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Reproductive agency and projects: Germans searching for egg donation in Spain and the Czech Republic
Reproductive BioMedicine Online (2011) 23, 600– 608
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SYMPOSIUM: CROSS-BORDER REPRODUCTIVE CARE ARTICLE
Reproductive agency and projects: Germans searching for egg donation in Spain and the Czech Republic Sven Bergmann Department of European Ethnology and Centre for Transdisciplinary Gender Studies, Humboldt University, Berlin, Germany E-mail address: [email protected] Sven Bergmann is a cultural anthropologist and a PhD candidate at the Department of European Ethnology at Humboldt University, Berlin. He has a scholarship in the German Science Foundation (DFG) research training group ‘Gender as a Category of Knowledge’ at the Centre for Transdisciplinary Gender Studies at Humboldt University, Berlin. He is a member of the newly formed research network ‘Economies of Reproduction’ (http://economies-of-reproduction.org). Abstract German patients in search of IVF with egg donation (which is prohibited by German law) are increasingly deciding to travel
to clinics in other countries (mostly to the Czech Republic and Spain) that are able to provide them with the eggs of other women. Through three case studies of German couples who crossed international borders for IVF with egg donation, this article provides insight into these transnational practices aiming to circumvent restrictions in reproduction, whatever they may be. The material for this article is based on ethnographic fieldwork and interviews conducted in Germany, Spain and the Czech Republic, as well as research undertaken on IVF internet bulletin boards. The concepts of ‘reproductive agency’ and ‘reproductive projects’ are used to analyse the ways in which people search for information about treatments and clinics in other countries, how they embed the practice into their daily lives and how they deal with and position themselves regarding the need for reproductive travel. RBMOnline ª 2011, Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved. KEYWORDS: anonymity, cross-border reproductive care, ethnography, IVF, kinship, transnationalism
Introduction European patients search for reproductive treatments outside their national boundaries for quite diverse reasons, in part because regulations among countries differ widely. There exists a wide range of motives for travelling to other countries for treatment: evading national bans on certain techniques (e.g., gamete donation or preimplantation genetic diagnosis (PGD)), avoiding waiting lists, searching for higher quality services and lower prices and avoiding limitations on the choice of donors or access for unmarried couples, single mothers and homosexual couples. This
article explores the transnational practice of searching for IVF treatment with egg donation from the perspective of German patients. It is based on research undertaken on the practice of gamete donation in a number of different European countries. Data were collected through ethnographic fieldwork, specifically participant observation and in-depth interviews. Substantial fieldwork in a Spanish IVF clinic was undertaken in 2006 (with a followup in 2011) and in a Czech IVF clinic in 2007; additionally, six other Spanish and Czech clinics and one Spanish and two Danish sperm banks were sites of ethnographic research.
1472-6483/$ - see front matter ª 2011, Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.rbmo.2011.06.014
German patients searching for egg donation
The German regulatory situation In the clinics in Spain and the Czech Republic where this research was conducted, German patients primarily sought egg donation, which is strictly forbidden by German law. Some German patients were seeking PGD and, only in a few cases, conventional IVF. In Germany, egg donation is prohibited by the Embryo Protection Act (1990) which states (for cases of practitioners, not patients): ‘Anyone will be punished with up to three years imprisonment or a fine, who: 1. transfers into a woman an unfertilized egg cell produced by another woman, 2. attempts to fertilize an egg cell artificially for any purpose other than bringing about a pregnancy of the woman from whom the egg cell originated [. . .]’. The intent of this German law is not to protect egg donors, but is instead concerned with the prohibition of research on embryos and the prevention of so-called ‘fragmented motherhood’ (Hieb, 2005). While sperm donation is legal and not viewed as interfering with concepts of kinship and nature, German regulation draws upon the old Roman law principle mater semper certa est. When a third party is involved, e.g. the donor of reproductive materials, then the naturalized definition of genetic lineage, in which at least the mother can be determined with certainty, becomes complicated (Strathern, 2005, pp. 67–71). Because IVF challenges legal definitions of kinship that are based on naturalized assumptions, it has become such a controversial issue and an area full of state-regulated interventions. Although patients in search of reproductive treatments form only a small percentage of those seeking medical treatments abroad (Carrera and Lunt, 2010), they draw a lot of national media attention as they are part of an ethically contested field. National prohibition of certain practices has triggered transnational and circumventive treatment-seeking practices of patients. Indeed, mobility in reproductive affairs is nothing new in Europe and in Germany: for example, similar to an ongoing Irish case (Gilmartin and White, 2011), many German women went to The Netherlands to get abortions since the 1970ies. In both cases of reproductive travelling, there is a tendency of morally scandalizing the mobility of patients (or its national causes), much in the same way that practices such as organ trafficking are viewed. Other fields of biomedical mobilities as dental treatment or cosmetic surgery do not raise such public interest. While the increasing travel for reproductive medicine is seen as an ‘unsolvable moral dilemma’ (Beck, 2007, p. 132) and a threat for the state in German bioethical discourse, patient mobility via circumvention of (national) regulative and ethical ‘containers’ can also be regarded as ‘moral pluralism in motion’ (Pennings, 2002). However, the patients whom I have interviewed often lamented about having to travel for reproduction. In contrast to survey results in other European countries which found unambiguous support of egg donation, a German study detected rather split attitudes: of the slight majority (50.8%) of participants who approved (of) a legalization of egg donation in Germany, 36.9% did so only for medial reasons, in contrast to only 2% for age reasons (Sto ¨bel-Richter et al., 2009, pp.
601 126–127). Through data from recent studies (Shenfield et al., 2010) and own observations in internet forums, it has been revealed that German patients often choose the neighbouring Czech Republic for treatment with egg donation, followed by Spain and after that by Poland, Russia, the Ukraine, South Africa and the USA.
Egg donation in Spain and the Czech Republic Why have Spain and the Czech Republic become the most important destinations for egg donation inside the European Union (Shenfield et al., 2010, p. 1367)? Cities like Prague and Barcelona have become ‘global cities’ of reproduction because they possess tourism, business and technology amenities ranging from international airports and telecommunication infrastructures to skilled lab technicians. Tourism infrastructure still matters for medical mobilities, which are built upon these long-established tourism platforms, in Spain for more than 40 years and in the Czech Republic since the ‘Velvet Revolution’ in 1989. According to the World Tourism Organization Spain is among the ‘top international destinations’, ranging from place 2 to 4 during the last years (UNWTO website), and Prague is the 20th most important destination in the world (euromonitor.com ranking). But without having an established donor system and a large pool of donors, Spanish and Czech clinics would not have become such important IVF destinations for foreign patients. Some of the bigger and more well-known clinics in Spain and the Czech Republic have installed waiting lists up to several months for egg donation, as they are overrun by patients. For some patients, particularly the British who often want to circumvent their national waiting lists, this has become unattractive. In effect, new players have entered the market over the last years, among them smaller clinics and also clinics that now only concentrate on the core business of egg donation. Whereas in countries like Denmark, Sweden and the UK, egg donation is possible but has to be performed non-anonymously and only with low reimbursement rates for donors, in countries like Spain and the Czech Republic egg donation is strictly anonymous for donors and recipients (the clinics act as brokers of reproductive substances and keep personal data private). Although in Spain and the Czech Republic the donation of gametes is regulated and marketed as ‘altruistic’, the compensation rate for donors is much higher than what is paid in other countries. Recruitment of gamete donors in Spain is done by advertisements on the radio, in popular free daily newspapers and via placards and flyers on university campuses. Recruitment strategies invocate altruism and solidarity, but also in some cases address reproductive capacity and the potency of potential donors. Whereas posters do not display monetary information, on clinical websites there is a notice about the usual ‘compensation rate’ of 900 Euros. Clinicians said that, in fact, the majority of donors were informed by word-of-mouth from people who already donated. In the course of the current research in the Czech Republic, not a lot of public advertisements were noted. Some clinics display information on their website. A clinic in Prague uses another strategy, working closely with gynaecologists in rural areas of the country who inform their
602 clients about the possibility of being an egg donor. Because wages for female labourers are very low in that part of the Czech Republic, the price paid for egg donation (about 800 Euros, which ranges between different clinics) is much more than an average monthly salary. Whereas the Czech clinics visited recruit only donors of Czech nationality, Spanish clinics were much more interested in having a more heterogeneous donor pool. In the Czech Republic, where mostly Russians and Ukrainians migrate, these populations were excluded from donation. However, in Spain, clinics are actively recruiting East European migrants or Erasmus students from other countries as donors, in order to provide Northern European patients with phenotypically similar donors. A remarkable finding of this research is that in a majority-white European population, the high variation of phenotypes in Northern and Eastern Europe, e.g. of eye and hair colour, was of great concern both for clinics (Spanish law obliges clinics to match similar phenotypes) and for some patients, though not all. Some German couples assumed – as evidenced in interviews and on IVF internet forums – that they would not be able to find a donor in Spain with blue eyes and because of that decided to seek treatment in the Czech Republic. They based their presumptions, however, on the perception of the European nation as ethnically homogenous, not considering the fact that countries in Southern Europe have been transformed because of high levels of immigration, in which people from Latin America and Eastern Europe are among the largest groups. Migrants may be particularly interested in the additional income of 900 Euros. Thus, whereas some Czech clinics focus their donor recruitment on young women from poorer rural regions, the Spanish transnational fertility market has created new gendered part-time jobs for migrants. Class, low current economic capital (as in the case of students) and migration are thriving factors in gamete donation, in cases when it is done mostly for financial gain.
Methodology and data collection When German medical mobilities are analysed within a push-and-pull factors scheme, there is on the one side Germany’s prohibitive law towards egg donation and on the other side the possibility of circumventing this law by travelling to other European countries where the practice is legal and clinics advertise for international patients. Although these legal and structural conditions seem obvious, anthropologists have shown in other fields of mobilities, such as migration, that people employ much more multilayered strategies than moving unidirectionally from point A to point B, and that these projects are intertwined with biographical reasons, gender and identity, social networks and imagination. The following three cases of German patients will illustrate their motivations and decisions to travel, how they were informed about egg donation and subsequently embedded the practice into their everyday lives and how it reshaped their position as persons or couples with an unfilled wish to become parents. In total, 36 patients (couples or individuals) were interviewed, 19 at a clinic in Barcelona, 14 at a clinic in Prague and three independent of clinical contexts – all patients
S Bergmann and clinics have been given pseudonyms. Patients in the Spanish clinic were mostly met by attending the physician’s consultations (consent was obtained beforehand). In the Czech clinic, few consultations were intended; instead, patients were introduced by the head physician or his secretary or met in the cafeteria of the clinic for longer interviews. In 29 cases, patients were heterosexual, mostly married, couples. Of the seven women who were alone, three were travelling without their partners and four identified themselves as single. In Spain, lesbians and single-mothers-by-choice have access to reproductive treatment; in the Czech Republic only heterosexual couples are treated. Fifteen of these interviews were conducted with patients from Germany, 10 from the UK, four from Spain, four from Italy, one with a French woman, one with an Irish woman and one with a couple from Kosovo. Regarding the form of treatment, six attended the clinics for conventional IVF (in one case with sperm donation), 21 for IVF with egg donation (three with sperm donation), six for embryo donation and three patients came because of an IVF treatment with PGD. Although some interviewees already had one child (either through assisted reproduction treatment or from previous relationships), most couples had a history of unsuccessful IVF treatments in their home countries. In selecting the three case studies for this article, this study chose to concentrate on patients from Germany because two other articles already address the UK (Hudson and Culley, 2011) and Italian patients (Zanini, 2011).
Case A: Silja and Raul Kramer: ‘You feel constrained by the state’ The Kramers, both in their forties, were met in October 2007 at an infertility clinic in Prague. After the couple underwent three failed IVF treatments in Germany, they were quietly advised by their German IVF practitioners to try egg donation and were given the addresses of clinics in the Czech Republic, Poland and Spain. The Kramers researched the clinics on the internet and eventually decided to try egg donation in a big IVF clinic in Warsaw, which again failed. Although they had been quite satisfied with the Polish clinic, they lamented its long waiting lists. Furthermore, to get scheduled with an egg donor required Silja Kramer to be on stand-by for weeks and it cost her all of her annual paid vacation. As a consequence the couple chose to try embryo donation in Prague, which is easy to reach by car from their home town in southern Germany. Since Raul Kramer was diagnosed with low sperm motility, the couple decided to substitute both their reproductive substances by using a frozen embryo out of another IVF cycle. Because in this case no donor needs to be stimulated, the couple received a fixed date for the embryo transfer. In order to spend about a week in Prague, the Kramers had taken 9 days paid leave from work. On the day they were met, they had set off for Prague at half-past five in the morning and had just finished their first meeting at the clinic. In spite of his earlier diagnosis, Raul Kramer had a sufficient semen analysis, according to the Prague clinic.
German patients searching for egg donation Nevertheless, the couple decided to stay firm on their decision to use a frozen embryo. However, they were now trying a ‘double track’ solution: if embryo donation failed, they would put themselves on the waiting list for fresh egg donation at the same clinic (in 2007 the clinic’s waiting list for egg donation was about 10 months). The Kramers were only met during this, their first, time in Prague. There was no opportunity to contact them later due to their wish of ensured anonymity and therefore it is not known whether a pregnancy was established or whether the couple continued treatment. The Kramers told about the desperate narratives they read in German internet forums. On the one hand, the couple was reflexive about the pull of IVF as an ‘obstacle course’ and a ‘way of life’ (Franklin, 1997, pp. 101–167) that can engross couples for years without setting limits regarding an end to treatment. On the other hand, when referring to the narratives they read, they slightly distanced themselves from these stories told by ‘others’, who had tried and failed for years. In IVF, the demarcation line between having a last choice and seeing no point in treatment any longer is blurry, especially because ‘miracles’ after years of treatment occur and then circulate in internet bulletin boards. These types of cases underpin the notion of ‘having to try’ (Franklin, 1997, p. 174). The Kramers were governing their own practices by reflecting at a distance that there are more desperate ‘others’. Later, Raul Kramer said that despite their remaining childlessness, they had not reacted for years because they had been focused on other topics like building their house. Such narratives of privileging career opportunities, house building or other forms of delaying one’s desire for a child, show that these decisions are in retrospect, in a situation of secondary infertility (because of age) often regretted. The Kramers were forthrightly criticized by their German IVF practitioner for delaying starting infertility treatment. Silja Kramer explained that they had surely heard of infertility problems in other couples or in the media before but had never imagined themselves as part of this group. Instead of lingering on his own situation, Raul Kramer moved his critique towards German law and demographic policy. He did not understand why sperm donation is allowed but egg donation is prohibited in Germany, and this, as he stated, in a time where birth rates are declining every year. Rather, he demanded that the state should support middle-class academic couples like the Kramers that ‘make a positive contribution to society’. In his argument he echoed the pejorative predicament that reproduction in the lower classes functions, in contrast, seemingly well. This discursive strand, which discriminates against lower classes and sometimes parts of the non-Western migrant population, is a recurrent statement in the German debate – actualized in 2010 through a controversial book by Thilo Sarrazin, a former politician and member of the Executive Board of Deutsche Bundesbank (Mani and Segelcke 2011; Wolin, 2010). The ‘‘Sarrazin debate’’ is like a keyword in Germany which needs not to be explained by a reference – for the international reader I suggest this new reference. The article by Wolin is good in embedding the debate in European right-wing politics but the article which I found recently by Mani & Segelcke explains much more in detail the debate, its course and its main protagonists.
603 The Kramers felt ‘constrained by the state’, as their treatment abroad caused them additional costs and other problems. Their failed attempts of seeking successful infertility treatment abroad had been a sufficient life constraint for the couple, not only because borders had to be crossed, and personal vacation time cut off, but also because secretiveness surrounded their attempts. Since the Kramers wanted to avoid speculations up front, they concealed the incorporation of IVF treatment in their everyday life. As a result of peoples’ well-meant expectations (when will they finally get pregnant?), many infertile couples interviewed felt under constant pressure and stressed about conceiving ‘in public’ (meaning that they felt that every one of their steps and ‘successes’ was being observed). For this reason, the Kramers preferred to make up stories and excuses, avoiding questions about travel plans or weekend activities but at the same time regretted not sharing this part of their life with their friends or sometimes even felt discomforted by doing so. Nevertheless, in the case that treatment was successful, the couple was planning to tell the child about their use of an egg donor. Silja Kramer argued that, although with embryo donation there would be no genetic link to the child, she thought that parenting and social factors will have much more influence on children than heredity and genes. Merely physical resemblance, she ironically admitted, is something which cannot be modelled upon social parenting. It was for this reason that the Kramers were opting for some kind of phenotypic matching. Among the patients interviewed or observed during their consultations, some were more concerned than others with good matching, whereas some had not yet thought about it before coming to an IVF clinic.
Case B: Jeanette Weigand: ‘With my own egg cells I would not have tried it again . . .’ When the research was started in 2006, a call for interviewees was set up in a German IVF internet forum: three people replied, among them Jeanette Weigand. In May 2006, when the interview was held in a hotel lobby in Berlin, Jeanette Weigand was 40 years old. She arrived with her sleeping 8-month-old baby who was born via egg donation in Spain with the spermatozoa of her partner (who, in contrast to interviews with other couples, was fairly invisible in her narrative). Jeanette Weigand’s IVF history is one of a journey: after four IVF/intracytoplasmic sperm injection (ICSI) treatments in Germany, her German IVF practitioner recommended that she go to Belgium for treatment, which is not far from her home town in the west of Germany. In Brussels she had another three ICSI cycles, combined with PGD and blastocyst selection (both prohibited in Germany), but, again, all treatments failed. Then her German gynaecologist suggested trying egg donation in Spain and recommended a big clinic in Valencia. Following this, Jeanette Weigand collected information about clinics in Spain, and also in the Czech Republic and South Africa, as both countries offered cheaper treatment options than Spain. Notwithstanding, she decided for Spain in the end because it was logistically the most easy to fly from her home town to Valencia and she knew the country well.
604 Jeanette Weigand said that, if someone has no personal contact with other insiders, the internet is the only possibility to gain access to information about IVF treatment abroad. Besides reading reports from other patients on several web pages, she made some internet acquaintances and shared a feeling of solidarity with other persons affected. She contacted the clinic in Valencia via email. During her first clinical visit she was accompanied by a Germanspeaking assistant throughout all consultations and medical exams. The Spanish clinic worked with a queuing system via waiting lists. For Jeanette Weigand this had not been very comfortable: as she said with an ironic undertone, ‘you are in the waiting loop . . . and that’s not so nice. And then one day there was the call: ‘‘We have a donor for you – do you want her?’’ I mean, what should I have said . . .?’ Upon hearing the news that a donor had been identified, Jeanette Weigand immediately booked a flight and arrived in the clinic a few days after the call. But at this point another frustration occurred: due to circumstances that were never clarified, all embryos were designated as ‘nearly dead’ after day 2 of fertilization. Although the local practitioners advised against using these embryos, Jeanette Weigand decided that two ‘not dead at all’ embryos were to be transferred. In spite of the estimated low success rate with these devastated embryos (practitioners spoke of 0.5–1%), one transferred embryo led to a positive pregnancy test and resulted in giving birth to her baby – all the clinicians involved spoke of this as some kind of miracle. In contrast to most other interviewees, Jeanette Weigand’s case has been subsequently followed up. Via her entries in the IVF internet forum, it is known that she returned to the Valencian clinic for another successful egg donation in 2007. This time, both transferred embryos developed and she became the mother of twins that were born weeks early but recovered well. In the forum she refers to her children after the place of procreation in the lab: ‘my Spaniards’ or ‘my Valencianos’. She had stayed on the forum to advise others in the case of egg donation and the nurture of babies. In 2009 she returned to Valencia for a transfer with two cryopreserved embryos out of her previous treatment. Again, she became pregnant with twins, to whom she gave birth at the end of 2009. Now she has five children, all assisted in Valencia, and among them four with the oocytes from a single donor. Jeanette Weigand’s case is like a picture book story about egg donation – too good to be true: after seven IVF cycles with her own eggs failed, she moved to egg donation and succeeded in the first treatment (even though practitioners did not believe the donor egg quality to be able to develop into a pregnancy). Also, in her following two treatments, one fresh embryo transfer and one cryotransfer, all embryos established a pregnancy (resulting in two sets of twins). She said that if the first attempt in Valencia would not have succeeded, she was sure she would have had another egg donation. But, she continued, she would never again have an IVF with her own ova because of the high stimulation (an experience she has passed down to a younger woman able to develop more oocytes). After years of failed attempts she now has five children. In her opinion, egg donation is easier to naturalize than adoption because the process of gestation creates a special relation towards the child that is lacking in adoption.
S Bergmann Therefore, genetic material mattered less to her (she remarked that it seems to be more important for males). She favoured anonymity in gamete donation because of the emotional difficulty for the recipient. Explaining her position, she remembered her mood when she was sitting in the waiting room in Valencia and was speculating which women would be recipients like her and which would be the donors. In that moment, she argued, it would have been totally uncomfortable for her to know her donor since she would have been afraid that the donor could have claims for the child. Nevertheless, she favoured openness towards the child at a latter age. She believed that a legalization of egg donation in Germany would challenge the tabooing of these topics and does not understand why sperm donation is allowed but egg donation is not. Because going for treatment in another country was not a bad experience for her, she would also consider doing it again in other medical cases, if the treatment and service would be better than in her home country.
Case C: Dagmar and Ralf Ritter: ‘to help other couples . . .’ When 36-year-old Ralf Ritter and his 47-year-old wife Dagmar were met in April 2006, they had already tried various infertility treatments for over 10 years. When the Ritters decided to seek treatment with egg donation outside of Germany in 2001, they also launched a web page where they displayed all their gathered data and experience ‘to help other couples’ with information on egg donation. Sometime later, they upgraded the web page with a cautious moderated internet forum that has since then generated lively participation and discussion. As opposed to most forum participants (in November 2010 there were over 2500 members) who remain anonymous, the Ritters are in quest of publicity for their claim to legalize egg donation in Germany. Dagmar Ritter had older children from a former marriage who live with their father in the USA. Because the function of her ovaries was declining, several infertility treatments in Germany had failed (and one led to a miscarriage). Physicians finally advised the couple to stop treatment because of Dagmar Ritter’s age and sent them information about adoption. Because of a very low number of adoptees and a strict adoption proceeding in which a lot of would-beparents are ruled out (Hamra, 2007), adoption as an alternative to infertility treatment is in fact difficult to achieve in Germany: at the end of the year 2009 818 children and juveniles noted for adoption faced 7139 applications for adoption, a ratio of 1:9 (data from Federal Statistical Office of Germany website). In the Ritter’s case, adoption did not make sense at all, as they said, because Dagmar Ritter was regarded as too old for adopting an infant. Through researching the internet, the couple learned from US web pages about egg donation as a substitute method for female reproductive substances. As a result, they researched 85 clinics in Europe, the USA and some other countries and contacted all with a questionnaire about available treatments with egg donation, prices and translation service to English or German. Then they published the results on their web page. Out of the few clinics
German patients searching for egg donation that responded, the Ritters chose two in the Czech Republic and one in Slovakia for a first visit. Ralf Ritter remarked that in 2001 it was still possible to get a first consultation in European IVF clinics without paying, while nowadays most clinics are demanding ‘outrageous amounts of money’ for it. Reasons for driving to the two neighbouring countries were not only the easy accessibility by car but also the lower treatment prices compared with most Western European IVF clinics, which were far too expensive for the Ritters’ limited budget (he is a paramedic, she is a housewife). Further factors arose that impacted their decision making as they visited the clinics. Whereas the centre in Bratislava had a very ‘aseptic flavour’ and the clinical ambience in Prague seemed way too posh for them (regarding observed dress codes by other patients and the stiff reception from the head physician), they felt at home right away in a little clinic in Brno, mostly because the director seemed to be a very likeable guy with whom they had instantly ‘some kind of mutual trust’. All three attempts in this clinic in 2001 failed, at which point the physician advised them to pause for a while. However, the couple changed directly to the clinic in Bratislava where another two treatments in 2002 failed. The Ritters then came in contact with a gynaecologist of German origin in Cape Town whom they believed to have new ideas, based on the fact that he found new indications for Dagmar Ritter’s infertility, such as thyroid problems. She stated that German practitioners had not noticed that and added: ‘It is unbelievable. You have to go for treatment in another country to have doctors that tell you what’s really up’. Since 2003 the Ritters have travelled each year to South Africa for an IVF with egg donation. As in Jeanette Weigand’s case, the Ritters have been followed up through their steady reports in their internet forum. After four unsuccessful attempts in Cape Town, the couple decided to go for treatment in a new clinic in Brno that specialized in egg donation. Again, it failed: ‘Business as usual’ wrote the Ritters sarcastically in a forum entry about this last treatment. In autumn 2009, Dagmar Ritter wrote an entry that her husband had left her without stating why. Ralf Ritter still remains administrator of the web page and writes a newly launched blog about egg donation. In the case of the Ritters, it is interesting to see how the couple chose their clinics. In addition to price, accessibility and the ability of clinicians to speak in German or English, emotional factors had been highly important for them. When transnational assisted reproduction is analysed quantitatively or with a rational-choice-model, there is a preference for a simplification of the field by giving a lot of importance to push-and-pull factors (Crooks et al., 2010), as well as only relating to economic and regulatory reasons. However, what is neglected in these models is the power of emotion, imagination and the role of clinical ambience (cf. Knoll, 2005). The Ritters were struck in one clinic by a highly medicalized atmosphere. In another, they felt humiliated by status and class. In the end it was those factors that led the couple first to a small clinic in Brno where they felt literally ‘at home’ and later to South Africa. Since the latter represented to them a place they had always wanted to visit, going for treatment there also fulfilled an old holiday dream. Because the couple relied only on the husband’s sin-
605 gle income, they started to combine treatments and holidays because of time (his annual minimum leave) and financial constraints. For this reason, the couple did not believe the term ‘reproductive tourism’ to be disrespectful, especially since their reproductive travel included safaris in Kruger National park and beach holidays at the Cape of Good Hope.
Discussion: reproductive agency and projects This exploration of the term ‘reproductive agency’ has relied on peoples’ initiatives and intentions to drive their reproductive matters beyond borders formed by regulatory laws or societal norms. Doing so, they also cross the frontier of passiveness that is inscribed into the Latin meaning of ‘patient’ (someone to whom something happens): ‘Agency refers to the socioculturally mediated capacity to act’ (Ahearn, 2001, p. 112). In the words of US anthropologist Sherry Ortner, agency is the ‘disposition towards the enactment of ‘‘projects’’’ (Ortner, 2006, p. 152). The three cases presented in this article illustrate that agency of German patients in enacting their individual projects was on the one side triggered by reproductive technologies which can enable their child-wish projects and on the other side detained by national regulation that prohibits certain treatment methods. Agency in these cases was not in first instance discussed as decisions and choices for or during a reproductive treatment, as pre-eminently done by Sarah Franklin (1997) and Strathern (1992, pp. 153–185) as a blueprint for governing (consumer’s) choices in contemporary British neoliberalist culture or an active individual decision to objectifying the body in reproductive treatment (Thompson, 2005, pp. 179–204). Rather, the focus was centred on agency in choosing mobility to circumvent national regulation to fulfil one’s own goals, which contradict, in the case of Germany, the law and also majority moral beliefs. Therefore, to stress agency here is meant to consider biomedical mobility as a new issue in theorizing human reproduction, which brings the emerging research area closer to studies of transnational mobilities (foremost addressed in the studies of transnational migration, see Levitt and Jaworsky, 2007, for a survey). In all three cases discussed, people crossed several borders to search for IVF and egg donation in other countries and different clinics, in order to enact their project in opposition to what is possible in their home country. By doing so, these so-called patients have become pioneers in crossing borders for reproductive treatment and therefore can be characterized as some kind of ‘moral pioneers’ (Rapp, 1999, pp. 306–311) in circumventing and overriding national regulations and ethical dilemmas. As a network between these individual tactics, the internet has become the most important platform for information and research about reproductive treatments and IVF clinics. Reports by patient-pioneers in internet bulletin boards serve as a test run and as a consumer’s analysis for other people affected. In contrast to the Kramers who distance themselves as ‘only passive readers’, Jeanette Weigand felt that she was an active participant in internet forums and felt that it was a space where people share solidarity, in contrast to daily life where there is often no one with whom
606 to talk. For information about assisted reproduction and the exchange of personal experience with it, the internet has become the most important medium for IVF patients, as well as for the advertisement of internationally orientated infertility clinics (Speier, 2011). The Ritters, as providers of one German forum, have helped to construct an online community for information about egg donation in other countries. Without the internet the actual global market for IVF and the phenomena of travelling patients would not be imaginable. For some of the (mostly female) users, the internet forums have become part of their everyday life and a place in which forum members become affected with each others’ destinies of infertility: they share the happiness about a positive pregnancy test, grief about another negative test or a miscarriage, and even give each other pep talks when someone is in a waiting line for a treatment or a test. Most patients met in the course of this study have used the internet and message boards for researching information about treatment and clinics. Among the internet communities, there is a division into conventional IVF users and recipients of oocytes; some members of the latter group feel discriminated and excluded inside general IVF communities, because of the different legal status and also as a result of media reports about the dark sides of egg donation like bad treatment for donors and the risk of hyperstimulation (Nahman, 2011). Egg donation enables the ‘project of parenthood’ (Boltanski, 2005) by means of substituting gametes. Because the experience of gestation is sustained, here kinship is seen as more authentic in comparison to adoption (Jeanette Weigand) – and in some cases easier to access than adoption (Ritters). However, stories such as that of the Kramers tell also about couples who regret having waited ‘too long’ (due to other life planning causes and restrictions), because now their only chance to become pregnant lies in an IVF with substituted eggs. For others, who already have older children, egg donation becomes an interesting option when these kids have left home or when they are, as in other cases, in a new partnership and want ‘to complete their family’ with a child that is of both parents (such as in the Ritter’s case and several others in the current data). In most cases, egg donation serves as a substitution method for women older than 40 years who are confronted with declining bodily processes. In these cases, reproductive borders semantically describe not only state regulations but also bodily boundaries: reproductive age is increased despite the declining production of reproductive substance. Or, as another German couple put it, the biggest or hardest step is not to decide to cross borders for treatment, but rather to try IVF with donated eggs because ‘nobody likes to give up on her own genes’. The practice of egg donation is seen as much more stigmatizing than conventional IVF not only due to its illegitimate status in Germany but because of the fear of the non-acceptance of having a child with egg donation. As such, concealment strategies and phenotypic matching may also help to install social legitimacy in kinship. Most patients preferred the anonymity of donation in Spain and the Czech Republic, although some would have been open to tell the child later about its origin. Whereas the Ritter’s case is quite outrageous in how much publicity was gener-
S Bergmann ated about their situation (they appeared on several TV documentaries), the Kramer’s case is the opposite, as they opted for concealment as a temporal strategy: until they receive a pregnancy and a child, they will keep their project secret. For people like Jeanette Weigand, the ‘online intimacy’ of the internet forum is the only place to talk about the problem. All three cases opted for anonymity but later for openness with the child – in contrast, disclosure of the donor is in most cases impossible due to Spanish or Czech law. Among the interviewees who practice concealment, such as the Kramers, many argued that this kind of operating in the shadows is a constant problem for them. These ‘games’ they play are characteristic of people’s agency between structural conditions like workplace arrangements, family’s and friends’ expectations and their opportunities to circumvent the felt restrictions via travelling for treatment abroad but naming it a holiday. People use these tactics to embed reproductive treatment and travelling in their everyday lives. Going to another country or big city materially and symbolically represents anonymity and distance that help to keep IVF clandestine (Bestard Camps, 2004, pp. 69–83). Most interviewees had been in conventional IVF treatment in Germany before they sought out egg donation. While some were advised by their practitioners to do so, the physicians of others declared that all possibilities had been utilized. Thus, the starting point of looking for treatment abroad depended on quite different levels of information. While most patients learned about egg donation as an alternative method from the internet and gathered information about clinics, Jeanette Weigand and Silja Kramer were given names of clinics abroad by their physicians. But while there had been some implicit support by German practitioners in some cases, most patients had to orient themselves anew in order to cross state and bodily borders for egg donation. The project to search for a treatment abroad was evaluated differently by the interviewees, ranging from scandalizing the fact (Kramers) to negotiating its positive side effects (Weigand). In terms of British sociologist Anthony Giddens (1984, pp. 25, 169), structures have both constraining and enabling effects for human agency, certainly depending on actors’ access to resources. Whereas Jeanette Weigand, the woman with the most financial resources among the three cases, advocates a consumer’s model in medicine that could imply looking for better quality or prices in other countries, couples like the Kramers and the Ritters confront German policy. In fact, the couple with the lowest income (the Ritters) saw the first step as changing German reproductive law. In contrast, Raul Kramer lamented the lack of German state support for middle-class couples in legal, financial and also educational terms regarding reproduction: he demanded more information about declining ovulation and reproductive age in the health system. These different positions towards state regulation of reproductive affairs ranged from paternalistic (Kramer) and reformist (Ritters) towards enterprising or neoliberal (Weigand), and they illustrate the interplay of categories like class in travelling for reproductive treatment. In contrast, the majority of interviewees anticipated the egg donors to be younger and poorer than themselves. These anonymized and imaginary non-relations between recipients
German patients searching for egg donation and donors are coined by English anthropologist Monica Konrad (2005) as ’nameless relations’. In conclusion, this article has shown that reproductive borders formed by national regulations, access restrictions or waiting lists, as well as by bodily boundaries like reproductive age or declining ovulation, are circumvented by the practice of seeking out egg donation abroad. Hence, these new mobilities have been characterized as forms of reproductive agency, used to achieve reproductive projects through new forms of mobility. In other words: to leave one’s country (even only for some days of treatment) because of alternative options in another country is still one of the key issues why people migrate. Even though agency is mostly not conducted as a form of active resistance against national regulations here, it is a helpful concept to describe tactics of patient-subjects like circumvention and concealment without representing them as passive and medicalized objects. In addition, reproductive agency is mingled with forces of imagination. Whereas most quantitative research cannot decode factors like emotion and imagination, finding a suitable clinic abroad depends on a variety of factors, such as emotion and imagination, which are difficult to ascertain utilizing only quantitative methods. Although between EU countries, travel conditions such as the reduction of border controls and the increase of low-cost airlines have facilitated inner-European mobility, closeness in Europe cannot be measured by geographical parameters only. For Jeanette Weigand who was raised in West Germany (the former FRG), Spain felt nearer than the Czech Republic because she is more familiar with a country that has a long history of tourism (since the 1960s) and remains today the most favoured international destination for German tourists. Post-socialist states like the Czech Republic, in comparison, represent for many west Germans an ‘Eastern Bloc flavour’, as another interview partner put it, even though the Czech Republic is geographically speaking part of middle Europe, as is Germany or Austria. But in contrast to other possible destinations, e.g. the Ukraine or Russia, the Czech Republic is seen as much more related to the ‘West’: EU citizens need a visa for Russia, which makes transnational treatments with schedules for synchronizing donors and recipients projects with intensive planning and imponderability. One element that is pushing people towards egg donation is the imaginative power of gestation and resemblance. While the guarantee to have one’s own pregnancy via IVF with donated eggs is naturalizing an ‘unnatural’ method, the practice of donor–recipient matching guarantees some parameters of resemblance to stabilize this individual project of parenthood. IVF clinics in countries with liberal legislation and a well-established tourism infrastructure benefit from these emerging reproductive mobilities. Throughout attracting donors with higher compensation rates than other countries, Spain and the Czech Republic could serve local and international patients with eggs donated anonymously. Throughout this form of anonymous gamete donation, clinics in Spain and the Czech Republic perform a model of non-reciprocity and concealment between donor and recipient. Unless the position of the donor is reduced as a provider of reproductive substance, for the normative recipients such as the heterosexual couple it serves as a model of concealing IVF and donation.
607 But with more discourse on disclosure and donor children’s rights, it is disputable if it will serve as a longstanding tool in reproduction with gametes of a third party.
Acknowledgements The author thanks the IVF clinics and sperm banks that have provided access for this ethnographic research and to all patients, donors, medical and administrative staff who talked about their experiences. Thanks to Katrin Amelang and Molly Moran for proofreading this article, to the two anonymous reviewers for helpful comments and to Zeynep Gu ¨rtin-Broadbend and Marcia C. Inhorn for the wonderful workshop and this special issue. This research was financed by a scholarship of the German Research Foundation (DFG) in the Research Training Group ‘Gender as a Category of Knowledge’ at Humboldt University in Berlin.
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608 Levitt, P., Jaworsky, N., 2007. Transnational migration studies: past developments and future trends. Ann. Rev. Soz. 33, 129–156. Mani, B.V., Segelcke, E., 2011. Cosmopolitical and transnational interventions in German studies. Transit 7. Available from:. Nahman, M., 2011. Reverse Traffic: intersecting inequalities in human egg donation. Reprod. Biomed. Online 23, 626–633. Ortner, S., 2006. Anthropology and Social Theory: Culture, Power, and the Acting Subject. Duke University Press, Durham. Pennings, G., 2002. Reproductive tourism as moral pluralism in motion. J. Med. Ethics 28, 338–341. Rapp, R., 1999. Testing Women, Testing the Fetus: the Social Impact of Amniocentesis in America. Routledge, New York. Shenfield, F., De Mouzon, J., Pennings, G., Ferraretti, A.P., Nyboe Andersen, A., De Wert, G., Goossens, V., 2010. Cross border reproductive care in six European countries. Hum. Reprod. 25, 1361–1369. Speier, A., 2011. Brokers, Consumers and the Internet: How North American Consumers Navigate their Infertility Journeys. Reprod. Biomed. Online 23, 592–599. Sto ¨bel-Richter, Y., Goldschmidt, S., Bra ¨hler, E., Weidner, K., Beutel, M., 2009. Egg donation, surrogate mothering, and
S Bergmann cloning: attitudes of men and women in Germany based on a representative survey. Fertil. Steril. 92, 124–130. Strathern, M., 1992. After Nature: English Kinship in the Late Twentieth Century. Cambridge University Press, New York/Cambridge. Strathern, M., 2005. Kinship, Law and the Unexpected: Relatives are always a Surprise. Cambridge University Press, New York/Cambridge. Thompson, C.M., 2005. Making Parents: The Ontological Choreography of Reproductive Technologies. MIT, Cambridge, MA. Wolin, R., 2010. Ghosts of a Tortured Past: Europe’s Right Turn. Dissent 58, 58–65. Zanini, G., 2011. Abandoned by the State, Betrayed by the Church: Italian experiences of cross-border reproductive care. Reprod. Biomed. Online 23, 565–572. Declaration: The author reports no financial or commercial conflicts of interest. Received 21 April 2011; refereed 7 June 2011; accepted 27 June 2011.
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SYMPOSIUM: CROSS-BORDER REPRODUCTIVE CARE ARTICLE
Reproductive agency and projects: Germans searching for egg donation in Spain and the Czech Republic Sven Bergmann Department of European Ethnology and Centre for Transdisciplinary Gender Studies, Humboldt University, Berlin, Germany E-mail address: [email protected] Sven Bergmann is a cultural anthropologist and a PhD candidate at the Department of European Ethnology at Humboldt University, Berlin. He has a scholarship in the German Science Foundation (DFG) research training group ‘Gender as a Category of Knowledge’ at the Centre for Transdisciplinary Gender Studies at Humboldt University, Berlin. He is a member of the newly formed research network ‘Economies of Reproduction’ (http://economies-of-reproduction.org). Abstract German patients in search of IVF with egg donation (which is prohibited by German law) are increasingly deciding to travel
to clinics in other countries (mostly to the Czech Republic and Spain) that are able to provide them with the eggs of other women. Through three case studies of German couples who crossed international borders for IVF with egg donation, this article provides insight into these transnational practices aiming to circumvent restrictions in reproduction, whatever they may be. The material for this article is based on ethnographic fieldwork and interviews conducted in Germany, Spain and the Czech Republic, as well as research undertaken on IVF internet bulletin boards. The concepts of ‘reproductive agency’ and ‘reproductive projects’ are used to analyse the ways in which people search for information about treatments and clinics in other countries, how they embed the practice into their daily lives and how they deal with and position themselves regarding the need for reproductive travel. RBMOnline ª 2011, Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved. KEYWORDS: anonymity, cross-border reproductive care, ethnography, IVF, kinship, transnationalism
Introduction European patients search for reproductive treatments outside their national boundaries for quite diverse reasons, in part because regulations among countries differ widely. There exists a wide range of motives for travelling to other countries for treatment: evading national bans on certain techniques (e.g., gamete donation or preimplantation genetic diagnosis (PGD)), avoiding waiting lists, searching for higher quality services and lower prices and avoiding limitations on the choice of donors or access for unmarried couples, single mothers and homosexual couples. This
article explores the transnational practice of searching for IVF treatment with egg donation from the perspective of German patients. It is based on research undertaken on the practice of gamete donation in a number of different European countries. Data were collected through ethnographic fieldwork, specifically participant observation and in-depth interviews. Substantial fieldwork in a Spanish IVF clinic was undertaken in 2006 (with a followup in 2011) and in a Czech IVF clinic in 2007; additionally, six other Spanish and Czech clinics and one Spanish and two Danish sperm banks were sites of ethnographic research.
1472-6483/$ - see front matter ª 2011, Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.rbmo.2011.06.014
German patients searching for egg donation
The German regulatory situation In the clinics in Spain and the Czech Republic where this research was conducted, German patients primarily sought egg donation, which is strictly forbidden by German law. Some German patients were seeking PGD and, only in a few cases, conventional IVF. In Germany, egg donation is prohibited by the Embryo Protection Act (1990) which states (for cases of practitioners, not patients): ‘Anyone will be punished with up to three years imprisonment or a fine, who: 1. transfers into a woman an unfertilized egg cell produced by another woman, 2. attempts to fertilize an egg cell artificially for any purpose other than bringing about a pregnancy of the woman from whom the egg cell originated [. . .]’. The intent of this German law is not to protect egg donors, but is instead concerned with the prohibition of research on embryos and the prevention of so-called ‘fragmented motherhood’ (Hieb, 2005). While sperm donation is legal and not viewed as interfering with concepts of kinship and nature, German regulation draws upon the old Roman law principle mater semper certa est. When a third party is involved, e.g. the donor of reproductive materials, then the naturalized definition of genetic lineage, in which at least the mother can be determined with certainty, becomes complicated (Strathern, 2005, pp. 67–71). Because IVF challenges legal definitions of kinship that are based on naturalized assumptions, it has become such a controversial issue and an area full of state-regulated interventions. Although patients in search of reproductive treatments form only a small percentage of those seeking medical treatments abroad (Carrera and Lunt, 2010), they draw a lot of national media attention as they are part of an ethically contested field. National prohibition of certain practices has triggered transnational and circumventive treatment-seeking practices of patients. Indeed, mobility in reproductive affairs is nothing new in Europe and in Germany: for example, similar to an ongoing Irish case (Gilmartin and White, 2011), many German women went to The Netherlands to get abortions since the 1970ies. In both cases of reproductive travelling, there is a tendency of morally scandalizing the mobility of patients (or its national causes), much in the same way that practices such as organ trafficking are viewed. Other fields of biomedical mobilities as dental treatment or cosmetic surgery do not raise such public interest. While the increasing travel for reproductive medicine is seen as an ‘unsolvable moral dilemma’ (Beck, 2007, p. 132) and a threat for the state in German bioethical discourse, patient mobility via circumvention of (national) regulative and ethical ‘containers’ can also be regarded as ‘moral pluralism in motion’ (Pennings, 2002). However, the patients whom I have interviewed often lamented about having to travel for reproduction. In contrast to survey results in other European countries which found unambiguous support of egg donation, a German study detected rather split attitudes: of the slight majority (50.8%) of participants who approved (of) a legalization of egg donation in Germany, 36.9% did so only for medial reasons, in contrast to only 2% for age reasons (Sto ¨bel-Richter et al., 2009, pp.
601 126–127). Through data from recent studies (Shenfield et al., 2010) and own observations in internet forums, it has been revealed that German patients often choose the neighbouring Czech Republic for treatment with egg donation, followed by Spain and after that by Poland, Russia, the Ukraine, South Africa and the USA.
Egg donation in Spain and the Czech Republic Why have Spain and the Czech Republic become the most important destinations for egg donation inside the European Union (Shenfield et al., 2010, p. 1367)? Cities like Prague and Barcelona have become ‘global cities’ of reproduction because they possess tourism, business and technology amenities ranging from international airports and telecommunication infrastructures to skilled lab technicians. Tourism infrastructure still matters for medical mobilities, which are built upon these long-established tourism platforms, in Spain for more than 40 years and in the Czech Republic since the ‘Velvet Revolution’ in 1989. According to the World Tourism Organization Spain is among the ‘top international destinations’, ranging from place 2 to 4 during the last years (UNWTO website), and Prague is the 20th most important destination in the world (euromonitor.com ranking). But without having an established donor system and a large pool of donors, Spanish and Czech clinics would not have become such important IVF destinations for foreign patients. Some of the bigger and more well-known clinics in Spain and the Czech Republic have installed waiting lists up to several months for egg donation, as they are overrun by patients. For some patients, particularly the British who often want to circumvent their national waiting lists, this has become unattractive. In effect, new players have entered the market over the last years, among them smaller clinics and also clinics that now only concentrate on the core business of egg donation. Whereas in countries like Denmark, Sweden and the UK, egg donation is possible but has to be performed non-anonymously and only with low reimbursement rates for donors, in countries like Spain and the Czech Republic egg donation is strictly anonymous for donors and recipients (the clinics act as brokers of reproductive substances and keep personal data private). Although in Spain and the Czech Republic the donation of gametes is regulated and marketed as ‘altruistic’, the compensation rate for donors is much higher than what is paid in other countries. Recruitment of gamete donors in Spain is done by advertisements on the radio, in popular free daily newspapers and via placards and flyers on university campuses. Recruitment strategies invocate altruism and solidarity, but also in some cases address reproductive capacity and the potency of potential donors. Whereas posters do not display monetary information, on clinical websites there is a notice about the usual ‘compensation rate’ of 900 Euros. Clinicians said that, in fact, the majority of donors were informed by word-of-mouth from people who already donated. In the course of the current research in the Czech Republic, not a lot of public advertisements were noted. Some clinics display information on their website. A clinic in Prague uses another strategy, working closely with gynaecologists in rural areas of the country who inform their
602 clients about the possibility of being an egg donor. Because wages for female labourers are very low in that part of the Czech Republic, the price paid for egg donation (about 800 Euros, which ranges between different clinics) is much more than an average monthly salary. Whereas the Czech clinics visited recruit only donors of Czech nationality, Spanish clinics were much more interested in having a more heterogeneous donor pool. In the Czech Republic, where mostly Russians and Ukrainians migrate, these populations were excluded from donation. However, in Spain, clinics are actively recruiting East European migrants or Erasmus students from other countries as donors, in order to provide Northern European patients with phenotypically similar donors. A remarkable finding of this research is that in a majority-white European population, the high variation of phenotypes in Northern and Eastern Europe, e.g. of eye and hair colour, was of great concern both for clinics (Spanish law obliges clinics to match similar phenotypes) and for some patients, though not all. Some German couples assumed – as evidenced in interviews and on IVF internet forums – that they would not be able to find a donor in Spain with blue eyes and because of that decided to seek treatment in the Czech Republic. They based their presumptions, however, on the perception of the European nation as ethnically homogenous, not considering the fact that countries in Southern Europe have been transformed because of high levels of immigration, in which people from Latin America and Eastern Europe are among the largest groups. Migrants may be particularly interested in the additional income of 900 Euros. Thus, whereas some Czech clinics focus their donor recruitment on young women from poorer rural regions, the Spanish transnational fertility market has created new gendered part-time jobs for migrants. Class, low current economic capital (as in the case of students) and migration are thriving factors in gamete donation, in cases when it is done mostly for financial gain.
Methodology and data collection When German medical mobilities are analysed within a push-and-pull factors scheme, there is on the one side Germany’s prohibitive law towards egg donation and on the other side the possibility of circumventing this law by travelling to other European countries where the practice is legal and clinics advertise for international patients. Although these legal and structural conditions seem obvious, anthropologists have shown in other fields of mobilities, such as migration, that people employ much more multilayered strategies than moving unidirectionally from point A to point B, and that these projects are intertwined with biographical reasons, gender and identity, social networks and imagination. The following three cases of German patients will illustrate their motivations and decisions to travel, how they were informed about egg donation and subsequently embedded the practice into their everyday lives and how it reshaped their position as persons or couples with an unfilled wish to become parents. In total, 36 patients (couples or individuals) were interviewed, 19 at a clinic in Barcelona, 14 at a clinic in Prague and three independent of clinical contexts – all patients
S Bergmann and clinics have been given pseudonyms. Patients in the Spanish clinic were mostly met by attending the physician’s consultations (consent was obtained beforehand). In the Czech clinic, few consultations were intended; instead, patients were introduced by the head physician or his secretary or met in the cafeteria of the clinic for longer interviews. In 29 cases, patients were heterosexual, mostly married, couples. Of the seven women who were alone, three were travelling without their partners and four identified themselves as single. In Spain, lesbians and single-mothers-by-choice have access to reproductive treatment; in the Czech Republic only heterosexual couples are treated. Fifteen of these interviews were conducted with patients from Germany, 10 from the UK, four from Spain, four from Italy, one with a French woman, one with an Irish woman and one with a couple from Kosovo. Regarding the form of treatment, six attended the clinics for conventional IVF (in one case with sperm donation), 21 for IVF with egg donation (three with sperm donation), six for embryo donation and three patients came because of an IVF treatment with PGD. Although some interviewees already had one child (either through assisted reproduction treatment or from previous relationships), most couples had a history of unsuccessful IVF treatments in their home countries. In selecting the three case studies for this article, this study chose to concentrate on patients from Germany because two other articles already address the UK (Hudson and Culley, 2011) and Italian patients (Zanini, 2011).
Case A: Silja and Raul Kramer: ‘You feel constrained by the state’ The Kramers, both in their forties, were met in October 2007 at an infertility clinic in Prague. After the couple underwent three failed IVF treatments in Germany, they were quietly advised by their German IVF practitioners to try egg donation and were given the addresses of clinics in the Czech Republic, Poland and Spain. The Kramers researched the clinics on the internet and eventually decided to try egg donation in a big IVF clinic in Warsaw, which again failed. Although they had been quite satisfied with the Polish clinic, they lamented its long waiting lists. Furthermore, to get scheduled with an egg donor required Silja Kramer to be on stand-by for weeks and it cost her all of her annual paid vacation. As a consequence the couple chose to try embryo donation in Prague, which is easy to reach by car from their home town in southern Germany. Since Raul Kramer was diagnosed with low sperm motility, the couple decided to substitute both their reproductive substances by using a frozen embryo out of another IVF cycle. Because in this case no donor needs to be stimulated, the couple received a fixed date for the embryo transfer. In order to spend about a week in Prague, the Kramers had taken 9 days paid leave from work. On the day they were met, they had set off for Prague at half-past five in the morning and had just finished their first meeting at the clinic. In spite of his earlier diagnosis, Raul Kramer had a sufficient semen analysis, according to the Prague clinic.
German patients searching for egg donation Nevertheless, the couple decided to stay firm on their decision to use a frozen embryo. However, they were now trying a ‘double track’ solution: if embryo donation failed, they would put themselves on the waiting list for fresh egg donation at the same clinic (in 2007 the clinic’s waiting list for egg donation was about 10 months). The Kramers were only met during this, their first, time in Prague. There was no opportunity to contact them later due to their wish of ensured anonymity and therefore it is not known whether a pregnancy was established or whether the couple continued treatment. The Kramers told about the desperate narratives they read in German internet forums. On the one hand, the couple was reflexive about the pull of IVF as an ‘obstacle course’ and a ‘way of life’ (Franklin, 1997, pp. 101–167) that can engross couples for years without setting limits regarding an end to treatment. On the other hand, when referring to the narratives they read, they slightly distanced themselves from these stories told by ‘others’, who had tried and failed for years. In IVF, the demarcation line between having a last choice and seeing no point in treatment any longer is blurry, especially because ‘miracles’ after years of treatment occur and then circulate in internet bulletin boards. These types of cases underpin the notion of ‘having to try’ (Franklin, 1997, p. 174). The Kramers were governing their own practices by reflecting at a distance that there are more desperate ‘others’. Later, Raul Kramer said that despite their remaining childlessness, they had not reacted for years because they had been focused on other topics like building their house. Such narratives of privileging career opportunities, house building or other forms of delaying one’s desire for a child, show that these decisions are in retrospect, in a situation of secondary infertility (because of age) often regretted. The Kramers were forthrightly criticized by their German IVF practitioner for delaying starting infertility treatment. Silja Kramer explained that they had surely heard of infertility problems in other couples or in the media before but had never imagined themselves as part of this group. Instead of lingering on his own situation, Raul Kramer moved his critique towards German law and demographic policy. He did not understand why sperm donation is allowed but egg donation is prohibited in Germany, and this, as he stated, in a time where birth rates are declining every year. Rather, he demanded that the state should support middle-class academic couples like the Kramers that ‘make a positive contribution to society’. In his argument he echoed the pejorative predicament that reproduction in the lower classes functions, in contrast, seemingly well. This discursive strand, which discriminates against lower classes and sometimes parts of the non-Western migrant population, is a recurrent statement in the German debate – actualized in 2010 through a controversial book by Thilo Sarrazin, a former politician and member of the Executive Board of Deutsche Bundesbank (Mani and Segelcke 2011; Wolin, 2010). The ‘‘Sarrazin debate’’ is like a keyword in Germany which needs not to be explained by a reference – for the international reader I suggest this new reference. The article by Wolin is good in embedding the debate in European right-wing politics but the article which I found recently by Mani & Segelcke explains much more in detail the debate, its course and its main protagonists.
603 The Kramers felt ‘constrained by the state’, as their treatment abroad caused them additional costs and other problems. Their failed attempts of seeking successful infertility treatment abroad had been a sufficient life constraint for the couple, not only because borders had to be crossed, and personal vacation time cut off, but also because secretiveness surrounded their attempts. Since the Kramers wanted to avoid speculations up front, they concealed the incorporation of IVF treatment in their everyday life. As a result of peoples’ well-meant expectations (when will they finally get pregnant?), many infertile couples interviewed felt under constant pressure and stressed about conceiving ‘in public’ (meaning that they felt that every one of their steps and ‘successes’ was being observed). For this reason, the Kramers preferred to make up stories and excuses, avoiding questions about travel plans or weekend activities but at the same time regretted not sharing this part of their life with their friends or sometimes even felt discomforted by doing so. Nevertheless, in the case that treatment was successful, the couple was planning to tell the child about their use of an egg donor. Silja Kramer argued that, although with embryo donation there would be no genetic link to the child, she thought that parenting and social factors will have much more influence on children than heredity and genes. Merely physical resemblance, she ironically admitted, is something which cannot be modelled upon social parenting. It was for this reason that the Kramers were opting for some kind of phenotypic matching. Among the patients interviewed or observed during their consultations, some were more concerned than others with good matching, whereas some had not yet thought about it before coming to an IVF clinic.
Case B: Jeanette Weigand: ‘With my own egg cells I would not have tried it again . . .’ When the research was started in 2006, a call for interviewees was set up in a German IVF internet forum: three people replied, among them Jeanette Weigand. In May 2006, when the interview was held in a hotel lobby in Berlin, Jeanette Weigand was 40 years old. She arrived with her sleeping 8-month-old baby who was born via egg donation in Spain with the spermatozoa of her partner (who, in contrast to interviews with other couples, was fairly invisible in her narrative). Jeanette Weigand’s IVF history is one of a journey: after four IVF/intracytoplasmic sperm injection (ICSI) treatments in Germany, her German IVF practitioner recommended that she go to Belgium for treatment, which is not far from her home town in the west of Germany. In Brussels she had another three ICSI cycles, combined with PGD and blastocyst selection (both prohibited in Germany), but, again, all treatments failed. Then her German gynaecologist suggested trying egg donation in Spain and recommended a big clinic in Valencia. Following this, Jeanette Weigand collected information about clinics in Spain, and also in the Czech Republic and South Africa, as both countries offered cheaper treatment options than Spain. Notwithstanding, she decided for Spain in the end because it was logistically the most easy to fly from her home town to Valencia and she knew the country well.
604 Jeanette Weigand said that, if someone has no personal contact with other insiders, the internet is the only possibility to gain access to information about IVF treatment abroad. Besides reading reports from other patients on several web pages, she made some internet acquaintances and shared a feeling of solidarity with other persons affected. She contacted the clinic in Valencia via email. During her first clinical visit she was accompanied by a Germanspeaking assistant throughout all consultations and medical exams. The Spanish clinic worked with a queuing system via waiting lists. For Jeanette Weigand this had not been very comfortable: as she said with an ironic undertone, ‘you are in the waiting loop . . . and that’s not so nice. And then one day there was the call: ‘‘We have a donor for you – do you want her?’’ I mean, what should I have said . . .?’ Upon hearing the news that a donor had been identified, Jeanette Weigand immediately booked a flight and arrived in the clinic a few days after the call. But at this point another frustration occurred: due to circumstances that were never clarified, all embryos were designated as ‘nearly dead’ after day 2 of fertilization. Although the local practitioners advised against using these embryos, Jeanette Weigand decided that two ‘not dead at all’ embryos were to be transferred. In spite of the estimated low success rate with these devastated embryos (practitioners spoke of 0.5–1%), one transferred embryo led to a positive pregnancy test and resulted in giving birth to her baby – all the clinicians involved spoke of this as some kind of miracle. In contrast to most other interviewees, Jeanette Weigand’s case has been subsequently followed up. Via her entries in the IVF internet forum, it is known that she returned to the Valencian clinic for another successful egg donation in 2007. This time, both transferred embryos developed and she became the mother of twins that were born weeks early but recovered well. In the forum she refers to her children after the place of procreation in the lab: ‘my Spaniards’ or ‘my Valencianos’. She had stayed on the forum to advise others in the case of egg donation and the nurture of babies. In 2009 she returned to Valencia for a transfer with two cryopreserved embryos out of her previous treatment. Again, she became pregnant with twins, to whom she gave birth at the end of 2009. Now she has five children, all assisted in Valencia, and among them four with the oocytes from a single donor. Jeanette Weigand’s case is like a picture book story about egg donation – too good to be true: after seven IVF cycles with her own eggs failed, she moved to egg donation and succeeded in the first treatment (even though practitioners did not believe the donor egg quality to be able to develop into a pregnancy). Also, in her following two treatments, one fresh embryo transfer and one cryotransfer, all embryos established a pregnancy (resulting in two sets of twins). She said that if the first attempt in Valencia would not have succeeded, she was sure she would have had another egg donation. But, she continued, she would never again have an IVF with her own ova because of the high stimulation (an experience she has passed down to a younger woman able to develop more oocytes). After years of failed attempts she now has five children. In her opinion, egg donation is easier to naturalize than adoption because the process of gestation creates a special relation towards the child that is lacking in adoption.
S Bergmann Therefore, genetic material mattered less to her (she remarked that it seems to be more important for males). She favoured anonymity in gamete donation because of the emotional difficulty for the recipient. Explaining her position, she remembered her mood when she was sitting in the waiting room in Valencia and was speculating which women would be recipients like her and which would be the donors. In that moment, she argued, it would have been totally uncomfortable for her to know her donor since she would have been afraid that the donor could have claims for the child. Nevertheless, she favoured openness towards the child at a latter age. She believed that a legalization of egg donation in Germany would challenge the tabooing of these topics and does not understand why sperm donation is allowed but egg donation is not. Because going for treatment in another country was not a bad experience for her, she would also consider doing it again in other medical cases, if the treatment and service would be better than in her home country.
Case C: Dagmar and Ralf Ritter: ‘to help other couples . . .’ When 36-year-old Ralf Ritter and his 47-year-old wife Dagmar were met in April 2006, they had already tried various infertility treatments for over 10 years. When the Ritters decided to seek treatment with egg donation outside of Germany in 2001, they also launched a web page where they displayed all their gathered data and experience ‘to help other couples’ with information on egg donation. Sometime later, they upgraded the web page with a cautious moderated internet forum that has since then generated lively participation and discussion. As opposed to most forum participants (in November 2010 there were over 2500 members) who remain anonymous, the Ritters are in quest of publicity for their claim to legalize egg donation in Germany. Dagmar Ritter had older children from a former marriage who live with their father in the USA. Because the function of her ovaries was declining, several infertility treatments in Germany had failed (and one led to a miscarriage). Physicians finally advised the couple to stop treatment because of Dagmar Ritter’s age and sent them information about adoption. Because of a very low number of adoptees and a strict adoption proceeding in which a lot of would-beparents are ruled out (Hamra, 2007), adoption as an alternative to infertility treatment is in fact difficult to achieve in Germany: at the end of the year 2009 818 children and juveniles noted for adoption faced 7139 applications for adoption, a ratio of 1:9 (data from Federal Statistical Office of Germany website). In the Ritter’s case, adoption did not make sense at all, as they said, because Dagmar Ritter was regarded as too old for adopting an infant. Through researching the internet, the couple learned from US web pages about egg donation as a substitute method for female reproductive substances. As a result, they researched 85 clinics in Europe, the USA and some other countries and contacted all with a questionnaire about available treatments with egg donation, prices and translation service to English or German. Then they published the results on their web page. Out of the few clinics
German patients searching for egg donation that responded, the Ritters chose two in the Czech Republic and one in Slovakia for a first visit. Ralf Ritter remarked that in 2001 it was still possible to get a first consultation in European IVF clinics without paying, while nowadays most clinics are demanding ‘outrageous amounts of money’ for it. Reasons for driving to the two neighbouring countries were not only the easy accessibility by car but also the lower treatment prices compared with most Western European IVF clinics, which were far too expensive for the Ritters’ limited budget (he is a paramedic, she is a housewife). Further factors arose that impacted their decision making as they visited the clinics. Whereas the centre in Bratislava had a very ‘aseptic flavour’ and the clinical ambience in Prague seemed way too posh for them (regarding observed dress codes by other patients and the stiff reception from the head physician), they felt at home right away in a little clinic in Brno, mostly because the director seemed to be a very likeable guy with whom they had instantly ‘some kind of mutual trust’. All three attempts in this clinic in 2001 failed, at which point the physician advised them to pause for a while. However, the couple changed directly to the clinic in Bratislava where another two treatments in 2002 failed. The Ritters then came in contact with a gynaecologist of German origin in Cape Town whom they believed to have new ideas, based on the fact that he found new indications for Dagmar Ritter’s infertility, such as thyroid problems. She stated that German practitioners had not noticed that and added: ‘It is unbelievable. You have to go for treatment in another country to have doctors that tell you what’s really up’. Since 2003 the Ritters have travelled each year to South Africa for an IVF with egg donation. As in Jeanette Weigand’s case, the Ritters have been followed up through their steady reports in their internet forum. After four unsuccessful attempts in Cape Town, the couple decided to go for treatment in a new clinic in Brno that specialized in egg donation. Again, it failed: ‘Business as usual’ wrote the Ritters sarcastically in a forum entry about this last treatment. In autumn 2009, Dagmar Ritter wrote an entry that her husband had left her without stating why. Ralf Ritter still remains administrator of the web page and writes a newly launched blog about egg donation. In the case of the Ritters, it is interesting to see how the couple chose their clinics. In addition to price, accessibility and the ability of clinicians to speak in German or English, emotional factors had been highly important for them. When transnational assisted reproduction is analysed quantitatively or with a rational-choice-model, there is a preference for a simplification of the field by giving a lot of importance to push-and-pull factors (Crooks et al., 2010), as well as only relating to economic and regulatory reasons. However, what is neglected in these models is the power of emotion, imagination and the role of clinical ambience (cf. Knoll, 2005). The Ritters were struck in one clinic by a highly medicalized atmosphere. In another, they felt humiliated by status and class. In the end it was those factors that led the couple first to a small clinic in Brno where they felt literally ‘at home’ and later to South Africa. Since the latter represented to them a place they had always wanted to visit, going for treatment there also fulfilled an old holiday dream. Because the couple relied only on the husband’s sin-
605 gle income, they started to combine treatments and holidays because of time (his annual minimum leave) and financial constraints. For this reason, the couple did not believe the term ‘reproductive tourism’ to be disrespectful, especially since their reproductive travel included safaris in Kruger National park and beach holidays at the Cape of Good Hope.
Discussion: reproductive agency and projects This exploration of the term ‘reproductive agency’ has relied on peoples’ initiatives and intentions to drive their reproductive matters beyond borders formed by regulatory laws or societal norms. Doing so, they also cross the frontier of passiveness that is inscribed into the Latin meaning of ‘patient’ (someone to whom something happens): ‘Agency refers to the socioculturally mediated capacity to act’ (Ahearn, 2001, p. 112). In the words of US anthropologist Sherry Ortner, agency is the ‘disposition towards the enactment of ‘‘projects’’’ (Ortner, 2006, p. 152). The three cases presented in this article illustrate that agency of German patients in enacting their individual projects was on the one side triggered by reproductive technologies which can enable their child-wish projects and on the other side detained by national regulation that prohibits certain treatment methods. Agency in these cases was not in first instance discussed as decisions and choices for or during a reproductive treatment, as pre-eminently done by Sarah Franklin (1997) and Strathern (1992, pp. 153–185) as a blueprint for governing (consumer’s) choices in contemporary British neoliberalist culture or an active individual decision to objectifying the body in reproductive treatment (Thompson, 2005, pp. 179–204). Rather, the focus was centred on agency in choosing mobility to circumvent national regulation to fulfil one’s own goals, which contradict, in the case of Germany, the law and also majority moral beliefs. Therefore, to stress agency here is meant to consider biomedical mobility as a new issue in theorizing human reproduction, which brings the emerging research area closer to studies of transnational mobilities (foremost addressed in the studies of transnational migration, see Levitt and Jaworsky, 2007, for a survey). In all three cases discussed, people crossed several borders to search for IVF and egg donation in other countries and different clinics, in order to enact their project in opposition to what is possible in their home country. By doing so, these so-called patients have become pioneers in crossing borders for reproductive treatment and therefore can be characterized as some kind of ‘moral pioneers’ (Rapp, 1999, pp. 306–311) in circumventing and overriding national regulations and ethical dilemmas. As a network between these individual tactics, the internet has become the most important platform for information and research about reproductive treatments and IVF clinics. Reports by patient-pioneers in internet bulletin boards serve as a test run and as a consumer’s analysis for other people affected. In contrast to the Kramers who distance themselves as ‘only passive readers’, Jeanette Weigand felt that she was an active participant in internet forums and felt that it was a space where people share solidarity, in contrast to daily life where there is often no one with whom
606 to talk. For information about assisted reproduction and the exchange of personal experience with it, the internet has become the most important medium for IVF patients, as well as for the advertisement of internationally orientated infertility clinics (Speier, 2011). The Ritters, as providers of one German forum, have helped to construct an online community for information about egg donation in other countries. Without the internet the actual global market for IVF and the phenomena of travelling patients would not be imaginable. For some of the (mostly female) users, the internet forums have become part of their everyday life and a place in which forum members become affected with each others’ destinies of infertility: they share the happiness about a positive pregnancy test, grief about another negative test or a miscarriage, and even give each other pep talks when someone is in a waiting line for a treatment or a test. Most patients met in the course of this study have used the internet and message boards for researching information about treatment and clinics. Among the internet communities, there is a division into conventional IVF users and recipients of oocytes; some members of the latter group feel discriminated and excluded inside general IVF communities, because of the different legal status and also as a result of media reports about the dark sides of egg donation like bad treatment for donors and the risk of hyperstimulation (Nahman, 2011). Egg donation enables the ‘project of parenthood’ (Boltanski, 2005) by means of substituting gametes. Because the experience of gestation is sustained, here kinship is seen as more authentic in comparison to adoption (Jeanette Weigand) – and in some cases easier to access than adoption (Ritters). However, stories such as that of the Kramers tell also about couples who regret having waited ‘too long’ (due to other life planning causes and restrictions), because now their only chance to become pregnant lies in an IVF with substituted eggs. For others, who already have older children, egg donation becomes an interesting option when these kids have left home or when they are, as in other cases, in a new partnership and want ‘to complete their family’ with a child that is of both parents (such as in the Ritter’s case and several others in the current data). In most cases, egg donation serves as a substitution method for women older than 40 years who are confronted with declining bodily processes. In these cases, reproductive borders semantically describe not only state regulations but also bodily boundaries: reproductive age is increased despite the declining production of reproductive substance. Or, as another German couple put it, the biggest or hardest step is not to decide to cross borders for treatment, but rather to try IVF with donated eggs because ‘nobody likes to give up on her own genes’. The practice of egg donation is seen as much more stigmatizing than conventional IVF not only due to its illegitimate status in Germany but because of the fear of the non-acceptance of having a child with egg donation. As such, concealment strategies and phenotypic matching may also help to install social legitimacy in kinship. Most patients preferred the anonymity of donation in Spain and the Czech Republic, although some would have been open to tell the child later about its origin. Whereas the Ritter’s case is quite outrageous in how much publicity was gener-
S Bergmann ated about their situation (they appeared on several TV documentaries), the Kramer’s case is the opposite, as they opted for concealment as a temporal strategy: until they receive a pregnancy and a child, they will keep their project secret. For people like Jeanette Weigand, the ‘online intimacy’ of the internet forum is the only place to talk about the problem. All three cases opted for anonymity but later for openness with the child – in contrast, disclosure of the donor is in most cases impossible due to Spanish or Czech law. Among the interviewees who practice concealment, such as the Kramers, many argued that this kind of operating in the shadows is a constant problem for them. These ‘games’ they play are characteristic of people’s agency between structural conditions like workplace arrangements, family’s and friends’ expectations and their opportunities to circumvent the felt restrictions via travelling for treatment abroad but naming it a holiday. People use these tactics to embed reproductive treatment and travelling in their everyday lives. Going to another country or big city materially and symbolically represents anonymity and distance that help to keep IVF clandestine (Bestard Camps, 2004, pp. 69–83). Most interviewees had been in conventional IVF treatment in Germany before they sought out egg donation. While some were advised by their practitioners to do so, the physicians of others declared that all possibilities had been utilized. Thus, the starting point of looking for treatment abroad depended on quite different levels of information. While most patients learned about egg donation as an alternative method from the internet and gathered information about clinics, Jeanette Weigand and Silja Kramer were given names of clinics abroad by their physicians. But while there had been some implicit support by German practitioners in some cases, most patients had to orient themselves anew in order to cross state and bodily borders for egg donation. The project to search for a treatment abroad was evaluated differently by the interviewees, ranging from scandalizing the fact (Kramers) to negotiating its positive side effects (Weigand). In terms of British sociologist Anthony Giddens (1984, pp. 25, 169), structures have both constraining and enabling effects for human agency, certainly depending on actors’ access to resources. Whereas Jeanette Weigand, the woman with the most financial resources among the three cases, advocates a consumer’s model in medicine that could imply looking for better quality or prices in other countries, couples like the Kramers and the Ritters confront German policy. In fact, the couple with the lowest income (the Ritters) saw the first step as changing German reproductive law. In contrast, Raul Kramer lamented the lack of German state support for middle-class couples in legal, financial and also educational terms regarding reproduction: he demanded more information about declining ovulation and reproductive age in the health system. These different positions towards state regulation of reproductive affairs ranged from paternalistic (Kramer) and reformist (Ritters) towards enterprising or neoliberal (Weigand), and they illustrate the interplay of categories like class in travelling for reproductive treatment. In contrast, the majority of interviewees anticipated the egg donors to be younger and poorer than themselves. These anonymized and imaginary non-relations between recipients
German patients searching for egg donation and donors are coined by English anthropologist Monica Konrad (2005) as ’nameless relations’. In conclusion, this article has shown that reproductive borders formed by national regulations, access restrictions or waiting lists, as well as by bodily boundaries like reproductive age or declining ovulation, are circumvented by the practice of seeking out egg donation abroad. Hence, these new mobilities have been characterized as forms of reproductive agency, used to achieve reproductive projects through new forms of mobility. In other words: to leave one’s country (even only for some days of treatment) because of alternative options in another country is still one of the key issues why people migrate. Even though agency is mostly not conducted as a form of active resistance against national regulations here, it is a helpful concept to describe tactics of patient-subjects like circumvention and concealment without representing them as passive and medicalized objects. In addition, reproductive agency is mingled with forces of imagination. Whereas most quantitative research cannot decode factors like emotion and imagination, finding a suitable clinic abroad depends on a variety of factors, such as emotion and imagination, which are difficult to ascertain utilizing only quantitative methods. Although between EU countries, travel conditions such as the reduction of border controls and the increase of low-cost airlines have facilitated inner-European mobility, closeness in Europe cannot be measured by geographical parameters only. For Jeanette Weigand who was raised in West Germany (the former FRG), Spain felt nearer than the Czech Republic because she is more familiar with a country that has a long history of tourism (since the 1960s) and remains today the most favoured international destination for German tourists. Post-socialist states like the Czech Republic, in comparison, represent for many west Germans an ‘Eastern Bloc flavour’, as another interview partner put it, even though the Czech Republic is geographically speaking part of middle Europe, as is Germany or Austria. But in contrast to other possible destinations, e.g. the Ukraine or Russia, the Czech Republic is seen as much more related to the ‘West’: EU citizens need a visa for Russia, which makes transnational treatments with schedules for synchronizing donors and recipients projects with intensive planning and imponderability. One element that is pushing people towards egg donation is the imaginative power of gestation and resemblance. While the guarantee to have one’s own pregnancy via IVF with donated eggs is naturalizing an ‘unnatural’ method, the practice of donor–recipient matching guarantees some parameters of resemblance to stabilize this individual project of parenthood. IVF clinics in countries with liberal legislation and a well-established tourism infrastructure benefit from these emerging reproductive mobilities. Throughout attracting donors with higher compensation rates than other countries, Spain and the Czech Republic could serve local and international patients with eggs donated anonymously. Throughout this form of anonymous gamete donation, clinics in Spain and the Czech Republic perform a model of non-reciprocity and concealment between donor and recipient. Unless the position of the donor is reduced as a provider of reproductive substance, for the normative recipients such as the heterosexual couple it serves as a model of concealing IVF and donation.
607 But with more discourse on disclosure and donor children’s rights, it is disputable if it will serve as a longstanding tool in reproduction with gametes of a third party.
Acknowledgements The author thanks the IVF clinics and sperm banks that have provided access for this ethnographic research and to all patients, donors, medical and administrative staff who talked about their experiences. Thanks to Katrin Amelang and Molly Moran for proofreading this article, to the two anonymous reviewers for helpful comments and to Zeynep Gu ¨rtin-Broadbend and Marcia C. Inhorn for the wonderful workshop and this special issue. This research was financed by a scholarship of the German Research Foundation (DFG) in the Research Training Group ‘Gender as a Category of Knowledge’ at Humboldt University in Berlin.
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