The number of Chinese couples visiting Thailand and other Southeast Asian countries for fertility treatment has been rising since the Beijing government relaxed the country's one-child rule in 2016.
While Chinese couples can now have a second child, those who struggle to conceive still face problems. In-vitro fertilisation (IVF), a procedure under which human eggs and sperm are combined outside the body, remains highly restricted in their home country.
Consequently, more Chinese couples are seeking treatment in Thailand and other countries, adding a new dimension to the already heated competition in the field of medical tourism.
Zhang Yinzhe and his wife Xu Mengsha came to Thailand recently in hopes of having another child after having IVF treatment here. "There is an old saying in China: a son and daughter complete the family" the 31-year-old pilot from Beijing was quoted as saying by AFP.
According to Kasikorn Research Center, an affiliate of Kasikornbank, the massive growth in overseas travel by Chinese -- averaging 31% a year since 2012 -- has also given a lift to the medical tourism business in Asia. An estimated 480,000 Chinese went abroad for medical purposes in 2015, it said.
"Chinese people come to Thailand for the purposes of fertility and cosmetic treatment. In the case of fertility treatment, they mostly visit Bangkok Hospital," said Wanwisa Sriratana, a senior researcher at K-Research, referring to the country's largest hospital chain.
Of the 8.7 million Chinese tourists visiting Thailand in 2016, about 27,000 came for medical purposes, said Ms Wanwisa, citing figures from the Chinese online travel agency Ctrip.
In addition to heterosexual couples, a growing number of same-sex couples are looking for medical help to have children, noted Dr Wei Siang Yu, the founder and executive chairman of the Singapore-based Borderless Healthcare Group.
Male couples require egg donors and surrogate mothers to bear children. Surrogacy can be a challenge as it is now banned in many countries including Thailand. Female couples require only a sperm donor and most do not need IVF as intrauterine insemination is usually adequate, said Dr Wei.
Thailand has become a popular destination among Chinese seeking fertility treatment for a number of reasons, according to Nina Kao, CEO of Taiwan-based Overseas Medical Mission Center, affiliated with Taiwan-based Changhua Christian Hospital.
"The cost of fertility treatment in Thailand is affordable and overall services, from making an appointment to making an insurance claim, are good," she said. Chinese-Thai translators are available in many hospitals and the success rate of fertility treatments is high, although there is never a 100% guarantee that IVF will result in a successful pregnancy.
Piyavate Hospital, a private hospital in Bangkok, opened a fertility centre in 2012, providing counselling and a variety of treatments including IVF and intracytoplasmic sperm injection (ICSI) -- direct injection of a single sperm into an egg.
Ekachai Hospital opened its EKI-IVF Fertility and Genetic Center in February this year to serve people with reproductive problems. Its services include IVF, ICSI, percutaneous epididymal sperm aspiration (PESA) and testicular sperm aspiration (TESA), a method that directly finds and collects sperm from men who do not have sperm in their ejaculate, and preimplantation genetic diagnosis (PGD), which is used to increase the chances for a successful pregnancy.
Other forms of treatment remain a challenge, said Dr Wei, noting that in Thailand, there are strict laws related to egg donation and surrogate mothers. Establishing an egg clinic comes with many challenges, including the availability of a large number of part-time doctors to make sure that the provision of services can continue to grow and meet the demand from the marketplace.
"When the demand rises, one would naturally face an issue with the availability of resources not only in the form of medical personnel but also crucial support from service staff like embryologists, nurses, counsellors and the like," he said.
Thailand in 2015 banned foreigners from travelling to the country for commercial surrogacy contract arrangements. The option is now available only to opposite-sex married couples who are Thailand residents. The main impact of the ban, however, has been to drive the surrogacy business across the border, mainly to Cambodia. It is widely believed that the actual business arrangements in many cases are still handled in Thailand.
Cosmetic treatments are also popular with medical tourists visiting Thailand. Yanhee Hospital in Bangkok has become well known for its surgery and cosmetic treatments targeting Chinese clients. In addition to breast augmentation, facelifts, rhinoplasty and non-surgical cosmetic procedures, it offers Lasik and IVF as well as dental care, heart and general treatments.
Malaysia is one of the most popular destinations for Chinese patients, partly because it has a large ethnic Chinese population. The number of medical tourists arriving in Malaysia has been rising rapidly by 12-15% every year, said Dr Wei, citing figures from the Malaysia Healthcare Travel Council, set up by the health ministry to promote the country's services.
Dr Loke Wai Chiong, healthcare sector leader at Deloitte Southeast Asia, said Chinese tourists travelling to Malaysia visit mainly for plastic and dental surgery as well as non-surgical health treatments.
The majority of privately owned hospitals are certified by the Malaysian Medical Society of Quality of Health (MSQH), Malaysian MOH, International Organisation for Standardisation (ISO) and the Joint Commission International (JCI). Transport is also convenient with the Kuala Lumpur and Penang international airports serving airlines from around the world.
Singapore has the most efficient healthcare system in the world, according to a survey by Bloomberg, and major hospitals in the city-state are accredited by the JCI. Given its reputation for professionalism and high standards, it is often the top choice among foreign visitors for complex treatments despite the high costs.
And while South Korea is popular with many Chinese, especially for cosmetic surgery, the number of Chinese medical tourists dropped by 12% last year and revenue fell 26% from 2016 due to diplomatic and trade tensions between the two countries, said Dr Loke.
Despite South Korea's global reputation for cosmetic treatments and the wide availability of plastic surgery clinics, consumers still need to make sure they do their research and pick a clinic that is safe, cautioned Ms Wanwisa from K-Research. She points to local news reports about the unfortunate experience of Thai comedian Fang Fang, who visited Seoul and had plastic surgery that went wrong, resulting in disfigurement following many operations.
Thailand also has a number of cosmetic surgery clinics, most of which have good reputations among Chinese visitors, but the presence of illegal and non-credentialed clinics and reports of procedures gone awry continue to trouble the industry.
In order to attract foreign patients, especially Chinese tourists, Ms Wanwisa recommends that the country strengthen the credibility of treatments and services to gain an edge over rivals Malaysia and Singapore.
In addition to cosmetic surgery and fertility treatment, basic services such as general physical check-ups and dental care are popular among Chinese patients. Most hospitals have to further improve and develop their technology in order to compete with Malaysia in attracting more medical tourists, she added.
Malaysia is wooing more Chinese visitors, and last year introduced a new mobile application called Hartar that helps them conveniently search for all kinds of information bout tourism as well as medical services, said Dr Loke.
Since 2017, Malaysia has offered Electronic Travel Registration & Information (Entri) and e-visa facilities for Chinese visitors. The Entri service is available for people who stay in the country no longer than 15 days, with processing fees of 160 yuan, while an e-visa for a stay of up to 30 days costs 200 yuan.
Thailand provides visas that allow a stay of up to 90 days for certain purposes, which could attract more visitors from China and the CLMV (Cambodia, Laos, Myanmar and Vietnam) countries, according to a report on medical tourism by KPMG.
Meanwhile, most hospitals in Thailand are making Chinese language services available, as Malaysia and Singapore commonly use the language. K-Research forecasts that the number of Chinese travellers visiting Thailand for medical treatment will increase by 8-10% by 2023.
Tanate Kasemsarn, head of the infrastructure, government, healthcare and hotels practice with KPMG in Thailand, said most of the country's privately owned hospitals are accredited by the JCI, with highly experienced doctors and other professionals in wide range of specialties to serve patients from all over the world.
"There is an increasing demand for medical tourism from other countries, so the health service sector is one of the important emerging sectors in Thailand," he wrote in a report published in February.
Thailand is also looking to attract more foreign expertise in the medical field, mainly on the biotechnology and medical research side, which could pay long-term dividends in terms of strengthening the local medical sector and services to patients.
In January this year, the Thai government introduced a four-year Smart Visa to attract foreign investors and highly skilled professionals who invest or work in 10 targeted industries that include biotech and medical services.