Knowledge and decision making about future fertility and oocyte cryopreservation among young women

Fertility Knowledge and Educational Experiences of Graduating Medical Students: A Multi-Institution Survey

Objective: Our goal was to assess the fertility knowledge and educational experiences of graduating U.S. medical students to evaluate areas of improvement for future educational interventions. Design: Web-based cross-sectional survey. Subjects: Medical students graduating in 2023 from the University of Miami Miller School of Medicine (SOM), New York University (NYU) Grossman SOM, Wayne State University SOM, Perelman SOM at the University of Pennsylvania, and Mayo Clinic Alix SOM. Main Outcome Measures: Fertility-related knowledge and educational experiences of U.S. medical students in their final year of school. Results: In total, 117 students (14.4%) completed the survey. The average knowledge score was 78%. Twenty-three (22%) overestimated the age of most precipitous fertility decline, and 50 (52%) overestimated the chance of getting pregnant for a 40-year-old person with ovaries. One-third of students (30, 32%) incorrectly believe that physicians have equivalent infertility rates to the general population. Students were less cognizant of male fertility issues, incorrectly believing there was no negative impact on male fertility by age (43, 42%) among other factors. Seventy-five (81%) reported less than 5 hours of fertility-related education in medical school. Only one-third (32%) were satisfied or very satisfied with the fertility education they received. In an open-response question, students expressed interest in additional education on transgender and cancer patient care, fertility preservation, assisted reproductive technologies, and reproductive life planning in medicine. Conclusions: There is a need and an opportunity for medical education programs to enhance fertility education. Giving students and trainees the knowledge required to make informed decisions for their family-building purposes and improving their ability to counsel patients adequately should be a goal of future educational endeavors. The data collected in this study will serve as a guide for the development of fertility-related learning modules for medical students and trainees.

Timing of ICSI with Respect to Meiotic Spindle Status

The aim of this study was to evaluate the efficiency of using meiotic spindle (MS) visibility and relative position to the polar body (PB) as indicators of oocyte maturation in order to optimize intracytoplasmic sperm injection (ICSI) timing. This was a cohort study of patients younger than 40 years with planned ICSI, the timing of which was determined by MS status, compared with those without MS evaluation. The angle between PB and MS and MS visibility were evaluated by optical microscope with polarizing filter. Oocytes with MS evaluation were fertilized according to MS status either 5-6 h after ovum pick-up (OPU) or 7-8 h after OPU. Oocytes without MS evaluation were all fertilized 5-6 h after OPU. For patients over 35 years visualization of MS influenced pregnancy rate (PR): 182 patients with MS visualization had 32% PR (58/182); while 195 patients without MS visualization had 24% PR (47/195). For patients under 35 years, visualization of MS did not influence PR: 140 patients with MS visualization had 41% PR (58/140), while 162 patients without MS visualization had 41% PR (66/162). Visualization of MS therefore appears to be a useful parameter for assessment of oocyte maturity and ICSI timing for patients older than 35.

Randomized control trial of a decision aid for women considering elective egg freezing: The Eggsurance study protocol

BACKGROUND

Uptake of elective egg freezing has increased globally. The decision to freeze eggs is complex, and detailed, unbiased information is needed. To address this, we developed an online Decision Aid for women considering elective egg freezing. Decision Aids are the standard of care to support complex health decisions.

OBJECTIVES

This study will measure the impact of the Decision Aid on decision-making (e.g. decisional conflict, engagement in decision-making, distress, and decision delay) and decision quality (e.g. knowledge, level of informed choice, and regret).

METHODS AND ANALYSIS

A single-blinded two-arm parallel-group randomized controlled trial. Women considering elective egg freezing will be recruited using social media, newsletters, and fertility clinics. Data will be collected at baseline (recruitment), 6-month, and 12-month post-randomization. The primary hypothesis is that the intervention (Decision Aid plus Victorian Assisted Reproductive Technology Authority website) will reduce decisional conflict (measured using the Decisional Conflict Scale) at 12 months more than control (Victorian Assisted Reproductive Technology Authority website only). Secondary outcomes include engagement in decision-making (Perceived Involvement in Care Scale), distress (Depression, Anxiety, and Stress Scale), decision delay, knowledge, informed choice (Multi-dimensional Measure of Informed Choice), and decisional regret (Decisional Regret Scale).

ETHICS

The study was approved by the University of Melbourne Human Research Ethics Committee (Ethics ID: 2056457). Informed consent will be obtained from all participants prior to enrolment.

DISCUSSION

This is the first international randomized controlled trial that aims to investigate the effect of an elective egg freezing Decision Aid on decision-related outcomes (e.g. decisional conflict, informed choice, and regret). It is anticipated that participants who receive the Decision Aid will have better decision and health outcomes.

REGISTRATION DETAILS

ACTRN12620001032943: Comparing different information resources on the process and quality of decision-making in women considering elective egg freezing.

Factors affecting the decisions of women considering oocyte cryopreservation: A blog study

The aim was to explain the factors that affect the decision-making processes of women considering oocyte cryopreservation. In this study, a web page was scanned between March and April 2020 that was appropriate to the "Evaluation of the Quality and Content of Websites Form." As a result, 4 main themes (unknown process, financial burden, social stigma, and future concerns) were created from the experiences of 23 women. The majority of women feel anxiety associated with the oocyte cryopreservation process. It is recommended that reliable information should be presented to society by health care professionals.

Anti-Mullerian hormone (AMH) test information on Australian and New Zealand fertility clinic websites: a content analysis

OBJECTIVES

The anti-Mullerian hormone (AMH) test has been promoted as a way to inform women about their future fertility. However, data consistently show the test is a poor predictor of natural fertility potential for an individual woman. As fertility centre websites are often a primary source of information for reproductive information, it is essential the information provided is accurate and reflects the available evidence. We aimed to systematically record and categorise information about the AMH test found on Australian and New Zealand fertility clinic websites.

DESIGN

Content analysis of online written information about the AMH test on fertility clinic websites.

SETTING

Accredited Australian and New Zealand fertility clinic websites.

METHODS

Data were extracted between April and June 2020. Any webpage that mentioned the AMH test, including blogs specifically about the AMH test posted since 2015, was analysed and the content categorised.

RESULTS

Of the 39 active accredited fertility clinics' websites, 25 included information about the AMH test. The amount of information varied widely, and embodied four overarching categories; (1) the utility of the AMH test, (2) who the test is suitable for, (3) possible actions in response to the test and (4) caveats and limitations of the test. Eight specific statements about the utility of the test were identified, many of which are not evidence-based. While some websites were transparent regarding the test's limitations, others mentioned no caveats or included persuasive statements actively promoting the test as empowering for a range of women in different circumstances.

CONCLUSIONS

Several websites had statements about the utility of the AMH test that are not supported by the evidence. This highlights the need for higher standards for information provided on fertility clinic websites to prevent women being misled to believe the test can reliably predict their fertility.

Evidenced-based practice of decision-making process in oncofertility care among registered nurses: A qualitative study

AIM

The purpose of our study was to construct the context of the nursing action/role in oncofertility care.

DESIGN

Qualitative research.

METHODS

We applied grounded theory to guide the qualitative study. Data were collected through in-depth interviews with 12 nurses in Taipei. The data were collected from August 2018 to February 2019.

RESULTS

The core theme that described the role of nurses' decision-making in oncofertility care focused on understanding oncofertility from the self to the other. Care roles or actions in oncofertility that involved the process of psychological cognition were divided into four dimensions: perceiving the patient's changes and needs, triggering the self's emotions, empathizing with patient's situations and introspective care roles. Nurses who had experienced the phase of empathizing with the patient's situations developed more diverse roles and had positive actions toward oncofertility care. Based on the psychological changes for oncofertility decision-making process, implementing contextual training in oncofertility could help nurses create more positive actions in oncofertility care.

Variation in Self-Perceived Fecundity among Young Adult U.S. Women

BACKGROUND

Individuals' perceptions of their fecundity, or biological ability to bear children, have important implications for health behaviors, including infertility help-seeking and contraceptive use. Little research has examined these perceptions among U.S. women.

METHODS

This cross-sectional study examines perceptions of one's own fecundity among U.S. women aged 24 to 32 who participated in the 2009-2011 rounds of the National Longitudinal Survey of Youth (1997) cohort. Analyses were limited to 3,088 women who indicated that they or their partners never received a doctor's diagnosis regarding fertility difficulties.

RESULTS

Of the women in the sample, 67% perceived their hypothetical chances of becoming pregnant as very likely; the remainder perceived their chances as somewhat likely (13%), not as likely (15%), or provided a "don't know" response (6%). Twenty-six percent of Black women and 19% of Latina women perceived themselves as not very likely to become pregnant, compared with only 12% among non-Black/non-Latina women (p < .001). Only 6% of women with a college degree perceived their chances of becoming pregnant as not very likely, compared with 36% among women without a high school degree (p < .001). Racial/ethnic and educational differences persisted in fully adjusted models. Other factors associated with fecundity self-perceptions include partnership status, parity, fertility expectations, sexual activity, prolonged exposure to unprotected intercourse for at least 6 and/or 12 months without becoming pregnant, and self-rated health.

CONCLUSIONS

Findings indicate that self-perceived fecundity differs systematically by demographic and other characteristics. This phenomenon should be investigated further to understand how it may influence disparities in health behaviors and outcomes.

Planned oocyte cryopreservation (Planned OC): systematic review and meta-analysis of cost-efficiency and patients' perspective

BACKGROUND

Advances in vitrification techniques have enabled planned oocyte cryopreservation ('Planned OC').

OBJECTIVES

To explore the cost-efficiency and utilisation of planned OC, as well as patients' perspectives on the process.

SEARCH STRATEGY

A systematic search in PubMed/MEDLINE, Embase, Cochrane Database and PsychINFO, for all relevant studies published between January 2007 and December 2019.

SELECTION CRITERIA

The protocol followed PRISMA guidelines in PECO format, and was registered with PROSPERO.

DATA COLLECTION AND ANALYSIS

Two independent reviewers evaluated all manuscripts for inclusion eligibility. Authors were contacted for missing data. Included studies were assessed for risk of bias and for heterogeneity. Weighted effects were measured and plotted.

MAIN RESULTS

The search yielded 12 545 records, of which 43 were included. Planned OC is cost-efficient at 35, assuming 60% utilisation; and at 37 assuming utilising donor sperm when necessary. At 38 it is cost-efficient to defer planned OC in favour of undergoing 2 IVF cycles. Currently, utilisation of banked-oocytes within 22-58 months, is up to 15%. Nine percent of warmed banked oocytes result in life births. Online resources and treating physicians are equally important sources of information regarding planned OC. Most patients think planned OC is ideal before age 35 and are not fully aware of what the process entails and tend to overestimate the success rates. The main barrier to wider endorsement of planned OC is being wary of potential health implications or of limited success.

CONCLUSION

Planned OC is an adequate method for preserving fertility. However, knowledge gaps result in under-utilisation leading to reduced cost-efficiency.

TWEETABLE ABSTRACT

Identifying facilitators and barriers for wider adoption of banking oocytes can enhance the cost-efficiency of this modality.

Knowledge gaps in the understanding of fertility among non-medical graduate students

Objective

To assess knowledge of female and male fertility among students enrolled in a Master of Business Administration (MBA) program.

Design

Web-based cross-sectional survey.

Setting

Academic setting.

Patient(s)

Not applicable.

Intervention(s)

None.

Main Outcome Measure(s)

Knowledge of how female and male age impacts reproduction, fecundability, and success rates with in vitro fertilization (IVF).

Result(s)

A total of 133 female and male MBA students completed the survey. Nearly 10% of participants were not aware that women are born with a fixed number of oocytes and that oocyte quantity and quality decline with age. More than 30% of participants overestimated fecundability in women aged ≥35 years, and >50% overestimated IVF success rates in women older than 40 years. Fifteen percent of participants did not know that men have stem cells in the testes, and >25% were not aware that men experience a decrease in sperm concentration and quality with age. Nearly 30% believed that a man’s age never impacts reproductive outcomes. Less than 30% of participants correctly estimated fecundability and IVF success rates based on male age.

Conclusion(s)

These data highlight important knowledge gaps in a highly educated group of MBA students, most whom desire future childbearing. Specifically, there is a lack of understanding of both male and female reproductive aging and an overestimation of treatment success. As delayed childbearing continues, particularly among those with high educational attainment, attention should be focused on introducing broad fertility education at a younger age to improve future reproductive success.

Likelihood of achieving a 50%, 60%, or 70% estimated live birth rate threshold with 1 or 2 cycles of planned oocyte cryopreservation

PURPOSE

To characterize the likelihood of cryopreserving enough oocytes for 50%, 60%, or 70% estimated live birth rate (eLBR) with 1-2 planned oocyte cryopreservation (Pl-OC) cycles.

METHODS

We performed a retrospective cohort study utilizing all patients completing ≥ 1 Pl-OC cycle from 2016 to 2018 at a large single-center OC program. Subjects were categorized by age at retrieval and number of cycles. We extrapolated age-based oocyte thresholds for 50%, 60%, or 70% eLBR from previously published data. We calculated the proportion of subjects overall, and for each age group, whose number of frozen oocytes was greater than or equal to their age-based threshold for a 50%, 60%, or 70% eLBR after 1 and 2 cycles. OR for 60% eLBR with one cycle was calculated for age and AMH cutoff values and corroborated with logistic regression.

RESULTS

A total of 1241 subjects, completing 1799 Pl-OC cycles, were included. With one cycle, 66% (819/1241) achieved ≥ 50% eLBR and 51% (634/1241) achieved 70% eLBR. With two cycles, 79.6% (988/1241) attained ≥ 50% eLBR and 65.5% (813/1241) achieved 70% eLBR. Achieving 50%, 60%, or 70% eLBR with 1-2 cycles was significantly associated with both age (p < 0.001) and AMH (p < 0.001). Age < 37.5 and AMH > 1.995 were independently associated with attaining 60% eLBR with one cycle (age: OR 13.73; 95%CI 9.16-20.57, p < 0.001; AMH: OR 7.32; 95% CI 5.50-9.76, p < 0.001).

CONCLUSIONS

Younger age and higher AMH were associated with achieving 50%, 60%, or 70% eLBR thresholds with Pl-OC. Nevertheless, almost all subjects were successfully able to preserve enough oocytes for ≥ 50% eLBR in 1-2 cycles.

Fertility preservation in Hong Kong Chinese society: awareness, knowledge and acceptance

Background

Fertility preservation for both medical and non-medical reasons are gaining increasing attention world-wide. This study aimed to evaluate the awareness, knowledge and acceptance on fertility preservation in Hong Kong Chinese.

Methods

This was a cross-sectional study carried out between June 2016 to March 2017. A self-administered questionnaire was distributed by convenience sampling.

Results

Forty two percent of subjects returned the questionnaire (n = 296/697). Among them, only 54.3% were aware of any means of fertility preservation. Tertiary educated individuals are more aware than less educated individuals (73.6% versus 46.6%, p < 0.001). The most commonly known method is oocyte cryopreservation (94.3%). Most of the respondents (80%) were interested to know about fertility preservation, 84.1% considered fertility preservation counselling necessary and 83.3% would consider undergoing fertility preservation if a treatment has a high chance of causing infertility despite the possibility of delay in cancer treatment. Up to 93.9% agreed to set up a dedicated referral centre with government funding and 73.4% agreed that fertility preservation for medical indication should be provided as a government funded service. In terms of fertility preservation for non-medical reason, 65.5 and 70.4% agreed that fertility preservation should be offered to single men and women without partner respectively, while only 53.3 and 50% agreed that fertility preservation is acceptable for delay in childbearing for career development in female and male respectively.

Conclusion

There was a low awareness but positive attitude towards fertility preservation among Hong Kong Chinese. Acceptance towards medically indicated fertility preservation is high while a considerable number also accepts it for non-medical reasons. Educational campaigns are required to arouse awareness of fertility preservation to prevent individuals being deprived of the option due to lack of knowledge. Dedicated referral centre with established efficient patient referral pathways and financial support should be provided to improve the provision and uptake of fertility preservation service to enhance the reproductive potential and life options of women.

For whom the egg thaws: insights from an analysis of 10 years of frozen egg thaw data from two UK clinics, 2008-2017

PURPOSE

To better understand the characteristics of patients who returned to thaw their frozen eggs to attempt conception and their outcomes.

METHODS

A retrospective analysis of clinical records for all own egg thaw patients in two UK fertility clinics across 10 years, 2008-2017.

RESULTS

There were 129 patients who returned to thaw their eggs, of which 46 had originally frozen their eggs for social reasons and 83 for a variety of clinical, incidental, and ethical reasons (which we have called "non-social"). Women who had frozen their eggs for social reasons were single at time of freeze, with an average age of 37.7. They kept their eggs in storage for just under 5 years, returning to use them at the average age of 42.5. 43.5% were single at time of thaw, and 47.8% used donor sperm to fertilise their eggs. Women whose eggs were frozen for non-social reasons were almost all (97.6%) in a relationship at both time of freeze and thaw. They had an average age of 37.2 at first freeze and 37.6 at thaw, having kept their eggs in storage for an average of 0.4 years. Overall, there was a 20.9% success rate among women attempting conception with frozen-thawed eggs.

CONCLUSIONS

Despite widespread assumptions, many women attempting conception with thawed eggs had not initially frozen them for social reasons. Women who froze their eggs for social reasons presented distinctly and statistically different characteristics at both time of freeze and thaw to women whose eggs were frozen for non-social reasons.