Egg freezing for fertility preservation and family planning: a nationwide survey of US Obstetrics and Gynecology residents

Oocyte cryopreservation technologically has advanced significantly in the last three decades, and currently is considered an adjunct technique in fertility treatment all around the world. Oocyte cryopreservation initially was developed as a fertility sparing option for women undergoing cancer therapy or requiring bilateral oophorectomy for a medical condition. Most oncologic societies now recommend pre-treatment discussion of fertility preservation for women with cancer who are of childbearing age. More recently, the increasing age of first elective pregnancy and age-related infertility/subfertility has led to interest in and use of elective oocyte cryopreservation, referred to here as egg freezing (EF), among younger, healthy women. In Oct. 2012, egg freezing was reclassified from an experimental procedure to an elective procedure by the American Society for Reproductive Medicine [1], making EF available as a means of fertility preservation for women hoping to delay childbearing.

Currently, little is known about societal attitudes toward EF, in particular what makes women in favor of or against the procedure both ethically and personally. Surveys of the general population indicate that women who were 30–45 years old, had personally experienced infertility, and had higher levels of education had more favorable views of elective EF procedures [2]. Understanding how patients acquire knowledge regarding EF and what determines whether physicians have these conversations with interested patients is essential in improving informed decision on egg freezing.

Despite their central role in counseling patients on EF, little is known about medical trainees’ views on the procedure. Among medical students and house staff with prior knowledge of EF, 80% reported acquiring this knowledge through their formal education [3], indicating that EF is not well-covered in medical schools. A survey of U.S. Obstetrics and Gynecology (OB/GYN) residents indicated that 83% felt that they should begin conversations with their patients regarding fertility, and most felt that these conversations should occur during annual exams [4]. This survey also indicated that residents were under-informed about fertility; 47% overestimated the age of marked decline in female fertility, and over three quarters overestimated IVF success rates [4].

Additionally, medical professionals, especially residents, could be a target population for EF, as they are young individuals who may be delaying pregnancy until after they complete their residencies [5]. Given their medical background, residents are likely to be knowledgeable about EF or can easily learn about it, allowing them to make well-informed decisions regarding the procedure. However, although residents and medical students report delaying pregnancy [5], the reasons for doing so, and particularly how this may affect their views on EF, are not well-established. To evaluate resident views on EF and how education on EF impacts their views and practice, we surveyed US OB/GYN residents to determine 1) whether they intentionally delay having children during residency, 2) their reasons for this delay, 3) the extent of their knowledge about oocyte freezing and 4) how educational exposure to EF affects their views on oocyte freezing.

Despite the change of egg freezing from an experimental to elective procedure in 2012, there were only 8825 elective EF cycles in United States in 2016 [7]. Although this represents an increase of about 175% since 2013, it indicates that EF is still highly underutilized for fertility preservation. As public knowledge regarding EF increases and the technique becomes more widely available, ensuring that patients have accurate information about EF is essential so that women can make informed choices. OB/GYN residents, as future attending physicians, should be comfortable and have the knowledge base and skills to accurately and impartially counsel patients on EF. Specific curricular content on EF during residency training may translate into better patient information and awareness of the option of fertility preservation and increase access to egg freezing.

In this study, we have presented some of the first data on the relationship between resident education and their views on EF. Only half of the female residents in our study reported being comfortable counseling patients on EF. Residents who report receiving educational exposure to EF were statistically significantly more likely to report being comfortable counseling a patient on EF, indicating the importance of EF curricular exposure in successfully providing this service to female patients as part of the spectrum of discussion about fertility planning at the annual visit. While REI is considered part of the core residency experience, the exposure to formal REI rotations and Assisted Reproductive Technology varies widely among residency programs. Most residency programs have 4–8 weeks of a dedicated REI rotation, while others will incorporate this experience into a bundled benign gynecology outpatient training curriculum.

Our findings might inform residency program directors about factors important to their trainees regarding personal and professional attitudes toward EF and informs curriculum development. The length of exposure to a formal REI program did not affect comfort in counseling patients in EF, indicating that brief focused REI rotations exposing residents to Assisted Reproductive Technology could help improve patient access to OB/GYN physicians who are comfortable in discussing EF. This finding supports Anspach-Will et al.’s interventional study, which found that an hour-long educational session on EF was sufficient to significantly improve medical professionals’ knowledge-based scores about EF [3] and suggests that a brief but focused curriculum in EF could help improve resident confidence in discussing EF with patients. Female residents’ input regarding what they consider important for prospective patients to know could also guide training on EF.

Although we found that educational exposure did not affect female residents’ personal views about use of EF for themselves or other residents, our study provides valuable insight into residents’ own family planning choices and, particularly, reasons for delaying childbearing. Importantly, we found that almost three quarters of female residents reported delaying pregnancy due to their residency responsibilities. Although career plans were the most common reason cited for this delay, several other factors that could be accommodated by residency programs or institutions were also highly important to female residents, including accessibility and availability of childcare and concern for the effect of a maternity leave on their program. Almost a third were concerned about insufficient maternity benefits provided by their programs. Therefore, improving maternity leave benefits, providing mechanisms to reduce the strain maternity leave might create on a residency program, and improving childcare options could be significant institutional changes that could improve residents’ quality of life and prevent the need to delay childbearing. Programs could also consider providing EF as a benefit for female residents, as 65% indicated that they would prefer to work for a program that offered EF as a benefit. These data are similar to those found in a survey of 99 female US medical students, of which almost three quarters indicated that they would consider EF if the cost was covered by their employer [8]. While this survey was limited to Obstetrics and Gynecology residents, over half of medical school graduates are now female, indicating a growing cohort of women who potentially are delaying pregnancy because of residency demands and training requirements.

Given the frequency with which female residents delay childbearing, they possibly present an ideal population for consideration of EF. Despite this, only 46% of female OB/GYN residents indicated that they would consider EF for themselves and only 26% thought that all female residents should consider EF. Rates of personal interest in EF were much lower in our cohort than those found among female US medical students [8], which may be due to the fact that our cohort contained older participants with a greater practical knowledge of EF procedures and success rates. Residents in Obstetrics and Gynecology also might be more likely to have a partner and children than those women still in medical school. Knowledge about EF might also decrease likelihood of personal interest in EF; Tan et al. found that, after providing Singaporean medical students with an educational pamphlet about EF, those who would consider EF for themselves decreased from 70 to 49% [9], which more closely matches the rates we found among female OB/GYN residents, who would be presumed to have some knowledge of EF.

Our study also provides data on what might increase the likelihood for female residents to consider EF. The most commonly cited factors include having employer financial support, knowing that there is no increased harm or risk of abnormality of a baby conceived through EF, and not currently having a partner. The factors identified in our study were similar to those identified in a survey of 500 nulliparous but presumed-fertile women in Canada, who most commonly cited cost, risk to their own health, and risks to the child born from vitrified oocytes as concerns [10]. The frequency of concerns of cost in all of these studies indicates the importance of financial support, given that an EF cycle can cost over $10,000. The majority of female residents in this study estimated $2000–$5000 as an affordable cost. Resident concerns about the health of their offspring also indicate the importance of education and additional research on the effects of EF on the infants born from those oocytes.

Although our study provides important initial findings on the significance of REI education on comfort counseling patients on EF, as well as resident decisions regarding family planning, these data represent a very small sample of US OB/GYN residents (2.2%) [11]. The on-line survey was distributed to program directors via email. Dispersion of resident surveys is variable, and we are unable to verify that it was received by the intended respondents. There is likely respondent bias at both the program director and resident level. Additionally, although we sought responses from all U.S. residency programs, programs from the Southwest and Northwest and residents of non-Caucasian race/ethnicity are under-represented in this sample, reducing the generalizability of our findings. However, the percent of minority participants in our survey (19.5% non-Caucasian, non-Asian) was representative of those in US residency programs in 2014 (18.4%) [11]. We did not receive responses from a large number of male participants, and the percentage of female participants in our study (91.2%) was higher than that in US residency programs in 2016 (82.3%) [11]. We cannot therefore make any conclusions about the views of male OB/GYN residents on EF as a population or compare the views of male and female residents. However, our cohort is similar in size and distribution to that of the only other study we have found on US OB/GYN residents, which received responses from 5% of US residents [4], similarly predominantly from the Northeast and South, and our study therefore provides a valuable addition to the sparse literature on resident views on EF.

Because of the small response rate to our survey we are unable to identify significant relationships between educational exposure and resident views and comfort discussing EF. Although we identified two significant relationships, there may be other valuable associations that we were not powered to detect. Additionally, we are not able to determine linear relationships between level of comfort in counseling patients or level of interest in EF and educational exposures as these variables were recorded as binary. Finally, future studies are needed to determine the appropriate curricular content and timing of EF in medical education to best assure that patients are given the information necessary for informed decisions about this fertility sparing option.

Overall, our study indicates that residents are delaying childbearing for their careers but many are not interested in considering elective egg freezing as a means to preserve their own fertility. Additionally, residents are often uncomfortable counseling patients on elective egg freezing. However, increased educational exposure to EF could improve resident comfort in counseling patients, though it does not seem to have an impact on residents’ own views. Given the increasing use of EF and importance of resident knowledge and education on EF, our study provides important initial findings regarding the need for resident exposure to and education on EF during their residencies. Furthermore, our results provide insight into why nearly three quarters of US residents who responded to our survey choose to delay childbearing and can provide institutions with potential changes they could implement to improve resident quality of life and help to prevent the need for residents to choose between their careers and having children. Future work is needed on how to best educate residents on EF and how long such training needs to be. Additionally, our study provides direction for future research on how to improve access to and interest in EF for residents and other women planning on delaying pregnancy and how to provide better support so that residents can have children during residency and would not feel the need to delay pregnancy.