From esterilología to reproductive biology: The story of the Mexican assisted reproduction business.

Privately owned assisted reproduction clinics, which are potentially lucrative businesses, are not subject to the same restrictions imposed on publicly funded assisted reproduction services regarding, for example, patient eligibility, the range of protocols offered and cost. Public assisted reproduction services operate within existing government-run hospitals, which have limited infrastructure (e.g. space and staff) and funding, and thus need to negotiate the resources required to offer assisted reproductive technology within a complex bureaucracy. This might be one of the reasons for the limited range of protocols they offer (which varies between health services), for restricting their services to women under 35 who are in a heterosexual relationship, and for the limited scope they have in offering the services at a lower cost (since they are partially subsidised) (see Table 1 ). The limitations they impose suggest, among other things, a practical perspective, for they do not engage in gamete donation, cryopreservation or surrogacy, all practices that require extra material and bureaucratic infrastructure. Private assisted reproduction clinics, on the other hand, respond to a different, more capitalist, logic. Not only do they offer a wider range of treatments without restrictions in terms of gender or marital status, albeit at a higher cost (see Table 1 ), but they also employ complex managerial and marketing schemes, something previously unseen in Mexico in the area of biomedical health services. As a first step, these schemes involve the creation of an identity for the clinic. Many private assisted reproduction clinics have a corporate-like identity. This identity, which is not based on the reputation of the doctors that run them and work in them, is constructed using a name, a logo and a slogan which usually make reference to infertility, fertility, motherhood, reproduction, genetics, gametes, pregnancy, babies, hopes or desires. This separation between the identity of the clinician and the identity of the clinic allows a degree of independence between the clinic and the physician, an independence which is also present in the way the clinics operate: ‘due to the structure the new clinics are taking, patients are no longer “the doctor’s patient”, they are becoming “the clinic’s patients”’ (Head of Clinic, field notes 2008). The clinic’s identity is then used as part of a marketing scheme, which includes a presence in social media (e.g. Facebook, Twitter and Pinterest), advertising in the printed press (newspapers and magazines), on television, radio, billboards and in public spaces (e.g. bus-stops). These advertisements are coordinated by the PR department and are part of a scheme that tends to rely on promissory rhetoric ( Sunder Rajan, 2007 ); for example, during promotional events organized at conference venues with approximately 500 attendees per session, free consultations are offered as raffle prizes, discount vouchers are handed out for future treatments, payment options are presented, people are invited to share their testimonies of success and the basic elements of assisted reproductive technology are explained. It is in these last two activities above all where the clinics frame the use of assisted reproductive technology as something scientifically proven to work, both by quoting information published in scientific journals and by presenting testimonies of success. This message of almost certain success is then re-fuelled by media coverage of assisted reproductive technology, which is usually very uncritical and has mostly portrayed assisted reproductive technology as highly successful, as is illustrated in the following two examples, the first being a piece in a national newspaper and the second being information from a clinic´s website: As long as a woman has a uterus, she can achieve pregnancy, even if she is in menopause, and with the technique we offer, 80% of the couples reach pregnancy in only 40 days. ( Rivera, 2008 ). You will have a baby at home, or your money back.’ ‘We are the Latin-American clinic with the highest rate of success: 94% that you will have a baby at home ( sic Ingenes, http://www.ingenes.com consulted the 1July, 2015) As long as a woman has a uterus, she can achieve pregnancy, even if she is in menopause, and with the technique we offer, 80% of the couples reach pregnancy in only 40 days. ( Rivera, 2008 ). You will have a baby at home, or your money back.’ ‘We are the Latin-American clinic with the highest rate of success: 94% that you will have a baby at home ( sic Ingenes, http://www.ingenes.com consulted the 1July, 2015) These actions (the advertisements in the media and the promotional events) have played an important role in making assisted reproductive technology visible and they have contributed to the construction, socialisation and normalisation of these techniques. Because of the way infertility is framed – in terms of causes and procedures to overcome it – and the images that are used, established gender roles, kinship bonds and the power of science are also reaffirmed. The desire for children and the causes of infertility continue to be placed predominantly on women; however, there is a move towards lessening the importance of a genetic link with the future baby (thus laying the ground for a better acceptance of gamete donation) and finally, the great capacity of science and biomedical intervention in life processes is praised.

The previous section traced the epistemic turn that resulted in esterilología transforming into reproductive biology (highlights summarized in Table 2 ). This section looks at the establishment and consolidation of the assisted reproduction industry and the way it is regulated. This part of the story begins in the last decade of the twentieth century and covers the first decade of the twenty-first. During this period, treating infertility moved beyond the gynaecological service within hospitals and healthcare systems into the highly specialised assisted reproduction clinic. But above all, it developed into a healthcare service that resembles a commercial industry, particularly assisted reproduction clinics within the private sector. Towards the end of the 1990s, a second wave of clinics (approximately 11 in number) started to emerge in places other than Mexico City and Monterrey thus enabling the spread of assisted reproductive technology nationwide. Many of these clinics were established by the first generation of specialists trained at the clinics and services mentioned above. It must be remembered that assisted reproductive technology is expensive, requiring significant financial investment in equipment and materials and in employing a large number of staff; hence, practitioners interested in opening their own clinic who lacked the means to do so independently, had to find ways of coping with the significant financial and logistical challenges. Some physicians opened branches of larger clinics, following what I describe as the ‘network model’. Under this model there is one large well-equipped head-quarter clinic, which centralizes provision of the most expensive procedures and distributes the less technologically demanding parts of the treatments across many smaller satellite clinics. Other emerging professionals decided on an alternative ‘outsourcing model’; when physicians outsource assisted reproductive technology they either rent the equipment and perform the procedures themselves or they send the gametes to equipped clinics and have them perform the procedures (Cf. González-Santos, 2011 ). Here we can see the emergence of the first characteristic of an assisted reproduction clinic: it is a multidisciplinary group of collaborating specialists that includes physicians, biologists, nurses and administrative staff. As stated before, many of the clinics that opened towards the end of the twentieth century were established by doctors who had been trained at one of the first three facilities mentioned above. One exception was a clinic established in Guanajuato by doctors who had returned from training at a clinic in Valencia, Spain. The distinguishing characteristics of the way in which the Spanish clinic operated were its emphasis on becoming a multinational business, its strong use of marketing to promote services, and managerial strategies that allowed them to offer services at a lower cost. Even though physicians and biologists judged the Spanish clinic’s clinical and laboratory practices to be interesting, they also considered that they needed to be adapted in order to meet local needs and requirements. For example, in terms of how patients were managed, ‘Mexicans require a different bedside manner... they like being seen by the same doctor all through their procedure’ (Biologist, field-notes, 2007). Interestingly, as will be described below, Mexican clinics did eventually operate in the ‘Spanish’ fashion, in which patients are seen by more than one doctor throughout the cycle of treatment. A few years later, as a result of market research, the Spanish clinic opened its own branch in Mexico City and established its own training programme, all this as part of their efforts to establish a multinational assisted reproduction corporation. Recently, however, they merged with a local clinic that holds branches in several cities across the country ( www.ivi-fertilidad.com/es-mx/pacientes/ , accessed 26 June, 2016). As I have charted, both the USA and Spain influenced this stage of Mexican assisted reproduction, each in their own particular way. The USA influenced Mexican practice through physicians who came to Mexican clinics and through Mexican physicians going to the USA for training. Likewise, the influence of the USA was established in the alliances some Mexican clinics had with some USA clinics. The Spanish influence can be seen in the training received by some biologists and physicians, but mostly in the marketing strategies employed by the Mexican branch of the Spanish clinic and by those who trained there. The maturing of the first generation of assisted reproduction specialists trained by the forefathers at the clinics mentioned above resulted in the spread of assisted reproduction clinics beyond the original services and out of Mexico City and Monterrey. It was the first wave of private assisted reproduction clinics opening across the city and the country, slowly adding up to over 50 registered in The Federal Commission for the Protection of Sanitary Risk (COFEPRIS) in 2015. It is worth clarifying that many of the specialists who work predominantly in the public assisted reproduction services also work at private assisted reproduction clinics (although this is not so the other way around). This means, among other things, that people who attend the public healthcare service might be seen by the same doctor as someone who attends a private clinic. This also means that the community of assisted reproduction professionals is not clearly divided between those in the public sector and those in the private sector. This ‘double-shift’ is quite common within the Mexican healthcare system across all specialities; a consequence, at least partially, of economic factors.

The purpose of this paper has been to offer an overview of how assisted reproduction emerged and developed in Mexico by addressing two broad questions: (i) When and how did assisted reproductive technology become common practice within the area of reproductive medicine? and (ii) How did the Mexican assisted reproduction industry emerge? In doing so, this study has traced the development of the Mexican assisted reproduction industry from esterilología to reproductive biology, from a clinical practice to a reproductive industry, from individual doctors and their individual practices, to networks of clinics (see Table 2 for a summary). Throughout this narrative, certain aspects have been highlighted that I consider were prominent in this process and which are summarized below. First, this paper discussed the way in which gynaecologists, from the 1940s to the present day, have recognized and acknowledged the importance of family – and thus of child bearing – within the life of Mexicans, both as individuals and as a society. Second, it pointed out that during the twentieth century, biomedicine was concerned with and involved in the hormonal and surgical control of reproduction, either to limit the number of offspring or to help those who cannot reproduce unaided. Third, it told the story of how Mexican gynaecologists came into direct contact with those developing assisted reproduction techniques (specifically GIFT). These first three elements contributed strongly to what I call the epistemic shift ( Cámara de Diputados, 2004 ), which made the development of assisted reproduction possible. Although I would not argue that these elements were the only ones involved in this shift, they are the ones that clearly made assisted reproductive technology both accessible and acceptable to the biomedical community; they changed what assisted reproduction professionals considered to be their subject of concern – the legitimate questions or problems, the acceptable answers and solutions, and the valid and viable methods to deal with infertility. Within esterilología the question was ‘Why can’t this heterosexual couple achieve pregnancy after coitus?’. This suggests that the subject was the heterosexual couple, the accepted solution was to give the couple a genetically linked baby and the accepted method was to fix what was causing infertility in order to be able to achieve non-assisted pregnancy, leaving in place the conditions for further pregnancies to be non-assisted as well. In contrast, within the framework of reproductive biology the question is ‘How can I help this person to have a baby?’ (as indicated by the clinic’s slogans), the subject is the individual, their marital status or sexual orientation is irrelevant in terms of eligibility, the solution is to give the person a baby – a baby that does not necessarily have to be genetically linked to either parent – and the methods to achieve this can vary but do not imply curing infertility. The family planning campaigns and the epistemological perspective brought from abroad by both local and foreign physicians introduced a mind-set, which allowed reproduction to be considered as a biotechnologically manipulable matter and separated the couple from reproduction. While, the three elements discussed above contributed to the acceptance of assisted reproduction as a way of dealing with infertility (dealing not being the same as curing), the following ones contributed to the emergence of the assisted reproduction industry. Assisted reproductive technology is costly and complicated, and opening a clinic requires economic investment and trained staff, hence for many aspiring assisted reproduction specialists associating with colleagues was necessary, and probably the only way of opening a private clinic. This, together with the daily practical demands of the assisted reproduction protocols, established the conditions for clinicians to work as collaborating teams, giving rise to the assisted reproduction clinic. This assisted reproduction clinic became an entity, independent of the physician, making the recipients of the treatments patients (clients) of the clinic, rather than of the physician. Assisted reproduction clinics acquired a name, a logo and a website and they adopted marketing campaigns similar to those used by other businesses (for example, the cosmetic surgery industry), but which were not commonly used by individual physicians. All this established a new way of practicing medicine. As described earlier, the assisted reproduction industry has a particular way of offering healthcare, one that is very different from other sectors of healthcare. These particularities concern the way in which service providers (physicians, nurses and biologists) and users (patients) relate to each other, the clinics’ corporate-like configuration and its use of marketing strategies. In Mexico, patients and physicians were used to a face-to-face interaction in a medical setting. Physicians, as professionals, did not have a website, a Facebook page, a Pinterest profile or a Twitter account. Now they advertise and interact with patients online and through these social media portals. The effects of this new way of relating requires further research and perhaps even regulation, particularly considering what is being said in marketing strategies; for example, some clinics advertise by quoting high success rates and offering deals where they assure ‘you get a baby or your money back’. (Ingenes, television advertisement). This paper also looked at how a particular biotechnology was adopted and adapted in one particular context. At different points in Mexico’s assisted reproduction history, different assisted reproductive technology treatments have been crucial for its conformation. AI, for example, served to frame infertility as an illness, as a condition that can be and should be cured. This framing unified physicians dealing with infertility to react against this procedure, which they considered was merely a bypassing strategy and not a technique for curing the condition. Years later, GIFT marked the beginning of the high-complexity assisted reproductive technology service, both because its developers participated in the training of the first generations of assisted reproduction specialists and because it was with this technique that Mexico claimed its first successful case of medically assisted conception. Hence, in Mexico assisted reproduction has been more than just IVF and the techniques that came after it, even if today IVF and ICSI are the prominent techniques and GIFT is hardly ever used ( Zegers-Hochschild et al., 2016 ). Finally, this paper also analysed the way in which assisted reproduction is regulated in Mexico. It sought to highlight that both assisted reproduction practitioners and non-practitioner policymakers are engaged in the task of generating appropriate regulations and guidelines for the offering of assisted reproduction services. However, with the information available it has not been possible to determine why no regulation has yet been agreed upon. Further research is needed in this respect. Likewise, it has not been possible to examine closely the controversial and shifting business of surrogacy, due precisely to its volatility. Indeed, during the writing of this paper, the Mexican state of Tabasco went from being a place that had a flexible surrogacy law, making it attractive to those interested in surrogacy (e.g. gay couples), to becoming yet another location with a restrictive law imposed to limit reproductive tourism. This paper has laid out the first overview of how assisted reproduction emerged and developed in Mexico. In doing so, it has also identified areas that need further exploration. For example, there is need for a more detailed analysis of the professional biography of clinicians and biologists, to find out where they were trained, to understand the reasons behind the selection of a particular model for establishing a new clinic (i.e. the network model or the outsourcing model), and to track how the different clinical and laboratory practices were developed. Likewise, we still need to follow closely the regulatory efforts in order to see, on the one hand, how, if and when a national regulatory framework is established, and on the other, if and how individual practitioners and clinics follow those professional guidelines that do exist.

Currently, the Mexican assisted reproduction industry is collaterally regulated by laws and guidelines established by two federal bodies: CENATRA (National Transplant Centre) and COFEPRIS. I call this collateral regulation because the aspects of assisted reproduction overseen by CENATRA and COFEPRIS only incidentally fall into their jurisdiction; they do not have assisted reproduction-specific laws. CENATRA, established in 2000, is responsible for administering organ donation, and tissue and cell transplants through the National Transplant Registry where donors, recipients, procedures and the healthcare providers involved are recorded. Because gametes are cells, they register the donation of germinal cells (i.e. gametes). However, the infrastructure offered by CENATRA for gamete donation registry is not robust (anyone can upload data), hence the information they gather and produce lacks solidity. Similarly, COFEPRIS was created in 2001 to issue licences allowing healthcare establishments to deal with surgical and obstetric procedures and to handle organs, tissues and cells. Recently, it has taken on the task of conducting sanitary inspections of assisted reproduction clinics. To date, COFEPRIS has registered 52 assisted reproduction clinics ( GIRE, 2015 ) and, according to one physician, in 2016 they began a comprehensive campaign to verify that assisted reproduction clinics are working to appropriate standards (field-notes, 2016). In addition to the regulations established by COFEPRIS and CENATRA, there are some states within the federation that have active articles, mostly in their civil codes, that oversee specific aspects of assisted reproduction. These deal with issues related to establishing kinship when using assisted reproductive technology (in Aguascalientes, Colima, Morelos and Sonora), surrogacy (in Tabasco) and embryo donation (in Querétaro), as well as prohibiting the use of embryos for research or cryopreserving them (in Coahuila) ( GIRE, 2015 ). Little attention had been given to the existence of these articles until a debate surrounding surrogacy in Tabasco emerged. The debate arose when the laws in Thailand and India, traditionally considered as ‘the places to go’ for those who needed surrogacy but could not access it in their own country, became more restrictive. As a consequence, Tabasco became the new ‘place to go’, due to its permissive laws. In response, Tabasco’s laws were changed to allow only Mexican nationals to use surrogates, thwarting the reproductive tourism market that was on the brink of explosion. However, the story of how policymakers and assisted reproduction practitioners are trying to regulate these services is more complex than this. There are at least four interconnected arenas where regulation is being negotiated: (i) presentation of proposals by various political parties; (ii) expert forums organised by the Chamber of Deputies; (iii) practical guidelines dictated by the professional community (which are not legally binding); and (iv) a standard of practice currently under elaboration (which could be legally binding). As is described in more detail below, in most of these efforts professionals and policymakers are working in collaboration. The first proposal to regulate the assisted reproduction industry was presented by the then-emerging Green Party in 1999. Since then, each political party has presented its own proposal, resulting in more than 20 by 2012, yet none has been passed into law. Why this should be so is still under research. Some physicians have speculated that it might be because a law regarding assisted reproduction has no political value, others think it might be due to certain potentially controversial aspects covered these laws (e.g. the destiny of untransferred embryos and the use of assisted reproductive technology by homosexual couples). Establishing how the various proposals came into existence (for example, who came up with the idea of writing one or how the different elements were debated and agreed upon) is also still not clear. There are, however, some elements that can help to begin to paint a picture. The first of these elements lies within the motivations and justifications for the proposals. Most proposals start out by expressing a certain level of apprehension with the development of biotechnologies such as genetics and assisted reproductive technology. Specifically, there is concern with the use of these biotechnologies for purposes other than granting infertile couples or individuals the opportunity to procreate. This apprehension is justified because these biotechnologies are considered capable of affecting the reproductive and evolutionary process of humanity by offering the possibility to manipulate gametes and embryos with eugenic purposes. In addition to the social, ethical, juridical and biomedical implications, the use of biotechnologies have generated legal voids, both juridical and axiological, that need to be addressed. In light of this, representatives of several political parties have put forward different initiatives with the purpose of updating the existing laws, at least to a certain extent. Some proposals also mention the fact that other countries have already legislated these procedures and thus Mexico should do the same. A second element can be found in their content. Most initiatives seek to regulate the way assisted reproduction services are offered and to control cloning and stem cell research. All initiatives agree to allowing the use of most assisted reproduction procedures (AI, GIFT, IVF, ICSI) when being used to help a ‘traditional family’ have children using their own gametes and the wife’s uterus. The structure of this ‘traditional family’ can be inferred to be a stable heterosexual couple (not necessarily legally married) where the woman is aged between her early twenties and her early forties. It is when this traditional family model is altered that discrepancies between proposals appear: for example, allowing same-sex couples, single or widowed users, gamete or embryo donation, surrogacy or embryo selection (for other than medical reasons). This could suggest that what causes debate and disagreement is altering what is considered the ‘acceptable’ family structure. A third brush-stroke that can add to the picture is the participation of some physicians in the process of elaborating some of these proposals (field notes, 2007). Their participation, however, did not appear in the official documents of the proposals. In 2001 the Chamber of Deputies organised an expert forum with the purpose of helping policymakers understand the medical and legal implications of assisted reproduction and thus develop appropriate regulations for assisted reproduction services ( Galván Antillón, 2001 ). Seven different speakers were invited to talk about causes of infertility, embryo development, human genetics and the biological, technical, bioethical and legal aspects of assisted reproductive technology. Dr Gutierrez Najar, the leader of the team who achieved the first Mexican IVF-conceived baby, was among these experts. There were also two geneticists, one embryologist, one bioethicist and one lawyer, but no users, psychologists or nurses were invited. Although all speakers approved of the use of assisted reproductive technology, traditional gender roles and conservative Christian views were reproduced in these presentations. A few years later a second forum, called Assisted Reproduction in Mexico and its Expectations ( Cámara de Diputados, 2004 ) took place in four different cities (Cuernavaca [Morelos], Monterrey [Nuevo León], Guanajuato [Guanajuato] and Mexico City). As far as is known, evidence that this forum had any effect, other than familiarising policymakers with the topic, has not been published. In 2012, a group of assisted reproduction professionals from 34 centres, both public and private across the country, and one member of a non-governmental organisation (NGO), were organised into seven thematic groups to establish a National Consensus document on assisted reproduction. This document was published in two national biomedical journals simultaneously: in the Journal of the Society of Gynaecologists and Obstetricians ( Ginecología y Obstetricia de México ) and in the journal published by AMMR ( Reproducción de México ). The themes covered were: patient eligibility, ovarian stimulation protocols, ova aspiration, embryo transfer, hormonal support, cryopreservation and informed consent. In the publication they stipulate, for example, that single women or women in a heterosexual or homosexual relationships (not necessarily legally married) are eligible for assisted reproduction; that when it is a couple soliciting the services, both members of the couple must give their consent for the procedures; and that the destiny of surplus sperm, ova and embryos has to be clearly stipulated in the consent form. The consensus considers the possibility of donating or transferring non-used gametes and embryos to other couples for reproductive use or using them for scientific research ( Kably-Ambe et al., 2012 ). Although the consensus is not legally binding, it has great value because it implies a collaboration between biomedical professionals – who would more normally be competing with each other for clients – to arrive at a unified perspective on how assisted reproduction should be practiced. This is one more in a series of steps taken towards the professionalization and solidification of this biomedical specialty (cf. González-Santos, 2014 ). Currently, a new strategy is emerging regarding standards of practice. Rather than generating a general comprehensive law, assisted reproduction specialists (such as heads of clinics and members of professional associations), in conjunction with representatives of government offices (e.g. Ministry of Health), members of private and public hospitals and NGO are developing standards of practice for assisted reproduction services. This document is still under construction and the outcome of it is still very much uncertain. The purpose of this document is to establish a Mexican Official Norm (NOM) or standard for assisted reproduction. Those that already exist specify obligatory technical regulations, requirements and specifications for goods and services and cover a wide range of areas, including health services and practices. If passed, this assisted reproduction NOM would establish how diagnosis and treatment are conducted, the minimal requirements for infrastructure, and for the professional profile of the staff. It can be seen that policymakers and professionals collaborate in three of the four arenas, although the proportion and place each occupies differs. In the proposals and forums the professionals are fewer and have less power, while in the document for the standards of practice it is the professionals who lead the discussion and outnumber the non-biomedical contributors.

Mexico has a fairly well-established reproductive healthcare industry, with assisted reproductive technology as the main product. There are over 50 clinics operating in various cities across the country, offering a wide range of assisted reproductive technology treatments and with a prominent profile in the national media. There is an active professional association, established in the late 1940s, with approximately 450 members and its own specialised journal. According to the Latin American Registry of Assisted Reproduction (RedLara), in 2013 Mexico conducted 7204 cycles to prepare women for either IVF or for intracytoplasmic sperm injection (ICSI) making it the country with the third-highest number of reported cycles within the registry ( Zegers-Hochschild et al., 2016 ). This ranking should be considered with some caution however, because it was derived from data offered voluntarily by only 29 clinics, about half of those that exist in the country. When and how did assisted reproduction become common practice within the area of reproductive medicine? How did the Mexican assisted reproduction industry emerge and become this active? This paper explores these questions from the service providers’ perspective (the perspective of the user is equally important, although it will not be discussed here). Two aspects are highlighted that are suggest were important for the establishment of the Mexican assisted reproduction industry and for its subsequent development. The first one has to do with an epistemic shift that made these technologies acceptable to the practicing medical community. The second refers to the way in which the assisted reproduction biomedical community choreographed ( Thompson, 2005 ) the practical, technological and economic elements that are implicated in the provision of assisted reproduction services and thus established the assisted reproduction industry. The account of Mexico’s ‘repronational history’ ( Franklin and Inhron, 2016 ) offered in this paper is informed by the ethnographic work carried out at public and private clinics, medical and non-medical conferences, professional meetings and at online forums and websites, as well as from interviews with users and psychologists, the analysis of national journals, newspapers, magazines and legal documents. This account begins in the late 1940s and continues until the early 2000s, a period strongly marked by a shifting reproductive agenda, the growth of biomedicine, the strengthening of globalisation and neoliberal practices, and a constant yet unsuccessful struggle for democracy. The structure of the paper traces how the practice of biomedically assisted reproduction evolved locally. Part 1 describes the epistemic shift that allowed the biomedical community concerned with infertility to make sense of and accept the new technologies of assisted reproduction that were being pioneered overseas. Part 2 looks at the emergence and establishment of the biomedical assisted reproduction industry. Due to the complexity of the Mexican healthcare systems the important points of each system are summarized in Table 1 for clarity. Likewise, in Table 2 , an overview of the history of assisted reproduction in Mexico is provided, highlighting the major events that are discussed in this paper. Table 1 The Mexican healthcare system. Table 1 Healthcare scheme Institutions and hospitals offering assisted reproduction User eligibility Fees Assisted reproduction services offered Privately owned services These are privately owned medical groups all of which house assisted reproduction clinics: • Médica SurGrupo • ÁngelesStar Médica • American British Cowdray Hospital • Hospital Español This group also includes privately owned clinics that are not affiliated to a hospital. Anybody who can pay for it or has private insurance that covers it. The user pays for the service out of pocket or via their private insurance company. Fees are established by the doctor and/or the hospital and medication is bought from private pharmacies at market price. Low and high complexity assisted reproductive technologies. Work-related social security system Each scheme has its own set of hospitals throughout the country and all offer some sort of assisted reproduction services, although some only intermittently. People working in the following sectors have the right to use the social security scheme assigned to that sector: State workers: Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, (ISSSTE) Workers in the private sector: Instituto Mexicano del Seguro Social (IMSS) Workers in the Petrol Industry: Petroleos Mexicanos (PEMEX) Members of the military: Secretaría de la Defensa Nacional (SEDENA) Varies, depending on institution. ISSSTE: offers high complexity assisted reproductive technologies since 1996. Their services were set up with the assistance of Dr Gutierrez Najar. IMSS: only offers low complexity assisted reproductive technologies. PEMEX offers low and high complexity assisted reproductive technologies. The service is outsourced to private clinics. Public social security system Secretaría de Salubridad y Asistencia (SSA) Constituted by 12 institutes for the research and care of health related issues, and 14 general and specialised hospitals, including 3 psychiatric. The one concerned with assisted reproduction is the National Institute of Perinatology (INPer) Offered to people that are not eligible to the IMSS or ISSSTE health security system. There are restrictions on age, marital status, number of cycles and type of treatment. Fees are charged depending on the users’ income bracket and medication is offered at a reduced price. Low and high complexity assisted reproductive technologies. No gamete donation, embryo freezing or surrogacy are offered. Table 2 Overview of the history of assisted reproduction in Mexico. Table 2 Time frame Association Assisted reproduction context Legal and political context 1940–1966 Asociación Mexicana de Estudios en Esterilidad – AMEE Mexican Association for the Study of Sterility Infertility was considered a medical problem concerning both women and men, with negative effects for the individual, the couple and the nation. It was called conjugal infertility or marital sterility. Esterilología was the multidisciplinary medical speciality dedicated to studying and treating conjugal infertility. Since artificial insemination was not viewed as a curing procedure, it was considered unacceptable. 1950–1970 The first journal dedicated to the study of infertility was published: Estudios en Esterilidad 1961 The first AMEE annual conference was held (the 53rd conference was held in 2016) Population growth was desired, hence there were two sets of laws that strictly regulated and restricted contraception methods. The first was published in 1936 and the second in 1947. 1966–1992 Asociación Mexicana para el Estudio de la Fertilidad y Reproducción Humana – AMEFH Mexican Association for the Study of Fertility and Human Reproduction Reproductive biology is included in the general curricula of the medical degree and as a topic of inquiry in the research centres focused on reproductive biology. Reproduction was being studied and controlled through hormonal and surgical methods. Between 1985 and 1986 the first private assisted reproduction clinics were established, one in Mexico City and the other in Monterrey, Nuevo León. 1988 Mexico’s first assisted reproduction success stories: Carlos Esteban, conceived via GIFT, was born on 24 of February and Andrea, conceived via IVF, was born on the 23 March Population growth was starting to be framed as a problem, hence biomedical and political attention was shifted towards controlling fertility. In 1974 laws were passed to promote family planning strategies (Ley General de Población), a government body was created to overlook the family planning campaigns (CONAPO) and the media was used to promote these campaigns (using Mexican soap operas known as telenovelas ). 1992–to date Associacion Mexicana de Medicina Reproductiva – AMMR Mexican Association of Reproductive Medicine From 1993 on, new private assisted reproduction clinics began to open in Mexico City and other major cities across the country. In 2008 the first issue of the association’s new journal, Reproducción , was published. In 1999 the first proposal to legislate assisted reproduction was presented by the Green Party. Since then, over twenty proposals have been presented. In 2000 CENATRA was created. In 2001 COFEPRIS was created. CENTARA = National Transplant Centre; COFEPRIS = The Federal Commission for the Protection of Sanitary Risk; CONAPO = National Population Council; GIFT = gamete intrafallopian transfer. The Mexican healthcare system. Médica SurGrupo ÁngelesStar Médica American British Cowdray Hospital Hospital Español Overview of the history of assisted reproduction in Mexico. CENTARA = National Transplant Centre; COFEPRIS = The Federal Commission for the Protection of Sanitary Risk; CONAPO = National Population Council; GIFT = gamete intrafallopian transfer.