Providing More Help for Those Undergoing In-vitro Fertilisation

Mr Speaker, Sir, I beg to move, "That Parliament do now adjourn."

Question proposed.

Mr Louis Ng.

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.

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