| June 20, 2018

Baby blues

Baby blues
Rather than see surrogacy as only a means to exploit women, one must also consider the desperation of childless couples

Involuntary childlessness, in other words, inability to produce a baby, has always been a social and personal burden for married couples across cultures. Many technological interventions, commonly known under an umbrella term of Assisted Reproductive Technologies (ART), have been developed to get around this. Successful application of artificial insemination was first reported in the 19th century. Ever since, reproductive techniques have evolved into arrays of other sophisticated services available today, such as in-vitro fertilization (IVF), intra-cytoplasmic sperm injection, gamete intra-fallopian transfer and zygote intra-fallopian transfer.
Although various forms of ART have been around for a while in the West, ART's entry in Nepal is relatively recent. In 2005, doctors at Om Hospital announced delivery of a baby boy conceived through IVF technology, otherwise known as the test-tube baby in common parlance. Four years later in 2009, Republica published an elaborate story of the first test-tube baby.

All these reports on IVF and infertility have a similar narrative: Couples who have failed to conceive naturally, and hence are facing stress of childlessness, resort to modern technology that miraculously cures them of their ills. Nonetheless, the price they pay is hefty. IVF is not foolproof and has a small success rate. One must be ready to undergo multiple rounds of the procedure to be able to successfully conceive. Complications with mother's health are numerous—fatal risk of hyper-stimulation of ovary is one.

It is already a costly procedure to begin with, and every failure and repetition only stacks up the financial burden on distressed couples. The false high hopes it creates by advertising itself as a panacea for infertility is torturous to couples who, after buying into the hope, spend large sums, energy, time and emotions to constantly repeat the procedure and still fail to conceive.

Then there are ethical dilemmas IVF has generated: How should the unused embryos be handled? Should the "good" eggs be selected and the "bad" eggs discarded? This relates to the problem of eugenics; in case of donated egg, should it come from close kin or total stranger? This brings up relational dilemmas and also has a potential of ova being bought and sold.

It is relevant to discuss IVF because of the recent surge of media coverage on surrogacy. The coverage of surrogacy services in Nepali media is negative and advocates banning it citing the possible exploitation of women from low socio-economic status. Eventually, the Supreme Court (SC) issued an order on August 25 to halt surrogacy services in all health institutes and a week later the Ministry of Health and Population (MoHP) issued a warning to health institutes that offer the service. The Cabinet revoked its earlier decision of December 2014 to allow surrogacy.

Articles published in Nepali media only provide a one-sided dimension of what is at stake here: The use of ART and their governance. Instead of wholesale valorization of the miracles IVF brings to childless couples, public should be made aware of its perils as well. Likewise, rather than seeing surrogacy only as a means of exploiting women, one must also consider the desperation of childless couples who would undertake extreme measures to be able to overcome their childlessness. What is also missing from this monochromic story of surrogacy-as-nothing-but-commercial-exploitation is the fact that IVF is an integral part of surrogacy, making the former equally culpable for exploitation.

Indeed, Sama Resource Group on Women and Health—an NGO based in India working on women's health issues—was already critical of Indian government's policy draft on ART in 2008. The policy seems to be guided by the commercial ethos that promotes the interests of individual doctors practicing ART and its private sector providers. Our government also took the initiative, as early as 2012, to bring such regulatory policy to govern ART and surrogacy. However, the policy has yet to see the light of day.

Part of this sluggishness also could have resulted from the state's low priority of infertility issue. In 2014, a senior authority in the MoHP was quoted as saying that infertility was not the Ministry's priority because it was focused on reducing maternal mortality and neonatal death rates. Although there is no official study on infertility, the Ministry claims that 10 percent of the women of reproductive age are infertile.

Ironically, without substantial homework, the government has already recommended IVF, along with artificial insemination, as treatment for sub-fertility in National Standard for Reproductive Health Volume II: Other Reproductive Health in 2003. In the Article 12.14 of National Health Policy 2071, the government proposes to manage infertility through surrogacy. The only government hospital specializing in women's reproductive health, Paropakar Maternity Hospital, did not launch its IVF treatment until 2012, leaving only private participations in the field; therefore, today's burgeoning fertility industry should not be a surprise to anyone.

If medical tourism was not the goal behind permitting surrogacy, what was? Now after an industry worth billions of rupees has emerged in such a short time span, the Cabinet revoked its decision on the ground that Nepali women were being used as surrogates, which to me seems absurd.

If the state is so keen on protecting exploitation of Nepali women, it should also promulgate measures to prevent Nepali women from crossing the border to the south in order to become surrogate mothers—an open secret that seems to have "slipped" the state's moral compass. The outright criminalization of surrogacy service will only push the industry underground, for I am sure an industry of such a robust scale is not going to vaporize overnight. Instead, the government should carefully regulate the ART while being cautious of the pitfalls SAMA has highlighted in the case of India.

Now that the issue of ART has arrived at a critical juncture after the Cabinet's revocation of surrogacy services, there needs to be more public debates on surrogacy. Meanwhile, media should act as mediators in creating richer public dialogues on ART, not simply report monochromic stories. Only through such informed dialogues can we, as individuals and society, better understand and govern matters of infertility, ART, and surrogacy.

The author is pursuing Masters in South Asian Studies with focus on Medical Anthropology at University of Heidelberg, Germany
Gaurav Lamichhane

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