Transcript Document
Photo: TIME Photo: The Straits Times Photo: Santa Monica Reproductive Technologies
Survey Conducted to Evaluate the Position on Elective Oocyte Freezing in Singapore 9
th
April 2013
Copyrighted: BELRIS Ltd. – www.belris.sg
Table of Contents
Definition of Terms
Definition of Acronyms
Chapter 1: Study Background, Objectives and Scope
Chapter 2: Evaluating the Need for Elective Oocyte Freezing
Chapter 3: Regulatory Scenarios of Selected Countries
Appendix 3 4 5 9 30 36
Definitions of Terms
Terms here are defined for better understanding of the following report: Term
Assisted reproduction technology (ART) treatments Elective oocyte freezing Ever-married Intracytoplasmic Sperm Injection (ICSI) In-vitro fertilisation (IVF) Medisave No Religion Pre-implantation Genetic Diagnosis (PGD) Resident population Respondents
Definition
Clinical and laboratory techniques that involve the mixing of oocytes and sperms outside the body to enhance fertility Cryopreservation for non-medical purposes Status of having been married at least once, regardless of current marital status ICSI is a form of Assisted Reproductive Technology (ART) IVF is a form of Assisted Reproductive Technology (ART) Singapore’s national healthcare saving scheme which helps individuals set aside part of their income to meet future healthcare expenses The status of not being affiliated to any particular religion, of which free thinkers are included Genetic profiling of embryos or oocytes prior to fertilisation Singapore Citizens and Permanent Residents Persons who had supplied information for Clearstate or BELRIS surveys 3
Definitions of Acronyms
Acronyms here are defined for better understanding of the following report: Term
ART ASRM BELRIS ESHRE ICMR ICSI IVF KICs KOLs MOH MSQH PGD
Definition
Assisted Reproduction Technology Society for Assisted Reproductive Technology Bioethics Legal group for Reproductive Issues in Singapore European Society of Human Reproduction and Embryology Indian Council of Medical Research Intracytoplasmic Sperm Injection In-Vitro Fertilisation Key IVF Centres Key Opinion Leaders Ministry of Health Malaysian Society for Quality in Health Pre-Implantation Genetic Diagnosis 4
Chapter 1 Study Background, Objective and Scope
Photo: TIME Photo: Santa Monica Reproductive Technologies Photo: The Straits Times
Study Background
Photo: The Straits Times
Freezing oocytes (also referred to as ‘freezing eggs’), or cryopreservation, is a process which has been used in various parts of the world for various reasons to perserve a woman’s fertiltiy. The process many times involves In Vitro Fertilisation (‘IVF’), and the cooling of eggs to sub-zero temperatures (vitrification).
In October 2012, the Practice Committee of the American Society for Reproductive Medicine (‘ASRM’) and the Society for Reproductive Technology announced that oocyte freezing should no longer be considered experimental.* However, notably, ASRM did not endorse the technique for routine elective use. Similarly, the European Society of Human Reproduction and Embryology (‘ESHRE’) has recently stated that arguments against using the technology are not convincing.** The process of oocyte freezing starts in a similar manner as does regular IVF treatment. It involves the stimulation of a woman's ovaries with fertility medication before the oocytes are harvested. However, instead of creating embryos immediately, as is in the case in regular IVF, the oocytes are frozen to be used to create embryos at a later date.***
References:
*The Practice Committee of the American Society of Reproductive Medice and the Society of Reproductive Technology. Mature oocyte crypreservation: a guideline. Fertility and Sterility 2012 Oct 12.pii: S0015-0282(12)02247-9. **ESHRE Task Force on Ethics and Law, W. Dondorp, G. de Wert, G. Pennings, F. Shenfield, P. Devroey, et al. (2012). Oocyte cryopreservation for age-related fertility loss. Oxford Journals ***NYU Fertility Center. (n.d.). About the Egg Freezing Process. Retrieved March 19, 2013, from http://www.nyufertilitycenter.org/egg_freezing/cryopreservation_process 6
Study Objective and Scope
As with any IVF procedure, there are inherent medical risks to women such as ovarian hyper-stimulation. With regards to children born from the procedure, as with IVF, there is limited data on the success rates of fertilisation and live births, as well as the perinatal outcomes, i.e. whether there are any long-term effects on children born. In addition, there are important issues about whether access to this procedure should be a matter of choice or policy, and whether/what type and extent of regulations should be in place. Finally, there are issues of ‘fertility tourism,’ and related ethical concerns.
In Singapore, only married women under the age of 45 can undergo IVF treatment. Oocyte freezing may be considered for married women as part of the IVF procedure if necessary, e.g. while the couple is waiting for a sperm donor. Single women in Singapore are not allowed to undergo IVF treatment unless medically necessitated in order to preserve fertility (e.g. in cases of cancer).*
Study Objective: Evaluate the need for elective oocyte freezing in Singapore
To understand Singaporeans’ perspectives on elective oocyte freezing To understand regulatory scenarios in selected countries (Malaysia, Thailand, India and Australia) on elective oocyte freezing To identify and compile statistical information related to elective oocyte freezing
References:
*Ministry of Health. (2006). Directives for Private Healthcare Institutions Providing Assisted Reproduction Services. Singapore: Licensing & Accreditation Branch, Ministry of Health . See also, The Straits Times . (2012, April 12 ). Freezing the Egg to Delay Motherhood. Retrieved March 19, 2013, from Health Xchange : http://www.healthxchange.com.sg/News/Pages/freezing-egg-delay-motherhood.aspx
7
Source of Information
Evaluating the need for elective oocyte freezing in Singapore done through various primary and secondary research methodologies
Clearstate Quantitative Survey of Resident Women: The sample size for the survey was 410 respondents aged between 20 to 45 years (95% confidence level and 5% confidence interval for a target population). Clearstate prepared its own independent and anonymous contact list to ensure that the anonymity of respondents is maintained .
Primary Research
BELRIS Survey of Resident Women and Men: The sample size for the survey was 206 respondents aged between aged above 18 years. The survey was conducted online at www.belris.sg. Clearstate had utilised the data from this survey as an additional data source for analysis purposes.
Clearstate Qualitative Interviews of Key IVF Centres in Selected Countries: Clearstate conducted interviews with Key IVF Centres (‘KICs’) in Australia, India, Malaysia and Thailand to understand their perspectives on this topic. Clinicians from approximately 2-4 IVF centres were interviewed in each of the above-mentioned countries.
Clearstate Qualitative Interviews of IVF Clinics in Singapore: Clearstate conducted interviews with IVF clinicians in Singapore to understand their perspectives on this topic. 5 of such interviews were conducted.
Clearstate Qualitative Interviews of Key Opinion Leaders in Singapore: Clearstate conducted interviews with Key Opinion Leaders (‘KOLs’) in Singapore to understand their perspectives on this topic. KOLs from diversified backgrounds, who represent key women’s organisations, were interviewed for this study. 3 of such interviews were conducted.
Secondary Research
Secondary Sources Reviews: Clearstate also gathered information from regulatory reports and medical journals related to oocyte freezing, newspaper articles on policies or initiatives undertaken by government bodies, views of KICs and KOLs on discussion forums and any statistical information related to oocyte freezing.
8
Chapter 2 Evaluating the Need for Elective Oocyte Freezing in Singapore
Photo: TIME Photo: Santa Monica Reproductive Technologies Photo: The Straits Times
Rising median age of marriage, rising proportion of singles, and decreasing age-specific fertility rates of women below 35 are seen to impact population trends in Singapore
According to the Population Trends 2012 report published by the Singapore Department of Statistics, a total of 27,258 marriages* were registered in 2011, which was 12% higher than the 24,363 registered in 2010.
However, age-specific marriage rates fell for those below 30 years of age in 2011; men aged 25 to 29 years and women aged 20 to 24 years experienced the largest fall compared to 2001 (Chart 1).
Over the past decade, there had been an increase in the median age for first time marriages for both genders. In 2011, the median age for first marriage for males was 30.1
years as compared to 28.8 on 2001. Similarly for women, the median age for first time marriage in 2011 was 28.0, an increase from 26.2 in 2001.* Statistics published in the report also indicate that in 2011, the proportion of singles among total resident population had increased to 32% from 30% in 2001.* Age-specific fertility rates had fallen for resident women aged below 35 years over the past decade. In 2011, those within the age group of 25 to 29 years registered the largest drop to 73 births per 1,000 women, down from 96 per 1,000 women in 2001 (Chart 2).
Chart 1: Age-Sex Specific Marriage Rate # Source: Population Trends 2012, Singapore # Age-Specific Marriage Rate is defined as the number of marriages registered within a specific age group during the year, out of every thousand unmarried population in the same age group Chart 2: Age-Specific Fertility Rates ##
References:
*Department of Statistics, Ministry of Trade & Industry. (2012). Population Trends 2012. Singapore
Source: Population Trends 2012, Singapore ## Age-Specific Fertility Rates is defined as the number of births registered within a specific age group during the year, out of every thousand female population in the same age group
Rising number of childless or one-child families for ever-married women in Singapore
Statistics from the Population Trends 2012 report reflect an increase in the proportion of childless ever married women in their thirties and forties over the past decade.* The proportion of ever-married resident women aged 30 to 39 years who were childless increased from 15.3% in 2001 to 20.9% in 2011 (Chart 3).
The proportion of ever-married resident women aged 40 to 49 years who were childless increased from 6.7% in 2001 to 9.1% in 2011 (Chart 3).
There is an increasing trend of families with only one child. Among ever-married women aged 40 to 49 years who were likely to have completed child bearing, the proportion with one child increased from 15.7% in 2001 to 19.4% in 2011 (Chart 3).
BELRIS survey results indicate a trend towards delayed family formation with the majority of married resident population (men and women) stating they had their first child between the age of 31 to 35 years (Chart 4).
References:
*Department of Statistics, Ministry of Trade & Industry. (2012). Population Trends 2012. Singapore
Chart 3: Ever-Married Resident Women by Age Group and Number of Children Born (2001 versus 2011)
46,7% 42,7%
No children
2001 2011
1 Child
2001 2011 15,3% 20,9% 6,7% 9,1% 3,8% 4,4% 31,1% 36,0% 24,5% 28,4% 15,7% 19,4% 10,4% 12,9% 15 - 29 30 - 39 40 - 49
Years
Above 50
Source: Population Trends 2012, Singapore
15 - 29 30 - 39 40 - 49
Years
Above 50 30%
Chart 4: Age when First Child was Born
Men (n=33) Women (n=102) 39% 42% 28% 15% 15% 0% 6% No Children 18 - 25
Source: BELRIS quantitative survey
26 - 30 31 - 35 9% 10% 36 - 40 6% 0% 41 - 45 (Chart 4) BELRIS Survey, Question: What age did you have your first child?
Base, Respondents who are married n=135
Unmarried respondents had indicated that their ideal age to start having children is between 31 to 35 years old, with job/financial security as the most mentioned reason for delaying pregnancy
Of a total of 71 unmarried respondents in the BELRIS survey, 50% of men and 41% of women stated that their ideal age to start having children is between 31 to 35 years old (Chart 5).
Of a total of 202 respondents (both married and unmarried) in the BELRIS survey, the most mentioned reason for delaying pregnancy was ‘job/financial security’ which was mentioned by 88% of men and 74% of women (Table 1).
54% of men and 65% of women indicated looking for ‘relationship stability’ as a reason for delaying pregnancy (Table 1).
Overall, 34% of respondents indicated they would delay pregnancy based on their belief that there will be no problems having children in the late 30s (Table 1).
Chart 5: Ideal Age to Start Having Children
Men (n=20) 35% 25% 50% 41% Women (n=51) 5% 18% 5% 6% 5% 6% 0% 0% Does not want Children 18 - 25 26 - 30
Source: BELRIS quantitative survey
31 - 35 36 - 40 41 - 45
Table 1: Reasons for Delaying Pregnancy Reasons for Delaying Pregnancy Total (n=202)
Job/Financial security Relationship stability 78% 62%
Men (n=52)
88% 54% 0% 4% Above 45
Women (n=150)
74% 65% Belief that there will be no problem having children in the late 30s 34% 38% 33%
Source: BELRIS quantitative survey
(Chart 5) BELRIS Survey, Question: At what age do you want to start having children?
Base, Respondents are NOT married n=71 (Table 1) BELRIS Survey, Question: If you wished to have children, what would be the reasons for delaying getting pregnant?/ (Table 1) BELRIS Survey, Question: What do you feel are the reasons for women delaying getting pregnant?
Base, Respondents who are married + Respondents are NOT married and want to have children n=202 12
Low oocyte freezing experience rate in Singapore
Based on the Clearstate survey, 10 out of 410 respondents had undergone oocyte freezing over the past 5 years.
Table 2 indicates a mix of respondents who had their oocytes frozen either for medical reasons or as part of fertility treatment (i.e. IVF treatment).
Singapore Assisted Reproduction Guidelines:*
Based on current guidelines by Ministry of Health on Assisted Reproduction (AR): Procedures to have oocytes frozen for elective reasons for single women is not allowed Only married women, under 45 years old, with the consent of her husband, may undergo IVF treatments or other AR treatments
Table 2: Reasons Given for Resident Women having Undergone Oocyte Freezing over the Past 5 Years
For Medical Reasons
Preserving eggs prior to receiving cancer treatment Either family history of early menopause, endometriosis or premature ovarian failure
For Fertility Treatment
During IVF treatment
Source: Clearstate quantitative survey Number of Respondents 3 (30%) 1 (10%) 6 (60%) Marital Status 2 single and 1 married All married All married
(Table 2) Clearstate Survey, B31: Why did you get your eggs frozen for medical reasons? Base, Respondents who have undergone egg freezing n=10 Reference: *Source: Licensing & Accreditation Branch, Ministry of Health. (2006). Directives for Private Healthcare Institutions Providing Assisted Reproductive Services. Singapore.
Majority of respondents indicated having ‘some knowledge’ of oocyte freezing technology
72% of respondents stated that they believe they have ‘some knowledge’ of oocyte freezing technology (Chart 6).
The average rating when respondents were asked to rate their level of overall knowledge of oocyte freezing technology on a scale of 1 to 5 # was 2.45 (Table 3).
# 1 is having 'no knowledge at all' and 5 is having 'a lot of knowledge Chart 6: Familiarity with Oocyte Freezing Technology (n=400)
I have detailed knowledge of the technology 7% I have some knowledge of the technology 72% I am aware of the existence of egg-freezing but do not have any details of the technology 20% Never heard of it 1% 0% 20% 40% 60% 80% 100%
Source: Clearstate quantitative survey
No Knowledge At All
Source: Clearstate quantitative survey 1
16%
Table 3: Rating of Overall Knowledge of Oocyte-Freezing Technology
2 3 4 5
40%
32%
12% 1%
A lot of Knowledge
(Chart 6) Clearstate Survey, C5: Please indicate ‘Yes’ if you are aware that egg-freezing can be used for each of the following and “No” if you are not aware (Table 3) Clearstate Survey, C3: On a scale of 1‐5, how would you rate your overall knowledge of egg-freezing technology for women? 1 is no knowledge at all and 5 is have lot of knowledge Base, Respondents who have NOT undergone egg freezing n=400 14
An increasing number of women in Singapore are seeking IVF treatment in recent years
According to a Straits Times article published in July 2011, statistics from the Singapore Ministry of Health showed that the number of women opting for Assisted Reproduction Technology (ART) treatments (with IVF being the most common) had increased between 2006 and 2009 from 1,933 to 3,271 (Chart 7).* Proportional to the increase in number of women seeking ART treatments, statistics from the Singapore Ministry of Health also showed that the number of babies born via ART increased by 65% from 717 babies in 2006 to 1,158 babies in 2009 (Table 4).*
Chart 7: Number of Women Opting for Assisted Reproduction Technology (ART) Treatments
3 271 2 627 2 179 1 933
Table 4: Number of Babies Born to Mothers through Assisted Reproduction Technology (ART) Treatment Year Total Number of Babies
2006 717 2007 2008 804 927 2009 1,158
Source: The Straits Times (Data from Singapore Ministry of Health)
2006 2007 2008
Source: The Straits Times (Data from Singapore Ministry of Health)
2009 Fertility specialists in Singapore interviewed by Clearstate had stated that an increase in awareness, and women becoming more forthcoming in seeking IVF and other ART treatments, have contributed to an increase in the number of babies born via ART.**
“It is not a (social) stigma anymore in Singapore to seek fertility treatment. Once they (women) realized the possibility of a fertility issue, they are likely to seek treatment immediately.”
– Fertility Specialist, Singapore
“Awareness level is higher among more educated people as they are typically the ones making the enquires, the recent newspaper articles (on oocyte freezing) have also helped raising awareness in Singapore. Hence the demand of IVF is on the rise in the country.”
– Fertility Specialist, Singapore Reference: *Data source from Ministry of Health (MOH), The Straits Times. (2011, July 23). Fertility business booming in Singapore. Retrieved March 19, 2013, from Health Xchange, http://www.healthxchange.com.sg/News/Pages/Fertility business-booming-in-Singapore.aspx
**Clearstate qualitative interviews with Singapore KICs 15
Singapore IVF rates are lower than certain developed nations; Enhanced government support may raise IVF rates in Singapore
According to the ICMART (International Committee for Monitoring Assisted Reproductive Technologies), there is an estimate of approximately 1.5 million ART cycles (IVF inclusive) performed globally each year.* In Singapore, the number of ART cycles is lower than certain developed nations.
A comparison of figures from 2009 indicate that Singapore performed approximately 656
#
cycles per million population** as compared to some European nations, such as Denmark and the United Kingdom which performed 2,726 cycles per million and 879 cycles per million respectively (Table 5).*
Table 5: Comparison of ART Cycles Per Million Population (2009) Country ART Cycles Per Million Population
Denmark 2,726 Belgium Sweden 2,562 1,800 Germany 830 Italy United Kingdom 863 879 Reference: *European Society of Human Reproduction and Embryology's IVF Monitoring Consortium (2012, July 1). European Society of Human Reproduction and Embryology. Retrieved March 19, 2013, from Science Daily: http://www.sciencedaily.com /releases/2012/07/120702134746.htm
**The Straits Times. (2011, July 23). Fertility business booming in Singapore. Retrieved March 19, 2013, from Health Xchange: http://www.healthxchange.com.sg/News/Pages/Fertility-business-booming-in-Singapore.aspx
***National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. (2012, November 2). Assisted Reproductive Technology Surveillance — United States, 2009. Retrieved March 19, 2013, from Centers for Disease Control and Prevention: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6107a1.htm?s_cid=ss6107a1_e ****Ministry of Health. (2013). Hey Baby. Retrieved March 19, 2013, from Enhanced Co-Funding For Assisted Reproduction Technology (ART) Treatment: http://www.heybaby.sg/havingchildren/art.html
*****The Business Times. (2012, June 02). When time is of the essence. Retrieved March 21, 2013, from The Business Times lifestyle: http://www.businesstimes.com.sg/archive/thursday/lifestyle/wellness/when-time-essence 16
Singaporean receptivity to IVF is likely to accelerate ART use in the future
71% of respondents to the Clearstate survey (includes singles and ever-married respondents who have not conceived any children via IVF) indicated that they would consider IVF if the need arose (Chart 8).
The perception of success by respondents if IVF treatment was used to have a baby was 5% believing it would be ‘extremely successful,’ while 80% believing it would be ‘sometimes successful’ (Chart 9).
Chart 8: Percentage of Respondents Who Would Consider IVF (n=407) #
Yes 71% No 29%
# Includes respondents that have gone through IVF treatment but have yet successfully had a child
(Chart 8) Clearstate Survey, A7: Would you consider In vitro fertilization (IVF) if need arises?
Base, Respondents who are Single, Never married or Married/Divorced/Widowed/Separated (with no children or children conceived via natural pregnancy) n=407 (Chart 9) Clearstate Survey, A8: How successful do you think IVF treatments are? Base, All respondents n=410
Source: Clearstate quantitative survey Chart 9: Perception of IVF Success (n=410)
Extremely successful, 5% Has complications, 12% Not successful; 3% Sometimes successful; 80%
Source: Clearstate quantitative survey
17
IVF success rates (both live births and clinical pregnancies
#
) are seen to decline with the increase in age in Singapore
Ms Tan Su Shan, Nominated Member of Parliament (NMP), directed the following question on the live birth success rates of IVF treatment at different ages in Singapore to Mr Gan Kim Yong, Minister of Health during a Sitting of Parliament.
Oral Answer by Mr Gan Kim Yong, Minister of Health, to Parliamentary Question on Success Rates of IVF Treatment
NMP: Ms Tan Su Shan
To ask the Minister for Health what are the success rates of live births arising from In-vitro fertilisation (IVF) for Singapore women aged below 35 years of age and those above 35 years of age.
Answer:
The success rate of live births from In-vitro fertilisation (IVF) using fresh embryos was 23% based on most recent data from 2010. In particular, the success rate of live births from IVF for women below 35 years of age was 34%, while for women 35 years of age and older, the success rate of live births was 14%. These rates have been fairly consistent over the last five years, from 2006 to 2010.
On a similar note, the clinical pregnancy success rate of IVF treatment for women 35 years of age and younger is higher than that for women older than 35 years of age, as observed in the clinical pregnancy success rates of IVF treatment reported by 2 clinics in Singapore (Chart 10 and Chart 11).
Chart 10: IVF Clinical Pregnancy Success Rates Reported By A Private Clinic in Singapore By Age (2011)
##
66,7% 43,0% 28,6% 28,6%
Chart 11: IVF Clinical Pregnancy Success Rates Reported By A Public Clinic in Singapore By Age (2012)
##
42,0% 38,0% 16,0% 11,0% 20 - 30 31 - 35 36 - 40
Source: Clearstate qualitative interviews with Singapore KICs
41 - 45 20 - 30 31 - 35
# A successful clinical pregnancy is a pregnancy where the fetal sac is seen in the uterus with an ultrasound after the IVF procedure has taken place ## IVF success rate varies between individual clinic due to factors such as patient volume, health conditions of patients etc.
36 - 40
Source: Clearstate qualitative interviews with Singapore KICs
41 - 45 18
IVF live birth success rates using fresh versus frozen embryos from patient oocytes
While it has been generally accepted that IVF success rates are seen to decline with the increase in age of a woman, a clinic summary report conducted on all American Society for Assisted Reproductive Technology (SART) member clinics suggests that IVF live birth success rates also differ when using fresh or thawed embryos from patient oocytes.* The IVF live birth success rates for fresh embryos from patient oocytes declined at a faster rate with the passing of age compared to the IVF live birth success rates for thawed embryos from patient oocytes (Chart 12).
46,2%
Chart 12: IVF Live Birth Success Rates Using Fresh versus Frozen Embryos from Patient Oocytes (2011)
39,3% 38,4% 35,7% 27,4% 30,3% 24,5% 16,6% 16,5% 6,5% Notably, frozen embryo transfers among women aged 38 and over resulted in a higher number of live births that fresh embryo transfers (Chart 12).
Under 35 35 - 37 38 - 40 41 - 42 Above 42 Fresh Embryos from Patient Oocytes - Percentage of transfers resulting in live births Thawed Embryo from Patient Oocytes - Percentage of transfers resulting in live births
# Source: Society for Assisted Reproductive Technologies (SART), the United States # The ages of the women at point of embryo freezing were undetermined
Reference: *Society for Assisted Reproductive Technology. (2011). Clinic Summary Report. Retrieved March 19, 2013, from SART: IVF Success Rates: https://www.sartcorsonline.com/rptCSR_PublicMultYear.aspx?ClinicPKID=0 19
The response in Singapore for providing single women with the option of elective oocyte freezing is generally positive
81% out of 410 respondents from the Clearstate survey support single women being given the option to undergo elective oocyte freezing in Singapore.
Further analysis of the Clearstate survey indicate that a large majority of respondents across marital status, age, religion and educational backgrounds support elective oocyte freezing for single women.
Table 6: Support for Oocyte Freezing for Single Women across Marital Status, Age Groups, Education Levels and Religions (n=410) Table 6.1: Breakdown by Marital Status # Marital Status # of Respondents
Supports Elective Oocyte Freezing
Single, never married
172 90%
Married/Divorced/ Widowed/Separated
238 74% There is a higher proportion of single, never married respondents (90%) supporting elective oocyte freezing compared to ever-married respondents (74%) (Table 6.1).
More than 80% of women aged between 20 to 35 support elective oocyte freezing while less than 80% of women aged above 35 support elective oocyte freezing for single women (Table 6.2).
Support for elective oocyte freezing for single women has largely been consistent amongst all education levels (Table 6.3).
Table 6.2: Breakdown by Age Group # Age Group # of Respondents
Supports Elective Oocyte Freezing
20 - 25
71 93%
26 - 30
72 82%
Table 6.3: Breakdown by Education Level # Education Level # of Respondents
Supports Elective Oocyte Freezing
Primary & lower
4 75%
Secondary
72 75%
31 - 35
87 84%
Diploma
127 85%
36 - 40
94 72%
University
175 82%
41 - 45
86 76%
Post graduate
32 72% Across religions, 86% of Buddhist respondents, 75% of Christian respondents, 64% of Hindu respondents, 74% of Muslim respondents, 84% of Taoist respondents and 83% of respondents without religious affiliation support single women being given the option to undergo elective oocyte freezing in Singapore (Table 6.4).
Table 6.4: Breakdown by Religion # Religion # of Respondents
Supports Elective Oocyte Freezing
Buddhism Christianity
127 86% 91 75%
Hinduism
11 64%
Islam
42 74%
Taoism
31 84%
No Religion
107 83%
Others
1 100%
Source: Clearstate quantitative survey # Representative samples within each category in the Clearstate survey are slightly higher or lower than in the respective national proportions (refer to Appendix)
(Table 6) Clearstate Survey, E4: Do you think women who can’t find partners to marry until a certain age (say 30) should be given the choice to freeze their eggs for future use?
Base, All respondents n=410 20
Respondent belief regarding the potential implications of elective oocyte freezing on society
With regard to to the potential implications of elective oocyte freezing on society, 66% of the Clearstate survey respondents stated they believed that Singaporeans would delay getting married while 60% stated they believed there would be an increase in pregnancy risks (Chart 13).
48% of respondents believed that allowing elective oocyte freezing would have ethical, religious or moral implications on society (Chart 13).
Chart 13: Belief Regarding Implications of Elective Oocyte Freezing on Society (n=410)
Ethical, religious or moral issues 48% Increase in healthcare cost Singaporeans will be getting married later Increase in pregnancy related risks Others 2%
Source: Clearstate quantitative survey
57% 66% 60%
“With Singapore women becoming more career minded, this service might be exploited by both the medical practitioners and women who might want to delay pregnancy. Success rate is unknown and the side effects on the children is also unrepresentative.”
– Clearstate
quantitative survey respondent
“Will this eventually end up raising other question as to whether one can
actually sell the frozen eggs to some other want-to-be mothers who are not able to produce eggs even during their younger days?”
– Clearstate
quantitative survey respondent
“There will be a lot of outcry from religious organisation and society on the availability and how it can encourage people to go through it despite knowing that the action would be frown upon or even not allowed in some religion”
– Clearstate quantitative survey respondent
“Firstly I'm a Catholic so IVF itself is not an option”
quantitative survey respondent
– Clearstate (Chart 13) Clearstate Survey, E2: What implications, if any, do you think egg- freezing will face if it is allowed in Singapore for elective purposes?
(Quotes from respondents) Clearstate Survey, E2.1: Could you please elaborate on your answer to the ethical, religious or moral issues that egg- freezing will face if it is allowed in Singapore for elective purposes?
Base, All respondents n=410 21
The belief that elective egg freezing has potential implications in society for ethical, religious or moral reasons, differs across age groups, education levels and religious backgrounds
The 31 to 35 age group contains the greatest proportion of respondents (56%) who had indicated that ethical, religious or moral issues could be a potential implication of elective oocyte freezing on society (Table 7.1).
The post-graduate education level group contains the greatest proportion of respondents (53%) who had indicated that ethical, religious or moral issues could be a potential implication of elective oocyte freezing on society (Table 7.2).
The Muslim respondent group contains the greatest proportion of respondents (76%) who had indicated that ethical, religious or moral issues could be a potential implication of elective oocyte freezing on society (Table 7.3).
Chart 13: Belief Regarding Implications of Elective Oocyte Freezing on Society (n=410) Table 7 : Belief that ‘Ethical, Religious or Moral Issues’ have Potential Implications on Elective Oocyte Freezing in Society across Age Groups, Education Levels and Religions (n=410)
Ethical, religious or moral issues Increase in healthcare cost
48% (198)
57%
Table 7.1: Breakdown by Age Group # Age Group # of Respondents
Indicated
20 - 25 71
34%
26 - 30 72
51%
31 - 35 87
56%
36 - 40 94
49%
41 - 45 86
49% Singaporeans will be getting married later Increase in pregnancy related risks 66% 60%
Table 7.2: Breakdown by Education Level # Education # of Respondents
Indicated
Primary & lower Secondary Diploma University 4
25%
72
46%
127
44%
175
52%
Post graduate 32
53% Others 2%
Table 7.3: Breakdown by Religion # Religion # of Respondents
Indicated
Buddhism Christianity Hinduism 127
42%
91
57%
11
27%
Islam 42
76%
Taoism 31
39%
No Religion 107
42%
Others 1
100%
Source: Clearstate quantitative survey # Representative samples within each category in the Clearstate survey are slightly higher or lower than in the respective national proportions (refer to Appendix)
(Chart 13/Table 7) Clearstate Survey, E2: What implications, if any, do you think egg- freezing will face if it is allowed in Singapore for elective purposes?
Base, All respondents n=410 22
The belief that elective egg freezing has potential implications in society by increasing healthcare cost, differs across age groups, education levels and religious backgrounds
The 31 to 35 age group contains the greatest proportion of respondents (60%) who had indicated that an increase in healthcare cost could be a potential implication of elective oocyte freezing on society (Table 8.1).
The secondary education level group contains the greatest proportion of respondents (61%) who had indicated that an increase in healthcare cost could be a potential implication of elective oocyte freezing on society (Table 8.2).
The Muslim and Hindu respondent groups contain the greatest proportions of respondents (64% each) who had indicated that an increase in healthcare cost could be a potential implication of elective oocyte freezing on society (Table 8.3).
Chart 13: Belief Regarding Implications of Elective Oocyte Freezing on Society (n=410) Table 8: Belief that ‘Increase in Healthcare Cost’ has Potential Implications on Elective Oocyte Freezing in Society across Age Groups, Education Levels and Religions (n=410)
Ethical, religious or moral issues Increase in healthcare cost 48%
57% (234) Table 8.1: Breakdown by Age Group # Age Group # of Respondents
Indicated
20 - 25 71
59%
26 - 30 72
58%
31 - 35 87
60%
36 - 40 94
55%
41 - 45 86
53% Singaporeans will be getting married later Increase in pregnancy related risks 66% 60%
Table 8.2: Breakdown by Education Level # Education # of Respondents
Indicated
Primary & lower Secondary Diploma University 4
50%
72
61%
127
56%
175
58%
Post graduate 32
47% Others 2%
Table 8.3: Breakdown by Religion # Religion # of Respondents
Indicated
Buddhism Christianity Hinduism 127
57%
91
51%
11
64%
Islam 42
64%
Taoism 31
55%
No Religion 107
59%
Others 1
100%
Source: Clearstate quantitative survey # Representative samples within each category in the Clearstate survey are slightly higher or lower than in the respective national proportions (refer to Appendix)
(Chart 13/Table 8) Clearstate Survey, E2: What implications, if any, do you think egg- freezing will face if it is allowed in Singapore for elective purposes?
Base, All respondents n=410 23
The belief that elective egg freezing has potential implications in society in that people will get married later, differs across age groups, education levels and religious backgrounds
The 20 to 25 age group contains the greatest proportion of respondents (71%) who had indicated that marriage at a later age could be a potential implication of elective oocyte freezing on society (Table 9.1).
The post-graduate and primary & lower education level groups contain the greatest proportions of respondents (75% each) who indicated that marriage at a later age could be a potential implication of elective oocyte freezing on society (Table 9.2).
The Buddhist respondent group contains the greatest proportion of respondents (69%) who indicated that marriage at a later age could be a potential implication of elective oocyte freezing on society (Table 9.3).
Chart 13: Belief Regarding Implications of Elective Oocyte Freezing on Society (n=410) Table 9: Belief that ‘Singaporeans Will Be Getting Married Later’ has Potential Implications on Elective Oocyte Freezing in Society across Age Groups, Education Levels and Religions (n=410)
Ethical, religious or moral issues Increase in healthcare cost 48% 57%
Table 9.1: Breakdown by Age Group # Age Group # of Respondents
Indicated
20 - 25 71
76%
26 - 30 72
71%
31 - 35 87
61%
36 - 40 94
62%
41 - 45 86
64% Singaporeans will be getting married later Increase in pregnancy related risks
66% (271)
60%
Table 9.2: Breakdown by Education Level # Education # of Respondents
Indicated
Primary & lower Secondary Diploma University 4
75%
72
64%
127
65%
175
66%
Post graduate 32
75% Others 2%
Table 9.3: Breakdown by Religion # Religion # of Respondents
Indicated
Buddhism Christianity Hinduism 127
69%
91
65%
11
64%
Islam 42
62%
Taoism 31
68%
No Religion 107
64%
Others 1
100%
Source: Clearstate quantitative survey # Representative samples within each category in the Clearstate survey are slightly higher or lower than in the respective national proportions (refer to Appendix)
(Chart 13/Table 9) Clearstate Survey, E2: What implications, if any, do you think egg- freezing will face if it is allowed in Singapore for elective purposes?
Base, All respondents n=410 24
The belief that elective egg freezing has potential implications in society in that it will increase pregnancy related risks, differs across age groups, education levels and religious backgrounds
The 26 to 30 age group contains the greatest proportion of respondents (64%) who had indicated that an in pregnancy related risks could be a potential implication of elective oocyte freezing on society (Table 10.1).
Apart from the primary & lower education level group, the post-graduate education level group contains the next highest proportion of respondents (69%) who had indicated that an in pregnancy related risks could be a potential implication of elective oocyte freezing on society (Table 10.2).
The Taoist respondent group contains the greatest proportion of respondents (77%) who had indicated that pregnancy related risks could be a potential implication of elective oocyte freezing on society (Table 10.3).
Chart 13: Belief regarding Implications of Elective Oocyte Freezing on Society (n=410) Table 10: Belief that ‘Increase in Pregnancy Related Risks’ has Potential Implications on Elective Oocyte Freezing in Society across Age Groups, Education Levels and Religions (n=410)
Ethical, religious or moral issues Increase in healthcare cost 48%
57% Table 10.1: Breakdown by Age Group # Age Group # of Respondents
Indicated
20 - 25 71
59%
26 - 30 72
64%
31 - 35 87
57%
36 - 40 94
63%
41 - 45 86
57% Singaporeans will be getting married later Increase in pregnancy related risks 66%
60% (246) Table 10.2: Breakdown by Education Level # Education # of Respondents
Indicated
Primary & lower Secondary Diploma University 4 72 127 175
100% 60% 56% 61%
Post graduate 32
69% Others 2%
Table 10.3: Breakdown by Religion # Religion # of Respondents
Indicated
Buddhism Christianity Hinduism 127
58%
91
56%
11
64%
Islam 42
57%
Taoism 31
77%
No Religion 107
61%
Others 1
100%
Source: Clearstate quantitative survey # Representative samples within each category in the Clearstate survey are slightly higher or lower than in the respective national proportions (refer to Appendix)
(Chart 13/Table 10) Clearstate Survey, E2: What implications, if any, do you think egg- freezing will face if it is allowed in Singapore for elective purposes?
Base, All respondents n=410 25
Perspective among respondents on elective oocyte freezing for themselves is mixed
22% of respondents from the Clearstate survey stated it will be ‘somewhat likely’ or ‘very likely’ that they will opt for elective oocyte freezing for themselves in the future, while 31% of respondents stated it will be ‘somewhat unlikely’ or ‘very unlikely’ that they will opt for elective oocyte freezing for themselves. The remaining 47% of the respondents indicated that they are “unsure” whether they will opt for elective oocyte freezing (Chart 14).
Of the respondents who are likely to consider elective oocyte freezing, the most selected reason was to have a ‘safety net’ in case of future health problems (66%), followed by having the option to preserve their fertility with younger eggs (65%) and to have sufficient time to be financially and emotionally prepared for children (60%) (Chart 14.1).
Of the respondents who are unlikely to consider elective oocyte freezing, the most selected reason was high cost of treatment (54%), followed by health concerns such as health risks involved (37%), and physical and emotional discomfort in retrieving eggs (34%). 22% of respondents indicated ethical and moral reasons for their hesitation towards considering elective oocyte freezing for themselves (Chart 14.2).
Chart 14.1: Reasons for Interest in Elective Oocyte Freezing for Oneself (n=91) Chart 14: Likelihood of Opting for Elective Oocyte Freezing in the Future for Oneself (n=410) Chart 14.2: Reasons for NOT Opting for Elective Oocyte Freezing for Oneself (n=125)
Preserve my fertility with my younger eggs to increase chances of pregnancy later in my life
65% 18% 4% 18%
Large expense involved Physical and emotional discomfort in retrieving eggs for egg-freezing
34% 54%
It takes the pressure off to rush into having children until I am financially and emotionally prepared
60% 13%
Health risks involved
37%
Ethical/moral reasons
22%
Freezing eggs as a form of 'insurance' or 'safety net' in case of health problems in future that may affect or damage fertility'
66% 47%
Planning to have children in the near future
14%
I do not think I will struggle to conceive naturally
35%
Others
1% Source: Clearstate quantitative survey
Very unlikely Not sure Very likely Somewhat unlikely Somewhat likely Others
15%
(Chart 14) Clearstate Survey, D3: If egg-freezing for elective purposes is allowed in Singapore, how likely are you to undergo egg-freezing in the future? Base, All Respondents n=410 (Chart 14.1) Clearstate Survey, D4: Why do you think you would undergo egg freezing in the future? Base, Respondents who are likely or somewhat likely to undergo egg freezing n=91 (Chart 14.2) Clearstate Survey, D5: Why are you unlikely to undergo egg-freezing in the future? Base, Respondents who are unlikely or somewhat unlikely to undergo egg freezing n=125 26
Perspective among respondents on elective oocyte freezing for themselves differs across marital status, age groups, education levels and religious backgrounds
As indicated by the Clearstate survey, there is a higher proportion of single, never married respondents (24%) who stated it will be ‘somewhat likely’ or ‘very likely’ that they will opt for elective oocyte freezing for themselves as compared to ever-married respondents (21%) (Table 11.1).
Conversely, there is a higher proportion of ever-married respondents (35%) who stated it will be ‘somewhat unlikely’ or ‘very unlikely’ that they will opt for elective oocyte freezing for themselves as compared to single, never married respondents (24%) (Table 11.1).
Table 11: Likelihood of Opting for Elective Oocyte Freezing in the Future for Oneself across Marital Status, Age Groups, Education Levels and Religions (n=410) Table 11.1: Breakdown by Marital Status # Marital Status # of Respondents
‘Somewhat Likely’ and ‘Very Likely’ Unsure ‘Somewhat Unlikely’ and ‘Very Unlikely’
Single, never married 172
24% 52% 24%
Married/Divorced/ Widowed/Separated 238
21% 44% 35% The proportion of respondents who stated it will be ‘somewhat unlikely’ or ‘very unlikely’ that they will opt for elective oocyte freezing for themselves increases with each ascending age group (Table 11.2).
36% of women aged 41 to 45 stated that it will be ‘somewhat unlikely’ or ‘very unlikely’ that they will opt for elective oocyte freezing for themselves as compared to 25% of women aged 20 to 25 (Table 11.2).
The proportion of respondents who stated it will be ‘somewhat likely’ or ‘very likely’ that they will opt for elective oocyte freezing for themselves increases with higher education level (Table 11.3).
Notably, the proportion of respondents who indicated that they are unsure decreases with the rise in education level (Table 11.3).
Table 11.2: Breakdown by Age Group # Age Group # of Respondents
‘Somewhat Likely’ and ‘Very Likely’ Unsure ‘Somewhat Unlikely’ and ‘Very Unlikely’
Table 11.3: Breakdown by Education Level # Education Level # of Respondents
‘Somewhat Likely’ and ‘Very Likely Unsure ‘Somewhat Unlikely’ and ‘Very Unlikely’
20 - 25 71
21% 54% 25%
Primary & lower 4
0% 75% 25%
26 - 30 72
25% 49% 26%
Secondary 72
15% 54% 31%
31 - 35 87
27% 45% 28%
Diploma 127
23% 48% %
36 - 40 94
18% 47% 35%
University 175
22% 46% 32%
41 - 45 86
20% 44% 36%
Post graduate 32
38% 34% 28% There is a higher proportion of Christian and Muslim respondents who stated it will be ‘somewhat unlikely’ or ‘very unlikely’ that they will opt for elective oocyte freezing for themselves as compared to respondents of other religious backgrounds (Table 11.4).
Table 11.4: Breakdown by Religion # Religion # of Respondents
‘Somewhat Likely’ and ‘Very Likely’ Unsure ‘Somewhat Unlikely’ and ‘Very Unlikely’
Buddhism Christianity Hinduism 127
26% 46% 28%
91
15% 46% 39%
11
46% 27% 27%
Islam 42
14% 50% 36%
Taoism 31
29% 42% 29%
No Religion 107
21% 53% 26%
Others 1
100% 0% 0%
# Representative samples within each category in the Clearstate survey are slightly higher or lower than in the respective national proportions (refer to Appendix) Source: Clearstate quantitative survey
(Table 11) Clearstate Survey, D3: If egg-freezing for elective purposes is allowed in Singapore, how likely are you to undergo egg-freezing in the future? Base, All Respondents n=410 27
The most important reason selected by respondents for not opting for elective oocyte freezing for themselves differ across religious backgrounds
The most important reason selected by Christian respondents for not opting for elective oocyte freezing for themselves was ethical and moral concerns (29%) (Table 12).
On the other hand, the most important reason selected by Muslim and Buddhist respondents for not opting for elective oocyte freezing for themselves was the large expenses involved (34% for each group of respondents) (Table 12).
Meanwhile, the most important reasons selected by respondents without religious affiliation for not opting for elective oocyte freezing for themselves was the belief that they will not struggle to conceive naturally (29%) (Table 12).
Table 12: Most Important Reason for NOT Opting for Elective Oocyte Freezing for Oneself by Religion
#
(n=125) Most Important Reason for NOT Opting for Elective Oocyte Freezing for 0neself Buddhist Respondents # of Responde nts % Distributi on Christian Respondents # of Responde nts % Distributi on Hindu Respondents # of Responde nts % Distributi on Muslim Respondents # of Responde nts % Distributi on
Large expenses involved Physical and emotional discomfort in retrieving eggs for egg-freezing Health risks involved Ethical/moral reasons Planning to have children in the near future I do not think I will struggle to conceive naturally Others
TOTAL Source: Clearstate quantitative survey
12 6 4 1 2 5 5
35
34% 17% 12% 3% 6% 14% 14%
100%
5 2 2 10 3 9 4
35
14% 6% 6% 29% 9% 25% 11%
100%
1 0 0 0 0 2 0
3
33% 0% 0% 0% 0% 67% 0%
100%
5 0 2 1 2 3 2
15
34% 0% 13% 7% 13% 20% 13%
100% Taoist Respondents # of Responde nts % Distributi on
2 0 1 0 2 2 2
9
22% 0% 12% 0% 22% 22% 22%
100% No Religion Respondents # of Responde nts % Distributi on
7 3 2 2 2 8 4
28
25% 11% 7% 7% 7% 29% 14%
100% # Representative samples within each category in the Clearstate survey are slightly higher or lower than in the respective national proportions (refer to Appendix)
(Table 12) Clearstate Survey, D5.1: What is the MOST important reason that deters you from undergoing egg-freezing in the future? Base, Respondents who are unlikely or somewhat unlikely to undergo egg freezing n=125 28
There are Singaporean couples travelling abroad to seek fertility treatments such as IVF
Based on Clearstate qualitative interviews with fertility centres in Singapore, Malaysia, Thailand, India and Australia, Singaporean couples are travelling abroad to seek fertility treatments such as IVF.
In general, the reasons for doing so are: o o Seeking alternative IVF facilities overseas for treatment after multiple failed IVF cycles in Singapore.
Seeking lower costs of IVF treatment, especially upon exceeding government subsidy limit.
# o For medical procedures that are restricted in Singapore such as the use of PGD for gender selection during IVF treatment.
Table 13: Overview of Singaporean Couples Seeking IVF treatment overseas from Clearstate qualitative interviews with fertility centres Malaysia
According to fertility clinics interviewed, a its closer proximity to Singapore.
large number of Singaporean couples travel to Johor Bahru for IVF treatment due to
Thailand India Australia
A reputable IVF clinic in Johor Bahru sees more than 30 Singaporean couples each year.
On the average, the interviewed fertility clinics in Bangkok see less than 10 Singaporean couples each year.
On the average, the interviewed fertility clinics in Mumbai, Hyderabad and Delhi see less than 5 Singaporean couples each year.
On the average, the interviewed fertility clinics in Melbourne and Sydney see less than 5 Singaporean couples each year.
Source: Clearstate qualitative interviews with Singapore KICs # Prior to 2013, the Singapore government had a co-funding limit of S$3,000 per ART cycle for Singaporeans, up to three cycles only
29
Chapter 3 Regulatory Scenarios of Selected Countries
Photo: TIME Photo: Santa Monica Reproductive Technologies Photo: The Straits Times
Summary of ART Regulations in Selected Countries
Table 14: Summary of ART Regulations in Selected Countries Gender Selection in IVF
Australia
Prohibited (except for medical reasons)
India
Prohibited
Malaysia
Prohibited
Regulations for ART/IVF Regulations for Surrogacy
Regulated Allowed (altruistic) Unregulated, yet practiced (legislation initiated) Unregulated, yet practiced (legislation initiated) Unregulated, yet practiced (legislation initiated) Unregulated, not practiced
Fiscal Support by Government
Subsidised (~75% covered under Medicare) Unsubsidised (pay out-of-pocket) Unsubsidised (pay out-of-pocket)
Regulations on Oocyte Freezing
Allowed Unregulated, yet practiced Unregulated, yet practiced
Cost of treatment (IVF)
SGD2,500 to SGD3,000 per cycle
Glossary:
1.
2.
3.
4.
Altruistic: No monetary compensation allowed Medicare: Australia’s publicly funded universal healthcare system Medisave: Singapore’s national healthcare saving scheme Pay out-of-pocket: Payment from individual funds About SGD 6,000 per cycle SGD4,000 and SGD 8,000 per cycle 5.
6.
7.
Prohibited: Banned by legislation (law) Regulated: Governed by legislation (law) Unregulated: Lack of existing legislation (law)
Thailand
Unregulated, yet practiced Unregulated, yet practiced Unregulated, yet practiced Unsubsidised (pay out-of-pocket) Unregulated, yet practiced SGD 6,000 to SGD 7,500 per cycle
Singapore
Prohibited (except for medical reasons) Regulated Prohibited Subsidised (Medisave) Prohibited (for elective/single women) SGD 6,000 to SGD 13,000 per cycle 31
Australia
Australia has regulations in place for fertility treatment
Table 15: Demographics of Australia Population size
22,015,576 (July 2012 est.)*
Birth rate Infertility Cost of IVF Treatment
1.9 births per woman (2011 est.)* One in six Australian couple** Out-of-pocket payment for an IVF treatment cycle costs about SGD 2,500 to SGD3,000***
Opinions of KCIs in Australia on Oocyte Freezing
Cryo-preservation of oocytes is gaining popularity, particularly amongst younger women who freeze their eggs as a form of insurance against age-related fertility decline.
“Embryologist strongly believe allowing oocyte freezing at an early age has improved the success of IVF rates in Australia. There have been several studies both domestic and international which support this hypothesis. One of the key reasons Australia has higher success rates in IVF is the progressive nature of regulations in this regard.”
–
Embryologist, Sydney ***
Regulations on IVF and Fertility Treatments
Australia is said to lead the world in having the highest pregnancy and live birth rates through ART.*** Australians are entitled to reimbursement from the National Health Scheme- Medicare for most fertility treatments such as IVF and Intracytoplasmic Sperm Injection (ICSI).**** Gender selection can be done via PGD, for medical reasons (e.g. to prevent the transmission of a gender-linked genetic disease).
**** Elective oocyte freezing is permitted in the Australia.**** Fertility clinics adhere to the National Australian Health Ethics Committee guidelines when providing any fertility treatment.**** Reference: *Central Intelligence Agency. (2013). Australia. Retrieved March 19, 2013, from The World Factbook: https://www.cia.gov/library/publications/the-world-factbook/ **Fertility Society of Australia. (2013). Retrieved March 19, 2013, from Home Page: http://www.fertilitysociety.com.au/ ***IVF Australia. (2012). Retrieved March 19, 2013, from IVF Australia: http://ivf.com.au/ivf-fees/ivf-costs ****National Health and Medical . (2013, February 13). Assisted Reproductive Technology (ART) Research Council. Retrieved March 19, 2013, from Assisted Reproductive Technology (ART) 32
India
India is well known for the provision of fertility treatments but remains unregulated
Table 16: Demographics of India Population size Birth rate Infertility Cost of IVF Treatment
1,205,073,612 (July 2012 est.)* 2.6 births per woman (2011 est.)* 15 to 20 million couples yearly** One complete IVF cycle at an urban clinic about costs SGD6,000 Costs for freezing and storing the eggs will range from SGD600 to SGD1,000 a year***
Opinions of KOLs in India on Oocyte Freezing****
Cryo-preservation of oocytes is currently offered by doctors mainly in Mumbai, Bangalore, Hyderabad and Delhi where there is an awareness of the availability of the service, although it is still not considered popular amongst women in India.
“Egg-freezing is still rare (...) Awareness is very low in general public and even amongst doctors. Those who make initial enquiries are more familiar but still require assurances about the process…India still largely being a conservative society, there is still reluctance for women to step forward and undertake fertility-related procedures before marriage.”
–
Director, Private IVF Centre in New Delhi
Regulations on IVF and Fertility Treatments
Provision of fertility services remains unregulated across India (e.g. age limit of IVF pregnancy) although most clinics in major cities adhere to international recognised as well as Indian Council of Medical Research (ICMR) guidelines.***** The ART Regulation Bill, drafted by the ICMR in 2010 to regulate and govern ART procedures, is still under consideration by legislation.***** Fertility tourism in India is growing rapidly, with the reputation of affordable fertility treatments such as IVF and surrogacy driving this growth.** Reference: *Central Intelligence Agency. (2013). India. Retrieved March 19, 2013, from The World Factbook: https://www.cia.gov/library/publications/the-world-factbook/ **International Institute of Population Sciences. (2011, June 27). Retrieved March 19, 2013, from Infertility: A growing concern: http://www.indianexpress.com/news/infertility-a-growing-concern/967209 ***The Washington Post. (2010, August 13). The Washington Post. Retrieved March 19, 2013, from In India, age often doesn't stop women from seeking help to become pregnant: http://www.washingtonpost.com/wp dyn/content/article/2010/08/12/AR2010081206876.html?sid=ST2010081300007 ****Clearstate qualitative interviews with Singapore KICs *****Indian Council of Medical Research . (2010). Indian Council of Medical Research . Retrieved March 19, 2013, from http://www.icmr.nic.in/ & The Assisted Reproductive Technologies (Regulation) Bill - 2010 33
Malaysia
Malaysia’s market is presently unregulated
Table 17: Demographics of Malaysia Population size
29,179,952 (July 2012 est.)*
Birth rate Infertility rate Cost of Treatment
2.6 births per woman (2011 est.)* 15%** The cost for one-cycle of IVF in fertility clinics ranges between SGD4,000 and SGD8,000***
Opinions of KOLs in Malaysia on Oocyte Freezing****
No laws exist regulating oocyte freezing, thus cryopreservation of oocytes is currently offered for medical as well as elective reasons by fertility doctors.
“Egg-freezing and embryo freezing is currently not illegal in Malaysia and hence our IVF clinic supports demand from all over Malaysia and Singapore.”
– Infertility Specialist, Private IVF Centre in Johor Bahru
Regulations on IVF and Fertility Treatments
Fertility treatment remains unregulated in Malaysia although the Ministry of Health has initiated legislation in 2011 with the proposal of the Assisted Reproductive Technique Services Act.** The act will address issues such as surrogacy, sperm and egg banking, and sperm donation to make the Malaysian market more progressive.** Fertility centres will have to be licensed once the proposed National ART Act is passed.** Drafting exercise for the proposed legislation was expected to be completed in 2012.** Fertility centres are accredited by international bodies (such as the Joint Commission International) and Malaysian Society for Quality in Health (MSQH).***** Reference: *Central Intelligence Agency. (2013). Australia. Retrieved March 19, 2013, from The World Factbook: https://www.cia.gov/library/publications/the-world-factbook/ **ASIAONE. ( 2011, February 27). ASIAONE. Retrieved March 21, 2013, from Laws on fertility treatment by 2012: http://www.asiaone.com/Health/News/Story/A1Story20110227-265537.html
***Borneo Post. (2012, April 25). Retrieved March 19, 2013, from IVF triplets born at Raja Permaisuri Bainun Hospital: http://www.theborneopost.com/2012/04/25/ivf-triplets-born-at-raja-permaisuri-bainun-hospital/ ttp://www.theborneopost.com/2012/04/25/ivf-triplets-born-at-raja-permaisuri-bainun-hospital/ ****Clearstate qualitative survey of key opinion leaders *****Malaysian Society for Quality in Health. (2011). Retrieved March 19, 2013, from Malaysian Society for Quality in Health: http://www.msqh.com.my/web/ 34
Thailand
Thailand is well known for the provision of fertility treatments but remains unregulated
Table 18: Demographics of Thailand Population size: Birth rate: Cost of Treatment
67,091,089 (July 2012 est.)* 1.6 births per woman (2011 est.)* Thailand is considered a major fertility tourism hub in the region with its price competitiveness for IVF being between SGD6,000 to SGD7,500 per cycle**
Opinions of KOLs in Thailand on Oocyte Freezing**
Cryo-preservation of oocytes is currently offered by doctors but mainly targeted foreign patients due to low awareness among and affordability to local patients.
“Oocyte freezing is quite a new concept to Thai people. Additionally, IVF treatments are not reimbursable for Thais. Hence, there is no demand for such procedures locally. We mainly get enquires from foreign patients. Singaporeans form a small proportion of these (foreign) patients.”
–
Infertility Specialist, Public IVF Centre in Bangkok
Regulations on IVF and Fertility Treatments
There are currently no laws governing fertility treatment in Thailand but doctors adhere to medical and ethical guidelines set out by the Thai Medical Council and Royal Thai College of Obstetricians and Gynaecologists (RTCOG).*** IVF treatments are largely popular amongst overseas patients as they are typically able to enjoy reimbursement from their individual insurance schemes.** Thailand is one of the few countries in the region that allows gender selection treatment via PGD.*** The availability of PGD has attracted patients from countries where gender selection is not allowed (including Singapore**** and India*****).
Reference: *Central Intelligence Agency. (2013). Australia. Retrieved March 19, 2013, from The World Factbook: https://www.cia.gov/library/publications/the-world-factbook/ **Clearstate qualitative survey of key opinion leaders ***Chiang Mai University. (2007). Surveillance of ART and PGD practice in Thailand. Chiang Mai ****Straits Times (2011, August 21). Straits Times. Retrieved March 23, 2013, Gender spenders: http://www.healthxchange.com.sg/News/Pages/Gender-spenders.aspx
*****The Times of India. (2010, December 27). The Times of India. Retrieved March 19, 2013, from To ensure prized baby boy, Indians flock to Bangkok: http://articles.timesofindia.indiatimes.com/2010-12 27/india/28239140_1_indian-couples-indians-flock-baby-boy 35
APPENDIX
Photo: TIME Photo: The Straits Times Photo: Santa Monica Reproductive Technologies
Appendix A: BELRIS Quantitative Survey – Age Profile of Respondents
Age Group
18 – 25 26 – 30 31 – 35 36 – 40 41 – 45
TOTAL Not Married, Men # of Respondents
7 9 2 1 1
20 % Distribution
35% 45% 10% 5% 5%
100% Respondent Breakdown by Marital Status (n=206)
Not Married 34% Married 66%
Age Group
26 – 30 31 – 35 36 – 40 41 – 45 Above 46
TOTAL Married, Men # of Respondents
2 5 10 7 9
33 % Distribution
6% 15% 30% 21% 28%
100% Age Group
18 – 25 26 – 30 31 – 35 36 – 40 41 – 45 Above 46
TOTAL Not Married, Women # of Respondents % Distribution
14 11 12 28% 22% 23% 9 2 3
51
17%.
4% 6%
100% Age Group
26 – 30 31 – 35 36 – 40 41 – 45 Above 46
TOTAL Married, Women # of Respondents % Distribution
6 6% 13 13% 18 18% 42 41% 23
102
22%
100%
BELRIS Survey, Question: What is your gender? How old are you?
Base, All respondents n=206 37
Appendix B: Clearstate Qualitative Interviews – List of IVF Clinics Interviewed
List of IVF Clinics Interviewed Country
Australia India
City
Melbourne Sydney (Branches at Multiple Locations) Mumbai Hyderabad New Delhi
Number of IVF Centres Interviewed
1 1 2 1 1 Malaysia Singapore Thailand Johor Bahru Petaling Jaya Singapore Bangkok 1 2 5 3
Facility Ownership
Private Private All private Private Private Private All private 4 private and 1 public All private 38
Appendix C: Clearstate Quantitative Survey – Marital Status of Respondents
Marital Status of Clearstate Survey Respondents (n=410) versus National Proportion (2010)*
# 62,9% 37,1% 42,0% 58,0% Single, Never Married
Respondents
Married/Divorced/Widowed/Separated
National Proportion
# Latest available data on resident women aged between 20 to 44 from the Singapore Department of Statistics. Censuses of Population are conducted once in every ten years by the Singapore Department of Statistics
References:
*Department of Statistics, Ministry of Trade & Industry. (2010). The Census of Population 2010 . Singapore Clearstate Survey, A5: What is your current marital status?
Base, All respondents n=410 39
Appendix D: Clearstate Quantitative Survey – Age Profile of Respondents
Age Profile of Clearstate Survey Respondents (n=410) versus National Proportion (2012)*
17,9% 17,3% 17,8% 17,6% 21,0% 21,2% 21,9% 22,9% 21,4% 21,0% 20 - 25 years 26 - 30 years
Respondents
31 - 35 years 36 - 40 years
National Proportion
41 - 45 years
References:
*Department of Statistics, Ministry of Trade & Industry. (2012). Population Trends 2012. Singapore Clearstate Survey, S3: Which age bracket do you fall under?
Base, All respondents n=410 40
Appendix E: Clearstate Quantitative Survey – Education Level of Respondents
Education Level of Clearstate Survey Respondents (n=410) versus National Proportion (2010)*
# 37,6% 27,9% 50,4% 22,4% University & Above ## 31,0% Diploma
Respondents
12,2% 17,6% 1,0% Secondary
National Proportion
Primary & Lower # Latest available data on resident non-student women aged between 20 to 44 from the Singapore Department of Statistics. Censuses of Population are conducted once in every ten years by the Singapore Department of Statistics ## Includes University (42.6%) and Post-graduate (7.8%) respondents
References:
Clearstate Survey, A1: What is the highest level of education you have completed?
*Department of Statistics, Ministry of Trade & Industry. (2010). The Census of Population 2010 . Singapore Base, All respondents n=410 41
Appendix F: Clearstate Quantitative Survey – Religious Background of Respondents
Religious Background of Clearstate Survey Respondents (n=410) versus National Proportion (2010)*
# 31,3% 20,3% 15,0% 31,0% 22,2% 6,1% 10,2% Buddhism Christianity 2,7% Hinduism
Respondents
Islam 8,0% 7,6% 18,7% 26,1% Taoism No Religion
National Proportion
Others # Latest available data on resident women aged between 20 to 44 from the Singapore Department of Statistics. Censuses of Population are conducted once in every ten years by the Singapore Department of Statistics
References:
*Department of Statistics, Ministry of Trade & Industry. (2010). The Census of Population 2010 . Singapore Clearstate Survey, A3: What is your religious affiliation?
Base, All respondents n=410 42