What to Know, What to Ask

More difficult than finding clinics is actually understanding the similarities and differences between the clinics.  There is no "best" clinic.  Each clinic has a different approach to providing its services, and each intended parent needs to decide which approach they're most comfortable with.  In going through the process, and in discussions with other intended parents, these are the main differences we've identified (so far, the list keeps growing):

Cost: While there are differences in costs, it's probably more important to understand what is included in the published rates and what is not included.  Rotunda may be slightly more expensive, Delhi-IVF slightly less expensive.  Either way, you need to ask the clinics for their most recent prices, as they do change periodically. Being priced in Rupees, the price in your currency varies based on current exchange rates. The clinics will provide rates in advance, although there are many factors that are unknown. How much medication will be required to stimulate follicle growth? Will there be one baby or twins? Factors like these affect your final cost. In general, an unsuccessful try will cost less than US$10,000, while the successful delivery of a single baby without complications will cost between US$20,000 and US$25,000. You’ll need to add hotel and airfare on top of that.  See the India surrogacy costs section for more details.

Payment Terms:  Most clinics and agencies request you pay upon certain milestones.  For example, at the beginning of each trimester if the pregnancy is positive.  A smaller number of agencies request full payment up front (even before the egg transfer) and offer a refund if there is no pregnancy.  Unfortunately, when crossing international boundaries, it can be difficult to get money back that you are owed.   

Success Rates: The clinics do publish self-reported success rates. Rotunda, Kaival and Delhi-IVF all report success rates of around 50%.  Surrogacy India, being much newer, announced their first surrogacy birth on 1 May, 2009.  When asking about success rates, make sure you are clear about the definition of success.  What you care about is the "take home baby rate"; often this is not what the clinics use in their definition of success.  Questions you can ask about the definition include:
  - Is it based on a successful chemical pregnancy, clinical pregnancy (fetal heartbeat detected), or live birth (see this description of chemical pregnancy vs. clinical pregnancy)?    
  - Is it per cycle, or per person?  
  - Have any unsuccessful cases been excluded from the statistics for any reason? 
  - Does the clinic only work with younger couples more likely to be successful? 
  - Does this include self cycles, egg donor cycles (generally higher), or both?  
  - Does this include fresh cycles, frozen cycles or both?
  - Can this be broken down by age of the egg donor (older has lower success rates)?

Also, keep in mind that these success rates tend to be self reported and are not validated by any third parties.  So it's unwise to rely solely on them.  From very informal feedback and discussions with other couples, we suspect success rates (successful baby delivery per cycle) are certainly not above 50%, and more likely around 33%.  

Interestingly, the most effective way to improve success rates is, if one has enough embryos, to implant them into two surrogates in one cycle.  This does increase the odds of having multiple children, but can also reduce the odds of a multiple pregnancy depending on how many eggs are transferred.   

Location:  Rotunda and Surrogacy India are both located in Mumbai, a big city of 16,000,000 people. That means direct international flights, many embassies and consulates to get the baby's passport, international restaurants but also more expensive hotels and more traffic/pollution.  Kaival is located in the relatively small town of Anand, further from high volume international airports and with much more limited hotel and food options.  Being a small town, the staff tends to be friendlier than in big-city Mumbai or Delhi.  Delhi-IVF is located in Delhi which, as the nation's capital, is a big city with modern amenities available. 

Responsiveness:  India’s sense of time and sense of good responsiveness is different from the U.S. In India, it’s common to be 45 minutes late for a business appointment. It’s accepted and considered normal. This seems to flow over into email communications as well.  Because of this cultural difference, you need to follow-up frequently. Surrogacy India and Delhi-IVF seem to be the most responsive to questions and comments. Rotunda and Akshanka are okay.  In general, if you haven’t heard feedback within 2 or 3 days, follow-up. You may have to follow-up two or three times before you get feedback.  Also, Rotunda and Anand have become quite popular, and seem to have more queries than they are able to handle.  Don't take slow responses personally, just keep following-up.  Dr. Gupta from Delhi IVF was quoted as saying "There's so many inquiries now I've given up replying to them all".

Lead Time:  Many of the clinics are quite busy, the lead time to find a gestational carrier can be quite long.  Kaival tends to have longer lead times - up to 6 months - with Rotunda and Surrogacy India often having lead times of two or three months.  These lead times do vary quite a bit, so do check directly with the clinic.  

Selecting a Surrogate:  Some clinics/agencies allow more involvement in the surrogate selection process than others.  Regardless, the information available about the surrogates is relatively limited.  Rotunda lets you select your surrogate, informatoin available includes a photos, age, education, number of children and religion.  Dr. Patel in Anand selects the surrogates, but will send you photos. 

Surrogate Living Conditions:  Rotunda and Anand both provide a dormitory for the gestational carriers to live in, which allows for somewhat closer monitoring.  However, it is not compulsory for the carriers to use the dormitory.  Surrogacy India generally has gestational carriers to live at home, but requires the home have electricity, running water and a separate bathroom. 

Known egg donors:  India's guidelines for Accreditation, Supervision and Regulations of Assisted Reproductive Technology Clinics are just that - guidelines which have not yet passed into being law (as of mid 2009).  And they are still being discussed and modified.  One of the more controversial aspects is the prohibition on using known egg donors (such as a friend or relative).  Surrogacy India has been strictly following these rules, and does not allow known egg donors.  Rotunda has been allowing known egg donors and working to see whether this particular rule can be changed when/if the guidelines become law. 

Number of Embryos: Rotunda will implant up to 7 embryos into a gestational carrier.

Number of Surrogates:  If you plan in advance, and if you have enough embryos, Rotunda and Kiran will allow you to transfer embryos to two surrogates at the same time.  This is one of the few controllable factors that can materially improve success rates.   

Frozen Embryos:  Rotunda will allow you to freeze extra embryos (and will coordinate this process). Surrogacy India will use frozen embryos.  Akanksha does not freeze embryos, preferring to use fresh embryos for every cycle in order to maximize success rates (for both the intended parents and the gestational carrier).  There is an additional cost for this, so check and plan ahead. 

Meeting the Gestational Carriers: Whether or not to meet the gestational carrier is a very personal choice. Certainly there are language, cultural and economic differences that not everyone is prepared for. Rotunda generally does not encourage meeting the gestational carriers. Surrogacy India does encourage interaction between the two.

Gay/Lesbian/etc. Friendly:  Rotunda and Surrogacy India are both friendly and support surrogacy for non-traditional arrangements. Kaival is not friendly to gay couples or individuals.

Breast Feeding: Current literature indicates that colostrum, the initial milk generated after pregnancy, helps the baby’s immune system. Rotunda’s gestational carriers very rarely breast feed the baby after birth, often because the husbands won’t allow their wives to do this. Akanksha does encourage the gestational carrier to breast feed the baby for several days after birth. 

Some other things to keep in mind that can be true with any of the clinics:

Wire Transfers.  Some intended parents have reported that their wire transfers were lost.  Fill out the wire transfer paperwork very carefully.  You may consider wiring a small test sum in advance.  And if a wire transfer is lost, ask the clinic if you can pay by cash when you arrive (although this won't help in the recovery of a lost wire transfer) rather than continuing with more wire transfers.  Other alternatives are to overnight a cashiers check directly to the clinic and/or to pay by credit card (usually with a 2% for Visa/Mastercard to 4% for Amex surcharge.)

Medical Tests of donors and the surrogate: The reputable clinics conduct screening tests of the donors and surrogates including for STDs, hepatitis, chlamydia, etc.  Check with the clinic for their exact procedures. 

Baby's sex.  Due to infanticide issues, India has passed laws preventing doctors from disclosing the sex of the baby.  You'll learn your baby's sex at birth.

Multiple births.  In general, the biggest risk from assisted reproductive technology treatment is multiple births, including twins and triplets.  Multiple birth babies are:
 - more likely to be premature and have low birth weight
 - the risk of death before birth or within the first week is 4 times greater for twins and almost 7 times greater for triplets
 - the incidence of cerebral palsy is 5 times higher for twins and 18 times higher for triplets

In the U.K., 24% of IVF births in 2005 were twins or triplets, while the figure was close to 30% in the U.S.

Because it is dangerous for both the babies and surrogates health, many Indian clinics will conduct a "selective reduction" if the egg transfer results in three or more viable fetuses. 

Cost for failed attempts.  IVF success rates are generally around 35%.  Surrogacy may be higher because eggs are implanted in younger women, but probably not higher than 50% per cycle, no matter what an individual clinic may claim.  Realistically, you will likely require more than one try to become pregnant.  Make sure you understand your total cost of a failed try and the cost of a successful try.  Although this varies by clinic, a failed try (no positive pregnancy) is about 1/3 the cost of a successful pregnancy without complications.  Delhi IVF lists the price of a failed attempt at US$5,000 to US$6,000 with a successful attempt costing approximately US$17,000 to US$18,000. 

Extra costs.  If the baby has a difficult delivery, or the mother requires extra medical care, you will have to pay for extra costs incurred. See the costs section.

Contract / Legal Agreement with surrogate.  The clinics will generally have you enter into a legal agreement with the surrogate.  There have not yet been any reported cases of the surrogate wanting to keep the baby, so the legal agreements have not yet been tested by India's courts (that we are aware of).  Although the legal agreement may (or may not) stand up in an Indian court of law, India seems to have had many fewer surrogacy legal issues than other countries. 

What contract did you use with your surrogate?

Used contract provided by clinic, reviewed it myself, and signed it with no changes
83% (5 votes)
Used contract provided by clinic, reviewed it myself, and signed it with minor changes
17% (1 vote)
Worked with a lawyer and provided my own contract
0% (0 votes)
Used contract provided by clinic, had a lawyer review it, and signed it with no/minor changes
0% (0 votes)
Used contract provided by clinic, had a lawyer review it, and signed it with major changes
0% (0 votes)
Total voters: 6
Add your answer

Contract / Legal agreement with clinic.  Also be aware that the legal agreement provided by the clinic is typically between you and the surrogate; often there is no legal agreement between you and the clinic/hospital/agency.  Most people seem fine with this, but you should at least be aware of it.  There are attorneys who will help draft and oversee a "Service Provider Agreement" between the intended parents and the clinic; using such an attorney does add another party into the process but may provide peace of mind.  To date, most intended parents have not drafted separate service provider agreements. 

In an interview for the Wall Street Journal, Mike and Mike said:

...concerned that the agreements they were given to sign with the surrogate and the clinic were too vague, [Mike and Mike] spent $3,000 in legal fees to have a U.S. lawyer rewrite them. In retrospect, Mr. Aki, 43, wonders whether the revised contracts would have been honored in India's byzantine legal system anyway. Luckily, the process went smoothly.   

Your local IVF Doctor.  In order to minimize your time spent away from home, you will likely want to start your IVF cycle locally, and then fly to India just for the transfer.  This can help reduce the length of the trip from three weeks to a bit over a week.  Most local IVF specialists do not have experience operating in such a "satellite" capacity, where they are mainly monitoring progress and providing reports to the India doctors and clinics.  If you want to start your cycle locally, you'll have to get your local IVF specialist on board.   

Indias Assisted Reproductive Technology proposed laws:  India's guidelines for Accreditation, Supervision and Regulations of Assisted Reproductive Technology Clinics are just that - guidelines which have not yet passed into being law.  And they are still being discussed and modified.  There are two main areas to be aware of in these guidelines that are still being discussed, but could affect your surrogacy plans:
1) Using a donor egg from a relative is prohibited.  Some clinics are already following this rule.
2) Full payment must be made to the gestational surrogate before a pregnancy is confirmed.  This could significantly increase the cost of negative cycles. 

Birth Certificate:  The same guidelines also dictate the names to be put on the birth certificate.  Current practice is to put the intended parents name on the birth certificates, especially if they are both the genetic parents.  In the case of an anonymous egg donor, the name of the gentic father will be used with "unknown" as the mother.  However, a court case in Anand did direct that a surrogate mothers name be put on the birth certificate (this was with an egg donor, not an embryo from the intended parent) rather than "unknown".  For U.S. citizens, this generally doesn't cause a problem because U.S. law generally requires only one genetic parent to be a citizen - see later sections on getting a passport and consular report of birth abroad (the equivalent of a birth certificate for babies born overseas).  So, while the issue of which names to put on the birth certificate is generally not causing problems today, it is one to be watched, and one to then coordinate with your embassy before the baby's birth.

Citizenship:  Do work closely with your embassy, consulate and or legal professionals to establish what steps will be necessary to get your baby's passport and citizenship.  This is generally required before being able to leave India with the baby.  The U.S. has reasonably clear rules.  The U.K.'s rules seem to be getting clearer, but still seem to result in a two or three month stay in India before securing a passport for the baby.

As you can see, many factors affect which clinic is right for you.  Policies do change, so communicate with the clinics to confirm their current policies and then decide which you'd like to work with. 

If you are really cynical about surrogacy, and the possiblity of getting scammed, there are many ways clinics can take advantage of you.  This is unlikely to happen with reputable clinics, but one Ukranian web site, for example, states:

We regularly receive complaints from foreigners regarding scams involving surrogacy. Numerous foreigners have lost money to so called «surrogacy agencies» and individuals that claimed they could arrange for surrogacy services for comparatively low prices. Normally these «very competitive» firms are just swindlers. A quality service can not be cheap. Typically, the Ukrainian correspondent asks the foreigner to send money or credit card information for living expenses, travel expenses, or medical costs for the surrogate and then disappears or informs that the surrogate lost the pregnancy. It is not uncommon for foreigners to become victims of mistreatment and extortion by these criminal «agencies» after the pregnancy is confirmed. Sometimes even some medical doctors from reproduction clinics are also engaged in their criminal activities.

So if you prefer to take this risk and act on your own, please check twice all their identifications, all legal documents and certificates (including the clinic’s and your MD’s diploma). Always ask to show you the originals and keep a copy. Hire an independent interpreter, preferably a foreigner. Please check what’s included and what’s not in the contract. It should be explicitly mentioned in written form.

If you are informed that the surrogate gets pregnant, always ask for the original reports about her health with her name on it. It would be helpful in the court if she somehow «loses» her false pregnancy.

And of course always ask for an independent DNA test to prove that the child is really yours — it’s a wide-spread scam to pass off some stolen baby or a child who has been «refused» immediately after delivery by some adolescent or low-class mother as intended parents' after a false surrogate’s pregnancy. Please don’t hesitate to contact us should you need any legal assistance in case of any problems or an attorney to represent you in the court. Our lawyers have vast experience in such cases.

The key is, do your research.  If you are working with a newer clinic or agency, make sure you are comfortable with them.  If you can, get references.  And, if you can, make sure a reputable doctor is providing you updates of the process. 

 

If you have comments or updated information on any of the above, please leave them in the comments link below.   

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