The word "surrogate" means substitute or replacement and a surrogate mother is one who lends her uterus to another couple so that they can have a baby. In the West where fewer and fewer babies are offered for adoption, surrogacy is gaining popularity, despite controversial legal and ethical issues.

Which kinds of women need surrogates? The commonest reason is a woman who has no uterus. The uterus may be absent from birth (Mullerian agenesis); or may have been removed surgically (hysterectomy for life-saving reasons, such as excessive bleeding during a caesarean). Other women who may wish to explore surrogacy include those whose uterus is incapably damaged because of utrine tubercullosis or a hermanni's syndrome; or those who have had multiple miscarriages; or who have failed repeated IVF attempts for unexplained reasons.

Women who agree to become surrogates may do so for compassionate reasons. These include a sister, mother or close friend of the couple. They may also do so for financial remuneration - and this could be a woman, with or without children, known or unknown to the couple, who rents her womb for a fee.

There are two main kinds of surrogacy:

1. The surrogate mother provides the egg. In this case, the surrogate is inseminated artificially by the husband's sperm. In this case, the infertile woman has no genetic relationship to the baby.

2. More commonly, the infertile woman provides the egg, which is then either transferred to the surrogate mother by GIFT along with her husband's sperm; or fertilized in vitro by IVF with her husband's sperm and an embryo transfer performed to the surrogate's uterus, which then acts as an incubator for the next nine months.

Certain guidelines have been laid down to try to minimize misuse of the surrogacy technique; and a surrogate motherhood contract needs to be drawn up, which should specify that the child will become the legitimate adopted child of the infertile couple, i.e., the intended parents. This needs to be signed by the couple, the surrogate, and her husband.

The "legal waters" of surrogate motherhood will continue to be murky, and there are no laws or guidelines in India as yet. This is why the element of trust between the couple and the surrogate mother is so important.

It is vital that the surrogate and the couple consider the future of the child. The receiving mother should ideally be present at the birth and care for the baby in hospital. She can even be prepared for breastfeeding (induced lactation) by hormone treatment.

Surrogacy has spawned a host of legal and emotional issues to which there are no "right" answers. For example:

What will you do if the surrogate insists on keeping the child?

How much should you pay the surrogate?

If she gets ill as a result of the pregnancy who will pay the medical costs?

Is it possible to put the receiving mother's name as mother on the birth certificate?

Will you tell the child about the surrogacy?

Will surrogates undertake pregnancy for profit?

What happens if the child is handicapped and is unwanted by the couple and the surrogate mother?

What happens if the surrogate dies during child birth?

Many people are worried about the possibility of the surrogacy technique being misused. They feel it may allow the exploitation of poor women who may be used as "mother machines" to bear babies - much like the wet nurses of yesteryear.

Surrogacy has received quite a lot of bad press recently, especially when the contract goes sour and there is a dispute over the baby between the commissioning parents and the surrogate mother. Such a situation makes headline news. The Courts then need to have the wisdom of Solomon to assign the rights of the "genetic" mother; the "birth" mother; and the "social or rearing" mother.

Nevertheless, we must remember that surrogacy does offer one method of achieving parenthood to a few couples who could never have a baby by any other means.

The road to surrogacy is a rocky one and requires much thought. This is perhaps the most complex and difficult way to achieve parenthood.

Credits: Dr. Aniruddha Malpani, MD and DR. Anjali Malpani,