Sun, beach, culture, gastronomy… and fertility treatments. Spain is a mecca for reproductive tourism, a world leader in this field that every year receives thousands of women and foreign couples who come to our country in search of making their dream of having a child, of starting a family, come true. Almost more than the journey of your life, it is the journey of life. The one that Ana Obregón did but in the opposite direction. According to data from the Spanish Fertility Society (SEF), (provided by some 320 clinics), international patients underwent almost 13,600 in vitro fertilization (IVF) cycles in 2020 (latest data available), 11% of the total .
There are clinics, especially in Barcelona, Bilbao or Valencia, where this percentage exceeds 35%. France, Italy, the United Kingdom and Germany are the main emitting countries. The reason? “We are a leading country and also Spanish laws are very guaranteeing,” says gynecologist Manuel Muñoz, director in Alicante of the Valencian Infertility Institute (IVI), with centers in 30 cities. “They come for the quality of the service we offer and for the results,” adds Pascual Sánchez, also a gynecologist, co-founder and medical director of Ginemed, another of the reference groups in assisted reproduction with thirteen centers in Spain and two in Portugal.
For Antonio Urriés, president of the Association for the Study of Reproductive Biology (Asebir) and director of the Assisted Reproduction Unit at Hospital Quironsalud Zaragoza, the Spanish law, which was first enacted in 1988, is the key to why Assisted reproduction in Spain has been at the top of the world for decades. These ‘national’ techniques have helped bring 30,000 babies into the world, 10% of all those born in Spain in 2020. The mothers had an average age of 35 to 39 years.
Spanish legislation, the quality of the treatments and their results encourage thousands of women and couples to cross the border every year
Together with the Czech Republic, Denmark and Belgium, Spain is a European power in assisted reproductive techniques. In 2020, 13,588 IVF cycles were performed on people from abroad, 26% less than the previous year due to the covid effect. The pandemic brought a sudden stop, which also affected Spanish patients, although to a lesser extent. In 2020, a total of 127,000 IVF treatments were undertaken (14% less than in 2019) and 24,800 artificial insemination (almost 24% less). The three experts consulted explain that the centers are already recovering the figures prior to the pandemic and in some cases “even exceeding them.”
One in ten cycles (specifically 10.6%) were performed on patients from outside Spain, but there are clinics that, due to their location in large capitals with good air connections, double, triple and even quadruple these percentages. For example, in the network of IVI centers, the average number of foreign couples or women is 26%, “but we have clinics in Barcelona where these percentages are much higher, 35 or 40%,” says Manuel Muñoz, a specialist in reproductive medicine and director of IVI Alicante and the Center of Excellence in Ovarian Rejuvenation.
France, Italy, the United Kingdom and Germany are the countries of origin of the vast majority of patients treated in Spanish clinics. Only France and Italy account for 60% of all treatments for patients from abroad with 40% and 22% respectively. Since 2014, the year in which the Spanish Fertility Society began to register the countries of origin, this has always been the case. “Many take advantage of their holidays to enjoy the climate and tourism and to undergo their fertility treatment,” says Dr. Pascual Sánchez, co-founder of Ginemed, who began his activity in Seville 30 years ago and whose website offers information in Spanish, English , French, German, Italian, Portuguese, Russian and Chinese. For some time now there are more and more patients from Africa, mainly from Morocco and Equatorial Guinea. And also from French-speaking countries in sub-Saharan Africa “where medicine is not so developed and they end up coming to Spain,” Sánchez adds.
And why is Spain a world mecca for reproductive treatments? If we strictly abide by the responses of foreign patients, we see that only a minority come for reasons of legal vetoes in their countries of origin or for economic reasons. In fact, and according to data from 2020, almost 85% do not offer any particular reason when asked why they chose a Spanish center. But in the opinion of the biologist and embryologist Antonio Urriés, president of Asebir, the main reason lies in our legislation. There are countries where egg donation is prohibited, or their waiting lists are extended to two years (too long when we talk about women over 35); in other countries women without a partner or lesbians cannot access this type of treatment.
“We are one of the countries that perform the most techniques in the world, the only one we do not do is surrogacy, which in Spain is prohibited”
President of the Association for the Study of Reproductive Biology
In Germany, for example, the genetic analysis of embryos is prohibited and in the United Kingdom donors cannot be anonymous, which has given rise to bizarre situations, such as requesting alimony from a donor . “Techniques that are prohibited in other countries have been routinely done here for decades. We are one of the countries that performs the most assisted reproduction techniques in the world, the only one that we do not do is surrogacy,” explains Urriés. Just the one that Ana Obregón has chosen to become a mother at 68 thanks to a surrogate in the United States.
Manuel Muñoz abounds along the same lines: «Our legislation is very guaranteeing. Donations in Spain are anonymous and no one can claim parental authority in that sense. Muñoz also adds that the donation culture is deeply rooted here, including that of gametes (eggs or sperm).
Just over 30,000 children came into the world in 2020 thanks to assisted reproduction techniques (in vitro fertilization or artificial insemination) developed in clinics in our country. It is the lowest figure since 2015, although clearly influenced by the pandemic, which also reduced the total number of patients (Spanish and foreign) and the number of cycles. All in all, they represent almost 10% of all births in Spain in 2020, just over 341,000. The paradox arises that until 2018 the number of children born thanks to this type of treatment did not stop growing, while the births of children in Spain decreased.
Regarding the ages of the patients, there is a clear difference according to the fertility treatments chosen. Most of the younger women opt for artificial insemination, a low-complexity technique in which the semen sample is introduced into the uterus after a process of ovarian stimulation. 54% of those under 35 years of age choose this treatment compared to 42% of women between 35 and 39 years of age, and only 4% of those aged 40 or over.
On the other hand, the percentage of age groups turns around in vitro fertilization (the eggs are fertilized in a laboratory before being transferred to the woman), a more complex and much more expensive technique (between five and six times more expensive than ). It is the treatment preferred by 75% of those over 35 years of age compared to 25% of those under this age. In Spain, says Manuel Muñoz, there is no legal age limit to undergo fertility treatment. «But there is a tacit agreement between all the clinics not to do treatments above the age at which a pregnancy can be achieved naturally, that is, when the menopause comes, which in Spain is around 50 or 51 years of age on average. ».
Catalonia is the second most populous autonomous community in Spain (7.7 million) behind Andalusia (8.4) and ahead of the Community of Madrid (6.7) and the Valencian Community (5), but it is the first in total number of cycles (treatments). It is followed by Madrid, the Valencian Community and Andalusia. In relation to the number of cycles per thousand inhabitants, the Basque Country is the leader, something in which its proximity to France has to do. In Spain there are about 400 centers scattered throughout the country, most of them private.
“The centers in the Basque Country and also in Catalonia usually receive a good number of patients from France,” says the president of Asebir, who recalls that it was not until 2021 when the neighboring country finally approved the bioethics law, which authorizes assisted reproduction for lesbian couples and single women. Until then, some two thousand French women went out to countries like Spain each year to receive artificial insemination.
In Spain it is “impossible” for what happened in the Netherlands to happen with a Dutch donor who has fathered 500 children. “The Sirha system prevents this scenario”
Director of the Valencian Infertility Institute (IVI) in Alicante
And in case there were any doubts… what happened to the Dutch donor sued in the Netherlands after having fathered more than 500 children, breaking all legal limits (in his country the maximum is 25 children) could not happen in Spain. The Sirha system (Assisted Human Reproduction Information System) approved in 2021 prevents this scenario from occurring in Spain. «When a donor candidate goes to a reproduction clinic, they are automatically assigned a number that is linked to their filiation data, and that limits the possibility that they can go from clinic to clinic and exceed the limit of live newborns that it marks. the law, that there are six per donor”, illustrates the gynecologist of the Valencian Institute of Infertility.
The data is extracted from the ‘National Activity Registry 2020-SEF Registry’, which is the official registry of Assisted Reproduction Techniques of the Ministry of Health, and its previous editions. In this document, two parts are differentiated: IVF/ICSI (In Vitro Fertilization / Intracytoplasmic Sperm Injection), consisting of the union of the ovum with the sperm in the laboratory, in order to obtain a suitable number of embryos available for transfer to the maternal uterus, and AI (Artificial Insemination), consisting of the artificial deposit of semen in the female reproductive tract, to try to shorten the distance between the ovum and the spermatozoon and facilitate the meeting between the two. The study population is made up of all the Spanish centers that develop assisted reproduction techniques and their participation is mandatory. In 2020, 313 centers participated (between 80% and 70% are private).
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