Louis asked the Minister for Health considering that gender bias for Pre-implantation Genetic Screening (PGS) can now be blinded, whether the Ministry will consider permitting women with recurrent miscarriages or a history of infertility to seek PGS in Singapore.

Dr Amy Khor (for the Minister for Health): MOH had previously received requests to allow Pre-implantation Genetic Screening (PGS) to identify chromosomal abnormalities in embryos created through in-vitro fertilisation (IVF), with the aim of improving the chances of conceiving. We had not granted approval so far as the published evidence had been unclear. In recent years however, newer technologies for PGS have emerged and some jurisdictions have now allowed PGS.

MOH is therefore reviewing the clinical effectiveness of PGS and its ethical implications. To assess clinical effectiveness, NUH will be conducting a three-year pilot PGS programme which will commence by early next year.

MOH will also look into the ethical concerns and regulation of PGS. For example, we will need to ensure that embryos are not eliminated solely based on parental preferences on characteristics such as gender.

MOH will consult stakeholders and the public to gather views.

Louis: Can I just ask her if there is any criteria for this trial that is going to be carried out at NUH for people that want to participate in this trial?

Dr Amy Khor:  The eligibility criteria for people to participate in this trial as well as all the other details, such as funding and so on, are being worked out and will be available closer to the date of commencement.

Source: Hansard (Parliament of Singapore)

Louis delivered his budget cut on Co-funding for ART at Private Hospitals at Committee of Supply 2017 as follow.

Louis: We have a strong focus on urging Singaporeans to start a family and trying to assist those who are not ready to start a family yet. This is important but we should also provide more help for those who want to start a family but are facing difficulties conceiving.

It has been four years since the Government enhanced the co-funding of Assisted Reproduction Technology (ART) treatments and it should be time for us to review this. We currently only provide the co-funding for treatments done at public hospitals. The success rate at private hospitals or clinics may be higher, and as such I hope we can extend the co-funding for the last fresh cycle to be done at private hospitals and clinics. This will help couples who have tried repeatedly at public hospitals and have not been able to have a successful pregnancy. This will also help alleviate the large demand for the ART treatments at our public hospitals.

Source: Hansard (Parliament of Singapore)

Louis asked the Minister for Health (a) what are the reasons for setting the criteria disallowing women below the age of 35 to take part in the three-year clinical trial for Pre-Implantation Genetic Screening (PGS); (b) whether the Ministry will consider lowering this age limit for women; and (c) whether the Ministry will consider allowing women below the age of 35 to take part on a case-by-case basis.

Mr Gan Kim Yong (MOH): Pre-Implantation Genetic Screening (PGS) is a test for chromosomal abnormalities in embryos created through in vitro fertilisation (IVF), before the embryos are implanted into the uterus. MOH recently approved a three-year pilot for PGS. This will commence at the National University Hospital (NUH) in 2017.

Under the pilot programme, patients who fulfil at least one of the following clinical criteria will be eligible

a. Age 35 years old and above, regardless of prognosis
b. Two or more recurrent implantation failures, regardless of age
c. Two or more recurrent pregnancy losses, regardless of age

In other words, women of any age can participate in the pilot if they have had two or more recurrent implantation failures or pregnancy losses. For those without recurrent implantation failures or pregnancy losses, the minimum age is set at 35 years. This is because literature evidence and overseas experience have shown that the chance of a baby born with chromosomal abnormalities for mothers aged 35 and above is significantly higher. Countries such as the UK and Canada have similarly recommended that PGS be made available to women aged 35 years and above, regardless of prognosis.

Source: Hansard (Parliament of Singapore)

Louis asked the Minister for Health for each year in the past three years what is the Assisted Reproductive Technology success rate for public and private centres respectively for couples (i) under 30 years old (ii) between 30 years old and 35 years old (iii) between 36 years old and 40 years old and (iv) above 40 years old.

Dr Amy Khor (for the Minister for Health): The success rates for Assisted Reproductive Technology (ART) decline with increasing age and, in fact, drops precipitously after the maternal age of 35. For public centres, success rates are 29.5% for women below 30, 27.1% for women from 30 to 35, 16.1% for women from 36 to 40, and 6.1% for women above 40. A similar trend is observed in the private centres, where the success rates stand at 26.7% for women below 30, 24.6% for women from 30 to 35, 17.3% for women from 36 to 40, and 6.7% for women above 40.

Our clinical data also shows that overall, from 2013 to 2015, the average ART success rates are 21.3% at the public centres and 19% at the private centres. 

Louis: Thank you, Madam. I thank the Senior Minister of State for the reply. Can I just check with the Senior Minister of State if MOH is going to review the subsidies for ART treatments?

Dr Amy Khor: The ART co-funding was enhanced in 2013 along with the Medisave withdrawal for ACP − that was also enhanced in 2013. We have been monitoring the average bill sizes and we will review if the average bill sizes rise such that it significantly affects affordability.

Louis: Sorry, Madam. Just one more question. Not just the subsidies but also is it possible to increase the number of cycles, at least for those between 36 and 40? I note the success rate does drop but I think the trend is that people are having children much later now.

Dr Amy Khor: I think when we review the age at which we capped the ART co-funding, really it is based on evidence. As shown from statistics, the success rates actually drop drastically after age 35; for women above 40, it is at about 6%. Therefore, we will continue to see what the success rates are, before we consider whether we can extend. But at this point in time, there is no decision to extend this age limit.   

Source: Hansard (Parliament of Singapore)

Louis asked the Minister for Health how many couples and what is the percentage of couples who did not have a successful pregnancy after the three cycles of Assisted Reproductive Technology (ART) treatment that is subsidised by the Government.

Mr Gan Kim Yong (MOH):  Under the assisted reproductive technology (ART) co-funding scheme, eligible couples can receive up to 75% in co-funding from the Government for ART treatment cycles, for a maximum of three fresh and three frozen ART cycles, until the patient reaches 40 years of age.

MOH's AR database captures information on the number of live-births by individual ART cycles, and thus the success and failure rates at each cycle. Of Government-funded cycles of ART between 2013 and 2015, 75.3% were unsuccessful after the first cycle. This figure increased to 79.3% and 81.9% after the second and third cycles respectively. The likelihood of a successful cycle of ART is higher for those who are younger.

Note Please refer to Annex A for the breakdown by year.

Source: Hansard (Parliament of Singapore)

Louis asked the Minister for Health whether the Ministry will consider making neo-natal insurance for IVF compulsory at the point of a positive pregnancy blood test rather than at the point of embryo transfer.

Dr Amy Khor (for the Minister for Health): The Assisted Reproduction Programme (ARP) insurance scheme provides protection against possible high costs in neonatal bills incurred by babies conceived via in-vitro fertilisation (IVF). This is in recognition of the higher risks and costs that these babies potentially face at birth. For example, couples undergoing IVF run a higher risk of multiple pregnancies, and this may result in the premature birth of babies who may need neo-natal intensive care.

Couples are currently required to purchase ARP insurance at the point when they enrol for IVF. This makes the insurance premiums more affordable for all couples using IVF.

MOH is currently reviewing this policy. If the requirement to purchase insurance is deferred to a later stage, such as upon successful pregnancies from IVF, the risk pool will be smaller and the insurance premiums higher. 

Louis: I thank the Senior Minister of State for saying that we are going to review this. One, what is the timeframe of this review? Second, it is not just the time you sign up for the IVF insurance, but also I am wondering whether we can get more companies to offer this neo-natal insurance. Because at this point, only one company offers it. If we can get more companies, then, obviously, the pricing might improve as well. 

Dr Amy Khor: The ARP insurance scheme was awarded via open tender to Great Eastern in 2011. MOH has decided that there is no need to have more than one provider currently because the pool is relatively small. In 2016, there were about 3,500 policies. But we will review this as necessary, going forward.

As regard to the review to our ARP insurance policies, the conditions and criteria, we are looking at this and we are looking at several issues. We will come to a decision in due course.

Source: Hansard (Parliament of Singapore)

Louis asked the Minister for Health whether the Ministry can provide an update on the review it is conducting on getting more companies to offer neo-natal insurance for in-vitro fertilisation.

Mr Gan Kim Yong (MOH): The Assisted Reproduction Programme (ARP) insurance scheme provides protection against unexpected cost of neonatal care incurred by babies conceived via in-vitro fertilisation (IVF), in the event that specialised care is required. It provides a cash benefit of $150 or $300 per day, if the baby is admitted to a Special Care Nursery or a Neonatal Intensive Care Unit (NICU) respectively. Since 1994, couples are required to purchase ARP insurance when they enroll for IVF, as MediShield did not previously cover neonatal conditions.

With the introduction of MediShield Life, it now provides universal coverage for all Singapore Citizens (SC) from birth. It provides coverage of up to $700 per day of normal ward hospitalisation and $1,200 per day of Intensive Care Unit (ICU) hospitalisation. The MediSave Grant for Newborns (MGN), introduced since 2012, can also be used to offset hospitalisation costs, up to the MediSave withdrawal limits of $450 per day. We will also be extending MediShield Life coverage to serious pregnancy or delivery complications, which will take effect from 1 April 2019.

MOH has therefore decided to remove the requirement for couples to purchase ARP insurance before undergoing IVF, effective 1 April 2019. Insurers may continue to offer ARP insurance or similar products, if they assess that there is sufficient demand. Couples who wish to have additional coverage beyond MediShield Life and MediSave, can still purchase ARP insurance or other maternity insurance plans in the private insurance market to meet their needs.

Source: Hansard (Parliament of Singapore)

Louis asked the Minister for Health (a) what is the rationale behind barring women above 45 years old from receiving in-vitro fertilisation (IVF) treatments in Singapore; (b) what is the rationale behind limiting the number of IVF fresh cycles for women above 40 years old; and (c) whether the Ministry is planning to review these restrictions.

Dr Amy Khor (for the Minister for Health): The success rates of Assisted Reproduction (AR) procedures decrease and the likelihood of medical complications and adverse pregnancy outcomes increases with maternal age. It is therefore important that patients are well informed of the risks and outcomes of such procedures.

To protect patients’ interests, the current age limit for AR procedures, including in-vitro fertilisation (IVF), is set at age 45. However, MOH considers appeals on a case-by-case basis.

 In addition, the current IVF limit is set at 10 fresh cycles for women aged 40 and below, and five fresh cycles for women above 40. This is because there are increased clinical risks with multiple cycles of ovarian stimulation and oocyte retrieval. These risks include ovarian hyper-stimulation syndrome (OHSS), bleeding and infection.

 We recognise that recent advancements in AR technology have improved safety of AR procedures in general. The Government reviews these limits regularly and will take into account such technological advancements and other medical and social considerations, including the risk of chronic diseases, pregnancy or delivery complications, and continued low success rates of pregnancy and live births for women of higher maternal age.

Louis: I thank the Senior Minister of State for the reply. I understand the concerns and risks that she mentioned but I think these are concerns and risks that parents should consider and decide whether they want to have a child, and not something that the Government should decide.

So, two clarifications. One, whether MOH will review this policy of restricting the number of IVF cycles after 40 and restricting IVF completely after 45; and, two, how long will such a review take?

Dr Amy Khor: Let me say that besides Singapore, some countries like Belgium and Israel also impose AR age limits due to medical and social concerns of pregnancy and child-bearing at older ages.

In Singapore, the current AR age limit of 45 is set based on empirical evidence that shows that the chances of conception are very low at older ages. In fact, for AR success rates, it falls sharply at age 40, from 17.1% for women of ages between 35 to 39, to less than 7% for women from age 40 to 44. And then it falls further to about 4% for women aged 45 and above. In addition, there are also increased medical risks and complications as well as adverse pregnancy outcomes for women of older ages. As I have said in my reply, this is really set to protect the patients' interests. Nonetheless, MOH does consider appeals on a case-by-case basis.

For the treatment cycle limit of five fresh cycles for women above the age of 40, again this is due to concerns of increased clinical risks with older ages, with multiple cycles of ovarian stimulation and oocyte retrieval. Notwithstanding this, as I have also said, we recognise that there have been recent advancements made in AR technology that have actually improved the safety of AR procedures in general, we regularly review these limits and will take into account such technological advancements as well as professional standards of care and other patient factors. It is an on-going review, so we will make the announcements if we decide to change these limits.

Louis: I just want to make one point. I understand the policy intent but what all this is driving is that these parents who want to have kids are just going to Johor to do the IVF cycles, and that places a lot of undue stress on them to travel to another country to do something that they want to do, which our Government is prohibiting them to do.

Dr Amy Khor: My response will be that, as I have said, even as there are advancements made in AR technology and it is safer, lower risk now to women for the AR procedure, we need to continue to highlight to couples who want children that notwithstanding the advancement in AR technology, the chances of conception, of pregnancy, at older ages have not increased, remain low. The medical risk and adverse pregnancy outcomes also remain. That has to be highlighted, so that they do not have false high expectations of success for such AR procedures at older ages.

Source: Hansard (Parliament of Singapore)

Visit Louis’s Facebook Post for why he raised these questions.

The policies on IVF were revised to offer more support as follow:

• The Government will lift the age limit of 45 years old for women to undergo in-vitro fertilisation (IVF), and will allow some co-funded treatments to be started at a later age.

• The number of assisted reproduction technology (ART) cycles a woman can undergo will also no longer be capped.

Source: The Straits Times

Louis asked the Minister for Health (a) when will the review of the pilot Pre-Implantation Genetic Screening programme be completed; and (b) how will the Ministry determine whether the pilot has been successful.

Mr Gan Kim Yong (MOH): MOH started a three-year pilot on Pre-Implantation Genetic Screening (PGS) in 2017, to test for chromosomal abnormalities in pre-implanted embryos created through in vitro fertilisation (IVF). Under this pilot, women who are 35 years and above, or any woman with two or more recurrent implantation failures, or two or more pregnancy losses were recruited.

Thus far, 298 patients have been enrolled under the pilot study. The pilot is scheduled to end in December 2019. MOH will evaluate the clinical outcomes from the pilot in consultation with experts before deciding if PGS should be a routine clinical service.

The pilot study outcomes include comparing the embryo implantation success rates, pregnancy rates and live birth rates between women on IVF programmes who had received PGS with those who had not received any PGS.  The review will take into consideration the available international evidence concerning PGS testing, the ethical challenges associated with PGS and the regulatory framework that needs to be established for governing PGS.

Source: Hansard (Parliament of Singapore)

(Supplementary Question) Louis: Thank you, Sir. I agree with the Senior Minister of State that our policies should be based on science. But science also tells us that stress faced is a key factor in determining whether an IVF is successful. I think a lot of the couples are very stressed because of the finances involved in an IVF cycle. If MOH can then provide the subsidies, reduce the stress, then, maybe we will have a higher percentage of success for IVF cycles for those age 40 and above.

Dr Amy Khor: I thank the Member for his questions. The fact is that we introduced the Government co-funding scheme for ART procedures in 2008. This was in order to reduce the out-of-pocket payment for couples who want to go through ART procedures at our public AR centres, in addition to being able to use their MediSave for these procedures. We have, in fact, been enhancing this co-funding scheme since then – in 2013, 2018 and just in January this year – in order to support couples in their parenthood aspirations, including couples who may marry later and still wish to try for a child. 

As I have said, such policies have to be objectively determined based on the empirical evidence. What we are doing now is to try and strike a balance between encouraging couples to marry and fulfil their parenthood aspirations early and if they have difficulty conceiving naturally, to receive IUI or ART treatment early, versus the need to also support couples who may marry later and wish to have a child.

We will continue to monitor the clinical evidence and where it is possible and appropriate, we will update the criteria.

Source: Hansard (Parliament of Singapore)

Louis asked the Minister for Health (a) what have been the results of the review of the pilot Pre-Implantation Genetic Screening programme; and (b) whether the programme can be made a routine clinical service.

Mr Gan Kim Yong (MOH): MOH started a three-year pilot on Pre-Implantation Genetic Screening (PGS) in 2017, to test for chromosomal abnormalities in pre-implanted embryos created through in vitro fertilization (IVF). 

The pilot study compares the embryo implantation success rates, pregnancy rates and live birth rates between women who had received PGS, with those who had not received PGS. Thus far, over 350 patients have been enrolled under the study, but only 104 have been tested for PGS, as some of the patients changed their minds after enrolment and proceeded with embryo transfer directly without performing PGS, or decided to freeze their embryos instead. There has also been delayed recruitment due to the ongoing COVID-19 situation.

Of the 104 patients who underwent PGS so far, 60 completed their embryo transfers. This has led to 31 pregnancies with 15 live births, and 8 pregnancies is still ongoing. There is a need to recruit further number of patients into the PGS pilot programme to enable a robust evaluation of the clinical efficacy of PGS.

The review will also take into consideration available international evidence concerning PGS testing, the ethical issues associated with PGS and the regulatory framework that needs to be established for governing PGS, before it can be made a routine clinical service. PGS will remain accessible to eligible patients until the full evaluation is complete.

Source: Hansard (Parliament of Singapore)

Louis asked the Minister for Health whether the Ministry is aware of any scientific studies which suggest that the Pre-Implantation Genetic Screening will negatively affect the success rates of embryo implantation, pregnancy and live births for people who go through in-vitro fertilization (IVF).

Mr Gan Kim Yong (MOH): Published studies on Pre-Implantation Genetic Screening (PGS) have reported mixed findings, ranging from those with favourable outcomes for PGS in selected patient groups, to those that find that PGS does not improve, or may even result in lower, in-vitro fertilization success rates. For example, a 2013 randomised controlled trial (RCT) found that the sustained implantation rate and delivery rate per cycle were significantly higher in the PGS group compared to the control group. However, a 2018 RCT found that PGS did not increase live birth rates in women of advanced maternal age, while a 2011 meta-analysis of RCTs showed lower live birth and ongoing pregnancy rates in the PGS group compared to the control group.

However, given the limitations of the studies (such as suboptimal recruitment), the clinical efficacy of PGS remains widely debated. More data is needed before we can conclude on the clinical efficacy of PGS. 

Source: Hansard (Parliament of Singapore)

Louis asked the Minister for Health whether the Co-Funding for Assisted Conception Procedures (ACP) scheme can be extended to private Assisted Reproduction (AR) centres.

Mr Gan Kim Yong (MOH): Currently, co-funding for Assisted Conception Procedures (ACP) is available at public Assisted Reproduction (AR) centres. Current utilisation rates at our public AR centres are around 70%, and there is sufficient capacity for couples seeking ACP such as Assisted Reproduction Technology treatments and Intra Uterine Insemination. The wait times are not long as patients should be able to commence on the next cycle once they are assessed to be medically ready. This usually takes two to six weeks.  

We recognise that there may be some couples who wish to seek treatment at private AR centres and will study the proposal to extend the co-funding to private AR centres while ensuring charges remain reasonable. In addition, couples who seek treatment at private AR centres can use their MediSave. Up to $15,000 can be withdrawn either from the patient’s or her spouse’s MediSave for ACP, and this helps to reduce the out-of-pocket costs for the procedures.

Source: Hansard (Parliament of Singapore)

Louis held a public consultation to gather feedback from couples undergoing IVF for his 6th Adjournment Motion.

Louis spoke up in Parliament for those undergoing IVF and offered four proposals on how the government can help them.

Louis: Sir, I have shared stories about my children numerous times in this House. Being a parent to Ella, Katie and Poppy has been one of the greatest joys for my wife Amy and I. 

I share so many stories of them because I am so grateful that I have three happy, healthy children. I am grateful for all the lessons they have taught me and they have undoubtedly made me a better person. I love and treasure them so much and I want to share the joys of being a parent with everyone. 

Sir, beyond all these, I am simply grateful that I am able to have kids. Amy and I fought very hard to have children. There was a point in our lives when we could not have kids. 

The story I have shared less is that we were able to have our three children only with the help of in-vitro fertilisation, or IVF.

Going through IVF was like being on an emotional roller coaster ride. It was a journey filled with pain and anguish, excitement and disappointment, and hope and happiness at times. It was financially, physically and emotionally draining. 

We were only able to have a child at our seventh IVF attempt. 

When we were undergoing IVF, I was taking home a salary of about $2,000 a month. We had to pour all our income and savings towards having a child.

Like us, many couples have struggled to conceive. KK Women's and Children's Hospital says 15% of couples are unable to conceive within 12 months of trying for a baby. This number is also increasing. There were over 7,700 assisted reproduction procedures carried out in 2017, up from about 5,500 in 2013 – a 40% increase in just four years.

Fertility is an existential problem in Singapore and the Government has done much, such as expanding the Baby Bonus Scheme, to provide more support to couples in their decision to have children and to lighten the financial costs of raising children.

But I do not think we are doing enough for those who want but struggle to have children. I met several such couples at a dialogue session I organised last November through the Singapore IVF Support Group. The couples spoke candidly about the many challenges they faced and I thank them for sharing their personal stories and passionate recommendations with me. Today, I will share their stories with you and offer four proposals on how the Government can help couples like them.

My first proposal is for the Government to subsidise more cycles of IVF. For most couples, IVF is a story of trying and trying again because only about 18% of attempts succeed. This is not a cheap procedure. Each cycle, each roll of the dice, can cost up to $15,000 at our public hospitals. The Government does help with subsidies for six cycles. Starting from the seventh cycle, you pay the full unsubsidised amount. This is a painful reality for many couples.

One couple I met are Josephine and Winston. They have gone through nine IVF cycles, paying about $20,000 out-of-pocket and $15,000 via MediSave already. Today, they are still without a child and will continue to try. It will cost them.

Another couple I met are Cheryl and Keith. They were luckier. By their sixth cycle, the very last subsidised IVF cycle, they managed to conceive and are now happy parents to a bubbly one-year-old. But they now find themselves in an agonising position of wanting a second child. They wonder: can we really afford to go through IVF unsubsidised?

I should pause here and clarify that nobody chooses to do a seventh cycle of IVF unless they have to. Each cycle involves mood-changing medication, weeks of daily painful injections and multiple visits to the doctor.

We can and we should do more. I am not proposing that we extend subsidies to unlimited cycles of IVF. I propose that we extend subsidies to the seventh and eighth IVF cycles. If needed, we can reduce the subsidies for these cycles to ensure that the scheme remains sustainable. 

Sir, I should add that the Government has previously increased the number of subsidised cycles. This was done about seven years ago and it is time for us to review this again. If the argument is that most couples have a successful pregnancy before or during their sixth cycle, then extending subsidies to the seventh and eighth cycle would not cost the Government much. Why not, then? We should remember that this additional subsidy is meant for couples, such as Josephine, Winston, Cheryl and Keith, who have clearly shown, through years of trying, that they are serious about wanting to become parents. They deserve our support.

My second proposal is to introduce subsidies for pre-implantation genetic diagnosis, or PGD, and allow the balance to be paid out of MediSave, subject to a limit. PGD is sometimes conducted during IVF cycles and it is important in two ways. One, for couples with a family history of genetic disorders, it ensures that the embryo does not inherit serious medical conditions. Two, PGD increases the likelihood of a pregnancy being successful. Studies done by researchers at the University of Valencia and at Japanese hospitals found that PGD significantly reduced miscarriages and increased the chances of pregnancy. This, of course, means happier outcomes for couples. It might also mean lower costs for the Government, as fewer IVF cycles may be needed before a successful pregnancy. 

Yet, for all its benefits, not a single dollar of subsidy or MediSave is available for PGD. PGD can be expensive. For Amelia and Geoffrey, paying $18,000 for PGD was the only way to prevent their second child from inheriting a rare genetic disease that can lead to liver failure. Another couple, Sophia and John, had already faced three miscarriages. They found that a genetic condition was at fault and had to pay $10,000 for PGD to prevent more miscarriages and to avoid birth defects.

I hope the numbers are as big a shock for Members of this House as they were for these couples. These are huge sums of money. 

Sir, my proposal is that we extend the current IVF subsidy structure to PGD. For Singaporean couples, this means a 75% subsidy for PGD for subsidised IVF cycles. PGD is needed only by a small percentage of couples. So, overall subsidy costs for the Government are likely to be limited. We should also allow PGD to be paid using MediSave, subject to a cap, so that MediSave does not get exhausted by such procedures. This is already the case for IVF treatments. Couples deserve their chance to have healthy children and we should support them.

My third proposal is to remove the quota on fresh and frozen cycles for subsidised IVF treatment. Currently, the Government's subsidy of six IVF cycles comes with a condition: three of the cycles must be "fresh" and the other three must be "frozen". I will spare this House the scientific nitty-gritty of what "fresh" and "frozen" mean. But suffice to say, expert opinion is split and the medical literature is inconclusive about whether one is clearly better than the other. Indeed, Minister Gan himself said last October, "The success rates for fresh and frozen eggs are largely comparable."

Sir, I think this quota adds unnecessary stress on couples undergoing IVF. Some couples may need one fresh cycle and five frozen cycles while others may need five fresh cycles and one frozen cycle. Giving couples more flexibility might help reduce the stress and anxiety these couples face and lowering their stress and anxiety levels might help increase their success rate. I propose we drop the three-fresh, three-frozen quota for IVF subsidies. We simply provide subsidies for a given number of cycles, which can be either fresh or frozen.

My final recommendation is about time. Financial subsidies are important but providing people with precious time is also important. I propose we introduce fertility leave for both husbands and wives to take time off work for IVF treatments. IVF is an extremely stressful journey. This is particularly true for working women who have to juggle their career alongside the side effects and time commitments of their IVF treatments. 

Sir, I asked over 160 people who worked while they were undergoing IVF. More than half found it difficult to take time off work for IVF-related treatments. The existing 14 days of sick leave is insufficient for them. Some end up taking no-pay leave and this is a strain on their already tight budgets due to IVF. 

As for men, I believe we want to be with our wife during these tough times. When I spoke with Amelia and Geoffrey, Geoffrey told me that he wished he could take more time to accompany Amelia to her IVF appointments. But he cannot take medical leave to accompany his wife to these appointments.

So, the reality is that even on the sacred topic of making a baby, many Singaporeans are dependent on the goodwill of their employers, and this is not right. I propose that we allow husbands and wives to take several days of fertility leave per year. To ensure the leave is taken for its intended purpose, we can consider requiring employees to furnish MCs from fertility clinics and allow fertility clinics to provide men with MCs when they accompany their wife for their IVF appointments.

In addition to allowing Singaporean women to more easily access IVF treatments, fertility leave also has two additional positive side effects. First, it could help with our fertility rates. South Korea, a country with fertility rates nearly identical to ours, introduced fertility treatment leave as part of their efforts to raise fertility rates. Second, it makes clear that fertility treatments like IVF are not the concern of women alone. The emotional support of their husbands is essential. Just like parenting, conception should be a two-person job.

Sir, let me end by saying that the Government has done a lot in expanding access to and affordability of assisted conception treatments. Over the years, we have introduced the co-funding scheme for IVF treatments, increased the co-funding to more cycles and also increased the co-funding limits. We have also lifted the age limit of 45 years old for women to undergo IVF and extended IVF subsidies to women who are 40 years or older. 

I also raised the issue of pre-implantation genetic screenings, or PGS, previously and I am glad the Government has started a pilot for this. It is also positive news that the Government is considering allowing IVF subsidies to be applied at private fertility treatment centres and is reviewing Government support for PGD and PGS. These are all welcome developments. But we can and we should do more.

In summary, my proposals are, one, increase the number of subsidised IVF cycles from six to eight; two, introduce subsidies for PGD; three, remove the three-fresh, three-frozen quota for IVF subsidies; and, four, introduce fertility leave for all employees.

These proposals will help more couples undergoing IVF and, most importantly, reduce their stress levels as they embark on this stressful but potentially rewarding IVF journey – potentially rewarding for the couples and also for Singapore as we try hard to increase our total fertility rate. 

Sir, I will say again that parenthood has been one of the best journeys of my life. Ella, Katie and Poppy bring us immeasurable joy every single day and, of course, to be honest, immeasurable pain at times as well. My three little ones are, fortunately and unfortunately, as stubborn as me. 

I have more stories to share. Recently, Poppy gave me a kiss in the morning and said, "I love you, daddy" and went back to sleep. I love these warm fuzzy feeling moments. 

I love the silly moments, too. I sometimes find photos Katie has taken of herself on my phone without me knowing and some selfies she took together with me while I was asleep. Those are the only photos on my phone when my centre parting is not perfectly dead-centre. 

And I love the proud moments. Ella will pick up snails and caterpillars and move them off the pavement so nobody will step on them. As they said, "Teaching a child not to step on a caterpillar is as valuable to the child as it is to the caterpillar."

Sir, I hope everyone will have the chance to experience these moments and to share these stories about their loved ones. 

The road here was a difficult one. For Amy and I, as well as Josephine, Winston, Cheryl, Keith, Amelia, Geoffrey, Sophia and John, and many, many other couples, parenthood is a castle with high walls. We must do everything we can to open the gates to those who come knocking. 

I know I am asking for the Government to give out more money, increase our expenditure at a time when our budgets are tight. But what we are offering fellow Singaporeans is a chance to become a parent and that is truly priceless. 

Let me end with a quote, as always. 

"Nothing brings us more elated joy or paralysing fear. Nothing is so wonderful and daunting, heart-breaking and soul-lifting, taxing and exhilarating as raising a child. And certainly nothing will stretch us, inspire us and motivate us to better ourselves quite like being the one that little person looks up to."

I should also end by saying that I am not speaking up to get more subsidies so that I can have more children. Sir, my castle is full. I am terribly outnumbered with a queen and three princesses. This castle is permanently closed.

But, Sir, I know what others are going through and I hope we do more for them so that more couples can enjoy the gift of parenthood.

Ms Rahayu Mahzam(The Parliamentary Secretary to the Minister for Health): Mr Deputy Speaker, Sir, I would like to thank Mr Louis Ng for his passionate speech and for raising the proposals on how greater support can be provided to couples who undergo IVF. We share his concern on the importance of supporting couples with parenthood aspirations. This has always been a whole-of-Government priority for us and we will continue to work towards providing better support for couples in this journey. 

First, let me share some of the efforts made over the years to ensure greater affordability of assisted reproduction technology, or ART, for Singaporeans. The ART co-funding scheme, which was first introduced in 2008, aims to provide co-funding for ART treatments performed at public assisted reproduction, or AR centres – namely SGH, NUH or KKH – for couples where at least one spouse is a Singapore Citizen, or SC. 

Since then, enhancements have been made progressively to better support couples with parenthood aspirations. In 2013, the co-funding quantum for SC-SC couples at our public AR centres was raised from 50% for up to three fresh cycles with a cap of $3,000 per cycle to 75% with a cap of $6,300 per cycle to help defray further costs. At that time, co-funding of 75% for up to three frozen cycles, capped at $1,200 per cycle, was also introduced. Couples were hence able to benefit from co-funding of three fresh and three frozen cycles, or a total of six cycles.

In April 2018, the co-funding cap per fresh cycle was further increased from $6,300 to $7,700 while the cap per frozen cycle was increased from $1,200 to $2,200. With effect from 1 January 2020, we further enhanced Government co-funding to allow up to two of the six existing co-funded ART cycles to occur after the women turned 40 as long as they have attempted assisted reproduction or intra-uterine insemination, or IUI, procedures before age 40. 

Patients can also use MediSave to help offset the out-of-pocket payment at both public and private AR centres. Patients can withdraw up to a lifetime limit of $15,000 from their own or their husband's MediSave Account to pay for assisted conception procedures, or ACPs, which include ART and IUI. There is no cap on the number of cycles and patients may use up to $6,000 for the first cycle, $5,000 for the second cycle and $4,000 for the third and subsequent cycles. These withdrawal limits are designed to strike a balance between supporting couples with their costs of treatment today and helping them conserve funds for their healthcare needs in retirement. 

After co-funding and MediSave usage for the first cycle, eight in 10 eligible SC couples would incur no out-of-pocket expense while nine in 10 eligible SC couples could expect to pay no more than $500. Couples who find themselves unable to cope with unexpectedly large bills – for instance, as a result of complications – even after co-funding, may appeal to use MediSave beyond the current limits to pay for treatment. Such appeals will be considered on a case-by-case basis.

I trust Mr Ng would appreciate that as much as we would like to help as many couples with their parenthood aspirations, we also need to balance the need to meaningfully and responsibly allocate public funds on this. As we work on improving the affordability of ART, we must continue our evidence-based approach to guide our co-funding eligibility criteria. Clinical evidence has shown that the success rate for ART carried out beyond age 40 decreases significantly, with the probability of pregnancy complications also increasing with maternal age.

Success rates are 26.6% for women below 30, 24.6% for women from 30 to 34, 17.1% for women from 35 to 39, and 6.7% for women 40 and above. While the success rate is low in women aged 40 years and above, we acknowledge that there are still successful cases. It is not just a matter of Government funding but the strain of couples to keep trying. Hence, we must continue to encourage couples to marry and start families early in order to maximise the chances of conception. For those who have challenges, we will continue to build a support eco-system for them, but co-funding needs to be feasible and take into account clinical efficacy.  

Mr Ng has requested to introduce co-funding for more ART cycles beyond the existing limit of six cycles. Currently, the number of co-funded ART cycles is set at three fresh and three frozen cycles based on clinical evidence, which shows that the success rate of ART decreases with age as each successive cycle progresses. 

I appreciate Mr Ng's suggestion and understand where he is coming from. At the same time, we should continue to stay grounded by the clinical evidence regarding the efficacy of ART for successive cycles to ensure that Government funding is used in a cost-effective way. It may be useful to note that amongst the women who successfully achieve pregnancy, these women undergo an average of two AR cycles before doing so.

I accept though that this is an emotional process and couples may want to keep trying. Couples can, nevertheless, continue to tap on their MediSave up to the $15,000 lifetime limit. We will monitor the clinical evidence and review the criteria if new data suggests improved outcomes.

Mr Ng also suggested to provide co-funding for preimplantation genetic diagnosis, or PGD, of up to 75% within the six ART cycles.

PGD is currently offered to patients at risk of transmitting serious inheritable diseases that are due to single gene mutations or chromosomal structural rearrangements at around $10,000 to $19,000 per cycle. A pilot study on PGD conducted by NUH has found some evidence that PGD is able to lower the risk of serious disease in the child as well as increase the likelihood of carrying the child to term. PGD, indeed, appears to have benefits which could lead to better outcomes. However, the cost of the procedure is high.

We note Mr Ng's argument that subsidising PGD may mean lower costs for the Government as fewer IVF cycles may be needed before a successful pregnancy. MOH is working to mainstream PGD as a clinical service for couples who need it and is studying whether it is cost-effective to be eligible for subsidies. We will also look at the proposal to allow PGD to be paid using MediSave. We will release more details on this review when ready. Meanwhile, patients continue to be supported by co-funding of other associated costs, such as for AR treatments.

One other suggestion raised by Mr Ng was to provide flexibility for couples to choose between fresh and frozen cycles for the six co-funded ART cycles. Co-funding for three fresh and three frozen cycles is a considered approach that allows couples to freeze and store excess embryos produced from fresh cycles and to follow up with a frozen treatment cycle subsequently.

Co-funding had, in the past, been limited to three fresh cycles only as previous assessments showed that fresh cycles had significantly higher success rates than frozen cycles. However, we understand that, from a clinical perspective, going for more fresh cycles can potentially increase the risks of ovarian hyper stimulation, which is a known complication of fresh cycles.

As the success rates for frozen ART cycles improved over the years and were close to that of fresh cycles in 2009 and 2010, the decision was hence made to extend co-funding to three frozen cycles instead of introducing more fresh cycles to encourage couples to use their frozen embryos left over from previous fresh cycles so that they will not need to go through fresh cycles again just to be eligible for co-funding.

Co-funding a permutation of three fresh and three frozen cycles is expected to be more cost-effective than six fresh cycles as the charges for a frozen cycle is lower than that of a fresh cycle and the success rates of both options are expected to be comparable.

Nevertheless, I agree with Mr Ng that some couples might have different preferences and needs and may, for instance, wish to utilise more frozen cycles instead of fresh cycles. MOH recognises this and is able to cater to such situations. Couples may approach MOH to request to tap on their unutilised co-funding for fresh or frozen cycles.

For example, a patient who has utilised one fresh cycle and three frozen cycles can request for co-funding for an additional frozen cycle since there are two unutilised fresh cycles remaining. The co-funding would be capped based on the limit for frozen cycles and the patient would then have one remaining fresh cycle.

Similarly, a patient who has utilised one frozen cycle and three fresh cycles can utilise their co-funding for an additional fresh cycle since there are two unutilised frozen cycles remaining. The co-funding would also be capped based on the limit for frozen cycles and the patient would then have one remaining unutilised frozen cycle.

Basically, this means that co-funding can be extended to a maximum of six cycles, with a maximum of three cycles co-funded up to the cap for fresh cycles.

Mr Ng has proposed gender-neutral fertility leave for the couple undergoing assisted conception procedures based on the issuance of a Medical Certificate.

Today, women who are undergoing ACPs are entitled to hospitalisation leave, given their medically-invasive nature. This allows them to take time off work to attend the treatments and get proper rest after. Some doctors also provide husbands who accompany their wives for oocyte retrieval or embryo transfer with memos, which certain employers recognise by extending a day off. We encourage employers to be sensitive to the needs of couples who may need to make use of these existing provisions.  

I am sympathetic to calls for more gender-neutral leave but I also recognise that any enhancement to leave provisions for fertility must strike a balance between meeting the needs of employees and employers' operational constraints. In extending or introducing leave schemes, we should avoid inadvertently affecting the employability of individuals who use it.

What is clear though is that all parties can benefit from greater flexibility at the workplace. I encourage employers to be understanding and supportive of their employees, both women as well as their husbands, who are undergoing ART. This could include allowing employees time-off or allowing husbands to work from home to be by their wife's side as she recuperates.  

In conclusion, I would like to thank Mr Ng for his candour in sharing his personal story. Parenthood indeed brings immeasurable joy, as the experiences Mr Ng shared about his "castle" show us.

However, some unfortunately face difficulties in achieving the hopes of becoming parents. We understand how emotional and challenging the journey can be.

I would like to reiterate the Government's commitment towards supporting Singaporean couples in their pursuit for parenthood. The suite of measures that have been rolled out over the years bears testament to how policies are continually reviewed to keep pace with new clinical evidence and achieve more effective outcomes. While we may not be able to meet the demands of each and every couple, we will continue to do our part in providing the best support we can and adopt a balanced, evidence-based approach to serve our citizens better.

Once again, I thank Mr Ng for his suggestions and hope that we can continue to work together on this front.

Mr Deputy Speaker: Mr Ng, you have got less than three minutes for clarifications and that includes Ms Rahayu Mahzam's reply.

Louis: Okay, I will keep it really short. Just two clarifications.

One, I thank the Parliamentary Secretary for sharing that they are going to review subsidies for PGD. Can I just ask how long this review will take and when we can expect the results? Two, just wondering whether we will review the number of subsidised IVF cycles again? Again, as I have shared, it was seven years ago that we reviewed it. Is there an upcoming review for this?

Ms Rahayu Mahzam: Thank you, Deputy Speaker. Mr Ng, the review is still ongoing. We do not have the information that can be released at this juncture. We will update, as and when an outcome arises from review.

In respect to the number of cycles, as I explained, the basis on which the number of cycles for which subsidies and co-funding are given is pegged to clinical evidence. At this juncture, there is no new clinical evidence. If something comes up and it is something that we can review, we will consider the proposals that you have made.

Source: Hansard (Parliament of Singapore)

Subsidies Provided for In-Vitro Fertilisation (IVF) Treatments in Past Five Years and Expected Increase in Subsidies Expenditure

Louis asked the Minister for Health (a) for each year in the past five years, what is the total amount of subsidies provided for In-Vitro Fertilisation (IVF) treatments; and (b) based on current amount of subsidies and data, what is the expected increase in subsidies expenditure where subsidies are provided beyond the current three fresh and three frozen subsidised cycles for (i) an additional fresh cycle (ii) an additional frozen cycle (iii) two additional fresh cycles and (iv) two additional frozen cycles respectively.

Mr Gan Kim Yong (MOH): To support couples in fulfilling their marriage and parenthood aspirations, the Government provides co-funding for patients seeking Assisted Reproduction Technology (ART) procedures, including In-Vitro Fertilisation (IVF), to defray their out-of-pocket costs for such procedures at public hospitals. Eligible couples can receive up to 75% in co-funding from the Government for ART treatment cycles, for a maximum of three fresh and three frozen ART cycles. From 2015 to 2019, annual co-funding provided has increased more than 40% from approximately $14 million in 2015 to $20 million in 2019.  

Government support for ART is based on clinical evidence that the success rate of ART decreases for successive cycles as a woman progresses in age. In 2019, among the 48 couples who utilised their sixth co-funded cycle, close to 75% of the women were aged 35 and above at the time of their sixth co-funded cycle. Clinical data shows that while success rates exceed 24.6% for women aged 34 and below, this falls to 17.1% for women from ages 35 to 39, and falls further to 6.7% for those aged 40 and above. Given the significantly lower success rate for couples undergoing additional co-funded cycles beyond the sixth cycle, it is important that we remain grounded by the clinical evidence when extending co-funding to more cycles at this point, while bearing in mind that the couple will still be subject to the emotional strain faced in each attempt. Hence, we must continue to encourage couples to seek treatment early, in order to maximise the chances of conception.

Co-funding of six cycles hence strikes a balance between providing financial support to couples with parenthood aspirations and ensuring that public funds are used in a targeted way.

Source: Hansard (Parliament of Singapore)

Effects of Introducing Gender-neutral Fertility Leave on Employability

Louis asked the Minister for Manpower (a) whether the Ministry has studied the effects of introducing gender-neutral fertility leave on the employability of the individuals who use it; (b) if so, what are the results of the study; and (c) if not, whether it intends to undertake such a study, or why not.

Mrs Josephine Teo (MOM): From time to time, there are suggestions for a variety of additional leave provisions to be provided. These include caregiver leave for aged parents, compassionate leave for bereaved children and grandchildren, and more annual leave. Mr Louis Ng has also proposed gender-neutral fertility leave and asked if MOM has studied the effects of gender-neutral fertility leave. We thank the Member for the suggestion, and will consider it along with other meaningful studies that can be undertaken as well as resources available. Keen researchers may also apply to the Social Policy Research Council for support.

Over the years, the Government has progressively enhanced leave provisions.  In 2013, we extended two days of childcare leave each year to parents with children aged seven to 12 years old. Later in 2017, we legislated the second week of paternity leave, increased shared parental leave to four weeks, and increased adoption leave for mothers to 12 weeks. More recently, we worked with tripartite partners to introduce the Tripartite Standards on Unpaid Leave for Unexpected Care Needs, which encourages employers to allow employees up to six weeks of unpaid leave to support their unexpected caregiving needs. The Government has led by example to adopt this set of Standards across the public sector.

Further enhancements to leave provisions require careful consideration. The Government has consistently taken a tripartite approach, taking on board the views and concern of employers, unions, and other stakeholders. In this period of heightened uncertainty in the economy and job market, we must also assess the overall impact of concurrent policy moves on employers and employability.

During public consultations on caregiving support, the feedback gathered from workers indicated that flexible work arrangements (FWAs) were more sustainable than leave provisions to help them meet their work and caregiving commitments. The tripartite partners have continuously reviewed and enhanced our efforts to support the provision of FWAs. Today, the vast majority of employees, including caregivers, have access to FWAs. In 2019, about 85% of employers offered some form of FWA. This has increased further during the COVID-19 period. We are doing more to entrench FWAs such as by implementing the recommendations of the Citizens’ Panel on Work-Life Harmony. These include growing a community of Work-Life Ambassadors who will advocate for FWAs and developing sector-specific Communities of Practice that will promote best practices for employers to implement FWAs.

Source: Hansard (Parliament of Singapore)

Louis asked the Minister for Health what is the 25th, 50th and 75th percentile of cycles required for successful pregnancy for those who undergo in-vitro fertilisation.

Mr Gan Kim Yong (MOH): Based on available data from 2008 to 2020, the 25th percentile of cycles undergone by a woman before achieving a successful live birth delivery1 from in-vitro fertilisation is one cycle. The 50th and 75th percentile of cycles is two cycles.

Source: Hansard (Parliament of Singapore)

Louis asked the Minister for Health whether the Ministry will consider requiring doctors to provide medical certificates to husbands accompanying their wives for In-vitro fertilisation (IVF) treatments at public hospitals.

Mr Gan Kim Yong (MOH): Medical certificates (MCs) are issued to patients only on proper medical grounds when they are unwell or unfit for work or school, to allow them to rest and recuperate at home. Due to the medically invasive nature of IVF treatments, women undergoing these treatments are issued MCs for them to take time off work to attend the treatments and get proper rest after.

As is generally the case for individuals who accompany patients for other procedures, MCs are not provided to husbands who accompany their wives for IVF. However, doctors may provide memos to the husbands, which some employers recognise by extending a day off.

Employers are encouraged to be understanding and supportive of the needs of their employees or spouses who are undergoing IVF treatments, and consider exercising greater flexibility at the workplace. This could include allowing husbands time-off, or providing work-from-home arrangements so that they could be with their wives during recuperation.

Source: Hansard (Parliament of Singapore)

Louis asked the Minister for Health whether the Ministry can allow any patient regardless of prognosis to participate in the pilot for Pre-Implantation Genetic Screening (PGS) so as to increase the number of patients enrolled under the pilot study.

Louis asked the Minister for Health (a) what is the average cost for participating in the pilot for Pre-Implantation Genetic Screening (PGS); and (b) whether the Ministry can consider completely subsidising these costs so as to increase the number of patients enrolled under the pilot study. 

Ms Rahayu Mahzam (for the Minister of Health): Under MOH's pilot for Pre-Implantation Genetic Screening (PGS), the intended objective is to improve in-vitro fertilisation (IVF) success rates leading to live births for specific groups of women who have an increased risk for embryos with chromosomal abnormalities. Any woman who fulfills one of the following clinical criteria is eligible for PGS: (a) 35 years and above, regardless of prognosis; (b) suffered two or more recurrent implantation failures; or (c) experienced two or more pregnancy losses.

These eligibility criteria are not set arbitrarily but developed with reference to available international evidence and aligned with clinical practices in overseas assisted reproduction centres.

PGS is a technically complex procedure which carries potential risks, including damage to the embryos during the biopsy, with impact on their subsequent development, and should be reserved for women who fulfil the eligibility criteria to undergo the procedure.

MOH provides substantial funding for the PGS pilot programme. It has extended $1.7 million in funding to support the manpower and operations of the PGS laboratory, and half of the PGS consumables costs. As a result, participating patients are charged only the remaining costs of the PGS consumables which average about $1,100 per test, as well as the cost of the embryo biopsy to remove cells for PGS testing which ranges from $2,500 to $4,500.

PGS is performed together with IVF. For IVF, patients can receive Government support through the Assisted Reproduction Technology co-funding scheme as well as tap on their MediSave.

A total of 367 patients were recruited for the PGS study, more than the targeted 300 patients. MOH will continue to assess the clinical effectiveness of PGS, including looking at overseas data and collecting more data from cases here in Singapore. MOH will also explore options for co-sharing of costs of PGS for patients who are keen to be part of the study, but have affordability concerns. If PGS is included as a mainstream healthcare service, it will then be assessed for means-tested subsidies.

Louis: I thank the Parliamentary Secretary for the reply. I understand, as the Parliamentary Secretary mentioned, over 300 people enrolled for PGS but only about a hundred actually did PGS. So, could I ask MOH what are the main reasons why people did not proceed with PGS. And, two, what steps MOH is taking to increase the enrolment of PGS and decrease the the drop-out rate. And third, the feedback on the ground is that there is a cost issue. So, I hope MOH can look into this and fully subsidise this so that more people can participate in this trial and, hopefully, we can then nationalise it to benefit more people.

Ms Rahayu Mahzam: I thank the Member for the question. The high attrition rate of about 71.7% of enroled subjects before reaching the stage of embryo biopsy and PGS testing, indeed, remains a challenge. Prior to the start of the pilot, the evaluation team had determined that the target of 300 patients with PGS testing would be needed to achieve statistical significance.

As of 30 September 2020, as mentioned earlier, 367 patients were enroled but only 104 had enrolled biopsies performed. Almost half of the patients changed their minds after the ovarian stimulation and fertilisation stage, and proceeded with embryo transfer directly without performing PGS or decided to freeze their embryos instead. Other patients did not proceed with a biopsy due to medical reasons, such as poor quality of the blastocyst or embryo arrest. And of these 69 patients with euploid embryos, 60 underwent embryo transfers. This led to 31 pregnancies with 15 livebirths, eight miscarriages and eight on-going pregnancies.

As the Member rightly pointed out, we do need a bit more data to fully study this to understand its clinical effectiveness. MOH is doing its best to try and assist and support as many patients as possible to go through this process and this remains something that we will continue to review. 

And as far as the cost is concerned, this is something that we understand is a challenge. For the patients who really need support for this, we will look into this matter. But as it is at the moment, there is limited and inconclusive evidence on the clinical effectiveness. We do need to proceed carefully with this process because there is also an impact on the embryo. There is a low risk, but there is still risk to the embryo and we do need to make sure that the right people proceed for this procedure.

Source: Hansard (Parliament of Singapore)

Extension of Assisted Reproduction Technology Co-funding Scheme to Couples above Age 40

Louis asked the Minister for Health whether the Ministry can extend the Assisted Reproduction Technology co-funding scheme to couples where the wife is 40 years or older at the point of marriage.

Mr Gan Kim Yong (MOH): The Assisted Reproduction Technology (ART) co-funding scheme supports couples who face difficulty in conceiving naturally. In January 2020, the scheme was enhanced to allow women who had attempted an ART or Intra-Uterine Insemination (IUI) procedure before 40 years old to tap on up to two of the six co-funded ART cycles at age 40 or later. This aims to encourage couples to start their families early and those with difficulty conceiving to consider the ART procedures early.

The age criterion of 40 years old is set based on clinical evidence that the success rate of conception for a woman who undergoes ART treatment decreases with age, with significantly lower success rate after 40. Nonetheless, we do consider appeals on a case-by-case basis for couples with extenuating circumstances.  

Source: Hansard (Parliament of Singapore)

Extending Pilot for Pre-Implantation Genetic Screening to Private Clinics

Louis asked the Minister for Health whether the Ministry can consider extending the pilot for the Pre-Implantation Genetic Screening to private clinics so as to increase the number of patients enrolled under the pilot study.

Mr Gan Kim Yong (MOH): Pre-Implantation Genetic Screening (PGS) is currently available to any woman who fulfils one of the following clinical criteria: (i) 35 years and above regardless of prognosis, (ii) suffered two or more recurrent implantation failures, or (iii) experienced two or more pregnancy losses. 

At present, eligible patients from all private assisted reproduction (AR) clinics and hospitals can be referred to the three public AR centres, namely, National University Hospital (NUH), KK Women’s and Children’s Hospital, and Singapore General Hospital for in-vitro fertilisation treatment and embryo biopsy. The biopsied samples will then be sent to the NUH PGS laboratory.

The Ministry of Health is reviewing ways to increase patient recruitment to the pilot study, and we will give careful consideration to the Member of Parliament’s suggestion.

Source: Hansard (Parliament of Singapore)

Number of Couples Undergoing In-vitro Fertilisation Treatments in Past Five Years

Louis asked the Minister for Health for each year in the past five years, what is the number of couples undergoing in-vitro fertilisation treatments.

Mr Gan Kim Yong (MOH): Based on available data, the numbers of assisted reproduction treatment cycles undergone by women annually from 2015 to 2019 are as follows (rounded off to the nearest hundred): 7,100 cycles in 2015, 7,200 cycles in 2016, 7,700 cycles in 2017, 8,500 cycles in 2018 and 8,700 cycles in 2019.

Source: Hansard (Parliament of Singapore)

Allowing Patients with Specific Conditions to Exceed MediSave Withdrawal Limits for In-vitro Fertilisation-related Procedures

Louis asked the Minister for Health under what specific conditions do we allow patients to exceed the MediSave withdrawal limits for in-vitro fertilisation-related procedures.

Mr Gan Kim Yong (MOH): MediSave is primarily intended to help Singaporeans put aside savings for their basic healthcare needs in retirement, including hospitalisation expenses, costly outpatient treatments, and premiums for national health insurance schemes. The withdrawal limits for Assisted Conception Procedures (ACP) are designed to strike a balance between supporting couples with their immediate expenses, and preserving sufficient savings for old age.

These limits are generally sufficient to cover the cost of ACP at public Assisted Reproduction (AR) centres, after co-funding. After co-funding and MediSave usage for the first cycle, 8 in 10 eligible Singaporean couples would incur no out-of-pocket expense, while 9 in 10 eligible Singaporean couples could expect to pay no more than $500. 

Nevertheless, some couples may encounter unexpectedly large bills for ACP. Each appeal is assessed holistically and on a case-by-case basis, taking the patient's unique circumstances into account, such as the family's financial and social situation. For instance, we have in the past approved appeals from couples who were unable to afford the cost of their treatment even after co-funding and MediSave use, due to unexpected medical complications during a cycle. 

The Government will continue to support Singaporean couples in their pursuit for parenthood. We will continue to review our healthcare financing schemes for ACP to ensure that they remain relevant and adequate for Singaporeans' needs.

Source: Hansard (Parliament of Singapore)

Louis delivered the following 3 Budget Cuts at Committee of Supply 2021.

Raise IVF MediSave Withdrawal Limits

Louis: Sir, in 2013, the Government started allowing the use of MediSave for IVF, subject to a withdrawal limit per cycle and per patient. Recently, many couples have called for an increase in these limits to better meet IVF costs.  

MOH has said, "Couples who find themselves unable to cope with unexpectedly large bills, for instance, as a result of complications, even after co-funding, may appeal to use MediSave beyond the current limits" on a case-by-case basis. It has been over seven years since we reviewed these withdrawal limits. I hope we can conduct a review and consider increasing the limits on the use of MediSave for IVF and not just on a case-by-case basis. IVF is a costly procedure. It would be a pity for couples who are unable to afford it but have funds in their MediSave, to be denied the gift of parenthood.  

Use MediSave for IVF TCM Treatments

Louis: In the dialogues I have organised on IVF, many couples told me that they have achieved better results from supplementing their IVF treatments with TCM. Some doctors recommend TCM treatment for certain patients as it may optimise results. TCM treatments such as acupuncture can act as a supplementary method for patients to increase their chances of success.  

My wife also, upon the advice of our doctor, did TCM during our IVF treatments. Some might say that TCM does not work, while others say it does, but we can all agree that it does help provide an ease of mind, that we have tried everything we can do to have a successful IVF cycle.   

TCM can be expensive. Couples I have spoken to end up spending around $500 to $1,000 a month, on top of already mounting IVF costs. Can we allow couples to use their MediSave which they are allowed to use for IVF and subject to the current withdrawal limits, for TCM treatments associated with IVF? 

Rollover Excess IVF Co-funding

Louis: Last month, I proposed extending co-funding to the seventh and eighth IVF cycles to support couples who need more cycles to conceive successfully. MOH responded that, "We also need to balance the need to meaningfully and responsibly allocate public funds on this." 

In this case, rather than provide additional funding after the sixth cycle, will MOH allow co-funding leftover from the first six subsidised IVF cycles to be rolled over into the seventh and eighth cycle? Can it also allow any co-funding leftover from the three subsidised fresh cycles to be used for the subsidised frozen cycles?  

These are funds the Government has already budgeted for. It is win-win solution as it allows couples to complete additional cycles using subsidies that we have already budgeted for without additional allocation needed. 

Ms Rahayu Mahzam (for the Minister for Health): Mr Louis Ng asked about supporting couples undergoing IVF. Today, eligible Singaporean couples undergoing Assisted Conception Procedures, or ACP, in public Assisted Reproduction centres can receive co-funding support for the different procedures. 

The co-funding applies to each Assisted Reproduction Technology (ART) cycle, and the patient would either receive the co-funding of 75% of the cost or the capped co-funding amount, whichever is lower. As such, there is no remaining balance to be rolled over. However, MOH regularly reviews the clinical evidence around the number of cycles to co-fund. At present, on average, women undergo two ART cycles before achieving pregnancy successfully. Evidence shows that the success rate of ART decreases with maternal age, as each successful cycle progresses. It is not just about Government funding, but the strain of couples to keep trying. Hence, we must continue to encourage couples to marry and start families early, to maximise the chances of conception.

After co-funding, the current MediSave per-cycle limits are generally sufficient to cover the cost of a ACP cycle at public Assisted Reproduction Centres. As not all couples go through multiple cycles, we have allowed a higher MediSave withdrawal limit for the first two cycles so that more of the lifetime limit can be used. MediSave can be used to pay for all standard procedures for each method of treatment, such as the priming of the uterus, egg recovery and fertilisation processes. However, as Traditional Chinese Medicine treatments associated with IVF are not part of mainstream evidence-based treatment, there are no plans to allow MediSave for their use currently. 

MOH remains committed towards supporting Singaporean couples in their parenting journeys, and will continue to review the MediSave withdrawal limits to ensure they remain relevant and adequate for Singaporeans, as we balance immediate expenses with retaining sufficient savings for basic healthcare needs in old age. 

Apart from supporting couples, we enabled early intervention and enhanced subsidies for vaccinations under the National Childhood Immunisation Schedule, or NCIS, for all Singaporean children at polyclinics, and extended them to CHAS GP clinics across Singapore in November 2020. We have also added vaccines against chicken pox, influenza and pneumococcal disease to the NCIS. 

For Singaporean children up to the age of six, we have extended full subsidies for childhood developmental screenings at CHAS GP clinics, to allow for early detection and timely intervention for any developmental delays. There is also support for their families. From last November, subsidies have been extended to vaccinations under the National Adult Immunisation Schedule, or NAIS, at CHAS GP clinics and polyclinics for all eligible Singaporean adults. 

Louis: Thank you, Sir. I thank the Parliamentary Secretary on the reply on the IVF policies. There is quite a fair bit of good suggestions out there on IVF and that is why I filed so many cuts, Parliamentary Questions and Adjournment Motion. Could I ask whether MOH can consider setting up a citizen workgroup to really deep dive into this issue of IVF here in Singapore?

Ms Rahayu Mahzam: I thank Member for the suggestion. I am sure that this is something we can consider and I will follow up with the Member after the Budget and Committee of Supply debates are over.

Source: Hansard (Parliament of Singapore)

Louis asked the Minister for Health whether couples who have pre-implantation genetically screened embryos stored overseas can have their embryos shipped to Singapore given current travel restrictions during the pandemic.

Ms Rahayu Mahzam (for the Minister for Health): Happy International Women's Day to all! During the pandemic, MOH received appeals from some couples to import their pre-implantation genetically screened embryos stored overseas. 

In reviewing each appeal, the Ministry considered whether processes and standards employed by overseas assisted reproduction (AR) centres are aligned to Singapore’s regulatory requirements under the Licensing Terms and Conditions for AR Services (AR LTCs). The Ministry may on an exceptional basis allow importation of the embryos, subject to conditions. These conditions include: (a) declaration by the overseas AR centre that the relevant requirements under the AR LTCs, including the handling, processing and storage of the embryos, are adhered to; (b) that no other findings besides the presence or absence of chromosomal aberrations are reported, and (c) proper documentation of the screening test results that were provided to the patient and attending physician in our local AR centres. 

Local AR centres which receive the tested embryos must also continue to ensure compliance with the AR LTCs.

Louis: Thank you, Sir. I thank the Parliamentary Secretary for the reply. Could I ask whether we can make this more of a standard application? So, rather than an appeal and on exceptional basis, could we just have an application form during this pandemic where the couples cannot travel overseas to do their IVF during this period, can we have an application form where they can fill in to apply to transfer their embryos back to Singapore?

Ms Rahayu Mahzam: I thank the Member for the clarification. Typically, the applicants or those who are asking for this will usually just write in to appeal to MOH and we would provide them the answer and tell them what the necessary requirements are. But we can look into the suggestion and see how this information can be made more accessible, and perhaps, a form that is simplified for the purposes of this application.

Source: Hansard (Parliament of Singapore)

Louis asked the Minister for Health (a) whether the Ministry is providing assistance to those undergoing assisted reproductive technology procedures overseas but have not been able to continue their treatment due to travel restrictions; and (b) whether the Ministry is considering setting up specific travel arrangements for them so that they can continue their treatment overseas.

Mr Ong Ye Kung (MOH): The Ministry of Health (MOH) has received appeals from couples who were unable to continue their assisted reproduction (AR) treatment overseas due to the COVID-19 travel restrictions, and seeking to import their stored gametes or embryos for treatment in Singapore instead. To support these couples, the Ministry established a process for such appeals to be submitted by the AR practitioners on behalf of their patients. This allows MOH to review such requests expeditiously and facilitate the importation of the gametes/embryos where appropriate. 

Fully vaccinated couples may use the Vaccinated Travel Lanes (VTLs) to travel overseas to continue their AR treatment in these countries. Couples travelling to countries where no VTL arrangement has been set up will be subject to the quarantine requirements both abroad and locally. Alternatively, they may write in to MOH for us to review their request to import their gametes/embryos and continue with treatment locally.

Source: Hansard (Parliament of Singapore)

Louis asked the Minister for Manpower (a) whether an update can be provided on any studies that have been undertaken by the Ministry to study the effects of introducing gender-neutral fertility leave on the employability of the individuals who use it; (b) whether such studies have been or will be conducted and, if so, when will the results of the studies be available; and (c) if no studies have been conducted yet, why not.

Dr Tan See Leng (MOM): I thank the Member for his question. The Ministry had provided an answer to his question a year ago. Since then, we have not undertaken any study on gender-neutral fertility leave. We have also not received any proposals from the research community to study this issue. As explained in the reply last year, researchers could apply to the Social Science Research Council if there is interest.

We will conduct useful studies where we can, taking into account available resources. It is not realistic to undertake every study that is suggested. However, we welcome other stakeholders to conduct robust studies on issues of interest, and to share the findings to enrich the discussion.

Source: Hansard (Parliament of Singapore)

Louis asked the Minister for Health for each year in the past five years, what is the respective mean and median cost in the public hospitals for (i) a fresh In-vitro fertilisation (IVF) cycle and (ii) a frozen IVF cycle.

Mr Ong Ye Kung (MOH): The mean and median charges of a fresh In-Vitro Fertilisation (IVF) cycle and a frozen IVF cycle in local public Assisted Reproduction (AR) centres from 2017 to 2021 can be found in Table 1 below. 

Source: Hansard (Parliament of Singapore)

Louis asked the Minister for Health in the past two years (a) how many applications has the Ministry received to import embryos back to Singapore for Assisted Reproductive Technology procedures; (b) how many of such applications have been successful; and (c) what are the main reasons provided for rejections.

Ms Rahayu Mahzam (for the Minister for Health): Since the process was established in June 2021 to review applications to import embryos back to Singapore for Assisted Reproduction treatment for couples affected by the COVID-19 travel restrictions, MOH has received 62 such applications.

 Of these, 59 applications were successful; three were unsuccessful. Three were unsuccessful as they did not meet the regulatory requirements stipulated in the Licensing Terms and Conditions for Assisted Reproduction Services, such as exceeding the allowed egg donor age limit.

Louis: Thank you, Sir. I thank the Parliamentary Secretary for the reply. Two clarifications. Can the Parliamentary Secretary share what are the other reasons why there was such a high rate of rejection?

Two, I asked earlier whether MOH can establish a standardised application form so that people can just fill in to apply to import the embryos back to Singapore. I think that will help reduce the stigma of couples undergoing IVF and also reduce the stress. So, a standard application, rather than an appeal which makes them feel like they are begging to import their own embryos back to Singapore.

Ms Rahayu Mahzam: I think the Member for the question. Firstly, I just want to express how I understand the anxieties of the couples going through this process, especially during such times. I know their concerns and the urgency of such situations.

I would just like to highlight though that I mentioned earlier that there were 62 applications in total, 59 were successful. So, it is not really a high rate of rejection and really, the rejection was as a result of not meeting the regulatory requirements stipulated in our licensing terms and conditions for Assisted Reproduction (AR) services. So, that is something that they would need to align with.

In respect of the other point about the standard forms for application, I recall that we had this exchange, about a year back, in relation to this matter and Mr Louis Ng had raised this point about making it convenient and using a standard form. We had taken on board Mr Ng's previous suggestion. 

To facilitate the MOH review of the increasing number of appeals at that juncture, MOH developed an online application form, specifically for the purposes of such appeals. A circular was issued on 3 June 2021 to all licensees providing AR services under the Private Hospitals and Medical Clinics Act that set up the conditions for appealing to import gametes or embryos during the COVID-19 travel restrictions and the information that MOH would require the information required to carry out its review. I hope that addresses the Member's query.

Source: Hansard (Parliament of Singapore)

In the White Paper on Singapore Women’s Development, the Government proposed that women aged 21 to 35 in Singapore could soon choose to freeze their eggs regardless of their marital status; but only legally married couples will be able to use the frozen eggs for procreation.

Currently, egg freezing in Singapore is only permitted for medical reasons. This includes, for example, conditions where the treatment is known to affect fertility, or conditions where the risk of ovarian cancer requires the removal of ovaries and fallopian tubes. Elective egg freezing will be implemented with the introduction of the Assisted Reproduction Services Regulations under the Healthcare Services Act in early 2023.

Source: Channel News Asia