Anoop Gupta slumps in his swivel chair and surveys what the day has brought his Delhi fertility clinic: a rich housewife who wants to check on the pregnancy of her 21-year-old peasant surrogate; a rural farming couple, both past middle age and seeking an heir after their son was killed in an accident, who need an egg donor; a mother of a developmentally delayed teenager shepherding the surrogate carrying the quadruplets that will maximize her chance for a "normal boy;" a British IT consultant who needs a hormone injection as part of in-vitro fertilization that would cost five times more back home; a Montreal woman who wants profiles of egg donors; and a Toronto mother of two toddler girls who wants a male embryo implanted.
It's a regular day in his packed and humming clinic, where poor women in bright saris and tribal jewellery wait beside women whose vast Louis Vuitton handbags spill over the sides of their chairs.
When 60-year-old Ranjit Hayer gave birth to twins in Calgary two weeks ago - babies conceived with donor eggs collected, fertilized and implanted in India - the news caused an uproar in Canada.
A woman of Ms. Hayer's age would not be treated at a Canadian assisted-reproduction facility; she suffered potentially life-threatening pregnancy complications linked with her age, and her children were seven weeks premature.
But here in his thriving Delhi clinic, Dr. Gupta often sees 10 women like Ms. Hayer before lunch. His clinic literature boasts of 500 post-menopausal pregnancies; "even grandmother can be mother," it says.
Canadians may have been caught off guard by Ms. Hayer's imported embryos, but in the global community of infertility, India is the salvation destination, the country where an unregulated reproductive-technology sector makes anything possible. Mr. Gupta's practice is just one of an estimated 150 clinics across India offering assisted reproduction.
"Total madness is prevailing," said Imrana Qadeer, a professor of public health at Jawaharlal Nehru University and a campaigner for regulated assisted reproduction. "It is a totally unregulated thing ... in India the doctors get away with a lot of things because people trust them and also there is lot of ignorance about technologies. ... Women are vulnerable, they can be pressured, and it's spreading like wildfire."
The surrogacy business is worth an estimated $500-million a year. And while the private clinics in India do not provide any figures on the number of other procedures they perform or the income they generate, no one disputes that the baby-making business is enormously lucrative. Behind the counter at Dr. Gupta's Delhi IVF & Fertility Research Centre, a staff member sits counting huge bricks of rupees; the lineup to pay for drugs or scans or embryos snakes all the way down the staircase.
Dr. Gupta, a genial workaholic with a zealot's admiration for the possibilities of assisted reproduction, considers himself a sort of Santa Claus figure. He promises the endless stream of anxious women that his success rate is about 50 per cent, that they too will have babies. "I feel very happy, very satisfied - if you see so many happy patients who are blessed - they cannot forget you in a lifetime."
But with the babies come a passel of ethical questions. How old a mother is too old? Who looks out for the rights of surrogates, who are usually poor women, often unable to read the contracts they sign with a thumbprint? Where is the line between commissioning an embryo to avoid passing on hereditary disease, and eugenics?
Patients are drawn to Dr. Gupta's clinic, in an upscale quarter of the capital city, because they have heard he has the best success rates. But if he turns them away - too old, too poor - there are plenty of alternatives. Patients report hearing of other clinics where the doctor will inseminate a woman who is 65, will let a woman carry triplets, will find a surrogate they can afford.
Dr. Gupta said 10 per cent of his clients are foreign; most are like Ms. Hayer, people of Indian origin now living abroad. His clinic has policies, as all are supposed to, under a non-binding directive from the Medical Council of India: he said his cut-off age for women bearing children is 50.
But minutes later he happily reported on the case of a 59-year-old woman in whom he implanted embryos the day before; he made her walk 10 kilometres a day for a month to prove she was fit enough. "You could not say she is 59 from looking at her, her system is immaculate."
Does he have qualms about creating a mother that old - who may not even live to see her child into adulthood? "These days, children want to leave their parents by the time they are 15 anyway," he chirped.
"I considered turning that couple away but I thought it would be giving them stress rather than happiness, so that's why I did it."
Dr. Gupta, who works with his wife, Alka Gupta, the clinic's "chief embryologist," is particularly excited about the chance to offer donor egg embryos or surrogacy to women whose first-born children have some sort of congenital problem. "All these people with abnormal babies - thalassemia [a blood disorder] juvenile diabetes, a Mongol child [Down syndrome]" he enthused. "We can help them."
Surrogacy for foreign parents attracts the most attention in India; the practice was pioneered by a Gujarat doctor named Nayna Patel in 2003. Her clinic in the small town of Anand has an adjacent hostel where dozens of village women, many seeking a way to pay to educate their own children, wait out their pregnancies, hot and bored, before they deliver babies for North Americans and Europeans. The total cost is about $10,000, compared with $50,000 to $70,000 in the United States. (Commercial surrogacy is illegal in Canada).
"These surrogate mothers are just being kept there like baby factories," said Nandita Rao, a lawyer pushing for regulation of the fertility industry. "The women are just sitting there producing that child with no rights on that child and no rights on their health - the contract says if you don't produce the child, you don't get the money - so they go on with a pregnancy no matter what [the risk]and there is no maximum number on the times they can do this. In India, which is so fiercely patriarchal, many families are using their daughters-in-law as baby-churning factories."
Many of the best-known Indian fertility clinics offer a roster of surrogate profiles from which to choose. Better educated women command a higher price - perhaps a $7,000 fee, compared to $3,000 for a village woman in Gujarat. The buyer also pays medical and living costs.
One of Dr. Gupta's clients, Anita, a Delhi private-school teacher who didn't want her surname published, found her surrogate through an ad in a women's magazine. At 38, she had failed at IVF herself and sought a young woman to carry a baby made with donor eggs and her husband's sperm. The ad was placed by the surrogate's husband; the woman, Puja, 21, said quietly that she didn't like the idea and it took her three months to agree, that she gave in because her father-in-law has left the family with debts that they must pay. She has two small children of her own. Anita comes to hover over her ultrasounds; asked how Puja felt about carrying the twins developing in her womb, Anita replied blithely, "Oh, we haven't told her yet."
A year ago, Anita had another surrogate pregnancy under way with a woman she brought to stay at her home, but six months in, Anita began to suspect the surrogate was stealing. "We lost confidence in her, so we terminated that pregnancy," she said calmly.
It is part of the standard Gupta clinic surrogacy contract that a surrogate must terminate a pregnancy if the doctor directs her to do so. "We were more careful choosing someone this time," Anita added.
Yet if surrogacy is getting the most attention, much more of the other forms of assisted reproduction are going on here - for example, egg donation has shot up with the economic downturn, Dr. Gupta said.
Dr. Gupta won't allow clients to select the gender of their babies, but there are few other requests he will turn down. "Everyone can afford surrogacy," he said; many of his clients are rural farmers or the urban poor, people who have borrowed money or sold land to pursue IVF. "They feel they are nothing without a child," he said. "I ask, 'Can you sell [an acre]' Invariably the reply is yes. 'Then you can get a baby.' "
The Satyanarayans had no qualms. They are seeking a son to replace their teenage boy who died last year. "We have land and we want someone to have it when we go," Satyabati Satyanarayan said a few minutes after Dr. Gupta assessed her readiness for the donor eggs they will pay $6,500 to have fertilized and implanted.
While a Canadian IVF clinic will not implant more than two embryos in a woman under 37 for fear of creating a multiple-gestation pregnancy, Dr. Gupta's policy is less strict. "You can get a 40-50 per cent success by implanting three or four, and if they are multiple, we reduce the number - if more than two is [not desired]" he said. "Except with Muslims - they make a fuss [about aborting some of the embryos]"
He said that while he has created only four sets of triplets, his clients have given birth to more than 1,000 sets of twins. "It's a two-for-one bonus," he said with a grin.
Dr. Gupta sees 100 patients each day; counselling for assisted reproduction consists of a few minutes of chat with women about their options to maximize the chances of pregnancy. Upstairs, his wife merges the eggs he harvests in the early morning with sperm collected from sheepish men emerging from a room with a selection of DVDs. In her spotless lab, the only quiet place in the teeming three-storey clinic, dozens of embryos grow each day. Downstairs, her husband decides who will get them. "There is no regulation, so you do the most ethical thing you can," he said.
Assisted reproduction includes a host of procedures and techniques, some common and some still experimental. These are among those offered in Indian clinics.
IN VITRO FERTILIZATION
This is one of the most commonly used procedures. A woman's eggs are combined with a man's sperm in a dish in a laboratory. Once fertilization has occurred, the resulting embryos develop for 3 to 5 days before being placed in a woman's uterus.
A man's sperm is placed into a woman's egg with a microscopic needle, rather than many sperm positioned close to the outside of the egg, as in IVF, in a dish in a lab. Once fertilization occurs, the resulting embryo is placed in a woman's uterus.
DONOR EGG OR EMBRYO
An egg donated by one woman is mixed with a man's sperm and the resulting embryo is implanted in another woman's uterus. This procedure also can be done with a donated embryo.
One woman agrees to carry an embryo to term and give the baby to another woman after birth.
In a lab, one of the outer layers of an early embryo is perforated by chemical, mechanical, or laser-assisted methods to assist in implantation of the embryo in the uterus.
IN VITRO MATURATION
A process that matures a woman's eggs in the lab, rather than naturally in the ovaries.