Lavanya*, a 35-year-old mother of two girls from Bengaluru, became pregnant once again in January 2019. Lavanya and her husband, both techies, got the pregnancy confirmed. However, her in-laws, who live in Ludhiana, Punjab, did not want another girl child. Lavanya says that her husband and in-laws convinced her that an abortion would be the best solution..The couple then decided to pursue the In Vitro Fertilisation (IVF) route. “We went to quite a lot of clinics in Bengaluru. We visited at least seven of them and they were not willing to tell us whether the embryo is male or female. We heard it is quite common in Mumbai and Delhi but my family did not want to take the risk. My husband and I considered adoption but my in-laws were against it,” she says. .In April that year, Lavanya’s husband booked tickets to Bangkok. “He told me that we were leaving for a holiday in Thailand, just a few days before we were to travel, saying it was for our wedding anniversary,” she adds..The couple landed in Bangkok in mid-April. After a week in Krabi and Phuket, they returned to Bangkok, and it was then that her husband informed her that he had arranged for an additional six-day stay. He wanted her to visit an IVF clinic where he had taken an appointment through an agent in New Delhi. .“It was here that I learned that it was legal in Thailand to determine the sex of the child. My in-laws were very adamant that we have a boy. Although my husband never forced me to get it done, I was initially angry that he had done all this without consulting me. We talked about it and I agreed to get the IVF treatment,” Lavanya says. .Lavanya got the necessary scans, injections and blood tests required to stimulate and monitor ovarian response to the treatment. On day 3 and day 5, biopsies were performed for the Pre-Implantation Genetic Diagnosis (PGD), where the embryo is checked for genetic disorders. However, Lavanaya and her husband paid an additional Rs 80,000 to be able to determine the sex of the child..“I was glad it was a boy. I don’t think I could have gone through another abortion," she says..\r\tDemand for sex-selective IVF.Lavanya and her husband are one among many couples who look for sex-selective IVF. Doctors at IVF clinics that TNM spoke to say that they get 30 to 40 such requests per month. However, since sex-selective IVF is banned in India under the Pre-Conception and Pre-Natal Diagnostics Techniques (PC-PNDT) Act, doctors say that they have to counsel the patients about the process..Although Pre-implantation Genetic Diagnosis (PGD) in India is legal, it can be used only to detect genetic disorders in the embryo like cystic fibrosis, thalassemia, sickle cell anemia, phenylketonuria, among others. In 2019, a hospital in New Delhi’s Karol Bagh was raided by the PC-PNDT Cell of the Delhi Health Department. The hospital was allegedly involved in sex determination of the embryo through PGD and was charging Rs 8.5 lakh for the procedure. .“I have been working in this field (IVF) since the last 10 years and there are so many people who ask us whether we can tell them the sex of the embryo. Ten years ago, the number of requests were a lot. Almost everyone who came wanted a boy. But over the last few years, when people know that the regulations are very stringent, the number of requests have reduced. But they end up going to Thailand or Russia. They don’t mind paying more money for that,” says Dr Shivani, of SCI Healthcare in New Delhi. Dr Shivani says that she has to counsel her patients about the existing laws and why sex determination is not possible. .Corroborating Dr Shivani’s statement, a senior doctor with a hospital in Bengaluru, says that couples opting for IVF offer them money to disclose the sex of the embryo. “I have had cases where couples tell me that no one has to know that you told us the sex of the embryo. They try to justify it by stating that they are spending huge amounts of money as they want a male child,” the doctor told TNM on condition of anonymity. .Speaking to TNM, Dr Prabhu, of the PC-PNDT Cell with the Karnataka Health Department, says that there are several monitoring committees at the state and district level, who conduct checks to ensure that sex-determination does not occur. Dr Prabhu, who is also a part of the state-level monitoring committee, says that the cell has not received any complaints about sex-selective IVF so far. .“The problem here is that it is difficult to monitor sex determination via IVF. When the PGD procedure is done, the doctors will know the sex of the baby. So to actually determine whether they are disclosing it to their clients is very difficult. It could be communicated orally or through gestures and we would never know. This is also a problem in sex determination during ultrasounds. But it is easier to detect those cases than the sex-determinaton in IVF clinics,” Dr Prabhu says. .Dr Prabhu, who is a member of the State Inspection Monitoring Committee, which monitors clinics and labs involved in prenatal diagnostics, says that the committee members conduct inspections of all IVF centres once in two months..“We even conduct decoy operations regularly. Generally, we check their paperwork and see if there are discrepancies. But even during decoy operations, the clinics and diagnostic centres were not found to be violating norms. But there is also a loophole. There are many people involved in one case, like the treating doctor, the person who takes samples, the lab technicians. While the clinics are registered, not everyone working there has to maintain a record of every single test they did. So, we cannot know if a test was done but not recorded,” he says. .He says it is easier to keep track of sex selection that happens through ultrasound scans because the committee receives more tips, adding that their decoy operations have worked better for ultrasound sex detection than IVF..\r\tThe ‘foreign’ route.While clinics are not legally allowed to determine the sex of the embryo, the PC-PNDT Act does not stop people from going to countries where sex-selective IVF is legal. Over the years, medical tourism to countries like Thailand, specifically for sex-selective IVF, has grown into a considerable market. .Speaking to TNM, an agent who organises stays for couples looking for IVF in Thailand, says that prior to the coronavirus pandemic, the business was thriving. “We used to get at least 5,000 to 6,000 requests every year. However, we only helped them get in touch with clinics. There are quite a lot of agencies that help couples look for IVF treatment abroad, and they too were getting a lot of requests,” he says. .According to a doctor at an IVF clinic in Bangkok, most of the couples from India, who go for IVF treatment, ask for sex determination. “We get a lot of such requests. We have seen many cases where the woman would not know that their partner wants to know the sex of the child. I have seen many cases where the couples want to try again until they have a boy child. There have been times when pregnant women and their husbands come here and ask us if we can tell them the baby’s sex too. There was one case about five or six years ago when the woman was forced to get an abortion by her husband after they returned to India,” the doctor says. .\r\tThe need for regulation.Speaking to TNM, Hari Ramasubramanian, a lawyer specialising in the PC-PNDT Act, says that although, the PC-PNDT Act is very rigorous and does not have many loopholes to allow sex determination of the embryo in IVF centres, there is a need for regulating genetic testing labs. .“Many clinics also have testing facilities. If the labs and clinics are separate with different managements, then there has to be communication between the two. Although the clinic is registered under a person’s name, there are many other professionals working there like the gynecologists, embryologist, lab technicians who perform the tests. As far as the legislation goes, we cannot do anything more. Implementation is where the problem is. Genetic testing and genetic clinics should not be in the same place and communication should be monitored. If all medical professionals working at these centres are registered with the PNDT authority, they will be personally liable. If we register everyone inside, we can go into the details,” he says. .He further states that the larger problem lies in the implementation of the PC-PNDT Act. While state governments have state-level and district-level committees to monitor all facilities falling under the ambit of the law, the frequency of these checks is low. .“Most of the time, those monitoring these centres look at the paperwork. But the frequency with which it is done is also very less. Even if they are conducting inspections, there is no way they can actually narrow down on one specific person who would have done the sex determination. The government should look at ways to make the implementation of the Act more effective,” he adds. .Dr Prabhu, however, says that the only way anomalies can be detected is if there are more male children being born, according to the records of the clinics. However, here too, the government has to depend on the records kept by the clinics and it is difficult to find out if paperwork was not maintained for the sex determination test. .“There is a way to monitor this. For instance, we can see the substances required for performing PGD, and cross-verify to see if it matches the number of tests. Sometimes, clinics just write that they had to conduct the test twice or thrice for myriad reasons. This too is a fallacy. Unless society’s mindset changes regarding the preference for male children, no matter how much we regulate, they will still find a way to do it,” Dr Prabhu adds.