Baby Steps: 'Toughest period of my life', say women who underwent costly, emotional IVF process. Can more be done to support them?
SINGAPORE — After being diagnosed with endometriosis and fallopian tube blockage in her 20s, Ms Liew M H knew it would be very challenging to get pregnant.
She tried to conceive naturally with the help of traditional Chinese medicine for several years but at 35 realised her biological clock was ticking and she needed something more.
After consulting a doctor at KK Women’s and Children’s Hospital (KKH), she started her in-vitro fertilisation (IVF) journey.
Despite believing, like many, that IVF would be the immediate answer to her prayers, her first cycle failed. So did her second.
It took two years before her third round of IVF worked, and Ms Liew, then 37, became pregnant.
Ms Liew took a break for about two years, before trying again for a second child. She needed to go through IVF again, and, as with her first child, she failed the first two cycles.
By then, she had exhausted the maximum allowable withdrawal of S$15,000 from MediSave for assisted conception procedures.
Desperate, she started searching for cheaper alternatives and found that going to Johor Bahru, Malaysia, would cost less. She was successful in her first embryo transfer at a Johor Bahru clinic.
Speaking about the financial support provided by the Government, Ms Liew said: “The issue comes when there's a limit to it. But there's no limit to the times women like me have to try just to have a successful pregnancy.”
Ms Liew noted that women like herself may need more cycles to get pregnant, and once the limit has been reached, funds for the subsequent rounds will have to come from their own pocket.
“It’s like (the Government) is trying to support us, but it's not well-rounded as there’s a limit (to the coverage). It can be quite stressful because it feels like you have to get pregnant before you hit the limit, otherwise you will end up paying a lot more. That’s a problem we have to think about.”
In baby-scarce Singapore, where the total fertility rate (TFR) has been on a steady decline for decades, advocates say much more should be done to help those couples who do want children but have trouble conceiving.
This includes offering them more financial support for assisted reproductive procedures and access to pre-implantation genetic screenings (PGS) to screen embryos for abnormalities, as well as therapy for emotional support.
ENHANCED SUBSIDIES FOR IVF TREATMENTS
All six women TODAY spoke to about their IVF journey recounted the immense physical and emotional stress involved in the process.
Adding to this was the financial burden, with any couple undergoing IVF spending at least five digits on the procedure.
An IVF cycle involving fresh embryos in public hospitals typically costs between S$10,000 and S$16,000, while the rates could go up to S$25,000 in the private sector.
A frozen embryo transfer, which uses extra embryos stored after the fresh cycle, will cost around S$4,000 to S$5,000.
Because of the S$15,000 withdrawal limit from MediSave for assisted conception procedures like IVF and the less invasive intra-uterine insemination, and the cap on how much can be withdrawn per IVF cycle, most couples pay a portion of the cost out of pocket.
The Ministry of Health (MOH) has said before that such caps were set to ensure that couples do not prematurely deplete their MediSave balances.
A single cycle, which usually takes around six to eight weeks, consists of:
- Fertility checks, including blood tests and physical checks by the doctor to determine if there are any underlying medical conditions causing infertility
- Hormone injections to stimulate ovulation
- Egg retrieval
- Fertilisation process by embryologists
- Embryo transfer
There is also the cost of storing and freezing extra embryos that are retrieved for future use.
Some private clinics offer a one-time fee for a fresh cycle, which includes doctor appointments, injections, retrieval and the implantation process.
However, charges for additional doctor appointments, extra medications to reduce the likelihood of a woman’s body rejecting the embryo that’s been transferred, as well as the cost of procedures to retrieve the most viable sperm, are not included.
In many cases, women go through multiple cycles to conceive. On average, those under 40 achieve at least one pregnancy after three to four IVF cycles but in some cases women require more cycles as the pregnancies are not necessarily viable.
Financial consultant Yao Sueann, 36, for example, busted her MediSave cap from trying to conceive her first child at a private centre in 2018.
She was diagnosed with blocked fallopian tubes at 26 and had to have both tubes removed. When she got started on IVF, doctors found that she had an autoimmune disorder that increased her risk of suffering miscarriages.
Ms Yao underwent three fresh cycles to retrieve viable eggs, with each round costing at least S$12,000, and five frozen embryo transfers at S$8,000 each, which amounted to close to S$80,000 before subsidies.
“My husband and I wrote to MOH to ask if we could use more of our MediSave to cover the costs, but they rejected us,” she said.
In 2022, the couple wanted a second child. This time, Ms Yao underwent another five IVF cycles — one fresh, four frozen — before conceiving, costing her almost S$50,000 with no subsidies available.
“For someone like me with so many difficulties in getting pregnant, the lifetime withdrawal limit of S$15,000 is too little. It would be better if it were S$15,000 per child,” she said.
Meanwhile, marketing project manager Amanda Ong is relieved to have a healthy pregnancy after her second round of IVF. She suffered a miscarriage in June 2023 after her first transfer of embryos.
She was worried about the emotional and financial toll subsequent cycles would have on her, after having spent around S$5,600 after subsidies already.
“I think a lot of people stop doing IVF when they hit the limit. Since the Government is encouraging us to have more babies, it would be good if we could use more of our MediSave,” said the 28-year-old, who is now five months pregnant.
Another form of subsidy couples can tap for IVF treatments is the government co-funding scheme for public hospitals.
Under this scheme, eligible couples can get up to 75 per cent in co-funding from the Government for assisted conception procedures, covering a maximum of three fresh and three frozen cycles.
In some situations, women cannot fully utilise this scheme as they do not have enough embryos for frozen cycles.
Many couples also worry about the long wait time at public hospitals, given how fertility declines with age.
Ms Elissa, 35, who declined to give her full name, and her husband, for example, underwent fertility checks at KKH in 2020, but the results showed no anomalies.
She was given the mildest protocol — oral medication to help ovulation. However, it did not work even after three cycles. She then moved on to another treatment, superovulation and intrauterine insemination (SO-IUI), which involves placing prepared sperm directly into the uterus during ovulation.
But there was still no good news despite trying for another three cycles, and so the couple were put on the waitlist for IVF.
She was told it would be several months before they could get an appointment, and she did not want to wait any longer as she was 33 then.
"I was racing against the clock to get pregnant before hitting the age when doctors would start calling me 'older' or 'at higher risk.' Waiting forever at public hospitals felt like I was just losing time, so we decided to go private instead," she said.
Ms Elissa was successful in her first IVF cycle and has since given birth to a baby girl, but the procedure cost her S$22,000.
Looking back, she said, she wishes she had gotten more financial support from the Government.
“The treatments are very expensive and not all couples succeed on the first try,” she said. “Often, some couples choose to go private because of the shorter waiting time. Going private should not be a reason subsidy is not provided.”
Fertility centre Virtus Health managing director Tim Kwan agreed, noting that public hospitals generally have a longer average wait time of up to three months for an initial consultation.
“If co-funding subsidies are extended to private clinics, this may increase the options for couples and shorten the waiting period to the initial consultation and diagnosis,” he said.
“This also allows Singaporean couples to start their fertility treatment earlier, which in turn bolsters their chances of a successful cycle.”
Ms Rahayu Mahzam, senior parliamentary secretary for health, said in Parliament on Feb 7 that MOH was still in the midst of studying the extension of subsidies to private centres and that there was no timeframe for this yet.
In response to TODAY's queries on the waiting time for IVF, KKH said the number of couples seeking treatment increased by 20 per cent in 2021 after the pandemic.
Dr Liu Shuling, director of the hospital's IVF centre, said this was likely due to travel restrictions and flexible work arrangements, which allowed more patients to start their fertility treatments.
"Then, the centre had to manage the increase in the number of patients in addition to the previous cases, which were delayed – all while gradually resuming its full suite of services.
"The wait time for couples wanting to start IVF was impacted during this period. Despite the challenge, all essential fertility treatments at KKH continued without disruption," she said.
Dr Liu added that since 2023, there has been no wait time for couples seeking IVF treatment. "The patient can commence IVF as soon as she feels well and at her next menses."
ACCESS TO PRE-IMPLANTATION GENETIC SCREENING
Financial stresses aside, many of the women who have undergone IVF told TODAY that they wished they could have also gotten a PGS, which assesses the health of embryos before implantation.
This would have reduced their anxiety about the process, helped them avoid miscarriages or termination and saved their time and possibly money.
But in Singapore, the PGS, also known as pre-implantation genetic testing for aneuploidy (PGT-A), is a restricted service.
MOH launched a three-year pilot study for PGS in 2017, but it is only open to women who are 35 and above, or those regardless of age who have two or more failed IVF procedures or two or more recurrent pregnancy losses.
In 2020, MOH said only 104 patients had undergone PGS thus far and that it needed to recruit more patients into the pilot programme to enable a robust evaluation of the clinical efficacy of PGS.
Nee Soon GRC MP Louis Ng, who has been speaking up in Parliament on providing better fertility support to couples undergoing IVF, said the decision to proceed with PGS should be made by couples who are trying their best to conceive.
“We should leave these options to the couples who are trying, tell them what the risks are, and then they make the decision. It should be their choice, and not the Government’s.”
Under the pilot programme for PGS in Singapore, the cost for each participant after subsidies is an average of S$1,100 for consumables per test, and S$2,500 to S$4,500 for an embryo biopsy.
MOH has stressed that PGS is a technically complex procedure that carries potential risks and ethical concerns, such as damage to the embryos during the biopsy.
It said in 2020 that once the pilot programme is ready to be reviewed, the ministry would 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.
Ms Elissa bemoaned the stringent conditions, which made her ineligible, as she felt strongly about wanting to go for PGS to avoid wasting time.
“We experienced a huge scare with genetic abnormality during our first-trimester screening, which made us feel like it could have been avoided if we were allowed to do the pre-implantation screening,” she said.
“An embryo with abnormalities means there is a high chance of miscarriage. But we had to take our chances.”
According to experts, PGS improves the chances of a successful IVF pregnancy. While the success rate of conventional IVF is about 20 to 30 per cent, advocates say this can be increased to 70 to 90 per cent with PGS.
Due to the restrictions in Singapore, some women cross the border to have their embryos screened at Malaysian fertility clinics, particularly those in Johor.
Mr Ng said that although the lower cost in Malaysia is a major pull factor and cannot be controlled by the Government, changing the current rules on PGS would be a good step towards reducing the number of people seeking fertility treatments across the border.
“Why do we want to force Singaporeans to do it like this? We ought to support those who really want to have kids by giving them better access to procedures back home,” he said.
Monash IVF medical director Dr Kelly Loi said if PGS were more accessible, it would benefit many couples who may otherwise face miscarriages or grapple with the need to consider termination after the implanted embryo is later found to have a genetic condition.
“The fear of gender selection arising from PGS can be mitigated by having a policy in place that does not allow revealing the gender of the embryo to the couple,” she said.
Thomson Fertility Centre’s medical director, Dr Loh Seong Feei, expressed concern that Singapore’s policy on genetic testing might be overly limiting.
“The main purpose is to ensure the transfer of genetically normal embryos, so patients won’t have to go through the emotional distress of terminating pregnancies due to abnormalities, such as Down Syndrome.
“Expanding access to this service could greatly benefit more patients, so they can navigate their IVF journeys smoothly and deliver healthy babies,” he said.
When asked about MOH’s concern that PGS may harm embryos, Dr Loh acknowledged that all procedures carry inherent risks. However, he emphasised the importance of meticulous lab practices by healthcare providers to minimise these risks and optimise outcomes for patients.
“For women undergoing IVF, assessing embryo health before implantation is crucial,” he asserted.
"I’m concerned that those seeking this service may seek alternative options if unavailable locally.”
SUBSIDIES FOR COUNSELLING
The high costs, the physical torment that women have to put their bodies through for the IVF process and the anxiety involved in the whole journey that can culminate in the heartbreak of a miscarriage or termination — all of this makes for an emotional tumult that few are prepared for.
And because of the stigma that still shrouds fertility issues, many of the women who spoke to TODAY said they could not easily open up to friends and family.
Furthermore, given the massive expenses they were already pouring into the IVF process, few could afford to seek therapy.
“It was one of the toughest periods of my life, and I would not wish it upon anyone,” said Ms Elissa.
Having to isolate herself for an extended period to make sure her body was as healthy as possible so she could more easily conceive burdened her mental state.
“Because of how much was at stake, we took extreme measures to stay healthy during the treatment process. We made it a point to stay away from crowded places, gatherings with people and more, for more than two years.”
Then, there were the hormonal injections, which aggravated her mood swings.
“Crying bouts were extremely frequent during the process,” she recalled grimly.
The women TODAY spoke to called for subsidised or free counselling services to be offered as part of the IVF process.
“No one understood what I was going through,” Ms Yao said.
“At the same time, my friends and family members got pregnant easily. I clammed up. I didn’t like to talk to anyone about what I was going through, and sometimes, I was even defensive by telling people they don’t understand me.”
What was especially crushing was having to suffer repeated pregnancy failures and not knowing what went wrong.
“You can do your best to prepare for the retrieval. You eat well, sleep well and exercise regularly, yet you still wonder what went wrong when the doctor tells you the quality of your eggs is not good,” she said.
“Studying for exams and repeatedly failing them is enough to make anyone feel sad and disappointed. These emotions are worse with IVF and pregnancy failures.”
When she received a complimentary emotional counselling session at her second fertility centre, Ms Yao realised the difference that therapy could make.
“(The therapist) helped me open up my thoughts. This experience made me realise how everyone (going through IVF) should have access to emotional counselling. Otherwise, the process would be daunting and hurts your mental health,” she said.
Mr Ng, who himself has three children through IVF, said he hopes that Singapore will consider providing pre-treatment counselling to all couples who are undertaking the journey.
“Going through IVF is like an emotional roller coaster ride, and I believe we can provide counselling not just on the treatment process and finances but coping with the failed cycles and stresses of going through IVF,” he said.
FERTILITY EDUCATION IN SCHOOLS
Prior to starting IVF, the women TODAY spoke to said it was difficult to find helpful resources on a single platform on the IVF journey and they had to piece together information from online forums.
Experts said that Singapore should step up education about fertility.
Mr Kwan of Virtus Health pointed to a study on fertility knowledge in Asia, which showed that 76 per cent of respondents from Singapore reported low-to-moderate knowledge of infertility and conception before they were diagnosed with fertility issues.
“They had limited knowledge of key fertility concepts, and one of the facts they wished they had known earlier would be how infertility treatment success can be age-dependent after undergoing the emotional journey of infertility,” he said.
He advocates that couples undergo early fertility checks, even before they have firmly decided on having children.
“This would enable a prompt diagnosis of fertility issues and shorten the fertility journey from trying to conceive naturally to a successful conception.”
Ms Kimberly Unwin, a co-founder of Fertility Support SG, a community support group started by women facing fertility issues, said public education about fertility should start at a younger age so that the younger generation can understand what fertility is and how it can affect their future.
“And by educating the public in general, there will be more acceptance and understanding of couples who are going through infertility and fertility treatments. Couples will get better support, too,” she said.
Ms Ong, whose infertility struggles were due to her husband’s infertility, said more awareness also needs to be raised on male fertility.
“It should be as clear as the ads you see at the bus stop,” she said.
