Cross-border assisted reproduction care in Asia: implications for access, equity and

regulations
Author(s): Andrea Whittaker
Source: Reproductive Health Matters, Vol. 19, No. 37, Privatisation (May 2011), pp. 107-116
Published by: Reproductive Health Matters (RHM)
Stable URL: http://www.jstor.org/stable/41409155
Accessed: 26-04-2017 03:29 UTC

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 © 2011 Reproductive Health Matters.
A„ . , , REPRODUCTIVE
All A„ rights . , reserved. , HEALTH
Reproductive Health Matters 201 1 ; 19(37): 107- 1 16 iTidttGiS
0968-8080/11 $ - see front matter
PII: S0968-8080(l 1)37575-1 www.rhmjournal.org.uk

Cross-border assisted reproduction care in

implications for access, equity and regulat
Andrea Whittaker

Associate Professor, School of Population Health, Faculty of Health Sciences, University of Queensland,
Herston Qld, Australia. E-mail: a.whittaker2@uq.edu.au

Abstract: This paper gives an overview of the global commercialised market in ass
treatment in low-resource countries in Asia and raises concerns about access and
potential commercial exploitation of the bodies of subaltern women to service th
donated ova and surrogate pregnancy, and the need for protections through regu
systematic data about cross-border reproductive care is a significant obstacle to d
intervention. Little is known about the extent, experience or conditions of cross-bor
care outside of Europe and the United States. Further research is needed in Asia
effects of this trade upon local health systems, couples seeking care, and those w
tissues and nurturing capacities facilitate it. More attention needs to be paid to t
of publicly funded reproductive health services to address the inequitable distribu
and to investigate means to regulate this trade by governments, international NG
organisations and civil society groups in developing countries. The global trade in
reproduction challenges us to balance the rights of individuals to pursue health ca
borders with the rights of those providing services to meet their needs, especially v
in situations of economic disparity. ©2011 Reproductive Health Matters. All right

Keywords: cross-border reproductive care, reproductive tourism, assisted reproduc

commercialisation, Asia region

as an economic strategy for developing econo-

of international cross-border trade in medi- mies, linked into the overall trade in services
THE of cal international services, last decade chiefly
cal services, has cross-border providing
chiefly providingseen a rapid care trade
careexpansionfor
for in mobilemobile
medi- ratified under the General Agreement on Trade
patients who have the personal resources to travel. in Services (GATS) (1995) governed by the World
In the past, medical travel was associated with Trade Organization (WTO).3 Economic pressures
travel to wealthy nations for specialised health care such as the Asian economic crisis of 1997 have
unavailable elsewhere, but now it has expanded encouraged governments in a number of low-
to include travel by wealthy patients to develop- resource countries to find additional sources of
ing countries. Trade in medical services to for- revenue and resources to sustain health service
provision in their own countries. The trade is
eigners is promoted as a new export opportunity
for developing economies to generate foreign facilitated by the growth of private corporate
revenue, investment capital and tax revenue.1 hospitals, the ease of international travel and
It was estimated to be worth US$60 billion in global communication, and the increasing por-
2008 and is expected to grow to US$100 billiontability of health insurance.
by 2020.2 One category of this trade involves the move-
The growth of this market has become inter- ment by patients across international borders to
twined with the trade policies of many countries undertake assisted reproduction treatments and

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 A Whittaker / Reproductive Health Matters 201 1;19(37):107-1 1 6

surgery. It was first described by Knoppers and women in Asia to service the demand for gametes
LeBris in 1991 as "procreative tourism" to describe and surrogacy within the global reproductive
patients exercising "their personal reproductive trade. Finally, I summarise the prospects for regu-
choices in other less restrictive states".4 This lation of this trade.
includes travel for IVF (in vitro fertilisation), ICSI This overview is informed by work completed
(intracytoplasmic sperm injection) and associ- for a broader anthropological study of the use of
ated procedures, such as PGD (pre-implantation assisted reproductive technologies in Thailand
genetic diagnosis), gamete and embryo donation across seven months' fieldwork in 2007-2008.
and surrogate pregnancy. Throughout this paper, The broader study involved interviews and obser-
I use the term cross-border reproductive care vations in three private clinics and two public
consistent with the standardised definition pro- infertility clinics, and interviews with 3 1 patients
posed by the European Society of Human Repro- and staff, which included six foreign patients /
duction and Embryology (ESHRE),5 rather than couples who had travelled to Thailand.8
"reproductive tourism" or "infertility tourism"6'7
to avoid an association with touristic activities.8
In this paper, I give an overview of three issues Recent trends in reproductive
medical travel
arising from cross-border reproductive care in
low-resource settings in Asia. In it, I am particu- Although no accurate statistics on the numbers
larly referring to the movement of women and of patients travelling cross-border for reproduc-
men from developed economies to employ the tive care exist, particularly in developing coun-
services of private medicine and doctors - and tries,10 survey evidence suggests the market is
in some cases the bodies of poorer women - in growing. In 2010 approximately 6% of Canadian
developing countries to pursue their reproduc- IVF patients went to the United States for treat-
tive goals. Some of the concerns raised in this ment, 80% of them for anonymous donor eggs,
paper may also be applied to cross-border travel while 4% of IVF patients in the United States
for reproductive care between two high-income were from other countries.11 In Europe, major
economies, or to the regional movement of hubs for assisted reproduction treatment include
couples within Asia to obtain services or exper- Spain, Belgium, Cyprus, and the Czech Republic.
tise not available in their home countries. How- A 2010 European Society of Human Repro-
ever, I argue that cross-border trade involving duction and Embryology (ESHRE) survey of
patients from high-income countries in Europe, 44 clinics in six European countries estimated
the United States or Australia to low-income that 11,000-14,000 patients sought treatment
in other European countries annually.5 Jordan,
countries in Asia, raises particular concerns about
its effects on access and equity, in the context Israel
of and South Africa are important hubs in
the ongoing discussion of the effects of the com-the Middle East and Africa.
mercialisation and privatisation of reproductive In Asia, India and Thailand are major hubs
health services in this journal. for international assisted reproductive care, and
Petchesky9 has argued that neo-liberal, market-as such are the focus of this paper, although
oriented approaches to delivering reproductive Singapore, Malaysia and South Korea are increas-
ingly important as destinations, especially for
health services are failing to deliver real progress
in addressing the reproductive and sexual health regional patients. These services have usually
evolved through a combination of sophisticated
needs of the majority, and that the lack of public
accountability within the "free market" endangersmedical infrastructure and expertise, particular
standards of quality, access and the protection of
regulatory frameworks (or the lack of them), and
human rights. In this paper, I suggest that the lower wage structures, which allow for lower,
development of cross-border reproductive care in
competitive costs. In addition, good tourist infra-
Asia for export diverts resources and personnel structure and visa requirements, government poli-
towards those able to mobilise the financial cies supportive of medical travel in general, and
resources to travel, while the majority of infertile
the availability of translators, religious affiliation
couples continue to have little or no access to treat-
(for example Muslim patients may prefer to travel
ments. The second issue that this paper examines to Malaysia for care) all play important roles in
is the potential for the exploitation of subaltern
determining the popularity of these sites.12

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 A Whittaker / Reproductive Health Matters 201 1 ;19(37):107-1 16

The internet is the primary site of advertising Research guidelines dictate that surrogates do
by clinics offering assisted reproductive services not provide the eggs for couples when donated
and an important source of information and ova are required; these must be supplied by a dif-
online social networking for people seeking ferent donor.16 As will be discussed below, new
information. In addition, many patients utilise legislation was introduced in 2010 which pro-
medical facilitation companies specialising in motes legally enforceable contracts and a few
cross-border reproductive care. These usually other protections for surrogates, and intro-
have commercial links with specific clinics or duces restrictions against same-sex couples,
hospitals and arrange all inclusive packages, but India continues to have a highly permissive
including airfares, accommodation, clinic ser- legal environment. As with Thailand, there are
vices, and concierge services. For example, a no accurate figures available of the numbers of
company based in Singapore called Asian Sur- people travelling for assisted reproductive ser-
rogates contracts surrogates from countries in vices in India.
the region for people from Canada, US, France,
Belgium, Germany and Denmark.13 Thailand
Fertility.com facilitates travel to clinics offering Why infertility is a reason for
cross-border travel
"family balancing" and ova donation.
Thailand's first IVF birth occurred in 1987 A meta-analysis of fertility studies suggests
and there are now at least 30 clinics providingthat approximately 9°/o of couples across the
full clinical services for assisted reproduction.14world are infertile (defined as infertile for at
Of these, approximately six clinics service aleast 12 months).17 Demographic changes such
significant international clientele. In 2004 theas later ages of marriage, delayed childbearing
Thai government launched a deliberate strategy and other factors such as obesity and untreated
to encourage foreign medical travel to Thailand,sexually transmitted infections are contributing
promoting its sophisticated hospitals, well- to the demand for assisted reproductive tech-
trained medical staff and significant cost dif-nologies.18 This includes a high demand for bio-
ferential. The foreign patient trade is forecast medical interventions, with an estimated 56% of
to be worth US$4.3 billion in 201 2. 15 A full cycleinfertile couples seeking some form of care.17,19
of IVF at most of the leading private hospitals Other factors include the lack of expertise
in Thailand ranges in price from 80,000 bahtand services in some countries. Only 48 out of
(US$2,000) to 160,000 baht (US$4,000). Although 191 member States of the World Health Organi-
exact figures of the number of patients travellingzation have IVF facilities.19 For example, resi-
for reproductive care to Thailand is unknown,dents of many Pacific nations do not have access
approximately 400,000 foreign patients travel toto IVF services and may seek them in Australia,
Thailand each year for medical treatments.1New Zealand, the United States and Asia. Other
Thailand has become a popular destinationpeople travel in search of privacy and some trans-
for non-medical sex selection through pre- national migrant couples return to their countries
implantation genetic diagnosis and microsorting.of origin for treatment in a linguistically and cul-
Until recently, assisted reproduction in Thailandturally familiar setting close to extended family.20
has been largely self-regulated. The introduction Cost is also an important factor. In many
of a new Reproductive Health Bill will affect the countries without publicly funded access to
trade in Thailand, as it will include legal restrictionsthese services, medically assisted reproductive
on clinical practices, such as the banning of non- services are expensive, forcing couples to seek
medical sex selection and commercial surrogacy. more affordable care. Within the United States,
Since the advent of legalised commercial sur- not all states mandate full or partial insurance
rogacy and egg donation in India in 2002, a cover for assisted reproductive technologies,
number of clinics in Gujarat, Delhi and Mumbai requiring couples to pay the full expense.19 The
now specialise in providing commercial surro-International Federation of Fertility Societies21
gacy and ova donation services oriented pri-notes that essentially half of the countries sur-
marily towards foreign clients from the Unitedveyed have no third party reimbursement by
States, Britain and elsewhere, including expa-any national health plan or private health insur-
triate Indian couples. Indian Council for Medical ance company for assisted reproductive treatment.

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 A Whittaker / Reproductive Health Matters 201 1;1 9(37): 107-1 16

One of the prime reasons for seeking cross- privatisation of health systems generally carries
border reproductive care is to evade legal restric- negative consequences for public health sys-
tions on treatment in home countries. The ESHRE tems.27 The trade in health services, encouraged
found this to be the major motivator for cross- by WTO trade agreements, has differing effects
border travel to European clinics.5 Individual upon national public health systems, depending
countries may prohibit specific services for reli- upon the degree of privatisation already existing
gious or ethical reasons, or on the grounds that in a country, whether there is excess capacity
a service is not considered sufficiently safe.22'23 within the private sector, and the degree of
The International Federation of Fertility Socie- government control, subsidisation and regula-
ties21 lists a range of clinical practices which tion exerted over the private health sector.25
carry differing regulations in various jurisdic- Within many developing countries, few have
tions. These include: definitions of eligibility sufficiently developed regulatory environments
for treatment, number of embryos transferred, to forestall negative impacts.27
ciyopreservation, the availability of posthumous Negative effects generated by the develop-
insemination, sperm and egg donation, the ment of the international trade in health ser-
micromanipulation of sperm (ICSI) and embryos vices in low-income countries include a local
(assisted hatching and cytoplasmic transfer), "brain drain" of skilled medical staff from the
requirements regarding anonymity of donors, public health system into private, elite hospi-
pre-implantation genetic diagnosis, and IVF tals, affecting access for the local population.
surrogacy (particularly restrictions on commer- For example, a recent review of human resources
cial surrogacy). Regulations in home countries for health notes the effects in Thailand of the
may prohibit certain categories of individuals international trade in health services, which
from receiving a service due to age, marital requires highly specialised staff. The resources
status or sexuality, especially at public expense. needed to provide services to one foreign patient
For example, British women over 40 may not are estimated to be equivalent to those used to
access publicly-funded IVF services (due to the provide services for 4-5 Thais.28 In particular
low success rates for women over this age) and there has been a large shift in specialist medi-
there are long waiting times for appointments cal staff from the public sector to private hospi-
within the public system.24 tals.15 In 2008, staff at a public infertility clinic
at a major university hospital in Bangkok spoke
to me of the difficulties in recruiting specialist
Equity and access issues for nursing and laboratory staff when public sector
low-income countries
wages cannot compete with those offered at
A range of potential benefits and negative private clinics and hospitals.
effects have been described for the international Currently, the international trade in assisted
trade in health services for low-income coun- reproduction services does little to improve local
equity and access to treatment for local popula-
tries.25 Benefits include the generation of foreign
tions in low-resource countries. In developing
exchange, the creation of job opportunities through
countries, assisted reproduction treatment for
linkages with tourism, insurance, hotel and ser-
vice businesses, the utilisation of existing excess
infertility remains inaccessible for most couples
experiencing infertility.19 In 2001 the WHO
capacity among private hospitals, and the reten-
tion of some specialists who might otherwise
called for innovative approaches, such as the
move abroad for work. development of low-cost treatments and tech-
For low-income countries, a primary concern nology for low-resource settings.17'19 Yet even
is that the development of the foreign patient as these strategies are being implemented, a
trade in health services will have a detrimental number of developing countries are involved
effect upon the public health systems of these in the global trade in assisted reproductive care,
countries, by encouraging the farther develop- while their local populations still struggle to
ment of inequitable, two-tiered health systems,afford these technologies.
where elite, technologically sophisticated hos- In-vitro fertilisation costs are approximately
pitals, catering to wealthy foreign clients, stand50% higher than the gross national income per
beside poorly resourced public hospitals.26 The capita in many developing countries, including

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 A Whittaker / Reproductive Health Matters 201 1;19(37):107-1 16
India, Indonesia, China and Malaysia.18 One
possible strategy proposed by health policy ana-
lysts to address the distortions in public health
systems exacerbated by the international trade
in medical services is that a proportion of the
profits of the hospitals involved in cross-border
health services be used to subsidise public health
care and access for poorer local patients,16 but
this requires a sophisticated regulatory system
that does not exist in many countries in Asia.
Commercialisation of reproduction
and exploitation
Another concern with regard to cross-border
reproductive care is the global commercialisa-
tion of the body and of reproduction which
it entails.29 In particular, the trade in transna-
tional commercial surrogacy and commercial
gamete donation services raises questions about
the conditions under which ova and sperm are
exchanged and women hired to carry a preg-
nancy for others, and the protections required
for vulnerable groups providing these services,
particularly poorer women from developing
countries. There are diverse opinions as to the
effects and ethics of commercial surrogacy
arrangements; however, the growth of a global
trade in commercial surrogacy in developing
countries warrants particular attention, par-
ticularly in countries where the lack of regula-
tion offers little protection to women who act
as surrogates.
Commentators suggest that in globalised
commercial exchanges, the effects of extreme
poverty and patriarchal pressures create a "bio-
available" population of women ready to act as
surrogates or as egg donors in developing econo-
mies.31 The degree of exploitation involved in
such transactions depends upon whether there
is undue inducement, given the unequal eco-
nomic position of women donors/surrogates,
the level of control and coercion imposed upon
them, their subordination within the arrange-
ment, the degree of protection of their rights
throughout the treatment process or pregnancy,
and the extent of protection of their physical
and mental health. Feminist ethicist Donchin32
argues that the structural conditions under
which poor women live renders their choice to
become surrogates an "adaptive preference"
rather than a fully free autonomous decision.
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Under conditions of gender inequality which
restrict their opportunities in the paid workforce
they have limited choices and make pragmatic
decisions. Donchin argues that the global, com-
mercialised market exploits both impoverished
women who sell their bodily resources and vul-
nerable people crossing borders for these ser-
vices. She suggests there is a need to improve
the conditions under which paid surrogates "work"
and to address the unequal distribution of power
and wealth that generates exploitative rela-
tionships.32 In order to address these inequalities
within international surrogacy arrangements,
Humbryd33 calls for the establishment of "fair
trade international surrogacy", in which the
arrangements are regulated, focusing upon
minimising the potential harms to all parties
involved and ensuring fair compensation to sur-
rogate mothers.
Commercial surrogacy and commercial ova
donation are banned in a number of countries.
Such bans, combined with the difficulty in
locating altruistic surrogates and ova donors,
is fuelling the cross-border trade in interna-
tional commercial surrogacy and ova donation.
Same-sex couples constitute another signifi-
cant group seeking commercial surrogacy and
ova donations, who often do not have access
to surrogacy services in their home countries.
Although commercial surrogacy and ova dona-
tion are permitted in some states of the United
States, their prohibitive costs put them beyond
the means of many couples.
Since legalising commercial surrogacy in
2002, India has become an important hub of
commercial surrogacy and ova donation, able
to offer services at a significantly lower cost
and advertising a plentiful supply of surrogates
and donors. Ethnographic work in Indian sur-
rogacy clinics and Indian civil society groups
raises concerns about the conditions under
which commercial surrogacy and ova donation
is undertaken.34"36. The research notes that the
women preferred by clinics for surrogacy and
ova donation are poor and illiterate, and are
portrayed as having clear economic motives for
undertaking surrogacy without emotional com-
plications. In a study conducted with 42 surro-
gates in Anand in India in 2006-2008, 34 the
median family income of the surrogates was
reported at US$60 per month, meaning that 34
of the 42 women were below the poverty line.
Ill
 A Whittaker / Reproductive Health Matters 201 1;19(37):107-1 16

These researchers and activists question whether

such trade occurs across borders, it is very dif-
women in such dire financial need are free to
ficult to detect or regulate, or provide legal pro-
make choices about the risks they undertaketections
in to the women, children, or contracting
ova donation or pregnancy. The amounts parents
of involved.
money involved for surrogates were significant
in local terms - they were paid approximately
The prospects for regulation
300,000 Rupees (US$7,500) - around one-third
of the fees paid by contracting parents. Such
Across the world there is great diversity in the
commercial inducements may entice women regulatory
to frameworks governing assisted
disregard the risks involved and face pressure
reproductive technologies, and it is this diversity
from their family to be involved.34 A number
which encourages the movement of patients
of surrogates report having no contracts seeking
and to avoid restrictions on certain prac-
no third party legal representation.35'36 While
tices.22,40,41 It is clear that a number of develop-
they receive medical care for the term of their
ing countries in Asia are struggling to regulate
surrogate pregnancies, this is not offered the
forrapidly growing assisted reproduction market
any of their own subsequent pregnancies,
within their jurisdictions, as well as the com-
despite the increased risks to their health. Simi-
plexities of the international trade. For example,
lar concerns are raised as regards commercial although commercial surrogacy was legalised in
ova donation in developing countries, and
2002 in India, it has taken eight years before
whether women donors are fully informed of
legislation mandating enforceable contracts and
the risks involved or whether financial induce- some degree of protection for contracting parents,
ments encourage them to overlook the risks, surrogates and donors has been enacted. Despite
including the possible over-stimulation of their a large foreign trade in Thailand, the new Repro-
ovaries to maximise egg production. ductive Health Bill to regulate assisted repro-
In response to concerns over surrogacy con- ductive technologies has awaited ratification for
ditions in India, the Assisted Reproductive years due in part to the instability of the govern-
Technologies (Regulation) Bill 2010, awaiting ment. Meanwhile, the lack of regulation has pro-
approval by the Law Ministry at this writing, duced a lucrative international trade. For foreign
contains some protections for surrogates. It sets patients, there is little legal protection in cases of
an upper age limit for surrogates at 35, allows malpractice across borders.
no more than five live births, limits the number Policy researchers note the difficulties in achiev-
of times a woman can undergo embiyo transfer ing consensus over the degree to which inter-
for the same couple, and forbids clinics from national medical travel should be subjected to
sending Indian women abroad to act as surro- control and the appropriate balance between
gates. Importantly, it will also make surrogacy individuals' autonomy and the need to ensure
contracts legally enforceable. Nevertheless, India adequate protections.22 Discussing the issue
will continue to have one of the most permissive from a US perspective, Cortez42 provides a useful
laws on surrogacy in the world.37 framework of the various policy and legal
In other developing countries, commercial approaches available to a state for regulating
arrangements for surrogacy or ova donation medical travel, including cross-border reproduc-
may occur with little scrutiny, either due to the
tive care. Unilateral options include efforts to:
illegal nature of these transactions, or a lack of
regulate patient travel, regulate referral networks
regulation. This is particularly the case for (for example, by licensing brokers or restricting
women who move between countries to act referrals), regulate health insurers, provide over-
as surrogates or ova donors.38 In some casessight through agencies to monitor the movement
such movement is voluntary, but in others, it
of patients, and provide codes of practice and
involves the trafficking of women. For exam-guidelines. As Cortez notes, some of these are
ple, in February 2011, the media reported impractical to implement (such as regulating
a police investigation in Thailand involvingindividual travel, or regulating advertising on
14 Vietnamese women, seven of whom werethe internet) and legal precedents in each juris-
pregnant, who had been trafficked to act as diction will have consequences for what can
surrogates for a Taiwanese company.39 Because
be achieved. Multilateral approaches include

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 A Whittaker / Reproductive Health Matters 201 1;19(37):107-1 16

cooperation between countries to regulate pro- order to influence legislation and guidelines on
viders and intermediaries, and cooperation to assisted reproduction services transnationally.
standardise accreditation, clinical practices, and There is also a need for representation of the
outcomes reporting.42 people who provide the services, such as gamete
Although there have been some recent suc- donors and surrogates.
cesses in brokering multilateral agreements on A lack of systematic data about cross-border
global health issues, such as international organ reproductive care is a significant obstacle to
transplantation and tobacco control, even within debate and policy intervention. Little is known
the European Union, agreements on cross-border about the extent, experience or conditions of
trade in health care have proven practically cross-border reproductive care outside of Europe
impossible to broker.43 International harmo- and the United States. Further research is needed
nisation of laws is unlikely.22 Two countries in Asia on the local effects of this trade upon
have made the highly controversial move to local health systems, couples seeking treatment
enact legal sanctions against citizens involved and services, and those women whose body tis-
in certain forms of cross-border reproductive sues and nurturing capacities facilitate it. More
care.41 In 2010, Turkey banned cross-border attention needs to be paid to the provision of
publicly funded assisted reproduction services,
travel for assisted reproduction services involv-
ing third party donation of sperm or eggs, to address the inequitable distribution of treat-
under item 231 of the Turkish Penal Code, ment and to investigate means to regulate this
according to which it is illegal to "change or
trade by governments, international NGOs, pro-
obscure a chilďs ancestry", with a punishment fessional organisations and civil society groups
of 1-3 years imprisonment.44 Two Australian in developing countries.43
states, New South Wales45 and Queensland,46 Cross-border reproductive care raises ques-
have legislated to ban residents from beingtions concerning the limits of individuals' repro-
involved in any commercial surrogacy arrange- ductive autonomy and rights to seek desired
ments, including overseas, on the grounds of treatment options and recognition of ethical
consistency with state laws which only allowpluralism and social justice within the context
altruistic surrogacy. However, it is not clear of global capitalism.22'32 Cross-border repro-
how such laws might be enforced, and whetherductive care challenges our current regulatory
such coerced conformity is justified. Such bans regimes and poses questions over the rights of
states to regulate the reproductive lives of citi-
may simply act to reinforce discrimination against
zens. Within the process of neoliberal economic
certain groups of patients, or force cross-border
commercial surrogacy or gamete donation to goglobalisation, national systems of health gov-
underground, while turning some parents orernance are being reconfigured as health care
infertile couples into criminals. is increasingly framed as a tradeable commodity
Civil society organisations, including medical rather than a "public good".48 There is a need to
professional associations, patient and healthinterrogate more carefully the particular histori-
consumer groups have important roles to play cal conditions and trajectories involved in such
travel and recognise that structural influences
in monitoring the effects of cross-border repro-
ductive care and to lobby governments for of race, ethnicity and class are involved in the
increased protections for those involved. Forrelationships between cross-border patients,
their clinicians, donors and surrogates. In sum,
example, the European Society for Human Repro-
duction and Embryology (ESHRE) has a Taskalthough mobility in pursuit of health care is
Force on Cross-Border Reproductive Care, whose celebrated by some as the ultimate neoliberal
aim is to gather reliable data on the number ofconsumer "choice" and "freedom", not all travel
patients who cross European borders to access is equal and more work is needed to probe the
assisted reproductive technologies, and the rea- economies, politics, practices, relations and
sons why they travel.5 International umbrella assumptions that underpin this trade.
organizations for patients, such as International
Consumer Support for Infertility (iCSi),47 have aAcknowledgements
I wish to thank the World Health Organization
useful role to play in the dissemination of infor-
mation and to present patients' perspectives in Centre for Health Development for permission

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 A Whittaker / Reproductive Health Matters 201 1 ;19(37):107-1 1 6

to draw upon commissioned work undertaken
for the " Workshop on the movement of patients
across international borders - emerging chal-
lenges and opportunities for health care sys-
tems", Kobe , 24-25 February 2009 . Thanks
also to participants of that workshop for their
discussion of these issues . This paper does not
reflect the views of WHO or its member states .
This work also draws upon research under-
taken for an Australian Research Council Dis-
covery Project , funded by the Australian
government (DP 1094895).

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Résumé Resumen
Cet article donne un aperçu du marché mondial En este artículo se expone una vision general
de la procréation médicalement assistée dans les del mercado comercializado internacional en
pays à faibles ressources d'Asie. Il s'inquiète de el tratamiento de reproducción asistida en
l'accès et l'équité, la potentielle exploitation países asiáticos de bajos recursos, y se plantean
commerciale du corps des femmes subalternes inquietudes en cuanto al acceso y la equidad, la
qui satisfont la demande de dons d'ovules et de posible explotación comercial del cuerpo de
mères porteuses, et la nécessité de réglementations mujeres subalternas para atender la demanda
de protection. Un manque de données systématiques de óvulos donados y maternidad subrogada y la
sur les soins génésiques transfrontaliers est un necesidad de protecciones mediante reglamentos.
obstacle majeur au débat et aux interventions La falta de datos sistemáticos sobre el turismo
politiques. On sait peu de choses de l'étendue, reproductivo es un obstáculo significativo para el
de l'expérience ou des conditions des soins debate y la intervención de políticas. No se sabe
génésiques transfrontaliers hors de l'Europe et mucho acerca del alcance, la experiencia o las
des États-Unis. De nouvelles recherches sont condiciones del turismo reproductivo fuera de
nécessaires en Asie sur les conséquences de ce Europa y Estados Unidos. Aún es necesario realizar
commerce sur les systèmes locaux de santé, les más investigaciones en Asia sobre los efectos de
couples demandant des soins, et les femmes este comercio en los sistemas de salud locales, en
dont les tissus corporels et les capacités porteuses parejas que buscan atención médica, y en aquellas
les facilitent. Il faut accorder davantage d'attention mujeres cuyo cuerpo y capacidad para nutrir lo
à la prestation de services de santé génésique facilitan. Se debe prestar más atención a la
financés par les pouvoirs publics pour corriger prestación de servicios de salud reproductiva
la répartition inéquitable des traitements et financiados públicamente, a fin de eliminar la
prospecter des moyens de faire réguler ce injusta distribución de tratamiento e investigar
commerce par les gouvernements, les ONG los medios para la regulación de este comercio por
internationales, les organisations professionnelles gobiernos, ONG internacionales, organizaciones
et les groupes de la société civile dans les pays profesionales y grupos de la sociedad civil en
en développement. Le commerce mondial en países en desarrollo. El comercio mundial en
procréation assistée nous met au défi de reproducción asistida nos reta a sopesar los
concilier les droits des individus à rechercher derechos de las personas de buscar servicios
des soins de santé à travers les frontières avec de salud en otros países y los derechos de los
les droits de ceux qui assurent des services pour prestadores de servicios de atender sus necesidades,
répondre à ces besoins, en particulier les groupes especialmente grupos vulnerables en situaciones
vulnérables se trouvant dans une situation de de disparidad económica.
disparité économique.

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