Attitudes towards cross-border reproductive care among infertile Japanese patients
© The Japanese Society for Hygiene 2013
Received: 25 January 2013
Accepted: 21 May 2013
Published: 9 June 2013
The attitudes towards cross-border reproductive care (CBRC) held by infertile Japanese patients have not been explored. The objective of the present study was to examine interest levels, preferred destinations, motivations, and sources of information related to CBRC. Our findings provide a general outline of CBRC and the future of reproduction and assisted reproductive technology (ART) in Japan.
The study used a cross-sectional design. Data were collected from 2,007 infertile Japanese patients from 65 accredited ART clinics in Japan (response rate, 27.4 %) via anonymous questionnaires.
Most of the infertile Japanese patients who responded denied using CBRC. However, by group, 171 (8.5 %) patients in non-donor in vitro fertilization, 150 (7.5 %) in egg donation, 145 (7.2 %) in pre-implantation genetic diagnosis, and 129 (6.4 %) in surrogacy said that, depending on the situation, they might travel abroad in the future. Older respondents were more likely to express an intention to travel overseas for egg donation in the future. The most popular destination for CBRC was the United States. Popular reasons for interest in CBRC among those considering or planning using this approach to third-party reproduction were that egg donation or surrogacy was unavailable or that obtaining ethical approval takes too long in Japan, whereas these processes are legal and affordable overseas. However, high cost was the most common reason for hesitancy regarding CBRC. Among the participants who were considering or planning to travel abroad for this purpose, TV, medical agencies, print media, and message boards on websites were popular sources of information, whereas doctors, friends, and patient self-help groups were not.
Although CBRC among infertile Japanese patients is not at present common, the demand for and use of this approach may increase in the future in the context of the increasingly aging population. Lack of regulation and unavailability of third-party reproduction is a major cause of CBRC among Japanese patients. Health care provider faces an urgent need for giving useful information for patients regarding CBRC.
Japan contains approximately 600 accredited in vitro fertilization (IVF) clinics, and these performed more than 200,000 IVF cycles in 2009 . Recent demographic changes, such as marrying older and delaying childbearing, contribute to the increased demand for assisted reproductive technology (ART) in Japan, and it was estimated that more than 460,000 patients underwent this kind of treatment in 2002 . However, no comprehensive legislation related to ART is in force in Japan. Several guidelines published by professional bodies have prohibited the use of several technologies and, overall, these guidelines are followed. Thus, pre-implantation genetic diagnosis (PGD) for sex selection and third-party reproduction procedures, except for sperm donation, are not readily available to infertile Japanese patients [3–5].
These regulations pertaining to the practice of reproductive medicine in Japan have forced infertile patients to travel overseas for certain procedures, and an increasing number of infertile couples seek fertility treatments overseas. The United States is the major destination of such couples because several states have legalized commercial third-party reproduction procedures, such as egg donation and surrogacy. However, more recently, Asian countries, such as India, Thailand, and Malaysia, also emerged as major destinations for infertile patients who seek infertility treatment abroad. This is because of the considerable competitive advantages of the ART industries in these countries due to liberal legislation and cheaper labor. Because of legal and economic advances, these countries are attracting increasing numbers of overseas patients, including those from Japan.
This phenomenon has been referred to in various ways, such as “reproductive tourism”, “reproductive travel”, “health travel”, “reproductive exile” [6, 7], and “cross-border reproductive care”. Among these terms, cross-border reproductive care (CBRC) is used in the present study to avoid stigmatization and to provide a neutral term. So, CBRC means transnational travel by patients to obtain particular infertility treatments.
Reasons for CBRC include: (a) prohibitions or restrictions on certain forms of treatment, such as third-party reproduction procedures and PGD, (b) exclusions in the availability of treatment to certain categories of people, such as same-sex couples or single females, (c) the high cost of treatment in the home country, (d) a lack of expertise in the home country, (e) a shortage of gamete donors or the seeking of anonymous donors, (f) long waiting lists, and (g) a desire for higher success rates or a higher quality of care abroad [8–11].
CBRC gives rise to a series of ethical, legal, and social issues. However, little is known about this phenomenon. The Task Force on Cross-Border Reproductive Care set up by the European Society for Human Reproduction and Embryology (ESHRE) has conducted an extremely valuable study to gather reliable data on the number of patients who cross European borders to access assisted reproductive technologies and the reasons prompting them to travel for this type of care [12, 13].
Except for a few published reports [14–17], including that by the ESHRE task force, little is known about the extent, experience, or conditions of CBRC outside Europe and the United States. Further research is needed in non-Western countries about patients’ attitudes regarding CBRC.
It is necessary to understand the attitudes of infertile Japanese individuals towards CBRC. The present study will thus provide a general overview of attitudes toward CBRC and facilitate the prediction of future reproductive and ART scenarios in Japan. The objective of the present study was to examine interest levels, preferred destinations, motivations, and informational resources related to CBRC among infertile Japanese patients.
Materials and methods
A quantitative survey using a self-administered anonymous questionnaire was used. After obtaining approval from the Ethics of Committee of the Kanazawa Graduate School of Medical Sciences, we mailed a request for cooperation to 578 accredited ART clinics throughout Japan, and 65 clinics agreed to participate in our study. Each clinic was sent a number of questionnaires according their request. In all, we mailed 7,309 questionnaires for distribution to patients. The mean (±SD) number distributed by each clinic was 115 ± 32.9, and the median was 50. Sample size was not determined before starting the study. The percentage of patients who received questionnaire was different in each clinic. The majority of ART centers in Japan belong to the private sector so they predominate in our study. The 65 clinics cover six major regions in Japan. Distribution according to region was as follows: 4/64 (6.3 %) in the Hokkaido and Tohoku regions, 21/174 (12.1 %) in the Kanto and Koshinetsu regions, 4/55 (7.3 %) in the Hokuriku and Tokai regions, 11/90 (12.2 %) in the Kinki region, 12/60 (20.0 %) in the Chugoku and Shikoku regions, and 7/52 (13.5 %) in the Kyushu and Okinawa regions. We asked each clinic to have their receptionist distribute the questionnaire to all patients for a certain period to avoid selection bias. Completed questionnaires were sealed in a white envelope and returned to the clinics or mailed directly to the researchers by each respondent. A total of 2,007 questionnaires were returned (response rate, 27.5 %) between November 2011 and March 2012. As respondents did not indicate the clinic they were attending, the response rate for each clinic is unknown.
Data on demographic characteristics (age, marital status, education) were obtained from the questionnaires. To evaluate experience with infertility, data on variables related to infertility treatments were obtained (history of treatment, duration of use of the temperature method, number of AIH, number of IVF cycles, number of pregnancies). Major causes of infertility among the participants were also assessed.
To evaluate current attitudes towards CBRC in infertile Japanese patients, seven categories of reproductive technology were assessed, using five options. The seven categories of reproductive technology were: non-donor IVF, pre-implantation genetic diagnosis (PGD), sex selection, egg donation, sperm donation, embryo donation, and surrogacy. The latter four technologies are known as “third-party reproduction processes”. The five options were “have already done”, “have plans to do”, “have considered”, “would consider in the future”, and “would never consider”.
For those participants who would consider treatment abroad, preferred destinations were assessed for the seven reproductive technologies to assess demand and future trends surrounding CBRC. Preferable destinations were divided into five areas: United States, Europe, India, South Korea, and Thailand or Malaysia. Participants were allowed to choose multiple options.
Reasons for interest in and hesitation regarding CBRC were explored using 17 predefined options. Participants were allowed to choose multiple options. These included push factors, pull factors, and facilitating factors. Reasons for hesitation regarding CBRC were explored using 17 options. Participants were allowed to choose multiple options. These included legal factors, costs, and concerns over the child’s welfare. Information resources were assessed using eight options; participants were allowed to choose multiple options.
Calculations were performed using “IBM SPSS Statistics (ver. 19.0 for Windows)”, a software package developed by the IBM Corporation (Armonk, N.Y., USA). Chi square tests were used to evaluate differences between two categories; p values <0.05 were considered to indicate statistical significance.
Characteristics of respondents (n = 2,007)
Age (36.3 ± 4.9)
Junior high school
Junior college or technical college
University or graduate school
Temperature methoda (n = 1,549)
Artificial insemination by husband (AIH; n = 971)
Number of IVF cycles (including ovum collection; n = 918)
Number of pregnancies
Main cause of infertility
Fallopian tube-related factors
Problems with sexual intercourse‡
Not otherwise classified
The mean treatment history of participants was 31.43 ± 29.07 months; 59.5 % had a treatment history of <3 years, 21.8 % had a history of 3–5 years, and 13.9 % had a history of >5 years. The mean number of IVF cycles (from attempt to ovum collection) was 3.16 ± 4.58. Regarding the major causes of infertility, “aging” was selected by 22.3 % of the respondents, “uterine/cervical abnormalities” by 14.3 %, “ovum/ovary-related factors” by 12.6 %, “fallopian tube-related factors” by 12.4 %, and “sperm issues” by 11.6 %; “not otherwise classified” was selected by 10.4 % of the respondents.
Current attitudes towards cross-border reproductive care and factors influencing in CBRC
Current prevalence of and attitudes towards CBRC among infertile Japanese patients (n = 2,007)
A. Have already done
B. Have plans to do
C. Have considered
D. Would consider in the future
Any intention to go abroad in the future (=B + C + D)
E. Would never consider
10 (0.5 %)
1 (0.0 %)
11 (0.5 %)
159 (7.9 %)
171 (8.5 %)
1,756 (87.5 %)
70 (3.5 %)
2 (0.1 %)
1 (0.0 %)
6 (0.3 %)
138 (6.9 %)
145 (7.2 %)
1,765 (87.9 %)
95 (4.7 %)
1 (0.0 %)
77 (3.8 %)
77 (3.8 %)
1,840 (91.7 %)
89 (4.4 %)
3 (0.1 %)
2 (0.1 %)
15 (0.7 %)
133 (6.6 %)
150 (7.5 %)
1,775 (88.4 %)
79 (3.9 %)
1 (0.0 %)
1 (0.0 %)
2 (0.1 %)
47 (2.3 %)
50 (2.5 %)
1,870 (93.2 %)
86 (4.3 %)
1 (0.0 %)
3 (0.1 %)
62 (3.1 %)
65 (3.2 %)
1,853 (92.3 %)
88 (4.4 %)
1 (0.0 %)
2 (0.1 %)
4 (0.2 %)
123 (6.1 %)
129 (6.4 %)
1,790 (89.2 %)
87 (4.3 %)
Associations between current attitudes towards CBRC and background variables were also explored. We found that attitudes towards undergoing egg donation abroad and age were strongly correlated. Older patients expressed more interest in travelling abroad for egg donation. For instance, 12.0 % (n = 21) of those aged younger than 29 years, 7.3 % (n = 39) of those aged 30–34 years, 9.8 % (n = 68) of those aged 35–39 years, 11.5 % (n = 52) of those aged 40–44 years, and 40.8 % (n = 29) of those aged older than 45 years answered they have already done or expressed any intention to travel abroad in the future for this purpose (data not shown in tables or figures).
Preferred destinations for CBRC
Reasons for and against CBRC
The main reason was “difficulty finding a surrogate domestically”, followed by “difficulty finding egg donors domestically”, “higher success rates abroad”, and “time-consuming Japanese ethical review process”.
CBRC information resources
In the present study, most participants denied the possibility of having or considering CBRC and very few had traveled abroad. This is in contrast to an online survey conducted in the United Kingdom in 2008 (n = 339 responses), in which 76 % of respondents indicated they would consider travelling abroad and 22 % reported having already done so . CBRC among Japanese patients is currently not a mainstream issue. However, a considerable proportion of Japanese respondents (n = 259, 12.9 %) expressed the possibility of going abroad in the future, depending on the situation. Moreover, older patients expressed more interest in CBRC. Indeed, egg donation is known to be a particularly effective treatment for patients who are aging or lacking ova. Recently, the number of Japanese infertile patients travelling to Asian countries such as Thailand and Malaysia for egg donation has increased. This suggests that the number of infertile patients seeking CBRC may increase in the future as the population ages and the number of infertile patients increases. Of particular relevance is the continuing trend to marry and have children later in life, which increases the likelihood of seeking an egg donor. For example, the mean age of Japanese women at the birth of their first child has shifted from 25.7 years in 1975 to 30.1 years in 2012 . “Aging” was the most common cause of infertility, cited by 22.3 % of the participants.
In this study, the most popular CBRC destination for Japanese infertile couples was the United States. Several agencies for US CBRC exist in Japan. We can also assume that the United States is a popular destination for CBRC due to familial ties and/or a large population of Japanese-Americans as potential gamete donors. Additionally, the potential for having caregivers of Japanese descent is higher in various parts of the United States. Moreover, several TV stars have publicized their experiences of CBRC, seeking egg donation and surrogacy in the United States, possibly influencing patient perceptions and responses and, therefore, our findings. It is noteworthy that India was selected as a destination for those seeking surrogacy and South Korea for those seeking gamete donation. This might reflect the fact that India is a well-known low-cost destination for commercial surrogacy and that South Korea has physical and genetic proximity to Japan. With regard to seeking third-party reproduction procedures in emerging Asian countries, there is great concern regarding the exploitation of women who belong to socioeconomically vulnerable populations . Medical tourism in emerging Asian countries is attracting increasing numbers of patients from around the world because of attractive pricing. Issues regarding CBRC should be discussed among authorities in various fields, including medical practitioners and researchers.
Factors influencing interest in CBRC may include institutional barriers to access to several reproductive technologies in Japan due to guidelines and reports published by professional bodies and the government that ban third-party reproduction and PGD for sex selection. If infertile Japanese patients seek such technologies, they have no choice but to go abroad. However, a major reason for hesitancy regarding CBRC was the economic barrier; indeed, this was the most popular answer among study participants. Medical insurance does not cover infertility treatment domestically, and treatment abroad may result in enormous costs. Other studies have also reported that the cost of treatment abroad was a negative factor for CBRC [12, 21]. Another negative factor indicated by some participants was the language barrier affecting the collecting of information and hindering communication with medical staff (51.0 %). However, this situation may differ from that in Western countries. Shenfield et al.  reported that over 90 % of participants received satisfactory information in their own language. Other factors may stimulate or inhibit CBRC; these may differ by country.
We also found that the internet has become the major source of information for Japanese patients seeking CBRC. Respondents who intended to go abroad in the future were seeking information on CBRC primarily via the internet, including the websites of medical agencies and internet message boards. Another major source was printed media. Similar results were reported by Shenfield et al. , who noted that the internet was the main source of information for Swedish, German, and British patients. Other sources included friends, relatives, and patient organizations; however, these were less important [12, 22]. At the same time, a large number of study participants felt that they lacked information (41.0 %). Although the internet is a valuable information source for patients, the quality and validity of the information may be questionable. Patients should be provided with valid and adequate information regarding CBRC, including information on its negative aspects.
Our study has several limitations. Data were self-reported anonymously; thus, it is not possible to guarantee the accuracy of the information provided. This study is cross-sectional and therefore could not explore causal relationships. The percentage of patients who received questionnaire was different in each clinic and there was selection bias. Moreover, participants in the present study were currently undergoing infertility treatment in domestic clinics/hospitals. This is somewhat incompatible with seeking or considering CBRC at the same time, which could have led to underestimation of CBRC and may have reduced the validity of this study to some extent. The percentage of missing data in each questionnaire ranged from 0.9 to 10.1. Therefore, the relatively low response rate and large amount of missing data might have caused bias: more people who would never consider CBRC completed the questionnaire, whereas patients who had undergone CBRC left several items of the questionnaire blank. It is important to recognize that generalizations from such data should be made with caution. As experience with CBRC is currently very rare among infertile Japanese patients, it is necessary to use a qualitative approach to studying patients who have undergone CBRC to obtain more detailed information. Although this study is limited in the aforementioned ways, it is also the first and only published study using a large sample (n = 2,007) drawn from throughout ART clinics in Japan (n = 65) to investigate the general situation with regard to CBRC. Such a large sample enabled the exploration of overall attitudes towards CBRC in average infertile Japanese patients. Specifically, no other study has examined such a large sample of infertile patients.
Based on this initial study, further research on CBRC using appropriate designs and more reliable and valid indicators should be conducted. More comprehensive and systematic data collection is required before any clear conclusions can be drawn about the global picture regarding CBRC.
We thank all the respondents who participated and the clinics and staff who provided assistance. The research was supported by the Funding Program for Next Generation World Leading Researchers in 2010–2013 (LZ006).
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