Is egg freezing a good response to socioeconomic and cultural factors that lead women to postpone motherhood?

In western societies, a growing number of women are currently turning to social egg freezing, a technique that makes it possible to freeze oocytes and thus preserve female reproductive possibilities. The current ethical debate has focused on normative aspects concerning the question of whether social egg freezing empowers women's reproductive autonomy. Due to this narrow focus on autonomy, deeper questions concerning the socio-economic conditions and cultural factors that lead women to delay reproduction, to feel pressured by their biological clock, and thus to consider social egg freezing have not yet received sufficient attention and analysis. The aim of this study was to broaden the ethical debate by focusing on whether social egg freezing is a good response to the socioeconomic and cultural constraints that lead women to postpone motherhood, and therefore whether it can be seen as a means of achieving what in virtue ethics is known as a 'good life'. I will argue that while social egg freezing can be seen as a means to empower women to adapt to current socioeconomic constraints, it is not an adequate response to cultural factors, as these cannot be solved by simply extending a woman's fertility.

Reproductive experiences of women who cryopreserved oocytes for non-medical reasons

STUDY QUESTION

What are the reproductive experiences of women who cryopreserve oocytes for non-medical reasons?

SUMMARY ANSWER

One in three women had been pregnant at some stage in their lives and while most still wanted to have a child or another child, very few had used their stored oocytes, predominantly because they did not want to be single parents.

WHAT IS KNOWN ALREADY

The number of healthy women who freeze oocytes to avoid age-related infertility is increasing. Evidence about reproductive outcomes after oocyte cryopreservation for non-medical reasons is needed to help women make informed decisions.

STUDY DESIGN SIZE, DURATION

A cross-sectional survey was carried out. Study packs which included a self-administered questionnaire were mailed by clinic staff to 193 eligible women.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women who had stored oocytes for non-medical reasons at Melbourne IVF, a private ART clinic, between 1999 and 2014 were identified from medical records and invited to complete an anonymous questionnaire about their reproductive histories and experience of oocyte cryopreservation.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 10 survey packs were returned to the clinic marked 'address unknown'. Of the 183 potential respondents, 96 (53%) returned the questionnaire. One respondent provided only free-text comments, thus data from 95 respondents were compiled. The mean age at the time of freezing oocytes was 37.1 years (SD ± 2.6, range: 27-42) and the average number of oocytes stored was 14.2 (SD ± 7.9, range: 0-42); 2% had attempted to store oocytes but had none suitable for freezing, 24% had stored <8 oocytes, 35% had 8-15, 25% had 16-23 and 14% had stored >23 oocytes. About one-third of respondents (34%) had been pregnant at some point in their lives. Six women (6%) had used their stored oocytes and three of them had given birth as a result. The main reason for not using stored oocytes was not wanting to be a single parent. Of the 87 (91%) women who still had oocytes stored, 21% intended to use them while 69% indicated that their circumstances would determine usage. The mean number of children respondents would ideally have liked to have was significantly higher than the number of children they expected to have (2.11 versus 1.38, P < 0.001).

LIMITATIONS, REASONS FOR CAUTION

The limitations are inherent to any anonymously completed questionnaire: participation bias, missing data and the possibility that some questions or response alternatives may have been ambiguous.

WIDER IMPLICATIONS OF THE FINDINGS

The findings add to the very limited evidence about the reproductive outcomes experienced by women who freeze oocytes for non-medical reasons and can be used to help women make informed decisions about whether to store oocytes.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by Melbourne IVF. K.H. has received honoraria from Merck-Serono, J.M. is a clinician at Melbourne IVF, F.A. is a Melbourne IVF employee, J.F. is supported by a Monash Professorial Fellowship and the Jean Hailes Professorial Fellowship which receives funding from the L and H Hecht Trust, managed by Perpetual Trustees Pty Ltd. M.K., N.P., M.H., M.P. and C.B. have no competing interests.

TRIAL REGISTRATION NUMBER

Not applicable.

Cryopreservation of Ovarian Tissue: Opportunities Beyond Fertility Preservation and a Positive View Into the Future

In current years, ovarian tissue cryopreservation (OTC) and transplantation is gaining ground as a successful method of preserving fertility in young women with primarily cancer diseases, hereby giving them a chance of becoming biological mothers later on. However, OTC preserves more than just the reproductive potential; it restores the ovarian endocrine function and thus the entire female reproductive cycle with natural levels of essential hormones. In a female population with an increased prevalence in the loss of ovarian function due to induced primary ovarian insufficiency (POI) and aging, there is now, a need to develop new treatments and provide new opportunities to utilize the enormous surplus of follicles that most females are born with and overcome major health issues associated with the lack of ovarian hormones. Cell/tissue-based hormone replacement therapy (cHRT) by the use of stored ovarian tissue could be one such option comprising both induction of puberty in prepubertal POI girls, treatment of POI and premature menopause, and as primary prevention at the onset of menopause. In the current review, we explore known and entirely new applications for the potential utilization of OTC including cHRT, social freezing, culture of immature oocytes, and a modern ovarian resection for women with polycystic ovaries, and discuss the indications hereof.

Oocyte vitrification for elective fertility preservation: the past, present, and future

PURPOSE OF REVIEW

Oocyte cryopreservation is no longer experimental and one of its rapidly growing indications is elective fertility preservation. Currently there is no sufficient evidence to support its practice and therefore its place in IVF remains uncertain.

RECENT FINDINGS

Vitrification has superior post-thaw survival and fertilization outcomes compared with oocytes that were frozen with the slow-freeze technique. Oocyte vitrification produces similar IVF outcomes compared with fresh oocytes and is not associated with further obstetrical or perinatal morbidity. Undergoing elective oocyte cryopreservation between ages 35 and 37 will optimize live birth rates as well as cost effectiveness from mathematical models.

SUMMARY

In women who delay child bearing, elective oocyte cryopreservation in the mid 30s may be beneficial in terms of live birth rates and cost effectiveness. Prospective studies of women who have undergone oocyte cryopreservation and are now attempting conception are needed before official recommendations can be made regarding elective egg freezing.

No. 356-Egg Freezing for Age-Related Fertility Decline

OBJECTIVE

To provide a comprehensive review and evidence based recommendations for Canadian fertility centres that offer social egg freezing.

OUTCOMES

In social egg freezing cycles we evaluated thawed oocyte survival rates, fertilization rates, embryo quality, pregnancy rates, and live birth rates. We also review how these outcomes are impacted by age, ovarian reserve, and the number of eggs cryopreserved. Finally, we discuss the risks of social egg freezing, the alternatives, the critical elements for counselling and informed consent, and future reporting of egg freezing outcome data.

EVIDENCE

Published literature was reviewed through searches of MEDLINE and CINAHL using appropriate vocabulary and using key words ("oocyte cryopreservation," "egg freezing," "egg vitrification," "social egg freezing," and "elective egg freezing"). Results included systematic reviews, randomized controlled trials, controlled clinical trials, and observational studies. Expert opinion based on clinical experience, descriptive studies, or reports of expert committees was also included to discuss aspects of egg freezing not currently rigorously studied.

VALUES

The evidence obtained was reviewed and evaluated by the Clinical Practice Guideline (CPG) Committees of the Canadian Fertility and Andrology Society (CFAS) under the leadership of the principal authors.

BENEFITS, HARMS, AND COSTS

Implementation of this guideline should assist the clinician to develop an optimal approach in providing counselling for egg freezing while minimizing harm and improving patient outcomes during treatment.

VALIDATION

These guidelines have been reviewed and approved by the membership of the CFAS and by the CPG Committees of CFAS and The Society of Obstetricians and Gynaecologists of Canada (SOGC).

SPONSORS

CFAS and SOGC.

RECOMMENDATIONS

Egg freezing experiences of women in Turkey: From the social context to the narratives of reproductive ageing and empowerment

This article explores egg freezing experiences of women in Turkey. Since 2014, it has been legal in Turkey to use egg freezing technology for ageing women, while it was previously allowed only for disease-related purposes. In cooperation with a private fertility clinic in Istanbul, the authors conducted 21 interviews with older, single women who held either professional or managerial positions and who were undergoing or had undergone the procedure. Drawing on a qualitative analysis of these interviews, the authors explore the social context in which women postpone motherhood and decide to freeze their eggs. The study also looks at the women’s emotional responses to ageing that were triggered by the experience of egg freezing and their narratives of empowerment as a result of the procedure.

Oocyte Cryopreservation for Fertility Preservation in Healthy Women

Advancements in methods of fertility preservation have resulted in more options available to women seeking to postpone reproduction. Preservation of unfertilized oocytes provides women with the possibility for reproduction even after age-related declines in fertility might make conceiving a child difficult to impossible. As oocyte cryopreservation rises in popularity among women, it is crucial for nurses and other clinicians to understand the background, process, ethical issues, and risks involved to help women make informed medical decisions.

Ovarian reserve testing: a user's guide

Ovarian reserve is a complex clinical phenomenon influenced by age, genetics, and environmental variables. Although it is challenging to predict the rate of an individual's ovarian reserve decline, clinicians are often asked for advice about fertility potential and/or recommendations regarding the pursuit of fertility treatment options. The purpose of this review is to summarize the state-of-the-art of ovarian reserve testing, providing a guide for the obstetrician/gynecologist generalist and reproductive endocrinologist. The ideal ovarian reserve test should be convenient, be reproducible, display little if any intracycle and intercycle variability, and demonstrate high specificity to minimize the risk of wrongly diagnosing women as having diminished ovarian reserve and accurately identify those at greatest risk of developing ovarian hyperstimulation prior to fertility treatment. Evaluation of ovarian reserve can help to identify patients who will have poor response or hyperresponse to ovarian stimulation for assisted reproductive technology. Ovarian reserve testing should allow individualization of treatment protocols to achieve optimal response while minimizing safety risks. Ovarian reserve testing may inform patients regarding their reproductive lifespan and menopausal timing as well as aid in the counselling and selection of treatment for female cancer patients of reproductive age who receive gonadotoxic therapy. In addition, it may aid in establishing the diagnosis of polycystic ovary syndrome and provide insight into its severity. While there is currently no perfect ovarian reserve test, both antral follicular count and antimüllerian hormone have good predictive value and are superior to day-3 follicle-stimulating hormone. The convenience of untimed sampling, age-specific values, availability of an automated platform, and potential standardization of antimüllerian hormone assay make this test the preferred biomarker for the evaluation of ovarian reserve in women.

Attitudes towards Social Oocyte Freezing from a Socio-cultural Perspective

INTRODUCTION

The tendency to delay parenthood is increasing. It is partly driven by the availability of early reproductive technologies such as social oocyte freezing, the cryopreservation of oocytes for non-medical purposes. The goal of this study was to investigate relationships between attitudes towards social oocyte freezing and different socio-cultural backgrounds in a German sample cohort.

MATERIALS AND METHODS

A quantitative online questionnaire was compiled. A total of 643 participants completed the questionnaire which included items on attitudes toward social oocyte freezing, socio-demographics and items, obtained from the German DELTA Institute for Social and Ecological Research, devised to indicate specific milieus. Data were analyzed using parametric and non-parametric methods.

RESULTS

There were clear correlations between attitudes towards social oocyte freezing and socio-cultural background, gender, cohort age, fertility problems, and attitudes to fertility. Positive attitudes towards social oocyte freezing were linked to struggles with fertility, a current or general wish to have a child, and flexible, progressive and self-oriented values. Participants who preferred to become parents at a younger age tended to reject cryopreservation.

CONCLUSIONS

The huge number of university graduates, persons with fertility problems, and persons from specific socio-cultural backgrounds in our sample point to distinct groups interested in reproductive technologies such as social oocyte freezing. The investigated differences as a function of socio-cultural background suggest that more research into the desire to have children in German society is needed. In conclusion, it may be necessary to develop targeted family planning interventions to prevent affected women from buying into a false sense of security, thereby risking unwanted childlessness.

Medical and elective fertility preservation: impact of removal of the experimental label from oocyte cryopreservation

PURPOSE

The purpose of this study was to compare baseline characteristics and ovarian stimulation outcomes between patients presenting for medically indicated vs. elective fertility preservation consultation and to determine the impact of the 2013 ASRM guidelines on oocyte cryopreservation on the patient population presenting for fertility preservation consultation.

METHODS

Retrospective cohort study conducted at an academic center. Study population included 332 patients presenting for medically indicated fertility preservation consultation and 210 patients presenting for elective consultation.

RESULTS

Patients presenting for elective fertility preservation consultation were more likely to be of advanced age, non-Caucasian, highly educated, single, nulligravid, and meet criteria for diminished ovarian reserve (DOR). Additionally, patients presenting electively were more likely to have fertility insurance benefits. A higher percentage of patients with insurance benefits for oocyte cryopreservation proceeded to stimulation. There were no differences in stimulation parameters or number of retrieved oocytes between the groups when adjusted for age. Following release of the ASRM guidelines on oocyte cryopreservation, there was no difference in the percentage of patients in the medical group who proceeded with stimulation; however, a higher percentage of patients presenting electively underwent ovarian stimulation.

CONCLUSION

Although the populations presenting for medical compared with elective fertility preservation differ at baseline, ovarian stimulation parameters and outcomes are similar when adjusted for age. Insurance benefits for fertility preservation are not comprehensive and impact the decision to proceed with stimulation in all patients. The publication of the ASRM guidelines on oocyte cryopreservation increased utilization of this technology among patients presenting electively; however, they remained at an advanced age and with decreased ovarian reserve parameters.

Random-start ovarian stimulation in women desiring elective cryopreservation of oocytes

The current study investigates the utility of random-start ovarian stimulation in women desiring elective oocyte cryopreservation. Women in the study cohort underwent random-start ovarian stimulation, and were subdivided based on the phase of the menstrual cycle that ovarian stimulation began, i.e. early follicular, late follicular or luteal phase. Women undergoing conventional cycle day (CD) 2/3 ovarian stimulation start were controls. A total of 1302 women were included - 859 (66.0%) conventional CD 2/3, 342 (26.3%) early follicular, 42 (3.2%) late follicular and 59 (4.5%) luteal ovarian stimulation starts. There was no difference in the demographics or baseline ovarian stimulation characteristics. The duration of ovarian stimulation (11 versus 9 days; P < 0.001) and total dosage of gonadotrophins administered (4095.5 versus 3155 IU; P < 0.001) was higher in the random-start group. The number of total and MII oocytes in the control and random-start groups was similar. A non-significant trend towards increased cycle cancellation was noted in the late follicular start group (7.1%). Study findings indicate the number of total and MII oocytes derived from random-start protocols initiated during any phase of the menstrual cycle is similar to conventional CD 2/3 ovarian stimulation start protocols in women desiring elective oocyte cryopreservation.

Oocyte and ovarian tissue cryopreservation in European countries: statutory background, practice, storage and use

STUDY QUESTION

What is known in Europe about the practice of oocyte cryopreservation (OoC), in terms of current statutory background, funding conditions, indications (medical and 'non-medical') and specific number of cycles?

SUMMARY ANSWER

Laws and conditions for OoC vary in Europe, with just over half the responding countries providing this for medical reasons with state funding, and none providing funding for 'non-medical' OoC.

WHAT IS ALREADY KNOWN

The practice of OoC is a well-established and increasing practice in some European countries, but data gathering on storage is not homogeneous, and still sparse for use. Ovarian tissue cryopreservation (OtC) is only practiced and registered in a few countries.

STUDY DESIGN SIZE AND DURATION

A transversal collaborative survey on OoC and OtC, was designed, based on a country questionnaire containing information on statutory or professional background and practice, as well as available data on ovarian cell and tissue collection, storage and use. It was performed between January and September 2015.

PARTICIPANTS/MATERIALS SETTING AND METHODS

All ESHRE European IVF Monitoring (EIM) consortium national coordinators were contacted, as well as members of the ESHRE committee of national representatives, and sent a questionnaire. The form included national policy and practice details, whether through current existing law or code of practice, criteria for freezing (age, health status), availability of funding and the presence of a specific register. The questionnaire also included data on both the number of OoC cycles and cryopreserved oocytes per year between 2010 and 2014, specifically for egg donation, fertility preservation for medical disease, 'other medical' reasons as part of an ART cycle, as well as for 'non-medical reasons' or age-related fertility decline. Another question concerning data on freezing and use of ovarian tissue over 5 years was added and sent after receiving the initial questionnaire.

MAIN RESULTS AND THE ROLE OF CHANCE

Out of 34 EIM members, we received answers regarding OoC regulations and funding conditions from 27, whilst 17 countries had recorded data for OoC, and 12 for OtC. The specific statutory framework for OoC and OtC varies from absent to a strict frame. A total of 34 705 OoC cycles were reported during the 5-year-period, with a continuous increase. However, the accurate description of numbers was concentrated on the year 2013 because it was the most complete. In 2013, a total of 9126 aspirations involving OoC were reported from 16 countries. Among the 8885 oocyte aspirations with fully available data, the majority or 5323 cycles (59.9%) was performed for egg donation, resulting in the highest yield per cycle, with an average of 10.4 oocytes frozen per cycle. OoC indication was 'serious disease' such as cancer in 10.9% of cycles, other medical indications as 'part of an ART cycle' in 16.1%, and a non-medical reason in 13.1%. With regard to the use of OoC, the number of specifically recorded frozen oocyte replacement (FOR) cycles performed in 2013 for all medical reasons was 14 times higher than the FOR for non-medical reasons, using, respectively, 8.0 and 8.4 oocytes per cycle. Finally, 12 countries recorded storage following OtC and only 7 recorded the number of grafted frozen/thawed tissues.

LIMITATIONS REASONS FOR CAUTION

Not all countries have data regarding OoC collection, and some data came from voluntary collaborating centres, rather than a national authority or register. Furthermore, the data related to use of OoC were not included for two major players in the field, Italy and Spain, where numbers were conflated for medical and non-medical reasons. Finally, the number of cycles started with no retrieval is not available. Data are even sparser for OtC.

WIDER IMPLICATIONS OF THE FINDINGS

There is a need for ART authorities and professional bodies to record precise data for practice and use of OoC (and OtC), according to indications and usage, in order to reliably inform all stakeholders including women about the efficiency of both methods. Furthermore, professional societies should establish professional standards for access to and use of OoC and OtC, and give appropriate guidance to all involved.

STUDY FUNDING/COMPETING INTERESTS

The study was supported by ESHRE. There are no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Ethics of medical and nonmedical oocyte cryopreservation

PURPOSE OF REVIEW

To assess the effectiveness and ethical dimensions of oocyte cryopreservation for both medical and social indications.

RECENT FINDINGS

As more women are postponing motherhood for a variety of reasons, including lack of partner, for completing career plans and reaching financial stability, they are resorting to oocyte cryopreservation. To make informed choices, women rely on their primary care physicians (PCPs) for initial advice, but PCPs are not always fully prepared to discuss oocyte cryopreservation. Interestingly, there are mixed feelings among obstetricians/gynecologists on whether oocyte cryopreservation should be used for elective reasons, whereas it is fully supported for medical indications.

SUMMARY

Oocyte vitrification has become an established procedure for safeguarding future reproductive chances for medical reasons, and its use is progressively expanding. There is an urgent need in preparing future PCPs and obstetricians/gynecologists as to how to initiate discussions with their patients about elective oocyte banking consistent with fully respecting patient autonomy so as to facilitate informed decisions.

[Fertility preservation in women of the childbearing age: Indications and strategies]

Advances on cryopreservation techniques now allow considering oocyte, embryo or ovarian tissue freezing for female fertility preservation. Originally developed for patients suffering from cancer, fertility preservation has rapidly invaded others medical fields, and represents now the standard of care for all young patient diagnosed with a disease that could impair fertility or having to receive possibly gonadotoxic treatment. As a result, autoimmune diseases, some genetic pathologies or iterative pelvic surgeries, at risk of premature ovarian failure, have become common indications of fertility preservation. In addition, the social egg freezing aiming at preventing the age-related fertility decline is still debated in France, although authorized in numerous countries. This review will discuss the different strategies of fertility preservation in young girls and women of reproductive age, regarding different medical or non-medical indications.

Awareness of the effects of postponing motherhood among hospital gynecologists: is their knowledge sufficient to offer appropriate help to patients?

PURPOSE

The aim of this study is to ascertain the awareness of hospital gynecologists about the effects of woman's age on spontaneous fecundity and on the efficacy of assisted reproduction techniques (ARTs).

METHODS

One hundred fifty-six gynecologists working in public or private Italian hospitals, without specific experience in reproductive medicine and ART, were administered a multiple-choice answer questionnaire addressing (a) the effect of age on woman's spontaneous fecundity, (b) the tools to estimate the ovarian follicular reserve, and (c) the outcome of ART in women above 40 years.

RESULTS

Approximately half of the interviewed gynecologists indicated the woman's age limit for successful reproduction between 44 and 50 years; fertility lifespan was believed to be prolonged by oral contraception, pro-fertility medical treatments, or ART. The correct meaning of serum FSH measurement was known by approximately one third of the interviewed doctors. The effectiveness of ART for women of advanced age was overestimated by half of the gynecologists, especially in case of patients having regular cycles and/or small follicles at ultrasound.

CONCLUSIONS

Overall, the survey clearly showed that the knowledge of hospital gynecologists about the effects of age on woman's fertility and ART effectiveness is largely insufficient to offer scientifically correct, helpful information to patients. Properly targeted corrections to academic and periodical educational programs for Ob/Gyn specialists are warranted.

ART results with frozen oocytes: data from the Italian ART registry (2005-2013)

PURPOSE

This study is a retrospective collection of aggregated data from all the Italian ART centers reporting to the Italian National Register from cycles started between January 2005 and December 2013.

METHODS

Data from both slow freezing (SF) and vitrification (V) were assessed for the period 2007-2013, while during the years 2005-2006 cryopreservation was exclusively performed by SF.

RESULTS

In the study period, a total of 2,526,024 oocytes were retrieved (from 378,543 retrievals), of which 1,346,061 (53.3 %) were inseminated in fresh cycles and 214,481 (8.5 %) were cryopreserved. Cryopreserved oocytes were used in 24,173 cycles yielding 19,453 transfer cycles (80.5 % of the thawing/warming cycles) and 3043 clinical pregnancies (15.6 % per transfer). A significant difference in implantation (8.7 vs 12.9 % OR 1.30 CI 1.20-1.40) and pregnancy rates per transfer (12.2 vs 14.9 % OR 1.34 CI 1.23-1.46) was found between SF and V. Complete outcome data was available for 2708 pregnancies (89.8 %), leading to 1882 deliveries and 2152 live births. Neonatal major congenital anomalies were 0.9 % (20/2152).

CONCLUSIONS

A wide variation in pregnancy rates were found among different centers and lower rates were reported in donor cycles and in centers with more experience.

Family intentions and personal considerations on postponing childbearing in childless cohabiting and single women aged 35-43 seeking fertility assessment and counselling

STUDY QUESTION

What characterizes childless women aged 35 years and above seeking fertility assessment and counselling in relation to their reproduction and are there significant differences between single and cohabiting women?

SUMMARY ANSWER

Despite the women's advanced age and knowledge of the age-related decline in fecundity, 70% of the single women sought fertility assessment and counselling to gain knowledge regarding the possibility of postponing pregnancy.

WHAT IS KNOWN ALREADY

Recent studies have indicated an increasing demand for ovarian reserve testing in women without any known fertility problem to obtain knowledge on their reproductive lifespan and pro-fertility advice. Women postpone their first pregnancy, and maternal age at first birth has increased in western societies over the past two to four decades. Postponed childbearing implies a higher rate of involuntary childlessness, smaller families than desired and declining fertility rates.

STUDY DESIGN, SIZE, AND DURATION

Baseline data from a cross-sectional cohort study of 340 women aged 35-43 years examined at the Fertility Assessment and Counselling (FAC) Clinic at Copenhagen University Hospital from 2011 to 2014. The FAC Clinic was initiated to provide individual fertility assessment and counselling.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Eligible women were childless and at least 35 years of age. All completed a web-based questionnaire before and after the consultation including socio-demographic, reproductive, medical, lifestyle and behavioural factors. Consultation by a fertility specialist included transvaginal ultrasound, full reproductive history and AMH measurement.

MAIN RESULTS AND THE ROLE OF CHANCE

The study comprised 140 cohabiting and 200 single women. The majority (82%) were well-educated and in employment. Their mean age was 37.4 years. Nonetheless, the main reasons for attending were to obtain knowledge regarding the possibility of postponing pregnancy (63%) and a concern about their fecundity (52%). The majority in both groups (60%) wished for two or more children. The women listed their ideal age at birth of first child and last child as 33 (±4.7) years and 39 (±3.5) years, respectively. Of the single women, 70% would accept use of sperm donation compared with 25% of the cohabiting women (P < 0.001). In general, 45% considered oocyte vitrification for social reasons, yet only 15% were positive towards oocyte donation. The two groups were comparable regarding lifestyle factors, number of previous sexual partners, pregnancies, and ovarian reserve parameters.

LIMITATIONS, REASONS FOR CAUTION

The women in the present study were conscious of the risk of infertility with increasing age and attended the FAC Clinic due to a concern about their remaining reproductive lifespan, which in combination with their high educational level could impair the generalizability to the background population.

WIDER IMPLICATIONS OF THE FINDINGS

The results indicate that in general women overestimate their own reproductive capacity and underestimate the risk of future childlessness with the continuous postponement of pregnancies.

Oocyte cryopreservation beyond cancer: tools for ethical reflection

PURPOSE

This article offers physicians a tool for structured ethical reflection on challenging situations surrounding oocyte cryopreservation in young healthy women.

METHODS

A systematic literature review offers a comprehensive overview of the ethical debate surrounding the practice. Ethical Counseling Methodology (ECM) offers a practical approach for addressing ethical uncertainties. ECM consists of seven steps: (i) case presentation; (ii) analysis of possible implications; (iii) presentation of ethical question(s); (iv) explanation of ethical terms; (v) presentation of the ethical arguments in favor of and against the procedure; (vi) examination of the individual patient's beliefs and wishes; and (vii) conclusive summary.

RESULTS

The most problematic aspects in the ethical debate include the distinction between medical and non-medical use of oocyte cryopreservation, safety and efficiency of the procedure, and marketing practices aimed at healthy women. Female empowerment and enhanced reproductive choices (granted oocyte cryopreservation is a safe and efficient technique) are presented as ethical arguments supporting the practice, while ethical reservations towards oocyte cryopreservation are based on concerns about maternal and fetal safety and wider societal implications.

CONCLUSIONS

Oocyte cryopreservation is gaining popularity among healthy reproductive age women. However, despite promised benefits it also involves risks that are not always properly communicated in commercialized settings. ECM offers clinicians a tool for structured ethical analysis taking into consideration a wide range of implications, various ethical standpoints, and patients' perceptions and beliefs.

Does company-sponsored egg freezing promote or confine women's reproductive autonomy?

PURPOSE

A critical ethical analysis of the initiative of several companies to cover the costs of oocyte cryopreservation for their healthy employees. The main research question is whether such policies promote or confine women's reproductive autonomy.

RESULTS

A distinction needs to be made between the ethics of AGE banking in itself and the ethics of employers offering it to their employees. Although the utility of the former is expected to be low, there are few persuasive arguments to deny access to oocyte cryopreservation to women who are well informed about the procedure and the success rates. However, it does not automatically follow that it would be ethically unproblematic for employers to offer egg banking to their employees.

CONCLUSIONS

For these policies to be truly 'liberating', a substantial number of conditions need to be fulfilled, which can be reduced to three categories: (1) women should understand the benefits, risks and limitations, (2) women should feel no pressure to take up the offer; (3) the offer should have no negative effect on other family-friendly policies and should in fact be accompanied by such policies. Fulfilling these conditions may turn out to be impossible. Thus, regardless of companies' possible good intentions, women's reproductive autonomy is not well served by offering them company-sponsored AGE banking.

Fertility preservation in women with endometriosis: for all, for some, for none?

The increasing confidence with the techniques of oocyte and ovarian cortex freezing has prompted their potential use for patient categories other than those at risk of early menopause due to cancer treatments. Women affected by every iatrogenic or pathologic condition known to compromise ovarian function severely have been considered as potential candidates for fertility preservation. Among them, women with endometriosis may represent a particularly suitable group since they are at increased risk of premature ovarian exhaustion and about half of them will experience infertility. Based on the currently available notions on the intricate relationships between endometriosis, infertility and damage to the ovarian reserve, we speculate that fertility preservation may be of interest for women with endometriosis, in particular for those with bilateral unoperated endometriomas and for those who previously had excision of unilateral endometriomas and require surgery for a contralateral recurrence. Young age at diagnosis may be an independent but pivotal additional factor to be taken into consideration in the balance of the pros and cons of fertility preservation. On the other hand, we argue against the introduction of fertility preservation for endometriosis in routine clinical practice. To date, only few cases have been reported and there are insufficient data for robust cost-utility analyses. It is noteworthy that endometriosis is a relatively common disease and systematically including affected women in a fertility preservation program would have profound clinical, logistic and financial effects. More clinical data and in-depth economic analysis are imperative prior to recommending its routine use.