Most of these patients come from neighbouring countries: 38% from France and 29% from the Netherlands. They seek treatments that they cannot access in their home countries for one of a number of reasons: because it is illegal, because they don't qualify (for example, they are too old) or because waiting lists are too long.

This fertility tourism is due in part to the existence of distinct legal frameworks in different countries. For example, lesbian couples and single women are not allowed to have donor insemination in France, so many of them seek treatment next door in Belgium.

In the Netherlands, sperm extraction from the testicle is not done, but it is in Belgium. Both neighbouring countries also have a different take on sperm and egg donation. In the Netherlands, children born from a donated egg and/or sperm have the right to know the identity of the donor(s). In France, it's the opposite: sperm donation must be anonymous.

Belgian law, meanwhile, caters for all: it ensures anonymity, unless both donor and recipient agree otherwise. If a Dutch couple wants an anonymous donation, this is guaranteed by default in Belgium, while a French couple may obtain insemination at a Belgian hospital from a known donor - a friend, for example.

Although these examples are cases of law evasion, these patients are not guilty of breaking any law. "You only break the law of the country you're in and cannot be prosecuted when you return. This is the territoriality principle," explains Pennings.

Surrogacy law vacuum
But one type of treatment raises important ethical questions in Belgium: surrogacy. Again, France and the Netherlands have differing laws on the subject: it is forbidden in France but accepted in the Netherlands (under specific conditions) since 1997. In Belgium, says Pennings, "there is nothing in the law that forbids it, so, strictly-speaking, it's allowed."

At the same time, if a case goes to court in Belgium, the outcome can be uncertain. Under Belgian law, a woman who gives birth to a child is automatically its mother, so all parties involved must make an agreement beforehand that the child will be adopted by the intended parents. This legal vacuum means that some foreign patients come to Belgium to evade a rule in their own country. On the other hand, it also means that Belgian patients travel to other countries where surrogacy is recognised as legal to benefit from better-defined conditions.

Last month, the EU Council adopted a position to clarify the rights of patients seeking medical treatment in another EU country and "facilitate the access to safe and high-quality cross-border health care". However, consensus among EU countries on fertility treatment is highly unlikely since they have such polarised views on the question. That leaves fertility specialists deciding for themselves how to handle the ethical, legal and psychological aspects associated with requests from foreign patients.

On 18 October, the European Society for Human Reproduction and Embryology (ESHRE), an association of specialists, called for a professional code of practice on cross-border reproductive care. This, it hopes, will provide guidance to medical teams, better protect patients, donors and potential surrogates, and prevent bad practices sullying the reputation of the profession as a whole.

"We have no objection to patients seeking reproductive treatments outside their home countries because it enhances their autonomy and allows free patient movement in Europe," says Françoise Shenfield, fertility professor at University College London, on behalf of ESHRE. "But to protect patient safety, we believe there should be a code of practice to protect patients, donors and potential surrogates." Such a code of practice would have no legal value, but it may push policymakers to improve the legal framework. Belgian practitioners agree that a surrogacy law is necessary. In Liège, the regional hospital La Citadelle has been carrying out surrogacy procedures since 1992 and collaborates with the Ministry of Justice. "We're a kind of laboratory to inform the legislative debate," explains professor Michel Dubois.

But the question is when such legislation will be forthcoming. Pennings: "Every time there is a bad case in the news, some proposals are put forward, and then die down."

Surrogacy in Belgium
Three centres are known to practice surrogacy in Belgium: La Citadelle in Liège, Saint-Pieter University Hospital in Brussels and Ghent University Hospital. "Belgium is small, so if we come across a relevant case, we refer the patient to another colleague," explains Professor Herman Tournaye of the University Hospital Brussel, which does not carry out surrogacy procedures.

Because there is no legislation, every fertility centre has to decide if and how it will handle surrogacy cases. The process includes in-depth medical examination of both the intended and surrogate mother as well as consultations with a psychologist. Cases are discussed with the hospital fertility team and with an ethics committee.

Surrogacy remains the last resort and conditions are very strict. Out of about 25 requests per year on average, only three or four are accepted at La Citadelle. Foreign patients may only be included if they speak French to allow for thorough follow-up and counselling by psychologists and lawyers.

Ghent University Hospital only accepts requests where the "role of the surrogate mother is purely gestational, and the child is genetically related to both desiring parents" and only if the intended parents provide the surrogate themselves. The hospital received 21 such requests between 2004 and 2007; six were given the green light.

It also only accepted Belgian citizens "to avoid legal problems at the moment of adoption in the country of origin". The main reasons for refusing treatment were psychological, such as an unstable relationship
between the people involved or dubious intentions of the surrogate, such as financial benefits.

www.eshre.eu

What is surrogacy?
A surrogate mother is a woman who becomes pregnant, carries and delivers a child on behalf of another couple (the "intended" parents). Before the procedure, the surrogate mother agrees to hand over the child to the intended parents after delivery.

How often is surrogacy carried out?
Surrogacy is a last resort solution when the intended mother cannot bear the child herself, such as in case where a woman was born without a uterus or lost it to cancer or because a pregnancy would put her health or life at risk.

Is surrogacy ethically acceptable?
Yes, according to the ESHRE ethics task force, which states that it is acceptable "if it is an altruistic act by a woman to help a couple for which it is impossible or medically inadvisable to carry a pregnancy". Of course, there are specific conditions to fulfil. In particular, it should involve no payment whatsoever and be a well-informed, voluntary decision.

Is the surrogate mother related to the baby?
In some cases, the surrogate mother provides her own egg, so she is the baby's biological mother. In other cases, the surrogate mother has no genetic link with the baby; an embryo is produced in vitro from an egg and sperm from the intended parents (and/or donors) and then implanted in her womb.

Who can be a surrogate mother?
Surrogate mothers are often close friends or family members (for example the sister or mother of one of the intended parents). The ESHRE ethics task force also recommends that the surrogate be between 35 and 45 years old and already have at least one child.

Are there any health risks?
The risks (including miscarriage and multiple pregnancies) and pregnancy success rates are generally comparable to those brought by similar procedures of embryo implantation without surrogacy. Psychologically, the procedure seems to be experienced positively after careful selection and adequate counselling, although there have been exceptional cases of surrogates who wanted to keep the baby.