Early in the process of freezing my eggs at a fertility clinic in Hsinchu, I sat across from a consultant who patiently answered my many what-ifs: What would happen to my eggs if I died? What if I missed a payment? And my most pressing question, the scenario I felt was most likely: what if I was ready for children but had yet to find a partner? Could I undergo IVF with a sperm donor?
“No,” the consultant told me. “In Taiwan, you can only undergo IVF if you’re married.”
I was 36 years old then. A year prior, I’d ended a five-year relationship and I decided to freeze my eggs precisely because I had no idea when I might find the person I wanted to marry. Freezing my eggs would alleviate some of the pressure, I thought. And if in several years I had yet to meet someone, I would try to make a baby alone. But the consultant was telling me this wouldn’t be possible, at least not in Taiwan.
Taiwan takes pride in being one of the most progressive countries in Asia. Yet if you dig a little beneath the surface, you’ll find a society that’s still fairly conservative when it comes to the definition of family. Patrilineal requirements for citizenship were only loosened in 2000, and many people, particularly those in the older generation, consider a strong, healthy family to be a traditional one with children raised by a married mother and father, with support from the paternal grandparents. So while women in Taiwan today have greater independence and gender-equality compared to previous generations, many may still believe marriage to be a prerequisite to having children.
This tracks with the statistics. Registered marriages in Taiwan saw a steep decline in 2020, with a record low of 121,702. The already low birth rate stumbled again in 2020, with just 165,259 births, a sharp seven percent decline from 2019, when Taiwan’s birth rate of 1.167 children per woman was considered by the United Nations to be one of the lowest in the world.. The fact that both marriage and birth rates are so low is no accident. For Taiwanese citizens, the father’s name is only included on the baby’s birth certificate if the new parents are married.
It’s not a stretch to say that the expectation of marriage before having children, coupled with delayed marriage for most people, has contributed to the chronically low birth rate in Taiwan. The government has been trying to tackle the country’s low fertility rate since 2008, but the program has seen modest success. The fertility rates from the last few years are an improvement from 2010, when the rate of 0.89 was so low that President Ma Ying-jeou proclaimed it a national crisis.
The limited success of the government’s fertility programs seem to point to the existence of other issues affecting the birth rate that are not as easily addressed by economic incentives, ones that may have more to do with a shifting attitude among young people about what they expect in a partner and co-parent, and the ways in which these expectations chafe against traditional norms.
“I do feel pressured to get married,” said 31-year old Jessie Chiang. But she and many of her friends are hesitant. Their chief concern, aside from the financial pressure of raising a child, is ending up with a 豬隊友, literally translated to “pig teammate”. A partner, she explained, “who doesn’t know what to do or how to support you, who is helpless even when the child is crying. He might not take responsibility or might run away when things get tough.”
Chiang says she feels many among her generation, including herself, would consider being a single parent. “Even though being a single mother is really hard,” she said, “all the decisions on how to raise your child are ones you can make yourself.” When I asked her if she thought society might judge single mothers, she said, “I really respect single mothers. It’s so difficult — she’s pursuing what she wants and at the same time she has to find a way to balance her financial situation and take care of her child. That’s the behavior of someone willing to bear incredible responsibility.”
Despite evidence of changing attitudes towards marriage and children, the Taiwan government’s strategies for improving the fertility rate has largely focused on incentivizing people already in or entering into heterosexual marriages. Government support for those seeking alternative routes towards raising a family remains largely non-existent.
One of the alternative routes, egg freezing, is no longer rare among Taiwanese women. Angie Yu, who is 36 and without a partner, said many of her friends froze their eggs when they were 34; however, she never thought she’d do it in lieu of “the natural way”. But amidst the COVID pandemic, she decided to go ahead. “It’s like buying insurance for myself, because I want to have kids, but it’s not happening any time soon.”
Unfortunately, egg freezing in Taiwan is a steep investment for those on an average Taiwanese salary. One cycle can cost between $100,000 and $150,000NT before the annual fee for storing eggs, which can average between $4,000 and $6,000NT a year. There are currently no government subsidies to help absorb these fees.
“I have a pretty normal Taiwanese salary, maybe a little bit higher than the normal salary, and I would not be able to afford this myself,” said 28-year old Alex, who requested I not share her last name. When we spoke, she was beginning the process of freezing her eggs as an emergency procedure to preserve her fertility. Diagnosed with stage-two tongue cancer in September 2020, she was told by her doctors she would have to make a decision immediately about whether she wanted to freeze her eggs ahead of her chemotherapy. Amidst digesting all the information about the procedure, she also had to contend with the cost.
“I was a bit shocked that in Taiwan it wasn’t covered at all,” she said. Fortunately, Alex’s parents helped foot the bill since she hasn’t been able to work for several months while on medical leave. “I can’t help but think about all the other people who are in situations that are similar or worse.”
Dr. Hannah Chang, a Taiwanese fertility acupuncturist currently practicing in California, believes these types of fertility preservation procedures for patients of cancer and other diseases should be covered by the National Health Insurance. However, when asked if she thought the government should help subsidize the cost of freezing eggs as an elective procedure, she demurred.
“One concern I have is predatory behavior from the side of fertility clinics,” she said. “I think if the government does help fund this, it might encourage fertility clinics to advertise or push for more women to freeze their eggs when it might not be in these women’s best interest. I think a better option would be making this procedure a tax write-off, so the clinics aren’t getting the reimbursement, but the patients are, thus discouraging clinics from investing in advertisements for egg freezing.”
Dr. Chang added that she believes the government should educate the public on the possibilities of egg freezing, as long as its potential downsides are also noted, specifically the fact that it might not be as effective as regular IVF treatments. She also says that only a small percentage of Taiwanese women who freeze their eggs go back to use them, despite the money already spent towards it.
Still, for women such as Yu and Alex, egg freezing is a step towards the family that they might want some day, and one of the only legal medical procedures currently available to them. Other countries aren’t so lucky. Vickie Wang, a 35-year old Taiwanese woman who has lived in Shanghai for many years, took time off from her job in 2018 and flew back to Taiwan to freeze her eggs. She said, “I knew that in China, I’d have to be married. In Taiwan, at least I can do it while I’m single.”
The fertility clinic where I chose to freeze my eggs, Taiwan IVF Group, is all glass and gleaming white walls, with high ceilings, red waiting chairs, carefully chosen plants and large windows that let in loads of natural light. It feels like a beauty spa, a choice that I’m sure was conscious on the part of the designers.
Taiwan IVF Group’s beautiful building is indicative of the strong reputation Taiwan’s assisted reproduction field enjoys in Asia. With more than 80 fertility clinics, Taiwan is considered an industry leader. Dr. Fu-Hsing Chang (no relation to Dr. Hannah Chang) is the director at Gene IVF, a clinic with branches in Taipei and New Taipei City. He estimates that about 60 percent of his patients in a given year are from overseas. This is comparable to other fertility clinics in Taiwan.
Couples fly from China, Hong Kong, Macau, the Philippines, Japan and other countries, to access Taiwan’s cutting-edge technology and high success rates, as well as its reputation for experienced, well-educated doctors and transparency in data reporting. Additionally, Taiwan allows for the use of donor eggs or sperm (though not both at the same time), unlike many other countries. “[For international patients], the value is really high, because the price is a third to half of the cost overseas,” Dr. Chang said.
However, there’s a flipside to Taiwan’s IVF industry, particularly for those who already reside in Taiwan. It might be hailed as one of the best internationally, but the country’s current laws concerning who can receive reproductive assistance and under what circumstances leave many people out of luck. While single heterosexual women in Taiwan with no known fertility issues can freeze their eggs and hold onto hope that they might get married one day and use IVF to start a family — for everyone else, this isn’t an option yet.
In 2016, after trying and failing for months to conceive with her partner at the time (someone she had no intention of marrying), Michelle Senczi, an American woman who has lived in Taiwan for more than a decade, was told by her gynecologist that it would be difficult for her to conceive naturally and carry a baby to term. “She said my best bet would be to try IVF,” Senczi recalled. “I said, ‘Okay, great, there’s still a possibility. So what do I do from here?’ She said, ‘There’s nothing you can do, because you’re not married.’”
According to Taiwan’s Assisted Reproduction Act of 2007, a heterosexual married couple can receive assisted reproduction within certain specific parameters: (1) one spouse has to be either diagnosed as suffering from infertility or with a major hereditary disease that would affect the health and viability of a naturally conceived child, (2) at least one spouse has to have healthy reproductive cells that can be used, and (3) the wife’s uterus has to be able to carry the fetus. The full act also contains other breathtaking stipulations, but I won’t go too much further into detail.
Put plainly, married heterosexual couples can make a baby with a locally donated egg and the husband’s sperm, or locally donated sperm and the wife’s egg, as long as the embryo is implanted in the wife’s own womb. So while my unmarried self could theoretically donate my eggs to be used by a married couple visiting from Japan, those same eggs could never be used to conceive my own child if I never married.
Aside from unmarried individuals, the act also excludes same-sex couples, and while not explicitly so, many trans couples due to Taiwan’s laws around gender. Dr. Hannah Chang attributes the narrow requirements of the act to Taiwan’s social conservatism. “Lawmakers, they’re mostly in their 50s, so they’re very conservative. It doesn’t matter if they’re DDP or KMT, they’re very conservative when it comes to this.”
Nowhere is Taiwan’s tension between its progressive reputation and its conservative backbone more apparent than when it comes to laws concerning LGBTQ family planning. Despite becoming the first Asian country to legalize gay marriage in 2019, the law — which doesn’t redefine marriage in its civic code but is rather a separate law — is rife with limitations, thanks to pressure from conservative groups in Taiwan.
Adoption for same-sex married couples is similarly restrictive — a partner can only adopt the biological children of the other. “LGBTQ can only adopt as a single individual, not as couples. So if you as an LGBT individual get married, because of the marriage equality law, you lose the chance to adopt,” explained Chia-Jong Chu of Taiwan LGBT Family Rights Advocacy (TLFRA). “We get many phone calls where they say, ‘I’m here with my spouse and we just got married and we want to adopt,’ and my answer is, ‘Oh, I’m sorry, you’re married? You should have adopted first.’”
Vera and Sharon, a couple in their mid-thirties who asked to have their real names withheld, have not married yet despite being together for years. The reason: they want to leave adoption open as an option. The grad school sweethearts hope it won’t come to that. They currently have several embryos frozen in Japan that they’re hopeful will lead to pregnancy once COVID travel restrictions are lifted. For the two women, that will be the culmination of an emotional and expensive journey that began after the same-sex marriage act passed in Taiwan in 2019.
It started with buying donor sperm from a sperm bank in the United States, which they had sent to Cambodia for an IUI, or intrauterine insemination, procedure. At the same time, Sharon began receiving the necessary shots and medications to prepare her body. But two days before their flight to Cambodia, they received devastating news. Cambodian officials would not release the sperm from customs. Before they could find a solution, the sperm defrosted, rendering it useless. The couple, having already paid for tickets and taken days off from work, flew to Cambodia anyway, transforming what was supposed to be a trip to begin their new family into a bittersweet vacation.
That was in October 2019. In January 2020, after researching TLFRA’s forums and receiving recommendations from other lesbian couples in Taiwan, Vera and Sharon went to Japan. This time, they decided to do IVF. “We’re both getting older,” they told me. “So even though IVF is more expensive, it has a higher success rate.” But even in Japan, what they were doing wasn’t legal.
Japan, like Taiwan, only allows IVF for married heterosexual couples. So how did they get around this? “Sharon told [the hospital] her husband hadn’t been able to accompany her to Japan,” Vera said, and the doctors didn’t ask for any evidence of a marriage. The visit was a success. After egg retrieval and fertilization, the couple now has four embryos frozen in Japan.
The next step is to implant the embryos, but given the global pandemic, the couple doesn’t know when they might be able to return to Japan. “I do worry about [my uterus getting older],” Sharon admitted. Chu of TLFRA says the pandemic has had a significant impact on lesbian couples hoping to conceive. “For women, time is very precious,” she told me. “Every month counts. LGBTQ couples used to have ways to overcome the difficulties [of the law] by flying themselves to another country. But now, with COVID…it’s all gone now. They just have to wait, and we don’t know how long it will be.”
While gay men hoping to be fathers might not have to worry about age in the same way lesbians might, they face their own hurdles. Often their best option for conceiving biological children involves surrogacy, which is currently illegal in Taiwan, for married heterosexual couples too.
Alex Hsu and his partner, aged 50 and 45 respectively, opted to undergo the surrogacy process in California. There, surrogacy is allowed for both heterosexual and same-sex couples, regardless of marital status, and the law allows parents to establish legal parental rights to the child even before birth.
Two years ago, they flew to a clinic in Pasadena to provide sperm, which the clinic then froze. Upon their return to Taiwan, they spent months searching for a suitable egg donor, awaiting health screening results, signing paperwork and transferring money before finally achieving several viable embryos. They went through a similar process in choosing a surrogate before the embryos could be implanted. Once the surrogate was pregnant, they received updates through emails, texts, and video chats. As nine months approached, the couple flew back to the United States to await their child’s birth — in the middle of the pandemic, no less.
It was an extremely emotional process for the couple. “Our first set of transfers…it ended in miscarriage. We had to wait another six months before we could try again, and even the second time, only one survived.” It was obvious this experience still affected him deeply. “Even though everything was happening kind of remotely, and I was not physically — I mean, obviously I wasn’t carrying the baby…it still affected me very deeply.”
Thankfully, Alex and his partner’s journey has a happy ending. Their baby boy was born in August 2020, and came home to Taiwan after his passport was processed. After the couple gets married, they’ll be able to start the final leg of this long odyssey — legal adoption for the father not genetically linked to the child.
Both Hsu and Chu mentioned that they had heard of couples who opted to do surrogacy in countries where the process is cheaper. However, surrogacy in these countries is not without risk. In Russia and Ukraine, being gay is illegal, so couples have to forge a heterosexual marriage to pursue surrogacy. Additionally, practices among many of these countries are not well-regulated and may be exploitative. After a 2014 scandal in Thailand where Australian parents refused to take their Down Syndrome baby carried by a local woman, officials closed surrogacy to foreigners, citing concerns over “wombs for rent”. However, several clinics continued to operate, moving their businesses to Cambodia, which has since outlawed commercial surrogacy, and Laos, where the practice is still unregulated.
Given the ethical considerations of surrogacy, it’s not surprising that Taiwan has avoided it altogether. But that could soon change. According to Dr. Fu-Hsing Chang, an amendment to the 2007 act is currently being considered by the Legislative Yuan to allow surrogacy for married couples. Still, he warned it could take some time. “It might take three to six months, even two to three years for it to pass — if it passes at all.” The amendment draft, which passed its first reading in May 2020, will require at least two more readings to be implemented.
However, when I asked Chu at TLFRA about her thoughts on the amendment, she clarified that it doesn’t include LGBT couples. “There are times we want to join the meetings [to discuss the amendment] but we are rejected because the amendment itself doesn’t include same-sex couples, not to mention single women.” (I could not find a copy of the proposed amendment so could not verify the contents of the text.)
Hsu is circumspect about the possibility of policy change. “I think to strongly push for surrogacy for gay couples may be a little difficult right now.” He explained that he believes certain well-funded Christian-based organizations might see the inclusion of gay couples as a reason to protest the passing of a surrogacy amendment. But he was quick to emphasize that he certainly wanted to see the change made for gay couples.
He continued, “For the record, I am pulling for the LGBT family union groups’ push to have gay couples included in the change of law. But I’m more of a realist and think the more likely outcome is to first have surrogacy for heterosexual couples passed. Once surrogacy becomes more commonplace and more accepted by society, and more gay couples like myself have done surrogacy abroad and raise healthy heterosexual children — because one of the crazy notions is that gay parents are going to raise gay children — I think once people see more examples, change will come.”
Any change in the law in Taiwan to allow surrogacy is likely to meet rigorous regulation, ensuring that all involved — parents, surrogate, and child — are protected. Dr. Fu-Hsing Chang stressed to me that Taiwan would not allow commercial surrogacy. “This would be for people with a medical need, such as women whose uteruses have trouble carrying pregnancies.”
Hsu, for his part, hopes that once surrogacy is acceptable in Taiwan, people might let go of their misconceptions of why people want this option at all. “Some opponents [of legalizing surrogacy] think you’re just letting rich people who don’t want to go through the pain of carrying a child outsource it to other people. But that’s not the case in most of the scenarios. The majority of people are doing surrogacy because they really want a baby. They really want to carry their own baby, but they just can’t.”
Despite the logistical challenges, both Alex Hsu and his partner, and Vera and Sharon are among the luckier ones, because they had the financial means to seek assistance outside of Taiwan. Vera and Sharon’s trips to Cambodia and Japan including travel expenses cost $150,000NT and $580,000NT respectively. When I asked Hsu how much he and his partner spent on surrogacy in the US, he replied, “$170,000 to $200,000.”
“NT dollars?” I asked.
Economic access came up with almost every person I spoke with. “The right to raise a family should not be class-based,” Hsu said. “Right now, the cost is so prohibitive. It’s basically saying that if your parents don’t have the money or you aren’t in finance or a doctor, forget about it, you can’t do it.”
Just like the high costs of freezing eggs, IVF and surrogacy are out of reach for most Taiwanese. According to the Taiwanese Society for Reproductive Medicine, the average cost of one round of IVF in Taiwan runs between $120,000 to 180,000NT, though certain clinics charge up to $250,000NT. The National Health Insurance does not cover the majority of the fees. For an average Taiwanese person, where the most common monthly wage is around $29,000NT, this number is already a challenge. But to travel out of the country — where IVF procedures can run up to three times as high, and surrogacy costs run even higher — is a near impossibility for most people who need assistance starting a family.
Hsu and his partner were able to pay for their surrogacy out of pocket because they were older and more established in their careers, but according to Hsu, many Taiwanese men turning to surrogacy skew younger, compared to those in Singapore and Hong Kong. “It’s the parents who are financing the process,” he said. He believes that despite any uneasiness towards their sons’ sexual orientation, Taiwanese parents still place importance on the continuation of their bloodline, particularly for sons.
Vera and Sharon, however, never considered asking family or friends for financial support. “We felt this is our own private business, so it was our own responsibility.” They financed their IVF procedure in Japan with money they had been putting towards buying a house. If it was legally possible, they would have done so in Taiwan. “If we’re spending this much, why not let the money stay in Taiwan for Taiwanese people to make instead?” said Sharon.
The economic argument just might help shift the laws. Dr. Hannah Chang told me that many founders of Taiwan’s big IVF centers have been publicly lobbying for a legal change to allow same-sex couples and single women the ability to undergo IVF. “Obviously, there’s a component that is about society progressing. But I think there’s another component that’s economical. Taiwan’s birth rate is dropping, so I think they’re seeing fewer couples in their clinics. So obviously, if the amendment allows for single women and same-sex couples, they’re going to have more opportunity for business.”
But progress in Taiwan requires patience. “The fact that you can take your eggs out of Taiwan was only written in 2016,” she said, referring to the fact that frozen eggs can now be packed and shipped overseas at the owner’s request. “[The 2007 act] took 13 years to be completed and passed in the legislature. So I think regardless of the birth rate and how much the government wants to push it, it just is a matter of fact that these laws are going to take a long time.”
As for me, I’ll tell you that it didn’t completely register with me that I couldn’t use my frozen eggs without a husband. I was too focused on getting through the two weeks of fertility drugs and egg extraction. Since then, as time goes on and my chances of conceiving naturally grow slimmer, I think about what I’ll do if I need to use those eggs. I don’t know if I will ever get married. It’s not a dream of mine. But I have always known I want to be a mother. I know it so deeply within me that the idea that it might not happen, whether because of biology or circumstance or law — it hurts.
I originally set out to write this piece as a personal essay, but the more I talked to people, I realized that the issues at hand affect thousands of people whose stories go relatively unknown. I was moved by the lengths people would go to in order to have a child. Not just the financial cost, but the emotional toll, the challenge of undergoing medical procedures in a totally foreign country. The trust placed in the care of doctors, clinics, surrogates, advocates, even FedEx delivery agents, and the often disappointing results. That sincere and utmost desire to realize a dream of a baby — it’s something that can’t quite be conveyed when discussing the cold technicalities of who is allowed to use what cells when and where.
Despite the low fertility rate in Taiwan, it’s clear there are many people in this country who dream of having a family, although the shape and appearance of that family might be different from what some people might picture. If Taiwan truly wants to be a progressive nation — and not just offer an outward semblance of it — it must offer the same support to same-sex and single-parent families as it does to so-called traditional ones. For a society that places so much importance on family, how can it continue to deny this pathway to those who yearn for it the most?
Perhaps, in the end, it’s the strength and value of direct family bonds that will change societal opinion. “Even though the older generation thinks having children this way isn’t ‘normal’, we know that once we have a baby, our parents are likely to be accepting,” Sharon said. “We know how excited they are about having grandchildren.”
Alex Hsu says the birth of his son has drawn him and his parents closer together. “Before my son was born, I talked to my father once a week. But now I FaceTime my parents at least once a day. They want to see [their grandson] every day.” He says this is a common story he hears among his friends who have gone through the process. “Before the child is born, grandparents are always like, ‘Why are you doing this? [The child] will be bullied.’ But as soon as they see the baby, it’s the best thing ever. There’s something magical about that.”
Main image by Khoa Pham via Unsplash