Improving Access to Fertility Preservation for Young Cancer Patients

ADJOURNMENT MOTION

The Deputy Leader of the House (Mr Zaqy Mohamad): Mr Speaker, Sir, on behalf of the Leader, I beg to move, "That Parliament do now adjourn."

Question proposed.

Improving Access to Fertility Preservation for Young Cancer Patients

Mr Speaker: Dr Tan Wu Meng.

6.47 pm

Dr Tan Wu Meng (Jurong): Mr Speaker, I declare that I am a medical doctor looking after cancer patients. In my Member of Parliament capacity, I have also met Clementi residents who are young cancer patients.

Many of us know someone who has cancer – a loved one, a friend or a colleague. Some cancer patients are younger. About six out of 100 cancer patients diagnosed each year in Singapore are under the age of 40. Young cancer patients.

If you look at the Singapore Cancer Registry, between 2017 and 2021, each year, on average, 340 young men and 620 young women under the age of 40 were diagnosed with cancer – about 1,000 young men and women. Young patients, under 40. In the prime of their life. Some trying to start a family, hoping to become parents someday. Some might not yet have found a life partner, have not yet decided whether they want to have children, but wanting to keep their options open and not close off their future choices.

But when a cancer hits you or your loved ones, sometimes, things change suddenly and decisions have to be made on a timeline that you and your loved ones did not expect. Because some cancer treatments, while trying to save the patient's life and cure the cancer, some of these treatments can also affect a patient's fertility. For example, some chemotherapy treatments can affect fertility, sometimes, for the long term. We know from the experience of young cancer patients who became infertile after life-saving cancer treatment that their infertility can be emotionally devastating even years later, among the survivors.

So, what is the current situation in Singapore?

In a Parliamentary Question earlier this year, I asked about fertility preservation for cancer patients undergoing medically necessary treatment where the medically necessary treatment can affect the patient's fertility. These fertility preservations may include sperm freezing, egg freezing or in vitro fertilisation (IVF). I asked the Ministry of Health (MOH) whether the Ministry has evaluated the available insurance policies on the commercial market.

Let me quote from MOH's answer, "MOH does not evaluate private insurance coverage of fertility preservation therapy as these are optional products subject to insurers' commercial considerations." Furthermore, MOH said, "MediShield Life does not cover fertility related treatments as it was designed as a basic health insurance scheme."

In short, today, fertility preservation is deemed optional by the insurance industry, even if you are a cancer patient undergoing medically necessary treatment which may affect your fertility. In short, today, fertility related treatments, even for cancer patients, are not covered under MediShield Life because these are not considered part of basic healthcare.

Mr Speaker, today, I call upon the Government to take a fresh look. This is not just my own view. I have met young healthcare workers across different hospitals and different hospital clusters. They care for young cancer patients, walking with them through the cancer diagnosis, treatment and recovery. They see the ups and downs, the pain, the suffering and sometimes, the heartbreak.

Some are trying to help young cancer survivors realise their dream of having children someday despite the treatment journey, despite the side effects of medically necessary cancer treatment. These young healthcare workers have put together a number of views and suggestions and approached me in their personal capacities. I have looked, discussed with them and raised their suggestions to MOH because I personally found their suggestions to resonate with me and I have sympathy for their views. Let me share their thinking and some recommendations for the Government's consideration.

The first recommendation: can MOH and the Monetary Authority of Singapore (MAS) work with the insurance industry so that fertility preservation for cancer patients is covered under Integrated Shield Plans? This is not a major policy deviation, in my view, and, as I will explain to you, it is actually a harmonisation of existing policy principles.

Today, healthcare insurance already covers restoration of natural biological function when someone has been seriously injured. If tomorrow, you are in a life-threatening car accident, you undergo emergency surgery and, as part of that life-saving surgery, you need to undergo some kind of reconstruction which preserves your ability to start a family, if you have bought insurance, you would expect the insurer to cover it.

So, why is it different when someone has an accident of fate – a life-threatening cancer? When a cancer patient has life-saving treatment which may compromise their fertility and then needs to restore natural biological function after the illness, surely the insurers could consider it the same way too.

Sir, people do not choose to get cancer, so there is no moral hazard arising from including this under insurance coverage. The insurers should move on this.

To help shape market norms and send a signal to the healthcare insurance sector, I call upon MOH to be the first mover – to see the issue through the lens of natural biological function and preserving or restoring natural biological function so that a fellow Singaporean who becomes ill with cancer and undergoes fertility preservation should be considered the same way as a Singaporean in a major accident who undergoes reconstructive surgery to preserve their ability to have a child.

Today, only one of these patients would be covered by MediShield Life for the purpose of preserving the ability to have children. Both should be covered.

If MOH moves on this for MediShield Life, it will shape the market and send a strong message to the private sector insurance providers – the healthcare insurers, financial institutions – and encourage them to do the same. That is the first recommendation.

The second recommendation: to front-load the funding for fertility preservation for patients who are young cancer patients undergoing medically necessary treatment that might compromise their fertility.

Today, married couples undergoing assisted conception procedures in a public hospital can receive co-funding from MOH up to 75% if the couple are both Singaporeans. But what happens if a young woman diagnosed with cancer is not yet married and finds that she has to go for egg freezing to preserve her fertility? To preserve her prospect of having a family in the future? Is there a way to mobilise the future funding and front-load this to help that young cancer patient at a time when the fertility preservation is most likely to be helpful, early on, to help preserve her fertility for the future?

The third recommendation: I also call upon the Government and MAS to work together with the banks and financial institutions to provide interest-free loans for young cancer patients needing fertility preservation.

Let me share, by comparison, an example from the education sector.

Today, students on a full-time Ministry of Education course at a polytechnic or autonomous university can apply for tuition fee loans. The loan is interest-free during the first few years when the course of study is ongoing and, importantly, when young students have not had the chance to start work and accumulate savings and financial resources of their own. The purpose of this policy – the interest-free loan – is to ensure that students do not forego the long-term benefits of higher education because of short-term challenges with cash flow.

The same approach can be applied for young cancer patients. Some have fallen sick early in life before building their careers. They may be low on savings, low on resources, low on MediSave at that point in life. If they come from a family starting with less, their parents may not be able to underwrite some of these costs.

But if the banks provide interest-free loans, it will help ensure young cancer patients do not miss out on fertility preservation because of cash flow concerns. It will help ensure a young cancer patient does not have to choose between their long-term prospects of starting a family, their long-term fertility prospects, and, on the other hand, short-term cash flow considerations.

This approach will also help some young cancer patients who come from a sandwiched class situation, where they may not be very wealthy, but at the same time, this will assist with some of the cash flow situation too.

The fourth recommendation: on better supporting philanthropy in the fertility preservation sector. The philanthropy sector is an important part of Singapore's social fabric. Several voluntary welfare organisations support cancer patients, including young cancer patients.

Can the Government help crowd-in and stimulate philanthropy to support young cancer patients needing fertility preservation? For example, can the existing 250% tax deduction on charitable donations be enhanced further for specific designated charities or even a specific fund for fertility preservation that could be co-managed by MOH or the health authorities in the public sector? Can there be matching grants to help multiply the impact of charitable donations to help needy young cancer patients when it comes to fertility preservation?

There are many ways to concentrate and focus funding and co-funding. Six years ago, in this House, I moved an Adjournment Motion on helping patients with rare diseases. The Government later set up a Rare Disease Fund, which receives 3-for-1 dollar matching of public donations with tax deduction.

Fertility preservation for young cancer patients is a different issue, but I wonder if MOH and the Ministry of Finance can draw lessons from that experience and see what can be done for young cancer patients seeking fertility preservation.

Mr Speaker, some might ask: why go through such effort to help a relatively small number of Singaporeans – 1,000 young cancer patients per year? To that question, let me say this. Even if just 1,000 young cancer patients a year, even if only 6% newly diagnosed cancer patients are young, under the age of 40, if it happens to you or your loved one, you are 100% affected.

In life, we do not get to choose whether we are born lucky or unlucky. We do not get to choose whether early in life we are diagnosed with cancer. But as a society, we can choose how to look out for one another at the individual level and in how we build our social compact. We can choose whether to be more inclusive and to help young cancer patients worrying about whether someday, they can have a chance to start a family.

We mention the potential beneficiaries being about 1,000 a year but the actual number might well be less, because not every young cancer patient may seek to take up the proposals to support them further. But I suggest to this House: it is worth us considering and trying.

There is a broader important point, that a young cancer patient should not have to forego fertility preservation and the chance of starting a family some day, giving up on dreams of a family, because of cost concerns, tight cash flow, or because a private insurer decided that it is optional to preserve fertility, even if you are a cancer patient who did not ask to get cancer, even if you are a cancer patient undergoing medically necessary treatment that might affect your future childbearing potential.

Our approach to supporting Singaporeans into that dream of starting a family someday, is also about a broader message within Government and to our Singapore society. In an era of fewer children being born, when Singapore's total fertility rate (TFR) has dropped to 0.97, the TFR below 1.0 for the first time in Singapore's history, the message we send is all the more important. A message must be sent that every child matters, every potential child matters and that every opportunity to start a family can be a moment of hope. And for those who seek that hope, we must try to support that and not let it be taken away early in life during to accidents of fate.

Mr Speaker, as we take Singapore forward as part of Singapore's Forward SG, this is a call for change. It is a call for a fresh look, it is a call for action, a call to help support young cancer patients in their hopes and dreams and especially dreams of a family. [Applause.]

Mr Speaker: Minister of State Rahayu Mahzam.

7.04 pm

The Minister of State for Health (Ms Rahayu Mahzam): Mr Speaker, Sir, I would first like to thank Dr Tan Wu Meng for raising the plight of young cancer patients who desire fertility preservation. These patients already suffer the misfortune of a cancer and the side effects of cancer treatment. We deeply empathise with the anxiety and emotional distress that they face.

Mr Speaker, the Government has supported and remains committed to supporting the parenthood aspirations of all Singaporeans.

In 2008, the Government introduced co-funding for Assisted Reproduction (AR) treatments, such as In-Vitro Fertilisation, or IVF, at public AR centres. Any couple where at least one spouse is a Singapore Citizen would be eligible for this co-funding.

Over the years, we have made enhancements to further support couples requiring AR treatments. We raised the Government co-funding quantum in 2013 and again in 2018. We also increased the number of co-funded cycles. Today, a Singaporean citizen couple can enjoy up to 75% in Government co-funding for up to three fresh cycles and three frozen cycles. This is subject to a dollar cap of up to $7,700 for each fresh cycle and up to $2,200 for each frozen cycle.

On top of co-funding, we allow MediSave use of up to $6,000 for the first cycle, $5,000 for the second cycle and $4,000 for the third and subsequent cycles, with a lifetime limit of $15,000.

In 2020, we expanded our co-funding coverage to include Intra-Uterine Insemination, or IUI, to provide better support to couples who may prefer less invasive procedures. The Government would co-fund up to three IUI cycles, subject to a dollar cap of up to $1,000.

We also recognised that couples who marry late also have parenthood aspirations and wanted to give them the best shot at it. In 2020, we removed the statutory age limit of 45 years old which restricted when a woman may go for AR treatments. This allowed more couples to undergo procedures like IVF, as long as they were considered suitable for the procedure by their doctor. We also allowed couples to tap on up to two out of six co-funded AR treatments above the age of 40, as long as they had attempted AR before the age of 40. This was so that we do not inadvertently encourage couples to start their families too late, given the higher likelihood of clinical complexities associated with late pregnancies.

Last July, we took a further step. Women between the ages of 21 to 37 are now able to undergo elective egg freezing. Prior to last July, women were only allowed to do so on medical grounds. This shift came after careful consideration, recognising that there may be women who desire to preserve their fertility because of personal circumstances, such as being unable to find a partner when they were younger.

The policy shifts we have made over these years reflect the Government's ongoing commitment to support fertility and parenthood. This is an ongoing journey. We will continue to refine our policies to ensure that these continue to meet Singaporeans' aspirations and needs in the area.

On this note, I thank Dr Tan for his recommendations on financing fertility preservation procedures among young cancer patients.

We note that some young married couples are facing a situation where one of them is afflicted with cancer and will be receiving treatment. Yet, they are still currently trying to start a family. Today, these couples are eligible to tap on Government co-funding and their MediSave for embryo freezing as part of their AR treatments, to preserve the option of having children in the future.

For singles who want to undergo fertility preservation so that they can have children in future, we recognise these procedures can be quite expensive. For example, egg freezing alone can cost up to $10,000. Other fertility preservation procedures, like egg storage or ovarian tissue storage, can cost several thousand dollars over the course of five years. Today, young women can already tap on MediSave for egg freezing, if it is done on medical grounds, such as due to their cancer treatment. If they get married in the future and would like to use their eggs for AR treatments, they can also receive Government co-funding support and use MediSave for their treatments.

MOH will study Dr Tan's proposals to extend Government co-funding and insurance, bearing in mind there may be other medically necessary treatments for conditions besides cancer that could affect fertility of young Singaporeans.

I would also like to acknowledge Dr Tan's other recommendations, such as to support philanthropic initiatives in the fertility preservation sector and to collaborate with financial institutions to provide interest-free loans for fertility preservation.

To bolster philanthropic efforts in the fertility preservation sector, Dr Tan has proposed enhancing the current 250% tax deduction rates for donations and introducing Government matching grants, similar to the approach taken for the Rare Disease Fund. Today, donations made to Institutions of a Public Character, or IPCs, that focus on supporting cancer patients, will qualify for a tax deduction of 250%. This is consistent with other IPCs in Singapore, which is high compared to other jurisdictions. We appreciate the support that existing cancer charities provide to patients, such as the support from the Singapore Cancer Society, Breast Cancer Foundation and Children's Cancer Foundation. But we also note that they may encounter difficulties in prioritising fertility treatments for these patients if it means diverting funds from other cancer patients.

As for the suggestion of interest-free loans, like the Tuition Fee loans, we note that these are ultimately financed and subsidised by Government, similar to the co-funding support that is currently already available for AR treatments. We will, however, continue to review the adequacy of co-funding and other support to address the fertility treatments for these patients and welcome any additional support that charities can provide alongside, to address affordability issues.

Question put, and agreed to.

Resolved, "That Parliament do now adjourn."

Mr Speaker: Pursuant to Standing Order 2(3)(a), I wish to inform hon Members that the Sitting tomorrow will commence at 11.00 am.

Adjourned accordingly at 7.11 pm.