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

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.

Medical Students' Perspectives on Family Planning and Impact on Specialty Choice

Importance

Physicians are known to delay childbearing compared with nonphysicians and to experience higher rates of age-related pregnancy complications. Delay of childbearing is more pronounced in surgical specialties, and family planning and building goals may influence specialty choice.

Objective

To assess medical students' perspectives on the development of family planning goals and the timing of family building within a medical career to elucidate how these perceptions impact their choice of specialty.

Design, Setting, and Participants

This qualitative study included fourth-year medical students at the University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada, and was conducted between May and August 2021. Participants were purposively sampled to maximize diversity of gender and specialty choice. Interviews were conducted via videoconferencing software that were recorded, transcribed verbatim, and verified for accuracy. Thematic analysis was completed independently by 2 researchers and consensus on final themes was reached through discussion among study investigators. Data were analyzed between September and December 2021.

Main Outcomes and Measures

Participants were asked to share their perceptions of personal family planning goals, support currently in place, family planning education in medicine and factors contributing to their choice of specialty and program. Thematic analysis was completed.

Results

A total of 34 fourth-year medical students (median [range] age, 26 [24-33] years; 23 females [67.6%]) were interviewed. Four main themes were identified: (1) there is no ideal time to family build in a medical career, (2) family planning is a taboo topic, (3) surgical specialties offer less support for family building, and (4) residents who have children are perceived to place a burden on their colleagues. Medical students considered their family planning while deliberating among specialty choices and their experiences were highly influential in shaping their specialty selection.

Conclusions and Relevance

Results of this qualitative study suggest that medical students perceive that family building during training may have unfavorable implications for team dynamics and relationships with colleagues, and these perceptions may affect specialty choice and family planning goals. Integration of family planning discussions and support for family building into medical curricula is needed along with efforts to improve culture by supporting team dynamics and workload when students take parental leave.

Exploring the knowledge, attitudes, and perceptions of women of reproductive age towards fertility and elective oocyte cryopreservation for age-related fertility decline in the UK: a cross-sectional survey

STUDY QUESTION

What are the knowledge, perceptions and attitudes towards fertility and elective oocyte cryopreservation (OC) for age-related fertility decline (ARFD) in women in the UK?

SUMMARY ANSWER

Awareness of OC for ARFD has reportedly improved compared to studies carried out almost a decade ago, but inconsistencies in knowledge remain regarding the rate of miscarriage amongst specific age groups, the financial costs and optimal age to undergo OC for ARFD.

WHAT IS KNOWN ALREADY

The age of first-time motherhood has increased amongst western societies, with many women of reproductive age underestimating the impact of age on fertility. Further understanding of women's awareness of their fertility, the options available to preserve it and the barriers for seeking treatment earlier are required in order to prevent the risk of involuntary childlessness.

STUDY DESIGN, SIZE, DURATION

A hyperlink to a cross-sectional survey was posted on social media (Instagram) between 25 February 2021 and 11 March 2021.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women from the general population aged 18-50 years were invited to complete the survey.

MAIN RESULTS AND THE ROLE OF CHANCE

In total, 5482 women fulfilled the inclusion criteria and completed the survey. The mean age of participants was 35.0 years (SD 10.25; range 16-52). Three quarters (74.1%; n = 4055) disagreed or strongly disagreed they felt well informed regarding the options available to preserve their fertility, in case of a health-related problem or ARFD. The majority overestimated the risk of miscarriage in women aged ≥30 years old, with 14.5% correctly answering 20%, but underestimated the risks in women ≥40, as 20.1% correctly answered 40-50%. Three quarters (73.2%; n = 4007) reported an awareness of OC for ARFD and 65.8% (n = 3605) reported that they would consider undergoing the procedure. The number of women who considered OC for ARFD across age groups were as follows: 18-25 (8.3%; n = 300), 26-30 (35.8%; n = 1289), 31-35 (45.9%; n = 1654), 36-40 (9.6%; n = 347), 41-45 (0.3%; n = 13), and 46-50 (0.1%; n = 2). The majority of women (81.3%; n = 4443) underestimated the cost of a single cycle of OC for ARFD (<£5000). Furthermore, 10.4% (n = 566) believed a single cycle would be adequate enough to retrieve sufficient oocytes for cryopreservation. Approximately 11.0% (n = 599) believed OC for ARFD may pose significant health risks and affect future fertility. Less than half agreed or strongly agreed that the lack of awareness regarding OC for ARFD has impacted the likelihood of pursuing this method of fertility preservation further (41.4%; n = 2259).

LIMITATIONS, REASONS FOR CAUTION

Results from cross-sectional studies are limited as interpretations made are merely associations and not of causal relationships. The online nature of participant recruitment is subject to selection bias, considering women with access to social media are often from higher socioeconomic and education backgrounds, thus limiting generalizability of the findings.

WIDER IMPLICATIONS OF THE FINDINGS

Further education regarding the financial costs and optimal age to undergo elective OC to increase the chances of successful livebirth are required. Clinicians should encourage earlier fertility counselling to ensure that OC is deemed a preventative measure of ARFD, rather than an ultimate recourse to saving declining fertility.

STUDY FUNDING/COMPETING INTEREST(S)

No funding was required for this article. There are no conflicts of interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

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.

Patients' and providers' perspectives on the decision to undergo non-urgent egg freezing: a needs assessment

BACKGROUND

Previous research has demonstrated that patients have difficulty with the decision to undergo non-urgent egg freezing (EF). This study aimed to investigate the decisional difficulties and possible decisional support mechanisms for patients considering EF, and for their providers.

METHODS

This qualitative study involved a needs assessment via individual interviews. Participants included patients considering EF at one academic fertility clinic and providers from across Canada who counsel patients considering EF. 25 participants were included (13 providers and 12 patients). The interview guide was developed according to the Ottawa Decision Support Framework. Interviews were transcribed, and transcripts analyzed for themes and concepts using NVIVO 12.

FINDINGS

Multiple factors contributing to decisional difficulty were identified, including: (1) multiple reproductive options available with differing views from patients/providers regarding their importance; (2) a decision typically made under the pressure of reproductive aging; (3) uncertainty surrounding the technology/inadequate outcome data; (4) the financial burden of EF; (5) inherent uncertainty relating to potential decision regret; and (6) differing perceptions between patients/providers regarding the role providers should play in the decision. Additionally, potential sources of decisional support were identified, including provision of basic information before and/or during initial consultation, followed by an opportunity during or after initial consultation for clarifying information and helping with value judgements. Individualized counselling based on patient values, adequate follow-up, psychosocial counselling, and peer support were also emphasized.

CONCLUSIONS

More decisional support for women considering EF is needed. Suggestions include a patient decision aid in conjunction with modified healthcare provider counselling, support and follow up.

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.

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.

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.

Age-related fertility decline: is there a role for elective ovarian tissue cryopreservation?

Age-related fertility decline (ARFD) is a prevalent concern amongst western cultures due to the increasing age of first-time motherhood. Elective oocyte and embryo cryopreservation remain the most established methods of fertility preservation, providing women the opportunity of reproductive autonomy to preserve their fertility and extend their childbearing years to prevent involuntary childlessness. Whilst ovarian cortex cryopreservation has been used to preserve reproductive potential in women for medical reasons, such as in pre- or peripubertal girls undergoing gonadotoxic chemotherapy, it has not yet been considered in the context of ARFD. As artificial reproductive technology (ART) and surgical methods of fertility preservation continue to evolve, it is a judicious time to review current evidence and consider alternative options for women wishing to delay their fertility. This article critically appraises elective oocyte cryopreservation as an option for women who use it to mitigate the risk of ARFD and introduces the prospect of elective ovarian cortex cryopreservation as an alternative.

Advanced Maternal Age Deteriorates the Developmental Competence of Vitrified Oocytes in Mice

Advanced maternal age (AMA) is known to be related to the decrease in the quality and quantity of oocytes. Oocyte vitrification is now considered an established assisted reproductive technology for fertility preservation. However, it remains unclear whether the oocytes in older women are more sensitive to various insults during vitrification. Thus, we evaluated whether AMA affects cellular and molecular features and developmental outcomes of oocytes after vitrification in mice. The oocytes were grouped as young fresh (YF), young vitrified/warmed (YV), aged fresh (AF), and aged vitrified/warmed (AV). The survival rate of AV oocytes was significantly lower than that of YV oocytes. The rates of fertilization, cleavage, and blastocyst formation of AV oocytes were significantly lower than those of other groups. AV oocytes were represented as aberrations in mitochondria distribution, microvacuole size, and autophagosome formation, leading to delayed embryo development in mice. This delay was associated with a reduced number of total cells and trophectoderm in the blastocyst developed from AV oocytes. Collectively, AMA exaggerates the vulnerability of oocytes to cryo-damage that occurs during vitrification in mice, suggesting that the current vitrification protocols optimized for oocytes from young females should be modified for oocytes from aged women.

Live birth and perinatal outcomes using cryopreserved oocytes: an analysis of the Human Fertilisation and Embryology Authority database from 2000 to 2016 using three clinical models

STUDY QUESTION

Are live birth (LB) and perinatal outcomes affected by the use of frozen own versus frozen donor oocytes?

SUMMARY ANSWER

Treatment cycles using frozen own oocytes have a lower LB rate but a lower risk of low birth weight (LBW) as compared with frozen donor oocytes.

WHAT IS KNOWN ALREADY

A rising trend of oocyte cryopreservation has been noted internationally in the creation of donor oocyte banks and in freezing own oocytes for later use in settings of fertility preservation and social egg freezing. Published literature on birth outcomes with frozen oocytes has primarily utilised data from donor oocyte banks due to the relative paucity of outcome data from cycles using frozen own oocytes.

STUDY DESIGN, SIZE, DURATION

This was a retrospective cohort study utilising the anonymised database of the Human Fertilisation and Embryology Authority, which is the statutory regulator of fertility treatment in the UK. We analysed 988 015 IVF cycles from the Human Fertilisation and Embryology Authority (HFEA) register from 2000 to 2016. Perinatal outcomes were assessed from singleton births only.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Three clinical models were used to assess LB and perinatal outcomes: Model 1 compared frozen own oocytes (n = 632) with frozen donor oocytes (n = 922); Model 2 compared frozen donor oocytes (n = 922) with fresh donor oocytes (n = 24 706); Model 3 compared first cycle of fresh embryo transfer from frozen donor oocytes (n = 917) with first cycle of frozen embryo transfer created with own oocytes and no prior fresh transfer (n = 326). Preterm birth (PTB) was defined as LB before 37 weeks and LBW as birth weight <2500 g. Adjustment was performed for confounding variables such as maternal age, number of embryos transferred and decade of treatment.

MAIN RESULTS AND THE ROLE OF CHANCE

The LB rate (18.0% versus 30.7%; adjusted odds ratio (aOR) 0.61, 95% CI 0.43-0.85) and the incidence of LBW (5.3% versus 14.0%; aOR 0.29, 95% CI 0.13-0.90) was significantly lower with frozen own oocytes as compared with frozen donor oocytes with no significant difference in PTB (9.5% versus 15.7%; aOR 0.56, 95% CI 0.26-1.21). A lower LB rate was noted in frozen donor oocyte cycles (30.7% versus 34.7%; aOR 0.69, 95% CI 0.59-0.80) when compared with fresh donor oocyte cycles. First cycle frozen donor oocytes did not show any significant difference in LB rate (30.1% versus 19.3%; aOR 1.26, 95% CI 0.86-1.83) or PTB, but a higher incidence of LBW (17.7% versus 5.4%; aOR 3.77, 95% CI 1.51-9.43) as compared with first cycle frozen embryos using own oocytes.

LIMITATIONS, REASONS FOR CAUTION

The indication for oocyte freezing, method of freezing used (whether slow-freezing or vitrification) and age at which eggs where frozen were unavailable. We report a subgroup analysis of women using their own frozen oocytes prior to 37 years. Cumulative LB rate could not be assessed due to the anonymous nature of the dataset.

WIDER IMPLICATIONS OF THE FINDINGS

Women planning to freeze their own eggs for fertility preservation or social egg freezing need to be counselled that the results from frozen donor egg banks may not completely apply to them. However, they can be reassured that oocyte cryopreservation does not appear to have a deleterious effect on perinatal outcomes.

STUDY FUNDING/COMPETING INTEREST(S)

No specific funding was sought for the study. The authors have no relevant conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Planned Oocyte Cryopreservation: Outcomes, Motivations, and Involvement of Primary Health Care Providers

Background: With improvements in oocyte cryopreservation and widespread delays in childbearing, planned oocyte cryopreservation (POC) has become an increasingly attractive option. This study aimed to (1) review POC cycle outcomes at an academic in vitro fertilization (IVF) center and (2) examine POC users' motivations for pursuing POC, fertility knowledge, and the involvement of their primary health care providers (PHP). Materials and Methods: POC cycle outcomes were collected from IVF records of the 224 women who underwent ≥1 cycle from 2012 to 2018. The 198 who were reachable by e-mail were invited to complete an online survey. The study was approved by the University of Toronto Research Ethics Board (No. 32951). Results: Mean age of the 224 women at first cycle was 36.4 (range: 25-42), with a significant decrease in anti-Müllerian hormone level (p = 0.001) and mean number of oocytes retrieved (p = 0.006) and cryopreserved per cycle (p = 0.042) with increasing age. From those invited for survey participation, 98 (49.5%) questionnaires were returned, with 86 evaluable. Majority of respondents were Caucasian (66%), single (93%), and earned a gross annual income of >$70,000 (74%). Strongest motivation for pursuing POC was concern about age-related fertility decline in the absence of a partner. Respondents' annual income was positively correlated with the number of completed cycles (p = 0.032). Half the respondents correctly identified age of onset of marked fertility decline as ≥35 years. In only 19% of cases was the conversation PHP initiated, and 29% never discussed POC with their PHP. Conclusions: More than 50% of women underwent POC at an age when fertility has begun to markedly decline. It is important for PHPs to identify and discuss POC with appropriate patients and offer accurate preliminary information and timely referrals for those interested in exploring this option.

Elective oocyte cryopreservation for age-related fertility decline

PURPOSE

Women who pursue fertility at an advanced age are increasingly common. Family planning and sexual education have traditionally focused on contraception and prevention of sexually transmitted diseases. A focus should now also be placed on fertility awareness and fertility preservation. This manuscript aims to give an update on the existing evidence around elective oocyte cryopreservation, also highlighting the need for fertility education and evidence-based, individualized counselling.

METHODS

A thorough electronic search was performed from the start of databases to March 2020 aiming to summarize the existing evidence around elective egg freezing, the logic behind its use, patient counselling and education, success rates and risks involved, regulation, cost-effectiveness, current status and future perspectives.

RESULTS

Clinician-led counselling regarding reproductive aging and fertility preservation is often overlooked. Elective oocyte cryopreservation is not a guarantee of live birth, and the answer regarding cost-effectiveness needs to be individualized. The existing studies on obstetric and perinatal outcomes following the use of egg freezing are, until now, reassuring. Constant monitoring of short-term and long-term outcomes, uniform regulation and evidence-based, individualized counselling is of paramount importance.

CONCLUSIONS

Elective oocyte cryopreservation is one of the most controversial aspects of the world of assisted reproduction, and a lot of questions remain unanswered. However, women today do have this option which was not available in the past. Elective oocyte cryopreservation for age-related fertility decline should be incorporated in women's reproductive options to ensure informed decisions and reproductive autonomy.

'Nothing will stop me from giving the gift of life': a qualitative analysis of egg donor forum posts

Online spaces are increasingly important for our collective consciousness and provide an opportunity to document changing ideas, subjectivities and experiences surrounding new reproductive technologies. This paper reports on the first study of egg donation and online discussion boards in UK-based forums. Using thematic analysis, we investigated how donors use online forums and explored how they present themselves as possible donors in online spaces. Three major themes were identified: 'using online forums to exchange knowledge and experiences', 'egg donation as a gift' and 'having a drive to donate'. Findings from the study reveal how donors enter online spaces looking for advice, presenting themselves as available and weaving themselves into an online community. There exist multiple ways in which donors construct and narrate their own participation in the process of egg donation. Presenting a donor identity in these online forums is not a straightforward matter of helping by giving but also involves a specific drive. While more research is needed on the range of possible motivations, this study gives a better understanding of the available online information and the co-construction of donor identities on discussions boards.

Assessing the quality of decision-making for planned oocyte cryopreservation

PURPOSE

This survey study aims to examine the quality of planned oocyte cryopreservation (POC) decision-making in the domains of decision change, decision difficulty, decision regret and informed choice.

METHODS

Of the 224 women who completed at least one POC cycle between 2012 and 2018 at a Canadian academic IVF centre, 198 were reachable by email for anonymous survey participation.

RESULTS

Ninety-eight questionnaires were returned (response rate 49.5%). Of these, 86 fully completed questionnaires were analyzed for this study. Eighty-eight percent of respondents stated that it was a 'good decision' to cryopreserve oocytes, in retrospect. Despite this, 31% found the decision-making process to be 'difficult'. Three in five (61%) would have made 'exactly the same' decision without any change, yet slightly over a third (35%) would have made a 'similar' decision, but with option-related changes and process-related changes. A negative correlation between 'decision regret' and 'informed choice' was found (p < .005). Those who stated that they would have made exactly the 'same' POC decision were found to have a significantly higher 'informed choice' score compared to others who would have made a 'similar' or 'completely different' decision, in retrospect (p < .001). Respondents with lesser 'decision regret' were significantly more likely to appraise their decision as a well-informed choice (p < .001).

CONCLUSIONS

Our findings show that high-quality POC decision-making is accompanied by the perception of being able to make an informed choice, which can be achieved by providing patients with adequate information and individualized counselling to help patients set realistic expectations of cycle outcomes.

Guidelines informing counseling on female age-related fertility decline: a systematic review

PURPOSE

To identify, appraise, and assess clinical practice guidelines informing patient counseling on female age-related fertility decline.

METHODS

Searched electronic database records from January 1, 2006, to September 10, 2018, and professional society websites. The search terms included iterations of "guideline," "counseling," "preconception," "age-related fertility decline," and "reproductive life planning." English-language professional organization guidelines addressing patient counseling on age-specific reproductive health topics were included. Assessed the methodological quality of included guidelines using the AGREE II instrument. Guidelines were categorized as high quality or low quality based on AGREE II scores. Extracted age-specific reproductive health recommendations of high-quality guidelines.

RESULTS

The search identified 2918 records. Nineteen records addressed counseling on age-related fertility decline; only 6 focused only on reproductive aging, with the remaining 13 covering related topics. Eleven met criteria for high quality. All high-quality guidelines had high "rigor of development" scores on AGREE II. Ten high-quality guidelines stated an age at which female fertility declines, ranging from 30 to "late 30s." One recommended a specific age at which patients should be counseled. Five of eleven high-quality guidelines did not discuss the obstetric and perinatal risks of advanced maternal age.

CONCLUSIONS

Few high-quality guidelines address counseling on female age-related fertility decline, and existing guidance on reproductive aging counseling is inconsistent and incomplete. Greater rigor of development and incorporation of age-specific counseling recommendations into clinical practice guidelines could lead to improved patient anticipatory guidance and more informed reproductive choices.

Parenthood desire, childbearing plans and oocyte utilization among women who previously underwent planned oocyte cryopreservation

RESEARCH QUESTION

To examine the motivations, life circumstances and parenthood aspirations of a cohort of women who underwent planned oocyte cryopreservation (POC) at a Canadian academic IVF centre.

DESIGN

A single-site, cross-sectional, anonymous quantitative study using a study-specific questionnaire administrated via SurveyMonkey®. Of the 224 women who completed at least one POC cycle between 2012 and 2018, 198 were reached by email and invited to participate.

RESULTS

Of the 98 (49.5%) questionnaires returned, 86 were fully completed and were analysed. Mean age at first POC cycle was 35.7 ± 2.4 (range 27-43) and at survey was 37.7 ± 2.5 years. At POC, 77% were single and 97.7% childless. At survey, 96% had not attempted to use their cryopreserved oocytes, yet 26 (30%) had tried natural conception or fertility treatments. Of these, three conceived naturally and two by assisted reproduction. Eighty-five per cent expressed a strong motherhood desire and 67.1% indicated that usage of their cryopreserved oocytes was mostly contingent on relationship status. Many expressed a desire for shared genetic parenthood within a committed relationship. Forty-seven per cent did not want to carry a pregnancy beyond the age of 46.

CONCLUSION

The findings of this study confirm the central role of age and relationship status in influencing women's POC decisions and oocyte utilization plans. The late age at POC could be explained by women using it toward the end of their peak reproductive years to leverage their remaining chances of genetic motherhood. Surveying women at later points following POC would help to gain a more comprehensive picture of their oocyte utilization and disposition plans.

Is there a correlation between paternal age and aneuploidy rate? An analysis of 3,118 embryos derived from young egg donors

OBJECTIVE

To investigate a possible correlation between chromosomal aberrations and paternal age, analyzing embryos derived from young oocyte donors, with available preimplantation genetic testing for aneuploidy results from day 5/6 trophectoderm biopsy obtained by next-generation sequencing for all 24 chromosomes.

DESIGN

Retrospective cohort study.

SETTING

Canadian fertility centre.

PATIENT(S)

A total of 3,118 embryos from 407 male patients, allocated into three paternal age groups: group A, ≤39 years (n = 203); group B, 40-49 years (n = 161); group C, ≥50 years (n = 43).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The primary outcomes were aneuploidy, euploidy, mosaicism, and blastocyst formation rates. Secondary endpoints were comparison of specific chromosome aneuploidy, segmental and complex (involving two chromosomes + mosaicism >50%) aneuploidy, and analysis of overall percentage of chromosomal gains and losses within each group.

RESULT(S)

The study included 437 in vitro fertilization (IVF) antagonist cycles using 302 oocyte donors in which preimplantation genetic testing for aneuploidy was performed. Overall, 70.04% of embryos were euploid, 13.9% were aneuploid, and 16.06% were mosaic. No significant differences among paternal age groups A, B, and C were found in euploidy rates (69.2%, 70.6%, 71.4%, respectively), aneuploidy rates (14.7%, 12.8%, 13.9%, respectively) or mosaicism rates (16.1%, 16.6%, 13.6%; respectively). The fertilization rate was lower in group C compared with group B (76.35% vs. 80.09%). No difference was found in blastocyst formation rate between the study groups (median 52% [interquartile range, 41%, 67%] vs. 53% [42%, 65%] vs. 52% [42%, 64%], respectively). A generalized linear mixed model regression analysis for embryo ploidy rates found older oocyte donor age to be independently associated with embryo aneuploidy (odds ratio = 1.041; 95% CI, 1.009-1.074). The rate of segmental aneuploidies was significantly higher in the older versus younger paternal age group (36.6% vs. 19.4%).

CONCLUSION(S)

No association was found between paternal age and aneuploidy rates in embryos derived from IVF cycles using young oocyte donors, after adjusting for donor, sperm, and IVF cycle characteristics. Advanced paternal age ≥ 50, compared with younger paternal ages, was associated with a lower fertilization rate and increased rate of segmental aberrations.

Evaluating the Quality and Reliability of Online Information on Social Fertility Preservation

OBJECTIVE

With the rising trend of postponing motherhood, there has been an increasing rate of infertility. Social fertility preservation offers the potential to overcome this age-related infertility, and many women are turning to the Internet to seek medical information. The aim of this study was to evaluate online information on social fertility preservation.

METHODS

This study used five search terms-"egg freezing," "fertility preservation," "social egg freezing," "social fertility preservation," and "oocyte cryopreservation"-to identify the most popular sites as rated by Google. Accuracy of information and quality of websites were rated on the basis of four categories: Silberg's accountability criteria, Abbott's aesthetic criteria, Flesch-Kincaid readability score, and the Canadian Fertility and Andrology Society (CFAS) and the Society of Obstetricians and Gynaecologists of Canada (SOGC) recommendations (Canadian Task Force classification III).

RESULTS

Study investigators identified the 21 most used websites. The average Silberg score was 6.57, with 85.7% of websites meeting the criteria for adequate accountability. Only one website (4.8%) did not meet the criteria for appropriate aesthetic appeal. The average Flesch-Kincaid readability score was 11.39, equivalent to a grade 11 reading level, which is significantly higher than the reading level of the general population. A total of 57% of websites contained less than half of the evidence-based recommendations provided in CFAS and SOGC recommendations.

CONCLUSION

Online information on social fertility preservation is easily accessible and aesthetically pleasing, but information is not easily readable and does not reflect evidence-based recommendations. Hence, health care professionals must fill the knowledge gaps and adequately counsel their patients to optimize a woman's chance at a successful pregnancy.

[Causes of oocyte vitrification and its value in assisted reproductive technology]

OBJECTIVE

To explore the causes of oocyte vitrification and its application in assisted reproduction.

METHODS

We retrospectively analyzed the data of 26 patients with 27 cycles of oocyte vitrification cryopreservation undergoing intracytoplasmic sperm injection (ICSI) and embryo transfer between January, 2008 and October, 2018. The causes of oocyte vitrification and the outcomes of ICSI and clinical pregnancy were analyzed.

RESULTS

The causes of oocytes vitrification included mainly azoospermia or severe spermatogenesis disorder of the husband, failure to obtain sperms from the husband, failure of the husband to be present on the day of oocyte retrieval and acute diseases of the husband to not allow sperm collection. A total of 274 oocytes were frozen in 27 oocyte retrieval cycles, and 217 eggs were thawed in 19 cycles with a survival rate of 81.11% (176/217). The normal fertilization rate, cleavage rate and high-quality embryo rate was 74.81% (98/131), 89.80% (88/98) and 36.73% (36/98), respectively. Fifteen patients underwent embryo transfer, and the clinical pregnancy rate and live birth rate was 53.33% (8/15) and 33.33% (5/15), respectively. Compared with patients below 35 years of age, the patients aged above 35 years had significantly lower oocyte survival rate after thawing (82.76% vs 74.42%, P=0.211), clinical pregnancy rate (77.78% vs 16.67%, P=0.041) and live birth rate (55.56% vs 0, P=0.044).

CONCLUSIONS

Oocytes vitrification can be used as a remedy for infertile couples who fail to provide sperms due to male factors on the day of oocyte retrieval. Vitrification of the oocytes does not significantly affect the fertilization rate or the clinical pregnancy rate. The survival rate of the thawed oocytes is related to the age of the wife, and an age younger than 35 years can be optimal for achieving favorable clinical pregnancy outcomes after oocyte vitrification.

ANZSREI consensus statement on elective oocyte cryopreservation

BACKGROUND

One in six Australian women and couples suffer infertility. A rising proportion relates to advanced maternal age, associated with poorer oocyte quality and in vitro fertilisation (IVF) outcomes. Internationally, oocyte cryopreservation technology applied to oocytes vitrified before 35 years provides similar live-birth statistics compared to IVF treatment using fresh oocytes. Oocyte cryopreservation is accessible in Australasian settings and elective uptake is increasing. For women accessing treatment, oocyte cryopreservation may expand future family building options.

AIMS

To develop the first Australasian Certification in Reproductive Endocrinology and Infertility (CREI) subspecialist-led consensus guideline on oocyte cryopreservation.

METHODS

The ANZSREI ACCEPT (Australasian CREI Consensus Expert Panel on Trial evidence group) met in 2017 and 2018 and identified clinical aspects of care for inclusion and review. Review of the available evidence was conducted and consensus statements prepared. Areas of dissent of expert opinion and for further research were noted.

RESULTS

Consensus was reached on definition and best practice in oocyte cryopreservation for freeze method, controlled ovarian stimulation, medical risk reduction and treatment and outcomes counselling. The term 'social egg freezing' may marginalise, stigmatise or attribute social blame to women, and there is a need to revise this to a neutral and non-judgemental term such as elective or planned oocyte cryopreservation.

CONCLUSION

Oocyte cryopreservation has the potential to improve cumulative live birth outcomes for women. Implementation of this guideline should facilitate an optimal approach for providing care.

Advanced Maternal Age in IVF: Still a Challenge? The Present and the Future of Its Treatment

Advanced maternal age (AMA; >35 year) is associated with a decline in both ovarian reserve and oocyte competence. At present, no remedies are available to counteract the aging-related fertility decay, however different therapeutic approaches can be offered to women older than 35 year undergoing IVF. This review summarizes the main current strategies proposed for the treatment of AMA: (i) oocyte cryopreservation to conduct fertility preservation for medical reasons or "social freezing" for non-medical reasons, (ii) personalized controlled ovarian stimulation to maximize the exploitation of the ovarian reserve in each patient, (iii) enhancement of embryo selection via blastocyst-stage preimplantation genetic testing for aneuploidies and frozen single embryo transfer, or (iv) oocyte donation in case of minimal/null residual chance of pregnancy. Future strategies and tools are in the pipeline that might minimize the risks of AMA through non-invasive approaches for embryo selection (e.g., molecular analyses of leftover products of IVF, such as spent culture media). These are yet challenging but potentially ground-breaking perspectives promising a lower clinical workload with a higher cost-effectiveness. We also reviewed emerging experimental therapeutic approaches to attempt at restoring maternal reproductive potential, e.g., spindle-chromosomal complex, pronuclear or mitochondrial transfer, and chromosome therapy. In vitro generation of gametes is also an intriguing challenge for the future. Lastly, since infertility is a social issue, social campaigns, and education among future generations are desirable to promote the awareness of the impact of age and lifestyle habits upon fertility. This should be a duty of the clinical operators in this field.