Care Tourism

Advancing technology and growing medical tourism have helped in vitrio fertilsation thrive in India, but with little regulation. Egg donors are chosen and paid according to their profile, with touts and agencies arranging them for hospitals and recipients. And the donor is often at risk, a fact highlighted by the death of Sushma Pandey, 17, in Mumbai.

With the Assisted Reproductive Technology (Regulation) Bill of 2010 hanging fire, the only attempt at regulation is a set of guidelines, revised several times, by the Indian Council of Medical Research. Clauses in the guidelines appear to contradict each other on the donor’s ideal age, but Sushma would have been under the lower limit in any case.

In the absence of regulation and of “egg banks” — sperm banks do exist — IVF centres and hospitals often perform as banks, authorities say. “Once the law is made, IVF centres and hospitals cannot perform the role of banks,” says Dr R S Sharma, ICMR deputy director general (reproductive medicine), who has been involved in the drafting of the ART Bill. He cites malpractices such as the role of middlemen and the exploitation of donors.

With no checks on clinics yet, many IVF centres are thriving only on cases of egg donation and surrogacy. Dr Tanya B Rohatgi, senior consultant (reproductive medicine) at Max Superspecialty Hospital in Delhi, says, “Egg donation and surrogacy should be practised as the last resort. But in our country we have so many IVF clinics that perform only these two procedures.”

There is no database of ART clinics either, and hence no centralised records of complications developed by the donor.

Donor’s health

The guidelines are silent on the dosage of inducing agents, with the result that donors in higher demand are often made to produce more eggs than what is safe for them. A healthy woman produces one egg every month. For donors, doctors give gonadotrophins, injections that stimulate the ovaries into producing more eggs. After these mature, the donor is put under anaesthesia and the eggs are retrieved via needles and guided by an ultrasound image.

“The guidelines do not specify any dose of gonadotrophins. While the dose should be individual-specific, ethically one should only attempt at extracting five to 18 viable eggs after stimulation,” says Dr Suneeta Mittal, head of AIIMS’s IVF unit. “There are many centres extracting as many as 50 eggs by increasing the dose to dangerous levels.”

High doses can lead to a condition known as ovarian hyper-stimulation. OHS involves hormonal imbalances that can lead to life-threatening conditions. Doctors say the risk is in higher in younger women — who are in higher demand.

If care is not taken during extraction, it can also lead to injuries in the ureter, the fallopian tube, the ovary and the pelvis. A gynaecologist from a Delhi IVF centre says one donor came back after four months with an injured kidney.

“In the West there are dosage specifications. The mild-to-moderate range is considered safe but many clinics in India do not stick to it, because our guidelines do not specify any such thing,” says Dr Abha Majumdar, chief of the IVF centre at Sir Gangaram Hospital.

Many clinics, doctors say, go up to 40-50 eggs so that one donor can serve more than one couple. “If I tell a couple the waiting list in my clinic is two months, and a neighbouring clinic says they can provide a suitable donor within 15 days, will they wait? So we sometimes share eggs taken from a donor in a single cycle — even the ICMR guidelines permit that, provided we are able to extract at least 14 eggs in the cycle,” says a gynaecologist at an IVF centre in Delhi.

Demand & supply

A market that banks on anonymity puts a premium on looks. “Age 28, Qualification: B Com, 5’1”, black eye, black hair. Healthy with no illness, blood pressure etc. Did work as Man(a)ger,” reads an advertisement on the Delhi IVF website. Health Ministry officials say they cannot act against any internet advertisement.

“Donors get paid on the basis of their looks and education. It could range from Rs 35,000 to Rs 75,000 but for a really good-looking graduate donor it could go up to Rs 1 lakh,” says Dr Anoop Gupta of Delhi IVF Fertility Research Centre, insisting “we do all the tests and rarely extract eggs for more than two cycles from one donor”. The tests are for HIV and other sexually transmitted diseases, hepatitis B and C, and genetic diseases like thalassaemia.

Though there is an anonymity clause in the guidelines, most recipients prefer to have at least one glimpse of the donor, say those associated with the process. Not too many bother about the donor’s name but the surname sometimes matters for caste reasons, though recipients don’t insist on this as frequently as they do on the caste of a sperm donor.

Most donors are provided to hospitals by agencies, while touts help strike a deal in some cases, with advertisements calling for donors. “They pay you up to Rs 40,000 every time you donate,” the online advertisement for one clinic reads.

With hospitals unwilling to name the agencies they deal with, just how much reaches the donor is unclear. “Agencies charge as much as the donor. It can be in the range of Rs 20,000-25,000,” says IVF specialist Dr Mangla Telang, insisting they ensure the guidelines are followed. And Dr Nalini Mahajan of Mother and Child Hospital says, “The agency we source our eggs from charges a cumulative Rs 70,000 for each donor though we prefer to do the tests ourselves.”

Recipient couples too are uncertain how the payment is broken up. A Delhi-based couple says, “We paid Rs 3 lakh. We don’t know how much the donor or the agency was paid out of this.”

Many agencies have tie-ups with international donors, or offer Indian donors abroad. “NRIs see Indian donors as a cheap option. They have packages where doctors in the home country examine the donor, while the couple are examined in their country,” says Dr Rohatgi. In such “agreements”, the couple only come to the donor’s country for a week, when the medical procedures are carried out.

The laws

The guidelines allow both advertisement for and payment to egg donors. This is unlike the laws for organ donation, which frown on payment. Authorities say the two cannot cannot be compared.

“We have a very high population of infertile couples, so we need as many donors as possible,” says Dr Sharma of ICMR. In gamete (sperm and eggs) donation, part of the payment goes into funding the tests.

There also is ambiguity about the ideal age of a donor. Clause 3.5.8 reads: “Gametes produced by a person under the age of 21 shall not be used. The accepted age… for the donor woman [should be] between 18 and 35 years.” Later article 3.7.4 says the donor’s age should be between 21 and 35.

The ideal gap between consecutive donations is about three cycles. The guidelines limit extractions to six in a lifetime; the Mumbai donor had at least three since age 16.

Supreme Court advocate Rajeev Dhawan, part of the ART Bill drafting committee, says there will be no scope for middlemen once the ART law comes into effect. “The point of the bill is transparency and any centre — like the one in Mumbai — found involved in violations should be shut down.”

The ICMR is in the process of putting together a voluntary national registry of ART clinics and banks. “We have contacted 886 banks so far, of which 226 have shown an interest in registering,” says Dr Sharma.

source: http://www.indianexpress.com / Home> IE> Story / by Abantika Ghosh & Pritha Chatterjee / New Delhi, Monday July 16th, 2012