Another side of tourism: Malaysia as a hub for controversial IVF embryo sex selection

WITH many countries reopening their borders as the Covid-19 pandemic recedes due to increasing vaccination worldwide, medical tourism by patients seeking IVF (in vitro fertilisation) procedures banned in their home countries but available abroad, is once again on the rise.

One of the most controversial of these is sex selection by genetic testing of IVF embryos, a procedure known as preimplantation genetic screening (PGS) or preimplantation genetic testing-aneuploidy (PGT-A).

Although PGS (PGT-A) was originally developed as a technique to screen genetically defective IVF embryos to prevent birth defects such as Down syndrome, it can also be readily used for sex selection. To date, PGS (PGT-A) is currently the best and most effective method of sex selection available in the market. If a woman becomes pregnant through IVF with this technique, the success rate of sex selection is close to 100%.

Concerned that such new reproductive technologies would further skew the sex ratio of their populations, many Asian countries with unbalanced sex ratios due to son preference, such as China and India, have banned the use of PGS (PGT-A) for embryo sex selection. It is widely deemed to be immoral and unethical in reinforcing traditional gender bias and sexism, and encouraging couples to favour having children of one gender over the other, thereby eliciting much controversy in some Asian countries where women are regularly subjected to strong societal discrimination and gender-based violence.

To circumvent such regulations, many richer couples from countries with such a ban travel abroad to more liberal jurisdictions where PGS (PGT-A) for sex selection is permitted. In recent years, Malaysia has emerged as a medical tourism hub for this controversial procedure, with many well-established IVF clinics offering cost-competitive medical fees to foreign patients.

Indeed, there have been news reports of many couples from neighbouring Singapore travelling to Malaysia for embryo sex selection as the procedure is banned in Singapore. This has caused much concern among Singaporean health authorities, leading to severe restrictions being placed on the import of PGS-tested frozen embryos into Singapore.

It must be noted that many patients who seek to do embryo sex selection at Malaysian IVF clinics are ethnic Chinese from Singapore and China, as the procedure is banned in their home countries. Such patients often prefer Malaysia over Western countries, not only because of cheaper medical fees but also because many fertility doctors here can speak Mandarin.

In fact, some foreign fertility clinics in Singapore and China have collaborative ties with Malaysian IVF clinics that do the sex selection tests. Such clinics are permitted to initiate the IVF treatment process for their patients by performing hormone injections to stimulate egg production while the patient is still overseas, so as to shorten their stay in Malaysia for the sex selection procedure.

Another alternative for Singaporean patients with busy schedules is to do the entire IVF process in Singapore, but freeze all their embryos and export them to a Malaysian IVF clinic for the sex selection procedure. However, they would then have to travel overseas for transfer of the sex-selected embryos into the womb. By contrast, the export of IVF embryos is banned in China.

Son preference and obsession with having male heirs are deeply ingrained in Chinese culture, more so in the case of traditional Chinese family businesses, where family members tend to be more conservative than the general population.

Although these days daughters can be educated and trained to be astute and capable businesswomen matching men, they are seen as not being able to carry the family lineage. Instead, the children that they bear are strictly considered to belong to their husband’s family. Hence, if the family has no male heir, their entire wealth is deemed to be inherited by their sons-in-law belonging to another family lineage.

Moreover, the traditional Taoist/Confucian rite of ancestor worship requires male heirs to carry out prayer offerings to their deceased ancestors, lest their dead family members become “hungry ghosts”.

In the early 20th century, the famous Indonesian Chinese tycoon Oei Tiong Ham (aka Sugar King of Java) was fearful of his wealth being inherited by his many daughters, because Dutch colonial laws stipulated that he cannot draft a will that denied his daughters their rightful inheritance. To evade such laws, he moved to Singapore, where he made a will that passed his entire estate only to his sons when he died in 1924.

In the old days, it was common and socially acceptable for a rich Chinese man to have several wives and concubines. Hence, by having more sons, a rich family could very rapidly have many descendants through polygamy, thus efficiently propagating and spreading their lineage throughout the general population. By not having a male heir, the family’s wealth would be passed on to their sons-in-law, who in turn will “abuse” their inheritance to spread their own seed through polygamy.

Although times have changed drastically and such old social norms are long gone, ancient Chinese cultural traits that have evolved over millennia die hard and still persist. This could explain why son preference and obsession with having male heirs are so prevalent among traditional Chinese business families in Asia.

DR ALEXIS HENG BOON CHIN

China

The letter writer is a Singaporean working as an associate professor of Biomedical Science at Peking University, China.