Age Limit to be Eligible for Government Co-funded Assisted Reproductive Technology Procedures

4 Er Dr Lee Bee Wah asked the Minister for Health (a) in respect of a woman who is older than 40 years old, why is she required to have attempted assisted reproduction or intra-uterine insemination (IUI) procedures before age 40 to be eligible for Government co-funded Assisted Reproductive Technology (ART) procedures; and (b) whether this requirement can be removed as women are marrying later.

The Senior Minister of State for Health (Dr Amy Khor Lean Suan) (for the Minister for Health): The Assisted Reproduction Technology (ART) co-funding scheme was introduced to support couples who face difficulty in conceiving naturally. In January 2020, the scheme was enhanced to allow couples who have attempted assisted reproduction (AR) or Intra-Uterine Insemination (IUI) procedures before 40 years old to tap on up to two of the six co-funded ART cycles for AR procedures at age 40 or later.

The age criterion of 40 years old is set based on current clinical evidence which shows that the chance of conception for a woman who undergoes ART treatment decreases with age, with significantly lower success rate after 40. The ART co-funding is therefore directed towards those who attempted their first assisted reproduction procedure before age 40. Couples are encouraged to start their families early. Those with difficulty conceiving should also consider fertility or ART treatment early.

We will continue to monitor the clinical evidence and update the eligibility criteria where appropriate.

Mr Speaker: Er Dr Lee Bee Wah.

Er Dr Lee Bee Wah (Nee Soon): Thank you, Sir. I have a few supplementary questions. First, for those who marry late, for example, if they marry at age 40, it is impossible to meet the requirement to carry out IUI before age 40. Will this be considered? The second question is, residents tell me that they are normally encouraged to do IUI first, and then IVF, as IUI is less invasive but the success rate is much lower. I would like to ask what is the success rate for IUI and IVF respectively. The third question is, can the Ministry encourage people to go straight for IVF for those age 35 and above, so as not to waste time and money? I was told the process to make appointment could take a few months to a year. There is one more question, can Ministry remove the requirement of having to go through at least two rounds of IUI before going for IVF? Give couples an option to go for IVF directly and this can save the women time and inconvenience.

Dr Amy Khor Lean Suan: I thank the Member for her four supplementary questions. I will take the question about the requirement for couples to go through either IUI or AR before age 40, before they are eligible for co-funding for AR procedure in our public AR centres at age 40 or above. First, let me say that we recognise that more couples are getting married later and they do have parenthood aspirations. But unfortunately, even though there have been improvements in technology as well as better understanding of treatment needs, embryo culture and so on, the empirical evidence still shows that the success rate is very much linked to when the procedures are performed on the women.

The Member asked about success rates. For IVF, for instance, our latest data, 2018 data, show that the success rate of live births arising from IVF drops from around 23% for women age 30 to 34 years, to around 6% for women age 40 to 44 years; in fact, even further down to 0.6% for women age 45 and older. So, when we put the age criterion of 40 years, as I have said, we recognise that people are getting married later, and we do not want to put too low a cut-off age. The experts also feel that age 40 is reasonable, given the empirical evidence before them. Therefore, this age criterion, together with the requirement that couples need to have already tried AR or IUI before age 40 to qualify for this co-funding, really, the intent is to balance the need to support and encourage couples to receive AR procedures early for higher chance of success and at the same time, also, to support the needs of older couples who want to try for a child. It is a balanced approach, taking into account the scientific data and the social trends as well as the developments to date.

We will continue to monitor the clinical evidence and where appropriate, we will update the eligibility criteria.

With regard to the IUI co-funding, we only introduced this in January 2020. It was done to enhance our support for couples who have difficulties conceiving naturally. IUI, as the Member has rightly pointed out, is a less invasive procedure. So, depending on the assessment of the doctors, they will be advised whether they can go through IUI with co-funding up to three cycles before going to IVF, which is up to six cycles.

I do not have the success rates for IUI here, but I can give the information to the Member later.

There was also a question of couples marrying beyond age 40 and then, they are not eligible. They are not eligible for the Government co-funding scheme. But they still can use MediSave. So, for couples who want to go through ACP including ART and IVF, they can withdraw from MediSave up to a lifetime limit of $15,000. That does not have any age cap nor limit to the number of cycles. It is only for the Government co-funding that they will not be eligible for. The reason is because we need also to be mindful of the effectiveness of such financial support extended through Government co-funding. This has to be based objectively on the empirical evidence before us.

Mr Speaker: Er Dr Lee Bee Wah.

Er Dr Lee Bee Wah: Thank you, Sir. I agree with the Senior Minister of State that we need to be very careful with the funding. But I have one question, my second question earlier, for those who are aged 35 and above, instead of asking them to go through IUI, can we let them have an option to go for IVF? Many of them say that the success rate for IUI is very low and it is a waste of their time as their biological clock is not with them. Maybe the Ministry can consider letting them choose, give them an option to go for IVF straightaway.

Dr Amy Khor Lean Suan: As I have said, my understanding is whether to go IUI before going to IVF really depends on the doctors' assessment. I will have to stand corrected, but I do not think there is a policy that couples definitely have to go through IUI before IVF. But as the Member has also pointed out and also according to my understanding, IUI is less invasive, so it may be something that doctors advise them to try before going through AR procedures. As I have also said, even for AR, for women younger than age 30, where the success rate is highest, it is actually about 24%.

Mr Speaker: Mr Louis Ng.

Mr Louis Ng Kok Kwang (Nee Soon): Thank you, Sir. I agree with the Senior Minister of State that our policies should be based on science. But science also tells us that stress faced is a key factor in determining whether an IVF is successful. I think a lot of the couples are very stressed because of the finances involved in an IVF cycle. If MOH can then provide the subsidies, reduce the stress, then, maybe we will have a higher percentage of success for IVF cycles for those age 40 and above.

Dr Amy Khor Lean Suan: I thank the Member for his questions. The fact is that we introduced the Government co-funding scheme for ART procedures in 2008. This was in order to reduce the out-of-pocket payment for couples who want to go through ART procedures at our public AR centres, in addition to being able to use their MediSave for these procedures. We have, in fact, been enhancing this co-funding scheme since then – in 2013, 2018 and just in January this year – in order to support couples in their parenthood aspirations, including couples who may marry later and still wish to try for a child.

As I have said, such policies have to be objectively determined based on the empirical evidence. What we are doing now is to try and strike a balance between encouraging couples to marry and fulfil their parenthood aspirations early and if they have difficulty conceiving naturally, to receive IUI or ART treatment early, versus the need to also support couples who may marry later and wish to have a child.

We will continue to monitor the clinical evidence and where it is possible and appropriate, we will update the criteria.