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Who goes abroad for fertility treatment and why?

June 30, 2009

Amsterdam, The Netherlands: A substantial number of European patients travel to other countries for fertility treatment, both because they think that they will receive better quality care abroad and in order to undergo procedures that are banned in their home country says a study of the subject launched at the 25th annual conference of the European Society of Human Reproduction and Embryology today (Monday June 29). Study co-ordinator Dr. Françoise Shenfield, from University College Hospital, London, UK, said that this was the first hard evidence of considerable fertility patient migration within Europe. "Until now we have only had anecdotal evidence of this phenomenon", she said. "We think that our results will be of considerable value to patients, doctors, and policymakers."

During a one-month period, the ESHRE Task Force analysed data from participating clinics in six European countries: Belgium, the Czech Republic, Denmark, Slovenia, Spain and Switzerland. Clinics were asked to provide questionnaires to patients coming from abroad for treatment. The questionnaires asked about their age, country of residence, reasons for travelling to another country for treatment, which treatment they had received, whether they had received information in their own language, how they had chosen the centre they were attending, and whether they had received reimbursement from their home country's health system. 1230 forms were completed and returned.

"This may not seem to be a very high number", said Dr. Shenfield, "but it reflects only one month of events in a limited number of centres in six countries. The total number of treatment cycles per year can be estimated by extrapolating our monthly data to a year and by assuming that the centres represent no more than half of the centres in each of the countries studied. This leads to an estimate of at least 20 000 to 25 000 cross-border treatment cycles per year in these countries. It is, however, difficult to derive a number of patients from these numbers as patients receive more than one cycle to obtain a pregnancy, the mean number depending on the type of treatment."

Almost two-thirds of the patients surveyed came from four countries, with the largest number coming from Italy (31.8%), followed by Germany (14.4%), the Netherlands (12.1%) and France (8.7%). In total, people from 49 countries crossed borders for fertility treatment.

The main reason for going abroad for fertility was to avoid legal restrictions at home. 80.6% of the German patients surveyed have this as their primary reason, 71.6% of Norwegians, 70.6% of Italians, and 64.5% of French. Difficulties of access to treatment were cited more by patients from the UK (34.0%) than those from other countries.

Age also played an important part in the decision to travel for treatment. The average age across all countries was over 37.5, but German and UK patients tended to have a much higher age profile with 51.1% of Germans being aged over 40 and 63.5% of British. Civil status also varied between countries; overall 69.9% of all women were married and only 6.1% single. But 82% of Italian women were married, while 50% of French women were cohabiting (often in same sex couples), and 43.4% of Swedish women were single.

The majority of respondents were seeking assisted reproduction treatment (ART) only (73%) as opposed to 22.2% intrauterine insemination (IUI), and 4.9% both ART and IUI. These figures also varied between one country and other; there was a majority of IUI treatments for French (53.3%) and Swedish (62.3%) patients, with a majority of ART for most other countries.

Fertility treatment abroad is poorly reimbursed, says Dr. Shenfield. "Only 13.4% of the patients we surveyed received partial reimbursement, and as few as 3.8% were reimbursed totally for their treatment."

The most generous country was The Netherlands, with a partial or total reimbursement of 44.4% and 22.1% of patients. In France, patients could only be reimbursed for overseas treatment where there was a delay at home, and treatment that was illegal at home, for example for single women or homosexual couples, was not reimbursed at all.

"This was a pilot study carried out in a small number of countries, and hence has limitations", said Dr. Shenfield. "However, it confirms information already gathered by patient support groups and reported in the media. For example, Spain and the Czech Republic are popular destinations for oocyte donation; Swedes travel to Denmark for insemination, and French to Belgium.

"It has also enabled us to have concrete proof of the large numbers of Italians who cross borders to obtain treatments which were made illegal under the 2004 legislation, or because by doing so they will receive what they perceive to be better quality treatment. This may mean, for instance, the possibility of embryo freezing", she said.

In another study, Professor Guido Pennings from the University of Ghent, Ghent, Belgium, looked in more detail at the situation in his own country. 16 out of the 18 Belgian reproductive medicine centres which were licensed to handle oocytes and create embryos were surveyed on the nationality of foreign patients coming for treatment between 2000 and 2007, as well as on the type of treatment for which they came.

The researchers found that, since 2006, the flow of foreign patients into Belgium had stabilised at around 2100 patients per year, and that the majority of these were lesbian couples from France seeking sperm donation.

There appeared to be a clear correlation between legal prohibitions in patients' home countries and the numbers who travelled abroad, he said. "The changes in numbers of patients coming from a specific country for a specific treatment and changes in the law in that country are not coincidental.

"In France couples have to be heterosexual, in a stable relationship and of reproductive age in order to have access to assisted reproduction. In addition to the legal reasons, given the geographical closeness of the two countries and the fact that language difficulties are limited, it was not surprising to find French patients made up the largest percentage of those travelling to Belgium (38%). These were followed by patients from the Netherlands (29%), Italy (12%) and Germany (10%)", he said.

Professor Pennings believes that the numbers may be an underestimate. Not only did 2 out of the 18 qualifying centres not reply, but centres which only provided treatments that were less technically demanding, such as hormonal stimulation or artificial insemination, were not included. Additionally, no data were included from countries which provided fewer than five patients per year per centre.

"Although collection of data on the numbers of patients moving from one country to another is a first and important step, future research should include the experiences of patients, the difficulties they experience, the impact of such movements on the national health care systems, and the effects of, for instance, portability of insurance on the numbers", he said. "We will only be able to evaluate the phenomenon properly when we can see the full picture."

European Society for Human Reproduction and Embryology