The reproductive lifespan of women is limited by their biological clock. The quantity and quality of women’s eggs diminishes with age, with rapid decline beginning in the late thirties. For women who prefer to delay motherhood, egg freezing technology provides an opportunity to extend fertility by freezing and storing unfertilized eggs. The purpose of this quantitative, descriptive study was to assess attitudes toward the phenomenon called social egg freezing.
A survey was performed in the United States, and only legal age women (≥21 years old) were questioned on views with respect to freezing eggs for non-medical reasons, factors that could affect their decisions, and their awareness about reproductive aging and fertility. Reproductive age women were separately questioned on their willingness to freeze eggs based on the desire for children and their preferred age of motherhood.
The electronic questionnaire was completed by 59 women. The results indicated that 28.9% of the participants categorized themselves as potential social egg freezers, of which 13.6 % would definitely consider freezing their eggs. Conversely, 50.8% of the participants considered themselves as non-freezers, while 20.3% had no opinion. Factors such as the desire for a child, the preferred age of motherhood, the health safety of the children, and speaking with women who had undergone in vitro fertilization treatment had significant influence on participants’ decisions as potential freezers. The results suggest that freezing eggs for social reasons is ideal for a significant proportion of women. Therefore, it should be considered as a treatment option for women who would like to preserve their fertility. However, women should increase their knowledge of reproductive aging and fertility so they can make informed reproductive decisions.
The improved techniques for freezing human eggs have made the practice of egg freezingfor non-medical or social purposes a promising technology for women who wish to preserve their fertility (Porter, 2009). Today, many in vitro fertilization (IVF) centers offer social egg freezing to interested women (Rudick, Opper, Paulson, Bendikson, & Chung, 2010). This phenomenon has generated controversy, and the literature has revealed benefits (Silber, 2006) as well as disadvantages (Lockwood, 2011). What has been largely overlooked in this discussion are the attitudes of women, the potential beneficiaries of social egg freezing. Although there are a few European studies (European Society of Human Reproduction and Embryology, 2010), there is, surprisingly, no published study in the U.S. American women and women around the world deserve to participate in the discussion on egg freezing or any other technology related to reproductive health.
Women have a promising new option to preserve their fertility because egg freezing (oocyte cryopreservation) is no longer an experimental procedure (The American Society for Reproductive Medicine, 2012). Assisted reproductive technologies (ART), such as cryopreservation and storage of gametes (oocytes and sperm) and embryos, have made tremendous progress and have been used in IVF centers since the birth of the first IVF baby in 1978 (Gardner, Sheehan, Rienzi, Katz-Jaffe, & Larman, 2007).
There are two methods of cryopreservation: slow freezing and vitrification. Both methods freeze gametes and embryos; however, after years of research, scientists have learned that slow freezing, which has yielded successful results for embryos and sperm, does not work as well for oocytes due to their unique physiology (Saragusty & Arav, 2011). In the late 1980s, the slow freezing technique, which was used for the first time to freeze oocytes, “resulted in low oocyte survival rate, poor embryo development, and low birth rate” (Shkedi-Rafid & Hashiloni, 2011, p. 291). For this reason, for many years IVF centers mainly practiced oocyte cryopreservation for medical purposes and did not offer this procedure for social reasons (Shkedi-Rafid & Hashiloni, 2011).
Oocyte cryopreservation has been challenging because the human oocyte is an atypically large cell containing a significant amount of water, which renders it prone to the formation of ice crystals and cell breakage during cryopreservation (Kuwayama, Vajta, Kato, & Leibo, 2005). Preventing the formation of ice crystals in an oocyte was not possible with the slow freezing method; researchers developed the vitrification method as an alternative (Gook & Edgar, 2007). Vitrification involves the suspension of oocytes in a high concentration of cryoprotective solution, which is subjected to extremely rapid cooling (Zhang, Liu, Xing, Zhou, & Cao, 2011). The improved vitrification technique has produced successful egg freezing outcomes. Compared to the slow freezing technique, vitrification has significantly increased the rates of egg survival (81% vs. 67%), fertilization (77% vs. 67%), and pregnancy (5.25% vs. 1.7%) (Roupa, Wozniak, Tsipras, & Sotiropoulou, 2011).
In the early 2000s, the first live baby was born in the U.S. from vitrified oocytes (Katayama, Stehlik, Kuwayama, Kato, & Stehlik, 2003). According to Motluk (2011), “worldwide, it is estimated that fewer than 2000 people have been born from frozen eggs, about 400 of them in the United States” (p. 383). Currently the success rates of egg freezing are comparable to a fresh IVF cycle (Nagy et al., 2009). However, until recently, major medical regulatory bodies throughout the U.S. and Europe have had concerns about the potential risks that oocyte cryopreservation could pose; therefore, this procedure was considered experimental (Shkedi-Rafid & Hashiloni, 2011).
The committee of the American Society for Reproductive Medicine (ASRM) has removed the experimental label from the practice of egg freezing because sufficient evidence for its safety has been found (The American Society for Reproductive Medicine, 2012). Recently, these findings have prompted IVF professionals to consider oocyte cryopreservation as part of their routine practice for fertility preservation. In vitro fertilization professionals have traditionally offered freezing and storage of oocytes for medical purposes, but according to a recent study by Rudick et al. (2010), 66% of IVF clinics in the U.S., where oocyte cryopreservation technology is practiced, have started to offer this technology to patients for non-medical reasons.
Freezing eggs for non-medical reasons is also known as social egg freezing (Mertes & Pennings, 2012). The topic of social egg freezing has generated much discourse among professionals and policy makers in the U.S. and other countries (Mertes & Pennings, 2012). For example, Goold and Savulescu (2009) have highlighted the benefits of this practice, such as the ability of women to postpone child bearing until they fulfill goals and are ready for motherhood. By freezing young eggs, women can spend their optimal childbearing years pursuing higher education, building a successful career, or finding the right partner, for example, and effectively delaying the experience of motherhood until they are ready (Goold & Savulescu, 2009). Although the ideal age range for women to freeze their oocytes is believed to be between the ages of 31 and 35 (Molloy, Hall, Ilbery, Irving, & Harrison, 2009), women aged 36-40 years may also benefit from this technology.
Conversely, Molloy, Hall, Ilbery, Irving, and Harrison (2009) and Lockwood (2011) have pointed out the disadvantages associated with social egg freezing, such as the uncertainty of the pregnancy results, ethical implications, high costs, and potential harm. Opponents raise ethical concerns, arguing that social egg freezing gives false hopes to older women who have surpassed reproductive age: 41 and older (Mertes & Pennings, 2011). The pregnancy success rates for frozen oocytes retrieved from women aged 35 and younger are twice those of frozen oocytes retrieved from women in their forties and higher (Molloy et al., 2009). However, it may also be the case that oocytes collected and frozen from a woman at the age of 38 may have a better chance of leading to a successful pregnancy than fresh eggs collected from a woman at the age of 43 (Molloy et al., 2009).
Although ASRM has removed the experimental label from oocyte cryopreservation, the committee has not approved freezing eggs for social reasons because there is not yet enough data to estimate the risks, safety, and efficiency (ASRM, 2012). However, what this debate lacks is data about women’s attitudes and intentions toward the available technology for egg freezing.
Women are the potential beneficiaries of social egg freezing. As women age, the success rate for pregnancy decreases because the quality and quantity of oocytes decline (Mertes & Pennings, 2011). The incidence of infertility increases as women age, not because of the age of the womb, but because the age of the oocyte is what mainly affects the rate of conception or miscarriage (Goold & Savulescu, 2009). These biological constraints limit women’s reproductive choices; therefore, postponing childbearing to achieve other goals is not an easy decision for them (Mertes & Pennings, 2011). Egg-freezing technology can be an option for some women because they can freeze and store younger oocytes and use them when, or if, they want them. Freezing eggs can alleviate the pressure to bear children within the traditional biological window of time, allowing women to prioritize life goals, while preserving their fertility (Rudick et al., 2010).
Egg freezing technology specifically affects the lives of women (Noyes, Boldt, & Nagy, 2010); therefore, their input is critical to its development and application. Therefore, they are the ones who should decide if they might undergo social egg freezing and whether they might use this technology to increase reproductive choices and affect the quality of their lives. Interestingly, there are no published studies about the attitudes of U.S. women toward egg freezing for non-medical reasons. Conducting this kind of study in the U.S. is important because the demand for oocyte cryopreservation continues to grow (Noyes et al., 2010). Therefore, it is the responsibility of fertility professionals to inform women of egg freezing technology so they can better decide if this technology may or may not suit their needs. Secondly, women’s opinions on the topic are needed to understand what women expect from egg freezing technology, so the technology can be improved and services designed based on women’s needs.
The results of a few studies examining the attitudes of reproductive age women toward social egg freezing, conducted in European countries, found a significant number of women favored, or had positive feelings toward this phenomenon (Gorthi, Wright, & Balen, 2010; Nekkebroeck, Stoop, & Devroey, 2010; Stoop, Nekkebroeck, & Devroey, 2010). However, these studies do not represent the attitudes of a majority of women about social egg freezing, so more studies are needed - particularly in the U.S. - as more women become aware of their access to such technology.
The purpose of this quantitative, descriptive study was to explore the attitudes of legal aged U.S. women toward social egg freezing and to examine their awareness of reproductive aging and fertility.
R1: What are the attitudes of legal age U.S. women toward egg-freezing technology for non-medical purposes?
R2: What is the understanding of legal age women regarding fertility and aging?
The study design was a quantitative, descriptive survey.
The study focused on views of American women toward the practice of social egg freezing. The participants were women of legal age in the United States who had the desire to participate in an electronic survey and answer a prepared questionnaire about their views on social egg freezing. The participants were recruited and data collected using SurveyMonkey. The SurveyMonkey Audience project was set up to e-mail the study survey to certain numbers of qualified individuals (SurveyMonkey, 2012). To gain a more complete cultural perspective about the topic, women who had passed reproductive age were also encouraged to express their thoughts and share ideas about this technology.
In this study, consecutive sampling, which is one of the non-probability sampling techniques, was employed wherein women who met inclusion and exclusion criteria were recruited as they became available (Portney & Watkins, 2009). The inclusion criteria for the respondents included: (a) respondent had to be female; (b) respondent had to live in the U.S.; and (c) respondent had to be of legal age (21 years old and above). The exclusion criteria included (a) men; (b) respondents who did not live in the U.S.; and (c) respondents who were < 21 years old. Approval from the A.T. Still University Institutional Review Board (ATSU IRB) was obtained prior to data collection and participant recruitment.
To survey women’s attitudes about oocyte cryopreservation for non-medical purposes, a questionnaire was constructed based on the previous research conducted by Stoop et al. (2010). The permission e-mail can be found in Appendix A. The proposed survey tool resembles the Stoop et al. (2010) survey with regards to the intentions and attitudes towards oocyte cryopreservation for non-medical reasons among women of reproductive age (21-40 years) in Belgium. The modified survey can be found in Appendix B. A demographic questionnaire, modeled from demographic questions in Stoop et al. (2010), asked the participants about their age, educational level, relational status, children, and income (see Appendix B).
The original survey was used to question women about their willingness to freeze oocytes in the future, their fertility awareness, factors that would make women more likely to freeze their oocytes, attitudes and intentions regarding age of motherhood and desire for a child, and attitudes toward oocyte donation. For example, women were asked if they might have considered freezing their eggs; their answers were categorized as yes, no, maybe, or I do not know (Stoop et al., 2010). The proposed survey followed the same path and asked the same questions.
However, because women who were beyond their reproductive ages have also been included in the survey, the questions were modified to include their responses based on what they would likely had done if the option of egg freezing had been available for them during their reproductive years. To establish face and content validity, the preliminary draft of the survey was distributed to three experts in fertility to review the questionnaire who agreed that the contents were acceptable. The study did not have enough data to examine the reliability of the survey.
The questionnaire was distributed using an electronic survey. The survey cover letter is shown in Appendix C. SurveyMonkey, a web-based survey company, was used to distribute the questionnaire to women in the United States who were in the SurveyMonkey audience and who met specific criteria (SurveyMonkey, 2012). The electronic surveys allows “for anonymity and automatic tallying of responses” (Portney & Watkins, 2009, p.326). Participants were asked to answer 36 questions, and they had 30 calendar days to respond. The investigator received the results from SurveyMonkey through a secure link and the questionnaire was completed by 61 qualified participants.
Statistical analysis was conducted using the International Business Machines Statistical Package for Social Sciences (IBM SPSS) software, version 21.0. Descriptive statistics, including the mean, standard deviation, median, frequency, and valid percent were reported for the participants demographic variables, including age, educational level, relationship status, sexual orientation, number of children, income level, employment status, and infertility experience.
Age was tested for normality with the Kolmogorov-Smirnov (K-S) test, at p = .05. Frequencies and valid percentages were used to describe legal age American women’s attitudes toward social egg freezing and to determine their awareness about fertility and aging. The women’s desire for egg freezing was analyzed by descriptively comparing the valid percentages of women who would definitely freeze their eggs, who would consider it or who were not sure, or who would definitely not freeze their eggs. Frequencies and valid percentages were also used to analyze all of other survey items such as reproductive age women’s intentions to freeze their eggs, and the factors that would made legal age women to freeze their eggs.
Frequencies were run on the demographic variables used to describe the study sample. Table 1 contains a breakdown of demographic characteristics of the sample. The Kolmogorov- Smirnov test was performed for the variable, age, and the results showed a p-value >.05. This indicated that this variable was normally distributed. The mean age of the participants was 47.38 (SD=15.57), with range of 21-75 years. The participants were distributed across 26 states, with the majority of the respondents indicating they were from New York (13.1%). Most participants had a bachelor’s degree or higher (59%). Among the participants, 44.3% were married, while 23% were single (never married). A large majority of them (95.1%) were heterosexual (see Table 1).
Slightly more than half of the participants (53.3%) were the principal earner of their household. The participants’ median annual income was $25,000 - $49,999, and 9.1% of them had an annual income level of $75,000 and above (see Table 1). Similarly, the median annual income level of their partners was $25,000 - $49,000, with 16.7% of the partners reporting annual income levels of $75,000 and above. In addition, nearly half of the participants (45%) had a full time job, while others had either a part time job (10%) or were self-employed (11.7%).
Most of the participants (65.6%) had children. The results of the Kolmogorov-Smirnov test showed a p-value <.05 for this variable, indicating that the number of children was not normally distributed; the median number of their children was two. A majority of the participants (82%) had no experience with infertility. However, more than 50% of them either knew someone with a fertility problem (54.1%), or were aware of the egg freezing technique (55.7%; see Table 1).
This question examined the attitudes of women toward egg freezing technology for non-medical purposes. Three sections of the survey addressed this question. In the first section, the question was formulated as follows: “Would you consider (or might have considered if you had a chance) freezing eggs for social reasons?” The response categories were: yes, maybe, no, and I do not know. To simplify analysis, the sample was split into three groups: the potential freezers, who answered yes or maybe; the doubtful group, who said they were not sure; and non-freezers, who indicated that they would not freeze their eggs. The results were that of the 59 participants, 28.9% were potential freezers, 20.3% were doubtful, and 50.8% were non-freezers.
The second section addressed factors that would make legal age women more likely to freeze eggs. A majority of women responded that they could have been potential freezers if (a) they had the desire for a child (71.2%), (b) if they did not have children (69.5%), (c) if treatment was less complex (50.8%), (d) if it gave more guarantees for success (54.2%), (e) if the treatment was in a nearby hospital (50.8%), (f) if it did not affect future fertility (59.3%), (g) if it did not affect the health safety of the children (69.5%), and (h) if they had spoken to women who had undergone treatment (64.4%; see Table 2).
The last section, which solicited information related to reproductive-age women’s intentions to freeze eggs, examined their willingness to freeze eggs based on the desire for children and the age of motherhood. Reproductive-age women, who had a strong desire for a child and/or wanted children after the age of 29, were considered potential freezers. The results found that of the 26 reproductive-age participants, more than half of them had a strong desire to have a child, evidenced by indicating that they wanted at least one (more) child (57.7%), could imagine having (more) children (61.5%), and would want (more) children (69.2%). Close to half of the women (46.2%) indicated they would like their first child at age >29 years, and more than half of them (53.8%) intended to have their last child at age >35 years (see Table 3).
The purpose of this question was to examine legal age women’s understanding of fertility and aging. The results of testing participants’ awareness of reproductive aging and fertility showed that participants incorrectly were either too pessimistic (67.7%), and believed that their chances of becoming pregnant between the ages of 35-40 was ≤49%, or too optimistic (15.35%), and thought that their chances were ≥60%. Of the participants, only 16.9% correctly indicated that, in that category, their chances of conceiving were between 50-59%. There is a marked decrease in women’s ability to become pregnant between the ages 35-39 and only 42.4% of the participants were aware of it. Almost 35% of the women knew that the chance for a pregnancy to end with a miscarriage at the age of 40 years is 21-30%. Half of the participants (50.9%) incorrectly believed that between ages 40- 43, the chance of success from one in vitro fertility (IVF) treatment was ≥26%. In addition, a majority of the participants (91.6%) erroneously responded that at the age of 40, the risk of becoming pregnant with a child affected by Down-Syndrome was ≥5% (see Table 4).
This study explored the attitudes of legal age U.S women toward the relatively new technique of egg freezing for non-medical purposes. The study also examined the participants’ awareness about reproductive aging and fertility. Women’s fertility is largely dependent upon age. Fertility in women declines over time, and eventually ceases, so too do their chances for conception and pregnancy. Stoop et al. (2010) stated that “postponing having a child until after age of 35 years confront women with dramatically decreased pregnancy rates, which are even more pronounced if they postpone until the age of 40 years” (para. 31). Therefore, if women do not plan ahead, they may find themselves unable to conceive due to age-related infertility. Egg freezing, a new technique of assisted reproductive technology, can help women who choose to delay motherhood by storing their eggs for later use.
The results of the study suggested that although a significant proportion of women would consider or at least are open to the idea of social egg freezing, the majority of them did not have enough knowledge of reproductive aging and fertility. It is very important to increase women’s reproductive knowledge and their accessibility to fertility treatments that are safe, effective, and affordable if they wish to preserve their fertility.
Although this study was conducted with a small number of participants, it can be called a unique study because no studies have been published in the United States which examines women’s attitudes towards social egg freezing. The findings showed that a significant proportion of the participants considered freezing their eggs for social reasons, of which almost half responded that they would definitely undergo such a procedure. In contrast, a little more than half of the participants reported that they would definitely not consider freezing their eggs for social reasons. These results are consistent with previously reported data by Stoop et al. (2010) in Belgium, which questioned a large group of women of reproductive age about their views of social egg freezing and found that half of them considered themselves as non-freezers, while a relatively notable percentage of them considered themselves potential freezers. However, in Stoop et al. (2010) study, only a small portion of potential freezers reported that they would definitely consider the procedure.
In this study, reproductive age women were considered good candidates for egg freezing technology. Therefore, a separate set of questions was prepared for participants in this category. These questions examined the desire for children among reproductive age women, and their planned age for motherhood. There were 26 reproductive age women in this study, of which slightly more than half were willing to have (more) children at older ages. In addition to the desire to have children, other factors that influenced the decision-making process around social egg freezing among both reproductive and non-reproductive age women included the health safety outcomes of children born from in vitro fertilization, and opportunity to speak with women who had undergone in vitro fertilization treatment.
This study also examined women’s awareness about reproductive aging and fertility. Overall, a significant portion of the participants demonstrated inadequate knowledge about their fertility and aging. This fact may have played an important role in the results of this study, because if participants were unaware of age-related decline of women’s fertility, they may not have considered themselves to be less fertile at a more advanced age. A study conducted by Peterson, Pirritano, Tucker, and Lampic (2012) showed the lack of knowledge regarding fertility in college-aged women and men. Peterson et al. (2012) stated that their study participants, consisting of 246 randomly selected undergraduate university students, of which 138 were female, “significantly overestimated nearly every aspect of female fertility including the ages at which fertility declines” (p. 1381). Fertility awareness could help women to more successfully balance their reproductive lifespan, and, in some cases, use the egg freezing technology, which has recently become available for non-medical applications.
Although the findings of this study were consistent with the previous study by Stoop et al. (2010), limitations were identified. There are limited published studies that examine women’s attitudes towards social egg freezing, thereby limiting the reliability of the results of this study, as it cannot be compared with others. In addition, just over half of the participants were not in their reproductive years, and a majority of them had at least one child. This may have affected the accuracy of the findings because for these participants, the idea of social egg freezing may not seem as pertinent as it might to women who may want children, but have not yet had children. Finally, the small sample size and sampling methodology employed (i.e., via public opinion survey site) may limit the generalizability of these findings.
More research about women’s attitudes towards egg freezing for social reasons is needed for comparison and reliability. However, the new studies should mostly target women who are at risk of age-related infertility, but who may still be good candidates for egg freezing. Therefore, continued research about social egg freezing can be recommended for future investigators, with an emphasis on the attitudes of women between the ages of 25-35, who do not have children. Finally, it is highly recommended that women gain enough knowledge about age- related fertility issues so they can make informed reproductive decisions.
The purpose of this study was to investigate the attitudes of legal-age U.S. women toward social egg freezing and to examine their fertility knowledge. Despite the fact that egg freezing is a relatively new technology and that social egg freezing has recently become an option in most IVF centers, just over half of the participants were aware of it, and a significant proportion of them considered themselves to be potential freezers. However, the majority of participants showed inadequate knowledge of reproductive aging and fertility. Health and IVF professionals need to try harder to disseminate the information, because half of the ones who are aware are also open to the technology, and thus potential freezers. Despite the limitations, this study, which it is unique in its nature in the U.S., can open up a new venue for further explorations and discussions in regards to social egg freezing, and provide a good reference for future studies in this matter.
Dissemination-Publishable Paper for Applied Research Paper
A course assignment presented to the Arizona School of Health Sciences in partial fulfillment of the requirements for the Doctor of Health Science Degree A.T. Still University
December 7, 2013