I feel like I am enormously re-hashing issues that I have talked about in previous posts, but because I am still getting questions — I'm from Singapore, what do I do — I'm going to lay it out again, in a Singaporean context, although it can easily apply elsewhere.
Please do not take the material out of context. I am acutely aware that no other site has gone into this specific a detail as what I'm about to write, but since I have done ample research, I figure I might as well share it with those asking. However, the thing about infertility — every case is highly specific — so again, if you want to reach out personally, email me, as that is kind of the best way to talk about these issues.
**The Three Major Groups of Women**
If you are trying to conceive, you will fall into one of three categories. Group A is the vast majority of people who conceive naturally in a year or year and a half, and it includes people on Clomid cycles, a progesterone trigger shot to induce ovulation and women who succeed in getting pregnant via a natural or medicated IUI (who are these freaks anyway, those things really work?).
These are couples where the egg is of a normal quality and the sperm can actually penetrate the shell of the egg. If this is you, you are both normal and/or dodged a huge bullet.
The second group are women who take one or two IVF cycles to conceive and typically cycled at the public hospitals NUH, SGH or KKH on a fairly low dose or simple single drug protocol. Typically, you would have a normal AMH and FSH (7.5 each is 'normal') and your husband has variceole or low morphology, or you have screwed up cycles, or fibroids and occasional cysts. Or, you have mild issues of diminished ovarian reserve, without a high FSH or mild PCOS which enables you to produce many but still high quality eggs.
The range of women who fall into Group B is very wide. Although they have all experienced some of the emotional stresses of infertility and IVF, those who need two rounds of IVF stimulation may have experienced a chemical pregnancy, or a miscarriage without heartbeat, while those who only needed one magical round, are blithely unaware of longer-term risks and difficulties of IVF failure, other than it's 'very hard'.
If, despite having contemplated or had IVF, you have no idea what a 4BC embryo grade means and you are a huge proponent for IVF and "Just Keep Trying", you are definitely Group B.
If your wait has been bare (in Singapore, waiting for public-paid IVF takes less than 2 months), or if you have paid almost nothing for your IVF cycles (in Singapore, Medisave and government co-payments cover almost 100% of 3 full rounds of public hospital treatments) or if you are not in a public hospital only because you haven't had to pay that much, or if you are still excited about the prospects of TCM and acupuncture, you are in Group B.
You don't know first-hand, that the pain of slipping down the rabbit hole of multiple IVF failure is a thousand times worse than any of the series of injections you'll ever have to take, and you still reference number of 'cycles' meaning both fresh and frozen transfers, as opposed to full stimulations IVF cycles. You are Group B.
The third group are women who fail at their IVF cycles so spectacularly that they have been given the donor egg speech, or else known as Group C. This post is for this group of very special sisters.
**Group C**
How do you know you are in Group C? Here are some simple, though not complete, ways to tell.
You are in Group C, if you have failed an equal number of IVF cycles (no eggs retrieved, no fertilization, no transfer) as you have completed IVF cycles (made it to full 3 day or 5 day transfer). You are in Group C, if you are a low responder, have tried the highest dose of medication available in Singapore (450iu) and produce <10 eggs.
You are in Group C if you have an embryo issue — that is, most embryos fall apart after Day 2, are highly fragmented, granulated or are seldom at 8 cells by day 3. You are in Group C if both your husband and you have quality issues in sperm and egg, and if the dominant adjective of your >3 IVF cycles and results, has been "confusing". You are automatically in Group C if you are >40.
Group C is when you know the person who draws your blood is called, a plebotanist and you can name up to five different kinds of gonadotropic drugs because they've all been tried on you. You've tried Saizen, or Human Growth Hormone. You've been in public hospitals and private hospitals, because your government subsidy ran out. You can no longer be bothered with prenatal vitamins because you've taken enough to grow a three-year-old folic acid arm.
If you have heard the polite speech that involves 'using replacement gametes', if you have broken down in a doctor's office, you are Group C. If you've had sleepless nights or had nightmares thinking about carrying a child that doesn't look like you, or if you've asked yourself if you would rather a donor who is smarter or prettier. You are in Group C if people have referred you by the term "Recurrent IVF Failure" out loud.
You are in Group C when pregnant is no longer a hopeful word that involves those pretty maxi dresses and your birth announcements ala Blake Lively or your three best friends, but a sad-eyes bad word, because even the doubtfully fertile, have passed you with their pregnancies months ago.
And, with every pregnancy you have to grit your teeth to smile out a Congratulations when you actually have no interest in sharing in their smug fcking joy, because each pregnant friend is just confirming that you're the one, and you no longer have the confidence to think otherwise.
You are most probably in Group C because you are older, or have a high FSH combined with a low AMH (DOR) or have severe PCOS combined with severe male issues or recurrent miscarriage issues. You are in Group C if you have a lousy response to IVF meds. You are in Group C if you have a chromosomal abnormality issue that isn't getting solved via IVF or PGD. You are in Group C if your health bill is almost as substantial as several years-worth of your mortgage.
You are Group C because you know, there is always the possibility of a golden egg, but you are no longer so stupid as to think that if you just keep trying, it will be your turn on the 8th round of IVF by the sheer dumb luck of repetition. And you have wondered if you'd rather spend the next 8 years of your life waiting around or whether it's better to just move on, and not be the bitter lady pinning reports of 45-year-old IVF miracle mothers.
Most importantly, you are in Group C, because you have shit eggs.
Welcome! Drop me a mail, I would love to hear from you personally. And I'm very sorry — sorry for what you've already been through and sorry that this is happening to you.
**So, what do you do now?**
Other than wait around and curse how conventional and fertile your surroundings are?
Well, unfortunately, if you are in Singapore, your options are quite limited. This is the problem and the reason that there are so many of this kind of questions. We are limited in this regard, in Singapore.
There is one option that has often been presented to me as a silver bullet. CCRM, the Colorado Center for Reproductive Medicine, in Denver, Colorado. The primary reason that it has been suggested to me, is their experience with jialat cases.
I have looked up their protocols online and they have very comprehensive protocols involving a lot more drugs, but what really makes the difference is supposed to be the superior quality of the embryology, or the soup that the embryos swim in, which makes a difference to the quality and viability of the embryos.
I have a friend who failed IVF 4 times in Singapore, was told her eggs had dark shadows and that they would not have biological children, and who then went to CCRM, and went on twice, to carry two separate sets of biological twins. If that is not a calling card to drop everything and run there, I don't know what is.
CCRM works with DOR cases, it works with difficult cases, with older women and basically, if there is one place in the world where you can get pregnant, it's CCRM. It's also very expensive (US$35,000) and logistically difficult from Singapore. It is a last, blow-out bet. For those who can afford it and for those who still want to pursue IVF.
My issue with CCRM is not that I don't hope. It is that it requires three separate visits to Colorado from Singapore. I would run there tomorrow if we lived in the US. It is also the knowledge that there are women who fail at CCRM, generally women who don't produce enough eggs for fertilization or testing and that CCRM also does a lot of donor egg cases (so their entire success rate cannot be attributable to IVF alone).
It is also that one round at CCRM is so expensive that it is the same price as a full donor egg IVF or adoption process. I'm not sure I can justify spending a college education, especially if there is an equal probability in failing to conceive a child and then having to pay for a donor cycle.
Your second option, is to carry on with regular IVF in overseas or local private hospitals at full cost, if you have finished your government co-pay and Medisave benefits. You can also choose to do natural IVF, which is where you undergo egg retrieval for a single or a couple of eggs, without the use of much stim meds. This is less invasive and also less costly, but it takes many rounds of reiteration.
Your third option, is to move on to surrogacy (if the issue is recurrent miscarriage because of uterus issues), donor eggs, or adoption.
I want to say categorically, that whether you choose to adopt or not (and whether this involves an infant or a sperm or egg) is a highly personal decision. No one can define for you when enough is. No one, particularly not people who have never been through the process themselves, is qualified to opine or judge on this.
None of your options are costless and it depends on how you view being a mother, or being a parent, and, it often involves not just yourself but how it is regarded by your husband, and the rest of your family.
Different people make the decision for and against, based on their own situation, relationships and needs. But I do want to say, that it is not easy to come off multiple IVF cycles and approach adoption. It can feel like giving up and there are many substantial and equal reasons why women may want to carry their own pregnancy.
**Surrogacy and donor egg options**
To be clear, there are no surrogates nor anonymous donor eggs in Singapore. There is no bank (I think there might be a bank, but it is empty because there are no monetary incentives — you get a token $150). It would be extremely rare, to have an egg or embryo donated from an IVF couple in a Singapore hospital. If you can find someone who is willing to donate to you in Singapore or a surrogate on a non-commercial basis, your gynaecologist can arrange a donor cycle and transfer.
What I am addressing then, is what are your options if you require an anonymous donor? There are also many emotional issues and technical issues that you would want to think about, if you are thinking about donor eggs.
None of it will feel easy or fun, particularly after recurrent IVF failure. You do it because you are resilient enough to simply want to be a mother and to choose the optimism of dreaming about strollers, but you also do it not because of unseemly bravery, but because you don't have a choice about how to move on. It comes from a place of strength, but anyone who calls it (you) bravery, should have their patronising head examined.
I am only going to talk to the technical aspects because this is what my research covers and I am not planning to talk about the emotional aspects, as I don't have the requisite experience to know how to advise. However, an egg-donor mother Maya, put it really well, so I will paraphrase her experience.
"Before I entered the glamorous world of ART, I also had expectations of being pregnant, or a plan. Life. Doesn't. Go. As. Planned. I should have learned that by now.
I had to mourn the loss of not putting my parts together with my husband's parts in a magical night of creation. I had to shift the expectations I had about how and when I would have a baby. I had to re-examine my understanding of love and how I would raise a child. I had to let go of my hope that my children would have full biological siblings. And I had to remind myself constantly that none of this was my fault. That I was not a failure because our IVFs were not successful.
I had to be super conscious of the messages that I told myself, I had to find ways to adapt to our situation and to be kind to myself. I didn't need any more pressure, from other people who weren't flexible, who weren't open, or who in one way or another, were going to make me feel bad about my eggs and guilty about how much money we had to spend.
It takes a lot of work, patience, appreciation and strength to reframe this for yourself. It takes a lot to wait, for your outcome."
**Surrogacy and donor egg options for Singapore**
As established, you are keen on donor eggs because:
* You no longer want to do IVF, or have passed the number of IVF rounds (statistically I'd call this 5 medicated rounds of stimulation), that can be reasonably thought of as 'not affecting your health'
* You are being practical, that is time to bring in the big guns
* You are no longer able to fund IVF and the cost build-up, without success, would become overwhelming
* You have never, ever seen a positive pregnancy test
* You are okay with the idea of not passing on your own genes or likeness, but you would prefer to carry the pregnancy
* You would like to have a biological link to your husband or to one of you within the couple
* You would like to get to parenthood and off the infertility assembly line
But, how do you get to it?
For Singapore, the closest options are Thailand, Malaysia, India, the US, Eastern Europe. Taiwan has a two year wait for donor eggs for residents, donor eggs are illegal in China, Canada and unpaid in the UK.
There are some metrics for clinics and registries, and you have to make your own choice about how important each of these are to you. The first is cost, the second is logistics, the third is availability of donors of your ethnicity and the fourth is transparency and medical standards.
**Finding a clinic or a donor**
**Cost**
Cost is the main stress point and the management of costs across having a child, particularly the cost of repeated IVF, is something that leads a lot of couples to donor eggs, embryo adoption or infant adoption.
Clearly, donor egg IVF in developing countries are going to be cheaper ($12,000SGD) than in developed countries. There will be more service, more choices and hopefully, more flexibility. Donor egg IVF in developed countries, such as the US, will be many multiples the price ($19,000USD–$50,000USD).
Another offshoot of cost, is that some clinics may have refund or guaranteed programs, which help to ensure a certain level of quality of blastocysts, or a guaranteed transfer, or even delivery, but comes at a cost to 'buy' you some peace of mind.
**Logistics**
The second is logistics, coordinating any IVF cycle, will require a complicit doctor in Singapore. Most doctors are actually fairly understanding, they understand that anonymous donors are unavailable in Singapore and they will help you with medication, monitoring, scanning and testing.
However, think about the uncertainties and timing in regular cycles, then multiply that by 5 to get the level of intensity, uncertainty and insecurity that you will have to endure a two-continent IVF cycle.
Obviously, the further the distance, the more difficult it will be to coordinate. You will have to ask yourself and the clinic things like, do you prefer a fresh or frozen egg donation and what are their success rates with each? How many times do I have to visit the clinic?
The answer is usually 1–3x, once to consult, once to retrieve and once to transfer — depending on their level of efficiency, it could be less than three, depending on how long it takes to succeed, it could be much more than three. There is time difference, language and timing difficulties with getting emails and instructions. What if it's still a weekend there? What if the messages and communications are conflicting?
To add insult to injury, most cycles overseas will still wind up costing more than the list price because you will have to pay your doctor here, consultations and medical fees. You will also, be treated pretty callously by the nurses if not the doctors themselves, because you are technically, no longer a patient.
**Available donors**
The third one is self-explanatory, if you care that the child is of the same ethnicity (and you may not, a lot of people do not). The clinic you choose will not just look at a listed donor's age and educational background, but ask you what weight class, height, eye size and blood type you desire and what other parameters are important to you.
If you are Asian, particularly non-Indian Asian, then you will run into difficulties with often only having a handful of known donors for the hospital and the waiting time is notoriously long and the handful of donors are mainly Indian and Malay, but not Chinese.
**Transparency and Medical Standards**
The last issue is transparency and medical standards. First, egg donation may not succeed. We have all been trained, through IVF, to think that a young, fresh egg is going to be the panacea to your problems, but it may not be.
Young women, especially unscreened, unproven donors, may have their own issues and there is often no quantitative reason why transfers don't work. In Asia, I also tend to find that medical practitioners are very quick to blame the egg provider, when it may also be a deep-seated sperm issue that could run central to both your own and donor eggs.
Second, in the developing countries, unfortunately, you cannot be sure that what you have paid for and chosen on paper, is necessarily what you get. I don't want to impinge on individual clinic's authority, because I'm sure some are really legitimate and transparently run, but unfortunately, this system is set up in a way that weighs on the vulnerability of the recipient and the lack of choice.
My own research suggests that individual clinics do have good medical standards but how long they have been in practice, whether they have shady practices like sourcing too often from the same donors, arbitrarily splitting batches of eggs, and how accurately and fluidly they can communicate with recipients, leaves much to be desired.
Although there has been no documented case of infectious disease transmission via donor eggs, very few Asian clinics actually conform to the FDA standard, which is that donors must test after donation and eggs should be quarantined until disease can be removed as a risk, including infections like HIV which take up to 3 months to show up in a test.
Amusingly, Singapore is one of the places that actually does conform to those standards, for the rare egg donation cases that have ever taken place here. In less developed countries, there is always the fear that besides taking on the unknown, you are also putting your own health and well-being at risk.
Besides the medical oversight, the legislation is also more developed and historically entrenched in the US, so the entire IVF process is amply documented and monitored, and if an egg or sperm donor is used, they sign off their legal rights to the eggs and embryos created, they understand what is expected and what their commitments are. You should never doubt the reassurance that both these factors can afford you, but of course, they will charge you heftily for it.
**Is there any good news?**
Not really. Well, you won't pass on infertility to your child, if that helps. You get some level of choice, although the emotion of that choice may not justify having it.
I'm kidding. There are some reasons to be positive. First, donor egg IVF generally (not always!) is a game of persistence. If you try for long enough (notice I didn't say hard enough) you probably will succeed. Second, going through a pregnancy can still be less traumatising than bringing home an insta-baby and I speculate that it is a more intimate process.
There are also systems that allow for open, non-anonymous donors. Generally, this isn't encouraged, especially in Asia, but what you do know, is that are three of you, who desperately want you to succeed and who are love that this child is conceived and born. It is alternative, but it is a happy alternative.
You are being practical. You want to have a child, the people who love you enough, want you to have a child and will be open to how it happens. You will never have to do another injection again. You may need to let go of your child being tall, or having big eyes. But either way, the baby is yours and yours alone.
**Donor countries for Singaporean egg donor IVF**
**Thailand**
Let's start with the easiest — Thailand. This is particularly easy now, because Thailand has shut down commercial surrogacy, following the dodgy case of Australian parents abandoning their Down Syndrome twin and a Japanese billionaire fathering 17 children via egg donation and surrogacy.
The junta-government has not decided if this is against the Buddhist culture of Thailand and hence, the legislation even for donor eggs is in limbo.
In light of this, and police raids to determine if the clinics were operating without a proper medical IVF license (some were) or were supporting commercial surrogacy (most were), most clinics will honour old medical cases but as of mid-August, have shut down their in-house egg banks, if they had one and agencies will not reply to your enquiries about donor cycles.
Even before the unspoken ban, most large hospitals did not operate their own egg banks and only allowed egg donor IVF between relatives. Some more progressive clinics allowed egg donor IVF via anonymous donors arranged through external agencies and some others ran their own fresh and frozen egg bank program with pre-screened, recruited donors.
The clinics now all want to disassociate themselves with the process and you have to use an external agency to recruit your own donor, however, at this time, clearly, none of the agencies are in communication with recipients and none of the donors are interested.
In truth, even if the recruitment is separate from the process, the clinic cannot disassociate themselves legally because they are still responsible for the process on both the donor and recipient end, hence telling you to find an agency is just a polite way to tell you that they are not going to do donor IVF at all.
This is true both in Bangkok and in Chiang Mai. In Chiang Mai, some doctors may still go ahead with the process illegally, as they are more removed from the capital, however, if caught — well, you don't really need that kind of stress do you? To my mind, this ban will not last long but until it is clarified, there is not much prospect in it.
Second, even if the case that it comes back, in my experience, Thailand offers hands-down, the widest choice for clinics and Asian donors, and the most comprehensive amount of personal information, including current, childhood and family photos of donors, but the medical transparency of the system is terrible.
Thailand is a hub for medical tourism and given their longer history with IVF and fertility medicine, the facilities and administration of medicines and surgery is extremely proficient and professional, but additional medical questions and requests for testing will never be entertained or verified, records are slip-shod and their attitude toward blood testing or embryo quality generally, is very relaxed, almost indifferent.
It is the only place that I know of which will begin IVF stimulations or carry out transfers without ever having done a pelvic ultrasound. You would be lucky to see your doctor for 5 minutes once or twice and the conversations are striking in their paucity. Although the nurses are warm and kind, their happy-at-all-costs attitude, poor communication and use of medical terminology will make you cringe.
Yet it remains an attractive option, primarily because of the cost (<$5000SGD), the ease of access, the variety of clinics, the high inherent standard of care and the large pool of Asian and Chinese donors.
**Malaysia**
Malaysia has far fewer clinics than Thailand, probably about 4–5 clinics that really have any history and experience with egg donor cases and surrogacy. These clinics are frequently used in conjunction with Singaporean doctors and are Alpha Fertility, Tropicana Medical, Sunfert Fertility, and Metro Fertility.
For the Malaysian clinics, the logistics of coordination are greatly reduced, given the short 20 min–2 hour journey and the hospitals run their own in-house pre-screened anonymous donor program, however, there is less donor information available, they may arrange the donor matches rather than giving out profiles, and there is a distinct shortage of Chinese donors, usually less than 4–6 per hospital.
I have been more impressed with the fluidity and ease of medical conversations with nurses at Malaysian hospitals, as opposed to Thai hospitals, as there is much less of a language barrier and the cost is $10,000–$13,000SGD.
**India**
Similar to Thailand, India also has a reputation for being a medical tourism hub, because of the large number of clinics and hospitals that cater to IVF, donor IVF and surrogacy. However, I have not done enough research into the cost and availability, as the donors are largely, if not totally, of Indian descent. If this applies to you, finding a donor, or even having the donor come to Singapore, is a tedious but not difficult exercise.
**US**
I would put Eastern Europe, Spain and the US together, because Eastern Europe and Spain is probably not an option for most and it is similar to the developing countries options, at a lower cost for donor eggs ($12,000 SGD).
The US is by far, the most developed system for donor IVF, there are scores of clinics and the process and communications are very transparent. The top clinics are ranked by a SART study of success rates for both IVF and donor IVF every year.
The logistics are by far, the hardest to arrange, especially if you are considering a clinic that is not on the coasts, but, the efficiency of the whole process has been oiled to the point that most clinics only require you to visit once at transfer, or twice, prior to transfer for a uterine examination, sperm freeze and mock transfer.
There are registries that arrange egg donors, but most clinics also run their own in-house donor pools, of proven, pre-screened donors, so you can avoid paying in addition for a registry coordinated match. The incidence of infectious disease is low and the blood screenings are very vigilant, so there is a low barrier of 'discomfort' in the US.
The information provided on donors is beyond comprehensive, there are personality tests, genealogical examinations, audio interviews and most of the donors have attended a 2 or 4 year college. You can also arrange via legal arrangements, to have an open donation, meaning that you will remain in contact with the donor.
However, their donor pools have very few Asian donors, so although the quality is very good, if you choose to go down the route of in-house donor pools, you will have very little, or no selection in the final donor.
The cost of donor IVF in the US ranges from $17,000 for a single cycle of donor IVF and frozen egg transfers, to $38,000–50,000 for a fresh donor cycle with a success guarantee program for delivery or pregnancy past the first trimester.
This is the only program that can guarantee you some degree of success, or reassurance that you don't continue paying for entirely unsuccessful procedures, as most other clinics do not have such a program, or have a very limited program for two good quality blastocysts (this is both a subjective condition and it guarantees very little).
