Clinical Assisted Reproduction in Singapore Challenges Posed by Medical Tourism and Future Prospects for Growth

Transcription

1 Clinical Assisted Reproduction in Singapore Challenges Posed by Medical Tourism and Future Prospects for Growth [ Special Feature ] Alexis Heng Boon Chin Senior Research Scientist, IvyMed International Inc 696 Gail Avenue, Sunnyvale, Silicon Valley, CA 94086, USA Increasing Demand for Clinical Assisted Reproduction Services within the Asia Pacific Region In the past few decades, rapid economic growth and urbanization within the Asia Pacific region have contributed to a rising incidence of infertility among the general population. Of prime concern is the escalating trend of age-related female infertility caused by increasing numbers of urban women delaying marriage and child-bearing in pursuit of career and educational goals. The situation is made worse by sky-rocketing property prices and high living costs encountered in many large cities in the region, prompting many newly-wed couples to delay having children until they have stabilized their financial situation. It is a well-known fact that a woman s fertility drops sharply above the age of 35, due to rapid depletion of eggs within her ovary as menopause approaches. Thus, it is no surprise that the increasing demand for clinical assisted reproduction services in Asia is largely being fueled by infertility problems encountered by older women. Besides age-related female infertility, the fast-paced and stressful urban lifestyle has also taken a significant toll on male fertility. Moreover, heavy environmental pollution in some Asian countries like China has further contributed to a serious decline of male fertility in recent years. Volume 12 > Number 7 >

2 Hence, it is obvious that there are abundant business opportunities for health institutions providing fertility treatment within the Asia Pacific region. Singapore, being at the forefront of biomedical innovation and as a reputed hub for medical tourism appears to be well-positioned to take full advantage of such opportunities. Among the various accomplishments by Singaporetrained fertility doctors include Asia s first test-tube (IVF) baby (the late Professor Shan Ratnam), the world s first successful attempt at egg freezing leading to a live birth (Dr Christopher Chen, Gleneagles Hospital) and Asia s first Intra- Cytoplasmic Sperm Injection (ICSI) baby (Professor Ng Soon Chye, Gleneagles Hospital). Stringent Regulation by the Ministry of Health is Stifling the Growth of Clinical Assisted Reproduction Services in Singapore However in reality, future growth of clinical assisted reproduction services in Singapore is severely hampered by overly stringent regulations set by the Ministry of Health (MOH). Surrogate motherhood and embryo sex-selection for social reasons are banned under all circumstances, and there are prohibitive restrictions on financial compensation of sperm, egg and embryo donors above direct expenses. Genetic selection of IVF embryos, known as Preimplantation Genetic Diagnosis (PGD) requires case-by-case approval by the MOH for each and every individual patient. Moreover, fertility treatment is restricted to only legally married couples and older women above the age of 45 are banned from receiving any form of fertility treatment for childless women (< 35 years) with an unexplained cause of infertility, they are permitted to receive IVF treatment only after being unable to conceive within two or more years of marriage, and having tried alternative approaches to fertility management for at least one year. As expected, such stringent legislation has driven many childless Singaporean couples desiring or requiring such medical services to neighboring countries where the fertility industry is much less tightly-regulated. The situation for Singapore-based fertility practitioners is made worse by the cheaper medical fees and improving quality of clinical assisted reproduction services found in foreign fertility clinics within the region. For example in neighboring Malaysia, a standard IVF treatment cycle routinely costs about half the price compared to Singapore, and the standard of medical services there has vastly improved in recent years, with many Malaysian fertility clinics reporting pregnancy success rates P enang (8 fertility clinics ) K lang Ipoh that are comparable if not higher than Singaporean clinics. Currently, there are already three fertility clinics in nearby Johor Bahru and more than a dozen in Kuala Lumpur itself (Figure 1 and Table 1). Perhaps, the only competitive advantage that they lack is that Singaporean patients are not allowed to utilize their Medisave account for fertility treatment abroad. Additionally, it must be noted that the majority of Singaporean fertility doctors face a language handicap in being unable to communicate in Malay. In recent years, this has led many childless Indonesian Chinese couples to seek fertility treatment in Malaysia, since many of these patients are fluent only in Bahasa, and they would certainly feel comfortable with a doctor who can speak the language. Moreover, treatment in Malaysia is much cheaper and the standard and quality of medical services there is rapidly catching up with Singapore. K uantan K uala L umpur & s uburbs (21 fertility clinics ) M alac c a J ohor B ahru (3 fertility clinics ) Figure 1. The presence of several good fertility clinics in neighboring Malaysia is providing tough competition for Singapore-based fertility practitioners. Besides cheaper medical fees and improving standards of medical treatment, there is also much more liberal regulation of the fertility industry in Malaysia. Moreover, Malaysian fertility doctors can readily communicate in Bahasa, which is appealing to many Indonesian Chinese patients. 44 Volume 12 > Number 7 >

3 City/State Name of Clinic Address Contact (Tel & Fax) Kuala Lumpur Suburbs of KL, Selangor Penang Johor Bahru CC Chung Gynaecology and Assisted Reproduction Concept Fertility Centre Lot 3.4, Level 3, PNB Darby Park, 10, Jalan Binjai, Kuala Lumpur Tel: Fax: Damai Service Hospital, No , Jalan Ipoh Kuala Lumpur Tel: Fax: TMC Fertility Centre (Kepong) No.8, Jalan Prima, Metro Prima, Kepong, Kuala Lumpur Tel: Melbourne Fertility Services Hospital Universiti Kebangsaan Malaysia Hospital Pusrawi KL Fertility & Gynaecology Centre Gleneagles Intan Medical Centre, 282 & 286, Jalan Ampang Kuala Lumpur Jalan Yakob Latif, Bandar Tun Razak Kuala Lumpur Lot 149, Jalan Tun Razak Kuala Lumpur 604, 6th Floor, Wisma Perintis, 47, Jalan Dungun Kuala Lumpur Tel: Fax: Tel: Fax: Tel: Fax: Tel: Fax: Klinik Shankar 2, Jalan Lumut,, Kompleks Damai, Jalan Ipoh, Kuala Lumpur Tel: Lai Women & Fertility Pantai Cheras Medical Center, Suite 22, 3rd Floor, 1, Tel: Jln 1/96A, Taman Cheras Makmor, Kuala Lumpur Mak Women Specialist and No. 5, Ground Floor, Jalan 1/116B, Kuchai Entrepreneurs Park Tel/Fax: Fertility Centre Kuala Lumpur Pantai Medical Centre No. 8, Jalan Bukit Pantai, Kuala Lumpur Tel: Fax: Specialist Clinic for Woman 9A, Jalan Telawi 5,, Bangsar Baru, Bangsar, Kuala Lumpur Tel : Twin Towers Medical Centre KLCC University Malaya Medical Center Damansara Specialist Hospital Lot 401 F & G, Level 4, Suria KLCC Kuala Lumpur City Centre Kuala Lumpur Klinik Kesihatan Reproductive, O & G Dept., UMMC Kuala Lumpur 119, Jalan SS20/10, Damansara Utama Petaling Jaya, Selangor Tel: Fax: Tel: Fax: Tel: Fax: Subang Women s Clinic No. 17-1, Jalan USJ 9/5M, UEP Subang Jaya, Selangor Tel: Darul Ehsan Medical Center No. 32 & 34, Jln Tengku Ampuan Zabedah D/9D Seksyen 9, Shah Alam, Selangor Tel: Fax: Klinik Pakar Wanita & Fertiliti Ng 1590A, 1st Floor, Jalan Besar, Seri Kembangan, Selangor Tel: Metro Maternity & Fertility Center 34, Jln Pasar, Klang, Selangor Tel: Fax: Subang Fertility Centre Subang Jaya Medical Centre, 1, Jalan SS 12/1A, Subang Jaya, Petaling Jaya, Selangor Tel : Fax : TMC Fertility Centre (Main Branch) 55, Jalan SS 21/56B, Damansara Utama Petaling Jaya, Selangor Tel: Fax: Adventist Hospital 465, Jalan Burma, Penang Tel: Fax: Glasgow Specialist Centre , Pulau Tikus Plaza, Jalan Burma, Penang Tel: Fax: Gleneagles Medical Centre No.1, Jalan Pangkor, Penang Tel: Fax: icare Fertility Centre Island Hospital, 308, Macalister Road,, Penang Tel: Fax: Lam Wah Ee Hospital Jalan Tan Sri Teh Ewe Lim, Penang Tel: Fax: Loh Guan Lye Specialist Centre 19 & 21, Jalan Logan, Penang Tel: Fax: Singapore Women s Specialist Clinic 2B, Jalan Brown, Pulau Tikus, Penang Tel: Fax: Srigim Women & Children Hospital 12A, Jalan Mesjid Negeri, Penang Tel: Fax: TMC Fertility Centre Lot 18, Level 1, City Plaza,, No.21, Jalan Tebrau, Johor Bahru Tel: (Johor Bahru) Fax: Johor Specialist Hospital 39-B, Jalan Abdul Samad, Johor Bahru Tel: Fax: Klinik Pakar Sakitpuan Tan (England) 47, Jalan Harimau Tarum, Taman Century Johor Bahru Tel: Fax: Malacca Dr S.Selva Clinic Mahkota Medical Centre, Suite 105 No 3, Mahkota Melaka, Jalan Merdeka, Melaka Tel: Fax: Ipoh Klinik Pakar Wanita Ng 91, Jalan Kamaruddin Isa, (Jalan Fair Park), Ipoh Tel/Fax: Kuantan Table 1. List of fertility clinics in Malaysia and Brunei Darussalam. TMC Fertility Centre (Kuantan) B-14 & B-16, Lorong Tun Ismail 8, Sri Dagangan 2, Kuantan Sabah Assisted Conception Specialist Sabah Medical Centre,, Lorong Bersatu, Luyang, Kota Kinabalu, Sabah Sarawak Sibu Specialist Medical Centre No 52A-F, Block 3, STLD Jalan Brooke Drive Sibu, Sarawak London Fertility Centre Sdn Bhd 1st Floor, Lot 2753 & 2754, Central Park Jalan Tun Ahmad Zaidi Adruce Kuching, Sarawak Brunei IVF Unit, Jerudong Park Medical Centre Jerudong Park 2021, Brunei Darussalam Tel: Fax: Tel: Fax: Tel: Fax: Tel: Tel: Fax: Volume 12 > Number 7 >

4 Clinical Assisted Reproduction Services are Highly Vulnerable to Outsourcing and Foreign Competition Several unique characteristics of clinical assisted reproduction practice make it highly vulnerable t o o u t s o u r c i n g a n d f o r e i g n competition, compared to provision of other medical services. Firstly, the infertility of childless couples does not constitute a medical emergency that results in death or incapacitation of the patient. Hence, patients possess the luxury of time to search and choose fertility doctors and clinics that can provide the best value for their limited available finances. Secondly, unlike serious life-threatening diseases such as heart attack, stroke and cancer, patients are not physically incapacitated and are often fit to travel abroad for treatment. This would obviously favor medical tourism. Thirdly, fertility treatment is a big budget item, costing typically in the range of tens of thousands of dollars, unlike minor surgical procedures and dental treatment that are exceedingly cheaper. The much higher costs would motivate patients to survey and compare the price of treatment offered by various local and foreign clinics, before deciding on which of these would provide the best value for money. Lastly, as mentioned earlier, there exists much disparity in the regulation of clinical assisted reproduction services in different countries. Generally, there is a trend for richer countries to have stricter regulations compared to poorer developing countries. Hence besides the lower costs, fertility tourism by patients from richer developed countries may also be motivated by the ready availability of certain treatment procedures abroad, that may be banned in their home country, i.e. embryo sex-selection, commercialized egg donation and surrogacy. Potential Areas of Future Growth and Opportunities that should be Seized It is imperative to look at strategies to enhance the competitive advantage of the fertility industry in Singapore in attracting both local and foreign patients. Upon surveying recent scientific progress in the field of human clinical assisted reproduction, there appears to be three promising areas for future growth: (1) egg donation and surrogacy, (2) egg and ovary tissue freezing to extend female fertility and for donor egg banking, and (3) Preimplantation Genetic Diagnosis (PGD) to improve chances of pregnancy in older women and for ethical sex-selection (i.e. balancing families with children of one gender). A case will be made for the MOH to liberalize regulations in these areas of fertility treatment by critically re-examining relevant ethical and moral issues. Only then can the fertility industry in Singapore regain its competitive footing in attracting local and foreign patients, and retain its status as a center of excellence in human clinical assisted reproduction within the Asia Pacific region. Potential Growth area 1: Egg Donation and Surrogacy Under current health regulations in Singapore, egg donation is permitted but financial compensation of egg donors above direct expenses is strictly prohibited. Surrogate motherhood is banned under all circumstances. The severe shortage of egg donors in Singapore makes it imperative for the MOH to review its prohibitive restrictions on egg donor payment. It is proposed that donors should be given additional monetary compensation for the inconvenience, discomfort, pain, loss of time and medical risks faced in egg donation. A typical egg donation cycle takes up several hours of a donor s time, in addition to the hassle of commuting to and from her home, workplace and fertility clinic. Egg donors should rightfully be compensated for at least the statutory minimum wages per hour set by law for this period of time spent on egg donation. Additionally, it also suggested that extra financial compensation should be given for discomfort, pain and medical risks faced by the egg donor, similar to the fixed sum payment given to clinical trial volunteers. The MOH should also reexamine its blanket ban on surrogate motherhood. Childless women in Singapore who are medically unable to become pregnant or bodily unfit to carry a pregnancy to term have only two options to start a family: seek either child adoption or a surrogate mother abroad. The latter has attracted much attention by the media, with newspaper report of Chinese Singaporean couples traveling to India in search of surrogate mothers. If it is inevitable that some Singapore residents are going to engage in surrogacy (i.e. through medical tourism), it may be 46 Volume 12 > Number 7 >

5 better to permit and regulate it rather than pretend that it does not exist. Potential Growth Area 2: Egg and Ovary Tissue Freezing As mentioned earlier, a woman s fertility drops sharply above the age of 35. An emerging technology that can overcome this problem is egg and ovary tissue freezing through the novel technique of vitrification which avoids ice-crystallization, thus ensuring better survivability of the patient s frozen specimens. This would empower many working women by giving them more opportunities and choices in life. Instead of being hindered by family and childcare commitments early in life, they can give full pursuit to educational and career goals in the full bloom and vigor of their youth. Upon reaching middle age with a substantial amount of accumulated savings, they would have greater available financial resources for childcare and education of their offspring. Hence, the MOH should lift its restriction on older women above the age of 45 from receiving fertility treatment, particularly if they are utilizing their own frozen eggs and ovary tissue. This could lead to the subsequent development of egg and ovary tissue banking as a new business opportunity, in a manner similar to private cord blood banking. Besides fertility preservation for ambitious career women wishing to delay motherhood, egg freezing technology would also be useful for the banking of donor eggs from younger women, thereby providing a ready solution for many older women who are unable to conceive with their own eggs. A particular promising source of donor eggs would be the excess leftover eggs from patients undergoing fertility treatment. The use of powerful hormones in fertility treatment often leads to the production of excess numbers of eggs by younger women with mild infertility problems or with male partner infertility. These patients can be encouraged to freeze their excess eggs instead of embryos, so that when they achieve a successful pregnancy, their excess frozen eggs may be donated for a refund or discount in medical fees. Potential Growth Area 3: Preimplantation Genetic Diagnosis (PGD) to Improve Chances of Pregnancy in Older Women and for Ethical Sex- Selection in Family Balancing Currently, genetic selection of IVF embryos through PGD requires case-by-case approval by the MOH. This in turn hinders the use of PGD for improving chances of successful pregnancy in older women. Several clinical studies have shown that older women undergoing fertility treatment often have a higher proportion of genetically abnormal embryos that either cannot give rise to viable pregnancies (resulting in miscarriage), or even worse leading to the birth of a deformed child (i.e. Down Syndrome). Hence, the MOH should liberalize the use of PGD on older women, without the need for case-by-case approval. Volume 12 > Number 7 >

6 Additionally, by permitting the use of PGD in ethical sex-selection for balancing families with children of one gender, this would likely attract many patients from China and India, since embryo sex-selection for family-planning and social reasons is completely banned in these countries. Their rapidly growing middle class spurred by robust economic growth, would constitute a large pool of potential patients (Figure 2); and hence represent too valuable a business opportunity for Singaporebased fertility practitioners to miss. Conclusions Due to the much higher overhead costs of operating a clinic in Singapore, coupled with the improving standards of medical services in neighboring countries, it may be futile in the longterm for Singapore-based fertility practitioners to compete with foreign clinics on the cost-quality axis for standard and routine medical procedures. Instead, the best solution may be for Singapore-based fertility practitioners to innovate and come up with new technology platforms and novel treatment procedures not currently being offered by foreign health institutions within the region. By relaxing its stringent regulation of the fertility industry, the MOH in Singapore may encourage innovation and new technology development in this field. At the moment, the fertility industry in Singapore stands at a critical juncture whereby it risks losing its long-held advantage over foreign competitors; if overly stringent regulation of the industry is not relaxed soon. Hence, it is imperative that the MOH should act fast to liberalize legislation, or Singapore could forever lose its footing as a medical hub for fertility tourism within the region. n China Urban population: 562 million Economic growth rate (2007): 11.4% University graduates per year (2007): 5 million Legal status of embryo sex selection: Banned India Urban population: 331 million Economic growth rate (2007): 9.6% University graduates per year (2007): 3 million Legal status of embryo sex selection: Banned Figure 2. China and India, where embryo sex-selection for family planning and social reasons are completely banned. Balancing families with children of one gender through embryo sex-selection (PGD) appears to have strong grounds for moral and ethical justification, and should be allowed in Singapore. This in turn could attract many patients from China and India to travel to Singapore for fertility treatment. Rapid economic growth and urbanization in these two countries is giving rise to a burgeoning middle class numbering in the hundreds of millions, which would certainly represent a large pool of potential patients. Biography Dr Alexis Heng obtained his BSc degree (first class honors) from Imperial College London, his Masters in Clinical Embryology (MCE) degree with distinction from the National University of Singapore, and his PhD degree from the University of Manchester. He is currently working for an American multinational corporation in the biomedical industry. 48 Volume 12 > Number 7 >