Unraveling the Fertility Industry: Challenges and Strategies for Movement Building ...

International Consultation on commercial, economic and ethical aspects of Assisted Reproductive Technologies (ARTs)

January 22 – 24, 2010, New Delhi

Background

The escalation of birth technologies into a ‘fertility industry’ is a result of a multitude of reasons, the most primary amongst which is the premium placed on motherhood combined with the social stigma associated with infertility. A society that manufactures the desire for biological progeny, then stigmatizes the individuals who cannot or do not want to follow this social ‘dictat’ makes for a very fertile ground for the growth of the ‘fertility industry’. The importance and desire of having a biological child cuts across all class, caste and community groups and couples are willing to spend whatever is required to achieve this. The fact that the technology is available makes it impossible for couples to give up the quest for a child and the desire for a biological child makes them lose sight of the risks involved.

Providers of Assisted Reproductive Technologies (ARTs) have conveniently used the need for a child, to project this technology as being pro women. Governed by the language of demand and supply, this field of infertility ‘treatments’ is interested in generating profits through the sale of ARTs. Hence, women in these markets are not only sought as ‘clients’, their reproductive body parts like ova and uteri are also fragmented and commercialized. The fertility market issues a price tag to reproductive tissues and then appropriates them in order to sell the unfulfilled dream to millions of people, under the rubric of ‘choice’ and ‘rights’. The process of reproduction has been systematically pushed out of the personal domain into the commercial through these technologies.

Developing countries and the comparatively poorer populations within these countries have increasingly emerged as ‘suppliers’ of cheap labor (womb) and services (both medical services and egg donation). In a globalize economy with uneven regulation across countries, couples manage to access the services either in their own countries or elsewhere. This has led to the super-specialized phenomenon of reproductive tourism across the world. As part of this process, India is slowly turning into the surrogacy outsourcing capital of the world because of the lower costs involved, the lack of regulation in provision of ARTs, prohibition and unavailability of certain procedures in their own countries and minimum waiting periods. It is estimated that the surrogacy business alone is worth $445 million in India (1). In Chennai, for example, 207 women/couples from abroad accessed ART procedures in a private IVF clinic in 2006 alone (2). Given the extreme vulnerability of almost one-third of the Indian women due to poverty, exclusion, marginalization in labour and job markets, patriarchal structures in the social and family domain, low educational levels and the immediate financial gain through surrogacy becomes a key push factor.

Some of these underlying trends in this industry have emerged very clearly in the research on the various social, medical, economic and ethical implications of ARTs being conducted by Sama Resource Group for Women and Health. Our research in this area in India has thrown up a complex set of issues, some of which have to do with internal factors of poverty, religion, caste, gender and state apathy. Ethical practices, as such, almost cease to exist and worrying stories of unscrupulous means to maximize profit by cashing in on people’s vulnerability abound. Most women undergoing ARTs who are a part of the study report being given piecemeal and incomplete information about these procedures. The side effects are described by the providers as minimal, negligible and affecting only a few. Success rates are inflated. Often, the implantation rate or the chemical pregnancy rate was quoted as the success rate, rather than the live births rate or the “take home baby” rate.

It was also found that the providers often develop their own eligibility criteria for the couples according to which, quite often, single or homosexual women/men fall outside the purview of these services. Providers expressing reservation and even differentiating between one kind of ‘single woman’ from another gives a glimpse of the larger social framework, which has its basis in the institution of heterosexual marriage. An analysis of advertisements seeking surrogates and egg donor also brought up stereotypes, which revealed an obsession with particular kinds of physical features, indicating eugenic tendencies.

Reproductive tourism, explicitly targeting foreigners and Non Resident Indians (NRIs), is also clearly emerging as a burgeoning trend among ART clinics in India. Clinics go to great lengths to lure foreign couples with special packages, incentives and customized services. A significant number of websites devote a section on overseas clients. For example, some clinics located in Indian states, which are popular tourist destinations, have designed ‘IVF holidays’. The coupling of ART procedures with tours and holidays as a medical tourism package is fiercely marketed by the clinics in collaboration with the government has emerged as a new trend in ART promotion.

The role of the Indian state

It is also interesting to note that while supporting and encouraging these technologies, infertility has never been addressed as a public health issue in India. This has led to the overlooking of underlying factors that cause infertility in the first place. Thus the ‘infertility industry’ refers to only the ‘treatment’ options with no regard to the causative factors.

The ART industry in India remains, as of now, unchecked by any state rule or law. The lack of political will in regulating these technologies can be linked to the commercial gains being made by the state and the private entrepreneurs through the in-country rapid proliferation of clinics and the cross-country transactions for services, gametes and surrogates. Proliferation of clinics and unregulated practices have continued in spite of the National Guidelines for Accreditation, Supervision and Regulation of ART clinics in India developed by the Indian Council of Medical Research (ICMR) in 2005, as it has no legal binding. The intent of the recently released Draft Assisted Reproductive Technologies (Regulation) Bill & Rules-2008 also appears to promote the interest of the private sector providers of these technologies rather than regulate them while encouraging medical tourism. Thus, the role of state in dealing with infertility as an issue affecting women’s health and wellbeing has been grossly inadequate.

Challenges

In light of the above context and the recent developing trends, some of the important questions raised are as follows:

  • Although considered altruistic, intra family surrogacy may involve various kinds of pressures/compulsions and may be as physically and mentally exploitative as those with commercial transactions, if not more.
  • Accessing services, donors and surrogates from other countries raises important questions relating to the legal/political citizenship of the children born from these procedures.
  • Another contentious issue that is indirectly related to ARTs is that of stem cell research. India has a thriving IVF industry; “spare” human embryos are already traveling from IVF clinics to public and private research laboratories within and outside the country. This practice has led to a thriving nexus between the (in) fertility clinics and the stem cell research centres, raising many ethical and other important concerns.

Sama's engagement

Sama has been initiating discussions and debates around Assisted Reproductive Technologies in different movements and fora, especially with regard to their regulation. In the last three years, we have organized Consultations at regional and national level to understand the social, economic and ethical implications of these technologies. The research study and consultations have thrown up many more challenges and concerns. Some of these have been question that various movements are already grappling with, while others are the results of newer developments. The concerns range from market expansion of ARTs, the marketing of the dream, the demand- supply chain to its ideological underpinning of patriarchy: commodification and commercialization of body parts and processes and medical tourism in the context of ARTs.

Although the advancement of these technologies and the related discourse are at different stages in various countries, it is equally important to have the opportunity to learn from the experiences of each other. Although there are differential cultural connotations of infertility across space and time, the ‘fertility industry’ today has international ramifications in terms of:

  • Development of different kinds of ‘infrastructure’ and different kinds of agencies and agents to facilitate movements of results of research, technologies, personnel in search of such facilities and personnel willing to ‘host’ such facilities [through surrogacy, egg donation etc,];
  • State interventions through facilitation of creation of above infrastructure including enacting new laws or amending old ones
  • Resources being pumped in to research on newer technologies, specifically embryonic stem cell research, cloning etc.
  • Promotion of ARTs within the larger rubric of “medical tourism”;
  • Issues related to Intellectual Property Rights and commercial interests in the context of New Reproductive and Genetic Technologies (NRGTs)

The complex nature of the issues involved, the different levels at which they need to be dealt with, the range of people that need to be brought together – all these imply the need for continued alertness, preparedness, information sharing and strategizing. Therefore it is crucial to have a platform to discuss and debate the commercial, economic and ethical aspects of Assisted Reproductive Technologies (ARTs).

Through this consultation, we intend to:

  1. Share and exchange information emanating from activism, research, practices, policies and regulatory mechanisms gathered from the ground from across the world and thereby enable the development of a framework for ethical norms and regulations;
  2. Further the emerging debates on ‘new’ reproductive and genetic technologies in the context of public health and policy, research, ethics and practice;
  3. Comprehend the advancements and debates around scientific research on infertility care, stem cells and cloning and examine the research priorities in the context of access to basic health care;
  4. Locate the discussions and debate on ARTs within the framework of women’s health, rights and social justice;

 

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(1) IANS, (August 25th 2008), ‘Surrogacy a $445 mn Business in India’, The Economic Times (top)

(2) Babies waiting to happen, Sumithra Thangavelu, Businessline, Feb 02,2007 (top)