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Reproductive (Medical) Tourism HSS 2121 April 1, 2009 Raywat Deonandan, PhD Assistant Professor, Health Sciences, University of Ottawa.

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Presentation on theme: "Reproductive (Medical) Tourism HSS 2121 April 1, 2009 Raywat Deonandan, PhD Assistant Professor, Health Sciences, University of Ottawa."— Presentation transcript:

1 Reproductive (Medical) Tourism HSS 2121 April 1, 2009 Raywat Deonandan, PhD 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?)

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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

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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 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….

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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 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

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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.

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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

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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)

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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 1/50 th 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 1.Protection for couples travelling abroad 2.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?

51 More Issues India is popular also because of its familial laws: – In UK, a surrogate mother can change her mind and claim the baby as her own any time within the first 2 years of life – In India, the surrogate loses all rights to the baby at the point of delivery

52 More Issues Is remuneration fair? Should surrogates be paid global market rates? Social stigma of carrying the child of a man who is not your husband Loss of control of one’s body, as “client” and doctor have a vested interest in the surrogate’s nutrition and activities

53 Even More Issues Must protect vulnerable infertile Westerners from being fleeced by dishonest doctors and surrogates In instances of extreme poverty, is there really such a thing as choice for a surrogate? – Compare to instances of “choice” for an impoverished woman who “chooses” prostitution

54 Even More Issues! What kind of health follow-up are surrogates given? – Are they given post natal care, especially after the baby has been given up? What reproductive effects do surrogates suffer from? – Giving birth is dangerous – Potential for surrogate to become infertile

55 Disease Issues Reproduction is a vector Fluid associated with donated eggs and sperm may be infected with HIV, Hep C, etc... Maybe even Mad Cow Disease (unlikely)

56 Cases Despite dramatic shortages of “altruistically donated” sperm in the Western world, a gay man in New Zealand was not permitted to donate because he was from a high risk group for HIV Currently a case in the USA of an egg donor with Tay-Sachs disease; she has already produced 3 children

57 Legal Issues A child born to a surrogate mother in India… what are the legal steps to get it into the country of the “client”? – Formal adoption procedures? Can a surrogate mother in India benefit from parental laws of the client’s country? – Does she have the 2 year leeway in the UK?

58 “Cross Border Reproductive Care” Why is this the preferred terminology?

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61 Reminder of 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.

62 Are there additional ethical issues that apply specifically to reproductive tourism?

63 – Robustness of informed consent – this issue, as it pertains to the surrogate, is quite separate from that pertaining to the tourist. Social downstream impacts must also be communicated (eg, is a conservative society ready for a woman to carry baby for two gay men; will husband respond well to wife carrying the baby of another man; specific religions –eg, Muslim- concerns) – Custody rights – rights vary from country to country. To what extent is the industry affecting the drafting of custody rights legislation? – Cultural appropriateness – see (a): economic attraction of the industry may bring it to societies presently unprepared for some of the implications, eg gay parents, single mothers, carrying a child that is not your husband’s – Quality of care – surrogate’s physical health is maintained, but only to the extent that it benefits her pregnancy. What of social and mental health? What of her removal from care-giving milieu of her own community? If clinic provides her diet, does she still cook for her family?

64 – Limits of care – While the surrogate’s medical health is of prime importance during pregnancy, does this care end upon birth of the child? Is there an investment in post-partum care? To what extent does economics affect this trend? (Eg, a regular surrogate should be maintained in good health due to her ability to perform again.) – Remuneration – one reason tourists seek service is reduced cost abroad. But while remuneration for the surrogate is likely above what she would otherwise earn, it is likely below global market rates. – Abortion – selective reduction is a common occurrence in ART. Is surrogate aware and culturally responsive to this likelihood? – Medical advocacy – clinician responds to needs of the tourist. Is it a conflict of interest to also be care-giver to the surrogate?

65 What We Are Doing Step 1 – bring together ART regulatory bodies from key nations Step 2 – agree that these are issues worth considering Step 3 – Collect data! Step 4 – to be determined

66 Achievable Goal Establishment of international body to: – Monitor extent of reproductive tourism – Set forth international guidelines for appropriate ART/AHR care – Monitor quality control for doctors offering services to international clients – Monitor rights abuses of local women offering their reproductive tissue and services

67 Conclusions Reproductive freedom is a complex concept – Is reproductive tourism a win-win scenario, wherein the provider of a biological function is amply rewarded for sharing her gifts with the inferitle? – Is reproductive tourism exploitative, wherein the bodies of poor women are commodified for use by rich Westerners? – The best we can hope for right now is to maximize informed consent and empowerment of choice

68 Quotes


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