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Malaysia, a Fertility Hub?

March 3, 2023
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By Dr Alexis Heng Boon Chin

In recent years, Malaysia has emerged as one of Asia’s top destination for IVF medical tourism due to a combination of several factors. In particular, the high-quality treatment offered by numerous excellent fertility clinics in the country, which charge much lower medical fees compared to prices in developed countries.
Additionally, IVF regulations in Malaysia are considerably more liberal compared to many countries, particularly for sperm/egg donation, egg freezing and preimplantation genetic testing (PGT), which have attracted many foreign patients from other countries, where such treatment procedures are heavily restricted by strict laws.
Moreover, fertility specialists in multi-racial Malaysia have the ability to speak a variety of different languages, enabling them to communicate readily with foreign patients originating from large urban population centres in China, India and Indonesia, besides Western countries and the Middle-East.
Last but not least, Malaysia also has a well-developed tourism industry, with many excellent cost-competitive hotels and scenic tourist attractions, which undoubtedly provide a relaxing and conducive atmosphere for foreign patients undergoing IVF treatment.
Nevertheless, it must be noted that Muslim and Non-Muslim patients undergoing IVF treatment are subjected to different regulations. Most notably, social egg freezing together with sperm, egg and embryo donation are banned for Muslim patients who are bound by Syariah laws in Malaysia, whereas such procedures are permitted for Non-Muslim patients.

Polygenic testing as a new frontier in IVF treatment

An exciting development within the field of IVF and fertility medicine is the emergence of polygenic scoring in preimplantation genetic testing (PGT-P). These can be applied both for the prevention of genetic diseases, as well as as enhancement of socially-desirable traits such as intelligence, athletic ability and beauty standards linked to tallness, fair complexion, hair and eye colour.  
Polygenic testing refers to evaluating an individual embryo’s likelihood of developing an adult-onset, multi-factorial trait by analyzing the combination of specific genetic variants within its genome. For example, type II diabetes, height, skin complexion and obesity are such complex traits determined by the combination of multiple genes, so polygenic scores based on the presence of multiple gene variants are used to estimate the likelihood of developing such traits later in life.
Currently, artificial intelligence (AI) algorithms are specifically being developed for such complex screening and analytical processes in polygenic testing. In a recent medical breakthrough, researchers in China used polygenic testing to select IVF embryos with less risks of developing family-related diabetes, for parents with a family history of the disease.

Safety of polygenic testing compared to gene editing

The natural process of human fertilisation involves mixing and recombining genes from the sperm and egg to produce new genetic variants, which is why siblings born from the same set of parents can differ so much in looks, health and intellectual ability. Polygenic testing and selection of IVF embryos thus represents an attempt to overcome the unpredictability and randomness of the natural process of human fertilization to yield the best outcome. Unlike the serious safety issues with gene editing, there are minimal risks involved in polygenic testing and selection of IVF embryos, because there are no permanent man-made genetic modifications that would be passed down to future generations. It is basically a technique for picking the “winning ticket” in the “genetic lottery” of fertilisation for good health, intelligence and other socially-desirable traits.  

Utilising polygenic testing in human enhancement – a controversial but highly lucrative business opportunity

Besides preventing complex and multi-factorial diseases such as type II diabetes, polygenic testing can also be used to screen and select IVF embryos for non-disease socially-desirable traits such as intelligence, athletic ability and beauty standards linked to tallness, fair complexion, hair and eye colour. This represents a particularly lucrative business opportunity, because parents naturally and instinctively want the best for their children, particularly in hyper-competitive Asian societies such as Malaysia, Singapore and China, where the educational rat-race often starts early in life. Indeed, some bioethicists have even put forward the theory of “procreative beneficence”, which holds that parents have a significant moral right and reason to select, of the possible children they could have, to beget the child who is most likely to experience the greatest well-being – that is, the most advantaged child, the child with the best chance at having the best life.
A recent large-scale survey conducted in the USA showed that the desire to enhance the cognitive ability and academic performance of one’s offspring is not confined only to idiosyncratic and fringe elements of society. Out of the approximately 6,800 people being polled, 38 per cent of them indicated that they are willing to utilise genetic testing to enable their child to enter top-ranked elite universities. More surprisingly, 28 per cent of respondents indicated that they would even be willing to resort to germline gene editing to achieve this goal.
Nevertheless, it must be noted that there is an important distinction between embryo testing and selection to avoid serious harm from known genetic defects and for so-called ‘enhancement’, such as good looks, higher IQ and greater athletic prowess. The latter raises a range of ethical concerns and is a highly controversial issue that has provoked much-heated debate among healthcare professionals, biomedical scientists, lawmakers and religious leaders.

Major ethical issues in using polygenic testing for genetic enhancement

At the forefront of ethical concerns is the fear of worsening social equality, based on the rationale that only the rich can afford to use such expensive technologies to beget genetically-advantaged children. Whereas those at the lower rungs of the socioeconomic ladder will be rigorously excluded due to their lack of financial resources. Over several generations of cumulative genetic enhancement, it is posited that this may possibly lead to permanent stratification and divergence of humankind into genetically enhanced ‘Haves’ and ‘Have-nots’, which could in turn lead to new forms of slavery and exploitation. Such fears have thus prompted calls from various sections of society to impose an outright ban on these new technologies for genetic enhancement.
Then, there are also psychological and social issues. After spending so much money, parents may start having unrealistic expectations of their “specially-selected” offspring. Children born through such procedures may have disturbing feelings of being treated like “lab rats,” and that their parents do not love them unconditionally as who they are. After all, they had never consented to being “specially-selected” by polygenic testing in the first place.

Beware “slippery slope” of permitting polygenic testing only for disease prevention

Banning polygenic testing for genetic enhancement, while allowing its use for prevention of complex multi-factorial diseases such as type II diabetes, could possibly lead to a “slippery slope” situation. For example, in some countries, preimplantation genetic testing (PGT-A) of IVF embryos is often marketed as a means of preventing Down syndrome in older women. But on the sidelines, patients also secretly do sex selection because PGT-A inevitably reveals the sex of the embryos at the same time.
Hence, a similar “slippery slope” could also develop for polygenic testing, whereby the need to prevent family-related disease traits can be readily exploited as a “handy excuse” to also secretly select for socially-desirable traits such as intelligence and physical characteristics associated with beauty standards such as tallness and fair complexion.

Conclusions

It is anticipated that banning polygenic testing for genetic enhancement, while allowing its use for disease prevention will not give Malaysia any competitive advantages in IVF medical tourism, because most countries will likely be doing the same. It is only by permitting the use of polygenic testing for genetic enhancement that will make Malaysia a special destination for many rich foreign patients desiring genetically-advantaged offspring. Spending by such rich foreign patients visiting Malaysia will not only benefit the healthcare industry, but will also bring much benefits to other businesses in the tourism, hospitality, food and retail sectors.
Hence, the Ministry of Health in Malaysia (Kementerian Kesihatan Malaysia), should weigh all the aforementioned pros and cons of permitting polygenic testing for genetic enhancement, to give the country a competitive edge in IVF medical tourism, and cement its status as the fertility hub of Asia.

About the author: Dr Alexis Heng Boon Chin is an Associate Professor of Biomedical Science at Peking University, China. He had previously worked in the field of human clinical assisted reproduction research in Singapore, and has authored 50 international journal publications on ethical and legal issues relating to new reproductive technologies, in addition to also having published more than 280 scientific journal articles, which have garnered a cumulative H-index of 53. This is an opinion column. The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of this publication.

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