Photo:

TIME

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

9th April 2013
Photo: Santa Monica Reproduc8ve Technologies

Photo: The Straits Times

Table of Contents
Deni(on of Terms Deni(on of Acronyms Chapter 1: Study Background, Objec(ves and Scope Chapter 2: Evalua(ng the Need for Elec(ve Oocyte Freezing Chapter 3: Regulatory Scenarios of Selected Countries Appendix 3 4 5 9 30 36

Deni8ons of Terms
Terms here are dened for beKer understanding of the following report: Term
Assisted reproduc(on technology (ART) treatments Elec(ve oocyte freezing Ever-married Intracytoplasmic Sperm Injec(on (ICSI) In-vitro fer(lisa(on (IVF) Medisave No Religion Pre-implanta(on Gene(c Diagnosis (PGD) Resident popula(on Respondents

Deni8on
Clinical and laboratory techniques that involve the mixing of oocytes and sperms outside the body to enhance fer(lity Cryopreserva(on for non-medical purposes Status of having been married at least once, regardless of current marital status ICSI is a form of Assisted Reproduc(ve Technology (ART) IVF is a form of Assisted Reproduc(ve Technology (ART) Singapores na(onal healthcare saving scheme which helps individuals set aside part of their income to meet future healthcare expenses The status of not being aliated to any par(cular religion, of which free thinkers are included Gene(c proling of embryos or oocytes prior to fer(lisa(on Singapore Ci(zens and Permanent Residents Persons who had supplied informa(on for Clearstate or BELRIS surveys

Deni8ons of Acronyms
Acronyms here are dened for beKer understanding of the following report: Term
ART ASRM BELRIS ESHRE ICMR ICSI IVF KICs KOLs MOH MSQH PGD

Deni8on
Assisted Reproduc(on Technology Society for Assisted Reproduc(ve Technology Bioethics Legal group for Reproduc(ve Issues in Singapore European Society of Human Reproduc(on and Embryology Indian Council of Medical Research Intracytoplasmic Sperm Injec(on In-Vitro Fer(lisa(on Key IVF Centres Key Opinion Leaders Ministry of Health Malaysian Society for Quality in Health Pre-Implanta(on Gene(c Diagnosis

Photo: TIME

Chapter 1
Study Background, Objec8ve and Scope

Photo: Santa Monica Reproduc8ve Technologies

Photo: The Straits Times

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 womans fer(l(y. The process many (mes involves In- Vitro Fer(lisa(on (IVF), and the cooling of eggs to sub-zero temperatures (vitrica(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.***

Photo: The Straits Times

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. Sheneld, 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

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 eects 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).*

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

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

Source of Informa8on
Evalua8ng the need for elec8ve oocyte freezing in Singapore done through various primary and secondary research methodologies
Clearstate Quan8ta8ve Survey of Resident Women: The sample size for the survey was 410 respondents aged between 20 to 45 years (95% condence level and 5% condence 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 diversied backgrounds, who represent key womens organisa(ons, were interviewed for this study. 3 of such interviews were conducted. 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

Secondary Research

Photo: TIME

Chapter 2
Evalua8ng the Need for Elec8ve Oocyte Freezing in Singapore
Photo: Santa Monica Reproduc8ve Technologies

Photo: The Straits Times

Rising median age of marriage, rising propor8on of singles, and decreasing age-specic fer8lity rates of women below 35 are seen to impact popula8on trends in 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-specic 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 rst (me marriages for both genders. In 2011, the median age for rst marriage for males was 30.1 years as compared to 28.8 on 2001. Similarly for women, the median age for rst (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-specic 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).
Source: Popula8on Trends 2012, Singapore ##Age-Specic Fer8lity Rates is dened as the number of births registered within a specic age group during the year, out of every thousand female popula8on in the same age group

Chart 1: Age-Sex Specic Marriage Rate#

Source: Popula8on Trends 2012, Singapore

#Age-Specic Marriage Rate is dened as the number of marriages registered within a specic age

group during the year, out of every thousand unmarried popula8on in the same age group

Chart 2: Age-Specic Fer8lity Rates##

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

10

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

Sta(s(cs from the Popula(on Trends 2012 report reect 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 rst child between the age of 31 to 35 years (Chart 4).
30% 15% 0% No Children 6% 15 - 29 Chart 3: Ever-Married Resident Women by Age Group and Number of Children Born (2001 versus 2011) No children
46.7% 42.7%

1 Child
2001
31.1% 36.0% 28.4% 24.5%

2001

2011

2011

20.9% 15.3%

6.7% 9.1%

19.4% 15.7%

3.8% 4.4%

12.9% 10.4%

30 - 39 40 - 49 Above 50 Years

15 - 29

30 - 39

40 - 49 Above 50

Years

Source: Popula8on Trends 2012, Singapore

Chart 4: Age when First Child was Born Men (n=33) Women (n=102) 42% 39% 28% 15% 9% 10%

6% 0%

18 - 25

26 - 30

31 - 35

36 - 40

41 - 45

Source: BELRIS quan8ta8ve survey

References: *Department of Sta(s(cs, Ministry of Trade & Industry. (2012). Popula0on Trends 2012. Singapore (Chart 4) BELRIS Survey, Ques(on: What age did you have your rst child? Base, Respondents who are married n=135

11

Unmarried respondents had indicated that their ideal age to start having children is between 31 to 35 years old, with job/nancial 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/nancial 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
Men (n=20) 35% 25% 0% 0% 18 - 25 26 - 30 31 - 35 50% 41% 5% 18% 5% 6% 41 - 45 0% 4% Above 45 Women (n=51)

5% 6% Does not want Children

36 - 40

Source: BELRIS quan8ta8ve survey

Table 1: Reasons for Delaying Pregnancy

Reasons for Delaying Pregnancy Job/Financial security Rela(onship stability Belief that there will be no problem having children in the late 30s
Source: BELRIS quan8ta8ve survey
(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

Total (n=202) 78% 62% 34%

Men (n=52) 88% 54% 38%

Women (n=150) 74% 65% 33%

12

Low oocyte freezing experience rate in Singapore

Based on the Clearstate survey, 10 out of 410 respondents had undergone oocyte freezing over the past 5 years. Table 2 indicates a mix of respondents who had their oocytes frozen either for medical reasons or as part of fer(lity treatment (i.e. IVF treatment).
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
Number of Respondents For Medical Reasons For Fer8lity Treatment Preserving eggs prior to receiving cancer treatment Either family history of early menopause, endometriosis or premature ovarian failure During IVF treatment 3 (30%) 1 (10%) 6 (60%) Marital Status 2 single and 1 married All married All married

Source: Clearstate quan8ta8ve survey

(Table 2) Clearstate Survey, B31: Why did you get your eggs frozen for medical reasons? Base, Respondents who have undergone egg freezing n=10 Reference: *Source: Licensing & Accredita(on Branch, Ministry of Health. (2006). Direc0ves for Private Healthcare Ins0tu0ons Providing Assisted Reproduc0ve Services. Singapore.

13

Majority of respondents indicated having some knowledge of oocyte freezing technology

72% of respondents stated that they believe they have some knowledge of oocyte freezing technology (Chart 6). The average 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).
Chart 6: Familiarity with Oocyte Freezing Technology (n=400)
I have detailed knowledge of the technology 7% I have some knowledge of the technology 72% I am aware of the existence of egg-freezing but do not have any details of the technology Never heard of it 1% 0%
Source: Clearstate quan8ta8ve survey

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

knowledge

20%

20%

40%

60%

80%

100%

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

No Knowledge At All 1 16% 2 40% 3 4 12% 5 1%

32%

A lot of Knowledge

Source: Clearstate quan8ta8ve survey

(Chart 6) Clearstate Survey, C5: Please indicate Yes if you are aware that egg-freezing can be used for each of the following and No if you are not aware (Table 3) Clearstate Survey, C3: On a scale of 1-5, how would you rate your overall knowledge of egg-freezing technology for women? 1 is no knowledge at all and 5 is have lot of knowledge Base, Respondents who have NOT undergone egg freezing n=400

14

An increasing number of women in Singapore are seeking IVF treatment in recent years
According to a Straits Times 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).*
Chart 7: Number of Women Op8ng for Assisted Reproduc8on Technology (ART) Treatments 3,271 2,627 1,933 2,179 Table 4: Number of Babies Born to Mothers through Assisted Reproduc8on Technology (ART) Treatment

Year 2006 2007 2008

Total Number of Babies 717 804 927 1,158

2006

2007

2008

2009

2009

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

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

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

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

15

Singapore IVF rates are lower than certain developed na8ons; Enhanced government support may raise IVF rates in Singapore
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 gures 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.**** Table 5: Comparison of ART Cycles Per Million Popula8on (2009) Country Denmark Belgium Sweden Germany Italy United Kingdom United States Singapore ART Cycles Per Million Popula8on 2,726 2,562 1,800 830 863 879 2,361 656#

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)
#Number of ART cycles per million popula8on for Singapore is obtained by number of

women who used ART over total popula8on in 2009

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

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

16

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

Yes 71%

No 29%

Source: Clearstate quan8ta8ve survey

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

Extremely successful, 5% Has complica(ons, 12% Not successful; 3%

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

had a child

Some(mes successful; 80%

(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

Source: Clearstate quan8ta8ve survey

17

IVF success rates (both live births and clinical pregnancies#) are seen to decline with the increase in age in Singapore
Ms Tan Su Shan, Nominated Member of Parliament (NMP), directed the following ques(on on the live birth success rates of IVF treatment at dierent 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 ve years, from 2006 to 2010.

On a similar note, the clinical pregnancy success rate of IVF treatment for women 35 years of age and younger is higher than that for women older than 35 years of age, as observed in the clinical pregnancy success rates of IVF treatment reported by 2 clinics in Singapore (Chart 10 and Chart 11).
Chart 10: IVF Clinical Pregnancy Success Rates Reported By A Private Clinic in Singapore By Age (2011)## 66.7% 43.0% 28.6% 28.6% Chart 11: IVF Clinical Pregnancy Success Rates Reported By A Public Clinic in Singapore By Age (2012)## 42.0% 38.0% 16.0% 11.0%

20 - 30

31 - 35

36 - 40

41 - 45

20 - 30

31 - 35

36 - 40

41 - 45

Source: Clearstate qualita8ve interviews with Singapore KICs

Source: Clearstate qualita8ve interviews with Singapore KICs

#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.

18

IVF live birth success rates using fresh versus frozen embryos from pa8ent oocytes
While it has been generally accepted that IVF success rates are seen to decline with the increase in age of a woman, a clinic summary report conducted on all American Society for Assisted Reproduc(ve Technology (SART) member clinics suggests that IVF live birth success rates also dier 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).
Under 35 35 - 37 38 - 40

Chart 12: IVF Live Birth Success Rates Using Fresh versus Frozen Embryos from Pa8ent Oocytes (2011)
46.2% 39.3% 38.4% 35.7% 27.4% 30.3% 24.5% 16.6% 6.5% 16.5%

41 - 42

Above 42

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

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 #
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

19

The response in Singapore for providing single women with the op8on of elec8ve oocyte freezing is generally posi8ve
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 alia(on support single women being given the op(on to undergo elec(ve oocyte freezing in Singapore (Table 6.4).
Table 6: Support for Oocyte Freezing for Single Women across Marital Status, Age Groups, Educa8on Levels and Religions (n=410)
Table 6.1: Breakdown by Marital Status# Marital Status # of Respondents Supports Elec(ve Oocyte Freezing Single, never married 172 90% Married/Divorced/ Widowed/Separated 238 74%

Table 6.2: Breakdown by Age Group# Age Group # of Respondents Supports Elec(ve Oocyte Freezing 20 - 25 71 93% 26 - 30 72 82% 31 - 35 87 84% 36 - 40 94 72% 41 - 45 86 76%

Table 6.3: Breakdown by Educa8on Level# Primary & Post- Secondary Diploma University Educa8on Level lower graduate 4 72 127 175 32 # of Respondents Supports Elec(ve Oocyte Freezing 75% 75% 85% 82% 72%

Table 6.4: Breakdown by Religion#

Buddhism Chris8anity Hinduism Religion 127 91 11 # of Respondents Supports Elec(ve Oocyte Freezing Islam Taoism No Religion Others

42 74%

31 84%

107 83%

1 100%

86%

75%

64%

#Representa8ve samples within each category in the Clearstate survey are slightly higher or lower

Source: Clearstate quan8ta8ve survey

than in the respec8ve na8onal propor8ons (refer to Appendix) (Table 6) Clearstate Survey, E4: Do you think women who cant nd 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

20

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

Chart 13: Belief Regarding Implica8ons of Elec8ve Oocyte Freezing

on Society (n=410) Ethical, religious or moral issues Increase in healthcare cost Singaporeans will be gevng married later Increase in pregnancy related risks Others
Source: Clearstate quan8ta8ve survey

48% 57% 66% 60% 2%

(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

21

The belief that elec8ve egg freezing has poten8al implica8ons in society for ethical, religious or moral reasons, diers 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).

Chart 13: Belief Regarding Implica8ons of Elec8ve Oocyte Freezing

on Society (n=410) Ethical, religious or moral issues Increase in healthcare cost Singaporeans will be gevng married later Increase in pregnancy related risks Others 2% 48% (198) 57% 66% 60%

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)

Table 7.1: Breakdown by Age Group# Age Group # of Respondents Indicated 20 - 25 71 34% 26 - 30 72 51% 31 - 35 87 56% 36 - 40 94 49% 41 - 45 86 49%

Table 7.2: Breakdown by Educa8on Level# Primary & Post- Secondary Diploma University Educa8on lower graduate # of Respondents 4 72 127 175 32 25% 46% 44% 52% 53% Indicated Table 7.3: Breakdown by Religion# Religion # of Respondents Indicated
Buddhism Chris8anity Hinduism Islam Taoism No Religion Others

127 42%

91 57%

11 27%

42 76%

31 39%

107 42%

1 100%

Source: Clearstate quan8ta8ve survey

#Representa8ve samples within each category in the Clearstate survey

are slightly higher or lower than in the respec8ve na8onal propor8ons (refer to Appendix)

(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

22

The belief that elec8ve egg freezing has poten8al implica8ons in society by increasing healthcare cost, diers 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).

Chart 13: Belief Regarding Implica8ons of Elec8ve Oocyte Freezing

on Society (n=410) Ethical, religious or moral issues Increase in healthcare cost Singaporeans will be gevng married later Increase in pregnancy related risks Others 2% 48% 57% (234) 66% 60%

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)

Table 8.1: Breakdown by Age Group# Age Group # of Respondents Indicated 20 - 25 71 59% 26 - 30 72 58% 31 - 35 87 60% 36 - 40 94 55% 41 - 45 86 53%

Table 8.2: Breakdown by Educa8on Level# Primary & Post- Secondary Diploma University Educa8on lower graduate # of Respondents 4 72 127 175 32 50% 61% 56% 58% 47% Indicated Table 8.3: Breakdown by Religion# Religion # of Respondents Indicated
Buddhism Chris8anity Hinduism Islam Taoism No Religion Others

127 57%

91 51%

11 64%

42 64%

31 55%

107 59%

1 100%

Source: Clearstate quan8ta8ve survey

#Representa8ve samples within each category in the Clearstate survey

are slightly higher or lower than in the respec8ve na8onal propor8ons (refer to Appendix)

(Chart 13/Table 8) 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 in that people will get married later, diers 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).

Chart 13: Belief Regarding Implica8ons of Elec8ve Oocyte Freezing

on Society (n=410) Ethical, religious or moral issues Increase in healthcare cost Singaporeans will be gevng married later Increase in pregnancy related risks Others 2% 48% 57% 66% (271) 60%

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)

Table 9.1: Breakdown by Age Group# Age Group # of Respondents Indicated 20 - 25 71 76% 26 - 30 72 71% 31 - 35 87 61% 36 - 40 94 62% 41 - 45 86 64%

Table 9.2: Breakdown by Educa8on Level# Primary & Post- Secondary Diploma University Educa8on lower graduate # of Respondents 4 72 127 175 32 75% 64% 65% 66% 75% Indicated Table 9.3: Breakdown by Religion# Religion # of Respondents Indicated
Buddhism Chris8anity Hinduism Islam Taoism No Religion Others

127 69%

91 65%

11 64%

42 62%

31 68%

107 64%

1 100%

Source: Clearstate quan8ta8ve survey

#Representa8ve samples within each category in the Clearstate survey

are slightly higher or lower than in the respec8ve na8onal propor8ons (refer to Appendix)

(Chart 13/Table 9) 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

24

The belief that elec8ve egg freezing has poten8al implica8ons in society in that it will increase pregnancy related risks, diers 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) Ethical, religious or moral issues Increase in healthcare cost Singaporeans will be gevng married later Increase in pregnancy related risks Others 2% 48% 57% 66% 60% (246)

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)

Table 10.1: Breakdown by Age Group# Age Group # of Respondents Indicated 20 - 25 71 59% 26 - 30 72 64% 31 - 35 87 57% 36 - 40 94 63% 41 - 45 86 57%

Table 10.2: Breakdown by Educa8on Level# Primary & Post- Secondary Diploma University Educa8on lower graduate # of Respondents 4 72 127 175 32 100% 60% 56% 61% 69% Indicated Table 10.3: Breakdown by Religion# Religion # of Respondents Indicated
Buddhism Chris8anity Hinduism Islam Taoism No Religion Others

127 58%

91 56%

11 64%

42 57%

31 77%

107 61%

1 100%

Source: Clearstate quan8ta8ve survey

#Representa8ve samples within each category in the Clearstate survey

are slightly higher or lower than in the respec8ve na8onal propor8ons (Chart 13/Table 10) 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 (refer to Appendix)

25

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 sucient (me to be nancially 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: Likelihood of Op8ng for Elec8ve Oocyte Freezing in the Future for Oneself (n=410) 4% 65% 18% 13%
Chart 14.2: Reasons for NOT Op8ng for Elec8ve Oocyte Freezing for Oneself (n=125)
Large expense involved Physical and emo(onal discomfort in retrieving eggs for egg-freezing Health risks involved

Chart 14.1: Reasons for Interest in Elec8ve Oocyte Freezing for Oneself (n=91)
Preserve my fer(lity with my younger eggs to increase chances of pregnancy later in my life It takes the pressure o to rush into having children un(l I am nancially and emo(onally prepared Freezing eggs as a form of 'insurance' or 'safety net' in case of health problems in future that may aect or damage fer(lity'

18%

54% 34% 37% 22% 14% 35% 15%

60%

Ethical/moral reasons

66%

47%

Planning to have children in the near future I do not think I will struggle to conceive naturally

Others

1%

Source: Clearstate quan8ta8ve survey

Very unlikely Not sure Very likely

Somewhat unlikely Somewhat likely

Others

(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

26

Perspec8ve among respondents on elec8ve oocyte freezing for themselves diers across marital status, age groups, educa8on levels and religious backgrounds
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).
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)
Table 11.1: Breakdown by Marital Status#
Marital Status Single, never married Married/Divorced/ Widowed/Separated

# of Respondents
Somewhat Likely and Very Likely Unsure Somewhat Unlikely and Very Unlikely

172 24% 52% 24%

238 21% 44% 35%

Table 11.2: Breakdown by Age Group# Age Group # of Respondents

Somewhat Likely and Very Likely Unsure Somewhat Unlikely and Very Unlikely

20 - 25 71 21% 54% 25%

26 - 30 72 25% 49% 26%

31 - 35 87 27% 45% 28%

36 - 40 94 18% 47% 35%

41 - 45 86 20% 44% 36%

Table 11.3: Breakdown by Educa8on Level# Primary & Secondary Educa8on Level lower # of Respondents 4 72 0% 15% Somewhat Likely and Very Likely 75% 54% Unsure 25% 31% Somewhat Unlikely and Very Unlikely Table 11.4: Breakdown by Religion# Religion # of Respondents
Somewhat Likely and Very Likely Unsure Somewhat Unlikely and Very Unlikely

Diploma 127 23% 48% %

University 175 22% 46% 32%

Post- graduate 32 38% 34% 28%

Buddhism Chris8anity Hinduism

Islam

Taoism No Religion

Others

127
26% 46% 28%

91
15% 46% 39%

11
46% 27% 27%

42
14% 50% 36%

31
29% 42% 29%

107
21% 53% 26%

1
100% 0% 0%

#Representa8ve samples within each category in the Clearstate survey are slightly higher or

lower than in the respec8ve na8onal propor8ons (refer to Appendix)

Source: Clearstate quan8ta8ve survey

(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

27

The most important reason selected by respondents for not op8ng for elec8ve oocyte freezing for themselves dier across religious backgrounds
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 alia(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).

Table 12: Most Important Reason for NOT Op8ng for Elec8ve Oocyte Freezing for Oneself by Religion# (n=125)
Most Important Reason for NOT Op8ng for Elec8ve Oocyte Freezing for 0neself

Buddhist Respondents
# of Responde nts % Distribu8 on

Chris8an Respondents
# of Responde nts % Distribu8 on

Hindu Respondents
# of Responde nts % Distribu8 on

Muslim Respondents
# of Responde nts % Distribu8 on

Taoist Respondents
# of Responde nts % Distribu8 on

No Religion Respondents
# of Responde nts % Distribu8 on

Large expenses involved Physical and emo(onal discomfort in retrieving eggs for egg-freezing Health risks involved Ethical/moral reasons Planning to have children in the near future I do not think I will struggle to conceive naturally Others

12 6 4 1 2 5 5 TOTAL 35

34% 17% 12% 3% 6% 14% 14% 100%

5 2 2 10 3 9 4 35

14% 6% 6% 29% 9% 25% 11% 100%

1 0 0 0 0 2 0 3

33% 0% 0% 0% 0% 67% 0% 100%

5 0 2 1 2 3 2 15

34% 0% 13% 7% 13% 20% 13% 100%

2 0 1 0 2 2 2 9

22% 0% 12% 0% 22% 22% 22% 100%

7 3 2 2 2 8 4 28

25% 11% 7% 7% 7% 29% 14% 100%

Source: Clearstate quan8ta8ve survey

#Representa8ve samples within each category in the Clearstate survey are slightly higher or

lower than in the respec8ve na8onal propor8ons (refer to Appendix)

(Table 12) Clearstate Survey, D5.1: What is the MOST important reason that deters you from undergoing egg-freezing in the future? Base, Respondents who are unlikely or somewhat unlikely to undergo egg freezing n=125

28

There are Singaporean couples travelling abroad to seek 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 o o Seeking alterna(ve IVF facili(es overseas for treatment a}er mul(ple failed IVF cycles in Singapore. Seeking lower costs of IVF treatment, especially upon exceeding government subsidy limit.# For medical procedures that are restricted in Singapore such as the use of PGD for gender selec(on during IVF treatment.

Table 13: Overview of Singaporean Couples Seeking IVF treatment overseas from Clearstate qualita8ve interviews with fer8lity centres 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. Malaysia A reputable IVF clinic in Johor Bahru sees more than 30 Singaporean couples each year. On the average, the interviewed fer(lity clinics in Bangkok see less Thailand than 10 Singaporean couples each year. On the average, the interviewed fer(lity clinics in Mumbai, India Hyderabad and Delhi see less than 5 Singaporean couples each year. On the average, the interviewed fer(lity clinics in Melbourne and Australia Sydney see less than 5 Singaporean couples each year.
Source: Clearstate qualita8ve interviews with Singapore KICs

#Prior to 2013, the Singapore government had a co-funding limit of S$3,000 per ART cycle for Singaporeans, up to three cycles only

29

Photo: TIME

Chapter 3
Regulatory Scenarios of Selected Countries
Photo: Santa Monica Reproduc8ve Technologies

Photo: The Straits Times

30

Summary of ART Regula8ons in Selected Countries

Table 14: Summary of ART Regula8ons in Selected Countries

Australia
Gender Selec8on in IVF
Prohibited (except for medical reasons) Regulated

India
Prohibited Unregulated, yet prac(ced (legisla(on ini(ated) Unregulated, yet prac(ced (legisla(on ini(ated) Unsubsidised (pay out-of-pocket) Unregulated, yet prac(ced About SGD 6,000 per cycle

Malaysia
Prohibited Unregulated, yet prac(ced (legisla(on ini(ated) Unregulated, not prac(ced Unsubsidised (pay out-of-pocket) Unregulated, yet prac(ced SGD4,000 and SGD 8,000 per cycle

Thailand
Unregulated, yet prac(ced Unregulated, yet prac(ced Unregulated, yet prac(ced Unsubsidised (pay out-of-pocket) Unregulated, yet prac(ced SGD 6,000 to SGD 7,500 per cycle

Singapore
Prohibited (except for medical reasons) Regulated

Regula8ons for ART/IVF

Regula8ons for Surrogacy

Allowed (altruis(c) Subsidised (~75% covered under Medicare) Allowed SGD2,500 to SGD3,000 per cycle

Prohibited

Fiscal Support by Government Regula8ons on Oocyte Freezing Cost of treatment (IVF)

Glossary:
1. 2. 3. 4.

Subsidised (Medisave) Prohibited (for elec(ve/ single women) SGD 6,000 to SGD 13,000 per cycle

Altruis(c: No monetary compensa(on allowed Medicare: Australias publicly funded universal healthcare system Medisave: Singapores na(onal healthcare saving scheme Pay out-of-pocket: Payment from individual funds

5. 6. 7.

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

31

Australia
Australia has regula8ons in place for fer8lity treatment
Table 15: Demographics of Australia Popula8on size Birth rate Infer8lity Cost of IVF Treatment 22,015,576 (July 2012 est.)* 1.9 births per woman (2011 est.)* One in six Australian couple** Out-of-pocket payment for an IVF treatment cycle costs about SGD 2,500 to SGD3,000***

Opinions of KCIs in Australia on Oocyte Freezing Cryo-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 ***

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.****

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)

32

India
India is well known for the provision of fer8lity treatments but remains unregulated
Table 16: Demographics of India Popula8on size Birth rate Infer8lity Cost of IVF Treatment 1,205,073,612 (July 2012 est.)* 2.6 births per woman (2011 est.)* 15 to 20 million couples yearly** One complete IVF cycle at an urban clinic about costs SGD6,000 Costs for freezing and storing the eggs will range from SGD600 to SGD1,000 a year***

Opinions of KOLs in India on Oocyte Freezing**** Cryo-preserva(on of oocytes is currently oered 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 processIndia 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

Regula8ons on IVF and Fer8lity Treatments 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 aordable 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

33

Malaysia
Malaysias market is presently unregulated
Table 17: Demographics of Malaysia Popula8on size Birth rate Infer8lity rate Cost of Treatment 29,179,952 (July 2012 est.)* 2.6 births per woman (2011 est.)* 15%** 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 oered 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

Regula8ons on IVF and Fer8lity Treatments 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/

34

Thailand
Thailand is well known for the provision of fer8lity treatments but remains unregulated
Table 18: Demographics of Thailand Popula8on size: Birth rate: Cost of Treatment 67,091,089 (July 2012 est.)* 1.6 births per woman (2011 est.)* 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 oered by doctors but mainly targeted foreign pa(ents due to low awareness among and aordability 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

Regula8ons on IVF and Fer8lity Treatments 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 ock to Bangkok: hcp://ar(cles.(mesondia.india(mes.com/2010-12-27/india/ 28239140_1_indian-couples-indians-ock-baby-boy

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Photo: TIME

APPENDIX

Photo: Santa Monica Reproduc8ve Technologies

Photo: The Straits Times

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Appendix A: BELRIS Quan8ta8ve Survey Age Prole of Respondents

Not Married, Men Age Group 18 25 26 30 31 35 36 40 41 45 TOTAL # of Respondents 7 9 2 1 1 20 % Distribu8on 35% 45% 10% 5% 5% 100% Respondent Breakdown by Marital Status (n=206)

Married, Men Age Group 26 30 31 35 36 40 41 45 # of Respondents 2 5 10 7 9 33 Married, Women Age Group 26 30 31 35 36 40 41 45 Above 46 TOTAL # of Respondents 6 13 18 42 23 102 % Distribu8on 6% 13% 18% 41% 22% 100% % Distribu8on 6% 15% 30% 21% 28% 100%

Not Married, Women Age Group 18 25 26 30 31 35 36 40 41 45 Above 46 TOTAL # of Respondents 14 11 12 9 2 3 51 % Distribu8on 28% 22% 23% 17%. 4% 6% 100%

Not Married 34%

Above 46

Married 66%

TOTAL

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

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Appendix B: Clearstate Qualita8ve Interviews List of IVF Clinics Interviewed

List of IVF Clinics Interviewed Country Australia City Melbourne Sydney (Branches at Mul(ple Loca(ons) India Mumbai Hyderabad New Delhi Malaysia Johor Bahru Petaling Jaya Singapore Thailand Singapore Bangkok Number of IVF Centres Interviewed 1 1 2 1 1 1 2 5 3 Facility Ownership Private Private All private Private Private Private All private 4 private and 1 public All private

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Appendix C: Clearstate Quan8ta8ve Survey Marital Status of Respondents

Marital Status of Clearstate Survey Respondents (n=410) versus Na8onal Propor8on (2010)*# 62.9%

37.1%
58.0% 42.0%

Single, Never Married Respondents

Married/Divorced/Widowed/Separated Na(onal Propor(on

#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

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

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

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Appendix D: Clearstate Quan8ta8ve Survey Age Prole of Respondents

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

21.0% 17.9% 17.8%

21.2% 17.3% 17.6%

21.9%

21.4%

22.9%

21.0%

20 - 25 years

26 - 30 years

31 - 35 years

36 - 40 years

41 - 45 years

Respondents

Na(onal Propor(on

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

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

40

Appendix E: Clearstate Quan8ta8ve Survey Educa8on Level of Respondents

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

37.6% 27.9% 50.4% 22.4% 12.2% 17.6% 1.0% University & Above
##

31.0%

Diploma Respondents

Secondary

Primary & Lower

Na(onal Propor(on

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

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

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Appendix F: Clearstate Quan8ta8ve Survey Religious Background of Respondents

Religious Background of Clearstate Survey Respondents (n=410) versus Na8onal Propor8on (2010)*#
31.3%

20.3% 15.0% 22.2% 6.1% 10.2% 2.7% Buddhism Chris8anity Hinduism Respondents Islam

18.7%

31.0%

26.1% 8.0% 7.6% Taoism No Religion

0.6% 0.2% Others

Na(onal Propor(on

#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

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

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

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healthcare"

www.clearstate.com

www.eiu.com

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