I'm super sick and infectious with a bad viral throat and respiratory inflammation. Yes, other friends are out being super singles or pregnant, and I'm dousing myself in cold showers, more medication and copious jugs of fluids, while my throat is so raw and my sinuses so congested that I sound like a breathing, dry-heaving, blistered-mouth elephant.
I guess what finally got to me was either a) my sins of not sleeping well from the overwhelming stress, or b) the masseur last Friday who was clearly ill, coughing all over my face. Since I can't go anywhere, or have spent the last 72 hours pretty much sleeping continuously, I thought I'd tackle one of the bigger questions that always comes up in emails. What is the cost of infertility treatment, and how much is this going to set us back? The answer in Singapore, where public hospital programs for infertility are largely subsidized, can vary a lot depending on the class of patient that you are, and the type of treatment that you respond to.
Broadly, there are two components to financial help with assisted reproduction treatment in Singapore — the first is the government co-payment program and the second is the use of Medisave, which is from your own compulsory healthcare savings fund. The eligibility is that you are under 40 years of age and are, or are married to, a Singaporean citizen. The amounts vary depending on a number of criteria, but the gist is that you will get up to a 75% co-pay from the government, up to $6,300 for each of 3 fresh rounds of ART, and a 75% co-pay for up to $1,200 for all the associated frozen transfers from those 3 fresh rounds.
The second scheme allows you to draw from Medisave, up to $6,000 for the first treatment cycle, $5,000 for the second treatment cycle and $4,000 for third and subsequent cycles, up to a full limit of $15,000 per patient.
The cost of a full cycle of IVF at a public hospital is approximately $12,000–14,000, depending on your medication cost. So, if you seek IVF in a public hospital, it is virtually free.
[Table in the post, headed "Govt Co-pay scheme": Fresh — Singapore Citizen (SC) Couple: 75%; up to $6,300; SC-Permanent Resident Couple*: 55%; up to $4,600; SC-Foreigner Couple*: 35%; up to $3,000. Frozen — SC Couple: 75%; up to $1,200; SC-PR Couple*: 55%; up to $900; SC-Foreigner Couple*: 35%; up to $600.]
The first thing I would say to anyone who is experiencing any elementary issue with fertility is, therefore, go to a PUBLIC HOSPITAL. The reason is that infertility can be a deep and black sinkhole, and you don't know when you begin how much you would have to pay on this journey. I wanted to save some help, in case we needed it for later. There is a human tendency to think, "this will be over soon. I can manage a few odd payments here and there while we continue to try naturally." Resist this urge.
The applicable public hospitals are National University Hospital (NUH), Singapore General Hospital (SGH), and KK Women's and Children's Hospital (KKH). Their waiting queues are not short, as you can imagine, so if you are planning forward for IVF, put yourself on the list, even if you are not sure. If you change your mind later, it is a whole lot easier to back out than to get signed up. The average wait time for a first appointment is 3 weeks, and then 1–2 months to the first IVF, which, all things being equal, cannot be considered long.
Even if you begin with IUI, and most women will do at least two of these, you can pay for almost the entirety of the medication and process via Medisave in a public hospital. Looking back, I wish that I had not pushed on to 4 medicated IUIs — the medical cost and the amount of medication I took was easily equivalent to an IVF. What I didn't realize at that time was that the amount of medication we were put on was actually very prolonged and extremely expensive.
I also wish that I had done the rounds in a public hospital, because there isn't very much difference in outcome and service. For the 4 rounds of medicated IUIs and three actual IUI processes that we did at Mt Elizabeth, we paid a grand total of $8,659.75, which is HUGE. Although the IUI process itself only (I shouldn't say only, IUIs only take 2 minutes to complete — so the going rate is much more expensive than the female equivalent of hiring a high-class hooker) cost $750, our medical bills from scans, Gonal-F and Cetrotide medications easily cost another $1,700 per cycle. A similar process would have cost far less in a public hospital, $600–1,000 per round, toward which I could have considered using Medisave.
We were made to do two separate rounds of fertility workups at both Mt Elizabeth and NUH, which are not covered by any medical program and which cost $700–900 each. If you are employed, those may be covered by your employer's health benefits.
The first round of IVF at NUH was entirely free, with the $5,385 govt copay and the $6,000 Medisave claim, as we never proceeded to transfer and didn't pay for it. This is also where we discovered that the Gonal-F medical protocol at the public hospitals, unfortunately, wasn't working for us. They were unwilling to use any other medical protocol, so we had no choice but to abandon the public hospital route and return to private hospital care. This made me pretty angry, that the public service was so inflexible, despite being so well-resourced, and that the government co-pay was not applicable at private hospitals, for women who were not there through choice.
Our second mistake was not to use the government co-pay for the second, cancelled round of IVF at NUH. This was cancelled after just 9 days, leaving us with a $3,400 bill primarily for medication consumed up to that point. Looking back, we were ill-advised not to claim this, as we were never going to return to a government hospital and had no further opportunity to use the govt co-pay. At that time, I wanted to save the Medisave amounts for later treatments, if we needed them, but I have no idea why the centre did not suggest applying the govt co-pay toward the cycle.
We used the remaining $5,000 and $4,000 for our subsequent two rounds of IVF treatment back at Mt Elizabeth. The excess out-of-pocket expenses were $6,040 in the third IVF round and, in the fourth round, with the addition of the expenses for freezing, storage and FET transfer of embryos, this swelled to $15,008.
I am not going to stand here and lie that the amount we've spent in this process doesn't hurt, particularly as it was all unsuccessful. I am also fully aware that there are women without any medical help, or who are over 40, and who pay the entirety of costs out of pocket, so we are still lucky to have this access and I am grateful. However, I think the main lesson to take away is that infertility is a costly and painful problem, and it needs to be approached and planned for in a practical way.
The cost of treatment, and of later pursuing continued and increasingly expensive treatment, is one of the most constant limitations and major sources of stress for both sides in the couple. Your medical dosages, costs and procedures need to be carefully recorded and monitored, as they escalate very quickly once the process of treatments starts, and you need to be vigilant with making fresh claims when available. This budget both determines your threshold of options, as well as the lifestyle choices you can have outside of trying to conceive.
Can you reduce your treatment cost by going overseas to a developing country? The short answer to that is yes — to Malaysia, Thailand or India (these are the most logical logistical options). My own experience here, and that of many women that I have talked to, is that at least in reputable clinics in Thailand (I'm referring to proper hospitals like Bumrungrad or clinics like SAFE and SART, which have experienced hospital doctors and more than 5 years of operating history), the standard of care is extremely comparable. In fact, the service levels are much higher, the protocol was more well controlled, and the post-retrieval medications were much more kiasu — they involved more painkiller, antibiotic and anti-spasmodic than I had ever been prescribed in Singapore.
However, with Medisave assistance and government co-pay, costs in Singapore are most definitely lower. It is only if you have exhausted the govt co-pay, Medisave, and if you are at a private hospital, that you will see a cost benefit. To illustrate this, I have included this breakdown of the component costs.
The difference between Singapore and Thailand costs comes primarily from the big price difference in medicine cost, doctor's fees and freezing costs. However, remember that you also need to pay for airfare and hotel stays if you are travelling to do IVF. You may also need initial monitoring and scans in Singapore, for which you will need to pay out-of-pocket.
[Cost table image in the post, headed "Component costs of IVF (SGD)":
Mount Elizabeth Singapore / NUH Singapore / SAFE Fertility Bangkok
IVF with ICSI: $7,435, not including consultations and scans (+$800) / $5,669 (including all consultations and scans) / $4,727, including all consultations and scans
Medicine: Gonal-F, 75iu: $75 / $74.20 / $74.16
Medicine: Menopur, 75iu/150iu: $72 / — / $61.80/$123.60
Medicine: Elonva, 150iu: $3,000 / Unavailable / $1,454
Medicine: Cetrotide, 75iu: $95 / $91.71 / $96.80
Medicine: Orgalutran, 75iu: $80 / — / $98.80
Medicine: Crinone, per stick: $15 / — / $9.80
Medicine: Progynova: $17.40 / — / $11.70
Embryo Culture (IVF): Included in IVF / Included in IVF / $706
Embryo Freeze (FET): $1,262 / — / $470
Embryo Thaw (FET): $2,500 / — / $588
Embryo Transfer: $1,000 (FET) / $749 (Fresh) / $1,765 (FET) / $980 (Fresh)
PGD testing for chromosomal abnormality or gender: Unavailable / Unavailable / $2,746 for 5 embryos]
Can you cover infertility with insurance in Singapore? Let me know if you have an alternative answer as to which healthcare insurance plan or provider covers fertility treatments, but in so far as I know, there is no medical insurance here which will pay out for fertility treatments.
However, you may want to get healthcare insurance or top up your medical insurance anyway, in the event that you expect to be pregnant, have children, or seek further treatments and checks related to women's health, but not necessarily fertility. The risk of birth defects or pregnancy complications may increase with IVF, and many insurers will ask if pregnancy is achieved via ART when you sign up for pre-natal or women's health insurance.
