Cross-border Reproductive Care Research Articles

Social egg freezing and reproductive rights justification: A perspective from China.

Divergences and controversies are inevitable in the discussion of freedoms and rights, especially in the matter of reproduction. The Chinese first social egg freezing lawsuit raises the question: is the freedom to freeze eggs for social reasons justified because it is an instance of reproductive rights? This paper accepts social egg freezing as desirable reproductive freedom, but following Harel's approach and considering two theories of rights, the choice and interest theories of rights, we argue that social egg freezing is not a reproductive right because one cannot justify a right or an instance of rights via merely describing the function of those instances that have been justified as right, that is, the choice theory lacks justifying normativity. Since reserving fertility and a suspension from reproduction do not serve reproductive ends per se, the sufficient reason for demanding social egg freezing as a right should be found in other ends rather than in right-to-reproduce, that is, the interest theory denies the demand as a right-to-reproduce. Permitting it on any grounds without guaranteeing adequate and accessible resources, especially in light of cross-border reproductive care, raises serious questions about reproductive equality and violates the idea of reproductive rights. Therefore, any ground for social egg freezing should be weighed against whether more pressing reproductive needs, specifically those that are justified as rights, have been met. It would be social progress to shoulder these burdens for the vulnerable and then allow social egg freezing-if right-to-reproduce were not the only privilege of the few.

Gendering the beginning of life: Taiwanese gay fathers' navigation of preimplantation genetic diagnosis-assisted sex selection in transnational third-party reproduction.

Preimplantation genetic diagnosis (PGD) has been used not only to avoid genetic diseases and increase conception success rates but also to perform non-medical sex selection, particularly in the surging cross-border reproductive care (CBRC). In the context of commercialised biomedicine, assisted reproductive technologies, such as lifestyle sex selection, have been tailored to meet intended parents' preferences. However, there is a lack of analysis on how individuals' reproductive decisions on PGD-assisted sex selection were shaped within the sociocultural norms and CBRC. This article explores Taiwanese gay fathers' navigations on sex selection while seeking third-party reproduction overseas because of local legal constraints. Drawing on in-depth interviews with 53 gay fathers (to-be), I analysed how 'individual preferences' were dynamically shaped by local sociocultural norms and embedded within transnational settings of routinising PGD in chosen repro-destinations. The findings showed that gay fathers mobilised strategic discourses on non-medical sex selection from both the local and the global to negotiate their decisions in coherence with their LGBTQ+ identity and their role as sons carrying familial responsibility to procreate male heirs. This article proposed a nuanced understanding of gay fathers' reproductive practices of 'gendering the beginning of life' through PGD-assisted sex selection.

Debate 2: Cross Border Reproductive Care Should Be Banned

Motion: For The opinions expressed in this debate are not the personal opinions of the presenter but are points raised to provide a debate. CBRC is defined as “movement of persons from one jurisdiction to another in order to access or provide treatment. Often called “reproductive tourism” but it is “reproductive exile” Existed for many years before fertility treatment-Irish women going to England for abortion. Why? Either unavailable or more affordable. Avoid legal, religious, or ethical restrictions Do we want to encourage breaking the laws of home? Do we encourage exploitation of poor donors/surrogates? Do we want to encourage avoidance of record keeping of donors? CONCERNS Health and safety Legal difficulties, e.g., passport for child Exploitation Children as a “commodity” Children abandoned e.g., Abnormalities SAFEGUARDS Balance rights of individuals against rights of children Need global guidelines/laws- UNTIL THEN; BAN CBRC. Motion: Against Cross-border reproductive care (CBRC) has become a dynamic global phenomenon encompassing various fertility treatments and practices, including surrogacy, embryo donation, age limit, marital status, cost considerations, advanced technology, support systems, known clinician or clinic preference, frozen embryo use, international job transfers, sex selection, PGTA restrictions, and restrictions on the number of embryos transferred. This debate revolves around the motion against banning CBRC, acknowledging its multifaceted nature and the need for comprehensive evaluation of its legal, ethical, and economic implications. CBRC has emerged as a lifeline for individuals facing restrictive reproductive laws in their home countries, offering hope and expanded choices for family building. Critics express concerns over potential exploitation, inadequate regulations, and safety risks associated with CBRC. Ethical dilemmas arise regarding patient autonomy, justice, and discrimination, particularly for LGBTQI individuals seeking fertility treatments in less legally restrictive countries. International organizations such as ESHRE, ASRM, ICMART, and IFFS have initiated efforts to collect data and set guidelines for CBRC. However, more work is needed to establish standardized data registries and harmonize laws to accurately assess the magnitude and scope of CBRC worldwide. A balanced approach to CBRC involves collaborative global governance and cooperation to address challenges while upholding patient rights and ensuring responsible practices. Facilitating access to advanced fertility treatments and safeguarding against potential risks are paramount considerations in shaping the future of cross-border reproductive care. In conclusion, the complexities surrounding CBRC warrant thoughtful deliberation and international collaboration. Rather than imposing a blanket ban, an inclusive approach focusing on transparency, safety, and ethical considerations will foster a responsible and balanced implementation of cross-border reproductive care.

Identifying discrepancies between clinical practice and evidence-based guideline in recurrent pregnancy loss care, a tool for clinical guideline implementation

BackgroundPractice variation in recurrent pregnancy loss (RPL) care is common. International guidelines vary in their recommendations for the management of RPL couples, which could lead to an increase of cross border reproductive care. Currently, the Dutch RPL guideline is being adapted from the European Society for Human Reproduction and Embryology (ESHRE) guideline. We aim to identify discrepancies between RPL guidelines and RPL practice. These discrepancies could be considered in the development of a new guideline and implementation strategies to promote adherence to new recommendations.MethodsA nationwide survey on the management of RPL patients was conducted across all 107 hospital-based obstetrics and gynaecology practices in the Netherlands. The survey was sent via the Dutch Society for Obstetricians and Gynaecologists to all affiliated clinicians. The questionnaire consisted of 36 questions divided in four sections: clinician’s demographics, RPL definition, investigations and therapy. The data were compared to the recommendations given by the Dutch national guideline and the most recent guideline of the ESHRE.ResultsAll hospital-based practices (100%; n = 107) filled in the online questionnaire. The majority of respondents defined RPL similarly, as two or more pregnancy losses (87.4%), not obligatory consecutive (93.1%). More than half of respondents routinely perform thrombophilia screening ( 58%), although not advised by the ESHRE, while thyroid function (57%), thyroid auto-immunity (27%) and β2-glycoprotein antibodies (42%) in the context of antiphospholipid syndrome (APS) are recommended but investigated less often. Regarding parental karyotyping, 20% of respondents stated they always perform parental karyotyping, without prior risk assessment. because of RPL. Treatment for hereditary thrombophilia was frequently (43.8% (n = 137)) prescribed although not recommended. And finally, a considerable part (12–16%) of respondents prescribe medication in case of unexplained RPL.ConclusionWhile many clinicians perform investigations recommended by the ESHRE, there is a considerable variation of RPL practice in the Netherlands. We identified discrepancies between RPL guidelines and RPL practice, providing possibilities to focus on multifaceted implementation strategies, such as educational intervention, local consensus processes and auditing and feedback. This will improve the quality of care provided to RPL patients and may diminish the necessity felt by patients to turn to multiple opinions or cross border reproductive care.

The influence of the increasing use of assisted reproduction technologies on the recent growth in fertility in Czechia

This study aims to enhance the understanding of how the increasing use of assisted reproductive technologies (ART) has contributed to the increase in the total fertility rate (TFR) and to further delaying childbearing. Moreover, it addresses the gap in the methodology concerning the quantification of the effect of ART on fertility postponement. Czechia is one of few countries that are able to serve for the study of the demographic impacts of ART. ART and non-ART fertility rates were calculated using unique data on all children born in Czechia. Excluding mothers who received cross-border reproductive care, the proportion of ART live births in Czechia has not exceeded 4%. However, without ART the TFR would have stood at just 1.65 instead of 1.71 in 2020. ART significantly contributed to a reduction in childlessness and to the increase in fertility rates at ages over 35. Applying the decomposition method, the contribution of the use of ART to delaying childbearing between 2013 and 2020 was 4%. The findings have important policy implications. ART has the potential to support fertility recovery in the context of delayed childbearing. The findings served to alleviate concerns about the contribution of ART to the further undesired delay of childbearing.

P-455 Transnational Gestational Surrogacy During Covid-19 pandemics and War in Ukraine. A qualitative, interdisciplinary study of Danish infertile couples’ experiences in a world of change

Abstract Study question How do permanently infertile couples experience surrogacy in cross border reproductive care (CBRC) and which considerations do they have in relation to this? Summary answer The couples find surrogacy treatment in CBRC satisfying but feel forced to use CBRC, and estranged from own country, missing reproductive body, and home What is known already Permanently infertile couples in Denmark must go abroad if they want a genetically related child, as health care professionals are not allowed to assist in a surrogacy process. Divergent legislation on surrogacy worldwide often creates a demography of permanently infertile couples, moving around depending on which country permits gestational surrogacy. Only few academic studies have described how external circumstances as Covid-19 pandemics and the current war in Ukraine affect the world of surrogacy and even fewer studies have focused on the infertile couples’ situation. Study design, size, duration Semi-structured qualitative interviews, including a total of fourteen couples, were conducted with permanently infertile couples across Denmark from May 2022 to September 2022. The couples chose place, time and if they preferred to be interviewed individually or together. Eleven couples chose their own home, two preferred online interviews and one interview was held in another place. Each interview lasted for an average of 93 minutes. Participants/materials, setting, methods Fourteen infertile couples (N = 23 participants), majority heterosexual, in different stages from planning to use a gestational carrier to having two children through surrogacy were interviewed. Interview themes included “history of infertility”, “experiences with surrogacy”, “openness about one’s own situation”, and “considerations about surrogacy”. The majority used/had used Ukraine as destination of surrogacy. The interviews were recorded, anonymized, and transcribed. Data were analysed using Malterud’s method of systematic text condensation. Main results and the role of chance Most couples had a relative in Denmark who offered to be a gestational carrier, but all except one couple declined this offer as they felt very unsecure about the legal situation not only for them, but also for the carrier, and a potential child. Instead, they decided to go abroad, mainly to Ukraine, to have an enforceable transparent contract, professionals to advise and the possibility of using the intended mother’s eggs. They didn’t feel it as a “choice” but more as the only option to have the longed-for child. Many felt that Danish authorities on purpose tried to obstruct their way home with the new born which contributed to this sentiment of estrangement. According to Danish legislation if the gestational carrier was reimbursed, the intended mother cannot be granted legal motherhood at any time. This lack of acknowledgement of motherhood was not only a practical issue for the couple, but deeply affected the intended mothers of not being “worthy mothers”. The empirical realities of these couples within the context of a pandemic, a war, and borders that open and close are a confrontation and clear illustration of the different legislations on surrogacy in Denmark and worldwide. Limitations, reasons for caution The study participants had all chosen to be part of this study after advertisement in targeted internet forums. Hence, the results may not be directly transferred to all permanently infertile couples regarding attitudes towards being infertile and using surrogacy. Wider implications of the findings This study contributes to the understanding of being permanently infertile and the implications of the Danish and international legislation on surrogacy. Findings from our study will be useful to form the academic basis of a near-future revision of the existing surrogacy legislation. Trial registration number Institutional Review Board at Aarhus University, Denmark (HE 2022-001)

The reproductive silk route: transnational mobility of oocytes from Europe to Brazil

Assisted human reproduction has been deterritorialised into reproductive connectivity networks capable of adapting to contradictory laws, technological development and the mobility of people, reproductive substances, knowledge and capital. We reflect on the reproductive market and the dynamic capacity of cross-border reproductive care (CBRC), thanks to oocyte vitrification for egg donation, and on the legislative gaps that favour these flows. The purpose of the present study is to show the reproductive flows of oocytes from Europe to Brazil, which seem to have erratic route changes, leaving Spain and passing through other European countries, where they are stored, before arriving in Brazil. We carried out a qualitative study, based on documentary analysis of Brazilian Ministry of Health records on oocyte importation, the EU Coding Platform (System for Tissues and Cells), 10 in-depth interviews with key informants and legislative analysis on reproductive technologies in Spain, Brazil, Slovakia and Italy. This flow of oocytes underscores the flexibility and adaptability of transnational reproductive care.

Attitudes toward Reproductive Tourism and Cross border reproductive care (CBRC): Legal, Economic, Ethical issues and dilemmas, possibilities and limitations

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.
 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.
 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.
 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.

Spanish translation of the International Glossary on Infertility and Fertility Care, 2017.

In December 2014, the International Committee for Monitoring Assisted Reproductive Technology under the umbrella of the World Health Organization convened an expert meeting to re-examine, update and expand the infertility glossary previously published in 2009. Thus, the International Glossary of Infertility and Fertility Care was developed and published in 2017 simultaneously in Fertility and Sterility and Human Reproduction. In this article, we present the glossary translated into Spanish, obtained after evaluation by Argentinian experts in the field of assisted reproductive technologies, reviewed by Dr. Zegers-Hochschild and approved by the board of the Argentinian Society of Reproductive Medicine (SAMeR). The translation of the glossary to Spanish will facilitate communication between professionals responsible for the practice of ART in Spanish-speaking communities. Moreover, it will lend support to promote better understanding as well as safer and better care for Spanish-speaking minorities and those experiencing cross-border reproductive care.

Reproductive birth control after the coronavirus pandemic

Changes in measures and instruments of birth control are one of the consequences of the coronavirus pandemic in all countries with increased significance of reproductive components, i.e. concerning physiological capabilities of conception, gestation and childbirth. Pandemic-associated measures had diverse impacts on restrictive (aimed at reducing fertility) and expansionary (aimed at increasing fertility) methods of reproductive regulation: it did not take methods of pregnancy prevention and artificial termination of pregnancy long to adapt to the new conditions without changing the established trends, while assisted reproductive technologies, following administrative bans of the first days of mass lockdowns, demonstrated new development directions upon removal of bans. Against the background of the progress in the medical component, increasingly bringing in- vitro fertilization closer to natural conception, the scale of state funding and the number of free of charge programs for patients have increased, however, due to anti-epidemic control, cross-border reproductive care or fertility tourism, relevant for surrogacy and reproductive donation, has become more complicated. In Russia, this has intensified public discussions and contributed to further elaboration of reproductive legislation.

The impact of Covid-19 on gamete shipping by Australian and New Zealand patients.

Cross-border surrogacy and egg donor arrangements are an increasingly common means to family building. Establishing patterns of use has always been difficult in relation to Australian patients. Accurate data is stymied by lack of documentation of international third-party reproductive care available to Australian authorities. When international travel bans came into effect, it is hypothesised that those planning to use cross-border reproductive care had to rely significantly more on local in vitro fertilisation (IVF) clinics for services such as sperm freezing, embryo creation and gamete release procedures. To quantify and characterise the impact of the Covid-19-related travel ban on international and interstate gamete shipping by Australian IVF clinics. Thirty-one Australian and New Zealand IVF clinics were invited to provide de-identified data on interstate and international gamete export applications from two 12month time periods pre- and during Covid-19-related international travel lockdowns. Seven IVF organisations provided data on: patient age; type of gametes exported; destination country/state; and date gamete release approved. Most gametes (78%) were shipped to another Australian IVF clinic and 22% internationally. Patient-initiated shipping domestically and internationally both showed significant increases when comparing pre- and post-Covid datasets. Of the 21 destination countries reported for international shipments, the US was the commonest (39%), followed by Ukraine (21%) and Canada (9%). The inability of involuntarily infertile patients to travel internationally, rather than halt cross-border reproductive care, has led to a significant increase in the uptake of gamete shipping. The high proportion of internationally shipped gametes going to the US and Ukraine is likely a reflection of the availability of surrogates and donors and more amenable legal frameworks.

The Impact of Covid-19 Travel Restrictions on Gamete Shipping from Australian IVF Clinics

Background: Cross-border surrogacy and egg donor arrangements are an increasingly common means to family building. Establishing patterns of use has always been difficult in relation to Australian patients. Accurate data is stymied by lack of documentation of international third-party reproductive care available to Australian authorities. Since Australia’s international travel ban came into effect, it is hypothesised that those planning to use cross-border reproductive care have had to rely significantly more on local IVF clinics for services such as sperm freezing, embryo creation and gamete release procedures. Establishing the increase in gamete shipping as a result of the ban on non-essential travel will improve understanding of the resource impact on Australian IVF laboratories. Such data can also assist policymakers assess the utility of state-based regulations relevant to CBRC. Aim: Quantify and characterise the impact of the Covid-19-related travel ban on Cross-Border Reproductive Care amongst patients of Australian IVF clinics. Method: All Australian IVF clinics were invited to provide de-identified data on interstate and international gamete export applications from two 12 month time periods pre and during Covid-19 related international travel lockdowns. Each dataset included: patient age; type of gametes exported; destination country or state; and date gamete release was approved. Results: Results showed a very significant increase in gamete shipping in the twelve months after Covid-19 travel restrictions were enforced. They illustrate the comparative prevalence of shipping to established and newer destinations during the periods March 2019–February 2020 and June 2020–May 2021. The volume of shipping to the commonest destinations is quantified. Conclusion: The inability of involuntarily infertile patients to travel internationally, rather than halt cross-border reproductive care, has led to a significant increase in update of gamete shipping. This is likely associated with increased utilization of Australian IVF clinics for embryo creation purposes. The high proportion of internationally-shipped gametes going to the US and Ukraine is likely a reflection of the availability of surrogates and donors and the legal frameworks.

Donors: To Pay, or Not to Pay

Attitudes towards and concerns about recognition and payment options for donation in New Zealand and Australia Commercial inducement for the provision of gametes is prohibited in New Zealand and Australia. This has been argued to limit access to donor gametes and contribute to the pursuit of potentially unregulated cross-border reproductive care by domestic patients. 434 participants, including those with infertility and treatment experience, donors, recipients and clinic professionals, completed an online questionnaire assessing their support for a range of recognition and payment options, and their concerns about payment constituting financial reward. Overall, participants supported the reimbursement of direct costs associated with donation, including medical expenses, travel time, and unpaid time away from work relating to treatment. Nonmaterial forms of recognition or tokens of thanks received less support. Lowest ratings of support were noted for the outright payment of donors for the supply of their gametes. Concerns about payment related to assumptions about the type of donor motivated by financial reward, and the possibility that if paid donors might be more likely to conceal relevant treatment information. Further concerns included the increased financial burden for recipients and concern for donor-offspring wellbeing. Support for payment over and above reimbursement of costs was related to a belief that payment was necessary to ensure gamete supply. Sonja Goedeke: Sonja’s research focuses on the psychosocial and ethical implications of assisted reproductive technologies. She has published, presented and supervised projects related to egg and embryo donation, the concept of gifting in donation, counselling, cross border reproductive care, mild stimulation protocols, social egg freezing, policy/legislation, parenting/remaining child ‘free’ after IVF, embryo disposal decisions and the recognition/compensation of donors.

Donor Recruitment and Recipient Experience of a Newly Implemented Identity Release Donor Sperm Program

Background: A shortage of donor sperm exists in Victoria. In combination with COVID-19 affecting cross border reproductive care, the lack of donor availability necessitates increased attention to factors affecting recipient decision making. Aim: Newlife IVF launched their Identity Release Donor (IR; previously known as clinic recruited) Sperm Program in September 2020. Our aim is to examine donor recruitment and key factors in donor selection in an IR donor sperm program. Method: Data collected through routine interactions with potential donors and recipients, including donor allocation and reasons for decision making were examined. Qualitative data collected through counselling sessions with recipients were analysed using thematic content analysis. Results: From September 2020 to May 2021, 308 men responded to an online advertisement requesting more information about our IR program. Of these, 41% (N=126) completed an intake phone call wishing to proceed, however only 7% (N=22) undertook investigative testing. Ultimately 2.5% (N=8) of the initial cohort completed all requirements to date. To date, 106 recipient women/couples completed the compulsory counseling session and accessed the IR profiles. Seventy-five percent (N=80) selected a donor. Also, 75% stated there was more information in donor profiles than expected, and valued interviewer impressions of donor (international donor profiles). Recipients referred to the ‘letter to the offspring’, a hand-written note by the donor for potential offspring, as providing the most insight and weighed heavily in decision making. Of the 25% (N=26) who have not selected a donor to date, the majority (N=16) were undecided, disliked profiles (N=5), delaying treatment (N=2), or changing clinics (N=3). Conclusion: A small proportion of men who express interest via an online advertisement, translate to sperm donors. A high proportion of recipients who view donor sperm profiles select a donor and proceed with treatment. Recipients are motivated to learn about a donor and value the donor’s personal connection to a potential donor conceived offspring.

O-316 From insult to injury: war and cross border reproductive care (CBRC). Difficulties for patients and collaborators

Abstract From Insult to Injury: War and Cross Border Reproductive Care (CBRC) after Covid Ukraine has had a thriving fertility sector for many years, both for its citizens and foreigners, for whom it has been a very popular destination for cross-border commercial surrogacy, with an estimate of between 2000 and 2500 babies born each year. Such cross border reproductive activities had already been complicated by the Covid pandemics of the last 2 years, but when Russia invaded the country in February 2022, intended parents, surrogates, egg donors, agencies and local clinics faced an emergency which led to acute distress in addition to that already felt by all with a sudden war in Europe. We discuss the available facts with regards to the disruption to fertility services for all concerned, as well as the complex legal and ethical issues surrounding this emergency. Neighboring countries have been accepting (mostly women) refugees, who may need health care in a system stressed by extra numbers of patients. Intended parents have been trying to ensure their plans are confirmed whilst their surrogate has probably moved to a different jurisdiction. Above all, the voice of collaborators may have been overwhelmed by that of the (future) families they are contracted to help. All this, will leave its mark on CBRC in an area which has been a traditional European and recently Chinese hub for years to come.

P-347 Gamete donation in Italy: Ethical and legal consideration on the lack of specific regulation

Abstract Study question Given cross border reproductive care, is the lack of specific regulation on egg and sperm donation in Italy ethically acceptable nowadays? Summary answer Nowadays Italy has no national clear legal frame for donors, recipients, and donor-conceived persons. This setting hinders an ethical protection of competing interests and rights. What is known already The Italian Law on ART (40/2004) has undergone major changes; after sperm and egg donation ban lift, the Italian law n. 40 has not been replaced. Gamete donation is therefore allowed, but without specific national regulation. Moreover, given the lack of public information on donation and consequently the shortage of donors, many people still opt for CBRC. In this context, the only legal certainty is that no filiation link arises between donor and donor-conceived children. Political and legal debate on the right to know one's origins is missing. Legally speaking, gamete donation in Italy is actually in half-light. Study design, size, duration -- -- Participants/materials, setting, methods When it comes to ART, national legal frame has to be considered in a comparative view, since CBRC is a fact. Therefore, questioning the lack of specific regulation on egg and sperm donation in Italy has required a comparative analysis with other European legal systems, such as France, Spain and United Kingdom. Main results and the role of chance -- -- Limitations, reasons for caution When advocating a legal change, it should be considered the surrounding political environment; among Italian institutions a growing mistrust of science might be spotted nowadays. This, combined with the very well know Catholic heritage, is undoubtedly a reason for caution Wider implications of the findings A legal change in Italy, backed by a promotion of public information on gamete donation, might entail also an increase in the number of donors and enabling many people to avoid CBRC. The rights of donors, recipients and donor-conceived persons would be protected and more patients could be treated. Trial registration number not applicable

P-727 The demographic impact of increasing ART use on fertility - the case of Czechia

Abstract Study question What is the contribution of ART usage to the recent fertility trends - the total fertility rate (TFR) and birth timing - in Czechia? Summary answer The results revealed the contribution of the increasing use of ART to the ongoing childbearing postponement process. What is known already The demographic importance of the use of ART has increased substantially over the last two decades in the context of the ongoing fertility postponement process. The use of ART is likely to reduce involuntary childlessness and helps to offset part of the effect of increasing infertility due to fertility postponement. However, its use cannot make up for all births lost by the natural decline in fertility after age 35. The use of ART pushes the age limits of childbearing to extremely late ages. Moreover, ART may serve to create the illusion that childbearing can be postponed until late reproductive ages. Study design, size, duration The study is based on anonymised individual data from national health registers managed by the Institute of Health Information and Statistics and data available from the Czech Statistical Office. A unique database of individual data on each child born in the years 2013-2018 in Czechia allows the construction of detailed demographic fertility indicators in terms of the use/non-use of ART. Participants/materials, setting, methods The study employs demographic indicators characterising the level of fertility and its timing (total fertility rate, age-specific fertility rates, mean age of mothers at childbirth). These indicators are constructed using data for live births and are further disaggregated by whether or not the mother has undergone ART. Main results and the role of chance Both the number and the proportion of live births following ART increased steadily between 2013 and 2018. The proportions of ART-live births increased significantly with the age of the mothers (around 5% of children were born following ART to mothers aged 35-39 years, less than 10% to mothers aged 40-44, almost 40% to mothers aged 45-49 years). The ART-total fertility rate between 2013 and 2018 increased from 0.045 to 0.058 and the relative impact of ART on the TFR increased from 3.1% to 3.4%. Concerning childbearing timing, fertility after ART is significantly shifted towards the age of 39 years when the possibility of the financial contribution of health insurance companies ends in Czechia. The mean age of mothers at childbirth following ART reached 34.5 years in 2018, which was significantly higher than the non-ART mean age at childbirth (30.0 years). The difference in the ART and non-ART mean age at childbirth increased from less than 4 years in 2013 to 4.6 years in 2018. Therefore, the increase in ART usage is, on the one hand, a consequence of the fertility postponement process, but on the other hand, ART can be seen also as one of the “drivers” of fertility postponement. Limitations, reasons for caution Information on the use of ART was estimated based on information on ART cycles performed in Czechia; women who underwent ART abroad were classified as non-ART. Given that Czechia is more likely to be a destination country for cross-border reproductive care, we did not anticipate significant bias in the results. Wider implications of the findings The contribution of the increasing use of ART to the ongoing childbearing postponement process remains significant. Trial registration number not applicable

O-079 Cross-border reproductive care from France: an original digital survey to measure this phenomenon

Abstract Study question Can we accurately estimate CBRC from France and provide new insight on CBRC patients’ experiences and motivations? We present preliminary results of a digital survey. Summary answer Estimating CBRC is an important methodological challenge that requires extensive dissemination and collaboration among ART medical centres to avoid technique and destination bias. What is known already CBRC is a worldwide, growing and multifaceted phenomenon, involving many different countries, medical centres and associations, and concerning people with diverse sociodemographic characteristics and reasons for crossing borders. France is one of the top four European countries whose residents seek CBRC. However, the national scale of CRBC cannot be estimated from existing studies because of important methodological limitations. Quantifying CBRC is an important challenge to be taken up, in order to assess the extent of the phenomenon, which shows a mismatch between the national demands/needs of the population and the ART possibilities in a country. Study design, size, duration All French residents concerned by MAR are invited to fill in an online questionnaire between October 1st, 2021 and September 30th, 2022. These participants can also volunteer for post-survey interviews. Macro data are extracted from massive administrative data (registers). The survey has been approved by the French Ethics Commission (CNIL). The analysis will use cutting-edge statistical methodologies (Benchmark Multiplier) from “Hard-to-reach” population research to get annual estimates of CBRC patients from France. Participants/materials, setting, methods The inclusion criteria are being a French resident aged 18 and over who used in the past or are currently using ART in France or abroad, or considering it in the future. Mid-term survey results will be presented (October 2021 to March 2022). By the end of January 2022, 367 persons having used CBRC participated to the online survey. Main results and the role of chance The 367 first participants declared to have done 666 different CBRC (one CBRC is defined as using one technique in one center of one countries during a same year). The average number of CBRC by participant was thus 1.8. The majority of the first 367 respondents were in a union (62%), particularly in a same-sex couple (62% of those in a union). They were mainly between 30 and 40 years old (52%). They were informed about the survey mainly through social networks (68%) and associations (28%). Surprisingly, very few of them were informed by medical centres (1%). CBRC mainly concerns sperm donation (48%). Surprisingly, egg donation represents only 11% of CBRC. Regarding countries, Spain (50%) and Belgium (21%) appear as the main destinations followed by Portugal (9%) and Denmark (7%). Surprisingly, Greece is absent and some other countries represent a low proportion of CBRC from France, like those from Eastern Europe (6%). Limitations, reasons for caution Compared with the literature and with our previous study in 2010-2012, we consider that some techniques and destinations are underrepresented. It is therefore essential to better broadcast the survey, especially through more European medical centers for better coverage of the CBRC population. Wider implications of the findings This project is a first step to develop a larger European survey to estimate the size of CBRC. Trial registration number ANR-21-CE36-0006-01

Motives of patients crossing borders to pursue assisted reproduction - why the Czech Republic is a frequent choice for egg donation treatment.

Cross-border reproductive care is undoubtedly a current phenomenon. The number of people interested in receiving reproductive care abroad is increasing every year. This new context needs a political solution that would respond to the definition of standard care within the circumstances of providing healthcare to the citizens of another country. Patients that undergo reproductive treatment abroad very often face complications such as language problems, insufficient information, separation from family members, cultural differences and customs, potential unrealistic expectations, and also restrictions by law. This work is descriptive in nature and aims to illustrate the variables that come into play when choosing the Czech Republic over other destinations as a country to receive infertility treatment. We analyze the phenomenon by selecting documents used as sources of data. In our research, we focused on infertility treatment and justified the reasons why foreign citizens choose the Czech Republic over other destinations for infertility treatment. The variables that lead to the selection of cross-border infertility treatment in the Czech Republic include no waiting time, anonymous donations, international departments in various languages, and affordable prices compared to other destinations.

Cross-border reproductive care: an Ethics Committee opinion

Cross-border reproductive care is a growing worldwide phenomenon, raising questions about why assisted reproductive technology patients travel for care, what harms and benefits may result, and what duties health care providers may have in advising and treating the patients who travel for reproductive services. Cross-border care may benefit or harm assisted reproductive technology stakeholders, including patients, offspring, providers, gamete donors, gestational carriers, and local populations in destination countries. This document replaces the previous document of the same name, last published in2016.