was an attractive option.
A further important finding is that UK patients are not crossing
borders to avoid restrictive legislation, which would appear to be
the dominant reason among other European travellers. Shenfield
et al. (2010) reported legal reasons as the most important motivation
for Italian, German, French, Norwegian and Swedish patients. Legal
restrictions on forms of treatment and/or categories of people
denied treatment in several European countries are well documented
(Pennings, 2002, 2006a, b, 2009; Bartolucci, 2008; Pennings et al.,
2008, 2009; Ferraretti et al., 2010; Shenfield et al., 2010). For
example, Ferraretti et al. (2010) estimate that 160 million European
citizens have no full access to donor procedures in their own country.
In the UK, whilst the regulation of ART is comprehensive, there is
relatively liberal access to treatment. For those who can afford to pay,
the UK offers a wide range of treatment options, including
third-party-assisted treatments, PGD and preimplantation genetic
screening and non-commercial surrogacy. There are no formal legal
barriers to treatment on the grounds of sexual orientation, marital
status or age (though treatment of women over 50 years of age is
rare). In common with most European countries, the UK does not
allow potential parents to choose the sex of the embryos other
than for certain medical conditions, but no one in our study gave
sex selection as a reason for travelling abroad. On the other hand,
while few legal exclusions exist in the UK, it could be argued that
the shortage of donor gametes, a key driver for many, may relate,
at least in part, to the law on donor anonymity and regulations and
processes surrounding donor compensation in the UK (Hamilton
and Pacey, 2008).
Comparing our findings on reasons for travel with previous published work is difficult, as such studies are based on questionnaires,
and it is not always clear how questionnaire items relate to our qualitative data. For example, Shenfield et al. (2010) report that 34% of UK
patients gave ‘access difficulty’ as a reason for travelling abroad. This
category is derived from the questionnaire item which conflates
‘long waiting list, distance to centre, cost etc.’. However, among our
participants, it was clear that such issues could be exclusive and distinct reasons. For example, some patients were concerned about
2379
Study of UK residents having fertility treatment abroad
waiting lists, but cost was not an issue for them. Cost was important
for many, but ‘distance to centre’ did not present a barrier to anyone.
‘Previous treatment failure’ was the most commonly mentioned factor
among UK patients in the Shenfield et al. (2010) study (37.7%). Our
study can perhaps illuminate this survey finding. We found that 78%
of cases had received some form of treatment in the UK before
going overseas. In our sample, a substantial proportion of those
needing donor oocytes were seeking treatment abroad at the end
of a long history of other forms of treatment. In some cases they
had been unsuccessful in treatment with their own gametes, and
had now reached an age where donor oocytes were the only realistic
option. In other cases, patients using their own gametes had experienced repeated treatment failures in the UK, but reported that they
were not being offered any alternative treatments by UK clinics and
felt that they needed to ‘try something different’. In a small number
of cases (17%), patients were motivated to go overseas by a dissatisfaction with the level of care they received in their UK clinic and
several mentioned better success rates abroad (29%). The ESHRE
Task Force survey item conflated these two issues and in response,
28.3% of UK women gave ‘expecting a better quality and/or
outcome’ as one of their reasons for choosing a clinic abroad.
Shenfield et al. (2010) report that 26% of UK women indicated ‘a
wish for anonymous donation’ as one of their reasons for travelling
abroad. This was given as a reason in 10% of our cases and as the
dominant reason in just one case. However, this may be because in
discussion with participants, it was evident that for most of those
requiring oocyte donors there was, in effect, little choice in this
matter. They may or may not have desired an anonymous donor,
but having one was a simply an unavoidable corollary of having treatment in countries where donors were readily available and treatment
accessible and affordable. Our participants’ views on choice of donors,
anonymity and disclosure to offspring were complex and will be
reported separately.
Destinations and organization of travel
Our participants visited a wide range of countries, including several
long-haul destinations. The most popular country was Spain, followed
by the Czech Republic. This contrasts with the findings of Shenfield
et al. (2010) where 52% of UK patients had visited the Czech Republic
and 28% Spain. However, this may reflect the low response rate from
Spanish clinics to the ESHRE Task Force survey. The interviews in our
study suggest a complex relationship between reasons for travel, treatments sought and destinations. As we have seen, a desire for oocyte
donation was a key motivating factor for many people, and hence the
popularity of Spain, where around half of oocyte donation treatments
in Europe are carried out (de Mouzon et al., 2010). However, for
some people, we can see also the influence of cost—with some travelling to clinics in the Czech Republic, reporting this as a cheaper
alternative.
The significance of the geographical and cultural specificity of destination countries, and the relevance of travel costs and convenience
have been suggested in other studies (Pennings et al., 2009; Whittaker,
2009; Inhorn and Shrivastav, 2010; Whittaker and Speier, 2010). Pennings et al. (2009) have identified the significance of vicinity in crossborder travel to Belgium. The relative absence of formal shared care
arrangements amongst study participants may reflect the timing of
the study, and the fact that until fairly recently, many UK-based clinicians may have been unsure about the legal consequences of becoming involved in forms of treatment overseas that might contravene UK
regulations, such as treatment involving anonymous donors (HFEA,
2010d). It would appear that a greater number of clinics in the UK
now offer shared care arrangements with overseas clinics (HFEA,
2010c), although there is little precise information on this issue. An
important finding of our study is that peer networks and especially
internet fora were almost universally used by our participants and
were considered invaluable in helping people initiate and manage
the process of cross-border treatment. This confirms both anecdotal
reports and some existing evidence (Blyth, 2010).
Embryo transfer and multiple pregnancies
Our data suggest that we should exercise caution in concluding that
treatment abroad will inevitably result in more higher order pregnancies than similar treatment in the UK. Although we have a relatively
small sample, as Table V shows, most cycles involved the transfer of
two embryos (70%). In 2007, 81% of UK transfers involved two
embryos (HFEA, 2009).
It could be the case that the clinics most commonly visited by participants in this study (in Spain and Czech Republic) are not routinely
transferring larger numbers of embryos. Data on embryo transfer for
these two countries are not included in the European IVF Monitoring
reports (de Mouzon et al., 2010); however, a recent paper argues that
the implementation of Spanish Fertility Society guidelines on embryo
transfer has resulted in a reduction in multiple pregnancy rates from
2002 to 2003 (Cabello et al., 2010). Within Europe as a whole
there is a clear trend towards the transfer of fewer embryos (de
Mouzon et al., 2010). The small number of patients in our study
who had four or more embryos transferred had visited countries
outside Europe such as the USA, India and the Ukraine. Data for
2006 show that over 60% of transfers in the Ukraine involved three
or more embryos (de Mouzon et al., 2010).
The twin pregnancy rate for our sample (19%) was similar to that
for Europe as a whole in 2006 (19.9%) (de Mouzon et al., 2010)
and close to the target for annual birth rates from fertility treatment
in the UK for 2010 issued by the HFEA (2010a). In 2008, the multiple
pregnancy rate for all IVF treatments in the UK was 23.2% (HFEA,
2010e). A study by McKelvey et al. (2009) of one London-based multiple pregnancy unit concluded that over a 11-year period (1996 –
2007) higher order pregnancies occurred in 94 women having IVF
treatment, 24 of whom had this treatment abroad: it is not clear
from this study however, what percentage of the unit’s patient population this represents, or that the individuals concerned were UK citizens. Furthermore the dates encompass a period when MET was
more common in many countries (including the UK).
Limitations and strengths of the study
Limitations of the study include the size of the sample and the fact that
participants were self-selecting. They were, however, recruited
through a number of different sources in order to give some diversity
in this regard. Representativeness is unknown, as there are no reliable
data on the extent or nature of cross-border travel from the UK.
However, the similarities with the 53 UK respondents in Shenfield
et al. (2010) afford some confidence in the sample. The majority of
2380
participants had accessed treatment in Europe, although we did
capture the experiences of 12 cases where people had gone further
afield. We did not have access to medical records and are thus
relying on participants to accurately recall their diagnoses and treatments. There were also fairly high rates of success (though comparable to rates in the UK for similar treatments) among these
participants, which may have influenced both their readiness to take
part in the study and how they reported their experiences. Those
with adverse outcomes or those who have had selective fetal
reduction may have been less willing to come forward. However,
the accounts of those who did not achieve a pregnancy are not substantially more positive or negative than the accounts of those who
were successful. This was not a questionnaire study and we are presenting numerical data derived from qualitative interviews.
The major strength of the study is the generation of detailed data
with over 4000 minutes of discussion with individuals allowing the
investigators to probe answers and check meaning and interpretation.
Previous studies have relied on pre-coded questionnaires for patients,
or indirect reports of patient motivations from clinics. Our approach
has allowed us to complement this work and interrogate findings.
The study is also unique in having outcome data for an identifiable
group of patients who have been abroad, allowing us to see the
whole treatment journey.
Conclusions
People travelling from the UK have diverse pathways to overseas
treatment. A desire for timely and affordable treatment with donor
gametes (especially oocytes) was clearly evident in a high percentage
of cases. Others were seeking treatment with their own gametes and
gave a wide range of reasons, including cost, perceived higher success
rates and dissatisfaction with UK treatment. Women were older on
average than those having treatment in the UK, but this was often a
consequence of the length of time they had been trying to conceive
before going abroad. The numbers of twin pregnancies were similar
to that following treatment in the UK and no one had a higher
order multiple pregnancy. Further research, both quantitative and
qualitative, is needed to explore the implications of cross-border
treatment for donors, offspring and healthcare systems.
Authors’ roles
L.C.: Principal investigator; led study design; assisted in data collection;
analysis and interpretation; led study write up and manuscript preparation. N.H.: Project researcher and co-applicant, contributed to
study design, carried out data collection and analysis, contributed to
write up and manuscript preparation. F. Rapport, E. Blyth,
W. Norton and A. Pacey, grant co-applicants, made a substantial contribution to study design and interpretation of data, as well as manuscript preparation and final approval of manuscript.
Acknowledgements
The authors thank Clare Lewis-Jones, Infertility Network UK, Daisy
Network, National Gamete Donation Trust, British Infertility Counselling Association, Donor Conception Network, the HFEA, Progress
Culley et al.
Educational Trust, Fertility Friends, and the individual advisory group
members for their involvement and support for the study. Special
thanks go to the participants for giving their time and allowing us to
hear their personal testimonies.
Funding
The study was funded by the Economic and Social Research Council.
Grant reference: RES 000-22-3390.
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