Cross-border Reproductive Care in Czechia: Insights from National Registry Data

Cross-border reproductive care: an Ethics Committee opinion.

Assessing the use of assisted reproductive technology in the United States by non–United States residents

Oocyte Donation Does Not Influence Adversely the Outcome of Assisted Reproductive Technologies

Study question How common is cross-border reproductive care (CBRC) in the U.S. among international same-sex male intended parents? Do CBRC LBRs differ compared to domestic counterparts? Summary answer A substantial number of international same-sex male intended parents seek CBRC in the U.S. LBRs per transfer are reassuring and comparable to domestic counterparts. What is known already Same-sex male intended parents often work with a gestational carrier to have a genetically related child(ren); however, restrictive and/or discriminatory policies in their home countries may prevent access. Intended parents may seek CBRC in countries like the U.S. due to favorable regulations. However, the volume of CBRC activity among same-sex male intended parents has been difficult to estimate accurately due to poor sexual orientation data collection. Capitalizing on national databases that identify same-sex male intended parents is the first step to describing CBRC trends and their associated outcomes in a marginalized population that is often excluded in the literature. Study design, size, duration This national retrospective cohort study included U.S. based gestational carrier embryo transfer cycles from the Society for Assisted Reproductive Technology (SART) database in the years 2017–2020. Among participating clinics (n = 488), 6,168 cycles among same-sex male intended parents were identified. Relative risks (RRs) for LBRs per transfer were compared for cycles including domestic (i.e., U.S. based, n = 3,052) and internationally based (n = 3,080) patients. LBR and country data were missing for 546 and 36 cycles, respectively. Participants/materials, setting, methods The inclusion criteria were transfer cycles among male patients with male partners. Unadjusted and adjusted RRs for LBRs per transfer were calculated to compare domestic (reference) and internationally based groups using multivariable Poisson and logistic regression models with generalized estimating equations (GEEs). Models were adjusted for donor age, transfer type (i.e., fresh, frozen), day of transfer, number of embryos transferred, male infertility, and the use of intracytoplasmic sperm injection, assisted hatching, and preimplantation genetic testing. Main results and the role of chance Between 2017 and 2020, 6,168 cycles with an embryo transfer to a gestational carrier occurred among same-sex male intended parents in the U.S. In half of the cycles, the U.S. was a destination for CBRC (50%, n = 3,080) among which (48%, n = 1,540) were from one of 23 European countries. Regarding countries of residence for CBRC cycles (n = 3,080), those most reported were China (23%), France (19%), Israel (13%), Spain (11%), the United Kingdom (6.1%), Australia (4.1%), Germany (3.7%), Italy (2.6%), Switzerland (1.5%), Canada (1.5%), Belgium (1.4%), Singapore (1.0%), Taiwan (1.2%), Norway (1.2%) and The Netherlands (0.92%). Additionally, there were 76 cycles from 8 countries in South America (2.3%), 9 cycles from 6 countries in Africa (0.27%), and 3 cycles from 2 countries in Central America (0.089%). Most cycles were in the U.S. West (72%, n = 4,441; e.g., California [47%]). Median oocyte age was 26 years (interquartile range 24,28) with a majority of cycles involving single embryo transfer (78%, n = 4,802). LBR per transfer was 69% (n = 3,867). There was no statistical difference between live births for domestic versus CBRC cycles in the unadjusted (RR 1.14, 95% confidence interval [CI] 0.96, 1.37; p: 0.141) or adjusted regression models (aRR 1.06, 95% CI 0.86, 1.32; p: 0.572). Limitations, reasons for caution The SART surveillance system captures most (∼90%) but not all embryo transfer cycles in the US. Current gender identity data were not available. Only the individual identified as the patient (and not the partner) indicated country of residence. The rationale for pursuing CBRC in the U.S could not be explored. Wider implications of the findings This study highlights a substantial amount of CBRC among same-sex male intended parents choosing the US for reproductive care. Implementing improved sexual orientation and gender identity data collection strategies are critical to filling CBRC data deserts not only among same-sex male intended parents but all sexual and gender minority populations. Trial registration number Not applicable

International Committee for Monitoring Assisted Reproductive Technologies world report: assisted reproductive technology, 2014†.

STUDY QUESTIONWhat are the characteristics, motivation and experience of French patients seeking cross-border reproductive care (CBRC)?SUMMARY ANSWERFrench patients seeking CBRC are same-sex couples, single women who are not eligible for assisted reproduction technologies (ARTs) in France and heterosexual couples seeking oocyte donation due to extremely limited access to this technique in France, while their choice of Greece as a destination is influenced by financial issues.WHAT IS KNOWN ALREADYCBRC is a new, increasing, complex and poorly understood phenomenon. A few studies have investigated UK, German or Italian CBRC patients, but none have specifically investigated French patients although France is one of the top four countries of origin of CBRC patients in Europe.STUDY DESIGN, SIZE, DURATIONA cross-sectional study was carried out in 2010–2012 in three ART centres in Greece, Belgium and Spain in order to investigate French patients treated in these centres. Recruitment was prospective in Greece and Belgium and retrospective in Spain. The overall response rate was 68%, with 128 French patients participating.PARTICIPANTS/MATERIALS, SETTING, METHODSFrench patients filled in a questionnaire. Information was collected on their socio-economic characteristics and their search for ART treatment in France and in other countries.MAIN RESULTS AND THE ROLE OF CHANCEIn the Belgian centre, 89% of French patients used sperm donation whereas oocyte donation was used by 100% of patients in the Greek centre and 74% of patients in the Spanish centre. The majority (94%) of French patients using sperm donation in Belgium were not legally eligible for access to ART in France as they were same-sex couples or single women, and the main criterion of choice of centre was its geographical proximity (71%). Most of the French patients using oocyte donation in Greece and Spain fulfilled criteria for fully reimbursed oocyte donation treatment in France as they were heterosexual couples (99%) with the woman aged <43 years (65%). For these couples, CBRC was motivated by the extremely limited access to oocyte donation in France. Half of French CBRC patients using oocyte donation in Spain had a low/intermediate occupational level (such as primary school teachers, nurses, administrative officers or sales agents, workers and employees) and this proportion was much higher in Greece (82%, P < 0.01).LIMITATIONS, REASONS FOR CAUTIONLarger and more wide-ranging studies are needed as this study included only 128 patients who may not be representative of all French CBRC patients, especially because the study was carried out only in three ART centres and these too may not be representative.WIDER IMPLICATIONS OF THE FINDINGSCBRC among French patients had been thought to reflect mainly law evasion. This study showed that the reality is much more complex and that CBRC among French patients reflects both law evasion and limited access to oocyte donation in France. It also brings new insight into the characteristics of the patients by suggesting a certain degree of ‘democratization’ in access to such care. However, the choice of centre seemed related to socio-economic characteristics, in that the Greek centre treated a less advantaged population than the Spanish centre.STUDY FUNDING/COMPETING INTEREST(S)This study was supported by French public research funds, the Institute Emilie du Châtelet from the Ile-de-France Region, the Biomedicine Agency and the Research Institute of Public Health (IReSP). There are no conflicts of interest.TRIAL REGISTRATION NUMBERNot applicable.

The goal of the present study is to discuss the issue of Cross-Border Reproductive Care known as CBRC and Reproductive Tourism. The subject is of great interest as this type of tourism has been flourishing in recent years, without, however, being thoroughly researched, regarding the very important, health, quality of medical care, financial, ethics, legality and transparency or illegality, aspects concerning the processes that are carried out for the desired result of human reproduction. In addition, one of the sharpest-increasing types of Cross-Border Reproductive Care is international surrogacy. Thousands of interested people travel abroad for IVF and ICSI treatment, or with the aim to employ the paid services of foreign surrogates. The search for solutions has made CBRC a global industry. It is a multibillion-euro international industry introducing unique legal, financial, ethical, and risk-management challenges and disputes.&#x0D; The current study addressed this gap by examining Greek citizens’ attitudes toward Reproductive Tourism and Cross border reproductive and their legal, financial, ethical, consequences. To test the research hypotheses, a survey was conducted on 652 Greek citizens, who answered a questionnaire, which was distributed electronically in the format of a Google form. For the data analysis the study used the multiple correspondence analysis – MCA of sphere of multivariate data analysis.&#x0D; The results discuss, as far as the legal dimensions are concerned, the restriction on specific reproductive treatments in the country of residence. IVF and ICSI are allowed in almost all countries but there are legal restrictions regarding the age of the woman or the couple, unmarried couples, single woman, gay, transgender and same-sex couples. As far as the financial dimension of the CBRC is concerned, the study discusses the lack of financial data that is a natural consequence of the lack of both national and global registers. The cost of infertility treatment seems to be one of the most basic reasons for those interested to seek assisted reproductive services outside the borders of their country of origin and residence, and the commercialization of health is an ethical issue that deserves further study in relation to the country of destination. In addition, the study discusses main ethical issues regarding donors and surrogate mothers, among others, which have to do with their exploitation, their moral and physical harm, possible child abuse, parental rights and the sale of babies which are considered of a major importance. Donor or surrogate mothers may suffer from serious and even life-threatening complications. Donor or surrogate mothers from low and economic backgrounds do not have the possibility of legal support and coverage and cannot claim parental rights. Additionally, the study debates the high cost of treatments, health and care benefits, the economic exploitation of women from countries with weak economies, the instrumentalization of women, the legal issues and rights of descendants born in destination countries and in terms of their repatriation, the correct information and informed consent for the medical procedures to be performed, as well as many others because the list is long.&#x0D; According to the study the need that is obvious, due to the great impact of the CBRC, concerns the creation of a universal protocol through the European Council and the College of Obstetrics and Gynaecology (EBCOG) as well as the American College of Obstetrics and Gynaecology (ACOG) to remove all the above mentioned issues , issues and moral dilemmas that above all will guarantee the good of health, justice, non-harm, the good of justice, autonomy and self-determination and finally, human rights.

Association of state insurance coverage mandates with assisted reproductive technology care discontinuation

Study question Is progesterone receptor (PGR) downregulation disrupted within endometrial epithelial compartment, during embryo receptivity phase in assisted reproductive technology (ART) cycles? Summary answer PGR is not downregulated in endometrial epithelial cells from ART cycles during embryo receptivity phase. What is known already Progesterone (P4) promotes the downregulation of its own progesterone receptor (PGR). During the mid-luteal phase, PGR is downregulated in endometrial epithelial cells (EEC), a critical process for embryo implantation. Embryos are unable to attach to the maternal surface when PGR expression is sustained in EEC. Non-physiologic ovarian steroid produced or employed in ART cycles may alter endometrial development compromising its receptivity. Scarce information is available whether PGR is downregulated in EEC from ARTs including ovarian stimulation for in vitro fertilization (IVF) cycles or hormonal endometrial preparation for frozen thawed embryo transfer (HEP-FET). Study design, size, duration Cross sectional study including endometrial samples from fertile women during natural cycle (FNC, n = 23), from infertile women submitted to IVF (n = 19) and from infertile women who underwent mock HEP-FET (n = 35). Samples were obtained between 2018–2019. Sample size was calculated considering a power of 90%, alpha error=0.05, an expected PGR expression of 2 and 0.5 in ART and FNC groups, respectively, having a standard deviation=0.9. At least 9 patients would be necessary in each group. Participants/materials, setting, methods Endometrial samples were obtained during mid-luteal phase scheduled 7 days after ovulation in FNC, 5 days after oocyte retrieval in IVF without embryo transfer or 5 days after P4 supplementation in HEP-FET. Immunohistochemistry was employed to quantify PGR using histologic score (Hscore). PGR mRNA levels were determined by qRT-PCR from EEC dissected by laser capture microdissection. Anova test was used for comparing means of Hscore and mRNA among groups. Statistical significance was established as P &amp;lt; 0.05. Main results and the role of chance No statistical differences were found in demographic characteristics including age, body mass index or endometrial thickness. The PGR expression was reduced in FNC compared to IVF and HP-FET endometria (0.6 ± 0.1, 1.9 ± 0.9 and 2.2 ± 0.9 respectively; P &amp;lt; 0.0001). The PGR mRNA levels from ECC dissected by laser capture microdissection were higher in IVF and HP-ET cycles compared to FNC (10.6 ± 3.1, 13.6 ± 2.3 and 0.8 ± 0.1 respectively; P &amp;lt; 0.0001) corroborating the elevated PGR Hscore in EEC from ART cycles. Limitations, reasons for caution This is a descriptive study reporting failure of PGR downregulation in endometria from ART cycles with vaginal P4 supplementation during the luteal-phase. Whether interference or resistance to P4 signal is the mechanism involved in the failure of PGR down regulation in ART cycles needs to be determined Wider implications of the findings: PGR downregulation within EEC was shown in FNC. The retained PGR expression detected in most ART cycles may interfere with embryo implantation and might explain the restricted pregnancy success. Future studies might reveal whether PGR evaluation in EEC can predict embryo implantation. Trial registration number Not Aplicable

Assisted reproductive technologies (ART) in Canada: 2004 results from the Canadian ART Register

Assisted reproductive technologies (ART) in Canada: 2003 results from the Canadian ART Register

The attitudes towards cross-border reproductive care (CBRC) held by infertile Japanese patients have not been explored. The objective of the present study was to examine interest levels, preferred destinations, motivations, and sources of information related to CBRC. Our findings provide a general outline of CBRC and the future of reproduction and assisted reproductive technology (ART) in Japan. The study used a cross-sectional design. Data were collected from 2,007 infertile Japanese patients from 65 accredited ART clinics in Japan (response rate, 27.4%) via anonymous questionnaires. Most of the infertile Japanese patients who responded denied using CBRC. However, by group, 171 (8.5%) patients in non-donor in vitro fertilization, 150 (7.5%) in egg donation, 145 (7.2%) in pre-implantation genetic diagnosis, and 129 (6.4%) in surrogacy said that, depending on the situation, they might travel abroad in the future. Older respondents were more likely to express an intention to travel overseas for egg donation in the future. The most popular destination for CBRC was the United States. Popular reasons for interest in CBRC among those considering or planning using this approach to third-party reproduction were that egg donation or surrogacy was unavailable or that obtaining ethical approval takes too long in Japan, whereas these processes are legal and affordable overseas. However, high cost was the most common reason for hesitancy regarding CBRC. Among the participants who were considering or planning to travel abroad for this purpose, TV, medical agencies, print media, and message boards on websites were popular sources of information, whereas doctors, friends, and patient self-help groups were not. Although CBRC among infertile Japanese patients is not at present common, the demand for and use of this approach may increase in the future in the context of the increasingly aging population. Lack of regulation and unavailability of third-party reproduction is a major cause of CBRC among Japanese patients. Health care provider faces an urgent need for giving useful information for patients regarding CBRC.

Assisted reproductive technologies (ART) in Canada: 2006 results from the Canadian ART Register

Assisted reproductive technologies (ART) in Canada: 2007 results from the Canadian ART Register

When Darine El-Chaar began her residency in obstetrics and gynecology at the University of Ottawa five years ago, she grew curious about the potential health repercussions of assisted reproductive technologies (ART), the catchall term for procedures used to help couples artificially conceive a child. ART involves surgically removing eggs from a woman’s ovaries, combining them with sperm in the laboratory, and returning them to the womb.1 Women undergoing ART take “fertility drugs” such as clomiphene citrate and gonadotropins to stimulate the production of many eggs rather than the single egg that would normally grow during their monthly menstrual cycle.2 El-Chaar wondered about the influence that ART procedures, as well as the underlying infertility itself, might have on the health of children conceived. She is one of many researchers working to answer the fundamental question of whether introducing fertility drugs and manipulating eggs and sperm in a laboratory setting—in essence, altering the primal environment—sets the stage for adverse health effects in children. Artist’s rendering of intracytoplasmic sperm injection, in which a single sperm is inserted into an egg. Although some research indicates such a risk exists, there haven’t been enough large-scale studies to ascertain if the potential effects are severe enough over the long term to deter couples from seeking infertility treatments. Meanwhile, some findings are pointing the way toward possible refinements to improve health outcomes for ART babies.