SPECIAL CONTRIBUTION Cross-border fertility services in North America: a survey of Canadian and American providers Edward G. Hughes, M.B., F.R.C.S.(C.), a and Deirdre DeJean, M.Sc. b a Department of Obstetrics and Gynecology and b Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada Objective: To identify the scope and volume of cross-border fertility services in Canada and the U.S. and to eval- uate the three-way communication between patients and their service providers in 2008. Design: Mail and on-line surveys of cross-border fertility care activity were sent to 34 Canadian and 392 American fertility clinics and clinicians. Main Outcome Measure(s): Clinician and patient experience with assisted reproductive technologies. Result(s): The most commonly reported cross-border treatment sought by Canadians was anonymous donor–oo- cyte in vitro fertilization (IVF; 363 out of 452, 80%). For patients entering Canada to receive fertility treatment, the largest demand was for IVF (106 out of 146, 73%). The majority of out-of-country patients received by U.S. clinics sought standard IVF (927 out of 1,809, 51%), most of these coming from Europe (25%) and Latin America (39%). The largest proportion of patients leaving the U.S. to receive IVF (41%) or donor-egg IVF (52%) traveled to India/ Asia. Concurrence was seen between Canadian and U.S. clinics’ ratings of key data that should be provided along with returning patients. Experience of earlier patients with individual centers and perceived safety and effectiveness of care are the key factors in choice of destination. Conclusion(s): Anonymous donor–oocyte IVF is the main assisted reproductive technology sought by Canadians traveling to the U.S. India and Asia are the main destinations for U.S. women leaving the country for their fertility care. Three-way communication between patients and sending and receiving clinics is an important element of safe and effective care. (Fertil Steril Ò 2010;94:e16–e19. Ó2010 by American Society for Reproductive Medicine.) Key Words: Cross-border fertility care, anonymous donor–egg IVF, communication Fertility patients seek assisted reproductive technologies (ART) abroad for a variety of reasons. While restrictive regulation in the home country may be the most powerful factor, other potential rea- sons to seek cross-border care include cost, perceived effectiveness, accessibility, and availability of donor gametes from a variety of eth- nic groups (1). Crossing national borders to receive ART poses spe- cial challenges for the continuity, quality, and ethics of care. For infertility clinicians on both sides of this process, the migration of patients creates a shared responsibility, often without clear lines of communication. Procedures for quality assurance, communication, and shared management vary between countries and are developed on a case-by-case basis between international infertility providers. In March 2004, the Canadian federal bill C-13, ‘‘Assisted Human Reproduction (AHR) Act,’’ became law. The act has three main aims: to prohibit unacceptable practices, such as human cloning, to ensure health and safety for Canadians taking part in ART, and to control re- search in ART. Prohibited practices, including reimbursement for egg donation and surrogacy, are now the main impetus for cross-border care. The purpose of the present study was to investigate the extent of cross-border ART services involving Canadian and American in- fertility clinics and current practices of care collaboration and com- munication between patients and clinics in Canada and abroad. The study was designed to inform the development of communication and management tools with the aim of improving the quality care for fertility patients who cross borders. These ‘‘prompters’’ will be published elsewhere. The study’s objectives were: 1) To identify the scope of cross-border services, defining what ser- vices are sought in Canada and the U.S., and where patients come from and go to for ART; 2) To estimate the volume of cross-border fertility services in Canada and the U.S.; and 3) To evaluate the three-way communication between patients and their two service providers. MATERIALS AND METHODS The study protocol and surveys were evaluated and approved by the Hamilton Health Sciences Research and Ethics Committee. The U.S. survey was also reviewed and approved by the Research Committee of the Society for Assisted Reproductive Technology (SART), a subsociety of the American Society for Reproductive Received August 24, 2009; revised November 16, 2009; accepted December 2, 2009; published online February 11, 2010. E.H. has nothing to disclose. D.D. has nothing to disclose. Commissioned by Assisted Human Reproduction Canada. Based on a presentation by the first author at the First International Forum on Cross-Border Reproductive Care, January 14–16, 2009, Ottawa, Ontario, Canada. Reprint requests: Dr. Edward Hughes, Department of Obstetrics and Gynecology, Medical Center, McMaster University, 1200 Main Street West, Hamilton, Ontario, Canada (FAX: 905-521-2627; E-mail: hughese@mcmaster.ca). Fertility and Sterility â Vol. 94, No. 1, June 2010 0015-0282/$36.00 Copyright ª2010 American Society for Reproductive Medicine, Published by Elsevier Inc. doi:10.1016/j.fertnstert.2009.12.008 e16