guardian - The fertility tourists

The fertility tourists
The ads are brazen: 'healthy young women - superovulated exclusively for you!'. The fees are half those of UK clinics ('flights and hotel included!'). And the industry is unregulated, leaving doctors free of legal and ethical constraints. No wonder more and more Europeans are going to India for fertility treatment. Raekha Prasad reports
Raekha Prasad
Wednesday July 30 2008
At the end of last year, Ekaterina Aleksandrova boarded a plane in London and flew to Mumbai. It wasn't her first trip there - she is a management consultant and often goes abroad on business. But this time she went to have five embryos implanted in her womb. A couple of days later she flew back to Europe. While on business in Hong Kong in January, she discovered she was pregnant with just one embryo.
For Aleksandrova, 42, this was the culmination of a six-year struggle to become a mother. She divorced at 29, and hadn't been in a serious relationship since she was 34. "I always wanted to have a child but the men kept saying, 'Why don't we travel?'" she says. "It wasn't that I was obsessed with my career, I just couldn't get men to be a father."
First, she tried to adopt in Germany, where she holds citizenship, but that didn't work out. Then, in 2004, she moved to the UK to take advantage of this country's more liberal attitude to single women who need IVF. She spent £18,000 in less than three years, trying and failing to conceive at a private Harley Street clinic. When she finally conceived in India, Aleksandrova was in a state of "shock and disbelief".
The baby she is due to give birth to in September has no genetic link with Aleksandrova. The colour of its eyes, length of its legs and slope of its nose will be determined by a man and a woman who are strangers not only to her, but also to each other. Her baby's biological parents live 7,000km apart, and are separated by language, culture and currency. All they share is their decision to ply their gametes in the global fertility bazaar where Aleksandrova shopped for the ingredients of life, perusing and eventually paying for eggs and sperm. Aleksandrova bought the sperm online from a Danish sperm bank retailing in New York. The $1,600 (£800) price-tag included shipping to Mumbai, where her Indian doctor helped get the tiny frozen container through customs unscathed. There, the Danish sperm was used to fertilise the fresh eggs of an Indian woman who was paid 40,000 rupees (£500).
Alexsandrova first began surfing foreign fertility clinics' websites in the winter of 2006/7. Impressed with the Indian doctor's responses to her email inquiries, she flew out to Mumbai for a couple of days the following April to investigate further. She then visited the Taj Mahal.
She brought home a Punjabi-style pyjama suit for the baby to wear if it was a boy, and bangles if it was a girl. India has a fascinating culture, she says, and she plans to bring the child to India to expose him or her to "50% of their background". The prospect of raising a mixed-race child doesn't faze her. The daughter of a diplomat, she was born in Pakistan and says she has fond memories of her childhood Pakistani friends. "I'm curious to know how the baby's going to look being Danish-Indian. I like coloured kids. I find them cute. I find mixed blood gives a bit of a boost."
She plans to tell the child the truth about the way he or she was conceived. "You can't lie to your child all your life," she says. But she hasn't yet thought about the fallout if the child wants to know more about its genetic parents. "It's preferable that they're kept anonymous. What's the meaning of finding out?"
Aleksandrova herself knows very little about the donors. Her baby's father, she learned from the bank's online catalogue, is 6ft 4in, an architectural student from a family of doctors and "musical". She knows even less about the baby's biological mother, the egg donor. They have never met and donor anonymity prevails in India. "The doctor asked me what I wanted. I said I wanted a young, healthy woman with a child. Because I'm Caucasian, I wanted a fair-skinned person. The doctor said 'she is good-looking with some education'. I'd love to know more. But I trust him. I don't think he picks someone off the street," she says.
In Britain, there is an acute shortage of women donors. Had she stayed here, Alexsandrova would have faced a long wait for eggs, a bill of £7,000, and a cap on the number of embryos planted in her womb - a restriction aimed to prevent high-risk multiple pregnancies but, in her eyes, a curb on her chances to have a baby.
It is different in India; there, the market rules. Clinics' websites offer "many healthy young fertile Indian women" who are "superovulated exclusively for you" in dollar rates payable online by credit card. Moreover, Aleksandrova's Indian clinic put more than double the number of embryos allowed in the UK into her body. "I understand multiple-births are not a good thing," she says. "But for women like me whose bodies reject embryos, the higher the number, the greater my chance."
Alexsandrova is part of a growing number of global fertility tourists from rich countries such as Britain who fish for cut-price genetic material from India's pool of highly trained, English-speaking doctors.
It is a phenomenon wholly distinct from medical tourism, where patients needing a hip replacement or heart bypass receive identical treatment minus the waiting list and the large bills. Reproductive holidays in India are a real getaway from conditions back home. Fertility tourists are often people desperate to break free from not only financial, but also legal and ethical constraints, in a bid to create life. And Indian clinics woo patients with the language of free choice and a can-do attitude.
Age, for example, rarely poses a barrier in India. Earlier this year, twin girls conceived by IVF in India were born in the Midlands to a British Indian couple with a combined age of 131. Their mother, thought to be 59, is one of the oldest women in Britain to give birth.
Ethnicity is no problem either. Those making the trip to India are not just people of Indian descent who want a baby who resembles them. Increasingly, they are white couples that have no problem with the idea of having brown babies.
India was the second country in the world after the UK to produce a "test-tube baby" - the Indian girl was born just 67 days after Louise Brown in 1978 - but it has yet to create a single law regarding infertility treatment. Instead, Indian IVF doctors are self-regulating and only have to refer to a set of guidelines, not work within them.
Meanwhile, Britain has spent the past 30 years reforming infertility laws through public debates. These began with the Warnock Committee in the early 80s, which examined the moral, scientific and religious issues raised by IVF and led to the establishment of the world's first statutory body of its kind - the Human Fertilisation and Embryo Authority - to license and monitor clinics.
Three decades of scrutiny of IVF techniques in Britain has resulted in a recognition of the emotional maelstrom inherent in the creation of life. The result is that not only do British doctors consider the scientific possibilities of having a child, but also the impact of assisted reproduction on a child's emotional wellbeing, human rights and racial identity. Just because you can do something does not mean you should, is the maxim in Britain. The opposite appears to be the case in India.
There, the growing number of white westerners turning up for fertility treatment is reported in the press not as an ethical dilemma, but simply as another example of how the country is "booming": it is a source of national pride that India is getting foreigners pregnant where their own countries have failed. "Move over yoga, Ayurveda, there's a new Asian hip trend starting up ..." begins a story in the Indian Express on a British couple at a Mumbai clinic.
Similarly, while Diane Blood faced years of legal challenge and moral handwringing in her quest to use her dead husband's sperm for IVF, her Indian counterpart, "Puja", became India's first woman earlier this year to conceive with her dead husband's sperm. There was no fanfare, legal wrangling or public debate; her pregnancy was simply reported as a happy ending to a sad story.
One of India's most vocal proponents of patient choice is Dr Aniruddha Malpani, a favourite among British fertility tourists. To get to his clinic, on the edge of Mumbai's upmarket shoreline, his foreign patients must travel from the shiny new airport, past glass towerblocks in the shadow of which ragged children play in fetid pools beside pavements where they sleep, before arriving in a street lined with palm trees. A lift carries them several floors up into the compact, white-walled clinic where nurses scuttle between clean, sparse private bedrooms.
More than half the clinic's patients are from abroad. Hundreds like Alexsandrova, who have had no success in their own country, come to the man who says "yes". Sitting behind his desk in a small office, Malpani is a fast-talking defender of patients' rights, and sees the people he treats as consumers of a technology that needs only the lightest of regulation. As long as people can pay, let them decide, he says. He rails against the "sociologists" who question whether science can act without ethical restraint. "In whose interests are we doing this stuff? Should there be someone sitting in judgment? It's best for the mother to decide what's best."
Malpani turns out to be master of medical propaganda. He calls his patients "reproductive exiles" from medical establishments that are hostile to their desire to have children. The people who come are not desperate, he says, they have been disempowered - and his team is intervening to allow them to "build families".
Malpani taps on the keyboard in front of him while we talk. When challenged on a point, he types rapidly and spins round the screen on which flashes the relevant web page to back up his argument. The impression is of a man in a hurry to prove the world wrong, with all the arguments at his fingertips.
In Britain, people conceived since 2005 by a donor have the right to information about their genetic parent once they reach the age of 18. Children conceived using donor eggs, sperm or embryos in India have no such right; there, donors remain anonymous. That's as it should be, insists Malpani: receiving an embryo from a stranger is no different from getting pregnant after a one-night stand, he says. "If someone just slept with someone and decided to have the baby, no one would ask her to reveal his identity. Just because it's a clinic, why do these questions get asked?"
Malpani also sees no problem with his clinic giving white patients the eggs and embryos of Indian donors, saying, "They've thought about it", before enthusing about how "alike" donor-conceived children's mannerisms are to their birth parents.
British medical thinking, he says, is not designed with the patient in mind. In Britain doctors and patients are encouraged to transfer a maximum of two embryos into the uterus. Any more and the risks of premature birth, smaller babies and children with language and behavourial disorders increases substantially.Malpani transfers up to five embryos. "We have the flexibility to give a woman the best chance," he says. "If they don't get pregnant at all, they are the ones to suffer."
By his own admission, Malpani is a libertarian. He is also a respected fertility expert - his IVF clinic has been named among India's best - with a CV boasting a string of awards and scholarships for his clinical skills.
His greatest advocates, however, are those patients he has enabled to have a child. Sitting on the sofa in their living room more than 6,500km away from Mumbai in Market Rasen, Lincolnshire, are Brian and Wendy Duncan. Wendy, 42, pulls her three-year-old daughter, Freya, on to her lap: the little girl was conceived with Malpani's treatment.
"Freya is just like me. I delivered her and experienced every moment of her growing," says Duncan.
What is striking on first meeting mother and daughter, however, is their difference: Duncan is the palest of redheads while Freya has the dark skin, black hair and brown eyes of an Indian. She looks nothing like her father, either, who is also white. To conceive Freya, Duncan had five fertilised embryos from an Indian couple implanted into her womb.
Duncan was denied IVF treatment on the NHS because she already had a daughter, now 22, and was both overweight and a smoker. So the Duncans went private, borrowing £8,000 for one IVF cycle, which failed. For their second attempt, in India, they spent half that amount, including flights and hotels. "I wanted a child. The system in Britain didn't allow me to have one, so I had to look for an honest alternative," Duncan says.
While ethical decisions in India are left in the hands of individual doctors, in Britain each proposed embryo or gamete donation is considered by a clinic's mandatory ethics committee made up of lay people, clinicians, nurses and counsellors. There is no blanket ban on interracial donation, says Pip Morris of The National Gamete Donation Trust, "but the donor would be matched as closely as possible to the recipient".
"For example, if you had two black recipients and a white donor then that would be questioned and refused. If there's any doubt about the welfare of the child, then a donation would not go ahead."
Duncan says Freya's racial difference is irrelevant to her. "I wasn't bothered when she was born and I'm not concerned now. What matters is that she gets all the love and care she needs growing up." But what if it's relevant to Freya? "Of course I'll tell her if she asks about it. But if she doesn't, I won't stick my neck out to tell her."
Duncan argues Freya's looming questions about the fact her genetic parents are from a different continent, culture and race will be little different from those of her eldest daughter, from a previous relationship, who is mixed race. "When I told my older daughter about her origin there was no problem and it shouldn't be too difficult for Freya to understand the dynamics of it."
In the global market of commercial fertility, India remains one of the cheapest places to buy gametes. In America the going rate for an egg from an Ivy League student is around $60,000 (£30,000). An Indian egg never fetches more than 40,000 rupees (£500), and in the country's small towns a woman is paid as little as 5,500 rupees (£70).
It is almost impossible to get an accurate picture of exactly who India's donors are. The issue is shrouded in secrecy. Part of the reason appears to be the social stigma of being a donor in a conservative society. When asked about the backgrounds of their donors, IVF doctors give a standard response: they are from lower middle-class families, and are all married, with at least one child. One says they might work as a secretary or in a shop and generally have "a little education". But all the doctors claim donors refuse to be interviewed.
Perhaps one unspoken reason for the secrecy is the ugly reality that some donors in a country as poor as India trade their eggs simply to stay afloat financially.
In a dusty rural hamlet near the city of Anand, in the western state of Gujarat, Pushpa clutches her seven-year-old daughter's hand and stares at the cement floor of her house. The 25-year-old sold one of her eggs to pay off crippling debts after the family was reduced to eating just one meal a day. Her husband earns 2,800 rupees (£35) a month labouring on a construction site. "A moneylender would have stripped us of whatever little gold we had. I could not let my last bit of security go," she says.
The emphasis placed on informed consent, rights and counselling for egg donors in rich countries are absent in Anand. Moreover, the medical risks associated with farming eggs, such as pelvic infection or ovarian hyperstimulation syndrome - which in severe cases can be life-threatening - are often hidden from donors."The doctor told me there were no risks; that donating was just selling something that will be wasted away from my body anyway," Pushpa says.
Of even more concern, say critics of India's unregulated IVF industry, is the way that some doctors try to maximise profits by overdosing donors with hormones to stimulate them. "The amount of drugs pushed into them is way above the recommended dose," says Dr Puneet Bedi, a Delhi-based consultant obstetrician and gynaecologist specialising in foetal medicine. "If guidelines say to give 10 shots, they'll give 20 to increase the harvest rate and optimise their conception rates. Because IVF is a completely commercialised industry in India, it's all about delivering to whoever's paying."
The result is that the risk to a donor's health is amplified, says Bedi. While in Britain there is officially a 1% to 2% chance of egg donors getting hyperstimulation syndrome, Indian donors face "a many, many fold risk" in comparison. "We don't really know what happens to these women. Who pays for her life-threatening treatment? Nobody cares. Nobody's answerable."
Pushpa is matter-of-fact about her decision. "You wouldn't ask me why I did it if you'd ever lived on one meal a day," she says bitterly. "Selling the egg was quite easy. I was given some medicine; they took it out. I got the money."
So lucrative was the 5,600 rupees (£70) she received for donating, she did it twice more. "I wanted to send my children to a good school. They will have a better future. This was only possible because of me - a woman. After all, men can't produce eggs," she says.
She doesn't know who bought her eggs. "I don't feel exploited; here, in the villages, every aspect of life is exploitative - where you can work, what you can eat, when you have sex. This is the best option available to me," Pushpa says.
Not all Indian egg donors come as cheap as Pushpa. At the top of the country's social ladder are urban college students, who sell their eggs to bankroll their penchant for new clothes and gadgets. Sipping a cappuccino on the terrace of a cafe in a bustling Mumbai business district, one 20-year-old physics student - who agrees to speak anonymously - explains why she sold her eggs to one of the city's infertility clinics for 20,000 rupees (£250).
Some of her friends had sold their eggs and so she began searching clinics' websites. "If I can earn more money than getting a part-time job, then why not?" she says. "I needed to buy a new mobile and wanted to go abroad on vacation with my friends. I have always had what I wanted in life. But for my own enjoyment, I can't ask my parents for money all the time."
Although she is dressed in jeans, a T-shirt and designer shades, like any other affluent student in India's financial capital, she is acutely aware of the stigma surrounding donation in India. "My parents must never find out. They wouldn't understand why I did it," she says. "They'll think I'll never be able to be a mother myself. It's in the best interests of the family to keep it a secret."
Time is up. She waves down a taxi and hops inside. "I couldn't afford this ride earlier and now I can," she says as the car pulls away. "What's wrong with that?"