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

Mapping ethical, legal, and social implications (ELSI) of fertility preservation

RESEARCH QUESTION

The study examines the ethical, legal, and social implications of fertility preservation, highlighting its importance across oncofertility, elective egg freezing, and posthumous assisted reproduction, as well as its impact on transgender individuals undergoing gender-affirming surgeries.

DESIGN

A comprehensive analysis of 600 articles, focusing on a diverse range of disciplines, including bioethics, psychology, and sociology, to explore public and healthcare professionals' knowledge, patient experiences, and regulatory constraints.

RESULTS

The body of literature is growing, indicating increasing recognition of FP's significance. Key themes included the centrality of counseling and informed decision-making, especially in oncofertility and EEF, and ethical debates surrounding informed consent and the autonomy of involved individuals. The analysis underscored a western-centric bias in current research, emphasizing the need for more inclusive and culturally sensitive studies.

CONCLUSIONS

The study calls for a nuanced understanding of FP, advocating for policies that consider ethical, cultural, and social dimensions. It suggests the necessity for interdisciplinary research to address identified gaps, particularly in understanding non-Western perspectives and ensuring equitable access to FP services globally. Moreover, the review emphasizes the importance of integrating patient-centric approaches and ethical frameworks to guide FP practices and policies, ensuring they respect diverse values and meet individuals' needs.

Social Egg Freezing for Single Women in China: Legal and Ethical Controversies

Social egg freezing is an emerging topic in China, where single women currently face restrictions in accessing this service at medical facilities. Administrative regulations prohibit single women from accessing all forms of assisted reproductive technologies. Both the first lawsuit filed by a single woman seeking to freeze her eggs and a legislative proposal aiming to protect single women's rights to access assisted reproductive technologies were denied. This has sparked controversy and discussion about the reproductive rights of single women and the legitimacy of their access to medical and technical assistance. Laws and family planning policies related to women's reproductive rights in China have undergone dramatic changes in recent years, owing to shifts in population growth trends and societal attitudes toward marriage and childbirth, subsequently leading to a notable enhancement in women's reproductive autonomy. Meanwhile, factors such as marital status and career considerations have led to a delay in childbearing, triggering a growing need and advocacy for fertility preservation among single women. In China, the pursuit of social egg freezing by single women comes into conflict with the strict regulatory restrictions on assisted reproductive technologies. This study delves into the profound impacts of demographic changes, marital trends, fertility culture, and other social factors on female fertility in China. It also discusses the legislative issues and medical-social ethical concerns associated with the application of social egg freezing for single women. Additionally, this study offers regulatory suggestions aimed at enhancing women's reproductive health and autonomy, as well as the avoidance of potential ethical risks.

Awareness and attitude toward oocyte cryopreservation for non-medical reasons: a study on women candidates for social egg freezing

PURPOSE

The present study was to investigate awareness and attitudes toward female fertility and aging, desire for a child and motherhood, and oocyte freezing for non-medical reasons among women candidates for Social Egg Freezing (SEF).

MATERIALS AND METHODS

This was a cross-sectional study on all 216 women who sought oocyte cryopreservation for nonmedical reasons at Royan Institute. A 24-item self-administered questionnaire measured knowledge and attitudes to SEF. Responses were as yes/no or a 4-point Likert scale.

RESULTS

Only 40% of participants accurately indicated that having a sexual partner does not help to preserve their fertility. A quarter of women correctly recalled chance of pregnancy with unprotected intercourse during a period of a year, for women 20 to 40 years old. Only one-third of respondents accurately identified the age-related fertility decline at 35-39 years. Only 6.9% correctly mentioned the low chance of pregnancy after egg freezing at 35 years old. Almost a third of women knew that the age range of 31-35 years is the right age to freeze an egg with the highest chance of pregnancy. Aging and health of offspring were most influential in women's decisions on SEF.

CONCLUSION

In conclusion, there was significant gaps in knowledge about age-related fertility decline, and egg cryopreservation conditions and its complications. It is crucial to impart to these women a better knowledge about fertility and a realistic picture about SEF, especially on the number of high-quality retrieved mature oocytes and live birth rates depend on women's age.

Medical technologies, time, and the good life

Against the backdrop of emerging medical technologies that promise transgression of temporal limits, this paper aims to show the importance that an individual lifetime's finitude and fugacity have for the question of the good life. The paper's first section examines how the passing of an individual's finite lifetime can be experienced negatively, and thus cause "suffering from the passing of time." The second section is based on a sociological analysis within the conceptual framework of individualization and capitalism, which characterizes many modern individualized and consumerist societies and explains how the described problem of time's passage is particularly relevant today. The paper then proceeds to show and discuss how individuals employ various, primarily medical, enhancement-technologies like social egg freezing, anti-aging-medicine and physical- and neuro-enhancement in an attempt to overcome time's passing. Finally, the paper seeks to explain why such attempts fail and, moreover, why it is exactly the awareness of time's passing that can constitute a prerequisite for a good life.

Is social egg freezing (oocyte cryopreservation) for single women permissible in Islam? A perspective from Singapore

Elective egg freezing (oocyte cryopreservation) for fertility preservation - commonly referred to as social egg freezing or non-medical egg freezing, will be permitted in Singapore from 2023. There is a need for clear religious directives on social egg freezing for the minority Muslim population in Singapore, due to conflicting Fatwas on this medical procedure that were issued in different Islamic countries, in particular Egypt and Malaysia. Although social egg freezing would be beneficial for the fertility preservation of many single Muslim women who are unable to start a family due to various personal circumstances, there are also various potential risks and harms of this medical procedure at the individual and societal level. Hence, based on Maqasid Al-Shariah, by which preventing harm takes precedence over securing benefit in medical treatment (Tadawi), it is posited that social egg freezing should be classified as Makruh, which is permissible but discouraged in Islam.

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.

'I feel that injustice is being done to me': a qualitative study of women's viewpoints on the (lack of) reimbursement for social egg freezing

Background

During the last decade, the possibility for women to cryopreserve oocytes in anticipation of age-related fertility loss, also referred to as social egg freezing, has become an established practice at fertility clinics around the globe. In Europe, there is extensive variation in the costs for this procedure, with the common denominator that there are almost no funding arrangements or reimbursement policies. This is the first qualitative study that specifically explores viewpoints on the (lack of) reimbursement for women who had considered to uptake at least one social egg freezing cycle in Belgium.

Methods

To understand the moral considerations of these women, drawing from twenty-one interviews, this paper integrates elements of a symbiotic empirical ethics approach and thematic analysis.

Results

We identify four themes: (1) being confronted with unclear information; (2) financial costs as ongoing concern; (3) necessity of coverage; (4) extent of reimbursement. In the first theme, we found that some women were concerned about the lack of clear information about the cost of social egg freezing. In the second theme, we report moral sentiments of injustice and discrimination which some women attributed to their struggles and needs not being recognised. The third theme illustrates diverse views on reimbursement, ranging from viewing social egg freezing as an elective treatment not appropriate for reimbursement to preferences for greater public responsibility and wider access. Finally, we describe the participants’ varying proposals for partial reimbursement and the idea that it should not be made available for free.

Conclusions

This research adds important empirical insights to the bioethics debate on social egg freezing, in particular by presenting (potential) users’ views on the lack of reimbursement. While there is much more to say about the ethical and political complexities of the reimbursement of this procedure, our study highlighted the voices of (potential) users and showed that at least some of them would welcome the coverage of SEF through the public healthcare insurance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-022-00774-z.

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.

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.

Unveiling the controversy on egg freezing in The Netherlands: A Q-methodology study on women's viewpoints

Preserving the option to conceive through egg freezing (oocyte cryopreservation) is surrounded by value conflicts and diverse viewpoints, particularly when non-medical or so-called 'social' reasons are involved. The debate is controversial and shaped by normative perceptions of the life course, including concepts regarding reproductive ageing, gender, motherhood and biomedicalization. To unravel the controversy and systematically identify the variety of viewpoints on egg freezing, a Q-methodology study was conducted in The Netherlands between December 2018 and October 2019. Thirty-four women of reproductive age participated in the study. They ranked 40 statements according to their level of agreement, and explained their ranking during follow-up interviews. Data were analysed using by-person factor analysis and interpreted using both quantitative and qualitative data. Four viewpoints, of which the fourth was bipolar, were identified: (1) cautious about egg freezing technology; (2) my body, my choice; (3) egg freezing is unnatural; and (4) have children and have them early. The distinct viewpoints illustrate different prioritizations of values and normative dimensions of biomedical innovations. By knowing more about the prevalent opinions on egg freezing and the surrounding controversy, policy makers and practitioners can make better informed decisions in terms of promoting and providing patient-centred infertility care. The findings furthermore stimulate continuing scholarly work on egg freezing and other innovations in reproductive medicine which may continue to disrupt normative standards.

Women's viewpoints on egg freezing in Austria: an online Q-methodology study

Background

Egg freezing has emerged as a technology of assisted reproductive medicine that allows women to plan for the anticipated loss of fertility and hence to preserve the option to conceive with their own eggs. The technology is surrounded by value-conflicts and is subject to ongoing discussions. This study aims at contributing to the empirical-ethical debate by exploring women’s viewpoints on egg freezing in Austria, where egg freezing for social reasons is currently not allowed.

Methods

Q-methodology was used to identify prevailing viewpoints on egg freezing. 46 female participants ranked a set of 40 statements onto a 9-column forced choice ranking grid according to the level of agreement. Participants were asked to explain their ranking in a follow-up survey. By-person factor analysis was used to identify distinct viewpoints which were interpreted using both the quantitative and the qualitative data.

Results

Three distinct viewpoints were identified: (1) “women should decide for themselves”, (2) “we should accept nature but change policy”, and (3) “we need an informed societal debate”. These viewpoints provide insights into how biomedical innovations such as egg freezing are perceived by women in Austria and illustrate the normative tensions regarding such innovations.

Conclusions

Acknowledging the different prioritizations of values regarding assisted reproductive technologies is important to better understand the underlying normative tensions in a country where egg freezing for social reasons is currently not allowed. The study adds new empirical insights to the ongoing debate by outlining and discussing viewpoints of those directly affected: women. Following up on the lay persons perspective is particularly important in the context of future biomedical innovations that may challenge established norms and create new tensions. It therefore also adds to the societal debate and supports evidence-informed policy making in that regard.

"It's Just Another Added Benefit": Women's Experiences with Employment-Based Egg Freezing Programs

BACKGROUND

In 2014, companies began covering the costs of egg freezing for their employees. The adoption of this benefit was highly contentious. Some argued that it offered women more reproductive autonomy, buying time to succeed in their careers and postpone childbearing. Others suggested this benefit might place inappropriate pressure on women, unduly influencing them to freeze their eggs to prioritize their career over reproduction. Although ethical problems with this benefit have been explored, there has not been research analyzing the perspectives of women working for companies that offer employer-based egg freezing. Furthermore, existing empirical studies often focus on the experiences of egg freezers rather than the young women thinking about, but not yet using, this technology. Methods: Through in-depth semi-structured interviews, we explore the perceptions and attitudes of 25 women employees of companies with employer-based egg freezing. Results: These women describe delaying childbearing for a multitude of reasons, including not having a partner, and the desire to achieve social and career goals. Many women did not know that their employers covered egg freezing before the interview (44%; 11/24), suggesting this benefit is not essential to their career and family-building decisions. While women did not describe pressure to use this technology, they did describe how this benefit would not solve the difficulties of becoming a mother while excelling in their careers. Conclusion: Although women may not feel pressure to freeze their eggs and delay childbearing, they still feel constricted in their reproductive options. While employer programs may offer women the ability to delay childbearing, many saw this delay as postponing problems with work-life balance rather than solving them. We suggest that sociocultural shifts, such as workplace daycare, flexible workplace hours, and acceptability of non-biological parenthood, might allow women to feel more empowered about their reproduction choices.

A follow-up survey on the reproductive intentions and experiences of women undergoing planned oocyte cryopreservation

RESEARCH QUESTION

What are the current reproductive attitudes and experiences of women who have previously undergone planned oocyte cryopreservation (OoC)?

DESIGN

Retrospective questionnaire-based cohort study involving women who had previously undergone planned OoC between January 2009 and September 2016 at a single centre. Eligible women were contacted via e-mail and invited to complete an anonymous standardized questionnaire that had been developed to evaluate their current relationship status and reproductive situation, their attitudes towards planned OoC and their future reproductive intentions.

RESULTS

Of 460 women who had completed at least one OoC cycle, questionnaires were obtained from 138 women. After a mean (± SD) follow-up of 4.5 ± 2.4 years, two-thirds of respondents (65%) anticipated using their oocytes at some point in the future. The respondents reported an overwhelmingly positive attitude towards planned OoC, with 98% indicating they would recommend this intervention to others. Overall, 83% of respondents were single at the time they requested OoC but only 44% were single at the time they completed the survey. While 43/62 (69%) of women became pregnant after undergoing OoC, the majority 30/43 (70%) of these pregnancies were achieved without using their vitrified oocytes. Finally, 13/28 (46%) who used their cryopreserved oocytes stated that they had achieved a live birth.

CONCLUSIONS

The majority of women who undergo OoC do not regret their experience and many have found a partner in subsequent years. Twenty-one per cent of respondents who attempted to conceive after OoC had a live birth using their cryopreserved oocytes.

Elective egg freezing without medical indications

The aim of this review is to provide current knowledge on fertility preservation for non-medical reasons in women willing to postpone childbearing. The topic is highly debatable, starting from disagreement about its terminology, the number of eggs necessary to predict chances of success, and the safety and socio/ethical point of view. Cost analysis and discrepancies among countries' recommendations and regulations are described to confirm the controversies and unsolved issues around this very interesting topic. Finally, an overview on the returning rate of women among "egg bankers" and reasons behind their decisions are illustrated.