Wombs for hire

In the courtyard of a nondescript house in Anand, India’s milk capital, a couple of women are busy collecting jamuns falling from a large tree. A few are watching television while others are chatting desultorily. They are taking a break from a tailoring class. Coincidentally all are pregnant but none is carrying her biological child. They are surrogates, who have offered their wombs to couples that cannot have a child.

About 450 km away, in a dimly-lit Mumbai chawl , live seven surrogates. Food and medicines are brought to them by the ART (Assisted Reproductive Technology) bank they are contracted to. Family members are not allowed to visit and their living conditions are nowhere near those in the Anand house. They look pale and tired but are bravely bearing up with the dream of getting Rs 4.5 lakh. And if the client couples are happy and generous, surrogates could end up with tips of anything from Rs 10,000 to a whopping Rs 5 lakh.

In Coimbatore, a photograph of a woman hangs alongside those of various Gods in the puja room of a modest home. The woman is no blood relative of the couple that lives there. She is a surrogate “but no less than God to us… but for her, our family tree would have come to an end,” says the husband. The couple declined to be identified. “Going for surrogacy was an emotional rollercoaster. But, finally, our dream came true,” says the wife. The duo had a baby at Dr Nayana Patel's clinic in Anand.

Surrogacy is a boon for childless couples and a source of income for many women. And it is a business for lawyers, agents, ART banks and, of course, doctors. With about 6,000 surrogacy births estimated in 2012, and each costing Rs 12-15 lakh, surrogacy is a Rs 900-crore industry. And growing rapidly — at 20 per cent, say some doctors.

SURGE IN DEMAND

What explains this boom in the womb-for-hire business?

It’s not just about rising infertility rates and the availability of specialist doctors. There are a variety of reasons from the real to the mundane. Says Dr Anjali Malpani, infertility specialist in Mumbai’s upmarket Colaba area: “Professionals, especially from the IT and banking sectors, want to avoid taking a mid-career break as they can reach the senior-management level in their thirties by being in continuous service. There is an increase in the number of such women opting for surrogacy.” Women from the world of glamour also throng Malpani’s clinic with requests for surrogacy.

Dr Nayana Patel, who put Anand on the global surrogacy map, corroborates this: “People are marrying late and are career-oriented. A lot of people from the IT and BPO industry approach me.”

Most interestingly, single men are looking to become a parent via surrogacy. “More surprisingly, these men have the backing of their parents. There is a change in the way people view surrogacy now,” says Dr Shivani Sachdev Gour, who runs Surrogacy Centre India (SCI) in Delhi. Single parents use donor eggs or sperm to have their own child. Dr Gour started off in 2008 handling one case a month. Now, she sees 25-30 patients every month.

Says Dr Sweta Gupta, Consultant, Reproductive Medicine and IVF, at New Delhi’s Moolchand Fertility and IVF Centre: “There is increased awareness about surrogacy. The majority of the people who understand gynaecological limitations in certain cases are opting for it.”

This is a far cry from the times when Americans, Europeans or Australians, who could not conceive naturally, would come to India to get surrogate babies as the cost of the procedure here is a fraction of that in their own countries. Even in the late 1990s, when Indians started to opt for surrogacy in some measure, relatives would often agree to bear the child, driven purely by altruism.

Today, surrogacy has come out of the shadows and many women are offering their wombs on rent out of choice. Some of them are not even from impoverished families. Many are quite open about surrogacy and offer their services with the full knowledge of their husbands, parents or relatives.

Take the case of Raima Sagar, who opted to be a surrogate after she lost her job when the store she was a manager in shut down. “Surrogacy helped me and my husband repay a debt of Rs 5 lakh we had taken some years back,” she says, adding that she has registered herself with an ART bank to be a surrogate again.

At Dr Patel’s Akanksha Infertility Clinic, nurses from middle-class families often volunteer, but this is mainly for money. Hansa, a 40-year-old nurse, has already had two surrogate babies. “I could buy a house and educate my son from the money I got. Owning a house was impossible otherwise,” she says. Her son is in college and she is not averse to becoming a surrogate again.

Typically, doctors prefer women between 22 and 43 to be surrogates. Also, they should have finished raising their own families and be in good health, says Dr Patel.

THE BUSINESS OF BABIES

What of the economics of surrogacy? Surrogates get Rs 4-4.5 lakh after the child is born (see table). They also get Rs 5,000 a month for a year for food/supplements. Then there are expenses on medicines, medical tests and the delivery as well as charges paid to lawyers, doctors and ART banks. In all, the total cost comes close to Rs 15 lakh.

With money involved on this scale, it is no surprise that surrogacy clinics are mushrooming. There are over 500 surrogacy centres across India, though only 156 are enrolled with the National Registry of Assisted Reproductive Technology Clinics.

In the absence of any norm, anyone can open an infertility or ART clinic. A law is, however, in the making with the Ministry of Law and Justice looking at a draft ART (Regulation) Bill. It is likely to be tabled in Parliament in the monsoon session.

According to Girish Nigudkar, Founder-CEO of Intermedics, an importer and supplier of IVF equipment, hormones, medicines and disposables since 1992, an IVF clinic is born every week. IVF, or in-vitro fertilisation, is the process of creating an embryo outside the human body and implanting it in the biological mother.

In the case of surrogacy, the carrier of the embryo is an outsider. Nigudkar says it costs Rs 50 lakh to Rs 1 crore to set up a clinic depending on the services offered. There are about 700 IVF clinics in the country, of which 500 also offer surrogacy services.

SURROGACY HUBS

Though surrogacy is a nationwide phenomenon, Delhi leads in terms of the number of cases handled, followed by Mumbai and Hyderabad. Delhi and Mumbai have a large pool of doctors and, more importantly, embassies and consulates that facilitate foreign nationals with surrogacy procedures.

Hyderabad shot into prominence only in the last few years. “The setting up of an international airport (in 2008) and the opening of a US Consulate (in 2009) boosted the number of people coming here for surrogacy,” says Dr Samit Sekhar, surrogacy and IVF programme director at Hyderabad’s Kiran Infertility Centre. His clinic handles some 15 cases every month, mainly patients from abroad. Dr Sekhar says if Hyderabad had consulates for Spain, Australia and the UK, the number of cases would be even higher.

“We chose India because not only is the quality of doctors and medicines here world class, but also because costs are much lower,” say a beaming Richard Riopel, a Canadian. He and his wife had a child through a surrogate a little over a month ago. Most importantly, he says, surrogates in India are under the care of ART banks, NGOs, etc. “This ensures that they take their food and medicines on time and also do not take drugs or alcohol, which can harm the baby.”

Of surrogacy itself, they say it was the last option. “We had done many cycles of IVF, but were unsuccessful. Surrogacy helped us complete our family.” says Riopel.

Consulates and embassies have a significant role to play as a child born through surrogacy to foreign parents in India is stateless and has to get a passport to go back to the home country of its parents. “Embassies recognise the child. For surrogacy in India, a permission letter is required from the respective country,” says Dr Gour.

So far, 11 countries have given the letter, including the UK, the US, Australia, Canada, Argentina, Brazil, Ireland, Senegal, Mongolia, Israel and Chile. Couples who try to bypass the rules often end up with cancelled visas. Sometimes the child has to be left behind in India for a few months till the paperwork is done.

The non-medical complications of surrogacy are many, particularly on the legal front (see box). This is where lawyers play a key role, finalising terms and agreements among all the parties, including the surrogates, says Amit Karkhanis, a partner at Kaylegal & Associates.

“In 2006, we got a case where the parents-to-be were being blackmailed by a surrogate, who was threatening to keep one of the twins she was carrying. Legal agreements are essential before starting the procedure.” These agreements cover paperwork related to visas as well.

UNEASY PREGNANCY

Surrogacy may be well accepted in towns and cities but in the hinterland it is not quite out in the open, at least not for the surrogates.

Women usually hide surrogacy from the extended family. An agent, speaking on condition of anonymity, explains: “Surrogates tell their relatives that they are going to a bigger city for one-two years for work. But their husbands are in the know.”

Surrogates usually live away from their own families during the course of pregnancy. This is to ensure that they take food and medicines on time, are near medical help in case of an emergency, and to make sure they are not subjected to any abuse. While this is good for their physical health, staying away from families takes a toll on their emotional wellbeing. “Our children are allowed to visit us only once a week — on Sundays. And the rest of the family is not permitted to meet us. But since all of us here need monetary support, we put up with this,” said a surrogate, who did not want to reveal her identity.

As for the agents, typically they are women who have themselves been surrogates and know the ropes. “We get good commissions. And it is not just money; we are helping needy women as well as people who want to be parents,” says Mumbai-based Mangala Damle, an agent, who has been a surrogate twice.

ART banks are an inevitable link in the surrogacy chain as the Indian Council of Medical Research guidelines restrain doctors from dealing directly with surrogates.

Dr Patel has set up Anand Surrogate Trust to look after the surrogates and provide them vocational training for a dignified life after childbirth.

Elsewhere, NGOs have stepped in. Amma, in Hyderabad, for instance, has about 60 marginalised women from 23 districts of Andhra Pradesh under its wing. These women can be surrogates if they want to. “Surrogacy is just a part of our work. We take care of women who opt to be surrogates by giving them food and taking them for medical check-ups,” says Seshai Sai, an activist at Amma.

Surrogacy in India is no more in its infancy, but the situation of the surrogates has not changed in the last 10 years.

Barring patchy help from a handful of organisations, most of them live a life of subsistence away from their own families. “Surrogacy needs to be regulated,” says Dr Patel. Regulation may be just one solution to the problem.

A more viable alternative would be to encourage adoption of children who don’t have a family and home.

The making of a surrogate baby

Parents desirous of having a surrogate child approach a specialist doctor, who examines them to check if they can conceive naturally. If they cannot, the doctor will introduce the couple to an Assisted Reproductive Technology, or ART, bank. The ART bank puts the parents-to-be in touch with women volunteering to be surrogates. Parents can choose the woman they want to carry their child. The doctor will then use the parents’ eggs and sperm to create an embryo in the lab and implant it in the surrogate. If the parents’ egg or sperm cannot be used, they can buy them from donors.

Difference between IVF and surrogacy: IVF, or in-vitro fertilisation, is the process of creating an embryo in a lab and implanting it into the prospective mother. In surrogacy, the embryo is implanted into another woman (the surrogate).

Rights and responsibilities

Surrogacy involves a maze of legal issues, and so, detailed contracts are drawn up to spell out each party’s rights and responsibilities.

SURROGATE’S RIGHTS

The surrogate has the right to compensation, as agreed. She also has the right to be taken care of by the couple and the clinic during pregnancy and for three months after the child is

Karkhanis, a partner at Kaylegal & Associates, says there have been stray cases of differences that were sorted out. He cites a 2006 case, where a woman threatened to hold onto one of the twins she was carrying unless the couple met her demands. Lawyers “sorted out” the matter and the couple got both infants. There is apparently no sex selection. Doctors deny practising the procedure, which is illegal.

If the child dies, the surrogate still gets the payment. If the surrogate dies, the compensation for her family is decided by the contract, as there is no insurance for pregnancy in India. In most cases, the compensation is double what the woman would have got, and amounts to around Rs 8-9 lakh. “There is a need for a law in this area,” says Karkhanis.

>rashmi.p@thehindu.co.in

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