Singapore faces an existential demographic challenge, with its total fertility rate (TFR) plummeting to a new low of 0.87 in 2026.
This alarming trend is expected to prompt calls for increased government intervention, particularly concerning IVF and Assisted Reproductive Technologies (ART).
Proposed policy actions will likely focus on expanding accessibility through enhanced subsidies and financial support, alongside liberalising restrictive ART regulations.
However, a closer examination reveals two crucial considerations that must precede any policy deliberation.
Firstly, expanding IVF/ART accessibility is unlikely to significantly alleviate Singapore’s demographic crisis.
International data from other developed nations indicates that IVF/ART can contribute, at most, to around 10% to a country’s total live births.
Such modest contribution is insufficient to substantially improve Singapore’s TFR of below 1.0.
Secondly, there are diminishing returns associated with increased public funding for IVF/ARTs. As subsidies and financial assistance expand, they tend to be allocated to more complex and expensive procedures, benefiting a smaller pool of patients with more severe fertility issues.
Therefore, it is imperative to highlight potential caveats regarding policy actions aimed at broadening ART access.
Extending IVF Subsidies To Private Clinics
Many aspiring parents advocate for extending current public hospital IVF co-funding to private fertility clinics, citing reduced waiting times and access to higher-quality medical services.
However, this proposal presents a fundamental contradiction: life-threatening diseases like cancer and heart disease are not prioritized for subsidies in private hospitals.
Furthermore, questions arise regarding the optimal allocation of public funds. Would additional resources be better spent on enhancing and expanding IVF services within public hospitals?
Unlike the public sector, private clinics are driven by shareholder profitability, raising concerns about the cost-efficiency of public funding in such settings.
Normalising PGT-A Procedures
The normalisation of Preimplantation Genetic Testing for Aneuploidy (PGT-A) for genetic screening of IVF embryos is another contentious issue.
Currently, PGT-A is undergoing clinical trials in public hospitals with inconclusive results. Proponents argue for its necessity in Singapore due to the rising trend of older motherhood, which is associated with increased risks of chromosomal abnormalities like Down syndrome.
There have also been calls to financially assist older women undergoing PGT-A, either through direct subsidies or use of Medisave.
Nevertheless, there are several red flags. Numerous large-scale multi-center clinical trials worldwide have consistently shown that PGT-A does not significantly improve IVF success rates.
Consequently, major professional bodies in the United States and United Kingdom caution against its widespread and injudicious application.
Concerns also persist regarding the reliability of PGT-A, with allegations of misdiagnosis leading to the discarding of viable IVF embryos, resulting in lawsuits.
For instance, Australian fertility company Monash IVF compensated 700 former IVF patients A$56 million for faulty genetic testing that compromised their chances of parenthood.
Overcoming Shortage Of Donated Sperm, Eggs, And Embryos
Singapore faces a severe shortage of donated sperm, eggs, and embryos for infertile IVF patients, primarily due to strict prohibitions on monetary compensation for donors.
The Bioethics Advisory Committee (BAC) previously deemed such payments as undue financial inducements. However, with the legalization of elective egg freezing from 2023, a gradual accumulation of unused frozen eggs is anticipated.
These could potentially be donated to infertile older women with poor-quality eggs. An argument can be made that former elective egg-freezing patients should receive partial compensation for donating their unused frozen eggs, as this would reimburse them for medical fees already incurred.
Conversely, it is counter-argued that egg-freezers incur these medical fees for their own reproductive goals, and a subsequent decision to donate does not retroactively transform private treatment costs into donation-related expenses.
Policy Changes On Elective Egg Freezing
Proposals to extend subsidies and Medisave use for elective egg freezing aim to enable younger women with lesser savings to undergo this expensive procedure when their egg quality is optimal. There have also been calls to further extended the curent age limit of 37 years.
However, a fundamental contradiction exists: the overwhelming majority of women who freeze their eggs do not eventually use them, as evidenced by several overseas studies. Estimates suggest that that less than one in 10 of egg freezers will ultimately utilise their frozen eggs, leading to a significant waste of public subsidies or Medisave.
Furthermore, the primary justification for elective egg freezing—the need for more time to find a compatible life partner—is problematic.
In many countries, including Singapore, more women graduate from universities than men, creating a mating gap due to traditional expectations of women marrying men with equal or higher education.
This persistent incompatibility in marriage expectations cannot be resolved by expanding access to egg freezing.
Permitting Surrogacy
The question of permitting surrogacy for infertile patients raises concerns about the potential for an altruistic arrangement morphing into a commercial transaction.
There is a significant risk of black market agencies emerging to covertly source surrogate mothers for Singaporean couples, particularly from less economically developed countries.
This could involve clandestine under-the-table payments to impoverished foreign women, potentially leading to diplomatic fallout from transnational child-custody disputes between Singaporean couples and foreign surrogate mothers.
Expanding IVF Access For Non-Traditional Family Formation
The contentious issue of encouraging non-traditional family formation by permitting single women and same-sex partners to access IVF in Singapore necessitates concurrent policy changes to maintain legal consistency.
For instance, allowing IVF for same-sex partners would be incongruous if same-sex marriages remain prohibited. Similarly, permitting single women to undergo sperm donor IVF would contradict current public housing policies that discriminate against unmarried mothers.
Investing In Emerging ARTs
Calls for government investment in the research and development of newly emerging ARTs, such as in vitro gametogenesis (IVG) and mitochondrial transfer therapy (three-parent IVF), are also anticipated.
IVG, a novel technology for creating functional sperm and eggs from other human body cells, has shown promise in animal studies.
The three-parent IVF technique offers a potential solution for older women with poor egg quality by transferring healthy egg contents from young donors.
The challenge for Singapore lies in its current lack of research in these areas, making it unlikely to lead the race if it attempts to initiate research at this stage.
Given the much smaller pool of patients with extremely severe fertility problems that would require such advanced technologies, a more prudent and cost-effective approach might be to await the maturation of these technologies in other countries and subsequently import them through licensing agreements.
In conclusion, as the government deliberates policy actions on ARTs to address the nation’s low birthrate, it must carefully consider these significant caveats and potential pitfalls to ensure effective and ethically sound outcomes.
Dr Alexis Heng Boon Chin, originally from Singapore, is an associate professor of biomedical science at Peking University, China.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of Ova.
