Using compulsory pension funds for social egg freezing – a viewpoint from Singapore

Many countries worldwide implement compulsory pension funds and medical savings schemes that are contributed to by both employees and employers. In some countries, employees are allowed to withdraw from such funds to pay for fertility treatments, such as IVF.

In Singapore, the compulsory pension fund that all citizens and permanent residents must subscribe to is the Central Provident Fund (CPF), the medical component of which is known as MediSave. Under current health regulations, married couples in Singapore may withdraw up to SGD$6000 (£3300) for their first IVF cycle, SGD$5000 (£2700) for their second cycle and SGD$4000 (£2200) for their third cycle, from either of their CPF MediSave accounts; with a lifetime withdrawal limit of SGD$15,000 (£8200).

As a response to the drastic decline in birth rates over the past few years, the Singapore government is currently deliberating whether to lift the ban on social egg freezing for single women (see BioNews 1119). If the ban is lifted, it is likely that many prospective patients will want to use their CPF MediSave account to fund social egg freezing, which is highly expensive in Singapore. Social egg freezing is currently unaffordable and inaccessible to many young single women, who don't have adequate savings yet have optimal egg quality for freezing. Nevertheless, it can be argued that CPF Medisave use for social egg freezing is unethical, cost-inefficient and wasteful.

First and foremost, this elective medical procedure is non-essential for sustenance of either health or life of the patient, but is instead attributed solely to personal life choices. Hence, using CPF Medisave for social egg freezing is unethical as it depletes funds that may be required for medical contingencies in the future, particularly during old age. Currently, Singapore government policy allows CPF MediSave use only for life-threatening or health-threatening medical conditions, with IVF treatment being the only exception. Nevertheless, this is justifiable, based on the grounds that married couples' infertility problem is involuntary and not a personal choice. If it does become legal to use CPF MediSave for social egg freezing, then why not allow cosmetic surgery to be funded?

Second, a clear distinction must be made between deliberate creation of a medical situation versus lifestyle risks. For example, a heavy smoker is at a higher risk of lung cancer, yet is allowed to use CPF MediSave for funding lung cancer treatment. Likewise, a construction or shipyard worker is at an increased risk of accidental workplace injury, yet is allowed to use CPF MediSave for treatment of occupational injuries. Hence, it may be argued that the fast-paced and busy work schedule of some professions could be considered a lifestyle risk and occupational hazard that results in women not marrying or starting a family when they are building their career. This in turn may justify the use of CPF Medisave for social egg freezing. Nevertheless, in the first two examples, although there are obvious elements of lifestyle risks, there is no deliberate and wilful creation of a medical situation. The smoker and the construction worker are not deliberately choosing to develop lung cancer or have an accident respectively, although the risk is there. But the career women is choosing to undergo an elective medical procedure so that she can pursue her career. Not only is the egg extraction surgery invasive, but there are also risks of ovarian hyperstimulation syndrome, a potentially life-threatening condition where the body overreacts to injected hormones.

Third, social egg freezing may be too cost-inefficient to warrant funding by CPF MediSave. The freezing or cryogenic process always causes some damage to human eggs, despite new technological innovations such as ice-free vitrification protocols. According to the American Society of Reproductive Medicine (ASRM), the pregnancy success rate for egg freezing is relatively low, at around 2 to 12 percent per frozen egg. Likewise, the Human Fertilisation and Embryology Authority (HFEA) in the UK, reported that only about one in five IVF treatment cycles using a patient's own frozen eggs is successful. The low success rates may be further aggravated by the late age at which most women freeze their eggs, typically in their mid-thirties to early forties. Given such poor success rates and low cost-efficiency, many women often require multiple egg freezing cycles to obtain sufficient numbers of frozen eggs to have a reasonable chance of a future pregnancy. How many egg freezing cycles would the CPF board be willing to fund for each individual? Would this not rapidly deplete an individual's CPF MediSave fund and be deemed highly wasteful?

Finally, most women who freeze their eggs, don't eventually use them, as reported by two Australian studies. In the first study published in 2017, researchers surveyed nearly 100 women who elected to freeze their eggs between 1999 and 2014 for the purpose of delayed childbearing, and found that just six percent of women had used their frozen eggs at the time of the survey, with only three percent of them having given birth. The second study published in 2021, reported similar findings – that of the 4048 women who had stored their frozen eggs in Victoria, Australia, less than four percent (159 women) came back to use their eggs in 2020. Consequently, the second study estimated that at best, only one in five patients will eventually use their frozen eggs.

In conclusion, both the Singapore government and CPF board have a public duty to ensure that citizens' CPF savings are wisely and prudently used. Singaporean women currently have one of the world's highest life expectancies (86.1 years). Hence, it is imperative to ensure that there is sufficient money within women's CPF MediSave for medical contingencies over their long lifespan. Based on the aforementioned reasons, permitting the use of CPF Medisave to fund social egg freezing may not be in the patient's best interest and may in fact contravene the public mission of the CPF board.