Planned oocyte cryopreservation for women seeking to preserve future reproductive potential: an Ethics Committee opinion

Eggsurance? A randomized controlled trial of a decision aid for elective egg freezing

STUDY QUESTION

Does a purpose-designed Decision Aid for women considering elective egg freezing (EEF) impact decisional conflict and other decision-related outcomes?

SUMMARY ANSWER

The Decision Aid reduces decisional conflict, prepares women for decision-making, and does not cause distress.

WHAT IS ALREADY KNOWN

Elective egg-freezing decisions are complex, with 78% of women reporting high decisional conflict. Decision Aids are used to support complex health decisions. We developed an online Decision Aid for women considering EEF and demonstrated that it was acceptable and useful in Phase 1 testing.

STUDY DESIGN, SIZE, DURATION

A single-blind, two-arm parallel group randomized controlled trial was carried out. Target sample size was 286 participants. Randomization was 1:1 to the control (existing website information) or intervention (Decision Aid plus existing website information) group and stratified by Australian state/territory and prior IVF specialist consultation. Participants were recruited between September 2020 and March 2021 with outcomes recorded over 12 months. Data were collected using online surveys and data collection was completed in March 2022.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Females aged ≥18 years, living in Australia, considering EEF, proficient in English, and with internet access were recruited using multiple methods including social media posts, Google advertising, newsletter/noticeboard posts, and fertility clinic promotion. After completing the baseline survey, participants were emailed their allocated website link(s). Follow-up surveys were sent at 6 and 12 months. Primary outcome was decisional conflict (Decisional Conflict Scale). Other outcomes included distress (Depression Anxiety and Stress Scale), knowledge about egg freezing and female age-related infertility (study-specific measure), whether a decision was made, preparedness to decide about egg freezing (Preparation for Decision-Making Scale), informed choice (Multi-Dimensional Measure of Informed Choice), and decision regret (Decision Regret Scale).

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, 306 participants (mean age 30 years; SD: 5.2) were randomized (intervention n = 150, control n = 156). Decisional Conflict Scale scores were significantly lower at 12 months (mean score difference: -6.99 [95% CI: -12.96, -1.02], P = 0.022) for the intervention versus control group after adjusting for baseline decisional conflict. At 6 months, the intervention group felt significantly more prepared to decide about EEF than the control (mean score difference: 9.22 [95% CI: 2.35, 16.08], P = 0.009). At 12 months, no group differences were observed in distress (mean score difference: 0.61 [95% CI: -3.72, 4.93], P = 0.783), knowledge (mean score difference: 0.23 [95% CI: -0.21, 0.66], P = 0.309), or whether a decision was made (relative risk: 1.21 [95% CI: 0.90, 1.64], P = 0.212). No group differences were found in informed choice (relative risk: 1.00 [95% CI: 0.81, 1.25], P = 0.983) or decision regret (median score difference: -5.00 [95% CI: -15.30, 5.30], P = 0.337) amongst participants who had decided about EEF by 12 months (intervention n = 48, control n = 45).

LIMITATIONS, REASONS FOR CAUTION

Unknown participant uptake and potential sampling bias due to the recruitment methods used and restrictions caused by the coronavirus disease 2019 pandemic. Some outcomes had small sample sizes limiting the inferences made. The use of study-specific or adapted validated measures may impact the reliability of some results.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first randomized controlled trial to evaluate a Decision Aid for EEF. The Decision Aid reduced decisional conflict and improved women's preparation for decision making. The tool will be made publicly available and can be tailored for international use.

STUDY FUNDING/COMPETING INTEREST(S)

The Decision Aid was developed with funding from the Royal Women's Hospital Foundation and McBain Family Trust. The study was funded by a National Health and Medical Research Council (NHMRC) Project Grant APP1163202, awarded to M. Hickey, M. Peate, R.J. Norman, and R. Hart (2019-2021). S.S., M.P., D.K., and S.B. were supported by the NHMRC Project Grant APP1163202 to perform this work. R.H. is Medical Director of Fertility Specialists of Western Australia and National Medical Director of City Fertility. He has received grants from MSD, Merck-Serono, and Ferring Pharmaceuticals unrelated to this study and is a shareholder of CHA-SMG. R.L. is Director of Women's Health Melbourne (Medical Practice), ANZSREI Executive Secretary (Honorary), RANZCOG CREI Subspecialty Committee Member (Honorary), and a Fertility Specialist at Life Fertility Clinic Melbourne and Royal Women's Hospital Public Fertility Service. R.A.A. has received grants from Ferring Pharmaceuticals unrelated to this study. M.H., K.H., and R.J.N. have no conflicts to declare.

TRIAL REGISTRATION NUMBER

ACTRN12620001032943.

TRIAL REGISTRATION DATE

11 August 2020.

DATE OF FIRST PATIENT’S ENROLMENT

29 September 2020.

Determining the optimal daily gonadotropin dose to maximize the oocyte yield in elective egg freezing cycles

OBJECTIVE

Ovarian stimulation (OS) with high daily gonadotropin doses are commonly offered to patients attempting social/elective egg freezing. However, the optimal daily gonadotropin dose that would allow a higher oocyte yield in the successive IVF cycle attempt was not settled and should be determined.

PATIENTS AND METHODS

Data from all women admitted to our IVF unit for social/EEF, who underwent two consecutive IVF cycle attempts, with only those who used in the first attempt a starting daily gonadotropin dose of 300IU were analyzed. Patients characteristics and OS variables were used in an attempt to build a logistic model, helping in determining the daily gonadotropin dose that should be offered to patient during their second EEF attempt, aiming to further increase their oocyte yield.

RESULTS

Three hundred and thirteen consecutive women undergoing two successive IVF cycle attempts were evaluated. Using logistic regression model, two equations were developed using individual patient-level data that determine the daily gonadotropin dose needed aiming to increase the oocyte yield in the successive cycle. (a): X=-0.514 + 2.87*A1 + 1.733*A2-0.194* (E2/1000) and (b): P = EXP(X) / [1 + EXP(X)].

CONCLUSIONS

Using the aforementioned equations succeeded in determining the daily gonadotropin dose that might result in increasing oocyte yield, with an AUC of 0.85. Any additional oocyte retrieved to these EEF patients might get them closer to fulfil their desire to parenthood.

Planned oocyte cryopreservation: a systematic review and meta-regression analysis

BACKGROUND

Awareness of the age-related decline in fertility potential has increased the popularity of planned oocyte cryopreservation (POC). However, data regarding outcomes of POC, including rates of women returning to thaw oocytes, as well as pregnancy and live birth rates, are scarce and based mostly on small case series.

OBJECTIVE AND RATIONALE

POC was defined as cryopreservation exclusively for prevention of future age-related fertility loss. The primary outcome was live birth rate per patient. The secondary outcomes included the return to thaw rate and laboratory outcomes. A meta-regression analysis examining the association between live birth and age above 40 or below 35 was conducted.

SEARCH METHODS

We conducted a systematic database search from inception to August 2022. The search included PubMed (MEDLINE) and EMBASE. Our search strategies employed a combination of index terms (Mesh) and free text words to compile relevant concepts. The systematic review and meta-regression were undertaken following registration of systematic review (PROSPERO registration number CRD42022361791) and were reported following guidelines of Preferred Reporting Items for Systematic Review and Meta-Analyses 2020 (PRISMA 2020).

OUTCOMES

The database search yielded 3847 records. After the selection process, 10 studies, conducted from 1999 to 2020, were included. Overall, 8750 women underwent POC, with a mean cryopreservation age of 37.2 (±0.8). Of those, 1517 women returned to use their oocytes with a return rate of 11.1% (± 4.7%). The mean age at the time of cryopreservation for women who returned to use their oocytes was 38.1 (±0.4), with an average of 12.6 (±3.6) cryopreserved oocytes per woman. In a meta-analysis, the oocyte survival rate was 78.5% with a 95% CI of 0.74-0.83 (I2 = 93%). The live birth rate per patient was 28% with a 95% CI of 0.24-0.33 (I2 = 92%). Overall, 447 live births were reported. In a sub-group analysis, women who underwent cryopreservation at age ≥40 achieved a live birth rate per patient of 19% (95% CI 0.13-0.29, I2 = 6%), while women aged ≤35 years old or younger had a higher live birth rate per patient of 52% (95% CI 0.41-0.63, I2 = 7%).

WIDER IMPLICATIONS

POC emerges as a feasible option for women aiming to improve their chances of conceiving at a later reproductive age. Nonetheless, it must be acknowledged that the overall success rates of POC are limited and that the likelihood of successful live birth declines as the age at cryopreservation rises. With increasing interest in POC, the collation of comprehensive and high-quality data is imperative to clearly define the outcomes for various age groups.

REGISTRATION NUMBER

CRD42022361791.

Storage trends, usage and disposition outcomes following egg freezing

RESEARCH QUESTION

What happens to eggs after egg freezing?

DESIGN

A retrospective cohort study was performed spanning 2012-2022. Data were obtained from seven assisted reproductive technology clinics in Victoria, Australia. Aggregated, de-identified data were collected on cycles that resulted in egg freezing and the following outcomes, including treatment involving thawed eggs and disposition outcomes of surplus eggs.

RESULTS

The number of patients with eggs in storage grew rapidly from 144 in 2012 to 2015 in 2022. In 2022, 73% of patients had stored their eggs for <5 years, 25% for 5-10 years, and 2% for ≥10 years. Most thaw cycles (600/645, 93%) involved eggs that had been frozen for <5 years, of which 47% had been frozen for <6 months. Overall, the live birth rate per initiated thaw cycle was 12%. Across the study period, 2800 eggs from 286 patients were either discarded, donated or exported. Of the 128 patients who discarded their eggs, 32% had stored their eggs for <5 years, 32% for 5-10 years and 36% for >10 years. Of the 23 patients who donated their eggs to someone else, all but four had stored their eggs for <5 years. No eggs were donated to research over the study period.

CONCLUSIONS

This study shows that very few patients have made the decision to use or relinquish their eggs. Strategies may be needed to address the prolonged storage of surplus eggs, and ensure that patients are supported to make decisions regarding the fate of their eggs which align with their preferences and values.

Decision regret, and other mental health outcomes, following fertility preservation in the transgender individual compared to the cisgender woman

PURPOSE

This study aimed to (1) determine differences in depression, anxiety, body image, quality-of-life (QOL), and decision regret scale (DRS) scores in transgender individuals undergoing fertility preservation (FP) compared to those who decline and (2) determine if DRS score following FP varies between transgender individuals and cisgender women.

METHODS

Sixteen transgender birth-assigned (BA) females and 13 BA males, undergoing FP consultation at an academic center between January 2016 and November 2019, were compared to each other and cisgender cohorts with pre-existing data: 201 women undergoing elective oocyte cryopreservation (EOC) between 2012 and 2016 and 44 women with cancer undergoing FP between 1993 and 2007. Outcomes included demographics; validated scales for depression, anxiety, body image, QOL (see below) in the trans cohort; DRS score in all three cohorts.

RESULTS

Of 29 transgender individuals participating, 10 BA females (62%) and 12 BA males (92%) underwent FP. Beck Depression Inventory II, Hospital Anxiety and Depression Scale, Body Image Scale for Transsexuals, Satisfaction with Life Scale, Short Form Health Survey-36, and DRS scores were not significantly different between trans individuals who underwent FP and those who declined. On univariate modeling, regret was significantly lower in transpeople undergoing FP compared to those who did not (OR 0.118, p = 0.03). BA female and BA male transpatients undergoing FP reported DRS median scores 5 (mean 9) and 7.5 (mean 15), respectively, both were not significantly different from cisgender women (p = 0.97, p = 0.25) nor from each other (p = 0.43).

CONCLUSIONS

Depression, anxiety, body image, and QOL, in a group of individuals presenting for FP consultation, appear similar between transpeople undergoing FP and not, while regret is significantly lower in those choosing FP. FP is an option for transgender individuals without significant differences in regret compared to cisgender women.

Racial Disparities in Fertility Care: A Narrative Review of Challenges in the Utilization of Fertility Preservation and ART in Minority Populations

Significant ethnic and racial disparities exist in the utilization and outcomes of assisted reproductive technology (ART) in the United States. The popularity of fertility preservation (FP) procedures, a specific application of ART for those desiring to delay childbearing, has increased; however, many minority populations have seen a less rapid uptake of these services. Minority patients pursuing ART are more likely to have poorer in vitro fertilization (IVF) and pregnancy outcomes. These outcomes are used to predict success after FP and may lessen the appeal of such procedures in these populations. Suboptimal outcomes are further compounded by challenges with receiving referrals to, accessing, and paying for FP services. Resolving these disparities in minority populations will require culturally appropriate education surrounding the benefits of ART and FP, the demonstration of favorable outcomes in ART and FP through continued research engaging minority participants, and continued advocacy for expanded access to care for patients.

Impact of employer-covered planned oocyte cryopreservation on decision-making for medical training

PURPOSE

To characterize how employer coverage of planned oocyte cryopreservation (POC) might impact medical career decision-making.

METHODS

A cross-sectional survey was distributed to all medical students at two large academic programs in December 2022 to better understand attitudes towards childbearing, POC, and how employer coverage of POC might influence future career decisions.

RESULTS

Of the 630/1933 (32.6%) medical students who participated, 71.8% identified as women and 28.1% as men. More women (89.2%) than men (75.1%, P < 0.001) felt pressure to delay childbearing. Regarding childbearing, women more than men were concerned about the physical demand of residency (76.5% vs. 50.8%, P < 0.001), stigma in residency hiring practices (41.2% vs. 9.0%, P < 0.001), and parental leave interfering with team dynamics (49.6% vs. 20.9%, P < 0.001). Respondents were more likely to pursue POC if it were covered by residency employer health insurance (60.0% vs. 11.6%, P < 0.001). Women were more likely than men to state that employer-sponsored POC would influence their residency ranking (46.0% vs. 23.7%, P < 0.001), pursuit of additional degrees (50.9% vs. 30.5%, P < 0.001), and pursuit of fellowship training (50.9% vs. 30.5%, P < 0.001). Additionally, 25.4% of women and 19.8% of men felt their choice in medical specialty would be impacted by employer-sponsored POC.

CONCLUSIONS

Medical students, particularly women, feel pressure to delay childbearing during medical training and are concerned about future fertility. Both male and female students were interested in employer-sponsored POC and more likely to pursue it with financial coverage. Further research is needed to determine the full impact of employer-sponsored POC on medical career decision-making.

Oocyte vitrification for fertility preservation is an evolving practice requiring a new mindset: societal, technical, clinical, and basic science-driven evolutions

Infertility is a condition with profound social implications. Indeed, it is not surprising that evolutions in both medicine and society affect the way in vitro fertilization is practiced. The keywords in modern medicine are the four principles, which implicitly involve a constant update of our knowledge and our technologies to fulfill the "prediction" and "personalization" tasks, and a continuous reshaping of our mindset in view of all relevant societal changes to fulfill the "prevention" and "participation" tasks. A worldwide aging population whose life priorities are changing requires that we invest in fertility education, spreading actionable information to allow women and men to make meaningful reproductive choices. Fertility preservation for both medical and nonmedical reasons is still very much overlooked in many countries worldwide, demanding a comprehensive update of our approach, starting from academia and in vitro fertilization laboratories, passing through medical offices, and reaching out to social media. Reproduction medicine should evolve from being a clinical practice to treat a condition to being a holistic approach to guarantee patients' reproductive health and well-being. Oocyte vitrification for fertility preservation is the perfect use case for this transition. This tool is acquiring a new identity to comply with novel indications and social needs, persisting technical challenges, brand-new clinical technologies, and novel revolutions coming from academia. This "views and reviews" piece aims at outlining the advancement of oocyte vitrification from all these tightly connected perspectives.

The use of fertility treatments among reproductive-aged women after cancer

OBJECTIVE

To examine whether female cancer survivors are more likely to pursue care for infertility after cancer than women without cancer.

DESIGN

Population-based cohort study involving detailed interviews regarding reproductive history.

SETTING

Not applicable.

PATIENTS

Female cancer survivors aged 22-45 years, who were at least 2 years after a cancer diagnosis between the ages of 20 and 35 years (n = 1,036), and age-matched comparison women with no cancer history (n = 1,026).

EXPOSURE

History of cancer vs. no history of cancer.

MAIN OUTCOME MEASURE(S)

Each cancer survivor was randomly matched to a comparison woman, who was assigned an artificial age at cancer diagnosis equal to that of her match. Matching was repeated 1,000 times. Outcomes of visiting a doctor for help becoming pregnant or undergoing fertility treatment were modeled using Cox proportional hazards regression, comparing survivors after a cancer diagnosis to age-matched comparison women, adjusted for race, income, residence, education, and parity.

RESULTS

Only 25.5% of cancer survivors reported meeting their desired family size before a cancer diagnosis. The median time from diagnosis to interview among survivors was 7 (interquartile range 5-11) years. Cancer survivors were more likely to report having no children (32.6%) at the interview compared with women with no cancer history (19.5%). Survivors were not more likely to visit a doctor for help becoming pregnant compared with women without a cancer history, matched on birth year and followed by the age at which cancer survivors received their diagnosis (hazard ratio [HR] 1.16, 95% simulation interval [SI] 0.78-1.74). Compared with cancer-free women, cancer survivors had similar probabilities of pursuing any treatment (adjusted HR [aHR] 0.88, 95% SI 0.46-1.56), using hormones or medications (aHR 0.86, 95% SI 0.46-1.63), or undergoing intrauterine insemination (aHR 1.26, 95% SI 0.40-5.88) to conceive. Cancer survivors were slightly more likely to pursue surgical interventions to become pregnant (HR 1.55, 95% SI 0.67-3.71). Of those who visited a doctor but declined to pursue fertility treatment, one-quarter of women reported declining treatment due to cost.

CONCLUSION

Cancer survivors did not use fertility treatments at higher rates than the general population. Further counseling and education surrounding fertility options are recommended for young adult female cancer patients after treatment is completed.

Planned Oocyte Cryopreservation: A Review of Current Evidence on Outcomes, Safety and Risks

Although oocyte cryopreservation was initially used as a fertility preservation strategy for medical indications, it is now is increasingly used to circumvent age-related infertility. Outcomes following planned oocyte vitrification, also known as elective egg freezing, are limited. Current studies show higher success rates for individuals undergoing fertility preservation treatment under age 35. Additionally, while freezing 20 oocytes is optimal to achieve pregnancy, freezing at least 8-10 oocytes is recommended. While fertility is not guaranteed, current evidence demonstrates that planned oocyte vitrification is an overall safe, low risk method of fertility preservation to reduce the risk for age-related infertility.

Planned oocyte cryopreservation: the state of the ART

The objective of this review is to provide an update on planned oocyte cryopreservation. This fertility preservation method increases reproductive autonomy by allowing women to postpone childbearing whilst maintaining the option of having a biological child. Oocyte cryopreservation is no longer considered experimental, and its use has increased dramatically in recent years as more women delay childbearing for personal, professional and financial reasons. Despite increased usage, most patients who have undergone oocyte cryopreservation have not yet warmed their oocytes. Most women who cryopreserve oocytes wait years to use them, and many never use them. Studies have demonstrated that oocyte cryopreservation results in live birth rates comparable with IVF treatment using fresh oocytes, and does not pose additional safety risks to offspring. Based on current evidence, cryopreserving ≥20 mature oocytes at <38 years of age provides a 70% chance of one live birth. However, larger studies from a variety of geographic locations and centre types are needed to confirm these findings. Additional research is also needed to determine the recommended age for oocyte cryopreservation, recommended number of oocytes to cryopreserve, return and discard/non-use rates, cost-effectiveness, and how best to distribute accurate and up-to-date information to potential patients.

The first nationwide website survey of the availability and costs of medical and non-medical oocyte cryopreservation in Japan

Research question

How does the cost-related oocyte cryopreservation (OoC) vary by the facility in Japan, and what data is provided on the websites about OoC procedures?

Design

Website survey. The websites of all 621 facilities that provide assistive reproductive technology registered in Japan were surveyed in 2021. Data included the rates of explicit statements regarding the provision of OoC for only medical reasons (medical only group) or non-medical reasons (non-medical group). Based on whether or not facilities that perform OoC clearly stated the cost on their websites, we compared the costs of OoC and annual storage cost between medical only and non-medical groups. Furthermore, we examined the stated number of OoC procedures performed and their clinical outcomes.

Results

Of the 621 facilities, 146 (23.5%) clearly stated that they offer OoC on their websites. Of the 88 medical only groups and 58 non-medical groups, 24 (27.3%) and 42 (72.4%) clearly stated the OoC cost, and 27 (30.7%) and 44 (75.9%) clearly states the annual oocyte storage cost, respectively. The OoC costs were significantly higher for the non-medical group than in the medical group. In the medical only group, the annual storage cost remained almost the same regardless of the number of oocytes, while in the non-medical group, the annual storage cost was 2-3 times higher than in the medical only group. Only 16 facilities (16/146, 11.0%) had mentioned the number of OoC procedures, and five facilities (3.4%) provided information on the clinical outcomes after OoC.

Conclusion

Costs related to OoC are higher for the non-medical group in Japan. In addition, the websites contain scant information on the costs and clinical outcomes of OoC.

Fertility Preservation as an Option for Women with Genetic Disorders: Insights from a SWOT Analysis on Elective Oocyte Freezing and Preimplantation Genetic Testing

This paper uses a SWOT (strengths, weaknesses, opportunities, and threats) analysis to overview the option of fertility preservation in women with genetic diseases, who would later use preimplantation genetic testing for monogenic disorders, in order to not transmit their condition. Strengths associated with elective oocyte freezing are ethical considerations, overall maternal and fetal safety, and effectiveness, if performed at <35 years of age. Weaknesses are related to costs and rare but present (<1-3%) risks of maternal complications. Counselling on fertility management aimed at preventing infertility offers a valuable opportunity, the same as it has been in oncological patients' care. The potentially high percentage of women with genetic conditions who would return to use their frozen oocytes also represents an opportunity together with the minimization of the need for egg donation, which has higher obstetrical risks compared to the use of autologous oocytes. Finally, a threat is represented by the potential psychological distress to young women who could never attempt to become pregnant through preimplantation genetic testing, or do it before any decline in their fertility. Potential unknown future long-term health risks for children conceived after egg vitrification/thawing are also a threat, but current knowledge is reassuring. Altogether, early counselling on the option of fertility preservation should thus be incorporated into standard care of all patients with any genetic condition.

Outcomes of Social Egg Freezing: A Cohort Study and a Comprehensive Literature Review

The purpose of this study is to evaluate the live birth outcome following oocyte thaw in women who underwent social egg freezing at Guy's Hospital, alongside a detailed published literature review to compare published results with the current study. A retrospective cohort study was conducted between January 2016 and March 2022 for all women who underwent egg freezing during this period. Overall, 167 women had 184 social egg freezing cycles. The mean age at freeze was 37.1 years and an average of 9.5 eggs were frozen per retrieval. In total, 16% of the women returned to use their frozen eggs. The mean egg thaw survival rate post egg thaw was 74%. The mean egg fertilisation rate was 67%. The pregnancy rate achieved per embryo transfer was 48% and the live birth rate per embryo transfer was 35%. We also noted that irrespective of age at freezing, a significantly high live birth rate was achieved when the number of eggs frozen per patient was 15 or more. Despite the rapid increase in social egg freezing cycles, the utilisation rate remains low. Pregnancy and live birth rate post thaw are encouraging if eggs are frozen at a younger age and if 15 eggs or more were frozen per patient.

Information and decision support needs: A survey of women interested in receiving planned oocyte cryopreservation information

PURPOSE

Identifying the information and decision support needs of women interested in receiving planned oocyte cryopreservation (POC) information.

METHODS

An online survey of Australian women, aged 18-45, interested in receiving POC information, proficient in English, with internet access. The survey covered POC information sources, information delivery preferences, POC and age-related infertility knowledge (study-specific scale), Decisional Conflict Scale (DCS), and time spent considering POC. Target sample size (n=120) was determined using a precision-based method.

RESULTS

Of 332 participants, 249 (75%) had considered POC, whilst 83 (25%) had not. Over half (54%) had searched for POC information. Fertility clinic websites were predominately used (70%). Most (73%) believed women should receive POC information between ages 19-30 years. Preferred information providers were fertility specialists (85%) and primary care physicians (81%). Other methods rated most useful to deliver POC information were online. Mean knowledge score was 8.9/14 (SD:2.3). For participants who had considered POC, mean DCS score was 57.1/100 (SD:27.2) and 78% had high decisional conflict (score >37.5). In regression, lower DCS scores were associated with every 1-point increase in knowledge score (-2.4; 95% CI [-3.9, -0.8]), consulting an IVF specialist (-17.5; [-28.0, -7.1]), and making a POC decision (-18.4; [-27.5, -9.3]). Median time to decision was 24-months (IQR: 12.0-36.0) (n=53).

CONCLUSION

Women interested in receiving POC information had knowledge gaps, and wanted to be informed about the option by age 30 years from healthcare professionals and online resources. Most women who considered using POC had high decisional conflict indicating a need for decision support.

Oocyte Cryopreservation for Medical and Planned Indications: A Practical Guide and Overview

Oocyte cryopreservation (OC) is the process in which ovarian follicles are stimulated, the follicular fluid is retrieved, and mature oocytes are isolated and vitrified. Since the first successful pregnancy utilizing previously cryopreserved oocytes in 1986, OC has become increasingly utilized as an option for future biologic children in patients facing gonadotoxic therapies, such as for the treatment of cancer. Planned OC, also termed elective OC, is growing in popularity as a means to circumvent age-related fertility decline. In this narrative review, we describe both medically indicated and planned OC, focusing on the physiology of ovarian follicular loss, OC technique and risks, timing of when OC should be performed, associated financial considerations, and outcomes.

Systematic protocol and methodology needed for pre-procedure counselling of elective egg freezing patients in Singapore

Upon legalization of social egg freezing in Singapore from 2023 onwards, compulsory pre-procedure counselling is mandated for all prospective patients to enable informed choice about whether to undergo the procedure. Being a newly introduced medical procedure in Singapore, there are currently no clear directives on what pre-procedure counselling for elective egg freezing should entail. Due to pervasive media and internet influences, prospective egg freezing patients could be misled into believing that the procedure represents a guaranteed path to future motherhood, contrary to statements by professional bodies such as the American Society for Reproductive Medicine (ASRM) and the British Fertility Society (BFS). Hence, comprehensive counselling is recommended to provide women with evidence-based information (e.g. success rates of social egg freezing for women of their age) to ensure they make informed decisions and to avoid possible decision regret. For this purpose, a systematic protocol and methodology for pre-procedure counselling of women considering elective egg freezing was developed, incorporating flowcharts and decision trees that are specifically tailored to the unique sociocultural values and legal restrictions in Singapore. Questions relating to the why, what, how, where and when of the egg freezing procedure should be addressed, which could serve as a roadmap to facilitate informed decision-making by women considering elective egg freezing.

The development and phase 1 evaluation of a Decision Aid for elective egg freezing

BACKGROUND

Elective egg freezing decisions are complex. We developed a Decision Aid for elective egg freezing and conducted a phase 1 study to evaluate its acceptability and utility for decision-making.

METHODS

The online Decision Aid was developed according to International Patient Decision Aid Standards and evaluated using a pre/post survey design. Twenty-six Australian women aged 18-45 years, interested in receiving elective egg freezing information, proficient in English, and with access to the internet were recruited using social media and university newsletters. Main outcomes were: acceptability of the Decision Aid; feedback on the Decision Aid design and content; concern raised by the Decision Aid, and; utility of the Decision Aid as measured by scores on the Decisional Conflict Scale and on a study-specific scale assessing knowledge about egg freezing and age-related infertility.

RESULTS

Most participants found the Decision Aid acceptable (23/25), balanced (21/26), useful for explaining their options (23/26), and for reaching a decision (18/26). Almost all reported satisfaction with the Decision Aid (25/26) and the level of guidance  it provided (25/26). No participant reported serious concerns about the Decision Aid, and most would recommend it to other women considering elective egg freezing (22/26). Median Decisional Conflict Scale score decreased from 65/100 (Interquartile range: 45-80) pre-Decision Aid to 7.5/100 (Interquartile range: 0-37.5) post-Decision Aid review (p < 0.001). Median knowledge score increased from 8.5/14 (Interquartile range: 7-11) pre-Decision Aid to 11/14 (Interquartile range: 10-12) post-Decision Aid review (p = 0.01).

CONCLUSION

This elective egg freezing Decision Aid appears acceptable and useful for decision-making. It improved knowledge, reduced decisional conflict and did not raise serious concerns. The Decision Aid will be further evaluated using a prospective randomised control trial.

STUDY REGISTRATION

ACTRN12618001685202 (retrospectively registered: 12 October 2018).

Elective egg freezers' disposition decisions: a qualitative study

OBJECTIVE

To explore the factors that influence elective egg freezers' disposition decisions toward their surplus-frozen oocytes.

DESIGN

Qualitative.

SETTING

Not applicable.

PATIENT(S)

Thirty-one participants: 7 past; 6 current; and 18 future oocyte disposition decision-makers.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Qualitative thematic analysis of interview transcripts.

RESULTS

Six inter-related themes were identified related to the decision-making process which are as follows: decisions are dynamic; triggers for the final decision; achieving motherhood; conceptualization of oocytes; the impacts of egg donation on others; and external factors affecting the final disposition outcome. All women reported a type of trigger event for making a final decision (e.g., completing their family). Women who achieved motherhood were more open to donating their oocytes to others but were concerned about the implications for their child and felt responsibility for potential donor children. Women who did not achieve motherhood were unlikely to donate to others due to the grief of not becoming a mother, often feeling alone, misunderstood, and unsupported. Reclaiming oocytes (e.g., taking them home) and closure ceremonies helped some women process their grief. Donating to research was viewed as an altruistic option as oocytes would not be wasted and did not have the "complication" of a genetically-linked child. There was a general lack of knowledge around disposition options at all stages of the process.

CONCLUSION(S)

Oocyte disposition decisions are dynamic and complex for women, exacerbated by a general lack of understanding of these options. The final decision is framed by: whether women achieved motherhood, dealing with grief if they did not achieve motherhood, and considering the complexities of donating to others. Additional decision support through counseling, decision aids, and early consideration of disposition when eggs are initially stored may help women make informed decisions.

Reconsideration of the safety and effectiveness of human oocyte cryopreservation

Mature oocyte cryopreservation (OC) has become increasingly common since the American Society for Reproductive Medicine declared OC to no longer be experimental. Utilization of the open vitrification protocol has led to a marked improvement in the efficacy of oocyte cryopreservation. However, the safety and effectiveness of this cryopreservation method remain controversial. A previous report stated that among all initiated recipient cycles, the live-birth rate among recipients of all ages was significantly higher when using fresh donor oocytes (FDOs) rather than cryopreserved donor oocytes (CDOs). Confounding patient characteristics were noted as possible causes. OC stands as an acceptable elective medical intervention for preserving fertility in women. To further understand the effects of OC on the live birth rate resulting from fresh versus cryopreserved donor oocytes, reported data from the Society for Assisted Reproductive Technology from 2013 to 2020 were analyzed. The mean of the mean live-birth rate in all ages resulting from FDOs was 49.0% (44.6-53.3%) versus 41.0% (39.1-43.2%) for CDOs (difference, 8.0% [95% confidence interval, 5.35-10.57%], p value < 0.001). The lower live-birth rate observed for CDOs versus FDOs has been consistent throughout past decades. While there has been no reported increase in the aneuploidy rate for CDOs compared to FDOs, differences in the nondisjunction separation rate among different chromosomes were described in a recent report. Open vitrification culture medium usually contains high concentrations of cryoprotectants, such as 15% dimethyl sulfoxide (DMSO) and 15% ethylene glycol (EG). Recent studies showed that tissue culture with 0.1% DMSO or 10% EG resulted in deregulation of gene expression, disruption of epigenetic imprints, and accumulation of reactive oxygen species. The addition of melatonin, which can remove reactive oxygen species from vitrification medium, was shown to improve CDOs qualities and functions to conditions similar to those of FDOs; however, there were insufficient data to conclude that melatonin could improve the lower live-birth rate. These factors that affect live birth rates, birth defects, birth weights and developmental health cannot be ignored and perhaps need to be studied again and followed when evaluating the true effectiveness of human oocyte cryopreservation.

Patients' and providers' perspectives on non-urgent egg freezing decision-making: a thematic analysis

BACKGROUND

The decision to undergo non-urgent egg freezing (EF) is complex for patients and providers supporting them. Though prior studies have explored patient perspectives, no study has also included the separate perspectives of providers.

METHODS

This qualitative study involved semi-structured individual interviews exploring the decision to undergo EF. Participants included patients considering EF at one academic fertility clinic and providers who counsel patients about EF from across Canada. Data analysis was accomplished using thematic analysis. Data saturation was met after interviewing 13 providers and 12 patients.

FINDINGS

Four themes were identified and explored, illuminating ways in which patients and providers navigate decision-making around EF: (1) patients viewed EF as a 'back-up plan' for delaying the decision about whether to have children, while providers were hesitant to present EF in this way given the uncertainty of success; (2) providers viewed ovarian reserve testing as essential while patients believed it unnecessarily complicated the decision; (3) patients and providers cited a need for change in broader societal attitudes regarding EF since social stigma was a significant barrier to decision-making; and (4) commonality and peer support were desired by patients to assist in their decision, although some providers were hesitant to recommend this to patients.

CONCLUSIONS

In conclusion, the decision to undergo EF is complex and individual patient values play a significant role. In some areas, there is disconnect between providers and patients in their views on how to navigate EF decision-making, and these should be addressed in discussions between providers and patients to improve shared decision-making.

Elective egg freezing patients may benefit from increasing the maximal daily gonadotropin dose above 300IU

OBJECTIVE

Nowadays, patients attempting social/elective egg freezing has spread globally. Ovarian stimulation (OS) with high daily gonatotropin doses, are commonly offered to this group of patients, aiming to achieve the maximal oocytes cohort with minimum IVF cycle attempts. We aim to assess the IVF-ET outcome, and specifically the oocyte yield, of patients undergoing two successive IVF cycle attempts for elective egg freezing (EEF), and whether changing the daily gonadotropin dose in the second IVF cycle attempt, affect the outcome.

PATIENTS AND METHODS

All women admitted to our IVF unit for social/EEF, who underwent 2 consecutive IVF cycle attempts, with only those who used in the first attempt a starting daily gonadotropin dose of 300 IU were included. Ovarian stimulation characteristics, duration of OS, number of retrieved oocytes, number of mature oocytes were assessed and compared between the 1st and the 2nd IVF cycle attempts, and between the different daily gonadotropin doses and the oocyte yields in the 2nd cycle attempt (increase, decrease or no change).

MAIN OUTCOME MEASURES

Oocytes and mature oocytes yield in the 2^nd as compared to the 1^st IVF cycle attempt.

RESULTS

A reduced oocyte yield in the 2nd cycle attempt was observed in those who highly responded in the 1st attempt, regardless the daily dose in the 2nd cycle attempt (whether it was increased, no change and decreased). Moreover, the proportion of patients with same or more oocytes in the 2nd IVF cycle attempt was significantly lower in patients with high peak E2 levels, compared to those with peak E2 levels < 9175 pmol/L. Among patients with high peak E2 (> 9175 pmol/L), those who achieved a lower oocytes yield in the 2nd IVF cycle attempt had lower basal Day-3 FSH/LH ratio (1.5 + 0.5 vs 1.8 + 0.8, p < 0.03) and higher oocyte (range: 7-28, median:10; vs range: 2-15, median:7) and mature oocytes yields. With a cut-off of 9 oocytes, 78.8% of those with > 9 oocytes and 61.8% of those with < 9 oocytes will achieve lower/higher oocytes yield in the 2nd IVF cycle attempt, respectively.

CONCLUSIONS

Ovarian stimulation with high daily gonatotropin doses (300 IU) should be offered to patients attempting social/EEF. Moreover, in their 2nd IVF cycle attempt, those with high peak E2 (> 9175 pmol/L) in the 1st attempt, and basal Day-3 FSH/LH ratio < 1.5 and/or more than 9 oocytes retrieved, should receive same OS protocol with no change in the daily gonadotropin dose.

Oocyte Cryopreservation: A 9-Year Single-Centre Experience

OBJECTIVE

Oocyte cryopreservation (OC) has increased in recent years; however, there is a paucity of published data on the use of cryopreserved oocytes and associated outcomes.

METHODS

A retrospective review of 748 OC cycles between 2013 and 2022 at a private fertility centre was performed. Outcome parameters for oocyte retrieval cycles were reviewed. For patients who returned for oocyte disposition, outcomes subsequent to oocyte re-warming, fertilization, and transfer were analyzed.

RESULTS

There were 748 OC cycles (653 elective and 95 non-elective) in 646 patients (556 elective and 90 non-elective). Patients were older at the time of freezing in the elective oocyte group compared with the non-elective group (36.5 vs. 28.8 y; P < 0.001). Sixty-five patients returned to warm and fertilize their oocytes (50 in the elective group and 15 in the non-elective group). The survival rate for warmed oocytes was 76.1% (541/711), and 66.2% of surviving oocytes were successfully fertilized, and 39.1% reached blastulation. Twenty-three patients underwent embryo transfers (10 after preimplantation genetic testing for aneuploidy), with 15 patients having at least 1 delivery or ongoing pregnancy.

CONCLUSIONS

To date, this is the largest published experience with OC in Canada. OC can lead to successful live births but does not guarantee a viable outcome for all patients. In this study, most patients with vitrified oocytes had not returned for disposition, so long-term follow-up is still required to verify the efficacy of OC.

A SART data cost-effectiveness analysis of planned oocyte cryopreservation versus in vitro fertilization with preimplantation genetic testing for aneuploidy considering ideal family size

OBJECTIVE

To determine the cost-effectiveness of planned oocyte cryopreservation (OC) as a strategy for delayed childbearing to achieve 1 or 2 live births (LB) compared with in vitro fertilization (IVF) and preimplantation genetic testing for aneuploidy (PGT-A) at advanced reproductive age.

DESIGN

Decision tree model with sensitivity analyses using data from the Society for Assisted Reproductive Technology Clinical Outcome Reporting System and other clinical sources.

SETTING

Not applicable.

PATIENT(S)

A data-driven simulated cohort of patients desiring delayed childbearing with an ideal family size of 1 or 2 LB.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Probability of achieving ≥1 or 2 LB, average and maximum cost per patient, cost per percentage point increase in chance of LB, and population-level cost/LB.

RESULT(S)

For those desiring 1 LB, planned OC at age 33 with warming at age 43 decreased the average total cost per patient from $62,308 to $30,333 and increased the likelihood of LB from 50% to 73% when compared with no OC with up to 3 cycles of IVF/PGT-A at age 43. For those desiring 2 LB, 2 cycles of OC at age 33 and warming at age 40 yielded the lowest cost per patient and highest likelihood of achieving 2 LB ($51,250 and 77%, respectively) when compared withpursuing only 1 cycle of OC ($75,373 and 61%, respectively), no OC and IVF/PGT-A with embryo banking ($79,728 and 48%, respectively), or no OC and IVF/PGT-A without embryo banking ($79,057 and 19%, respectively). Sensitivity analyses showed that OC remained cost-effective across a wide range of ages at cryopreservation. For 1 LB, OC achieved the highest likelihood of success when pursued before age 32 and remained more effective than IVF/PGT-A when pursued before age 39, and for 2 LB, 2 cycles of OC achieved the highest likelihood of success when pursued before age 31 and remained more effective than IVF/PGT-A when pursued before age 39.

CONCLUSION(S)

Among patients planning to postpone childbearing, OC is cost-effective and increases the odds of achieving 1 or 2 LB when compared with IVF/PGT-A at a more advanced reproductive age.

Usage and cost-effectiveness of elective oocyte freezing: a retrospective observational study

BACKGROUND

The previous model-based cost-effectiveness analyses regarding elective oocyte cryopreservation remained debatable, while the usage rate may influence the cost per live birth. The aim of this study is to disclose the usage and cost-effectiveness of the planned cryopreserved oocytes after oocyte thawing in real-world situations.

METHODS

This was a retrospective single-center observational study. Women who electively cryopreserved oocytes and returned to thaw the oocytes were categorized as thawed group. The oocytes were fertilized at our center and the sperm samples for each individual was retrieved from their respective husbands. Clinical outcomes were traced and the cumulative live birth rate per thawed case was calculated. The costs from oocyte freezing cycles to oocyte thawing, and embryo transfer cycles were accordingly estimated. The cumulative cost per live birth was defined by the cumulative cost divided by the live births per thawed case.

RESULTS

We recruited 645 women with 840 oocyte retrieval cycles for elective oocyte freezing from November 2002 to December 2020. The overall usage rate was 8.4% (54/645). After the storage duration exceeded ten years, the probabilities of thawing oocytes were 10.6%, 26.6%, and 12.7% from women who cryopreserved their oocytes at the age ≤ 35 years, 36-39 years, and ≥ 40 years, respectively (P = 0.304). Among women who thawed their oocytes, 31.5% (17/54) of women achieved at least one live birth. For the age groups of ≤ 35 years, 36-39 years, and ≥ 40 years, the cumulative live birth rates per thawed case were 63.6%, 42.3%, and 17.6%, respectively (P = 0.045), and the cumulative costs for one live birth were $11,704, $17,189, and $35,642, respectively (P < 0.001).

CONCLUSIONS

The overall usage rate was 8.4% in our cohort. The cumulative live birth rate was greatest in the youngest group and the cumulative cost per live birth was highest in the oldest group, which was threefold greater than that in the group aged ≤ 35 years. The findings added to the limited evidence of the usage rate in real-world situations, which could hopefully aid future analysis and decision-making in public health policy and for women willing to preserve fertility.

TRIAL REGISTRATION

None.

The use of fertility preservation services for cancer patients: a single institution experience

Objective

To analyze the use of services regarding fertility preservation (FP) in cancer patients at a single institution.

Design

A retrospective cohort study.

Setting

Academic medical center.

Patients

A total of 208 FP referrals.

Interventions

None.

Main Outcome Measures

Method of FP; time from referral to FP intervention.

Results

A total of 553 patients were referred to a reproductive specialist for FP in the setting of a medical diagnosis from 2011 to 2016. Of these, 208 patients satisfied the inclusion criteria and met with a reproductive specialist. Ninety patients underwent FP services. The average age at referral was 30.9 ± 7.9 years. Breast cancer (n=94, 45%) and leukemia/lymphoma (n=62, 30%) were the most prevalent cancer diagnoses. A 68.9% of patients underwent oocyte cryopreservation (n=62), 26.7% underwent embryo cryopreservation (n=24) and 4.4% underwent ovarian tissue preservation (n=4). The time interval from the referral to the FP intervention ranged from 1 to 810 days, with a median of 17 days.

Conclusions

In the setting of a cancer diagnosis, most patients undergoing FP intervention underwent oocyte cryopreservation, were <35 years old, and underwent FP intervention in <30 days from referral. Whereas FP should ideally be initiated at the time of cancer diagnosis, all patients with a cancer diagnosis should be referred to a reproductive specialist and counseled on options for FP to preserve the optionality for the reproductive future they desire.

Disposition preferences in oocyte preservation patients

PURPOSE

To characterize the frozen oocyte disposition preferences of patients undergoing medical and planned fertility preservation.

METHODS

All oocyte cryopreservation (OC) patients were identified between 2015 and 2018. Demographic information and fertility preservation (FP) indication (medical or planned) were identified for each patient. Oocyte disposition options included disposal, donation to research, or donation to a specified third party, which was decided at the time of initial consent and made available in the electronic medical record. The primary outcome was the disposition selection. Secondary outcomes included differences in demographic variables and disposition selections between medical and planned FP patients using chi-squared analysis.

RESULTS

A total of 336 OC patients with a documented oocyte disposition preference were identified in the study timeframe. Patients were on average 34.5 years old (SD = 5.1) and were predominantly White (70.2%), nulliparous (83.0%), with a BMI of 24.7 (SD = 5.4). A total of 101 patients underwent OC for medical FP and 235 for planned FP. In both groups, the most commonly selected disposition option was donation to research (50% planned, 52% medical), followed by donation to a specified third party (30% planned, 30% medical), and finally disposal of oocytes (20% planned, 18% medical). There were no significant differences in disposition selection between each group. When comparing patient variables between groups, medical FP patients were more likely to be under the age of 35 and were less likely to be nulliparous (p < .001).

CONCLUSION

This study shows that oocyte disposition choices are similar in patients undergoing OC for medical and planned indications. As donation to research was the most commonly selected option in both groups, it is time to start thinking of streamlining ways to utilize this potential research material in the future.

Fifteen years of autologous oocyte thaw outcomes from a large university-based fertility center

OBJECTIVE

To review the outcomes of patients who underwent autologous oocyte thaw after planned oocyte cryopreservation.

DESIGN

Retrospective cohort study.

SETTING

Large urban university-affiliated fertility center.

PATIENT(S)

All patients who underwent ≥1 autologous oocyte thaw before December 31, 2020.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The primary outcome was the final live birth rate (FLBR) per patient, and only patients who had a live birth (LB) or consumed all remaining inventory (cryopreserved oocytes and resultant euploid/untested/no result embryos) were included. The secondary outcomes were laboratory outcomes and LB rates per transfer.

RESULT(S)

A total of 543 patients underwent 800 oocyte cryopreservations, 605 thaws, and 436 transfers. The median age at the first cryopreservation was 38.3 years. The median time between the first cryopreservation and thaw was 4.2 years. The median numbers of oocytes and metaphase II oocytes (M2s) thawed per patient were 14 and 12, respectively. Overall survival of all thawed oocytes was 79%. Of all patients, 61% underwent ≥1 transfer. Among euploid (n = 262) and nonbiopsied (n = 158) transfers, the LB rates per transfer were 55% and 31%, respectively. The FLBR per patient was 39%. Age at cryopreservation and the number of M2s thawed were predictive of LB; the FLBR per patient was >50% for patients aged <38 years at cryopreservation or who thawed ≥20 M2s. A total of 173 patients (32%) have remaining inventory.

CONCLUSION(S)

Autologous oocyte thaw resulted in a 39% FLBR per patient, which is comparable with age-matched in vitro fertilization outcomes. Studies with larger cohorts are necessary.

The emergence of temporality in attitudes towards cryo-fertility: a case study comparing German and Israeli social egg freezing users

Assistive reproductive technologies are increasingly used to control the biology of fertility and its temporality. Combining historical, theoretical, and socio-empirical insights, this paper aims at expanding our understanding of the way temporality emerges and is negotiated in the contemporary practice of cryopreservation of reproductive materials. We first present an historical overview of the practice of cryo-fertility to indicate the co-production of technology and social constructions of temporality. We then apply a theoretical framework for analysing cryobiology and cryopreservation technologies as creating a new epistemic perspective interconnecting biology and temporality. Thereafter, we focus on the case of 'social egg freezing' (SEF) to present socio-empirical findings illustrating different reproductive temporalities and their connection to the social acceptance of and expectations towards the practice. SEF is a particularly interesting case as it aims to enable women to disconnect their reproductive potential from their biological rhythms. Based on 39 open interviews with Israeli and German SEF users, the cross-cultural comparative findings reveal three types of attitudes: postponing motherhood/reproductive decisions (German users); singlehood and "waiting" for a partner (Israeli and German users); and the planning of and hope for multiple children (Israeli users). For theory building, this analysis uncovers temporality formations embedded in gender and reproductive moral values; including the 'extended present', 'waiting', and 'reproductive futurism'. We conclude by discussing the contribution of our findings by advancing the theoretical framework of 'cryopolitics' highlighting the theoretical implications and importance of gendered and cultural imaginaries (re)constructing medical technological innovations and related temporalities.

Employer-based insurance coverage increases utilization of planned oocyte cryopreservation

PURPOSE

To determine the utilization of planned oocyte cryopreservation (OC) in the year immediately prior to, and the year of, insurance coverage commencement for employees at our institution.

METHODS

Patient demographics and cycle outcomes were retrospectively compared between the first OC cycles occurring in 2017 vs. 2018 according to insurance coverage and type, age, and the number of oocytes retrieved and cryopreserved. Continuous demographic variables including age, BMI, day 3 FSH and E2, AMH, gravidity, and parity were compared using student T-tests. Cycle outcomes, including the number of oocytes retrieved and cryopreserved were compared using linear regression models, adjusting for potential confounders including age, BMI, and ovarian reserve parameters.

RESULTS

Between January 2017 and December 2018, 123 patients underwent planned OC at our institution. Patient age ranged from 23 to 44 years and did not significantly differ from 2017 to 2018 (mean 34.9 vs. 35.2). There was a 12% increase in planned OC utilization from 2017 (N = 58) to 2018 (N = 65). Significantly, more patients had any insurance coverage in 2018 vs. 2017 (71.9% vs. 40.4%, p = 0.001), a 78% increase. From 2017 to 2018, the number of patients with hospital-based insurance coverage undergoing planned OC increased by a factor of 8 (5 to 41.5%, p < 0.001), while the number of self-pay patients significantly decreased (p = 0.001). No differences were found regarding cycle outcomes.

CONCLUSION

A greater proportion of women at our institution had insurance coverage for planned OC in 2018 vs. 2017. Employer-based insurance coverage for planned OC was associated with a significant increase in utilization by hospital employees.

Medical versus social egg freezing: the importance of future choice for women's decision-making

While the literature on oncofertility decision-making was central to the bioethics debate on social egg freezing when the practice emerged in the late 2000s, there has been little discussion juxtaposing the two forms of egg freezing since. This article offers a new perspective on this debate by comparing empirical qualitative data of two previously conducted studies on medical and social egg freezing. We re-analysed the interview data of the two studies and did a thematic analysis combined with interdisciplinary collaborative auditing for empirical ethics projects. Despite their different contexts, major similarities in women's decision-making and reasoning were found. We developed two main common themes. Firstly, women felt a clear need to plan for future options. Secondly, they manipulated decision-times by postponing definitive decisions and making micro-decisions. The comparison highlights that the passage of time and the preservation of future choice seems to permeate all aspects of the patient experiences in both studies. As a result of considering real-world lived experiences, we suggest that there are many overlaps in women's reasoning about egg freezing regardless of why they are making a decision to freeze. These overlaps are morally relevant and thus need to be further integrated into the existing arguments that have been canvassed in the flourishing egg freezing and fertility preservation debates across the field, and in policy and practice globally.

Enucleated oocyte donation: first for infertility treatment, then for mitochondrial diseases

There seems to be a consensus that enucleated oocyte donation (EOD) should only be used to reduce the risk of having a child with mitochondrial disorders. However, this paper argues that in the initial phase in which we are at the moment, EOD should first be used to remedy infertility caused by poor oocyte quality or poor embryonic development. That learning period will allow researchers to improve their technical skills and the knowledge of the best procedure before starting on high-risk cases. Mitochondrial carryover of pathologic mtDNA is the main cause of concern for the offspring. That risk does not exist in infertility cases. The application of EOD to treat infertility should at present be performed in a clinical research setting to obtain more evidence about efficacy and safety.

Fresh embryo transfer after in vitro insemination of fresh vs. cryopreserved anonymous donor oocytes: which has a better live birth rate? A Society for Assisted Reproductive Technology Clinic Outcome Reporting System analysis

OBJECTIVE

To determine if transfer of fresh embryos derived from fresh or cryopreserved donor oocytes yields a higher live birth rate.

DESIGN

Historical cohort study.

SETTING

Society for Assisted Reproductive Technology Clinic Outcome Reporting System database.

PATIENT(S)

A total of 24,663 fresh embryo transfer cycles of donor oocytes.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The primary outcome was live births per number of embryos transferred on day 5. The secondary outcomes included number of infants per embryo transfer, surplus embryos cryopreserved, and characterization of US oocyte recipients.

RESULT(S)

A total of 16,073 embryo transfers were from fresh oocytes and 8,590 were from cryopreserved oocytes. Recipient age, body mass index (BMI), gravidity, and parity were similar between the groups. Most recipients were of White non-Hispanic race (66.9%), followed by Asian (13.7%), Black non-Hispanic (9.3%), and Hispanic (7.2%). Fresh oocyte cycles were more likely to use elective single embryo transfer (42.5% vs. 37.8%) or double embryo transfer (53.2% vs. 50.4%) and resulted in more surplus embryos for cryopreservation (4.6 vs. 1.2). The live birth rate from fresh oocytes was 57.5% vs. 49.7% from cryopreserved oocytes. Negative predictors of live birth included the use of cryopreserved oocytes (odds ratio [OR] 0.731, 95% confidence interval [CI] 0.665-0.804), Black non-Hispanic race (OR 0.603, 95% CI 0.517-0.703), Asian race (OR 0.756, 95% CI 0.660-0.867), and increasing recipient BMI (OR 0.982, 95% CI 0.977-0.994) after controlling for recipient age, number of embryos transferred on day 5, and unexplained infertility diagnosis. The proportion of multifetal deliveries was greater in cycles utilizing fresh (26.4%) vs. cryopreserved (20.6%) oocytes.

CONCLUSION(S)

The live birth rate is higher with use of fresh oocytes vs. cryopreserved oocytes in fresh embryo transfer cycles. Negative live birth predictors include recipient Black non-Hispanic or Asian race and increasing BMI.

Revisiting selected ethical aspects of current clinical in vitro fertilization (IVF) practice

Ethical considerations are central to all medicine though, likely, nowhere more essential than in the practice of reproductive endocrinology and infertility. Through in vitro fertilization (IVF), this is the only field in medicine involved in creating human life. IVF has, indeed, so far led to close to 10 million births worldwide. Yet, relating to substantial changes in clinical practice of IVF, the medical literature has remained surprisingly quiet over the last two decades. Major changes especially since 2010, however, call for an updated commentary. Three key changes deserve special notice: Starting out as a strictly medical service, IVF in recent years, in efforts to expand female reproductive lifespans in a process given the term “planned” oocyte cryopreservation, increasingly became more socially motivated. The IVF field also increasingly underwent industrialization and commoditization by outside financial interests. Finally, at least partially driven by industrialization and commoditization, so-called add-ons, the term describing mostly unvalidated tests and procedures added to IVF since 2010, have been held responsible for worldwide declines in fresh, non-donor live birthrates after IVF, to levels not seen since the mid-1990s. We here, therefore, do not offer a review of bioethical considerations regarding IVF as a fertility treatment, but attempt to point out ethical issues that arose because of major recent changes in clinical IVF practice.

The effect of extended cryo-storage following vitrification on embryo competence: a systematic review and meta-analysis

PURPOSE

Few studies explored whether prolonged cryo-storage after vitrification affects embryo competence and perinatal outcomes. This systematic review and meta-analysis aims at highlighting any putative impact of cryo-storage duration on cryo-survival, miscarriage, live birth and major malformations.

METHODS

A systematic review was performed using MEDLINE (PubMed), ISI Web of Knowledge, Scopus and Embase databases up to June 2021. Data were combined to obtain a pooled OR, and meta-analysis was conducted using a random effects model. Out of 1,389 screened abstracts, 22 papers were assessed for eligibility, and 5 studies were included (N = 18,047 embryos). Prolonged cryo-storage was defined as > 12 months (N = 3389 embryos). Subgroup analysis was performed for untested vitrified cleavage stage embryos (N = 1739 embryos) and for untested and euploid vitrified blastocysts (N = 13,596 and 2712 embryos, respectively).

RESULTS

Survival rate, miscarriage, live birth and major malformation rates were all similar in the two groups.

CONCLUSION

These data further support the safety of long-term cryo-storage of human embryos beyond 12 months. This is reassuring for good prognosis patients with surplus embryos, couples seeking a second child from supernumerary embryos and women postponing the transfer for clinical or personal reasons.

Oocyte cryopreservation review: outcomes of medical oocyte cryopreservation and planned oocyte cryopreservation

BACKGROUND

The utilization of oocyte cryopreservation (OC) has become popularized with increasing numbers of reproductive-aged patients desiring to maintain fertility for future family building. OC was initially used for fertility preservation in postmenarchal patients prior to gonadotoxic therapies; however, it is now available to patients to circumvent age-related infertility and other diagnoses associated with early loss of ovarian reserve. The primary aim of this paper is to provide a narrative review of the most recent and robust data on the utilization and outcomes of OC in both patient populations. OC results in similar oocyte yield in patients facing gonadotoxic therapies and patients undergoing planned OC. Available data are insufficient to predict the live birth rates or the number of oocytes needed to result in live birth. However, oocyte yield and live birth rates are best among patients < 37.5 years old or with anti-mullerian hormone levels > 1.995 ng/dL, at the time of oocyte retrieval. There is a high 'no use' rate (58.9%) in patients using planned OC with 62.5% returning to use frozen oocytes with a spouse. The utilization rate in medical OC patients is < 10%. There is currently no data on the effects of BMI, smoking, or ethnicity on planned OC outcomes.

CONCLUSION

It is too early to draw any final conclusions on outcomes of OC in medical OC and planned OC; however, preliminary data supports that utilization of OC in both groups result in preservation of fertility and subsequent live births in patients who return to use their cryopreserved eggs. Higher oocyte yield, with fewer ovarian stimulation cycles, and higher live birth rates are seen in patients who seek OC at younger ages, reinforcing the importance of age on fertility preservation. More studies are needed in medical OC and planned OC to help guide counseling and decision-making in patients seeking these services.

Between "Medical" and "Social" Egg Freezing : A Comparative Analysis of Regulatory Frameworks in Austria, Germany, Israel, and the Netherlands

Egg freezing has led to heated debates in healthcare policy and bioethics. A crucial issue in this context concerns the distinction between "medical" and "social" egg freezing (MEF and SEF)-contrasting objections to bio-medicalization with claims for oversimplification. Yet such categorization remains a criterion for regulation. This paper aims to explore the "regulatory boundary-work" around the "medical"-"social" distinction in different egg freezing regulations. Based on systematic documents' analysis we present a cross-national comparison of the way the "medical"-"social" differentiation finds expression in regulatory frameworks in Austria, Germany, Israel, and the Netherlands. Findings are organized along two emerging themes: (1) the definition of MEF and its distinctiveness-highlighting regulatory differences in the clarity of the definition and in the medical indications used for creating it (less clear in Austria and Germany, detailed in Israel and the Netherlands); and (2) hierarchy of medical over social motivations reflected in usage and funding regulations. Blurred demarcation lines between "medical" and "social" are further discussed as representing a paradoxical inclusion of SEF while offering new insights into the complexity and normativity of this distinction. Finally, we draw conclusions for policymaking and the bioethical debate, also concerning the related cryopolitical aspects.

An unconventional path to conventional motherhood: A qualitative study of women's motivations and experiences regarding social egg freezing in the Netherlands

STUDY QUESTION

What are women's motivations for social egg freezing and what are their experience regarding the egg freezing process in the Netherlands?

SUMMARY ANSWER

Women who engage in social egg freezing are driven by feelings of fear, including the fear of not finding the suitable partner and fear of declining fecundity. They aim to fulfil their desire for having children with a partner. Alternative ways to achieve parenthood are considered if the conventional way of motherhood cannot be achieved.

WHAT IS ALREADY KNOWN

The reasons for social egg freezing are multi-fold, including amongst others economic, social, health, educational and career factors. The lack of a (stable) partnership, and a strong desire for a genetically related child with a committed partner are considered main reasons.

STUDY DESIGN, SIZE, DURATION

A qualitative interview study, including 20 women, was conducted in the Netherlands between October 2018 and August 2019.

MATERIAL & METHODS

Women between 32 and 42 years of age, who had completed the egg freezing trajectory for social reasons at three different medical centres in the Netherlands participated in the study. Semi-structured interviews were conducted face-to-face or via a teleconference tool and were recorded and transcribed verbatim. The interviews lasted between 30 and 90 minutes. Data were analysed using thematic content analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

This study identified one overall theme: "an unconventional path to conventional motherhood" and five interpretive theme's: "fear of not becoming a mother, peace of mind, an unconventional path to motherhood, conventional perspectives, and financial discrimination". Women were afraid of not becoming a mother in the future. Despite the fact that all kinds of alternatives were available, conventional motherhood was preferred. Women chose a non-conventional path to reach this goal and they had to let go of traditional perspectives. Although they had the feeling of being discriminated financially, it gave them 'peace of mind'. The preserved oocytes gave them the sense of a fertility insurance for the future.

LIMITATIONS, REASONS FOR CAUTION

The demographic profile displays a high degree of homogeneity, which may impact generalisability.

WIDER IMPLICATIONS OF THE FINDINGS

This study contributes to a better understanding of women who cryopreserve their oocytes for social reasons. Healthcare professionals need to be aware of these motivations and perspectives. Understanding the underlying factors and emotional considerations in the decision-making process is crucial to provide proper counselling and optimal patient-centered infertility care. Furthermore, it is important to raise awareness about the possibilities of pursuing (alternative) motherhood to support effective policy making. However, social egg freezing remains closest to women's preferences of conventional motherhood, even in a country like the Netherlands, which is known for its progressiveness and focus on gender equality. Last, policy makers need to stimulate cost-effectivity and prevent younger women of pursuing social egg freezing as kind of a prevention method.

'Why have women not returned to use their frozen oocytes?': a 5-year follow-up of women after planned oocyte cryopreservation

RESEARCH QUESTION

What are the reproductive choices and retrospective reflections of women at least 4 years after planned oocyte cryopreservation (POC)?

DESIGN

This was an internet survey, using the REDCap application, of women who underwent POC, at a single-centre university-affiliated IVF unit, 4-8 years before the survey. The questionnaire addressed reproductive choices and outcomes following POC.

RESULTS

Seventy-nine women who underwent POC during 2011-2014 were invited to participate, and 70 (89%) responded. Mean age at cryopreservation was 37.1 ± 2.4 (range 30-41) years, mean age at study participation 42.6 ± 2.6 (range 35-48) years, and mean time from first cryopreservation cycle to study participation 5.5 ± 1.3 (range 4-8) years. The main retrospectively reported reason for POC was not wanting to become pregnant without a partner (59, 84%). During the follow-up period, 44 women (63%) attempted to conceive either naturally or by assisted reproductive technology using fresh or cryopreserved oocytes. Of those, 28 women achieved a live birth (64% of those who tried to conceive). Fourteen respondents (20% of all respondents) reported using their cryopreserved oocytes, and three (21%) achieved a birth using those oocytes. Fifteen women (34%) of those who tried to conceive used donor spermatozoa.

CONCLUSIONS

The most common reasons for not using frozen oocytes were achieving pregnancy without frozen oocytes or preferring not to have a child without a partner. A considerable proportion of women who had POC and were not interested in being a single parent by choice eventually try to conceive using donor spermatozoa several years later.

The Risk of Congenital Anomalies by Fertility Treatment Modality

Importance

Up to 4% of all births in developed nations involve assisted reproductive technology (ART), along with other fertility treatment modalities. Thus, ART pregnancies constitute an important epidemiologic population with a known increased risk of congenital anomalies. In this review, we summarize current fertility treatment modalities and their associated risk of congenital anomalies.

Objective

To review the risk of birth defects among pregnancies conceived with ART and other fertility treatments.

Evidence Acquisition

Articles were obtained from PubMed and the American College of Obstetricians and Gynecologists and American Society of Reproductive Medicine committee opinions.

Results

In vitro fertilization has been associated with a 25% to 50% increased risk of birth defects, including abnormalities of these organ systems: cardiovascular (25%-40% of anomalies), genitourinary (10%-60%), gastrointestinal (10%-20%), and musculoskeletal (10%-35%). Although the data are mixed, intracytoplasmic sperm injection has also been found to be associated with an increased risk of defects, particularly hypospadias, when compared with conventional in vitro fertilization. The risk among fresh versus frozen cycles and cleavage stage versus blastocyst transfers remains uncertain. There appears to be no significant added risk with preimplantation genetic testing, although more studies are needed. Ovulation induction with oral agents appears safe and not associated with an increased risk of anomalies. Oocyte cryopreservation also appears safe, but the data are still limited, requiring future investigation.

Conclusions and Relevance

While the relative risk of birth defects among ART pregnancies is increased when compared with spontaneous conceptions, the absolute risk remains low. There are no standard screening recommendations for ART pregnancies. Per the American College of Obstetricians and Gynecologists, patients who have undergone ART should be counseled regarding the risk of birth defects and available antenatal evaluation, including fetal echocardiogram and detailed ultrasound evaluation.

Ethical issues in oocyte banking for nonautologous use: an Ethics Committee opinion

Ethical considerations for the banking of oocytes for nonautologous use are discussed.

Social Freezing: Pressing Pause on Fertility

Increasing numbers of women are undergoing oocyte or tissue cryopreservation for medical or social reasons to increase their chances of having genetic children. Social egg freezing (SEF) allows women to preserve their fertility in anticipation of age-related fertility decline and ineffective fertility treatments at older ages. The purpose of this study was to summarize recent findings focusing on the challenges of elective egg freezing. We performed a systematic literature review on social egg freezing published during the last ten years. From the systematically screened literature, we identified and analyzed five main topics of interest during the last decade: (a) different fertility preservation techniques, (b) safety of freezing, (c) usage rate of frozen oocytes, (d) ethical considerations, and (e) cost-effectiveness of SEF. Fertility can be preserved for non-medical reasons through oocyte, embryos, or ovarian tissue cryopreservation, with oocyte vitrification being a new and optimal approach. Elective oocyte cryopreservation is better accepted, supports social gender equality, and enhances women's reproductive autonomy. Despite controversies, planned oocyte cryopreservation appears as a chosen strategy against age-related infertility and may allow women to feel that they are more socially, psychologically, and financially stable before motherhood.