STI: Wombs for rent

June 13, 2009

Wombs for rent

Commercial surrogacy is big business in India. Critics, however, cry exploitation

By David Lee, Tan Wei Xin & Muhd Nurluqman Suratman

SEVEN months pregnant, Meena is praying that the child she is carrying will eventually deliver her family a better future. Stroking her swollen belly, the 34-year-old is as excited as any expectant mother, except the baby is not hers.

When the surrogate mother gives birth at Akanksha Infertility Clinic in Anand in India's north-western Gujarat state, the newborn will be handed to a childless American couple.

A successful delivery will make Meena 250,000 rupees (S$7,725) richer, a vast sum in her world. Her odd-job labourer husband Haresh would have to toil for 10 years just to earn that. The windfall is a welcome for the couple and their 10-year-old son.

'With the money, I won't have to worry about rent. I can buy a new house. My son will also have an education,' Meena says in her native Gujarati. 'And I am also doing a good deed by providing the childless couple a baby.'

The couple who hired Meena made their way from San Francisco, California, about a year earlier, to begin the surrogacy process. They are among the many desperate couples from around the globe, from Singapore to Switzerland, as well as Indians living abroad, flocking to India with revived hopes of finally having a child of their own. They are drawn by the attractive combination of highly qualified doctors, a flexible legal framework and low costs.

Mr John Lee and his wife, Sue, both 37-year-old Korean-Americans, have been trying for a baby for the last seven years, to no avail. After seven failed intra-uterine insemination (IUI) and three ill-fated in-vitro fertilisation (IVF) attempts, the couple turned to surrogacy as a last resort after reading encouraging testimonies on Internet forums.

'We have already busted more than US$100,000 (S$145,190) in the United States engaging top IVF experts with no results,' Mr Lee says. 'Of course, it helps that it is cheaper over here, as we have already depleted much of our savings trying to fulfil our dream.

'I think this is a major pull factor for most childless couples thinking about surrogacy.'

According to top surrogacy clinics in Ahmedabad and Mumbai, surrogacy cases have soared in the last five years. While there are no firm statistics recorded, doctors say about 500 to 600 surrogate babies could be born throughout the world each year, with around 200 coming from India.

India's average surrogacy success rate is 37.9 per cent - for every 100 surrogacy attempts, about 38 babies are born.

Unsuccessful cases are those where the baby is not carried to full-term, including instances when the surrogate mother suffers a miscarriage or when the doctors are unable to impregnate the surrogate.

Last year, experts estimated the wombs-for-rent industry to be worth US$445 million, with around 3,000 clinics across India offering surrogacy services.

Intending parents are charged around US$20,000 for the entire surrogacy process - from initial consultation to the recruitment of the surrogate, the pregnancy and the baby's delivery.

This may sound like a lot of money but in the US or Europe, the cost of a surrogate baby is about four times more.

Still controversial

DESPITE being hailed as a beacon of hope by many surrogate mothers and commissioning parents, surrogacy remains a controversial issue in India.

The nation was transfixed last year by the case of baby Manji, born to an Indian surrogate hired by a Japanese couple through Akanksha Infertility Clinic.

Manji's prospective parents, Mr Ikufumi Yamada, 46, and his ex-wife, Yuki, 42, divorced shortly before birth, so the baby became caught in a legal tussle for months.

Mr Yamada wanted to take home the child, but Indian law bars single men from adopting children.

Neither his ex-wife nor the surrogate mother wanted the baby, who was dubbed by Indian newspaper The Times of India as the nation's 'first surrogate orphan'.

Manji was finally allowed to leave the country only after the Supreme Court granted custody to Madam Emiko Yamada, the child's 75-year-old paternal grandmother.

Apart from tugging at the national heart-strings, the case set a significant precedent, as the Indian courts now deemed commercial surrogacy to be legal, although it had been going on for years.

However, the Indian surrogacy industry still faces a major test with the upcoming Assisted Reproductive Technology (Regulation) Bill and Rules, which doctors hope will be passed at the next parliamentary session. It is not known when the Bill will come into effect.

Experts say the new law offers greater certainty to key stakeholders. It states a surrogate baby will be recognised as the legitimate child of the commissioning couple, even if they divorce or separate, with the child's birth certificate carrying both genetic parents' names.

The Bill will also make it compulsory for foreigners seeking surrogacy services in India to provide documentary proof that they will be able to take the baby back to their home country.

Another key clause states that intended parents seeking surrogacy through assisted reproductive technology, such as IVF, and the surrogate mother 'shall enter into a surrogacy agreement which shall be legally enforceable'.

If and when the law is enacted, a committee of experts, non-governmental organisations and fertility clinicians will have the right to inspect and regulate clinics that offer surrogacy, says Dr Ajesh Desai, the director of Gujarat's State Institute of Health and Family Welfare.

Dr Gautam Allahbadia, a member of the drafting committee, says: 'All the grey zones in infertility treatment will become black and white.'

In addressing the surrogate's rights, the Bill also proposes that all her expenses shall 'be borne by the couple or individual seeking surrogacy'. It adds: 'The surrogate mother may also receive monetary compensation from the couple or individual, as the case may be, for agreeing to act as such surrogate.'

Attitudes are changing

SOME 450km south of Anand, the bustling financial hub of Mumbai has seen a sharp rise in the number of clinics offering surrogacy over the past five years.

Dr Sudhir Ajja, the founder of Mumbai-based fertility service provider Surrogacy India, believes the industry is set to open its doors even wider, in anticipation of the new regulatory regime.

'Surrogacy is becoming fully legalised, and the guidelines are very specific now. Everybody is okay with doing it,' says Dr Ajja. 'Initially, a lot of doctors were not willing to get involved.'

Critics say, however, proper regulation of the industry is overdue.

Dr H.D. Pai, a council member of the Federation of Obstetricians and Gynaecologists Society of India, believes surrogacy is giving India bad press.

'What is being projected is that India is a lawless market. People are getting exploited and foreigners are coming here to hire wombs. They should regulate it and fix the amounts, so there will be no exploitation,' he says.

But such criticism is rejected by Dr Nayna Patel, one of India's best-known surrogacy doctors and the director of Akanksha clinic. Her profile and that of India's surrogacy industry was raised when she appeared on Oprah Winfrey's television talk show two years ago.

She says her naysayers are just ill-informed. 'I have a surrogate's father-in-law and his son who think IVF is immoral and the surrogate has to sleep with someone else,' she says.

However, attitudes are changing. 'In 2003, I could not find one surrogate. In 2005, I had just 18. But last year, I had 175 surrogates...Now, men are coming to me and saying, 'My wife wants to be a surrogate, too.''

Initially, she notes, doctors placed ads in newspapers to recruit surrogates. Then, as news of this get-rich-quick scheme spread, most applicants either came forth or were introduced by others.

Until now, the industry has been subject only to guidelines set by the Indian Council of Medical Research (ICMR). Critics charge they are full of loopholes that may lead to exploitation. For example, clinics are not audited.

Mumbai-based lawyer Amit Karkhanis, an expert in medical law, says these fears are unfounded, as surrogacy can only be good for India. 'We follow the ICMR guidelines very strictly.'

'A 30-year-old woman who is in need of money can sell her body and sell sex, but it is better that she becomes a surrogate mother. It is a decent and noble way of earning money, plus you make some poor people happy,' he says.

Era of regulation

BUT because there is currently no standard sum paid to surrogate mothers, there has been a debate about whether the surrogates' interests are adequately protected.

Some get as little as 25,000 rupees, according to the National Commission for Women, an NGO based in New Delhi.

Mumbai-based journalist Deepa Suryanarayanan says: 'We are concerned. Does the surrogate mother in India, a woman who usually receives little or no education, really know what is stated in the forms before signing them? Having lived in poverty all her life, would she know whether she is underpaid?'

A quick survey of the going rates in Akanksha's wards is telling. A Brahmin surrogate gets about 300,000 rupees and a lower-caste woman, only half that amount.

Dr Patel is tight-lipped on the exact terms of the consent forms, which are largely about payment and the surrogate mother renouncing her right to the baby. But she maintains that they are translated into the surrogate mother's native language. And each clause is explained to her before she puts pen to paper, she adds.

She is also emphatic the surrogates all willingly hand over the babies after birth.

'Many surrogate mothers regard it not as 'handing over' the baby, but as 'giving back' the baby, as the child was never theirs to keep,' she says.

Meena echoes that sentiment.

'I don't think I will have any harsh feelings about returning the baby to the true parents. I might feel sad, but I know the baby does not belong to me. I will move on and be happy again because both parties will benefit.'

While Meena's husband understands that 'there is nothing dishonourable in surrogacy', she notes that many in largely conservative India still regard the practice as taboo.

'Most people think very badly of surrogacy. They think it means to sleep with other men. So, I don't tell my relatives and friends,' she says.

'It took Madam (Dr Patel) time to explain to Haresh what exactly is surrogacy. But he has been with me all this while, following the procedure, and he doesn't mind now.'

Like Meena, many surrogate mothers are recruited by word of mouth. Still, the supply rarely keeps up with demand. Dr Patel says the clinic sifts out inappropriate applicants hoping to be parents.

'Say, a childless couple comes through my door and the wife wants a baby so bad, but she has a missing uterus, how can I reject this couple? But if a woman says she wants a surrogate to help her carry a baby because she doesn't want the pregnancy to affect her work or her figure, I won't even consider. There are more needful couples to help,' she says.

Also, due to personal convictions, she does not entertain same-sex couples seeking surrogacy. However, the commercial, and by now global, nature of surrogacy has ensured that there are those who will welcome these clients.

One Mumbai-based clinic, Dr Allahbadia's Rotunda Fertility Clinic, has handled the surrogacy cases of 15 same-sex couples - none from India - whom he says now form 10 per cent to 20 per cent of his clientele.

'Ethically, I don't think there's anything wrong. Same-sex couples have their rights to a child, too. It is hard not to be moved by their genuine desire to have a child,' he says.

Legally, there is also nothing to stop gay or lesbian couples from approaching Dr Allahbadia to employ a surrogate's services in India.

However, if the draft Bill is passed without amendment, the long queues at clinics such as Akanksha or Rotunda may become a thing of the past.

India's new draft rules stipulate that couples like the Lees who require the services of a surrogate mother will have to approach surrogacy agencies, instead of going straight to an infertility specialist.

A surrogacy agency, also known as a semen bank, is an independent organisation in charge of providing donor sperm or egg for infertile couples who require such treatments. In terms of surrogacy, these semen banks act as middlemen, matching surrogate mothers to intended parents.

While the proposed changes could help boost the surrogacy industry in India by providing an explicit set of rules and regulations, it may also spell the end of Dr Patel's booming business. And she may not be allowed to keep her personal pool of surrogate mothers.

Although the Bill does not explicitly cast a blanket ban on clinics having their personal pool of surrogates, it states that 'individuals or couples may obtain the service of a surrogate through a semen bank, or advertise to seek surrogacy'. The Bill also forbids clinics from advertising to seek surrogacy for its clients.

In the event it comes into effect, Dr Patel says: 'The law is the law. I will not go against it. A doctor will always put the welfare of the patients as priority.'

SURROGACY: THE TWO MAIN FORMS

STRAIGHT SURROGACY is where the surrogate mother is impregnated artificially with the intending father's sperm using her own eggs.

That means the surrogate mother is the biological mother too - and the baby will be a genetic blend of her and the intending father.

In some cases, the intending father might be infertile, so a donor's sperm might be used to artificially impregnate the surrogate mother. That would mean the baby would look nothing like the intending parents.

GESTATIONAL SURROGACY is the most common type used in the surrogacy tourism industry.

With in-vitro fertilisation (IVF) technology, now commonplace in the medical world, the intending parents are both the biological parents. The intending father's sperm is used to impregnate the intending mother's eggs using IVF. A successful embryo is transplanted into the surrogate mother.

That means that the baby will bear no resemblance to the surrogate mother at all. Of course, the surrogate mother's general health will still have a bearing on that of the baby.

But two intending parents of one ethnic group who hire a surrogate mother of a different ethnic group will produce a child with features resembling their own, just as happens with a natural birth.

MILLION RUPEE BABY

PRICES and fees vary across different clinics throughout India, but this is what prospective parents typically pay:

ADMINISTRATIVE FEES

25,000 rupees (S$773): Processing and consultation for intending parents

50,000 rupees: Recruitment of surrogates (for clinics without a ready pool); screening of surrogates

FIRST STAGE (paid prior to procedure or at time of procedure)

200,000 rupees for a maximum of three IVF cycles. Even if the surrogate gets pregnant with one or two tries, the full amount has to be paid.

SECOND STAGE (paid when surrogate pregnancy is confirmed through ultrasound)

300,000 rupees: Surrogate compensation for three trimesters in total

50,000 rupees: Antenatal care for surrogate (nurse, nutritionist, maid service, etc)

75,000 rupees: Surrogate handler. She is a matron who liaises with the doctors and the surrogates living temporarily in houses or hostels. She acts as a counsellor for the surrogates and ensures that their needs (such as bills, groceries, housekeeping) are met.

50,000 rupees: Obstetric emergencies

75,000 rupees: Surrogate housing

100,000 rupees: Life insurance policy for the surrogate mother.

75,000 rupees: Delivery

TOTAL

1,000,000 rupees for successful surrogacy procedure resulting in a newborn baby, excluding food, travel, accommodation and other personal expenses.

What 1m rupees can buy in India

1 bungalow in a rural area

2 students' university education at a reputable college

3 hatchback cars

7 auto-rickshaws

500 nights' stay in the suites of Surabhi Regency, a simple but clean hotel five minutes from Akanksha Infertility Clinic

5,000 portions of butter chicken at a restaurant

50,000 packets of one-litre fresh cow's milk

100,000 portions of curd rice at a roadside stall

200,000 cups of masala Chai (tea)

To legalise it or not in Singapore?

While there are strong medical grounds for surrogacy in some cases, there are also legal issues

WHEN Ann and Ron (not their real names) moved here five years ago from India and became permanent residents, they could not wait to start a family. But a doctor here gave them some painful news - Ann was born with a small uterus, which cannot stretch enough to hold a growing foetus.

'When we knew about this, we were quite devastated and didn't know what to do. My husband loves children. If I knew about my condition before marriage, I wouldn't have married him just for this reason,' said the 31-year-old IT officer.

They were about to throw in the towel after six expensive and unsuccessful in-vitro fertilisation (IVF) attempts, when Ann was told her eggs were healthy enough to have her own child through surrogacy.

She started reading up about surrogacy in her country of birth - India. She read how the rent-a-womb industry there has attracted childless couples from all over the world with its low-cost and high-tech treatment.

Three years ago, she flew back to her hometown in Gujarat. After two unsuccessful IVF cycles, her surrogate is finally pregnant from her third IVF try.

Because surrogacy is illegal here, a steady stream of Singaporeans has been seeking such services in India.

A check with four fertility clinics in India indicates that over the past three to four years, more Singaporeans have been inquiring about renting a womb. A spokesman for Mumbai-based fertility service provider Surrogacy India said it has seen four Singaporean couples - three ethnic Chinese and one Indian - over the past 2-1/2 years.

A spokesman for another clinic in Mumbai, Rotunda Fertility Clinic, said it had received inquiries from about 10 Singaporean couples on surrogacy during its four years of operation. In Anand, in India's western state of Gujarat, the Akanksha Infertility Clinic has seen one or two Singaporeans a year over the past four years.

As a result, two leading fertility doctors have called for surrogacy to be legalised in Singapore on a limited basis - for cases where there are compelling medical grounds - since it has the requisite know-how and facilities.

Dr Jothi Kumar, 53, a senior obstetrician and gynaecologist at O & G Partners Clinic for Women and Fertility Centre, believes the current blanket ban here is 'unfair' to childless couples who have exhausted all other means.

He urged the authorities to permit 'limited surrogacy' to be made available selectively to patients who need it. Each legitimate case can be presented to a government-led review committee, which could then decide if surrogacy is warranted.

'My view is that legitimate couples who need access to this kind of thing are being deprived,' he said, adding that Singapore could lose out on becoming a prime 'medical tourism' destination in the process.

National University Hospital's Department of Obstetrics and Gynaecology senior consultant P.C. Wong, 57, who encounters about two cases a year that he considers to be genuine candidates for surrogacy, echoed Dr Kumar's suggestion.

He said surrogacy should be allowed here for 'medically indicated' cases. These include women who have no uterus, women who have suffered from repeated miscarriages, and women who would be prone to heart disease if they get pregnant. 'For these women, if they don't have surrogacy, there is no way they can have a baby,' he said.

Currently, it is illegal for a woman to become a surrogate mother here. Childless couples are prohibited from seeking surrogacy here. It is also unlawful for local doctors to help in surrogacy.

The Ministry of Health said surrogacy is not allowed to be performed in clinics and hospitals, under the directives for private health-care institutions providing assisted reproduction services.

However, the doctors believe that the authorities are hesitant to legalise surrogacy due to potentially explosive social, legal, moral and ethical issues.

One likely controversy, said Dr Kumar, is if the surrogate mother refuses to give up the child after delivery. Another concern is that career-minded or figure-conscious women might make use of surrogacy as a way to bypass getting pregnant themselves.

Identifying the legal mother of a surrogate child is another problem, said Dr Wong. 'The law states that the woman who gives birth to the baby is the mother,' he said. 'But now that might not be the case.'

Added to that, Archbishop Nicholas Chia, head of the Catholic Church in Singapore, said the Church is against surrogacy.

The Vatican website states: 'Surrogate motherhood represents an objective failure to meet the obligations of maternal love, of conjugal fidelity and of responsible motherhood; it offends the dignity and the right of the child to be conceived, carried in the womb, brought into the world and brought up by his own parents; it sets up, to the detriment of families, a division between the physical, psychological and moral elements which constitute those families.'

But despite this, Ann said she cannot wait to watch her parents' delight when they finally cradle their grandchild in their arms.

'That's going to happen now and I'm very happy. Surrogacy is a godsend to me,' she said.

Willing sellers and ...

For poor women who struggle to make ends meet, being a surrogate mum is a way to break out of the poverty trap.

EARNING a meagre 3,000 rupees (S$91) per month as a nurse, Hansha struggles to make ends meet.

After paying half her earnings on rent for a squalid one-room flat with neither electricity nor gas, she has barely enough to keep her 16-year-old son in school.

She worries constantly for her husband - a truck driver - who earns 15,000 rupees for long-haul trips transporting goods on India's treacherous highways.

The 39-year-old also has to provide for her sister, 15, and her ailing father, who lost his leg in a railway accident. They live in a tent near train tracks in the dusty town of Nadiad, 22km from Hansha's flat in Anand.

'It's very hard,' Hansha said in her native Gujarati. 'I have to take care of my family and work also.'

She works 14 hours a day, seven days a week, weighing patients, measuring blood pressure and giving injections at Anand's Akanksha Infertility Clinic.

It was through her work at the clinic that she learnt about the financial rewards of being a surrogate.

Hansha became a surrogate mother in December 2007 and delivered twins - a boy and a girl - for an American couple. For that, she earned 250,000 rupees - almost seven years worth of her monthly income.

For many lower-middle class women in India, surrogacy is a chance to escape the sinkhole of low wages and debt. 'This is the fastest route to money,' said Hansha.

Now, she lives in a simple three-room flat complete with gas stoves and ceiling lights. She has paid off all her debts, though her husband still drives trucks to supplement household income.

Owning a home is crucial in India as tenants can be held to ransom by unreasonable landlords. To buy her flat, 33-year-old Deepa, a school caretaker and a mother of two, also became a surrogate mother. In 2007, she rented out her womb to a United States-based Indian couple and delivered a baby boy.

However, the single mother was paid more as she was born into a higher Hindu caste (Brahmin), than Hansha, who is from the Vaishya caste. Such discrimination is common in one of the most rigid class-bound societies in the world.

Many clients, especially those of Indian descent, choose candidates based on caste, said Deepa. 'They do not mind paying more for a higher-caste surrogate. It is a religious thing also,' she added.

Carrying a baby for nine months was not easy, Deepa recalled. Besides enduring labour pangs, she had to hide her swollen belly from friends and relatives. In an intensely conservative society, social stigma is a risk all surrogates face.

'They think very badly of this thing so I don't want to tell,' Deepa said. 'Because of financial reasons, people do this. Otherwise no one will do this.'

But many critics suggest women like Hansha and Deepa are being financially exploited.

They have lambasted Indian legislators and doctors for enabling the outsourcing of wombs on the cheap. In the US, surrogate mothers get US$15,000 (S$21,770) to US$45,000, while their Indian counterparts get an average of just US$6,800.

But Dr Nayna Patel of the Akanksha clinic rejected this. 'America is a popular place for Europeans to find surrogates. Why don't you say Americans are exploiting surrogacy?'

Another criticism of surrogacy is that women like Hansha and Deepa can't help but form a close natural bond with the babies they are carrying, which they are later cruelly wrenched away from.

Mumbai-based lawyer Amit Karkhanis, an expert in medical law, said most surrogate mothers are bound by contract to return the newborn to its intended parents just weeks after delivery.

In the US, surrogates have refused to hand over their babies, citing emotional attachment, resulting in court cases.

Deepa admits she felt a strong bond with her surrogate child: 'When I had to give up the baby, I was heartbroken and I cried. But I told myself that the baby is not mine.'

Such incidents do not occur in Anand, insisted Dr Patel, because she accepts only women, like Hansha and Deepa, who already have children of their own. Also, surrogates have to go through intensive medical check-ups to ensure that they are physically and mentally fit.

Most importantly, she insists on consent from the surrogates' husbands and parents. As a last measure against fraud, the contract she drafts also ensures that the fees to surrogates are paid in instalments upon conception, delivery, then handover of the babies, to deter surrogate mothers from abortion.

Hansha and Deepa said they are happy that they successfully bore their babies and got paid in full. 'I am happy, I benefit and people at the other end benefit also,' Hansha said.

With more clinics vying for customers today, surrogacy fees are set at competitive rates of as low as 200,000 rupees. But despite the alleged price low-balling and exploitation, there is no shortage of womb suppliers.

'This amount could buy me a small house in Mumbai,' said Mangal, 29. As a widow who earns 6,000 rupees a month as a police officer in her native Marath, she struggles to pay her monthly rent of 1,500 rupees.

'A quarter of my salary goes towards rent. If I have my own place to stay, things will be so much easier. But I have not told my employers because if they knew, they would give me the sack.'

Seeking a better life, she, Rajeshri, 24, and Rehka, 27, have all recently signed up to be surrogates.

Rajeshri, a housewife, said: 'I was shocked when our local doctor said that carrying another person's child in my stomach was possible without sleeping with another man other than my husband.

'I told my husband, and initially he said 'no'. But I was able to convince him there is nothing immoral. And we won't be able to earn this kind of money in years.'

Housewife Rehka, whose painter husband brings home only 200 rupees a day, said: 'During the monsoon season, his income is badly affected. If I had a choice or other options to make this kind of money morally, I wouldn't do surrogacy.'

At Akanksha Infertility Clinic, Hansha readies a Taiwanese woman's forearm for an injection to help her ovulate.

She said she would gladly rent out her womb again, despite potential health risks and the prospect of having to live with fresh scars from another Caesarean section.

This time, Hansha wants to buy a house for her sister and father and move them out of their tent.

'If a good couple is willing to pay good money, I am ready to become a surrogate one more time.'

... Willing buyers

Couples from all over the world are turning to surrogacy in India for their chance to have a baby and start a family

THE three childless couples sitting in the Akanksha Infertility Clinic waiting room greet each other politely, almost wearily.

Strangers in a foreign land, they have only just met. But there seems to be an almost telepathic understanding as they begin to share their experiences and the circumstances that led them on the path to surrogacy.

John* and Sue, a Californian couple of Korean descent, shift about nervously in their armchairs. Both 37, they are veterans of seven intra-uterine insemination (IUI) and three in-vitro fertilisation (IVF) attempts.

John, a college consultant, explains their deep-seated frustration: 'We've been married for 11 years. That's a lot of time trying to have a baby.'

After spending a staggering US$100,000 (S$146,000) exhausting all options in pursuit of their dream of becoming parents, they came across a newspaper article on surrogacy in Dec 2007.

After researching the topic, they struck up e-mail correspondence with Dr Nayna Patel. 'After a short wait for an available surrogate, here we are,' he says.

Sue elaborates: 'Of the four surrogate mothers who were matched up to us, we chose a widow who really needs the money for the family. Her husband died a year ago from cancer and she has three kids - 14, nine and five - so they're really young. I feel for them.

'If we get a baby, our lives will be changed. We want to make a difference in their lives as well.'

Many foreign childless couples have been heading to India since Dr Kamala Selvaraj facilitated the country's first case of surrogacy back in 1994. Besides being attracted by the low costs of surrogacy, most say they head for India because of frustration with failed fertility procedures and a lack of alternatives in their native countries.

Huddling on the couch are a soft-spoken Icelandic couple, carpenter Haraldur, 33, and business manager Frida, 31. They have been disappointed by one of Europe's leading IVF specialists back home. Now they are hoping surrogacy will finally end their wait for a baby.

Frida says: 'We have tried for almost seven years. It just didn't happen. The only other option we have in Iceland is to adopt a baby, but that takes five years or more. We don't want to wait that long but we also don't want to adopt a baby. We want a big family.'

Perched opposite is another Californian couple, Tony, 42, a computer investigator, and Trisha, 34, who has lupus, a medical condition that makes it dangerous for her to conceive.

A mask covers part of Taiwan-born Trisha's face. She is feeling unwell, unused to the smell of buffalo dung and the local food.

'All that spice, I'm still recovering from diarrhoea. But nothing's going to come between me and my baby,' she vows.

The relentless heat and incessant honking do not add up to a conventional romantic holiday destination, but such fertility tourists are on the rise in India these days.

In the fast-paced financial capital of Mumbai, the business of surrogacy has turned itself into a one-stop centre for childless couples to enjoy a no-frills holiday and get a baby out of it.

In order to ease the culture shock and emotional distress, a Mumbai-based organisation is offering travel packages to its clients that covers airfare, lodging and crucially, a baby.

Surrogacy India is a first-of-its-kind fertility service provider in the country, claims founder Dr Sudhir Ajja, providing 'group tours' that handle the needs of every couple that wants to rent a womb.

'From the time they get down at the airport to the time they go back, we give them a fixed price and it covers anything that you can imagine,' Dr Ajja says. Packages cost about US$20,000 covering items like plane tickets, accommodation, transportation, a surrogate mother and three cycles of IVF. The surrogate mother gets about US$4,500.

Co-founder Dr Yashodhara Mhatre believes the all-encompassing package sets her clients' minds at ease by lessening the stress of the treatment, from the moment they arrive at the world's second-most populous nation.

'The clients are very apprehensive about India because it already has a 'Third World' tag attached to it. We wanted to make the journey much more comfortable for the patient,' Dr Mhatre says.

The organisation was started three years ago and business has picked up in the last year. Through its website - www.surrogacy india.com - Dr Mhatre and Dr Ajja link up and exchange information with foreign couples. By the end of last year, Surrogacy India delivered 10 babies to its clients, with a success rate of 35 per cent.

But as to how these fertility tourists intend to break the news to relatives and friends upon their return home - with new-born in tow - most of the couples interviewed say they are still undecided.

Frida says: 'I think nobody has done surrogacy in Iceland. We just told our friends we are coming here on holiday. We will worry about telling them later.'

It is not only foreigners. Locals and non-resident Indians make up the bulk of some surrogacy clinics' clientele in India.

Indian-born Deepak, 41, and Smita, 40, flew in from Georgia, Atlanta, where surrogacy is illegal, after 'every doctor had given up on her in America'.

Deepak says: 'My wife's body treats the embryo like a foreign object and she would run a fever, which kills the egg. So, she's an unsuitable candidate for IVF.'

Smita says: 'We were devastated then. But when I saw the Oprah Winfrey TV show on surrogacy, I felt there's light at the end of the tunnel. This is our first and last resort.'

But at least one prospective parent is already visualising a homecoming to India for his new 'complete family'.

Holding Sue's hand, John says: 'We hope that 10 years from now, we can come by here again and show our son or daughter where he or she was born.'

The house of nine months

Nadiad's new 'tourist' attraction

ABOUT 40km away from Akanksha Infertility Clinic is the city of Nadiad, a rural college township where temperatures in the summer can reach a scorching 45 deg C.

Famous for the Dharmasingh Desai Institute of Technology and the Ayurvedic College, Nadiad attracts migrants from all over India.

But the hot and dusty town has been attracting a different crowd in the past few years: fertility tourists from all over the world headed for the surrogate house. Here, the surrogate mums welcome prospective 'parents'.

Praying for a safe delivery

THE surrogates congregate daily to pray in front of an altar with framed images of Sikh gurus, Hindu gods and Jesus Christ.

Most of them pray for a successful delivery, while others pray for their own children back home.

A solitary television set sits in the living room, with only a wall clock on an adjacent wall for company. There are no tables in the entire house.

Not your usual residents

CAMOUFLAGED among other similarly nondescript two-storey buildings, the residence lies along a dusty main road near a railway track that links Ahmedabad to Mumbai.

The surrogate house, as most people in the area call it, is not even a house.

It is a second-storey apartment with four rooms and a kitchen.

It has electricity and constant water supply; metal-framed sliding windows with curtains; and two squatting flush toilets instead of the bucket type.

The rooms are sparse, and everything is tidied away behind built-in cupboards.

Bond of pregnancy

BOUGHT by Dr Nayna Patel, the surrogate house is an essential part of her surrogacy services at her Akanksha Infertility Clinic.

The apartment is near a hospital and there is a caretaker who looks after the surrogates.

The occupants may not live with their families during the course of their pregnancy. Their children and husbands can visit, but only during the day.

The surrogate mums support each other through their pregnancies.

A caretaker, 42-year-old Niermala Oedra, ensures that they keep their chin up during their stay at the house.

'I treat the surrogate mothers as my daughters and I always ask those around to take care of them in my absence,' she said.

'I feel sad whenever one of my 'daughters' leaves the surrogate house after delivery. We get together and cry for the one who leaves the house.'

India's Mother of Surrogacy

Fertility doctor helps poor Indian women earn their keep - as surrogate mums

IN DR Nayna Patel's office at her clinic in Anand, Gujarat, a makeshift altar sits on a shelf beside her desk, devoted to many gods and deities from all religions.

She has a Christian crucifix placed in the middle, alongside some figurines of Hindu gods; a small picture of guru Sai Baba pasted on the wall and, beside it, a framed photo of Mahatma Gandhi.

'I believe in all religions. It gives me spiritual calm and strength,' she says.

Most households in Anand have at least one of these figures on an altar. But sometimes, Dr Patel's picture sits there too. The women there revere the doctor so much they literally place her on a pedestal.

'I feel really bad about it but you can understand what they must have gone through to give me that respect,' she says.

The 49-year-old doctor recalls an Indian couple in their 30s so deep in financial despair they planned to commit suicide in front of a train, after leaving their three children at home. They decided to have their last meal - rice packed in a piece of newspaper - and by chance, saw an advertisement placed by Dr Patel.

The woman became a surrogate mother and that gave the couple and their three children a new lease of life.

Over the past six years, Dr Patel's Akanksha Infertility Clinic has helped many foreign women get a baby - and poor Indian women a better future.

Former surrogate mother Hansha, 39, got a small fortune in her terms - seven years' worth of her usual salary. 'Madam (Dr Patel) is like God to us. She helps us a lot,' says Hansha in her native tongue Gujarati. She delivered twins, a boy and a girl, for an American couple.

Dr Patel has won praise for helping get the surrogacy industry started in India. American talkshow host Oprah Winfrey even sent a film crew to her clinic in 2007. That episode, Wombs For Rent, lifted the doctor's profile internationally. 'That was my proudest moment,' she declares.

But there is also plenty of stinging criticism. Detractors from around the world accuse her of playing God, and exploiting poor women, she laments. 'My children get hurt when they hear the media reporting that I am exploiting the surrogate mothers,' she admits.

Dr H.D. Pai, a council member of the Federation of Obstetrics and Gynaecological Societies of India, blames Dr Patel for putting a price tag on life such that it deprives poor Indians of the chance to benefit from this procedure. 'She is making it too commercial,' he says. 'Anand is out of control.'

'It's not a doctor's role to deal with social issues. She just wants publicity.'

Also, Ahmedabad-based fertility specialist Himanshu Bavishi opposes Dr Patel's compulsory practice of housing surrogate mothers in communal residences throughout their pregnancies.

'This is inhumane - separating the surrogate mothers from their families. It's like treating them as slaves.'

In her own defence, Dr Patel said this gives surrogate mothers a good home and prevents them from taking up strenuous jobs during pregnancy, thereby cutting the risk of miscarriages. The home also serves as a shelter from scrutiny and finger-pointing by friends and relatives.

She insists she looks out for her wombs-for-hire in many other ways. For example, she has established a trust fund to help former surrogate mothers pay for their children's education. A major donor herself, she hopes to gather enough cash to cover the medical fees and college payments for the children of surrogates under her care.

'I really care for the surrogates from the bottom of my heart,' Dr Patel says. 'I'm not bothered by what people say because my conscience is clear and my surrogates know what I am doing.'