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Introduction

      From 2020 onwards, the Singapore government lifted the previous age limit (45 years old) on women receiving IVF treatment. It is anticipated that there will be a steady increase in egg donation cases in this small city-state, as many older women nearing or past menopause are often unable to produce enough viable eggs for successful fertility treatment. Under Singapore healthcare regulations, egg donors must fulfill the following criteria:

• Her donation must be altruistic, and she must not receive any monetary compensation in exchange for her donated egg
• She must be between 21 to 37 years of age, at the time of donation(for fresh egg donation) or when her eggs were frozen (for elective egg freezing patients). The egg donor does not need to be either a Singapore citizen or a permanent resident.
• Her blood must be tested negative for HIV, Hepatitis B and C, Syphilis,Cytomegalovirus (CMV IgG and CMV IgM), HTLV Type I and II. Additionally, her urine must also be tested negative for Gonorrhoea, Chlamydia and CMV. A second blood test must be repeated at 3 months after egg retrieval surgery.
• Her donated eggs must not result in more than 5 live birth events.
• She must undergo psychological assessment and mandatory counseling together with her husband (if married), before signing the donation consent form. There is a hiatus of 1 week between counseling and signing the donation consent, to give the prospective egg donor sufficient time to ponder her decision. Her husband is obliged to co-sign the consent form if she is married at the time of donation.
• Upon acceptance into the egg donation program, the donor's personal details are entered into the centralized IVF database system maintained by the Ministry of Health (MOH).

 Personal and family issues to consider in egg donation

     A woman contemplating egg donation needs to ponder various personal issues, as well as know and weigh all her available options. First of all, she must do her own soul-searching and ask herself whether she genuinely wants to have a child through the egg donation process. Is she being unduly pressured, coerced, or subjected to emotional blackmail by either her husband or her in-laws?  

      As the old saying goes, it takes two hands to clap in a successful marriage. If one partner is reluctant, while the other is willing, the marriage will never be happy. The same applies to child-rearing, except that this time, an innocent party in the form of a child may be adversely affected by the unwilling partner who is unhappily being coerced into the arrangement. 

     Another key issue to consider is whether she should eventually tell her child the truth of his/her conception through egg donation? Most seasoned fertility counselors would recommend that the child be told the truth when they reach school-going age. Numerous psychological studies and news reports have documented the emotional trauma and identity crisis that donor-conceived teenagers and adults go through when they suddenly and unexpectedly learn the truth about their conception, for example, through a family spat. Very often, this leads to strained and even estranged parent-child relationships. 

     Moreover, the recent popularization of direct-to-consumer genetic testing kits and associated genealogy and ancestry websites has made it much harder to conceal from donor offspring the truth about their conception. There is a possibility of the offspring inadvertently learning the truth about his/her conception through contact with DNA-matched relatives on such websites. As medical technology advances, it is envisioned that DNA testing will one day become a universal norm in healthcare.

Egg donation options that are available to female IVF patients in Singapore

     Here are the various options available to women in Singapore who are considering egg donation. Each of these has its advantages and disadvantages, which will be discussed in turn.

 Option 1: Travel overseas for egg donation at a foreign fertility clinic

      Currently, this appears to be the most popular option. The medical fees of foreign fertility clinics are often much cheaper compared to Singapore. The disadvantages are that there is no government co-funding, and you cannot utilize your Central Provident Fund (pension scheme) for fertility treatment. Moreover, there is also the hassle and costs of overseas travel and hotel stay. Some local Singaporean clinics have collaborative ties with foreign clinics (usually in Malaysia) that carry out egg donation. Hence, they would be able to advise you on egg donation overseas, as well as coordinate with foreign clinics in synchronizing hormonal injections to prepare your womb to be receptive for the egg donation procedure overseas.

     Moreover, Preimplantation Genetic Testing - Aneuploidy (PGT-A or PGS) of embryos, which is highly restricted in Singapore, is readily available overseas. Utilizing PGT-A in a foreign IVF clinic allows patients to select the sex of their embryos, which is currently banned in Singapore. Nevertheless, Singaporean patients must beware that the PGT-A technique only screens for large chromosomal abnormalities in IVF embryos but does not detect monogenic (single-gene) disorders. Hence, it is completely useless for preventing the transmission of most heritable genetic diseases from the egg donor to the offspring. In fact, it may be completely unnecessary to utilize PGT-A for egg donation cases, because in most cases the donors are young and therefore have very low chances of having chromosomal abnormalities in their eggs, unlike older women who are at high risk of conceiving a Down syndrome baby. Furthermore, there is also a risk of damaging the IVF embryo upon extracting cells (biopsy) for genetic testing.

     Very often, foreign IVF clinics exploit the fear of recipient patients regarding unknown genetic diseases carried by the egg donor to encourage them to take up the expensive PGT-A technique, while deliberately neglecting to tell them of the possibility of genetic carrier screening of egg donors through a simple blood test. Instead, ignorant patients are often pushed to do expensive PGT-A in egg donation cases, in the mistaken belief that PGT-A also screens for various other genetic diseases besides chromosomal abnormalities. Besides genetic testing of the egg donor’s blood sample before starting IVF, patients also have the option of doing NIPT (Non-Invasive Prenatal Testing) to detect genetic disorders in the fetus after getting pregnant.

     Singaporean patients must also beware that some foreign IVF clinics might take an extra cut of profit when sourcing egg donors for their patients from external agencies. This usually happens if the patient does not pay the agent or agency directly, but instead gives their money to the IVF clinic, who pay the agent or agency and keeps a portion for themselves as “administrative fees”. Hence, it may be cheaper for patients to directly contact foreign egg donor agencies and undergo treatment at their affiliated IVF clinics rather than requesting foreign fertility clinics to source egg donors.

     Additionally, Singaporean patients should try their best to use egg donors who reside locally within the same city as the foreign IVF clinic. They should avoid using traveling egg donors from out-of-town or out-of-state, who reside far away from the IVF clinic. It is much more difficult to control and monitor the ovarian stimulation cycle of traveling egg donors from out of town. If possible, they should insist that the egg donor regularly receives hormone injections (recorded) by a nurse at the IVF clinic itself.

Option 2: Seek out your relatives or close friends as egg donors

     The most obvious advantage of using a blood relative, such as a sibling or cousin, as an egg donor is that you have a genetic link to the conceived child. Additionally, you would also be familiar with any hereditary genetic diseases that run in the family. However, it may be challenging to find a “young enough” donor among your circle of friends and relatives, preferably below 30 years old, as recommended by most fertility clinics. Using older egg donors will decrease your chances of success.

     Here are the various fractions of DNA that you would share with your child, with different types of blood relatives as egg donor: full sister – 25%, half-sister or niece – 12.5%, first cousin – 6.25%, second cousin – 3.125%. Note that if you were using your own eggs, you would share 50% of your DNA with the child.

     The advantage of using a close friend is that you know her character and what she looks like, traits that may be inherited by the conceived child. The disadvantages are the lack of egg donor anonymity and increased chances of the secret of the child’s conception being leaked out, either deliberately or inadvertently, by a third party. Egg donation from close relatives may cause awkwardness and tension in future family relationships, particularly at family gatherings during major festivals such as the Chinese New Year.

Option 3: Import frozen donor eggs from an overseas egg bank

     Recently, IVF patients have been permitted to import frozen donor eggs into Singapore from foreign egg banks worldwide, which meet certain requirements, such as rigorous infectious disease screening of donors. The advantages are that donor anonymity is maintained, and there is a wide choice of donors available, even Asian and Chinese ones. Increasing demand worldwide has led to egg banks in Western countries recruiting donors of such ethnicity. Closer to home, there are also egg banks in Malaysia that can service Singaporean patients.

The major advantages of utilizing frozen versus fresh donor eggs include:

• Greater convenience, as there is no need to synchronize the timing and hormonal stimulation cycles of egg donors and recipient patients.
• The traveling and hotel costs associated with fresh egg donation (for foreign egg donors sourced by commercial egg donor agencies) are negated.
• Little or no waiting time, as frozen eggs are readily available.
• More certainty, because the exact number of frozen donor eggs is known and guaranteed. By contrast, for fresh egg donation, the number of eggs that will be retrieved from the donor after hormonal stimulation is unknown and non-guaranteed.

However, there are also several disadvantages of using imported frozen donor eggs:

• The costs of transporting frozen eggs into Singapore from abroad are very expensive, as it requires a special cryogenic container, as well as the preparation of special paperwork for the frozen eggs to pass through customs checks without undergoing an x-ray.
• The IVF success rates with frozen eggs are still significantly lower than fresh eggs, despite technological advances such as ice-free vitrification protocols.
• Because frozen donor eggs are highly delicate and fragile, the thawing protocol must be matched and compatible with the freezing (vitrification) protocol, similar to a lock and key. Only the same IVF lab that performs both the freezing and thawing processes can ensure this. Hence, for best results, patients should use the same fertility clinic or IVF lab that recruited the egg donor and froze her eggs, rather than transferring frozen donor eggs from one medical facility to another.
• Not all frozen eggs will survive the thawing process. Out of 10 frozen eggs, at most eight or nine will survive, provided the freezing and thawing procedures have been properly carried out by competent laboratory staff (embryologist).
• Asian/Chinese donor eggs may be more expensive to procure from Western egg banks, as compared to Caucasian ones, due to the scarcity of Asian/Chinese donors in Western countries. This problem may be overcome by sourcing from egg banks within Asia. Currently, there is an egg bank based in Penang, Malaysia (Egg Bank Asia), which specializes in sourcing ethnic Chinese egg donors.

Option 4: Look for an egg donor who is paid secretly, or utilize a foreign agency to send an egg donor to Singapore

     Strictly not recommended. Currently, there exist numerous websites that allow you to look for your egg donor. However, it is very unlikely that they will help you free-of-charge, and you will probably have to secretly pay them ‘under-the-table’. But after receiving some payment, there is no guarantee that they will fulfill their part of the bargain, in which case, you have no legal recourse for recovering your money. Because payment for egg donation is illegal in Singapore, in the first place, you will only implicate yourself in an illegal transaction if you decide to sue the would-be donor.

     Moreover, it may be difficult to ensure that the freelance egg donor faithfully follows the painful and tedious procedure of daily hormone injections to stimulate egg production within her ovaries. Utilizing a well-established foreign egg donor agency may be a ‘safer’ option, but it will be much more expensive. Besides the agency fees, there are also extra traveling and accommodation costs. Most reputable foreign agencies will insist on having a coordinator to accompany the donor to Singapore, to ensure that the donor punctiliously self-administers hormonal injections to stimulate her ovaries, as well as to make sure she fulfills her part of the contract. This would mean additional traveling and hotel costs for the coordinator.

     Furthermore, there is also the issue of illicit payments to the egg donor via the foreign agency. It may be difficult for such secret transactions to leak out, but if it does, one will end up in big trouble. Several years ago, a Singaporean magnate was jailed and fined for paying an Indonesian man to donate his kidney.

    Additionally, it must be noted that Singaporean IVF clinics would require both the recipient couple and the egg donor to sign a declaration form stating that the donation is altruistic. Hence, the crimes of perjury and bribery would be committed by signing a false declaration.

Option 5: Utilize the donation of unused surplus frozen eggs from former elective egg freezing patients at local fertility clinics

     These are currently very scarce, but may be more readily available in the future as more and more Singaporean women undergo elective freezing, which could lead to an accumulated surplus of unused frozen eggs within local IVF clinics. Studies from abroad have shown that the overwhelming majority of former elective egg freezing patients do not eventually utilize their frozen eggs. Some of them might be kind enough to donate to other patients in need. Besides former elective egg freezing patients, donated frozen eggs may be obtained from other less common sources:

• Single women facing premature menopause or undergoing medical treatment that will damage their fertility, such as chemotherapy, usually freeze their eggs.
• A few married couples undergoing IVF choose to freeze their excess unfertilised eggs instead of embryos for religious or personal reasons, as they view frozen embryos as ‘living entities’ that should not be culled through disposal.
• Contingency egg freezing is sometimes performed when the husband is unable to produce a usable sperm sample on the day of egg extraction surgery, for example, ejaculation failure due to stress.

As expected, patients would use their best-quality eggs for treatment, so the few frozen leftovers would be of questionable quality.