Socioeconomic inequalities in India's assisted reproduction

Following severe criticism and after rounds of deliberation over the Surrogacy Regulation Bill, the Union cabinet approved it after accepting the recommendations of a Rajya Sabha Select Committee (Upper House of the parliament). The long pending Assisted Reproductive Technology Bill that covers a larger gamut of aspects under the assisted reproduction also received the cabinet’s nod. As the Indian government is in the process of bringing in legislation for assisted reproduction, this series delves into on-the-ground realities.

PART 1

It’s lunch time: almost an hour past noon and the winter sun of December is too harsh. But it isn’t evident in the basement of the Akanksha Hospital in Anand district, some 80 kilometres from Gujarat’s capital city Ahmedabad. The circular tables along the long canteen hall are occupied by groups of women who have just finished their meal. The ones who are visibly tired retire for an afternoon nap while a bunch of them regroup for their daily afternoon activity.
Huddled around a table at the centre of the room, the conversation in Gujarati and Hindi rapidly shifts between topics— from morning prayer to their children; from lunch menu to the craft session that is about to begin; from health to womanhood and dealing with pregnancies— these women who until few weeks back didn’t know each other, share with one another some of their most personal and intimate stories. Among a wide range of differences, a commonality running through their lives is debt. And to overcome it, these women have found a common solution too: surrogacy.

Who’s a surrogate?
Thirty-five-year old Daksha* is among the nearly 100 surrogate mothers who are currently residing at the hospital's surrogacy hostel. Six years ago, when Daksha became a surrogate for the first time, she had a debt of about Rs 65,000 and her neighbour suggested surrogacy as an option. With the fee that was paid to her, she repaid loans, constructed a house and set up a roadside food stall along with her husband. The income from the food stall was sufficient to run the family and to take care of her two children, until Daksha’s husband met with an accident three years ago which pushed their lives back by a decade. After considering different options, she decided to take up surrogacy again and is now in her sixth month of pregnancy.
Women interviewed said they opted to be surrogates to support the financial needs of their family like better healthcare, education of children and repayment of debts. Many also blamed alcoholism of husbands as a primary reason to be surrogates as the men either don’t provide financial support or they have separated. Daksha claims that the Rs 4 lakh promised to her would go entirely towards treating her husband who remains immobile for a couple of years. “Doctors said the accident has affected his nervous system which would eventually trouble his head and needs to be operated on. If I’m able to save some money after his treatment, I’ll restart the food stall that is shut for months now,” says Daksha, who has completed her school education. Anand district, known for its largest co-operative dairy industry Amul, gained international attention as a ‘surrogacy capital’ in the mid-2000s, courtesy Dr Nayana Patel, the founder of the Akanksha Hospital, who is often praised and criticised in equal measure for ‘commercialising pregnancy’.
Amrita Pande terms these surrogacy hostels as “gendered spaces” in her book Wombs in Labour: Transnational Commercial Surrogacy in India. She states that these spaces which are often imagined to be the “most repressive form of surveillance, become an avenue for collective resistance.” “Some women use the hostel space to share information and grievances. Others come up with acts of collective action and even strategies for future employment,” writes Amrita. Dr Nayana also says that her hospital is uplifting the lives of several impoverished women and the life skill training programmes help rebuild lives. “When they have nothing, they come here; the ecosystem that we’ve built is crucial. It helps someone build a house, send children to schools and improve their overall wellbeing, and that is definitely a life changing experience,” says Dr Nayana.

In the name of surrogate
The Surrogacy (Regulation) Bill, 2019 aims to curb exploitation of surrogate mothers by banning commercial surrogacy and allowing only “close relatives” to be surrogate. The Bill states, “…necessary to enact legislation to regulate surrogacy services in the country, to prohibit the potential exploitation of surrogate mothers and to protect the rights of children born through surrogacy.” The deliberations over the Bill have largely focused on two facts: surrogacy has improved lives by overcoming financial constraints versus surrogates who
are the vulnerable lot in the assisted reproductive chain are subjected to exploitation. However, PM Arathi of the Council for Social Development, an advocacy institute in New Delhi, says that without addressing the ground reality on employment and wages in India, banning commercial surrogacy is neither a solution nor an answer. In her recent research paper ‘Silent Voices: A Critical Analysis of Surrogacy’s Legal Journey in India’, she adds, “When the state withdraws from its responsibility of providing universalisation of primary, secondary and higher secondary schooling, better housing for all, land redistribution and universalisation of healthcare, the banning of surrogacy is ultimately counterproductive.” Denying allegations of exploitation, Dr Nayana says hospitals presently arrange for legal contracts between couples and surrogates. She cautions that exploitation would arise if the Bill is passed and adds, “A ban doesn’t mean that there isn’t going to be any demand. The black market will become rampant where nobody would have control and none will have a place to complain.” Mumbai-based senior gynecologist Dr Nikhil Datar argues, “Any new advancement in science and in particular, medicine creates myriads of opportunities, but it comes attached with abuses too.” However, he calls for regulation as opposed to a blanket ban, noting, “It is definitely important for government agencies to step in to propose regulations that strike a social balance and address biological, ethical and legal issues. However, a regulation is different from curbing a medical advancement.” Talking about the reservations over the Bill, he adds, “Allowing only close relatives will ensure surrogacy itself becomes impossible. And, this leads to the crux of the problem— denying a woman her reproductive rights.”

The road to legislative intervention
In the last 15 years, several deliberations were made to regulate and supervise assisted reproductive technologies (ART) which deal with medical procedures for infertility, such as in vitro fertilisation (IVF), artificial insemination, etc. Apart from the initial set of guidelines in 2005, the Indian Council of Medical Research (ICMR) also formulated ART (Regulation) Bill, in 2008 that was redrafted twice in 2010 and 2014, only to remain in cold storage. While the ART Bill covers a larger gamut of medical procedures under the assisted reproduction, the current Bill only focuses on surrogacy. After getting passed in the Lower House, when the Surrogacy (Regulation) Bill, 2019 was introduced in the Rajya Sabha during the winter session, it faced opposition from various members across parties and moved to a Select Committee for review. The Committee while submitting its report earlier in February, recommended the removal of the ‘close relative’ clause and suggested any ‘willing woman’ to be surrogate.
Some other recommendations the Committee made include the tabling of the ART Bill before the Surrogacy Bill, inclusion of single women as commissioning parents and waiving off the five-year wait period after marriage to opt for surrogacy, if it is certified that the woman can’t conceive. Terming the ‘close relative’ clause as one of the most contentious issues, the Committee said the Bill ignores the ground reality of most Indian families where women have little decision-making authority. It also added that limiting the practice of surrogacy to close relatives is not only non-pragmatic and unworkable but also has no connection with the objective to stop exploitation of surrogates envisaged in the proposed legislation. Agreeing that surrogacy forms a very miniscule portion of assisted reproduction and the ban would not make any impact to curb exploitation, Mumbai-based ART expert Parikshit Tank says, “The overall proportion of couples who’d need surrogacy is limited to less than 2%.” While major amendments suggested to the Surrogacy (Regulation) Bill, 2016 by a Standing Committee were ignored earlier, it is yet to be seen if the latest recommendations would be implemented.

The cost of assisted reproduction
In the Standing Committee report (2017), Mrinal Satish, Associate Professor of Law and Executive Director at the Centre for Constitutional Law, Policy and Governance of the National Law University, observed, “…the contract entered into with the surrogate followed the ‘free market principle’ which meant that each contract was negotiated separately and the contract was devoid of the postnatal care, life insurance coverage and informed consent provision thereby entailing huge bargaining power disparity between the intending parents/clinics and the surrogate mothers.”
The Indian fertility healthcare, in its current form, is a strained cosmos of constantly roving patients from different regions of the country— sometimes from other countries too and, groups of young women—egg donors and surrogates, usually accompanied by agents. Invariably the waiting room at fertility centres across various cities in India is an intersection between the haves and have nots. The exorbitant costs involved in Assisted Reproductive Technology, lack of government intervention and monopolization by private healthcare providers has ensured that the assisted reproductive healthcare has grown into a multibillion-dollar profit generating industry often entangled with irregularities and disparities. In India, the proportion of ART’s growth— valued at $478.2 million in 2018 by Allied Market Research and estimated to reach $1.45 billion by 2026, makes it crucial that any law that addresses assisted reproduction ought to be more inclusive, balanced as well as non-exploitative.
The ART treatments can range anywhere from Rs 1.5 to Rs 20 lakhs depending on the procedure. Since, the success rate is minimal and as patients end up with multiple cycles of treatment, the cost shoots up. Parikshit admits that if ART is available in public healthcare, it would’ve served a higher number of people.

****
Back at the surrogate hostel in Anand, activity session for the afternoon has begun. A 28-year-old surrogate shows a navy blue coloured thread earring that she made during the previous jewellery making session. However, Daksha is not keen on the session. She wants to continue the discussion on surrogacy and in the process with much ease she succinctly simplifies the most complex debate around commercial surrogacy ban, the demand-supply chain and the necessity to address larger inequalities. She raises a question only to give the answer herself: “Will I agree to be my sister’s surrogate without any compensation? Definitely not.” “Even if we both agree as per all the laws (of altruistic surrogacy), who will pay for our treatment?” she asks. And, with precise articulation, she adds, “This (cycle) goes on only if the parties involved are rich and poor: those who need money and those who can afford. There needs to be an incentive for both parties and it’d break if either both are rich or poor.

PART 2

It was less than a week into the new year in 2014. Pon Kathiravan, a member of the CPI (ML), as per his daily routine at the party office in Namakkal district’s Komarapalayam was busy reading the morning newspaper. As he flipped through the pages, he realised the presence of a man in his 30s sitting across the table.
Before Kathiravan could realise what was happening, the man jumped from his chair and attacked Kathiravan. As Kathiravan, with multiple cuts on his head, hastily climbed down the stairs to get out of the building, he was stabbed again.
“Navaraj is his name. I had never seen him before, never saw him again,” recounts 59-year old Kathiravan, six years after the incident that completely shook his life.
He quickly clarifies: “After the incident, I saw him once when the police wanted me to identify him before the arrest. He is now out on bail.”
Just days before Kathiravan was stabbed, a then 27-year-old Sakunthala had approached the party office along with a neighbour who was also a party member. She wanted help in filing a complaint against her abusive husband Navaraj, and Kathiravan had helped her draft it. Later, police officials, after counselling the couple, arranged a mutual separation. Triggered by the series of incidents, Navaraj attacked Kathiravan and later stabbed Sakunthala, who too survived after multiple injuries. In the eight years of her married life, Sakunthala was forced by Navaraj and his mother to donate her oocyte (egg) 18 times at various hospitals in Tamil Nadu and Kerala. According to the police report, she was also forced to sell one of her kidneys soon after her wedding in 2006. When Sakunthala finally resisted, she was attacked.
Ignoring such regressive domestic environments that women like Sakunthala are forced to encounter, the latest Surrogacy Regulation Bill also conveniently evades other complexities around assisted reproduction like egg donation. In an attempt to “curb exploitation” of surrogate mothers it bans commercial surrogacy and allows only “close relatives” to be surrogates.
If the prime concern of the government is to curb exploitation of women, it should have brought in a regulative mechanism for egg donation too. More than surrogacy, it is the egg donation that is more rampant and exploitative, says Nikhil Datar, a Mumbai-based senior gynaecologist and advocate of reproductive rights.
Just days after Sakunthala was attacked in Tamil Nadu, Yuma Sherpa, a 23-year-old shop assistant, died mysteriously in the national capital of New Delhi, following a medical procedure that involved oocyte extraction procedure.
Four years before Yuma’s death, 17-year-old Sushma Pandey died in Mumbai of “brain haemorrhage and pulmonary haemorrhage due to ovarian hyper-stimulation shock syndrome”, after donating eggs thrice within 10 months. This was a brazen violation of the Indian Council of Medical Research (ICMR) guidelines which has fixed the age of those donating eggs to between 18 and 35.
The deaths of Yuma and Sushma gained national attention and raised a lot of questions on the legal and ethical aspects of Assisted Reproductive Technologies (ART). But no stringent rules were brought in. Earlier this month, a Select Committee made recommendations to the strongly criticized Surrogacy (Regulation) Bill, 2019, after the government failed to acknowledge the suggestions of a Standing Committee. And, last week the Union Cabinet approved the ART Bill that covers a larger gamut of medical procedures, unlike the Surrogacy Bill.
Besides all the legislative process, a curious case emerges in Tamil Nadu, where issues like prohibition, pollution and the current economic downturn are connected through an invisible thread: a $20 billion global fertility market services.

Domino effect 1: A secret called ‘batch’
In Komarapalayam, it is exactly six years since Sakunthala was attacked: neither the police officials nor the CPI (ML) members know her whereabouts.
As I unsuccessfully search for Sakunthala’s house through the streets of powerloom towns – Komarapalayam and the neighbouring Pallipalayam – a very closely guarded secret unfolds: a secret that the women hold to themselves, tucked in the midst of closing down of powerlooms and growing debt. It is called the ‘batch’.
Twenty-six-year-old Dhanam* is also part of the secret, something that her family doesn’t know and only her close friend and neighbour knows. She is hesitant, initially, to talk about the ‘batch’ that is filled with agony and pain, but often coloured in shame and stigma.
Dhanam was only 13 years old when she got married and hardly 18 when her husband, a powerloom worker in Komarapalayam, died. Dhanam, also employed in the powerloom industry, struggled to bring up her two sons. Even as she worked hard, her debts grew.
Apart from being a casual worker at construction sites she works in powerlooms too whenever she gets a job, while her debts have ballooned to more than Rs 1.5 lakh.
Dhanam remarried in 2014 in hopes of a better life for her and her sons. However, this time it hit her severely when the man turned abusive. With debts piling up and subjected to domestic violence, she was “offered help” by a friend.
“I was told there was an easier way to solve all my problems. The lady at the construction site told me she’d take me to a hospital where I’d be injected to take my fertile eggs and would be paid for it. At first, I was a little skeptical and thought about it for a while before agreeing.”
Unable to recollect when she first donated, Dhanam says it was “less than three years ago”.
She adds, “You remember when Rs 500 and 1,000 notes were scrapped? Since then it has become difficult to find regular jobs at construction sites and powerlooms. So, I went to the hospital for my first ‘batch’ with the lady who had suggested the idea.”
Sitting next to Dhanam, her 33-year-old friend Seetha* who is also an egg donor, nods in agreement. She adds that most of their friends decided to take up egg donation as a means of earning after they went through job cuts in the last couple of years.
“I was rejected in my first attempt as my ovulation was not good enough for (egg) retrieval. I was given medication and told to visit the hospital after a month. This time it was successful and I was paid Rs 15,000. Every single visit we make to the hospital to donate eggs is termed as ‘batch’,” claims Dhanam.
“Agents say ‘batch’, so we call it that too,” admits Dhanam, who has gone for “10 batches in three years,” neglecting the fact that repeated ovarian stimulations would take a huge toll on her health.

Domino effect 2: The two headwinds between warp and weft
The noisy yet rhythmically alternating clackety-clack sounds of the powerlooms’ weft and warp fill Pallipalayam’s earthy scent on a hazy afternoon. In one of the lanes, off the Erode main road, is a small powerloom unit that manufactures lungis, towels and bedsheets, and has 10 employees.
Forty-year-old R Sumathi, who has been working in the powerloom sector for over 20 years, is busy segregating the sized yarn before it is transferred to a ring package. Her parents were in the handloom sector and she started off assisting them since she was 13. She dropped out of school after Class 8 and since then her world has been spinning around looms.
“There are very few large powerloom units around Erode and Namakkal, most are smaller units run like cottage industry. Children assist parents, siblings would have a joint unit, spouses would do business together: all it needs is a little space. Every alternate house would have at least a single unit running throughout the day,” says Sumathi, who has witnessed the rise of the powerloom industry in the 1990s as a kid along with the downfall of handloom.
“And now, this too,” she adds, pointing to the large units in front of her. Sumathi adds that the powerloom business has been hit very badly in the last two years. Even as they were struggling to realise the impact of demonetisation, the new taxation – Goods and Services Tax (GST) – pushed things from bad to worse, and things have further plummeted in the last few months.
Sumathi, whose factory has halved its production from 12 powerlooms, points towards two buildings on the opposite road and says that the factories have remained non-operational for four months. With over 5.62 lakh powerlooms and more than 10.18 lakh people employed in the sector, Tamil Nadu has the second largest powerloom industry in the country, next to Maharashtra which employs over 15.54 lakh people across its 9.5 lakh looms. Five years ago, D Rathna, while working on women’s issues in Pallipalayam, came across women who sold oocytes due to financial constraints. She adds that the number of women from smaller towns around Erode and Namakkal who have turned to egg donation as a means of income has only increased in the last few years. This increase closely coincides with the growing debt and the shutting down of powerloom units in the twin towns of Pallipalayam and Komarapalayam following the two headwinds – demonetisation and GST. The cycle of economic crisis, job cuts and debt are not new to these towns. However, mapping the three-decade trajectory points to the larger socio-dynamic transition from kidney to oocyte sale.
The Textile Policy of 1985 followed by liberalisation of the Indian economy came as a huge blow to the handloom sector. As Pallipalayam and Komarapalayam – major centres for handloom – switched over to powerloom, there were major job losses and debt, turning the towns into a hub for a kidney racket in the late 80s and 90s. Kidney theft cases were emerging even after the adoption of the Transplantation of Human Organs Act by Tamil Nadu in 1994, leading the state to implement a set of rules for streamlining organ donation and transplantation in 2008. Now, more than a decade later, Tamil Nadu leads the country in organ transplantation.
In the last few years a newer problem has hit these towns in the name of oocyte sale, as the cycle of economic crisis, job cuts and debt recurs.
The women, who are almost an equal workforce in the unorganised powerloom sector, end up becoming suppliers to the infertility market, valued at nearly half a billion in India. The semi-urban setup of the two towns with a good mix of migrant population makes it easier for women to take up egg donation (and occasionally surrogacy), which would otherwise be viewed with stigma in a closely-knit rural setup. Many of the egg donors claim that they were initially stigmatised by their families, only to be later coerced into it once the family began to reap the financial benefits.
“When someone sold off one of their kidneys it was equated to a sacrifice, like the person did it to save (her/his) struggling family. But when women like us become a surrogate or egg donor for the well-being of the same family, it becomes a matter of shame for everyone around us,” says Dhanam.

Domino effect 3: Pollutants in Bhavani river
The heavy rains from the previous week have led to a good flow in the Bhavani river, the banks on which the powerloom towns are situated. After a small hiatus, the November rains are gearing up to pour again in the western region that has significantly contributed to the rise of fertility clinics in Tamil Nadu, a state with the second highest number of ART centres, next to Maharashtra.
Talking about the mushrooming of fertility centres in Erode and Namakkal, Dinakaran, who is with a non-profit organisation that works with women in Namakkal, claims that the districts of Erode, Tiruppur, Karur and Namakkal have all the elements required for the “infertility market’s supply chain”.
Apart from the availability of egg donors as “suppliers”, there is a “natural demand – infertility” that has developed due to the extreme contamination of the Bhavani river over the last three decades due to discharge of untreated water from the numerous dyeing and bleaching units of the textile industries.
The 217-km-long Bhavani river that courses through Coimbatore and Erode before its confluence with the Cauvery is Tamil Nadu’s second largest river and stretches around 91 km in Erode district. It’s a major source for agriculture and drinking water.
Various studies at different time periods by both union and state Pollution Control Boards have reported that the effluents severely affect the river and several legal proceedings have led the courts to direct the state to ensure that water is let out into the river only after effluent treatment. Yet, it remains unregulated and the river contaminated, according to locals.
“The pollution affects all those who live along the river. At least if there was sand on our river beds, it’d have filtered out the chemicals that are let off. But continuous plunder of the river sand has made even that impossible,” claims Dinakaran.
Mumbai-based ART expert Parikshit Tank states that it is important to start viewing the environment as a possible contributor to rise in the infertility rate.
“While pollution cannot be the sole reason, it could also be one of the possibilities. Lots of pollutants contain estrogen-like-chemicals and even if the concentration is very low, prolonged exposure to it will have ill-effects,” says Parikshit.
Medical practitioners in Erode and Namakkal point out that those in the age group of 30 to 40 are the first generation to have lived their entire lives with pollutants from dyeing and bleaching units.
Senior doctor V Jeevanandham, a pioneer in initiating co-operative hospitals in Erode, says that along with the contaminated water, extensive use of chemical fertilisers and pesticides in agricultural produce could also be a reason for infertility.
The doctor, who is currently running a de-addiction centre, adds that increasing levels of alcoholism in Tamil Nadu could be another reason too.

Domino effect 4: TASMAC, Tamil Nadu’s cash cow
Health implications aside, the social effects of alcoholism are numerous in Tamil Nadu where the state government is the sole wholesale and retail seller of liquor through its Tamil Nadu State Marketing Corporation (TASMAC), which is one of the largest contributors to the state’s coffers. Protests for prohibition galvanised around 2015 and since then there have been on and off agitations across the state. It became one of the prime promises of all political parties before the 2016 assembly elections and the AIADMK came back to power promising a “step-by-step prohibition”.
Back in Komarapalayam, as Dhanam contemplates going for the next ‘batch’, her friend Seetha is enquiring about the possibilities of selling one of her kidneys or becoming a surrogate.
Dhanam’s second marriage broke up after her husband started forcing her into frequent sale of eggs.
“He would take away all the money for drinking and I’d be left with nothing to feed my children. So, I don’t live with him anymore,” she says.
Seetha, another victim of child marriage, is also separated from her alcoholic husband and lives with her 18-year-old son, who has just begun to work at a retail outlet. Seetha, who has so far donated on seven occasions, is completely aware that her poor health will not allow her to stress her body any further.
“What else can I do; I’m in need of money to repay my loans,” she says.
Dhanam quickly adds: “If there is anything that should go, it’s the TASMAC shops… root cause of everything. If the men in our families weren’t alcoholic, we could’ve easily managed with the available income… it has ruined our lives.”
Meanwhile, attempts to trace Sakunthala are still futile as someone in Komarapalayam claims that she has moved to Coimbatore and no one seems to have her contact. But, in a span of six years there have been many Sakunthalas with similar, if not more harrowing, tales to tell.

PART 3
For twenty-six-year-old Dhanam*, a native of Komarapalayam in Namakkal district, it has become an ordinary affair to sell her oocyte (eggs) to manage her financial needs. She has donated on ten occasions in the last three years and her friend Seetha*, 33, has donated seven times between 2015 and 2018.
While Seetha hasn’t donated in the last one year due to deteriorating health and irregular menses, Ramya*, 35, from Pallipalayam who was a surrogate before turning to egg donation claims that she is “frequently falling ill and hasn’t donated in the last few months”.
Welcome to the prominent twin powerloom centres of Komarapalayam and Pallipalayam in Tamil Nadu, which is in the midst of a distressing economic situation. It has witnessed massive job cuts and as the equal workforce women face job crunch, many have turned to oocyte sale, as reported in the second part of the series.
Frequent egg donation has led to a stage where many women consider it as an option to earn money, to compensate for their regular income. A sum anywhere between Rs 15,000 and Rs 25,000 per donation would help in taking care of their families for three to four months or in repaying a portion of debt, overlooking their health.

‘Unbearable after-effects’
All donors who were interviewed complained of frequent fevers, anaemia, weight loss, fatigue and excessive bleeding along with extreme abdominal pain during their menstrual cycle.
“… can’t explain the amount of pain and bleeding during the three days, sometimes it (menstrual cycle) lasts more than five days. If injections during the medical procedure are painful, the after-effects are unbearable,” says Dhanam.
According to Dr Parikshit Tank, repeated ovarian stimulation which is needed for oocyte retrieval, “increases the chance of benign and cancerous problems in the ovary.”
“At our hospital we’ve an arbitrary cutoff of three donations per donor in her lifetime. While it is possible to maintain a record of donors who visit our hospital, currently with no centralised system, it’s impossible to track the total number of times a woman donates,” he says.
The Assisted Reproductive Technology (ART) Bill that has been long pending and approved by the Union cabinet in February, an oocyte donor shall be allowed to donate oocytes only once in her life and not more than seven oocytes shall be retrieved.

National registry for regulation
According to donors, following initial tests and scans, they’d be given hormonal injections for about a week. A test would be followed by oocyte retrieval procedure. While “new donors” are made to stay in the hospital to finish the entire process, “experienced donors” are given injections for self-use and they visit hospital after the stipulated period to complete the procedure.
When travelling to hospitals in other states, often a group of women are taken together by agents during which the food and travel costs are borne by the donor.
“There is no fixed amount that we’d receive; it all depends on our ovulation, the hospital, and the city or town we are taken to. We’d get anywhere between Rs 15,000 to Rs 25,000,” admits Dhanam who has gone to hospitals in Karnataka and Kerala, apart from all the main cities in Tamil Nadu.
“A portion of the money would obviously be deducted as commission by agents,” she says.
While the ART Bill has provisions for a national registry for regulation, supervision and prevention of misuse, experts have raised concerns over its feasibility considering that the infertility services market has already grown out of proportion, estimated at nearly half a billion dollars in India.
“Even though its (national registry) enactment is still indefinite, we only hope that activities like sperm and egg donation are not too severe because their donation is not like organ donation. The industry undeniably needs regulation but only to the extent that the services are not misused,” says New Delhi based Dr Rita Bakshi, senior gynaecologist and IVF expert.
In Komarapalayam, Dhanam is unaware of all the regulations. But she very well knows the toll regular egg donation has on her health and, claims that sometimes doctors and nurses at hospitals warn about the perils of frequent egg donation.
“But, what else can I do to feed my children.”

PART 4
Forty-year-old Sunitha*, a former surrogate mother who lives in a slum in Chennai's Vyasarpadi is unaware of all the debate around the assisted reproduction and surrogacy Bills. After our initial meetings, when I call her in November 2019 to meet again, Sunitha is a little busy.
“You know what happens even if there are slight rains in Chennai, right?” says Sunitha.
“We have been called (by Chennai Corporation) to clear the sewage water. I fell ill after working continuously for a week. Let the rain end, can we talk after that?” asks Sunitha.
Chennai’s stormwater drain system is one of the primary reasons for flooding during the northeast monsoon season. Clogged with sewage it becomes impossible for rainwater to drain, leading to inundation. Sunitha is employed as a casual worker by private contractors who have been tasked to clear the stormwater drain and sewerage by the Greater Chennai Corporation.
At her two-room house in Vyasarpadi, Sunitha is reminiscent of the child born to her through surrogacy, about six years ago. She admits that she was never involved in oocyte (egg) donation but has helped her friends and neighbours in reaching out to hospitals for surrogacy as well as selling fertile eggs.
“...not like an agent. But I help them,” clarifies Sunitha. She recently assisted her neighbour’s relative to turn surrogate and, “the woman had twins.”
Sunitha claims that she is not very active anymore due to her deteriorating health: Surrogacy, followed by the donation of one of her kidneys has affected her hugely. A mother of four, she opted to be a surrogate as she was unable to cope with the growing debt incurred by her husband.

Inherent casteism and racism
In November, the DMK Rajya Sabha member P Wilson termed the previous version of Surrogacy (Regulation) Bill as “irrational, whimsical and arbitrary”. He questioned the rationale behind allowing only “close relatives” to be surrogates.
“I am saying this with a heavy heart that it will promote casteism and racism. It will be used to divide people by adopting reproductive restrictions and choices... (an) Act cannot select the surrogate mother. The liberty to reproduce and bear (a) child should be left to the option of the parent,” he said.
However, in February the Union Cabinet approved replacing the term “close relatives” with any “willing woman” in the Surrogacy (Regulation) Bill and its nod for the Assisted Reproductive Technologies (ART) Bill. But one cannot deny that a casteist and racist approach is already existent in the assisted reproductive healthcare.
Despite the physical and mental toll frequent egg donation or surrogacy takes on women, there are certain unsaid norms and standards that she should fit into.
Twenty-six-year-old Dhanam*, a native of Komarapalayam in Namakkal district says that criteria like age, health condition and weight, aside, other standards for egg donation include complexion and caste.
According to Sunitha, apart from the medical procedure, the paperwork also involves multiple stages in which the agents representing the hospital bring forms where details are filled along with the surrogate’s or donor’s photograph.
“Complexion, height, weight, caste and religion are noted. The fairer, taller and slimmer the woman is, the preference is more. While some are specific about the physical appearance of the donor, others are particular about caste,” explains Sunitha.
“I’ve heard others say that few are keen on food habits, but I haven’t encountered this,” she adds.
Her neighbor Rajeshwari*, 37, who was previously an egg donor says that she was rejected on several occasions because of her caste as well as dark complexion. Sunitha, who was never preferred for egg donation adds, “Often the aspect of caste comes into picture during egg donation more than surrogacy.”
Both Sunitha and Rajeshwari belong to the Scheduled Castes.
In gestational surrogacy, the child is not biologically related to the surrogate mother who is merely a gestational carrier. The embryo which may be produced through the in vitro fertilization (IVF) method, using the eggs and sperm of the intended parents or donors, is transferred to the surrogate who then carries the baby in her womb. As per the Indian Council of Medical Research (ICMR) guidelines and the proposed legislation, an oocyte donor cannot act as a surrogate mother for the couple to whom the oocyte is being donated.
Several women— especially egg donors— this reporter met across Tamil Nadu claimed that they were chosen based on complexion and/or caste.
However, only in Sunitha and Rajeshwari’s case photographs were taken by the agents to the hospital.
Twenty-eight-year-old Saranya* who is from a most backward community says that though she was questioned about caste, she was preferred for egg donation due to her fairer complexion compared to her friend.

Unsaid standards
“My friend has donated twice. While the agent would regularly approach me, my friend would be ignored based on complexion,” claims Saranya.
Agreeing that questions related to caste aren’t directly asked, Dhanam who is from one of the denotified communities (DNC) that falls under the most backward class in Tamil Nadu says, “The agents are usually people from our locality or those who know us personally and it is easier to find out our caste.
Usually, complexion or health conditions would be cited as reasons to ignore and caste wouldn’t be openly discussed.”
The donors as well as agents claim that the payment per donation varies depending on these unsaid standards too.
According to doctors, there are patients who are keen on religion, caste and food habits of the donors. Dr Parikshit Tank says that the need to match the physical characteristics is obviously a universal phenomenon which is seen in adoption too.
“However, as providers of healthcare we can’t assure some very unrealistic things. It is like going to a blood bank and getting transfused with what is available and matches, irrespective of whatever religious beliefs or food habits one may have,” he says.
But Nayana Patel of the Akanksha Hospital in Gujarat’s Anand district, well known across the globe for its surrogacy treatments, claims that it is “important to respect such beliefs.”
“It’s so hard to accept a donor gamete …it is not an easy thing. When there are donors available from every strata and religion, why to impose (certain aspects) upon them. We try to match as much as possible; if we aren’t able to, we inform the couple. Otherwise, I think it is important to respect the couple,” she says.
A 30-year-old woman in Coimbatore who is undergoing fertility treatments for about three years agrees that it is “of course difficult to accept donor eggs.”
“There could be a mental burden that the child is not of my genes. Also, there is a little hesitation when we consider the social background of donors,” she says.
In Tamil Nadu and Gujarat, the two states where this reporter interacted with donors and agents, complexion and caste preference, is common. While religion and food habit preferences were found to be rare in Tamil Nadu, it’s a dominant factor in Gujarat.
A 33-year-old surrogate in Gujarat who is five months pregnant claims that she has been asked by her commissioning parents to follow a vegetarian diet and a prayer routine until her delivery.
Back in Chennai, Sunitha is not convinced. “All these treatments are said to be an advancement in medical science. Yet, newer ways to discriminate continue to exist, isn’t it?” she asks.

*Names changed to protect identity.