Elective Egg Freezing in Singapore - Subsidies, Discounts, Reimbursement and Refund of Medical Fees

[Angelica Cheng]

Subsidies and reimbursement of medical fees - revisiting the old concept of egg-sharing donation in elective egg freezing (fertstert.org)

At present, a major challenge in clinical assisted reproduction is the increasing shortfall and ever rising demand for donated eggs worldwide, due to increasing prevalence of age-related female infertility arising from the well-established tendency towards late motherhood in economically developed urban societies. At the same time, greater awareness of age-related decline in female fertility among the better-educated younger generation has motivated increasing numbers of single women to preserve their fertility via elective egg freezing (EEF). The surplus unused frozen eggs from elective egg freezing patients can thus be a valuable source of donation to other patients in need, in particular older women with depleted ovarian reserves [1, 2].

For this purpose, the old concept of egg-sharing [3] has been repackaged and rebranded in the context of elective egg freezing, with two major variations of the old scheme. The first variant, commonly referred to as “Freeze and Share” or “Freeze-sharing” [2], involves giving an elective egg freezing patient a substantial discount or subsidy on her medical fees, in return for donation of some of her retrieved eggs (typically half of the entire cohort of oocytes retrieved from one cycle) to another patient. The main drawback here is that elective egg freezers are unsure whether or not they will successfully achieve their reproductive goals in the future. Hence, there is an unsettling possibility that they may fail at conceiving with their stored frozen eggs, while still being unsure whether their donated eggs had led to the birth of an unknown genetic offspring out there. The second variant, as outlined by Pennings [2], involves either partial or full reimbursement of medical fees that had already been paid up by elective egg freezing patients, at a much later date when they decide that they no longer need their frozen eggs. At this stage, patients will be more sure of whether they had achieved or had given up their motherhood goals, when they decide to donate their unused frozen eggs in return for reimbursement of medical fees.

In soliciting egg donation from elective egg freezing patients by offering subsidies or reimbursement of medical fees, it is imperative that informed consent be obtained through extensive psychological counseling, which is in fact mandated by law in many jurisdictions. In particular, counseling for donation by elective egg freezing patients should address the following pertinent issues relating to (i) how would the prospective donor feel if recipients successfully conceived a child with their donated eggs, while they themselves failed in achieving their own motherhood goals, (ii) confidentiality issues and possible future contact by unknown offspring in jurisdictions where donor anonymity has been abolished, such as in the United Kingdom, where donor-conceived children can request the name and last known address of their donor when they reach the age of majority, (iii) possibility of accidental incest between one’s natural and donor-conceived offspring (consanguinity), and (iv) to fully understand the implications and emotional impact of one’s decision to donate. As pointed out by Crockin and Daar [4], the structure and format of the donation consent form itself can intentionally provide uniform disclosure of relevant information and risks, thereby promoting the fully informed consent of prospective egg donors.

A more recent development is the proliferation of cheap consumer DNA testing and associated ancestry/genealogy websites that enable an individual to trace unknown blood relatives worldwide. This is often readily-available via mail-order DNA home collection kits, and has increasingly rendered the concept of sperm and egg donor anonymity obsolete. Even though egg donors themselves may not have done such DNA testing and have not uploaded their genomic DNA profile on such websites, some of their family members or more distant relative might have done so, which means they could potentially be traced by their unknown donor-conceived offspring. Hence in countries where egg donor anonymity is still mandated, prospective donors among EEF patients should be counseled to be emotionally and mentally prepared for possible unexpected contact with their unknown donor-conceived offspring in the future, despite being assured of anonymity and confidentiality by their fertility clinic.

Additionally, a number of ethical issues have largely been overlooked in reapplying the old concept of egg-sharing to elective egg freezing. It is likely that the offer of subsidies or reimbursement of medical fees might alter the dynamics of decision-making by women in choosing to donate their unused frozen eggs. Indeed, this point was overlooked by the study of Caughey et al. [1], which investigated the disposition decisions of elective egg freezing patients towards their surplus frozen oocytes, and revealed that women who had achieved motherhood were more open to donating their oocytes to others, whereas those who did not achieve motherhood were unlikely to donate. For many egg freezers who had successfully achieved motherhood, they often face the moral dilemma of needing to reciprocate doing good to others via egg donation. As highlighted by Caughey et al. [1], disposition/donation decisions were often based on a lack of information or misinformation, with little if any professional advice being sought or provided by medical doctors and fertility counselors. This is further complicated by intense emotions associated with patients having achieved motherhood or not, which can be life-altering because of open-identity donation in some jurisdictions. Hence, there is a dire need for survey and interview-based studies similar in methodology to that utilized by Caughey et al. [1], to investigate in detail how the offer of either subsidies (“Freeze and Share” schemes) or reimbursement of medical fees might influence the dynamics of decision-making by elective egg freezing patients; whether to discard their surplus frozen oocytes, donate for research or IVF treatment of another woman.

The dissimilar circumstances of elective egg freezing patients versus conventional non-patient egg donors will undoubtedly exert a strong influence on their decision-making dynamics. For example, conventional non-patient egg donors do not usually pay any medical fees, whereas in the donation of surplus frozen eggs, elective egg freezing patients would have already paid up substantial medical and cryostorage fees [1, 2]. As mentioned by Caughey et al. [1], after investing so much time, money and effort in egg freezing, and paying expensive storage fees over several years; they would naturally feel a sense of loss if their unused frozen eggs were simply discarded or donated for research. Offering reimbursement of medical fees could therefore be a “tipping-point” in influencing decision-making by elective egg freezing patients, by inducing them with financial benefits in return for donation to others. Hence, some women who had not achieved motherhood and who were initially reluctant to donate their unused frozen eggs [1], may change their minds upon being offered reimbursement of medical fees. Therefore, it is imperative that future studies must also examine underlying ethical issues, whether offering subsidies or reimbursement of medical fees could represent a trespass on the patient’s autonomous decision-making process.

 

[Angelica Cheng]

Another major ethical issue that has also been largely overlooked is that market forces based on supply and demand may possibly encourage discriminatory practices in reimbursed egg donation, as well as “Freeze and Share” schemes. For example, based on the current dynamics of the egg donation market in the USA, certain races or ethnicity of egg donors such as East Asians, Jews and East Indians are in higher demand but in shorter supply, as compared to other races/ethnicity; which in turn has led to substantially higher levels of monetary compensation for non-patient egg donors of such ethnicity, as widely reported in the news media [5]. Hence, there is a strong likelihood that such market forces may also influence varying levels of reimbursement or medical fee subsidies given to elective egg freezing patients based on their race/ethnicity, which could in turn trigger accusations of racial discrimination and unfairness. Worse still, depending on volatility and fluctuations of the egg donation market, there may be little or no demand for egg donors of some less-in-demand minority race/ethnicity, which would mean that elective egg freezing patients of such race/ethnicity may be unable to donate their eggs in return for reimbursement or subsidies on their medical fees, thereby leading to much resentment and unhappiness.

Besides race/ethnicity, another key factor influencing demand in the egg donation market, is the well-known preference for specific donor traits by recipients of donated eggs. For example, high SAT (Scholastic Aptitude Test) scores, graduation from prestigious universities, athletic ability, musical or artistic talent, and even physical attributes related to beauty standards such as height, complexion, stature, eye and hair color [5]. Hence, similar to the egg donation market for non-patient donors, elective egg freezing patients who possess more of such desirable traits may also receive higher levels of reimbursement or subsidies on their medical fees.

A possible regulatory safeguard against such aforementioned discriminatory practices, would be to mandate a fixed sum of money that can be given as reimbursement or subsidy of medical fees to all elective egg freezing patients, regards of race/ethnicity and personal attributes, if they qualify for egg donation in the first place. Another safeguard would be to restrict information sharing of the personal attributes of prospective egg donors with recipient patients. In particular, photos of prospective donors, and information about their educational levels, athletic ability and musical/artistic talents should not be shared with recipient patients. It is thus recommended that recipient patients be strictly matched as closely as possible to prospective donors with similar physical attributes such as race/ethnicity, blood group, height, weight, complexion, eye and hair color, and should not be allowed to select for physical traits that they themselves do not possess. For example, a short dark-haired and dark-skinned recipient patient should not be allowed to choose a tall blonde fair-skinned donor. Such safeguards would thus prevent market forces from encouraging discriminatory practices in the procurement of egg donation from elective egg freezing patients.

Yet another pertinent ethical issue is the possibility of fertility clinics maximizing profits, by dividing up the donated frozen eggs from one EEF patient for allocation to multiple cycles or multiple recipient patients, which may contravene good medical practice and ethics. Take for example, an EEF patient in her late thirties, who was advised by her doctor to freeze 20 eggs to achieve an 80% chance of pregnancy, which required her to undergo 3 cycles of egg freezing. Later, say that this patient conceived naturally, and decided to donate her 20 unused frozen eggs to other patients in need. To maximize profits, the IVF clinic may decide to divide the cohort of 20 donated eggs into 4 batches of 5 frozen eggs each, which will be used for 4 separate IVF cycles with different recipients. This may not be in the best interests of recipient patients, because fewer of these presumably lower quality eggs derived from an older woman in her late thirties, are being allocated to each treatment cycle. Hence, it may be necessary to draft stringent regulatory and ethical guidelines to prevent such possible abuse from taking place. Perhaps regulatory authorities can mandate that the entire cohort of donated frozen eggs from one EEF patient, should be used in one cycle for one recipient patient only. Any resulting surplus embryos can then be frozen down for that one recipient patient.

In conclusion, besides mandating rigorous and comprehensive counseling for prospective donors, other regulatory safeguards are also needed in reapplying the old concept of egg-sharing donation to elective egg freezing, so as to prevent the various potential abuses, exploitative business practices, and conflicts of interests, as outlined above. Perhaps, to avoid ethical breaches and ensure fairer distribution, egg-sharing donation may be better managed by a government-run agency based on a centralized donor registry and waiting list of prospective recipient patients.

References
1. Caughey LE, White KM, Lensen S, Peate M. Elective egg freezers' disposition decisions: a qualitative study. Fertil Steril. 2023 Apr 7:S0015-0282(23)00151-6.
2. Pennings G. When elective egg freezers become egg donors: practical and ethical issues. Reprod Biomed Online. 2023 Apr 2:S1472-6483(23)00206-7.
3. Ahuja KK, Simons EG, Fiamanya W, Dalton M, Armar NA, Kirkpatrick P, Sharp S, Arian-Schad M, Seaton A, Watters WJ. Egg-sharing in assisted conception: ethical and practical considerations. Hum Reprod. 1996 May;11(5):1126-31.
4. Crockin SL, Daar J. American society for reproductive medicine updates consent forms for egg donation. Virtual Mentor. 2014 Apr 1;16(4):302-3.
5. Heng BC. Factors influencing the reimbursement rate of egg donation within a competitive free-market system. Reprod Biomed Online. 2007 Jul;15(1):16-8.
DOI: 10.1016/b35dde22-de6f-47ac-95d1-a93a88b84bfc