Response to Adjournment Motion on “Providing more help for those undergoing IVF”, 4 Jan 2021
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.
Enabling Couples to Fulfil Parenthood Aspirations
2 First, let me share some of the efforts made over the years to ensure greater affordability of Assisted Reproduction Technology (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 (AR) centres (namely SGH, NUH or KKH), for couples where at least one spouse is a Singapore Citizen (SC).
3 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 3 fresh cycles with a cap of $3,000 per cycle, to 75% with a cap of $6,300 per cycle, to help to further defray costs. At that time, co-funding of 75% for up to 3 frozen cycles, capped at $1,200 per cycle was also introduced. Couples were hence able to benefit from co-funding of 3 fresh and 3 frozen cycles, or a total of 6 cycles.
4 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 out of the six existing co-funded ART cycles to occur after the women turn 40, as long as they have attempted assisted reproduction or intra-uterine insemination (IUI) procedures before age 40.
5 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 (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.
6 After co-funding and MediSave usage for the first cycle, 8 in 10 eligible SC couples would incur no out-of-pocket expense, while 9 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.
7 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 rates1 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 ecosystem for them, but co-funding needs to be feasible and take into account clinical efficacy.
Creating a Support Ecosystem that Balances Clinical Efficacy
8 Mr Ng has requested to introduce co-funding for more ART cycles, beyond the existing limit of 6 cycles. Currently, the number of co-funded ART cycles is set at 3 fresh and 3 frozen cycles based on clinical evidence which shows that the success rate of ART decreases with age, as each successive cycle progresses.
9 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 2 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 this criteria if new data suggests improved outcomes.
10 Mr Ng also suggested to provide co-funding for Pre-implantation Genetic Diagnosis (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 $10k to $19k 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.
11 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 3 fresh and 3 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 3 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 3 fresh and 3 frozen cycles is expected to be more cost-effective than 6 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.
12 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 cycle(s). 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 cycle, and the patient would then have one remaining fresh cycle. Similarly, a patient who has utilised one frozen cycle and three fresh cycles can request for 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 cycle, and the patient would then have one remaining unutilised frozen cycle. Basically, this means that co-funding can be extended to a maximum of 6 cycles, with a maximum of 3 cycles co-funded up to the cap for fresh cycles.
13 Mr Ng has proposed gender-neutral fertility leave for the couple undergoing Assisted Conception Procedures (ACPs) based on the issuance of a Medical Certificate (MC). 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.
14 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.
15 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.
CONCLUSION
16 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.
17 Once again, I thank Mr Ng for his suggestions and hope that we can continue to work together on this front. Thank you Mr Deputy Speaker.
---
[1] Based on average ART success rates by patient’s age group from 2014 to 2018.