Speech by Minister Indranee Rajah at NUS Bia Echo ACRLE Conference

Professor Chong Yap Seng, Dean, Yong Loo Lin School of Medicine, National University of Singapore
Professor Brian Kennedy, Director, Bia-Echo Asia Centre for Reproductive Longevity and Equality (ACRLE), Yong Loo Lin School of Medicine, National University of Singapore
Associate Professor Mahesh Choolani, Head of Department, National University of Singapore, Department of Obstetrics & Gynaecology
Ms Nicole Shanahan, Founder and President, Bia-Echo Foundation
Distinguished Speakers
Ladies and gentlemen

It is a great pleasure to be here with you today at the NUS Bia-Echo Asia Centre for Reproductive Longevity & Equality (ACRLE) conference. The conference brings together academics, clinicians, policymakers and healthcare practitioners from different disciplines to discuss the important issues of reproductive longevity and equality. I welcome such platforms for conversations and collaborations because they contribute to overall efforts to improve support for women and families in Singapore and elsewhere.

Our Population Challenges

At the recent Committee of Supply Debate in Parliament, I shared the two demographic challenges that Singapore faces – an ageing population, and a persistently low total fertility rate.

Preliminary estimates indicate that our resident total fertility rate is 0.97 in 2023, dropping below 1.0 for the very first time. While some part of this can be attributed to Covid-related challenges it is nevertheless a significant milestone in a long downward trend. This is an existential issue for us, with implications for our society and economy. With fewer births, family sizes get smaller, and more Singaporeans will have smaller and weaker familial support networks that can care for them when they age. Our workforce will also shrink, making it increasingly challenging to maintain a strong and vibrant economy, and to create opportunities for the next generation.

Encouraging Singaporeans on Starting Families Early

Fertility is becoming a global issue. While many countries are seeing a drop in their TFR, given Singapore’s small size, we feel the impact much more keenly than other countries with larger total populations and greater resources. Why is fertility falling? The reasons vary.  However, one key reason that appears to be common globally is that individual priorities and societal norms are shifting.  Like many other young people around the world, Singaporeans are prioritising other life and personal goals ahead of getting married and having children.

But there is a silver lining. The silver lining is that marriage and parenthood aspirations remain strong among most of our young Singaporeans. A majority still intend to marry and they do want children.^[1] So where does this balance out? I think it really is in the area of competing priorities. Because with more competing priorities, Singaporeans are now tending to marry and have children later. There has been a continuing trend towards later marriages and subsequently later births. The median age of a resident mother at first birth has also increased from 30.4 years a decade ago, in 2012, to 31.4 years in 2022. ^[2] Essentially, as far as the Millennials and the Gen Zs are concerned, marriage is something that comes after many other milestones.

And this presents a challenge, because age affects fertility. Studies show that fertility declines with age for both men and women. Therefore, if couples are marrying later or marrying but having children later, fertility is inevitably affected.

Here in Singapore, we have increased support for couples who have difficulties conceiving and would like to tap on fertility treatments.

• The Government provides co-funding for Assisted Conception Procedures (ACPs) to defray the costs of starting a family. Today, eligible couples can receive up to 75% in co-funding from the Government for Assisted Reproduction Technology (ART) and Intra-Uterine Insemination (IUI) treatments at public healthcare institutions.

• They can also tap on their MediSave to help them with the ACP treatment costs, up to a lifetime withdrawal limit of $15,000 per patient.

• We also implemented Elective Egg Freezing last year to give women the option to preserve their fertility because of personal circumstances.

However, these measures notwithstanding reproduction technologies cannot fully compensate for age-related decline in fertility. For instance, over 70% of married and single respondents from our 2021 Marriage & Parenthood Survey think that ART, such as In-vitro Fertilisation (IVF), would have very high success rates for women above age 40. In reality, based on 2017 to 2021 data in Singapore, the ART success rate was only around 17.2% for women aged 35 years to 39 years old. This fell to about 6.4% for those aged 40 and above.

There are age-related risks in terms of conceiving and carrying the baby successfully to term. Thus, we encourage couples, if they can, to pursue their parenthood plans early.

Besides age, there are also other causes of infertility, such as lifestyle choices and health conditions. Couples who have difficulty conceiving should seek medical help early, to check for the causes or factors that affect their fertility in a timely manner. Fertility cannot be taken for granted and there is a limited biological window for conceiving successfully.

In this regard, I am heartened to know that the ACRLE, established under the NUS Yong Loo Lin School of Medicine, is trying to find ways to help women preserve and improve their reproductive systems.  I understand that their research shows the rate of ovarian ageing in each woman differs. This means that some women could be predisposed to accelerated ageing in their ovaries and potentially reduced reproductive lifespans. Risk factors include exposure to gonadotoxic medical treatments such as chemotherapy and radiotherapy, family history of early menopause, and smoking.

Such research is important. If we can better understand the biological, environmental, and social factors that influence a woman’s reproductive health and longevity, we can better develop and invest in the appropriate interventions to support women’s reproductive and general health.

I understand the Centre is also studying the true ovarian lifespan of women and why menopause occurs, as there is a correlation between a woman’s reproductive health and her general health. Beyond conception and fertility, ACRLE’s efforts to deepen knowledge and understanding of the menopause process can help improve women’s general health, as we spend a significant portion of our lives in the post-menopausal stage. Prioritising one’s health will empower our women to lead heathier and more vibrant lives.

Raising Awareness, Building a Supportive Workplace Culture

I am also glad that research and medical advances have paved the way for more information exchange and meaningful discussions around improving women’s reproductive and general health. The Government will continue to do its part to support couples on their marriage and parenthood journey, including fertility health treatments. However, medical advances and the Government’s support alone are not enough. The wider community plays an important role in providing greater assurance and support to couples with fertility issues.

Fertility health is a difficult topic to broach. We have made some progress. It is certainly easier to talk about it today than a decade ago but many still feel embarrassed discussing fertility health concerns.  It is as though they feel that they are lacking in some ways. As such, public health education and advocacy is very important and I am glad that ACRLE has identified this as one of the four strategic areas to be featured at the conference.

We must continue to raise awareness on fertility health among Singaporeans.  We should begin by addressing myths about fertility health, such as the misconception that people who are generally healthy will not have fertility health issues, or that fertility is only a woman’s issue. Neither of this is true. Men can suffer from fertility issues as well, not just age-related but also lifestyle related. We should regard fertility health in the same way as we regard any other health issue – which is that if a problem exists it should be addressed as soon as possible and without stigma.  Couples who have issues conceiving should seek medical help early so that they can receive appropriate and timely interventions. We must also continue to invest in more upstream efforts, to encourage couples to build and nurture relationships, and proactively plan for their marriage and parenthood journey earlier, even as they pursue other aspirations and goals in their lives. So fertility is not just a medical issue, it is also a social issue, a lifestyle issue, and we have to see it in that broader context.

As a society, as friends and colleagues, we can be more understanding and sensitive to the challenges faced by couples undergoing fertility treatments. The journey can be very lonely and trying. In this vein, grounds-up efforts can provide valuable community support. For example, Fertility Support SG, was started in 2020 by a group of ladies who faced fertility health issues, has created a community where couples facing fertility health concerns could come together to share their experiences and provide mutual support in a safe space and they also made it their mission to have an educational platform so that resources can be shared and couples know where to go for assistance.

Employers must also play their part in making the workplace culture more family-friendly, and to better support couples in managing work and personal commitments. HR policies should include couples undergoing fertility treatments, some of which can be time-sensitive as there are specific windows that couples must catch for treatment to be administered.  Couples may need to take time off work or require some flexibility in their working hours to attend these medical appointments. A lot of employers do not understand that when the woman has to go off for fertility treatment, why the husband needs time off as well, but they should, because you should see them as a couple and you see the support for the couple as a whole. One way to build a family-friendly workplace and environment for families is to adopt flexible work arrangements (FWA), not to be confused with work from home. Work From Home is a subset of flexible work arrangements. Flexible work arrangements is a much broader range, which includes flexi-load, flexi-time, flexi-space. The new Tripartite Guidelines on FWA Requests, that was launched last week, will be mandatory for all employers to consider requests for flexible work arrangements. It sets out how employees should request for FWAs, as well as how employers should consider these requests and communicate the outcomes properly.

Conclusion

Let me conclude by reiterating the importance of research and advocacy efforts to improve and advance the reproductive health and longevity of women. Even as the work gets underway, we encourage our young Singaporeans to actively grow and develop relationships, and plan towards their marriage and parenthood aspirations early, while they pursue other life goals.

In parallel, we will also develop a comprehensive suite of strategies, including policy interventions, and foster societal norms that embrace children and families, and build family-friendly workplaces and communities.  We must make a whole of society effort to strengthen the overall ecosystem of support for families and transform Singapore into a place that is truly Made For Families.

I look forward to hearing your professional perspectives about reproductive health longevity and I wish you all a fruitful conference. Thank you very much.

[1] According to the 2021 Marriage & Parenthood Survey conducted by NPTD, 80% of young single respondents aged 21 to 35 years old indicated that they intend to marry. Among single respondents, 77% reported that they want children.

[2] According to the Population in Brief 2023 report.