Marketing Reproduction: Assisted Reproductive Technologies and Commercial Surrogacy in India

The Context

The largely private Assisted Reproductive Technology (ART) market in India capitalises on the prevalent patriarchal normative understanding of infertility and childlessness as ‘abnormal’, and also on the near absence of public health access to infertility care in the public health domain. The proliferation of ARTs, as a state-of-the-art facilities for women to become mothers, is one of the best examples of a response to the demands of the market. The ARTs industry in India, including surrogacy, attracts an increasing cross-border movement, which leads to a need of analysing involvement of different stakeholders, as well as regulation of the industry. The medical establishment, particularly the private infertility care market, seems to capitalise on these cultural norms and values in order to sustain itself and flourish. Capitalist endeavour will always use patriarchal normative ideology to its best advantage. The proliferation of assisted reproductive technologies (ARTs) ¹ —a distinct group of procedures designed to circumvent infertility by assisting in conception and carrying pregnancy to term—is one of the best examples of state-of-the-art facilities being marketed with the justification by providers that they are merely responding to the market demand—more precisely, to the demand of women to become mothers. Further, the desire for children is laced with the eugenic notion of genetic/biological belonging in patriarchal societies. These social conditions are used by the medical profession and the medical market to promote ARTs. In doing so, their focus is on delivering a child to the infertile couple through technological means, bypassing the infertility rather than curing it. Hence, the priority area of intervention in these state-of-the-art clinics is neither preventive nor curative; clinics act as producers of babies, often of selected genetic traits. This situation is compounded by the total neglect of preventive infertility care in the public health sector.

It is important to understand why ARTs have become a part of the private medical market. With the globalisation of trade in services and the rise in medical tourism, India has emerged as an attractive destination for medical services in general, and more recently, reproductive services in particular. For the last few years, India’s ‘fertility industry’ has experienced rapid expansion under globalisation, with the country emerging as one of the leading global destinations for ‘fertility tourism’ or ‘reproductive tourism’ today. This article emerges from Sama’s several years’ research and advocacy ² on ARTs and commercial surrogacy. ³ It explores and maps the significant growth of the ART industry and increasing cross-border movement for ART procedures and surrogacy. It also analyses the ART industry and the different layers of stakeholders involved with differential hierarchies and looks at current regulation.

Medical Market and Medical Tourism

The emergence of the medical market can be attributed to the development of managed care, corporatised medicine and the rise of the biotechnology industry. Technology in general, and biotechnology in particular, is fuelling health care as a product by dragging more and more patients into the health care system. India’s pharmaceutical, biotechnology and medical equipment markets are closely linked and in the throes of rapid expansion. India is perceived as a big market by the multinational pharmaceutical industry (Sama, 2010). The global medical tourism market accounted for more than 19 million trips in 2005, with a total value of $20 billion. Many countries are experiencing double-digit growth in medical tourism, which is forecast to grow to 40 million trips, or 4 per cent of the volume of all global tourism, by 2010 (Tourism Research and Marketing [TRAM], 2006). According to one estimate by Professor Rupa Chanda, ‘medical tourism is slated to fetch an impressive $4 trillion on a world-wide scale’ (cited in Chhabria, 2005, p. 3). A World Trade Organization (WTO) study—conducted in Thailand, Malaysia, Jordan, Singapore and India—concludes that the number of medical travellers to these five countries alone was almost 1.3 million in the year 2003, collectively earning almost $1 billion in treatment cost. Medical travel expenditure in these five countries is growing at the rate of above 20 per cent every year (Chhabria, 2005). According to Giuseppe Tattara (2010, p. 3), a professor of economic policy, ‘India is the second Asian provider for medical tourism with an inflow of 4,50,000 tourists in 2007.’ A joint report by the Confederation of Indian Industry (CII) and McKinsey Consultants projects that there is a 30 per cent growth annually in medical tourism in India, and this could become a $1–2 billion business by 2012 (Netscribes, India, 2008). In 2004 alone, around 150,000 foreigners visited India for treatment, and these numbers have been rising by 15 per cent each year (Ibid.). Regarding the growth of the ARTs within the medical tourism industry, figures are not readily available. Although there are no accurate figures for the number of individuals who travel to India for ARTs, including surrogacy, it is estimated that the ‘surrogacy business’ alone is worth $445 million (Indo-Asian News Services [IANS], 2008). Beyond this, the number of couples and individuals coming to India to access ARTs and surrogacy is not accounted for. This is also largely due to the fact that until recently, many of those coming from abroad to avail of ARTs and surrogacy in India came on a tourist visa. Since 2013, the Ministry of Home Affairs, Government of India, has made it mandatory for foreigners to apply for a medical visa in case they intend to commission surrogacy.

The Burgeoning ART Industry in India

Situated within a globalising and corporatised medical market, fertility tourism has expanded beyond the domestic market, bolstered in good measure by support from the Indian state. ART clinics offers multiple services, including in vitro fertilisation (IVF), intra-cytoplasmic sperm injection (ICSI), intrauterine insemination (IUI), egg donation, sperm donation and stem cell research. The ART market is not limited to only IVF procedures but also includes commercial surrogacy and commercial egg donations. And as India’s ART industry grows, so do commercial surrogacy and commercial egg donation. In the absence of a functional, mandatory national registry for recording and monitoring of ARTs, statistics on the number of surrogacies being arranged in India for foreigners are not available. According to a newspaper report, 50 clinics are added every year to the current 500 IVF clinics in the country; egg donation is on the rise among women aged 18–35 years (Kohli, 2010). However, figures regarding the extent of the ART ‘industry’ are mainly restricted to discussions on surrogacy. For instance, in the year 2008, the surrogacy business was reported to be worth $445 million in India, while more recent reports put the rough estimate of the commercial surrogacy market at over 2,000 crores (US$ 379,362,661.93) (Kohli, 2010). The ‘phenomenal growth’ of this sector is also demonstrated by the fact that the international umbrella organisation for infertility consumers, the International Consumer Support for Infertility, lists Indian groups alongside African and South American groups, as well as by the aggressive advertisements of Indian ART providers in a bid to attract foreign clients (Mulay & Gibson, 2006, p. 84). A market research report notes:

With infertility treatment stabilising in the major markets, pharmaceutical companies are exploring other markets where assisted reproduction techniques (ART) are in growing clinical supply and demand. India is an attractive market because of its highly pronatalist culture, ART-seeking South Asians living abroad and preference for branded products. (Datamonitor, 2002, p. 1)

The growth of the fertility industry has not been unilinear. Sama’s research indicates that the ART clinics (consisting of stand-alone ART clinics, fertility clinics, IVF wings in multi-speciality hospitals and obstetrics and gynaecology clinics, besides other forms) are no longer concentrated in metropolitan and big cities, but are also appearing in smaller towns and cities that otherwise lack even basic civic amenities and necessary health care facilities (Sama, 2010). Clinics located in metros and larger cities, exploring potential markets in the rural and semi-urban areas, have tried innovative schemes and methods to reach this market and attract ‘customers’. On the other hand, clinics in smaller cities and towns providing these technologies express their keenness to establish a practice in bigger cities and metros towards expanding their services beyond their user base. The ART clinics in the smaller towns and cities offer a wide variety of services and technologies at varied costs, catering to a variety of consumers. Thus, while a single IVF cycle in Orissa costs anywhere between ₹ 30,000 and ₹ 80,000, in Tamil Nadu, it ranges from ₹ 50,000 to ₹ 3 lakh, and in Uttar Pradesh, from ₹ 65,000 to ₹ 1 lakh. Surrogacy fees may differ from one city to the next, with charges in metropolitan cities being relatively higher (Sama, 2012). So, while surrogates in Delhi were offered, on an average, between ₹ 2 lakh and ₹ 3.5 lakh, in Punjab, they were offered between ₹ 1.5 lakh and ₹ 2 lakh (Sama, 2012).

Hence, clinics offering ARTs, including commercial surrogacy arrangements, to both domestic and international clients are not situated in the major metropolitan and big cities (like Kolkata, Mumbai, Delhi and Chennai) alone, but have also sprung up in smaller cities like Pune, Chandigarh, Indore, Bhopal, Ahmedabad, Lucknow and Madurai. Anand (a town in the western state of Gujarat) has become the epicentre of India’s commercial surrogacy industry.

Even though foreigners frequent India to avail of ART services, there are an equally large number of Indians who are ‘consumers’ of ARTs and surrogacy. Often, clinics in small towns and cities are primarily sourced by local consumers. Foreign clienteles are found accessing clinics in the bigger cities in India. The cost differential, therefore, may be interesting to record in relation to the kind of gaps that exist in the pricing of ART services and technology. However, most studies and newspaper reportage are more concerned with showcasing the gap in pricing that exists between Indian and foreign surrogacy fees and services. This ‘gap’ is used as a significant reason to showcase how and why surrogacy in India is popular and attracting a clientele from across the world. But discussions regarding pricing differences within India are largely missing. Sama’s studies on ART and surrogacy find the neoliberal market structure impacting not only the client base but also the kind of regulations that the clinics wish to have in place (Sama, 2012). Here, it is important to note that the variations in practice, client base, structure of the clinic and the services it offers may help in the proliferation of ART but introduces difficulty in regulation.

Reproductive Tourism/Fertility Tourism

The oft-used term ‘reproductive tourism’ often glosses over the reality that those travelling to avail these facilities are seriously busy with cost, emotions and risks which the procedures entail. These aspects are ignored in this coinage and what is projected is a fun-filled holiday destination embedded in the language of sun, sand and sea. It is this unease with the term ‘tourism’ that has made some authors like Eileen Smith-Cavros use a much more neutral term like ‘travel IVF’ (Smith-Cavros, 2009). However, such neutral terms often fail to bring out the contested nature of the issue itself and tend to oversimplify it. Jones and Keith (2006, p. 251) note that the travel for medical services can be categorised into two distinct forms, ‘obligatory or elective’, depending on whether or not the treatments/procedures are available and/or legal in the home country of the individuals. This is to classify individuals who travel for medical services by choice even if it is available in their home country and those who are obliged to do so. At the ground level, this translates itself into the fact that as the cost of IVF in the West escalates and developed countries enact laws, in response to emerging ethical, religious and health concerns that restrict usage of conception technologies, countries like India become the chosen site. However, what is unique about ARTs and services, as opposed to other medical treatment (e.g., dental surgery), is that apart from the cost factor, the major push and pull factors for travel IVF include restrictive laws relating to access of these technologies in the home countries and little or non-existing legislation in others (Smith-Cavros, 2009).

The other contributing factors that have created a conducive environment for fertility tourism, mainly for surrogacy, are: lack of regulation; comparatively lower costs than in many developed countries (for instance, Canada, the United Kingdom [UK] and the United States [US]); less waiting time; possibility of close monitoring of surrogates by commissioning parents; availability of a large pool of women willing to be surrogates; and infrastructure and medical expertise of international standards. Among these, the key reason why people from other countries are attracted to the ‘baby business’ here is the cost advantage that India offers vis-à-vis developed countries. In the US, not only is surrogacy many times more expensive than it is in India, but the surrogate is also in a better bargaining position (Oza, 2006). In addition to medical expenses related to the pregnancy, the surrogate is given health insurance for the period of involvement, as well as all other expenses, including maternity care and clothing. Further, the commissioning parents also pay for expenses pertaining to the independent lawyer who would have to be hired by the surrogate. While in the US, up to 50 per cent of the cost of ART with a surrogate arrangement goes to the surrogate, in India, most of the money is appropriated by sperm banks, clinics, etc. (Qadeer, 2009).

Third-party Promotional Strategies

In addition to the clinics that are engaged in providing and promoting ARTs, including surrogacy, the industry in India includes several other players. These include a wide array of organisations and personnel catering to the clientele, both national and international: health care consultants; various bodies associated with the hospitality industry; travel agencies; law firms; surrogacy agents; tourism departments; and surrogacy hostels. The players have sprung up to provide diverse kinds of support services to the ART and surrogacy industry. According to the study conducted by Sama, Jawaharlal Nehru University and Kings College London:

the new roles for certain NGOs as recruiting sites, the naming of recruiting agents as ‘social workers’, the provision of hostels to protect pregnant surrogates from the disapproval of their neighbours, the assistance to set up a bank account for the payments, all suggest a curious attempt at incorporation of the most extreme form of commercial activity for the poor—the sale or hire of one’s own body—into the language and forms of social development. (Deepa V. et al., 2013)

Many ART clinics in India have tied up with foreign hospitals and companies to solicit ‘clients’ globally in a bid to expand their clientele. These services are included in the medical tourism services that are supported and incentivised under international agreements, such as the General Agreement on Trade in Services (GATS) under the WTO. These incentives include the ability to raise capital at low interest rates and eligibility for a low import duty on medical equipment (Mulay & Gibson, 2006). In the absence of any potent national legislation and inconsistent state policies globally, how such international agreements give effect to and shape the industry is a matter of grave concern. As pointed out in the Global Health Watch 3 report (Global Health Watch 3, 2011), the lopsided free trade mandate brushes aside all ethical questions in the expanding ‘bio-capital’ industry. The medical procedures involved, the kind of compensation being awarded to donors and surrogates for their services and genetic material and the storage and use of frozen eggs and embryos, all raise ethical issues.

Like any other market, the ART market also deploys common strategies to create a demand, such as offering of packages, schemes, concessions; inflating success rates; aggressive advertising; use of attractively designed websites and brochures; and advertising on walls and hoardings in streets, on local cable channels and bus stops. A significant number of clinic websites in India are found to have promotional material for attracting couples, including from other countries. Some of these sites even devote an exclusive section for overseas couples, where packages, incentives, discounts and ‘deals’ are promoted. These generally combine boarding, lodging and other facilities for enjoying the local tourist attractions, alongside the ART ‘treatment’ schedules (Sama, 2010). The concept of packages in IVF gained popularity with the rise in medical tourism in the country. Clinics in metropolitan cities like Delhi and Mumbai, where there is large influx of foreign couples and individuals for various ART services, offer IVF cycles in packages that include tours and travel excursions to nearby tourist attractions like the Taj Mahal, Jaipur palaces and spas in Goa or Kerala. This is evident through analysis of promotional materials of various clinics, such as websites and brochures (Sama, 2010). Several clinics had a section extolling their achievements and milestones on their websites and brochures, in addition to advertising in journals and newspapers. Claiming to be the first or the oldest is a modus operandi that clinics employ to demonstrate superior expertise and experience.

The language used in the promotional material provides insight into the politics behind the promotion. The material often includes a paragraph or two about the trauma of infertility, and establishes that the providers ‘understand’ the distress of the infertile couple and ‘empathise’ with them. Another interesting aspect of the way IVF is marketed to patients from other countries is in terms of the process being completely stress-free as compared to the one that they would typically undergo in their home countries. However, in selling the stress-free concept, it is remarkable that most clinics will emphasise aspects like less number of days to complete a treatment cycle and five star accommodation, whereas it is well known—scientifically as well as from ‘patient’ testimonies—that all those who undergo treatment will experience a period of stress as a result of the high likelihood of failure of the process. Therefore, to suggest that clinics here can provide a stress-free process is a fallacy and really trivialises the gravity and profound consequences that those who seek treatment are faced with.

Infertility is first magnified as a serious, urgent and traumatic impairment, and then ARTs are offered as the decidedly final solution for it; the ‘new hope’. This medicalisation of childlessness is part of the larger politics behind the commercialisation of both fertility and infertility. The immense social pressure on women to bear a child has enabled the industry to justify the existence of ARTs by portraying them as beneficial to women; when, in fact, ARTs have reinforced the societal norm of the linear progression of marriage to motherhood which alone can pave the way for ‘complete’ womanhood, thus excluding alternative forms of parenthood, voluntary childlessness or even non-heteronormativity.

Various taglines utilise patriarchal normative ideology to its advantage: ‘When desolate homes resonate with children’s laughter’; and ‘The moment a child is born, the mother is also born. She never existed before…’ Such advertisements are found in public places such as bus stops and local cable channels. Similar messages were also visible on the clinics’ websites. A study by Sama (2008) on websites and advertisements of ART clinics analysed that,

‘The slogans recognise the social pressure on women to bear children, there is no attempt to question this pressure. Rather, they reinforce motherhood as the natural destiny of every woman. The industry has also used this social pressure to justify the existence of ARTs, thus portraying them as beneficial to women.’ (Sama, 2008)

In addition to clinic websites which often maintain donor lists, advertisements in the classified sections of newspapers and magazines is another popular method of obtaining egg donors. Selection criteria are implicit in the language used in the advertisements, most of which seek a fair-complexioned and educated female donor. In addition, some of the other commonly sought qualities include being ‘broad minded’, from a ‘decent family’ and ‘good looking’. It is fair to say, based on the large number of advertisements in popular magazines as well as egg donation programmes on clinic websites, that there has been a decrease in the stigma of seeking unrelated donors for IVF.

Egg donation—wanted healthy married women with children and fair complexioned aged below 30 years to donate eggs for my use only. All facilities. Suitable reward and secrecy assured. Apply P.O. Box No. 6032, Chennai – 600 083. (Sama, 2010)

However, the parameters within which donors are sought continue to be extremely rigid and wholly governed by socio-cultural considerations, while donors do not remain unaffected by the stigma that surrounds egg donation. Most donors rarely reveal to their family, children or associates the fact that they are selling eggs. In many cases, financial distress is cited as the reason why couples/women are willing to engage in the sale of eggs.

Surrogate agencies make large profits by recruiting commercial surrogates, whose services are aggressively advertised. The ‘selling point’ becomes the ‘quality’ of the surrogate, which is determined by her social background, looks, etc., and preferably, by proven fertility.

The advertisements for surrogates highlight this, and typically read, ‘Good looking, fair, 27-year-lady from respected family available for surrogate mother. Only rich and genuine people contact.’ As Barbara Rothman puts it, ‘Once the priceless is priced, market considerations take over’ (cited in Sama, 2006, p. 72). Surrogacy, according to the media, has been added to the long list of ‘jobs’ being transferred to low-cost economies like India.

ARTs are marketed through lucrative strategies and incentives to attract persons into the buying and selling of reproductive parts, treating the human body as any other commodity. In an increasingly commercialised world, this commodification of the (female) body raises crucial questions of bodily integrity and reproductive rights and justice. The supply and demand in the case of ARTs is defined in the ways in which infertility is related to the woman’s body. ART providers work through the double-bind rhetoric of advertising that positions them as emancipatory (Arora, 1996) and as alleviating the ‘women’s burden’ of infertility. Nadimpally, Marwah and Shenoi (2011) note:

ART providers label these technologies ‘pro-women’, and as expanding women’s reproductive choices. They claim ART is a ‘gender-sensitive’ technology, and alleviates the suffering that infertile women have to otherwise experience. The images, language, and slogans used to promote ARTs serve to reinforce the ‘tragedy’ of childlessness and the sentimentality of childbearing, particularly motherhood, while deliberately ignoring, omitting, or playing down the concerns and complications that come with medical intervention, such as side-effects, efficacy, and costs. While ARTs may ‘deliver’ women from the social pressure to be mothers, they do not question or challenge this pressure (like side effects, costs, and efficacy).

The ART industry raises many problematic questions through its practices—many of which have to do with the long-term and short-term impacts of their use on women’s and children’s health. Studies point towards increased risk for perinatal, obstetric, pediatric and other outcomes. Complications in pregnancy, birthing, genetic disorders in children born through IVF, painful treatment protocols, psychological outcomes like depression and other adverse outcomes are common in ART use, but rarely discussed or reported. In the film on surrogacy Can We See the Baby Bump, Please? (Sama, 2012b), one of respondents who goes through extensive ART treatment notes how she has been given around 600 injections during various treatment cycles, to no avail. The medical regimen left her battling erratic menstrual cycles, increasing depression and no sign of a pregnancy. And even though academic research suggests that ARTs have a significant impact on men as well as women, the medical discourse on ART is geared towards identifying the woman’s body as incapable and therefore requiring medical intrusions (Martin, 2001; Rowland, 1992).

Packages, Schemes and Concessions

Packages, schemes and concessions comprise the primary modus operandi/strategy adopted by the ART industry to promote itself and expand the market towards maximising income and profits. Packages and schemes in the fertility industry include ‘money back guarantee’, egg-sharing schemes, ‘shared-risk scheme’, ‘economy IVF packages’, ‘refundable IVF packages’, etc. (Sama, 2010). Packages like the Special Care Package, which cover the expenses of the user and the attendant throughout their stay in India, and the Travel Package, which includes tours to different places of the ‘client’s’ choice, are being widely promoted. The package includes a range of services, including provision of letters for obtaining a visa, designing pre- and post-holiday itineraries for the clients, a support system and human contact at all points and stages of the ‘client’s’ treatment in India and facility of a nurse or guide (if required) for ‘post-vacationing’ in India.

The coupling of ART procedures with tours and holidays as a medical tourism package has emerged as a new trend, and is being fiercely marketed by the clinics in collaboration with the governments and other players, such as tour operators, etc. The egg-sharing scheme was popular among clinics, especially in smaller cities and towns in the sample. This scheme commits a woman undergoing IVF to sharing her eggs with another woman undergoing IVF in lieu of a reduction in cost of her (the one who gives the egg for sharing) IVF cycles. Basically, the idea was to charge the couples as much as they could pay, and in case they could not, to give them a discount so that they would not go away from the clinic and also, in case of a failed cycle, would undergo the succeeding cycles in the same clinic.

While packages and schemes benefited both parties, concessions were expressions of the providers’ benevolence and prerogative, with expectations at least of some clinics of earning the goodwill of users who might give them wider word-of-mouth publicity. Packages and schemes seemed to create a sense of competition among users, inciting them to seize the opportunity as soon as possible in order to reduce overall costs. The availability of packages creates anxiety and a sense of urgency among couples to opt for a procedure within a specified time. While packages and schemes are long term, concessions are usually time bound. Thus, although the providers talked about these schemes, packages and concessions as ‘helpful’ to users and as acts of benevolence, clinics’ interests and gains cannot be underestimated.

Television (TV) Soaps, Films and International TV Shows

The promotional literature and websites of ART clinics, articles and reports in the media as well as advertisements are rich sources of information for an assessment of the current status and practice of ART in India. The material developed by ART clinics to publicise and promote services for infertility may not explicitly use the language of marketing, but many who have studied the material have pointed out that the evolution of this competitive service environment has indeed led clinics to focus on two important marketing decision variables—product performance (success rate) and price.

The process of using mass media as well as the Internet to market ART based on the above-mentioned variables has created a strange paradox: on the one hand, these processes have been normalised and almost routinised so that it no longer seems odd that one may find an advertisement for egg donation in a women’s magazine like Women’s Era; and on the other, the actual experience (narrative) of achieving conception by women, whose bodies/body parts are often the sites for most of the interventions, is invisible. Bharadwaj (2000) describes the media narratives about ART as ‘powerful rhetorical devices’ that tend to fluctuate between two positions of ‘awe and mistrust’ and ‘marvel of science’.

Domestic TV soaps as well as films on childlessness, and ‘treatments’ for childlessness like IVF and surrogacy, have contributed to the public imagination, in addition to the local moral worlds and discourses of women and couples who access ARTs. Filhaal, a mainstream Bollywood film, starring two popular actresses, is about a surrogacy arrangement between two friends and its many accompanying emotional complications (Sama, 2010).

Internationally, an estimated eight million viewers of the Oprah Winfrey Show (Brooks, 2007) were informed that the new phenomenon of ‘women helping women’, wherein Americans go to India to hire surrogates, is not exploitation. Rather, it is a ‘confirmation of just how close our countries can be’. In fact, Winfrey refers to an American couple interviewed as ‘cultural ambassadors’ to India, and benefactors of the women whose wombs they rent.

Conclusion

Such a commercialised and diverse practice means that infertility treatment itself is not necessarily uniform across geographical areas or even within one area. The lack of any form of protocol has added to worries regarding ethical and unethical practices. In terms of legal regulation, the Indian Council of Medical Research’s (ICMR) National Guidelines for Biomedical Research (2005) forms one standard for the administration of ART, which has been followed by the draft bill on the regulation of ARTs (including surrogacy), which itself has many avatars—from 2005 to 2013. While these draft regulations direct ways in which the technology and treatment are to be administered, lack of enforcement and the fact that the bill has been drafted by industry stakeholders like IVF practitioners brings into question many of its clauses. Problematic inclusions and exclusions from these draft legislations are mostly concerned with the health of the surrogate or the woman seeking infertility treatment. In a situation where private players (corporations and individuals) and the market play a significant role in the research, expansion and formation of the ART industry, and global capital is instrumental in shaping trade agreements and policies, it becomes essential for the state to have a regulatory role, particularly towards safeguarding the rights of vulnerable individuals.

The urgent need is to better regulate the ART industry overall and to introduce regulatory measures with regard to the way individual clinics market their services using media such as websites and brochures. It is of utmost importance that immediate attention be devoted to developing a binding code of good practice regarding the content of promotional material, the provision of counselling services and obtaining informed consent to ensure transparency and ethical administration of ARTs. A code of conduct in relation to clinic advertising and promotional materials should ideally follow the ICMR guidelines that prohibit advertising for donors and surrogates. Especially, the presentation of donors and surrogates in terms of cultural traits of colour and ethnicity are problematic. Also, language, tone and tenor of clinic websites and advertising should be such that it positions infertility not as a lack or stigmatised state of being. This, along with minimum standards for the kinds of information that must be compulsorily included; for example, information on side effects, risks and costs, among other things, can help immensely in regulating the industry and guaranteeing ethical care for those who seek ‘treatment’. Vigilance should also come from public advocacy groups, the media and from medical professionals themselves as a step towards self-regulation. While these are important steps towards alleviating the damage done by these technologies so far, a well-oiled regulatory mechanism may not be sufficient. The government should also play a proactive role in public education about the issues and concerns involved.

The concept that appears to be marketed by the clinics is that ART is an ‘easy’ solution to problems related to infertility and the achievement of conception. This is in direct contradiction to the scientific fact that till date, the average success rate (defined as the ‘take home baby rate’) has been approximately 25 per cent. Therefore, while it is fair to say that ARTs indeed provide choices to men and women who are infertile, for many couples, this choice often does not automatically and ‘easily’ lead to the birth of a child. We also need to reiterate that primacy should be given to the documentation of the underlying causes of infertility within the holistic framework of the larger determinants of public health/women’s health. Other factors at play in the broader Indian context also need to be addressed. Poverty, in particular, plays a role in pushing the wheel that makes ARTs go round, and exacerbates the commercialisation and commodification of women’s bodies.

In the end, we need to arrive at a concrete strategy to address the proliferation of these technologies. At what level do we oppose them: do we fight the social reasons that are pushing couples to opt for these; or the political and economic forces that are supporting the actual establishment and functioning of the clinics; or the overall trend of medicalisation and invasion of the female body? Do we strike at the economic dimensions, the politics or the ethical issues?