ART services in Turkey-Legal regulations

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ASSISTED REPRODUCTION TREATMENT

SERVICES IN TURKEY,

LEGAL REGULATIONS AND ETHICAL ASPECTS

Tevfik YoldemirAssociate Professor, MD, BBA, MMktg

Marmara University, School of Medicine

Department of Obstetrics and Gynecology

Division of Reproductive Medicine

Istanbul, Turkey

Background

• Introduced on 6 March 2010, ‘Legislation Concerning Assisted

Reproduction Treatment Practices and Centres’ (Official

Gazette no. 27513) sets out the latest version of Turkey’s

assisted reproduction regulations.

• Limitations regarding the licensing of private IVF centres,

specifications on gamete and embryo storage and restrictions

on the number of embryos that can be transferred to a

patient (only one for women aged under 35 in their first and

second cycle of IVF, and a maximum of two embryos for

women in their third or subsequent cycles or over 35 years of

age) (Reproductive BioMedicine Online 2010; 21, 729– 731)

Background

• Item 18.7 of the new legislation explicitly states that if it is

discovered that an individual has travelled abroad to receive

fertility treatment using donor eggs, donor spermatozoa or

surrogacy, then ‘the person who has conducted this

procedure, the persons who have referred patients or acted

as intermediaries, the impregnated person, and the donor’

will be reported to the state prosecutor’ (Official Gazette no.

27513) (Reproductive BioMedicine Online 2011; 23, 555– 564)

Assisted reproduction in Turkey

• The introduction of (partial) funding for IVF by the state and

social security institutions in 2005 and 2006 has been

instrumental in broadening access and providing opportunities

for the sector’s market expansion.

• Figures from the Ministry of Health attest to an accelerated

growth during this period, with the number of licensed fertility

clinics rising almost 50%, from 66 in 2005 to 91 in 2007.

• Despite the mandatory reporting of such figures by clinics to the

Ministry of Health since 1996, no reliable data on the number

and outcome of assisted reproduction cycles in Turkey are

available (Reproductive BioMedicine Online 2010; 21, 729– 731)

Turkey’s assisted reproduction regulation on

third-party reproductive assistance

• The initial legislation, entitled ‘By-law on Centres for Assisted

Procreation’ (Official Gazette no. 19551), was superseded by

the ‘By-Law Concerning Treatment Centres for Assisted

Procreation’ on 19 November 1996 (Official Gazette no.

22822).

• This comprehensive piece of legislation detailing definitions,

prohibitions and all necessary requirements (including

building and physical environment specifications, equipment,

materials and personnel) for assisted reproductive practice

was subsequently updated a further four times –

• Twice in January 1998 (Official Gazette no. 23227 and Official

Gazette no. 23244), once in March 2001 (Official Gazette no.

24359) and once in July 2005 (Official Gazette no. 25869)



• From the very outset of Turkey’s assisted reproduction

regulation, any treatment involving third-party reproductive

assistance, namely the use of donor eggs, donor spermatozoa

or surrogates, has been prohibited.

• The legislation provides the following definition for ‘Assisted

Reproduction Treatments’:

• Procedures, accepted as treatment methods by modern

medicine, which involve assisting the fertilization of the

prospective mother’s egg with her husband’s sperm in various

ways, enabling them to fertilize outside of the body when

necessary, and transferring the gametes or the embryo back

to the prospective mother’s genital organs (Official Gazette

no. 25869, item 4f).

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• The exclusivity of treatment provision to married couples

using their own gametes is reiterated at the start of Section 5

Prohibitions:

• The use of the eggs and sperm or the embryo of applicants

undergoing ART for any other purpose, or in the treatment of

other applicants, or the use of those [spermatozoa, eggs or

embryos] obtained from anyone other than the applicants in

the treatment of the applicants, or the storage, use, transfer,

and sale [of spermatozoa, eggs or embryos] for any sort of

purpose falling outside the definitions of this legislation, are

prohibited (Official Gazette no. 25869, item 17)



• Until the amendments of 2010, the assisted reproduction

legislation or any other item in Turkish law did not address the

use of donor spermatozoa, donor eggs or surrogacy, or made

any provisions for penalties or consequences for engaging in

such activities.

• The 2010 version of the legislation, alongside a range of other

restrictions to assisted-reproductive-technology practice, also

contains three new items specifically related to this matter.



• Item 18.5 sets out the legal ramifications that will result if

third-party assisted reproduction is practised by a Turkish

clinic:

• In the event of a discovery at any stage of a pregnancy

achieved against any of these prohibitions [on third-party

reproductive assistance], the [assisted reproduction practice]

certificates of the involved persons will be nullified, the centre

will be closed indefinitely, and all personnel will be

indefinitely barred from working at ART centres (Official

Gazette no. 27513, item 18.5).



• Items 18.6 and 18.7 stipulate penalties for CBRC involving third-

party assisted reproduction:

• If it is discovered that any centre and/or any centre personnel

has participated in acts of referring or sending patients to

domestic or international ART centres, encouraging patients or

acting as intermediary, in a way that is in contravention with

the legislation, such centres will be closed down for 3 months

in the first instance, and indefinitely in the event of such acts

being repeated.

• Those who are not centre personnel but are discovered to have

acted as intermediaries in such cases will have their certificates,

if such exist, nullified by the Ministry (Official Gazette no.

27513, item 18.6)



• In the event of a discovery at any stage of practices

contravening the particulars outlined in the items 18.4, 18.5

and 18.6, the person who has conducted this procedure, the

persons who have referred patients or acted as intermediaries,

the impregnated person, and the donor will be reported to the

state prosecutor.’ (Official Gazette no. 27513, item 18.7)

• Article 231 of the Turkish Penal Code, states that it is illegal to

change or obscure a child’s ancestry, with a punishment of 1–3

years of imprisonment .

Attitudes towards third-party

reproductive assistance in Turkey

• Turkey’s highest religious authority, the Presidency of

Religious Affairs, supports the application of assisted

reproductive technology as an infertility treatment for a

husband and wife couple using their own gametes as specified

by the regulatory parameters in Turkey.

• [IVF] is no longer permissible if a foreign element is included,

meaning if the sperm, eggs or womb belong to a person

outside of the husband–wife couple.

• According to the general principles of the religion of Islam,

there is an imperative for a legitimate child to belong,

whether by sperm or egg or womb, to a wedded husband–

wife couple

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reproductive assistance in Turkey• According to the first available data from Turkey regarding

public opinion towards egg donation, there are high rates of

approval for this form of fertility treatment, with only 15% of

respondents showing ‘complete objection’ .

(Hum. Reprod. 2006;21, 318–323)

• More than half of the women and two-thirds of the men

(wrongly) thought that their religion (i.e. Islam) would allow

egg donation if they needed it and more than half stated that

they would prefer egg donation to adoption.


reproductive assistance in Turkey• The attitudes of 368 women who had applied for infertility

treatment were investigated using self-completion

questionnaires consisting of 38 items determining socio-

demographic status, previous history with infertility and

opinions. They found acceptance rates of 23.3% for egg

donation, 15.1% for surrogacy and only 3.4% for sperm

donation.

• It is difficult to know how to interpret what is meant by

‘acceptance’ in this study, since they also report that when

asked what they would do if their IVF treatment failed, 59.7%

of respondents answered that they would ‘do nothing’, 38.3%

would pursue adoption and only 2% would consider gamete

donation.


reproductive assistance in Turkey• 250 women who had applied for infertility treatment with a

questionnaire containing seven socio-demographic items and

five questions on attitudes towards surrogacy and egg

donation, for which they found acceptance rates of 24% and

26% respectively. (Pak. J. Med. Sci. 2009;25, 36–40)

• Patients’ (anticipated) responses to IVF failure suggested

adoption to be the preferred solution (59.6%), followed by

accepting egg donation (26%), doing nothing (25.6%) and

accepting a surrogate mother (24%).

Cross-boarder reproductive care

• Northern Cyprus, Greece and the USA became popular

destinations for Turkish patients contemplating CBRC to

access donor gametes and, although conducted with

discretion and secrecy, reproductive tourism became big

business.

• 4000–5000 Turkish couples who annually cross borders for

third-party assisted reproduction, predominantly seeking egg

donation (Reproductive BioMedicine Online 2010; 21, 729– 731)


• Turkish clinics, spurred on by demand, formed partnerships

with Cypriot clinics or opened Cypriot ‘branches’, allowing

them to retain a large proportion of treatment profits.

• Unlike the examples of Sunni Muslim patients ‘quietly slipping

across transnational borders to ‘‘save their marriages’’

through the use of donor gametes’ in neighbouring Shi’ite

countries , the CBRC of Turkish patients was supported, in

most cases, by an institutional infrastructure.

• Short geographical distances, cultural similarities and linked

personnel were translated into smooth cross-border

treatment cycles for patients.


• Turkish egg donors were often ‘prepared’ in Turkish IVF

clinics, undergoing the routine protocols of ovarian

stimulation alongside normal IVF patients.

• Usually, they would be sent to Cyprus a day before egg

collection, along with matched and synchronized recipients,

so that fertilization using donor gametes was performed

outside of national borders.

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• Donors were free to fly back in less than 48 h and care was

taken to ensure that donors and recipients never encountered

one another.

• Recipients too were only required to be abroad for a very

short time, usually 3–5 days.

• Official documents were kept that would enable a tracing of

the donor, and any identifying details of donors, or of donor–

recipient pairs, were kept absolutely confidential


• The ‘Legislation Concerning Assisted Reproduction Treatment

and Centres’ (Official Gazette no. 27513), published on 6

March 2010 states the the new restrictions on embryo

transfer numbers (article 18.8b),

• specifying a single embryo for women under 35 years of age

on their first or second cycle,

• a maximum of two embryos for women over 35 or having

subsequent cycles of IVF treatment.


• Although men and women engage in CBRC for a wide variety

of reasons, legal restrictions form one of the central

motivations for patients across Europe

(Hum. Reprod. 2009;24, 3108–3118; Hum. Reprod. 2010;25,1361–1368)

• For such patients, CBRC functions as ‘a safety valve’ allowing

them to demonstrate ‘moral pluralism in motion’

(J. Med. Ethics 2002;28, 337–341)


• It is unclear how the Turkish state prosecutor could have any

legal powers over the activities of receiving clinics or donors

recruited in other jurisdictions where third-party reproductive

assistance is legally practised.

• However, although the government cannot coerce conformity

from citizens intent on pursuing CBRC, it can certainly make

their lives more difficult.

• The regulation can only target Turkish clinics’ activities, rather

than the activities of individual patients.

Embryology

• According to article 18.9; sex selection either by choosing the

gonad and/or embryo is not permitted.


has participated in acts of sex selection, in a way that is in

contravention with the legislation, such centres will be closed

down indefinitely.

• The person(s) involved in such acts will lose their licences.

Embryology

• According to article 18.10, the fetal reduction is prohibited.


has participated in acts of fetal rewduction,, such centres will be

closed down for 3 months in the first instance, and indefinitely in

the event of such acts being repeated.

• Article 18.11 regulates the conditions when gonadal tissue

storage is permitted.

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Embryology

• According to article 18.12; in the case of obtaining more

embryos from the candidates, embryos are stored frozen

with the consent of both spouses.

• Should the storage period exceed one year, spouses should

re-apply every year stating their continuous demand for

preservation of the embryo, with written and signed

declarations.

• In cases of mutual request from the spouses, death of one of

the spouses, divorce or end of the fixed period of

preservation, the embryos shall be destroyed/terminated

after being recorded by a commission established by the

directorate .

J Turkish-German Gynecol Assoc 2012; 13: 191-5

Embryology

• According to article 18.13, the samples aforementioned in sub-

sections 18.11 and 18.12 of the same article shall be stored no

more than five years.

• A storage period of more than five years is subject to the

permission of the Ministry of Health.

• Counting and evaluation of the stored samples shall be carried

out by means of the commission which is to be established

within the relative directorate.

• Should samples which have not been recorded in time are

detected, administrative sanction in the form of supervision shall

be carried out. J Turkish-German Gynecol Assoc 2012; 13: 191-5

Thank you for your attention

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ART services in Turkey-Legal regulations