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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.
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Original Article
Financing future fertility: women’s views on funding egg freezing
Molly Johnston, Giuliana Fuscaldo, Stella May Gwini, Sally Catt, Nadine
Maree Richings
PII: S2405-6618(21)00021-6
Reference: RBMS 166
To appear in: Reproductive Biomedicine & Society Online
Received Date: 30 December 2020
Revised Date: 19 May 2021
Accepted Date: 19 July 2021
Please cite this article as: M. Johnston, G. Fuscaldo, S. May Gwini, S. Catt, N. Maree Richings, Financing future
fertility: women’s views on funding egg freezing, Reproductive Biomedicine & Society Online (2021), doi:
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Financing future fertility: women’s views on funding egg freezing
Molly Johnstona,b,*, Giuliana Fuscaldoc,d, Stella May Gwinic,e, Sally Catta, Nadine Maree
aDepartment of Obstetrics and Gynaecology, Monash University, Clayton, Australia
bMonash Bioethics Centre, Monash University, Clayton, Australia
cUniversity Hospital Geelong, Barwon Health, Geelong, Australia
dEastern Health Clinical School, Monash University, Box Hill, Australia
eSchool of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
*Corresponding author. E-mail address: (M. Johnston).
Abstract 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.
KEYWORDS: egg freezing, oocyte cryopreservation, public funding, affordability,
accessibility, egg disposal
Demand for egg freezing (EF) for fertility preservation has increased dramatically in recent
years. The number of EF cycles undertaken in Australia/New Zealand increased by 311%
from 2010 to 2015, and by 880% in the USA from 2010 to 2016 (Johnston et al., 2021). EF
was initially offered to women who faced premature infertility as a result of illness, such as
endometriosis or premature ovarian insufficiency, or medical treatments, such as
chemotherapy for cancer (referred to as ‘medical’ EF). However, recent studies suggest that
the dramatic increase in EF cycle numbers is the result of increased demand for ‘non-
medical’ EF (Balkenende et al., 2018; Gürtin et al., 2018; Human Fertilisation and
Embryology Authority, 2018; Schon et al., 2017). Women seek non-medical EF as a pre-
emptive measure to increase their chance of conceiving later in life when their fertility may
be compromised due to age-related fertility decline.
Financial considerations for EF are significant; for many people, the cost of EF is
prohibitively high and prevents access (Anazodo and Gersti 2016; Inhorn et al., 2018b, 2019;
Petropanagos et al., 2015; Santo et al., 2017). A study in the USA that investigated women’s
experience of EF found that cost was the greatest barrier to pursuing EF. One-third of
participants reported that they sought financial support, mainly from family members, to help
cover procedural costs (Hodes-Wertz et al., 2016). The cost of one cycle of EF varies around
the world, ranging from US$3200 in Israel to US$10,000 in the USA (Inhorn et al., 2019); in
Australia, one cycle can cost up to US$7500 (Bowden, 2015).
Healthcare funding greatly assists people in their ability to access expensive medical
treatments; traditional sources of funding are public/government funding and private health
insurance (PHI). In many nations, public funding via taxpayer contributions is available for
selected assisted reproductive technology (ART) treatments because procreation is
recognized as an important life goal, and funding is justified with the reasoning that the
decision to have children should not depend on income (Pennings et al., 2008). However,
funding for EF is inconsistent around the world; in a survey of 27 European countries in
which EF is available, 14 countries had some form of public healthcare funding for medical
EF, but none of them offered funding for non-medical EF (Shenfield et al., 2017). In
Australia, women seeking medical EF are eligible for rebates via Medicare (the public
healthcare system) (Australian Government Services Australia, 2019), but women seeking
non-medical EF are not eligible for Medicare funding and must self-fund the procedure.
There is some debate amongst feminist scholars and bioethicists on the ethical issues raised
by EF (Harwood, 2015), including whether EF enhances reproductive freedom or constitutes
undue pressure and promotes pronatalist views (Petropanagos et al., 2015; Ravitsky and
Lemoine, 2014). These issues, and the impact that funding EF may have on them, will be
discussed in a forthcoming publication that explores the rising trend of employers offering
financial support for their employees to access EF (Johnston et al., in press).
In 2012, after many years of development, EF was declared to be a ‘non-experimental
procedure’ (Ethics Committee of the American Society for Reproductive Medicine, 2013).
Despite this change in status and the huge surge in uptake of EF (Schon et al., 2017), policies
governing access to, and funding for, EF have not been updated in Australia. Presently, EF is
not a stand-alone item for rebate in the Australian Medicare system; it is claimed under item
numbers that are used for standard in-vitro fertilization cycles. The recent increase in demand
for EF prompts the need to review how EF is funded.
A few studies have investigated the public’s views about how EF should be funded. A
Canadian survey of 500 childless women reported that support for public funding for EF
varied by indication: 80.2% versus 45.5% for medical EF and non-medical EF, respectively
(Daniluk and Koert, 2016). Funding for EF was positively received in a recent study that
surveyed 71 women of childbearing age from Hong Kong; 93% supported funding for
medical EF and 77% supported funding for non-medical EF (Hong et al., 2019). In Italy, a
report on 930 female tertiary students indicated divided opinions on how non-medical EF
should be funded; approximately half of the respondents indicated that it should be self-
funded, one-third supported public healthcare funding, 13.9% supported funding via PHI, and
2.5% supported employers covering the costs of non-medical EF for their female staff (Tozzo
et al., 2019).
These previous studies suggest that opinions are divided about funding for EF.
However, people’s opinions towards, and evaluations of, healthcare systems are influenced
by their experiences and knowledge of their own healthcare systems (Kikuzawa et al., 2008;
Schneider, 2020). Currently, little is known about the views of Australian women about
funding EF in terms of who should cover the costs of EF, and if funding arrangements should
differ depending on whether the indication for EF is medical or non-medical. In addition,
little is known about the disposition of surplus eggs following EF, which might influence
assessments of the costs associated with EF. Given that some women may freeze their eggs
but never use them, the costs of unused eggs might be seen to add to the costs associated with
EF. Conversely, Polyakov and Rozen (2021) suggest that surplus eggs that result from EF
have tangible benefits for society if they are donated, and this could also weigh into funding
The aim of this study was to investigate women’s opinions about how EF should be
funded, and to explore their views on the fate of frozen eggs that are not required for personal
<A>Materials and methods
An online, cross-sectional survey was conducted in Victoria, Australia between April 2018
and May 2018. The project was approved by an institutional human research ethics
committee. The survey was hosted through the Research Electronic Data Capture (REDCap)
platform and consisted of 35 questions, adapted with permission from the Fertility
Preservation Survey designed in Canada by Daniluk and Koert (2016). 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.
This article reports on a section of the survey that invited participants to respond to
questions about funding for EF, and intentions about the disposition of surplus eggs.
Participants were asked to consider how the costs of EF should be covered in two instances:
(i) where medical conditions threaten fertility (e.g. severe endometriosis or undergoing
treatment for cancer); and (ii) where fertility is threatened for non-medical reasons. Non-
medical reasons included: lacking a suitable partner with whom to have children; deferring
childbearing due to education/career advancement; or not feeling financially secure enough to
raise a child at the time. Participants responded via fixed-response items. Full coverage
options included: publicly funded, funded by PHI, or self-funded. Partial funding included:
co-payment shared between the public system and the individual, or co-payment shared
between the public system and PHI. In addition, participants could suggest other possible
funding options via a free text box. To investigate decisions about the disposition of eggs that
are no longer required after EF, participants were asked to indicate whether they would
consider the following options, via a five-point Likert scale (never/not likely/somewhat
(i) donate surplus eggs to medical research;
(ii) donate to a friend or family member (known recipient);
(iii) donate to an egg donor programme (unknown recipient); and
(iv) dispose of surplus eggs.
In the following analysis, the options ‘never’ and ‘not likely’ were combined and are
reported as ‘unlikely’, and the options ‘likely’ and ‘definitely’ were combined and are
reported as ‘likely’.
The survey was advertised online through social media and parenting forums. Female,
Australian residents aged 18–60 years were invited to complete the survey. A wide age range
was used to invite the views of women who may be interested in EF, as well as those who
have passed their reproductive years but could have accessed ART in their lifetime and could
reflect upon their available options, choices and experiences.
<B>Statistical analysis
Data were analysed using Stata Version 15 (StatCorp, College Station, TX, USA).
Categorical data are presented as frequencies and percentages. Age is presented as median
and interquartile range (IQR; 25th and 75th percentiles). Opinions on preferred funding source
for medical or non-medical EF were converted to binary variables (i.e. yes or no) for each of
the five possible responses: public funding, funded by PHI, self-funded, co-payment by the
individual and the public system, and co-payment by the public system and PHI. Unadjusted
Poisson regression with robust/sandwich estimator for variance [preferred estimator for
relative risk with binary outcomes (Barros and Hirakata, 2003)] was used to examine the
relationship between opinions on who should cover the cost of EF (dependent variable) and
participant characteristics (independent variable). The results were reported as risk ratios
(RR) with 95% confidence intervals (CI). Associations between opinions on access to EF and
opinions on funding were explored using Chi-squared test. Venn diagram visualization was
created using BioVinci Version 1.1.5 (BioTuring Inc., San Diego, CA, USA). Vertical bar
graphs were created using GraphPad Prism Version 8.4.2 for macOS (GraphPad Software,
San Diego, CA, USA) and horizontal bar graphs were created using Microsoft Excel Version
16.31 (Microsoft Corp., Redmond, WA, USA). Qualitative description, as described by
Sandelowski (2000), was used to analyse the small number of free text responses received.
In total, 656 participants were included in the analysis. The median age of the sample was 28
years (IQR 23–37 years) and approximately half (n=327) were either living with a partner or
married. The majority of participants were employed [290 (44%) full-time and 186 (28%)
part-time], and 213 (33%) were students. As per the Socio-Economic Indexes for Areas
(Australian Bureau of Statistics, 2013), most participants (n=460, 70%) resided in areas of
high socio-economic advantage, and two thirds of the sample (n=441, 67%) had PHI. 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.,
<B>Funding for medical egg freezing
The majority of participants (87%) supported public funding (full or partial) for medical EF
(Figure 1). Just under half of the survey sample (46%) indicated that the costs of medical EF
should be covered completely through the public system. In relation to the possibility of co-
payment, there was more support for payment shared between the public system and PHI
than there was for co-payment by the public system and the individual (31% versus 11%,
respectively). A small number of participants (8%) endorsed complete coverage by PHI for
medical EF. Similarly, very few participants thought that medical EF should be solely self-
funded (2%). Fourteen individuals provided suggestions about alternative options for
funding, which are reported further below.
<insert Figure 1 near here>
Relationship status had a significant influence on support for certain types of funding
(P=0.011). Partnered participants were more likely than single participants to support full
public funding (living with partner 55% versus single 37%, RR=1.50, 95% CI 1.18–1.91,
P=0.001; married 52% versus single 37%, RR=1.43, 95% CI 1.13–1.82, P=0.003). Similarly,
participants with children were more likely to support full public funding compared with
childless participants (58% versus 42%, RR=1.37, 95% CI 1.16–1.62, P<0.001).
<B>Funding for non-medical egg freezing
Opinions on how non-medical EF should be funded were divided (Figure 2). Forty-two
percent of participants suggested that the public system should support non-medical EF to
some degree. Of these individuals, 6% indicated that complete public funding for non-
medical EF is appropriate. There was more support for partial funding of EF than complete
funding through the public system. Twenty-one percent of participants supported co-payment
by the public system and the individual, and 15% supported co-payment by the public system
and PHI. The majority did not support public funding for non-medical EF; 31% thought it
should be completely self-funded and 23% supported coverage by PHI. Twenty-four
individuals suggested alternative funding options which are reported below.
<insert Figure 2 near here>
Age was significantly correlated with support for certain types of funding (P<0.001);
participants aged ≥40 years were significantly more likely to support self-funding than
participants aged <25 years (50% versus 29.9%, RR=1.67, 95% CI 1.28–2.19, P<0.001).
Relationship status was also significantly correlated with support for certain types of funding
(P=0.013); married participants were significantly more likely to support self-funding than
single participants (38% versus 27%, RR=1.40, 95% CI 1.03–1.90, P=0.033).
Views about access to non-medical EF were correlated with support for certain types
of funding (P<0.001) (Figure 3). People who did not support access to non-medical EF were
less likely to support public funding of EF and more likely to support self-funding.
Participants who supported access to non-medical EF indicated broad support for different
funding sources; they were more likely to support co-payment by the public system and PHI,
but less likely to support self-funding.
<insert Figure 3 near here>
<B>Funding for ‘other’ options
A small percentage of participants provided suggestions via a free text box for additional
comments about how EF should be funded; 24 (4%) suggested an alternative funding option
for non-medical EF, with the majority suggesting co-payment by the individual and PHI.
Similarly, of the 2% of participants that provided suggestions for how medical EF should be
funded, the majority supported co-payment by PHI and the individual, with the exception of
three unique comments that focused on equity, income testing and severity of the risk to
infertility, respectively, as illustrated by the following direct quotes:
I'm unsure. Egg freezing is not a necessary procedure, but on the other hand, why should
wealthy people be able to access it, but not poorer people? [51-year-old, married student
without PHI].
It should be income tested and if the person can afford it, then they should pay half, or their
insurance should pay half. But in cases of young women with endometriosis/PCOS
[polycystic ovary syndrome], it should be entirely [publicly] subsidised so young women of
19–20 can go ahead and freeze their eggs [57-year-old, married volunteer with PHI].
[Publicly funded] but depends on likelihood of adverse risk being realised; i.e. if her medical
condition has a 50% chance of making her infertile in the next 2 years, as opposed to 0.1%
chance [24-year-old dating, without PHI].
<B>Disposition intentions
Participants were invited to consider the hypothetical situation that they had undergone EF
and were faced with the decision of what to do with surplus eggs. In response to this
hypothetical situation, most participants (71%) indicated that they would be likely to donate
eggs to medical research. More than half of the participants indicated that they would be
likely to donate eggs to someone else, with slightly more indicating support for donating to
someone known to them (59%) compared with an unknown recipient (52%). Approximately
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one-quarter (24%) of participants indicated that they would be likely to discard any surplus
eggs (Figure 4).
<insert Figure 4 near here>
To the authors’ knowledge, this is one of very few studies, and the first Australian study, to
report on women’s views about how EF, for both medical and non-medical indications,
should be funded. The research found that a very high proportion of participants (87%)
support some form of public funding for medical EF, with 46% indicating support for full
coverage of the costs of medical EF by the public system. There was half as much support for
public funding of non-medical EF, with 42% indicating support for some form of financial
support through the public system, and 6% supporting complete coverage by the public
system. Over 50% of participants indicated that if they froze their eggs but did not use them,
they would consider donating them to a recipient or for use in medical research.
Interestingly, the views reported on public funding for both medical and non-medical
EF do not reflect the current funding scheme operating in Australia. Currently, only medical
EF is eligible for rebates through Medicare, and only approximately 50% of the costs are
rebated. The findings from this study suggest that almost one in two participants believe that
Medicare should cover the full cost of medical EF, and over 40% of participants believe that
Medicare should cover a proportion of the costs associated with non-medical EF. However,
this view was not shared by all participants; those aged ≥40 years, married participants and
those who did not support access to non-medical EF were more likely to prefer self-funding
for non-medical EF.
The discrepancy between views about public funding for medical and non-medical EF
suggests that some participants do not consider them to be analogous or equally eligible for
public healthcare funding. This finding is consistent with findings of earlier studies, which
suggest greater acceptance for the use of public funding for medical EF than for non-medical
EF (Daniluk and Koert, 2016; Hong et al., 2019). Views about when EF should be funded
may reflect the public’s views about what constitutes a medically necessary intervention. In a
German study, respondents who considered infertility to be a disease were more likely to
support complete public funding for ART treatments (Rauprich et al., 2010). Additionally, in
a large multinational survey of 6110 people, over 50% of participants supported public
funding for ART for individuals with primary infertility or decreased fertility as a result of a
medical condition (e.g. cancer); however, ≤30% supported public funding for individuals
seeking ART after having a child, or in instances where childbearing had been delayed
(Fauser et al., 2019). The findings from these earlier studies along with the present findings
suggest that the public are more supportive of funding for ART treatments that they consider
to be medically necessary.
Some scholars have raised arguments against funding non-medical EF. One objection
to the funding of non-medical EF is that the usage rate is too low to make it cost-effective
(Ben-Rafael, 2018). Given that the uptake of non-medical EF has only increased recently, the
present authors agree with previous observations that it may be too early to draw conclusions
about the true utilization of eggs stored for non-medical reasons (Cobo et al., 2016; Human
Fertilisation and Embryology Authority, 2018). However, early investigations have reported
rates of return that range between 3% and 26% (Cil et al., 2019; Gurtin et al., 2019;
Hammarberg et al., 2017; Jones et al., 2019; Wennberg et al., 2019). In comparison, a few
studies investigating rate of return after medical EF report that very few women have
returned to thaw their eggs (0–7%) (Dahhan et al., 2014; Garcia-Velasco, et al., 2013; Gürtin,
et al., 2019; Martinez, et al., 2014). In addition, sperm freezing, which is also offered for
fertility preservation, is supported with subsidies by the public healthcare system for men
facing gonadotoxic treatments (MBS Online, 2018), and the rate of return of men for frozen
sperm is also low (4–8%) (Ferrari et al., 2016; Tournaye et al., 2004). It is suggested that
despite the disanalogies between EF and sperm freezing, it is inconsistent to use low return
rates as a rationale against the funding of non-medical EF.
Cost-effectiveness is a common criterion used to determine whether a medical
intervention justifies public funding; however, evaluating cost-effectiveness for ART
treatments is complex (ESHRE Capri Workshop Group et al., 2015). Quality-adjusted life
years (QALY) is a standard indicator used to assess cost-effectiveness among clinical
treatments; however, there is debate about the appropriateness of using QALY to assess ART
treatments (Goldhaber-Fiebert and Brandeau, 2015). First, the question arises as to which life
or lives to assess in calculating the QALY gained following ART– the individual, the couple,
the child, the family or the extended family. Second, it is difficult to measure the value of
ART and fertility treatment as the benefits are multifaceted and the outcomes are varied.
Although there are concerns about the use of QALY to assess cost-effectiveness, robust
alternatives have not been identified (Carlson et al., 2020). A few studies have attempted to
determine whether EF is cost-effective, but have reached different conclusions regarding
whether, and at what age, EF is cost-effective (Devine et al., 2015; Hirshfeld-Cytron et al.,
2012; van Loendersloot et al., 2011). All of these studies have used the number of resultant
live births to measure the success of EF. However, many of the individuals who undergo EF
do so as a pre-emptive measure to safeguard their reproductive futures in the event that they
are unable to conceive naturally, rather than with the intention of using these eggs to
conceive (Hong et al., 2019; Pritchard et al., 2017). Furthermore, many women have
suggested that the benefit of EF is the feeling of reassurance provided by taking up the
opportunity to safeguard or increase the chance of having a baby in the future (Baldwin,
2018; Stoop et al., 2015), and many do not regret undergoing EF even if it proves to be
unsuccessful (Greenwood et al., 2018; Jones et al., 2019). It is suggested that EF can provide
individual benefits irrespective of whether women return to access their frozen eggs in the
future, and the use of live birth data alone to measure the value of EF may not be a true
reflection of the utility of EF.
Over 50% of participants in this study indicated that if their frozen eggs became
surplus to requirements, they would be most likely to consider donating their eggs to medical
research or to an infertile recipient. This high level of support for donating eggs is similar to
reports in previous studies. Hodes-Wertz et al. (2013) surveyed 183 women who had
undergone EF, and found that 63% were willing to donate their eggs to research if they did
not use them, and 11% said that they would consider donating their eggs to supply a donor
programme at an infertility clinic. Another survey reported that of the 71 women surveyed,
almost half indicated that they would consider donating eggs to infertile patients (34% to a
friend or family member, 10% to a donor programme), and 16% indicated that they would
consider donating eggs to research (Hong et al., 2019). These findings, along with the present
findings, support the suggestions of others (Lockwood and Fauser, 2018; Polyakov and
Rozen, 2021) that eggs frozen for personal use that are not required by the individual can be
of benefit in other ways, for example when they are donated to an infertile individual or
couple, or used for medical research. Therefore, the benefits of EF may extend beyond just
that of the individual, and could likely include benefits to the broader community. It is
acknowledged that there are some potential barriers to egg donation – for example, legal
requirements such as medical screening, mandatory counselling, and the lack of donor
anonymity in parts of Australia (VARTA, n.d.). Future research could examine disposition
practices in 5–10 years’ time to see how actions compare to the views reported in this study
and other research.
The results of this study suggest that many women would welcome the funding of EF
through either the public system or PHI. However, healthcare funding is limited, and
determining the best way to distribute limited funding is notoriously difficult and contested.
Worldwide, ART regulation is heterogeneous with regard to the services offered, the share of
public funding allocated, and eligibility criteria for access and funding. Across Europe, 39
countries provide some form of public financial support for ART; however, of these, 29
countries impose additional eligibility criteria. These can include female age, existence of
previous children, or patient body mass index (Calhaz-Jorge et al., 2020). It is not clear how
these various eligibility criteria are justified, and the lack of consistency in the criteria used
may lead to inequity. The medical/non-medical criterion is used in the allocation of EF
funding across the world (Shenfield et al., 2017); however, this distinction can be difficult to
define, and the categorization of conditions as either medical or non-medical is contested
(Colleton, 2008) and subject to change as the views of society evolve (Gilman, 2018). In
addition, the results of the present study suggest that some individuals regard medical and
non-medical EF as analogous. These challenges to the use of the medical/non-medical
distinction to determine the allocation of public funding warrant further consideration.
Further, the present findings suggest other possible funding approaches to EF, such as the
possibility of distributing funding via income testing, or whether funding should be allocated
based on the severity of the risk of infertility. Future research could investigate the fairness
and feasibility of these novel options.
Access to ART is limited by costs (Ethics Committee of the American Society for
Reproductive Medicine, 2015; McDowell and Murray, 2011; Nachtigall, 2006) and, despite
the availability of public funding that covers a portion of cycle expenses, disparities in access
to ART still exist as many individuals find it difficult to afford the out-of-pocket expenses
(Bitler and Schmidt, 2006; Gorton, 2019; Harris et al., 2016; Inhorn et al., 2018a). As
articulated by one participant, ‘why should wealthy people be able to access it, but not poorer
people?’; the current user-pay approach to EF privileges the wealthy and challenges the
principle of equity of access, and prompts further deliberation about the suitability of this
Like all surveys that rely on self-selected participation, it is likely that this study attracted
participants who had an interest in, or were more supportive of, ART in general. In order to
reduce the impact of bias, the study was advertised widely, and the inclusion criteria were
kept intentionally broad. A high proportion of participants were young women of high socio-
economic status, and therefore they may not have had reason to reflect upon fertility or
access to fertility preservation. Further, the sample was much younger than the average age
of individuals currently accessing egg freezing [approximately 38 years (Cil et al., 2019;
Human Fertilisation and Embryology Authority, 2018; Johnston et al., 2021)]. However, this
study was not seeking to be representative; rather, the aim of the study was to collect views
on EF which are largely unknown, especially in Australia, and to contribute to discussions on
future funding options for EF as well as disposition preferences for surplus eggs.
In many nations, the approach to funding EF appears to have followed the approach taken to
funding ‘standard’ ART cycles (Calhaz-Jorge et al., 2020), suggesting that funding for EF
may not have been considered specifically. The results of this study indicate that there is
significant support for public funding for medical EF, and, in particular, for potentially
increasing the proportion of costs that are subsidized through the public system in Australia.
This study also found some support for the funding of non-medical EF via the public system
or PHI. Further investigation and discussion are needed about the possibility of expanding
funding to include non-medical EF. In addition, this article describes challenges to the
medical/non-medical distinction, and questions whether it is a fair basis on which to
determine eligibility for funding; this also warrants further discussion. As affordability is a
significant determinant of accessibility, care is needed to develop policies that promote equity
of access for all.
The authors thank Judith Daniluk and Emily Koert for providing the initial questionnaire that
was used to inform this study. Gratitude is also extended to all individuals who volunteered
their time to share their views for this study. M.J. is supported by an Australian Research
Training Program Scholarship through Monash University.
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Declaration: The authors report no financial or commercial conflicts of interest.
Figure legends:
Figure 1. Proportional Venn diagram representing opinions on ‘How should medical egg
freezing be funded?’. Almost half of the participants thought that medical egg freezing
should be covered completely through the public funding system.
Figure 2. Proportional Venn diagram representing opinions on ‘How should non-medical egg
freezing be funded?’. Participant opinions were divided; the majority did not support public
funding for non-medical egg freezing.
Figure 3. Opinions on how non-medical egg freezing should be funded based on support for
access to non-medical egg freezing. People who did not support access to non-medical egg
freezing had little support for public funding of egg freezing, while people who supported
access to non-medical egg freezing had broad support for different funding sources.
Figure 4. Opinions on disposal intentions for surplus eggs amongst participants. The
majority of participants indicated that they would be likely to donate surplus eggs to research
or someone else.
Molly Johnston is an assistant lecturer in Monash Bioethics Centre at Monash
University (Australia). Her research interests are the ethics of, and policies
governing, reproductive technologies.
... However, the recent revision of the French bioethics law has defied all predictions and decided to offer partial reimbursement of the clinical procedure costs of 'non-medical' egg freezing [14]. Johnston et al. argued that the growing demand for SEF triggers the need for reviewing public funding [15]. There are public arguments for wider subsidies in the popular media of several countries including the UK and Belgium [16,17]. ...
... This study sheds light on how the current lack of reimbursement was perceived among women who wanted to initiate or had undergone at least one egg freezing cycle in Belgium. While women's concerns regarding the costs of freezing have often been mentioned as a side note in empirical studies on women's motivations to freeze their eggs [21,45], our study is one of the very few studies who investigated the topic in a systematic manner [15]. ...
... Others saw SEF as a response to a medical problem or, at least, as a treatment based on medical advice. These findings confirm previous work that has pointed to considerable ambiguity in recognising a (medical) need for this intervention [15,54,55]. ...
Full-text available
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.
... However, women with primary ovarian insufficiency, endometriosis or Turner Syndrome are ineligible for public funding, despite being conditions that many may consider as possessing the features that characterise a 'medical' indication for egg freezing. Conversely, in Australia, all the aforementioned reasons are considered as legitimate medical indications for egg freezing, and thus qualify for public funding (Johnston et al., 2021). The variation between how a 'medical' indication is interpreted within different funding policies suggests there is no general agreement for or nomenclature of what constitutes a genuine medical indication for egg freezing. ...
... As argued by Goold and Savulescu (2009), the women seeking non-medical egg freezing are analogous to those seeking medical egg freezing. Further, empirical data indicates that there is some public support for funding both medical and non-medical egg freezing (Johnston et al., 2021;Platts et al., 2021), suggesting that for some, the indication for egg freezing is not important to decisions of funding distribution. These challenges to the medical/non-medical distinction warrant further deliberation on the continued use of the distinction in egg freezing policy, including whether this distinction is morally relevant to funding decisions. ...
Full-text available
After two years of parliamentary discussion, Emmanuel Macron's government in France enacted the new bioethics law. What stands out in the revision of the bioethics law is the decision to offer partial reimbursement of the clinical procedure costs of ‘non-medical’ egg freezing; making France the first country in the world to do this. Our contention in this brief commentary is that the recent change in the French law presents an opportunity to reflect on the provision of public funding for egg freezing, including for what reasons funding is justifiable. The medical/non-medical distinction is used to distribute funding for egg freezing in many jurisdictions, worldwide. However, under the revised French bioethics law, this is the first instance where, for the purpose of determining eligibility for funding, the reason for egg freezing is irrelevant as public funding is available for both medical and non-medical egg freezing. This challenges the justification of using the medical/non-medical distinction within funding policies and prompts further consideration about whether this distinction is still relevant to funding decisions.
... Indeed, previous studies found public were divided over public healthcare funding for non-medical oocyte preservation. For example, a recent Australian study reported that while a large majority of women supported public funding for embryo freezing for medical reason, less than half (42%) indicated their support for funding to non-medical social embryo freezing [26]. The divided view over public funding of alternate treatment is an important consideration as affordability is a significant determinant of equity and accessibility to fertility treatment. ...
Full-text available
Objective To evaluate the clinical and cost-effectiveness of preimplantation genetic testing for aneuploidy, social freezing, donor and autologous assisted reproductive technology (ART) treatment strategies for women aged 35–45 following 6–12 months of infertility. Methods Four Markov decision-analytic models comprising: (i) Preimplantation genetic testing for aneuploidy (PGT-A); (ii) autologous ART from age 40 using oocytes cryopreserved at age 32 (social freezing); (iii) ART using donated oocytes (donor ART); (iv) standard autologous ART treatment (standard care) were developed for a hypothetical cohort of 35 to 45 years old ART naïve women with 6–12 months of infertility. Input probabilities for key parameters including live birth rates were obtained from the available literature. Deterministic and probabilistic sensitivity analyses were conducted to address uncertainty in estimating the parameters and around the model’s assumptions. Cost effectiveness was assessed from both societal and patient perspectives . Result(s) For infertile women at age 40 and above, social freezing is the most cost-saving strategy with the highest chance of a cumulative live birth at a lowest cost from a societal perspective. PGT-A and donor ART were associated with higher treatment costs and cumulative live-birth rates compared with the autologous ART. Among the four ART strategies, standard autologous ART has the lowest cumulative live birth rate of 45% at age 35 and decreasing to 1.6% by age 45 years. At a willingness-to-pay threshold of Australian dollars (A$)50,000, our model shows all alternative treatment strategies –PGT-A, social freezing and donor ART have a higher probability of being cost-effective compared to the standard autologous ART treatment. However, higher out-of-pocket expenditure may impede their access to these alternate strategies. Conclusion Given current evidence, all alternate strategies have a higher probability of being cost-effective compared to the standard autologous ART treatment. Whether this represents value for money depends on societal and individual’s willingness-to-pay for children conceived with ART treatment.
... Recent advances in vitrification techniques have markedly improved the efficacy of oocyte cryopreservation in terms of oocyte survival, pregnancy rates, and LBRs, which are now comparable to those achieved with fresh oocytes and IVF. The LBRs from vitrified oocytes have increased rapidly over the past decade [88,89] . Most live births are achieved using in vivo matured oocytes produced through standard ovarian stimulation cycles, whereas the LBR is low using cryopreserved IVM oocytes [90,91] . ...
Full-text available
The source of human oocytes is directly associated with the success of infertility treatment and fertility preservation. The number of oocytes obtained is possibly correlated with the success rate in terms of live birth rates. However, oocyte quality must be refined such that the number of oocytes is not positively correlated with the quality of oocytes. Different ovarian stimulation protocols can be used to obtain numerous oocytes. However, oocyte quality should be considered the most important factor affecting infertility treatment and fertility preservation. Infertile women are generally willing to take health-related risks to achieve a live birth, and ovarian stimulation using high-dose hormonal treatments may be harmful for both women and infants. Therefore, successful infertility treatment and fertility preservation should be defined as the birth of a healthy baby at term without compromising the health and safety of the mother and infant. Therefore, the source of high-quality oocytes must be carefully considered prior to infertility treatment and fertility preservation.
... While it is beyond the scope of this paper to evaluate all the normative implications of our empirical data, for instance whether or not egg freezing should be covered within the healthcare system and related considerations of broader access and social justice (Campo-Engelstein 2010; Mertes and Pennings 2012;Johnston et al. 2022), a new round of policy debate is necessary in light of the similarities of experience of both groups of women. Further empirical and normative work is now needed to fully capture and evaluate different stakeholders' viewpoints on the medical/nonmedical distinction used in the allocation of egg freezing funding. ...
Full-text available
While the literature on oncofertility decision-making was central to the bioethics debate on social egg freezing when the practice emerged in the late 2000s, there has been little discussion juxtaposing the two forms of egg freezing since. This article offers a new perspective on this debate by comparing empirical qualitative data of two previously conducted studies on medical and social egg freezing. We re-analysed the interview data of the two studies and did a thematic analysis combined with interdisciplinary collaborative auditing for empirical ethics projects. Despite their different contexts, major similarities in women’s decision-making and reasoning were found. We developed two main common themes. Firstly, women felt a clear need to plan for future options. Secondly, they manipulated decision-times by postponing definitive decisions and making micro-decisions. The comparison highlights that the passage of time and the preservation of future choice seems to permeate all aspects of the patient experiences in both studies. As a result of considering real-world lived experiences, we suggest that there are many overlaps in women’s reasoning about egg freezing regardless of why they are making a decision to freeze. These overlaps are morally relevant and thus need to be further integrated into the existing arguments that have been canvassed in the flourishing egg freezing and fertility preservation debates across the field, and in policy and practice globally.
Purpose The present study was to investigate awareness and attitudes toward female fertility and aging, desire for a child and motherhood, and oocyte freezing for non-medical reasons among women candidates for Social Egg Freezing (SEF). Materials and Methods This was a cross-sectional study on all 216 women who sought oocyte cryopreservation for nonmedical reasons at Royan Institute. A 24-item self-administered questionnaire measured knowledge and attitudes to SEF. Responses were as yes/no or a 4-point Likert scale. Results Only 40% of participants accurately indicated that having a sexual partner does not help to preserve their fertility. A quarter of women correctly recalled chance of pregnancy with unprotected intercourse during a period of a year, for women 20 to 40 years old. Only one-third of respondents accurately identified the age-related fertility decline at 35–39 years. Only 6.9% correctly mentioned the low chance of pregnancy after egg freezing at 35 years old. Almost a third of women knew that the age range of 31–35 years is the right age to freeze an egg with the highest chance of pregnancy. Aging and health of offspring were most influential in women’s decisions on SEF. Conclusion In conclusion, there was significant gaps in knowledge about age-related fertility decline, and egg cryopreservation conditions and its complications. It is crucial to impart to these women a better knowledge about fertility and a realistic picture about SEF, especially on the number of high-quality retrieved mature oocytes and live birth rates depend on women's age.
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To address the problem of endogeneity in public opinion research, this study examines the opinions of healthcare held by the foreign born, i.e. those not socialized in the system they are asked to evaluate. It (a) explores the degree to which the healthcare ratings of the foreign born depend on the country’s institutional healthcare setting; (b) stresses the importance of referential standards and the significance of knowledge and previous experiences of healthcare services in the country of origin; and (c) investigates differences in healthcare ratings with the length of time foreign born spent in the destination country. This study uses data from the seven rounds of the European Social Survey (2002–2014) and applies multilevel modelling techniques. Results show the institutional characteristics of healthcare services in the country of residence are associated with healthcare evaluations of the foreign born, in particular if these services are compared to those in the country of origin: the better healthcare institutions perform relative to those in the country of origin, the higher the healthcare ratings. Although comparisons with the country of origin seem relevant to all foreign born, they are sometimes more important to recent arrivals. This study suggests knowledge and experience of different healthcare institutions change perspectives and evaluations of healthcare. This finding enriches the discussion of the effects of socialisation and adaptation processes in the formation of public opinion.
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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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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.
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Objective: The aim of this study was to investigate the level of awareness and knowledge regarding elective oocyte cryopreservation (OC) among unmarried women of reproductive age in Korea. Methods: A survey was conducted among 86 women who visited a fertility preservation clinic for counseling about elective OC between December 2016 and May 2018. Participants were asked to fill out a questionnaire regarding their awareness and knowledge of fertility and OC. Results: The questionnaire was completed by 71 women. Among them, 73% decided to undergo OC after counseling. The main reason for making this decision was that they wished to maintain their fertility in the future (70.6%). Conversely, the high cost for the procedure was the main reason given by those who chose to forego this procedure. Regarding fertility and OC, the participants' knowledge was poor. Most women expected greater financial support from the government or from their place of employment. Conclusion: This study demonstrated that the awareness and knowledge about elective OC were relatively poor among the female Korean population. These findings may help clinicians in better counselling of their patients.
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 trend towards postponement of childbearing has seen increasing numbers of women turning towards oocyte banking for anticipated gamete exhaustion (AGE banking), which offers a realistic chance of achieving genetically connected offspring. However, there are concerns around the use of this technology, including social/ethical implications, low rate of utilisation and its cost-effectiveness. The same societal trends have also resulted in an increased demand and unmet need for donor oocytes, with many women choosing to travel overseas for treatment. This has its own inherent social, medical, financial and psychological sequelae. We propose a possible pathway to address these dual realities. The donation of oocytes originally stored in the context of AGE banking, with appropriate compensatory mechanisms, would ameliorate AGE banking concerns, while simultaneously improving the supply of donor oocytes. This proposed arrangement will result in tangible benefits for prospective donors, recipients and society at large.
STUDY QUESTION What are the cohort trends of women undergoing oocyte cryopreservation (OC)? SUMMARY ANSWER There has been a dramatic increase in OC cycles undertaken each year since 2010, and the demographics of women accessing OC has shifted to a younger age group, but so far very few women have returned to use their cryopreserved oocytes in treatments. WHAT IS KNOWN ALREADY Although OC, as a method of fertility preservation, is offered around the world, global data are lacking on who is accessing OC, who is returning to thaw oocytes and whether these trends are changing. STUDY DESIGN, SIZE, DURATION A trinational retrospective cohort study was performed of 31 191 OC cycles and 972 oocyte thaw (OT) cycles undertaken in the USA (2010–2016) and 3673 OC and 517 OT cycles undertaken in Australia/New Zealand (Aus/NZ; 2010–2015). PARTICIPANTS/MATERIALS, SETTING, METHODS Data were obtained from the USA Society for Assisted Reproductive Technology (SART) national registry and the Australian and New Zealand Assisted Reproduction Database (ANZARD). De-identified data were requested on all autologous oocyte freeze-all cycles and all cycles where autologous oocytes were thawed to be used in a treatment cycle for the time periods of interest. MAIN RESULTS AND THE ROLE OF CHANCE In both the USA and Aus/NZ, there has been a dramatic rise in the number of OC cycles performed each year (+880% in the USA from 2010 to 2016 and +311% in Aus/NZ from 2010 to 2015). Across both regions, most women undergoing OC were aged in their late 30s, but the average age decreased over time (USA: 36.7 years vs 34.7 years in 2010 and 2016, respectively). The number of women returning for thaw cycles was low (USA: 413 in 2016, Aus/NZ: 141 in 2015) and most thaw cycles (47%) across both regions involved oocytes that were frozen for <6 months. In the USA, a higher proportion of cycles resulted in a live birth when only thawed oocytes were used, compared to cycles that combined thawed oocytes with fresh oocytes (25% vs 11%, respectively; P < 0.001). Age at retrieval influenced live birth rate in the USA; 38% of thaw cycles started in women who stored oocytes when aged ≤35 years resulted in a live birth, whereas only 16% resulted in a live birth for women who stored oocytes when aged ≥36 years. Similar data were unobtainable from Aus/NZ. LIMITATIONS, REASONS FOR CAUTION There were limitations associated with both the SART and ANZARD data outputs received. The format in which the ANZARD data were provided, and the inconsistencies seen amongst cycle reporting in the SART dataset, restricted data interpretation. For example, both datasets did not provide a clear indication as to why women were undergoing OC and it was not possible to accurately calculate duration of storage for thaw cycles in the USA. We also did not obtain details on embryo quality from either database and acknowledge that embryo quality and subsequent outcome (embryo freezing or discard) would be of interest, especially when considering the efficacy of OC. WIDER IMPLICATIONS OF THE FINDINGS The data show that there is widespread demand for OC, and it is increasingly undertaken by younger women; however, the limitations encountered in the dataset support the need for a shift to a more uniform approach to data collection and presentation by large databases, worldwide. STUDY FUNDING/COMPETING INTEREST(S) This study received funding from the Fertility Society of Australia to support the ANZARD data extraction. M.J. is supported by an Australian Government Research Training Program Scholarship stipend. The authors declare no competing interests. TRIAL REGISTRATION NUMBER N/A.
Objectives The quality-adjusted life-year (QALY) has been long debated, but alternative estimation approaches have not been comprehensively evaluated. Our objective was to identify alternatives, characterize them by implementation feasibility, and evaluate the impact of implementing feasible options in cost-effectiveness models developed for the Institute for Clinical and Economic Review reports. Methods We conducted a literature review combining keywords relating to QALYs, methodology alternatives, and cost-effectiveness in PubMed, EconLit, Web of Science, and MEDLINE. Articles that discussed alternatives to the conventional QALY were included. Alternatives were characterized by type, data availability, calculation burden, and overall implementation feasibility. The subset of feasible alternatives, that is, sufficient data and methodology compatible with incorporation into common modeling approaches, were evaluated according to impact on incremental QALYs, incremental net monetary benefit (iNMB), intervention rankings, and proportion of interventions with a positive iNMB. Results We identified 28 articles discussing 9 alternatives. Feasible alternatives were using patient preference (PP) data; equity weighting according to baseline utility, fair innings, or proportional QALY shortfall; and the equal value of life-years-gained approach. All alternatives affected the incremental QALY and iNMB outcomes, rankings, and proportion of interventions with a positive iNMB. The PP alternative had the largest and most consistent impact. The PP impact on the proportion of interventions with a positive iNMB, was in the negative direction. Conclusions Our work is the first comprehensive evaluation of proposed alternatives to the conventional QALY. We found robust literature but few options that were feasible to be implemented in current healthcare decision-making processes.
Introduction: Social egg freezing enhances reproductive autonomy by empowering women with the capacity to delay their childbearing years, whilst preserving the opportunity to maintain biological relation with subsequent offspring. However, age-related obstetric complications, economic implications and the risk of unsuccessful future treatment make it a controversial option. Despite the upward trend in women electively cryopreserving their eggs, there is little data about the women's perceptions, having undergone the process. The aim of this study was to investigate the motivations of women who have undergone social egg freezing, identify their perceptions following treatment and assess potential feelings of regret. Material and methods: This cross-sectional survey, based at a fertility clinic in the UK, utilised an electronic questionnaire to assess the motivations and perceptions of women who underwent social egg freezing between 1st January 2008 and 31st December 2018. Results: 100 questionnaires were distributed, and 85 women responded (85% response rate). The most frequent reason for freezing oocytes was not having a partner with 56 (70%) women saying it 'definitely' influenced their decision. The majority of women (83%; n=68) knew there was a chance of treatment failure in the future and that a livebirth could not be guaranteed. More than half (n=39; 51%) disagreed or strongly disagreed that the 10-year UK storage limit is fair. One third of respondents (n=17; 33%) felt the storage time should be indefinite whilst 29% (n=15) believed it should be up to the age of 50. 20% (n=15) of the women who underwent social egg freezing have successfully had a baby or are currently pregnant, half (n=8; 53%) of whom conceived spontaneously whilst a quarter (n=4; 26%) used their stored oocytes. 91% (n=73) had no regrets over their decision to undergo social egg freezing. Conclusions: We demonstrate herein important and novel insight into the motivations and perceptions of women from a UK population who have undergone social egg freezing. Despite potential physical, psychological and financial burden, only a small minority of women experience regret after social egg freezing. We also highlight clear discontent with the Human Fertilisation & Embryology Authority (HFEA) storage limit amongst social egg freezers in the UK.
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.