Editor’s Note: This is Part Two of a conversation with Marcia Inhorn,aprofessor of Anthropology and International Affairs at Yale University.Inhorn’s recent presentation at the Center for Medical Tourism Research Conference in Austin, Texas,Reproductive Tourism: Global Trends, Middle Eastern Perspectives, garnered a lot of attention and praise. Medical Travel Today spoke with Inhorn after the conference to learn more on her studies in the world of Cross-Border Reproductive Care (CBRC) and trends in the reproductive travel industry. To read Part One of this conversation click here. MTT: How much do government restrictions on services drive the industry?

MI: It’s significant. CBRC is fueled by restricted access to in vitro fertilization (IVF) or intracytoplasmic sperm injection(ICSI), and often to donor gametes. You hear a lot of talk about transnational gestational surrogacy in India, but that’s really only a very small part of the total CBRC industry. It’s just the part that makes for a good story in the media. The reality is that most CBRC involves run-of-the-mill infertility issues – for example, older women with poor quality eggs seeking donor eggs. A lot of countries have restrictions on that, especially within the EU. There’s a lot of intra-European travel from so-called “restrictive” countries to “permissive” countries for treatment. And it’s a challenge for infertile European couples because Europe consists of a real patchwork of permissive and restrictive countries. There’s absolutely no legal harmonization to be found. You know Italy used to be the “Wild West” of European assisted reproductive technologies (ARTs). Everything was done there beginning in the early 1980s. Then in 2004, they came down with a law inspired by theVatican that pretty much shut down reproductive services. Again, it didn’t keep women or men from seeking ARTs, but rather it spawned a huge outmigration of Italians seeking services abroad. In fact, some Italian doctors simply moved their practices right across the border into permissive countries like Switzerland. MTT: So religion has a role where services are available? MI: Yes and no. In Italy, yes. In Spain, also a Catholic country, no. In fact Spain is very permissive regarding ART. Latin America, too, has a booming IVF industry. And while you might think the Islamic world would be restrictive, it’s actually much more permissive than Catholicism toward these technologies. They have a very different view of reproductive bioethics. In the Muslim world, the majority of the population doesn’t accept donor gametes — but not in all countries. Iran and Lebanon are the two Muslim-majority countries where donor gametes are available. In fact, as early as 2003, there was already a cross-border movement within the Middle East to both of those countries for donor eggs. It’s just done with a certain amount of secrecy, but at a good rate of success. Another interesting and important phenomenon that’s influencing treatment destination choices is what I call “return reproductive tourism.” Today, we have huge diasporic immigrant communities around the world. When members of these communities want a baby, they often choose to go home. They trust their home country’s medical system, where language is not an issue, they’re comfortable with the way care is delivered, and they get to be surrounded by family. The Middle East is very advanced scientifically and technologically, and they have highly developed systems for delivering care. It makes perfect sense that someone would come home for access to all that, plus the cultural comfort that comes with being home. Plus, when you’re dealing with something as sensitive as making an IVF baby, people want it done in line with their traditions and customs. So, there is a massive movement of diasporic community members going home for healthcare services. MTT: There are certainly a lot of factors at play in the industry. Even so, I’m going to ask the impossible question: what might the future hold for CRBC? MI: I can say with confidence it’s a booming industry and will continue to be one for some time to come. Exactly how and where the growth will come from is hard to nail down. Certainly clinics with robust websites are in a position to attract and receive foreign patients. Thailand, Singapore, the United Arab Emirates, Lebanon and India are all doing it well. As scholars, we see CBRC growing, but it’s really not well studied. It would be extremely useful if there was an international registry to track the number of “sending” and”receiving” patients. It’s unfortunate the data doesn’t exist. We know tens of thousands of people travel for ART every year, but we can’t prove it. Nonetheless, it’s a huge industry that will continue to grow, especially as the international middle class population grows. Travel for ART is largely a middle class phenomenon. It used to be the elite, but the Web has really leveled the playing field. Middle class people are Internet savvy and actively looking for where to go. Most IVF patients are not rich. They’re career-oriented, cost-conscious individuals. This is a big decision on so many levels. They’re being very thorough in their decision-making as it is often life and career changing. The one thing that could really affect the entire future of the industry is the practice of social egg freezing. In the past, they were able to successfully freeze sperm and embryos but never eggs. Now they can. What this means is that middle class women who want to have children, but are in the middle of their careers, can now put their eggs on ice. Basically, eggs are harvested and frozen for later use. With this technology you can quite literally delay your biological clock. You harvest your eggs when you’re younger and they’re healthy, and put them on ice until you’re ready. Major clinics have already started creating egg banks. If social egg freezing takes off in Western societies, it could eliminate the need to travel out of country for egg donation services, and who knows what else.But even so, CRBC will always happen. The issues of access, quality of care and waiting lists will most certainly keep it alive for the foreseeable future and beyond. About Marcia C. Inhorn Marcia C. Inhorn, Ph.D., MPH, is the William K. Lanman Jr., Professor of Anthropology and International Affairs in the Department of Anthropology and The Whitney and Betty MacMillan Center for International and Area Studies at Yale University.She is the current and founding editor of the Journal of Middle East Women’s Studies (JMEWS) and has served as director of the Council on Middle East Studies at Yale (2008-2011) and the Center for Middle Eastern and North African Studies at the University of Michigan (2004-2006). She is one of seven medical anthropologists in Yale’s Department of Anthropology. A specialist on Middle Eastern gender, religion, and health issues, Inhorn has conducted research on the social impact of infertility and assisted reproductive technologies in Egypt, Lebanon, the United Arab Emirates, and Arab America over the past 25 years.