This section will present a summary of the main findings of Sama's research regarding the operationalization of the ART industry in India today. Like any other market, the ART market also deploys common strategies to generate demand, such as offering packages, schemes, and concessions; inflating success rates; and undertaking aggressive advertising through the use of attractively designed websites, brochures, wall advertisements, street hoardings, bus stop signs, and announcements on local television channels  The industry is functioning through actors and collaborations at various levels, in an environment where the lack of binding standards or regulation is giving rise to medical malpractice and ethical concerns.
4.1. The Logic of Demand and Supply: What women want?
The predominantly private ART industry is characterized by market rhetoric and the language of demand and supply, and takes advantage of the prevailing ideology of patriarchy in society, as well as a collapsing public health system to promote itself. ART providers argue that with infertility "rampant and rising steadily" today, ARTs have become the "need of the hour". They cite higher rates of infections and ensuing complications, particularly in the absence of adequate gynaecological and obstetric services, as factors that contribute to the high infertility in India. Providers thus claim that they are merely responding to the demand of women "desperate" to become mothers . There is an increasing medicalisation and pathologisation of the condition of infertility, with the industry pushing for early medical intervention.
It is not surprising to find that women bear a disproportionate burden of the blame for infertility, including in cases of male factor infertility. Many women internalise this burden. In the event of childlessness, women are routinely harassed (mentally and physically, directly and indirectly, by the community and the family), denied their rightful share in the family's ancestral property, and even abandoned by their husbands . As such, 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. Further, given the culture of son preference that prevails in Indian society, and India's abysmally low child sex ratio, ARTs raise the fear that the unethical and discriminatory practice of sex selective abortion may be promoted through these technologies .
"IVF treatment in Singapore is expensive. While treatment in India costs between US$4,000 and US$5,000, more or less, it is at least 1-1/2 times more in Singapore. Besides, Indian doctors have a good reputation as being highly competent and compassionate.(sic)" - The website of an Indian IVF clinic
The chief reason for India attracting the 'baby business' from other countries is its cost advantage vis-à-vis developed countries. An IVF cycle in the US costs around $20,000 (approximately Rs 9,00,000) as opposed to $2,000 (approximately Rs 90,000) in India. A surrogacy arrangement, including IVF, costs about $11,000 (approximately Rs 5,00,000) in India, while in the US, surrogacy alone, excluding ART charges, costs $15,000 (Rs 6,75,000). In the UK, an IVF cycle costs about £7,000 (Rs 5,00,000 approx) and surrogacy costs about £10,000 (Rs7,00,000 approx) . There is no standardization of costs in the fertility industry, and prices for procedures like IUI, IVF and ICSI vary widely even within India .
Undergoing ART procedures involves many hidden costs, such as drugs, travel to the clinic, accommodation near the clinic, loss of work or wages due to repeated clinic visits, etc. When doctors quote treatment prices to users, these costs are often omitted. Nonetheless, despite hidden costs, which could be quite high, the research sample consisted of users from different classes, with several who were willing to push the limits of what they could afford in their quest for a biologically related child.
A significant number of the ART clinic websites were found to have exclusive sections devoted to overseas couples. While the amount of space dedicated to this varies, almost all the websites try to seek 'clients' from abroad through promotion of 'medical tourism packages' and incentives, such as discounts and deals on services provided. These generally combine boarding, lodging and other facilities for enjoying the local tourist attractions alongside the ART 'treatment' schedules. 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 excursions to nearby tourist attractions like the Taj Mahal, Jaipur palaces, spas in Goa or Kerala etc .
The procedure of IVF does not need any hospitalization it is a day care procedure. You have to visit our clinic for only consultation or Scan or for procedure and that takes not so much of time. .........The total Stay at Delhi will be around 15 to 20 days for a cycle. For stay in Delhi you can contact our Travel Agent ............ All types of accommodation facilities can be managed from budget to Five Star Category, it's depend on your Budget. During stay at Delhi you can also enjoy the City Tour of Delhi, Tour to Taj Mahal, Tour to Jaipur the Pink City and all attraction around Delhi if you like to relax during the procedure (sic).
- From the website of an Indian IVF Clinic
A return air ticket to India from the US costs about US $1000-1500. Your husband can accompany you, or you can hand-carry his frozen sperm in a dry shipper (which you will need to borrow from your local infertility clinic). The clinic is at Bandra, just 20 minutes from the International airport, and is truly in the heart of Bollywood country (Beverley hills of India!).
- From the website of a Mumbai-based Fertility Clinic
Almost all website home pages have links that guide the user to services and facilities available and other information related to infertility. Some of the areas that are commonly covered include - a section typically called 'About Us' which provides information about the clinic, facilities and personnel; details about the treatment options for various infertility problems and the services that the clinic provides; IVF success stories and testimonies from clients; success rates, charges/cost of various types of treatment; picture gallery, frequently asked questions, fertility 'myths and facts' and IVF videos .
Advertisements carry taglines that promise to 'fulfil dreams', romanticizing what may actually be a long, expensive, unsuccessful and risky medical intervention. Some of these taglines are:
When nature lets you down, our IVF experts step in and resume the process to bring you the gift of motherhood.
They say women make the world go round. How true! It is because they are mothers: The creators and sustainers of every generation.
The moment a child is born, the mother is also born. She never existed before.
The woman existed, but the mother, never. A mother is something absolutely new
With a play of words, a woman's role as a mother is both elevated and venerated to the exclusion of other roles that she performs in society. As such, the linear progression of marriage, motherhood and womanhood is being re/produced, excluding alternative forms of parenthood or voluntary childlessness .
4.4 (Tall) Claims
Many clinic waiting rooms display photographs of the provider carrying newborn babies, with captions proclaiming "firsts", and other breakthroughs and landmarks. Like any other commercial venture, the ART industry operates in a competitive market environment, which fuels claims of providers to milestones and successes apparently achieved by clinics. These serve to establish the credibility and competitiveness of the clinics, towards attracting users .
The city's first test tube baby arrives
In a short span of 3 years, we now delivered about 300 babies using the state-of-the-art facilities.
Unique test tube baby centre, which is the first in Orissa, and has delivered the 1st IVF and ICSI baby in Orissa.
4.5 Inflated Success Rates
Inflating success rates to attract consumers is also common in the ART industry. In order to promote their services and expand their clientele, ART providers quote success rates that are often exaggerated or unclear and misleading .
Success rate can be reported in various ways by clinics. Many report the embryo implantation or pregnancy rate as the success rate; these are higher than the live birth rate because a pregnancy may end in miscarriage, or induced abortion, or stillbirth. Clinics rarely quoted the take-home-baby or live birth rate as the success rate, and users are generally unaware of the difference. Moreover, the success rates quoted by clinics are nearly never substantiated on the basis of the number of users or the time period with regard to which they were calculated. This makes it difficult to discern the extent of the 'success' denoted by stand-alone figures and percentages. Further, success rates vary with the type of procedure used, whether IUI, IVF, or ICSI. Clinics, however, often quote one success rate, without any qualification indicating the specific procedure to which the rate refers .
Our pregnancy rates at 65-70% are among the highest in the world
Today we have a success rate of 40-50% per treatment cycle.
The success rate of ICSI & Test Tube Baby is 50% to 60% comparison to best Laboratory in the World.
These rates quoted by clinics exceed the internationally accepted success rates by a large margin, thus putting into question their authenticity. These rates were quoted by providers themselves, and were found in the promotional material of clinics. The 'success stories' too are magnified and over played.
4.6 Package Deals, Schemes, Concessions and Camps
The idea behind offering a 'package deal' is the same as in any other service - encouraging/luring the user to purchase more services or products, by projecting their combined cost as lower than the sum of their individual costs, thus making the deal seem economical. Packages in IVF gained popularity with the rise in medical tourism.
Clinics also offer schemes such as 'shared risk scheme', 'egg sharing scheme', and 'money back guarantee scheme', which reduce the treatment costs in ARTs . In the egg-sharing scheme, a woman undergoing IVF shares her eggs with another woman undergoing IVF in lieu of a reduction in the cost of her IVF cycles. This is becoming common even in clinics in smaller towns and cities.
While packages and schemes benefit both the user and the provider of Arts, concessions, another feature, may be given at random by the provider to specific users. These are expressions of the providers' benevolence, which in turn earn them goodwill and help to spread word about their clinic .
Yet another feature of the ART market is the organization of infertility camps by ART clinics, in line with camps for free health check ups, dental check ups, eye check ups etc that have been common in India. Now, ARTs have jumped on the bandwagon of this popular recruitment strategy. One clinic in UP held 'free infertility and IVF consultation camps' and provided special discounts on tests and procedures of IUI and IVF, if needed. These camps may be advertised in clinic websites, or local newspapers .
4.7. Actors and Collaborations in the ART Industry
ART clinics are not the only players in the business of promoting 'reproductive tourism' in India. Other emerging players include a wide array of organizations catering to clientele both at the national and international levels. These range from ART consultants, medical tour operators, surrogacy agents, the hospitality industry, and tourism departments to other organizations specializing in medical tourism promotion.
Consultancy agencies like Indian Med Guru and Forerunners Healthcare Consultants cater exclusively to international users. For example, Indian Med Guru defines itself as "... a consultancy for infertility treatment and artificial reproductive techniques, in India, which addresses the need of international patients" http://www.indianmedguru.com. Agencies like Trivector Scientific International and ART Associates provide "expertise" to ART clinics to upgrade their facilities and technical capacity for a more effective marketing of their services internationally. Such groups either specialise in a particular service or follow an approach of 'all-under-one-roof'. They tend to present their services as containing an element of social work/service. Royal Medical Tours (Mumbai) Pvt. Ltd. promotes health packages designed along the lines of regular tour packages, except with the added dimension of helping their clients obtain medical treatment .
In another interesting phenomenon emerging in the ART market today; joint collaborations are coming up, wherein ART clinics in India have tied up with international hospitals and agencies to solicit clients globally. Some of these companies are headquartered in the United States or in other countries, from where the clients are sourced. Planet Hospital (PH), a medical tourism agency with headquarters in California, has an exclusive surrogacy arrangement with Dr. Gautam Allahbadia, the Mumbai-based director of Rotunda--The Center for Human Reproduction. PH's client base is primarily American, but also consists of EU citizens and persons of Indian origin living in the United States. The company receives 15 to 20 inquiries per day regarding surrogacy . Rudy Rupak, co-founder and president of PH, said he expected to send at least 100 couples to India in 2008 for surrogacy, up from 25 in 2007, the first year he started offering the service. "Every time there is a success story, hundreds of inquiries follow," he asserted .
Reverse tourism is seen to occur in egg donation, with companies bringing in women from first world countries to donate their eggs as well as travel in India. Florida based Proactive Family Solutions (PFS) is one such subsidiary that recruits intended parents and egg donors. PFS provides intended parents with a pool of potential egg donors based on the client's criteria, which typically include hair and eye colour, and education level. The company takes care of everything the egg donor might need in India, and even accommodates the egg donor's academic schedule, arranging for her to travel to India during school breaks in case she is a student. The egg donor may also bring one person to accompany her from the US .
Surrogacy centres and hostels that house surrogate women for the duration of their pregnancy are also emerging. New and multiple actors, like surrogacy agents, are now part of this industry. One such surrogacy agent claimed that he was able to match, on an average, one couple with a woman willing to be a surrogate every month. In surrogacy hostels like the one in Anand, surrogate mothers are carefully chosen, and are cared for with nutritional and medical support, which-- given their typically low socio-economic backgrounds-- is ironically probably what they missed when they gave birth to their own children.
4.8 Market Without Rules
Can the standard competitive market model, with free market principles, be considered adequate for the health care sector? If we consider the ethical and physical hazards involved in malpractices, the unequal access to information between the users and providers, as well as the uncertainty of outcome of procedures, the answer must be no. Some of the medical malpractices that the study revealed were as follows:
There was a lack of standardization in treatment protocol, such as the number of cycles, gap between cycles, etc. This paves the way for the exploitation of users, both physically and economically. This was seen both within and across procedures like IUI, IVF, and ICSI.
Not only were procedural costs for IUI and IVF found to vary widely, even the costs of the drugs used were found to be disparate. This variation was found not only across the three research states of Tamil Nadu, Uttar Pradesh and Orissa, but also between clinics in the same state.
Side effects of the procedures, such as ectopic pregnancies, and the potentially fatal Ovarian Hyper Stimulation Syndrome (OHSS) were under-represented to users. Multiple births, which carry serious risks to the health of the mother and the children, were celebrated by clinics as an achievement, and widely advertised.
Users had inadequate and piecemeal information about their treatment, including procedures, drugs, side effects and overall costs. Counselling, which should be a mandatory, comprehensive and sustained process, was found to be a one-off information-giving exercise, if at all. This was in marked contradiction to the notion of "informed" choices that consumers are expected to make in a competitive market.
The process of obtaining informed consent was treated as a mere formality, with little attention being paid to the content of the informed consent form. In several instances, no form had been signed, or forms had been signed without being read, or by proxy.
Practices like sex selection, multiple embryo implantation and even the inducement of pregnancy in postmenopausal women, are common. Given the present climate for son preference, ARTs have the (unchecked) potential to encourage pronatalist eugenics and attitudes to design one's own child (preferably male). Though the Preconception and Pre-natal Diagnostic Techniques (Prohibition of Sex Selection), PCPNDT Act, (1994) 2003 prohibits sex selection before and after conception, and regulates the use of new reproductive technologies, evidence of the use of ARTs for sex selection was found in the research.
The absence of any legally binding regulatory mechanism is exploited to the maximum extent possible by providers. The only document guiding the conduct of ART clinics in India at present is the 'National Guidelines on Regulation, Supervision and Accreditation of ART clinics in India', released by the Indian Council of Medical Research (ICMR). This is non-binding in nature. In 2008, the Ministry of Health and Family Welfare (MOHFW) and the ICMR released the ART (Regulation) Bill and Rules 2008. While this was a welcome step towards regulation, concerns regarding the health and rights of women users were raised by civil society groups. Sama prepared a policy brief for parliamentarians in 2009, critiquing problematic provisions of the draft bill. Since then, the ICMR has released another revised version, the Draft ART (Regulation) Bill and Rules 2010. The 2010 draft has taken some of the civil society concerns into consideration, while excluding several others. As such, many ethical issues that are emerging out of unrestrained spread of the technologies remain. Thus, while regulation of ARTs is desirable, proposed legislation must centre-stage the rights of the most vulnerable, which in this case are the women users, surrogates, and the children born with ARTs.