SINGAPORE – Among the first patients Ms Amy Lee Shaw Ni met when she was cutting her teeth as a junior embryologist at Singapore General Hospital (SGH) was a young couple from Hong Kong hoping to get pregnant.

Their in-vitro fertilisation (IVF) treatment at the hospital’s Centre for Assisted Reproduction (Care) started in August 1993, around the same time the King of Pop Michael Jackson was performing in Singapore.

The procedure required the wife to regularly inject herself with follicle-stimulating hormone to boost the production of multiple eggs. Not wanting to miss watching the music legend and his moonwalk, the wife took the stimulation drug in a cooler bag to the concert and injected herself during the interval, Ms Lee recalls.

The wife later delivered triplets, one boy and two girls, as a result of three successful embryo implants.

Fast forward 30 years: Michael Jackson is gone, Taylor Swift reigns supreme, and Ms Lee is the chief embryologist at Care.

Practices in reproductive medicine have evolved, and couples are now advised against multiple embryo implantations to mitigate the risks of multiple pregnancies, including miscarriage, preterm labour, hypertension and diabetes.

Singapore’s total fertility rate (TFR) has also plummeted to a record low, dipping below 1 for the first time in the nation’s history. The TFR, which refers to the average number of babies each woman would have during her reproductive years, has continued its decline from 1.04 in 2022 and 1.12 in 2021.

The high cost of living and pervasive stress were cited as the main deterrents to parenthood among individuals aged 21 to 64, a study by the Institute of Policy Studies found.

Despite this concerning trend, more couples are looking to start families through assisted reproductive technology (ART) treatments, which include IVF and its variations.  

The latest Ministry of Health data reveals that about 10,500 cycles of ART treatment were carried out in 2022. This is an 81 per cent increase from the roughly 5,800 cycles recorded nearly a decade earlier, in 2013.

Dr Liu Shuling, director and senior consultant of the KKIVF Centre at KK Women’s and Children’s Hospital (KKH), says the centre saw a 40 per cent increase in couples seeking fertility treatment between 2014 and 2023. 

She attributes the surge to heightened awareness, growing societal acceptance, a higher treatment success rate, as well as more couples starting families at a later age.

Over the years, the Government has provided various forms of assistance to Singaporean couples considering or undergoing ART treatment. This includes lifting the age limit of 45 for women in January 2020 to increase its access for older couples. 

Singaporean couples who begin their fertility treatment before the age of 40 at public assisted reproduction centres at KKH, SGH and National University Hospital (NUH) are also eligible for government co-funding covering 75 per cent, or up to $7,700, for each round of fresh IVF cycle and up to $2,200 for a frozen IVF cycle.

In April, Health Minister Ong Ye Kung announced plans for SGH and KKH to progressively increase their ART treatment capacity over the next few years.

NUH expanded its IVF capacity by a third in 2022 after renovating its IVF laboratory. Once SGH and KKH’s expansions are completed, the combined ART capacity across the three hospitals is expected to increase by about 20 per cent. 

Even with more support, the journey for many couples struggling to conceive remains fraught with uncertainty.

Technical complexities

Ms Lee says: “Many people are familiar with the term IVF. What they may not be aware of is, it is a complex series of stringent procedures, where any deviations can jeopardise the cycle’s outcome.”

IVF is an intricate process, where eggs are combined with 100,000 sperm in a culture dish and the fastest sperm penetrates the egg to fertilise it.

In cases of low sperm count or compromised sperm motility, intracytoplasmic sperm injection (ICSI) is used. This technique requires the embryologist to select the most normal looking sperm under the microscope, immobilise it, and inject it directly into the egg using a fine glass needle to achieve fertilisation.

In a fresh IVF cycle, the successfully fertilised eggs or embryos are monitored for up to six days, to a stage ready for implantation into the female patient’s uterus, hopefully leading to pregnancy.

If immediate transfer is not feasible or there is a surplus of good quality embryos, they will be frozen and stored at minus 196 deg C in liquid nitrogen and thawed for later use.

All procedures must be conducted in a highly controlled environment mimicking the natural conditions of a womb, because eggs and embryos are extremely sensitive to fluctuations in temperature, pH level, humidity and air quality.

This is why embryologists often work in the dark, with eggs and embryos constantly maintained at 37 deg C during handling and observation. The culture media used to facilitate embryo’s growth and development, meanwhile, are always kept at a pH level between 7.2 and 7.4.

Assisted reproduction is also highly dependent on equipment such as the micromanipulator, which is used to perform the extremely delicate ICSI procedure of inserting a sperm into an egg.

As this device requires a high level of handling precision, Ms Lee says it takes a new embryologist an average of two to three years of on-the-job training before they are competent and licensed to use it to perform ICSI on the eggs of actual patients.

Despite advancements in the field, IVF does not always result in a successful pregnancy. It is common for couples to undergo more than one round of IVF stimulation and implantation of embryos. 

An imperfect lifeline

At SGH’s Care, approximately 40 per cent of fresh cycles result in pregnancy, says Ms Lee. Frozen cycles boast a slightly higher success rate of 50 per cent. The pregnancy rates are much higher now compared with the 20 per cent in early 1990s, when IVF was still in its infancy stage. 

Associate Professor Yu Su Ling, a senior consultant at SGH’s department of obstetrics and gynaecology, underscores the pivotal role of age in IVF success rates. Data collected at Care between 2014 and 2019 suggests that live birth rates drastically decline for women above the age of 40 seeking IVF treatment, with no recorded pregnancies for those aged 45 and above.

Harvesting eggs becomes increasingly difficult in older women, and even if eggs are obtained, there is no assurance of successful fertilisation, embryo maturation, or implantation, says Prof Yu.

“About 70 per cent of cases where pregnancy is not achieved can be attributed to embryo issues, with the remaining 30 per cent related to uterine factors,” she observes. “As of now, there is no significant breakthrough to address these female associated challenges.” 

Despite this, IVF remains a “lifeline” for many couples hoping for a child of their own, such as British couple Tina and Mayur Padia.

They have been based in Singapore since 2016, and successfully had a child in 2021 after four cycles of IVF.

Mr Padia, 43, had a low sperm count, and the couple underwent IVF treatment with Dr Suresh Nair at Seed of Life Fertility & Women’s Care Medical Centre, spending more than $100,000 on the treatments. 

Mrs Padia, 44, says: “We knew there are other options out there – adoption, egg and sperm donors, and surrogacy – but for couples who really want a child and can’t have one naturally, we wanted to explore treatment first before looking into alternatives.

“We were just mentally not ready to be in that space to think about other options because we were so obsessed and desperate to have a baby of our own,” she says.

Also, Singapore’s personalised and high quality medical services appealed to the couple. In Britain, access to IVF treatment through the National Health Service is governed by strict guidelines and regional availability, says Mrs Padia.

“Once we began our treatment journey here in Singapore, we felt a strong commitment to seeing it through and going back to the UK was no longer an option for us,” she explains.

Ms Sher Loh, 45, underwent three rounds of IVF between 2019 and 2021.

Unfortunately, in the first round, the implanted embryo failed to progress into a foetus. She became pregnant on her second IVF attempt, but the foetus’ heartbeat ceased in the fifth week. Her third cycle ended without a successful embryo implantation.

She said it did not surprise her that none of the cycles worked, as she had read numerous accounts online about the uncertainty of IVF. But the two miscarriages she suffered still took an emotional toll. She found it hard to come to terms with successfully getting pregnant but not being able to carry the babies to term.

With government co-funding, Ms Loh and her husband, Mr Jeff Teay, spent over $8,000 in total for two cycles of IVF treatment at KKH and NUH. Besides the process, the sum covered medication, along with traditional Chinese medicine and supplements. Their third cycle was done at a private clinic at a cost of around $10,000. 

“IVF is something that you can get addicted to. It will consume you because once you fail, you will think, okay, I must try again. It will go on and on until you don’t know when to stop,” says Ms Loh, who works in the semiconductor industry.

Ms Loh chose to stop the IVF treatment as she was already 42 when the third cycle was performed. Additionally, her doctor discovered a fibroid in her womb, which she knew would make it difficult for her to produce healthy eggs if she continued the procedures.

“The hardest part is not about going through the process, injecting myself or the physical pain. It’s the emotional and mental pain... From having a lot of hope and anticipation, to the devastating news that it was a miscarriage. After that, you have to pick yourself up and try again. It was torture.”

Childbearing ≠ femininity

For some, the IVF journey forces them to grapple with the notion of femininity and self-worth.

Chinese American psychotherapist Qi Zhai-McCartney, 43, went through three rounds of IVF, which resulted in a son, Max, now eight, and a daughter, Zoe, four, but also a miscarriage.

She had undergone fertility checks when she got married at 34, on the advice of friends.

Fertility experts told her that her ovarian reserve was unnaturally low, mirroring women in their 40s, and she should plan for a family as soon as possible.

While researching fertility preservation options, Mrs Zhai-McCartney often wondered why she had to push herself so hard to have children.

“Was it selfish of me to ‘force’ myself to become a mother? Was there something wrong with me?” she recalls asking herself.

“Then I thought about my own family. I came from a family where death was common (in) the 40s and 50s. My father had worked so hard to give me an education and a better life, and he died at age 50. So, what would be the point of it all, if I worked so hard to study and build a career abroad but left no lineage or legacy?” explains the former Asian equities sales associate, who has been living in Singapore since 2008.

Also, as an only child accustomed to frequent relocations across Asia and the US from a young age, Mrs Zhai-McCartney yearned for a large family. However, maintaining a demanding career in finance meant she needed to keep her fertility plans secret, or risk coming across as “not driven”.

But she knew she could wait no longer, given her body’s condition. Her first IVF treatment in 2016 was paid for via her insurance in the US. In her subsequent IVF treatment three years later, she paid between $10,000 and $12,000 for her stimulation medications and egg retrieval procedures at Alpha Clinic in Kuala Lumpur, Malaysia.

“IVF is a very trying process. I remember coming across a study when I was wondering if I should give up trying to have a second IVF baby. It says couples of a certain age try an average of seven times or more cycles before stopping. That number was unfathomably high to me,” she recalls.

“Many are willing to try cycle after cycle because IVF focuses on the ‘scientific precision’. It’s easy to fall into this idea that ‘if I just follow the protocol exactly, it will work out’.”

She also believes that society has the ingrained notion that pregnancy and childbirth are essential to women’s femininity, so challenges that arise can feel like a harsh judgment on their worth or if they are fit to be women.

Age played a big role in Ms Sophie Sanders and her husband’s decision to pursue IVF treatment when they got married in 2018. The 47-year-old yoga teacher and fertility support specialist says: “I admit I was also a little naive, thinking it’d be faster and less stressful than trying naturally.”

As the couple researched and talked to doctors, they realised that IVF wasn’t a sure thing. “We were aware that our chances might be low, but our approach was to do everything possible to give us the best outcome.”

Even after seven rounds of IVF treatment, she did not conceive.

“After several cycles, you realise IVF is not a magic bullet. Every woman’s body is unique and a one-size-fits-all approach just doesn’t work. Sure, a good doctor personalises the plan, but there are so many factors at play and trial-and-error involved.” 

Nonetheless, on a bad day, Ms Sanders couldn’t shake the feeling that she had “failed” as a woman, a wife, and was somehow broken.

“I think we can agree that as women living in today’s world, we are exceptionally busy and focused on our careers or passions and, at the same time, there’s also this innate desire to be a mother. It’s almost like it is written in our genes,” she says. “But for me, this will never define my worth as a woman.”

The turning point came when she realised these self-limiting beliefs were not exclusive to her fertility struggles, and that they were mostly driven by her inner fears. 

Gradually, Ms Sanders learnt not to be afraid of envisioning a future that may not necessarily align with the “best-case scenario” or match her own expectations, including stepping into motherhood.

“Being a woman, being strong and feminine, is about accepting who I am and who I am not... Maybe creating a family will happen, maybe it won’t, but however it goes, that’s just one piece of who I am.” 

Even with advances in reproductive medicine, KKIVF Centre’s Dr Liu says “it is not possible for IVF to achieve a 100 per cent success rate, and IVF should not be relied on to increase our fertility rate”.

“It is important to acknowledge the diverse experiences and challenges people face on their path to parenthood,” she notes empathetically.

Mrs Padia adds: “We know IVF is not a perfect method. But it is the only thing we have got to hold on to, even with all these complications, to even have a chance to have a biological child.”