fertility tourism fertility tourism fertility tourism (also referred to as reproductive tourism or cross border reproductive care) is the practice of traveling to another country or jurisdiction for fertility treatment, and may be regarded as a form of medical tourism. one can usually be considered as having fertility issues when they are unable to have a clinical pregnancy after 12 months of attempts with intercourse. infertility, or the inability to get pregnant, affects about 8-12% of couples looking to conceive or 186 million people globally. in some places, rates of infertility surpass the global average and can go up to 30% depending on the country. areas with lack of resources, such as assisted reproductive technologies (arts), tend to correlate with the highest rates of infertility. the main procedures sought are in vitro fertilization (ivf), artificial insemination by a donor, as well as surrogacy. these methods are types of assisted reproductive technology (arts). each of these three methods have varying popularity in different countries, with one method being more sought after in these destinations compared to another method in another country. people are mainly driven towards fertility tourism due to lack of resources and high costs, while other contributing factors include cultural, religious, legal, and safety and efficacy issues. other impacts on the need for fertility treatments from other countries include those who are infertile, single, of older age, or identify as a part of the lgbtqia+ community. with these rising conditions, people end up having to travel to other countries in order to get the fertility treatments not accessible to them in their home countries. ivf ivf laboratory destinations about 20,000 to 25,000 women (often accompanied by their partners) annually seek cross-border assisted reproductive technology (art) services. some countries are more popular than others as ivf destinations due to higher success rates and fewer regulations. even small countries such as barbados provide jci-accredited ivf treatment aimed at women from abroad. israel reproduction is a central goal in israel, a leading fertility tourism destination for in vitro fertilization (ivf) treatment with over three decades of major technologies in the assisted reproduction industry. the trajectory of assisted reproductive technology is outlined through the expansion of ivf, the globalization of donating gametes, and the privatization of service. united states many europeans travel to the united states because of the higher success rates and more liberal regulations under the fertility clinic success rate and certification act, which was passed in 1992. in the united states, affiliation between the right and left sides of the political spectrum motivated the protection of human life, even during the in vitro embryonic stages. india india and other asian countries are the main destinations for u.s. women seeking fertility treatment, being the destinations for 40% of u.s. women seeking ivf and 52% seeking ivf with egg donation. the success rate of embryonic transfer through ivf has continually increased, resulting in more pregnancy outcomes. mexico in recent years, mexico has become a destination for cross-border ivf treatment due to its liberal art and egg donation policies with over 50 clinics throughout the country that utilize assisted reproductive technology. mexico does not have legal regulations that restrict or prohibit ivf or egg donations in mexican clinics, making it a top destination for infertility treatment for people in the united states. iran the "iranian art revolution" is the term coined for the movement that has allowed the advancement of infertility treatment in iran with over 70 operating ivf clinics, making it the one of the countries with the highest amount of clinics in the middle east. ivf centers in iran use advanced methods and updated equipment in infertility treatment services. cost factors women from countries such as the united states and the united kingdom may travel for ivf treatment and medications to save money. the cost of one ivf cycle in the united states averages us $15,000, while for comparable treatment in mexico it is about us $7,800, thailand $6,500, india $3,300, and iran $2,500. when calculating these costs, the costs of the hotel, travel, and hospital stay may also be considered in addition to the medical treatment. egg donation egg donation is illegal in a number of european countries including germany, austria, and italy. many women then will seek treatment in places where the procedure is allowed, such as spain and the united states where donors can be paid for their donation. almost half of all ivf treatments with donor eggs in europe are performed in spain. ivf with anonymous egg donation is also the main art sought by canadians traveling to the u.s, and is the sought procedure for 80% of cross-border treatments by canadians. sex selection sex selection is prohibited in many countries, including the united kingdom, australia and canada, india, except when it is used to screen for genetic diseases. some women wishing to be sure of a child's sex may travel to countries where it is legal to perform a preimplantation genetic diagnosis (pgd, a potential expansion of ivf), which can be used for sex selection, such as in iran and the united states. multiple births the rate of complications increases as more and more embryos are implanted. many countries have no restriction on how many embryos may be transferred into the uterus at the same time, increasing the risk of multiple pregnancy and resultant potential complications. these complications may affect both the mother and the child. birth defects have been thought to arise from ivf, however not enough information is available on this topic. in 2005, 35% of all ivf–et births in the us were multiple births (twins, triplets, or more). the burden of multiple births generated by placing too many embryos is carried by the individuals and the home country. donor insemination two thousand babies are born from treatments using sperm donations every year. a woman may go to another country to obtain artificial insemination by donor. the motivation to seek donors from outside countries may come from a want for a greater variety of gamete donors. stricter laws or an inability to meet the criteria necessary in ones respective countries are other possible reasons. the practice is influenced by the attitudes and sperm donation laws in the host country. there is generally a demand for sperm donors who have no genetic problems in their family, 20/20 eyesight, with excellent visual acuity, a college degree, and sometimes a value on a certain height, age, eye colour, hair texture, blood type and ethnicity . according to sociology professor lisa jean moore, there is "anecdotal evidence" that sperm from blonde, blue-eyed men is most in demand. denmark denmark has a well-developed system of sperm export. this success mainly comes from the reputation of danish sperm donors for being of high quality and, in contrast with the law in the other nordic countries, gives donors the choice of being either anonymous or non-anonymous to the receiving couple. the maximum amount of families that may use the sperm of one donor is capped at 12. nordic sperm donors tend to be tall, with rarer features like blond hair or different color eyes and a light complexion, and highly educated and have altruistic motives for their donations, partly due to the relatively low monetary compensation in nordic countries. more than 50 countries worldwide are importers of danish sperm, including paraguay, canada, kenya, and hong kong. united states us sperm is equally sought out for. denmark and the united states both claim that they have the largest sperm bank supply. specifically, the california cryobank believes it is the largest sperm bank in the world. the donations from this sperm bank has reached over 100 countries and accounts for over 75,000 births globally. there is no limit as to how many families may use the donation of one sperm donor. shortages some countries such as united kingdom and sweden, have a shortage of sperm donors. sweden now has an 18-month-long waiting list for donor sperm. as a consequence of the shortage of donor sperm in uk in the late 1990s and the early years of the 21st century, british women travelled to belgium and spain for donor insemination, until those two countries changed their laws and imposed a maximum number of children one donor may produce. prior to the change in the law, the limit in the number of children born to each donor depended upon practitioners at fertility clinics, and belgian and spanish clinics were purchasing donor sperm from abroad to satisfy demand for treatments. anonymous donation was permitted in belgium and is a legal requirement in spain. these two countries also allowed single heterosexual and single and coupled lesbians to undergo fertility treatment. ironically, at the time, many belgian and spanish clinics were buying sperm from british clinics donated by british donors, and they were able to use that sperm according to local laws and limits. in addition, lesbian women from france and eastern europe travelled to these countries in order to achieve a pregnancy by an anonymous donor since this treatment was not available to them in their own countries. british fertility tourists must therefore now travel to other countries particularly those that do not include children born to foreigners in their national totals of children produced by each donor. britain also imports donor sperm from scandinavia but can only limit the use of that donor's sperm to ten families in the uk itself, so that more children may be produced elsewhere from the same donor. at least 250 swedish sperm recipients travel to denmark annually for insemination. some of this is also due to that denmark also allows single women to be inseminated. it is illegal to pay donors for eggs or sperm in canada. women can still import commercial u.s. sperm, but that is not true for eggs, resulting in many canadian women leaving the country for such procedures. surrogacy legal controversies and citizenship legality of surrogacy both gainful and altruistic forms are legal no legal regulation only altruistic is legal allowed between relatives up to second degree of consanguinity banned unregulated/uncertain situation there are differing amounts of laws and regulations on surrogacy around the world regarding the legality of surrogacy, who can be a surrogate or receive this service, if fertility tourism is legal, and if surrogates can be compensated for their services; dictate where potential parents travel to obtain surrogacy. for instance, there are places where there is a lack of laws or guidelines for surrogacy and many custody battles have resulted in outlawing surrogacy and deeming parental rights to the surrogate over the intended parents, or fully legalizing surrogacy all together. in countries where surrogacy is banned, there have been many instances where the intended parents go to different destination for surrogacy, but then have difficulty bringing their new children back to their countries. also, there are some countries that ban commercial surrogacy, but allow unpaid "altruistic surrogacy" and also provide contracts to the involved parties. the citizenship and legal status of a child resulting from surrogacy can be problematic. the hague conference permanent bureau identified the question of citizenship of these children as a "pressing problem" in the permanent bureau 2014 study (hague conference permanent bureau, 2014a: 84-94). according to the bureau of consular affairs, u.s. department of state, either one or both of the child's genetic parents must be a u.s. citizen for the child to be considered a u.s. citizen. in other words, the only way for the child to acquire u.s. citizenship automatically at birth is if he/she is biologically related to a u.s. citizen. further, in some countries, the child will not be a citizen of the country in which he/she is born because the surrogate mother is not legally the parent of the child. this could result in a child being born without citizenship. religious views there are many differing religious views surrounding surrogacy with regards to lineage and heritability, motherhood, and marital fidelity. judaism, hinduism, islam, and other christian denominations outside of catholicism generally approve of surrogacy, but each with some concerns. with judaism, there are concerns regarding legitimacy and most tend to believe that motherhood belongs to the person who actively delivers the child. hinduism views infertility as a curse to be cured by any means necessary, generally approving of surrogacy. there is islamic