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Surrogacy is
a hot topic in the Indian media right now - and
newspapers, magazines and TVs are full of talk-shows and
reports as to how India is poised to become the next
surrogacy outsourcing capital of the world. Not only
does India have a number of successful IVF clinics;
there are a lot of women who are willing to be
surrogates , so that surrogacy costs a fraction of what
it would in the West. While a surrogacy treatment cycle
would be about US $ 50000 in the US, it is about one
half to one fifth the price in India - a bargain by any
standards ! And in this day and age of globalisation and
market-driven economies, there is considerable demand
for this service !
The amount of media attention which surrogacy
attracts is huge, but it is completely
disproportionate to its utility in real life. Surrogacy
stories are full of human interest, which is why they
are so popular, but what I find very disappointing is
the fact that the media does not provide the right
perspective while covering this topic. I feel the
failing is because of innumeracy - of not realising how
uncommonly this particular treatment is needed in the
first place !
We need to remember that surrogacy is useful for only
a very small group of women. For example, a busy IVF
clinic which performs about 300 IVF cycles every year
will see only about 3 patients who medically need
surrogacy. Medically, the indications for surrogacy are
few and far between, and most infertile patients can be
helped with much simpler and easier treatment options.
The commonest reason is a woman who has no uterus. The
uterus may be absent from birth (Mullerian agenesis,
MRKH syndrome); or may have
been removed surgically (hysterectomy for life-saving
reasons, such as excessive bleeding during a caesarean).
Other women who may wish to explore surrogacy include
those whose uterus is irreparably damaged because of uterine
tuberculosis or Ashermann's s syndrome.
However, in real-life, when we we analyse the medical
histories of women who opt for surrogacy, we find that
the vast majority of the time it is usually infertile
couples who either :
1. have had multiple miscarriages; or
2. who have failed repeated
IVF attempts for unexplained reasons.
While these can be reasonable indications for
surrogacy, the fact is that it is often done because the
patient is fed up and frustrated with repeated IVF
treatment failures or miscarriages; and is looking for
alternative options. In a market economy, supply rises
to meet demand, and there are many clinics who are happy
to oblige these desperate couples - for the right price,
of course !
However, the fact is that many of these couples do
not need surrogacy at all ! They have a perfectly normal
uterus; and would be better of opting for donor eggs or
donor embryos, rather than surrogacy. Unfortunately,
they fail to realise this, partly because these options
are not adequately highlighted in the media; and because
some doctors prefer "pushing" the more lucrative
surrogacy treatment option ( as this means more bucks
for them !)
Unfortunately, it's hard for patients to think
straight when they are desperate, which often means they
opt for surrogacy rather than egg donation - a
choice which is much more complex , because of all the
legal, emotional and social issues involved - and also
needlessly expensive .
Let's look at the real-life problems involved in
surrogacy. Firstly, finding a surrogate can be extremely
difficult ! If you have a friend or relative who agrees
to be your surrogate, then your best option is
altruistic surrogacy. Not only is this much less
expensive, the risk of this going sour is much less.
Commercial surrogacy is much trickier, because you then
need to take extensive steps to protect your interests,
and ensure that the surrogate will hand over the child
to you after birth. Finding a reliable clinic, an honest
surrogate and a good lawyer can be hard work - it is
also very expensive !
If the surrogate is anonymous and
confidential, then you need to trust the clinic 100% -
and this can be a big mistake . When there is so much
money at stake, many doctors are tempted to cut corners
, partly because it's so easy to do so - and it's so
hard to check their actions ! It's easy to fool
vulnerable patients . For example, clinics or agencies
may take an advance fee and promise to find a suitable
surrogate - who then backs out at the last minute
because of a faked "personal or medical emergency". Some
clinics take the money ; claim to perform the treatment
; and inform the patient that the surrogate is pregnant.
They then add to the lie by saying that the surrogate
unfortunately miscarried, with the result that all the
money has been poured down the drain ( or into the
clinic's coffers). Since there is no way of verifying
any of this, the patient is completely at the doctor's
mercy - and woe betide the patient who falls into the
hands of an unscrupulous doctor ! Since many surrogates
who act as surrogates for purely financial
considerations are poor and malnourished, the babies
they give birth too are often low-birth weight as well.
Many patients also have unrealistic
expectations of surrogacy treatment. They think that it
is a 100% sure-shot affair , while in reality the
pregnancy rate is still only 50% per cycle.
Of course, the major problems with
surrogacy arise after birth. However, desperate patients
refuse to think so far ahead, and plan to "cross the
bridge" when they get to it - without thinking clearly
through the real-life hurdles they will encounter
at this time.
Let's look at this closely and
assume the treatment has been successful; the pregnancy
has been uneventful; and the child is now born in an
Indian clinic. Whose name is going to appear on the
birth certificate ? How will the infertile couple claim
parenthood ? How will they take the child back with them
to their home country after the birth ? And what happens
if the surrogate ( or her husband) changes her mind and
refuses to hand over the baby ? Or blackmails you for
custody ?
While many clinics talk about the "
Indian Council of Medical Research ( ICMR )
guidelines for surrogacy"; and about how they make the
surrogate sign an agreement to protect the infertile
couple, what they do not tell the patient is that the
guidelines are just a piece of paper which have no legal
validity whatsoever !
The Indian legal system today only
recognises the birth mother. There is no concept of DNA
testing for establishing paternity as far as the Indian
legal system goes, which means that the name on the
child's birth certificate has to be that of the birth
mother and her husband ! Many couples naively
plan to adopt the child and then take it back with them.
What they fail to realise is that adoption in India is a
long and convoluted process which can only be performed
by a recognized adoption agency - and you cannot select
a particular child for adoption !
Hopefully, the Indian parliament
will soon pass a law which regulates IVF and related
assisted reproductive technologies which may provide
some legal protection for infertile couples when they go
in for surrogacy treatment. However, no matter what laws
are passed and what contracts are signed, remember that
real-life can be very messy; and if the surrogate
chooses to dispute the contract after birth, then the
infertile couple is likely to find themselves embroiled
in a legal quagmire - and knowing the way the Indian
judiciary work, the child will be about 10 years old
before the problem is solved ! King Solomon's wisdom is
hard to come by in this day and age !
Before you consider surrogacy in
India, ask your doctor these questions.
1. Would I receive a birth
certificate stating my name as the
biological parent prior to leaving
India? Am I likely to have problems
with Indian immigration when I take
the child out of India ? What about
the laws in my own country ?
2. Is DNA testing available to
confirm the biological relation
between myself and the child
prior to leaving the country?
How and where is this done ? Is
this legally valid ?
3. How do you ensue the surrogate
takes the proper prenatal measures
during pregnancy?
In my opinion, the real danger with surrogacy in
India today is that it is being overused and misused
today. Without a safe legal framework to operate in,
patients are being misled and misguided.
The biggest tragedy is that it is
being used for women who do not need it in the first
place - women who can be successfully treated with much
simpler ( and less expensive) treatment options !
These are women who have had repeated IVF failures; or
recurrent miscarriages. They feel that their uterus is
defective, because it is "rejecting" the fetus, which is
why they opt to go in for surrogacy. They feel that if
they use a healthy woman's uterus to grow the embryo,
their problems will be solved.
Actually, this is a misconception.
The commonest reason for recurrent unexplained
miscarriages or repeated IVF failures is NOT a defective
uterus - it is usually poor quality eggs. Extensive
research has shown that embryos fail to implant ( and
miscarriages occur ) because of a genetic problem in the
embryos . It has been documented that these problems
become commoner as the eggs age, because older eggs have
a higher chance of being genetically abnormal. The
solution to this problem is not surrogacy, because
replacing a normal uterus with another woman's normal
uterus does not correct the underlying problem !
Not only is egg donation much
easier and less expensive; it also bypasses all the
social and legal problems associated with surrogacy.
Once the donor donates her eggs, she relinquishes all
rights to them; and since it's the infertile woman who
gives birth to the baby, it's her name which appears on
the birth certificate, thus preventing any problems in
the future. It's also much more satisfying for women,
because she is the one who experiences the pregnancy;
can bond prenatally to her baby; and gives birth to her
baby !
However, unless patients become
better informed, many of them will continue to opt for
surrogacy, when in fact the right answer to their
problem would be using donor eggs !
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