In March, Mumbai resident Shaheeda Khan*, 26, spent 20 days at a fertility clinic in Kerala, where doctors gave her hormone injections every day. The shots were aimed at stimulating her ovaries to make them produce multiple eggs, not just the one or two they would generate naturally in a month. At the end of the 20 days, several of Khan’s eggs were surgically extracted and fertilised in a laboratory – a procedure known as in-vitro fertilisation or IVF. Khan did not know where the sperms for the fertilisation process came from, nor what happened to the embryos. Some of these would be implanted in the wombs of women willing to bear children.

Though the clinic listed Khan as an “egg donor”, this was a euphemism. Khan was paid Rs 45,000 for undergoing the procedure.

Women like Khan are small parts of a global IVF machine that was valued at $15 billion in 2017, according to one estimate. Said a doctor who treats infertility in Chennai, requesting anonymity, “Eggs are the raw materials for IVF procedures and these donors are the suppliers.”

Though there is limited reliable information on the prevalence of infertility in India, this market report suggests that as more affluent Indians delay having a child until later in life and struggle with infertility, the IVF market in India is expected to grow at a compound annual rate of 15.8% from Rs 1,078 crore in 2016 to touch Rs 2,600 crore by 2022. Some doctors say that as many as two in ten infertile couples will require an egg donation. Many of these couples will turn to donors like Khan. But around the world, a debate is raging about the ethics of paying egg donors and about potentially putting them at physical risk.

Most egg donors in India are poor women and the money from selling their eggs is substantially more than what they otherwise earn. But over-stimulating the ovaries multiple times could have medical consequences. For instance, medical researchers are investigating whether women who take hormones for such procedures have a higher chance of developing cancer. The Assisted Reproductive Technology Bill that is yet to be passed by Parliament requires donors to be informed of the possible consequences of egg donation. However, most donors interviewed by for this story seemed to be unaware of the repercussions.

Fertility clinics usually recruit eggs donors through networks of agents and the donor’s eggs may be used to create embryos for more than one couple. Clinics say couples often have specific requests for the kind of egg donor they want. Sometimes, couples go as far as to recruit and pay donors themselves. Despite the constant demand for eggs, not all donors are in high demand. Khan’s eggs, for instance, are more popular in South India than Mumbai. “I am very dark so people from the south are more likely to take me as an egg donor than people from the north,” she explained.

This is the story of women like Khan – the reasons they have become donors, the risks they face, and what government and the medical industry must do to protect them.

Donor to agent – Savitri’s story

It was 37-year-old Savitri* who got Khan into the business of donating eggs. It was in 2010. Khan met Savitri through an acquaintance who had previously been a donor. By then, Savitri had already spent five years working as an agent for infertility clinics, helping them find egg donors and surrogate mothers who would rent their wombs to prospective parents.

As she had done with many other potential donors, Savitri’s first task was to persuade Khan’s husband to allow her to undergo the procedure. Many husbands are reluctant to allow their wives to be recruited as egg donors because they do not understand the process. “They feel that their wife will have to have sexual relations with another man,” said Savitri. “Once they know that this all happens in a laboratory and the woman has to undergo an operation, they send them happily.”

A doctor performs an n-vitro fertilisation procedure called Intracytoplasmic Sperm Injection. (Credit: Reuters/Kacper Pempel)

Savitri had been introduced to the infertility industry by a woman who lives in her neighbourhood in the Mumbai satellite town of Ulhasnagar. She became an egg donor at the age of 21. Three years later, in 2005, she became a surrogate. It was not a happy experience. “To give away the child was emotionally disturbing and my own son was also disturbed,” said Savitri who spent her entire pregnancy in the home of the couple who had paid her to bear the child. “My son was young and he lived with me in the house. He still asks me where his younger sister is.”

In 2005, Savitri decided to become an agent. Since then, she has recruited more than 100 women for clinics, which pay her a commission for each candidate ready to sell her eggs or be a surrogate. It can be a fiercely competitive business, where loyalty is commanded only by money. “I have had cases where an egg donor took the injections from me and got her eggs retrieved at a clinic which paid her more,” said a doctor requesting anonymity. “Once I had a surrogate who got pregnant and later underwent an abortion as another clinic was paying her more to be a surrogate.”

According to Savitri, this is how the business functions. “Some doctors cheat surrogates and donors and sometimes the donors do it to the doctor. No one here is for charity.”

Still, Savitri, like so many others at the lower end of the infertility business, says it’s the only way she can secure her future. A few months ago, Savitri left her abusive husband, taking her teenage son with her. “I could get out of the marriage because I had an income of my own,” she said. “Many women do this work because they have no other way to earn money.”

Wanted: An egg donor

Shaheeda Khan is what they call a positive egg donor: she has donated eggs five times in the past eight years and all the embryos have resulted in pregnancies, said Savitri. As a result, Khan is in great demand by infertility clinics.

Like so many other donors, Khan is in the business because she believes it’s the best way for someone like her, with only a ninth-standard education, to support her family. Khan lives in the eastern Mumbai neighbourhood of Mankhurd with her two children, one four and the other 11, and her husband. He is attached to a binding press but it does not get regular work. On the days that he does, he gets paid Rs 300 to Rs 400. But most days, Khan said, he comes home without having worked.

When Khan first donated her eggs at a clinic in Mumbai’s Bandra neighbourhood eight years ago, she was paid Rs 15,000. She received three times that amount for her last donation, in March. Despite this, money is always tight. To cut her costs, she has sent her daughter to study in a madrassa in the powerloom town of Malegaon and thinks she will have to send her son there too, once he is older. Khan explained: “It is too expensive to raise two children in Mumbai.”

Despite receiving large chunks of money over the years, she was unable to stash any of it away for herself. “My family knows that I can make money easily and now everyone demands money from me,” Khan said. “People borrowed money from me and I didn’t end up saving for myself.”

Not all egg donors who have just about finished high school make as much money as Khan. Payments to them usually start at Rs 20,000. College graduates get paid more for their eggs, with their fees running into lakhs of rupees, said Gaurav Wankhede who runs an agency which supplies surrogates and egg donors. Many agencies that find donors for fertility clinics classify them as graduates and non-graduates. Some prospective parents who cannot afford educated egg donors ask non-graduate donors to take IQ tests, which their doctors facilitate, said Dr Sulbha Arora, an infertility specialist working with the chain of fertility clinics called Nova IVI Fertility Clinic.

A surrogate mother at a clinic in India.( Credit: AFP/Sajjad Hussain)

Indian Council for Medical Research guidelines for infertility clinics do not allow donors to meet couples who are going to use their eggs. But Khan’s agent Savitri said that some couples are willing to pay extra to visit the donor, believing that they might get some sense about the quality of the donor’s genes. In addition to having a donor who is academically qualified, most couples want to ensure that the donor is light skinned and attractive – and are willing to pay a premium for this.

Agencies put in great effort to meet the requirements of clients. “For couples who are ready to pay and insist on a very educated, good looking donor, we have arranged flight attendants, lawyers,” said Wankhede. He even arranges for Caucasian donors for couples from the West who come to India for IVF procedures.

Rakhi Ghoshal, a working editor of the Indian Journal of Medical Ethics, said that the fertility industry takes advantage of the insecurity of couples who have been diagnosed with infertility. This is because of the cultural perception in India that equates fertility with a successful marriage.

Ghoshal also worries about that the marketing campaigns of IVF clinics create the impression that these are easy procedures. “It is perceived as if one walks into a clinic, and in nine months gets a child,” Ghoshal said. “The limitations, success rate and the physical, emotional and financial distress of people undergoing these procedures needs to be spoken about and communicated to society.”

Few couples opting for IVF understand the risks that the procedure poses to donors. To begin with, it is uncomfortable. “The injections they give on the waist are painful,” said Shaheeda Khan. She is worried that she may not be able to be a donor anymore. “I am not getting any younger,” said Khan. “It is best I make the most of money and invest it right so I don’t have to beg around.”

Two of the five egg donors interviewed complained of some complications they suffered following egg donation.

The next part of this story will explore the medical risks of egg donation.

*Name change to protect identity.