A NEW study brought out by the Centre of Social Medicine and Community Health, JNU, Sama-Resource Group for Women and Health and King’s College London, entitled ‘Reproductive Tourism in India: Actors, Agencies and Contemporary Transnational Networks’, maps trends in this unregulated sector. It notes that the “expansion and proliferation of Assisted Reproductive Technologies (ARTs) has been facilitated by economic globalisation. The key features of globalisation, such as crossing boundaries, the increased role of markets in health care, the state’s withdrawal from provisioning, are all significant in the context of ARTs. A transnational fertility market is created wherein reproductive tissues like sperm, ova, and uteri are traded like any other commodity to make profit.” In fact, according to the study, India has emerged as the surrogacy outsourcing capital of the world and it quotes a business newspaper as having suggested that as an integral part of the growing medical tourism industry, the fertility industry is “slated to bring in additional revenue of $1–2 billion by 2012”. Excerpts from a draft of this study, focusing on the scenario in the Indian capital of New Delhi.
From the high-end corporate hospitals such as Apollo and Medanta, to multi-speciality trust hospitals such as Gangaram, to large public sector institutions such as the Maulana Azad Medical College and the All India Institute of Medical Sciences (AIIMS) and to nursing homes and single-doctor clinics, a large number of institutions (in Delhi) offer Assisted Reproductive Technologies (ARTs). We do not have the numbers of each of these types of institutions, and how many of these offer surrogacy.
Motivation: The public sector institution offers surrogacy services where medically indicated, but only altruistic surrogacy. The leading obstetrician and gynaecologist from a top public sector institution admitted that they have performed IVF in some cases where they were not sure if it was altruistic surrogacy. In short, this is not what they probe in great detail, but they do not themselves find women either as donors or surrogates. This doctor said that she once had a patient, a doctor who bore a surrogate baby for her sister-in-law who was also a doctor, married to a doctor, since they could not have their own biological baby they sought one. ‘We do counsel about adoption, but the urge to have their own child is very strong here,’ she said. She gets about five to six surrogacy cases a year and they are all Indian couples, desperate to have their own baby. The surrogates, according to her, are clearly doing this to educate their children and get ahead in life.
At the trust hospital, the focus is on infertility and IVF, not on surrogacy. They perform about two to three surrogacy births a year and about a hundred IVFs. The commissioning couple brings the surrogate. The doctors ask no questions, but make sure the papers are in order. The hospital does not cater to foreign clients, but has had NRI (Non Resident Indian) clients. Their charge is the same whether for IVF or surrogacy – INR 1 lakh per cycle. Their charge is also the same whether or not the couple is Indian or NRI. The doctor felt ‘masala’ media coverage had in fact boosted the industry that sorely needs regulation.
At the only private hospital that agreed to be interviewed, the doctor said that she had been providing IVF services since the early 1990s. She did have some clients seeking surrogacy, but she did not like the issues attached to it and so had stopped catering to such clients.
She has since restarted offering this service since she knows a reliable Third Party Agency that handles all legal and other issues. She deals only with the medical aspect, till a pregnancy is successful, after which an obstetrician takes over.
All the respondents agreed that the Bollywood actor Aamir Khan had provided a boost to the ‘industry’ (when he chose this route to have a baby with his wife, Kiran Rao) which was not seen as desirable.
All the doctors were aware of some doctors running hostels for surrogates where they could be monitored and supervised. This was, of course, against ICMR guidelines. On the other hand, surrogates clearly need such institutions since they need to stay away from home for a long period and then return claiming that they had been away on work, so that their neighbours do not find out about their pregnancies. Many of the commissioning couples also prefer the surrogate to stay in a hostel so that they could be in regular contact with the surrogate, and, indeed, bond with her, even as the doctor keeps an eye on her and supervises her diet and medication. The surrogate’s husband and children are permitted to visit her regularly…
Network for knowledge acquisition: All the doctors interviewed were highly qualified specialists. They had all studied in public medical colleges and completed their post graduation in India. Two of them had worked in IVF centres abroad, one in USA and the other in UK. After her stint in USA, the doctor at the trust hospital had worked with a leading IVF specialist to learn on the job.
All of them have been in this field for twenty years or more and have in a sense been participant observers to the growth of the ART. All of them are members of Federation of Obstetric and Gynaecological Society of India (FOGSI) and Indian Society for Assisted Reproduction (ISAR). In the public sector institution, post-graduates are trained in assisted reproduction. The other doctors interviewed, one from the trust hospital and the other from a clinic, are also involved in training workshops as members of ISAR.
Future scenario: Unless the Bill is passed into law, there is only a bleak picture of unregulated proliferation of the ART. This is partly related to the demand factor, but more significantly due to the supply factor. The ART offers better rates of return on investment, second only to the radio-imaging industry (body scanning etc), where capital requirements are much higher.
Regulation Concerns: All respondents were of the view that highly exaggerated claims of success are being made. In view of the severe shortage of embryologists, people not adequately qualified are also passing off as embryologists. There are no standard guidelines for facilities and the practice. There are no uniform rates for charges and payments.
Among the unethical practices repeatedly mentioned by all respondents are: 1) The harvesting of up to 20 eggs; 2) The insertion of any number of embryos; 3) The widespread practice of embryo-sharing.
Everyone is aware that embryo sharing occurs. Patients come and say that such and such doctor they had consulted in the past had told them that the quality of eggs/embryos from the couple was not good and that they would facilitate a good embryo donor. The couples say they were charged anything from INR 20,000 to 50,000 for the embryo donation they received, but that pregnancy had not occurred. They have no papers at all to verify anything, but they invariably say they had signed the legal consent papers for this.
No one has any doubts that surrogacy needs to be regulated. But there is also cynicism about being able to regulate anything in our country. The ICMR guidelines need to be made into law. That will create a good deal of transparency because the clinic cannot then deal directly with surrogates, the ART banks will. This separation is essential. The registration of such banks would also mean that middlemen, who now thrive, would be weeded out. But questions were also raised about ICMR’s ability to implement the law when it is passed. (WFS)