The authors have declared that no competing interests exist.
A novel technological innovation called Elective Oocyte Freezing (EOF) has emerged as a solution for women who wish to preserve their fertility to delay childbearing for non-medical reasons. This technology has grown in popularity as women have undertaken a greater role in the workforce and faced the dilemma of balancing work and family. In spite of the rising trend of Singaporean women postponing childbearing to advance their careers, EOF is currently prohibited in Singapore. Many Singaporean individuals have declared this policy to be both outdated and a threat to women’s reproductive rights. However, prior to this survey, no research, to my knowledge, has analyzed Singaporean female professionals' interests in EOF, if made available. Through this quantitative, cross-sectional, 4-part survey, I conclude that if EOF was permitted, encouraged, and subsidised by the Singaporean government, Singaporean women possess a strong interest in freezing their eggs for social purposes This paper further demonstrates an existing positive relationship between 48 Singaporean female professionals’ interest in EOF prior to and following reading an information leaflet. Specifically, after being informed of the social benefits presented by EOF, participants were significantly more inclined to freeze their eggs if such practice was permitted in Singapore. This conclusion suggests that the Singaporean government should re-evaluate their position on EOF in order to facilitate childbearing dilemmas faced by the increasing number of women entering the country’s workforce each year. Additionally, as this policy is currently a subject of debate in Singapore, the implications of this research, revealing Singaporean female professionals’ interest in EOF, create a foundation for both future research and the possible evaluation of this policy. If this conclusion is corroborated with subsequent research, further evidence may substantiate my findings regarding the desires of Singaporean women and possibly result in a change of legislation.
In recent years, women have increasingly entered public spheres of activity. As a result of this increased involvement, many women are choosing to have their first child at an older age, globally known as delayed childbearing
Following the 1950s, as Singapore transformed from a small fishing village to “an economic giant of the Asia-Pacific region,” the efforts of the Singaporean government put forth efforts to encourage female participation in the labor force were evident
Over the past few decades, the global trend of delaying childbearing in high-income countries has emerged due to investment in education, development of a professional career, and difficulties in finding a partner
Unfortunately, as delayed childbearing trends increase, many problems emerge for women. Prior to the age of 30, women have an 85% chance of conceiving within a year
Through preserving the fertility and reproductive potential of a woman's oocytes, EOF serves as “insurance” to help women conceive at later ages
In spite of the social benefits of EOF, the practice is currently prohibited in Singapore under section 6(5), Clause 5.39 of the Private Hospitals and Medical Clinics Act on Assisted Reproductive Services, reading
Essentially, healthy women at peak fertility are not permitted to freeze their eggs under Singapore’s existing policy
International stances regarding EOF differ drastically. In the United States, for example, companies such as Facebook and Apple have subsidized EOF in their employee benefit packages to retain female workers
In regards to the ethicality of EOF, insufficient data on this novel technology gives women a “false sense of security”
Alternatively, the current legislation is highly attributed to the social goals of the Ministry of Social Family and Development. The ministry encourages Singaporeans to “fulfil their marriage and parenthood goals as early as possible”
As medical technologies advance and delayed childbearing rates escalate, EOF has strived to appeal to young women around the world. Research has shown that EOF offers “important benefits to women who anticipate becoming pregnant at an advanced age”
In order to predict Singaporean women’s interest in EOF, we must analyze the interests of women in other developed countries where EOF is permitted. Marcia Inhorn, an anthropology professor at Yale University, utilized a binational analysis to compare the socio-demographic factors that led women to freeze their eggs in the U.S. and Israel. The study found that in both Israel and the United States, the lack of a stable partnership and career building were primary motivators leading women to freeze their eggs
In addition to the motivations of women who have already frozen their eggs, it is also important to highlight the interest and awareness of EOF amongst women who have not previously considered the procedure. In a qualitative survey conducted by Courtney Stanton, the Associate Director of Takeda Pharmaceuticals, the interest and awareness of EOF was analyzed amongst women in the U.S. between the ages of 25 to 35. The findings of this study revealed that 61% of participants expressed “moderate to extreme interest” in EOF after learning about the treatment
Contrary to the interest reported in previous studies, Johanna Kostenzer’s Q-methodology study introduces a new viewpoint regarding EOF found amongst surveyed women in Austria, another country which prohibits EOF (Kostenzer). In this study, Kostenzer identified a common viewpoint amongst participants: “prolonging fertility beyond the fertile life age” is unnatural, and thus should not be permitted through EOF (Kostenzer). Supporting this viewpoint, one participant claimed in the qualitative interview that egg freezing “should - if at all - only be allowed in exceptional cases” (Kostenzer)
Essentially, women in countries that permit EOF, such as the U.S., have shown interest in the treatment, as demonstrated in Stanton’s study. On the other hand, concerns persist amongst women in countries that do not permit EOF, such as Austria.
Differences in perceptions of women internationally, as well as their level of interest in the procedure, beg the question of interest within Singapore. In a cross-sectional survey by the Journal of Obstetrics and Gynecology Research, Dr. Shu Qi Tan, a medical officer of KK Women's and Children's Hospital, breached the surface of this discussion. In her study, Dr. Tan surveyed medical students, assuming that EOF awareness is “higher among this medically inclined group”
In summary, while participants in Kostenzer’s study disapproved of EOF, the findings by Tan, Inhorn, and Stanton highlight the existing interest and various motivations leading many women to freeze their eggs. Altogether, these findings demonstrate the research that has been conducted on this topic, as well as reveal the potential gaps in the research, acting as a basis for further investigation.
Although studies have explored the interests of women around the world in freezing their eggs, the extent to which permitting EOF in Singapore would appeal to a range of Singaporean women has yet to be investigated. Such a study could contribute to this field of research by highlighting unexplored interest that Singaporean women may have on a procedure that is both growing in public interest and is “revolutionary for women’s choices”
Specifically, the question I intend to answer is:
The initial hypothesis is that after learning about EOF, Singaporean female professionals will be more interested in freezing their eggs if government actions are taken to legalize, encourage, and subsidize EOF in Singapore. In other words, women would be highly interested in EOF to preserve their oocyte’s reproductive potential and delay childbearing.
Currently, an estimated small number of Singaporean women have travelled overseas to freeze their eggs for elective purposes. A quantitative study conducted by Clearstate, a Healthcare Research Consultancy, explored the annual number of Singaporeans that freeze their eggs at fertility clinics in countries nearby to Singapore. In Thailand, the interviewed fertility clinics see an average of 10 Singaporean couples each year
The cost of storing eggs ranges from $600-1,000 SGD a year, and in Thailand, the cost of using stored eggs to undergo In Vitro Fertilization (IVF) treatment ranges from $6,000-7,5000 SGD per cycle
In March 2021, Cheng Li Hui, a Singaporean Member of Parliament, proposed the revisitation of existing policy on EOF
In this study, I utilized a quantitative cross-sectional method. Quantitative methods “emphasize objective measurements and the statistical, mathematical, or numerical analysis of data” in order to collect numerical data and “generalize it across groups of people” to explain a phenomenon
Cross-sectional studies are defined as “observational studies that analyze data from a population at a single point in time,” or in other words, taking a “snapshot of a group of individuals”
The participants of this survey comprise 48 Singaporean female professionals between the ages of 20 to 39. I chose to survey only females as egg-freezing does not require sperm – unlike fertilized egg-freezing, the more commonly used IVF treatment, does (“Egg Freezing”)
Additionally, for this study, a professional will be defined as “a person who has the type of job that needs a high level of education or training”
Lastly, from 2000 to 2011, the percentage of childless women between the ages of 30 to 39 rose 8.6% - higher than any other age group recorded
I began by creating a 3-part survey using Google Forms. Prior to the questionnaire, I provided an introduction including minimal information about the study. The introduction is included below in Appendix A.
The first section of this survey included two parts: a Demographic Information Sheet (DIS) and Initial Assessment Questions about EOF. The questions were derived from my seminal source, a study by the Journal of Obstetrics and Gynecology Research entitled “Social Oocyte Freezing: A Survey Among Singaporean Female Medical Students”
After completing the Demographic Information Sheet and the Initial Assessment multiple-choice questions from Section 1, participants were asked to read an information leaflet, which was derived from Tan’s study
Ultimately, after reading the information leaflet, participants concluded the survey by responding to prompts on a Likert-Scale. These prompts focused on the participants’ “intentions for (EOF) if made available” in Singapore
Disagree” (1). I chose to use a 5-point scale to ensure I was collecting the most diverse data. The following statements are included below in Appendix D.
After collecting my responses, I closed the survey and transferred the collected data into Google Sheets. The results are included in Appendix E.
In each row, the most selected sentiment is highlighted. For example, in response to the statement “If Medisave covered oocyte freezing, I would be more amenable to freezing my eggs,” the majority of participants responded by selecting “strongly agree.” Thus, that box is highlighted.
Following the organization and grouping of the general collected data, I grouped responses into three subgroups, based on age, religion and responsiveness to information on egg freezing. In addition, participants responded both before and after reading the information leaflet to a question regarding their interest in freezing their eggs.
Once all the data was organized, I calculated whether or not the difference between each subgroup was statistically significant using a two-sample t-test. This test compares the means of two independent groups to determine whether statistical evidence indicating that two groups are significantly different exists
The first subgroup I analyzed was based on age. The general cohort, ranging from Singaporean women between the ages of 20 to 39, were split into two subgroups. The first group, comprising 20 participants, included women aged 20 to 29. The second group, comprising 28 participants, included women aged 30 to 39. For each statement presented on the Likert-scale, I used the aforementioned t-test method to calculate whether the difference in responses between the two age groups were statistically significant. The data for two of the eight statements are included in
I would consider freezing my eggs at some point in time (after reading the information leaflet) | ||
Age Group 20-29 | Age Group 30-39 | |
Mean | 3.8 | 3.571428571 |
Standard Deviation | 1.151657844 | 0.8789122667 |
p-value from |
||
I would consider oocyte freezing to focus on my career and postpone family planning | ||
Age Group 20-29 | Age Group 30-39 | |
Mean | 3.7 | 3.29 |
Standard Deviation | 1.031095483 | 0.9533267587 |
p-value from |
The p-value calculated for all 9 statements between both age groups proved to be statistically insignificant, confirming the null hypothesis that no statistically significant difference exists based on the age of participants. In other words, the p-value was always greater than 0.05, which indicates that there is no statistically significant difference in regards to interest in egg freezing based on age. As shown above in
The second variable I analyzed was based on the religious affiliations of the participants.
As many religious groups are “strongly opposed” to egg freezing
I would consider freezing my eggs at some point in time (after reading the information leaflet) | ||
Non-Religious | Religious | |
p-value from |
||
Social egg freezing should be offered to women of all ages | ||
p-value from |
Out of all 9 statements, only one proved to have a statistically significant difference on the basis of religion: “Social egg freezing should be offered to women of all ages.” This analysis highlights that non-religious Singaporean women are more accepting of the idea of allowing
women of all ages to freeze their eggs compared to their religious counterparts. However, in terms of participants’ personal interest, which were addressed in the remaining 8 statements, no statistically significant difference was found between non-religious and religious participants.
The last variable I analyzed using the t-test was whether participants’ interest changed after reading the information leaflet. Prior to reading the information leaflet, in Section 1 of the survey, participants were asked “Would you consider freezing your eggs at some point in time?” Participants responded to this question by selecting one of three response options: “Yes,” “I don’t know” and “No,” which represented values 3, 2, and 1, respectively. Similarly, after reading the information leaflet, in Section 3, participants responded to the statement “I would consider freezing my eggs at some point in time” presented on the 5-point Likert-Scale. The response options ranged from “Strongly Agree” (5), “Agree” (4), “Undecided” (3), “Disagree” (2), and “Strongly Disagree” (1). I assessed whether the differences in responses before and after reading the information leaflet were statistically significant. If the difference were statistically significant, such results could reveal the importance of informing Singaporean women about EOF to accurately assess their interest.
While calculating the p-value for these two values, a limitation emerged. Since the Section 1 question was presented on a 3-point scale whilst the Section 3 prompt was presented on a 5-point scale, I could not directly compare the two sets of data. In order to create the most accurate comparison, I converted both scales to 3-point scales. I accomplished this by having both “strongly agree” and “agree” represent 3, “undecided” represent 2, and both “disagree” and strongly disagree” represent 1 for the Section 3 responses to align with Section 1’s 3-point scale. The data for the before and after question is included in
I would consider freezing my eggs at some point in time | ||
Before Reading Information | After Reading Information | |
Leaflet | Leaflet | |
0.8789122667 | ||
p-value from t-test 0.0388948947 |
Overall, the difference in interest amongst all 48 participants proved to be statistically significant, resulting in a p-value of 0.03. Participants were significantly more likely to express interest in EOF subsequent to reading the information leaflet, which included information about the cost, success rates, and social benefits provided by social egg freezing. This demonstrates the importance of educating Singaporean women about egg–freezing in order to accurately assess their interest.
Ultimately, these findings support the initial hypothesis that after learning about EOF, Singaporean female professionals would be more interested in freezing their eggs if government actions are taken to legalize, encourage, and subsidize EOF in Singapore. The average response to all 9 prompts assessing women’s interest in EOF lied between 3 and 5, or “undecided” and “strongly agree.” This indicates that the majority of participants demonstrated at least some interest or consideration in regards to freezing their eggs. More specifically, participants were most interested in freezing their eggs if the treatment was subsidized by the government or covered by Singapore healthcare programs, such as MediShield Life.
The results of this study suggest that women are interested in freezing their eggs and would likely do so if further steps were taken by the Singapore government to legalize, encourage, and subsidize EOF in Singapore. With respect to the age group and religious affiliation of the participants, no significant difference in responses were identified. This signifies that Singaporean females between 20-39, whether they are religiously affiliated or not, are likely to express interest in freezing their eggs. While the variables of age and religion proved to be statistically insignificant, one variable did result in a significant difference: the presence of an information leaflet. Participants were significantly more likely to express interest in egg-freezing subsequent to reading the information leaflet, which included information about the cost, success rates, and social benefits provided by EOF, highlighting the importance of educating Singaporean women about EOF to accurately assess their interest.
While this study provided new insights into the interest of Elective Oocyte Freezing amongst Singaporean female professionals, the limitations of this research must be addressed.
An initial limitation to this study was the sample size of 48 participants. While participants ranged in age groups, religious affiliations, and races, the interests of 48 participants is not representative of the entire population of Singaporean female professionals. If this research were to be used to provide a strong argument as to why legalizing EOF in Singapore would reflect Singaporean’s best interests, more participants are needed.
Another limitation to this research is that as the survey was sent out electronically and recorded anonymously, I was unable to account for who had and had not completed the survey. Therefore, it is important to recognize that those who did participate in the survey might have had an inherent bias or prior interest in freezing their eggs, as opposed to those who chose not to take the survey. Unfortunately, due to the feasibility and confidentiality of this survey, this limitation is unavoidable.
Lastly, participants were collected through Singaporean women’s rights organizations, such as AWARE, who have previously lobbied in support of policy to expand female reproductive rights. Thus, associated participants may have been more amenable to the idea of legalizing a practice like EOF. In future research, participants should be selected through a method that is more random of the population as a whole to reduce bias.
While there are limitations to be accounted for, ultimately, the findings of this survey provide a gateway for future research on egg-freezing in Singapore, an ever-evolving topic of discussion. This study has scratched the surface of the gap of research regarding Singaporean female professionals’ interest in freezing their eggs if EOF was permitted. However, if Singaporeans want to provide sufficient reasoning as to why reforming the current policy on egg freezing is necessary, further research must be completed.
In subsequent studies, researchers should examine the effects that permitting EOF would have on familial structures and culture in Singapore. For instance, the aforementioned Ministry of Social Family and Development worry that egg freezing will “inadvertently cause more to delay marriage or parenthood”
Similarly, in 2019, the Singaporean government declared that they are working to create more opportunities for citizens to play a “bigger role” in addressing policy making issues
Another aspect to address in future research is the effect permitting egg freezing could have on increasing Singapore’s low fertility rate. Ever since reaching “below replacement” fertility levels in 1975, Singapore has been suffering an extremely low fertility rate
Instead, in order to increase Singapore’s fertility rate, the government should “change the economic and social institutions, regulation affecting working conditions, and popular norms” to more readily combine work and child-rearing
Overall, as this discussion on whether egg-freezing should be permitted in Singapore persists, especially with the call to action by MP Cheng Li Hui, this study and further research will be essential to reverse Singapore’s outdated policy. More importantly, it will provide Singaporean women with reproductive insurance so they no longer have to make the difficult choice between work and family.
This information leaflet is derived from a study completed by the Journal of Obstetrics and Gynaecology Research by Dr Tan Shu Qi, Medical Officer of KK Women's and Children's Hospital. Please read and respond to the questions on the following
There is an increasing trend for young women to delay their childbearing plans till later in their reproductive years. This is largely attributed to postgraduate academic pursuit and higher levels of professional achievement. Studies have shown a trend for young women to delay their child bearing age. However, the ability to conceive is strongly influenced by a woman's age. Older women more commonly experience subfertility by the time they are ready to become pregnant. As many women started to become aware of the age‐related decline in fertility, interest in the emerging technologies of fertility preservation has grown. Our study aims to look at societal opinions on social oocyte freezing to halt the effects of time on reproductive function.
Fecundity refers to the ability to reproduce. The fertility of a woman is mainly influenced by her age. The progressive loss of oocytes that occurs from fetal life until menopause is one of the defining features of the age‐related decline in female fertility. The oocyte pool peaks at birth. Subsequently, progressive atresia occurs, and happens at an accelerated rate after the age of 37 in normal women till menopause.As the number of oocytes declines over time, the quality of oocytes also declines, resulting in an increased prevalence of aneuploid oocytes due to dysfunctions of the meiotic spindle. Studies have consistently demonstrated a declinein pregnancy rates with advancing maternal age, with higher rates of miscarriage among older women. These relationships are best illustrated by outcome data from clinics performing in vitro fertilization. With age‐relate decreasing fecundity coupled with the delay in childbearing age in modern society, Leridon et al.1 have shown that this has resulted in an up to 73% increase in need for fertility treatments
The first successful pregnancy from oocyte cryopreservation was reported in 1986. However, oocyte freezing is still regarded as a relatively experimental procedure by most major regulatory bodies in the United States and Europe, particularly for social Indications. This is due to concerns about the procedure's success rates and safety for future offspring. However, with improving techniques like vitrification for oocyte freezing, there is an increasing trend for social oocyte freezing, especially in ladies who are postponing childbirth to a later age. For women who do not have a participating male partner and are not interested in using donor sperm, oocyte cryopreservation is generally the preferred option until a suitable partner is found
Traditionally, oocytes are frozen via slow freeze method, but with poor outcomes. Vitrification is a relatively new approach to oocyte freezing. The first reported live birth from vitrified human oocytes was in 1999. It is based upon the principle that metabolically active cells can be cooled so rapidly that ice does not have time to form. Successful use of vitrification procedures has been reported in animal models, and the number of human live births resulting from vitrification of oocytes is encouraging. Several case series showing promising results have been published. A meta‐analysis including five reports on vitrification estimated fertilization rates of 74 percent (637/859), clinical pregnancy rates per transfer of 45.5 percent (61/134), and live birth rate per transfer of 36.6 percent (49/134).
Potential candidates will generally undergo baseline ovarian reserve testing prior to initiating treatment. The processes of embryo and oocyte cryopreservation are identical to that of in vitro fertilization up until the time of the oocyte retrieval. Controlled ovarian hyperstimulation with daily injectable gonadotropins is initiated in the early follicular phase or after an interval on the birth control pills, and continues for approximately 10 to 14 days to achieve multiple peri‐ovulatory follicles. The oocyte retrieval is performed via needle aspiration utilizing transvaginal ultrasound guidance, typically under conscious sedation. Mature oocytes retrieved are frozen on the day of the oocyte retrieval.For sufficient oocyte collection (usually about 20 oocytes), 3 cycles of oocyte stimulation and retrieval are usually required. COST The cost of embryo and oocyte cryopreservation procedures is comparable to that of in vitro fertilization. A single cycle including monitoring visits, surgical, anaesthesia and embryology is approximately $8000. For 3 cycles, the cost is estimated at $24 000. Annual storage fees are approximately $400 per year.LONG TERM FOLLOW UP OF CHILDREN There is limited data on the long term follow up of children for oocyte vitrification techniques. In the largest study, Chian et al.3 (2008) reported data on 200 children. The mean birth weight was 2920 grams for singletons and 2231 grams for multiples. The low birth weight rate among singletons was 18% and among multiples 80%. The premature delivery rate was 26% for singletons and 71% for multiple pregnancies. The incidence of congenital malformations was 2.5%. A review by Wennerholm et al.4 revealed a total of 221 successful infants born via this technique, but there is no long term child follow up data for cryopreservation techniques as of now
In Singapore, however, under section 6(5) of the Private Hospitals and Medical Clinics Act on Assisted Reproductive Services, known as CAP 248, clause 5.39 states that “AR Centres shall only store gametes and embryos if such storage is medically indicated or where the gametes and embryos have been donated for research,” signifying that Singaporean women are unable to freeze their eggs for non-medical or social purposes. With this law, various problems emerge for Singaporean women. As women’s oocyte fertility begins to decrease in their 30s, making it more difficult for older women to have children, by prohibiting oocyte freezing for social purposes, Singaporean women could potentially be faced with the predicament of whether to risk advancing their careers to get married and start a family while their eggs are still fertile or risk having kids to achieve leadership positions in the workforce (Khoo 2014)
Vitrification of oocytes promises to be an effective method of fertility preservation for women. We would like to gauge the opinion of future professional women, such as yourself, on fertility preservation with oocyte cryopreservation.
STRONGLY AGREE(5) | AGREE (4) | UNDECIDED(3) | DISAGREE (2) | STRONGLY DISAGREE (4) | ||
I would consider oocyte freezing if I have no suitable partner yet | ||||||
I would consider oocyte freezing to focus on my career and postpone family planning | ||||||
Even if I had to pay with self-cash, I would still be interested in freezing my eggs | ||||||
If MediShield Life covered oocyte freezing, I would be more amenable be more amenable eggs | 21 | 20 | 3 | 3 | 0 | 4.255 |
If there is government subsidy available for egg freezing, I’d be more amenable to freezing my eggs | 21 | 20 | 4 | 3 | 0 | 4.229 |
If the government legalized Elective Oocyte Freezing, I would be interested in freezing my eggs | 19 | 16 | 9 | 3 | 0 | 4.085 |
If the government encouraged oocyte freezing, I would be more amenable to freezing my eggs | 19 | 14 | 11 | 3 | 0 | 4.043 |
Social oocytes freezing should be offered to women of all ages | 20 | 20 | 3 | 5 | 0 | 4.146 |
Overall, after reading the information leaflet, I would consider freezing myoocytes at some point in time | 12 | 14 | 16 | 6 | 0 | 3.667 |