Dr. Gayathiri Ganesan Ram provides an overview of surrogacy in 3 sentences or less: Surrogacy involves a woman carrying and delivering a child for another couple, and can be done through natural or IVF means using the genetic parents' gametes. It is an option for women unable to carry a pregnancy themselves due to medical reasons. The document outlines the counseling, treatment, and legal considerations involved in surrogacy arrangements in India.

1. SURROGACY
Dr. Gayathiri Ganesan Ram
MS(O.G), Fellow in Reproductive Medicine and
Andrology.
Consultant Reproductive Medicine Specialist
ARC Fertility Hospitals

2. INTRODUCTION
• The earliest mention of the term `surrogacy' is
in the Old Testament of the Holy Bible
• The story is told that, because Sarai had been
unable to bear Abraham a child, she
suggested to him that he `go unto my maid
Hagar; it may be that I may obtain by her'.
Abraham did as he was told and, at the age of
90 years, he was able to father a child by
Hagar, and Ishmael was born.

3. • Until the introduction of modern assisted
reproductive techniques, `traditional or partial
surrogacy' was the only means of helping
women who had no uterus or major
abnormalities of the uterus to have children.

4. • The term `surrogate mother' or `surrogate' is
usually applied to the woman who carries and
delivers a child on behalf of another couple.
• Rent – a – womb.

5. • Genetic couple, commissioning couple, intended
parents – the couple who provide the sets of
gametes.
• Surrogate host – The woman receiving the
embryos created from the gametes of the genetic
couple.
• Natural surrogacy, traditional surrogacy,partial
surrogacy – eggs belong to female carrying the
baby, the intended host is inseminated wuth the
semen of the husband of the genetic couple.

6. • Gestational surrogacy, IVF surrogacy – a
treatment by which gametes of the genetic
couple or intended couple in a surrogacy
arrangement are used to produce embryos
and these embryos are transferred to a
woman who agrees to act as a host for these
embryos.

7. • Commercial surrogacy – surrogate is paid over
and above the necessary medical expenses.
• Altruistic surrogacy – surrogate is paid only
the necessary pregnancy related expenses and
at times nothing at all.

8. INDICATIONS
• Women without a uterus but with one or both
ovaries functioning. Women with congenital
absence of uterus, hysterectomy for cancer or
fibroid.
• Women who suffered repeated miscarriage,
failed ivf cycles.
• Severe heart disease where pregnancy is CI

9. COUNSELLING
• The aim is to prepare both couples contemplating
this treatment to consider all the facts and to
look carefully at the implications for them, both
short-term and long-term.
• For the proposed host and her partner, careful
consideration must also be given to the
implications of their proposed action on their
existing children.

10. TREATMENT OF GENETIC MOTHER
• Stimulation with gonadotrophins.
• Oocyte retrieval.
• Embryos are frozen for minimum of 3 months.
• During the last month, host mother is further
counselled, genetic parents have to undergo
HIV test,if negative then go for HRT.

11. SURROGACY TREATMENT
• Endometrial preparation with HRT.

12. QUARANTINE OF HIV STATUS
• Regulations in the UK require that the sperm
of the commissioning or genetic
husband/partner must be `quarantined' for 6
months before being used, or the embryos
created with his sperm must be frozen and
quarantined for 6 months (Human Fertilisation
and Embryology Authority, 2001).

13. • . The genetic husband/partner then has a further
test of his HIV status and the embryos may be
transferred or the sperm thawed and used to
create `fresh' embryos for transfer to the
surrogate host.
• This policy is governed by the rule which states
that sperm used in surrogacy arrangements must
be treated in the same way as donor sperm,
which, by law in the UK, must be frozen and
quarantined for 6 months before it can be used.

14. GENERAL CONSIDERATION
• A child born through surrogacy must be
adopted by the genetic (biological) parents
unless they can establish through genetic
(DNA) fingerprinting (of which the records will
be maintained in the clinic) that the child is
theirs.

15. • Surrogacy by assisted conception should normally
be considered only for patients for whom it
would be physically or medically impossible/
undesirable to carry a baby to term.
• Payments to surrogate mothers should cover all
genuine expenses associated with the pregnancy.
Documentary evidence of the financial
arrangement for surrogacy must be available. The
ART centre should not be involved in this
monetary aspect.

16. • Advertisements regarding surrogacy should not
be made by the ART clinic. The responsibility of
finding a surrogate mother, through
advertisement or otherwise, should rest with the
couple, or a semen bank
• A surrogate mother should not be over 45 years
of age. Before accepting a woman as a possible
surrogate for a particular couple’s child, the ART
clinic must ensure (and put on record) that the
woman satisfies all the testable criteria to go
through a successful full-term pregnancy.

17. • A relative, a known person, as well as a person
unknown to the couple may act as a surrogate
mother for the couple. In the case of a relative
acting as a surrogate, the relative should
belong to the same generation as the women
desiring the surrogate.
• She should not act as surrogate for more than
3 times in her life.

18. • A prospective surrogate mother must be tested for HIV
and shown to be seronegative for this virus just before
embryo transfer.
• She must also provide a written certificate that (a) she
has not had a drug intravenously administered into her
through a shared syringe, (b) she has not undergone
blood transfusion; and (c) she and her husband (to the
best of her/his knowledge) has had no extramarital
relationship in the last six months. (This is to ensure
that the person would not come up with symptoms of
HIV infection during the period of surrogacy.) The
prospective surrogate mother must also declare that
she will not use drugs intravenously, and not undergo
blood transfusion excepting of blood obtained through
a certified blood bank.

19. HIGHLIGHTS OF ICMR GUIDELINES
• The ART clinic shall not play a role in
commercial surrogacy arrangements.
• It entitles the surrogate to receive financial
compensation.
• Close members of the infertile couple can act
as surrogate.
• The birth certificate shall have the name of
the genetic parents.

20. • The surrogate must surrender all parental
rights as regard the child in writing.
• It specifies that surrogacy arrangements are a
viable option only for infertile couples or for
those whose pregnancy can prove to be
hazardous.
• ART clinics has to get approval from
appropriate accreditation authorities. Legally
justified.

21. NOT OPPOSED TO PUBLIC POLICY
• Agreement to give or take child

22. GENETIC LINKAGE
• Mere adoptation does not give a genetic
linkage to child.
• Birth Certificate – name of genetic parents.

23. INDIA ADVANTAGE
• Surrogate has no legal rights over the child.
• Cost factor is much less.
• Financial compensation is allowed to the
surrogate.
• No long waiting lists.
• Birth certificate in the name of the genetic
parents.
• Good results and very efficient IVF treatment.

24. BABY MANJI CASE
• Last summer, a baby girl named Manji was born to an Indian surrogate. These
days, there's nothing too unusual about that: According to The Economist, the
Indian surrogacy market is now worth about half a billion dollars. Surrogates are
typically poor uneducated women from rural villages. Fertility clinics pay them
between $4,500 and $5,000 for carrying a pregnancy, and charge their clients -
many of whom come from outside the country - about twice that.
In this case, the arrangement got sticky not because the surrogate wanted to keep
the baby (a common concern for those hiring a surrogate) but because the
Japanese couple who were the "intended parents" had divorced. The husband still
wanted to raise Manji, but his ex-wife did not.
The father found himself in a catch-22. India requires that a child be legally
adopted before leaving the country, but bars single men from adopting. Manji's
father was denied travel documents for the baby. The situation was widely covered
in Indian and global media, and grew into a legal and diplomatic crisis.
Manji was eventually permitted to leave for Japan, but the debate within India
about surrogacy has continued.