Motivy pacientů překračujících hranice za účelem podstoupení terapie asistované reprodukce – proč je Česká republika častou volbou pro terapii s darovanými oocyty
Přeshraniční reprodukční péče je nepochybným fenoménem současnosti. Zájemců o poskytování reprodukční péče v zahraničí každým rokem přibývá. Tato nová skutečnost vyžaduje politické řešení, které by reagovalo na definici standardní péče v podmínkách poskytování zdravotních služeb občanům jiné země. Pacienti, kteří podstupují reprodukční léčbu v zahraničí, se velmi často potýkají s komplikacemi, jako jsou jazyková bariéra, nedostatečná informovanost, odloučení od rodinných příslušníků, kulturní rozdíly a zvyky, možná nerealistická očekávání a také omezení ze zákona. Tato práce má deskriptivní charakter a jejím cílem je ilustrovat proměnné, které vstupují do hry při výběru České republiky před jinými zeměmi pro léčbu neplodnosti. Tento fenomén analyzujeme výběrem dokumentů používaných jako zdroje dat. V našem výzkumu jsme se zaměřili na léčbu neplodnosti a definovali jsme několik důvodů, proč zahraniční pacienti dávají v léčbě neplodnosti přednost České republice před jinými destinacemi, a to absence čekací doby, anonymní dárcovství, mezinárodní oddělení v různých jazycích a dostupné ceny ve srovnání s jinými zeměmi.
A. Dostálová 1,2
; F. Güell 3
Faculty of Health and Social Sciences, University of South Bohemia in České Budějovice, Czech Republic
1; Medistella, Mediversvm s. r. o., Prague, Czech Republic
2; Institute for Culture and Society ICS-UNAV, Mind-brain Group, Pamplona, Spain
Ceska Gynekol 2022; 87(2): 137-143
Cross-border reproductive care is undoubtedly a current phenomenon. The number of people interested in receiving reproductive care abroad is increasing every year. This new context needs a political solution that would respond to the definition of standard care within the circumstances of providing healthcare to the citizens of another country. Patients that undergo reproductive treatment abroad very often face complications such as language problems, insufficient information, separation from family members, cultural differences and customs, potential unrealistic expectations, and also restrictions by law. This work is descriptive in nature and aims to illustrate the variables that come into play when choosing the Czech Republic over other destinations as a country to receive infertility treatment. We analyze the phenomenon by selecting documents used as sources of data. In our research, we focused on infertility treatment and justified the reasons why foreign citizens choose the Czech Republic over other destinations for infertility treatment. The variables that lead to the selection of cross-border infertility treatment in the Czech Republic include no waiting time, anonymous donations, international departments in various languages, and affordable prices compared to other destinations.
infertility – medical tourism – in vitro techniques – fertility clinics – ovum donors
There are several initial qualities that provide patients with the desire to seek healthcare outside of their home country. The top of the list is the development of technology, which fundamentally affects the provision of healthcare at several levels. First, it continues to develop advanced medical technologies. Second, there is implementation of increasingly successful methods for diagnosis and treatment. Third, in an indirect way, globalization has permitted people to plan holidays or business trips with the main objective of receiving medical treatment at a selected destination. Furthermore, the internet helps to facilitate the sharing of useful information and allows more affordable travel. The number of people interested in providing reproductive care abroad increases annually. This new context needs a political and legislative solution to respond to defining standard care, the circumstances of providing reproductive care to the citizens of another country, the conditions of payment, etc. Certainly, the close economic, labor, social, and tourist interconnection of countries within the European Union will not be possible without a clear definition and transparent regulation of this situation. European medical professional societies create guidelines and documents for defining lege artis procedures, with varying degrees of binding force or enforceability. At the state or regional level, the arrival of foreign patients on the one hand can bring financial gains, but on the other hand can also improve with the provision of care at the organizational, personnel, material, and other levels. Directive 2011/24/EU lays down basic rules for cross-border healthcare in the EU member states and sets out the objective of further safety and high quality of cross-border healthcare within the Union, promoting cooperation on healthcare between member states. For patients, the situation can be further complicated by language problems, insufficient information, separation from family members, cultural differences and customs, potential unrealistic expectations, as well as restrictions by law. Cross-border reproductive care (CBRC) indicates movements of candidate healthcare recipients from one country where treatment is not available to another country where they can receive the necessary treatment, and this also applies to people seeking infertility treatment . The main causes of CBRC are, on one hand, when treatment is forbidden by law and, on the other hand, when patients are not eligible for the therapy in their home country; for example, single mothers by choice or lesbian couples. Long waiting lists, lack of expertise or equipment, safety or personal wishes for privacy are other factors to be considered .
The Czech Republic is an important European destination for assisted reproduction, especially for egg donation. According to Czech Republic government data, the recipients of eggs are overwhelmingly foreigners; more than 85% of all recipients are foreigners . The following graph (Graph 1) shows the share of foreign receivers of donated oocytes over several years.
The main reason for this study is to explain why European citizens and citizens from other countries choose the Czech Republic, over other destinations, as a country in which to carry out donor egg fertility treatments. The main goal of this paper is to provide explanations and reflections about cross-border reproductive care in the Czech Republic so that professionals and social scientists can understand aspects of this growing phenomenon. We are going to present the most common reasons, in our opinion, that foreign patients take into account when considering the Czech Republic as one of the first options for receiving infertility treatment. For each of the exposed variables, we will first offer a general overview of different European countries, and then show the reality of each variable in the Czech Republic. In the discussion, and taking these variables into account, we will analyze the competitive value of the Czech Republic against the rest of Europe.
This work is descriptive in nature and does not use quantitative appraisals or quantitative synthesis of data. No formal quality assessments were made. The aim of this article is to illustrate the variables that come into play when choosing the Czech Republic over other destinations as a country to receive infertility treatment. We analyze the phenomenon by selecting documents used as sources of data (principally experimental research, as well as guidelines and legislative documents).
General variables for choosing a specific country for assisted reproductive technology (ART) service
In this section, we are going to present the most common reasons, which in our opinion is European citizens and citizens from other countries exploring the Czech Republic as a potential destination to receive infertility treatment. Each state has the right to specify the conditions under which it is possible to treat patients undergoing reproductive medicine, and this provision is valid by law  and, in this sense, the most common variables will thereby be related to the legislation of each country. Among them, we highlight two: personal status (heterosexual/lesbian couple, single mothers by choice) and age limit.
In Europe, states are increasingly liberal in their approach to single and lesbian couples. For example, Belgium, Denmark, Finland, Spain, and the United Kingdom have a liberal approach to assisted reproduction; these countries do not require a medical indication to undergo in vitro fertilization (IVF) therapy, and at the same time, therapy for single patients or lesbian couples is allowed . Single patients can undergo IVF in Spain, Belgium, the United Kingdom, and Greece . Belgium was a top-rated destination for single patients from neighboring France . The movement of French single mothers by choice and lesbian couples to Belgium was studied in detail by Van Houf et al . This study reported that they felt personally hurt and were criticized in public by many. Some participants also reported they felt that their basic right to reproduce was not recognized, and they indicated several inconsistencies in the French policy to support that claim. Lesbian couples and single women do not need to travel abroad for donor sperm treatment anymore, since the law was changed in 2021 . Lesbian couples cannot be treated, for example, in Italy or Slovenia .
In the Czech Republic, only heterosexual couples can undergo therapy . Lesbian couples and single patients cannot be treated there. This criterion is indicative as to why only a specific sample of patients go to the Czech Republic.
Postponing parenthood (mainly due to non-existence of a partner and due to personal decision, i.e., in lieu of a career) is a consequence of moving the upper age limit to have a child. Therapy options with donated oocytes have increased the upper age limit for recipients, so some countries have responded to this fact by regulating this limit. Each European country has different age limits set by law. These age limits vary by country. Finland, Germany, and the United Kingdom do not have a statutory upper limit for the recipient. On the other hand, Belgium, Denmark, and the Netherlands have a stringent age limit of less than 45 . In Spain, according to the law , only the lower limit of 18 years is given for the treatment of IVF; the upper age limit is not set. In Spain, every woman has the right to use assisted reproduction to treat infertility using donated oocytes, regardless of her sexual orientation or marital status. ART centers are obligated to specify the risks of late pregnancy for both the recipient and the offspring, which may be caused by motherhood at a clinically inappropriate age . In the Czech Republic, medically-assisted reproduction can be performed on a woman of childbearing age if her age does not exceed 49 years based on a written request from a woman and a man who intend to undergo this medical service together .
Variables in specific donor context
One of the reasons to travel for reproductive treatment is a prohibited therapy in the country of origin. For example, for legislative reasons, patients from Germany most often choose foreign clinics. This is mainly since the law in this country does not allow therapy with donor gametes [1,12]. Next, we are going to expose donor compensation, donor anonymity, donor profile and IVF payments as reasons that may be influencing choosing the Czech Republic as the country where to receive ART with donor gametes.
For each ART center, it is essential to have a sufficient number of oocyte donors to offer patients appropriate and high-quality treatment. The lack of donors also causes very long waiting lists, which is why clinics themselves actively seek donors and offer them financial compensation to cover the costs linked to the donation, as well as high-standard gynecological care, or other benefits. In France, reimbursements can only be claimed for proven expenses. According to HFEA (Human Fertilization & Embryology Authority), in the United Kingdom, the compensation of the costs per cycle is EUR 750 to cover the financial loss associated with donations . In Spain, this compensation is around EUR 980 . According to the law , this compensation must not be considered commercial or profitable. The only possible compensation for oocyte donors is compensating for physical activity, lost work gains, and travel costs. It is therefore not possible to approach compensation as an economic offer. In the Czech Republic, only costs associated with donations are reimbursed to the anonymous donor. These reimbursements are paid by the provider who performed the egg collection, which may require payment from the recipient receiving the treatment . Compensation for oocyte donors in the Czech Republic is around EUR 1,000. The upper limit for oocyte donor compensation is currently a very popular topic among related professionals. Due to the growing number of oocyte recipients, the need for new donors is increasing. The amount for compensation to donors is also increasing disproportionately. The Society of Assisted reproduction and the Ministry of Health of the Czech Republic recommend setting the limit for compensation for egg donation to EUR 1,000 with regard to the foreign practice of some countries . Many clinics also run different websites for egg donors with more detailed information, free consultation options, and compensation information.
Whether or not the donor is anonymous is a variable that can be decisive when choosing one destination over another. In this regard, only the United Kingdom, the Netherlands, Sweden, and Finland allow non-anonymous oocyte donation. At the same time, these countries prohibit anonymous donations. The opposite model is applied in most member states, namely Greece, Spain, France, Denmark, Slovenia, and Estonia, where oocyte donation is strictly anonymous . There is an increasing tendency to give priority to the rights of offspring conceived via gamete donation programs to know their genetic origins. Some countries have changed the conditions for the donation from anonymous to non-anonymous, for example, the United Kingdom and Portugal. In Portugal, the law was changed in 2018 and only non-anonymous donation has been possible since then . In the Czech Republic, according to the Act on Specific Health Services , gamete donation is strictly anonymous, and the healthcare provider is obliged to ensure mutual anonymity of the donor and the infertile couple simultaneously. An anonymous donor can only be a woman who has reached 18 and has not exceeded the age of 35, or a man who has reached the age of 18 and has not exceeded the age of 40 . According to Rumpíková et al  there is a growing tendency to introduce the open identity system in gamete donation. On the other hand, there is no evidence that anonymity of gamete donation is harmful and any change has to be very carefully considered, taking into account all possible consequences.
Not all countries have legislation where the donor must have a specific profile. In France, it is mostly a young mother with an average age of 30, has a university degree, and her intentions of donating the eggs are purely altruistic. In Belgium, the profile of the donor is similar to France, with the difference that she usually is donating for the first time and only to family members or friends . In Spain, a donation is a matter of rather single or divorced childless women who donate for both altruistic and mainly financial reasons . In the Czech Republic (Graph 2), the oocyte donors are almost exclusively Czech citizens; in fact, over 99% of all egg donors are Czech citizens . The donor, in the Czech Republic, is mostly a young mother, living in a relationship, frequently with a secondary education, who has donated several times and has experience with donations . Majority of Czech donors reported that the main motivation to donation was altruism (helping infertile couples) along with economic motivation and the benefit of testing their own fertility. Anonymity was also one of the most important factors when considering donation .
IVF payments with donated eggs in different countries
Each European country has a different system of payments for assisted reproduction. Most countries pay either full or partial treatment-related reimbursements to the clinic where the patient is receiving treatment, or to the patients directly. In countries such as France, Italy, Belgium, Finland, and Estonia, both systems are applied . Belgium pays for up to six IVF cycles, conditional upon completing the cycles by 40 years of age. France covers up to four IVF cycles, conditional upon a maximum age of 43 years . Health insurance companies in the Czech Republic pay for three IVF cycles, whereas in the case of a single embryo transfer in the first two cycles, then the right to have four IVF cycles arises. The maximum upper age is limited to 40 years of age. The lower limit is 22 years, or 18 years in women with bilateral fallopian tube obstruction .
In the United Kingdom, the price of IVF with donated oocytes exceeds EUR 12,000 .
The average treatment cost of IVF with donor eggs in Spain is approximately EUR 8,000  In the Czech Republic, the price of IVF therapy with donated oocytes for foreign clients is around EUR 5,000 [22,23], and additional laboratory techniques such as ICSI, assisted hatching, or prolonged cultivation to blastocysts, are frequently included in basic packages.
Other variables of interest
Another variable of interest is the role of agencies and healthcare providers, mainly in the anonymous process of gamete donation . In this sense, the role of professional agencies and healthcare providers from the Czech Republic in facilitating, mediating, and providing oocyte donation from Czech donors to patients is very important. The role of facilitators has been characterized as one of ‘intimate labor” [25,26]. This characterization of Czech agencies, echoed in other analyses of those facilitating travel for cosmetic surgery and providing both logistical and emotional support as unique qualities included in their services .
We also find reasons that, although not directly related to the treatment, can be understood as legitimate reasons when choosing the Czech Republic over other destinations. We primarily determined three reasons: the waiting lists, language and holiday period. The main reasons for the French traveling for treatment are due to their long waiting times and lack of donors. Furthermore, Spain and the Czech Republic have no waiting periods due to large active databases of oocyte donors. Patients from the United Kingdom often choose the Czech Republic for timely and affordable treatment . Spain attracts patients to the summer “holiday” atmosphere and a large selection of donors according to various phenotypes. Many patients travel to Spain to protect their privacy, claiming they are only going to relax on the beach while also undergoing fertility treatment. The Czech Republic, a country known as the heart of Europe with many cultural and historical monuments and a multicultural and modern capital city, definitely has a lot to offer. Patients who travel long distances, such as those from USA/Canada or Australia, can take advantage of being in Europe and stay longer to maximize the opportunity to visit surrounding countries while they are in the Czech Republic for their fertility treatment. Language assistance is also an important aspect. Some clinics in Spain, faced with the increasingly notable influx of French patients, have chosen to incorporate native French experts among their professionals, making language an international claim for French-speaking patients . The difference in price for foreign clients is the cost of language assistance during the entire therapy if patients choose to receive assistance by a treatment coordinator in their native language. In this sense, the Czech Republic is well-placed in the international market. Spoken English is the standard among all private ART centers and a majority of the public hospitals also offer ART treatments for international patients. Moreover, according to clinic websites, the other most common languages used within fertility units are German, Italian, French, and Slovenian, and less frequently Russian, Polish, Romanian, Spanish and Hungarian.
In literature, we see that the reasons for patients traveling for treatment have been divided into two groups: legal restrictions, and the availability of therapy due to age or civil status , where this availability can have different meanings:
1. A specific diagnostic or therapeutic method is not offered at all in a given country for ethical or technical reasons.
2. Although the method is ethically acceptable and technically captured, there is a lack of “material” resources to apply it to the required extent. This is typical of transplant procedures, where there is a shortage of organs suitable for transplantation.
3. The method is offered, but for some applicants it is too expensive.
4. The method is offered and affordable, but in circumstances that do not suit a particular applicant, such as it not reaching the required quality.
In our research, we have focused on infertility treatments, and we have justified the reasons why we think that European citizens and citizens from other countries choose the Czech Republic, over other destinations, to receive infertility treatment. The variables that lead to choosing foreign patients to undergo their fertility treatment in the Czech Republic, compared to other destinations, seem to be no waiting time, anonymous donorship, international departments in different languages, and affordable prices. In this context where the passing of months plays against reproductive capacity, where there is no flexibility in the travel schedule, and no waiting time, without a doubt, favors the Czech Republic compared to other destinations such as Belgium, France, and the United Kingdom. The fact that the donorship is anonymous can also be an important variable when choosing the Czech Republic; anonymity reassures clients in the face of future legal and existential problems. International departments offering different languages can also be an important variable when it comes to offering security and clarity of information, and also in the personalization of treatment between professionals and patients. In this sense, the Czech Republic has an advantage over other European countries.
Conclusion and future directions
The Czech Republic is also definitely one of the most frequently selected countries for egg donation treatment by international patients in Europe. In the Czech Republic, the majority of IVF cycles with donor eggs are requested by international patients who primarily seek anonymous donors, no waiting times, and experienced medical centers that use the latest technology. IVF centers in the Czech Republic are not open to single patients and lesbian couples, and the age limit is strictly determined at 48 years +364 days, so patients choose Spain and other countries with more open legislation. The affordability of IVF treatment in the Czech Republic when compared to other countries is also a strong economic motive. Cross-border reproductive care is definitely an important sector for the Czech economy, and IVF centers very often promote their services in different countries/languages so they can still receive an important number of foreign patients, especially for egg donation or double-donation treatments.
In addition to the variables studied in this work, there are others that are as yet not in play either among the population or fertility professionals. In our opinion, there are two relevant variables that must be of primary focus for optional treatment planning. The first is the quality of information given by clinics about health risk outcomes that involve ART, and the compromise to minimize those risks; the second being the compromise between fertility clinics and healthcare systems in general, including research on the causes of infertility in order to recover it.
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Gynaecology and obstetrics