Surrogacy
CEO STATEMENT FOR SURROGACY
The most beautiful celebration in the history of a family is the welcoming of a new member into its fold. The joy of parenthood!! The shouldering of enormous responsibility as a parent. To create the unbreakable bond of the family

Reproductive medicine today has path breaking modalities that offer solutions for those who have a handicap in the process of natural conception. There are also those who will be incapable of carrying that conception within them. This could be for myriad reasons. Since also has provided for a solution here and that is surrogacy

The English dictionary defines Surrogate as – ‘Substituting another person or thing, especially bearing a child’. The hospital has a program to support those incapable of carrying that conception within them. The surrogacy program in the hospital is vibrant. The success rate is around forty percent. The surrogates are carefully investigated and selected.
The hospital offers collateral support – such as identifying a legal person for drafting agreements, arranging for the surrogate to be examined throughout her confinement and also deliver the patient in the hospital (should the patient so desire). Thus we extend care to the patient right from conception to delivery

The preceding paras may have raised a few questions in the minds of those who are considering enrolling in our surrogacy program. Please do feel free to contact the department (Tel ………). They have a brochure that deals with the subject mater in detail and expressed in simple language.

For those inclined please do experience the professionalism, warmth, empathy and comfort of the hospital. If you want to embark upon a surrogacy program and do not know how to, we have a one stop solution for you. All you have to is call . . . . . . .

Achieving the parenthood through surrogacy program is a road less traveled.
The couples who dream to be parents and have surrogacy as the only way to do it surely need someone who will ease the process and on whom they can completely    rely upon to take care of their unborn child.

 We, the Hiranandani Hospital surrogacy program team, understand the roller coaster of emotions from  excitement to anxiety, from ecstasy to fear, from joy to self doubt that a  couple goes through during this period. It is indeed a stressful period because the couple is entering a phase of the unknown. It is a dark tunnel with hope and light ahead. But passing that tunnel towards hope and light may be very difficult. . Your most precious treasure, your child is with somebody else!

You are always unsure as to who that person is, whether she will take care of your child, whether she will have enough nutrition to deliver a healthy full term baby. Every minute you will wonder as to what is happening to the baby.

Our team fully understands this and we give a very humane touch to this entire program. You are not treated as only clients or one more opportunity to earn money but as parents who are longing for a child in their life. The surrogate is also not only as just another person, but we also try and ease her journey by caring for her as one does for their near and dear ones. The compassion, the personal touch, and the care makes our program a little different. We walk the entire journey of achieving the parenthood through surrogacy with you. You will find us at every step from taking the decision to the birth of your baby keeping in mind the privacy and dignity of couples and maintaining utmost transparency in the process. You are informed about the progress of the baby from time to time including the cd’s of the sonography where you can see your baby kicking around and you can be assured of the well being of the baby. According to us, this helps you to bond with your baby even before the birth of the baby..

1.What is surrogacy?
The word surrogate originates from Latin word surrogatus (substitution) – to act in the place of. The term surrogacy is used when a woman carries a pregnancy and gives birth to a baby for another woman and thus making another couple's dreams of parenthood come true. When the baby is born, the intended parents who contracted the surrogacy arrangement will be the legal parents of the child
Surrogacy is gaining popularity as this may be the only method for a couple to have their own child and it also gives a chance to share your own genes with your baby and hence emotional bonding.

2.What is the history of surrogacy?
Infertility is age old calamity in family life and we find the references in our Hindu   
mythology about surrogacy in the the story of queen Gandhari and her hundred children & also in Old Testament in which Hagar, the maid servant of Sarah lies with Abraham to bear a child for her infertile mistress.

3.What are the types of surrogacy?
A.IVF / Gestational surrogacy
This is more common form of surrogacy. This is where the surrogate woman carries a pregnancy created by the egg and sperm of the genetic couple. The egg of the wife (genetic mother) is fertilized in vitro (in the laboratory) by husband’s sperms (genetic father) by IVF/ICSI procedure, embryo transfer is performed (embryo is released) into the surrogate’s uterus and the surrogate carries the pregnancy for nine months. Thus the surrogate only carries the baby of the commissioning couple and the child is not genetically linked to the surrogate.

B.IVF & Egg Donation (IVF/ED) Program or gestational surrogacy with an egg donation Donor Ovum is fertilized with sperm of the intended biological father. Resulting embryos are implanted into the uterus of the surrogate. The surrogate carries the pregnancy for nine months. Thus the surrogate only carries the baby of the commissioning couple and the child is not genetically linked to the surrogate.

C.Traditiona l/ Natural surrogacy
This is where the surrogate is inseminated (washed Semen of the male partner is put in the uterine cavity of the surrogate) or IVF/ ICSI procedure is performed on the
surrogate with sperms from the male partner of an  Infertile Couple. The child that results is genetically related to the surrogate and to the male partner but not to the female partner. It is not done as it involves genetic contribution of the surrogate which can lead to emotional attachment of the surrogate  to the baby and legal problems later on.

4.To whom surrogacy is advised?
A.IVF Surrogacy
1.Most commonly it is indicated in women whose ovaries are producing eggs but they do not have a uterus in cases like :
a. Congenital absence of uterus (Mullerian agenesis)
b. Surgical removal of uterus (hysterectomy) due to cancer, severe hemorrhage (bleeding) during Caesarian section or rupture uterus.
2. A woman whose uterus is malformed by birth (unicornuate uterus, T shaped uterus, bicornuate uterus with rudimentary horn) or damaged uterus (T.B of the endometrium, severe Asherman’s Syndrome) or at high risk of rupture (previous uterine surgeries which may have resulted in opening of the uterine caity) and is unable to carry pregnancy to term can also be recommended IVF surrogacy.
3. Women who have repeated miscarriages or have repeated failed IVF cycles may be advised IVF surrogacy in view of unexplained factors which could be responsible for failed implantation and early pregnancy wastage.
4. Women who suffer from medical problems like diabetes, heart or kidney diseases like chronic nephritis whose long term prospect for health is good but pregnancy would be life threatening(the pregnancy can deteriorate the existing medical problems).
5. Woman with Rh incompatibility (These are Rh negative women, who are exposed to Rh positive antigen and have developed antibodies to Rh positive antigen. They cannot carry an Rh positive baby as the antibodies which are formed in the mother’s body will affect the baby).
B. IVF & Egg Donation (IVF/ED) Program or gestational surrogacy with an egg donation
It is advised for couples where the biological mother’s ovarian reserve is poor due to any surgeries or advanced maternal age or there is any genetic abnormality in the mother which can be transmitted to the baby and husband’s sperm count is normal.

5.Is Surrogacy right for you?
For some couples, opting for surrogacy is a very straight forward decision but for others there are lots of things to be considered and thought about before taking the decision about surrogacy. There are lots of complex issues involved. It is an emotional roller coaster ride for the couple, the families and friends. It is a decision where the ‘right’ and the ‘wrong’ are very individual things. An infertility specialist or a counselor can help the couple seeing things in correct perspective. Other options to surrogacy like adoption or further infertility treatment can be considered.

5.)What are the screening criteria for surrogate? How is a surrogate chosen?
The illeffects of maternal health on the fetus are well known; hence choosing the right surrogate is the most important part of the programme.
Surrogate is the woman who is going to keep your baby for 9 months in her womb & will be giving it away to you.
These women do it for the family’s economic needs and also a strong desire to complete someone’s dream of becoming parents.
For us the important factors are her physical fitness to carry the pregnancy and her emotional stability to undergo the program.
And that’s why we at our Center have very meticulous and stringent criteria for choosing a surrogate.
Things which are see before taking the surrogate in the programme:
• The surrogates are between 21-35 years of age. This is the most fertile period of reproductive age group. Below 21 years and above 35 years there is increased chance of abortions and other pregnancy complications.
• They are married with previous normal deliveries, healthy babies and no complications during pregnancy or delivery. Thus their fertility potential is tested. Having previous children means they already have an emotional bonding with their own children and will be less likely to get attached to the baby which they are going to carry as a surrogate.
• Detailed medical history (history of high blood pressure, diabetes, jaundice, asthma, tuberculosis etc. is looked into)
• Detailed surgical history (any operations in the past which can in any way affect pregnancy or delivery)
• Personal history (history of smoking, drinking, drug abuse, tobacco, mishri [oral tobacco] use which negatively impact reproductive outcome)
• Family history (history of any illness in the family like tuberculosis which is a communicable disease)
• It is made sure that the surrogate has had an uneventful obstetric history (like no repeated miscarriages, no antenatal, intranatal and postnatal complications in previous pregnancies).
• A physical and gynecological examination is done for the surrogate. This includes checking for vital parameters like pulse, blood pressure, respiratory rate, cardiac status, per abdomen evaluation, per speculum evaluation to rule out vaginal infection and cervical erosion and per vaginal evaluation.
• Routine investigations like haemoglobin ( to rule out anaemia which can cause IUGR and preterm labour), routine urine examination (to rule out asymptomatic bacteruria which again is the commonest cause of preterm labour), liver function tests and renal function tests( to know the baseline in case there is any problem later), random sugar evaluation (to rule out diabetes), X Ray chest (to rule out active tuberculosis), ECG (to rule out cardiac abnormalities) are done.
• Tests like TSH (to rule out thyroid disorders like hypothyroidism or hyperthyroidism which may affect pregnancy) and prolactin (hyperprolactinemia may affect fertility potential) are also done.
• The surrogate and her partner are screened for infectious diseases like Hepatitis B, Hepatitis C, HIV and VDRL.
• Thalessemia screening is also done (a thalessemia trait can cause chronic anemia).
• Detailed pelvic sonography is done to assess the uterus, ovaries and endometrium. Uterine pathologies like fibroids, adenomyosis etc., ovarian pathologies like ovarian cysts, endometriomas, uterine pathologies like endometrial polyps, other pathologies like hydrosalpinx, fluid in the pouch of Douglas suggestive of pelvic inflammatory disease are ruled out by pelvic sonography.
• Other tests for uterine receptivity (subendometrial blood flow) are done to ensure maximum chances of success. Subendometrial blood flow is done by transvaginal power color Doppler to find out how much blood reaches the inner layer of the endometrium. The best results are obtained when the flow is reaching the innermost zones. A dummy cycle exactly mimicking the original cycle is done for them. Only those surrogates are chosen whose blood flow is reaching the innermost zones are selected.
• The surrogate along with her husband also undergoes a psychological evaluation to evaluate the fitness to become a surrogate.
The surrogate is also interviewed by ethical committee (consisting of a Priest, social  Worker, businessman, a housewife, industry representative, independent gynecologist).There are various questions asked to determine her willingness to carry the child for 9 months and readiness to hand over the child immediately after birth. This meeting is recorded on camera to give us a solid legal backing.
The surrogates are chosen after all the above factors are carefully evaluated and there are no negative factors in the history, physical evaluation, gynaecological evaluation, investigations, pelvic sonograpy or the endometrial blood flow.
A detailed financial and legal agreement is then made between the surrogate, her care taker and the commissioning couple to ensure and protect the rights and duties of both the surrogate and the commissioning couple.

6.What is the procedure involved?
For IVF surrogacy matching of cycles of the genetic mother and the surrogate is done by adjusting menstruation dates by oral contraceptive pills.
When the cycle starts, the surrogate is put on estrogen tablets to prime the uterus.
Protocol used for genetic mother is day 2 protocol or day 21 protocol depending on the age of the genetic mother and other test results.
For the day 2 protocol called the antagon protocol, oral contraceptive pills are given in the previous month. On 2nd day of the periods gonadotropin injections are started. USG Monitoring is done daily. When the size of the follicle reaches 14 mm the genetic mother is given antagon injection to prevent surge of endogenous hormones.
For the day 21 protocol called the long protocol GnRH analogues are started on day 21 of the previous cycle. Once the genetic mother gets her periods, gonadotropin injections are started.
In both the cases the patients are monitored daily. When the follicle reaches 18 mm size HCG trigger is given. The surrogate is started on progesterone tablets on the day of HCG injection to the genetic mother.
Oocyte retrieval is done 36 hours later which is generally day 12/13 of the cycle. On the same day the genetic father gives his semen sample. The eggs of the genetic mother are fertilized with sperms of the genetic father in the laboratory by IVF / ICSI procedure.
The embryo which has resulted from the above mentioned procedure is transferred into the womb of the surrogate under ultrasound guidance. The surrogate is then put on luteal support using progesterone tablets / injections and pregnancy is confirmed 15 days later.

7.How is the nine months journey like with surrogate?
The surrogate is treated as a high risk pregnancy and is cared for by 2 consultant gynecologists in our hospital (She will be seen by us in the department and also sent to one more obstetrician in the hospital). Appointments are scheduled with the consultants every two weeks for the first 8 months and then weekly in the last month.
After embryo transfer beta hCG (a blood test to confirm pregnancy) is done after 15 days. If the blood test is positive, it is repeated every 4th day till the value reaches around 25,000 Miu/litre(a specific rise in beta hCG is expected and this expected rise  indicates the progress of pregnancy.
Once the beta hCG values reach 25,000mIU/litre, we do a transvaginal sonography in the department wherin most of the times we can see a gestational sac, a yolk sac, A fetal pole and most of the times the heart beat of the baby.
Ultrasound is done at 6 weeks from radiology department to confirm pregnancy and the viability of the baby,
At 12 weeks, an ultrasound is done from radiology department to assess growth and certain parameters like nuchal thickness which if increased is a soft marker for Down’s syndrome.
At 12 weeks after the sonography for nuchal fold thickness, a double marker test is done to assesss the risk of the fetus for trisomy 21 (Down’s syndrome) and trisomy 18. Other blood tests like complete blood count, routine urine examination and TSH tests are also done simultaneously.
At around 16-17 weeks of gestation a triple marker test is done again to assess the risk of of the fetus for trisomy 21 (Down’s syndrome) and trisomy 18 and neural tube defects.
At 16 weeks amniocentesis is performed if the genetic mother’s age is more than 35 years after counseling and in consultation with the genetic parents.
At 18 -20 weeks a detailed level III ultrasound is done from radiology department to detect any structural abnormalities in the baby.
2 doses of Inj TT are given between 24 and 34 weeks of gestation.                   
At 28 weeks and 34 weeks colour Doppler is performed from the radiology department to assess the growth of the baby and rule out intra uterine growth retardation. Fetal well being tests like non stress tests are done as and when required.
The surrogates visit our Centre every 2 weeks which ensures that the growth of the fetus is adequately monitored and if there is any problem, it can be picked up at the earliest. This helps us to issue treatment at the earliest and ensure a good outcome for the pregnancy.
At every visit, cervical length is monitored through transvaginal ultrasound. This is a novel technique to pick up shortening of the cervix at the earliest. This helps us in identifying the mothers who may have a risk of preterm delivery and doing a cervical encirclage (putting a stitch around the cervix so that further shortening of the cervix and opening up of the mouth of uterus does not occur) As they say ‘A stitch in time saves nine’, so our stitch well advance in time almost eliminates the risk of preterm delivery and subsequent fetal mortality and morbidity.
We also give them antibiotics (vaginal as well as oral) during the 2nd trimester of pregnancy to prevent vaginal infection which is the commonest cause of preterm labor. We also give them tablets containing lactobacillus which ensures that the pathological organisms from the vagina are replaced by these bacilli and normal vaginal flora is maintained.
Today after managing thousands of high risk pregnancies (all our IVF/ICSI/IUI/ surrogate pregnancies) we can boast that none of our babies have delivered before 34 weeks of gestation and none of them have required intensive NICU care.
We also monitor AFI (amniotic fluid index) at every visit through abdominal sonography. Thus we can pick up oligohydramnios (less liquor) and IUGR at the earliest. This is not possible only with a clinical examination. When it is detected on clinical examination, the oligohydramnios and IUGR are already in moderate to severe category. This helps us in detecting even mild IUGR and oligohydramnios. The treatment in the form of bed rest, extra protein supplements, nitrous oxide donors etc starts at the earliest and further progression is prevented.
We have done a pioneer study in the use of vaginal Viagra (sildenafil citrate) in the treatment of IUGR and oligohydramnios.
All the above measures ensure that none of our babies are less than 2.5 kgs and require NICU care due to low birth weight or prematurity
Detailed information is given to the surrogates about diet during pregnancy.
They are regularly provided with iron, calcium protein supplements including protein powder from the hospital.
Thus it is taken care that adequate nutrition reaches the baby and baby’s growth is maintained.
 We have an LDRP (Labour Delivery Recovery Puerperium) room for delivery which is equipped to handle any obstetric emergency. We have a concept of full time obstetricians who are available 24 hours.
Our NICU setup is also completely equipped to handle any neonatal complications, with a neonatologist who is available round the clock. We have an NICU portal which will give you detailed information about the NICU care and the statistics will prove the highest level of care that is offered in the NICU.
You can have a look at our LDRP ROOMS, OT , NICU. Please click the link.
We keep the couple posted on the progress of the baby and send them ultrasound pictures and blood reports as and when they are done.

Dr L H Hiranandani Hospital
“Your family hospital TM”

ISO 9001:2000 CERTIFIED
DAR & NABCB ACCREDITED
A NABH Accredited Hospital

8.What is the success rate of surrogacy?
The   success rate of surrogacy is around 60% carry home baby rate.

9.What are the different ways children born through surrogacy may receive breast milk?
Just because baby is born through surrogacy does not mean he or she cannot receive breast milk and the many health benefits it provides. Breast fed babies have been found to have higher IQs, more protected from leukemia and be less likely to have problems with obesity. Breast milk protects babies from getting diarrhea, ear infections and respiratory problems such as asthma. Premature babies who receive breast milk are more protected from infections and high blood pressure later in life. Breast milk contains the protein CD14 which works to develop B cells which are immunity cells that are needed in the production of antibodies in an infant to build the babies immunity system.

The babies may drink breast milk acquired through milk bank, breast milk donor may be located or the intended mother may induce lactation before birth of the baby.

Induced lactation has been embraced by the nursing community as a welcome method to enhance the bonding relationship between a new mother and baby born through surrogacy. It is best to make the goal – bonding & enjoyable breast feeding rather than producing as much breast milk as possible. Prolactin and oxytocin are the two pituitary hormones that cause lactation to occur. They may be stimulated despite the woman’s inability to carry a child. Lactation may be induced a number of ways and the amount of milk a non lactating woman can produce through inducement varies from woman to woman. The most common way women induce lactation is through manual or mechanical stimulation. With this method lactation is induced by massage, nipple manipulation and sucking either by the baby or breast pump. The second common method used is hormone therapy whereby a woman uses herbal remedies such as Fenugreek or is prescribed medications such as Domperidone and Metoclopromide (Reglan*) to induce and increase her milk supply. Induced lactation milk skips the colostrum phase and more resembles mature breast milk.
Manual stimulation of lactation usually takes between two and seven weeks and hormone therapy usually takes between one to four months. For this reason intended mothers usually begin during the final trimester of their surrogate mother’s pregnancy.

10.What are the advantages of surrogacy?
a.This may be the only chance for some couples to have a child which is biologically completely their own (IVF surrogacy ) or partly their own (gestational surrogacy)
b. The genetic mother can bond with the baby better than in situations like adoption.

11.What are the disadvantages of surrogacy?
a.It is highly controversial topic and can involve many legal complexities.
b.The surrogates may face medical / obstetric complications during pregnancy which puts extra financial burden on the commissioning couple.
c.From the babies point of view the concern lies with IUGR and preterm delivery.
In some cases the surrogacy technique may be ‘misused’ like career oriented women, figure conscious woman, models etc. may just ‘hire’ women on ‘rent’ to carry their biological child. Of course, this is strictly not ethical, should be vehemently banned and prohibited.
In short surrogacy is an exiting and innovative yet complex and a little frightening way to achieve parenthood.

12.What about the legal formalities?
The baby will be handed over to the commissioning couple immediately.  We have a lawyer, Mr.  Amit Karkhanis, who will handle all your legal formalities like the contract of surrogacy, the legal formalities involved in taking the baby back to your country, the birth certificate of the baby etc.  You can mail him on
amitkarkhanis@kaylegal.in

13.Surrogacy for gay couples?
We as a team believe, every couple has the right to be parents, regardless of sexual  
orientation. Every couple is special and we make no distinction between heterosexual  couples and gay couples. We focus on the desire and the intent of a couple to create their own family. We believe that all our couples deserve to be treated with dignity, Compassion and respect.

14.The cost factor
The cost of the surrogacy program is around 18,000-20,000 US dollars. The main advantage is that you pay in 5 installments. This ensures that you pay for each trimester and do not spend extra money.
For example if there is a missed abortion in the first trimester, you have paid only for the first trimester. You need not pay any other installments. This is much better than running around asking the Center for refund when you have paid the entire amount.
The installments can be paid by cash or credit card or can be deposited by wire transfer

15. There are other programmes around there ….. Why we?
The Hospital is the first NABH accredited multispeciality hospital of Mumbai and the standards of functioning are maintained in each department. The surrogate and the intended parent’s do not have to run around for anything during this entire programme because all the services needed are provided under one roof and all the essential departments’ are under one roof in this multispecialilty hospital.
We have fully functional and 24 hrs facility in the following departments:
1) An Excellent Labour delivery room well equipped according to the standards of NABH & is very well in coordination with the team of obstetricians and Gynecologists.

2) Full time highly qualified Obstetricians and Gynecologists who take care of the Surrogate mother throughout the 9 months of pregnancy and have delivered many so far.

3) Full time highly qualified Pediatricians with excellent experience in the field of   neonatal intensive care

4) Fully equipped Neonatal intensive care unit with well trained & experienced staff in the field

5) Full time critical care specialists with fully equipped Intensive care facility in case of emergencies.

6) 24 hr Ultrasonography services with advanced equipments.

7) Facility to admit the surrogate mother in antenatal period if needed for treatment.

8) Facility to admit the biological parents after the birth of the baby till the baby needs to stay in the hospital.

 9) You are updated about the progress of the pregnancy from time to time by mails With the details of ongoing treatment and cd’s are also given as and when sonography is done from the radiology department. .

10) Well equipped and fully functional pathology laboratory and 24 hrs blood bank.

11) You will be given time to time information on progress of pregnancy and the baby through mail with the help of graphs and images.

12) A consent by ethical committee gives a solid legal backing

13) Uterine receptivity as assessed by endometrial blood flow is the best marker for uterine receptivity according to recent literature. The surrogates are chosen only if the endometrial blood flow is good and this gives us the maximum chances of pregnancy.

14) Monitoring the surrogate more often with tests for cervical length and AFI drastically reduces neonatal morbidity and mortality rate.

15) The last but not the least important is the personal  and humane touch to the entire program

There are programs where the surrogate and the intended parents need to rush around for paperwork, legal issues and lot more. Here at Hiranandani Hospital you are taken care of the through entire process of surrogacy under one roof.
Neither the commissioning couple nor the surrogate has to run around for even a   
single thing. The staff co-ordinates all the tests and procedures without a single moment of anxiety for you. Our program ensures you more legal safety.

The hospital offers collateral support – such as identifying a legal person for drafting agreements, arranging for the surrogate to be examined   throughout her confinement and also deliver the patient in the hospital.  Thus we extend care to the patient right from conception to delivery.
Thus from IVF cycle to surrogacy to antenatal care to delivery to completing all the legal formalities, everything will be handled in the hospital.

16.International couples:
We welcome couples from all over the world to our programme. The cost of    
Surrogacy at our center is definitely much lesser than other programmes abroad.
You may have to visit our center a couple of times and the number, duration and nature of visit will be discussed after going through the case in detail. Our Public relation manager will be taking care of finding and booking an accommodation in the nearest
Vicinity for you.
During your first consultation which can be done over the phone or on skype on a fixed timing Predecided after taking an appointment following things will be discussed before you come down to start with the programme.

• Financial aspects of surrogate parenting.

• The documentation that is required to have you recognized as the legal parents and how to obtain the necessary documents to allow you to legally return home with your child.

• An overview of the medical aspects of an IVF cycle and if necessary, a discussion of your medical history

• Description of how we screen surrogate mothers and give details on the matching
process between couples and surrogate mothers and discussion on what characteristics you want in your surrogate mother

• Whether gestational surrogacy, or gestational surrogacy with an egg donor is the right Program for you.

Your final visit will be during the birth of your baby

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