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“Law and Policy on Surrogacy: A Socio-Legal Study in India”
2015
Chapter – II
Surrogacy and Elements Involved
Human reproduction is a form of sexual reproduction resulting in the conception of
a child through sexual intercourse between man and woman. During intercourse, the
interaction between the male and female reproductive organs results in fertilization of
woman’s ovum by the male sperm resulting into childbirth after the gestation period.1
Approximately, 84 % of women conceive within one year of having irregular unprotected
sexual intercourse, which has been brought to 92 % after two years and 93 % after three
years. For women upto 25 years old, the cumulative conception rate is 60 % during first
six months and 85 % during one year, but conception rates for women aged over 35 years
is less than half of this.2
As opined by Dr. Anirudh Singh, surrogacy is opted by most of the people because
of their complicated medical conditions and not merely out of their convenience. A
woman may have ovaries but no uterus, which means that she can produce healthy eggs
but is unable to conceive. She may also have undergone the process of hysterectomy, i.e.,
removal of the uterus, owing to some uterinal disease; she may be affected by the effects
of chemical or mechanical contraception, such as pelvic inflammatory disease associated
with the use of an intra-uterine device, or by the effects of sexually transmitted diseases;
spontaneous or induced abortion.3
1
http://www.shrishtiivf.com/Reproduction.htm; last visited on 15/05/2013, time: 09:00 am (IST), place:
Meerut, (UP), India.
2
Infertility Treatments for Women: A Review of the Bio-medical Evidence, The Women’s Health Council,
Ireland, Full Report, 2009, p.17.
3
This information is based upon a discussion with Dr. Anirudh Singh of Dr. Singh Test Tube Baby Centre,
Opp. DIG Residence, Near Circuit House, Civil Lines, Meerut (UP).
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Wider causes of infertility may include alcohol and tobacco consumption, use of
illicit drugs, environmental and industrial pollutants, stress, nutritional imbalance,
hormonal disorders, effect of physico-chemical alterations in habitats, pesticides,
pollutants, mutagens in human body through consumption of food sprayed with herbicide,
insecticide etc.4
In the opinion of the researcher, some fertile couples may also seek the services of
a surrogate mother in situations when the female cannot physically bear a pregnancy, or
when she is affected by a heart condition or chronic spontaneous abortion, or when she
may transmit a harmful genetic or other congenital condition to the child she might
conceive. Some of the problems may be solved by in-vitro fertilization, coupled with
ovum donation resulting in the childbirth through the process of surrogacy.
The successful rates of childbirth are as a result of natural IVF cycles, where
pregnancy rates have been reported varyingly between 0 and 30 % after embryo transfer. 5
This is most likely because the natural cycle depends solely upon the development of a
dominant follicle. As a result, ovarian stimulation was developed to generate more
follicles and therefore, more oocytes produced, replacing the natural cycle of IVF. This in
turn increases the probability of a successful pregnancy. However, IVF as practiced today
is complex, time-consuming and expensive. It generates much stress and side effects such
as ovarian hyper-stimulation. Thus, there has been a revival of interest in natural cycle of
IVF treatment in recent years.
The aim of medically assisted conception is to overcome the barriers preventing
spermatozoa from encountering oocytes in infertile couples. The origins of such
technologies can be traced to attempts to fertilize human oocytes outside the body. The invitro fertilization of human oocytes was accomplished only in 1944 by Rock & Menkin.6
Since then, the procedures for handling gametes have been refined and have led to various
techniques for the transfer of either gametes or embryos to the woman.
Infertility Treatments for Women: A Review of the Bio-medical Evidence, The Women’s Health Council,
Ireland, Full Report, 2009, p.19.
5
https://www.inkling.com/read/padubidri-shaws-textbook-gynecology-15th/chapter-17/infertility-andsterility; last visited on 25/05/2013, time: 10:00 am (IST), place: Meerut, (UP), India.
6
Rock J. and Menkin M.F., In vitro Fertilization and Cleavage of Human Ovarian Eggs, 1944, pp.100-105.
4
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Stages of Normal Reproduction in Women and Men:
Normal reproduction is a complex process that involves a series of steps. For
women, the steps include: a) Coordination between the hypothalamus, pituitary, and ovary to allow
development of usually, a single dominant egg (called oocyte);
b) Preparation of the lining of the uterus (called the endometrium) to receive an
embryo;
c) Release of the egg (ovulation) from the ovary;
d) Capture of the egg by the fallopian tube;
e) Interaction with sperm within the tube resulting in fertilization;
f) Transport of the fertilized egg (zygote) through the tube and into the uterine cavity,
as the zygote divides and becomes a multi-cell embryo; and
g) Implantation of the embryo into the endometrium, and development of the
placenta.7
For men, the steps include:
a) The first step in fertility is the production of gonadotropin releasing hormone
(GnRH) in the hypothalamus, which prompts the pituitary gland to manufacture
follicle stimulating hormone (FSH) and luteinizing hormone (LH);
b) FSH maintains sperm production and LH stimulates the production of the male
hormones;
c) Both the sperm and the male hormone production occur in the two testicles, or
testes, which are contained in the scrotal sac;
d) The production of sperm in the seminiferous tubules within each testicle. The head
of the sperm contains DNA and when combined with the egg’s DNA creates a new
individual. The tip of the sperm head is the portion called the ‘acrosome’, which
enables the sperm to penetrate the egg. The mid-section contains ‘mitochondria’,
which supplies the energy to the tail to move. The tail moves with whip-like
7
This information is based upon a discussion with Dr. Anirudh Singh of Dr. Singh Test Tube Baby Centre,
Opp. DIG Residence, Near Circuit House, Civil Lines, Meerut (UP).
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movements back and forth to propel the sperm towards the egg. In this process, the
sperm have to reach the uterus and the fallopian tube in order to fertilize a
woman’s egg.8
Conditions that affect any of these processes reduce the chances of conception in a
given cycle; if the condition is chronic, it can lead to the clinical condition of infertility.
Infertility is not a sexual disorder. Rather, it is a condition of the reproductive system that
can be caused by a number of factors occurring in both men and women. The male
reproduction is hormonally driven, requiring a normal functioning of hypothalamus and
pituitary gland. The male sperms are continually produced throughout a man’s lifetime.
During spermatogenesis and transport through the male reproductive tract, the male
spermatozoa are transformed into a highly specialized cell with its own motility and
enzymatic capacity to penetrate the egg. Epididymal function must be normal and the
accessory glands must be functional to produce normal seminal plasma. An intact nervous
system is also required to permit penile erection and normal ejaculation.
But in case of any problem in the process of reproduction, it is considered a
problem related to infertility and this is the time when one may plan to go for surrogacy.
Hence, before looking into the legal implications of the notion, it is essential to discuss the
factors responsible for the same.
2.2
Infertility in Men:
Male infertility can be due to many reasons such as oligospermia (few sperms),
non-motile sperms, azoospermia (lack of sperms) and androgen disorders which has
serious debilitating effects on the libido. Male infertility can be divided into:
a) Ejaculation Failure: - Ejaculatory failure is the inability to ejaculate. It has a variety of
causes, including pelvic nerve damage from diabetes mellitus, multiple sclerosis or
abdominal-pelvic surgery and spinal cord injury. It is important to distinguish ejaculatory
8
This information is based upon a discussion with Dr. Anirudh Singh of Dr. Singh Test Tube Baby Centre,
Opp. DIG Residence, Near Circuit House, Civil Lines, Meerut (UP).
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failure from the inability to achieve an erection, premature ejaculation and retrograde
ejaculation (ejaculating into the bladder and not into the penis). Rectal probe electroejaculation is a commonly performed technique that may enable patients to produce an
ejaculate capable of achieving a pregnancy. With rectal probe, the doctor electrically
stimulates the pelvic sympathetic nerves to induce a reflex ejaculation from which semen
is collected.
b) Ejaculatory Duct Obstruction: - Ejaculatory duct obstruction is diagnosed in
approximately 10 percent of men without sperm in the ejaculate. Usually caused by
stones, cysts or scar tissue blocking the prostate ducts, the condition is treated with a
simple outpatient procedure that involves removing portions of the ducts. Significant
improvements in semen quality occur in 70 percent of patients, which are associated with
a 20 percent to 30 percent pregnancy rate.9
c) Varicocele: - The varicocele is defined as dilated and twisted veins within the scrotum,
similar to varicose veins in the legs, and is basically a consequence of upright posture. A
varicocele can be found in 42 percent of infertile men and has an unquestioned statistical
association with infertility. However, 15 percent of normal fertile men also have a
varicocele. Varicocele surgery to bind off the twisted veins will improve semen quality in
roughly 67 percent of patients, with improvement most likely to be an increase in the
sperms’ ability to move spontaneously rather than sperm quantity.10 The pregnancy rate
following varicocele repair is approximately 40 percent, with pregnancy occurring at an
average of nine months after surgery. The varicocele remains the most correctable factor
when poor semen quality is discovered. Problems with sperm production are by far the
most common of the three, and can be detected during semen analysis.11
9
http://www.fertilityindia.com/male_infertility_and_vasectomy_reversal.php; last visited on 02/07/2013,
time: 08:00 am (IST), place: Meerut, (UP), India.
10
http://www.ucsfhealth.org/conditions/infertility_in_men/causes.html; last visited on 02/07/2013, time:
08:30 am (IST), place: Meerut, (UP), India.
11
http://umm.edu/health/medical/reports/articles/infertility-in-men; last visited on 02/07/2013, time: 09:00
am (IST), place: Meerut, (UP), India.
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2.3
Infertility in Women:
Maternal age is the most significant factor related to a woman’s ability to
conceive. While many women today are waiting to become pregnant, the ovary’s ability to
produce normal, healthy eggs declines with age, increasing the risk of chromosomal
abnormalities and unsuccessful implantation and pregnancy. The likelihood for successful
pregnancy begins to decrease in women in their early 30s. While this decline is initially
quite minimal, as the years pass the rate of decline increases and begins to rapidly
accelerate around age 37 to 38, with an acute fall beyond 42 years of age. Other factors,
such as endometriosis and uterine fibroids can also play a vital role in infertility, though
many women with these conditions conceive healthy children without trouble. Medical
practitioners recommend that women who have crossed the age of 35 should have a
fertility evaluation after attempting pregnancy for six months. Couples under the age of 35
should consider evaluation if they do not conceive after trying for a year.12
Causes of Infertility in Women: Normally, a woman may have regular menstrual periods, defined as regular cycles
occurring every 21 to 35 days, which always indicates that she ovulates regularly.
Ovulation of the egg occurs approximately 2 weeks before the start of the next period. If a
woman has cycles at intervals of greater than 35 days, it may indicate that she is not
ovulating an egg periodically. Ovulation of the egg is essential for pregnancy. It is a cause
of infertility, if menstrual cycles are infrequent or irregular in a couple attempting
pregnancy. One of the major cause of this may be the age of the woman, which is the most
significant factor related to her ability to conceive. But in addition to age, there are a
number of conditions that can interfere with a woman’s fertility, including endometriosis,
polycystic ovarian syndrome, pituitary tumors and pelvic inflammatory disease etc.
Infertility Treatments for Women: A Review of the Bio-medical Evidence, The Women’s Health Council,
Ireland, Full Report, 2009, p.17.
12
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a) Endometriosis: It is a chronic condition characterized by the growth of endometrial tissue in areas
other than uterine cavity, commonly in the pelvic cavity, including the ovaries. It occurs
when tissue from the membrane lining the uterus, called the endometrium, grows outside
the uterus. Approximately, 10 % of the infertile couples are infected with endometriosis
and between 20 to 30 percent of infertile women are estimated to have this condition. This
tissue acts just like the endometrium in accumulating blood in the monthly menses period,
but it has no place to shed the blood at the end of the cycle. It can cause irregular bleeding
between menstrual cycles. The accumulation of tissue and blood can lead to inflammation,
scarring and other problems. Symptoms include pain and cramping before and during
periods, pain during intercourse, fatigue, diarrhea, constipation, nausea and infertility.
Endometriosis can be treated with drugs or surgery to remove the cysts, which includes
hysteroscopy, which is a procedure that allows the doctor to look inside the uterus in order
to diagnose and treat the causes of abnormal bleeding. Hysteroscopy is done using a
hysteroscope, a thin lighted tube that is inserted into the vagina to examine the cervix and
inside of the uterus.13
b) Polycystic Ovarian Syndrome: In polycystic ovarian syndrome (PCOS), there is a long term inability to release
eggs to the uterus, where they can be fertilized — a process called ovulation. Elevated
insulin levels stimulate excess production of the hormone androgen, which cause some of
the unfertilized eggs to disintegrate, leading to inconsistent or no ovulation. Most women
with PCOS have multiple benign cysts in their ovaries. Symptoms include irregular
ovulation and menstrual periods, obesity, insulin resistance, acne and excessive hair
growth. PCOS, the number one cause of infertility, occurs in about 26 percent amongst the
white women aged 18-25 in United Kingdom. PCOS is diagnosed by: (a) irregular or
absent ovulation; (b) clinical and/or bio-chemical signs of excess androgen and (c)
polycystic ovaries. Its treatments include weight loss, medications including hormones,
medications to treat the insulin resistance associated with PCOS, or surgery to remove a
Infertility Treatments for Women: A Review of the Bio-medical Evidence, The Women’s Health Council,
Ireland, Full Report, 2009, pp-15-16.
13
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portion of the ovary or to drill holes in the ovary with a laser to reduce androgen
production.14
c) Pituitary Tumors: Pituitary tumors can lead to destruction of some of the hormone-secreting cells in
the pituitary gland, causing cessation of menstrual periods in women and reduced sperm
production in men. Because of their location, these tumors also can cause visual field
defects. Pituitary tumors are diagnosed by measuring hormone levels in the blood and
urine, from MRI or CT scans of the brain and by visual field tests. Treatments include
surgical removal of the tumor, radiation therapy, hormone replacement therapy etc.
d) Pelvic Inflammatory Disease: Pelvic inflammatory disease (PID) in the female reproductive organs often occurs
after a sexually transmitted disease such as gonorrhea or a chlamydia infection, or after
miscarriage, abortion or childbirth. It can cause inflammation and permanent scarring of
the fallopian tubes, abdominal pain and tenderness, fever and an unpleasant-smelling in
vaginal discharge. Repeated attacks may occur with or without reinfection. About 20
percent of infertility is attributed to scarring from PID. PID usually is diagnosed during a
pelvic examination, although samples of discharge may be analyzed. Antibiotics are the
usual treatment. Surgery or in-vitro fertilization (IVF) is used to treat infertility resulting
from PID.15
e) Additional Factors: These include: (1) Behavioural Factors: - It is well known that certain personal habits and
lifestyle factors impact health. Many of these may limit a couple’s ability to
conceive. These include: cigarette smoking, which lowers the sperm counts in men and
increases the risk of miscarriage, premature birth and low birth weight babies for women.
Smoking by either partner reduces the chance of conceiving with each cycle, either
naturally or by IVF, by one-third. The next factor is alcohol. Alcohol intake greatly
Infertility Treatments for Women: A Review of the Bio-medical Evidence, The Women’s Health Council,
Ireland, Full Report, 2009, pp-14-15.
15
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3831061/; last visited on 05/07/2013, time: 10:00 am
(IST), place: Meerut, (UP), India.
14
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increases the risk of birth defects for women and, if present in high levels in the mother’s
blood it may cause Fetal Alcohol Syndrome. Alcohol also affects sperm counts in
men. The third factor includes drugs, such as marijuana and anabolic steroids, which may
impact sperm counts in men. Cocaine use in pregnant women may cause severe
retardations and kidney problems in the baby and is perhaps the worst possible drug to
abuse during pregnancy. It is suggested that recreational drug use should be avoided by
the woman, both when trying to conceive and when pregnant.
(2) Environmental and Occupational Factors: - The ability to conceive may be affected by
exposure to various toxins or chemicals in the workplace or the surrounding environment.
Substances that can cause mutations, birth defects, abortions, infertility or sterility are
called reproductive toxins. Disorders of infertility, reproduction, spontaneous abortion,
and teratogenesis are among the top ten work-related diseases and injuries in the US
today. Despite the fact that considerable controversy exists regarding the impact of toxins
on fertility, the following four chemicals affect the most while conceiving, i.e., lead;
repeated exposure to radiation, ranging from simple x-rays to chemotherapy; ethylene
oxide, a chemical used both in the sterilization of surgical instruments and in the
manufacturing of certain pesticides. This may cause birth defects in early pregnancy and
also has the potential to provoke early miscarriage. The fourth chemical is
dibromochloropropane (DBCP), which is found in pesticides, has the ability to cause
ovarian problems leading to a variety of health conditions like early menopause that may
directly impact fertility.16
16
https://web.stanford.edu/class/siw198q/websites/reprotech/New%20Ways%20of%20Making%20Babies/C
ausefem.htm; last visited on 06/07/2013, time: 11:00 am (IST), place: Meerut, (UP), India.
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Fertility Treatment Options17:
S.No.
1.
Fertility Treatment Options
Medicines
a) Anti-Oestrogens
b) Gonadotrophin
c) Pulsatile Gonadotrophin Releasing Hormone
d) Dopamine Agonists
e) Aromatase Inhibitors
2.
Surgical Treatments
a) Ovarian Drilling
b) Fallopian Tube Surgery
c) Uterine Surgery
d) Surgery for Endometriosis
3.
Assisted Reproductive
a) IUI (Intra-Uterine Insemination)
Technology (ART)
b) IVF (In-Vitro Fertilization)
c) GIFT (Gamete Intrafallopian Transfer)
d) ZIFT (Zygote Intrafallopian Transfer)
e) ICSI (Intra-cytoplasmic Sperm Injection)
f) Donor Insemination (Eggs or Sperm Donation)
g) PGD (Pre-implantation Genetic Diagnosis)
h) IVM (In-Vitro Maturation)
4.
Other Treatments
NaPro Technology (Natural Procreative
Technology)
Infertility Treatments for Women: A Review of the Bio-medical Evidence, The Women’s Health Council,
Ireland, Full Report, 2009, p.27.
17
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2.4
Understanding the Meaning of Assisted Reproductive
Technology (ART): -
Traditionally, conception occurs through intercourse between a male and female,
with the male supplying the sperm and the female providing the eggs. But with the
changing times, this special feature of reproduction got destructed, extinguished and
infertility was considered as a curse for the individual and for the entire family. When
partners discover fertility problems, they opt to a variety of options to bring a child into
their lives. They may try to adopt one, or may choose from a variety of medical
technologies, one of which is Assisted Reproductive Technology or ART, which is a
fertility treatment that enhances a woman’s ability to get pregnant. ART has enabled
millions of people (including infertile men and women, single men and women, lesbian,
gay, transgender couples etc.) in the world to have biological children who otherwise
would not have been able to do so. In India, there has been an unprecedented and
unregulated growth of ART clinics providing IVF technology. Within the framework of
medical tourism, ARTs are the latest addition to the long list of medical services being
offered. Low costs, easy access to the otherwise highly regulated technologies and easy
availability of surrogate mothers and gamete donors have made India a favoured
destination for these procedures.
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Assisted Reproductive Technology (ART) Procedure
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Diagram of Egg Retrieval Procedure
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Major Events in the History of Medically Assisted
Conception18:
Major Events in the History of
Medically Assisted Conception
Year
Technique
1878
In vitro fertilization of rabbit and guinea-pig oocytes
1890
First transfer of mammalian embryo from one female to another
1909
Human pregnancy with donor semen
1944
In vitro fertilization of human oocyte
1970
Laparoscopic ovum pick-up
1973
Transient rise in human chorionic gonadotrophin
1978
Successful live birth of human baby by in vitro fertilization and
embryo transfer (IVF-ET) in a natural cycle
1980
IVF-ET used for treating unexplained infertility
1981
IVF-ET pregnancy in a clomifene-citrate-stimulated cycle
1981
Laparoscopic collection of human oocytes for IVF-ET under
ultrasound guidance
1982
Birth following oocyte and sperm transfer into the uterus
1983
Established pregnancy after transfer of donated embryos fertilized in
vitro
1983
Successful cryopreservation of human embryos
1983
Trans-vaginal aspiration of oocytes by culdocentesis
1983
IVF-ET used for the treatment of endometriosis and for infertility of
unknown cause
18
Recent Advances in Medically Assisted Conception, Report of a WHO Scientific Group, Geneva 1992,
World Health Organization, Switzerland, p.8.
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1984
Intra-uterine insemination with washed semen (IUI)
1984
IVF-ET used for the treatment of immunological infertility
1984
Pregnancy following oocyte donation and IVF-ET in a woman with
premature ovarian failure
1984
IVF-ET used for the treatment of male infertility
1984
Pregnancy after gamete intra-fallopian transfer (GIFT) by laparotomy
1984
GIFT by laparoscopy
1985
IVF-ET used for the treatment of hostile cervical factor
1985
Vaginal oocyte collection under ultrasound guidance
1986
Pregnancy after human oocyte cryopreservation
1986
Direct intra-peritoneal insemination (DIPI)
1986
Pregnancy after trans-laparoscopic zygote intra-fallopian transfer
(ZIFT)
1987
Pregnancy following pronuclear-stage tubal transfer (PROST)
1987
Ultrasound guided peritoneal oocyte and sperm transfer
1987
Oocyte donation and GIFT as treatment for premature ovarian failure
1987
Catheterization of the fallopian tubes from the vagina
1988
Pregnancy after transfer of multiple sperm under the zona pellucida
1989
Fallopian replacement of eggs with delayed intra-uterine insemination
(FREDI)
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Step-by-Step Medical Procedure of Gestational Surrogacy19:
Gestational surrogacy is a complicated procedure for the women involved. Both
the surrogate and the egg donor (whether the intended mother or a selected donor)
prepares for about a month in advance for the embryo retrieval and transfer. Beginning
roughly weeks prior to the embryo transfer, the surrogate begins GnRH Agoinst
(Lupron®) administration. This is a daily injection for roughly two and a half weeks to
suppress ovarian function in order to synchronize the two women’s menstrual cycles.
After about a week and a half the surrogate begins to take estrogen and progesterone
supplements, administered either vaginally, orally or through injection, to help support the
early stages of pregnancy. This continues until the pregnancy test, and possibly several
more weeks after pregnancy is established.
For the egg donor (whether of the intended mother or not), the process may begin
with oral contraceptives for cycles prior to the Assisted Reproductive Technology (ART)
cycle. This helps regulate the menstrual cycle, ensuring that GnRH Agonist is
administered at the right time. Oral contraceptives may also help prevent ovarian cysts,
which can develop during GnRH analogue therapy. About a week after the surrogate
begins GnRH Agonist administration, the egg donor begins the same GnRH Agonist
administration. For the egg donor, this is done primarily to prevent a premature LH
(luteinizing hormone) surge, which could cause the eggs to be released before they are
ready for retrieval. An ultrasound is performed around the time of the expected period to
examine the ovaries and make sure that there is no cyst.
After menstrual bleeding starts, ovarian stimulation also begins to support follicle
development. The two hormones necessary for ovulation are Follicle Stimulating
Hormone (FSH) and Luteinizing Hormone (LH). These hormones are known as
‘gonadotrophins’. There are a number of medications available to treat infertility that
contains gonadotrophins. FSH is a small protein that would be destroyed by digestive
enzymes in the stomach if taken orally; therefore, gonadotrophins are given by injection
under the skin or into the muscle. Follicle or egg development is monitored using vaginal
19
This information is based upon the interview and discussion with Dr. Anirudh Singh and Dr. Sashee Singh
of Dr. Singh Test Tube Baby Centre, Meerut (UP).
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ultrasounds and blood tests, performed frequently to see if medication prescriptions need
to be altered. After 7 to 12 days of ovarian stimulation, the egg donor is injected with
human chorionic gonadotropin (hCG), a natural hormone that completes the maturation
process of the oocytes. Timing is critical, as oocyte retrieval must be performed 34-36
hours after hCG administration. To retrieve the eggs, the egg donor is administered
anesthesia as a trans-vaginal ultrasound probe guides a long needle into each follicle. The
follicular fluid, oocytes, and granulosa (egg-supporting cells) cells are aspirated from the
follicles. The uterus, cervix and fallopian tubes are never penetrated in the procedure. A
physician is then required to collect the oocytes and follicular fluid in a test tube and an
embryologist locates the oocytes using a microscope. The egg donor is observed after the
procedure as medication wears off. She will commonly feel lower abdominal discomfort
and have some vaginal spotting for several days, but generally feels fully recovered in one
to two days. Eight to 15 oocytes are typically retrieved per patient.
In the embryology lab, eggs are then placed on a culture medium to support
development of the embryo and mimic the environment of the fallopian tube or uterus.
The dishes with eggs are placed in incubators to control the temperature and atmospheric
gasses. Sperms are removed from semen collected either that morning from the intended
genetic father or from frozen sperm, possibly from a sperm bank. After a few hours in the
incubator, the sperms are placed in the culture medium with the eggs and returned to the
incubator to develop. Individual sperm can also be injected into each egg using the intracytoplasmic sperm injection (ICSI) technique.
The next day, eggs are examined to make sure fertilization has begun. If so far
successful, eggs will now be zygotes, a single cell with two nuclei. After five days,
embryos should have developed into the blastocyst stage, where an embryo has 80 or more
cells. Selection of the best embryos for transfer is based mostly on normal visual
appearance, though this does not guarantee a genetically normal embryo.
The best appearing embryos are implanted into the surrogate’s uterus using a thin
embryo transfer catheter that passes through the surrogate’s cervix to the top of the uterus.
The number of embryos implanted depends on the surrogate and egg donor’s age, and on
the appearance of the embryos. The more implanted the more likely for a successful
attachment, but also higher probability of multiple births. Excess embryos not transferred
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can be frozen. The surrogate begins to take progesterone supplements on the day or day
after oocyte retrieval to help prepare the uterine lining for implantation. A pregnancy test
is done 9 to 12 days after embryo transfer, and again a few days later if test is positive. If
the second test is still positive, she continues with hormonal supplements and has frequent
follow-ups with the fertility clinic. After 8 to 10 weeks of pregnancy, the surrogate can
begin seeing a regular obstetrician.
This technology of artificial insemination involves a woman achieving pregnancy
by non-involvement of sexual activity with a male partner, which includes fertilization
involving manipulation of gametes/embryos outside the human body and transfer of
gametes/embryos into the uterus/womb of the female. Here, the surgical removal of eggs
from a woman’s ovaries, combining them with sperm in the laboratory, and returning
them to the woman’s body or donating them to another woman for child-bearing, called
the surrogate mother takes place. It is a popular technique for artificial procreation used by
infertile childless couples. Its relative simplicity has made it an extremely popular method.
One would be wondering as to why such kind of artificial means is adopted by
women to achieve pregnancy. The reasons are several and could involve her immune
system rejecting her partner’s sperm as invading molecules; she may be having issues with
the cervix such as cervical scarring, cervical blockage from endometriosis, or thick
cervical mucus; if the male partner is impotent, then donor sperm may be used.20
A woman in want of such artificial insemination to achieve pregnancy can obtain
sperm from her male partner or from a sperm donor. The sperm is usually obtained
through masturbation or through the use of electrical stimulator, although a special
condom, known as ‘collection condom’ may be used to collect the semen during
intercourse. The sperm provided by a sperm bank is produced by a donor attending the
sperm bank’s premises in order to ascertain the donor’s identity on every occasion. The
donor masturbates within the premises of the sperm bank and provides an ejaculation in a
small container. The contents of the container are usually extended with chemicals in
order to provide it for insemination. The sperm is then frozen and isolated for a period of
usually six months and the donor is re-tested prior to the sperm being used for artificial
20
http://www.evmshealthservices.org/index.cfm/fuseaction/site.content/type/86923.cfm; last visited on
20/07/2013, time: 11:00 am (IST), place: Meerut, (UP), India.
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insemination. The artificial introduction of sperm into the uterus of a woman usually takes
place with the help of a syringe.
There are a number of ART techniques adopted such as Intra-Cytoplasmic Sperm
Injection (ICSI), Gamete Intra-Fallopian Transfer (GIFT), Zygote Intra-Fallopian Transfer
(ZIFT), embryo transfer, In vitro fertilization (IVF) (which is commonly known as “testtube baby technology”) and most importantly and widely used is ‘Surrogacy’, which is not
a technique, but an arrangement, is also included under the umbrella term of ART. The
ART techniques are discussed as under:21
a) Intra-Cytoplasmic Sperm Injection (ICSI): It
is
an assisted
reproductive
technology
(ART) used
to
treat
sperm-
related infertility problems in both males and females. ICSI is used to enhance the
fertilization phase of in-vitro fertilization (IVF) by injecting a single sperm directly into a
mature egg. The fertilized egg is then placed in a woman's uterus or fallopian tube. In
ICSI, all the steps are similar to the procedure of IVF, except the step of fertilization.
Normally in IVF one egg is mixed with 100,000 sperms and one of the sperms fertilizes
the egg on its own. In contrast, in ICSI each egg is held and injected with a single live
sperm. This micro-fertilization is done with the help of a machine called the
Micromanipulator. Similar to IVF, ICSI differs in the fertilization process. Unlike in IVF,
where one egg is mixed with 1 lakh sperms, with fertilization taking place on its own,
ICSI is a technique where each egg is held and injected with a single live sperm. This
micro-fertilization is also done with the help of a machine called the Micromanipulator.
For fertilization, ICSI involves the taking up of a single sperm in a fine glass
needle which is injected directly into an egg. This egg is then incubated and examined.
The embryo is then transferred back into the womb of the woman two or three days after
fertilization. In this process, not all the eggs collected will be of a high enough quality or
are mature enough to be suitable for injection. In conventional IVF, the eggs and sperm
are mixed together in a dish and the sperm fertilizes the eggs naturally.
21
Spar, Debora L., The Baby Business: How Money, Science, And Politics Drive The Commerce Of
Conception, 2006 ed.
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Following are the circumstances in which ICSI may be appropriate to be used: a) when the sperm count is severely low;
b) poor quality of sperms;
c) when the sperms are abnormal;
d) when the sperm has been recovered directly from the epididymis or the testicles, from
the urine or by electro-ejaculation;
e) where there are high levels of anti-bodies in the semen;
f) when there have been previous fertilization failures.
Men who have very few sperm count or no sperm count in their semen, or who
have high numbers of abnormal sperms that are unable to fertilize an egg and would
previously have had little or no chance of fathering their own genetic offsprings are been
offered the facility of ICSI which gives them a real hope of having their own genetically
related child.22
b) Gamete Intra-Fallopian Transfer (GIFT): GIFT is an assisted reproductive procedure introduced for the treatment of nontubal infertility. It has been a popular procedure because it results in better pregnancy rates
as compared to regular IVF procedure. It involves removing a woman’s eggs, mixing them
with sperm and immediately placing them into a fallopian tube, along with the man’s
sperm. This technique introduced by endocrinologist Dr. Ricardo H. Asch in 198423,
allows fertilization to take place inside the woman’s uterus and solves the problem of
unexplained infertility. GIFT was introduced in an era when oocyte recovery was done
laparoscopically and therefore, delivering gametes into the fallopian tube did not involve
any extra-surgical procedure. Indications for GIFT include endometriosis and male
infertility. Ovulation induction with clomiphene citrate combined with hCG and intrauterine insemination (IUI) is used to treat infertility in non-tubal situations.
GIFT is a modified version of IVF technology. Like IVF, this procedure involves
retrieving an egg from the woman, fertilizing it, and implanting the resulting embryo in
22
http://www.advancedfertility.com/icsi.htm; last visited on 22/07/2013, time: 01:00 pm (IST), place:
Meerut, (UP), India.
23
http://embryo.asu.edu/pages/ricardo-hector-asch-1947; last visited on 22/07/2013, time: 04:00 pm (IST),
place: Meerut, (UP), India.
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the uterus, here the process goes more quickly. While in traditional IVF, the embryos are
observed and raised in a laboratory for 3 to 5 days, in GIFT, the sperm and eggs are just
mixed together before being inserted and, with luck, one of the eggs will become fertilized
inside the fallopian tubes. It takes, on average, four to six weeks to complete a cycle of
GIFT. First, the woman must take a fertility drug to stimulate egg production in
the ovaries. The doctor will monitor the growth of the ovarian follicles, and once they are
mature, the woman will be injected with Human Chorionic Gonadotropin (hCG). The eggs
will be harvested approximately 36 hours later, mixed with the man’s sperm, and placed
back into the woman’s fallopian tubes using a laparoscope. Placement of the gametes in
the fallopian tubes takes advantage of the protective tubal environment. The tubal
environment enhances oocyte maturation and sperm function allowing for better embryo
development. The other major advantage of GIFT is better synchronization between the
developing embryo and the uterine endometrium as it enters the uterine cavity only by day
5 or 6 as compared to a day 2 or 3 transfer in IVF cycle.
A woman must have at least one normal fallopian tube in order for GIFT to be
suitable. It is used in instances where the fertility problem relates to sperm dysfunction,
and where the couple has idiopathic infertility of which the cause is unknown. Some
patients may prefer the procedure to IVF for ethical reasons, since the fertilization takes
place inside the body. This is a semi invasive procedure and requires laparoscopy. GIFT is
not technically in vitro fertilization because with GIFT fertilization takes place inside the
body, not on a petri dish.24
GIFT is an assisted reproductive procedure that involves the following:
1)
A woman’s ovaries are stimulated with medications to increase the probability of
producing multiple eggs.
2)
Eggs are collected through an aspiration procedure. The semen is collected in nontoxic, wide mouthed sterile plastic container. It is advisable to freeze at least 2
semen samples prior to the procedure to ensure availability of a sample if problems
with collection occur.
24
http://www.infertile.com/infertility-treatments/gift.htm; last visited on 25/07/2013, time: 08:00 am (IST),
place: Meerut, (UP), India.
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The semen is allowed to liquefy before it is examined microscopically to quantify
the concentration and percentage of motile sperms. Liquefied semen is washed
with human tubal fluid medium supplemented with 8 percent maternal serum. The
best quality eggs are then immediately mixed with mobile sperm and placed in a
special catheter.
4)
The mixture of eggs and sperm are transferred to the woman through a
laparoscopic procedure by placing a catheter in the fallopian tube and injecting the
egg/sperm mixture. Standard double puncture laparoscopy technique is hereby
used.
5)
The last step is to watch for early pregnancy symptoms. The fertility specialist will
probably use a blood test to determine if pregnancy has occurred.
It has been suggested that pregnancy rates would be better if the tube on the side of
the dominant ovary, from which maximum number of oocytes were retrieved, was chosen
for transfer. GIFT and ZIFT can be used to treat many types of infertility, except in cases
where there is damage to or abnormalities of the fallopian tubes. These techniques can
also be used in cases of mild male infertility, as long as the sperm is capable of fertilizing
an egg. If the woman is not capable of producing eggs that can be used in GIFT, but her
partner's sperm is capable of fertilization, they might consider getting eggs from a donor.
One reason for using an egg donor is age. Women over 35 are less likely to have viable
eggs and more likely to have children with birth defects than younger women. A woman
with premature ovarian failure, a condition in which menopause has begun early, might
also consider a donor if she wants to carry a child.
As with most fertility procedures, success depends on the couple's age and the
woman’s egg quality. It is estimated that approximately 25-30% of GIFT cycles result in
pregnancy, with a third of those being multiple pregnancies. The First GIFT baby in the
UK was Todd Holden born on October 1986. The First GIFT baby in the US was
Kaitlynne Kelley born on 28th April, 1987.The first application of this method in Latin
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America was held in Argentina on 13th May, 1986 and was led by Dr. Ricardo H. Asch
and the treatment was successfully completed with the birth of Manuel Campo Lopez.25
c) Zygote Intra-Fallopian Transfer (ZIFT): ZIFT is also a modified version of IVF technology. It is an assisted reproductive
procedure similar to in-vitro fertilization and embryo transfer, the difference being that the
fertilized embryo is transferred into the fallopian tube instead of the uterus. It is
an infertility treatment used when a blockage in the fallopian tubes prevents the normal
binding of sperm to the egg. Egg cells are removed from a woman’s ovaries and fertilized
in-vitro in a petri dish in a laboratory.
The fertilized eggs, at this stage called zygotes, which are placed in the fallopian
tubes within 24 hours by the use of laparoscopy and because of this the procedure is also
referred to as tubal embryo transfer (TET). The woman must have healthy tubes for ZIFT
to work. ZIFT is commonly chosen by couples who have failed to conceive after at least
one year of trying and who have failed five to six cycles of ovarian stimulation with
intrauterine insemination (IUI). ZIFT has been used in infertility situations where at least
one fallopian tube is normal and other IVF treatments have failed.26
ZIFT is an assisted reproductive procedure that involves the following steps:
1)
A woman’s ovaries are stimulated with medications, especially hormone injections
to stimulate the development of the ovarian follicles.
2)
Eggs are then retrieved by trans-vaginal needle aspiration through an ultrasound
while the patient is under light sedation.
3)
Those eggs are fertilized in a laboratory in a procedure identical to IVF. During the
ZIFT procedure, fertilized eggs are transferred within 24 hours, as against 3-5 days
used in a regular IVF cycle.
25
http://www.sooperarticles.com/health-fitness-articles/pregnancy-articles/gift-gamete-intrafallopiantransfer-its-success-advantages-disadvantages-156706.html; last visited on 25/07/2013, time: 10:00 am
(IST), place: Meerut, (UP), India.
26
http://www.womens-health.co.uk/infertility/zift.html; last visited on 27/07/2013, time: 11:00 am (IST),
place: Meerut, (UP), India.
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The fertilized eggs are then transferred through a laparoscopic procedure where a
catheter is placed deep in the fallopian tube through a very small incision in the
abdomen of the intended woman while she is under general anesthesia.
5)
The final step is to wait and watch for early pregnancy symptoms. The fertility
specialist will probably use a blood test to determine if pregnancy has occurred.27
d) In-Vitro Fertilization (IVF): -
27
http://www.midwestivf.com/treatments/zift.php; last visited on 27/07/2013, time: 01:00 pm (IST), place:
Meerut, (UP), India.
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In-vitro fertilization (IVF) is a process by which egg is fertilized by sperm outside
the body. IVF is a major treatment for infertility when other methods of assisted
reproductive technology have failed. The process involves monitoring and stimulating a
woman’s ovulatory process through the use of a drug that enables her to super-ovulate or
to produce more eggs in one cycle than she normally does, removing ovum or ova (egg or
eggs) by suction through a needle inserted into her ovaries and fertilizing them in a petri
dish in a fluid medium in a laboratory with her partner’s or donor’s sperm. The fertilized
egg (zygote) is cultured for 2-6 days in a growth medium and is then transferred by a thin
catheter through the intended woman’s vagina into her uterus, where it is hoped that it will
grow into healthy surrogate baby/babies.28
The first successful birth of a “test tube baby”, Louise Brown, occurred in 1978,
who was born as a result of natural IVF cycle where no stimulation was made. Robert G.
Edwards, the physiologist developed this therapy and was awarded the Nobel Prize in
Physiology or Medicine in 2010.29
The term in-vitro, is derived from the Latin meaning in glass, which is used
because early biological experiments involving cultivation of tissues outside the living
organism from which they came, was carried out in glass containers such as beakers, test
tubes, or petri dishes. Today, the term in-vitro is used to refer to any biological procedure
that is performed outside the organism, it would normally be occurring in, to distinguish it
from an in vivo procedure, where the tissue remains inside the living organism within
which it is normally found. A colloquial term for babies conceived as the result of IVF,
i.e., “test tube babies”, refers to the tube-shaped containers of glass or plastic resin,
called test tubes that are commonly used in chemistry labs and biology labs in the
shallower containers called petri dishes.
Unlike the simpler process of artificial insemination, in which sperm is placed in
the uterus and conception precedes otherwise normally, IVF involves combining eggs and
sperm outside the body in a laboratory, i.e., in a test tube and placing of embryo(s) in the
28
Sher Geoffrey, Virginia Marriage Davis and Stoess Jean, In Vitro Fertilization: The A.R.T. of Making
Babies, 3rd ed. 2005, pp. xvii-xviii.
29
http://www.nobelprize.org/nobel_prizes/medicine/laureates/2010/popular-medicineprize2010.pdf; last
visited on 28/07/2013, time: 02:30 pm (IST), place: Meerut, (UP), India.
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uterus of the intended woman. IVF is a complex and expensive procedure. Only about 5%
of couples with infertility opt for it. However, since its introduction in the U.S. in 1981,
IVF and other similar techniques have resulted in more than 200,000 babies.30
IVF may be used to overcome female infertility in the woman due to problems of
the fallopian tube, making in vitro fertilization difficult. It may also assist in male
infertility, where there is a defect in sperm quality, and in such cases intra-cytoplasmic
sperm injection (ICSI) may be used, where a sperm cell is injected directly into the egg
cell. This is used when sperm have difficulty penetrating the egg, and in these cases the
partner's or a donor's sperm may be used. ICSI is also used when sperm numbers are very
low. When indicated, the use of ICSI has been found to increase the success rates of IVF.
According to National Institute for Health and Clinical Excellence (NICE) guidelines, IVF
is to be used where there is an unexplained infertility for women who have not conceived
after 2 years of regular unprotected sexual intercourse. IVF is never considered the first
step in the treatment of infertility. Instead, it is reserved for cases in which other methods
such as fertility drugs, surgery, and artificial insemination do not work.31
When it comes to infertility, IVF may be an option if either of the couple has been
diagnosed with:
a) Endometriosis
b) Low sperm counts
c) Problems with the uterus or fallopian tubes
d) Problems with ovulation
e) Antibody problems that harm sperm or eggs
f) The inability of sperm to penetrate or survive in the cervical mucus
g) An unexplained fertility problem
30
http://www.webmd.com/infertility-and-reproduction/guide/in-vitro-fertilization; last visited on
28/07/2013, time: 03:59 pm (IST), place: Meerut, (UP), India.
31
http://www.dailymail.co.uk/health/article-1028430/Infertile-couples-denied-IVF-NHS-postcode-lotterymeans-just-chance.html; last visited on 28/07/2013, time: 05:00 pm (IST), place: Meerut, (UP), India.
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There are five basic steps in the IVF and embryo transfer process which includes the
following32:
1) Stimulation of Egg Maturation in the Ovaries: This process is also known as
‘ovarian stimulation or ovulation induction’, where a woman takes medications to
stimulate the ovaries to make many mature eggs at one time. These medications
are given by injection for a period of 8-14 days. Multiple eggs are desired because
some eggs will not develop or fertilize after retrieval. Egg development is
monitored using trans-vaginal ultrasound to examine the ovaries, and urine or
blood test samples are taken to check hormone levels. When the eggs are mature,
as determined by the size of the ovarian follicles and the level of estrogen, an HCG
injection initiates the ovulation process. The eggs are taken out 34 to 36 hours after
the injection by the health care service provider.
2) Egg Retrieval: This process is used to remove the eggs from the ovaries so that
they can be fertilized. Eggs are retrieved through a minor surgical procedure that
uses ultrasound imaging to guide a hollow needle through the pelvic cavity.
Sedation and local anesthesia are provided to reduce and remove potential
discomfort. The eggs are removed from the ovaries using a hollow needle, a
procedure called follicular aspiration. The steps of egg retrieval involve:
a) An ultrasound probe is inserted into the vagina to visualize the ovaries
and the follicles, which contain the eggs;
b) A needle is inserted through the wall of the vagina to the ovaries; and
c) Suction is used to pull the eggs from the ovaries into the needle.
3) Secure the sperm: The sperm usually is obtained by ejaculation is prepared for
combining with the eggs.
4) Fertilization: In a process called insemination, the sperm and eggs are placed in
incubators located in the laboratory. The incubators enable fertilization to occur. In
32
http://www.nlm.nih.gov/medlineplus/ency/article/007279.htm; last visited on 29/07/2013, time: 09:00 am
(IST), place: Meerut, (UP), India.
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some cases where there is a lower probability of fertilization, intra-cytoplasmic
sperm injection (ICSI) may be used, where a single sperm is injected directly into
an egg using a needle in an attempt to achieve fertilization. The eggs are monitored
to confirm that fertilization and cell division are taking place. Once this occurs, the
fertilized eggs are considered embryos. About 60 % of IVF in the United States is
performed with ICSI. The number of pregnancies from IVF using natural
fertilization is about the same as the number resulting from ICSI. The embryos that
develop from IVF procedure are then placed into the uterus from 1 to 6 days after
retrieval.
5) Embryo Transfer into the Uterus: The embryos are usually transferred into the
woman’s uterus from one to six days after retrieval, but in most cases the transfer
occurs between two to three days following egg retrieval. At this stage, the
fertilized egg has developed into a two-to-four cell embryo. The transfer process
involves a speculum33 which is inserted into the vagina to expose the cervix. A
predetermined number of embryos are suspended in fluid and gently placed
through a tube into the womb. Here the embryo should be implanted into the lining
of the uterus 6 to 10 days after retrieval. This process is often guided by
ultrasound. The procedure is usually painless, but some women experience mild
cramping.34
For IVF to be successful, it typically requires healthy ova, sperm that can fertilize,
and a uterus that can maintain a pregnancy. Due to the costs of the procedure, IVF is
generally attempted only after less expensive options have failed. IVF is also indicated in
cases where any of its expansions is of interest, that is, a procedure that is usually not
necessary for the IVF procedure itself, but would be virtually impossible or technically
difficult to perform without concomitantly performing methods of IVF. Such expansions
‘Speculum’ means a medical tool for investigating/dilating the opening of body cavity for medical
examination of the interior parts.
34
http://www.nlm.nih.gov/medlineplus/ency/article/007279.htm; last visited on 29/07/2013, time: 10:00 am
(IST), place: Meerut, (UP), India.
33
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include pre-implantation genetic diagnosis (PGD) to rule out presence of genetic
disorders, as well as egg donation or surrogacy where the woman providing the egg is not
the same who will carry the pregnancy to term.
The goal of such procedures is to successfully fertilize a human egg, resulting in an
embryo. That embryo is then implanted into a woman’s uterus for gestation. Thus, the
equation which is understood by the researcher involves: -
Egg + Sperm = Zygote
Embryo
Child
The development during this time actually encompasses multiple steps with
increasing cell division. Initially the sperm fertilizes one or more eggs, resulting in a
zygote. The zygote develops in a blastocyst within a few days. The blastocyst becomes an
embryo once it has developed cells to support both the fetus and the placenta.
The success rate of IVF procedure depends on a number of factors including
patient characteristics and treatment approaches. But it is also important to understand that
pregnancy rates are not the same as live birth rates. In the United States, the live birth rate
for each IVF cycle is approximately:

30 to 35% for women under age 35

25% for women ages 35 to 37

15 to 20% for women ages 38 to 40

6 to 10% for women ages over 4035
35
http://www.uptodate.com/contents/in-vitro-fertilization-ivf-beyond-the-basics; last visited on 10/08/2013,
time: 02:00 pm (IST), place: Meerut, (UP), India.
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Step-by-Step Medical Procedure of Gestational Surrogacy
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Third Party Assisted ART:
ART has helped many infertile couples to fulfill their dreams of having a child of
their own. Innovative techniques have been introduced to achieve pregnancies in various
types of infertility and also to improve existing pregnancy rates. However, pregnancy rates
are still unacceptably low and the cost of technology is very high. Alternative techniques
to ART have been introduced from time to time with the intent of achieving pregnancy
while avoiding the high cost of ART. In countries like India, the social pressures on a
couple to reproduce are very high and the per capita income is low and no funding is
available for treatment, hence, the use of third party assisted ART becomes important to
have a child of their own genes. This may involve:
a) Sperm Donation: Couples may use donated sperm when a man does not produce
sperm or produce very low count of sperms, or if he has a genetic disease. Donated sperms
can be used with intra-uterine insemination (IUI) or with IVF.
b) Egg/Oocyte Donation: This can be used when a woman does not produce
healthy eggs that can be fertilized. An egg donor undergoes ovary stimulation and egg
retrieval steps of IVF. The donated egg is then fertilized with a sperm from the woman’s
partner and the resulting embryo is placed into the woman’s uterus. This process of egg
donation may be helpful for women who have primary ovary insufficiency; have had
chemotherapy or radiation therapy; have had surgical removal of the ovaries; were born
without ovaries; are carriers of known genetic diseases; are infertile because of poor egg
quality.
Oocyte donation, unlike its male counterpart of sperm donation, has been a routine
clinical treatment, with widespread introduction of IVF. Prior to the advent of IVF, there
was neither a source of oocytes for donation to the laboratory nor clinical techniques
available to ensure successful fertilization and transfer of the resulting embryos. This
technique was first described by Craft in 1982 and later modified by Bucktt and Tan.36
Oocyte donation has now become a widely used treatment for infertility which is due to
36
Buckett WM and Tan SL, Alternative Assisted Conception Techniques, in Brinsden, PR (ed.), A Textbook
of In Vitro Fertilization and Assisted Reproduction, 2nd ed. 1999, pp.243-255.
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premature menopause. Oocytes are incubated for 6 hours prior to insemination. Then four
to six oocytes and 20,000 sperms are transferred into the uterine cavity in 20 mL culture
medium with a normal embryo transfer catheter. Further, a simplification of the procedure
entailed transfer of gametes into the uterine cavity without pre-incubation.37
Oocyte with sperm is transferred directly into the uterine cavity. The patients who
require donor oocyte fall under two main groups:
i.
Women with non-functioning ovaries:
1. Premature ovarian failure
2. Ovarian agenesis
3. Bilateral oophorectomy
4. Menopause
ii.
Women with functioning ovaries:
1. Risk of inheritable genetic disease in children
2. Failed IVF due to poor quality oocytes
3. Inaccessible ovaries38
There is a growing demand for oocyte donation from women in their early 40s
who fail to conceive after several cycles of IVF with their own oocyte, resulting into an
equal or possibly higher pregnancy rate than through routine IVF procedure. Medically it
is proved that women after 40 have better pregnancy rates with donor oocytes. Transfer of
fresh embryo results in higher pregnancy rate than that of frozen-thawed embryos. There
are also a small but growing number of post-menopausal women desiring pregnancy
through oocyte donation. The main sources of oocyte donors include infertile woman’s
close friend or relative and infertile patients undergoing IVF treatment, who donate their
excess oocytes. The age of the oocyte donor is an important factor in achieving good
37
Ransom MX, Garcia AJ et. al, Direct Gamete Uterine Transfer in Patients with Tubal Absence or
Occlusion, Journal of Assisted Reproduction and Genetics, 14 (1), 1997, pp.35-38.
38
http://www.sart.org/detail.aspx?id=1894; last visited on 15/08/2013, time: 10:00 am (IST), place: Meerut,
(UP), India.
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pregnancy rate, though the age of the recipient is not that significant. An ideal donor is a
woman between the age group of 21 to 35 years, with previous successful pregnancies, is
in a stable relationship and has completed her family.39 The advantages attached to this
procedure are that it avoids the laboratory cost of IVF-ET and it also avoids the surgical
costs because it is performed through a needle injection. But a major disadvantage of this
needle injection procedure is that for complete aspiration of fluid, the needle may have to
be withdrawn and reinserted a number of times, thus increasing the risk of trauma and
infection.
c) Surrogate and Gestational Carriers: If a woman is unable to carry a pregnancy to
term, she and her partner may choose a surrogate or a gestational carrier. A surrogate
motherhood involves a woman bearing the child of another woman. Where the woman
cannot produce eggs, the couple enters into a contract with a surrogate, whereby the
surrogate is artificially inseminated with the sperm of the male partner of the couple. The
surrogate then bears the child to term. The resulting child gets biologically related to the
surrogate and to the male partner. Surrogacy can be used when the female of the couple
does not produce healthy eggs that can be fertilized.
In contrast, a gestational carrier is implanted with an embryo, where the woman
willing to have a child of her own, can produce eggs but is unable to carry a child to term.
The embryo is externally formed by in-vitro fertilization with husband’s sperm and wife’s
ova and thereupon the embryo is implanted in surrogate mother’s womb to bear the child
to term. Here the child is not biologically related to the surrogate and the child born would
inherit the genetic code of the contracting couple. The surrogate is paid by the couple for
renting her womb. This alternative can be used when a woman produces healthy eggs but
is unable to carry a pregnancy to its full term. If needed, egg or sperm donation can also
be used in this situation.
The culture in the West is more tech-savvy with ‘rent or borrow a sperm’ or ‘renta-womb’ kind of lifestyle. People have this mental set up that atleast the baby is made
with their own gametes, even though nourished in a rented body and with sisters, sister-in39
Patki, Ameet; Nadkarni, Suprana et al., Oocyte Donation, published in Rao, Kamini A and Chen,
Christopher, Endoscopy in Infertility, 1st ed. 2007, pp.382-383.
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laws and even mothers lending their uterus, it finds greater acceptability. Surrogacy is also
in culture these days because in the West it is not that easy to adopt a baby owing to tough
adoption and paternity laws.
In India, most of the women opt to rent out their wombs chiefly because of
monetary reasons. These women may also have babies of their own and many of them are
not first time mothers. These surrogate mothers are basically financially deprived, whose
husbands have either passed away or have left them or do not pay any attention towards
the household responsibilities. These women rent their wombs for carrying the child of an
infertile couple only as a means to run their family. One surrogate mother received $ 8,000
for the same and relinquished all the rights in the infant to the infants’ parents. This was
done by her as she wanted to secure her daughter’s future. India is having 1.2 billion
population and has emerged as a preferred destination for a number of couples from
around the world who are looking for a low-cost, trouble-free way of becoming parents.40
India has emerged as a hub for medical tourism because of the availability of
advanced medical technology, cheap availability of women to bear a child and most
importantly lack of legal scrutiny which has ensured commercial surrogacy a boom in
Indian markets. This practice is not only attracting the foreign couples to have a surrogate
baby in India but is also booming the Indian couples, whether they are infertile or not, the
examples are of Bollywood stars Aamir Khan and Shahrukh Khan.41
40
http://www.washingtonpost.com/world/in-india-a-rise-in-surrogate-births-for-west/2013/07/26/920cb5f8efde-11e2-8c36-0e868255a989_story.html; last visited on 17/08/2013, time: 11:59 am (IST), place: Meerut,
(UP), India.
41
Shah Rukh Khan opted for surrogacy and Aamir Khan’s wife Kiran Rao opted for surrogacy as Kiran did
not want to de-shape her body figure and spoil future prospects of her career.
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“Law and Policy on Surrogacy: A Socio-Legal Study in India”
2015
Example of Bollywood Star Shahrukh Khan
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“Law and Policy on Surrogacy: A Socio-Legal Study in India”
2015
Example of Sex selection test during surrogacy by
Bollywood star Shahrukh Khan
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“Law and Policy on Surrogacy: A Socio-Legal Study in India”
2015
However, in the absence of a regulation or law on the same, some unscrupulous
agents are luring poor, uneducated women into signing surrogacy contracts which are not
fully understood by such women. The worry is about the increasing exploitation of poor
Indian women who undergo pregnancies to earn money which is a matter of great concern.
These surrogate women in the wake of earning money to run their family, undergo
pregnancy several times, ruining their health. The other problem relates to legal aspects.
The issue of ownership and the rights of commissioning couples and surrogate hosts have
largely arisen from surrogacy arrangements because they are unsupervised by expert
doctors, counselors, lawyers and most importantly have no binding effect due to the lack
of legislative action on it.
However, the only legal measures left are the National Guidelines for
Accreditation, Supervision and Regulation of ART Clinics in India, issued by the Indian
Council of Medical Research in 2005; recommendations of the Law Commission of
India42 and the guidelines provided by the Hon’ble Supreme Court through the ratios of its
decided cases43, which are insufficient to handle the issue of commercial surrogacy.
42
228th Report of Law Commission of India, Need for Legislation to Regulate Assisted Reproductive
Technology Clinics as well as Rights and Obligations of Parties to a Surrogacy, August 2009.
43
Baby Manji Yamada v. Union of India, AIR 2009 SC 84; Jan Balaz v. Anand Municipality and Others,
AIR 2010 Guj 21; K. Kalaiselvi v. Chennai Port Trust, Represented by the Chairman, Chennai,
W.P.No.8188 of 2012; decided by Madras HC on 4th March, 2013.
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