Conference Paper: Fertility and Inequality Across Borders: Assisted Reproductive Technology and Globalization

23 10 2009

Eileen Smith‐Cavros
(Nova Southeastern University)

To read this article and its associated commentaries for free just click on the PDF links below.

Smith‐Cavros PDF

Commentary 1 PDF – Jyotsna Gupta (University for Humanistics in Utrecht, The Netherlands)

Commentary 2 PDF – Lauren Jade Martin (The Graduate Center, CUNY)

In order to post your comment and response, please use the comments box at the bottom of this post. All comments are moderated and will appear shortly after they are submitted.



Globalization is affecting even the most private decisions people make in their lives including how to start a family. Many residents of higher income countries are beginning families later in life, as many couples commit and/or marry later and many women choose to establish themselves in careers first. Since infertility issues increase with age, these couples therefore are more likely to experience infertility issues. In addition, an increasing number of single parents and gay and lesbian couples desire to begin families. Today in higher income nations, Assisted Reproductive Technology (ART) is available which allows most couples or singles wishing to start their own family to find success with their own genetic materials or with donor sperm and/or donor egg. The price of ART in higher income nations, however, is often not fully covered (or not covered at all) by insurance; and if it is covered, waiting lists can be lengthy. As a result, ART clinics have sprung up across the globe, particularly in middle income countries, and patients often travel thousands of miles from their homes to seek success at lower costs. This article surveys academic and popular literature to examine the societal, ethical, medical, and familial implications that arise with this relatively new concept of “Travel ART.”



10 responses

23 10 2009
Eileen Smith-Cavros

Comments to Reviewer Lauren Jade Martin

Martin’s review of my paper is a helpful one that brings out an important issue. She is quite correct that the flow of Travel ART is not only from upper income nations to lower. As she comments, women and families from other upper income nations with legal restrictions do sometimes travel to countries such as the US and Spain for ART procedures. Other upper income ART travelers might travel to the US for procedures due to our larger donor pool (more highly compensated than most other nations) or even because of perceived higer quality or higher success rates.
As Martin noted, this does complicate the discussion and remove it from being a single-directional issue of upper income consumers to lower income providers. This complicating factor and the length necessary to propoerly address it (it is a paper in itself!) is why it is not addressed in this abstract. However, I believe a brief mention of it as an issue would be very useful in acknowleding it as another direction of flow in Travel ART. This comment also reminded me to consider that even if all economic and legal inequalities were addressed in relation to ART access ( a highly unlikely process in the short-term), it would not necessarily preclude the need or market for Travel ART.
The point that Martin makes about the need for research on how the children of Travel ART consumers (and I might add the children and family of Travel ART donors) are faring also deserves emphasis.
Thanks for your comments on my abstract. They were constructive and helpful, particularly in considering the importance of additional market factors on Travel ART.

23 10 2009
Eileen Smith-Cavros

Comments to Reviewer Jyotsna Gupta

Thank you for an insightful and detailed commentary on my abstract.
I especially appreciate the commentary in relation to “push and pull” factors, a term that succintly and very accurately highlights important aspects of Travel ART.
I also agree that updating the adoption source would be very helpful. International adoption has changed so much with the Hague convention and with age and availability of children in the U.S. that a more current source/sources is needed. In addition, the current recession has undoubtedly also had an impact on foreign adoption (from the U.S. side and the international side) that could change the dynamics of both adoption and ART at least temporarily.
Unfortunately, data on the number of those who are “involuntarily childless” is problematic at best. So many infertile women write their own scripts post-diagnosis. For example, a women and/or man biologically unable to have a child “decide” not to use ART or to have children…is it choice, is it financial, is it “settling,” is it satisfaction…? The definition and admission of “involuntary” seems inherently problematic. The way people perceive “involuntary childlessness” has great potential to change after the “decision” of childlessness is made (or is accepted). A couple (for their own well-being) who can’t have children may decide they didn’t really “want” them or “need” them anyway, thereby not defining themselves as “involuntarily childless.” Actually, this is a great opportunity for research in itself!
The additional sources that you suggested as part of the ongoing theoretical debate are all important pieces of research and theory relevant to this abstract topic. Their mention certainly highlights the active theoretical debates going on in reference to Travel ART. I agree that these debates are critical and an important part of the literature. I think the inclusion of these articles is eminently necessary because of their strong perspectives.
I hope that the abstract is not just “safe” but demonstrates that I see both the potential (and the reality) for the exploitation of women in Travel ART as well as the potential for a bridge between women. I truly don’t think it is inherently either one of these and that each Travel ART situation is actually quite unique to its participants, place, and situation. What I hoped to accomplish in this particular abstract is to pinpoint gaps in the published Travel ART data (both quantitative and qualitative) which I believe could further support some of these impassioned and important theoretical articles you bring to the forefront. There are several articles you mention that I have read as well as several that I have not read yet, and I quite look forward to reading those.
I completely agree with your comment that ethical concerns do deserve more mention in this debate (which I began to do with a brief comment on “informed consent”) but could certainly expand as well as an expansion of legislative issues.
I also understand your perspective that from a medical standpoint, IVF is not a direct “treament” of infertility or infertility-related issues. Technically, IVF is just what you described, a “bypass.” Many patients, of course, perceive IVF, and all forms of ART, as fertility “treatment” because (if it works) it does treat (fix) the social concept and stigma of infertility, if not the biological reality. Socially, someone who was once “infertile” now considers themselves “fertile” and “treated” successfully, in a practical sense if not clinical, but this distinction is not addressed in the abstract. Your point about the use of the term “treatment” in terms of medical terminology remains very well-taken!
I so appreciated your emphasis and comments on the important of psychological issues and support also being addressed in Travel ART for all parties concerned. It is a major issue that is rarely addressed.
I really appreciate the time that you took and the detail you provided in this critique. From the additional sources you discussed to your thought-provoking comments, my research in this field will be the better for your commentary.

23 10 2009
Jyotsna A. Gupta

Dear Eileen,
Thanks for taking my comments in a positive way, as they were meant to be constructive. The question of `informed consent’ that you mention in your response is a crucial one, and deserves serious attention. However, research done in various clinical settings and for diverse medical procedures shows the hollowness of the concept in various countries (my own experience is from research in India) where patient rights are less developed versus the power of medical service providers, aggravated by lack of (functional) literacy . These pose barriers to `informed consent’ making it no more than just a piece of paper tucked away in a file, which may be used to protect the latter rather than the former in a legal suit. More research needs to be done on this aspect in relation to `travel IVF’.
I wish you success in your further research and would like to keep this exchange of ideas going in other forums even after the conclusion of this conference.

23 10 2009
Eileen Smith-Cavros

Dear Jyotsna,
Your comments were indeed very constructive. And I agree with your interpretation of “informed consent” as troublesome and malleable. It is a challenge in my mind in all donor ART procedures, not just Travel ART. Since to my knowledge there have been few studies (and even fewer long term studies given the relative newness of the technology) of egg donors and potential effects of egg donation (particularly repeated donation or donation with high medication/stimulation measures) on reproductive health and/or general well-being, the concept of “informed” is a bit nebulous in itself.
I, too, hope that we can keep this conversation going after the conference is over.

24 10 2009
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24 10 2009
Lauren Jade Martin


Excellent point on the need for research on the children and family of the donors and surrogates! I imagine this could yield much important information on the uniqueness of different localities, for example the separation of Indian surrogates from their own children while they live in dormitories, versus, say, the children of American surrogates whose moms are at home with them but growing larger with a child that will not be recognized as their sibling.

This reminds me, have either of you (or anyone else who wants to jump into the conversation) seen Arlie Hochschild’s recent article on reproductive tourism in India in the American Prospect this month?


24 10 2009
Eileen Smith-Cavros

Hi Lauren,
I haven’t seen the article yet, but I look forward to reading it.
I also saw your dissertation topic online in the conference bio section…am also looking forward to reading that dissertation at some point when it’s available!

24 10 2009
Jyotsna A. Gupta

Dear Lauren anmd Eileen, the comparative aspect in different socio-economic cultural settings is extremely interesting to research.
Lauren, I knew Arlie was working on the issue, but have not seen the article you mentioned. Could you send me either a link to it, or a pdf? Thanks,

25 10 2009
Lauren Jade Martin

Eileen and Jyotsna,

Here is the link to the Hochschild article:

And I look forward to the day when I’ll be able to share my dissertation with the both of you!


30 10 2009

Greetings from The Management. We’re thrilled that you’ve found such fruitful grounds for discussion and exchange. You’re welcome to continue here after today.

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