Krinos Trokoudes knows this much about women: "If you pay something," he says with a smile, "you get lots of girls." Coming from a silver-haired man in a white lab coat, the remark sounds a little unseemly, but he does not mean it the way you may think.
Trokoudes is an embryologist. His business is harvesting human eggs, and every year, hundreds of women are impregnated at his Pedeios IVF Treatment Centre in the Cypriot capital, Nicosia. In 1992, he made the Guinness Book of World Records after a 49-year-54-day-old patient he had impregnated via in vitro fertilization delivered a healthy baby girl; at the time, the mother was the oldest person ever to have given birth after IVF. Trokoudes's record has since been shattered (two years ago, a 70-year-old Indian woman birthed IVF-conceived twins), but his achievement helped establish Cyprus's reputation as a home of doctors who are willing to push the frontiers of the fertility industry.
Over the past decade, global demand for human eggs has grown uncontrollably, proliferating in lockstep with a fertility industry that has become a billion-dollar global behemoth. Three decades after the introduction of in vitro fertilization, some 250,000 test-tube babies are born each year. While the vast majority are still the products of their biological mother's eggs, the desire of older, often postmenopausal women to become moms has fed the rapid growth of egg trading, a business that now reaches from Asia to America, from the richest neighborhoods of London and Barcelona to backwaters in Russia, Cyprus, and Latin America.
This business features well-meaning doctors and assembly-line charlatans, desperate parents and unlikely entrepreneurs, and the most unusual sourcing: women of childbearing age. It is unevenly regulated when it is regulated at all, producing startling, tech-driven examples of the comparative advantage that economist David Ricardo described in the early 19th century. Poor women from poor countries sell their eggs to entrepreneurial doctors, who then sell them to rich aspiring parents from rich countries. This has given rise to a set of spectacularly engaging issues: Is it really okay to treat a woman the way we treat a hen, pumping her up with hormones so we can farm more eggs for sale? Do the standards we apply to produce ball bearings also apply to the stuff of life and the women who bear it? Is a human egg a widget and the donor nothing more than a cog?
These are fundamental questions about outsourcing and efficient markets, except that they involve people, not things. Unfortunately, nearly all of the Western world has punted on the ethical dilemmas. Some countries, like Israel, prohibit egg harvesting on their own territory yet still reimburse citizens for IVF, even if it's done with donor eggs, as long as they're acquired elsewhere. U.S. law says nothing about egg donation, though the American Society of Reproductive Medicine has nonbinding guidelines that deem unethical any payment beyond reimbursement for lost wages and travel. In Cyprus as in the rest of the EU, "compensation is allowed, but payment is not," says Cypriot health ministry official Carolina Stylianou, who leads the regulation of the island's fertility clinics. Yes, that is as murky as it sounds.
All this mystery has helped create a vibrant marketplace, with a wide range of prices and available services. In the U.S., a full-service egg implantation -- including a donated egg, the lab work, and the IVF procedure -- costs upward of $40,000. In Cyprus, you can get the same service for $8,000. In the U.K., a prospective parent might wait two years to get an egg, given that country's strict limits on egg donation. In Spain, on the other hand, waiting times are extremely short -- you can have an egg implanted two weeks after requesting one. And as for selling (or donating, if you prefer) an egg, the price is truly all over the map: An American woman gets an average of $8,000 per batch of eggs, but can ask upward of $50,000 if she's an Ivy League grad (a 100-point increase in SAT score correlates with a $2,350 rise in egg price); on the other hand, an uneducated Ukrainian flown to Cyprus for the extraction process will get a few hundred dollars -- and a few days in the sun -- for her eggs.
Cyprus has more fertility clinics per capita than any other country. Whether licensed or unlicensed, they offer IVF as well as an array of other fertility services, even some that are typically proscribed elsewhere, like sex selection. People travel here from Israel, from Europe, from all over the world. Waiting times are short, prices are competitive, there are lovely beaches to pass the time between treatments, and the care is often as good as elsewhere in the world. Couples that want a child can find cut-rate help here; poor women find a market for their eggs. Cyprus is an egg bazaar that answers, and capitalizes on, desperation on both sides of the demand-and-supply equation.
As is true of more traditional bazaars, the laws of this one are not exactly transparent. Consider the grandly named International IVF & PGD Centre. The clinic was founded in 1996 as a go-to destination for Israelis seeking fertility treatment abroad, after paid egg donation was banned domestically. Known locally as the Petra Clinic, it can be found down a little-used coastal road between the fishing villages of Zygi and Maroni. Especially on blustery winter days, when steady gusts of cold, salty wind barrage the dilapidated compound, it does not seem like an auspicious place to start a life.
The day before I planned to visit Petra, I spoke by phone with Oleg Verlinsky, the son of the late owner of the clinic (part of an estate that is now in probate). He informed me that Petra is not primarily a fertility clinic, though it did perform fertility-related procedures, including egg donation. He also discouraged me from visiting the clinic, which he said is used almost exclusively to treat rare genetic blood disorders.
This surprised me. The clinic's Web site told a different story. In early February, for example, it listed a menu of egg donors, including a raft of Russians and Ukrainians. After undergoing hormone treatments locally, they are flown to Cyprus for egg extraction. Then they go home. The site had no photographs of the donors, but it offered detailed descriptions. For instance, No. 17P was described as a 23-year-old, 175-cm, 59-kg chestnut-haired, brown-eyed artist and university grad. Her blood type is B-positive. She would be arriving on-island on February 10, ready to have her eggs harvested.
Despite Verlinsky's admonitions, I drove out to the Petra Clinic. With its red-brick walls bearing crucifixes and gargoyles, it has the look of a partially rehabbed Old World monastery. I was received by its Russian administrator, a tired fortysomething woman named Galina Ivanovina. She was defensive, explaining that over the past few years, many journalists, mostly British, have erroneously portrayed the clinic in a bad light, arguing, for instance, that it intentionally hyperstimulates patients to produce dangerously large batches of eggs.
Nonetheless, she was happy to reveal the clinic's practices as we sat in a glum basement room whose walls were covered with crookedly hung foreign medical certifications and diplomas. According to Ivanovina, the women who come to the clinic to donate "do it for economic reasons. Nothing else." For her time and the potential risk to her body, each donor receives about $500. The physical dangers are real. Ivanovina told me the story of one donor who nearly died.
Three months after my visit, Cypriot police raided the Petra Clinic. They accused the clinic of trafficking in human eggs, but that wasn't why it was shuttered. The authorities closed it for allegedly performing procedures other than the one for which it was licensed: treating patients with the blood disorder thalassemia. "It was supposed to be a major center for the treatment of thalassemia," Verlinsky now concedes. "But centers opened in other places. There wasn't a huge demand. And we saw that people required egg donation."
As the word donor suggests, the preferred supplier of human eggs is a woman who gives away her eggs as an altruistic act. According to EU law, member states like Cyprus must "endeavor" to ensure voluntary, unpaid donation of human oocytes, though compensation covering lost wages and travel is permissible. The key, says EU health commissioner Androulla Vassiliou, is "where member states draw the line between financial gain and compensation."
Customers and suppliers easily get around this sophistry. "It is twice as difficult to adopt a cat as it is to procure a human egg," says Glenn Edwards McGee, editor of The American Journal of Bioethics. According to a 2010 study by the European Society of Human Reproduction and Embryology, nearly 25,000 egg donations are performed in Europe for fertility tourists every year. More than 50% of those surveyed traveled abroad in order to circumvent legal regulations at home. The Cypriot government estimates that, each year, 1 in 50 women on the island between the ages of 18 and 30 sells her eggs. One NGO analyst says that among the island's Eastern European immigrants, the rate may reach 1 in 4, and some women give up their eggs several times in a year. By comparison, only 1 of every 14,000 eligible American women donates.
"Donation is described as an altruistic act, which means no payments," says Savvas Koundouros, a Cypriot embryologist, as he draws heavily on a cigarette. "It sounds strange to all of us that a person would receive so many injections over weeks and then undergo general anesthesia just because they are kind people." Koundouros has impregnated more women than Genghis Khan -- and thanks to a system that does not in any way rely on altruism, he plans to seed many, many more. He recently invested more than 1 million euros in a state-of-the-art IVF clinic in the resort city of Limassol.
The fertility supply chain creates a number of unlikely opportunities. Natasha, a Russian immigrant who works for one of Cyprus's best-known clinics and who requested anonymity to protect her job, has carved out a living for herself as an egg scout. She describes a typical donor: "She starts a relationship with a Cypriot she meets on the Internet and comes here thinking she will have a good life. But in two or three months, they break up. She has no job, no visa, no place to stay, and no way to get money. For Russians here, it is hard to get legal papers, and she needs to make money quickly. All she has is her health, and if she is lucky, she is also quite beautiful." Natasha, who says she has never met a woman who gave up her eggs for any reason other than money, tells me that Russian woman are in highest demand, "because of their complexion."
But doctors can't rely solely on scouts to fill the pipeline. Carmen Pislaru, a Romanian who used to dance in Cypriot cabarets, says she was still in the hospital recovering from her fourth child's birth when her doctor, who had helped arrange for the child's adoption, asked if she wanted to sell her eggs. "He knew I was in a desperate position," she says. "I had no money and no way to support my family."
Pislaru says she turned down the doctor's offer -- $2,000 in cash -- on the spot. She was worried about the physical effects, she says. But the relentless physician called her every week for the next month, hoping that she'd change her mind. Failing that, he pressured her to put him in touch with women who might say yes. She gave him some names, and several of her acquaintances took him up on the offer. "Many women sell their eggs here to make ends meet," she says. "We're all vulnerable."
Peter Singer, the Ira V. Decamp professor of bioethics at Princeton, doesn't necessarily have a problem with the sale of eggs. "I don't think that trading replaceable human body parts is in principle worse than trading human labor, which we do all the time, of course. There are similar problems of exploitation when companies go offshore, but the trade-off is that this helps the poor to earn a living," he says. "That's not to say that there are no problems at all -- obviously, there can be -- and that is why doing it openly, in a regulated and supervised manner, would be better than a black market." Note that he says "would be."
While the clinics of Cyprus sometimes feel like frontier outposts, the ones in Spain can seem like established fortresses. Spain has been the top destination for European fertility tourists since the mid-1980s. At Barcelona's Institut Marquès, a 14th-century carriage house in one of the poshest parts of town, you can understand why.
Inside, behind sliding-glass doors and whooshing air locks, are two embryology labs where workers in blue scrubs and ventilated face masks have turned baby-making into a completely unromantic science. One woman seated in front of a computer monitor zooms her microscope in on a dish of sperm squiggling around a giantess of a human egg. The technician turns a dial on her control panel, inches a hypodermic needle toward her chosen sperm, presses a button, and sucks the chosen one into a separate chamber, where a tiny knife lops off its tail. "If we cut off the tail, it helps the genetic material escape once we implant it into the egg," she explains. Then she thrusts the needle's point through the egg's cell wall and injects the bundle of genes inside. Conception.
If this embryo takes and becomes a child, it will probably grow up in Britain. In 2007, the U.K. banned payments to egg donors. In 2009, the Institut Marquès opened a satellite office in London, offering full-service, pregnancy-guaranteed packages for as little as $37,000 for three IVF cycles. The stream of foreign customers has become so steady that the clinic no longer waits for patients to sign on before tracking down appropriate donors. Instead, it keeps a bull pen of women on hormones, ready to give up their eggs. "Sometimes we will lose the eggs if we can't find a customer, but it's a trade-off," says embryologist Josep Oliveras. "This way, we can guarantee a steady supply."
Business at the Institut Marquès has been boosted by a Spanish law that prohibits patients from selecting their donor's characteristics. Matching donors is now left entirely to the doctor's discretion. Clinics are allowed to describe broad details about their donor base, and they do recruit heavily among students in order to assure customers that they have eggs with university pedigree. But a much more reliable source of egg donations -- especially with unemployment soaring past 20% -- has been Spain's population of South American immigrants, many of them illegals with few ways to earn money. That's fine with most buyers, says Olivia Montuschi, cofounder of Britain's Donor Conception Network, which works with families who have conceived via donated genetic material. (Montuschi's son and daughter were conceived with donor sperm after her husband was found to be infertile.) "The vast majority of women don't care where the eggs actually come from. They are so down the line with unsuccessful fertility treatment at that point that they will go anywhere and do anything."
Nicole Rodriguez, a Chilean immigrant, says she sold her eggs to another clinic shortly after arriving in Spain. "We weren't wetbacks -- we were students of the visual arts -- but I didn't have permission to work yet," she says. "It seemed like easy money." She knew what the clinics wanted: "My skin is a little bit dark, but it was fortunate for me that it was winter and my skin was paler. When I arrived at the clinic, they asked me what my skin color was. I had put on a lot of makeup, so they said my skin was white."
She laughs while recounting her first conversation with a clinic recruiter: "I had asked, 'How much do you pay for eggs?' The woman corrected me, saying, 'You mean for the donation of eggs.' I said, 'Excuse me, excuse me -- the donation of eggs.' " During harvesting, she chose to go under general anesthesia. When she woke up, an envelope of cash was lying next to her. "It was like they had thrown cash on a bed stand after seeing a prostitute," she says. The payment of $1,400 was enough for her to live on for three months.
The technology is at a point now," says David Sher, founder and CEO of the Switzerland-based fertility-services company Elite IVF, "where if you provide the sperm, we can basically FedEx you a baby." Most parents, of course, would not see the transaction in such coldly efficient terms. To them, the upside of this poorly regulated marketplace is still nothing short of miraculous.
Lavi Aron and Omer Shatzky are two gay men living in Tel Aviv. In February 2008, in order to have their marriage recognized in Israel, they wed in Toronto. But the dream of having children seemed impossible. "As a gay couple, it is nearly impossible to adopt here," says Aron. "The only real option was to hire a surrogate, but oh, the cost." Friends in similar situations had found that the price of surrogacy and egg donation could easily exceed $300,000, with years of legal wrangling.
But Elite IVF made it comparatively easy, given that the couple was willing to take the procedure global. In the same way that Orbitz searches multiple airlines for the best deals and cobbles together a trip for a lower price, Sher found a Caucasian egg donor living in Mexico City who was willing to give up her eggs. But Mexico does not have extensive laws to protect the rights of intended parents. So Sher flew a surrogate mother business class from the U.S. to Mexico to have the eggs implanted -- one with sperm from Aron, the other with sperm from Shatzky. The brother and sister were born in California last November as American citizens.
"It was like winning the lottery for us," says Aron. "Genetically, one belongs to him and one belongs to me. But they're also siblings because they come from the same egg donor. We could not have a better family than this. Everyone is connected to each other." Within weeks, Aron and Shatzky were able to arrange legal adoptions of the children and bring them back to Tel Aviv. Total cost: $120,000.
Perhaps more than any other company, Elite IVF has transformed baby-making into a globalized, industrialized process. For Sher, outsourcing is simply the inevitable outcome of the science that allowed procreation to move out of the bedroom and into the lab. Like the Petra Clinic and the Institut Marquès, Elite IVF offers clients cheaper access to eggs and a full suite of fertility treatments; unlike those more-localized operations, Elite operates worldwide, with offices and partner clinics in Britain, Canada, Cyprus, Israel, Mexico, Romania, and the U.S. Sher plans to expand soon to Turkey, taking advantage of new bans on egg donation there.
Sher sees the regulatory and price differentials in eggs as an opportunity to reduce the cost of raw materials, pass the savings on to his customers, and offer them virtually any fertility service that they can't get at home. Want sex selection, which is illegal in most countries? A Mexican clinic can help you. Too old for IVF in the U.S.? Cyprus is the answer.
Today, Elite IVF's network of clinics, egg sellers, and surrogate moms produces between 200 and 400 children per year, helping create families like Aron and Shatzky's. And it's just going to get more complicated. "The future is designer babies," says Sher. He describes an offer he once received from an investor interested in partnering with Elite IVF. "Surrogates in Asia would carry the eggs of superdonors from America -- models with high SAT scores and prestigious degrees who would be paid $100,000 for their eggs. Those babies could sell for $1 million each -- first to his friends, then to the rest of the world."
Sher declined the offer, but says it is only a matter of time before someone moves in that direction. At that point, maybe governments will get more involved. McGee, the bioethicist, predicts that "we will soon begin to recognize the danger of an ant-trail model of reproduction whereby strangers without any responsibility to each other and clinicians able to vanish in a puff of smoke meet in a transaction that culminates in humanity's ultimate act: creation."
For now, we're left to consider Alma Hassina and Yehonnatan Meir, the babies bouncing on the laps of Aron and Shatzky. There is no word to describe their relationship. Born of the same egg donor, fertilized by the sperm of different fathers, and delivered from the womb of a surrogate mother, they are both twins and half-siblings. They're also poster children for the possibilities enabled by IVF and globalization. And for kids like them, prospective parents will do just about anything.
This article was funded in part by a grant form the Pulitzer Center on Crisis Reporting.