SOME OF PATEL'S CUSTOMERS view the residency program as an insurance policy of sorts. "When I was told by my doctor they could get someone in Stockton [California], I don't know what they're eating, what they're doing. Their physical environment would have been a concern for me," says Sarah, a 40-year-old from Berkeley who runs a catering company with her husband and teaches Jewish ethics lessons to children. "The way they have things set up here is that the surrogate's sole purpose is to carry a healthy baby for someone."
I met Sarah (a pseudonym, per her request) in the hallways of the Laksh Hotel, which caters to Akanksha's surrogacy tourists. For many, this India excursion represents the final stage of an expensive and emotional quest for genetic parenthood—their last option after a series of failed fertility treatments. She tried for years to conceive, and after extensive testing was told she never would. Adoption didn't appeal to her. Then she read a news article about Patel and knew immediately that she wanted to come to Anand. "Money was definitely one of the reasons, but it was like my gut feeling," she says. "This is where I needed to be." Sarah and her husband resolved to keep their undertaking secret from friends and neighbors—at least until they returned home with a baby.
Surrogacy, one lawyer tells me, is "employment, plain and simple. Foreigners are not coming here for their love of India. They are coming here to save money."
In the United States, a surrogate and her clients must establish a relationship before coming to a fertility clinic, but Sarah has barely met Saroj, the woman Akanksha hired to carry her child. They connected just once, briefly, at the clinic a few minutes after embryos from her eggs fertilized with her husband's sperm were implanted in Saroj's uterus. That was nine months ago. She's been back in Anand for a few days, and hasn't yet gone to visit Saroj, although she will spend time with her later. "The clinic wants to keep a separation," Sarah tells me. "This is what your job is: I'm the mother. She's the vessel."
But this is where the ethos of commercial surrogacy becomes confusing. Sarah is quick to add that Saroj is giving her one of the most precious gifts a person can offer. "The clinic won't let someone be a surrogate more than twice, because they don't want to see themselves just as a surrogate," she says. "That shouldn't be a job."
Then how to view it? Oprah showcased Jennifer and Kendall, a childless couple who had tried everything else but couldn't afford the American surrogacy system. With Patel's help, Jennifer became a mom, and an Indian woman was lifted from poverty—a transaction part business and part sisterhood. Yet it's a setup fraught with all the ambiguities of the global labor market: When you buy sweatshop sneakers it allows someone's family to eat. But you also know you're getting a bargain only because the people making the shoes are poor.
Clinics work hard to present surrogacy—to surrogates and clients alike—as an act of altruism, and insist that the women offer their wombs out of a sense of communal responsibility, not simply because they need a paycheck. The boilerplate contracts Akanksha has its clients and surrogates sign are correspondingly vague about the nature of the service being provided.
"Is it work? Is it charity?" Amit Karkhanis, a prominent surrogacy lawyer whose clients include Mumbai's largest surrogacy provider, asks me rhetorically over $8 coffees at a swank hotel. Cocking one eyebrow, he offers his own opinion: "Surrogacy is a type of employment, plain and simple. Foreigners are not coming here for their love of India. They are coming here to save money."
Indeed, although most Indian surrogates get roughly the same percentage of the total fees—about a quarter—as their American counterparts, the vastly lower cost of living in India offers huge savings to American clients. "Surrogacy is a form of labor," lawyer Usha Smerdon, who runs a US-based adoption-reform group called Ethica, told me in an email. "But it's an exploitative one, similar to child labor and sweatshops driven by Western consumerism...I challenge the notion that within these vastly differential power dynamics that surrogates are truly volunteering their services, that hospitals are operating aboveboard when driven by a profit motive."
Besides India, only a handful of countries—including the United States, Ukraine, Thailand, Israel, and Georgia—allow surrogacy for pay, and most of those have imposed strict regulations. France, Greece, Japan, and the Netherlands forbid even unpaid arrangements, and no country, not even India, recognizes surrogacy as a legitimate form of employment. America leaves regulation to the states: Eight recognize and support it and have mandated health safeguards and counseling for surrogates. Three, plus the District of Columbia, have banned it outright. And the rest have either deemed surrogacy contracts unenforceable, left surrogacy for the courts to deal with through case law, or simply ignored the practice.
India's Council of Medical Research (which plays an FDA-like role) has come up with proposed surrogacy guidelines that caution against some practices already in common use in Anand and elsewhere, such as allowing the clinics to broker surrogacy transactions. But these nonbinding rules, considered a starting point for national legislation, ignore other glaring ethical issues, such as whether it's okay to impose C-sections on a surrogate or, for that matter, make them live in a group dormitory for nine months.
Doctor Nayna Patel has been praised and vilified for her clinic's controversial practices. Either way, she's hardly lacking for clients or women seeking to be surrogates.
Implantation is another dicey issue. For healthy young women, the American Society for Reproductive Medicine advises American doctors to implant just one—and certainly no more than two—embryos in a woman's uterus per attempt. The Indian guidelines recommend no more than three for surrogates. But Patel's clinic routinely uses five or more embryos at a time. Using more embryos boosts the success rate but also results in multiple births, which are far riskier for the woman and often lead to premature delivery and dire health problems in the infants. Although it's impossible to verify, Akanksha claims an implantation success rate of 44 percent—similar to other Indian clinics—compared with a US norm of 31 percent. Several of the surrogates I met in Anand were pregnant with twins. (Akanksha's policy is simply to abort any additional fetuses.)
While the guidelines clearly state that "the responsibility of finding a surrogate mother, through advertisement or otherwise, should rest with the couple," Akanksha advertises far and wide for surrogates in local-language newspapers, and many hospitals have responded to demand by hiring headhunters. At Mumbai's imposing Hiranandani Hospital, physician Kedar Ganla introduces me to a gaunt woman named Chaya Pagari—his direct line to the slums. The 40-year-old "medical social worker," as Ganla calls her, sits uncomfortably in his office and meets my questions with hesitation. Given her sparse résumé, "recruiter" would be a more apt title. Ganla pays Pagari 75,000 rupees (about $1,650) for each surrogate he accepts. He's already accepted three this year, she tells me—meaning she's making as much as the women she recruits. "Between us brokers," she adds, "there is near constant competition to find surrogates."
Doctor Anoop Gupta does things a bit differently. He runs Delhi IVF, the clinic where I met Kristen Jordan, and where his waiting room is packed with chatty patients. Next to Akanksha's spartan vibe, it is night and day, with wood-paneled walls and a brightly lit aquarium exuding a sense of security and warmth usually lacking in Indian medical facilities.
Clad in green scrubs and a blue hairnet, Gupta is constantly on the move and has little time for questions. Instead, he has me observe a constant stream of patients who have come to him from as far away as Ireland and California, or from as close as a few blocks away. While most are here for routine fertility treatments, Gupta has at least seven surrogates on the rolls this month. "In India the government makes it difficult to arrange an adoption, while having your own genetic child through a surrogate is legal and easy," the doctor says as he slathers a clear gel on the paddles of an ultrasound machine. The only hurdle, as he sees it, is finding a surrogate who isn't motivated by desperation.
The cloistered Akanksha surrogates "sit, they talk, and they sleep," says a rival clinic's employee. "It's just not right."
For this, he relies on Seema Jindal, his medical coordinator, who is a licensed social worker and registered nurse at the clinic. Her recruiting method has a twinge of evangelism: "I ask just about every woman I meet socially if she has thought about surrogacy." She focuses on women who have completed college and are well-off enough not to have to rely on the clinic's payments for basic needs. Otherwise, she says, "How do they know they are not being exploited?"
Several months before our interview, Jindal took a train to Gujarat to snoop on Patel's operation firsthand and suss out ways to make her own clinic more profitable. In her view, the residency program is degrading. "They sit, they talk, and they sleep," she says. "It's just not right."
One of Jindal's recruits, a 32-year-old social worker named Sanju Rana, is here for her ultrasound. Unlike the Anand surrogates, she is college educated and plans to work full time throughout her pregnancy. She's been promised $7,500 for her services, and has Gupta's direct phone number. During the procedure, Rana, already a mother of two, is surprised to learn that she is carrying twins for an American couple. She's worried, she tells me, but she will most likely carry them to term. "They are good people, and have been childless for so long," Rana says.
SARAH IS CHILDLESS no longer. It took five weeks to finalize her newborn's status as a United States citizen, complete with a shiny blue-and-silver passport and a no-objection certificate issued by the Indian government. But she has since traded the smog and chaos of Anand for her quiet neighborhood in North Berkeley, where the realities of motherhood have kicked in.
The small apartment she and her husband share with another renter now feels too cramped, and the couple is looking for an upgrade. The electric piano her husband once played daily sits unused in the corner of a room dominated by a crib and assorted baby gear. As we chat, Sarah bounces Zoe, her healthy blue-eyed girl, on one knee. "It already seems like a thousand years ago that we were in India," she says. "But we are so grateful for what Saroj has given us."
Sarah says she was surprised when Patel offered her a choice of birthdays. But she chose, and then waited expectantly while the clinic delivered Zoe via C-section. "There was an intensity in her eyes," Sarah recalls of the handover. "It was hard for her, and you could see how much she cared for Zoe." In the end, though, the baby had to come home with her mother.
Correction: Sarah had been back in Anand just a few days when she first met the reporter, not three weeks; she later visited with Saroj, the surrogate mother.