February 26, 2024

Singapore must prevent abuses in donation of unused surplus frozen eggs

A recent Channel News Asia article, “Egg donation in Singapore: What couples with complex infertility need to know if they want to have a baby”, highlighted a severe shortage of altruistically-donated eggs for infertile patients in need.

As elective egg freezing (EEF) is permitted in Singapore from July 2023, unused surplus frozen eggs can be a promising new source for altruistic donation. Indeed, studies have shown that most women who freeze their eggs do not eventually use them. Furthermore, sociological studies from the USA and Australia have shown that around 25% to 30% of former EEF patients opt to donate their unused frozen eggs for IVF treatment of other patients. Assuming that 80% patients who freeze their eggs do not eventually use them, as estimated by Australian researchers, this would extrapolate to about 20% to 25% of eggs frozen in Singapore being available for donation to IVF patients in need, which is indeed a huge number. Nevertheless, it is imperative that the health authorities in Singapore exercise vigilance in preventing potential abuses in egg donation by local fertility clinics and doctors.

The most pressing ethical issue relates to the conflict of interest faced by fertility clinics, doctors and their affiliated counselors in persuading patients to donate unused frozen eggs, as they will be earning additional medical fees by performing donation procedures on recipient patients. There is a risk that the doctor-patient fiduciary relationship will be abused during the donation consent process, especially if doctors had developed a level of trust and rapport with their former EEF patients.

By “sugar-coating” altruistic egg donation as a kind deed, doctors and fertility counselors can easily mask their conflicting interests, and exploit the “feel good” factor of bringing joy to others in need, when coaxing EEF patients to donate their unused frozen eggs.  

It is well-known that donated eggs from Asian women are in high demand worldwide, not only in mainland China, but also in many Western countries due to the substantial presence of Asian immigrant communities in these countries.

Indeed, it was widely reported in the American news media that Asian donors receive higher levels of monetary compensation that Caucasian donors in the USA, simply because there is higher demand for their donated eggs. In mainland China, there is currently a severe shortage of donated eggs, because it is mandated that donated eggs can only be altruistically donated by IVF patients undergoing treatment, with donation from non-patients being banned.

In Singapore, monetary payment for egg donation is currently prohibited, and donors are required by law to be altruistic. Nevertheless, if there is an accumulated surplus of unused frozen eggs of former EEF patients within Singapore in coming years, local fertility clinics can capitalize on the high worldwide demand for Asian donors eggs by offering these donated eggs to foreign patients. Such foreign IVF patients are likely more inclined and willing to pay higher medical fees.

This in turn might possibly give local fertility clinics the opportunity to participate in “covert egg trading”, by surreptitiously marking up their medical fees for egg donation, particularly to foreign patients. Such “marked-up” medical fees could thus be a “cover-up” for the sale of altruistically-donated frozen eggs, which are in high demand but short supply worldwide.

Not only will there a gross violation of medical ethics in this case, but there will also be a lack of distributive justice for Singaporean and permanent resident IVF patients in need, who by right should get priority over foreign patients in receiving these altruistically-donated eggs.

Another possible breach of medical ethics, is that fertility clinics might divide-up and allocate the donated unused frozen eggs from one EEF patient to multiple IVF cycles or multiple recipients, so as to maximize the amount of medical fees that can be earned from a single donation.

The situation is further complicated by the fact that doctors often advise older women to freeze more eggs to have reasonable chances of success, because eggs of older women tend to be of lower quality. Hence, older women who have conceived naturally may have more unused frozen eggs available for donation, which means more opportunities for unscrupulous fertility clinics to divide up the eggs from one donor for allocation to multiple recipients and treatment cycles.

Confusion and misconception can easily arise from the common practice of commercial egg banks recommending much fewer frozen eggs for a single donation cycle, because these eggs are usually derived from much younger women and hence are of much higher quality. Hence, the utilization of six good-quality and young frozen eggs for a single donation cycle, as recommended by a commercial egg bank, can easily be confused with six lower-quality eggs donated by a much older former EEF patient. 

Ethical breaches can also arise from fertility clinics and their affiliated psychological counselors withholding or downplaying key information relating to sociological risks in egg donation. In particular, issues relating to the obsolescence of donor anonymity and confidentiality due to widespread DNA testing, as well as increased risks of accidental incest among donor-conceived offspring due to “Genetic Sexual Attraction”.

The proliferation of cheap DNA home collection/testing kits and associated ancestry/genealogy websites that enable individuals to trace unknown blood relatives worldwide, has rendered egg donor anonymity and confidentiality obsolete.

Although egg donors may not have done such DNA tests themselves or uploaded their genomic DNA profiles on these websites, some of their family members or more distant relatives may have done so, meaning that they could be tracked down by their unknown donor-conceived offspring.

Therefore, in countries like Singapore that still mandate egg donor anonymity, it is imperative that prospective donors should be advised to be mentally and emotionally prepared for the possibility of future unintended contact with their donor-conceived offspring, despite repeat assurances by their fertility clinics and counselors that their anonymity and confidentiality will be well-protected.

Additionally, prospective egg donors must also be made aware of the risks of accidental incest occurring among their natural and donor-conceived offspring due to the phenomenon of “Genetic Sexual Attraction“. This refers to sexual attraction between close relatives, such as siblings or half-siblings separated at birth, who meet for the first time in adulthood.

Although rigorous academic studies on “Genetic Sexual Attraction” are lacking to date, there is widespread anecdotal evidence from numerous news media reports. As the old saying goes, “There is no smoke without fire”, which thus hints at something inherent in human socio-biology.

In the natural family situation, due to psychological imprinting of the “Westermarck effect”, siblings of the opposite sex who have been familiarized with each other as children, do not mutually attract each other.

The risks of accidental incest due to “Genetic Sexual Attraction” may be further exacerbated by the small size and high population density of Singapore, which increases the chances that the egg donor’s offspring might inadvertently meet and sexually attract each other.

Hence, the Singapore Ministry of Health must remain vigilant in preventing such potential abuses and exploitation by fertility clinics, so as to protect the welfare of patients and ensure that their doctors act in their best interests.

One solution may be to ban fertility clinics and doctors from controlling the distribution of donated frozen eggs from their former EEF patients to other patients in need. Instead, this would be better managed by a government-run centralized egg donor registry and waiting list of prospective recipient patients, which will thus ensure more equitable distribution of altruistically-donated frozen eggs.

Alexis Heng