Surrogacy: Baby Blues

Pinki Virani’s book, Politics of the Womb, takes a look at the world of surrogacy and why caution needs to be exercised all the way. An extract:

Couples are going out of their way to have children when self-declared infertile—crossing cities, countries, continents—so that a doctor somewhere, anywhere, can deliver their dream. Fertility clinics reward them by calling them exceptional persons to have travelled the distance ‘only so that they can know the joy of holding a child in their arms’. What they don’t smirk about—‘only because of their ability to pay’—is good business manners in a sector which trades on hope. Does Ivf actually work in reversing infertility? Or is the fertility clinic a futility clinic for those patients who never get heard about, the statistics of the Ivf failure rate.

Among other things, fertility clinics are largely secretive and unless forced by a regulatory body are not likely to provide true, never mind accurate, information. Statistics will not have clarity even if there is a regulatory body, it will need to be one with a clear mandate from the patient’s point of view.

What follows below are some minimum policy points on what any regulatory authority for reproduction must have. These provisions have also been referred to in certain chapters that follow which provide concrete examples of why a regulatory authority is needed….

What must be ensured, so that women and their bodies are not treated like cattle, in countries like India [which does not have one until September 2016] is a human fertilization authority which plays a pivotal and composite role:

• It certifies the following of laid-down and evolving policies by the government which has been responsive to overwhelming evidence.

• It regulates the licensing of assisted reproduction clinics and overviews the licensed clinics and doctors within.
• It puts up a website of these clinics so that patients can see for themselves their annual success rates, and on which parameters. For example, how much of this result is due to surrogates [even when altruistic]. For another, how many babies were born preterm, before the nine-plus months. In which case how many were emergency caesarean and why, how many elective caesarean. A clinic’s success rate may only be graded on the live births through their process, i.e. newborns which survive to be taken out of the hospital.

Fertility clinics are largely secretive and unless forced by a regulatory body are not likely to provide true, never mind accurate, information.

• The authority oversees all aspects of assisted reproductive techniques—including the all-important dosage of hormones and other medicines—in self and third-party reproduction. For example, forced ovulation for the purpose of needing eggs for the Ivf process cannot have hormonal doses which go beyond producing, say, a baker’s dozen of thirteen. This approximation is being used to underscore that it varies from the body of woman to woman. However there are medical limits on ovarian hyper-stimulation in which women’s bodies should not be harvested as they pose very great risk for her. These limits, which are laid down by maximum egg numbers must be stipulated by the authority on numbers and patient age-level basis.
• The woman cannot be put through another round of ovarian stimulation if the first batch has been medically declared as ‘duds’. Neither women, the intending genetic-birth-mother nor the altruistic surrogate birth-mother can be inserted with more than one embryo at one time. The surrogate cannot be subjected to more than three cycles of Ivf.

All donors must be in excellent emotional, mental and physical health. They must pass a psychological assessment which the clinic must organize with a trained psychologist….

• The authority keeps abreast of medical advancements and new medicines in the field of reproduction to also monitor those products, their efficacy and their side effects. Instructions and guidelines are to be issued accordingly to the licensed clinics.
• The authority ensures that third-party reproduction is non-commercial, i.e. altruistic and provides for pre-counselling and post-donation follow-up.
• The authority ensures that the third-party reproduction is not anonymous. So that the altruistic sperm donor understands he is the intending child’s genetic-father. So that the altruistic egg donor understands she is the intending child’s genetic-mother. And the altruistic surrogate understands that she is the intending child’s birth-mother.
• During donation, it ensures maximum health precautions for them. It finalizes the language of the medical and legal framework of all third-party altruistic reproduction, be they for surrogacy, egg or sperm donation. It ensures an appropriate insurance policy for the altruistic egg donor and surrogate, the premium for which is payable by the intending parents, in the event of life-damaging medical negligence or death during donation, or immediately after, if related to the donation.

Neither the intending genetic-birth-mother nor the altruistic surrogate birth-mother can be inserted with more than one embryo at one time.

• The authority holds the fertility clinic and its doctors within responsible for life-damaging medical negligence or death during donation, or immediately after if related to the donation. The authority also holds the same responsible if there is any medical negligence or death during assisted reproduction or immediately after related to the procedures of a direct patient who is the biological mother, i.e. an intending mother who is both, a genetic-mother and a birth-mother. The authority takes action accordingly, as per its rules and guidelines which include the patients or their surviving families filing appropriate criminal charges. Till such time as the cases are pending in court, the authority suspends the licence of the fertility clinic and takes steps to ensure that the doctor[s] directly allegedly responsible for the negligence or death are not permitted practice on other patients.
• The authority sets down reasonable expenses to be paid in cheque [not cash, the kind that slushes around every country not controlling commercial surrogacy], to the donors for their medical expenses, time away from work if any and commuting costs for medical needs connected with the donation. The authority ensures that the altruistic surrogate is not separated from her own family and friends and her food is not a forced and dramatic change from her regular dietary habits. The woman cannot be prevailed upon to live in a dormitory, hotel or in the home of the intending parents.
• The authority holds accountable the fertility clinic, and takes action accordingly if it is found negligent in all of the following. The altruistic surrogate, the altruistic egg donor and the altruistic sperm donor must be only within the age band of twenty-three years and thirty-five years. If any are married, permission must be secured from the spouse. If the surrogate is married, she must have had a biological child of her own, i.e. delivered through her own body with her own ova, before she can carry for another. No donor can have consanguineous [relationship by blood] connections with either the intending mother or the father…. For the same reason, that of the intending child’s future, the combined age of the woman and man availing of altruistic third-party reproduction must not be more than a total of eighty-five years. And they should have been cohabiting for a minimum of five years including the time taken to try for all assisted reproductive therapies and cycles upon themselves. All altruistic acts of third-party reproduction may be performed only once by the same person, so as not to create complications of disparate step-siblings for the intending child….
• The authority holds the fertility clinic and the doctor responsible for ensuring the following. The third-party reproduction donors must be citizens of the same country as the country of citizenship of the intending child. In the case of the altruistic surrogate, she must not be planning on leaving the country till twelve months after the baby is born. Fertility clinics counselling the two intending mothers, before the third-party reproduction process is undertaken, must advise both on the benefits of breastfeeding the intending child. Accordingly, there should be advice that the birth-mother, i.e. the altruistic surrogate who carried the child to term, can for the first six months exclusively breastfeed the newborn, the remaining six can be in its weaning away. In this manner the child’s healthy start to life is optimized.
• All donors must be in excellent emotional, mental and physical health. They must pass a psychological assessment which the clinic must organize with a trained psychologist and must be paid for by the intending parents. The donors must have no criminal history. They must not have tattoos or piercings in the last nine months and should not be smokers or drinkers; drug-users must be weeded out immediately by the clinic. Surrogate mothers must have a support system in place in the form of some family or friends, and must be based in a stable residential environment.

• The clinic is to be held responsible in ensuring the informed consent of the direct patient and the altruistic donors. Informed consent includes making sure that they understand that all of the following is involved: repeated blood work, lots of bodily ingestion of Ivf medications which will be oral and also subcutaneous and intramuscular injections of hormones. The clinic must explain which of these have side effects and what it will mean for the woman’s body….
• The authority must also lay down that each clinic’s gynaecologist-obstetrician must personally explain to the direct patient i.e. the biological mother [genetic-plus-birth-mother], and the altruistic surrogate that there might be an emergency caesarean and its risks, as also what it entails from the beginning of the operation to her body’s healing post the stitches….
• The authority will lay down that the clinic is to ensure that the egg donor receives adequate bed rest and medical attention post the donation. The clinic will ensure that the surrogate birth-mother of the child receives adequate bed rest and medical attention post each cycle and also post-partum [post-delivery]. For which all payments will be made by the parents.