|Year : 2018 | Volume
| Issue : 4 | Page : 359-364
Knowledge about age-related decline in fertility and oocyte cryopreservation: A national survey
Karissa C Hammer1, Alyssa N Kahan1, Louis F Fogg1, Mark A Walker2, Jennifer E Hirshfeld-Cytron2
1 Department of Obstetrics and Gynecology, Rush University Medical Center, Chicago, IL, USA
2 Fertility Centers of Illinois, Chicago, IL, USA
|Date of Web Publication||28-Dec-2018|
Dr. Jennifer E Hirshfeld-Cytron
900 N. Kingsbury, Suite RW6, Chicago, IL 60610, (312) 222-8230
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: Women worldwide are delaying childbearing, but are they aware of the age-related decline in fertility? Aims: The aim of this study is to investigate awareness of age-related decline in fertility and oocyte cryopreservation. Settings and Design: A primary analysis of a cross-sectional electronic survey with a nationally representative sample of nulliparous women aged 25–45 years. Subjects and Methods: A national online survey performed March 4–March 9, 2016. Statistical Analysis Used: A linear regression model and ANOVA tests were performed. Results: A total of 1213 women completed the survey. A significant difference was discovered in fecundity knowledge between women who identified as in a partnership compared to those who did not. Partnered women were more likely to respond “know a lot” about the age-related decline in fertility, whereas unpartnered women were more likely to respond “never heard of it” (P < 0.01). Partnered women are also more likely to respond that they would have made different life choices had they been more knowledgeable about fertility at a younger age (P = 0.01). The majority of the survey population had heard of oocyte cryopreservation but did not know much about it. Conclusions: Slightly over half of participants had an understanding of the natural age-related decline in fertility. Having a partner significantly increased the likelihood that a woman reported more knowledge about fertility. More effort is necessary to educate all women on assisted reproductive technologies and the natural age-related decline in fertility, specifically single women of childbearing age.
Keywords: Fecundity, fertility preservation, oocyte cryopreservation
|How to cite this article:|
Hammer KC, Kahan AN, Fogg LF, Walker MA, Hirshfeld-Cytron JE. Knowledge about age-related decline in fertility and oocyte cryopreservation: A national survey. J Hum Reprod Sci 2018;11:359-64
|How to cite this URL:|
Hammer KC, Kahan AN, Fogg LF, Walker MA, Hirshfeld-Cytron JE. Knowledge about age-related decline in fertility and oocyte cryopreservation: A national survey. J Hum Reprod Sci [serial online] 2018 [cited 2020 Nov 30];11:359-64. Available from: https://www.jhrsonline.org/text.asp?2018/11/4/359/248939
| Introduction|| |
Women have begun delaying childbearing to ages that may leave them unintentionally childless.,, In the United States, the birth rate for women aged 40–44 years has gradually increased over the last three decades, while the birth rate for women aged 30 years has declined. Women overestimate their ability to become pregnant from unprotected intercourse at any age, and they are not sufficiently informed about the age-related decline in female fecundity.,,,, We investigate nulliparous women in the US and their awareness of the age-related decline in fertility and the technology of oocyte cryopreservation. We hypothesized that participants would have limited knowledge on this topic.
| Subjects and Methods|| |
This is a primary analysis of a cross-sectional study approved by the Institutional Review Board of Rush University Medical Center. An online questionnaire was offered nationally in the United States through multiple web-based recruiting panels by Kupersmit Research from March 4 to March 9, 2016. The survey was anonymous and consisted of 43 questions regarding demographics, understanding of infertility, concern for infertility, awareness of cryopreservation technologies, and interest in using cryopreservation [Supplement 1 [Additional file 1]]. The survey was originally intended for marketing research by industry standards. Women were eligible for inclusion in the study if they met the following criteria: female gender, age 25–45 years, and nulliparous. [Table 1] demonstrates the demographics of the survey participants.
A primary analysis of this data set demonstrated significant differences in responses based on partnership. Results were then stratified based on partnered women versus unpartnered women. The “partnered” group included women who responded to the survey as married or living with a partner; the “unpartnered” group included women who responded that they were single, divorced, or widowed. We excluded 14 women from our analysis who had responded “would rather not say” to the survey item inquiring about relationship status. Our specific aims of this study were to first investigate public awareness of the age-related decline in fertility and oocyte cryopreservation and second to analyze the impact of partner status on awareness of age-related decline in fertility and oocyte cryopreservation. Our primary outcomes were percent of nulliparous women aware of the age-related decline in female fertility. Secondary outcomes included responses to questions concerning familiarity with oocyte cryopreservation, whether women 35 years old or older would have made different life choices had they been more knowledgeable about fertility at a younger age, and whether these same women 35 years old or older would have frozen their eggs at a younger age had they known about the age-related decline in fertility.
The survey included four questions assessing women's knowledge about infertility and oocyte cryopreservation. The first question prompted the participants with the following quote, “Many women think it's common to get pregnant after 35, but after 35, ovarian reserve (egg supply) declines, miscarriage rates increase and pregnancy is considered high risk.” Participants were next asked if they had heard of this statement before and were given the following answer choices: “Yes, I have heard a lot about this,” “Yes, but I have only heard a little about it,” or “No, I have not heard of this before.”
The second question stated, “Some women choose to undergo a procedure where eggs are removed from their ovaries and frozen for future use, freezing their biological clock and helping with their future family planning goals,” followed by the question, “How familiar are you with this procedure?” Women were given the following answer options: “I have never heard of it before,” “I have heard of it, but don't know much about it,” “I know a little bit,” or “I know a lot about it.”
The third and fourth questions were answered only by women 35 years old and older. The third question asked participants how strongly they identified with the statement, “I would have made different life choices had I been more knowledgeable about fertility at a younger age.” The fourth question similarly asked participants to what degree they agreed with the following statement, “I would have considered freezing my eggs when I was younger had I known how common it is for women over 35 to face challenges getting pregnant and having a baby”.
Responses were analyzed using SPSS software (IBM Corporation, Chicago, IL, USA). A linear regression model and ANOVA tests were utilized to determine significant differences in responses. Participants' demographics were compared using contingency tables.
| Results|| |
Of the 1213 women who completed the survey, 98.8% were included in our analysis. [Table 1] demonstrates demographics of the study population. The majority of participants were from urban locations, employed, and identified as heterosexual. In regard to ethnicity, over 70% of the study population identified as white, a proportion comparable to the US population. When asked about annual income, the largest proportion of women in the study answered that they had a household income of $50,000–$74,999, which is comparable to the median US household income of $53,889. The survey consisted of 44.4% partnered women and 55.6% unpartnered women. There were no significant differences between these two study groups in regard to age distribution, region, population, or sexuality. Partnered women included in our study were more likely to be employed, have a higher income, and attended religious services more frequently than unpartnered women, and this finding was significant [Table 1].
Response results can be seen in [Table 2]. When analyzing all responses about the age-related decline in fertility, we found that 52% responded that they “have heard a lot about this,” 37% responded that they “have heard a little about this, and 11% “have never heard of it” [Figure 1]. When analyzed by partner status, those that responded that they “have heard a lot about this” were more likely to be partnered, 51%, whereas those that responded that they “have never heard of it” were more likely to be unpartnered, 63.2%. This finding was significant, P < 0.01 [Table 2] and [Figure 2].
|Figure 1: Nulliparous women's awareness of the age-related decline in fertility. Women were prompted with the following: “Many women think it is common to get pregnant after 35 years of age, but after 35, ovarian reserve (egg supply) declines, miscarriage rates increase, and pregnancy is considered high risk.” Then asked have you heard this before? The overall responses are shown. Black and white dots represents the response “have heard a lot about this,” horizontal stripes represents the response “heard a little about this,” and grid represents “have not heard of this before”|
Click here to view
|Figure 2: Association of relationship status and knowledge about the age-related decline in fertility. Participants were prompted with the following: “Many women think it is common to get pregnant after 35, but after 35, ovarian reserve (egg supply) declines, miscarriage rates increase, and pregnancy is considered high risk,” followed by the question, “Have you heard this before?” The diagonal stripes represent partnered women. The solid bars represent unpartnered women. **P < 0.01|
Click here to view
When participants were asked about their familiarity with the technology of oocyte cryopreservation, majority of participants responded that they have, “heard of it, but don't know much about it,” 48%, with the least number of participants citing that they, “know a lot,” 7%, about oocyte cryopreservation [Figure 3]. When analyzed by partnership status, those that responded they had “never heard of it” in regard to oocyte cryopreservation were more likely to be unpartnered, 58.3%, and so were those who responded “know a lot,” 58.1%. Responses of “know a little” were more likely to be partnered women, 52.1%. There was a significant difference in responses, P < 0.05 [Table 2] and [Figure 4].
|Figure 3: Familiarity with oocyte cryopreservation in women 35 years old and above. Women were prompted with, “Some women choose to undergo a procedure where eggs are removed from their ovaries and frozen for future use, freezing their biological clock, and helping with their future family planning goals,” followed by the question, “How familiar are you with this procedure?” Black and white dots represent responses “know a lot,” horizontal stripes represent “know a little,” grid represents “never heard of it,” and solid black represents “heard of it, but do not know much”|
Click here to view
|Figure 4: Association of relationship status and familiarity with oocyte cryopreservation for women 35 years old and above. Women were prompted with, “Some women choose to undergo a procedure where eggs are removed from their ovaries and frozen for future use, freezing their biological clock, and helping with their future family planning goals,” followed by the question, “How familiar are you with this procedure?” The diagonal stripes represent partnered women. The solid bars represent unpartnered women .*P<0.05|
Click here to view
For women 35 years old and older, majority of respondents who were neutral with the concept of making different life choices had the individual been more knowledgeable about fertility at a younger age. Individuals who identified strongly with this statement were more likely to be partnered [Table 2]. When asked more specifically if a woman would have frozen her eggs had she known about the age-related decline in fertility, majority of respondents reported they either did “not really” or “not at all” identify with this statement. When analyzed by partnership status, those that had identified strongly that they would have used oocyte cryopreservation were more likely to be unpartnered, 56.3%. This finding was not statistically significant [Table 2].
| Discussion|| |
This study examines a national sample of nulliparous women of reproductive age in the United States and their understanding of the natural age-related decline in female fertility and the available reproductive technology of oocyte cryopreservation that can combat this phenomenon. We found a significant difference in responses between women who identified as partnered versus unpartnered. Our data demonstrate that women without a partner are less likely to be aware of the natural age decline in fertility. Unpartnered women are also likely to know less about the technology of oocyte cryopreservation.
Women in the US are delaying childbearing, often for social reasons which often include lack of partner. Multiple surveys of college students have demonstrated that women are planning on delaying childbearing to an age that has a known decline in fertility., Previous studies have also highlighted lack of partner as one of the most common reasons for delaying childbearing.,, To our knowledge, this is the first survey study to specifically analyze the effect of partnership status on fertility knowledge. It seems that women are often citing lack of partner as a reason to delay childbearing without knowing that they could be unintentionally sabotaging their chances at conceiving. Furthermore, single women have limited knowledge about the opportunity to stop the biological clock and utilize the technology of oocyte cryopreservation.
The technology for oocyte cryopreservation is supported by our general public and health-care professionals., This survey was completed four years after the American Society for Reproductive Medicine (ASRM) removed the “experimental” label from oocyte ryopreservation technology. In light of such academic support, we expected that our study population would know more about this technology. However, we found that participants had very little knowledge on oocyte cryopreservation. Other studies have investigated college students, individuals undergoing infertility treatment, and the general public; all found a need to improve education efforts.,,,, Of those that have undergone oocyte cryopreservation, majority wish they had known and undergone the procedure at a younger age. We need to recognize this gap between the medical community understanding and patient knowledge by focusing on providing accurate information for our nulliparous patients at young ages about the age-related decline in fertility and the opportunity for cryopreservation.
Limitations of this study include the lack of male participants, inability to assess education level of participants, small sample size for a national survey, and the nature of a survey format. A recent study analyzed male and female views on oocyte cryopreservation and found that male participants were more likely to disagree with the use of oocyte cryopreservation for social reasons such as lack of a partner, career advancement, or educational aspirations. It is unclear how including males would have impacted our outcomes on knowledge level. Educational level was not assessed in this survey. Previous studies focused on college students and health-care professionals, future studies should investigate education level associated with fertility knowledge. We suspect that education level would have strengthened our findings that women nationally have little knowledge about the age-related decline in fecundity and about oocyte cryopreservation. Survey format puts the study at risk for nonresponse bias, voluntary response bias, and response bias.
We routinely discuss contraception with our patients, but this topic should be broadened to family planning and include the natural age-related decline in fertility and available technologies such as oocyte cryopreservation. The majority of providers agree that this discussion should be had with patients; but who is responsible for having it, when should it be given and in what format? Future research is required to investigate methods of fertility education.
This study demonstrates that partnership increases the likelihood that an individual is aware of the natural age-related decline in fertility, but this does not seem to correlate with an increase in understanding of oocyte cryopreservation. Those without a partner often delay childbearing, but they do not realize they may be planning for pregnancy at an age with a known decline in fertility and an at-risk pregnancy. The majority of participants had very little knowledge on the option for oocyte cryopreservation. Previous studies have shown that patients desire more knowledge on fertility. We need to empower women with knowledge on the age-related decline in fertility and options for elective oocyte cryopreservation.
The authors would like to thank Kupersmit Research for collecting this national survey data.
Financial support and sponsorship
This study was financially supported by the Fertility Centers of Illinois.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Baizan P, Arpino B, Delclòs CE. The effect of gender policies on fertility: The moderating role of education and normative context. Eur J Popul 2016;32:1-30.
Mills M, Rindfuss RR, McDonald P, te Velde E; ESHRE Reproduction and Society Task Force. Why do people postpone parenthood? Reasons and social policy incentives. Hum Reprod Update 2011;17:848-60.
Skoog Svanberg A, Lampic C, Karlström PO, Tydén T. Attitudes toward parenthood and awareness of fertility among postgraduate students in Sweden. Gend Med 2006;3:187-95.
Martin JA. Births in the Unites States, 2015. NCHS Data Brief; 2016. p. 258.
Azhar E, Seifer DB, Melzer K, Ahmed A, Weedon J, Minkoff H, et al.
Knowledge of ovarian reserve and reproductive choices. J Assist Reprod Genet 2015;32:409-15.
Bureau USC. Selected Economic Characteristics 2011-2016 American Community Survey 5-Year Estimates. American Fact Finder; 2015.
Cooke A, Mills TA, Lavender T. Advanced maternal age: Delayed childbearing is rarely a conscious choice a qualitative study of women's views and experiences. Int J Nurs Stud 2012;49:30-9.
Bureau USC. Profile of General Population and Housing Characteristics: 2010. Bureau USC; 2010.
Hamilton BE, Martin JA, Osterman MJ, Curtin SC, Matthews TJ. Births: Final data for 2014. Natl Vital Stat Rep 2015;64:1-64.
Peterson BD, Pirritano M, Tucker L, Lampic C. Fertility awareness and parenting attitudes among American male and female undergraduate university students. Hum Reprod 2012;27:1375-82.
Lampic C, Svanberg AS, Karlström P, Tydén T. Fertility awareness, intentions concerning childbearing, and attitudes towards parenthood among female and male academics. Hum Reprod 2006;21:558-64.
Lewis EI, Missmer SA, Farland LV, Ginsburg ES. Public support in the United States for elective oocyte cryopreservation. Fertil Steril 2016;106:1183-9.
Bunting L, Tsibulsky I, Boivin J. Fertility knowledge and beliefs about fertility treatment: Findings from the international fertility decision-making study. Hum Reprod 2013;28:385-97.
Chan CH, Chan TH, Peterson BD, Lampic C, Tam MY. Intentions and attitudes towards parenthood and fertility awareness among Chinese University students in Hong Kong: A comparison with western samples. Hum Reprod 2015;30:364-72.
Tan SQ, Tan AW, Lau MS, Tan HH, Nadarajah S. Social oocyte freezing: A survey among Singaporean female medical students. J Obstet Gynaecol Res 2014;40:1345-52.
Yu L, Peterson B, Inhorn MC, Boehm JK, Patrizio P. Knowledge, attitudes, and intentions toward fertility awareness and oocyte cryopreservation among obstetrics and gynecology resident physicians. Hum Reprod 2016;31:403-11.
Stoop D, Nekkebroeck J, Devroey P. A survey on the intentions and attitudes towards oocyte cryopreservation for non-medical reasons among women of reproductive age. Hum Reprod 2011;26:655-61.
Hampton KD, Mazza D, Newton JM. Fertility-awareness knowledge, attitudes, and practices of women seeking fertility assistance. J Adv Nurs 2013;69:1076-84.
Hampton K, Mazza D. Fertility-awareness knowledge, attitudes and practices of women attending general practice. Aust Fam Physician 2015;44:840-5.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]