Clarity sought on Centre’s ban on surrogacy for foreigners New directive of ICMR leaves Indians married to outsiders and NRIs in a fix

A recent notice (dated October 10) from the Indian Council of Medical Research (ICMR) to leading In Vitro Fertilisation (IVF) clinics in Hyderabad has become a source of anguish for the Chowdhary couple. The cause for worry is the ICMR directive to clinics that said ‘surrogacy will be limited to Indian married couples only and not to foreigners’.

“I am a person of Indian origin and my parents are from Hyderabad. I am settled in New Zealand but my father, mother and other relatives live here. What should I do now? Will the Indian government consider me a foreigner?” asks an upset Ramesh Chowdhary (first name changed on request).

The couple from New Zealand had come to Hyderabad and underwent IVF treatment in the hope of having a child. And when IVF failed, surrogacy was the only option left. The recent decision of the Union government to ban surrogacy for foreigners has put the couple and the IVF clinic in a fix, prompting the clinic management to write a letter to the ICMR seeking clarification on the classification of foreigners.

The decision to ban surrogacy among foreigners has raised some prickly questions among IVF clinics in Telangana because there is no clarity whether surrogacy facilities can be extended to Indians married to foreigners, NRIs and persons of Indian origin.

Commercialisation

Then, there are also the questions of commercialisation, involvement of third party (known as agents) and exploitation of the gullible people that have been largely left unanswered.

“I am not sure how this decision to ban surrogacy for foreigners will help. However, there is a definite need to strengthen regulatory aspects of commercialisation, involvement of agents and the threat of exploitation of families. There is also a lot of clarity needed on issuing of visas for the baby born out of surrogacy for a foreign couple,” says Dr. K. Anuradha of the Anu Test Tube Baby Centre.

Many also cite the lack of clarity on legal issues pertaining to surrogacy.

“There is no clarity of rules on surrogacy. Moreover, there is a thin line that divides altruistic and commercial surrogacy. Many couples prefer to bring their close relatives as surrogates who can bear children for them. However, not all are lucky. Such persons do try to opt the commercial way of surrogacy,” says Dr. P Praveena, Baby’s Life Hospital, Hanamkonda, Warangal.

Specialists in the sector agree to the fact that in developed countries, IVF and surrogacy are prohibitively expensive, which drives foreigners to destinations like India and Thailand.

Deep-rooted issues

However, they point out that banning surrogacy to foreigners does not necessarily address the deep-rooted issues like the health of a surrogate mother, who will take responsibility of the surrogate infant in case they have a congenital condition or an abnormality.

IVF specialists also draw attention towards family disputes related to property etc. “There is definitely two sides to the story. What if the surrogate mother after few years decides to claim the surrogate child? However, for women from poor families, it could be a good option,” says Dr. E. Kavitha Reddy, senior Gynaecologist and IMA secretary from Nizamabad.

“What is the need of the hour is to regulate third party reproduction protecting all stakeholders, not ban a technology which can help infertile couple,” said co-chairman, Nova IVI Fertility Centre, India, Dr. Manish Banker.

(With inputs from Gollapudi Srinivas Rao in Warangal and P. Ram Mohan in Nizamabad)

Can We Turn Stem Cells Into Eggs?

Northwestern University biologist Jonathan Tilly is certain he’s found egg-making stem cells in adult mice. If he’s right, it would refute decades-old work that showed female mammals finish making all their eggs before or shortly after birth. This might make it possible to grow new eggs inside the ovaries of older women.

In a feature for Science last week, Jennifer Couzin-Frankel wrote about the ongoing scepticism many reproductive biologists have towards both Tilly’s work and OvaScience, the fertility-treatment company he helped found.

Tilly says he’s proven the existence of these stem cells by every method imaginable. But sceptics, and there are many, argue that he has relied chiefly on appearance and genetic markers to identify them. Most reproductive biologists insist that the cells be caught in the act of undergoing meiosis, the cell division unique to sperm and eggs in which bits of DNA are swapped between chromosomes. They also want to see that the resulting eggs can be fertilised and create offspring.

In short, before reproductive biologists are willing to agree that Tilly has found precursors of eggs, they want to see evidence that these cells actually turn into eggs.

Nevertheless, OvaScience has pressed on: it now offers their first modification of standard IVF based on the disputed research in Canada, Panama, Spain, Turkey, and Dubai. In the AUGMENT treatment, mitochondria are isolated from the putative immature egg cells and injected into a patient’s egg along with a sperm cell.

AUGMENT costs $US25,000 on top of the astronomical costs of a ‘normal’ round of IVF, and although the company claims the technique can give older eggs additional energy for early development, so far all of its successes have been in younger women. Some critics say AUGMENT’s chances of success are no different than normal IVF: if true, women using it could be doubling the price of their treatment for no good reason.

ART Bill may close doors to surrogacy for foreigners

With the Centre’s proposed Assisted Reproductive Technology (ART) Bill likely to be tabled in the winter session of Parliament, foreigners and those not included in the “couple” category may be unable to avail the services of an Indian surrogate.

Simply put, the Bill narrows the services to Indian couples or a foreigner married to an Indian citizen. This will put the brakes on the surrogacy business, which currently stands at Rs. 900 crore and is a growing industry.

Also, by defining a couple as a married man and woman, the proposed Bill shuts the door on homosexuals and people in live-in relationships.

“Surrogacy is a method of assisted reproduction. The Assisted Reproductive Technology (ART) industry has evolved into a multi-billion rupee industry. India is internationally known as a booming centre of a fertility market. The industry is growing fast because of cutting-edge technology, trained medical staff, availability of rented wombs, and the fact that it offers very competitive pricing,” said Dr. Rita Bakshi, a member of the Indian Society of Third Party Assisted Reproduction (INSTAR).

India is among a handful of countries — which includes Georgia, Russia, Thailand, Ukraine and a few States in the US — where women can be paid to carry a couple’s genetic child through a process of in-vitro fertilisation (IVF) and embryo transfer.

Dr. Bakshi added that if the Bill comes into force, fertility tourism in India will slip to the back seat.

“At present, close to 20 per cent of the intended parents seeking surrogates in India are foreigners. The Indian surrogacy market is pegged to be around Rs. 900 crore. According to a 2012 study by the Confederation of Indian Industry (CII), around 10,000 foreign couples visit India to commission surrogacy,” said Dr. Bakshi.

According to fertility experts, “transparency, ethical guidelines, regulated environment and enhanced clinical practice are the need of the hour”. They say that the business, driven by sound medical facilities, is based on simple economics.

Mr. Vivek Kohli, who runs Baby Joy IVF Centre, says the proposed Bill will lead to discrimination among Indian and foreigners and directly affect medical tourism in India.

“These days India has become the hub of medical tourism. People travel from across the world for medical treatment. If organ transplant is fine, then why this double standard for surrogacy?” Mr. Kohli asks.

However, some people have come out in support of the proposed Bill. Dr. (Brig) R.K Sharma, HOD at IVF Primus Super Speciality Hospital said: “We are fortunate that we are in this noble work where we can provide the joy of parenthood to people not only from our own country, but from people all around the world. But, indirectly it creates a negative impact about our country that our women are so poor that they rent there womb for survival. If this is banned, it would be beneficial for our image.”

Many legal experts also feel that it is “poverty, illiteracy and the lack of power that women have over their own bodies”, which is the driving force behind the surrogacy market.

Women rights groups, too, believe that the draft Bill is a step in the right direction as it will end the present confusion and help regulate the functioning of IVF centres, besides ensuring quality checks and accountability of ART clinics.

“It will also be a step forward in protecting the interest and health of the surrogate mother,” says the All India Democratic Women’s Association (AIDWA).

Dr. Richa Sharma of INSTAR, meanwhile, said that what the industry needed was a strong regulation “to streamline the ART process and stop unethical practices being carried out”.

“Often we have heard episodes of harvesting of multiple oocytes for egg extraction, implantation of multiple embryos, and the practice of embryo donation or sharing. All of these require women to undergo hormonal interventions. It is exploitation that needs to be stopped, not services,” she said.

Foreigners may no longer hire wombs in India

Foreign national couples may no longer be able to choose India as their destination to bring them the joy of parenthood. The government, in its newly-drafted Assisted Reproductive Technology (ART) (Regulation) Bill, 2014, has proposed to bar foreigners from commissioning surrogacy in India.

Instead, the government has proposed allowing surrogacy only to couples who live together legally as per the Indian Consititution — Overseas Citizens of India (OCI), People of Indian origin (PIO), Non-Resident Indian’s (NRIs) and a foreigner married to an Indian citizen.

Contrary to the recommendation of the Women and Child Development (WCD) ministry, which had earlier proposed the health ministry to widen the definition of “couples by allowing surrogacy to everyone who wants to avail ARTs and surrogacy, irrespective of marriage”, the new draft remains quiet on live-in relationships, unmarried couples and single parents.

According to the draft, being put up for suggestions and comments by the Department of Health Research under the Union health ministry, OCIs, PIOs and foreigner married to an Indian citizen, commissioning surrogacy in India shall be married and the marriage should have sustained at least for two years.

They will have to submit a certificate conveying that the woman is unable to conceive their own child and the certificate shall be attested by the appropriate government authority of that country.

Those seeking surrogacy will also have to appoint a local guardian who shall be legally responsible for taking care of the surrogate during and after the pregnancy etc.

As per the draft if OCI, PIO and a foreigner married to an Indian citizen seeks sperm or egg donation, or surrogacy in India, and a child or children are born as a consequence, the child or children, even though born in India, shall not be an Indian citizen but shall be entitled to Overseas Citizenship of India under Section 7A of the Citizenship Act, 1955.

The draft also proposed that only Indian citizens shall have a right to act as a surrogate, and no assisted reproductive technology bank or assisted reproductive technology clinic shall receive or send an Indian woman for surrogacy abroad. The draft also states that no ART procedure shall be performed on a man and a woman below the age of 23 years and above the age of fifty years in case of women and 55 years in case of men.

According to the new draft, surrogate mother shall be an ever married Indian woman with minimum 23 years of age and shall have at least one live child of her own with minimum age of three years. “No woman shall act as a surrogate for more than one successful live birth in her life and with not less than two years interval between two deliveries. The surrogate mother shall be subjected to maximum three cycles of medications while she is acting as surrogate mother,”says the draft copy.

In the event that the man intending to act as sperm donor is married, the consent of his spouse shall be required before he may act as sperm donor, it adds.

The draft makes it mandatory for all those commissioning couple including OCI,PIO, NRIs and foreigner married to an Indian citizen who have availed of the services of a surrogate to accept the custody of the child or children irrespective of any abnormality that the child or children may have. “Commissioning couple shall submit a certificate indicating that the child/children born in India through surrogacy is/are genetically linked to them and they will not involve the child/children in any kind of pornography or paedophilia,” it further says.

US IVF clinics help Aussie parents select their baby’s gender

About one out of five couples who come to HRC Fertility, a network of fertility clinics in southern California, doesn’t need help getting pregnant. Instead, they come for what is called family balancing, or non-medical sex selection.

According to the network’s medical director, Daniel Potter, these couples usually have one, two or three children and want in-vitro fertilisation to guarantee a child of the other sex.

In Australia, couples under­going IVF treatment do not have the right to choose their unborn child’s sex but in the US they do, and Potter sees 15 to 20 visiting Australian couples every month.

“Typically it’s women wanting to have a daughter, that’s 80 per cent of what we do,” he says.

“Since they were little, the child modelling parenting behaviour has created an entity that for them is usually a daughter. For many women, they have projected the future with that entity: taking her to ballet class, walking down the aisle, that kind of thing. When they have two boys, and they find out they’re pregnant for the third time and (it’s another) boy, (if) they’re crying it’s not because they … resent that son, they’re crying to mourn the loss of that entity they’ve had their whole life.”

Non-medical sex selection is a controversial practice legal in only a few countries, including the US and Mexico. It involves the same technology used to screen for genetic diseases, pre-implantation genetic testing, and even though safety concerns have been addressed, the broader ethical questions remain. In Australia, the National Health and Medical Research Council has floated those ethical questions again as part of a rewrite of guidelines for clinicians and researchers on the use of assisted reproductive technology.

Even in the US, these ethical questions have engendered a mixed response. In June the American Society for Reproductive Medicine issued a position paper saying practitioners are under “no ethical obligation to provide or refuse to provide non-medically indicated methods of sex selection”. But the ethics committee of the American Congress of Obstetricians and Gynecologists reaffirmed last year a committee opinion opposing the practice of sex selection for personal and family reasons.

“We don’t want people to use technology that’s really intended to help couples with medical needs for non-medical reasons,” says Sigal Klipstein, head of the ACOG ethics committee. She says IVF is considered a very safe procedure, but as with any medical procedure there is a low risk of bleeding and infection, as well as overstimulation of the ovaries.

Potter says about half the patients he sees for non-medical sex selection come from abroad. He was recently in Australia for reunions with about 60 families he helped to select their children’s sex, including the Kanavans from Victoria.

Katie Kanavan, 33, travelled from her home in Melbourne to Potter’s clinic twice to undergo IVF/PGD. She already had three boys, all conceived naturally. She and her husband, Stuart, wanted to ensure their next child was a girl and had no such guarantee in Australia. “We wanted to give our boys a sister and we wanted to have a daughter as well,” she says.

The Kanavans spent about $US50,000 on two cycles of IVF/PGD and travel expenses. “It was a pretty big gamble for our family,” Katie Kanavan says. “We saved a lot. We did take money out on our mortgage.” They now have a girl, Ruby-Rose, 2. “We’ve completed our family,” Kanavan says. “I’d do it in a heartbeat again.”

Family balancing should be allowed locally, says David Molloy, chairman of the IVF Directors group in Australia. But it could not be publicly funded, given the range of views on such issues. While well-off parents were paying big money to travel to the US, others were trying unconventional and unproven methods at home, such as “intercourse timing, douching (or) powdered bulls’ testicles”.

“Given there’s a whole heap of unauthorised gender selection happening in bedrooms around Australia, I think it’s reasonable to allow scientific gender selection that actually does work,” Molloy says. He says patients frequently ask about the possibility of choosing their baby’s sex.

Michael Chapman, vice-president of the Fertility Society of Australia, acknowledges that most people may oppose the concept but says about 60 per cent of IVF patients want the option. He considers that reasonable, given how emotionally and financially invested they had to be in IVF.

The NHMRC’s Australian Health Ethics Committee, which produced the draft guidelines, suggests the public debate “would be enhanced through the exploration of some of the complex ethical and social issues raised by non-medical sex selection, through the use of illustrative case studies”.

Those case studies extend beyond family balancing to the replacement of a deceased child and borderline medical reasons, such as where a couple has a boy with autism and believes there would be less chance of their second child having autism if it were a girl.

Arthur Caplan, ethics director at New York University’s medical school, says family balancing can become a smokescreen for families that want boys: “When you are treating the fertile in order to produce something that they prefer as opposed to a disease, I do think you’re really opening the door to a potential slope toward eugenics.”

Potter says although there have been cases of couples wanting a child capable of providing bone marrow to a sick sibling, they were rare.

Sometimes family balancing is sought in second marriages, where a couple wants only one child and there are children from previous relationships, but mothers wanting daughters is the most common cause.

Potter says the Australian women he sees do not have firm views on whether the ethical guidelines should change, instead arriving just “happy and very appreciative that we are there to provide the service to them”.

Like Molloy, he believes that if there is no public funding involved, opposition to sex selection will fade away.

David Kaufman, a program director at the US National Human Genome Research Institute, doesn’t expect a trend to emerge for designer babies. Unlike sex selection, genetic testing of embryos for other traits is much more complicated because most of them are governed by multiple genes. “In most cases we don’t even know all the genes and even if we did you’re pretty unlikely to produce an embryo with the perfect combination of all those genes,” he says.

Potter says every case is different and the couples he helped all had their own, sometimes deeply emotional, reasons for wanting to choose a boy or a girl.

“These are not monsters, these are normal loving families who would like to have a gender represented in their family that currently isn’t,” he says.

Success Stroy of My Parenthood

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