Perceptions of oocyte banking from women intending to circumvent age-related fertility decline

Machine learning for predicting elective fertility preservation outcomes

This retrospective study applied machine-learning models to predict treatment outcomes of women undergoing elective fertility preservation. Two-hundred-fifty women who underwent elective fertility preservation at a tertiary center, 2019-2022 were included. Primary outcome was the number of metaphase II oocytes retrieved. Outcome class was based on oocyte count (OC): Low (≤ 8), Medium (9-15) or High (≥ 16). Machine-learning models and statistical regression were used to predict outcome class, first based on pre-treatment parameters, and then using post-treatment data from ovulation-triggering day. OC was 136 Low, 80 Medium, and 34 High. Random Forest Classifier (RFC) was the most accurate model (pre-treatment receiver operating characteristic (ROC) area under the curve (AUC) was 77%, and post-treatment ROC AUC was 87%), followed by XGBoost Classifier (pre-treatment ROC AUC 74%, post-treatment ROC AUC 86%). The most important pre-treatment parameters for RFC were basal FSH (22.6%), basal LH (19.1%), AFC (18.2%), and basal estradiol (15.6%). Post-treatment parameters were estradiol levels on trigger-day (17.7%), basal FSH (11%), basal LH (9%), and AFC (8%). Machine-learning models trained with clinical data appear to predict fertility preservation treatment outcomes with relatively high accuracy.

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.

Too much equity - is there such a thing? The public discourse surrounding elective egg freezing subsidy in Israel

BACKGROUND

The preservation of human ova for future fertilization has been made available to healthy women in 2011-2012. This treatment, dubbed elective egg freezing (EEF), is undertaken primarily by highly educated unpartnered women without children, concerned of age-related fertility decline. In Israel, treatment is available to women aged 30-41. However, unlike many other fertility treatments, EEF is not state subsidized. The public discourse of EEF funding in Israel is the focus of the present study.

METHOD

The article analyzes three sources of data: press presentations of EEF; a Parliamentary Committee discussion dedicated to EEF funding; interviews with 36 Israeli women who have undertaken EEF.

RESULTS

Numerous speakers raised the issue of equity, claiming that reproduction was a state interest and therefore, a state responsibility, including securing equitable treatment to Israeli women of all economic strata. Highlighting the generous funding of other fertility treatments, they claimed that EEF was inequitable, discriminating against poorer single women, who could not afford it. Few actors, however, rejected state funding as intervention in women's reproductive lives and called for reconsideration of the local reproductive imperative.

CONCLUSION

The invocation of equity by Israeli users of EEF, clinicians and some policy makers as grounds for a call to fund a treatment that serves a well-established subpopulation seeking to relieve a social rather than a medical problem, illustrates the profound context-embeddedness of notions of health equity. More generally, it may suggest that using an inclusive language in a discourse of equity may potentially be invoked so as to promote the interests of a particular subpopulation.

Women's reflections on timing of motherhood: a meta-synthesis of qualitative evidence

INTRODUCTION

Fertility declines with increasing age, especially in women. In recent decades women's age at the birth of their first child has risen markedly in many countries, and an increasing number of women do not establish a family until their late-twenties to mid-thirties. Although there can be various reasons that couples experience fertility problems, advanced maternal age is the most frequent cause for difficulties with achieving pregnancy.

OBJECTIVE

In this meta-synthesis, we investigated reflections on timing of motherhood in women who have not yet had children.

METHODS

A systematic literature search of six electronic databases and manual searches of reference lists identified eight qualitative studies published between 2011 and 2018 that focused on women's reflections on timing of motherhood. The studies were assessed with the Critical Assessment Skills Programme (CASP) quality appraisal tool. The results were synthesized using Noblit and Hare's meta-ethnographic approach as described by Malterud.

FINDINGS

An overall theme of 'Timing of motherhood' and four overlapping subthemes were identified: Making a life-changing decision, The right time, Fear of regret, and Plan B. The dilemmas associated with timing of motherhood leave women of reproductive age balancing their priorities and values against a biological deadline for having children naturally or through assisted reproductive technology.

CONCLUSIONS

Women of reproductive age are aware that they must make a life-changing decision as to if or when to have children, but they consider having children at 'the right time' to be important. Simultaneously, while some women are reluctant to have children for various reasons, they express fear that waiting too long could result in their regretting not having children later in life. Although women of reproductive age express concern about their ability to achieve pregnancy, they have limited focus on the medical risks associated with postponing motherhood. There is a need to establish preventive health initiatives to support women of reproductive age in their considerations regarding timing of motherhood.

TRIAL REGISTRATION NUMBER

PROSPERO: CRD42020175151.

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.

The needs of subfertile couples continuing to attempt natural conception: in-depth interviews

STUDY QUESTION

What are the experiences and the support and sexual advice needs of subfertile couples continuing to attempt natural conception after the diagnostic fertility work-up?

SUMMARY ANSWER

Exploration of the experiences of couples showed that couples would have appreciated fertility clinic staff embedding expectant management into the fertility clinic trajectory, supportive staff with female and male patient interactions and advice on common experiences of peers and on managing their lifestyle, distress and subfertility-related sexual challenges.

WHAT IS KNOWN ALREADY

Dutch and British professional guidelines advise newly diagnosed subfertile couples with a 'good prognosis' to continue to attempt natural conception and do not require fertility clinic staff to interact with patients. Fertility clinic staff and subfertile couples struggle to follow these guidelines as they feel an urgent need for action. Subfertile couples might benefit from sexual advice, as subfertility is negatively associated with sexual functioning, which is important for natural conception.

STUDY DESIGN SIZE DURATION

Twelve one-time in-depth interviews (2015-2017) were conducted with 10 heterosexual couples and 2 women whose partners did not participate, then the interviews were subjected to inductive content analysis, reaching inductive thematic saturation.

PARTICIPANTS/MATERIALS SETTING METHODS

The 22 interviewees had experienced 3-18 months of expectant management after their diagnostic fertility work-up in a Belgian or a Dutch tertiary fertility clinic. The face-to-face in-depth interviews explored positive and negative experiences and unmet needs. The transcribed interviews were subjected to inductive content analysis, by two researchers discussing initial disagreements.

MAIN RESULTS AND THE ROLE OF CHANCE

Couples would appreciate fertility clinic staff embedding expectant management in the fertility clinic trajectory, by starting off with reassuring couples that their very thorough diagnostic fertility work-up demonstrated their good chance of natural conception, and by involving couples in deciding on the duration of expectant management and by planning the follow-up appointment after expectant management up front. Couples had encountered sexual challenges during expectant management and had an interest in sexual advice, focused on increasing pleasure and partner bonding and preventing the rise of dysfunctions. The couples agreed that a (secured) website with evidence-based, non-patronizing text and mixed media would be an appropriate format for a novel support programme. Couples were keen for interactions with fertility clinic staff which addressed both partners of subfertile couples. Couples also valued advice on managing their lifestyle and distress and would have liked information on the experiences of their peers.

LIMITATIONS REASONS FOR CAUTION

Recall bias is plausible given the retrospective nature of this study. This explorative interview study was not designed for examining country or gender differences in experiences and needs but it did generate new findings on inter-country differences.

WIDER IMPLICATIONS OF THE FINDINGS

Rather than simply advising expectant management, fertility clinics are encouraged to offer couples who continue to attempt natural conception after their diagnostic fertility work-up, supportive patient-staff interactions with advice on common experiences of peers and on managing their lifestyle, distress and sexual challenges related to subfertility.

STUDY FUNDING/COMPETING INTERESTS

Funded by Flanders Research Foundation and the University of Amsterdam. There are no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

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.

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.

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.

Decision regret and associated factors following oocyte cryopreservation in patients with diminished ovarian reserve and/or age-related fertility decline

PURPOSE

To evaluate the prevalence and factors associated with decision regret following oocyte cryopreservation (OC) in women with diminished ovarian reserve (DOR) and/or age-related fertility decline (ARFD).

METHODS

A cross-sectional survey study was conducted to five hundred fifty-two women with DOR and/or ARFD who underwent OC between 2014 and 2019 in two private-assisted reproductive units in Istanbul, Turkey. Decision regret was measured using the validated Decision Regret Scale (DRS).

RESULTS

The median and mean DRS scores were 10 (interquartile range: 25) and 13.4 (SD: 13.2, range 0-70), respectively. Eighty-five (52.5%) women reported mild regret and 26 (16%) had moderate to severe regret. Decision regret was inversely associated with the belief in fate regarding childbearing and trust in the efficacy of OC.

CONCLUSIONS

The prevalence of severe decision regret among patients with DOR and/or ARFD undergoing OC is low. Women who had belief in fate and trusted in the efficacy of oocyte cryopreservation had significantly lower decisional regret.

Current perspectives on social oocyte freezing

Demand for oocyte freezing in absence of a medical indication is growing as women delay childbirth and seek to extend the window of opportunity for parenthood. The optimum age for oocyte freezing is below 35 years, whereas currently the mean age of women undergoing oocyte freezing in the UK is 38 years. Nearly half of women undergoing oocyte freezing are not in a relationship. The treatment is not publicly funded and the average price for a complete oocyte freezing and thawing cycle, including annual storage fees, could reach over £7000. The live birth rate per oocyte thaw cycle is 18% and is influenced by age at the time of oocyte freezing. Women considering social oocyte freezing should be thoroughly counselled about the efficacy, limitations, cost implications and alternatives to oocyte freezing and provided with the appropriate support to enable a truly informed reproductive choice.

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.

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.

A Survey of Women Who Cryopreserved Oocytes for Non-medical Indications (Social Fertility Preservation)

To evaluate the expectations, experiences, and fertility awareness status of women who underwent social oocyte cryopreservation. Cohort survey study was conducted at an academic medical center. All women who underwent social oocyte cryopreservation between January 2015 and June 2016 were recruited. One hundred thirty-three women were contacted by phone to participate in a survey. The questionnaire investigated the initial motivation towards freezing, intentions to use cryopreserved oocytes, treatment experience, awareness of fertility and knowledge about chances of having a live birth with their frozen oocytes. The mean age at the time of oocyte freezing was 38.5 ± 2.68 years. The average number of mature oocytes cryopreserved was 5.48 ± 6.6 (1-16). Two major motivations were absence of a male partner (40%) and an anticipated age-related fertility decline (42%). Almost 60% overestimated the chances of natural conception, as well as the success of IVF at the age of 40 years. Half of the oocyte bankers reported that fertility declined between ages 35 and 39, but only 28% of patients estimated the live birth rate per cryopreserved oocyte correctly. Overall 98.8% stated that they would recommend oocyte cryopresevation to a friend, and 72% felt more secure in terms of reproductive potential. Despite comprehensive personalized counseling prior to the start of ovarian stimulation, many women do not seem to have a realistic understanding of reproductive aging. Even though gamete cryopreservation provides some insurance, overestimating the effectiveness of oocyte cryopreservation can also lead to a false sense of security. Clinical Trial Registration: 2016.086.IRB1.006.

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.

Social egg freezing and donation: waste not, want not

The trend towards postponement of childbearing has seen increasing numbers of women turning towards oocyte banking for anticipated gamete exhaustion (AGE banking), which offers a realistic chance of achieving genetically connected offspring. However, there are concerns around the use of this technology, including social/ethical implications, low rate of utilisation and its cost-effectiveness. The same societal trends have also resulted in an increased demand and unmet need for donor oocytes, with many women choosing to travel overseas for treatment. This has its own inherent social, medical, financial and psychological sequelae. We propose a possible pathway to address these dual realities. The donation of oocytes originally stored in the context of AGE banking, with appropriate compensatory mechanisms, would ameliorate AGE banking concerns, while simultaneously improving the supply of donor oocytes. This proposed arrangement will result in tangible benefits for prospective donors, recipients and society at large.

Exploring women's attitudes, knowledge, and intentions to use oocyte freezing for non-medical reasons: A systematic review

INTRODUCTION

Women are postponing childbearing and preventing age-related fertility decline with oocyte freezing for non-medical reasons (OFNMR). The objective of this systematic evaluation was to gain an understanding of women's attitudes and knowledge of, and intentions to use OFNMR among users of OFNMR and the general public.

MATERIAL AND METHODS

A systematic search of MEDLINE, EMBASE, and PyschINFO databases was undertaken, for studies that examined the psychosocial attitudes among women toward OFNMR. The search was limited to English language and no time restriction was set for publications. Extracted data were analyzed using thematic analysis and the study was performed according to PRISMA guidelines with prospective PROSPERO registration (CRD4201912578).

RESULTS

Overall, 35 studies met the inclusion criteria. Studies were broadly categorized into studies investigating users or potential users of OFNMR, and studies examining the views of members of the general public. Users of OFNMR have good knowledge of age-related fertility decline and awareness of the OFNMR procedure. Lack of partner was identified as the most common motivating factor to undertake OFNMR, with cost as a predominant concern. Knowledge among the general public of OFNMR is highly variable. Underestimation of age-related fertility decline is common among the general public. Intentions of women to use OFNMR also varied drastically between studies.

CONCLUSIONS

Women are predominantly motivated to freeze eggs by the lack of a suitable partner, but cost is a significant barrier. Increasing the number of women pursuing OFNMR at an earlier stage may positively impact upon the risk of future involuntary childlessness. Better information should be made available to both women and men about their fertility and options to inform their reproductive decision-making.

Predicting the chance on live birth per cycle at each step of the IVF journey: external validation and update of the van Loendersloot multivariable prognostic model

OBJECTIVE

To study the performance of the 'van Loendersloot' prognostic model for our clinic's in vitro fertilisation (IVF) in its original version, the refitted version and in an adapted version replacing previous by current cycle IVF laboratory variables.

METHODS

This retrospective cohort study in our academic tertiary fertility clinic analysed 1281 IVF cycles of 591 couples, who completed at least one 2nd-6th IVF cycle with own fresh gametes after a previous IVF cycle with the same partner in our clinic between 2010 and 2018. The outcome of interest was the chance on a live birth after one complete IVF cycle (including all fresh and frozen embryo transfers from the same episode of ovarian stimulation). Model performance was expressed in terms of discrimination (c-statistics) and calibration (calibration model, comparison of prognosis to observed ratios of five disjoint groups formed by the quintiles of the IVF prognoses and a calibration plot).

RESULTS

A total of 344 live births were obtained (26.9%). External validation of the original van Loendersloot model showed a poor c-statistic of 0.64 (95% CI: 0.61 to 0.68) and an underestimation of IVF success. The refitted and the adapted models showed c-statistics of respectively 0.68 (95% CI: 0.65 to 0.71) and 0.74 (95% CI: 0.70 to 0.77). Similar c-statistics were found with cross-validation. Both models showed a good calibration model; refitted model: intercept=0.00 (95% CI: -0.23 to 0.23) and slope=1.00 (95% CI: 0.79 to 1.21); adapted model: intercept=0.00 (95% CI: -0.18 to 0.18) and slope=1.00 (95% CI: 0.83 to 1.17). Prognoses and observed success rates of the disjoint groups matched well for the refitted model and even better for the adapted model.

CONCLUSION

External validation of the original van Loendersloot model indicated that model updating was recommended. The good performance of the refitted and adapted models allows informing couples about their IVF prognosis prior to an IVF cycle and at the time of embryo transfer. Whether this has an impact on couple's expected success rates, distress and IVF discontinuation can now be studied.

"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.

Knowledge about the impact of age on fertility: a brief review

Delayed childbearing is currently a major challenge in reproductive medicine as increased age has an important impact on successful conception, both in natural and in assisted reproduction. There is a lack of knowledge about the impact of age on fertility, even in highly educated populations. A number of initiatives have been taken to increase fertility awareness. Health care providers have been encouraged to talk with patients about their reproductive life plan (RLP) for almost a decade based on recommendations from the Centres for Disease Control and Prevention. This concept has been explored successfully in Swedish contraception counselling. A growing number of online interventions aim to raise fertility awareness. These websites or interactive tools provide relevant information for individuals and couples as they consider whether they want children, when they should have them, and how many they may wish to have. These interventions are important, because research depicts that knowledge helps people in their decision-making process. With new fertility preservations such as egg freezing now available, additional education is needed to be sure that women and couples are well informed about the cost and low success rates of this intervention.

Social freezing of oocytes: a means to take control of your fertility

In the last few decades, there have been tremendous developments of assisted reproductive technologies, but the outcome of in vitro fertilization is highly dependent on the age of the oocyte. The introduction of vitrification offers a possibility to freeze eggs proactively in younger years and use them at later ages, also called social egg freezing. Knowledge about age-related fertility decline is insufficient among many women, and there is an overoptimistic trust that in vitro fertilization can overcome this. The awareness of proactive egg freezing is limited, both among doctors and in the general population. This review aims at increasing the knowledge about proactive egg freezing and offers a means to advise women correctly. It deals with national guidelines, the best age and optimal number of eggs to freeze, and the chance to succeed. Creating more public awareness about age-linked fertility decline and elective egg freezing may help women reproduce at their own pace - to take control of their fertility.

Elective egg freezing: what is the vision of women around the globe?

Aim

The interest in oocyte cryopreservation (OC) for nonmedically indicated reasons is increasing. Knowing women's beliefs and knowledge from various geographic regions could help providers to understand the similarities and differences that could facilitate proper counseling.

Materials & methods

Articles about social egg freezing published over the past 18 years were extracted from the literature.

Results

We demonstrated that there are common rationales toward OC among women in the USA and other countries. The ultimate goal was to prolong fertility. The most commonly reported reasons were aging, lack of partner, career and financial status.

Conclusion

The beliefs and rationales toward elective OC among women in the USA and other countries are consistent.

Effectiveness of social egg freezing: protocol for systematic review and meta-analyses

INTRODUCTION

Social egg freezing is storing egg for the purpose of preserving fertility and delayed childbearing. Currently, little is known about the utilisation and effectiveness of this approach. This review aims to determine (1) the proportion of women who used their stored eggs, and (2) the egg survival rate through vitrification, and the clinical pregnancy rate and live birth rate per 100 women partaking in the procedure, and among women who stored their eggs for medical reasons.

METHODS AND ANALYSES

This systematic review will be done according to the items listed in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. PubMed, Embase, Scopus, The Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Cochrane Library and Health Technology Assessment databases will be searched to identify eligible studies published since 2012. Two reviewers will independently appraise the eligibility and quality of the studies based on preset checklists and extract the data using a data extraction template. Outcomes of interest are proportion of women who used their stored eggs, egg survival rate, pregnancy rate and live birth rates. We will determine the presence heterogeneity among studies using the Cochrane's Q test. The percentage of total variation across studies, which is due to statistical heterogeneity, will be calculated using the I² statistics. Outcomes of interest will be pooled together using metaprop programme STATA V.14.

ETHICS AND DISSEMINATION

For this review, ethical committee approval is not required. We will use publically available data from previously published studies. The final report of the review will be disseminated through publication on national or international journal, and it will be presented on different scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD42018114254.

Women's attitudes and beliefs about using fertility preservation to prevent age-related fertility decline-A two-year follow-up

OBJECTIVE

The health belief and transtheoretical model were used to describe how women make decisions about fertility preservation (FP) and identify factors that predict their decisions.

METHODS

This is a two-year prospective study with 107 childless women aged 30-37. Women filled anonline survey assessing individual factors, intentions to do FP, variables of the health belief model, FP decisional stage and FP behaviour.

RESULTS

Women´s intentions, desire and number of children wanted decreased, fertility knowledge and perceived susceptibility to infertility increased and perceived severity of infertility decreased. A low number of women progressed through the stages of the decision-making process. Only 14% reached a decision and all decided not to do FP. Women's baseline intentions to do FP predicted their decision.

CONCLUSION

Women at the optimal age range to do FP (28-35 years) do not engage in decision-making about it, which reflects their initial low intentions to do FP. Women's decision about FP is influenced by their perceptions about the technique.

PRATICAL IMPLICATIONS

Women with a high desire for parenthood and within the optimal age range to do FP should receive accurate information about it and could benefit from prompts to engage in active decision-making about doing it.

Physicians' attitudes towards using elective oocyte cryopreservation to accommodate the demands of their career

PURPOSE

Among medical professionals, there appears to be a significant lack of knowledge about oocyte cryopreservation. Medical professionals may be potential candidates for elective oocyte cryopreservation due to the demands and commitments of medical training. There is a paucity of data on this topic among medical professionals. The aim of this study was to assess knowledge, understanding, and beliefs towards elective egg freezing among medical professionals to assess whether they are potential candidates for elective egg freezing.

METHODS

This is a cross-sectional descriptive study in a university-based training program. All medical students, residents, fellows, and faculty were included. An online survey was emailed to potential participants. It included demographic questions regarding childbearing decision-making factors, fertility knowledge, and attitudes towards using elective oocyte cryopreservation.

RESULTS

A total of 1000 emails were sent. Of those, 350 completed surveys were received. On average, 33% of responders provided a correct answer to each fertility knowledge question. The duration of training and the heavy workload with long duty hours were the most common influencing factors when deciding the timing of childbearing. Overall, 65% of the male and female responders were concerned about their future fertility. Among those women who had future fertility concerns, 8% were not aware of egg freezing as a fertility option and wished they had had an opportunity to freeze their eggs at an earlier time.

CONCLUSIONS

Physicians' childbearing decisions can be affected by the demands of their careers. Elective oocyte cryopreservation could be considered an option for family planning. Educational sessions and awareness programs are needed to provide information about available fertility preservation options, which can potentially decrease the rate of regret.

Elective and Onco-fertility preservation: factors related to IVF outcomes

STUDY QUESTION

Is the indication for fertility preservation (FP) related to success in IVF cycles after elective-FP (EFP) for age-related fertility decline and FP before cancer treatment (Onco-FP)?

SUMMARY ANSWER

Although success rates were lower in cancer patients, there was no statistically significant association between malignant disease and reproductive outcome after correction for age and controlled-ovarian stimulation (COS) regime.

WHAT IS KNOWN ALREADY

FP is increasingly applied in assisted reproduction, but little is known about the outcome of IVF cycles with vitrified oocytes in FP patients.

STUDY DESIGN, SIZE, DURATION

Retrospective, observational multicenter study of vitrification cycles for FP and of the warming cycles of women who returned to attempt pregnancy from January 2007 to May 2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In all, 6362 women (EFP = 5289 patients; 7044 cycles + Onco-FP = 1073 patients; 1172 cycles) had their oocytes vitrified for FP. A logistic regression analysis was performed to examine the impact of indication for FP corrected for age at vitrification. The protocol used for COS was also included as a possible confounder. The main outcome measures were oocyte survival and live birth. A detailed description of the baseline and clinical data is provided, with comparisons between EFP and Onco-FP. The cumulative live birth rate (CLBR) per utilized oocyte according to age at vitrification was analyzed in those patients returning to use their oocytes.

MAIN RESULTS AND ROLE OF CHANCE

Age at vitrification was significantly older in EFP patients (37.2 ± 4.9 vs. 32.3 ± 3.5 year; P < 0.0001). Fewer oocytes were retrieved and vitrified per cycle in EFP (9.6 ± 8.4 vs. 11.4 ± 3.5 and 7.3 ± 11.3 vs. 8.7 ± 2.1, respectively; P < 0.05), but numbers became comparable when analyzed per patient (12.8 ± 7.4 vs. 12.5 ± 3.2 and 9.8 ± 6.4 vs. 9.5 ± 2.6). Storage time was shorter in EFP (2.1 ± 1.6 vs. 4.1 ± 0.9 years; P < 0.0001). In all, 641 (12.1%) EFP and 80 (7.4%) Onco-FP patients returned to attempt pregnancy (P < 0.05). Overall oocyte survival was comparable (83.9% vs. 81.8%; NS), but lower for onco-FP patients among younger (≤35 year) subjects (81.2% vs. 91.4%; P > 0.05). Fewer EFP cycles finished in embryo transfer (50.2% vs. 72.5%) (P < 0.05). The implantation rate was 42.6% and 32.5% in EFP versus Onco-FP (P < 0.05). Ongoing pregnancy (57.7% vs. 35.7%) and live birth rates (68.8% vs. 41.1%) were higher in EFP patients aged ≤35 than the Onco-FP matching age patients (P < 0.05). The reason for FP per se had no effect on oocyte survival (OR = 1.484 [95%CI = 0.876-2.252]; P = 0.202) or the CLBR (OR = 1.275 [95%CI = 0.711-2.284]; P = 0.414). Conversely, age (<36 vs. ≥36 y) impacted oocyte survival (adj.OR = 1.922 [95%CI = 1.274-2.900]; P = 0.025) and the CLBR (adj.OR= 3.106 [95%CI = 2.039-4.733]; P < 0.0001). The Kaplan-Meier analysis showed a significantly higher cumulative probability of live birth in patients <36 versus >36 in EFP (P < 0.0001), with improved outcomes when more oocytes were available for IVF.

LIMITATIONS, REASONS FOR CAUTION

Statistical power to compare IVF outcomes is limited by the few women who came to use their oocytes in the Onco-FP group. The patients' ages and the COS protocols used were significantly different between the EFP and ONCO-PP groups.

WIDER IMPLICATIONS OF THE FINDINGS

Although the implantation rate was significantly lower in the Onco-FP patients the impact of cancer disease per se was not proven'. EFP patients should be counseled according to their age and number of available oocytes.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used for this study. The authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Running out of time: exploring women's motivations for social egg freezing

Objective: Few qualitative studies have explored women's use of social egg freezing. Derived from an interview study of 31 participants, this article explores the motivations of women using this technology. Methods: Semi-structured interviews were conducted with 31 users of social egg freezing resident in UK (n = 23), USA (n = 7) and Norway (n = 1). Interviews were face to face (n = 16), through Skype and Facetime (n = 9) or by telephone (n = 6). Data were analyzed using interpretive thematic analysis. Results: Women's use of egg freezing was shaped by fears of running out of time to form a conventional family, difficulties in finding a partner and concerns about "panic partnering", together with a desire to avoid future regrets and blame. For some women, use of egg freezing was influenced by recent fertility or health diagnoses as well as critical life events. A fifth of the participants also disclosed an underlying fertility or health issue as affecting their decision. Conclusion: The study provides new insights in to the complex motivations women have for banking eggs. It identifies how women's use of egg freezing was an attempt to "preserve fertility" in the absence of the particular set of "life conditions" they regarded as crucial for pursuing parenthood. It also demonstrates that few women were motivated by a desire to enhance their career and that the boundaries between egg freezing for medical and for social reasons may be more porous than first anticipated.

Knowledge and attitudes regarding elective oocyte cryopreservation in undergraduate and medical students

Background

To assess knowledge and attitudes regarding elective oocyte cryopreservation among female undergraduate students (UG) and medical students (MS) in Eastern Virginia.

Methods

An anonymous cross-sectional study surveying female UG at a local university and MS at our academic medical center in May of 2017. The survey contained questions on demographic information, interest in fertility preservation, and knowledge about age related changes in fertility.

Results

There were 74 of 102 female UG and 95 of 117 female MS who responded, for a response rate of 73 and 81% respectively. UG were significantly younger than MS (21.4 vs 26.8, p < 0.001). Further, UG generally planned on conceiving at a younger age than MS (age 26–30 vs 31–35), and favored younger ages to consider oocyte cryopreservation (age 26–30 vs 31–35). Only a minority of both UG and MS were willing to undergo egg freezing at the current price of approximately $10,000 (15% vs 26% respectively, p = 0.044). Moreover, 73% of students overall responded that they would be more likely to freeze oocytes if their employer paid. Notably, both UG and MS underestimated age of fertility decline.

Conclusion

Both UG and MS revealed a need for education on age-related changes in fertility. Most UG and MS would not undergo elective oocyte cryopreservation at the present cost but would consider it at a lower cost.

Electronic supplementary material

The online version of this article (10.1186/s40738-019-0057-9) contains supplementary material, which is available to authorized users.

Conceptualising women's motivations for social egg freezing and experience of reproductive delay

As the average age of motherhood in many Western countries continues to rise, the spectacle of the older mother and the trend towards delayed childbearing has been the subject of much public debate and interest. Concurrent to this trend has been the development and use of a new form of fertility preservation - social egg freezing - a technology which by its very nature is meant to enable reproductive delay. Whilst previous studies have been able to provide insights into the complex and often interrelating structural, economic, and relational factors shaping the timing of motherhood, and in some cases women's use of social egg freezing, fewer studies have clearly demonstrated the way these factors themselves, as well as the accounts of individual women, can be seen as being shaped by ideological and discursive forces. Drawing on interviews with 31 users of social egg freezing this article will demonstrate how women's accounts of reproductive delay and use of egg freezing technology can be seen as being shaped by neoliberal rationality, heteronormativity, discourses of 'appropriate parenting' and gendered ideologies of parenthood.

To freeze or not to freeze: decision regret and satisfaction following elective oocyte cryopreservation

OBJECTIVE

To characterize the degree of decision regret following elective oocyte cryopreservation (EOC) for social indications, and identify factors associated with regret.

DESIGN

Retrospective cohort survey study.

SETTING

Academic center.

PATIENTS

Two hundred one women who underwent EOC for fertility preservation between 2012 and 2016.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Decision Regret Scale (DRS) score, from 0-100, with a cut-off >25 indicative of moderate to severe regret; and attitudes regarding decision satisfaction.

RESULTS

Median DRS score was 0 (interquartile range 0-15) and the mean was 10 (range 0-90). Thirty-three women (16%) experienced moderate to severe decision regret. Factors associated with decision regret included: number of eggs frozen, perceived adequacy of information prior to EOC, adequacy of emotional support during EOC, and patient-estimated probability of achieving a live birth using their banked eggs. In a multivariate logistic model, increased perceived adequacy of information (adjusted odds ratio 0.63, 95% confidence interval 0.42-0.97) and patient-estimated probability of achieving a live birth (adjusted odds ratio 0.80, 95% confidence interval 0.67-0.96) were associated with reduced odds of regret. One hundred sixty-seven women (88%) reported increased control over reproductive planning following EOC. One hundred eighty-three (89%) affirmed they will be happy they froze eggs, even if they never use them.

CONCLUSIONS

The risk of decision regret following EOC is non-negligible. Low number of mature oocytes cryopreserved is a risk factor for increased regret, while perceptions of adequate information and emotional support, and increased patient-estimates of achieving a live birth using banked eggs are associated with reduced risk of regret.

Attitude towards ovarian tissue and oocyte cryopreservation for non-medical reasons: a cross-sectional study

PURPOSE

To assess the attitude towards ovarian tissue and oocyte cryopreservation for non-medical reasons.

METHODS

Cross-sectional electronic survey in 248 Swiss women aged 15-35 years, nationally representative for educational level.

RESULTS

Most women did not worry about an age-related fertility decline. Two-thirds of women would consider using hormone therapy (HT) for menopausal symptom relief although concerns about side effects and risks were still high. Acceptance of cryopreservation of oocytes (19%) or ovarian tissue (13%) for postponing fertility or menopause was generally low, but increased (37%) if both goals could be achieved with one surgery. Cryopreservation of ovarian tissue for postponing menopause was acceptable for 22% of women. Not having a suitable partner until age 35 increased the likelihood of considering postponing fertility by cryopreservation (p < 0.001) and had a stronger impact on that decision than the factor "pursuing a career" (p < 0.001).

CONCLUSION

More education on age-related fertility decline, menopause and HT (benefit-risk ratio) is needed. Furthermore, the political and socioeconomic discussion should focus on women's needs, especially on compatibility of career and family.