The Hindu Business Line : Babies waiting to happen

ART family: Sri Lankan couples at a gathering back home with their babies, who were born through assisted reproductive technology at Chennai's Prashanth Hospitals.

Lying down at the general ward of an IVF clinic in Chennai, Shanthi anxiously feels her stomach. She is 52 years old, thrilled to be six-months pregnant with twins, yet gnawed by fears about the outcome of her assisted reproduction. "This is my first pregnancy after 27 years of marriage and I feel like I'm in the middle of a miracle," she says, listening to the sound of her baby's heartbeat through a device. "I pray the babies will be alright."

Elsewhere, the Bhatias, who live in Dubai, are vacationing in Mumbai with two-year-old Meghna. Meghna is an IVF baby, and mother Sheetal says she was "tense during the entire process but happy she had this chance". Next month, Sheetal will try for a second child at a Mumbai clinic.

Male and female infertility is a common problem in India, more common than diabetics. Before 1978 — when Louise Brown (England) and Kanupriya (India), the world's first two test-tube babies were born — there was no means to treat couples incapable of natural reproduction.

The scientific breakthrough set off rapid developments in IVF, culminating in the birth of Harsha, India's first scientifically documented test tube baby, in 1986 (Kanupriya's birth had gone unrecognised as it was mired in ethical and moral controversies). "We didn't have so much knowledge, experience or equipment as we do now," says Dr Indira Hinduja, the gynaecologist responsible for Harsha's birth. "When I started I didn't even know how an egg looked."

Research in Assisted Reproductive Technology (ART) — which includes Artificial Insemination (AI), In Vitro Fertilisation-Embryo Transfer (IVF-ET) and Intracytoplasmic Sperm Injection (ICSI) — has since grown by leaps and bounds. Today, eggs are frozen for later use, embryos screened for genetic disorders, and databases developed to help find ways to minimise miscarriages.

As scientists gain in confidence over choosing the right permutation-combination to ensure pregnancy and a healthy child, couples feel more assured. "I know success rates are low, but I researched well on my doctor, the technology and process used on me, and feel that I have tried my best," says Vrinda, 34. Her tests were negative but the account executive didn't try again — "it was too painful for me" — and is happy with her decision.

In IVF, the ovum is fertilised outside the body and the fertilised egg is transferred to the uterus. The process does entail its share of pain, starting with the series of hormone-stimulating injections to increase the egg-count, stages when the eggs are retrieved from the uterus, and later inserted back as embryos.

There is mental and emotional strain, doubts, anxiety, and even paranoia. The waiting period can be very lonely for some. "I stay alone most of the time, and start to imagine all sorts of things happening to the baby. It's terrifying," says Ranthika, 40, a patient from Sri Lanka.

And if women are going through the process with Greek-like stoicism, it's only the promise of pregnancy that keeps them going. Keerthi has, since December 2005, survived five failed IVF attempts, including two in which she saw the baby grow to be two months old. "I got so close every time, which is why I feel I must try again. I sometimes think I have seen two children," says the 44-year-old, managing a smile. Keerthi has been married for 18 years, and is now undergoing IVF for the sixth time.

New solutions

According to the Indian Council of Medical Research, about 10-15 per cent (or 13-19 million) of married couples in India are infertile. Apart from factors like low sperm count, infections, chronic disease and erectile dysfunction in the male and age, damaged fallopian tubes, low egg production and fibroids in the female, fertility doctors say lifestyle changes of the 21st century have also adversely affected fertility.

ART is working on ways to get past these problems with success rates, according to ICMR, at just about 30 per cent. In some clinics, these numbers are touching a high of nearly 50 per cent. "Research is locating new ways of finding solutions for infertility, and application of knowledge is on the rise," says Dr Anoop K. Gupta, Medical Director, Delhi IVF & Fertility Research Centre.

Chennai-based Dr Geetha Haripriya, Chairperson, Prashanth Hospitals, seconds that. "Newer drugs, better lab technology, better acceptance of the treatment, increasing use of donor eggs and sperms, and surrogacy is bringing great changes to ART," says the gynaecologist, who named the hospital after her son who was conceived through IVF.

In the early years of ART, a telescope was inserted into the woman to retrieve eggs; today it involves just a needle prick. "The inventor of the laparoscope, for instance, put up with everything short of being beaten up. Forty years later, the equipment was indispensable. Changes in medicine will go on," says Dr G.A. Rama Raju, Director of Hyderabad's Krishna IVF Clinic.

These progresses have led to more clinics, more doctors and more patients. There are over 300 IVF clinics in India, and new ones opening every month. Globally, over one million IVF babies have been born after Louise Brown. A WHO report puts the global ART market at over Rs 25,000 crore a year.

Global interest

Interestingly, even foreigners are making a steady beeline to India. "A lawyer from America came to us on her own. She had never been to India before," says Dr Aniruddha Malpani of Malpani Infertility Clinic in Mumbai, to indicate changing Western mindsets about healthcare in "third world" countries.

A driving factor is cost. One IVF cycle costs $20,000 in the US and £3,500 in the UK, says Dr Malpani (also the first, together with wife Anjali, to open India's first sperm bank in Mumbai in 1990). Quality treatment is available in India at a much cheaper cost.

Dr Kamala Selvaraj (centre) had delivered south India's first test-tube baby.

In Chennai, 207 patients from abroad sought help from Dr Kamala Selvaraj of G.G. Hospital in 2006 alone. Dr Kamala had delivered south India's first test tube baby, first GIFT and PROST twins, India's first surrogate baby and has other ART-firsts for the region.

Another emerging trend pertains to patients travelling to India for Indian donor eggs. "Recently I treated a lesbian couple from Finland who wanted a baby with Indian characteristics. They are even willing to wait," says Dr Gupta. Many single mothers are also beginning to consider ART an option.

The concerns

Given its many possibilities, some see ART as ideal ground for making quick money. There are IVF clinics that shut shop in just a couple of months, after pocketing their lakhs. In others, the procedures are not regulated. "In many cases, pregnancy can occur with simpler means like AI but, sadly, patients just don't know their options," says Dr C.P. Puri, Director, National Institute for Research in Reproductive Health.

Jyotsna, 43, is concerned. "As patients, we tend to take the doctor's word for a prescribed method of ART. It is difficult to find out if the doctor is merely putting up an act," she says. Jyotsna, a Canadian-Indian, has rented an apartment in Chennai for the treatment. She is three months pregnant after ICSI, a procedure in which a sperm is physically transferred to an egg.

There is growing unease over the likely ethical and moral complications arising from surrogacy, and the use of donor eggs and sperms in the absence of effective laws. "We don't have statutory law for ART. Procedures must be brought into the framework of effective laws, and quickly," says Dr Rama Raju.

Guidelines for accreditation, supervision and regulation of ART clinics in India were framed by ICMR together with the National Academy of Medical Sciences (NAMS) in 2005, but enforcement remains a challenge.

In December 2006, the government formed a National Accreditation Committee for ART centres. "There is a need for more accountability, transparency and better standards of care, which the committee will discuss," says Bangalore-based Dr Kamini A. Rao, President, Indian Society for Assisted Reproduction, and a committee member.

Meanwhile, the experts are asking/analysing crucial questions on ways to reduce the nearly 75 per cent failure rate, shortage of sperm and eggs, surrogacy, use of donor eggs and sperms, and multiple embryo transfers, which often lead to low birth-weight and pre-term delivery. "The committee meeting hopes to address these issues to ensure standardisation of procedures," says Dr Puri.

The outlook

Looking ahead, experts say ART could spread to Tier II and Tier III cities and foresee a reduction in costs. "Like in the West, if insurance companies can include IVF in their health schemes, it will create a dramatic difference," says Dr Malpani.

There is increasing worry over whether babies born through ICSI are healthy, leading to more research in that area. Chromosome screening is being considered an important means to reduce the rate of miscarriage.

There is also special focus on the intricate procedure of Pre-implantation Genetic Diagnosis (PGD), where a part of the fertilised egg is taken, its DNA content examined, and abnormalities, if any, corrected.

Very few clinics in the world use PGD. "In India, people are being trained, and technical aspects standardised. As long as the egg is not damaged, the benefits can be many," says Dr Puri.

The Malpani Infertility Clinic was the first in Asia to use PGD — they ensured that the embryo didn't have signs of developing Down's Syndrome — to achieve pregnancy.

As experiments are put in place, rules framed and advancements monitored, many childless couples will keep their fingers crossed.

"Advances are what a society or country permits, but you can't prevent science," says Dr Indira, who has delivered over 2,000 babies through assisted reproduction since Harsha, who is now 20 and studying third-year science, and hopes to do a PhD.

Harsha, by the way, calls her "godmother".

* Most names of patients have been changed on request

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Babies waiting to happen