Tammuz International Surrogacy agency, which opened its doors in South Africa in 2008, is in search of women under the age of 31.
At first glance the prospect appears enticing. An all-expenses-paid holiday in Mumbai, including flights, visas, breakfast and dinner, transport to and from the airport and a little sightseeing. Of course there are the hormones. First an oral contraceptive pill and then self-administered injections, twice a day for two weeks. Then there are the repeated transvaginal scans and a barrage of blood tests, including one for HIV.
The hormones cause hot flushes and menopausal-type symptoms initially, and then bloating, mood swings and crankiness. With such heightened symptoms of premenstrual syndrome, the agency's website advises that you may need extra time-outs on your holiday, so it is best to leave your boyfriend behind. Anyway, smoking, drinking and sex are forbidden.
On the designated pick-up day, a triggering agent will be injected and, under general anaesthesia, a needle will be inserted through the vaginal wall and into the abdominal cavity to suck up the multiple ripe eggs, forced to bud from the ovaries. That day will be spent in hospital. The agency describes it as a relaxing experience, where the "many girls all donating at the same time", can "make friends and catch up on gossip".
Although there are risks, the agency states reassuringly that these are rare. Ovarian hyperstimulation syndrome, or OHSS, affects about 1% of donors and resolves completely within two weeks, according to the agency. "If there are complications," the agency continues, somewhat ominously, "where you need to remain in hospital in Mumbai, you must do so."
What the agency doesn't tell you is that OHSS occurs after retrieval when fluid collects in the abdominal cavity and – in severe cases – around the lungs and heart, causing breathing difficulties. Ovaries may swell to 12 times or more their normal size of an almond and – turgid and heavy – are at risk of twisting on their stalks and losing their blood supply, a condition that requires urgent surgery and may result in the loss of the organ. OHSS, for which there is no specific treatment, can be fatal, with women dying of renal failure or strokes.
Dr Paul le Roux is a fertility specialist in Cape Town and president of the South African Society of Reproductive and Endoscopic Gynaecologists. Last year, the group he heads called on the department of health to launch an investigation into agencies such as Tammuz, which is one of four international ovum donation agencies operating in South Africa. Others are Global Egg Donors, FertilityCareSA and New Life, all of whom recruit women for donation in countries such as India and Thailand.
The society's concerns centre on possible health risks to vulnerable young women, particularly regarding the use of HCG, a type of pregnancy hormone used in ovum release. Lucrin, a safer agent, is used in most parts of the world, including South Africa.
However, after treating several women who have returned from India with OHSS, and receiving reports of others, Le Roux believes that many Indian fertility clinics are still using HCG which, in spite of its dangers, results in a larger ovum haul but puts women at a higher risk for OHSS. He is also concerned that flying with even mild OHSS greatly increases the risk of deep-vein thrombosis. Other risks of egg donation include bowel and bladder puncture, which can cause serious surgical emergencies.
To ensure a high standard of care in South Africa, the South African Society of Obstetricians and Gynaecologists has guidelines and an accreditation system for ovum donation agencies that includes a code of conduct. Because of concerns of possible health risks to donors agencies sending women overseas will not be accredited, and South African fertility specialists are requested not to work with them.
But despite the society's concerns, Zolani Zenzile, spokesperson for the Western Cape department of health, told the Mail & Guardian that, according to the department's investigation only one agency in South Africa was recruiting women for egg donation overseas. Zenzile noted that there is no statuary provision preventing women from donating eggs in other countries.
Tammuz, New Life, and FertiltyCareSA all appear to be recruiting egg donors for foreign travel. They did not respond to requests for interviews.
Robyn Newman, founder of Global Egg Donors, declared in a telephonic interview from California that she does not have offices in South Africa, but that she does have "less than a dozen" South African donors on her books. She said donors should be careful about which agency they use because standards in Indian clinics vary.
'I think the risks depend on which agency you go through," says "Kim", a serene, 20-something egg donor, with porcelain skin and blue eyes, who asked to remain anonymous because Tammuz requires their donors to sign a contract forbidding media contact. "Some girls do get 'hyperstim' [OHSS], but the agency takes good care of them. They watch us very closely."
Kim has donated three times in India and four times before that in South Africa. South African regulations only allow an individual to donate six times. She describes the trips to India as "incredible" and "amazing".
According to its website, Tammuz was founded in Israel by Doron Mamet after he and his male partner in Israel had a daughter by surrogacy. The South African branch of Tammuz, according to Kim, comprises just a pair of "co-ordinators" who hold regular recruitment dinners at local restaurants. Tammuz does not have offices.
Kim says that the agency now has over 400 donors on its books – some as young as 18 – and groups of about 20 young women are flown to the subcontinent every two months.
"We all get pretty moody from the hormones and sometimes there are catfights," says Kim. "But it ends up a fun holiday. You get to help somebody and the money is always useful."
Agencies stress that donors should have an altruistic desire to provide the childless with offspring, however the process has economic underpinnings. Donors are prohibited from being paid, but they are "reimbursed for their time and discomfort." In addition to the free flights and hotels, women travelling to India receive about R20 000, compared with R6 000 for donation here in South Africa.
But for agencies like Tammuz, recruiting egg donors is just a sideline. Their main business is producing babies through surrogate mothers for clients around the world, for which they need a constant supply of human eggs from women like Kim.
In a science fiction-like chain of events, eggs removed from a donor, (or the client herself) are mixed with sperm from the intended father or donor. The
resulting embryos are implanted into another hormonally prepped woman who will then bear and give birth to the baby or babies. Surplus embryos are frozen for future use.
Tammuz has a variety of plans on offer, all of which are detailed on its website. Most costly is the "West Plan", in which the entire process takes place in the United States for around $100 000. This includes surrogate fees of $18 000 to $22 000, with a supplement of $3500 to $5000 for twin pregnancies, and a reimbursement of up to $3 000 for a Caesarean section. Additional costs include psychological consultation and legal counselling for the surrogate as well as life insurance, maternity clothes, baby-sitting fees, housework assistance and travel expenses.
However, Tammuz – not unlike sports shoe manufacturers and call centres – has discovered that it is far more cost-effective to outsource the entire process to India where, for example, frozen embryos can be shipped overseas and implanted into an Indian carrier, producing a baby for as little as $32000, inclusive, of which the surrogate will receive between $5000 and $8 000.
For a few thousand dollars more, Tammuz will fly South African egg donors to India, where the resulting embryos can be implanted fresh. South Africans are a cheaper alternative to American donors who expect $6 000 to $10 000 for their eggs. To cut costs even more, Tammuz offers a scheme of egg sharing, in which eggs from a single donor are divided between two or more clients. To entice customers, Tammuz advertises the availability of high-yield donors, capable of producing 18 to 24 eggs at a time.
International fertility tourist trade
According to Le Roux, inducing donors to produce such high numbers of eggs, and then triggering with HCG, means that roughly one in 33 women giving up her eggs may require hospitalisation for OHSS after the procedure.
But Tammuz is just one of the hundreds of fertility agencies operating in India, where a vast pool of impoverished, often illiterate, women compete to carry a pregnancy for as little as a few thousand dollars. In an attempt to attract the lucrative international fertility tourist trade, India legalised commercial surrogacy in 2003, joining a smattering of countries such as the Ukraine, Thailand, Russia, Georgia and some parts of the United States.
Some countries allow strictly regulated altruistic surrogacy, in which the surrogate is compensated only for her medical expenses. In other countries, such as France, Japan, Greece, Sweden, Norway, Italy and the Netherlands, surrogacy is banned.
Altruistic surrogacy is legal in South Africa, and surrogates are reimbursed with a standard fee of about R150 000 for the inconvenience of pregnancy, but only if the commissioning couple and the surrogate all reside in the country and there is medical proof that the intended mother is physically unable to bear a child. The high court must examine any contract between the surrogate and the parents or parent, before the implantation of embryos can proceed.
The global demand for fertility services has surged of late as women in industrialised countries delay pregnancy until their late thirties. These medical interventions – if allowed at all in the home country – are costly, and promise various degrees of success.
In 2007 an American couple appeared on Oprah Winfrey's show to tell their story of how a quest for an affordable surrogacy service took them to a clinic in India – a transaction presented as a win-win situation, in which the happy couple took home a baby and a disenfranchised woman escaped poverty by receiving 10 times her annual salary. Demand for Indian surrogates skyrocketed. Hollywood and Bollywood celebrities, by publicly choosing surrogacy, have also glamorised the process.
It is now thought that about 25 000 fertility tourists currently visit India yearly, resulting in several thousand babies born to local surrogates in an industry estimated to be worth more than $2-billion annually.
"Wherever we stay in India [to donate eggs] there are always couples picking up their babies. Surrogacy is so huge," says Kim.
Surrogacy candidates are usually presented as warm-hearted women with a wish to help the childless, but when the Centre for Social Research in India surveyed 100 Indian surrogates, the researchers found that the pregnancy carries high levels of social stigma and their motivation is primarily financial desperation.
The surrogates, who must have children of their own, hoped to buy a dwelling or pay for their children's education. Roughly half the women were literate, many were presented with contracts only after four months of pregnancy and very few were given copies of the signed contract to keep. Almost all were told they were giving birth for a married couple and that the woman had no uterus. Because the fees paid to the surrogates proved insufficient to buy a small dwelling or pay for higher education for their children, many of the women expressed a need to undergo further pregnancies.
Several centres – including the Akankshya clinic featured on Oprah – have attracted controversy by sequestering the pregnant surrogates in hostels away from their husbands and children for the gestation period. Commissioning parents pay the clinic extra fees for the service, and although the scheme is presented as an opportunity for poor, hard-working women to get some decent food and rest for the first time in their lives, the subtext is that the surrogates will be kept safe and free from substance abuse and possible sexually transmitted infections.
In a bid to be competitive many clinics offer an array of "guaranteed programmes". New Life India's website, for example, advertises: "We will guarantee a baby or you will get your money back!" Clients must be prepared to share ovum donors, and the resulting embryos will be implanted into two surrogates. Tammuz offers three surrogates in their programme.
Indian regulations currently permit the implantation of three embryos at a time, although certain fertility websites openly advertise the implantation of four embryos, twice the international recommendation of no more than two.
On its website New Life India warns prospective clients in the "guaranteed programme" that they could be responsible for two pregnant surrogates and that "embryo reduction" will only be undertaken for pregnancies of triplets or more. Parents not wishing for more than one baby are to grant New Life India the right to give extra babies up for adoption.
According to the Centre for Social Research's report, surrogates in their study were routinely implanted with five or more embryos, of which three often took root. "Foetal reduction procedures", or selective abortions, were performed on women carrying triplets or more, thus providing commissioning parents with an opportunity to select for gender.
Because of the high numbers of embryos implanted per surrogate, twin rates at some clinics can run at 75%, three times the internationally accepted rate. Some agencies pay surrogates an extra $1 000 or $2 000 to carry twins, even though the complication rate is more than twice that of a singleton pregnancy.
Last year the Guardian reported on the death of Premila Vhagela, a 30-year old Gujarati mother of two, who suffered a seizure while waiting for a check-up for the child she was carrying for an American couple. Vhagela died soon after the live baby was delivered by Caesarean section.
Surrogates often sign contracts stating that they voluntarily accept "all side effects and discomfort" related to the pregnancy – thus releasing the medical professionals, commissioning parents and lawyers from all liabilities. Vhagela most likely died of eclampsia, a very serious condition, which usually affects one to two percent of natural pregnancies and accounts for 18% of all maternal deaths.
Surrogate pregnancies have increased risk for all gestational complications and some research suggests eclampsia may be as much as 10 times more common in pregnancies resulting from donor eggs.
Until January this year, there were no official laws in India pertaining to surrogacy. This allowed contracts to be left to the discretion of the clinics and surrogates. Babies are given the nationality of the commissioning parents and the surrogate mother's name does not appear on the birth certificate. Amid mounting global pressure, the Indian department of home affairs issued the new regulations, which offer surrogacy services only to couples married for at least two years and from countries recognising surrogacy. Singles and same-sex couples will no longer be eligible. Fertility clinics have responded with an outcry of protest.
But international fertility services are not restrained by borders, and clinics are mushrooming in countries where women are poor and legislation lax or nonexistent.
High-yield egg donors
Meanwhile, the website of New Life South Africa, the most recent unaccredited agency to begin operations in this country, provides a glimpse into the global tendrils of the business. With branches in the Ukraine, Poland, Thailand, Georgia, India and Armenia, New Life offers a cornucopia of assisted reproduction services from laser assisted hatching to testicular sperm extraction.
Many surrogates are available in the country of your choice and a large pool of high-yield egg donors, including South Africans, are willing to fly to your destination. Maternity house fees are low. Looking for pre-implantation gender selection to "balance the family"? Choose a clinic in the Ukraine where an Estonian embryologist will assist. HIV positive? A surrogate in Thailand will carry your child. To avoid the inconvenience of unnecessary travel, frozen embryos and sperm can be shipped to the clinic of your choice. And, according to the website, egg donors must sign contracts accepting HCG as their triggering agent.
In an email response to the Mail & Guardian's request for an interview, Mariam Kunkunashvili, founder and director of New Life International and herself the mother of children through surrogates, replied only "Why we have to explain the ways how we work?"
Among the clients providing online testimony to New Life's services are an Azerbaijani couple who currently have four pregnant surrogates in Georgia. And in this brave new world, in which unsettling transactions exist between commissioning clients, for-profit agencies and women offering their reproductive abilities for cash, New Life advertises that it accepts payment in convenient instalments.
Martinique Stilwell is a medical doctor and a writer