The Red Market (14 page)

Between 1996 and 1999 that is exactly what an Israeli doctor named Zion Ben-Raphael was accused of doing to his patients without their knowledge. In one case he took 181 eggs from a single unknowing donor, breaking up the batch into lots and selling them to thirty-four paying patients seeking babies. In the course of his tenure thirteen women were hospitalized because of the massive doses of hormones he delivered. Shortly after the scandal was uncovered by the newspaper
Haaertz,
Israel banned all paid egg donation. But the ban sent couples abroad, kick-starting the Petra Clinic’s career.

It was just one of a series of similar incidents with Israeli doctors. In July 2009 in Romania, police arrested two Israeli doctors for operating a scheme to bring Israeli fertility tourists to Bucharest for implantation. A sixteen-year-old factory worker was hospitalized and nearly died after selling her eggs to them.

WHILE THE CLINICS OF
Cyprus sometime feel like frontier outposts, the ones in Spain seem like established fortresses. Spain has been the top destination for European fertility tourists since the mid-1980s. At Barcelona’s Institut Marquès, a fourteenth-century carriage house in one of the poshest areas of town, you can understand why they’ve made a fortune in the egg business.

Inside, behind sliding-glass doors and whooshing air locks, are two embryology labs where a half dozen workers in blue scrubs and ventilated face masks help turn baby-making from a romantic endeavor into a scientific one. One woman looking at her computer monitor zooms in on an area full of squiggling sperm and a giant human egg. She turns a dial on a control panel and slowly manipulates a microscopic hypodermic needle toward a lone squirming sperm. As it’s lined up she presses another button and sucks it up into a chamber off the computer screen. Once there a tiny knife lops off its tail.

“If we cut off the tail it helps the genetic material escape once we implant it into the egg,” she says. Then, as if to punctuate the sentence, she thrusts the needle’s point through the egg’s cell wall and squirts the tiny genetic bundle inside. Presto. Life via laboratory.

This embryo, along with its siblings, has two paths. Two or three of the strongest and most obviously viable will be implanted into a woman who hired the clinic’s services, while the five or six excess embryos will sit cooling in a liquid nitrogen bath just in case the first batch doesn’t take. Only then will they get a chance to form into something more significant than a bunch of cells.

If one does take and becomes a child then it will probably grow up in Britain. In 2009 the Institut Marquès opened a satellite office in London, offering full-service, pregnancy-guaranteed packages for as little as $37,000 for three IVF cycles. Since each cycle has an approximate 30 percent chance of becoming a viable pregnancy, the overall odds are good.

The stream of foreign customers is so steady that the clinic no longer waits for patients to sign on before tracking down appropriate donors. Instead it keeps a bullpen of women on hormones, ready to give eggs. The clinic simply matches up incoming customers with eggs that are already coming in along the supply chain.

“Sometimes we will lose the eggs if we can’t find a customer, but it’s a trade-off. This way we can guarantee a steady supply,” says Joseph Oliveras, an embryologist at the clinic. The system allows for very short waiting times. It also helps that according to Spanish law, the patient has no control over selecting their donor’s characteristics. Matching donors is entirely left to the doctor’s discretion, usually by phenotype, but the choice is also probably influenced by availability.

Clinics recruit heavily at Spanish universities and occasionally pepper campuses with flyers. A college diploma is a selling point to customers especially when they can’t know much more than this about the donor. However, much more reliable and less talked-about sources of human eggs—especially in Spain, where unemployment soars close to 20 percent—are illegal South American immigrants who have few other options to earn money.

That’s fine with most buyers, says Olivia Montuschi, cofounder of Britain’s Donor Conception Network, which works with families who have conceived via donated genetic material. (Montuschi’s son and daughter were conceived with donor sperm after her husband was found to be infertile.) “The vast majority of women don’t care where the eggs actually came from. They are so down the line with unsuccessful fertility treatment at that point that they will go anywhere and do anything.”

Nicole Rodriguez (a pseudonym), a Chilean immigrant, says that she sold her eggs to another clinic shortly after arriving in Spain. “We weren’t wetbacks—we were students of the visual arts—but I didn’t have permission to work yet,” she says. “It seemed like easy money.” She knew what the clinics wanted. “My skin is a little bit dark, but it was fortunate that it was winter and I was really pale at the time. When I arrived at the clinic, they asked me what my skin color was. I had also put on a lot of makeup, so that they said that my skin was white.”

She laughs while recounting her first conversation with a clinic recruiter: “I had asked, ‘How much do you pay for eggs?’ The woman corrected me, saying, ‘You mean your donation of eggs.’ I said, ‘Yes, excuse me, excuse me—the donation of eggs.’ ” During the harvesting she chose to undergo general anesthesia. When she woke up, an envelope of cash was lying next to her. “It was like they had thrown cash on a bed stand after seeing a prostitute,” she says. The payment of $1,400 was enough for her to live on for four months.

Claudia Sisti, a former patient assistant and international coordinator at the clinic Dexeus in Barcelona, says that these women’s experiences are all fairly similar. “Most of the donors were from Latin America; it was easy money for them,” she says. Some of the donors even tried to go pro: “One Brazilian woman I knew sold her eggs four or five times in the course of a year and got sick. She was very thin, but they always accepted her into the programs.”

Most egg donors I was able to track down independent of the clinics’ PR department told similar stories.

A second woman, Kika, an immigrant from Argentina, says that when she gave her eggs she was surprised to see a room full of other South Americans there for the same reason. “They weren’t Spanish. They were immigrants. It made me think that this was an immigrant thing, like they were all looking for a way to survive.” The injections didn’t go well though. “All of the eggs they harvested were too big; the doctors called them super eggs and decided to stop the treatment. They only paid me half the money they promised because they weren’t able to get the full batch.” The reduced payment gives credence to the argument that the clinic wasn’t compensating her for the time and trouble, but the number of eggs they were able to use.

In the end, and despite how clinics and administrators like to talk about it, eggs trade like commodities and move like widgets through supply chains. As the clinics continue to formalize donor recruitment strategies and streamline the pregnancy process, they create a new paradigm for how the world approaches flesh sales. In a way, the human egg is the test case—better than even the kidney—to determine how hospitals will treat commercialization of human tissues if the world tears down barriers on the market.

“The technology is at a point now,” says David Sher, founder and CEO of the Switzerland-based fertility service company Elite IVF, “where if you provide sperm, we can basically FedEx you a baby.” Most parents, of course, would not see the transaction in such cold and efficient terms. To them, the upside of this poorly regulated marketplace is still miraculous.

Lavi Aron and Omer Shatzky are two gay men living in Tel Aviv. In order to have their marriage recognized in Israel they wed in Toronto in February 2008. But the dream of having children seemed out of reach. “As a gay couple, it is nearly impossible to adopt here,” says Aron. “The only real option was to hire a surrogate, but oh, the cost.” Friends in similar situations had found the price of surrogacy and egg donation could easily exceed $300,000, and take years of legal wrangling.

But Elite IVF made it comparatively easy as long as the couple was willing to take the procedure global. In the same way that Orbitz searches multiple airlines for the best deals and cobbles together a trip for a lower price, Sher found a Caucasian egg donor living in Mexico City who was willing to give up her eggs. But Mexico does not have extensive laws to protect the rights of intended parents. So Sher flew a surrogate mother business class from the United States to Mexico for implantation—one sperm came from Aron, the other from Shatzky. The brother and sister were born in California as US citizens in November 2010.

“It was like winning the lottery for us,” says Aron. “Genetically, one belongs to him, the other belongs to me. But they’re also siblings because they come from the same egg donor. We couldn’t have a better family than this; everyone is related to each other.” Within weeks Aron and Shatzky were able to arrange legal adoptions for the children and bring them back to Tel Aviv. Total cost: $120,000.

There are many companies that provide similar services to Elite IVF. Together they helped turn baby-making into a globalized, industrialized process where the baby is simply the final product of an informal assembly line. For Sher, who lives in Arizona with his wife, outsourcing is simply the inevitable outcome of the science that allows procreation to move out of the bedroom and into the lab. Like the Petra Clinic and the Institut Marquès, Elite IVF offers clients cheaper access to eggs and a full suite of fertility treatments; unlike those more-localized operations, Elite operates worldwide, with offices and partner clinics in Britain, Canada, Cyprus, Israel, Mexico, Romania, and the United States. Sher plans to expand soon to Turkey, taking advantage of the expected surge of demand there now that the country has banned egg donation.

Sher sees the regulatory and price differentials in eggs as an opportunity to reduce the cost of raw materials and services, and pass the savings on to his customers, offering them virtually any fertility service they can’t get at home. Want sex selection, which is illegal in most countries? A Mexican clinic can help you. Too old for IVF in the United States? Cyprus is the answer.

Today Elite IVF’s network of clinics, egg sellers, and surrogate moms produces between two hundred and four hundred children per year, helping create families like Aron and Shatzky’s. And it’s just going to get more complicated. “The future is designer babies,” says Sher. He describes an offer that he once received from an investor interested in partnering with Elite IVF. “Surrogates in Asia would carry the eggs of superdonors in America—models with high SAT scores and prestigious degrees who would be paid $100,000 for their eggs. Those babies could sell for $1 million each—first to my investor’s friends, then to the rest of the world.”

Sher declined the offer, but says that it is only a matter of time until someone moves in that direction. At that point—when the situation is just plain weird—maybe governments will get involved. McGee, the bioethicist, predicts that “we will soon begin to recognize the danger of an ant-trail model of reproduction whereby strangers without responsibility to each other and clinicians able to vanish in a puff of smoke meet in a transaction that culminates in humanity’s ultimate act: creation.”

For now, we’re left to consider Alma Hassina and Yehonnatan Meir, the babies bouncing in the laps of Aron and Shatzky. There is no word to describe their relationship. Born of the same donor, fertilized by the sperm of different fathers, and delivered in the womb of a surrogate mother, they are both twins and half-siblings. They are also poster children for the possibilities enabled by IVF and globalization. Parents will do just about anything for kids like them. Donors will do just about anything for the right price.

The residency unit at the Akanksha Infertility Clinic in Anand, India. These surrogate mothers are kept under close watch during their nine months of pregnancy and usually give birth through cesarean section. Their families are allowed rare visits, and the only obvious source of entertainment in the house is a single television set playing Gujarati soaps. Foreign parents pay about $14,000 to have a child through this clinic. The surrogates earn about $6,000.

F
ROM ITS POCKMARKED
exterior walls and stark interior, you’d never guess that this pink three-story building a few blocks from the train station houses India’s most successful surrogate childbirth business. But when Oprah raved about the Akanksha Infertility Clinic in the fast-growing city of Anand, it become an overnight success. The clinic fertilizes eggs from donors, implants and incubates embryos in the womb of a surrogate mother, and finally delivers contract babies at a rate of nearly one a week.

Since 2006 Dr. Nayna Patel, Akanksha’s founder, has been the subject of dozens of gushing articles in addition to that game-changing 2007
Oprah
segment, which all but heralded Patel as a savior of childless middle-class couples and helped open the floodgates for the outsourcing of American pregnancies. Autographed photos of Ms. Winfrey are displayed prominently throughout the clinic, which claims to have a waiting list hundreds deep. According to news reports, Akanksha receives at least a dozen new inquiries from potential surrogacy customers every week.

The doctor, clad in a bright red-and-orange sari, sits at a large desk that takes up about a third of the room. Heavy diamond jewelry dangles from her neck, ears, and wrists. Her wide grin projects a mixture of politeness and caution as she beckons me to sit in a rolling desk chair. I showed up here without an appointment, fearing Patel would refuse to see me if I phoned in advance: Despite all the laudatory press, in the weeks prior to my visit a spate of critical articles had appeared, focusing on the clinic’s controversial practice of cloistering its hired surrogate mothers in guarded residency units.

Among the claims is that Akanksha is little more than a baby factory. “The world will point a finger at me,” Patel responds when I ask her about the criticism. “She will point, he will point. I don’t have to keep answering people for that.”

As if to prove it, she politely evades my questions for the next twenty minutes, and then abruptly escorts me out when I ask about the residency units again. But in a town as small as Anand, I can track down where the women are without the doctor’s assistance.

On a quiet street about a mile away from the clinic, a government ration shop issues subsidized rice to an endless stream of impoverished clients. Across the road is a squat concrete bungalow enclosed by concrete walls, barbed wire, and an iron gate. Police once used it as a storehouse for bootleg liquor captured in Eliot Ness–style raids. (Like the rest of India’s Gujarat state, Anand is a dry city.) The security measures were intended to keep away bootleggers who might be tempted to reclaim the evidence.

Now the building functions as one of two residential units for Akanksha’s surrogates. They aren’t prisoners here. But they can’t just up and leave, either. The women—all married and with at least one previous child—have swapped freedom and physical comfort to enroll as laborers in India’s burgeoning medical and fertility tourism industry. They will spend their entire pregnancies under lock and key. A watchman wearing an official-looking uniform and armed with a bamboo cane monitors everyone’s movements from the front gate. Visits by family members are limited but, in most cases, they are too poor to make the trip.

Outdoor exercise, even a walk around the block, is a no-go. To get past the guard, the women must have an appointment at the clinic or special permission from their overseers. In exchange, they stand to receive a sum that’s quite substantial by their meager standard of living, but that the clinic’s foreign customers understand is a steal. Most of the customers come from outside of India, and three of the city’s boardinghouses are constantly booked with American, British, French, Japanese, and Israeli surrogacy tourists. Accompanied by my interpreter, I cross the street to the bungalow, where a friendly smile and a purposeful, confident walk get me past the gatekeeper. In the hostel’s main living quarters, some twenty nightgown-clad women in various stages of pregnancy lie about, conversing in a hurried mix of Gujarati, Hindi, and a bit of English. A lazy ceiling fan stirs the stagnant air, and a TV in the corner—the only visible source of entertainment—broadcasts Gujarati soaps. A maze of iron cots dominates the classroom-sized space and spills out into the hallway and through additional rooms upstairs. It is remarkably uncluttered given the number of people living here. Each surrogate has only a few personal belongings, perhaps just enough to fill a child’s knapsack. In a well-stocked kitchen down the hall, an attendant who doubles as the house nurse prepares a midday meal of curried vegetables and flatbread.

The women are pleasantly surprised to have a visitor. It’s rare, one tells me, for a white person to show up here. The clinic discourages personal relationships between clients and surrogates, which, according to several sources, makes things easier when it comes time to hand over the baby.

Through an interpreter, I tell the women that I’m here to learn more about how they live. Diksha, a bright, enthusiastic woman in her first trimester, elects herself spokeswoman, explaining that she used to be a nurse at the clinic. She left her home in neighboring Nepal to find work in Anand, leaving behind her two school-age children. She reasons that she could earn just as much as a surrogate as she could working full-time tending to them. She’ll use the money she makes to fund her children’s education. “We miss our families, but we also realize that by being here we give a family to a woman who wants one,” Diksha says. She and her dormmates are paid $50 a month, she says, plus $500 at the end of each trimester, and the balance upon delivery.

All told, a successful Akanksha surrogate makes between $5,000 and $6,000—a bit more if she bears twins or triplets. (Two other Indian surrogacy clinics catering to foreign couples told me they paid between $6,000 and $7,000.) If a woman miscarries, she keeps what she’s been paid up to that point. But should she choose to abort—an option the contract allows—she must reimburse the clinic and the client for all expenses. No clinic I spoke with could recall a surrogate going that route.

Diksha is the only Akanksha surrogate I meet who has an education to speak of. Most of the women hail from rural areas; for some, the English tutor Patel sends to the dormitories several times a week is their first exposure to anything resembling schooling. But they’re not here to learn English. Most heard about the clinic via local newspaper ads promising straight cash for pregnancy.

Among the justifications for cloistering the surrogates—Akanksha isn’t the only clinic doing it—is the facilitating of medical monitoring and the providing of better conditions for the women than they might have back home. Kristen Jordan, a twenty-six-year-old California housewife, opted for a Delhi clinic that recruits educated surrogates and doesn’t cloister them after she learned that some clinics hire “basically very, very poor [people who are] strictly doing it for the money.” For their part, the Akanksha surrogates tell me that their swollen bellies would almost certainly make them the subject of gossip back home. Even so, those who have been on the ward longer than Diksha don’t seem terribly thrilled with the whole setup.

I sit down next to Bhavna. She’s far along and bulging in her pink nightgown and wearing a gold locket around her neck. She looks older than the rest and more tired. It’s her second surrogacy here in as many years, she tells me. Apart from occasional medical checkups, she hasn’t left this building in nearly three months, nor has she had any visitors. But $5,000 is more than she would make in ten years of ordinary labor.

I ask for her view of the overall experience. “If we have a miscarriage we don’t get paid the full amount; I don’t like that,” she says. But she’s thankful to be here and not at the clinic’s other hostel, a few towns away in Nadiad, which isn’t as nice. When I ask what happens after she hands over the baby, she replies that the cesarean section will take its toll. “I will stay here another month recovering before I am well enough to go home,” Bhavna says. No surrogate I interviewed expected a vaginal birth. Even though C-sections are considered riskier for the baby under normal circumstances and double to quadruple the woman’s risk of death during childbirth, the doctors rely on them heavily. They are, after all, far faster than vaginal labor and can be scheduled.

We’re joined by a second woman, who has dark brown eyes and wears a muumuu embroidered with pink flowers. I ask them whether they think they’ll have trouble handing over their newborns. “Maybe it will be easier to give up the baby,” says the second woman, “when I see it and it doesn’t look like me.”

The clinic isn’t that worried about the women keeping the children for themselves and tying up the handoff with legal challenges, but another reason that Akanksha may keep such a close eye on their surrogates is the worry that some of the women may go into business for themselves. In 2008 Rubina Mandal, an ex-surrogate, decided that the Anand model was a perfect platform for fraud. She began posing as one of the clinic’s representatives and duping Americans into sending her advance fees for medical checkups.

According to a warning posted on the Akanksha website “Ms. Mandal is not a doctor, she is a fraud and has been known to dupe innocent couples, hence please be mindful in any dealings with her. Moreover, Ms. Mandal may be using our clinic’s name in her efforts to lure innocent couples.” Below the warning is a grainy black-and-white photo of Mandal wearing a black necklace and impeccably parted hair. The fraud is understandable, if egregious. With so much potential profit in surrogacy, some women want a bigger cut of the action. To date, Mandal has not been apprehended.

INDIA LEGALIZED SURROGACY IN
2002 as part of a larger effort to promote medical tourism. Since 1991, when the country’s new procapitalist policies took effect, private money has flowed in and fueled construction of world-class hospitals that cater to foreigners. Surrogacy tourism has grown steadily here as word has gotten out that babies can be incubated at a low price and without government red tape. Patel’s clinic charges between $15,000 and $20,000 for the entire process, from in vitro fertilization to delivery, whereas in the handful of American states that allow paid surrogacy, bringing a child to term can cost between $50,000 and $100,000, and is rarely covered by insurance. “One of the nicest things about [India] is that the women don’t drink or smoke,” adds Jordan, the Delhi surrogacy customer. And while most American surrogacy contracts also forbid such activities, Jordan says, “I take people in India more for their word than probably I would in the United States.”

Dependable numbers are hard to come by, but at minimum, Indian surrogacy services now attract hundreds of Western clients each year. Since 2004 Akanksha alone has ushered at least 232 babies into the world through surrogates. By 2008 it had forty-five surrogates on the payroll, and Patel reports that at least three women approach her clinic every day hoping to become one. There are at least another 350 fertility clinics around India, although it’s difficult to say how many offer surrogacy services, since the government doesn’t track the industry. Mumbai’s Hiranandani Hospital, which boasts a sizable surrogacy program of its own, trains outside fertility doctors on how to identify and recruit promising candidates. A page on its website advertises franchising opportunities to entrepreneurial fertility specialists around India who might want to set up surrogacy operations with an endorsement from Mumbai. India’s Council on Medical Research (which plays an FDA-like role—except that it has far less power to actually enforce its edicts) predicts that medical tourism, including surrogacy, could generate $2.3 billion in annual revenue by 2012. “Surrogacy is the new adoption,” says Dehli fertility doctor Anoop Gupta.

Despite the growth projections, surrogacy is not officially regulated in India. There are no binding legal standards for treatment of surrogates, nor does state or national authority have the power to police the industry. While clinics like Akanksha have a financial incentive to ensure the health of the fetus, there’s nothing to prevent them from cutting costs by scrimping on surrogate pay and follow-up care, or to ensure they behave responsibly when something goes wrong.

In May 2009, for instance, a young surrogate named Easwari died after giving birth at the Iswarya Fertility Centre in the city of Coimbatore. A year earlier, her husband, Murugan, had seen a newspaper ad calling for surrogates and pressured her to sign up to earn the family extra money. As a second wife in a polygamous marriage, Easwari was hard-pressed to refuse. The pregnancy went smoothly and she gave birth to a healthy child. But Easwari began bleeding heavily afterward, and the clinic was unprepared for complications. Unable to stop Easwari’s hemorrhaging, clinic officials told Murugan to book his own ambulance to a nearby hospital. Easwari died en route.