Singapore saw its total fertility rate fall to a historic low of 1.1 in 2020. Minister in the Prime Minister's
thehomeground.asia
Singapore saw its total fertility rate fall to a historic low of 1.1 in 2020. Minister in the Prime Minister's Office (PMO) Indranee Rajah, told Parliament in February 2021 that the cause is perhaps the COVID-19 pandemic, which resulted in some Singaporeans postponing their marriage, and others delaying parenthood plans. The situation has led to a vigorous debate for the Singapore Government to lift its long-standing ban on non-medical egg freezing for single women.
Working with the Association of Women for Action and Research (AWARE), the women's and youth wings of the People's Action Party (PAP) released two separate papers at end-July, each calling on the Government to take action to tackle discrimination and advance women's development in Singapore; and that women should also be allowed to freeze their eggs for non-medical reasons. The government will, in turn, input their response in a soon-to-be released White Paper.
To avoid any hiccups if social egg freezing is permitted in Singapore, there are various pertinent socio-legal issues that need to be addressed by establishing comprehensive legislation and coherent ethical guidelines:
Strict standard guidelines on information about medical risks and failure rates
Older women, in particular, should be made aware that they need to undergo multiple egg collection and freezing cycles to obtain a sufficient number of frozen eggs to have a reasonable chance of future pregnancy. For women who choose to freeze their eggs just once, they would be in for a very big disappointment should they fail to conceive in the future with their own eggs.
According to the American Society of Reproductive Medicine (ASRM), the pregnancy success rate for egg freezing is relatively low, at around 2 percent to 12 percent per frozen egg. There are scientific data published in reputable medical journals such as “Fertility & Sterility” and “Human Reproduction” that claim high success rates of in-vitro fertilisation (IVF) with frozen eggs, but these may be misleading to patients who lack specialised knowledge in the area. Patients are often not aware that many of such published studies were based on frozen donated eggs of young women between the ages of 20 and 25 years, collected specifically for use by infertile patients.
Egg freezing, or oocyte cryopreservation, therefore provides women the possibility of preserving younger and possibly healthier eggs until they are ready to start a family. (Photo source: Getty Images)
An example is the recent publication (2020) by Laura Rienzi and colleagues in the journal Human Reproduction, which analysed the data of several previous studies. It was reported that the average survival rate of frozen eggs was 86 percent with very high success rates of around 60 percent achieved in patients, when eight to nine frozen eggs were utilized in each IVF treatment cycle. However, this study was based on frozen eggs donated by young women with an average age of 25.7 years.
This is certainly not reflective of older career women, who are typically aged from mid-30s to early-40s, who are attempting to freeze their much lower-quality eggs. To ensure there is no misinformation on the subject, the Ministry of Health (MOH) should prepare a booklet, pamphlet or have a website page containing relevant information for women intending to do egg freezing.
Social egg-freezing may encourage single motherhood
Unmarried women who choose to freeze their eggs do so with the strong expectation that they will use them one day, regardless of their future marital status. If they remain single, it is likely that some of them may consider single motherhood. Although current health regulations in Singapore ban unmarried women from undergoing fertility treatment with donated sperm, there are no laws stopping single women from exporting their frozen eggs for in vitro fertilisation (IVF) abroad using donor sperm.
Stringent safeguards should therefore be in place to ensure that frozen eggs are used within the context of marriage and traditional family structure. This is also stressed by the PAP Youth and Women’s wing, in response to concerns that allowing the procedure would encourage people who are not in a traditional family nucleus, such as same-sex couples and single women, to have children. Such concerns were voiced by many in a survey conducted by Tampines MP Cheng Li Hui in 2019, which involved more than 700 respondents.
At the end of the day, the Government is obliged to acquiesce to conservative religious and family values of the majority of Singaporeans.
This could result in MOH, firstly, insisting on patients producing a valid marriage certificate before being allowed to export frozen eggs overseas. Secondly, have the woman's husband approve of and sign off on the export of her frozen eggs because of the legal implications for him. Under Singapore law, a woman's husband is, by default, presumed to be the legitimate father of any child born to the woman and because of that, she should not be allowed to export her frozen eggs overseas without his consent.
Thirdly, couples need to sign a declaration that a third-party surrogate will not be used with the exported frozen eggs, otherwise they will be barred from applying for adoption, residency and citizenship procedures for the child born from surrogacy using the frozen eggs. But on sympathetic grounds, the authority can waive this condition should the woman be medically unfit to carry a pregnancy to term herself.
Unfair for government to co-fund IVF for married women who had previously frozen their eggs
Social egg freezing is unlikely to be subsidised by the government because it is an elective procedure. Nevertheless, IVF treatment is subsidised. Should the single woman, who had undergone elective egg freezing later expect to undertake IVF using her frozen eggs, then she cannot apply for government subsidies for the treatment at public hospitals. Or else, this would not only be unfair but also lengthen waiting lists for subsidised IVF treatment and take resources away from married couples with fertility problems, and placing unnecessary burden on the already crowded public healthcare system. It may not be unreasonable to place such patients with frozen eggs at the bottom of such waiting lists or exclude them altogether.
More importantly, subsidising frozen egg IVF would be wasteful and cost-inefficient, since the egg freezing process itself significantly reduces the chances of conception. This would be akin to putting coins in a bag with holes.
Clear directives for dealing with unused, unclaimed frozen eggs
One foreseeable problem of social egg freezing is the accumulation of excess unused and unclaimed frozen eggs in storage within fertility clinics.
It is found that less than 1 in 5 women who freeze their eggs return to use them later. (Photo source: Cleveland Clinic)
An Australian study published in 2017 reported that the majority of women who freeze their eggs do not eventually use them. The researchers had surveyed nearly 100 women who elected to freeze their eggs between 1999 and 2014 for the purpose of delayed childbearing. They found that just 6 percent of the women had used their frozen eggs at the time of the survey, with 3 per cent of them having given birth.
Another Australian study published in 2021, reported similar findings — that of the 4,048 women who had stored their frozen eggs in Victoria, Australia, only less than 4 percent or 159 women came back to use their eggs in 2020. This led to calls to avoid wastage, by donation of these unused frozen eggs to infertile women who need them.
Women also need to sign a form agreeing to the proper disposal of their eggs should they die or if they have not paid storage fees for up to three years. Another suggestion is to place a limit on the storage duration of frozen eggs, after which, there would be mandatory disposal of these eggs. Until recently in Britain, there was a storage limit of 10 years for both frozen eggs and sperm, but this will be extended up to 55 years under new laws, pending the approval by the British parliament.
Then what if the frozen eggs are lost or accidentally destroyed by the fertility clinic itself?
Many local fertility clinics store frozen eggs or embryos in cryogenic tanks that need to be topped up regularly with liquid nitrogen, leaving room for human error. With such possibilities of failure, damage to the frozen eggs are often irreversible. To help safeguard the interest of these women, there should be enforced insurance and compensation schemes to cover accidental loss of the frozen eggs.
Most commonly, disposed frozen eggs are treated as clinical waste, making them convenient to be used for training purposes, especially for new laboratory workers hired for IVF procedures.
Currently, the ethical issue here is hazy and ill-defined. Unlike research and treatment, there is no "document trail" to help trace the unauthorised use of disposed frozen eggs for training, clearly violating the woman's rights to her eggs, especially when she has not given prior consent.
Law on the donation of unused frozen eggs
Another important consideration is the option of donating unused frozen eggs to other patients who are infertile. In such cases, there are three issues that must be addressed:
(i) Spousal consent
Spousal consent must be sought at the time of egg donation to other patients. The woman may have had her eggs frozen when she was still single, but once when she is married and wishes to donate her eggs, the authorities need to ensure there is informed consent from the donor’s spouse, in case of the possibility of accidental incest (between the couple’s children and unknown donor-conceived offspring). It is only right that the husband be made aware and consent to accepting such risks for his children. More importantly, the donor’s husband must consent to forgo any future offsprings from the donated frozen eggs, particularly if his wife is already near or past the age of menopause.
(ii) Knowing there are lower chances of conception
The freezing or cryogenic process always results in some damage to the egg, however minimal, so frozen donor eggs are not nearly as good as fresh donor eggs. Also, women tend to be older when they freeze their eggs socially and the older the donor, the lower the egg quality, reducing the chances of an IVF success for the recipients.
It is also likely that prospective donors would have used the best eggs for their own fertility treatment, so the donated, unused leftovers may be of questionable quality. Therefore prospective recipients must be informed that chances of conception using the frozen eggs are significantly lower than fresh donor eggs.
(iii) Avoiding conflict of interest
Fertility doctors should be prevented from persuading former patients to donate unused frozen eggs to their current patients as this would be considered conflict of interest — both ethically and under the eyes of the law. This is because of the risk of the doctor-patient fiduciary relationship being abused during the consent process, particularly if doctors know that their former patients are grateful to them for previously successful treatment.
Fertility clinics should also not exercise control over the distribution and allocation of donated frozen eggs to other patients. Instead, this should be handled directly by the authorities, based on a centralised donor registry and a waiting list of potential recipient patients, similar to that for organ donation in Singapore.
Financial help for single women freezing their eggs
If social egg freezing is permitted without provision of any financial assistance, then the procedure would only be available to those who can afford it. This could likely spark accusations of unfairness and class bias in access to treatment, which would facilitate the reproduction of a select ‘elite’ group of rich women. The NGO AWARE had called for the procedure to be made accessible to all women regardless of their marital status, financial capacity and educational status.
AWARE has called for the social freezing of eggs to be made accessible to all women regardless of marital status, financial capability and educational level (Photo source: Freepik)
While it is difficult to justify direct government subsidies for egg freezing, as it is an elective procedure linked to personal life choices, there are several alternative strategies that can be considered and allowed to be exercised.
First, younger women should be allowed to use their Central Provident Fund (CPF) for egg freezing. Second, the Government could consider providing low-interest loans to fund egg freezing, pegging it to CPF ordinary account interest rates. This would be, similar to that of HDB housing loans or loans for university tuition fees. Third, younger women should be allowed to donate some of their retrieved eggs to infertile patients, in return for subsidies from these patients, which would ease the financial burden of egg freezing.
This option is highly controversial, tantamount to government-sanctioned selling of eggs. But this is already practiced in the USA and Britain, and MOH may consider looking at how such a scheme operates in these countries with safeguards in place.
Expert Talk: Social Egg Freezing Overseas For Women In Singapore
In recent years, there have been intensive debate on permitting social egg freezing for single women in Singapore, due to the increasing trend of reduced fertility arising from late marriages and delayed childbearing.
Indeed, the Singapore news media have reported several cases of local single women traveling abroad to freeze their eggs, due to current ban on fertility clinics performing this procedure on unmarried women without valid medical reasons.
Because egg freezing is such an expensive medical procedure, it would be wise and prudent for Singaporean single women to take necessary precautions before traveling abroad for treatment.
In particular, they have to be wary of misleading advertisements and marketing gimmicks by foreign fertility clinics.
There is a high risk of them being duped by misinformation on egg freezing, which could lead to wastage of their hard-earned money, in addition to them suffering much disappointment upon failing to conceive in the future.
Social Egg Freezing Process For Women In Singapore
Here are some advice and warnings for single Singaporean ladies considering egg freezing overseas:
When to freeze your eggs First and foremost, single women should freeze their eggs as young as possible, preferably before the age of 35. There is strong medical evidence that a woman’s fertility drops sharply after the age of 37 (American College of Obstetricians and Gynecologists Committee).
The overwhelming majority of single women make the mistake of freezing their eggs too late, in their late thirties or early forties, when their egg quality has substantially declined.
The high financial costs of egg freezing often discourage many younger women from freezing their eggs, until they feel the pangs of desperation upon getting older, with their biological clock ticking away.
Check the health of your ovaries
Check the health of your ovaries and your ovarian reserves at a local fertility clinic, before traveling abroad for egg freezing.
Ovarian reserves are determined by measuring your blood serum levels of AMH (Anti-Müllerian Hormone) and FSH (Follicular Stimulating Hormone), together with ultrasound assessment of antral follicle counts within the ovary.
If you are diagnosed with low ovarian reserves, you will likely require more egg freezing cycles to obtain an adequate number of frozen eggs for a reasonable chance of future pregnancy.
This means spending more time and money.
Polycystic Ovary Syndrome (PCOS) occurs in about 10% of women of reproductive age, and is a major cause of infertility.
Although a higher number of eggs are typically recovered from PCOS versus normal patients during assisted reproduction treatment, the eggs are often less mature and poorer in quality, which may compromise the success of egg freezing.
Moreover PCOS patients are more prone to ovarian hyperstimulation syndrome (OHS), which increases the risk of cancellation of egg freezing cycles, leading to wastage of their hard-earned money. To avoid future disappointment, do not freeze your eggs if you have PCOS or low AMH levels.
If you have such medical conditions, the better option maybe to try conceiving a baby as soon as possible (possibly with assisted reproduction techniques), rather than do egg freezing.
Be prepared for multiple egg freezing cycles
To attain a reasonable chance of future pregnancy, be prepared to undergo multiple egg freezing cycles to obtain sufficient number of frozen eggs, especially if you are an older woman with low ovarian reserves.
Even that is no guarantee of having a child in the future.
For many single women who freeze their eggs overseas and make that journey just once, they can expect a very big disappointment should they fail to conceive in the future with their own frozen eggs.
Table. Estimated number of eggs and egg retrieval cycles necessary to conceive one child at different ages (From Center for Human Reproduction, 21 East 69th Street,New York, NY 10021, USA)
Age (years)
21-25
26-32
33-38
39-42
Estimated minimum number of eggs for a single child
10
15
20
25-30
Estimated number of egg freezing cycles required to reach the above-quoted number
1
2
3-4
4-6
Check the health of your womb
Check the health condition of your womb with a local clinic, before traveling abroad for egg freezing. One must beware of uterine fibroids that commonly develop in women between 30 and 40 years of age.
Uterine fibroids have been reported to lower the chances of pregnancy in older women doing in vitro fertilization (IVF) with their frozen eggs.
Hence, it is not just the number and quality of your frozen eggs, nor is it just about your age at which you freeze your eggs.
The health condition of your womb at the time that you are using your frozen eggs also matters a great deal. This issue has largely been overlooked and neglected by many single women freezing their eggs.
Adapt a healthy lifestyle
Before traveling overseas for egg freezing, maintain a healthy lifestyle and regularly take fertility supplements and vitamins for a few months to improve egg quality. Supplements and vitamins that can enhance egg quality include:
Coenzyme Q10 (CoQ10)
DHEA (Dehydroepiandrosterone)
L-Arginine
Myo-Inositol
Glutathione
There are now commercially-available products that combine all these supplements and vitamins into one package, to specifically enhance female fertility prior to in vitro fertilization or egg freezing.
Don’t fall for advertisements
Be extra skeptical of advertisements by foreign fertility clinics that claim high pregnancy success rates with frozen egg.
Many foreign fertility clinics will tell you that high pregnancy success rates (40% to 60%) with frozen egg are published in reputable medical journals, and are achieved using the latest vitrification technology that avoids ice crystallization damage.
What they don’t tell you is that such high pregnancy success rates are based on frozen donor eggs from young healthy women (20 to 25 years of age, with low body mass index and high ovarian reserves).
Egg donors are carefully selected to be the most fertile group of women in the entire population. For example in America, only 5% of female applicants are accepted to be egg donors.
This is not reflective of older career woman freezing their eggs, who are typically aged between their mid-30’s to early-40’s, with variable body mass index and much lower ovarian reserves.
Hence, good results on egg freezing published in reputable medical journals are highly-skewed, because most of these studies compared fresh versus frozen eggs from carefully-selected, young, healthy and highly-fertile egg donors.
Beware that the pregnancy success rates with frozen eggs drop exponentially with increasing age, due to rising incidence of chromosomal abnormalities in the frozen eggs.
As such, the IVF success rates with frozen eggs from older women are very much lower than that advertised by foreign fertility clinics.
In the American news media, there have been many stories of women freezing more than 10 egg, but found that none of these can yield a successful pregnancy, leading to much heartbreak and disappointment.
Check track record of the clinic
When choosing a foreign fertility clinic for egg freezing, do not just consider the price, but also check that they have a track record of live births with frozen eggs.
It is best for the fertility clinic to have publications in international medical journals, which proved that they had actually successfully achieved live births with frozen eggs.
Yet, less than 5% of assisted reproduction clinics in the USA fulfill such criteria.
Despite the much lower costs of egg freezing in the developing countries of Southeast Asia, such as Malaysia and Thailand, one must beware of the reliability and quality of medical facilities and services in such countries.
Pick a country that encourages quality control of clinics
Choose to do egg freezing in a country where there are strict regulations and good quality-control of fertility clinics. It is not just about costs!
This is crucial, because there had been catastrophic failures in the refrigeration of frozen eggs, as reported by the American news media.
Developed countries like Australia and America usually have stricter regulations and better quality control of fertility clinics, as compared to developing countries like Malaysia and Thailand.
For example, in Australia, fertility clinics are regularly inspected and audited by the Fertility Society of Australia (FSA) and the Reproductive Technology Accreditation Committee (RTAC) of Australia. Are fertility clinics in Malaysia and Thailand subjected to similar mandatory inspections and audits?
The fact that you can read the news about frozen egg storage failures in the USA confirm that American assisted reproduction clinics are subject to strict regulatory oversight and good quality control.
Hence, they quickly acknowledged their failures publicly, despite knowing that they will likely be sued by patients for millions of dollars.
Can such transparency and honesty be expected of private fertility clinics in developing countries like Malaysia and Thailand, where government regulation and oversight are much less stringent?
Make sure to know about the laws
Some women may remain single and may want to consider single motherhood. In that case, they should initially take note of relevant laws in the country in which they freeze their egg.
For example, Malaysia and Thailand ban in vitro fertilization of single women with donor sperm, whereas this is permitted in Australia, America and most of Europe.
In conclusion, the most important factor that ensures future reproductive success with egg freezing is the age at which a woman freezes her eggs.
Despite technological advancements such as vitrification technique that minimizes damage to frozen eggs from ice crystallization, single women should beware that the pregnancy success rates with frozen eggs is still significantly lower than that of fresh eggs.
thehomeground.asia
