Surrogacy
What is Surrogacy ? Why INDIA for Surrogacy !
Surrogacy is a method of assisted reproduction. The word surrogate originates from Latin word surrogatus (substitution) - to act in the place of. The term surrogacy is used when a woman carries a PREGNANCY and gives birth to a baby for another woman.
Surrogacy is gaining popularity as this may be the only method for a couple to have their own child and also because adoption, process may be a long drawn out process.
What are the types of surrogacy?
• IVF / Gestational surrogacy
• Traditional / Natural surrogacy
IVF / Gestational surrogacy
This is a more common form of surrogacy. In this procedure, a woman carries a PREGNANCY created by the egg and sperm of the genetic couple. The egg of the wife is fertilized in vitro by the husband's sperms by IVF/ICSI procedure, and the EMBRYO is transferred into the surrogate's uterus, and the surrogate carries the pregnancy for nine months. The child is not genetically linked to the surrogate.
Traditional / Natural surrogacy
This is where the surrogate is inseminated or IVF/ICSI procedure is performed with sperms from the male partner of an infertile couple. The child that results is genetically related to the surrogate and to the male partner but not to the female partner.
Who might opt for Surrogacy
A. IVF Surrogacy
1. Primarily, IVF surrogacy is indicated in women whose ovaries are producing eggs but they do not have a uterus. For e.g., in the following cases:
a) Congenital absence of uterus (Mullerian agenesis)
b) Surgical removal of the uterus (hysterectomy) due to cancer, severe hemorrhage in Caesarian section or a ruptured uterus.
2. A woman whose uterus is malformed (unicornuate uterus, T shaped uterus, bicornuate uterus with rudimentary horn) or damaged uterus (T.B of the endometrium, severe Asherman's Syndrome) or at high risk of rupture, (previous uterine surgeries for rupture uterus or fibroid uterus) and is unable to carry pregnancy to term can also be recommended IVF surrogacy.
3. Women who have repeated miscarriages or have repeated failed IVF cycles may be advised IVF surrogacy in view of unexplained factors which could be responsible for failed implantation and early pregnancy wastage.
4. Women who suffer from medical problems like diabetes, cardio-vascular disorders, or kidney diseases like chronic nephritis, whose long term prospect for health is good but pregnancy would be life threatening.
5. Woman with Rh incompatibility.
B. Traditional Surrogacy
1. Women who have no functioning ovaries due to premature ovarian failure. Here Egg Donation also can be an option.
2. A woman who is at a risk of passing a genetic disease to her offspring may also opt for traditional surrogacy.
What are the screening criteria for surrogate in INDIA.
Medical Tourism's network of hospitals in India, has a very meticulous and stringent criteria for choosing a surrogate. The surrogates are between 21-35 years of age. They are married with previous normal deliveries and healthy babies. Detailed medical history, surgical history, personal history, and family history is looked into.
History of blood transfusion and addiction is also taken. It is made sure that the surrogate has an uneventful obstetric history (no repeated miscarriages, no ante-natal, intra-natal and post-natal complications during previous pregnancies). The surrogate and her partner are screened for infectious diseases like sexually transmitted diseases, Hepatitis B, Hepatitis C, HIV, VDRL. Thalassemia screening is also done.
Detailed pelvic sonography is done and other tests for uterine receptivity are performed to ensure maximum chances of success. A detailed financial and legal agreement is then drawn up between the surrogate and the commissioning couple.
What are the protocols adopted for IVF Surrogacy in India.
For IVF surrogacy in India, matching of cycles of the genetic mother and the surrogate is done by adjusting menstruation dates by oral contraceptive pills. When the cycle starts, the surrogate is put onto estrogen tablets to prime the uterus.
The protocol used for the genetic mother is day 2 protocol or day 21 protocol, depending on the age of the genetic mother and the other test results. For the day 2 protocol, called the antagon protocol, oral contraceptive pills are given in the previous month. On the 2nd day of the periods, gonadotropin injections are started. USG Monitoring is done daily. When the size of the follicle reaches 14 mm, the genetic mother is given an antagon injection to prevent the surge of the endogenous hormones. For the day 21 protocol, called the long protocol, GnRH analogues are started on day 21 of the previous cycle.
Once the genetic mother gets her periods, gonadotropin injections are started. In both the cases, the patients are monitored daily. When the follicle reaches 18 mm size hCG trigger is given. The surrogate is started onto progesterone tablets on the day of hCG injection that is given to the genetic mother. Oocyte (egg) retrieval is done 36 hours later, which is generally day 12 or 13 of the cycle. On the same day the genetic father gives his semen sample.
The eggs of the genetic mother are fertilized with sperms of the genetic father in the laboratory by IVF / ICSI procedure. The resulting EMBRYO is then transferred into the womb of the surrogate under ultrasound guidance. The surrogate is then put on luteal support using progesterone tablets / injections, and pregnancy is confirmed 15 days later.
Step-by-Step procedural details for Surrogacy with Indian Surrogate.
The surrogate is treated as a high risk pregnancy and is cared for by 2 consultant gynecologists in our hospital. Appointments are scheduled with the consultants every three weeks for the first 6 months, then every 15 days for the next 2 months and then weekly / biweekly in the last month. Blood tests and ultra sound are done as and when required. Routine blood tests like hemoglobin, blood group, VDRL, HBsAG & HIV are done. Special care is given, and tests are done to pick up any obstetric or medical complications like hypertension, diabetes etc., at the earliest. 2 doses of injection Tetanus are given during pregnancy.
The baby's growth is monitored stringently. Ultrasound is done at 6 weeks to confirm pregnancy and the viability of the baby, then at 12 weeks to assess growth and certain parameters like nuchal thickness. At 18 -20 weeks, a detailed level III ultrasound is done to detect any abnormalities in the baby. At 16 weeks, after councelling and with the consultation of the genetic parents, amniocentesis is performed, if the genetic mother's age is more than 35 years. At 28 weeks and 34 weeks, color Doppler is performed to assess the growth of the baby and rule out intra uterine growth retardation.
Fetal well being tests, like non stress test, are done as per the requirement. Detailed information is given to the surrogates about nutrition and diet during pregnancy. They are regularly provided with supplements from the hospital.
Thus, adequate care and precaution is taken, to ensure that sufficient and optimum nutrition reaches the baby. We have a LDRP (Labor Delivery Recovery Puerperium) room for delivery which is equipped to handle any obstetric emergency. Our NICU setup is also completely equipped to handle any neonatal complications, with a neonatologist who is available round the clock. We keep the couple posted on the progress of the baby and send them ultrasound pictures and blood reports as and when they are done.
Legislative Developments & National Guidelines of Surrogacy in India
No surprisingly surrogacy agreements have posed a series of social, ethical and legal issues, which needs to be carefully evaluated. This evaluation must be read in the backdrop of the conservative attitude of the people on this issue. While countries like U.K., Australia, and the U.S.A. have taken efforts to legislate in this regard, in India, the medical fraternity too has been trying hard to lobby for the formalization of National Guidelines governing such arrangements.
The National Guidelines have a separate segment outlining the rights of the child. Once born, he or she is treated as the legitimate child of the infertile couple. In order to avoid psychologically devastating consequences, the Guidelines provide for non-disclosure of the identity of third party donors especially if the children are under 18 years of age. In case of inquisitive children this restriction has been relaxed, to prevent any form of identity crisis.
Moreover, the National Guidelines lay down that before allowing a woman to be a surrogate, the ART clinics must certify that she is medically fit to undertake such a responsibility. The clinics are to take special measures to ensure that she is not an AIDS carrier. This has been done to prevent congenital diseases.
The Guidelines further lay down that a HIV positive woman shall out rightly not be refused treatment by ART clinics. Instead, would be redirected to appropriate counseling service centers where she shall be informed about the potential hazards it may cause to the unborn child].
A key factor complicating reform of the commercial surrogacy industry is the lack of capacity in current Indian law to address emerging issues. This is an outgrowth of the government’s enthusiastic promotion of a business climate that is friendly to the medical tourism industry, which was founded on the outsourcing model pioneered in other industries in India. At both the national and the state level, the Indian government promotes the country’s reputation as a premier destination for medical tourism, 9 because the industry serves as a driver of economic growth as well as an income generator for the state in the form of tax revenue. The absence of industry regulation attracts patients and keeps fertility treatment costs low.
The legitimizing of reproductive processes, like surrogacy, means legitimizing its outcome too. Therefore, the law not only has to adapt to the new technology, but has to meet the challenge of marrying the old with the new without unsettling what we hold dear.
