ART services in Turkey-Legal regulations

1. 02.11.2014
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ASSISTED REPRODUCTION TREATMENT
SERVICES IN TURKEY,
LEGAL REGULATIONS AND ETHICAL ASPECTS
Tevfik Yoldemir
Associate Professor, MD, BBA, MMktg
Marmara University, School of Medicine
Department of Obstetrics and Gynecology
Division of ReproductiveMedicine
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Procreation’ (Official Gazette no. 19551), was superseded by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)
Turkey’s assisted reproduction regulation on
third-party reproductive assistance
• 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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Turkey’s assisted reproduction regulation on
third-party reproductive assistance
• 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)
Turkey’s assisted reproduction regulation on
third-party reproductive assistance
• 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.
Turkey’s assisted reproduction regulation on
third-party reproductive assistance
• 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).
Turkey’s assisted reproduction regulation on
third-party reproductive assistance
• 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)
Turkey’s assisted reproduction regulation on
third-party reproductive assistance
• 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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Attitudes towards third-party
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.
Attitudes towards third-party
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.
Attitudes towards third-party
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)
Cross-boarder reproductive care
• 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.
Cross-boarder reproductive care
• 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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Cross-boarder reproductive care
• 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
Cross-boarder reproductive care
• 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.
Cross-boarder reproductive care
• 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)
Cross-boarder reproductive care
• It is unclear how the Turkish state prosecutor could have any
legal powers over the activities of receiving clinics or donors
recruited in other jurisdictionswhere 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.
• If it is discovered that any centre and/or any centre personnel
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.
• If it is discovered that any centre and/or any centre personnel
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
tevfik@yoldemir.com