report on elective oocyte freezing in singapore apr 2013

Photo: The Straits Times

Photo: TIME

Photo: Santa Monica Reproduc8ve Technologies

9th April 2013

Survey Conducted to Evaluate the Posi8on on Elec8ve Oocyte Freezing in Singapore

2

Table of Contents

  Defini(on of Terms 3

  Defini(on of Acronyms 4

  Chapter 1: Study Background, Objec(ves and Scope 5

  Chapter 2: Evalua(ng the Need for Elec(ve Oocyte Freezing 9

  Chapter 3: Regulatory Scenarios of Selected Countries 30

  Appendix 36

2

3

Defini8ons of Terms

Terms here are defined for beKer understanding of the following report:

Term Defini8on

Assisted reproduc(on technology (ART) treatments

Clinical and laboratory techniques that involve the mixing of oocytes and sperms outside the body to enhance fer(lity

Elec(ve oocyte freezing Cryopreserva(on for non-‐medical purposes

Ever-‐married Status of having been married at least once, regardless of current marital status

Intracytoplasmic Sperm Injec(on (ICSI) ICSI is a form of Assisted Reproduc(ve Technology (ART)

In-‐vitro fer(lisa(on (IVF) IVF is a form of Assisted Reproduc(ve Technology (ART)

Medisave Singapore’s na(onal healthcare saving scheme which helps individuals set aside part of their income to meet future healthcare expenses

No Religion The status of not being affiliated to any par(cular religion, of which free thinkers are included

Pre-‐implanta(on Gene(c Diagnosis (PGD) Gene(c profiling of embryos or oocytes prior to fer(lisa(on

Resident popula(on Singapore Ci(zens and Permanent Residents

Respondents Persons who had supplied informa(on for Clearstate or BELRIS surveys

4

Defini8ons of Acronyms

Acronyms here are defined for beKer understanding of the following report:

Term Defini8on

ART Assisted Reproduc(on Technology

ASRM Society for Assisted Reproduc(ve Technology

BELRIS Bioethics Legal group for Reproduc(ve Issues in Singapore

ESHRE European Society of Human Reproduc(on and Embryology

ICMR Indian Council of Medical Research

ICSI Intracytoplasmic Sperm Injec(on

IVF In-‐Vitro Fer(lisa(on

KICs Key IVF Centres

KOLs Key Opinion Leaders

MOH Ministry of Health

MSQH Malaysian Society for Quality in Health

PGD Pre-‐Implanta(on Gene(c Diagnosis

5 Photo: The Straits Times

Photo: TIME


5

Chapter 1

Study Background, Objec8ve and Scope

6

Study Background

Freezing oocytes (also referred to as ‘freezing eggs’), or cryopreserva(on, is a process which has been used in various parts of the world for various reasons to perserve a woman’s fer(l(y. The process many (mes involves In-‐Vitro Fer(lisa(on (‘IVF’), and the cooling of eggs to sub-‐zero temperatures (vitrifica(on).

In October 2012, the Prac(ce Commicee of the American Society for Reproduc(ve Medicine (‘ASRM’) and the Society for Reproduc(ve Technology announced that oocyte freezing should no longer be considered experimental.* However, notably, ASRM did not endorse the technique for rou(ne elec(ve use. Similarly, the European Society of Human Reproduc(on 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 s(mula(on of a woman's ovaries with fer(lity medica(on before the oocytes are harvested. However, instead of crea(ng 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 Prac(ce Commicee of the American Society of Reproduc(ve Medice and the Society of Reproduc(ve Technology. Mature oocyte crypreserva(on: a guideline. Fer0lity 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 cryopreserva(on for age-‐related fer(lity loss. Oxford Journals ***NYU Fer(lity Center. (n.d.). About the Egg Freezing Process. Retrieved March 19, 2013, from hcp://www.nyufer(litycenter.org/egg_freezing/cryopreserva(on_process

Photo: The Straits Times

7

Study Objec8ve and Scope

As with any IVF procedure, there are inherent medical risks to women such as ovarian hyper-‐s(mula(on. With regards to children born from the procedure, as with IVF, there is limited data on the success rates of fer(lisa(on and live births, as well as the perinatal outcomes, i.e. whether there are any long-‐term effects on children born. In addi(on, there are important issues about whether access to this procedure should be a macer of choice or policy, and whether/what type and extent of regula(ons should be in place. Finally, there are issues of ‘fer(lity 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 wai(ng for a sperm donor. Single women in Singapore are not allowed to undergo IVF treatment unless medically necessitated in order to perserve fer(lity (e.g. in cases of cancer).*

References: *Ministry of Health. (2006). Direc0ves for Private Healthcare Ins0tu0ons Providing Assisted Reproduc0on Services. Singapore: Licensing & Accredita(on 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 : hcp://www.healthxchange.com.sg/News/Pages/freezing-‐egg-‐delay-‐motherhood.aspx

Study Objec8ve: Evaluate the need for elec8ve oocyte freezing in Singapore

  To understand Singaporeans’ perspec(ves on elec(ve oocyte freezing

  To understand regulatory scenarios in selected countries (Malaysia, Thailand, India and Australia) on elec(ve oocyte freezing

  To iden(fy and compile sta(s(cal informa(on related to elec(ve oocyte freezing

8

Source of Informa8on Evalua8ng the need for elec8ve oocyte freezing in Singapore done through various primary and secondary research methodologies

Secondary Research

Secondary Sources Reviews: Clearstate also gathered informa(on from regulatory reports and medical journals related to oocyte freezing, newspaper ar(cles on policies or ini(a(ves undertaken by government bodies, views of KICs and KOLs on discussion forums and any sta(s(cal informa(on related to oocyte freezing.

Primary Research

Clearstate Quan8ta8ve 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 popula(on). Clearstate prepared its own independent and anonymous contact list to ensure that the anonymity of respondents is maintained.

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 u(lised the data from this survey as an addi(onal data source for analysis purposes.

Clearstate Qualita8ve 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 perspec(ves on this topic. Clinicians from approximately 2-‐4 IVF centres were interviewed in each of the above-‐men(oned countries.

Clearstate Qualita8ve Interviews of IVF Clinics in Singapore: Clearstate conducted interviews with IVF clinicians in Singapore to understand their perspec(ves on this topic. 5 of such interviews were conducted.

Clearstate Qualita8ve Interviews of Key Opinion Leaders in Singapore: Clearstate conducted interviews with Key Opinion Leaders (‘KOLs’) in Singapore to understand their perspec(ves on this topic. KOLs from diversified backgrounds, who represent key women’s organisa(ons, were interviewed for this study. 3 of such interviews were conducted.


Photo: TIME


9

Chapter 2

Evalua8ng the Need for Elec8ve Oocyte Freezing in Singapore

10

Rising median age of marriage, rising propor8on of singles, and decreasing age-‐specific fer8lity rates of women below 35 are seen to impact popula8on trends in Singapore

10

References: *Department of Sta(s(cs, Ministry of Trade & Industry. (2012). Popula0on Trends 2012. Singapore

  According to the Popula(on Trends 2012 report published by the Singapore Department of Sta(s(cs, 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 (me 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 (me marriage in 2011 was 28.0, an increase from 26.2 in 2001.*

  Sta(s(cs published in the report also indicate that in 2011, the propor(on of singles among total resident popula(on had increased to 32% from 30% in 2001.*

  Age-‐specific fer(lity 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: Popula8on 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 popula8on in the same age group

Chart 2: Age-‐Specific Fer8lity Rates##

Source: Popula8on Trends 2012, Singapore ##Age-‐Specific Fer8lity Rates is defined as the number of births registered within a specific age group during the year, out of every thousand female popula8on in the same age group

11

Rising number of childless or one-‐child families for ever-‐married women in Singapore

11


  Sta(s(cs from the Popula(on Trends 2012 report reflect an increase in the propor(on of childless ever-‐married women in their thir(es and for(es over the past decade.*

  The propor(on 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 propor(on 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 propor(on 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 forma(on with the majority of married resident popula(on (men and women) sta(ng they had their first child between the age of 31 to 35 years (Chart 4).

(Chart 4) BELRIS Survey, Ques(on: What age did you have your first child? Base, Respondents who are married n=135

30%

0%

15%

39%

9% 6%

15%

6%

28%

42%

10%

0%

No Children 18 -‐ 25 26 -‐ 30 31 -‐ 35 36 -‐ 40 41 -‐ 45

Men (n=33) Women (n=102)

Chart 4: Age when First Child was Born

Source: BELRIS quan8ta8ve survey

Chart 3: Ever-‐Married Resident Women by Age Group and Number of Children Born (2001 versus 2011)

Source: Popula8on Trends 2012, Singapore

46.7%

15.3% 6.7% 3.8%

42.7%

20.9%

9.1% 4.4%

15 -‐ 29 30 -‐ 39 40 -‐ 49 Above 50

2001 2011 No children

Years

31.1% 24.5%

15.7% 10.4%

36.0% 28.4%

19.4% 12.9%

15 -‐ 29 30 -‐ 39 40 -‐ 49 Above 50

2001 2011 1 Child

Years

12

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 men8oned 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 men(oned reason for delaying pregnancy was ‘job/financial security’ which was men(oned by 88% of men and 74% of women (Table 1).

  54% of men and 65% of women indicated looking for ‘rela(onship 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

5% 0%

35% 50%

5% 5% 0% 6% 0%

25% 41%

18% 6% 4%

Does not want

Children

18 -‐ 25 26 -‐ 30 31 -‐ 35 36 -‐ 40 41 -‐ 45 Above 45

Men (n=20) Women (n=51)


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%

Rela(onship stability 62% 54% 65%

Belief that there will be no problem having children in

the late 30s 34% 38% 33%

(Chart 5) BELRIS Survey, Ques(on: At what age do you want to start having children? Base, Respondents are NOT married n=71

(Table 1) BELRIS Survey, Ques(on: If you wished to have children, what would be the reasons for delaying gevng pregnant?/ (Table 1) BELRIS Survey, Ques(on: What do you feel are the reasons for women delaying gevng pregnant?

Base, Respondents who are married + Respondents are NOT married and want to have children n=202


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  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 fer(lity treatment (i.e. IVF treatment).

Low oocyte freezing experience rate in Singapore

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Number of Respondents Marital Status

For Medical Reasons

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

For Fer8lity Treatment

During IVF treatment 6 (60%) All married

Singapore Assisted Reproduc8on Guidelines:*

Based on current guidelines by Ministry of Health on Assisted Reproduc(on (AR):

-‐  Procedures to have oocytes frozen for elec(ve 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

Source: Clearstate quan8ta8ve survey

Reference: *Source: Licensing & Accredita(on Branch, Ministry of Health. (2006). Direc0ves for Private Healthcare Ins0tu0ons Providing Assisted Reproduc0ve Services. Singapore.

(Table 2) Clearstate Survey, B31: Why did you get your eggs frozen for medical reasons? Base, Respondents who have undergone egg freezing n=10

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(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

1%

20%

72%

7%

0% 20% 40% 60% 80% 100%

Never heard of it

I am aware of the existence of egg-‐freezing but do not have any details of the technology

I have some knowledge of the technology

I have detailed knowledge of the technology

Chart 6: Familiarity with Oocyte Freezing Technology (n=400)


  72% of respondents stated that they believe they have ‘some knowledge’ of oocyte freezing technology (Chart 6).

  The average ra(ng 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 2 3 4 5

16% 40% 32% 12% 1%

No Knowledge At All

A lot of Knowledge

Table 3: Ra8ng of Overall Knowledge of Oocyte-‐Freezing Technology


Majority of respondents indicated having ‘some knowledge’ of oocyte freezing technology

#1 is having 'no knowledge at all' and 5 is having 'a lot of knowledge

15

An increasing number of women in Singapore are seeking IVF treatment in recent years

Reference: *Data source from Ministry of Health (MOH), The Straits Times. (2011, July 23). Fer(lity business booming in Singapore. Retrieved March 19, 2013, from Health Xchange, hcp://www.healthxchange.com.sg/News/Pages/Fer(lity-‐business-‐booming-‐in-‐Singapore.aspx **Clearstate qualita(ve interviews with Singapore KICs

  According to a Straits Times ar(cle published in July 2011, sta(s(cs from the Singapore Ministry of Health showed that the number of women op(ng for Assisted Reproduc(on Technology (ART) treatments (with IVF being the most common) had increased between 2006 and 2009 from 1,933 to 3,271 (Chart 7).*

  Propor(onal to the increase in number of women seeking ART treatments, sta(s(cs 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).*

  Fer(lity 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) s0gma anymore in Singapore to seek fer0lity treatment. Once they (women) realized the possibility of a fer0lity issue, they are likely to seek treatment immediately.” – Fer8lity Specialist, Singapore

“Awareness level is higher among more educated people as they are typically the ones making the enquires, the recent newspaper ar0cles (on oocyte freezing) have also helped raising awareness in Singapore. Hence the demand of IVF is on the rise in the country.” – Fer8lity Specialist, Singapore

Year Total Number of Babies

2006 717

2007 804

2008 927

2009 1,158

Table 4: Number of Babies Born to Mothers through Assisted Reproduc8on Technology (ART) Treatment

1,933 2,179

2,627

3,271

2006 2007 2008 2009

Chart 7: Number of Women Op8ng for Assisted Reproduc8on Technology (ART) Treatments

Source: The Straits Times (Data from Singapore Ministry of Health) Source: The Straits Times (Data from Singapore Ministry of Health)

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  According to the ICMART (Interna(onal Commicee for Monitoring Assisted Reproduc(ve Technologies), there is an es(mate 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 na(ons. A comparison of figures from 2009 indicate that Singapore performed approximately 656# cycles per million popula(on** as compared to some European na(ons, such as Denmark and the United Kingdom which performed 2,726 cycles per million and 879 cycles per million respec(vely (Table 5).*

  The number of ART cycles per million popula(on in the United States was approximately 3.5 (mes 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.*****

  Star(ng 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 co-‐funding of S$3,000) of ART treatments. Medisave can also be used to reduce the out-‐of-‐pocket expense.****

  In addi(on to the men(oned enhanced government support, Singaporeans’ recep(vity to IVF may also raise IVF rates in coming years.

Country ART Cycles Per Million Popula8on

Denmark 2,726

Belgium 2,562

Sweden 1,800

Germany 830

Italy 863

United Kingdom 879

United States 2,361

Singapore 656#

Table 5: Comparison of ART Cycles Per Million Popula8on (2009)

Sources: European Society of Human Reproduc8on and Embryology's IVF Monitoring Consor8um, United States Assisted Reproduc8ve Technology Surveillance Report and The Straits Times (Data from Singapore Ministry of Health)

Singapore IVF rates are lower than certain developed na8ons; Enhanced government support may raise IVF rates in Singapore

#Number of ART cycles per million popula8on for Singapore is obtained by number of women who used ART over total popula8on in 2009

Reference: *European Society of Human Reproduc(on and Embryology's IVF Monitoring Consor(um (2012, July 1). European Society of Human Reproduc0on and Embryology. Retrieved March 19, 2013, from Science Daily: hcp://www.sciencedaily.com-‐ /releases/2012/07/120702134746.htm **The Straits Times. (2011, July 23). Fer(lity business booming in Singapore. Retrieved March 19, 2013, from Health Xchange: hcp://www.healthxchange.com.sg/News/Pages/Fer(lity-‐business-‐booming-‐in-‐Singapore.aspx ***Na(onal Center for Chronic Disease Preven(on and Health Promo(on, Division of Reproduc(ve Health. (2012, November 2). Assisted Reproduc0ve Technology Surveillance — United States, 2009. Retrieved March 19, 2013, from Centers for Disease Control and Preven(on: hcp://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 Reproduc(on Technology (ART) Treatment: hcp://www.heybaby.sg/havingchildren/art.html *****The Business Times. (2012, June 02). When 0me is of the essence. Retrieved March 21, 2013, from The Business Times lifestyle: hcp://www.business(mes.com.sg/archive/thursday/lifestyle/wellness/when-‐(me-‐essence

17

Singaporean recep8vity 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 percep(on 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 ‘some(mes successful’ (Chart 9).

(Chart 8) Clearstate Survey, A7: Would you consider In vitro fer(liza(on (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

Chart 8: Percentage of Respondents Who Would Consider IVF (n=407)#

Yes 71%

No 29%


Has complica(ons,

12% Not

successful; 3%

Some(mes successful;

80%

Extremely successful, 5%

Chart 9: Percep8on of IVF Success (n=410)


#Includes respondents that have gone through IVF treatment but have yet successfully had a child

18

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 ques(on on the live birth success rates of IVF treatment at different ages in Singapore to Mr Gan Kim Yong, Minister of Health during a Sivng of Parliament.

Oral Answer by Mr Gan Kim Yong, Minister of Health, to Parliamentary Ques8on 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 fer(lisa(on (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 fer(lisa(on (IVF) using fresh embryos was 23% based on most recent data from 2010. In par(cular, 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).

Source: Clearstate qualita8ve interviews with Singapore KICs

43.0%

66.7%

28.6% 28.6%

20 -‐ 30 31 -‐ 35 36 -‐ 40 41 -‐ 45

Chart 10: IVF Clinical Pregnancy Success Rates Reported By A Private Clinic in Singapore By Age (2011)##

42.0% 38.0%

16.0% 11.0%

20 -‐ 30 31 -‐ 35 36 -‐ 40 41 -‐ 45

Chart 11: IVF Clinical Pregnancy Success Rates Reported By A Public Clinic in Singapore By Age (2012)##


#A successful clinical pregnancy is a pregnancy where the fetal sac is seen in the uterus with an ultrasound aner the IVF procedure has taken place ##IVF success rate varies between individual clinic due to factors such as pa8ent volume, health condi8ons of pa8ents etc.

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IVF live birth success rates using fresh versus frozen embryos from pa8ent oocytes

46.2%

38.4%

27.4%

16.6%

6.5%

39.3% 35.7%

30.3%

24.5%

16.5%

Under 35 35 -‐ 37 38 -‐ 40 41 -‐ 42 Above 42 Fresh Embryos from Pa(ent Oocytes -‐ Percentage of transfers resul(ng in live births Thawed Embryo from Pa(ent Oocytes -‐ Percentage of transfers resul(ng in live births

Chart 12: IVF Live Birth Success Rates Using Fresh versus Frozen Embryos from Pa8ent Oocytes (2011)

Source: Society for Assisted Reproduc8ve Technologies (SART), the United States

#

#The ages of the women at point of embryo freezing were undetermined

Reference: *Society for Assisted Reproduc(ve Technology. (2011). Clinic Summary Report. Retrieved March 19, 2013, from SART: IVF Success Rates: hcps://www.sartcorsonline.com/rptCSR_PublicMultYear.aspx?ClinicPKID=0

  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 Reproduc(ve Technology (SART) member clinics suggests that IVF live birth success rates also differ when using fresh or thawed embryos from pa(ent oocytes.*

  The IVF live birth success rates for fresh embryos from pa(ent oocytes declined at a faster rate with the passing of age compared to the IVF live birth success rates for thawed embryos from pa(ent oocytes (Chart 12).

  Notably, frozen embryo transfers among women aged 38 and over resulted in a higher number of live births that fresh embryo transfers (Chart 12).

20

The response in Singapore for providing single women with the op8on of elec8ve oocyte freezing is generally posi8ve

Educa8on Level Primary & lower

Secondary Diploma University Post-‐

graduate # of Respondents 4 72 127 175 32

Supports Elec(ve Oocyte Freezing

75% 75% 85% 82% 72%

Religion Buddhism Chris8anity Hinduism Islam Taoism No Religion Others

# of Respondents 127 91 11 42 31 107 1


86% 75% 64% 74% 84% 83% 100%

Table 6: Support for Oocyte Freezing for Single Women across Marital Status, Age Groups, Educa8on Levels and Religions (n=410)

Table 6.4: Breakdown by Religion#


Marital Status Single,

never married Married/Divorced/ Widowed/Separated

# of Respondents 172 238 Supports Elec(ve Oocyte Freezing

90% 74%

  81% out of 410 respondents from the Clearstate survey support single women being given the op(on to undergo elec(ve oocyte freezing in Singapore.

  Further analysis of the Clearstate survey indicate that a large majority of respondents across marital status, age, religion and educa(onal backgrounds support elec(ve oocyte freezing for single women.

  There is a higher propor(on of single, never married respondents (90%) suppor(ng elec(ve oocyte freezing compared to ever-‐married respondents (74%) (Table 6.1).

  More than 80% of women aged between 20 to 35 support elec(ve oocyte freezing while less than 80% of women aged above 35 support elec(ve oocyte freezing for single women (Table 6.2).

  Support for elec(ve oocyte freezing for single women has largely been consistent amongst all educa(on levels (Table 6.3).

  Across religions, 86% of Buddhist respondents, 75% of Chris(an respondents, 64% of Hindu respondents, 74% of Muslim respondents, 84% of Taoist respondents and 83% of respondents without religious affilia(on support single women being given the op(on to undergo elec(ve oocyte freezing in Singapore (Table 6.4).

Table 6.3: Breakdown by Educa8on Level#

Table 6.2: Breakdown by Age Group#

Table 6.1: Breakdown by Marital Status#

Age Group 20 -‐ 25 26 -‐ 30 31 -‐ 35 36 -‐ 40 41 -‐ 45

# of Respondents 71 72 87 94 86


93% 82% 84% 72% 76%

(Table 6) Clearstate Survey, E4: Do you think women who can’t find partners to marry un(l a certain age (say 30) should be given the choice to freeze their eggs for future use? Base, All respondents n=410

#Representa8ve samples within each category in the Clearstate survey are slightly higher or lower than in the respec8ve na8onal propor8ons (refer to Appendix)

21

(Chart 13) Clearstate Survey, E2: What implica(ons, if any, do you think egg-‐ freezing will face if it is allowed in Singapore for elec(ve 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 elec(ve purposes?

Base, All respondents n=410

  With regard to to the poten(al implica(ons of elec(ve oocyte freezing on society, 66% of the Clearstate survey respondents stated they believed that Singaporeans would delay gevng married while 60% stated they believed there would be an increase in pregnancy risks (Chart 13).

  48% of respondents believed that allowing elec(ve oocyte freezing would have ethical, religious or moral implica(ons on society (Chart 13).

Chart 13: Belief Regarding Implica8ons of Elec8ve Oocyte Freezing on Society (n=410)

2%

60%

66%

57%

48%

Others

Increase in pregnancy related risks

Singaporeans will be gevng married later

Increase in healthcare cost

Ethical, religious or moral issues


“With Singapore women becoming more career minded, this service might be exploited by both the medical prac00oners and women who might want to delay pregnancy. Success rate is unknown and the side effects on the children is also unrepresenta0ve.” – Clearstate quan8ta8ve survey respondent

“Will this eventually end up raising other ques0on 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 quan8ta8ve survey respondent

“There will be a lot of outcry from religious organisa0on and society on the availability and how it can encourage people to go through it despite knowing that the ac0on would be frown upon or even not allowed in some religion” – Clearstate quan8ta8ve survey respondent

“Firstly I'm a Catholic so IVF itself is not an op0on” – Clearstate quan8ta8ve survey respondent

Respondent belief regarding the poten8al implica8ons of elec8ve oocyte freezing on society

22

The belief that elec8ve egg freezing has poten8al implica8ons in society for ethical, religious or moral reasons, differs across age groups, educa8on levels and religious backgrounds   The 31 to 35 age group contains the greatest propor(on of respondents (56%) who had indicated that ethical, religious or moral issues

could be a poten(al implica(on of elec(ve oocyte freezing on society (Table 7.1).

  The post-‐graduate educa(on level group contains the greatest propor(on of respondents (53%) who had indicated that ethical, religious or moral issues could be a poten(al implica(on of elec(ve oocyte freezing on society (Table 7.2).

  The Muslim respondent group contains the greatest propor(on of respondents (76%) who had indicated that ethical, religious or moral issues could be a poten(al implica(on of elec(ve oocyte freezing on society (Table 7.3).


2%

60%

66%

57%

48% (198)

Others






Table 7 : Belief that ‘Ethical, Religious or Moral Issues’ have Poten8al Implica8ons on Elec8ve Oocyte Freezing in Society across Age Groups, Educa8on Levels and Religions (n=410)

Age Group 20 -‐ 25 26 -‐ 30 31 -‐ 35 36 -‐ 40 41 -‐ 45


Indicated 34% 51% 56% 49% 49%


# of Respondents 127 91 11 42 31 107 1

Indicated 42% 57% 27% 76% 39% 42% 100%

Educa8on Primary & lower



Indicated 25% 46% 44% 52% 53%




(Chart 13/Table 7) Clearstate Survey, E2: What implica(ons, if any, do you think egg-‐ freezing will face if it is allowed in Singapore for elec(ve purposes? Base, All respondents n=410


23

The belief that elec8ve egg freezing has poten8al implica8ons in society by increasing healthcare cost, differs across age groups, educa8on levels and religious backgrounds   The 31 to 35 age group contains the greatest propor(on of respondents (60%) who had indicated that an increase in healthcare cost could

be a poten(al implica(on of elec(ve oocyte freezing on society (Table 8.1).

  The secondary educa(on level group contains the greatest propor(on of respondents (61%) who had indicated that an increase in healthcare cost could be a poten(al implica(on of elec(ve oocyte freezing on society (Table 8.2).

  The Muslim and Hindu respondent groups contain the greatest propor(ons of respondents (64% each) who had indicated that an increase in healthcare cost could be a poten(al implica(on of elec(ve oocyte freezing on society (Table 8.3).


2%

60%

66%

57% (234)

48%

Others






Table 8: Belief that ‘Increase in Healthcare Cost’ has Poten8al Implica8ons on Elec8ve Oocyte Freezing in Society across Age Groups, Educa8on Levels and Religions (n=410)

Age Group 20 -‐ 25 26 -‐ 30 31 -‐ 35 36 -‐ 40 41 -‐ 45


Indicated 59% 58% 60% 55% 53%


# of Respondents 127 91 11 42 31 107 1

Indicated 57% 51% 64% 64% 55% 59% 100%




Indicated 50% 61% 56% 58% 47%






24

The belief that elec8ve egg freezing has poten8al implica8ons in society in that people will get married later, differs across age groups, educa8on levels and religious backgrounds   The 20 to 25 age group contains the greatest propor(on of respondents (71%) who had indicated that marriage at a later age could be a

poten(al implica(on of elec(ve oocyte freezing on society (Table 9.1).

  The post-‐graduate and primary & lower educa(on level groups contain the greatest propor(ons of respondents (75% each) who indicated that marriage at a later age could be a poten(al implica(on of elec(ve oocyte freezing on society (Table 9.2).

  The Buddhist respondent group contains the greatest propor(on of respondents (69%) who indicated that marriage at a later age could be a poten(al implica(on of elec(ve oocyte freezing on society (Table 9.3).


2%

60%

66% (271)

57%

48%

Others






Table 9: Belief that ‘Singaporeans Will Be Gerng Married Later’ has Poten8al Implica8ons on Elec8ve Oocyte Freezing in Society across Age Groups, Educa8on Levels and Religions (n=410)

Age Group 20 -‐ 25 26 -‐ 30 31 -‐ 35 36 -‐ 40 41 -‐ 45


Indicated 76% 71% 61% 62% 64%


# of Respondents 127 91 11 42 31 107 1

Indicated 69% 65% 64% 62% 68% 64% 100%




Indicated 75% 64% 65% 66% 75%






25

The belief that elec8ve egg freezing has poten8al implica8ons in society in that it will increase pregnancy related risks, differs across age groups, educa8on levels and religious backgrounds   The 26 to 30 age group contains the greatest propor(on of respondents (64%) who had indicated that an in pregnancy related risks could be a

poten(al implica(on of elec(ve oocyte freezing on society (Table 10.1).

  Apart from the primary & lower educa(on level group, the post-‐graduate educa(on level group contains the next highest propor(on of respondents (69%) who had indicated that an in pregnancy related risks could be a poten(al implica(on of elec(ve oocyte freezing on society (Table 10.2).

  The Taoist respondent group contains the greatest propor(on of respondents (77%) who had indicated that pregnancy related risks could be a poten(al implica(on of elec(ve oocyte freezing on society (Table 10.3).

Chart 13: Belief regarding Implica8ons of Elec8ve Oocyte Freezing on Society (n=410)

2%

60% (246)

66%

57%

48%

Others






Table 10: Belief that ‘Increase in Pregnancy Related Risks’ has Poten8al Implica8ons on Elec8ve Oocyte Freezing in Society across Age Groups, Educa8on Levels and Religions (n=410)

Age Group 20 -‐ 25 26 -‐ 30 31 -‐ 35 36 -‐ 40 41 -‐ 45


Indicated 59% 64% 57% 63% 57%


# of Respondents 127 91 11 42 31 107 1

Indicated 58% 56% 64% 57% 77% 61% 100%




Indicated 100% 60% 56% 61% 69%






26

Perspec8ve among respondents on elec8ve 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 elec(ve 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 elec(ve oocyte freezing for themselves. The remaining 47% of the respondents indicated that they are “unsure” whether they will opt for elec(ve oocyte freezing (Chart 14).

  Of the respondents who are likely to consider elec(ve oocyte freezing, the most selected reason was to have a ‘safety net’ in case of future health problems (66%), followed by having the op(on to preserve their fer(lity with younger eggs (65%) and to have sufficient (me to be financially and emo(onally prepared for children (60%) (Chart 14.1).

  Of the respondents who are unlikely to consider elec(ve 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 emo(onal discomfort in retrieving eggs (34%). 22% of respondents indicated ethical and moral reasons for their hesita(on towards considering elec(ve oocyte freezing for themselves (Chart 14.2).

(Chart 14) Clearstate Survey, D3: If egg-‐freezing for elec(ve 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


18%

13%

47%

18%

4%

Very unlikely Somewhat unlikely Not sure Somewhat likely Very likely

Chart 14: Likelihood of Op8ng for Elec8ve Oocyte Freezing in the Future for Oneself (n=410)

1%

66%

60%

65%

Others

Freezing eggs as a form of 'insurance' or 'safety net' in case of health problems in future that may affect or damage fer(lity'

It takes the pressure off to rush into having children un(l I am financially and emo(onally

prepared

Preserve my fer(lity with my younger eggs to increase

chances of pregnancy later in my life

Chart 14.1: Reasons for Interest in Elec8ve Oocyte Freezing for Oneself (n=91)

Chart 14.2: Reasons for NOT Op8ng for Elec8ve Oocyte Freezing for Oneself (n=125)

15%

35%

14%

22%

37%

34%

54%

Others

I do not think I will struggle to conceive naturally

Planning to have children in the near future

Ethical/moral reasons

Health risks involved

Physical and emo(onal discomfort in retrieving eggs for egg-‐freezing

Large expense involved

27

Perspec8ve among respondents on elec8ve oocyte freezing for themselves differs across marital status, age groups, educa8on levels and religious backgrounds

Age Group 20 -‐ 25 26 -‐ 30 31 -‐ 35 36 -‐ 40 41 -‐ 45


‘Somewhat Likely’ and ‘Very Likely’ 21% 25% 27% 18% 20%

Unsure 54% 49% 45% 47% 44%

‘Somewhat Unlikely’ and ‘Very Unlikely’ 25% 26% 28% 35% 36%

Table 11: Likelihood of Op8ng for Elec8ve Oocyte Freezing in the Future for Oneself across Marital Status, Age Groups, Educa8on Levels and Religions (n=410)



Educa8on Level Primary & lower



‘Somewhat Likely’ and ‘Very Likely 0% 15% 23% 22% 38%

Unsure 75% 54% 48% 46% 34%

‘Somewhat Unlikely’ and ‘Very Unlikely’ 25% 31% % 32% 28%

Marital Status Single,

never married Married/Divorced/ Widowed/Separated

# of Respondents 172 238

‘Somewhat Likely’ and ‘Very Likely’ 24% 21%

Unsure 52% 44%

‘Somewhat Unlikely’ and ‘Very Unlikely’ 24% 35%

Table 11.1: Breakdown by Marital Status#



# of Respondents 127 91 11 42 31 107 1

‘Somewhat Likely’ and ‘Very Likely’ 26% 15% 46% 14% 29% 21% 100%

Unsure 46% 46% 27% 50% 42% 53% 0%

‘Somewhat Unlikely’ and ‘Very Unlikely’ 28% 39% 27% 36% 29% 26% 0%


(Table 11) Clearstate Survey, D3: If egg-‐freezing for elec(ve purposes is allowed in Singapore, how likely are you to undergo egg-‐freezing in the future? Base, All Respondents n=410

  As indicated by the Clearstate survey, there is a higher propor(on of single, never married respondents (24%) who stated it will be ‘somewhat likely’ or ‘very likely’ that they will opt for elec(ve oocyte freezing for themselves as compared to ever-‐married respondents (21%) (Table 11.1).

  Conversely, there is a higher propor(on of ever-‐married respondents (35%) who stated it will be ‘somewhat unlikely’ or ‘very unlikely’ that they will opt for elec(ve oocyte freezing for themselves as compared to single, never married respondents (24%) (Table 11.1).

  The propor(on of respondents who stated it will be ‘somewhat unlikely’ or ‘very unlikely’ that they will opt for elec(ve 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 elec(ve oocyte freezing for themselves as compared to 25% of women aged 20 to 25 (Table 11.2).

  The propor(on of respondents who stated it will be ‘somewhat likely’ or ‘very likely’ that they will opt for elec(ve oocyte freezing for themselves increases with higher educa(on level (Table 11.3).

  Notably, the propor(on of respondents who indicated that they are unsure decreases with the rise in educa(on level (Table 11.3).

  There is a higher propor(on of Chris(an and Muslim respondents who stated it will be ‘somewhat unlikely’ or ‘very unlikely’ that they will opt for elec(ve oocyte freezing for themselves as compared to respondents of other religious backgrounds (Table 11.4).


28

The most important reason selected by respondents for not op8ng for elec8ve oocyte freezing for themselves differ across religious backgrounds

Most Important Reason for NOT Op8ng for Elec8ve Oocyte Freezing

for 0neself

Buddhist Respondents

Chris8an Respondents

Hindu Respondents

Muslim Respondents Taoist

Respondents No Religion Respondents

# of Responde

nts

% Distribu8

on

# of Responde

nts

% Distribu8

on

# of Responde

nts

% Distribu8

on

# of Responde

nts

% Distribu8

on

# of Responde

nts

% Distribu8

on

# of Responde

nts

% Distribu8

on

Large expenses involved 12 34% 5 14% 1 33% 5 34% 2 22% 7 25% Physical and emo(onal 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% Planning to have children in the near future 2 6% 3 9% 0 0% 2 13% 2 22% 2 7% I do not think I will struggle to conceive naturally 5 14% 9 25% 2 67% 3 20% 2 22% 8 29%

Others 5 14% 4 11% 0 0% 2 13% 2 22% 4 14%

TOTAL 35 100% 35 100% 3 100% 15 100% 9 100% 28 100%

Table 12: Most Important Reason for NOT Op8ng for Elec8ve Oocyte Freezing for Oneself by Religion# (n=125)


(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

  The most important reason selected by Chris(an respondents for not op(ng for elec(ve 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 op(ng for elec(ve 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 affilia(on for not op(ng for elec(ve oocyte freezing for themselves was the belief that they will not struggle to conceive naturally (29%) (Table 12).


29

There are Singaporean couples travelling abroad to seek fer8lity treatments such as IVF

  Based on Clearstate qualita(ve interviews with fer(lity centres in Singapore, Malaysia, Thailand, India and Australia, Singaporean couples are travelling abroad to seek fer(lity treatments such as IVF.

  In general, the reasons for doing so are:

o  Seeking alterna(ve IVF facili(es overseas for treatment a}er mul(ple 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 selec(on during IVF treatment.

Malaysia

  According to fer(lity 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.

Thailand   On the average, the interviewed fer(lity clinics in Bangkok see less

than 10 Singaporean couples each year.

India   On the average, the interviewed fer(lity clinics in Mumbai,

Hyderabad and Delhi see less than 5 Singaporean couples each year.

Australia   On the average, the interviewed fer(lity clinics in Melbourne and

Sydney see less than 5 Singaporean couples each year.

#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

Table 13: Overview of Singaporean Couples Seeking IVF treatment overseas from Clearstate qualita8ve interviews with fer8lity centres



Photo: TIME


30

Chapter 3

Regulatory Scenarios of Selected Countries

31

Summary of ART Regula8ons in Selected Countries

Australia India Malaysia Thailand Singapore

Gender Selec8on in IVF Prohibited

(except for medical reasons)

Prohibited Prohibited Unregulated, yet

prac(ced

Prohibited (except for medical

reasons)

Regula8ons for ART/IVF Regulated Unregulated, yet

prac(ced (legisla(on ini(ated)

Unregulated, yet prac(ced

(legisla(on ini(ated)


Regulated

Regula8ons for Surrogacy Allowed (altruis(c)


(legisla(on ini(ated)

Unregulated, not prac(ced


Prohibited

Fiscal Support by Government

Subsidised (~75% covered under

Medicare)

Unsubsidised (pay out-‐of-‐pocket)



Subsidised (Medisave)

Regula8ons on Oocyte Freezing

Allowed Unregulated, yet

prac(ced Unregulated, yet

prac(ced Unregulated, yet

prac(ced Prohibited (for elec(ve/

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

5.  Prohibited: Banned by legisla(on (law) 6.  Regulated: Governed by legisla(on (law) 7.  Unregulated: Lack of exis(ng legisla(on (law)

1.  Altruis(c: No monetary compensa(on allowed 2.  Medicare: Australia’s publicly funded universal healthcare system 3.  Medisave: Singapore’s na(onal healthcare saving scheme 4.  Pay out-‐of-‐pocket: Payment from individual funds

Glossary:

Table 14: Summary of ART Regula8ons in Selected Countries

32

Australia Australia has regula8ons in place for fer8lity treatment

Popula8on size 22,015,576 (July 2012 est.)*

Birth rate 1.9 births per woman (2011 est.)*

Infer8lity 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***

Regula8ons on IVF and Fer8lity Treatments

  Australia is said to lead the world in having the highest pregnancy and live birth rates through ART.***

  Australians are en(tled to reimbursement from the Na(onal Health Scheme-‐ Medicare for most fer(lity treatments such as IVF and Intracytoplasmic Sperm Injec(on (ICSI).****

  Gender selec(on can be done via PGD, for medical reasons (e.g. to prevent the transmission of a gender-‐linked gene(c disease). ****

  Elec(ve oocyte freezing is permiced in the Australia.****

  Fer(lity clinics adhere to the Na(onal Australian Health Ethics Commicee guidelines when providing any fer(lity treatment.****

Opinions of KCIs in Australia on Oocyte Freezing

  Cryo-‐preserva(on of oocytes is gaining popularity, par(cularly amongst younger women who freeze their eggs as a form of insurance against age-‐related fer(lity 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 domes0c and interna0onal which support this hypothesis. One of the key reasons Australia has higher success rates in IVF is the progressive nature of regula0ons in this regard.” – Embryologist, Sydney ***

Reference: *Central Intelligence Agency. (2013). Australia. Retrieved March 19, 2013, from The World Factbook: hcps://www.cia.gov/library/publica(ons/the-‐world-‐factbook/ **Fer0lity Society of Australia. (2013). Retrieved March 19, 2013, from Home Page: hcp://www.fer(litysociety.com.au/ ***IVF Australia. (2012). Retrieved March 19, 2013, from IVF Australia: hcp://ivf.com.au/ivf-‐fees/ivf-‐costs ****Na(onal Health and Medical . (2013, February 13). Assisted Reproduc0ve Technology (ART) Research Council. Retrieved March 19, 2013, from Assisted Reproduc(ve Technology (ART)

Table 15: Demographics of Australia

33

India India is well known for the provision of fer8lity treatments but remains unregulated

Popula8on size 1,205,073,612 (July 2012 est.)*


Infer8lity 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***

Opinions of KOLs in India on Oocyte Freezing****

  Cryo-‐preserva(on 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 s(ll not considered popular amongst women in India.

“Egg-‐freezing is s0ll rare (...) Awareness is very low in general public and even amongst doctors. Those who make ini0al enquiries are more familiar but s0ll require assurances about the process…India s0ll largely being a conserva0ve society, there is s0ll reluctance for women to step forward and undertake fer0lity-‐related procedures before marriage.” – Director, Private IVF Centre in New Delhi


  Provision of fer(lity services remains unregulated across India (e.g. age limit of IVF pregnancy) although most clinics in major ci(es adhere to interna(onal recognised as well as Indian Council of Medical Research (ICMR) guidelines.*****

  The ART Regula(on Bill, dra}ed by the ICMR in 2010 to regulate and govern ART procedures, is s(ll under considera(on by legisla(on.*****

  Fer(lity tourism in India is growing rapidly, with the reputa(on of affordable fer(lity treatments such as IVF and surrogacy driving this growth.**

Reference: *Central Intelligence Agency. (2013). India. Retrieved March 19, 2013, from The World Factbook: hcps://www.cia.gov/library/publica(ons/the-‐world-‐factbook/ **Interna(onal Ins(tute of Popula(on Sciences. (2011, June 27). Retrieved March 19, 2013, from Infer(lity: A growing concern: hcp://www.indianexpress.com/news/infer(lity-‐a-‐growing-‐concern/967209 ***The Washington Post. (2010, August 13). The Washington Post. Retrieved March 19, 2013, from In India, age o}en doesn't stop women from seeking help to become pregnant: hcp://www.washingtonpost.com/wp-‐dyn/content/ar(cle/2010/08/12/AR2010081206876.html?sid=ST2010081300007 ****Clearstate qualita(ve interviews with Singapore KICs *****Indian Council of Medical Research . (2010). Indian Council of Medical Research . Retrieved March 19, 2013, from hcp://www.icmr.nic.in/ & The Assisted Reproduc(ve Technologies (Regula(on) Bill -‐ 2010

Table 16: Demographics of India

34

Malaysia Malaysia’s market is presently unregulated

Popula8on size 29,179,952 (July 2012 est.)*


Infer8lity rate 15%**

Cost of Treatment The cost for one-‐cycle of IVF in fer(lity clinics ranges between SGD4,000 and SGD8,000***

Opinions of KOLs in Malaysia on Oocyte Freezing****

  No laws exist regula(ng oocyte freezing, thus cryopreserva(on of oocytes is currently offered for medical as well as elec(ve reasons by fer(lity 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.” – Infer8lity Specialist, Private IVF Centre in Johor Bahru


  Fer(lity treatment remains unregulated in Malaysia although the Ministry of Health has ini(ated legisla(on in 2011 with the proposal of the Assisted Reproduc(ve Technique Services Act.**

  The act will address issues such as surrogacy, sperm and egg banking, and sperm dona(on to make the Malaysian market more progressive.**

  Fer(lity centres will have to be licensed once the proposed Na(onal ART Act is passed.**

  Dra}ing exercise for the proposed legisla(on was expected to be completed in 2012.**

  Fer(lity centres are accredited by interna(onal bodies (such as the Joint Commission Interna(onal) and Malaysian Society for Quality in Health (MSQH).*****

Reference: *Central Intelligence Agency. (2013). Australia. Retrieved March 19, 2013, from The World Factbook: hcps://www.cia.gov/library/publica(ons/the-‐world-‐factbook/ **ASIAONE. ( 2011, February 27). ASIAONE. Retrieved March 21, 2013, from Laws on fer(lity treatment by 2012: hcp://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: hcp://www.theborneopost.com/2012/04/25/ivf-‐triplets-‐born-‐at-‐raja-‐permaisuri-‐bainun-‐hospital/ cp://www.theborneopost.com/2012/04/25/ivf-‐triplets-‐born-‐at-‐raja-‐permaisuri-‐bainun-‐hospital/ ****Clearstate qualita(ve survey of key opinion leaders *****Malaysian Society for Quality in Health. (2011). Retrieved March 19, 2013, from Malaysian Society for Quality in Health: hcp://www.msqh.com.my/web/

Table 17: Demographics of Malaysia

35

Thailand Thailand is well known for the provision of fer8lity treatments but remains unregulated

Popula8on size: 67,091,089 (July 2012 est.)*

Birth rate: 1.6 births per woman (2011 est.)*

Cost of Treatment Thailand is considered a major fer(lity tourism hub in the region with its price compe((veness for IVF being between SGD6,000 to SGD7,500 per cycle**

Opinions of KOLs in Thailand on Oocyte Freezing**

  Cryo-‐preserva(on of oocytes is currently offered by doctors but mainly targeted foreign pa(ents due to low awareness among and affordability to local pa(ents.

“Oocyte freezing is quite a new concept to Thai people. Addi0onally, IVF treatments are not reimbursable for Thais. Hence, there is no demand for such procedures locally. We mainly get enquires from foreign pa0ents. Singaporeans form a small propor0on of these (foreign) pa0ents.” – Infer8lity Specialist, Public IVF Centre in Bangkok


  There are currently no laws governing fer(lity 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 pa(ents 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 selec(on treatment via PGD.***

  The availability of PGD has acracted pa(ents from countries where gender selec(on is not allowed (including Singapore**** and India*****).

Reference: *Central Intelligence Agency. (2013). Australia. Retrieved March 19, 2013, from The World Factbook: hcps://www.cia.gov/library/publica(ons/the-‐world-‐factbook/ **Clearstate qualita(ve survey of key opinion leaders ***Chiang Mai University. (2007). Surveillance of ART and PGD prac0ce in Thailand. Chiang Mai ****Straits Times (2011, August 21). Straits Times. Retrieved March 23, 2013, Gender spenders: hcp://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: hcp://ar(cles.(mesofindia.india(mes.com/2010-‐12-‐27/india/28239140_1_indian-‐couples-‐indians-‐flock-‐baby-‐boy

Table 18: Demographics of Thailand


Photo: TIME


APPENDIX

36

37

Appendix A: BELRIS Quan8ta8ve Survey – Age Profile of Respondents

BELRIS Survey, Ques(on: What is your gender? How old are you? Base, All respondents n=206

Married 66%

Not Married 34%

Married, Men

Age Group # of Respondents % Distribu8on

26 – 30 2 6%

31 – 35 5 15%

36 – 40 10 30%

41 – 45 7 21%

Above 46 9 28%

TOTAL 33 100%

Married, Women


26 – 30 6 6%

31 – 35 13 13%

36 – 40 18 18%

41 – 45 42 41%

Above 46 23 22%

TOTAL 102 100%

Not Married, Men


18 – 25 7 35%

26 – 30 9 45%

31 – 35 2 10%

36 – 40 1 5%

41 – 45 1 5%

TOTAL 20 100%

Not Married, Women


18 – 25 14 28%

26 – 30 11 22%

31 – 35 12 23%

36 – 40 9 17%.

41 – 45 2 4%

Above 46 3 6%

TOTAL 51 100%

Respondent Breakdown by Marital Status (n=206)

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Appendix B: Clearstate Qualita8ve Interviews – List of IVF Clinics Interviewed

Country City Number of IVF Centres Interviewed Facility Ownership

Australia Melbourne 1 Private

Sydney (Branches at Mul(ple Loca(ons) 1 Private

India Mumbai 2 All private

Hyderabad 1 Private

New Delhi 1 Private

Malaysia Johor Bahru 1 Private

Petaling Jaya 2 All private

Singapore Singapore 5 4 private and 1 public

Thailand Bangkok 3 All private

List of IVF Clinics Interviewed

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Appendix C: Clearstate Quan8ta8ve Survey – Marital Status of Respondents

References: *Department of Sta(s(cs, Ministry of Trade & Industry. (2010). The Census of Popula0on 2010 . Singapore

42.0%

58.0%

37.1%

62.9%

Single, Never Married Married/Divorced/Widowed/Separated

Respondents Na(onal Propor(on

Marital Status of Clearstate Survey Respondents (n=410) versus Na8onal Propor8on (2010)*#

#Latest available data on resident women aged between 20 to 44 from the Singapore Department of Sta8s8cs. Censuses of Popula8on are conducted once in every ten years by the Singapore Department of Sta8s8cs

Clearstate Survey, A5: What is your current marital status? Base, All respondents n=410

40

Appendix D: Clearstate Quan8ta8ve Survey – Age Profile of Respondents

17.3% 17.6% 21.2%

22.9% 21.0%

17.9% 17.8%

21.0% 21.9% 21.4%

20 -‐ 25 years 26 -‐ 30 years 31 -‐ 35 years 36 -‐ 40 years 41 -‐ 45 years


Age Profile of Clearstate Survey Respondents (n=410) versus Na8onal Propor8on (2012)*

Clearstate Survey, S3: Which age bracket do you fall under? Base, All respondents n=410


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Appendix E: Clearstate Quan8ta8ve Survey – Educa8on Level of Respondents

Clearstate Survey, A1: What is the highest level of educa(on you have completed? Base, All respondents n=410

50.4%

31.0%

17.6%

1.0%

37.6%

22.4%

27.9%

12.2%

University & Above Diploma Secondary Primary & Lower


Educa8on Level of Clearstate Survey Respondents (n=410) versus Na8onal Propor8on (2010)*#

##


#Latest available data on resident non-‐student women aged between 20 to 44 from the Singapore Department of Sta8s8cs. Censuses of Popula8on are conducted once in every ten years by the Singapore Department of Sta8s8cs ##Includes University (42.6%) and Post-‐graduate (7.8%) respondents

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Appendix F: Clearstate Quan8ta8ve Survey – Religious Background of Respondents

31.0%

22.2%

2.7%

10.2% 7.6%

26.1%

0.2%

31.3%

20.3%

6.1%

15.0%

8.0%

18.7%

0.6%

Buddhism Chris8anity Hinduism Islam Taoism No Religion Others


Religious Background of Clearstate Survey Respondents (n=410) versus Na8onal Propor8on (2010)*#

Clearstate Survey, A3: What is your religious affilia(on? Base, All respondents n=410


#Latest available data on resident women aged between 20 to 44 from the Singapore Department of Sta8s8cs. Censuses of Popula8on are conducted once in every ten years by the Singapore Department of Sta8s8cs

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healthcare"

43

report on elective oocyte freezing in singapore apr 2013

Health & Medicine

oocyte freezing

vitro ferlisaon ivf

ivf procedure

process of oocyte

freezing eggs

regular ivf treatment

ferlity elecve oocyte

reproducve issues