What IVF patients should know about importing frozen donor eggs into Singapore

by Dr Alexis Heng Boon Chin

A recent Channel News Asia article entitled “Egg donation in Singapore: What couples with complex infertility need to know if they want to have a baby”, described the challenges faced by infertile women seeking egg donors in Singapore, which are in short supply due to strict regulations that require egg donation to be altruistic.

Nevertheless, the import of frozen donor eggs from approved foreign egg banks (some of which are in Malaysia) is permitted by the Singaporean Ministry of Health.

It must be noted that egg donors are restricted to three live births in Singapore, so it is necessary for your fertility clinic to check with the egg bank whether frozen eggs from the same donor have previously been used in Singapore.

Alternatively, Singaporean patients can also travel overseas for fresh egg donation at a foreign IVF clinic, of which Malaysia is an increasingly popular destination.

Hence, IVF patients requiring egg donation in Singapore have to choose between fresh versus frozen egg donation.

It is thus necessary for them to understand the various advantages and drawbacks of frozen versus fresh egg donation, before making their choice.

The major advantages of frozen donor eggs are as follows:

• More convenient and easier to manage, because there is no need to synchronize the treatment cycle of the recipient patient with that of the egg donor.
• The number and quality of eggs are known and guaranteed for frozen egg donation, unlike the case of fresh egg donation where there is also a risk of cycle cancellation due to medical complications in the donor such as ovarian hyperstimulation syndrome (OHS).
• Frozen eggs are readily-available, so shorter time span from choosing an egg donor to IVF embryo transfer. Unlike fresh egg donation, there is no waiting time for various medical procedures to be performed on the egg donor, such as ovarian stimulation and egg retrieval.
• More rigorous and comprehensive screening of egg donors for genetic defects and infectious diseases. This is because egg banks usually export internationally to various countries worldwide, such as USA and Australia, where there are strict regulations for genetic testing and infectious disease screening. For example, infectious diseases such as HIV and Syphilis have an incubation period of several weeks, so it is best to test the egg donor for such diseases twice over an interval of 3 to 6 months. Two such tests are usually done for frozen egg donation, unlike fresh egg donation, where the donor is only tested once before egg collection. To comply with strict regulations in Western countries, egg banks usually test the blood samples of their donors for common genetic diseases such as spinal muscular atrophy, alpha and beta-thalassemia, and fragile-X syndrome. However, in Malaysia, egg donors are not routinely subjected to routine genetic testing of their blood samples due to lack of regulations. Instead, worried recipient patients are pushed and encouraged to do much more expensive embryo genetic testing (PGS/PGT-A) that risks damaging the embryo, without improving IVF success rates.
• Save the hassle and costs of traveling for fresh egg donation, particularly for Singaporean patients with busy work schedules.
• Most egg banks permit release of the egg donor’s identity to donor-conceived offspring at 18 years of age, in compliance with regulations in Western countries. By contrast, fresh egg donation in Malaysia is usually anonymous.

Nevertheless, frozen egg donation also has several disadvantages as follows:

• Lower IVF success rates with frozen versus fresh donor eggs. A 2020 study on 36,925 IVF cycles demonstrated that fresh eggs yield better success rates than frozen eggs. Fresh eggs had a 47.7% live birth rate, versus 39.6% for frozen eggs.
• Not all frozen eggs will survive the thawing process. Out of 10 frozen eggs, at most 8 or 9 will survive, provided the freezing and thawing procedures have been properly carried out by competent laboratory staff (embryologist).
• The survival rate of frozen eggs is heavily dependent on whether the thawing procedure is compatible with the freezing procedure, analogous to a key and lock. By transferring the frozen eggs from an egg bank to another IVF lab with different operating procedures and protocols, there is a risk that the survival rate of frozen eggs may be drastically lowered due to non-compatible protocols for freezing and thawing by different labs.
• Expensive shipping costs due to transportation of frozen eggs requiring a special cryogenic container and special paperwork that exempt these from being exposed to x-ray during custom checking and clearance.
• Remote risks of damage to frozen eggs during transport due to malfunctioning cryogenic containers, as well as unforeseen accidents and delays.
• Frozen eggs collected from a single cycle (typically 12 to 20 eggs from a young healthy donor) are usually split among multiple recipient patients, each receiving a batch of between 6 to 8 eggs. By contrast, all fresh eggs collected from a single cycle are yours. This means that not only is fresh egg donation more cost-effective, but more available eggs also translate to better chances of IVF success.
• Better chances of having genetically-related siblings, if you desire more than one child. More available eggs being collected in a fresh egg donation cycle will translate to surplus IVF embryos that can be frozen down and used later to conceive a second or even third child. It is often difficult to find the same donor again for multiple frozen egg donation cycles, particularly in the case of Singapore that restrict three births for each egg donor.
• Wider and more extensive choice of fresh egg donors, as compared to the limited number of frozen egg donors in egg banks. Because to date, fresh egg donation is still way more popular than frozen egg donation.
• Sex selection by embryo genetic testing (PGT-A/PGS) is currently banned in Singapore. So if you import frozen donor eggs into Singapore, there is no possibility of sex selection. This is however possible if you travel to Malaysia for fresh egg donation.
• IVF medical fees are much more expensive in Singapore compared to Malaysia and other neighboring countries. It may be much cheaper and better value for money by traveling to Malaysia for fresh egg donation, rather than doing frozen egg donation in Singapore.

Alternative fresh egg donation arrangement for IVF patients with busy work schedules

For IVF patients with busy work schedules, an alternative arrangement may be to use a nearby local IVF clinic to administer hormone injections to prepare the patient’s womb to be receptive for transfer of IVF embryos, which is the most time-consuming part of the egg donation process for recipient patients.

In this case, only two long-distance trips are required for fresh egg donation. The first trip for sperm collection from the husband, which is used to fertilize the fresh donor eggs to produce IVF embryos that are then frozen down (embryos tend to survive the freezing process much better than unfertilized eggs). The second trip for transfer of the frozen IVF embryos to the wife.

Indeed, a number of Singaporean IVF clinics have collaborative ties with Malaysian IVF clinics in Penang and Kuala Lumpur in carrying out such fresh egg donation arrangements. Patients must note that budget air travel is much cheaper than using a courier company to transport frozen sperm or IVF embryos to and fro in such arrangements.

Moreover, it must be noted that Singapore currently bans the import of frozen IVF embryos that have been genetically tested with PGS/PGT-A, as this will inevitably reveal the sex of the embryos, which is illegal in Singapore.

Beware of unethical and fraudulent practices in fresh egg donation

Egg banks exporting frozen eggs to reputable fertility clinics worldwide have a reputation to maintain, as well as the need to comply with strict regulations set by many Western countries.

This would mean that established egg banks that have been operating for some years most likely adhere to certain standards of ethical business practices. The same cannot be said of many small-time egg donor agents and agencies in Malaysia that are completely unregulated.

One unethical and fraudulent practice that prospective recipient patients have to be particularly wary of in fresh egg donation is the switching of donors after patients have selected their choice.

It must be noted that egg donation in Malaysia is anonymous, and patients are not allowed to meet donors. Based on anecdotal evidence from website blogs, such fraudulent cases have already occurred in Malaysia with some small-time egg donor agents and agencies.

This is because it is not easy to match the work or study schedule of prospective egg donors with that of recipient patients.

For example, the patient’s selected egg donor may have a sudden and unexpected change in their schedule that leave them with no time to participate in the lengthy and tedious fresh egg donation cycle requiring numerous medical appointments.

In that case, some unscrupulous small-time agents may find it convenient to just switch to another available donor with the same blood group, without informing the recipient patient.

To prevent such fraudulent practices, it is recommended that the patient check with their clinic on the recorded height, weight and age of the egg donor, when she has her first medical appointment for health checks and blood testing for HIV and other infectious disease.

Her weight may vary a little, but her height and age should match the donor profile selected by the recipient patient. Yet another unethical practice that recipient patients have to beware, is that some IVF clinics may take a cut of profit if they are asked to source egg donors from various agents and agencies.

This usually happens if the patient do not pay the agent or agency directly, but instead give their money to the IVF clinic, which pays the agent/agency and keeps a portion to themselves as “administrative fees”.

By contrast, pricing is transparent in the case of frozen egg donation, and patients pay directly to the egg bank.

In conclusion, different IVF patients have varying budgets, circumstances and expectations.

They have to ponder carefully and weigh the various pros and cons of fresh versus frozen egg donation in deciding which is best suited for them.