My time in India ended up being a rather different-to-expected kind of adventure – I contracted a virus (probably on the flight from Russia, I suspect) and became quite ill with fevers, headaches and severe dehydration.  Unfortunately, as I was travelling alone, managing these symptoms was more difficult that usual and after being in India for just 3 days I ended up in hospital, needing IV fluids.  This experience gave me a very unwanted insight into medical treatment in India.  The first hospital was of a very questionable standard and I was eventually transferred by land ambulance to a second facility.  Although this was a significant improvement, the standard here still made me really appreciate the Australian healthcare system in a way I never could have otherwise.  I was released after 3 days and decided that I needed to go home to Australia and finish my recuperation.  This means that I had to cut short my journey but I did not feel physically or emotionally well enough to continue my Fellowship for another week.  I lost around 5kg during this process and got an infection in my arm at the cannula site.  My time in India also severely exacerbated my pre-existing asthma, and I can’t tell if that is due to the virus or the unbelievable pollution levels in Delhi (or a combination).

Before I became unwell, I did have a chance to speak to some local professionals who have been involved in the surrogacy industry, but my hospitalisation made me think again about some of the EXTRA risks of medical tourism (and in reality, surrogacy falls within that category).  Although I am grateful to the nurses and doctors who took care of me, I don’t think the care compared to what I would have received at home.  I am relieved that I had travelled with antibiotics in my suitcase as I ended up treating the cannula infection myself (and appear to have been fortunate that it was not an anti-biotic resistant strain of infection).  Some of the conversations with treating staff were very difficult – just getting the cannula removed from my arm (when I knew there was something very wrong) took over 12 hours of insistent demands from me.  My medical insurance company covered all costs (I believe) and eventually arranged to fly me home one I was medically cleared to fly, but I cannot understate how difficult it was to organise this.  I am so fortunate to have had my husband in Brisbane who spent 3 days relentlessly ringing and emailing the insurance company, negotiating on my behalf, while I was too ill to do this for myself.

The thought of being in a situation such as that while trying to care for a newborn – or worse, that the baby became/was born ill, fills me with dread.  You cannot be cleared to return to Australia until you are well, yet you do NOT want to stay in the facility until you cease to be ill.  This is a really tricky catch22 and certainly a situation to avoid if possible- unfortunately we can’t always choose our health.

Fortunately, before my trip was curtailed, I did manage to meet with a few surrogacy providers and got some sense of what is happening in India currently.  Most people would know that while the Indian Council for Medical Research has guidelines in place for fertility treatment, no specific regulatory framework exists.  Surrogacy has become an enormous industry in the past few years, providing surrogacy services to domestic patients, as well as large numbers of foreigners.  Australians have been significant users of Indian surrogacy services for some time, partly due to the relatively low cost of services, but also due to the relative proximity for travel.  In recent years, there has been an increasing tide of negative media attention about Indian surrogacy, with great convener about the quality go services, and the potential for exploitation of the Indian surrogates.  Despite this, the flow of Australians heading into India continued (and probably increased) until 2013 when the first draft of the Assisted Reproductive Technology Bill was released.  This Bill restricted access to heterosexual couples and (if passed) prevented single people or same sex couples from accessing surrogacy services.  As a result of the uncertainty created by this Bill, many clients sought services elsewhere, and demand was quickly catered for by Indian clinics establishing surrogacy services in Nepal.

The situation changed again in November 2015 (long after the itinerary for my trip had been cemented) and a further draft of the Bill was released, this time preventing any foreign couple (except for very specific conditions, and effectively excluding almost all Australians) from accessing surrogacy services in India.  Again, it is important to reinforce that this Bill has not been passed – it is not law – but it has created a legal limbo in which it is too dangerous for any foreign couples to proceed with new surrogacy agreements.  Surrogacy is still available, and arrangements continue to be set in motion for Indian nationals. For those foreign families who had already commenced the process in November (who had a pregnancy underway) there will also be no impact – they will be permitted to continue the surrogacy as normal, and birth certificates will be awarded without problem. The situation is very different however for anyone who had planned to commence an agreement after the redrafted Bill was released.

The situation is particularly difficult for families who have already created and cryopreserved embryos.  There are currently hundreds of families (not all Australian) with embryos frozen and stored in Indian clinics.  They are not able to use them in India, but neither are they able to have them shipped to their country of origin.  Imagine the distress for a family who believes themselves to be at their last chance to have a child (or a sibling for their existing child).  Perhaps the frozen embryos were created some time ago and the mother is now too old to create new viable embryos.  But this is a real risk of undertaking surrogacy in a country where the legal situation is uncertain and things can change in a legal instant.

A very similar situation currently also exists in Nepal, where around 300 families have cryopreserved embryos that cannot be used.  Nepal was a relatively recent entrant to the surrogacy industry, effectively providing services to families who were excluded by the first draft of the Indian Assisted Reproductive Technology Bill in 2013.  Until August 2015 when the Nepalese government abruptly ceased all surrogacy arrangements.  In that instance the impact was catastrophic for families, even for those with ongoing pregnancies, or with babies who had been recently delivered, as the Nepalese Government ceased issuing exit visas for the surrogate-born babies, and families were effectively unable to leave Nepal with their children.  This situation was eventually rectified (although dozens of families were stuck there for around 3 months) but no further surrogacy agreements can be commenced, and the already created embryos are in limbo.

So why the extraordinary response from these Governments to an industry which was bringing literally millions of dollars of foreign money into these countries?  From my conversations with those within the Indian industry, I can see there is deep division in regards how surrogacy is perceived.

On one hand, there is a belief that surrogacy services to exploit Indian surrogates, that these women are simply being used to achieve the child creation wishes of wealthy white westerners.  I suspect, at least in some clinics, there is absolute evidence of unethical practice and exploitation of Indian women.  Did I have an opportunity to witness this firsthand – of course not!  Unfortunately, none of the clinics I have visited during my trip gave access to the surrogates themselves, to discuss their experiences.  And really, if there had been a chance to speak with a surrogate directly, I suspect that the clinics would not have introduced me to someone who had had a negative experience.  However, there are just too many reports of exploitation and questionable practices (such as surrogates houses, high rates of cesarian sections etc) to ignore it all.

However, I was also offered a very different perspective: that some surrogates are achieving an improvement in their social standing as a result of their surrogacy experience.  I was told that for some women, the opportunity to be a surrogate (and to earn in 9 months what would normally take them 10 years) has increased their value as a wife and as a woman.  Some of these women earn far more than their husbands could hope to, and this provides them the opportunity to educate their children, buy property or learn new skills and start a small business for themselves.  The clinic I spoke to insisted that their surrogates be married, have at least one child of their own and have completed their own family.  They were only permitted to act as surrogates on one occasion, and they were encouraged to deliver vaginally.  These are excellent conditions for surrogacy, but does that apply at all clinics?

So which of these versions of surrogacy are true?  I suspect probably both, and the reality is completely dependent upon the ethics of the clinic and individual treatment of women.

However, there are still other issues with Indian surrogacy practice.  Transfer of multiple embryos is routine, and the risks of multiple pregnancy have already been discussed in earlier blogs.  There have been multiple instances reported where IPs discover they are “DNA negative” to their children.  DNA Negative is an innocuous euphemism which means “oops, sorry, we transferred somebody else’s embryo into your surrogate”, and there have been many reported instances of this in India, Thailand and Mexico in recent years (and elsewhere, I would assume).

What happens to the baby? Good question!

Where did the IP’s actual embryo go? Another excellent question!

Scary stuff.

For any person seeking surrogacy overseas, there is a personal responsibility to choose a country which has established legislation that restricts the way in which a clinic can do business.  When the state itself imposes the boundaries, the individual practices will inevitably improve.  And sometimes we need to choose treatments which are better than a regulation permits.  If we know it is in a surrogate’s best interest to have only 1 embryo transferred, and we can predictably enhance the health of our baby by only attempting for a singleton, then this is the choice that must be made (even if we are permitted to transfer 3 embryos).  Of course a surrogate will agree to more embryos being transferred – she is paid extra if she does, and she receives a bonus for a multiple birth.  Yes, she has consented, but can an uneducated rural girl really consent to the risks associated with this – and should we ever ask her to?  As parents, we also have a responsibility to make decisions which protect our children – deliberately choosing a multiple pregnancy and the associated risks of this, is NOT making a decision which is protective.

It is also critical that IPs consent to good treatment decisions for themselves.  In many of the clinic/services I met (not just India, but also USA and Russia) I had conversations with clinicians who mentioned the poor preparation for parenthood that some IPs exhibit.  Unfortunately, surrogacy at a distance can create an “unreality” in becoming a parent.  The added complexity of undertaking a treatment which is not permitted at home, means that for many IPs there is a cloak of secrecy around the upcoming birth and a lack of engagement with the usual parent preparation services.  I heard reports of IPs who were overwhelmed by a crying baby, and had no idea of settling techniques.  IPs who thought that you should feed the baby EVERY time she/he was unsettled (instead of just cuddling the baby, changing a nappy, or perhaps accepting that sometimes babies cry).  Becoming a parent is always tricky, but doing this in a hotel in a foreign country?  With not one, but 2, or even 3 babies? What if one of them is sick or premature?  What if you have no real experience of babies and no social supports nearby to assist?

It is expected that India will enact the ART Bill soon and a firm set of practice regulations will come into existence.  What impact will this have for those foreigners who were hoping to undertake surrogacy in India?  It’s really anyone’s guess at this stage but theories range from India reopening the industry, to Indian clinics establishing themselves elsewhere (perhaps Sri Lanka – the precedent for offshore satellite clinics was set when Indian clinics opened up in Nepal, but this puts in place the potential to repeat the hazards experienced there).  Some wonder if the Indian Government will permit families who already have cryopreserved embryos in India to commence a surrogacy arrangement, or to ship them elsewhere – we will have to wait and see.

Many thanks to Sonia Arora from New Life India and also to Poonam Jain from International Star Assistance for their time and insights.  Poonam Jain was incredibly helpful, as she has experience in surrogacy not only in India, but also in Nepal and Thailand and really does have an incredible knowledge of the region’s processes.

I found this wall relief (partial section of a larger work) in Gurudwara Bangla Sahib, a stunning Sikh temple in Delhi