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Egg freezing (EF) technology has improved significantly over the last decade, giving women more choice over their reproductive futures. Despite this advance, EF brings forth contentious ethical and regulatory issues. Policies controlling access to EF vary around the world and there is a lack of consensus about who should have access and what criteria are relevant in making these decisions. This study aimed to identify views of women about access to EF for both “medical” and “non-medical” risks to infertility. An online survey was administered to women aged between 18 and 60 years in Victoria, Australia between April and May 2018. A total of 1,066 individuals initiated the survey. The median age of the participants was 28 years and 81% were <40 years old. Almost all participants (98%) supported access to medical EF in situations where treatments (e.g. chemotherapy) or illnesses threaten fertility. Support for access to EF for non-medical indications was lower; 75% supported EF for “lack of suitable partner”, followed by “financial insecurity to raise a child” (72%) and “career/educational advancement” (65%). Older respondents (aged ≥40 years) were less likely than their younger counterparts to support all indications for non-medical EF. Our findings indicate broad support for EF. However, the variation in support between indications for non-medical EF suggests that individuals do not think about access to EF simply in terms of medical necessity. To reflect public views, future policy may need to consider access to EF beyond the medical/non-medical distinction.
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Sexual and Reproductive Health Matters
ISSN: (Print) 2641-0397 (Online) Journal homepage: https://www.tandfonline.com/loi/zrhm21
Cracked open: exploring attitudes on access to egg
freezing
Molly Johnston, Giuliana Fuscaldo, Nadine Maree Richings, StellaMay Gwini
& Sally Catt
To cite this article: Molly Johnston, Giuliana Fuscaldo, Nadine Maree Richings, StellaMay Gwini
& Sally Catt (2020) Cracked open: exploring attitudes on access to egg freezing, Sexual and
Reproductive Health Matters, 28:1, 1758441, DOI: 10.1080/26410397.2020.1758441
To link to this article: https://doi.org/10.1080/26410397.2020.1758441
© 2020 The Author(s). Published by Informa
UK Limited, trading as Taylor & Francis
Group
Published online: 27 May 2020.
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Cracked open: exploring attitudes on access to egg freezing
Molly Johnston ,
a
Giuliana Fuscaldo,
b
Nadine Maree Richings,
c
StellaMay Gwini ,
d
Sally Catt
e
a PhD candidate, Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia, 3168. Correspondence:
molly.johnston@monash.edu
b Associate Professor, Eastern Health Clinical School, Monash University, Box Hill, Australia; University Hospital Geelong,
Australia
c Teaching Associate, Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
d Adjunct Lecturer, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia; University
Hospital Geelong, Australia; Centre for Innovation in Mental and Physical Health and Clinical Treatment (IMPACT), School of
Medicine, Deakin University, Geelong, Australia
e Senior Lecturer, Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
Abstract: Egg freezing (EF) technology has improved signicantly over the last decade, giving women more
choice over their reproductive futures. Despite this advance, EF brings forth contentious ethical and regulatory
issues. Policies controlling access to EF vary around the world and there is a lack of consensus about who
should have access and what criteria are relevant in making these decisions. This study aimed to identify
views of women about access to EF for both medicaland non-medicalrisks to infertility. An online survey
was administered to women aged between 18 and 60 years in Victoria, Australia between April and May
2018. A total of 1,066 individuals initiated the survey. The median age of the participants was 28 years and
81% were <40 years old. Almost all participants (98%) supported access to medical EF in situations where
treatments (e.g. chemotherapy) or illnesses threaten fertility. Support for access to EF for non-medical
indications was lower; 75% supported EF for lack of suitable partner, followed by nancial insecurity to
raise a child(72%) and career/educational advancement(65%). Older respondents (aged 40 years) were
less likely than their younger counterparts to support all indications for non-medical EF. Our ndings indicate
broad support for EF. However, the variation in support between indications for non-medical EF suggests that
individuals do not think about access to EF simply in terms of medical necessity. To reect public views, future
policy may need to consider access to EF beyond the medical/non-medical distinction. DOI: 10.1080/
26410397.2020.1758441
Keywords: fertility preservation, egg freezing, public opinion, access, fertility, ART, womens health
Introduction
In many afuent nations there has been a shift in
the timing of parenthood.
1
In Australia, the
median age of mothers has risen from 26.3 years
in 1978
2
to 31.3 years in 2017.
3
The reasons for
this shift are multifactorial; however, one element
is thought to be lifestyle-related, with women
describing a desire for career-development or
building nancial security before having chil-
dren.
4,5
While fullling these goals lends to greater
gender equality and expands options for women, it
can also have some severe limitations in terms of
achieving family goals. When women postpone
childbearing, they risk not reaching their parenting
aspirations, as the chances of conceiving decrease
with age.
6,7
Oocyte cryopreservation or egg freezing(EF) is a
method of fertility preservation that may extend fer-
tility beyond the natural time that a woman is fer-
tile. Eggs are collected using Assisted Reproductive
Technology (ART), cryopreserved by vitrication
8
and placed in storage until a later time when they
can be used to create embryos through in vitro fer-
tilisation (IVF). The freezing process halts the aging
of eggs and enables women to consider pregnancies
at a later time. Initially EF was only offered to
women at risk of infertility from medical treatments
RESEARCH ARTICLE
1© 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://
creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non -commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited.
such as chemotherapy, or from illness such as pre-
mature ovarian failure (referred to as medicalEF).
However, more recently EF has become an option
for women faced with the prospect of age-related
infertility (referred to as non-medicalEF). Of the
emerging cohort of women accessing non-medical
EF, the majority report that the reason for choosing
to freeze eggs is due to not having a partner with
whom to have children.
912
It has been suggested
that it is the growing popularity of non-medical EF
that is driving the dramatic increase in EF cycles
seen worldwide.
1315
EF is offered around the world; however, pol-
icies and laws control access to EF in different
ways.Somenationsenforceadistinctionbetween
the medicaland non-medicaluse of EF; for
example, non-medical EF is prohibited in
France
16
and Singapore,
17
andonlypermittedin
Turkey for women with a low ovarian reserve or
history of premature ovarian failure.
18
In other
nations, varying age limits are enforced; Israel
restricts access only to women aged between 30
and 41 years,
19
in Germany EF is restricted to
women between the ages of 2049 years, and
in Denmark only a maximum age of 46 is
specied.
16
While cross-border differences in
healthcare are to be expected, the variety of
approaches to managing EF indicate a lack of con-
sensus about who should have access to EF, or
what criteria are relevant in making these
decisions. In addition, the inconsistencies
between criteria challenge the rationale behind
these requirements, which raises difcult ques-
tions about fair ways to govern access to EF.
In Australia the regulation of ART varies across
states and territories. In the state of Victoria, ART
is governed by the Assisted Reproductive Treatment
Act 2008 (Vic). This Act was drafted at a time when
EF was considered experimental
20
and access to EF
was limited to women with a medical indication
requiring fertility preservation. A recent review
into the 2008 Act, commissioned by the Victorian
Government, reported that there is confusion
over which parts of the Act apply to EF.
21
Further-
more, some stakeholders suggested that EF is out-
side the legislative scope of the Act as it does not
meet the current denitions of an ART treatment
procedure, because EF does not involve attempts
at fertilisation to produce embryos.
21
Notwith-
standing this confusion, both medical and non-
medical EF are currently offered in many clinics
around Australia, with government funding only
available for medically indicated EF.
The treatment scope of EF has dramatically
changed since the Victorian 2008 Act was enacted
and yet there has been no signicant update to
legislation, policy or guidelines to reect these
advancements. As demand for EF is likely to con-
tinue to increase, it is timely to review our
approach to this technology. Since novel technol-
ogies like EF have broader societal and ethical con-
sequences, consultation with key stakeholders is
crucial to understand the real-world experience
of potentially affected individuals and the compet-
ing interests of those involved.
22
Previous explora-
tory studies from Europe, Canada and the US have
reported that most people support medical EF, but
have some reservations about the use of EF for
non-medical indications.
2327
However, to date
no equivalent study has been conducted in Austra-
lia. The aim of this study was to explore attitudes
about access to EF for both medical and non-medi-
cal reasons in Victoria, Australia. The state of Vic-
toria was the rst jurisdiction in the world to
introduce legislation on ARTs (Infertility (Medical
Procedures) Act 1984) and is generally acknowl-
edged as a leader in the development of ART tech-
nologies and the regulation of ARTs.
28,29
Therefore,
Victoria is a key state to review public opinion on
emerging reproductive technologies. Data about
public attitudes signicantly contribute to under-
standing the acceptance of EF and can be used to
inform evidence-based policy and guidelines
worldwide.
Materials and methods
An anonymous, online, cross-sectional survey of
the general public was conducted in Australia
between April 2018 and May 2018. The survey,
hosted through the Research Electronic Data Cap-
ture (REDCap) platform, was advertised predomi-
nantly through online social media campaigns
via Facebook and parenting forums such as The
BubHub. Interested participants were invited to
follow a link to undertake the survey. The survey
comprised 35 questions that were adapted, with
permission, from the Fertility Preservation Survey
developed in Canada by Daniluk and Koert.
23
The
survey collected standard demographic data and
included questions that addressed; the timing of
parenthood, fertility intentions, beliefs about EF
(medical and non-medical) and decision-making
considerations in regard to EF. An overview of
those results was presented in part at the annual
meeting of the European Society of Human
M. Johnston et al. Sexual and Reproductive Health Matters 2020;28(1):114
2
Reproduction and Embryology.
30
This paper
reports on responses to part of the survey: the
questions that sought participantsviews about
whether access to medical and non-medical EF
should be permitted. Throughout the paper we
refer to access to EF by women, however the
authors acknowledge that access to EF may also
be relevant to individuals that do not identify as
women.
Participants were asked to respond, via a 5-
point Likert scale (strongly disagree/disagree/unde-
cided/agree/strongly agree), to questions about
whether they agreed that access to EF should be
allowed in the following situations:
(1) To preserve fertility for women who are about
to undergo treatments that could render them
infertile in the future (e.g. chemotherapy for
cancer)
(2) To preserve fertility for women who have
medical conditions that could render them
infertile in the future (e.g. endometriosis, pre-
mature menopause)
(3) To preserve fertility for women delaying child-
bearing because they do not have a partner
(4) To preserve fertility for women delaying
childbearing for career or educational
advancement
(5) To preserve fertility for women delaying child-
bearing because they do not believe that they
are nancially secure enough to raise a child
In the following analysis, the responses Agree
and Strongly Agreewere combined and referred
to as responses in support of the statement, and
the responses Disagreeand Strongly Disagree
were combined and referred to as responses not
supporting the statement. At the conclusion of
the survey, participants were invited to provide
free-text comments on any other factors that
were important to them regarding EF. The com-
ments were further analysed to identify those
that related to EF access.
Participants
The survey was open to residents of Australia aged
between 18 and 60 years. The age range selected
was to include those currently in their reproductive
lifespan, and those who had passed their repro-
ductive years but could have accessed ARTs in
their lifetime. This paper reports on data from
females who reside in the state of Victoria. While
we received a small number of responses from
all states and territories in Australia and from
people identifying as a gender other than
female, the number of responses was too low for
meaningful comparisons and they have been
excluded.
Statistical analysis
Data were summarised using frequencies and per-
centages. Socioeconomic status was measured
using Socio-Economic Indexes for Areas (SEIFA)
developed and designed by the Australian Bureau
of Statistics.
31
SEIFAs are indices that rank geo-
graphic areas on a scale of 110 according to socio-
economic advantage and disadvantage, taking into
account factors such as income levels, unemploy-
ment levels and educational attainment. This
study applied the Australian Bureau of Statistics
disadvantage indices: the higher the score the
lower level of disadvantage.
32
The association between participantsattitudes
towards medical EF and their demographics or par-
enting intentions and experiences were assessed
using Chi-squared tests. The relationship between
non-medical EF and participant demographics
was established using logistic regression adjusting
for age, highest level of education, relationship sta-
tus and socioeconomic status, and results were
reported as Odds Ratios (OR) with their 95% con-
dence intervals (CI). Models for the relationship
between parenting intentions and experiences,
and attitudes towards non-medical EF were
adjusted for age, highest level of education and
relationship status, as they were deemed the
most likely to confound the relationship, based
on the unadjusted analyses. Analyses
were conducted using Stata Statistical Software
version 15 (StataCorp. 2017. College Station, TX:
StataCorp LL).
Free-text comments collected from the nal
open-ended question were uploaded into NVivo
version 12 (NVivo qualitative data analysis Soft-
ware; QSR International Pty Ltd. Version 12,
2018). NVivo allowed for keyword searching and
thematic analysis, as described by Braun and
Clarke,
33
was used to identify common themes
across participantscomments. This process
involved assigning codes to represent features of
each data entry. Once the dataset was coded, the
resulting codes were then grouped into broader
themes. The themes were then reviewed to ensure
they were representative of the codes and allo-
cated a name. A report of the themes, with a selec-
tion of representative extracts was produced and
reviewed by co-authors.
M. Johnston et al. Sexual and Reproductive Health Matters 2020;28(1):114
3
Ethical approval
The research study was approved by the Monash
University Human Research Ethics Committee on
the 9th March 2018 (project number 10843).
Results
A total of 1,066 females initiated the survey. From
these, 410 were excluded from analysis as they
either initiated the survey but did not enter any
further data or did not reside within the geographi-
cal area of interest, which left 656 participants.
Demographics
Demographic data for the participants are outlined
in Table 1. The median age of the sample was 28
years and most participants were of high socio-
economic status. The majority of participants
identied as heterosexual women (87%) and at
the time of the survey, about a quarter of partici-
pants were single and about half were either living
with a partner or married. Approximately two
thirds of participants were not afliated with any
religion (65%). Participants were almost evenly dis-
tributed across education levels, and approxi-
mately three quarters were employed (full time
and part time).
Parenting intentions and experiences
Participantsparenting intentions and experiences
are reported in Table 1. Most participants were
childless (76%) and the majority (89%) had a sec-
ondary experience with infertility, i.e. they indi-
cated that they knew someone who had difculty
conceiving or who had experience with ARTs,
including EF. Half of the participants (53%)
reported that having a biologically related child
is important to them and a similar proportion
either had or wanted 12 children (56%). When
asked their views about the maximum age that a
woman should attempt to conceive, carry and
give birth to a child, half the respondents indicated
over the age of 40 years, and approximately three
quarters considered the ideal age for a woman to
conceive their rst child to be <30 years.
Attitudes towards medical EF
Overall, there was unanimous support (98%) for
access to EF for situations where medical treat-
ments or illnesses threaten fertility. There was no
signicant relationship between age, education
level, relationship status or socio-economic status
and support for both examples of medical EF. Simi-
larly, there was no signicant relationship between
parenthood, secondary experience with infertility,
number of desired children, importance of having
biological children or the ideal age a woman
should conceive their rst child, and level of sup-
port for medical EF. While there was a signicant
difference in support for medical EF between par-
ticipant opinions of the perceived oldest age a
woman should conceive a child, the level of sup-
port did not drop below 96% in either subgroup
(Table 2).
Attitudes towards non-medical EF
In relation to access to EF for non-medical risks to
fertility, there was strong support (65%) for all
indications among the respondents; lack of suit-
able partnerwas the highest supported indication
(75%), followed by nancial insecurity(72%) and
career/educational advancement(65%). Several
participants were undecided on whether EF should
be available for non-medical risks to fertility
(16.9%, 15.7% and 18.8%, respectively). There was
no signicant relationship between education
level or socio-economic level and attitudes towards
non-medical EF. There were varied levels of sup-
port for non-medical EF across age groups and
marital status (Figure 1). Respondents who were
aged 40 years were less likely to support EF for
lack of suitable partner (65% vs. 77%, OR: 0.47,
95% CI: 0.240.94, p= 0.032), career/educational
advancement (45% vs 69%, OR: 0.31, 95% CI:
0.180.53, p< 0.001) and nancial insecurity
(52% vs 77%, OR: 0.39, 95% CI: 0.220.68, p=
0.001) than respondents who were <40 years. Simi-
larly, married respondents were less likely to sup-
port EF for career/educational advancement (55%
vs 72%, OR: 0.39, 95% CI: 0.200.77, p= 0.007)
and nancial insecurity (60% vs 77%, OR: 0.41,
95% CI: 0.200.84, p= 0.014) than respondents
who were single.
Figure 2 presents the relationship between par-
enting intentions and experiences, and respon-
dentsattitudes towards non-medical EF.
Participants who indicated 40 years as the oldest
age a woman should try to conceive a child, were
signicantly more likely to support all indications
for non-medical EF than those who believed this
age should be <40 years (lack of suitable partner:
79% vs 71%, OR: 2.29, 95% CI: 1.264.18, p=
0.007; nancial insecurity: 74% vs 69%, OR: 1.66,
95% CI: 1.012.73, p= 0.047; career/educational
advancement: 70% vs 59%, OR: 2.06, 95% CI:
M. Johnston et al. Sexual and Reproductive Health Matters 2020;28(1):114
4
Table 1. Demographics and parenting intentions and experiences from an online survey
of women aged 1860 years
Characteristic N= 656
Age: Median (IQR) 28 (23, 37)
Religious afliation:n(%)
Catholic 112 (17.1)
Protestant 63 (9.6)
No religion 423 (64.5)
Other (including Judaism/Buddhism/Islam/Hinduism) 58 (8.8)
Highest attained education level:n(%)
Non-university education (include <Year12/up to Year12/Trade/Certicate) 229 (34.9)
University (undergraduate) 223 (34.0)
Postgraduate degree 204 (31.1)
Relationship status:n(%)
Single 181 (27.6)
Living with partner 155 (23.6)
Married 172 (26.2)
Other (including divorced/separated/dating) 148 (22.6)
Sexuality: n(%)
Heterosexual 571 (87)
Homosexual 19 (2.9)
Bisexual 52 (7.9)
Other (including asexual and prefer not to answer) 14 (2.2)
Primary occupation in preceding 12 months:n(%)
Paid employment full time 290 (44.2)
Paid employment part time 186 (28.4)
Student 213 (32.5)
Unemployed 14 (2.1)
Other (including volunteer) 42 (6.5)
Socio-economic status (based on postcodes):n(%)
SEIFA disadvantage deciles 13 64 (9.8)
SEIFA disadvantage deciles 46 128 (19.5)
SEIFA disadvantage deciles 710 460 (70.1)
Missing postcodes 4 (0.6)
Parenthood:n(%)
Childless 497 (75.8)
Parent (including biological/adopted/step) 159 (24.2)
Know someone who experienced difculty conceiving/used assisted conception or know someone who
has undergone oocyte cryopreservation:n(%)
No 72 (11.0)
Yes 584 (89.0)
M. Johnston et al. Sexual and Reproductive Health Matters 2020;28(1):114
5
1.303.27, p= 0.002). Perceiving <30 years as the
ideal age to rst conceive, considering having bio-
logically related children as moderately important
and desiring one or more children were all signi-
cantly associated with increased support for differ-
ent indications for non-medical EF (Figure 2).
Compared with those who did not want a child,
participants who hoped for 12 children were
almost ve times more likely to be supportive of
non-medical EF for lack of suitable partner(80%
vs. 68%, OR: 4.72, 95% CI: 1.9611.40, p= 0.001).
While the likelihood was lower for those who
wanted more than two children, support for non-
medical EF for lack of suitable partnerwas still
twice higher than that of participants who did
not want children (80% vs. 68%, OR: 2.86, 95% CI:
1.196.83, p= 0.018). There was no signicant
relationship between parenthood, or secondary
experience of infertility, and support for all
examples of non-medical EF.
Open text ndings
In the additional comments section provided at
the end of the survey, thoughts or concerns related
to EF access were identied and summarised into
three broad themes: Reasons for who should have
access to EF, Womens autonomy and informational
needs and Cost is a barrier.
Reasons for who should have access to EF
Participants offered a variety of reasons to explain
their views about when access to EF should be
allowed. While some participants supported
universal access: everyone should have access to
fertility treatments, including EF,others suggested
priority should be given to those who face medical
treatments or illnesses that may render them infer-
tile. As explained by one participant: for those
with conditions or health concerns that threaten fer-
tility, [they] should have the human right to sustain
their eggs in any which way they see t.Another
participant elaborated: [EF should] only be used
if there is a genuine medical reason not to put
your career rst because that is a choice not a neces-
sity.Some participants explained that the risks
associated with EF procedures and the unknown
factors like the impacts on the children conceived,
prevented them from supporting non-medical EF.
Womens autonomy and informational needs
Many participants in the study highlighted the
importance of reproductive autonomy. As
explained by one participant: its all about giving
women options and the power to choose when
and which stage of their lives they would like to
get pregnant. Another participant elaborated:
women should be supported with whatever choices
that they feel they need to make.However, many
participants alluded to an informational barrier
to EF, with one participant claiming, despite per-
sonal and family history of fertility issues I learnt
most of what I know about [EF] from this survey.
Another participant reected on their own experi-
ence with infertility: if I knew 10 years ago what I
know now, I would have frozen my eggs. I thought I
had all the time in the world.Participants called
Number of children hoped for:n(%)
None 56 (8.5)
12 367 (56.0)
>2 233 (35.5)
Importance of having a biologically related child:n(%)
Not important 181 (27.6)
Moderately important 130 (19.8)
Important 345 (52.6)
Perceived oldest age to conceive, carry and give birth:n(%)
<40 years 324 (49.4)
40 years 332 (50.6)
Perceived youngest age to conceive, carry and give birth:n(%)
<30 years 475 (72.4)
30 years 181 (27.6)
M. Johnston et al. Sexual and Reproductive Health Matters 2020;28(1):114
6
Table 2. Support for access to egg freezing for medical reasons by participants demo-
graphic characteristics and parenting intentions and experiences
Participantsdemographic characteristics and parenting
intentions and experiences
Supportive of egg freezing
when undergoing
treatment that may
cause infertility
e.g. chemotherapy
when medical
conditions
threaten fertility
e.g. endometriosis
n(%) p-Value n(%) p-Value
ALL participants 642 (97.9) 641 (97.7)
Age group (years)
<40 519 (97.6) 0.440 519 (97.6) 0.317
40 123 (99.2) 122 (98.4)
Highest attained education level
Non-university education 226 (98.7) 0.103 226 (98.7) 0.282
Undergraduate degree 215 (96.4) 216 (96.9)
Post-graduate degree 201 (98.5) 199 (97.6)
Relationship status
Single 177 (97.8) 0.533 177 (97.8) 0.840
Living with partner 153 (98.7) 152 (98.1)
Married 170 (98.8) 169 (98.3)
Other 142 (96.0) 143 (96.6)
Socio-economic status
SEIFA disadvantage deciles 13 63 (98.4) 0.902 62 (96.9) 0.310
SEIFA disadvantage deciles 46 126 (98.4) 125 (97.7)
SEIFA disadvantage deciles 710 449 (97.6) 450 (97.8)
Parenthood
Childless 484 (97.4) 0.277 483 (97.2) 0.224
Parent 158 (99.4) 158 (99.4)
Know someone who has had fertility issues
No 69 (95.8) 0.210 70 (97.2) 0.951
Yes 573 (98.1) 571 (97.8)
Number of children hoped for
None 53 (94.6) 0.228 53 (94.6) 0.119
12 361 (98.4) 362 (98.6)
>2 228 (97.9) 226 (97.0)
Importance of having a biologically related child
Not important 174 (96.1) 0.159 175 (96.7) 0.220
Moderately important 128 (98.5) 127 (97.7)
Important 340 (98.6) 339 (98.3)
M. Johnston et al. Sexual and Reproductive Health Matters 2020;28(1):114
7
for more informationand increased awareness
and knowledgeto support women to make an
informed decision.
Cost is a barrier
The cost of EF was addressed extensively, with
many participants linking accessibility with
affordability: cost is the limiting factor. It needs
to be more affordable.Participants reected on
their own experiences: Ive never looked into [EF]
as it has always seemed like an unattainable,
expensive procedure.Another participant com-
mented: career driven friends and I have discussed
[EF] as a future option for us, however the
Perceived oldest age to conceive, carry and give birth
<40 years 312 (96.3) 0.015 311 (96.0) 0.009
40 years 330 (99.4) 330 (99.4)
Ideal age to conceive rst child
<30 years 464 (97.7) 0.102 463 (97.5) 0.630
30 years 178 (98.3) 178 (98.3)
Figure 1. The relationship between non-medical egg freezing (EF) and participant demo-
graphics. Symbols represent the adjusted Odds Ratio (OR) and the bars indicate the 95%
condence intervals. The OR were adjusted for age, highest level of education, relation-
ship status and socioeconomic status
M. Johnston et al. Sexual and Reproductive Health Matters 2020;28(1):114
8
extraordinary costs is a signicant barrier. One par-
ticipant expressed their belief that any woman
should have [EF] available to them at a reasonable
cost,since, as reasoned by another participant:
having children is very important to most
women.
Discussion
To our knowledge, this is the rst Australian study
to explore views about access to egg freezing. We
surveyed a self-selected group of women from Vic-
toria, Australia about their views on whether EF
should be permitted for medical and non-medical
reasons and examined the inuence of demo-
graphics and parenting intentions and experiences
on opinions of EF. The level of support for medical
EF was at least 94% across all demographic sub-
groups, with only minor differences in support
seen between the perceived oldest age a woman
should conceive a child. In contrast, there was con-
siderable variation in support for non-medical EF
across participant demographic groups; younger
age (<40 years) and considering 40 years to be
the oldest age a woman should conceive a child,
were signicantly associated with increased sup-
port for all three indications for non-medical EF.
Our results suggest there is stronger support
overall for medical EF than there is for non-medi-
cal EF. This is consistent with the ndings of pre-
vious studies; a recent study from Sweden that
surveyed women aged 3039 years on the accept-
ability of medical and non-medical EF also found
that there was stronger support for medical EF
Figure 2. The relationship between non-medical egg freezing (EF) and participant parent-
ing intentions and experiences. Symbols represent the adjusted Odds Ratio (OR) and the
bars indicate the 95% condence intervals. The ORs for the relationship between parent-
ing intentions and experiences, and attitudes were adjusted for age, highest level of edu-
cation and relationship status
M. Johnston et al. Sexual and Reproductive Health Matters 2020;28(1):114
9
than there was for non-medical EF (94% vs. 70%,
respectively).
27
Similarly, a Canadian study reported
that 91.4% of the childless women they surveyed
were supportive of medical EF, whereas only 66%
of them supported non-medical EF.
23
This variation
in support suggests that medical and non-medical
indications for EF are perceived differently and
that medical reasons are judged to be more accep-
table reasons for seeking access to EF.
While support for medical EF appeared to be
independent of the possible reasons for seeking
medical EF (97.9% and 97.7% in support for EF
due to treatment and illness, respectively), support
for non-medical EF was dependent on the reason it
was sought. Our results are consistent with those of
a UK-Danish study that surveyed women aged 18
68 years and reported less support for non-medical
EF when it is sought to delay parenting to allow
career advancement or further education (66%,
cf. 65% in our study) and more support for EF
when it is sought because of the lack of suitable
partner (85%, cf. 75% see in our study).
24
In con-
trast, an American study that surveyed men and
women aged 1865 years, reported non-medical
EF for career/educational advancementwas the
highest supported (72.1%) indication for EF
amongst the other reasons for seeking
non-medical EF (lack of partner: 63%, nancial inse-
curity: 58%).
25
The variation in support for the different indi-
cations of non-medical EF suggests that partici-
pants did not consider the indications for non-
medical EF to be analogous. Findings from the
analysis of qualitative data suggest a possible
explanation for the diminished support EF for
career/educational advancementreceived in our
study. As explained by one participant, EF for
career/education advancement”“is a choice
not a necessity. Our ndings add support to a
view reported in the literature suggesting that EF
is more acceptable when it is sought for reasons
that are related to misfortune or beyond an indi-
viduals control (e.g. a cancer diagnosis, or not hav-
ing a partner) as opposed to reasons that are
perceived to be a lifestyle choice (e.g. for career
or educational goals).
34
As elaborated by Mertes,
35
the negative portrayal of the careerist woman
choosing to delay bearing children to focus on
her career, presents the decision to access EF as
an egoistic choice.
Views about the permissibility of EF for career
building are concerned with womens reproductive
choices and which choices are justiable. In her
discussion on reproductive choices, Petropana-
gos
36
argues that womens childbearing decisions
cannot be considered in isolation from their social
environment. Petropanagos
36
reasons there are
many obstacles in the education sector and in
the workplace that inuence womens childbear-
ing decisions. Such obstacles could include: the
cost and availability of childcare options,
37
the
structure of parental leave policies,
38
or whether
a workplace offers exible working arrange-
ments.
39
Indeed, studies indicate that highly edu-
cated women are more likely to have children
later in life and not reach their desired family
size.
40
Further, women report that the support or
lack of support that pregnant women receive in
their workplace inuences their decision about
when they may have children.
41
Therefore, consid-
ering the barriers women face in the workplace,
their decision to seek EF may be more multifaceted
than simply a preference for career progression
and delayed childbearing.
Furthermore, as Mertes
35
argues, the emerging
demographic prole of the women accessing
non-medical EF does not support the notion that
women are seeking EF so that they can delay par-
enthood to continue to build their careers. Current
research supports Mertess argument and shows
that most of the women accessing EF are doing
so in their late 30s and identify as wanting children
but not having found a partner yet.
912
Further,
analysis of data collected through qualitative inter-
views found that women view EF as their best
option to allow more time to nd a partner,
while also conserving their chances of genetic par-
enthood in the future.
42
This suggests that when
women access EF, they are motivated by a dimin-
ished ovarian reserve and a desire for genetic par-
enthood, rather than by a preference for career
advancement over having children. It is, however,
important to note that while EF may temporally
reassure women, the risk of failed treatment and
the implications of shifting the timing of childbear-
ing raise ethical concerns that require further con-
sideration. Further research is required to explore
peoples attitudes towards non-medical EF, in par-
ticular to clarify reasons that might explain the
variation in support for different indications for
non-medical EF and also to understand the
ambivalence towards non-medical EF, as indicated
by the small group of participants who were unde-
cided on whether access should be permitted.
The current study revealed that participants
share two other concerns about EF. Firstly, many
M. Johnston et al. Sexual and Reproductive Health Matters 2020;28(1):114
10
participants alluded to an informational barrier,
indicating that the lack of public awareness of EF
could prevent women from accessing this technol-
ogy. The claim that women are unfamiliar with EF
is not surprising as many studies have identied
that people of reproductive age have a poor under-
standing of fertility and of the capacity of ARTs to
overcome problems with infertility.
5,23,4345
In
addition, the information available to individuals
through ART clinic websites may not be accessible
to the lay public. Recent audits of ART clinic web-
sites indicated the quality of information provided
is poor and often not up to industry standards.
46,47
In some cases, information on treatments and suc-
cess rates was considered misleading and was
found to aggressively market some ART pro-
cedures,
48
including non-medical EF.
49
Our nd-
ings provide further evidence of the need to
improve the quality of the resources on fertility
and fertility preservation.
Secondly, while most of our participants sup-
ported access to EF, many noted the costs of EF
are prohibitive. In Australia, EF costs approxi-
mately AU$10,000 per cycle.
50
For individuals
with a medical indication for EF a rebate is avail-
able through the publicly funded health care sys-
tem, Medicare.
51
However, women seeking non-
medical EF are not eligible to receive the rebate
and must self-fund the costs. Therefore, while all
women are theoretically able to request EF,
unequal funding and the high procedural costs of
EF effectively exclude people who cannot afford
the procedure. The issue of affordability is relevant
to many ARTs, where the associated costs are an
insuperable barrier to accessing treatment.
51
The
report from the recent review into ART legislation
in Victoria recommended the establishment of
public ART services to support those who face
nancial difculties to access fertility treatments
in the private sector.
21
While it is unclear whether
a public clinic would offer non-medical EF, the
establishment of publicly funded clinics is one
step to broaden access to ART services. Other pos-
sibilities include a discussion of whether public
funding, via medical benets, should be extended
to include both medical and non-medical EF.
Limitations
The online format of the survey, and the predomi-
nant use of online recruitment may have limited
the number of people who could access the survey.
In addition, the participants self-selected their
involvement in this study and, therefore, the
views reported may not be representative of all Vic-
torian women. However, this study was not seeking
to be representative, but rather to provide a snap-
shot of the opinions of interested individuals on
access to EF and to collect data that were pre-
viously unknown in Australia. It is possible that
the results contain a selection bias in favour of
EF, because people interested in, or experienced
with, infertility might be more likely to respond
positively to new ARTs. Further, while experience
with pregnancy complications, infertility or ARTs
may inuence participant responses, these data
were not collected. Future research could explore
the inuence gravidity, parity and other factors
such as sexuality have on opinions towards EF.
Conclusion
Results from this research add to the limited data
on the publics attitudes towards EF and their
views about when access to EF should be per-
mitted. Our ndings concur with previous studies
and social commentaries suggesting that there is
widespread support for EF; however, there is
more support for medical EF than there is for
non-medical EF. Further, the ndings suggest
that people do not consider the possible reasons
for requiring non-medical EF to be analogous as
support for each reason varied. The current surge
of interest in EF requires careful policy responses
that consider cultural, demographic and nancial
determinants which inuence ART usage. Further
research is required to consider the ethical impli-
cations of increased reliance on EF as well as the
implications and potential risks of postponing
childbearing till later years. Current research is
under way to explore funding options for EF and
the ethical issues associated with the rationing of
EF funding based on medical and non-medical
distinctions.
Author contributions
MJ, GF, NMR and SC contributed to the conception
and design of the study. MJ was responsible for
data collection, and MJ and SMG conducted data
analysis. MJ drafted the manuscript and all authors
reviewed and contributed to the nal version.
Acknowledgements
Thank you to Judith Daniluk and Emily Koert for
providing the initial questionnaire used to structure
our study. Thank you to the staff at the Ofce of
M. Johnston et al. Sexual and Reproductive Health Matters 2020;28(1):114
11
Strategic Marketing and Communications at Mon-
ash University for their assistance with recruitment
material. Finally, thank you to all the participants
in the study for giving their time and sharing their
views.
Disclosure statement
No potential conict of interest was reported by the
author(s).
Funding
MJ is supported by an Australian Research Training
Program Scholarship through Monash University.
ORCID
Molly Johnston http://orcid.org/0000-0002-3786-
0843
StellaMay Gwini http://orcid.org/0000-0002-
0295-4575
Sally Catt http://orcid.org/0000-0002-7604-4507
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Résumé
La technologie de congélation ovocytaire sest sen-
siblement perfectionnée ces dix dernières années,
donnant aux femmes davantage de choix sur leur
avenir reproductif. En dépit de ces progrès, la con-
gélation ovocytaire suscite des questions éthiques
et régulatrices controversées. Les politiques con-
trôlant laccès à cette technique varient dans le
monde et un consensus fait défaut sur les per-
sonnes qui devraient y avoir accès et les critères
pertinents pour prendre ces décisions. Létude sou-
haitait connaître les idées des femmes sur laccès à
la congélation ovocytaire pour les risques « médi-
caux » et « non médicaux » de stérilité. Une
enquête en ligne a été administrée à des femmes
âgées de 18 à 60 ans à Victoria, Australie, entre
avril et mai 2018. Au total, 1066 personnes ont
commencé lenquête. Lâge médian des partici-
pantes était de 28 ans et 81% avaient moins de
40 ans. Presque toutes les participantes (98%)
approuvaient laccès à une congélation ovocytaire
médicale dans les situations où des traitements
(par exemple la chimiothérapie) ou des maladies
menacent la fécondité. Le soutien à laccès pour
des raisons non médicales était plus faible; 75%
appuyaient la congélation ovocytaire en cas de «
manque de partenaire approprié », 72% en cas «
dinsécurité nancière pour élever un enfant » et
65% pour privilégier « lavancement de la car-
rière/de léducation ». Les répondantes plus
âgées (de 40 ans ou plus) avaient moins de prob-
abilités que les plus jeunes de soutenir toutes les
indications pour une congélation ovocytaire non
médicale. Nos résultats indiquent un large soutien
à la congélation des ovocytes. Néanmoins, la vari-
ation du soutien entre les indications pour la con-
gélation ovocytaire non médicale suggère que les
personnes ne conçoivent pas laccès à cette techno-
logie simplement du point de vue de la nécessité
médicale. Pour traduire les idées de lopinion pub-
lique, les futures politiques devraient peut-être
envisager laccès à la congélation ovocytaire au-
delà de la distinction médicale/non médicale.
Resumen
La tecnología de congelación de óvulos (CO) ha
mejorado de manera signicativa en la última
década, por lo cual las mujeres tienen más
opciones para determinar su futuro reproduc-
tivo. A pesar de este avance, la CO suscita asun-
tos éticos y normativos contenciosos. Las
políticas que controlan el acceso a la CO varían
en todo el mundo y hay falta de consenso sobre
quién debería tener acceso y qué criterios son
pertinentes para tomar estas decisiones. El obje-
tivo de este estudio era identicar los puntos de
vista de las mujeres sobre el acceso a la CO por
riesgos médicosyno médicosde infertilidad.
Se administró una encuesta en línea a mujeres
entre 18 y 60 años, en Victoria, Australia,
entre abril y mayo de 2018. Un total de 1066
mujeres iniciaron la encuesta. La edad media
de las participantes fue de 28 años y el 81%
tenía <40 años. Casi todas las participantes
(98%) apoyaron el acceso a la CO médica en
situaciones donde los tratamientos (ej., quimio-
terapia) o enfermedades ponen en riesgo la fer-
tilidad. Hubo menos apoyo para acceder a la CO
por indicaciones no médicas; el 75% apoyó la
CO por falta de una pareja adecuada, seguido
de inseguridad nanciera para criar a un niño
(72%) y avance profesional/educativo(65%). Las
encuestadas de edad más avanzada (40 años)
eran menos propensas que las más jóvenes a
apoyar todas las indicaciones para la CO no
médica. Nuestros hallazgos indican amplio
apoyo para la CO. Sin embargo, la variación
en apoyo entre las indicaciones para la CO no
médica indica que las personas no piensan en
el acceso a la CO simplemente en términos de
necesidad médica. Para reejar las opiniones
públicas, futuras políticas posiblemente deban
considerar el acceso a la CO más allá de la dis-
tinción médica/no médica.
M. Johnston et al. Sexual and Reproductive Health Matters 2020;28(1):114
14
... It is therefore timely to investigate the views of Australian women on the introduction of ESEF to ensure that their insights inform the current debate and the development of policy and practice. In this paper we present findings on a study exploring women's views about ESEF, collected as part of a larger Australian survey that investigated attitudes to EF (Johnston et al. 2020). We provide an analysis of participant views for and against ESEF, as well as their concerns about this possible option. ...
... For each characteristic, except for age, two multinomial logistic regression models were run; one model had the participant characteristic of interest as the only independent variable and the second model was adjusted for age as a continuous variable. Age was adjusted since it has previously been demonstrated to be a confounding variable when examining attitudes toward applications of ARTs based on our previous findings (Johnston et al. 2020) and those of others (Fauser et al. 2019). A separate regression model was run for each participant characteristic and all participants were included in the analyses. ...
... The sample consisted of 656 women who resided in Victoria, Australia. A detailed description of the sample can be found in Johnston et al. (2020). Participants who resided outside of the state of Victoria were identified by their postcode of residence and were excluded from data analysis due to low representation. ...
Article
Background Since 2014, many companies have followed the lead of Apple and Facebook and now offer financial support to female employees to access egg freezing. Australian companies may soon make similar offers. Employer-sponsored egg freezing (ESEF) has raised concerns and there is academic debate about whether ESEF promotes reproductive autonomy or reinforces the ‘career vs. family’ dichotomy. Despite the growing availability of ESEF and significant academic debate, little is known about how ESEF is perceived by the public. The aim of this study was to explore women’s attitudes toward ESEF. Methods Women aged 18-60 years who resided in Victoria, Australia were invited to complete an online, cross-sectional survey investigating views toward egg freezing. Associations between participant demographics and their views about ESEF were assessed using multinominal logistic regression, adjusted for age and free text comments were analyzed using thematic analysis. Results The survey was completed by 656 women, median age 28 years (range: 18-60 years). Opinions on the appropriateness of employers offering ESEF were divided (Appropriate: 278, 42%; Inappropriate: 177, 27%; Unsure: 201, 31%). There was significantly less support for ESEF among older participants and those employed part-time (p < 0.05). While some participants saw the potential for ESEF to increase women’s reproductive and career options, others were concerned that ESEF could pressure women to delay childbearing and exacerbate existing inequities in access to ARTs. Conclusions Our analysis revealed that while some women identified risks with ESEF, for many women ESEF is not viewed as theoretically wrong, but rather it may be acceptable under certain conditions; such as with protections around reproductive freedoms and assurances that ESEF is offered alongside other benefits that promote career building and family. We suggest that there may be a role for the State in ensuring that these conditions are met.
... The questionnaire collected general demographics, and included questions on parenting aspirations, opinions about fertility preservation, and decision-making considerations related to EF. The survey also collected data on women's views about access to medical and non-medical EF, which have been reported elsewhere recently (Johnston et al., 2020) and are referred to in the current study to inform part of the analysis. ...
... Most participants (n=497, 76%) did not have children, and a high proportion (n=584, 89%) knew of someone who had either experienced infertility or had accessed ART, including EF, in the past. As reported previously, almost all participants (98%) supported access to medical EF, and a considerable proportion (72%) supported access to non-medical EF (Johnston et al., 2020). ...
Article
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Like other assisted reproductive technology (ART) procedures, the cost of egg freezing (EF) is significant, presenting a potential barrier to access. Given recent technological advancements and rising demand for EF, it is timely to reassess how EF is funded. An online cross-sectional survey was conducted in Victoria, Australia and was completed by 656 female individuals. Participants were asked their views on funding for both medical and non-medical EF. The median age of participants was 28 years (interquartile range 23–37 years) and most participants were employed (44% full-time, 28% part-time, 33% students). There was very high support for public funding for medical EF (n = 574, 87%), with 302 (46%) participants indicating support for the complete funding of medical EF through the public system. Views about funding for non-medical EF were more divided; 43 (6%) participants supported full public funding, 235 (36%) supported partial public funding, 150 (23%) supported coverage through private health insurance, and 204 (31%) indicated that non-medical EF should be self-funded. If faced with the decision of what to do with surplus eggs, a high proportion of participants indicated that they would consider donation (71% to research, 59% to a known recipient, 52% to a donor programme), indicating that eggs surplus to requirements could be a potential source of donor eggs. This study provides insights that could inform policy review, and suggests revisiting whether the medical/non-medical distinction is a fair criterion to allocate funding to ART.
... In the general population, several empirical studies have indicated that the most important barrier for those who would undergo SEF is the prohibitive cost [27][28][29]. However, inequality of access to this reproductive technology is not limited to costs. ...
Article
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Background During the last decade, the possibility for women to cryopreserve oocytes in anticipation of age-related fertility loss, also referred to as social egg freezing, has become an established practice at fertility clinics around the globe. In Europe, there is extensive variation in the costs for this procedure, with the common denominator that there are almost no funding arrangements or reimbursement policies. This is the first qualitative study that specifically explores viewpoints on the (lack of) reimbursement for women who had considered to uptake at least one social egg freezing cycle in Belgium. Methods To understand the moral considerations of these women, drawing from twenty-one interviews, this paper integrates elements of a symbiotic empirical ethics approach and thematic analysis. Results We identify four themes: (1) being confronted with unclear information; (2) financial costs as ongoing concern; (3) necessity of coverage; (4) extent of reimbursement. In the first theme, we found that some women were concerned about the lack of clear information about the cost of social egg freezing. In the second theme, we report moral sentiments of injustice and discrimination which some women attributed to their struggles and needs not being recognised. The third theme illustrates diverse views on reimbursement, ranging from viewing social egg freezing as an elective treatment not appropriate for reimbursement to preferences for greater public responsibility and wider access. Finally, we describe the participants’ varying proposals for partial reimbursement and the idea that it should not be made available for free. Conclusions This research adds important empirical insights to the bioethics debate on social egg freezing, in particular by presenting (potential) users’ views on the lack of reimbursement. While there is much more to say about the ethical and political complexities of the reimbursement of this procedure, our study highlighted the voices of (potential) users and showed that at least some of them would welcome the coverage of SEF through the public healthcare insurance.
Article
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Purpose Few options are available for preserving female fertility to postpone childbirth. Although egg freezing with successful thawing is now possible, women’ attitudes towards its use or the circumstances under which this technique may be considered remain unclear. Methods This study is a cross-sectional online survey. From November 2020 to January 2021, 848 questionnaires were collected through the Questionnaire Star Network platform, and a total of 750 valid answers were obtained. Results For more than 40% of the interviewees, the level of knowledge about egg freezing was only 0–25%; 36.9% of the interviewees supported elective egg freezing, and the main factor affecting their approval was major; approximately 60% of interviewees believed that being married should not be a condition for freezing eggs; and 56.7% of the interviewees supported the establishment of an egg bank in China, and the main factor affecting their acceptance was the place of residence. Conclusion College students generally have a high level of recognition regarding elective egg freezing and the establishment of an egg bank, but their level of knowledge about egg freezing is low. Relevant knowledge must be strengthened to help college students achieve a correct understanding of elective egg freezing and egg bank establishment and then guide college students in developing a scientific dialectical attitude towards this technology.
Article
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Increasing numbers of women are undergoing oocyte or tissue cryopreservation for medical or social reasons to increase their chances of having genetic children. Social egg freezing (SEF) allows women to preserve their fertility in anticipation of age-related fertility decline and ineffective fertility treatments at older ages. The purpose of this study was to summarize recent findings focusing on the challenges of elective egg freezing. We performed a systematic literature review on social egg freezing published during the last ten years. From the systematically screened literature, we identified and analyzed five main topics of interest during the last decade: (a) different fertility preservation techniques, (b) safety of freezing, (c) usage rate of frozen oocytes, (d) ethical considerations, and (e) cost-effectiveness of SEF. Fertility can be preserved for non-medical reasons through oocyte, embryos, or ovarian tissue cryopreservation, with oocyte vitrification being a new and optimal approach. Elective oocyte cryopreservation is better accepted, supports social gender equality, and enhances women’s reproductive autonomy. Despite controversies, planned oocyte cryopreservation appears as a chosen strategy against age-related infertility and may allow women to feel that they are more socially, psychologically, and financially stable before motherhood.
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Study question: How are ART and IUI regulated, funded and registered in European countries? Summary answer: Of the 43 countries performing ART and IUI in Europe, and participating in the survey, specific legislation exists in only 39 countries, public funding (also available in the 39 countries) varies across and sometimes within countries and national registries are in place in 31 countries. What is known already: Some information devoted to particular aspects of accessibility to ART and IUI is available, but most is fragmentary or out-dated. Annual reports from the European IVF-Monitoring (EIM) Consortium for ESHRE clearly mirror different approaches in European countries regarding accessibility to and efficacy of those techniques. Study design size duration: A survey was designed using the online SurveyMonkey tool consisting of 55 questions concerning three domains-legal, funding and registry. Answers refer to the countries' situation on 31 December 2018. Participants/materials settings methods: All members of EIM plus representatives of countries not yet members of the Consortium were invited to participate. Answers received were checked, and initial responders were asked to address unclear answers and to provide any additional information they considered important. Tables of individual countries resulting from the consolidated data were then sent to members of the Committee of National Representatives of ESHRE, asking for a second check. Conflicting information was clarified by direct contact. Main results and the role of chance: Information was received from 43 out of the 44 European countries where ART and IUI are performed. Thirty-nine countries reported specific legislation on ART, and artificial insemination was considered an ART technique in 35 of them. Accessibility is limited to infertile couples in 11 of the 43 countries. A total of 30 countries offer treatments to single women and 18 to female couples. In five countries ART and IUI are permitted for treatment of all patient groups, being infertile couples, single women and same sex couples, male and female. Use of donated sperm is allowed in 41 countries, egg donation in 38, the simultaneous donation of sperm and egg in 32 and embryo donation in 29. Preimplantation genetic testing (PGT) for monogenic disorders or structural rearrangements is not allowed in two countries, and PGT for aneuploidy is not allowed in 11; surrogacy is accepted in 16 countries. With the exception of marital/sexual situation, female age is the most frequently reported limiting criteria for legal access to ART-minimal age is usually set at. 18 years and maximum ranging from 45 to 51 years with some countries not using numeric definition. Male maximum age is set in very few countries. Where permitted, age is frequently a limiting criterion for third-party donors (male maximum age 35 to 55 years; female maximum age 34 to 38 years). Other legal constraints in third-party donation are the number of children born from the same donor (in some countries, number of families with children from the same donor) and, in 10 countries, a maximum number of egg donations. How countries deal with the anonymity is diverse-strict anonymity, anonymity just for the recipients (not for children when reaching legal adulthood age), mixed system (anonymous and non-anonymous donations) and strict non-anonymity.Public funding systems are extremely variable. Four countries provide no financial assistance to patients. Limits to the provision of funding are defined in all the others i.e. age (female maximum age is the most used), existence of previous children, maximum number of treatments publicly supported and techniques not entitled for funding. In a few countries, reimbursement is linked to a clinical policy. The definition of the type of expenses covered within an IVF/ICSI cycle, up to what limit and the proportion of out-of-pocket costs for patients is also extremely dissimilar.National registries of ART and IUI are in place in 31 out of the 43 countries contributing to the survey, and a registry of donors exists in 18 of them. Limitations reasons for caution: The responses were provided by well-informed and committed individuals and submitted to double checking. Since no formal validation was in place, possible inaccuracies cannot be excluded. Also, results are a cross section in time and ART and IUI legislations within European countries undergo continuous evolution. Finally, several domains of ART activity were deliberately left out of the scope of this ESHRE survey. Wider implications of the findings: Results of this survey offer a detailed view of the ART and IUI situation in European countries. It provides updated and extensive answers to many relevant questions related to ART usage at national level and could be used by institutions and policymakers in planning services at both national and European levels. Study funding/competing interests: The study has no external funding, and all costs were covered by ESHRE. There were no competing interests.ESHRE Pages are not externally peer reviewed. This article has been approved by the Executive Committee of ESHRE.
Conference Paper
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Study question: To investigate the therapeutic equivalence between a novel follitropin alpha biosimilar and the reference medication in women undergoing IVF. Summary answer: This study demonstrated similar therapeutic equivalence and safety profiles between two follitropin solutions in women who underwent controlled ovarian hyperstimulation (COH) in GnRH-antagonist cycles. What is known already: Biosimilars are not exact copies of the reference molecule due to the differences in genetic modifications of host cell lines and the manufacturing process. The manufacturer of biosimilars is required to conduct comparative, randomized pharmacokinetic/pharmacodynamic studies aiming to demonstrate that two medicines are equal at clinical level. The results of randomized, crossover, comparative study on the bioequivalence of follitropin alpha biosimilar indicated that a 300 IU single dose of biosimilar exhibits pharmacokinetic and safety profiles comparable to those of original follitropin in healthy young women. Study design, size, duration: A multicenter, randomized (1:1), embryologist-blinded, parallel-group, therapeutic equivalence study of two solutions of follitropin alpha. All of the subjects underwent COH using a GnRH-antagonist protocol. Over the 5-day fixed-dose regimen, the women received 150 IU/day of follitropin, followed by dose adaptation. A study power of 80% at a significance level of alpha=0.05, clinical equivalence margin of ±3.4 oocytes, the required sample size was 55 subjects per group and 110 subjects in total (intention-to-treat [ITT] population). Participants/materials, setting, methods: The inclusion criteria were: women aged 20-35 years old, established causes of infertility: tubal and/or male factors, first or second attempt at IVF/ICSI; 18 ≤ BMI ≤ 30 kg/m2; FSH ≤10 IU/l and oestradiol level ≤50 pg/ml; AMH≥1.0 ng/ml. The exclusion criteria were: women with established contraindications to the use of ART methods; PCOS; endometriosis. Of 118 women screened, 110 were randomized into the trial. Demographic and clinical characteristics were comparable between the treatment groups. Main results and the role of chance: The number of oocytes retrieved is the recommended primary endpoint as stated by European Medicinal Agency for the development of biosimilars containing follitropin. Similar numbers of oocytes were retrieved in both treated groups: 12.16±7.28 in the follitropin alpha biosimilar group and 11.62±6.29 in the reference group, with mean difference of 0.546±1.297 oocytes (95% confidence interval [CI]: -2.026, 3.116), p-value for equivalence of p=0.002 (ITT population). Additionally, no statistically significant differences were found for secondary endpoints: (1) in the number of follicles (≥16 mm) on the day of trigger injection 12.09±6.159 and 11.38±4.965 [95% CI: -1.405, 2.824], p=0.709; (2) in the number of MII oocytes 9.64±6.27 and 9.86±5.55 [95% CI: -2.455, 2.019], p=0.617; (3) and 2PN zygotes 8.13±6.61 and 8.76±5.85 [95% CI: -2.995, 1.723], p=0.445 (ITT population). The mean total follitropin doses (IU) per treatment cycle 1532.7±267.2 and 1517.9± 255.2 [95% CI: -83.9, 113.6] (p=0.488), duration of treatment (days) 9.75±1.08 and 9.73±1.03 [95% CI: -0.379, 0.416] (p=0.629) were similar in both groups. Ovarian hyperstimulation syndrome was observed in subjects with a positive pregnancy test in 0% and 3.64% of cases and after triggering ovulation in 7.27% and 3.64% for the biosimilar and reference medication groups, respectively. Limitations, reasons for caution: Normogonadotrophic patients enrolled in this study were representative, showing the ability of exogenous FSH to the stimulate development of multiple follicles in women without endocrine and ovarian disturbances during COH. Additional comparative studies are needed to confirm efficacy of the follitropin alpha biosimilar in patients with other causes of infertility. Wider implications of the findings: In this study, we demonstrated the therapeutic equivalence in terms of oocytes retrieved in women undergoing COH with a GnRH-antagonist cycle. Further post-authorization studies will be conducted to evaluate the efficacy of biosimilar in patients undergoing ART in GnRH-agonist cycles and with other causes of infertility: endometriosis, PCOS, poor response. Trial registration number: ClinicalTrials.gov: NCT03088137. Date of registration: 2 March, 2017, retrospectively registered, conducted between 08.02.2017 and 17.08.2018 Key words: follitropin alpha, biosimilar, recombinant follicle-stimulating hormone, FSH
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Background: What are the underlying socio-demographic factors that lead healthy women to preserve their fertility through elective egg freezing (EEF)? Many recent reviews suggest that women are intentionally postponing fertility through EEF to pursue careers and achieve reproductive autonomy. However, emerging empirical evidence suggests that women may be resorting to EEF for other reasons, primarily the lack of a partner with whom to pursue childbearing. The aim of this study is thus to understand what socio-demographic factors may underlie women's use of EEF. Methods: A binational qualitative study was conducted from June 2014 to August 2016 to assess the socio-demographic characteristics and life circumstances of 150 healthy women who had undertaken at least one cycle of elective egg freezing (EEF) in the United States and Israel, two countries where EEF has been offered in IVF clinics over the past 7-8 years. One hundred fourteen American women who completed EEF were recruited from 4 IVF clinics in the US (2 academic, 2 private) and 36 women from 3 IVF clinics in Israel (1 academic, 2 private). In-depth, audio-recorded interviews lasting from 0.5 to 2 h were undertaken and later transcribed verbatim for qualitative data analysis. Results: Women in both countries were educated professionals (100%), and 85% undertook EEF because they lacked a partner. This "lack of a partner" problem was reflected in women's own assessments of why they were single in their late 30s, despite their desires for marriage and childbearing. Women themselves assessed partnership problems from four perspectives: 1) women's higher expectations; 2) men's lower commitments; 3) skewed gender demography; and 4) self-blame. Discussion: The "lack of a partner" problem reflects growing, but little discussed international socio-demographic disparities in educational achievement. University-educated women now significantly outnumber university-educated men in the US, Israel, and nearly 75 other societies around the globe, according to World Bank data. Thus, educated women increasingly face a deficit of educated men with whom to pursue childbearing. Conclusion: Among healthy women, EEF is a technological concession to gender-based socio-demographic disparities, which leave many highly educated women without partners during their prime childbearing years. This information is important for reproductive specialists who counsel single EEF patients, and for future research on EEF in diverse national settings.
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Research shows that young people do not know much about their fertility. In the present study, we examined fertility knowledge and perceptions of a fertility educational brochure (i.e. ‘A Guide to Fertility’) in five focus groups with adolescents (16–18 years, n = 19) and emerging adults (21–24 years, n = 14) who were childless, not currently pregnant (or for men partner not pregnant) or trying to conceive but intending to have a child in the future. Participants (n = 33) reported having poor knowledge of a range of fertility topics and feelings of surprise, fear and concern in response to the brochure, despite perceiving benefits of the provision of fertility education and feasibility of ‘A Guide to Fertility’. Comparison between age groups showed that adolescents lacked confidence in their fertility knowledge and emerging adults more frequently referred to gender and family planning issues when considering the fertility information. The findings show the need and importance of ensuring fertility education is tailored to different age groups for it to be integrated at specific stages of the life course and optimize its benefits over costs. Results point to educators and researchers working together to determine how best to disseminate fertility information to relevant age groups.
Article
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Introduction: Recent evidence indicates that reproductive-age people have inadequate fertility awareness (FA) concerning fertility, infertility risk factors, and consequences of delaying childbearing. However, no study has tried to summarize these studies and to clarify the variables associated with FA, namely the role of gender, age, education, and reproductive status on FA. Methods: A literature search up to February 2017 was conducted using the EBSCO, Web of Science, Scielo, and Scopus electronic databases with combinations of keywords and MeSH terms (e.g. ‘awareness’ OR ‘health knowledge, attitudes, practice’ AND ‘fertility’; ‘fertile period’; ‘assisted reprod*’). Results: Seventy-one articles met the eligibility criteria and were included. The main results showed that participants report low-to-moderate FA. Higher levels of FA were shown by women, highly educated individuals, people who reported difficulties with conceiving, and those who had planned their pregnancies. Having or desiring to have children was not related to FA level. An inconsistent association between study participant age and FA was observed, with some studies indicating that older participants had higher FA, but others found an opposite result or did not find any association. Conclusion: The current findings suggest that interventions to increase FA are warranted, especially those targeting men, people with low education, and in family planning settings. Interventions and campaigns should be customized to meet individuals’ needs regarding FA. Because of the high heterogeneity regarding the assessment of FA, these conclusions must be interpreted with caution.
Article
Research question: What are the reproductive outcomes of women who bank oocytes for fertility preservation? Design: A prospective follow-up study of a cohort of 327 women who banked their oocytes for fertility preservation was carried out between July 2009 and August 2015. The indications for oocyte banking and outcomes of ovarian stimulation were collected from medical files. Follow-up data were obtained from an additional questionnaire. Results: In total, 243 out of 327 women (74%) responded and 228 women (70%) consented to participate and returned the questionnaire. The median time to follow-up of these women was 31 months. A total of 101 women (44%) were trying, or had tried, to become pregnant after oocyte banking, of which 66 became pregnant (65%). Five women reported an unintended pregnancy. Of these, 71 women became pregnant, 76% conceived naturally, 7% through intracytoplasmic sperm injection with their vitrified-warmed oocytes and 17% by other medically assisted reproduction treatments. Six women attempted to achieve a pregnancy using their banked oocytes. Of the six pregnancies achieved in five women, two resulted in a live birth. A total of thirty-eight women reported a live birth at the time of follow-up. Conclusion: Oocyte banking can be considered a form of risk management or preventive medicine because it is not certain that the women will experience sterility in the future.
Article
One of the important developments in assisted reproductive technology is the technique of oocyte preservation, which enables women to preserve their eggs when there is a threat of becoming infertile in the future. In spite of the still experimental status of this procedure, fertility clinics widely recommend it to healthy women who wish to postpone childbearing for social reasons. Since in fertility clinic’s websites appear extensive recommendations and promotion about this technology, it seems important to analyze their online persuasive communication. Our analysis applies a mixed methodology of content and discourse analysis from a framing theory perspective. It provides an in-depth analysis of the content of fertility clinics’ websites in Spain, describing their communication/information strategies regarding fertility preservation for social reasons. The present article confirms the inconsistency that exists in terms of the clarity of the information given by these websites, since the information is framed intending to attract more women to the egg freezing services.
Article
Research question: What can we learn from 5 years of egg-freezing practice in the UK? What are the different categories of egg freezing, and what are the social and demographic characteristics of patients, and their decisions regarding subsequent storage or thawing? Design: A retrospective analysis of clinical and laboratory data of all 514 cycles of 'own' egg freezing conducted at the London Women's Clinic in the 5-year period from the start of 2012 to the end of 2016. Results: This analysis, the first of its kind, develops a clearer picture of egg-freezing trends in the UK and fills in the details behind the Human Fertilisation and Embryology Authority's national figures. Four different categories of egg freezing are identified and the appropriate category allocated to each of the 514 cycles undertaken by 352 patients. To the established categories of 'medical' and 'social' already discussed in the literature, we add the two new categories of 'clinical' and 'incidental' egg freezing. We show how each of these categories presents a distinct egg-freezing patient profile, and discuss the similarities and differences between them across variables such as age, relationship status, number of eggs frozen, number of egg-freezing cycles undertaken, and the current status of frozen eggs. Conclusions: The data require a reconceptualization of the phenomenon of egg freezing, and argue for the importance of clearly and accurately differentiating between different categories of egg-freezing practice in clinical and national data collection in order to adequately inform future practice, regulation and the decision-making processes of patients considering these procedures.
Article
Most people want and expect to have children but lack of awareness about the biological limits of fertility may reduce their chance of achieving their parenthood goals. We surveyed Australian university students’ intentions and expectations for future parenthood, knowledge about fertility and preferred sources of fertility information. Male and female students (n = 1215) completed an anonymous 34-item online questionnaire. Fewer than 10% did not want children. Of those who wanted children, most (75%) wanted two or more. Although most participants wanted to have children within the biological limits of fertility they also expected to achieve many other life goals before becoming parents. Most underestimated the impact of female and male age on fertility (>75% and >95%, respectively). General practitioners and the Internet were the most preferred sources of fertility information. Almost all stated they would not feel uncomfortable if their general practitioner brought up the topic of future reproductive plans. To help women and men achieve their parenthood goals better education about fertility protection; proactive discussions with young people in primary care settings about reproductive life planning; and social policies and health promotion strategies that support becoming parents during the most fertile years are needed.
Article
Purpose: To evaluate the general knowledge of female graduate students on reproductive aging and fertility preservation options, as well as to investigate the perceptions, personal beliefs, and desires regarding fertility and preservation modalities. Materials and methods: A cross-sectional online survey study of female graduate students and medical trainees from academic institutions in Ohio was performed. Women were excluded if the online survey was incomplete or if they were >45 years. Results: Analysis of 590 surveys was performed (response rate of 26.3%). Ninety-four percent (557/590) of subjects were between 20 and 35 years. Our respondents tended to be nulliparous (87%), married or in a relationship (51%) and interested in future fertility (77%). The reasons cited for delaying childbearing were multi-factorial, with career building noted most commonly (69%). Nearly 60% of women reported they would consider fertility preservation in the future; however, the majority (87%) cited two or more barriers. When asked about their desire for information on fertility preservation, 28% desired to receive education on their choices and 36% wanted their Ob/Gyn to discuss fertility preservation options. Women >30 years were significantly more likely to desire future fertility, want more fertility preservation education and consider pursuing fertility preservation in the future. Conclusions: Graduate-level women often delay childbearing for professional pursuits. This study demonstrates a need for increased fertility preservation awareness and education, especially by Ob/Gyn providers.