Project proposal Reproductive tourism in India: A description of surrogate mothers and their offspring Background Medical student Malene Tanderup Kristensen Traditional surrogacy is defined as where the surrogate mother is artificially inseminated with the intended father s sperm; she carries the pregnancy and after delivery she gives the child and all parental rights to the intended parents. A more modern form of surrogacy is gestational surrogacy; here an in-vitro fertilized (IVF) embryo from the commissioning parents is transferred to the surrogate, which makes her genetically unlinked to the child. From an economic perspective there are two classifications of surrogacy. Altruistic surrogacy where the surrogate mother is often related to the commissioning parents, and is not compensated for her role, but al the expenses associated with bringing the embryo to term is compensated. Commercial surrogacy on the other hand financially compensates the surrogate mother beyond expenses associated with the pregnancy. 1 2 In 1985 the first case of a successful surrogate pregnancy was reported. 3 Since then it has been possible for infertile women to have biological related children without a functional uterus, or where pregnancy is contraindicated because of pre-existing disease or if the woman has a poor obstetrical history. Surrogacy has raised many ethical questions; e.g. whether it can be compared to organ transplant, whether it may harm the family structure, whether it is exploitation of the surrogate mothers. 2 Reproductive tourism (RT) is another issue to consider in the discussion of surrogacy. The market is quickly expanding due to lower cost in third world countries (US: $70.000, India: $25.000), fewer regulations on surrogacy and the possibility for surrogate mothers to waive their parental rights before birth, thus giving intended parents higher level of assurance that they will receive the baby. 1 In Denmark surrogacy is prohibited, however it is not clear if surrogacy exists either in Denmark or as reproductive tourism. The technical principles of surrogacy are the same as in the well known and used method of IVF. In gestational surrogacy the surrogate mother s and intended mother s/egg donor s menstrual cycle will be synchronized with hormones. Most common the intended mother is injected daily with gonadotropin to mature the follicles. When the follicles are ready she is given one dose of hcg and after 36 hours the oocytes are ready for retrieval. The surrogate mother is given oral oestradiol daily to stimulate the growth of the endometrium. When the intended mother is given hcg, the surrogate mother gets progesterone. The hormone replacement therapy to the surrogate mother is continued until 12 weeks gestation if embryo implantation and development have occurred. 2,4 Side 1 af 5
Over 4 million pregnancies have been achieved worldwide through IVF treatments. It has shown an increased incidence of several obstetrical and perinatal complications. Most of these are related to the high incidence of multiple gestations. Only few studies mention the complications due to gestational carrier programs. Duffy et al. and Soderstrom-Anttila V et al report complications due to surrogacy such as postpartum depression, hysterectomy, occipital infarct and an increased incidence of twin and triplet gestations. 5,6 The neonatal complications are mostly related to preterm delivery and low birth weight. 7,8 The question is whether the lack of obstetrical and perinatal complications is due to too small studies, unreported cases, or if it truly reflects a low number of complications. General aim: To describe the health of surrogate mothers and the organization of pregnancy and delivery care among the same in India Specific aims: To map Fertility clinics in New Delhi where surrogacy are carried out. To medically describe the surrogate mothers, infants and intended parents. To investigate the surrogate mothers reproductive complications. To investigate the pregnancy outcome among surrogate mothers in terms of gestational age, birth weight, APGAR score and need for neonatal hospitalization. Design: Post hoc analysis of a retrospective cross sectional study. Method: All the assisted reproductive technology (ART) clinics in New Delhi where surrogacy is carried out will be mapped and visited. Data will be collected via medical registers and interviews with the doctors, surrogate mothers and intended parents. Information on socioeconomic, health, reproductive history and information about the newborn will be collected. Side 2 af 5
Through a cross sectional study information about physical- and mental health of the surrogate mothers and intended mothers, details of the pregnancy and delivery, the outcome including birth weight, gestational age will be collected. Timeframe: 3 months in New Delhi: Mapping Fertility clinics in New Delhi where surrogacy are carried out and initial data collection from the clinics. 3 months at Aarhus University: Data processing and analysis. 3 months in New Delhi: Data collection and follow up. 3 months in Aarhus University: Data processing, analysis and finishing the report. Perspectives: The few studies on obstetrical and perinatal complications in surrogacy which have been published until now have only included women from industrialized countries with good health care. 5,6,7,8 No studies on the obstetrical and perinatal complications have been published from countries like India where there is a less well functioning public health care system. Most of the surrogate mothers in India are from poor and low middle class backgrounds. 9 We have yet no studies of the surrogate mothers, the outcome, the success rate of pregnancies, and the complications of surrogacy in lowresource countries. And still the market of reproductive tourism is growing, even though we do not know the health consequences for the participants. Worldwide the discussion of surrogacy is ongoing, whether to prohibit, regulate or legalize surrogacy. In Denmark, surrogacy is prohibited contrary to India where there are no law regulations on surrogacy. One of the issues of prohibiting surrogacy is if it results in more infertile couples who wish to make use of reproductive tourism. If this is the matter countries with restrictions will merely export their ethical issues to countries with no restrictions. Another issue of prohibition is if the infertile couples seek underground illegal surrogacy in Denmark. If a dispute occurs between the couple and the surrogate, they have no options of seeking professional help or bringing a case to court. 10 When a country like Denmark prohibits surrogacy, there are no possibilities to regulate or research into or follow the development of surrogacy. Ethical considerations: Helsinki Declaration guidelines on medical research will be followed. There will be obtained informed consent from all participants and all involved will be protected through anonymity of names and places. Side 3 af 5
All personal data are properly protected as required by the Danish Data Protection Agency and relevant Danish law. Feasibility: The study will be conducted in surrogacy fertility clinics in New Delhi, India. While in India, the student will have an office space at Delhi University, India. The student will work in collaboration with Dr. Sunita Reddy, Faculty in Centre of Social Medicine and Community health at Jawahalal Nehru University, and Prof. Tulsi Patel, Faculty of Dept. of Sociology, Delhi School of Economics at Delhi University. While in Denmark the student will have an office space within the research unit of Dept of Obstetrics and Gynecology, Aarhus University Hospital, Skejby, and work in collaboration with Dr. Birgitte Bruun Nielsen, Consultant Obstetrician and Associate Professor. This project focuses on the health of the surrogate mothers, their infants and the intended mothers and will be contextualized in the ongoing study Reproductive tourism in India: An ethnographic study on surrogacy by Dr. Sunita Reddy and Prof. Tulsi Patel. The study will, through in-depth interviews with doctors, surrogate mothers and intended parents, view the lived-experiences of the mothers along with emotional, social and cultural factors. Additionally, law, ethics, economics, and health trade issues will be explored. The narratives will help understanding the nuances in the whole process of surrogacy and the benefits and consequences of the same. The student s role: The student will map the surrogacy fertility clinics in New Delhi and actively visit the clinics to obtain data. Furthermore it is the student s task to analyze obtained data and present results in scientific forums, to write a draft manuscript for publication and to participate in an international conference. Side 4 af 5
1 Sreenivas Kiran and Campo-Engelstein Lisa Domestic and international surrogacy laws: Implication for cancer survivors, 2010 2 Raziel Arieh Eight years' experience with an IVF surrogate gestational pregnancy program, 2005 3 Utian et al. Successful pregnancy after in-vitro fertilization-embryo transfer from infertile woman to a surrogate, 1985 4 Goldfarb James M.: Fifteen years experience with an in-vitro fertilization surrogate gestational pregnancy program, 2000 5 Soderstrom-Anttila V et al Experience of in vitro fertilization surrogacy in Finland., 2002 6 Duffy Deirdre A Obstetrical complications in gestational carrier pregnancies, 2005 7 Parkinson Judy et al. Perinatal outcome after in-vitro fertilization-surrogacy, 1998 8 Serafini Paulo Outcome and follow-up of children born after IVF-surrogacy, 2001 9 Qadeer Imrana Social and ethical basis of legislation on surrogacy: need for debate, 2009 10 Semba Yukari et al Surrogacy: Donor conception regulation in Japan, 2010 Side 5 af 5