Singapore is a small, affluent and technologically advanced city-state located in Southeast Asia. Due to its lack of natural resources, this country relies heavily on its highly educated and skilled workforce to drive its economic engine. However, in recent years, Singapore has been facing a demographic crunch due to its ultra-low fertility rate and rapidly aging population, which poses an existential threat to its survival as a nation-state. The advent of new reproductive technologies such as in vitro gametogenesis (IVG) and stem cell-based embryo models (SCBEMs) may thus provide novel fertility treatment options for local patients, which may possibly alleviate Singapore's ultra-low birthrate. Nevertheless, these new technology platforms also raise various ethical, legal and social issues. It is anticipated that the application of SCBEMs (also known as synthetic embryos) in human reproduction will likely be banned because these entities are viewed as human clones. Conversely, IVG technology is expected to receive approval in Singapore for a narrow range of applications in human clinical assisted reproduction, as it seeks to recapitulate the natural process of human sexual reproduction and is more consistent with Singapore's family laws and sociocultural values. It is anticipated that IVG will be permitted for the treatments of primary infertility and age-related female infertility, facilitating transgender and intersex parenthood and preventing transmission of genetic diseases. However, the applications of IVG in posthumous reproduction, mass production of donor gametes, genetic enhancement of offspring, same-sex, solo- and multiplex-parenthood, will likely be banned.

     To date, Singapore’s Agency for Science, Technology and Research (A*STAR) has set up a lab - Endangered Species Conservation via Assisted Reproduction (ESCAR) Lab, at the Institute of Molecular and Cell Biology (IMCB), to work on animal models of IVG and SCBEMs. By claiming application in the conservation of endangered mammalian species, this would cleverly deflect public criticism that such technologies may be applied to human reproduction, while at the same time nurturing the capability to do so in the future if needed. Nevertheless, before further investing substantial resources in developing IVG and SCBEMs technology for human clinical assisted reproduction, a key consideration for Singaporean government healthcare policymakers is how much these emerging technologies can actually advance the national interest by boosting the country’s dismal birthrates. Hence, there should be a comprehensive, rational, and data-driven cost-benefit analysis to evaluate the extent to which these new technologies can help address Singapore's demographic challenges related to low fertility rates and a rapidly aging population. Perhaps, statistical information from other wealthy nations with low birth rates and well-established systems of public and private fertility clinics may provide some insight. For instance, recent statistics from Australia indicate that approximately 1 in every 18 infants is conceived through IVF and other ART. In Japan, the ratio is about 1 in 11.6 births resulting from IVF and other ART. Hence, even at best, the widespread application of IVF and other ART is unlikely to boost the total number of births by more than 10%. This would unlikely enhance the demographics of any nation that significantly fails to meet the replacement rate of 2.1 births per woman, as in the case of Singapore where the TFR hovers around 1.0.

     Furthermore, it is important to note that IVG and SCBEMs, due to their high costs, complexity and labor intensiveness, will likely only be used to treat the most intractable and challenging of infertility problems that cannot be addressed by IVF and other conventional ART. These cases are expected to represent only a small fraction of the total infertility cases in Singapore, severely limiting the impact of these new technologies on the overall birthrate. Moreover, the country's restrictive regulations on surrogacy, single parenthood, and same-sex parenthood, may further limit the impact of these new technologies on boosting the nation's birthrate, as well as financial returns from research and development.

     Even so, one could argue that investing in the research and clinical applications of these new technologies may serve a symbolic political purpose, demonstrating the Singapore government’s commitment to supporting and meeting the clinical needs of a tiny minority of local patients with extremely difficult and complex infertility problems. Then, there is also a matter of national pride and impact on the national psyche by being part of the international research effort on these highly novel and advanced reproductive technologies, which could enhance Singapore’s reputation and standing as a biomedical research hub par excellence on the international stage. Nevertheless, when it comes to spending tax dollars and utilizing national assets, Singaporean government policymakers must carefully balance such lofty objectives against more utilitarian and pragmatic considerations. For example, it can be counter-argued that the same funds could be better utilized to improve and subsidize social services aimed at boosting the nation's birthrate, such as expanding preschool education and childcare facilities. Such measures are expected to receive more enthusiastic public support and appreciation from a significantly larger group of prospective parents. Additionally, cost-benefit and cost-efficiency considerations are crucial when it comes to public funding. For example, if the costs of subsidizing these advanced medical procedures for difficult and complex infertility cases are five to ten times higher than that of regular IVF treatment, this would result in a significantly lower cost-efficiency in utilizing taxpayers' money to boost the national birthrate. Certainly, Singapore government policymakers would want to avoid ‘majoritarianism’ in overlooking the clinical needs of the tiny minority of patients with more difficult and intractable fertility problems, but due consideration must also be given to whether the same financial resources could be better allocated to more impactful initiatives.

     At the end of the day, Singapore's Ministry of Health (MOH) has a public duty and moral imperative to ensure that taxpayers' money is effectively and prudently utilized to address the country’s public healthcare needs. Investing in IVG and SCBEMs may result in the misallocation of public healthcare funds, given the small number of difficult infertility cases that require such expensive and labor-intensive solutions. Nevertheless, it must be noted that this is a public health viewpoint and not a patient perspective view. It might be the case that the Singapore government has, for the reasons presented, find no good justifications for subsidizing such highly-expensive medical technologies, but would permit these in clinical practice if patients are willing to pay out-of-pocket.