CALIFORNIA-BASED Clara and Jim Perry, both in their thirties, were childless despite five years of marriage due to infertility. A Google search led them to discover Anand, in the innards of Gujarat, a town that’s a mere blip on the global radar, but fast acquiring renown for its world-class in-vitro fertilization (IVF) procedures.

Late last year, the Perrys flew down to this unremarkable town in west India to fulfill their long-cherished dream of choosing a surrogate for their baby! 

The Californian duo are a fast multiplying breed of childless foreigner couples hotfooting to India for a surrogate. Though no official figures are available, Indian medical practitioners guesstimate that nearly a third of surrogate childbirths taking place worldwide are currently happening in India.

“After IT services,” says Dr. Nisha Kathuria, a Delhi-based gynecologist, “it's now the turn of babies to be outsourced from India." Adds obstetrician Dr. Tripat Kaur of Max Hospital, “In these times of globalisation and market-driven economies, there’s considerable demand for this service."

Indeed. In fact the Indian Council for Medical Research (ICMR), India’s premier medical research body, estimates that partly due to the upward spiral in the number of surrogacy outsourcing cases from India, the reproductive sector in the country will be worth a whopping $6 billion by 2008.

Also, a report by India Brand Equity Foundation and Ernst & Young 2007 states that outsourced healthcare will employ nearly 2,00,000 people in India by 2008, up from the current 20,000-odd employed in the healthcare/pharmaceutical business process outsourcing space.

“Surrogate is one of the well-accepted concepts of assisted reproduction,” reiterates India’s renowned IVF expert Dr Indira Hinduja. “It benefits patients who can’t conceive or carry a pregnancy to term. Such people can take the help of surrogates to carry their child in the uterus and then hand it over to the genetic parents post-delivery.”

Fuelling the surrogacy service from India is a slew of factors, including low medical costs, a highly qualified medical workforce and a relatively relaxed legal atmosphere. Interestingly, though surrogate trade is banned in several countries — including Italy, Australia, Spain and China — and is permitted with restrictions in the US, France and Germany —the Indian government is yet to formulate any laws on the subject. 

However, Dr. Hinduja informs that the ICMR and the National Apex Committee for Stem Cell Research and Therapy are in the process of forming guidelines which will assist IVF specialists, genetic parents, surrogate mothers and the newborn child in India. According to these guidelines, doctors and hospitals should not be involved in the monetary dealings between the couple and the surrogates. Also, a surrogate mother should not be over 45 years of age and no woman may act as a surrogate more than thrice in her lifetime.

Unlike the lax Indian legal scenario, the US law mandates that surrogate agreements be meticulously drawn out to delineate the responsibilities of intending parents, the number of IVF rounds the surrogate must endure and their living expenses to be borne out by the surrogate couple.

zzz“But in India,” explains Dr. Kathuria, “a country not known for championing women's rights, surrogacy has a high potential for abuse as the monetary stakes are high. The specialist cautions against surrogacy in financially exploitative terms, “It’s not like donating a kidney, after all” she opines. “Having a child is a deeply emotional issue.”

And that it is. But despite its overt emotional overtone, surrogacy isn’t regarded illegal in India either simply because no concrete laws exist in this regard which makes surrogates vulnerable to exploitation.

“When anything is influenced by economics, there’s invariably a dark side to it,” admits Dr Raman Prakash, a Mumbai-based psychologist who also counsels commissioning parents and surrogate mothers.

“If surrogacy becomes an avenue by which women, in relatively wealthy countries, select poorer women in our country to bear their babies, then it is economic exploitation, a kind of biological colonization.”

BE THAT as it may, surrogacy is fast becoming the biggest hope of childless couples who are flocking to Indian shores not only from the west, but also from Sri Lanka, Pakistan, Nepal, Bangladesh, Thailand and Singapore.

And a large reason for India becoming a hub for such a service is the cost factor. According to Dr Anoop Gupta, Medical Director, Delhi IVF and Fertility Research Centre, New Delhi, while the total cost of renting a womb in India works out to around $10,000 as compared to about $50,000 in the West! In the US, surrogate mothers are typically paid $15,000 and agencies claim another $30,000. In India, however, fertility clinics charge in the realm of $2,000-$3,000 for the procedure while a surrogate is paid anything between $3,000 and $6,000, a fortune in a country where the annual per capita income hovers around $500.

Dr. Gupta claims he has delivered over 3,000 surrogate children since he opened his clinic in 1995 and receives about six to 10 e-mails everyday from foreigners — mostly NRIs settled in the US and UK — seeking surrogacy as an option.

The highest demand, explain experts, are for the educated and fair-complexioned surrogates from North India. Currently, the main centres for surrogacy in India are New Delhi, Anand and Surat in Gujarat and Pune in Maharashtra.

Kaival Hospital in Surat has, for instance, in the last five years, delivered hundreds of surrogate babies with many more on the way. About 75 per cent of Kaival’s clients are NRIs from the UK, US, Japan and Southeast Asia. Dozens of enquiries from India and abroad inundate the hospital where experts vet and counsel parents/prospective surrogates. Both parties are required to sign an elaborate legal contract that covers the surrogate mother's rights to the baby and underline the financial terms.

Similarly, at Pune’s Ruby Hall Clinic and the Pune Fertility Centre in Shivajinagar requests for surrogates too pour in regularly. To meet this exponentially growing demand, the Pune Fertility Center recently invited ‘women in the 25-30 years age group’ to enroll as members under its ‘Surrogacy programme’. According to the Centre, monetary benefits play a key role in attracting women to surrogacy and the rent-a-womb contract can cost around Rs8-10 lakh.

IVF consultants at the Ruby Hall Clinic (one of the many clinics in India where women who can’t conceive or carry a baby can opt for surrogacy) in Pune, acknowledge that their outfit has been receiving numerous queries for surrogacy.  The clinic advises couples but admits that the financial aspect is none of their concern. The demand for surrogacy here is primarily from three segments -- women with a genetic problem, those whose ovaries don’t have eggs or from those who suffer premature ovarian failure.

But there’s no denying that money is the prime motivator in surrogacy cases even though the societal/familial support for such cases is usually zilch. In fact given India’s conventional attitudes towards sex and procreation, there’s often ostracism for potential surrogates. For instance, Rahita and Binod (names changed), both residents of Anand, have been living in a neighbouring village for the past few months to keep surrogate Rahita’s pregnancy a secret. “Otherwise, we’ll be treated like social pariahs,” says Binod. “This isn’t a respectable thing to do in our society.”

Though surrogacy is a lucrative temporary option for some, traditional attitudes, especially in the countryside, mean that Indian surrogate mothers often have to invent stories for their neighbours.

Most say they are carrying their husband’s child, and once the baby is delivered to the intended parents, they say the newborn died during childbirth. Some — like Rahita — even go to other towns and return after delivery, telling neighbours they were visiting relatives! “It’s a lie we have to tell. Else we can’t earn this much money,” says Rahita matter-of-factly. 

But does surrogacy tantamount to commodification of motherhood?

Yes and no. According to Dr Bhawna Patel, director, Asha Infertility Clinic, Anand, there’s nothing wrong in charging for carrying someone’s baby. In fact surrogacy, she feels, is a win-win situation for both — the couple and the surrogate woman. Childless couples, she opines, can become proud parents while the surrogates can better their lives financially.

However, Dr Sonia Pahwa, an infertility specialist, points out a worrisome trend which is an offshoot of the surrogacy trend. That of career women opting for third-party reproduction due to a time crunch.

“This is a very disturbing trend as often due to a skewed outlook, busy career women or those in the field of fashion and films, opt for the surrogate option. We usually discourage such cases,” says Dr. Pahwa.

However, doctors reiterate that certain parameters must be followed during a surrogate contract. For instance, a surrogate must be young (under 45 years), healthy and married with children of her own for physical, and more importantly, psychological support. “A mother is less likely to want to keep a surrogate baby if she already has her own children,” reasons Dr. Kathuria.

In India, she explains, the egg is usually from the intended mother or a donor to whittle down chances of the surrogate developing an emotional attachment to the baby.

However, she reiterates that both parties should sign a contract under which the couple pay for the surrogate's services and her medical care and the latter renounces her right to the baby, precluding chances of a possible custody battle later.

Also, warn experts, a surrogate’s health must be given utmost priority. This is especially important in India, a country where relaxed laws don’t push for a surrogate’s health. For example, Indian fertility doctors are allowed to implant up to six embryos in a donor’s womb. This creates the risk of multiple pregnancies and can lead to a baby’s premature birth, low birth weight, cerebral palsy, stillbirth or even the surrogate’s death. In the west, usually one or a maximum of three implants are allowed.   

Also, with the burgeoning trade, activists feel that surrogacy agreements in India must urgently address a few important issues like the mortality/morbidity rate of the surrogate and the human rights/legal protections afforded to them. Also, the emergency care provided to surrogates during pregnancy/birth-related complications as also an audit to oversee the funds distribution to the surrogates.

BUT AS social activist Nisha Jamval puts it, the focus is so much on the surrogate that the rights of the infertile couple are often overlooked.

“For instance who assures that the woman’s unused eggs or embryos are not harvested/stored/sold to couples who want fair-skinned children? Or to couples who don’t have viable eggs/sperms?” questions Jamval.

Other points to ponder, according to the activist —How are the intending parents assured that it is indeed their genetic child and not someone else’s embryo implanted? What happens if the surrogate dies during childbirth? Is there due compensation for her motherless children in that case?

What also needs to be attended is the postpartum, psychological or emotional support for poor women surrogates who are victims of an ossified mindset and cannot turn to their families or social networks for support.

These are just some of the sensitive questions which beg attention if India wants to continue with surrogacy trade.

As Dr. Hinduja sums it up, “There’s nothing wrong with surrogacy as an option as long as a legal agreement oversees the surrogate’s health and neither party is exploited. Also, due rights must be bestowed upon the surrogate child from the intending parents and the country of their origin.”

Only then can surrogacy be well and truly termed a ‘labor’ of love!   

A better option?

ACCORDING TO IVF experts, infertility affects about one out of every six couples worldwide. Infertility, however, is more than just the inability to conceive after 12 months of trying. It also includes women who can’t carry a pregnancy to term.

In the past, adoption was a way out for such women. But now, this notion is regarded as an archaic one as there are other better options for infertile couples who can now opt for advanced infertility treatments and egg/sperm/embryo donation.

Gestational Surrogacy

MOST intended parents prefer gestational surrogacy because the chances of the surrogate being able to keep their baby are slim. They also feel more in control because they can choose the genetics of the baby

An advantage to having an egg used by an ovum donor or the intended mother is that for the surrogate mother, it does away with the complex emotional issues of being a gestational/genetic donor mother. Many surrogate mothers find that their family is more receptive to such a surrogacy as they can view the surrogate carry their baby.

Using an Egg Donor

PARENTS who choose to have a gestational surrogate carry their child cannot genetically contribute to their offspring. Nor do they wish to have their surrogate mother be the genetic mother. These parents usually rely on outside assistance via sperm or egg donation.

While sperm donation has been around for years, egg donation is relatively new. In this process, a screened egg donor undergoes hormone therapy (usually injections) over many weeks which cause her ovaries to release more than one egg. Between one and 15 eggs are usually harvested during a surgical procedure. They are then inspected for quality and either frozen for use later or immediately mixed with sperm for the intended father or a sperm donor.