Fertility tourism: circumventive routes that enable access to reproductive technologies and substances.

"Fertility tourism" is a journalistic eye­catcher focusing on the phenomenon of patients who search for a reproductive treatment in another country in order to circumvent laws, access restrictions, or waiting lists in their home country. In Europe, the reasons why people seek reproductive treatments outside their national boundaries are quite diverse, in part because regulations differ so much among countries. Beginning with four examples of people who crossed borders for an in vitro fertilization (IVF) treatment with gamete donation, this article provides some insight into these transnational circumvention practices based on material from ethnographic fieldwork and interviews in Spain, Denmark, and the Czech Republic. In all three countries, gamete donation is made strictly anonymous. Clinical practices such as egg donor recruitment and phenotypical matching between donors and recipients serve to naturalize the substitution of gametes and to install social legitimacy through resemblance markers with the prospective child. In comparison to other areas of medical tourism, which are subjects of debate as a consequence of neoliberal health politics and international medical competition, mobility in the area of reproductive technologies is deeply intertwined with new forms of doing kinship. For prospective parents, it holds a promise of generating offspring who could pass as biogenetically conceived children. Therefore, IVF with gamete donation is mostly modeled after conceptions of nature. Through anonymity and concealment it creates forms of nonrelatedness that leave space for future imaginings and traces of transnational genetic creators.

The concerns during assisted reproductive technologies (CART) scale and pregnancy outcomes.

OBJECTIVE: To determine whether concerns specific to IVF/GIFT (i.e., side effects, surgery, anesthesia, not enough information, pain, recovery, finances, missing work, and live birth delivery) that were measured by the previously validated Concerns During Assisted Reproductive Technologies (CART) instrument are negatively associated with reproductive endpoints. DESIGN: Prospective study. SETTING: Seven centers in Southern California between July 1993 and June 1998. PATIENT(S): One hundred fifty-one women completed two questionnaires at baseline and at the time of the procedure. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Number of oocytes aspirated and fertilized, number of embryos transferred, pregnancy rates, and live birth delivery rates. RESULT(S): At baseline, women who were concerned about the medical aspects (i.e., side effects, surgery, anesthesia, not enough information, pain, and recovery) of the procedure had 20% fewer oocytes retrieved and 19% fewer oocytes fertilized, while simultaneously adjusting for female age, race, education, smoking status, parity, type of assisted reproductive technologies (ART) procedure (IVF or GIFT), type of infertility, and number of previous attempts. Women who were very concerned about missing work had 30% fewer ooyctes fertilized. For women who were moderately concerned about missing work, the odds ratio was 2.83 for not achieving a pregnancy. Women who were extremely concerned about the finances associated with the procedure had a very high risk (odds ratio [OR] = 11.62) of not achieving a successful live birth delivery. CONCLUSION(S): The CART scale identified two areas of concerns for women undergoing IVF or GIFT: "missing work/finances" and "medical aspects of the procedure."

A one-year experience with a capitated health care plan for infertility.

OBJECTIVE: To report on a one-year experience participating in a capitated healthcare plan for infertility. DESIGN: Prospective study. SETTING: University population. PATIENT(S): Reproductive-age women 15 to 50 years. INTERVENTION(S): The first-generation Lewin infertility algorithm and CATHI software were used to negotiate infertility services under a capitated arrangement for $0.50 per member per month. The following reports our experience for the fiscal year 1997. MAIN OUTCOME MEASURE(S): Infertility services rendered, pregnancy rate, cost of services, collection rates. RESULT(S): Five thousand forty-six women representing 39,689 member months generated 39 new and 198 return visits. Thirty-two percent of the patients required three visits or less; six patients generated 22% of the visits. Fifty-one percent listed infertility as one of their chief complaints; 31% had mixed diagnoses. Eight (7.6%) patients required surgery, 11 (10.5%) patients underwent either IVF or GIFT cycles. Total charges submitted were $176,636; the amount assigned to specialty care was $135,277, and to IVF/GIFT, $33,433. Total capitated payments, including copayments, was $126,256 under the reproductive medicine agreement and $32,891 under the infertility rider. This resulted in a 71% gross collections rate. CONCLUSION(S): This study indicates that entering into a capitated health care plan to provide an infertility benefit can produce a successful result.

Gamete intrafallopian transfer. A cost-effective alternative to donor oocyte in vitro fertilization in women aged 40-42 years.

OBJECTIVE: To investigate whether gamete intrafallopian transfer (GIFT) may be a cost-effective alternative to donor oocyte procedures in women 40 and older with good ovarian reserve. STUDY DESIGN: Retrospective review of records at an infertility clinic in a large multispecialty group practice. Twenty two consecutive women aged 40 and older underwent 24 stimulation cycles for laparoscopic GIFT procedures from 1988 to 1997. RESULTS: The mean GIFT cycle cost was $5,731. The delivery rate per stimulation cycle was 25.0%. The patients who gave birth were 40-42 years of age. The mean cost per delivered infant was $22,924. A previously reported value for mean cost per pregnancy for donor oocyte in vitro fertilization (IVF) was $30,457. Theoretical costs per delivery, generated from Society for Assisted Reproductive Technology outcome data for anonymous donor oocyte IVF in 1994 (delivery rate per transfer, 34.4%) for $8,000, $9,000 and $10,000 cycle costs were $23,256, $26,163 and $29,070, respectively. CONCLUSION: In women with good ovarian reserve, GIFT may be a cost-effective alternative to donor oocyte IVF at age 40-42.

Cost of assisted reproductive technologies for a health maintenance organization.

OBJECTIVE: To calculate the cost of assisted reproductive technologies (ART) for a health maintenance organization (HMO), assess factors that contribute to the cost per delivery and to analyze how utilization rates can be controlled by the use of clinical criteria. STUDY DESIGN: Pregnancy outcome and a cost analysis of all ART cycles at an HMO in a state with mandated coverage for these procedures was performed. All patients (n = 148) undergoing ART cycles insured by the HMO performed at one in vitro fertilization (IVF) center during 1990-1995 were studied. RESULTS: ART cycle outcomes and a cost analysis, including global cycle and cancellation charges, medication costs, obstetric costs and neonatal care costs, were assessed. ART cycles (n = 375) included IVF (n = 278), gamete intrafallopian transfer (n = 46), cryopreserved embryo transfer (ET) (n = 42), zygote intrafallopian transfer/tubal embryo transfer (n = 7) and donor oocyte (n = 2). Pregnancy outcome with IVF was 18.3% deliveries per retrieval, for gamete intrafallopian transfer 27.8% deliveries per retrieval and for frozen ET 19% per procedure. Overall, 62/148 (41.9%) of the patients delivered. There were 35 singletons, 22 twin sets and 5 triplet sets. This resulted in an average cycle cost per delivery of $36,417. The mean obstetric and neonatal charges were $9,329 for a singleton delivery, $20,318 for twins and $153,335 for triplets. If these charges are expressed in terms of the number of infants born, a twin pregnancy would cost $10,159 per infant and a triplet pregnancy, $51,112. The ART cycle cost per HMO plan member was $2.49 per annum. Our IVF utilization was 295 cycles per million population. CONCLUSION: An HMO can control the cost of ART services by establishing preauthorization clinical criteria. Our utilization rates might be used as a benchmark for other insurers considering ART coverage. The cost of ART ($2.49 per annum) would be only a small fraction of the typical annual insurance premium.

Health maintenance organizations; exclusion of gamete intrafallopian transfer and zygote intrafallopian transfer as basic health services--HCFA. Notice.

This notice informs the public of the determination by the Administrator of the Health Care Financing Administration that gamete intrafallopian transfer and zygote intrafallopian transfer are unusual, infrequently provided, and not necessary for the protection of individual health. This determination permits Federally qualified health maintenance organizations to exclude these services from the basic health services they must provide to their members.

Leuprolide acetate-prepared in vitro fertilization-gamete intrafallopian transfer cycles: efficacy versus controls and cost analysis.

OBJECTIVE: To evaluate the effect of gonadotropin-releasing hormone agonist (GnRH-a) when given through stimulation with gonadotropins versus stopping it as stimulation was initiated versus a control group unprepared in this manner. Also, to construct a cost analysis for this type of therapy in an in vitro fertilization-gamete intrafallopian transfer program (IVF-GIFT). DESIGN: Prospective, consecutive, randomized, with a control group. SETTING: An out-patient IVF-GIFT program. PATIENTS: One hundred new patients entering an IVF-GIFT program. INTERVENTIONS: In vitro fertilization or GIFT cycles with or without preparation (pituitary suppression) by GnRH-a administration in which suppression was continued or halted as gonadotropins were begun. MAIN OUTCOME MEASURES: Cancellation rates, ampules, and days of gonadotropin use, costs, estradiol (E2) level, egg numbers and quality, and pregnancy rates. RESULTS: Stopping GnRH-a (leuprolide acetate) therapy as stimulation was begun did not lessen the suppressive effect in reduction of spontaneous luteinizing hormone surge as seen with continued use of agonist. In contrast, the control group had a 30.3% cancellation rate before ovum retrieval. The E2 and egg data among the groups were similar, but as expected, agonist use led to the need for more and longer duration of gonadotropin stimulation. Pregnancy rates were not different by group. Costs were approximately even by the third initiated cycle.

Health policy dilemmas related to high technology infertility services.

As cost containment in health care becomes an important concern, the costs and benefits of specific health care services will be more closely examined. The costs and benefits of one type of health care, high technology infertility services, are explored in this paper. These services may be particularly susceptible to cost containment since they are costly, raise ethical issues, and because they currently are provided to healthy individuals not experiencing life-threatening illness who can afford them.

Simplifying assisted conception techniques to make them universally available--a view from India.

In-vitro fertilization and related assisted conception techniques are beyond the reach of most infertile couples in India because they are so expensive. Recent innovations such as the use of the natural cycle, the techniques of gamete intra-Fallopian transfer, intravaginal culture and transcervical oocyte--sperm transfer, vaginal ultrasound-guided oocyte retrieval and the availability of ready-to-use culture medium have helped to simplify assisted conception. Research today should focus on further developing these techniques so that better pregnancy rates can be achieved with them. These simplified inexpensive assisted conception techniques can then be adapted for conditions in the developing world, so that infertile patients the world over can benefit from them.

Gamete intrafallopian transfer (GIFT).

Gamete intrafallopian transfer (GIFT), developed in 1984, was the result of further studies on in vitro fertilization (IVF). Since that time many nurses have worked in settings near in vitro fertilization centers and, therefore, have a basic understanding of the technology. An overview is given of the GIFT procedure to prepare nurses to advise and refer couples who may qualify for GIFT and to highlight the shift in the fertility program nurse coordinator's functions toward the positions of administrator and consultant.