" GLOBAL: Medical tourism for infertile couples.."

Patients seek infertility services in a different country for various reasons. These procedures are regulated in most European countries, and the legal framework within which assisted reproductive technology can be practiced in a given country varies considerably. In some countries, the number of eggs that can be fertilized is limited (such as in Italy), the number of embryos selected for transfer is limited (such as in Germany), or the number of embryos that can be transferred is regulated (such as in the Scandinavian countries). In addition, certain procedures (preimplantation genetic testing, donor gamete use, surrogacy, or sex selection) may be allowed in some, but not all, European countries.

Neither the regulation nor the financing of these services is uniform. In some countries, the entire expense has to be covered by the patient, whereas in others, not only is the treatment reimbursed but the medication expense is as well. Restrictions in some countries prevent patients older than a certain age or with a certain reproductive history from undergoing reimbursed treatment. Availability and waiting times also vary. All of these factors drive patients to explore treatment abroad.

"It is estimated that 20,000 to 25,000 European couples receive in vitro fertilization (IVF) care abroad each year."

Under normal circumstances, assisted reproductive technology procedures are reported to national registries, and the data are forwarded to the European Society of Human Reproduction and Embryology (ESHRE) to compile the European IVF database. However, procedures performed abroad are rarely included in these databases and therefore are unaccounted for. The kind of assisted reproductive technology procedures that can be performed in a given country differ significantly throughout Europe. A classic example is donor egg use. About 10% of the patients undergoing assisted reproductive technology need this service, but it is not allowed in several European countries (Germany, Austria, and Italy). In other countries, such as Spain, donor egg use is allowed and the donor can be reimbursed for her expenses. Not surprisingly, patients from all over Europe choose Spain as their destination when it comes to donor egg use, and nearly half of all donor egg treatment cycles in Europe are performed in Spain. A United Kingdom study by The York Management School found that about one quarter of the multiple gestations in the UK were the result of fertility treatments provided overseas.

The assisted reproductive technology procedures that can be performed in a given country are influenced by the country's ethical, legal, traditional, and cultural characteristics. These differences will always exist and may at times exclude some patients from services, and these patients must seek services abroad. To make it easier for such patients to receive the desired services outside of their countries of residence, physicians should assist in the evaluation and follow-up of these patients in coordination with the physician team that actually performs the procedures. This would be more convenient for the patient and would guarantee high-quality care and adequate follow-up. Insurance companies could also cooperate and arrange the appropriate financial coverage for these procedures. Until these measures are introduced, physicians should adhere to available international guidelines when treating these couples, and therefore, complication rates can be reduced to the minimum. It is imperative that global standards be developed and the USA, European, and other nations take an active role in setting requirements, including rights of citizenship and immigration.