Document

Report
Photo: TIME
Survey Conducted to Evaluate the
Position on Elective Oocyte Freezing in
Singapore
9th April 2013
Photo: Santa Monica Reproductive Technologies
Copyrighted: BELRIS Ltd. – www.belris.sg
Photo: The Straits Times
Table of Contents
 Definition of Terms
3
 Definition of Acronyms
4
 Chapter 1: Study Background, Objectives and Scope
5
 Chapter 2: Evaluating the Need for Elective Oocyte Freezing
9
 Chapter 3: Regulatory Scenarios of Selected Countries
30
 Appendix
36
2
Definitions of Terms
Terms here are defined for better understanding of the following report:
Term
Definition
Assisted reproduction technology (ART)
treatments
Elective oocyte freezing
Clinical and laboratory techniques that involve the mixing of oocytes and sperms outside
the body to enhance fertility
Cryopreservation for non-medical purposes
Ever-married
Status of having been married at least once, regardless of current marital status
Intracytoplasmic Sperm Injection (ICSI)
ICSI is a form of Assisted Reproductive Technology (ART)
In-vitro fertilisation (IVF)
Pre-implantation Genetic Diagnosis (PGD)
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
Resident population
Singapore Citizens and Permanent Residents
Respondents
Persons who had supplied information for Clearstate or BELRIS surveys
Medisave
No Religion
3
Definitions of Acronyms
Acronyms here are defined for better understanding of the following report:
Term
Definition
ART
Assisted Reproduction Technology
ASRM
Society for Assisted Reproductive Technology
BELRIS
Bioethics Legal group for Reproductive Issues in Singapore
ESHRE
European Society of Human Reproduction and Embryology
ICMR
Indian Council of Medical Research
ICSI
Intracytoplasmic Sperm Injection
IVF
In-Vitro Fertilisation
KICs
Key IVF Centres
KOLs
Key Opinion Leaders
MOH
Ministry of Health
MSQH
Malaysian Society for Quality in Health
PGD
Pre-Implantation Genetic Diagnosis
4
Photo: TIME
Chapter 1
Study Background, Objective and Scope
Photo: Santa Monica Reproductive Technologies
Photo: The Straits Times
5
Study Background
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 InVitro 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.**
Photo: The Straits Times
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
Photo: TIME
Chapter 2
Evaluating the Need for Elective Oocyte
Freezing in Singapore
Photo: Santa Monica Reproductive Technologies
Photo: The Straits Times
9
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).
References:
*Department of Statistics, Ministry of Trade & Industry. (2012). Population Trends 2012. Singapore
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##
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
10
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 evermarried women in their thirties and forties over the
past decade.*
Chart 3: Ever-Married Resident Women by Age Group and Number of Children Born
(2001 versus 2011)
No children
46.7%
42.7%
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).
2001
31.1%
20.9%
15.3%
15 - 29
6.7% 9.1%
30 - 39
40 - 49
Years
36.0%
24.5%
2011
28.4%
15.7%
19.4%
10.4%
3.8% 4.4%
Above 50
15 - 29
30 - 39
40 - 49
12.9%
Above 50
Years
Source: Population Trends 2012, Singapore
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 childbearing, 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).
1 Child
2001
2011
Chart 4: Age when First Child was Born
Men (n=33)
Women (n=102)
39%
30%
42%
28%
15%
15%
9% 10%
6%
0%
No Children
18 - 25
6%
0%
26 - 30
31 - 35
36 - 40
41 - 45
Source: BELRIS quantitative survey
References:
*Department of Statistics, Ministry of Trade & Industry. (2012). Population Trends 2012. Singapore
(Chart 4) BELRIS Survey, Question: What age did you have your first child?
Base, Respondents who are married n=135
11
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




Chart 5: Ideal Age to Start Having Children
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).
Men (n=20)
Women (n=51)
50%
35%
5% 6%
0% 0%
Does not
want
Children
18 - 25
41%
25%
5%
26 - 30
31 - 35
18%
36 - 40
5% 6%
0% 4%
41 - 45
Above 45
Source: BELRIS quantitative survey
Table 1: Reasons for Delaying Pregnancy
Reasons for Delaying
Pregnancy
Total
(n=202)
Men
(n=52)
Women
(n=150)
Job/Financial security
78%
88%
74%
Relationship stability
62%
54%
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
For Fertility
Treatment
Number of Respondents
Marital Status
Preserving eggs prior to receiving cancer treatment
3 (30%)
2 single and 1 married
Either family history of early menopause, endometriosis or
premature ovarian failure
1 (10%)
All married
During IVF treatment
6 (60%)
All married
Source: Clearstate quantitative survey
(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.
13
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
Table 3: Rating of Overall Knowledge of Oocyte-Freezing Technology
No Knowledge
At All
1
2
3
4
5
16%
40%
32%
12%
1%
A lot of
Knowledge
Source: Clearstate quantitative survey
(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
1,933
2006
2,179
2007
2008
Source: The Straits Times (Data from Singapore Ministry of Health)

2009
Table 4: Number of Babies Born to Mothers through Assisted
Reproduction Technology (ART) Treatment
Year
Total Number of Babies
2006
717
2007
804
2008
927
2009
1,158
Source: The Straits Times (Data from Singapore Ministry of Health)
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/Fertilitybusiness-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).*

The number of ART cycles per million population in the United States was
approximately 3.5 times higher than Singapore at 2,361 cycles per million.***

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.**** European countries like
Belgium provide reimbursement for six ART cycles before the age of 43.*****


Starting from January 2013, the Singapore government co-funding limit has
increased to six ART cycles in public hospitals. Couples are eligible for up to three
fresh (maximum co-funding of S$6,300) and three frozen cycles (maximum cofunding of S$3,000) of ART treatments. Medisave can also be used to reduce the
out-of-pocket expense.****
Table 5: Comparison of ART Cycles Per Million Population (2009)
Country
ART Cycles Per Million Population
Denmark
2,726
Belgium
2,562
Sweden
1,800
Germany
830
Italy
863
United Kingdom
879
United States
2,361
Singapore
656#
Sources: European Society of Human Reproduction and Embryology's IVF
Monitoring Consortium, United States Assisted Reproductive Technology
Surveillance Report and The Straits Times (Data from Singapore Ministry of
Health)
#Number
of ART cycles per million population for Singapore is obtained by number of
women who used ART over total population in 2009
In addition to the mentioned enhanced government support, Singaporeans’ receptivity to IVF may also raise IVF rates in coming years.
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%
Source: Clearstate quantitative survey
Chart 9: Perception of IVF Success
(n=410)
Extremely
successful, 5%
Has
complications,
12%
Not
successful, 3%
#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
Sometimes
successful,
80%
Source: Clearstate quantitative survey
(Chart 9) Clearstate Survey, A8: How successful do you think IVF treatments are?
Base, All respondents n=410
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)##
Chart 11: IVF Clinical Pregnancy Success Rates Reported By A
Public Clinic in Singapore By Age (2012)##
66.7%
42.0%
43.0%
28.6%
20 - 30
31 - 35
36 - 40
28.6%
41 - 45
Source: Clearstate qualitative interviews with Singapore KICs
#A
38.0%
16.0%
20 - 30
31 - 35
36 - 40
11.0%
41 - 45
Source: Clearstate qualitative interviews with Singapore KICs
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
success rate varies between individual clinic due to factors such as patient volume, health conditions of patients etc.
##IVF
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.*
Chart 12: IVF Live Birth Success Rates Using Fresh versus Frozen
Embryos from Patient Oocytes (2011)
46.2%
39.3%
38.4%
35.7%
30.3%
27.4%
24.5%

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).
16.6%
6.5%
Under 35

Notably, frozen embryo transfers among women
aged 38 and over resulted in a higher number of live
births that fresh embryo transfers (Chart 12).
16.5%
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.
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).
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).
#Representative
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
Single,
never married
Married/Divorced/
Widowed/Separated
172
238
90%
74%
# of Respondents
Supports Elective
Oocyte Freezing
Table 6.2: Breakdown by Age Group#
Age Group
20 - 25
26 - 30
31 - 35
36 - 40
41 - 45
# of Respondents
Supports Elective
Oocyte Freezing
71
72
87
94
86
93%
82%
84%
72%
76%
Diploma
University
127
175
Postgraduate
32
85%
82%
72%
Table 6.3: Breakdown by Education Level#
Education Level
# of Respondents
Supports Elective
Oocyte Freezing
Primary &
Secondary
lower
4
72
75%
75%
Table 6.4: Breakdown by Religion#
Religion
Buddhism Christianity
Hinduism
Islam
Taoism
No Religion
Others
# of Respondents
127
91
11
42
31
107
1
Supports Elective
Oocyte Freezing
86%
75%
64%
74%
84%
83%
100%
Source: Clearstate quantitative survey
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
57%
Singaporeans will be getting
married later
66%
Increase in pregnancy related
risks
Others
Source: Clearstate quantitative survey
60%
2%
“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” – Clearstate
quantitative survey respondent
(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)
Ethical, religious or moral issues
48% (198)
Increase in healthcare cost
57%
Singaporeans will be getting
married later
66%
Increase in pregnancy related
risks
60%
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)
Table 7.1: Breakdown by Age Group#
Age Group
20 - 25
26 - 30
31 - 35
36 - 40
41 - 45
# of Respondents
Indicated
71
34%
72
51%
87
56%
94
49%
86
49%
Table 7.2: Breakdown by Education Level#
Primary &
PostEducation
Secondary Diploma University
lower
graduate
# of Respondents
4
72
127
175
32
Indicated
25%
46%
44%
52%
53%
Table 7.3: Breakdown by Religion#
Others
2%
Religion
# of Respondents
Indicated
Buddhism Christianity Hinduism
127
42%
91
57%
11
27%
Islam
Taoism
No Religion
Others
42
76%
31
39%
107
42%
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 (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?
(refer to Appendix)
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)
Ethical, religious or moral issues
Table 8.1: Breakdown by Age Group#
48%
Increase in healthcare cost
57% (234)
Singaporeans will be getting
married later
66%
Increase in pregnancy related
risks
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)
60%
Age Group
20 - 25
26 - 30
31 - 35
36 - 40
41 - 45
# of Respondents
Indicated
71
59%
72
58%
87
60%
94
55%
86
53%
Table 8.2: Breakdown by Education Level#
Primary &
PostEducation
Secondary Diploma University
lower
graduate
# of Respondents
4
72
127
175
32
Indicated
50%
61%
56%
58%
47%
Table 8.3: Breakdown by Religion#
Others
2%
Religion
# of Respondents
Indicated
Buddhism Christianity Hinduism
127
57%
91
51%
11
64%
Islam
Taoism
No Religion
Others
42
64%
31
55%
107
59%
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 (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?
(refer to Appendix)
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)
Ethical, religious or moral issues
Table 9.1: Breakdown by Age Group#
48%
Increase in healthcare cost
57%
Singaporeans will be getting
married later
66% (271)
Increase in pregnancy related
risks
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)
60%
Age Group
20 - 25
26 - 30
31 - 35
36 - 40
41 - 45
# of Respondents
Indicated
71
76%
72
71%
87
61%
94
62%
86
64%
Table 9.2: Breakdown by Education Level#
Primary &
PostEducation
Secondary Diploma University
lower
graduate
# of Respondents
4
72
127
175
32
Indicated
75%
64%
65%
66%
75%
Table 9.3: Breakdown by Religion#
Others
2%
Religion
# of Respondents
Indicated
Buddhism Christianity Hinduism
127
69%
91
65%
11
64%
Islam
Taoism
No Religion
Others
42
62%
31
68%
107
64%
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 (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?
(refer to Appendix)
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)
Ethical, religious or moral issues
Table 10.1: Breakdown by Age Group#
48%
Increase in healthcare cost
57%
Singaporeans will be getting
married later
66%
Increase in pregnancy related
risks
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)
60% (246)
Age Group
20 - 25
26 - 30
31 - 35
36 - 40
41 - 45
# of Respondents
Indicated
71
59%
72
64%
87
57%
94
63%
86
57%
Table 10.2: Breakdown by Education Level#
Primary &
PostEducation
Secondary Diploma University
lower
graduate
# of Respondents
4
72
127
175
32
Indicated
100%
60%
56%
61%
69%
Table 10.3: Breakdown by Religion#
Others
2%
Religion
# of Respondents
Indicated
Buddhism Christianity Hinduism
127
58%
91
56%
11
64%
Islam
Taoism
No Religion
Others
42
57%
31
77%
107
61%
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 (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?
(refer to Appendix)
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)
4%
Preserve my fertility with my
younger eggs to increase
chances of pregnancy later in my
life
65%
18%
Chart 14.2: Reasons for NOT Opting for Elective Oocyte
Freezing for Oneself (n=125)
18%
Physical and emotional discomfort
in retrieving eggs for egg-freezing
34%
13%
It takes the pressure off to rush
into having children until I am
financially and emotionally
prepared
60%
Health risks involved
Ethical/moral reasons
Freezing eggs as a form of
'insurance' or 'safety net' in case
of health problems in future that
may affect or damage fertility'
Others
54%
Large expense involved
47%
66%
1%
Source: Clearstate quantitative survey
Very unlikely
Not sure
Very likely
Somewhat unlikely
Somewhat likely
37%
22%
Planning to have children in the
near future
14%
I do not think I will struggle to
conceive naturally
35%
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).
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).

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: 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
samples within each category in the Clearstate survey are slightly higher or
lower than in the respective national proportions (refer to Appendix)
Married/Divorced/
Widowed/Separated
172
24%
52%
24%
238
21%
44%
35%
# of Respondents
‘Somewhat Likely’ and ‘Very Likely’
Unsure
‘Somewhat Unlikely’ and ‘Very Unlikely’
Table 11.2: Breakdown by Age Group#
Age Group
20 - 25
26 - 30
31 - 35
36 - 40
41 - 45
# of Respondents
71
21%
54%
25%
72
25%
49%
26%
87
27%
45%
28%
94
18%
47%
35%
86
20%
44%
36%
Secondary
Diploma
University
72
15%
54%
31%
127
23%
48%
%
175
22%
46%
32%
‘Somewhat Likely’ and ‘Very Likely’
Unsure
‘Somewhat Unlikely’ and ‘Very Unlikely’
Table 11.3: Breakdown by Education Level#
Primary &
lower
4
0%
75%
25%
Education Level
# of Respondents
‘Somewhat Likely’ and ‘Very Likely
Unsure
‘Somewhat Unlikely’ and ‘Very Unlikely’
Postgraduate
32
38%
34%
28%
Table 11.4: Breakdown by Religion#
Religion
# of Respondents
‘Somewhat Likely’ and ‘Very Likely’
Unsure
‘Somewhat Unlikely’ and ‘Very Unlikely’
#Representative
Single,
never married
Buddhism Christianity Hinduism
Islam
Taoism
No
Religion
Others
127
91
11
42
31
107
1
26%
46%
28%
15%
46%
39%
46%
27%
27%
14%
50%
36%
29%
42%
29%
21%
53%
26%
100%
0%
0%
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
Christian
Respondents
Hindu
Respondents
Muslim Respondents
Taoist
Respondents
No Religion
Respondents
# of
Responde
nts
%
Distributi
on
# of
Responde
nts
%
Distributi
on
# of
Responde
nts
%
Distributi
on
# of
Responde
nts
%
Distributi
on
# of
Responde
nts
%
Distributi
on
# of
Responde
nts
%
Distributi
on
12
34%
5
14%
1
33%
5
34%
2
22%
7
25%
Physical and emotional discomfort in
retrieving eggs for egg-freezing
6
17%
2
6%
0
0%
0
0%
0
0%
3
11%
Health risks involved
4
12%
2
6%
0
0%
2
13%
1
12%
2
7%
Ethical/moral reasons
1
3%
10
29%
0
0%
1
7%
0
0%
2
7%
2
6%
3
9%
0
0%
2
13%
2
22%
2
7%
5
14%
9
25%
2
67%
3
20%
2
22%
8
29%
5
14%
4
11%
0
0%
2
13%
2
22%
4
14%
35
100%
35
100%
3
100%
15
100%
9
100%
28
100%
Large expenses involved
Planning to have children in the near
future
I do not think I will struggle to conceive
naturally
Others
TOTAL
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 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
Seeking alternative IVF facilities overseas for treatment after multiple failed IVF cycles in Singapore.
o
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

According to fertility clinics interviewed, a large number of
Singaporean couples travel to Johor Bahru for IVF treatment due to
its closer proximity to Singapore.

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.
Malaysia
Thailand
India
Australia



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
Photo: TIME
Chapter 3
Regulatory Scenarios of Selected
Countries
Photo: Santa Monica Reproductive Technologies
Photo: The Straits Times
30
Summary of ART Regulations in Selected Countries
Table 14: Summary of ART Regulations in Selected Countries
Australia
India
Malaysia
Thailand
Singapore
Gender Selection in IVF
Prohibited
(except for medical
reasons)
Prohibited
Prohibited
Unregulated, yet
practiced
Prohibited
(except for medical
reasons)
Regulations for ART/IVF
Regulated
Unregulated, yet
practiced
(legislation initiated)
Unregulated, yet
practiced
(legislation initiated)
Unregulated, yet
practiced
Regulated
Regulations for Surrogacy
Allowed
(altruistic)
Unregulated, yet
practiced
(legislation initiated)
Unregulated, not
practiced
Unregulated, yet
practiced
Prohibited
Subsidised
(~75% covered under
Medicare)
Unsubsidised
(pay out-of-pocket)
Unsubsidised
(pay out-of-pocket)
Unsubsidised
(pay out-of-pocket)
Subsidised
(Medisave)
Regulations on Oocyte
Freezing
Allowed
Unregulated, yet
practiced
Unregulated, yet
practiced
Unregulated, yet
practiced
Prohibited (for
elective/single women)
Cost of treatment (IVF)
SGD2,500 to SGD3,000
per cycle
About SGD 6,000 per
cycle
SGD4,000 and SGD 8,000
per cycle
SGD 6,000 to SGD 7,500
per cycle
SGD 6,000 to SGD 13,000
per cycle
Fiscal Support by
Government
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
5.
6.
7.
Prohibited: Banned by legislation (law)
Regulated: Governed by legislation (law)
Unregulated: Lack of existing legislation (law)
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
1.9 births per woman (2011 est.)*
Infertility
One in six Australian couple**
Cost of IVF Treatment
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
Opinions of KOLs in India on Oocyte Freezing****
Population size
1,205,073,612 (July 2012 est.)*

Birth rate
2.6 births per woman (2011 est.)*
Infertility
15 to 20 million couples yearly**
Cost of IVF Treatment
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***
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/wpdyn/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
2.6 births per woman (2011 est.)*
Infertility rate
15%**
Cost of Treatment
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
Opinions of KOLs in Thailand on Oocyte Freezing**
Population size:
67,091,089 (July 2012 est.)*

Birth rate:
1.6 births per woman (2011 est.)*
Cost of Treatment
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**
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/2010-1227/india/28239140_1_indian-couples-indians-flock-baby-boy
35
Photo: TIME
APPENDIX
Photo: Santa Monica Reproductive Technologies
Photo: The Straits Times
36
Appendix A: BELRIS Quantitative Survey – Age Profile of
Respondents
Not Married, Men
Married, Men
Age Group
# of Respondents
% Distribution
18 – 25
7
35%
Respondent Breakdown by Marital
Status (n=206)
Age Group
# of Respondents
% Distribution
26 – 30
2
6%
31 – 35
5
15%
26 – 30
9
45%
31 – 35
2
10%
36 – 40
10
30%
36 – 40
1
5%
41 – 45
7
21%
41 – 45
1
5%
Above 46
9
28%
TOTAL
33
100%
TOTAL
20
100%
Not
Married
34%
Married
66%
Not Married, Women
Married, Women
Age Group
# of Respondents
% Distribution
Age Group
# of Respondents
% Distribution
18 – 25
14
28%
26 – 30
6
6%
26 – 30
11
22%
31 – 35
13
13%
31 – 35
12
23%
36 – 40
18
18%
36 – 40
9
17%.
41 – 45
42
41%
41 – 45
2
4%
Above 46
23
22%
Above 46
3
6%
TOTAL
102
100%
TOTAL
51
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
Number of
IVF Centres Interviewed
Facility Ownership
Melbourne
1
Private
Sydney
(Branches at Multiple Locations)
1
Private
Mumbai
2
All private
Hyderabad
1
Private
New Delhi
1
Private
Johor Bahru
1
Private
Petaling Jaya
2
All private
Singapore
Singapore
5
4 private and 1 public
Thailand
Bangkok
3
All private
Country
Australia
India
Malaysia
City
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%
58.0%
42.0%
Single, Never Married
Respondents
#Latest
Married/Divorced/Widowed/Separated
National Proportion
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)*
21.9%
21.0%
17.9%
21.4%
17.8%
22.9%
21.2%
17.3%
17.6%
20 - 25 years
26 - 30 years
Respondents
References:
*Department of Statistics, Ministry of Trade & Industry. (2012). Population Trends 2012. Singapore
31 - 35 years
36 - 40 years
21.0%
41 - 45 years
National Proportion
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%
22.4%
50.4%
12.2%
31.0%
17.6%
1.0%
University & Above
##
Diploma
Respondents
Secondary
Primary & Lower
National Proportion
#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%
18.7%
15.0%
31.0%
26.1%
22.2%
8.0%
6.1%
10.2%
7.6%
0.6%
0.2%
2.7%
Buddhism
Christianity
Hinduism
Respondents
#Latest
Islam
Taoism
No Religion
Others
National Proportion
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
healthcare
www.clearstate.com
www.eiu.com
43

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