IVF or in vitro fertilization is used by many couples that experience fertility issues. It is an assisted reproductive technology used to extract eggs, retrieve sperm, and then manually combine them in a laboratory dish. Once fertilized, the embryo is implanted into the uterus to grow a baby. Some women have pregnancy success following IVF treatments. In some places, this process is well known and seems very common place. However, there is more to it than meets the eye.
Almost every part of IVF is regulated by legislation. It has to be. A doctor is literally holding the ability to create life in their own hand. These laws protect doctors, parents, donors, surrogates, and children. They can also dictate who has access, what options are available, and the processes that are allowed to be used. What may be considered legal in one country is completely banned in another. It is important to know your rights and understand the laws that exist so you can choose a facility that will provide you with the best chance for success.
Legal and ethical issues can be very complicated. They range from your understanding belief on when life begins and religious views surrounding conception. What happens to eggs that have been fertilized, but are not implanted? There are also very grey lines related to testing and medical advancement. Where do we draw the line and what should be considered OK? Most countries have taken a stab at answering these questions and have implemented legislation.
Here are 15 laws on IVF treatments from around the world.
15 Hiding Behind A Mask
The anonymity of the donor has been a fairly common practice in IVF. However, some countries are stepping up their game when it comes to tracking information for later use. This includes both identifying and non-identifying information being preserved. Rules around how it is kept, how and when it can be released, and even who can request it. Portugal has a public national database of donors. In Hong Kong, sperm donation is allowed both anonymous and non-anonymous. However, egg donation must be non-anonymous.
In the UK, offspring are allowed to request non-identifying information at the age of 16 and identifying information at the age of 18. In Spain, non-identifying information will only be released if the offspring is sick with a serious illness. In the US it is the patients that get to specify their wishes. Those are followed as often as possible. The degree of anonymity varies greatly by country!
14 Cha Ching!
Surrogacy is a complex topic in IVF. It is important to understand the different definitions used and which apply to your scenario. Surrogacy can refer to the woman that carries a baby for another couple. Or it is the reference to treatments used to obtain a fertilized embryo. There are so many conflicts of interest when defining roles in the IVF process. Even the ability to be paid is heavily governed (sometimes forbidden)!
In Australia, the birth mother must be listed on the birth certificate. They also only allow "not for profit" surrogacy. In Brazil, the surrogate host must be related to the couple. Countries of predominantly Muslim faith do not allow surrogacy at all. In Thailand, the birth mother is the legal mother and the couple must adopt the child after birth. New Zealand requires all cases be reviewed by an ethics committee. In the US there are generally no limitations, though some states do not allow payment.
13 We Chose A...
There are several methods that can be used in the fertilization process to select the gender of the baby. The reasons provided for choosing to do this are preventing sex-linked inherited genetic disorders, family balancing, or for social reasons. The most commonly accepted one being to prevent sex-linked inherited genetic disorders. Regardless, the motivations of the couple is extensively reviewed ahead of time. The two most common ways it is done is through sperm sorting for insemination (75% accurate for boys and 85% accurate for girls) and IVF with PGD to transfer only embryos of the desired sex (99% accurate).
There are currently 9 countries that allow sex selection. Those countries are: Belgium, Czech Republic, Greece, Hong Kong, Israel, Libya, Russia, Saudi Arabia, and the United States. Many laws still govern this process. Some methods have a higher success rate. Those tend to be more expensive and only available in more affluent countries.
12 Setting A Timer
In many countries, embryos are allowed to develop for several days prior to implantation. At that time the selection process is done choosing the healthiest embryos for use. During the maturation process, some stimulation may be required to ensure successful fertilization and readiness of the embryos. In many countries it is allowed with either regulation or guidelines in place to ensure it is done ethically. Those guidelines are typically things like allowing it for research only, limiting it to certain facilities, or under certain medical circumstances.
The only two countries that notably do not allow it is Denmark and Senegal. In other countries, the early embryos must be used for implantation. Egg maturation processes are just starting to gain some traction as it is a newer technology. Over time we will likely see countries change their stance as more is known about it. For many it is still considered fairly experimental in nature.
11 Frozen: The Untold Story
The maximum time embryos are able to be frozen and then used is highly regulated. The intent of freezing is to make more embryos available for future use by preserving everything they can. This process is no longer viewed as experimental and is commonly practiced now as it is considered safe. Freezing eggs has actually simplified the process for IVF. Most countries allow the freezing of fertilized eggs. Where the legislation tends to come into play is around the time frame allowed.
Many countries limit it to 5-years. An extension may be available for cancer patients. Some countries will store up to 10 years with age restrictions for when the transfer can take place. Then there are places like Japan that will store for the duration of a marriage as long as the female partner is of reproductive age. Consent by both partners is typically required for both freezing and disposal of unused material.
10 Until Death Do Us Part
There are two common scenarios where sperm is used for IVF prior to the donor's death. The first would be someone that donates prior to medical treatment for a condition like cancer. If he then dies, he has provided consent as to his wishes following his death. In most countries, decisions regarding the use of sperm following death is made by a court of law or by the treating physician based on consent forms that have already been signed. This would be the typical way a widow could move forward with IVF following her husband's death.
The other scenario would involve retrieving sperm following brain death when the patient is unable to consent or make his wishes known. This is highly controversial and most countries prohibit this use. In the United States, some states allow sperm use after the donor's death. Israel only allows it with court order. Then there are countries that require donations to be discarded following a patient's death.
9 Pick A Number 1 To 10
The very first IVF birth was a result of one embryo being implanted. As the practice has been researched and advanced, the success rate was known to go up by implanting more than one embryo. The cost of the process rose. As did the risk of having multiple births. Many countries viewed this as reason to implement legislation to reduce the number of embryos allowed for transfer in each session. Many factors go into the number allowed to transfer like the age of the mother, the reason for infertility, and the number of pregnancies she has had.
In most cases the maximum number is 2 with a few countries allowing up to 3 given certain conditions are met. In the future, as IVF further advances and success rates continue to improve, the assumption is that more countries will implement legislation to limit the number of embryos to one or two maximum.
8 This Is A Stick Up
Sperm and egg donation are standard clinical practices when it comes to infertility treatment. However, there are many different variations in the application and collection of donations of this process. Legislation in this area is influenced by religious, ethical, and cultural traditions in each country. While sperm donation and banking has been around a long time, egg donation and storage is a fairly new idea. There is a lot of legislation being put in place regarding how and when these donations can be used. In some countries, donated sperm is not allowed in IVF at all.
For other countries, there is regulation related to the anonymity and screening of such donations. Egg donation is more widely accepted. However, in places like the UK, there is high regulation. They require donors to be screened and consent to be given to having their identity shared in the future. In China, it is only allowed with written permission where more eggs are retrieved than used.
7 Sorry, Can't Help You
In spite of infertility being recognized by the World Health Organization as a major health issue, insurance coverage available to IVF patients is varied. The majority of countries offer some sort of public or private coverage, typically partial coverage. However, there does not seem to be any standard eligibility criteria that is applied. Where eligibility requirements exist the most common are the age of the mother (typically under 40 or up to 44), the number of cycles of IVF offered, and the type of insurance they carry (public versus private).
In Israel, coverage is provided only for the first two live births and a medical issue must be documented to qualify for IVF. Both the US and the UK have variable coverage options. Most of the treatment is not covered. In Portugal, it is free for up to 3 cycles of IVF. Then there are countries like China that offer no support at all.
6 I Need To See Your License
As if you needed more pressure to get married! It is possible you could be asked to show your marriage certificate when being considered. There is legislation out there to help determine who is allowed to participate in IVF treatments. The standard seems to be to specify you must be in a "stable relationship". However, there is no real definition around stable relationship to ensure uniformity. There are some countries (mostly Islamic and South East Asian) that define a stable relationship as being married. Others are more loose in their definition and allow other relationship statuses to be considered stable.
There are 26 countries that allow single patients to participate. Then there are 14 countries that permit same sex couples access to treatment. Countries that currently do not consider marital status before offering IVF treatment are the United States, Finland, Ireland, Argentina, New Zealand, South Africa, Dominican Republic, and Mexico.
5 Wham Bam Thank You Ma'am
Micromanipulation techniques refer to how the egg is fertilized and have been designed to increase the chance of success for IVF. Microinsemination attempts to improve the fertilization process where there is impaired sperm function using a variety of techniques including surgery for retrieval. This practice seems to be generally accepted across the board clinically. Assisted hatching techniques are typically offered to patients with frozen or thawed embryos, or those that have had multiple failed attempts.
This practice is also widely accepted with few exceptions. Cytoplasmic transfer was developed to treat older women that were thought to have less viable eggs. Therefore, they borrowed part of a younger egg to mix with the older egg prior to fertilization. This version is only currently acceptable in 5 countries (Argentina, Greece, India, Kazakhstan, and the United Kingdom). The US prohibits cytoplasmic transfer and cloning requiring FDA approval. To date, no approval has ever been granted.
4 Is This Your Child?
Legislation regarding the welfare of the child has started springing up in a small number of countries. The thought behind this legislation is to ensure the child is being brought into a stable, good home. These countries choose to protect the child as these are elective, assisted pregnancies. For example, the UK uses this as part of their formal assessment during the first consultation. Questions related to the parents past convictions related to harming a child, contact with social services for care of current children, history of drug and alcohol abuse, history of violence, and medical history related to mental health.
They have the most robust legislation in this area. Other countries known for having child welfare regulations in place for IVF are Australia, China, Finland, Hong Kong, Italy, New Zealand, Norway, Slovenia, and Sweden. The United States is in the majority here offering no formal legislation. It is only briefly mentioned, but not addressed as a major concern.
3 Math Is No Fun
Selective fetal reduction is the process used to reduce the number of fetuses in a viable pregnancy where multiples exist. There are many laws surrounding this technique because you are essentially choosing which will be allowed to survive. Believe it or not there are 26 countries that allow this practice. Over the years it seems more and more countries are practicing this technique. The rise is due to the increase in the number of IVF pregnancies as the technology advances.
There is also a tie to the number of embryos allowed to transfer. Where selective fetal reduction is practiced, the laws typically leave the decisions in the hands of the treating physican to be decided by the individual patient's wishes. It is mainly South American countries that report laws that strictly prohibit selective fetal reduction. The assumption is their laws exist primarily due to religious beliefs surrounding when life begins.
2 It's In Your DNA
Pre-implementation genetic diagnosis (PGD) refers to the process of screening embryos for the possibility of genetic disorders. Ultimately, any embryos found to have genetic abnormalities are removed and discarded prior to the transfer process. This type of technology requires the couple to make moral decisions related to the difference between a pregnancy termination and the discard of non-transferred embryos.
PGD is reportedly allowed in majority of the countries that offer IVF. The only two countries that strictly prohibit the process are the Philippines and Switzerland. Where it is allowed, it is restricted to a small number of hereditary disorders. In the United States it is considered experimental. The legislation covers things like when it is performed, how, and who performs it. There are regional organizations popping up to cover these types of regulations. The demand for this procedure is expected to continue to increase. It is generally considered safe and has a low frequency of errors.
1 Science Is Fun
Scientific experimentation on human embryos creates a controversial, ethical conflict between eliminating human suffering and advancing medicine versus playing God and showing respect for the value of life. There is also the debate over the ethical legitimacy of stem cell research. Stem cell research uses cells with the ability to create more cells of the same type. Based on the complexities of these arguments, most countries prohibit any sort of experimentation in the IVF process.
Fairly recently, Argentina made some changes to their laws allowing limited experimentation on non-viable embryos. There are very strict protocols in place to govern that experimentation. China is currently the only country that has allowed human cloning with restrictions. Otherwise, most countries prohibit these activities while they hash out the pros and cons and establish an ethical line they feel good supporting. In spite of these laws, significant progress has been made on stem cell research.
Sources: Fertility Treatment Abroad, International Federation of Fertility Societies