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I just received this thoughtful questionnaire from a patient.

We are looking for “gestational surrogacy” in India. There are many clinics offering these services and before moving forward in this decision, we want to have more information about your clinic and some steps of the process. Here are our questions and concerns.


1. How many years of experiences in fertility and surrogacy does your clinic have?

20 years

2. What are the main steps and what is the time table of the whole process
a. Steps

The process is described in details at www.indiansurrogates.in

b. Timeframe

20 days

3. What is the delay from first contact to start of surrogacy?

3-4 months

4. What are the legal concerns with surrogacy?

Our legal consultant will take you through these

5. What are the legal procedures we have to go through?

Our legal consultant will draft the contract which you and the surrogate will have to sign before we start your treatment

6. What is the selection process for the surrogates?

We select the surrogate for you. We screen them for their health; and to rule out infectious diseases; and counsel them as well


7. What facilities do you provide and what control do you then have with surrogates?

The surrogate’s pregnancy is monitored by our obstetric consultant

8. What is the cost and what does it include?

US $ 25000

9. What other expenses / costs (not included) that are at my charge?

Travel

10. How much goes to the surrogate and how much goes to the clinic?

Described at www.indiansurrogates.in

11. What is the probability of success/failure?

Our pregnancy rate is 56% when we transfer 3 Grade A embryos

12. Has there ever been health related issues when the new born is taken back to the parents’ country?

No

13. Do you have a blog webpage where parents can share their experience with your clinic?

You can talk to some of our patients by email at www.drmalpani.com/ivfsuccessstories.htm

14. Why should we select your clinic more than another?

You can read about how we pamper our patients at http://www.drmalpani.com/ivf-treatment-at-malpani-ivf-clinic.htm

I just saw a patient who was 40 years old; she had had 2 miscarriages; and she wanted me to do surrogacy for her. I spent a long time explaining to her why I did not think this was her best choice. Surrogacy is an expensive and complex treatment option, which is best reserved for
women without a uterus. Research shows that the reason for failed implantation is much more likely to be genetically abnormal embryos ( because of poor quality eggs), rather than a uterine problem.

Her reasoning was completely different. The fact I got pregnant means my eggs are OK ! The fact I miscarried means my uterus is defective because it could not hold the baby. This means that if use a surrogate uterus, I will have a baby !

The reality is completely different. The fact that she conceived means her uterus is fine because it allowed the embryo to implant ! However, because the embryo was genetically abnormal, it could not grow any further ! We know that the commonest reason for a miscarriage is a genetic abnormality in the fetus, and this is Nature's defense mechanism, to prevent the birth of an abnormal baby. While these defects are often random, they are commoner in older women. This is because the eggs of older women have more genetically abnormalities, because they have "aged" and have genetic defects, which cannot be screened for. From a purely medical perspective, using donor eggs would be a much better option as it would give her a much better chance of having a baby ! This was my recommendation to her, which she found quite hard to accept.

Logically, it makes no sense for me to clear her misconceptions. After all, I should be quite happy to do surrogacy for her - this is what she wants and I can charge her much more for it ! However, I refused to treat her, and suggested she find another doctor.

I have observed that there are 2 kinds of patients. One group treats me as a professional. They are looking for medical advise and guidance; and want my professional inputs. They have an open mind, and are seeking to form a partnership with me. They want to tap into my professional knowledgebase, so they can make the right decision.

The other group treats me as a technician. They already know what they want - they just want me to do this for them. While this may not be great for my ego ( after all, doctors expect patients to do everything they tell them to !), I am mature enough not to get offended, and am happy to listen to my patients and weight their inputs.

Does this mean I am wishy-washy and will do everything my patients ask me to ? No !

I use a combination of rigidity and flexibility. I am happy to accept patient inputs and preferences and modify my protocols, as as long as they do not affect the outcome ! For example, if patients want us to use the long protocol rather than the short ( which we prefer because it needs fewer injections !)

Similarly, some patients want to use rec FSH for superovulation, instead of the urinary HMG we prefer ( because it's as good and much less expensive !) and I am happy to comply.

However, I will not allow them to do anything which I feel is not right ! I am a professional , and
the buck still stops with me. I will not let them make a wrong decision, no matter what. Thus, if a patient asks me to transfer 5 embryos , I will request them to find another doctor.

Many patients come to me with preconceived notions, especially if they have done IVF treatment elsewhere. Websites and Bulletin Boards are also powerful sources of information - both good and bad ! These patients can be quite a challenge for doctors . If they are well-informed, we can learn a lot from them - but if they are not, it can be quite frustrating to get them to separate facts from reality !

All doctors know that the commonest reason for a miscarriage is a genetic abnormality in the fetus, and this is Nature's defense mechanism, to prevent the birth of an abnormal baby. While these defects are often random, they are commoner in older women. This is because the eggs of older women have more genetically abnormalities, because they have "aged" and have genetic defects, which cannot be screened for. This means that the usual reason for a miscarriage is a problem with the embryo - and most women who miscarry have a completely normal and healthy uterus !

However, a patient who had early recurrent pregnancy losses has a completely different world view ! She feels that the fact that she got pregnant in her bedroom means her eggs must be fine. She usually has regular cycles , and since all her blood tests for ovarian reserve and ultrasound scans for follicular monitoring are normal as well, she has medical evidence to back up this belief ! ( Little does she realise how inefficient human reproduction is; and how common random genetic errors are, even in health fertile women ! )

In her opinion, the fact that she could not grow any of her babies in her uterus beyond 8 weeks clearly proves that it's her uterus which is faulty. This is why the "common sense" approach is - let's change the uterus !

It's true that surrogacy seems to be a logical choice - but this logic is flawed ! In reality , the fact that she got pregnant means her embryo implanted successfully, which is very strong evidence that her uterus is normal ! Using a surrogate's uterus will not improve her chances of having a baby at all ! After all, if her uterus is normal, how will using another woman's normal uterus help her ? However, because implantation is a "black box" area which we do not have the scientific tools to explore, there are still a lot of myths and misconceptions which surround the reasons behind a failed pregnancy. A woman who has had recurrent pregnancy losses has very low self-esteem. She naively believes that if the surrogate has had a normal birth in the past, this proves that her uterus and her body works better than her own - and this is why she chooses surrogacy as a treatment option.

In reality, she would be much better off using donor eggs or donor embryos ! Surrogacy is an expensive and complex treatment option, which is best reserved for women without a uterus; or whose uterus is irreparably damaged ( as proven by hysteroscopy).

Sadly, most doctors will not bother to educate her ! They are quite happy to do surrogacy for her, because this is much more profitable for them !

One of the major problems with surrogacy today is that it is overused and misused.

This is especially true when surrogacy is advised for patients who have failed multiple IVF cycles
or had multiple miscarriages. These patients are very depressed and have very low self esteem. They often end up believing that it's their uterus which is defective; and they therefore believe that surrogacy would be their best treatment option. They often approach IVF clinics asking for surrogacy treatment - and many doctors are happy to oblige, because this is a very profitable treatment option !

In reality, surrogacy is an expensive and complex treatment option, which is best reserved for
women without a uterus. Research shows that the reason for failed implantation is much more likely to be genetically abnormal embryos ( because of poor quality eggs), rather than a uterine problem.

For these patients, embryo adoption is a much better option. It is much less expensive; and has a higher success rate, since it's allowing us to bypass the basic problem. It's also much more socially acceptable, since it's the parent's name on the birth certificate, so that no one else needs to know that the child was born as a result of embryo adoption. Even better, it allows for much better bonding, as the mother can experience the pregnancy herself !

Unfortunately, most IVF doctors do not bother to explain alternative options to their patients , because they can charge much for surrogacy. This is actually a misuse of surrogacy treatment which preys on the infertile couple's ignorance and desperation !

Surrogacy in India gets a lot of press - and often for all the wrong reasons.

There's a lot of talk about how rich Westerners are coming to India for surrogacy and exploiting poor women by using their uterus to have a baby.

Actually, it is true that there is a lot of exploitation occurring - but it's not just the poor women who are being exploited.

In my opinion, a lot of the exploitation is by the IVF clinics - but not of the poor women, but of the rich infertile couples who come to them for treatment !

Many infertile couples are quite desperate to have a baby and are willing to clutch at straws. They've read a lot about how India has become the surrogacy capital of the world - and how it is much less expensive to do surrogacy in India than in other parts of the world. Because so many of them have failed many IVF cycles, they naively believe that surrogacy is the solution to all their problems. After all, the fact that they are infertile means that their bodies are defective. If they use a healthy young woman to have a baby, how can this possibly fail ?

They therefore scour the internet, looking for surrogacy treatment - and there are lots of doctors who are happy to oblige them, because surrogacy treatment spells big bucks for the clinic. Unfortunately, many doctors do not bother to educate the patient , which means a lot of them end up wasting a lot of their money pursuing the wrong treatment.

For example, for many older women, surrogacy is not a good treatment option. This is because their infertility is a result of their old eggs - there's nothing wrong with their uterus, which means that using another woman's uterus will not help to improve their chances of getting pregnant. It will just add to their costs, that's all !

However, in their desperation, they do not bother to do their homework or explore their options intelligently. Surrogacy seems to be the solution to their problems in their eyes and they are happy to pay the money, sign a contract and start treatment. Doctors are happy to pander to their whims - after all, which doctor in their right mind will turn away so much income when it's falling into his lap ? And what's wrong with doing the treatment - isn't this what the patient wants ? After all, if the patient wants it and is willing to pay for it, isn't it the doctor's job to provide the treatment ?

Doctors do not bother to explain to patients that the success rate with surrogacy is limited - especially when it is done with an older woman's eggs. When the surrogacy cycle fails, the infertile patient just blames herself - and signs up for another cycle !

Even worse, many doctors actively cheat their patients. They tell the patient the surrogate is pregnant by claiming that her HCG test is positive. The patients ( who are in the USA) have no way of verifying this - and are on top of the moon. They start celebrating - and then after 8 weeks, they get a phone call, saying - Sorry, your surrogate miscarried ! The patients just blame their fate - and are happy to try again . At least we achieved a pregnancy - maybe we'll be luckier the next time. The doctor has already collected his full fees for the first treatment cycle - and then very kindly offers the patient a discount for their second treatment cycle ! Patients are hooked - and some have done 4-5 surrogacy cycles, without ever getting a baby !

Sadly, there is no way of checking what is happening, as a result of which unscrupulous doctors merrily continue taking hapless patients for a ride. Many doctors really do not care what happens, as long as they get their payment - and there's always another sucker waiting in line !

It's just a matter of time till these malpractises are exposed - at which time , the shi*te will hit the fan and all IVF doctors, both good and bad will pay the price !

My suggestion to patients is simple - do your homework ! Your best protection against exploitation is information therapy !

I just got this email from a patient.

Doctor, I am now at my wit's end ! I have failed 4 IVF cycles at 2 different clinics. The doctor transferred 2 beautiful blastocysts each time ! What do I do next ? My doctor is advising surrogacy, since he believes my uterus is rejecting the embryos.

IVF failure is reproductive medicine's most frustrating problem ! When beautiful embryos fail to implant in a perfect cycle , it's often impossible to determine "what went wrong" ! A knee jerk reflex is to then consider surrogacy.

However, surrogacy is an expensive and complex treatment option, which is best reserved for
women without a uterus. Research shows that the reason for failed implantation is much more likely to be genetically abnormal embryos , rather than a uterine problem.

Just because the embryo transferred was a perfect looking blastocyst does not mean that it was genetically normal ! We still do not have the technology as yet to determine if the embryos are genetically fine. Even though PGD technology is improving, it's still going to take time till it becomes an established part of routine clinical practise. And even if the new PGD technology
( using CGH, or comparative genomic hybridisation , for example) will allow us to check all the 23 pairs of chromosomes, it still only provides a crude check that the chromosomal number is normal - not that there are no genetic defects in the embryo !

Until we can routinely screen all embryos for genetic perfection, the best option is to follow Sutton's Law - to go for where the gold is. If you have failed 4 IVF cycles ( where the embryos looked perfect , the uterine lining was excellent and the transfer was easy), the odds that this is an embryo problem are far more than it being a uterine problem. This is why the chances of success with donor egg IVF or embryo adoption are much higher than with surrogacy.

Of course, most patients want to pass on their own genes to their children, which is why these alternative can be much more difficult options to consider, but they are much easier than surrogacy - and much less expensive as well !

This is great news ! This will allow good IVF clinics to offer surrogacy ethically within a legal framework - and hopefully will help to protect infertile couples ( the intended parents) and the surrogate as well ! read more...

I saw a 30 year old woman today who wanted a second opinion. She had failed multiple IVF cycles in other clinics and had been advised surrogacy. When I reviewed her medical records, I found out that her ovarian reserve had never been properly tested. I checked her AMH levels, and found to my dismay that they were very low. She had very poor ovarian reserve and would need donor eggs if she wanted a baby. I was afraid she would be upset when I broke this news to her, and did so as gently as I could .

I answered all her queries :

Why didn't the other doctors do this test for me ?
How come I am still growing eggs if my AMH is so low ?
Can't we treat the AMH level ?

and then asked her - Are you angry with me for giving you this bad news ?

She looked at my crestfallen face , and then gave me an answer which proved she was wise beyond her years ! She reassured me - Please don't worry doc, actually, this is good news. At least we know now what our problem is, and rather than continuing to grope in the dark, we can explore options which will maximise our chances of success !

Truly I am blessed that I have the opportunity to learn so much wisdom from my patients daily !

We get lots of requests for surrogacy treatment . India is now acknowledged to be a global leader in IVF technology; and because surrogates are easily available and IVF treatment is much less expensive than in other parts of the world, many couples travel to India for surrogacy treatment.

While this is good news, because they can get cost effective treatment, the downside is that surrogacy gets very overused. Because it is very profitable, many doctors offer it to patients who do not need it - and even worse, those who will not benefit from it !

Typically, women who ask for surrogacy are older women, or women who have failed many IVF cycles. They are desperate and emotionally vulnerable and feel that the best solution to their problem of repeated failed embryo implantation is to use a surrogate. They have low self-esteem, and believe that fact that their embryos do not implant means that their uterus is defective. This is why they feel that using a surrogate is a logical answer which will help them to solve this problem ! They have very unrealistic expectations of surrogacy success rates - and a flawed understanding of reproductive biology

The commonest reason for failed embryo implantation is NOT a defective uterus, but rather genetically abnormal embryos. This is Nature's defense mechanism, to prevent the birth of an abnormal baby. While these defects are often random, they are commoner in older women. This is because the eggs of older women have more genetically abnormalities, because they have "aged" and have genetic defects, which cannot be screened for.

This is why if there is a problem with embryo implantation, changing the embryos is a better option than changing the uterus, which is why embryo adoption is often a much better option than surrogacy for these patients.

The reason is simple ! 9 times out of 10, the problem in patients with repeated failed IVF cycles is not with the uterus but with the eggs !

I think this fact needs to be emphasised. As women get older, they know their fertility declines. Most assume that this is because their reproductive system is aging - and for most women their reproductive system consists of their uterus. If menopause = no periods = nonfunctioning uterus, it is quite logical to conclude that increased age = reduce fertility = poorly functioning uterus. Seen from this perspective, changing the uterus to improve fertility by doing surrogacy treatment is very logical !

However, this logic is flawed. Hundreds of medical studies have proven that as a woman gets older and enters the menopause , even though her uterus stops functioning, this is only because of the absence of ovarian hormonal stimulation. If the uterus is exposed to estrogen and progesterone, it starts working one again - even if she is 72 years old !

I feel an effective solution to prevent the misuse of surrogacy is that this treatment option should be endorsed by two independent IVF specialists, before a patient is signed up for an IVF program. This should help to prevent the overuse and misuse of surrogacy treatment !