Reproductive (Medical) Tourism HSS 2121 April 1, 2009

1. Reproductive (Medical) Tourism HSS 2121 April 1, 2009 Raywat Deonandan, PhD ray@deonandan.com Assistant Professor, Health Sciences, University of Ottawa Former Chief Scientific Advisor, Assisted Human Reproduction Canada

2. You can download this presentation at: classes.deonandan.com

3. We are going to talk about: -Medical tourism (what is it?) -Reproductive tourism (what is it?) -The ethics of the above (what is ethics?)

5. The words, expletives, guttural moans and occasional odours coming out of my mouth do not necessarily reflect the opinion of Assisted Human Reproduction Canada

7. In General…. • What is “medical tourism”? 1. The act of (typically Western) medical professionals doing abroad to do “good work”, but in reality functioning as gawking tourists 2. The act of (typically Westerners) going abroad (to typically developing countries) to seek medical care.

8. The First Type • The act of (typically Western) medical professionals doing abroad to do “good work”, but in reality functioning as gawking tourists • The danger of every international health project • Whom does it really benefit? • “cowboy” global medicine • Sustainable?

9. The Second Type • The act of (typically Westerners) going abroad (to typically developing countries) to seek medical care. • Growing in popularity • Often tied to other tourist activities • Negative downstream consequences may not be immediately obvious EXAMPLE: Reproductive medical tourism

10. Summary of the Ethical Issues

11. Summary of the Ethical Issues • Misdirection of financial resources – those who seek services abroad deny their resources (i.e., outgoing funds) to their home community • Misdirection of medical resources – those who provide services to “tourists” are denying their services to their home community • Implications of insufficiency – the act of seeking services abroad implies that services are insufficient, in quantity, type, timing or affordability, in the home community • Criminality – if service seeking abroad is done to avoid laws at home, should the international community consider this criminal behavior? Is the provision of services therefore the abetting of such criminal behavior? • Quality control – if the health and welfare of “tourists” is a concern, how do we control for the quality and validity of medical services provided outside of one’s administrative jurisdiction? • Robustness of informed consent – are “tourists” provided with adequate and accurate representation of actual risks and probable success rates? Brokers may misrepresent facts. The above may apply to all types of medical tourism

12. We will revisit those ethical issues when we discuss the specific case of Reproductive Tourism In 4…3….2…1….

14. Terminology • Infertility: • One year of unprotected sex without conceiving a child • Includes both “sterile” and “subfertile” people • Sterile: • Will never conceive without medical assistance • Subfertile: • May still conceive without medical assistance

15. Infertility • About 15% of couples will be defined as “infertile” • But this only accounts for those who actually seek services; likely an underestimate -1990 estimate: >1 billion women worldwide are affected by “infertility” -only covers those of reproductive age who have been “diagnoses” **On the increase in Western nations**

16. Why Is Infertility On The Rise? • People waiting till later in life to have kids • Obesity and diabetes are on the rise • Environmental contaminants may be affecting hormone levels

17. The Available Infertility Services • Fertility drugs • IUI • IVF • ICSI • Gamete donation • Surrogacy

18. Fertility Drugs

19. IUI • Intra-uterine insemination • Artificial presentation of sperm into the vaginal canal • “turkey baster method”

20. IVF • In Vitro Fertilization • Creation of embryo in a dish, and returning it to the womb • “test tube babies” • Considered the vanguard ART technology

22. Louise Brown, Born July 25, 1978

23. The OctoMom!

24. My Hallowe’en costume next year Denny’s Octomom special: 14 eggs, no sausage, and the guy at the next table pays for it.

26. ICSI • Intra cytoplasmic sperm injection • Done in conjunction with IVF • Grab a sperm and force it into an egg • Used when sperm just can’t get the job done by themselves

29. Sperm Donation • Relatively simple • Donors are usually friends or family • Anonymous donors are rare and in demand

30. Egg donation • Very invasive • Expensive procedure • Hard to find donors

31. Surrogacy • A surrogate mother is a woman who agrees to gestate and give birth to a baby for someone else • Scenarios: • Surrogate receives sperm via IUI and uses her own egg • Surrogate donates egg, embryo created via IVF (with or without ICSI) • Another egg is used, embryo created via IVF (with or without ICSI)

33. Other Technologies • PGD – pre-implantation genetic diagnosis • IVM – in vitro maturation • “flash freezing” of eggs • Hybrids and cybrids

34. Statistics • Canada: • about 6500 IVF embryo transfers per year • USA: • About 120,000 IVF procedures per year • UK: • About 35,000 IVF procedures per year • Europe: • About 300,000 IVF procedures per year

35. Costs • One attempt at IVF costs $8000-$16000 • ICSI costs extra • Donated sperm costs $200-$600 (from US centre) • Donated egg costs $500-$20000 (from US source) • Surrogate services cost ~$50,000 or more

36. Canada’s Assisted Human Reproduction Act (2004) • Human cloning prohibited • Sex selection prohibited • In vitro gene alteration prohibited • Transplanting non-human gametes or embryos into a human is prohibited • Transplanting human gametes/embryos into a non-human for the purposes of creating a human • Create chimeras/hybrids

37. Canada’s Act • No payment for surrogacy • No paid brokerage for surrogacy • No payment for gametes • No paid brokerage for gametes • etc

38. The Law • Laws in different countries vary dramatically • In the US, it varies from state to state • In Australia, only one state has clear regulations • In UK, rules are well defined and monitored • In Israel, it’s the wild wild west • Etc.

39. So…. • Let’s say you’re an infertile couple in Canada who wish to: • Select sex of your baby • Pay for a surrogate mother • Pay for a sperm or egg donor • Pay less for a baby What do you do?

40. You Go Abroad • Example • In Virginia Mason medical centre in Seattle, 33% of patients are Canadian, most seeking to buy donor eggs • In India, “reproductive tourism” is a $450 million industry

41. Reproductive Tourism • The phenomenon of going abroad to seek reproductive technologies • Might be considered a form of Medical Tourism

42. South Asia • Currently, parts of the USA are the most popular destinations for “reproductive tourists” • But India is fast becoming an important destination

43. India • Surrogate mother in India costs <$5000 • Plethora of doctors, all English-speaking • Case study: • A British couple in 2006 spent 60,000 pounds on IVF in the UK without success, so they went to India and paid $3,300 for a surrogate mother

44. Why India? • Cost of IVF is 1/50th compared to USA • Generally believed that Indian women smoke and drink less (foetal health) • Enormous NRI community, who are now wealthy and infertile • Very few (in any) laws • Open acceptance of sex selection techniques

45. Why India? • In India, infertility is seen as a curse, so many surrogates report that they are doing charitable work by providing a child for an infertile couple

46. Nine of the 45 surrogates available at the Akanksha clinic in Anand, India, where at least one Western woman visits every day seeking a surrogate.

47. Akanksha clinic • Among the most famous in the industry • Surrogates are cloistered in secret locations • Clearly, there is some civil discontent • Surrogates rent their wombs for food, healthcare and cash amounting to about $6000 • A fortune for many of them; quite affordable for us

48. So, What’s The Problem? • From an international health/development point of view, what are the issues?

49. The Issues • Protection for couples travelling abroad • Protection for women selling services in poor countries

50. The Issues • Couples are bypassing the laws of their own countries; should they be prosecuted? • Informed consent… how informed are these women? • Choice…. In many places, how can we guarantee that women are not being forced to participate?