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Public support in the United States for elective oocyte cryopreservation
Public support in the United States for elective oocyte cryopreservation Erin I. Lewis, M.D.,a Stacey A. Missmer, Sc.D.,a,b,c Leslie V. Farland, Sc.D.,a,b and Elizabeth S. Ginsburg, M.D.a a
Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston; b Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston; and c Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
Objective: To determine whether public support for oocyte cryopreservation (OC) exists and if support varies by demographic factors. Design: Cross-sectional electronic survey. Setting: Not applicable. Patient(s): A nationally representative sample based on age, sex, and race of 1,064 people in the United States recruited by the company SurveyMonkey. Interventions(s): Completion of an online questionnaire. Main Outcome Measure(s): Supporters of OC for various indications were compared with participants who were neutral or in opposition by means of log binomial regression to calculate risk ratios. Statistical models were adjusted for demographic characteristics, including sex, race, age, income, sexual orientation, education, marital status, state political party affiliation, and history of being a parent. Result(s): OC for cancer patients was the indication most supported (89%), followed by delayed childbearing for career advancement (72%), current lack of a partner (63%), and insufficient funds for child rearing (58%). Despite considerable support for OC, only 37% agreed employers should fund egg freezing for employees. Older age was associated with lower support for all indications of OC. Younger age, single status, never being a parent, identifying as a sexual minority, and atheist/agnostic religion were associated with the survey taker personally considering OC. Compared with women, men demonstrated lower support for women undergoing OC for ‘‘lack of a male partner,’’ and for future use of cryopreserved oocytes without being married. Conclusion(s): In a nationally representative sample, the majority of respondents support elective OC. The indication for OC was associated with significant differences in support. (Fertil SterilÒ 2016;106:1183–9. Ó2016 by American Society for Reproductive Medicine.) Key Words: Oocyte cryopreservation, fertility preservation, egg freezing, social oocyte cryopreservation Discuss: You can discuss this article with its authors and with other ASRM members at https://www.fertstertdialog.com/users/ 16110-fertility-and-sterility/posts/11012-public-support-in-the-united-states-for-elective-oocyte-cryopreservation
I
n the past 20 years, the United States population has seen a 150% increase in first births in women 35–39 years of age, and the average maternal age at first birth has increased from 21.4 years in 1970 to 26.3 years in 2014 (1). In addition, the birth rate for women 40–44 years of age is at its highest rate since 1966, and it has steadily increased by 2% a year since 2000 (1). Clearly, U.S. data demonstrate that women are delaying childbearing,
with the most significant change being an increase of births among women R35 years of age. This phenomenon is not isolated to the U.S., with recent European data indicating that women are changing reproductive behaviors and postponing childbearing (2). Recent surveys attribute this change in age of motherhood to increasing educational, financial, and professional pursuits, as well as a woman's ability to control reproduction with the use of
Received April 14, 2016; revised July 4, 2016; accepted July 5, 2016; published online July 26, 2016. E.I.L. has nothing to disclose. S.A.M. has nothing to disclose. L.V.F. has received a National Cancer Institute Fellowship in Cancer Prevention (3R25CA057711) and a National Institute of Child Health and Human Development Predoctoral Fellowship (T32HD060454). E.S.G. has nothing to disclose. Reprint requests: Erin I. Lewis, M.D., Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115 (E-mail: eilewis@ partners.org). Fertility and Sterility® Vol. 106, No. 5, October 2016 0015-0282/$36.00 Copyright ©2016 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2016.07.004 VOL. 106 NO. 5 / OCTOBER 2016
birth control (2). Complicating this trend is the increased rate of aneuploidy, high-risk pregnancies, and first-trimester losses that accompany older maternal age (3). Interestingly, several studies have demonstrated that many people are not sufficiently aware of natural age-related decline of female fertility (4–7). In one study, 79% of 178 women who underwent elective oocyte cryopreservation lamented that they had not started the process sooner (8). This lack of awareness regarding knowledge of female fertility affects informed decision making in a population that is increasingly delaying childbearing. Oocyte cryopreservation had relatively low success rates in the past and was deemed to be ‘‘experimental’’ by the American Society of Reproductive 1183
ORIGINAL ARTICLE: FERTILITY PRESERVATION Medicine (ASRM) in 2008. However, in 2010, a randomized controlled trial by Cobo et al. evaluated 600 donor recipients who had received either fresh or vitrified donor oocytes, and found no difference in the recipient pregnancy rates. However, that study focused on oocytes from young women serving as donors and not women with a history of infertility or decreased ovarian reserve due to age or other factors (9). A 2013 ASRM committee opinion lifted the experimental designation of OC, but cautioned that there were not enough data on the ‘‘safety, efficacy, cost-effectiveness, and emotional risks’’ to recommend elective OC (10). Although the European Society of Human Reproduction and Embryology also emphasizes the importance of further investigation regarding safety, costeffectiveness, and psychologic factors that might arise with elective egg freezing, they also recommend that OC be available for the prevention of age-related infertility (11). Increasing numbers of centers are performing elective OC, or what is commonly called ‘‘social egg freezing,’’ in Europe and North America (12, 13). In 2012, of the 387 U.S. clinics registered as Society for Assisted Reproductive Technology members, 200 (51.7%) offered OC for either medical or social reasons. Of those offering OC, 147 advertised for social or elective egg freezing (14). The trend toward elective OC has likely continued to increase since 2012 with more and more centers providing the service to women who wish to positively affect their long-term reproductive potential. As OC gains more media attention, several studies have addressed the acceptance of elective OC among reproductive-age women (15–17) and among male and female health care workers (18, 19). The present study aimed to survey both men and women in the general public to decipher attitudes toward elective OC and personal use of the technology in the future. With American corporations such as Apple and Facebook recently announcing funding of elective OC for female employees, we aimed to find if the public supports OC as a reproductive right (20, 21).
anonymity of the survey takers to the investigators, Institutional Review Board approval was exempted. Before reading or completing the questionnaire (Supplemental Appendix), the participant read an introduction explaining the purpose of the study, which included contact information for the research team, as well as an explanation of the Health Insurance Portability and Accountability Act. Survey Monkey ensured anonymity of survey takers to the investigators. A brief description describing the process of ovarian stimulation and oocyte cryopreservation was provided. Participants were then asked to answer 15 multiple-choice questions and given the option to type descriptive text for questions where their answer did not fit the available choices. Participants were asked to select if they strongly agreed, agreed, were neutral, disagreed, or strongly disagreed to different indications for egg freezing. Specifically these questions began with the statement, ‘‘Doctors should offer egg freezing as a way to preserve fertility for women delaying childbearing because .’’ The next part of the survey addressed the participant's potential future use of OC and how comfortable they were sharing this information. To make the survey gender neutral these questions began with the phrase, ‘‘If you were a woman desiring to preserve fertility and you underwent egg freezing would you feel comfortable .’’ The queries pertaining to when a woman should use her frozen eggs began with the question, ‘‘If a woman underwent egg freezing for preservation of fertility should she only be able to use her eggs to create a pregnancy if .,’’ and participants were asked to select yes, no, maybe, or ‘‘I don't know.’’ The second part of the study addressed the participant's knowledge of a woman's fertility with such open-ended questions as, ‘‘At what age do you think a woman's eggs have a lower chance of creating a pregnancy?’’ The survey concluded with participants providing demographic data.
Statistical Analysis
MATERIALS AND METHODS An online questionnaire (Supplemental Appendix, available online at www.fertstert.org) was sent by the professional survey company, SurveyMonkey, to a nationally representative sample of 1,064 people reflecting U.S. demographic characteristics for age, sex, and race, from March 23 to April 12, 2015. The survey was continued until the responses were reflective of national census estimates of age, sex, and race, because these demographics have been found to be relevant in other population-based survey studies assessing attitudes toward fertility preservation and fertility awareness (4, 15). Survey takers were rewarded with a donation of $0.50 to a charity of the survey taker's choice and entry into a sweepstakes for $100.00 on completion of the survey. Inclusion criteria for taking the survey required U.S. citizenship, male or female sex, age 18–65 years, literacy in English, and available Internet access. Participants who were opposed to in vitro fertilization (IVF) under any circumstances were disqualified from completing the survey with the reasoning that IVF is an essential component for the future use of cryopreserved oocytes. Given the 1184
For the demographic factors provided, descriptive statistics were calculated and referent groups established by the use of either the most logical comparison group or the largest group for nominal predictors. The following referent groups were designated: sex (female ¼ referent), ethnicity (white ¼ referent), age (18–44 years ¼ referent), household income (R$80,000.00 ¼ referent), sexual orientation (heterosexual ¼ referent), education (college education ¼ referent), marital status (married ¼ referent), predominant state political party support (Democratic state ¼ referent), history of being a parent (yes ¼ referent), and religion (Catholic ¼ referent). Information regarding political party affiliation was extrapolated from the historical political party affiliation in the 2012 presidential election of the state in which the participant resided. Supporters of various indications for oocyte cryopreservation were compared with those participants who were neutral or in opposition by means of log binomial regression to estimate the relative risk of agreement. Statistical models were adjusted a priori for demographic factors including age and marital status to yield risk ratios (RRs) with 95% confidence intervals (CIs) and Wald two-sided P VOL. 106 NO. 5 / OCTOBER 2016
Fertility and Sterility® values of support. In addition to investigating the relationship between categories of income and age, a test of linear trend of association was performed. SAS 9.3 statistical software was used for all analysis.
RESULTS Of the 1,383 participants recruited, 253 (18.3%) declined to take the survey and 66 (5.8%) were against doctors ever performing IVF and were excluded. The distribution of participants across age, sex, geography, race/ethnicity, and education largely matched the general United States 2010 Census, whereas survey takers in general had a higher income, and fewer had been married or had children (Table 1). A majority of respondents (55.0%) personally knew someone with infertility. Survey takers were also largely familiar with infer-
TABLE 1 Demographic characteristics among those surveyed. Characteristic Age (y) 18–44 45–65 Race Asian African-American Hispanic/Latino Prefer not to answer White/Caucasian Other Income, $ %20,000 20,001–40,000 40,001–60,000 60,001–80,000 >80,001 Sexuality Heterosexual Mostly heterosexual Bisexual Mostly homosexual Homosexual Religion Christian-Catholic Christian-Protestant Atheist/Agnostic Buddhist/Jewish/Muslim/ Hindu/Other Education Grade school High school Associate degree Some college Bachelor degree Graduate degree Marital status Never married Married Separated Divorced Widowed Geographic region Democratic state Republican state
Women 590 (55.5)
Men 474 (44.6)
281 (47.6) 309 (52.4)
218 (46.0) 256 (54.0)
26 (4.4) 55 (9.3) 57 (9.7) 11 (1.9) 417 (70.7) 24 (4.1)
21 (4.4) 37 (7.8) 48 (10.1) 8 (1.7) 345 (72.8) 15 (3.2)
60 (10.2) 116 (20.0) 115 (19.5) 100 (17.0) 199 (33.7)
50 (10.6) 72 (15.2) 59 (14.6) 74 (15.6) 209 (44.1)
510 (86.4) 30 (5.1) 30 (5.1) 3 (0.5) 17 (2.9)
399 (84.2) 22 (4.6) 15 (3.2) 6 (1.3) 32 (6.8)
142 (24.1) 221 (37.5) 178 (30.2) 49 (8.3)
93 (19.6) 175 (36.9) 160 (33.8) 46 (9.7)
6 (1.0) 46 (7.8) 61 (10.3) 134 (22.7) 1180 (30.5) 163 (27.6)
4 (0.8) 37 (7.8) 40 (8.4) 104 (21.9) 151 (31.9) 138 (29.1)
197 (33.4) 273 (46.3) 13 (2.2) 78 (13.2) 29 (4.9)
253 (30.0) 265 (55.9) 8 (1.7) 47 (9.9) 12 (2.5)
295 (50.2) 293 (49.8)
237 (50.1) 236 (49.9)
Note: Data presented as n (%). Lewis. Views on oocyte cryopreservation. Fertil Steril 2016.
VOL. 106 NO. 5 / OCTOBER 2016
tility treatments, with 86.3% of respondents having heard of OC and 39.7% knowing someone who had undergone IVF. In terms of reproductive knowledge, when participants were asked ‘‘at what age a woman's eggs have a lower chance of creating a pregnancy,’’ the most popular answer was age 40 (32.0%), followed by age 35 (27.8%). A majority (66.5%) believed that the chance of a woman having a baby with Down syndrome increased with age.
Support of Elective Egg Freezing for Various Indications The majority of participants supported OC, with OC for cancer patients being the indication most supported (89.3%), followed by delayed childbearing for career advancement (72.1%), current lack of a partner (63.2%), and insufficient funds for child rearing (58.0%). Despite considerable support for OC, only 36.9% of participants agreed that employers should fund OC for female employees. Of the 123 (11.6%) participants against all indications for OC, the most common reason for dissent was being ‘‘unethical’’ (22.8%), followed by ‘‘creation of older parents unable to care for their children’’ (21.1%). Older age (45–65 years) was the demographic group most associated with lower support for OC for various indications: career and educational advancement (RR 0.91, 95% CI 0.83– 0.99), employee benefits for OC (RR 0.81, 95% CI 0.67–0.97), lack of funding for child rearing (RR 0.7, 95% CI 0.70–0.90), and lack of a male partner (RR 0.87, 95% CI 0.79–0.97). Fertility preservation in patients with a cancer diagnosis was the only indication where older age did not confer lower support. Other demographic characteristics, such as religious identification of ‘‘atheism or agnosticism,’’ never being a parent, increasing income, and never being married were all significantly associated with increased support for various indications to undergo elective OC (Fig. 1). Elective OC for ‘‘lack of a male partner’’ was the only indication for which male participants were less supportive than female participants (RR 0.91, 95% CI 0.83–0.99). There was no difference in support of OC by participant race, sexual orientation, education, or predominant state political party support.
Opinions on Personal Use of Elective Egg Freezing in the Future Only 17.8% (n ¼ 189) of survey takers would consider OC for themself or their partner in the future. In addition to older age (RR 0.36, 18–44 y vs. 45–65 y, 95% CI 0.24–0.53), marital status influenced whether or not the participants would contemplate personal use of OC in the future. Participants who had never been married (RR 3.25, 95% CI 2.25– 4.69) or who were single/divorced/widowed (RR 1.79, 95% CI 1.12–2.84) were much more likely to be receptive to OC for themselves or their partners compared with participants who were currently married. In addition, participants who identified themselves as a sexual minority (mostly heterosexual, bisexual, mostly homosexual, homosexual) 1185
ORIGINAL ARTICLE: FERTILITY PRESERVATION
FIGURE 1
Association between demographic factors and support for oocyte cryopreservation (OC; risk ratio). Symbols are placed at the risk ratio value, and the bars are indicate the 95% confidence intervals. Lewis. Views on oocyte cryopreservation. Fertil Steril 2016.
compared with heterosexuals were more likely to consider undergoing OC in the future (RR 1.65, 95% CI 1.04–2.62), as were those who had never been a parent (RR 1.83, 95% CI 1.19–2.82) and those identifying as atheist/agnostic compared with those identifying as Catholic (RR 1.6, 95% CI 1.06–2.64). When participants were asked if they would feel comfortable telling their friends or family if they had undergone elective OC, demographic characteristics were found to be significantly associated with opinion. Participants least comfortable telling their friends and family about potential personal OC were more likely from a racial or ethnic minority (RR 0.91 compared with white responders, 95% CI 0.85–0.97), 45–65 years of age (RR 0.92 compared with 18–44 years, 95% CI 0.86–0.99), or from a historically Republican state (RR 0.93 compared with a Democratic state, 95% CI 0.88–0.99). Greater household income demonstrated a significant linear trend (P¼ .01) regarding greater comfort relaying information about personal use of OC as well as affiliation with atheist/ agnostic religion (RR 1.17 compared with Catholic affiliation, 95% CI 1.07–1.29). Similarly, when participants were asked if they would feel comfortable telling future male partners if they had undergone elective OC, those with greater household income (linear trend: P¼ .04) as well as atheist/agnostic religious identification (RR 1.09 compared with Catholic religious identification, 95% CI 1.03–1.17) were more likely to tell future male partners about a previous OC procedure. Being from a historically republican state was associated with lower comfort (RR 0.94 compared with Democratic state, 95% CI 0.90–0.99) in conveying personal OC history to a participant's male partner. 1186
Opinions Regarding Future Use of Cryopreserved Oocytes When survey takers were asked in what specific circumstances a woman should use previously cryopreserved oocytes, several demographic characteristics were associated with differing opinion. Specifically, when queried if previously cryopreserved oocytes should be used only if a woman has not had children through spontaneous conception, participants belonging to a racial/ethnic minority (RR 1.48 compared with white responders, 95% CI 1.13–1.94), an older age group (RR 1.75, 45–65 y compared with 18–44 y, 95% CI 1.27–2.41), or from a historically Republican state (RR 1.36 compared with Democratic state, 95% CI 1.04–1.77) were more likely to agree. Those survey takers from the highest income bracket (>$80,000 annually; RR 0.49 compared with $20,000–40,000 annually, 95% CI 0.33–0.72), having a college degree or above (RR 0.71 compared with less than a college degree, 95% CI 0.54–0.92), or with an atheist/agnostic religious identification (RR 0.37 compared with a Catholic religious identification, 95% CI 0.24–0.55) were more likely to disagree. Moreover, when participants were asked if previously cryopreserved oocytes should be used to create a pregnancy only if a woman is married, male participants (RR 1.38 compared with female, 95% CI 1.04–1.85) and those with older age (linear trend: P¼ .04) were more likely to agree. Demographic characteristics that were not associated with the belief that previously cryopreserved oocytes should be used only if a woman is married included greater income (linear trend: P< .001), identifying as a sexual minority (RR 0.44 VOL. 106 NO. 5 / OCTOBER 2016
Fertility and Sterility® compared with heterosexual, 95% CI 0.21–0.92), having a college education or greater (RR 0.66 compared with less than a college degree, 95% CI 0.50–0.87), and atheist/agnostic religious identification (RR 0.22 compared with a Catholic religious identification, 95% CI 0.13–0.38).
DISCUSSION This study is the first to examine the American public's opinion regarding acceptable indications for elective OC, their potential personal use of this novel technology, and in what circumstances cryopreserved eggs should be used. A large majority of both men and women supported the use of elective OC, but fertility preservation for women before undergoing cancer treatment was still the most supported indication, with 89.3% in favor. Even though a majority accepted social OC, a minority (36.9%) of participants were supportive of employers funding OC for female employees deferring childbearing. Older age (45–65 years) was the strongest predictor of lack of support for social OC. In addition, older participants were more likely to believe that ‘‘never having children before’’ and ‘‘being married’’ should be required before women used their eggs in the future to create a pregnancy. The influence of sex was observed when participants were asked if they supported OC for ‘‘lack of a male partner,’’ with male participants less supportive than female participants. Male participants were also more likely to believe that a woman should be able to use frozen eggs only if she is married. Never having been a parent, never having been married, and religious identification of ‘‘atheism/agnosticism’’ were characteristics associated with greater support for social OC as well as potential personal use of the technology. Surprisingly, degree of education, race, sexual orientation, and political party affiliation of the participant's state of residence were not significantly associated with support for various indications of social egg freezing. Only when assessing the participant's comfort in sharing with friends/family or future male partners one's past use of OC, did being from a historically Republican state and identifying as a racial/ ethnic minority convey less acceptance than being from a historically Democratic state and identifying as white. Education level appeared to influence responses only when participants were asked if cryopreserved oocytes should be used only if a ‘‘woman hasn't had children before,’’ with those having a college education or higher less likely to be in favor than those with lower educational attainment. The findings in this study concur with other surveys assessing acceptance of elective OC. A recent 2015 survey study from Sweden, which focused primarily on reproductive-age woman (30–39 y), also found overwhelming support for OC for medical indications (94%), and a large majority (70%) deemed OC to be acceptable for social reasons (12). An Israeli study in 2011 found nearly 80% of assisted reproductive technology (ART) and bioethics experts to be in favor of OC for social reasons, whereas only 40% of the general public was accepting of OC for nonmedical reasons (19). Not surprisingly, these former survey studies in countries with active ART utilization (12, 19) demonstrate that certain populations familiar with OC were accepting of this new practice. The present VOL. 106 NO. 5 / OCTOBER 2016
research is the first to our knowledge to survey the general U.S. public of both sexes, all ages, and all occupations and found overall a majority supported OC for both medical and social reasons. Given that previous cross-sectional surveys regarding OC focused on specific populations, such as reproductive-age women (12, 15) or medical trainees (16, 17), very little is known about the preferences of older Americans toward newer ART. The present study indicates that a generational divide exists, and this can potentially become more relevant politically and socially as elective OC becomes more widespread and questions arise regarding whether this treatment should be viewed as a medical benefit with insurance coverage. When survey takers were asked specifically why they would ‘‘strongly disagree’’ to any form of social OC the most popular answers of its being ‘‘unethical’’ and the creation of ‘‘older parents unable to care for their children’’ reflect a disconnection between generations regarding family planning, given that it is now much more common for a woman to delay childbearing until age 35. The only areas of the survey for which men and women differed in support both related to marriage/partnership, with male sex associated with less support for single women undergoing OC for ‘‘lack of a male partner’’ and using frozen eggs in the future without being married. Remarkably, in a recent U.S. survey of women undergoing OC, an overwhelming 88% stated they did not have children sooner for ‘‘lack of a partner.’’ Data from women who have actually undergone elective OC demonstrate that they are largely unmarried (8). Although single woman make up the majority of those undergoing social OC, a survey of single women in the U.K. undergoing the procedure desired a partner and felt that parenting should ideally be undertaken within a stable and committed relationship (22). The sex differences in this survey perhaps elucidate an association with male sex and the traditional preference for a heterosexual two-parent household before undergoing fertility preservation treatment. Likewise, our study found that having been a parent conveyed less support for social OC. A recent Polish survey study assessing various views on ART found that fertile women were more likely to impose limitations on ART procedures compared with infertile women who had never had a child (23). Never having been a parent was also associated with support for employers funding OC for female employees, and having been a parent was correlated with lower acceptance of such employer support. This belief was also observed in a recent Lithuanian study assessing fertile versus infertile women's views on ART, finding that infertile woman were more likely to be in favor of financial coverage for ART technology than fertile women (24). It appears that those who are already parents or who have never experienced infertility are less likely to back financial coverage for those experiencing infertility or consciously delaying childbearing. Even though the U.S. population largely supported elective OC in our survey, strong public backing for employer financial coverage was lacking for this service. Similarly, a recent survey study directed at 238 U.S. Obstetrics and Gynecology (OB/GYN) residents found that trainees were more supportive of insurance covering OC for patients with a recent 1187
ORIGINAL ARTICLE: FERTILITY PRESERVATION diagnosis of cancer versus coverage for those patients who had electively delayed childbearing for career advancement (17). Although OB/GYN residents were found to be less supportive of insurance coverage for social OC, the cost may be prohibitive for some young women who want to undergo the procedure. This was exemplified in a recent survey study of 129 female Singaporean medical students, where only 45.7% would undergo OC for career advancement and 46.5% for lack of a partner. The number who would consider social OC increased to 71.3% if a government subsidy were available (16). A lack of coverage for OC by employers or insurance might limit the number of women who might benefit from OC in the future. Although our findings of overwhelming support for elective OC agree with recent international surveys assessing attitudes toward social egg freezing (12, 19), there are several limitations. Participants who did not support IVF (5.8%) under any circumstances were excluded because IVF is a necessary sequential step in fertilization of cryopreserved oocytes to create a pregnancy. Survey takers against IVF are likely also against OC, thus increasing the proportion of supporters of elective OC in our survey population compared with the general population across the U.S. The high rate of familiarity with OC (86.3%) may have been inflated compared with a nationally representative population, given that we excluded respondents who disapproved of IVF. Those participants in support of IVF may have more knowledge of other ART procedures such as OC. A 2011 Belgium study also found a high rate of familiarity with OC, with 77% of women aged 21–40 years reporting knowledge about the procedure (15). Only 20% of survey initiators did not complete the survey because of lack of support for IVF, and thus this restriction alone is not solely responsible for the high rate of familiarity with OC. Although the exclusion of dissenters to IVF may limit the external validity of the findings, we expect that the variation in support for different indications for OC may have been even stronger had all people against IVF procedures been included. In addition, the survey distributed by SurveyMonkey guaranteed that the responders were representative of the distribution of U.S. demographic factors of age, sex, and race, but it did not account for other factors such as income, education, sexual orientation, religion, and geographic location. Furthermore, political party affiliation was extrapolated from the political party of the state based on the voting record of the last presidential election in 2012, possibly misclassifying that demographic characteristic for the individual responders. However, we would expect this misclassification to be nondifferential regarding our outcomes of interest and thus attenuating any association with opinions of OC. Once deemed an experimental procedure, OC is now a rapidly growing practice. Although IVF clinics across North America and Europe have been performing an increasing amount of OC for the past few years with improved success (14, 25), information about U.S. public attitudes toward social OC is lacking. Our survey demonstrates that the U.S. public is supportive of doctors offering this elective procedure. However, only a minority of participants supported employers funding OC, indicating that the public 1188
generally does not view social egg freezing as a health right that would require mandatory insurance coverage. Despite this, the U.S. government has recently begun a pilot program to provide cryopreservation of oocytes and sperm for their active military, perhaps as a way to make the service more appealing and to retain female military personnel in their 20s and 30s when many leave to start a family (26). Information from this study can further guide ART clinics in understanding variations in support for social OC, as well as how comfortable their patient population feels about undergoing the procedure and potentially using cryopreserved oocytes in the future. Delaying childbearing may give women the opportunity to advance their careers, become more financially stable, find a partner, or become healthier before having children. Social OC provides the opportunity for this growing population of women to have a biologic child and to potentially avoid multiple and costly failed infertility treatments (27). The present study illustrates that demographic factors play a large role in support for elective OC, which will no doubt affect the policy and practice of this fertility-preserving procedure in the future.
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Avraham S, Machtinger R, Cahan T, Sokolov A, Racowsky C, Seidman DS. What is the quality of information on social oocyte cryopreservation provided by websites of Society for Assisted Reproductive Technology member fertility clinics? Fertil Steril 2014;101:222–6. Stoop D, Nekkebroeck J, Devroey P. A survey on the intentions and attitudes toward oocyte cryopreservation for nonmedical reasons among women of reproductive age. Hum Reprod 2011;26:655–61. Tan SQ, Tan AW, Lau MS, Tan HH, Nadarajah S. Social oocyte freezing: a survey among Singaporean female medical students. J Obstet Gynaecol Res 2014;40:1345–52. Yu L, Peterson B, Inhorn MC, Boehm JK, Patrizio P. Knowledge, attitudes, and intentions toward fertility awareness and oocyte cryopreservation among obstetrics and gynecology resident physicians. Hum Reprod 2016;31:403–11. Azhar E, Seifer DB, Melzer K, Ahmed A, Weedon J, Minkoff H. Knowledge of ovarian reserve and reproductive choices. J Assist Reprod Genet 2015;32: 409–15. Brezis M, Malkiel A, Chinitz D, Lehmann LS. Discordant views of experts and laypersons on the adoption of new fertility technology. Med Care 2011;49:420–3. Mertes H. Does company-sponsored egg freezing promote or confine women's reproductive autonomy? J Assist Reprod Genet 2015;32:1205–9.
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Lockwood G, Johnson MH. Having it all? Where are we with ‘‘social’’ egg freezing today? Reprod Biomed Online 2015;31:126–7. Baldwin K, Culley L, Hudson N, Mitchell H, Lavery S. Oocyte cryopreservation for social reasons: demographic profile and disposal intentions of UK users. Reprod Biomed Online 2015;31:239–45. Dembinksa A. Bioethical dilemmas of assisted reproduction in the opinions of Polish women in infertility treatment: a research report. J Med Ethics 2012;38:731–4. Blazeviciene A, Jakusovaite I, Vaskelyte A. Attitudes of fertile and infertile woman toward new reproductive technologies: a case study of Lithuania. Reprod Health 2014;11:1–7. Paramanantham J, Talmor AJ, Osianlis T, Weston GC. Cryopreserved oocytes: update on clinical application and success rates. Obstet Gynecol Surv 2015;70:97–114. Schmidt MS. Pentagon to offer plan to store eggs and sperm to retain young troops. New York Times; 2016. Devine K, Mumford SL, Goldman KN, Hodes-Wertz B, Druckenmiller S, Propst AM, et al. Baby budgeting: oocyte cryopreservation in women delaying reproduction can reduce cost per live birth. Fertil Steril 2015; 103:1446–53.
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Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston; b Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston; and c Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
Objective: To determine whether public support for oocyte cryopreservation (OC) exists and if support varies by demographic factors. Design: Cross-sectional electronic survey. Setting: Not applicable. Patient(s): A nationally representative sample based on age, sex, and race of 1,064 people in the United States recruited by the company SurveyMonkey. Interventions(s): Completion of an online questionnaire. Main Outcome Measure(s): Supporters of OC for various indications were compared with participants who were neutral or in opposition by means of log binomial regression to calculate risk ratios. Statistical models were adjusted for demographic characteristics, including sex, race, age, income, sexual orientation, education, marital status, state political party affiliation, and history of being a parent. Result(s): OC for cancer patients was the indication most supported (89%), followed by delayed childbearing for career advancement (72%), current lack of a partner (63%), and insufficient funds for child rearing (58%). Despite considerable support for OC, only 37% agreed employers should fund egg freezing for employees. Older age was associated with lower support for all indications of OC. Younger age, single status, never being a parent, identifying as a sexual minority, and atheist/agnostic religion were associated with the survey taker personally considering OC. Compared with women, men demonstrated lower support for women undergoing OC for ‘‘lack of a male partner,’’ and for future use of cryopreserved oocytes without being married. Conclusion(s): In a nationally representative sample, the majority of respondents support elective OC. The indication for OC was associated with significant differences in support. (Fertil SterilÒ 2016;106:1183–9. Ó2016 by American Society for Reproductive Medicine.) Key Words: Oocyte cryopreservation, fertility preservation, egg freezing, social oocyte cryopreservation Discuss: You can discuss this article with its authors and with other ASRM members at https://www.fertstertdialog.com/users/ 16110-fertility-and-sterility/posts/11012-public-support-in-the-united-states-for-elective-oocyte-cryopreservation
I
n the past 20 years, the United States population has seen a 150% increase in first births in women 35–39 years of age, and the average maternal age at first birth has increased from 21.4 years in 1970 to 26.3 years in 2014 (1). In addition, the birth rate for women 40–44 years of age is at its highest rate since 1966, and it has steadily increased by 2% a year since 2000 (1). Clearly, U.S. data demonstrate that women are delaying childbearing,
with the most significant change being an increase of births among women R35 years of age. This phenomenon is not isolated to the U.S., with recent European data indicating that women are changing reproductive behaviors and postponing childbearing (2). Recent surveys attribute this change in age of motherhood to increasing educational, financial, and professional pursuits, as well as a woman's ability to control reproduction with the use of
Received April 14, 2016; revised July 4, 2016; accepted July 5, 2016; published online July 26, 2016. E.I.L. has nothing to disclose. S.A.M. has nothing to disclose. L.V.F. has received a National Cancer Institute Fellowship in Cancer Prevention (3R25CA057711) and a National Institute of Child Health and Human Development Predoctoral Fellowship (T32HD060454). E.S.G. has nothing to disclose. Reprint requests: Erin I. Lewis, M.D., Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115 (E-mail: eilewis@ partners.org). Fertility and Sterility® Vol. 106, No. 5, October 2016 0015-0282/$36.00 Copyright ©2016 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2016.07.004 VOL. 106 NO. 5 / OCTOBER 2016
birth control (2). Complicating this trend is the increased rate of aneuploidy, high-risk pregnancies, and first-trimester losses that accompany older maternal age (3). Interestingly, several studies have demonstrated that many people are not sufficiently aware of natural age-related decline of female fertility (4–7). In one study, 79% of 178 women who underwent elective oocyte cryopreservation lamented that they had not started the process sooner (8). This lack of awareness regarding knowledge of female fertility affects informed decision making in a population that is increasingly delaying childbearing. Oocyte cryopreservation had relatively low success rates in the past and was deemed to be ‘‘experimental’’ by the American Society of Reproductive 1183
ORIGINAL ARTICLE: FERTILITY PRESERVATION Medicine (ASRM) in 2008. However, in 2010, a randomized controlled trial by Cobo et al. evaluated 600 donor recipients who had received either fresh or vitrified donor oocytes, and found no difference in the recipient pregnancy rates. However, that study focused on oocytes from young women serving as donors and not women with a history of infertility or decreased ovarian reserve due to age or other factors (9). A 2013 ASRM committee opinion lifted the experimental designation of OC, but cautioned that there were not enough data on the ‘‘safety, efficacy, cost-effectiveness, and emotional risks’’ to recommend elective OC (10). Although the European Society of Human Reproduction and Embryology also emphasizes the importance of further investigation regarding safety, costeffectiveness, and psychologic factors that might arise with elective egg freezing, they also recommend that OC be available for the prevention of age-related infertility (11). Increasing numbers of centers are performing elective OC, or what is commonly called ‘‘social egg freezing,’’ in Europe and North America (12, 13). In 2012, of the 387 U.S. clinics registered as Society for Assisted Reproductive Technology members, 200 (51.7%) offered OC for either medical or social reasons. Of those offering OC, 147 advertised for social or elective egg freezing (14). The trend toward elective OC has likely continued to increase since 2012 with more and more centers providing the service to women who wish to positively affect their long-term reproductive potential. As OC gains more media attention, several studies have addressed the acceptance of elective OC among reproductive-age women (15–17) and among male and female health care workers (18, 19). The present study aimed to survey both men and women in the general public to decipher attitudes toward elective OC and personal use of the technology in the future. With American corporations such as Apple and Facebook recently announcing funding of elective OC for female employees, we aimed to find if the public supports OC as a reproductive right (20, 21).
anonymity of the survey takers to the investigators, Institutional Review Board approval was exempted. Before reading or completing the questionnaire (Supplemental Appendix), the participant read an introduction explaining the purpose of the study, which included contact information for the research team, as well as an explanation of the Health Insurance Portability and Accountability Act. Survey Monkey ensured anonymity of survey takers to the investigators. A brief description describing the process of ovarian stimulation and oocyte cryopreservation was provided. Participants were then asked to answer 15 multiple-choice questions and given the option to type descriptive text for questions where their answer did not fit the available choices. Participants were asked to select if they strongly agreed, agreed, were neutral, disagreed, or strongly disagreed to different indications for egg freezing. Specifically these questions began with the statement, ‘‘Doctors should offer egg freezing as a way to preserve fertility for women delaying childbearing because .’’ The next part of the survey addressed the participant's potential future use of OC and how comfortable they were sharing this information. To make the survey gender neutral these questions began with the phrase, ‘‘If you were a woman desiring to preserve fertility and you underwent egg freezing would you feel comfortable .’’ The queries pertaining to when a woman should use her frozen eggs began with the question, ‘‘If a woman underwent egg freezing for preservation of fertility should she only be able to use her eggs to create a pregnancy if .,’’ and participants were asked to select yes, no, maybe, or ‘‘I don't know.’’ The second part of the study addressed the participant's knowledge of a woman's fertility with such open-ended questions as, ‘‘At what age do you think a woman's eggs have a lower chance of creating a pregnancy?’’ The survey concluded with participants providing demographic data.
Statistical Analysis
MATERIALS AND METHODS An online questionnaire (Supplemental Appendix, available online at www.fertstert.org) was sent by the professional survey company, SurveyMonkey, to a nationally representative sample of 1,064 people reflecting U.S. demographic characteristics for age, sex, and race, from March 23 to April 12, 2015. The survey was continued until the responses were reflective of national census estimates of age, sex, and race, because these demographics have been found to be relevant in other population-based survey studies assessing attitudes toward fertility preservation and fertility awareness (4, 15). Survey takers were rewarded with a donation of $0.50 to a charity of the survey taker's choice and entry into a sweepstakes for $100.00 on completion of the survey. Inclusion criteria for taking the survey required U.S. citizenship, male or female sex, age 18–65 years, literacy in English, and available Internet access. Participants who were opposed to in vitro fertilization (IVF) under any circumstances were disqualified from completing the survey with the reasoning that IVF is an essential component for the future use of cryopreserved oocytes. Given the 1184
For the demographic factors provided, descriptive statistics were calculated and referent groups established by the use of either the most logical comparison group or the largest group for nominal predictors. The following referent groups were designated: sex (female ¼ referent), ethnicity (white ¼ referent), age (18–44 years ¼ referent), household income (R$80,000.00 ¼ referent), sexual orientation (heterosexual ¼ referent), education (college education ¼ referent), marital status (married ¼ referent), predominant state political party support (Democratic state ¼ referent), history of being a parent (yes ¼ referent), and religion (Catholic ¼ referent). Information regarding political party affiliation was extrapolated from the historical political party affiliation in the 2012 presidential election of the state in which the participant resided. Supporters of various indications for oocyte cryopreservation were compared with those participants who were neutral or in opposition by means of log binomial regression to estimate the relative risk of agreement. Statistical models were adjusted a priori for demographic factors including age and marital status to yield risk ratios (RRs) with 95% confidence intervals (CIs) and Wald two-sided P VOL. 106 NO. 5 / OCTOBER 2016
Fertility and Sterility® values of support. In addition to investigating the relationship between categories of income and age, a test of linear trend of association was performed. SAS 9.3 statistical software was used for all analysis.
RESULTS Of the 1,383 participants recruited, 253 (18.3%) declined to take the survey and 66 (5.8%) were against doctors ever performing IVF and were excluded. The distribution of participants across age, sex, geography, race/ethnicity, and education largely matched the general United States 2010 Census, whereas survey takers in general had a higher income, and fewer had been married or had children (Table 1). A majority of respondents (55.0%) personally knew someone with infertility. Survey takers were also largely familiar with infer-
TABLE 1 Demographic characteristics among those surveyed. Characteristic Age (y) 18–44 45–65 Race Asian African-American Hispanic/Latino Prefer not to answer White/Caucasian Other Income, $ %20,000 20,001–40,000 40,001–60,000 60,001–80,000 >80,001 Sexuality Heterosexual Mostly heterosexual Bisexual Mostly homosexual Homosexual Religion Christian-Catholic Christian-Protestant Atheist/Agnostic Buddhist/Jewish/Muslim/ Hindu/Other Education Grade school High school Associate degree Some college Bachelor degree Graduate degree Marital status Never married Married Separated Divorced Widowed Geographic region Democratic state Republican state
Women 590 (55.5)
Men 474 (44.6)
281 (47.6) 309 (52.4)
218 (46.0) 256 (54.0)
26 (4.4) 55 (9.3) 57 (9.7) 11 (1.9) 417 (70.7) 24 (4.1)
21 (4.4) 37 (7.8) 48 (10.1) 8 (1.7) 345 (72.8) 15 (3.2)
60 (10.2) 116 (20.0) 115 (19.5) 100 (17.0) 199 (33.7)
50 (10.6) 72 (15.2) 59 (14.6) 74 (15.6) 209 (44.1)
510 (86.4) 30 (5.1) 30 (5.1) 3 (0.5) 17 (2.9)
399 (84.2) 22 (4.6) 15 (3.2) 6 (1.3) 32 (6.8)
142 (24.1) 221 (37.5) 178 (30.2) 49 (8.3)
93 (19.6) 175 (36.9) 160 (33.8) 46 (9.7)
6 (1.0) 46 (7.8) 61 (10.3) 134 (22.7) 1180 (30.5) 163 (27.6)
4 (0.8) 37 (7.8) 40 (8.4) 104 (21.9) 151 (31.9) 138 (29.1)
197 (33.4) 273 (46.3) 13 (2.2) 78 (13.2) 29 (4.9)
253 (30.0) 265 (55.9) 8 (1.7) 47 (9.9) 12 (2.5)
295 (50.2) 293 (49.8)
237 (50.1) 236 (49.9)
Note: Data presented as n (%). Lewis. Views on oocyte cryopreservation. Fertil Steril 2016.
VOL. 106 NO. 5 / OCTOBER 2016
tility treatments, with 86.3% of respondents having heard of OC and 39.7% knowing someone who had undergone IVF. In terms of reproductive knowledge, when participants were asked ‘‘at what age a woman's eggs have a lower chance of creating a pregnancy,’’ the most popular answer was age 40 (32.0%), followed by age 35 (27.8%). A majority (66.5%) believed that the chance of a woman having a baby with Down syndrome increased with age.
Support of Elective Egg Freezing for Various Indications The majority of participants supported OC, with OC for cancer patients being the indication most supported (89.3%), followed by delayed childbearing for career advancement (72.1%), current lack of a partner (63.2%), and insufficient funds for child rearing (58.0%). Despite considerable support for OC, only 36.9% of participants agreed that employers should fund OC for female employees. Of the 123 (11.6%) participants against all indications for OC, the most common reason for dissent was being ‘‘unethical’’ (22.8%), followed by ‘‘creation of older parents unable to care for their children’’ (21.1%). Older age (45–65 years) was the demographic group most associated with lower support for OC for various indications: career and educational advancement (RR 0.91, 95% CI 0.83– 0.99), employee benefits for OC (RR 0.81, 95% CI 0.67–0.97), lack of funding for child rearing (RR 0.7, 95% CI 0.70–0.90), and lack of a male partner (RR 0.87, 95% CI 0.79–0.97). Fertility preservation in patients with a cancer diagnosis was the only indication where older age did not confer lower support. Other demographic characteristics, such as religious identification of ‘‘atheism or agnosticism,’’ never being a parent, increasing income, and never being married were all significantly associated with increased support for various indications to undergo elective OC (Fig. 1). Elective OC for ‘‘lack of a male partner’’ was the only indication for which male participants were less supportive than female participants (RR 0.91, 95% CI 0.83–0.99). There was no difference in support of OC by participant race, sexual orientation, education, or predominant state political party support.
Opinions on Personal Use of Elective Egg Freezing in the Future Only 17.8% (n ¼ 189) of survey takers would consider OC for themself or their partner in the future. In addition to older age (RR 0.36, 18–44 y vs. 45–65 y, 95% CI 0.24–0.53), marital status influenced whether or not the participants would contemplate personal use of OC in the future. Participants who had never been married (RR 3.25, 95% CI 2.25– 4.69) or who were single/divorced/widowed (RR 1.79, 95% CI 1.12–2.84) were much more likely to be receptive to OC for themselves or their partners compared with participants who were currently married. In addition, participants who identified themselves as a sexual minority (mostly heterosexual, bisexual, mostly homosexual, homosexual) 1185
ORIGINAL ARTICLE: FERTILITY PRESERVATION
FIGURE 1
Association between demographic factors and support for oocyte cryopreservation (OC; risk ratio). Symbols are placed at the risk ratio value, and the bars are indicate the 95% confidence intervals. Lewis. Views on oocyte cryopreservation. Fertil Steril 2016.
compared with heterosexuals were more likely to consider undergoing OC in the future (RR 1.65, 95% CI 1.04–2.62), as were those who had never been a parent (RR 1.83, 95% CI 1.19–2.82) and those identifying as atheist/agnostic compared with those identifying as Catholic (RR 1.6, 95% CI 1.06–2.64). When participants were asked if they would feel comfortable telling their friends or family if they had undergone elective OC, demographic characteristics were found to be significantly associated with opinion. Participants least comfortable telling their friends and family about potential personal OC were more likely from a racial or ethnic minority (RR 0.91 compared with white responders, 95% CI 0.85–0.97), 45–65 years of age (RR 0.92 compared with 18–44 years, 95% CI 0.86–0.99), or from a historically Republican state (RR 0.93 compared with a Democratic state, 95% CI 0.88–0.99). Greater household income demonstrated a significant linear trend (P¼ .01) regarding greater comfort relaying information about personal use of OC as well as affiliation with atheist/ agnostic religion (RR 1.17 compared with Catholic affiliation, 95% CI 1.07–1.29). Similarly, when participants were asked if they would feel comfortable telling future male partners if they had undergone elective OC, those with greater household income (linear trend: P¼ .04) as well as atheist/agnostic religious identification (RR 1.09 compared with Catholic religious identification, 95% CI 1.03–1.17) were more likely to tell future male partners about a previous OC procedure. Being from a historically republican state was associated with lower comfort (RR 0.94 compared with Democratic state, 95% CI 0.90–0.99) in conveying personal OC history to a participant's male partner. 1186
Opinions Regarding Future Use of Cryopreserved Oocytes When survey takers were asked in what specific circumstances a woman should use previously cryopreserved oocytes, several demographic characteristics were associated with differing opinion. Specifically, when queried if previously cryopreserved oocytes should be used only if a woman has not had children through spontaneous conception, participants belonging to a racial/ethnic minority (RR 1.48 compared with white responders, 95% CI 1.13–1.94), an older age group (RR 1.75, 45–65 y compared with 18–44 y, 95% CI 1.27–2.41), or from a historically Republican state (RR 1.36 compared with Democratic state, 95% CI 1.04–1.77) were more likely to agree. Those survey takers from the highest income bracket (>$80,000 annually; RR 0.49 compared with $20,000–40,000 annually, 95% CI 0.33–0.72), having a college degree or above (RR 0.71 compared with less than a college degree, 95% CI 0.54–0.92), or with an atheist/agnostic religious identification (RR 0.37 compared with a Catholic religious identification, 95% CI 0.24–0.55) were more likely to disagree. Moreover, when participants were asked if previously cryopreserved oocytes should be used to create a pregnancy only if a woman is married, male participants (RR 1.38 compared with female, 95% CI 1.04–1.85) and those with older age (linear trend: P¼ .04) were more likely to agree. Demographic characteristics that were not associated with the belief that previously cryopreserved oocytes should be used only if a woman is married included greater income (linear trend: P< .001), identifying as a sexual minority (RR 0.44 VOL. 106 NO. 5 / OCTOBER 2016
Fertility and Sterility® compared with heterosexual, 95% CI 0.21–0.92), having a college education or greater (RR 0.66 compared with less than a college degree, 95% CI 0.50–0.87), and atheist/agnostic religious identification (RR 0.22 compared with a Catholic religious identification, 95% CI 0.13–0.38).
DISCUSSION This study is the first to examine the American public's opinion regarding acceptable indications for elective OC, their potential personal use of this novel technology, and in what circumstances cryopreserved eggs should be used. A large majority of both men and women supported the use of elective OC, but fertility preservation for women before undergoing cancer treatment was still the most supported indication, with 89.3% in favor. Even though a majority accepted social OC, a minority (36.9%) of participants were supportive of employers funding OC for female employees deferring childbearing. Older age (45–65 years) was the strongest predictor of lack of support for social OC. In addition, older participants were more likely to believe that ‘‘never having children before’’ and ‘‘being married’’ should be required before women used their eggs in the future to create a pregnancy. The influence of sex was observed when participants were asked if they supported OC for ‘‘lack of a male partner,’’ with male participants less supportive than female participants. Male participants were also more likely to believe that a woman should be able to use frozen eggs only if she is married. Never having been a parent, never having been married, and religious identification of ‘‘atheism/agnosticism’’ were characteristics associated with greater support for social OC as well as potential personal use of the technology. Surprisingly, degree of education, race, sexual orientation, and political party affiliation of the participant's state of residence were not significantly associated with support for various indications of social egg freezing. Only when assessing the participant's comfort in sharing with friends/family or future male partners one's past use of OC, did being from a historically Republican state and identifying as a racial/ ethnic minority convey less acceptance than being from a historically Democratic state and identifying as white. Education level appeared to influence responses only when participants were asked if cryopreserved oocytes should be used only if a ‘‘woman hasn't had children before,’’ with those having a college education or higher less likely to be in favor than those with lower educational attainment. The findings in this study concur with other surveys assessing acceptance of elective OC. A recent 2015 survey study from Sweden, which focused primarily on reproductive-age woman (30–39 y), also found overwhelming support for OC for medical indications (94%), and a large majority (70%) deemed OC to be acceptable for social reasons (12). An Israeli study in 2011 found nearly 80% of assisted reproductive technology (ART) and bioethics experts to be in favor of OC for social reasons, whereas only 40% of the general public was accepting of OC for nonmedical reasons (19). Not surprisingly, these former survey studies in countries with active ART utilization (12, 19) demonstrate that certain populations familiar with OC were accepting of this new practice. The present VOL. 106 NO. 5 / OCTOBER 2016
research is the first to our knowledge to survey the general U.S. public of both sexes, all ages, and all occupations and found overall a majority supported OC for both medical and social reasons. Given that previous cross-sectional surveys regarding OC focused on specific populations, such as reproductive-age women (12, 15) or medical trainees (16, 17), very little is known about the preferences of older Americans toward newer ART. The present study indicates that a generational divide exists, and this can potentially become more relevant politically and socially as elective OC becomes more widespread and questions arise regarding whether this treatment should be viewed as a medical benefit with insurance coverage. When survey takers were asked specifically why they would ‘‘strongly disagree’’ to any form of social OC the most popular answers of its being ‘‘unethical’’ and the creation of ‘‘older parents unable to care for their children’’ reflect a disconnection between generations regarding family planning, given that it is now much more common for a woman to delay childbearing until age 35. The only areas of the survey for which men and women differed in support both related to marriage/partnership, with male sex associated with less support for single women undergoing OC for ‘‘lack of a male partner’’ and using frozen eggs in the future without being married. Remarkably, in a recent U.S. survey of women undergoing OC, an overwhelming 88% stated they did not have children sooner for ‘‘lack of a partner.’’ Data from women who have actually undergone elective OC demonstrate that they are largely unmarried (8). Although single woman make up the majority of those undergoing social OC, a survey of single women in the U.K. undergoing the procedure desired a partner and felt that parenting should ideally be undertaken within a stable and committed relationship (22). The sex differences in this survey perhaps elucidate an association with male sex and the traditional preference for a heterosexual two-parent household before undergoing fertility preservation treatment. Likewise, our study found that having been a parent conveyed less support for social OC. A recent Polish survey study assessing various views on ART found that fertile women were more likely to impose limitations on ART procedures compared with infertile women who had never had a child (23). Never having been a parent was also associated with support for employers funding OC for female employees, and having been a parent was correlated with lower acceptance of such employer support. This belief was also observed in a recent Lithuanian study assessing fertile versus infertile women's views on ART, finding that infertile woman were more likely to be in favor of financial coverage for ART technology than fertile women (24). It appears that those who are already parents or who have never experienced infertility are less likely to back financial coverage for those experiencing infertility or consciously delaying childbearing. Even though the U.S. population largely supported elective OC in our survey, strong public backing for employer financial coverage was lacking for this service. Similarly, a recent survey study directed at 238 U.S. Obstetrics and Gynecology (OB/GYN) residents found that trainees were more supportive of insurance covering OC for patients with a recent 1187
ORIGINAL ARTICLE: FERTILITY PRESERVATION diagnosis of cancer versus coverage for those patients who had electively delayed childbearing for career advancement (17). Although OB/GYN residents were found to be less supportive of insurance coverage for social OC, the cost may be prohibitive for some young women who want to undergo the procedure. This was exemplified in a recent survey study of 129 female Singaporean medical students, where only 45.7% would undergo OC for career advancement and 46.5% for lack of a partner. The number who would consider social OC increased to 71.3% if a government subsidy were available (16). A lack of coverage for OC by employers or insurance might limit the number of women who might benefit from OC in the future. Although our findings of overwhelming support for elective OC agree with recent international surveys assessing attitudes toward social egg freezing (12, 19), there are several limitations. Participants who did not support IVF (5.8%) under any circumstances were excluded because IVF is a necessary sequential step in fertilization of cryopreserved oocytes to create a pregnancy. Survey takers against IVF are likely also against OC, thus increasing the proportion of supporters of elective OC in our survey population compared with the general population across the U.S. The high rate of familiarity with OC (86.3%) may have been inflated compared with a nationally representative population, given that we excluded respondents who disapproved of IVF. Those participants in support of IVF may have more knowledge of other ART procedures such as OC. A 2011 Belgium study also found a high rate of familiarity with OC, with 77% of women aged 21–40 years reporting knowledge about the procedure (15). Only 20% of survey initiators did not complete the survey because of lack of support for IVF, and thus this restriction alone is not solely responsible for the high rate of familiarity with OC. Although the exclusion of dissenters to IVF may limit the external validity of the findings, we expect that the variation in support for different indications for OC may have been even stronger had all people against IVF procedures been included. In addition, the survey distributed by SurveyMonkey guaranteed that the responders were representative of the distribution of U.S. demographic factors of age, sex, and race, but it did not account for other factors such as income, education, sexual orientation, religion, and geographic location. Furthermore, political party affiliation was extrapolated from the political party of the state based on the voting record of the last presidential election in 2012, possibly misclassifying that demographic characteristic for the individual responders. However, we would expect this misclassification to be nondifferential regarding our outcomes of interest and thus attenuating any association with opinions of OC. Once deemed an experimental procedure, OC is now a rapidly growing practice. Although IVF clinics across North America and Europe have been performing an increasing amount of OC for the past few years with improved success (14, 25), information about U.S. public attitudes toward social OC is lacking. Our survey demonstrates that the U.S. public is supportive of doctors offering this elective procedure. However, only a minority of participants supported employers funding OC, indicating that the public 1188
generally does not view social egg freezing as a health right that would require mandatory insurance coverage. Despite this, the U.S. government has recently begun a pilot program to provide cryopreservation of oocytes and sperm for their active military, perhaps as a way to make the service more appealing and to retain female military personnel in their 20s and 30s when many leave to start a family (26). Information from this study can further guide ART clinics in understanding variations in support for social OC, as well as how comfortable their patient population feels about undergoing the procedure and potentially using cryopreserved oocytes in the future. Delaying childbearing may give women the opportunity to advance their careers, become more financially stable, find a partner, or become healthier before having children. Social OC provides the opportunity for this growing population of women to have a biologic child and to potentially avoid multiple and costly failed infertility treatments (27). The present study illustrates that demographic factors play a large role in support for elective OC, which will no doubt affect the policy and practice of this fertility-preserving procedure in the future.
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