A growing interest in assisted reproduction has led to an increased amount of foreign genetic material in Brazil. Due to increasing demand, clinics that specialize in assisted reproductive technology have been importing more semen and eggs from countries such as the USA and Spain in recent years. Recent research by sociologist Rosana Machin, a professor at the Department of Preventive Medicine of the University of São Paulo’s School of Medicine (FM-USP), found what she calls an “international fertility economy.” By mapping the local assisted reproduction market, the study identified connections between domestic and foreign companies in terms of genetic material supply and IVF treatment. “On the one hand, these companies rely on existing demand in certain places, as is the case in Brazil. On the other, they are looking to take advantage of the medical and legislative possibilities offered in other countries,” reports Rosana.
The study was based on data from the Brazilian Health Regulatory Agency (ANVISA) and surveys conducted in fertility clinics. The most significant increase was in the amount of semen being imported, primarily from the USA. Renata Parca, from the ANVISA Blood, Tissues, Cells, and Organs Department, has confirmed the finding, reporting a 2,500% increase in semen samples imported between 2011 and 2016, according to data from the first report on imported semen samples for use in assisted human reproduction, released in the second half of 2017. Parca says that imports grew fastest from 2014, when the agency authorized the importation of 198 semen samples, rising to 377 in 2015, 436 in 2016, and 860 in 2017. Between 2015 and 2016, homosexual female couples accounted for the fastest growth, with a 279% increase in semen imports, followed by single women and heterosexual couples, for whom imports in the period increased by 114% and 85% respectively.
According to Parca, the data shows that assisted reproduction technology, initially aimed at heterosexual couples with fertility problems, is now commonly used in other situations. It also suggests that Brazil is engaged in an international exchange of genetic material. This hypothesis is reinforced by the arrival of the first batches of imported eggs last year. In 2017, ANVISA authorized the importation of 344 human eggs, the majority of which came from Ovobank, a company based in Spain. “According to ANVISA, most of the material imported into Brazil by Ovobank was destined for use by heterosexual couples, and was sent by one of their partner branches, located in Greece,” says the researcher.
Data from the Latin American Network of Assisted Reproduction (REDLARA), a scientific and educational institution that brings together more than 90% of the fertility clinics in the region, indicates that in 2014, 43.2% of births resulting from assisted reproduction in Latin America occurred in Brazil. The Brazilian Constitution prohibits the sale of blood and sex cells, which can be used in reproductive procedures only when donated anonymously. Spain also forbids the sale of semen or eggs, and donors must remain anonymous, but they do receive financial support from the clinics. Egg donors, for example, can receive as much as R$3,000. In the USA, meanwhile, semen and egg banks are allowed to pay for samples and often provide detailed information about their origin, including the family health history and physical characteristics of the donor.
Parca believes this is a key factor in attracting the attention of potential Brazilian recipients, because it offers a glimpse of the potential phenotype (observable characteristics) of their future baby. “US banks provide access to this information online. On some websites, people can even pay extra to listen to recordings of the donor’s voice or to see a photo of them as a child.”
New markets
In Brazil, the Federal Council of Medicine (CFM) has regulated assisted production practices since 1992 (see timeline). The Federal Supreme Court’s 2011 decision to recognize civil unions between homosexual couples, as well as the National Justice Council’s resolution that two years later made it mandatory for registry offices to register these unions and the birth and adoption of children by homosexual couples, has had a significant impact on the market, according to the study. Since gaining legal recognition of their status as a couple and acquiring the same rights as heterosexual couples regarding the paternity of children, whether through adoption or donated eggs and/or sperm, the number of homosexual couples seeking assisted reproduction has greatly increased. “Before these legal changes, if one woman in a homosexual couple became pregnant by artificial insemination, for example, her partner was not legally recognized as a mother. This, to a certain extent, discouraged female couples from investing in IVF,” Parca says.
She believes the increase in demand can be measured not only by the higher demand for genetic material from abroad, but also by the rising number of clinics operating in Brazil. In the early 2000s, estimates put the number of assisted reproduction centers in Brazil at just a few dozen. By the beginning of 2017, when the survey was still ongoing, there were 147 ANVISA-accredited clinics, 43 of which were located in the state of São Paulo. Today there are 182 companies in the sector, 90% of them private. To understand how they work, the research team sent questionnaires to all clinics, and received responses from 83 of them. The sample includes establishments that use highly complex technologies as well as clinics in small towns that work in partnership with larger laboratories or companies. Sixty percent of those that answered the questionnaire were located in the country’s Southeast region.
In this international environment, the survey also found an increased number of foreign couples—people who are not residents of Brazil—seeking assisted reproduction services in the country. Data from the study indicates that 80% of Brazilian clinics surveyed have registered foreign patients in recent years, most commonly from the USA and Angola. “This data includes situations where one partner is Brazilian and the couple cannot afford the procedure in the other partner’s country of origin, as well as foreigners living in Brazil and individuals who come to the country specifically to use Brazilian services,” Parca said. In Brazil, each in vitro fertilization (IVF) cycle costs an average of R$25,000, which includes treatment prior to the procedure and insertion of the embryo into the uterus. According to the American Society for Reproductive Medicine, the average cost of one IVF cycle in the USA is US$12,400 (about R$47,000). In the UK, private clinics charge roughly £5,000 (about R$25,000) per cycle.
Sociologist Maria Helena Oliva Augusto, a professor at the Department of Sociology at USP’s School of Philosophy, Languages and Literature, and Human Sciences (FFLCH-USP), believes that Angolan women come to Brazil for treatment due to cultural reasons and public health issues. According to her, women in Angola have an average of seven children each. “Motherhood is highly valued. If women do not get pregnant, they are stigmatized and lose the respect of their community. Husbands often abandon them or have children with other women,” said Augusto, who took part in the research project along with sociologist Douglas Mendosa, a professor at the Multidisciplinary Department of the Federal University of São Paulo (UNIFESP). In contrast, data from the World Health Organization (WHO) puts the infertility rate in Angola at 30%, well above the world average of 15%. “Assisted reproduction clinics in the country are not considered reliable. Because of the cultural similarities and lower prices compared to European and North American countries, Brazil is seen as an attractive option,” explains the researcher.
In Brazil, surrogate pregnancies are legally allowed between women in the same family only, and financial payment is strictly forbidden. To meet the growing demand for this type of procedure, says Parca, international companies that specialize in surrogacy management are establishing themselves in the country. One example is Israeli company Tammuz Family, which currently has branches in 14 countries. Since opening in Brazil in 2016, it has managed 38 surrogate pregnancies. Another 42 are in progress. “The company hire women in countries that regulate the process, such as the USA, Greece, Ukraine, Albania, and Russia, based on the profile of the couple trying for a baby,” she says.
ANVISA authorized the importation of 344 egg samples by a Spanish company last year
While some countries, such as Ukraine and Russia, only allow heterosexual couples to hire surrogacy services, it is legal for everyone in the USA. Surrogacy management companies act as mediators, collecting all the documentation needed from the surrogate mother to register the birth. With the birth certificate in hand, the child can be registered at the embassy of the country where the parents live and given a passport, which guarantees citizenship of the destination country. “The surrogacy market needs to be legally recognized in the country where the process occurs, otherwise the baby will not be able to obtain legal recognition as a citizen of the destination country,” she adds. In the United States, a surrogate pregnancy can cost up to US$120,000 (about R$454,000).
Legal debate
There is no legislation in Brazil regulating the assisted reproduction market, and the law has not kept up with the technological improvements and growing market. According to Silmara Juny de Abreu Chinellato, a professor and head of the civil law department at the USP Law School, surrogacy is one of the main subjects of the legal debate and needs regulation. “The contract between the pregnant woman and the genetic material donors that intend to register the child and assume paternity is problematic and questionable. If the pregnant woman decides she does not want to hand over the child, there are good arguments in her favor. Legally, in my interpretation, the contract can be considered null and void due to the illegal nature of the object, which is the gestation of a person,” says Chinellato.
In Brazil, the Childrens Act (ECA) gives all children the right to know their genetic identity, something also recognized in countries such as Germany, Sweden, Switzerland, and the UK. The law includes adopted children and by extension, those conceived using genetic material donated by people who are not their legal parents. Chinellato points out that although the CFM resolution states that sperm and egg donation must be anonymous, this does not prevent a child from filing a lawsuit demanding knowledge of their origin, as is their right according to the Brazilian Civil Code. “Hospitals, clinics, and gamete banks should retain donor data, because they could end up as defendants in legal cases started by those who were conceived from donated genetic material. The CFM resolution aims to maintain anonymity, but people also have the right to know their genetic origin,” says Chinellato. She emphasizes that although there is no specific legislation regarding assisted reproduction, there is a set of legal norms that guide the decisions made by judges.
Medicine has evolved faster than legislation, generating legal uncertainty
According to psychologist Maria Yolanda Makuch, from the Obstetrics and Gynecology Department at the University of Campinas (UNICAMP) Medical School, the right to know one’s origin is rarely discussed within families and can become an issue, according to the 2004 survey Parenting infants conceived by gamete donation, which involved 51 families who had used assisted reproduction methods in Australia, the USA, and Northern Europe. Although most respondents said they intended to tell their child how they were conceived, only half of the couples reported having addressed the issue five years after the birth. “This data shows that although medicine is evolving quickly, many people do not know how to deal with the situations that result from these advances,” she says.
As most legislative bills designed to regulate the industry have been systematically shelved by the Brazilian Congress, the CFM resolutions act as ethical guidelines and are the only reference for professionals in the sector. In addition to the debate over surrogacy, Chinellato notes that there are also important discussions to be had about the fate of surplus embryos—those that ultimately are not implanted in the womb during IVF treatment. Currently, the Biosafety Law (11,105/2005) allows them to be used for research, as long as donors do not refuse. “However, when there is no consensus between the options of discarding them, donating them for research, or implanting them, many embryos stored by clinics are abandoned or become the object of a dispute between the parents,” she says, highlighting that this kind of problem could be avoided if the country had specific legislation on the matter.
The UK is a leading example when it comes to regulation of the assisted reproduction industry, according to Dr. Luis Bahamondes, from the UNICAMP Department of Obstetrics and Gynecology. “The country has legislated every detail. From how many embryos can be transferred to a woman, when they can be discarded or donated for laboratory research, even at what age the child has a right to know their genetic identity,” he reports. Although the legislation in other European countries is not so advanced, the doctor notes that most have established regulations for assisted reproduction. Some, like the Netherlands, offer IVF under the public health system. Due to the increasingly international nature of the industry, experts agree that an international registry is needed. “In Brazil, although ANVISA certifies that imported material is sanitary, there is no public body that records how it is eventually used. Only the private clinics themselves maintain this information,” says Parca.
Elitist procedure
About 8% of couples are infertile worldwide. According to Bahamondes, some of the leading causes of female infertility include complications from poorly performed abortions and tubal obstructions caused by sexually transmitted diseases (STDs), both of which are most common among women from low-income backgrounds. Endometriosis, however, which can also cause infertility, most often affects women with greater incomes, for reasons that are still unknown. Obstruction of the vas deferens, which can also be the result of contracting an STD, is one of the most common causes of male infertility—with a higher prevalence among men with lower incomes. “People with more money have the ability to pay for examinations and treatment, while those with limited financial resources, despite their higher prevalence among those suffering from infertility, are often not even able to schedule an appointment to diagnose and identify the cause,” notes Bahamondes. According to him, 95% of assisted reproduction treatment in Brazil is accessible only to those with high incomes.
Public health issue
“Although the procedure is sometimes available through the Brazilian public health system (SUS), only a few university teaching hospitals offer free assisted reproduction treatment,” says Sandra Garcia, coordinator of the Population and Society Department at the Brazilian Center for Analysis and Planning (CEBRAP). According to the researcher, waiting lists are long at institutions such as the Hospital das Clínicas teaching hospital in São Paulo, and couples can wait as long as four years for treatment. “Up to the age of 25, a woman’s chances of getting pregnant via these techniques is about 30%. After turning 40, they have just a 10% chance,” explains Garcia. Between 2010 and 2014, she worked on a research project called “Assisted Reproduction in Brazil: Sociodemographic Aspects and Challenges for Public Policy,” through which she identified the emerging growth of semen imports from the USA. Regarding egg donation in Brazil, although paying donors is prohibited, Garcia found that they often receive a financial reimbursement, ranging from R$1,000 to R$2,000 per procedure.
In her opinion, the right to reproduction should be treated as a public health issue, especially given the country’s falling fertility rate. “Innovation in this area is continuous and the government needs to participate in regulating the industry, holding a public debate to help to develop specific legislation that considers these technological and sociocultural innovations,” she concludes.
Project
Reproductive technology and (in)fertility: Regulation, the industry, and our rights (2016–2018) (no. 15/20543-4); Grant Mechanism Regular Research Grant; Principal Investigator Rosana Machin Barbosa (USP); Investment R$40,848.43.
