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Abstract
Objectives The present study was designed to examine the attitudes towards oocyte cryopreservation among healthcare providers working in hospitals across specialties and potential influencing factors.
Design A cross-sectional study.
Setting The questionnaire was distributed among Chinese healthcare providers via the Credamo platform.
Participants There were 877 respondents recruited from 8 April to 8 May 2022, among whom 160 were identified as unqualified because of inconsistency between the IP and work addresses.
Outcome measures Individual attitudes towards oocyte cryopreservation under four different settings, familiarity with oocyte cryopreservation and perceived risks about oocyte cryopreservation of healthcare providers were measured using a self-designed questionnaire.
Results There were 877 respondents recruited, and 717 were identified as qualified respondents. Two latent classes of healthcare providers characterised by different attitudes towards oocyte cryopreservation under four different settings were identified, the supportive and reluctant. Familiarity with oocyte cryopreservation had a significant direct effect on perceived risks, with better familiarity predicting lower perceived risks (β=−0.102, p<0.05). Perceived risks showed a significant direct effect on participants’ attitudes towards oocyte cryopreservation, with higher perceived risks predicting a more reluctant attitude (β=0.165, p<0.001).
Conclusions The majority of healthcare providers held a reluctant attitude towards oocyte cryopreservation of unmarried women for non-medical reasons, which might relate to their worries about the risks to offspring’s health and lack of knowledge about a reproductive technique.
- Health Equity
- Health Services Accessibility
- Health policy
- MEDICAL ETHICS
Data availability statement
Data are available upon reasonable request. The data underlying this article is available from the corresponding author under reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The latent class analysis can help clarify clusters of healthcare providers’ attitudes towards oocyte cryopreservation.
Specific reasons for individuals on the decision for each question listed in this study were not collected.
This study did not invite other stakeholders.
Introduction
In recent decades, an increasing number of females worldwide have been able to pursue infertility treatment at more advanced maternal ages. According to one report from the Chinese Ministry of Civil Affairs, the number of marriages registered in China deceased from 13.47 million to over 8 million from 2013 to 2020, and the average age of the first childbearing continued to increase.1 With unprecedented advancements in oocyte cryopreservation, women who decide to postpone pregnancy can use their own eggs at a later age, instead of relying on donor oocytes.2 As this technology continues to improve, it may give rise to a new medical and social phenomenon involving oocyte cryopreservation to avoid infertility.3 Oocyte cryopreservation is still strictly regulated in mainland China. The Administrative Measures on Human Assisted Reproductive Technology states that the use of human-assisted reproductive technology should only take place in medical institutions for medical purposes. And the former Ministry of Health established Technical Specifications for Human Assisted Reproduction. This stipulated that single women should not be granted access to human-assisted reproductive technology. Thus, oocyte cryopreservation is not an option for unmarried women, but only for certain married patients who intend to get pregnant at a later age, in China.
Healthcare providers are vital communicators and are essential in facilitating the use of new medical technology. In the field of reproductive health, healthcare providers are the most preferred and reliable source of information for women seeking advice.4 5 For instance, healthcare providers are uniquely suited to discuss the costs and risks associated with oocyte cryopreservation with their patients.6 However, not all healthcare providers in China are knowledgeable or comfortable counselling their patients on assisted reproductive technology including oocyte cryopreservation. Their knowledge and attitudes can significantly impact their willingness to initiate discussions with their patients. Therefore, before encouraging healthcare providers to fulfil their roles, it is crucial to evaluate their knowledge and attitudes towards oocyte cryopreservation.
Although there is limited research on the knowledge of oocyte cryopreservation among healthcare providers, several international studies have explored their attitudes. A study conducted among female medical staff at a tertiary hospital in South Korea noted that most considered planned oocyte cryopreservation as a woman’s right.7 Tsai’s study among resident physicians in the United States highlighted the need for improved fertility education across specialties.8 Another study among US obstetric and gynaecology resident physicians reported that only 40% believed residents should initiate discussions about elective oocyte cryopreservation with patients, and only 20% believed it should be part of an annual exam.9 However, no related studies have been conducted in the Chinese context.
The present study was designed to examine the attitudes toward oocyte cryopreservation among healthcare providers working in hospitals across specialties and potential influencing factors. It is based on three key research questions: (1) what are Chinese healthcare providers’ general attitudes towards oocyte cryopreservation? (2) Do the perceived risks of oocyte cryopreservation affect their attitudes? (3) Do familiarity with oocyte cryopreservation affect their attitudes? To our knowledge, this is the first study to explore these issues in a sample of Chinese healthcare providers.
Methodologies
Data collection
This was a cross-sectional questionnaire-based online survey conducted via the Credamo platform. Credamo offers a comprehensive set of features that make it an excellent choice for conducting surveys. It has access to a large and diverse pool of respondents, enabling researchers to reach their target audience quickly and efficiently.10 Credamo employs random sampling techniques and offers targeted recruitment options that allow us to reach healthcare providers working in medical institutions in mainland China. Our pilot study showed that about 40% of healthcare providers reported positive attitudes towards oocyte cryopreservation of women, married and unmarried. Thus, we anticipated a study population of approximately 600 healthcare providers as a sufficient sample size. Among 1055 potential respondents reached by the Credamo, 877 (83.1%) respondents from 50 cities were recruited from 8 April to 8 May 2022. The IP address can show which city the respondent was living at the time of the survey. According to the Guidelines on Conducting COVID-19 Prevention and Control on an Ongoing Basis released by the State Council, it was almost impossible that healthcare providers would leave their workplace during the survey time. Thus, 160 respondents were identified as unqualified because of the inconsistency between IPand work addresses. We believe this inconsistency is a sign of careless responses.
Study variables
The questionnaire comprised of four sections: (1) sociodemographic characteristics of participants, (2) individual attitudes towards oocyte cryopreservation under four different settings, (3) familiarity with oocyte cryopreservation and (4) perceived risks of oocyte cryopreservation (see online supplemental file 1).
Supplemental material
Sociodemographic characteristics included gender, age, hospital levels, types of healthcare providers, family economic status and marital status.
Individual attitudes towards oocyte cryopreservation were assessed with the following four questions: ‘what’s your attitude towards the provision of oocyte cryopreservation to unmarried women for non-medical reasons?’ ‘What’s your attitude towards the provision of oocyte cryopreservation to married women for non-medical reasons?’ ‘What’s your attitude towards the provision of oocyte cryopreservation to unmarried women for medical reasons?’ ‘What’s your attitude towards the provision of oocyte cryopreservation to married women for medical reasons?’
Familiarity with oocyte cryopreservation was assessed with the following three questions: ‘how well do you know about the technical procedures of oocyte cryopreservation?’ ‘How well do you know about the potential risks of oocyte cryopreservation?’ and ‘How well do you know about the indications of oocyte cryopreservation in China?’
Perceived risks about oocyte cryopreservation were assessed with the following questions: ‘How much do you worry about the risks of oocyte cryopreservation on women’s reproductive health?’ ‘How much do you worry about the risks of oocyte cryopreservation to offspring’s health?’
Data analysis
A latent class analysis (LCA) was conducted among participants (n=717) based on their attitudes towards oocyte cryopreservation under four different settings using Mplus V.8.3. LCA creates groups based on the similarity of participants’ response patterns to a set of variables. To identify the optimal number of classes, we examined the Bayesian information criterion (BIC), Lo-Mendell-Rubin (LMR) likelihood ratio test and entropy. An LCA model is considered fitting with a relatively lower BIC, a p-value of <0.05 of the LMR and relatively higher entropy. An entropy index of less than 0.6 indicates that more than 20% of individuals are classified incorrectly, whereas higher than 0.8 means that the classification accuracy exceeds 90%. Therefore, if the entropy index reaches 0.8 or higher, it can be considered that the classification is accurate. Optimal models were chosen based on the goodness of fit and parsimony. Individuals were allocated to their most likely latent class based on their posterior probability of class membership. After the optimal model was identified from the LCA, we stratified participants into two groups: (1) the supportive and (2) the reluctant. Then, participants’ social demographic characteristics, familiarity with oocyte cryopreservation and perceived risks were compared using Chi-squared tests.
The hypothesised integrated model was tested through path analysis using AMOS 22.0. Multiple indices were employed to assess the integrated model fit, including (1) insignificant chi-square coefficient or significant results when accompanied by other acceptable fit statistics for sample sizes of over 200, (2) the Comparative Fit Index (CFI) with values of higher than 0.90 and (3) the Root Mean Square Error of Approximation (RMSEA) with values of less than 0.05.
Patient and Public Involvement
It was not appropriate or possible to involve patients or the public in the design, conduct, reporting or dissemination plans of our research.
Results
Correlates of class membership were investigated with the optimal number of classes identified (table 1). If the BIC is sufficiently low and entropy is sufficiently high, it suggests that the model is simple yet accurate. In this case, the model with fewer classes should be chosen. Model 2 in table 1 showed a relatively lower BIC, and a p-value of the LMR was lower than 0.05 with fewer classes. Therefore, the present study chose Model 2 as the final model. There were 253 participants classified as Group 1 (the supportive) and 464 as Group 2 (the reluctant). Descriptive statistics of each class and comparisons are summarised in table 2.
Model fit statistics for each of the fitted latent class analysis model
Attitudes towards oocyte cryopreservation of healthcare providers stratified by group N (%)
Table 3 shows differences in participants’ characteristics between the supportive and reluctant group. These two groups did not show any differences in sociodemographic characteristics, including gender, age, hospital levels, types of healthcare providers, family economic status and marital status. Compared with the reluctant group, the supportive group reported a better self-rated understanding of the potential risks of oocyte cryopreservation and indications of oocyte cryopreservation in China. The supportive group was less worried about the risks of oocyte cryopreservation to women’s reproductive health or offspring’s health than the reluctant group.
Descriptive statistics of participants’ characteristics N (%)
As indicated by the analysis results in figure 1, the hypothesised structural model provided a good fit to the data (chi-square value=13.208, df=8, p=0.105) with CFI greater than 0.90 and the RMSEA smaller than 0.05. Familiarity with oocyte cryopreservation had a significant direct effect on perceived risks, with better familiarity predicting lower perceived risks (β=−0.102, p<0.05). Perceived risks showed a significant direct effect on participants’ attitudes toward oocyte cryopreservation, with higher perceived risks predicting a more reluctant attitude (β=0.165, p<0.001). All observed variables were significantly loaded on the corresponding latent constructs, suggesting a statistically reliable underlying construct (table 4).
Standardised solutions for the structural model of familiarity with oocyte cryopreservation, perceived risks and group. *p<0.05, **p<0.01, ***p<0.001.
Standardised factor loadings of observed variables on latent constructs
Discussion
To the best of our knowledge, this is the first study to investigate the attitudes towards oocyte cryopreservation of Chinese healthcare providers and its potential influencing factors. Our LCA model perfomed well with a relatively lower BIC, a p-value of <0.05 of the LMR and relatively higher entropy, which offered accurate classifications for subsequent analysis. The present study has generated three major findings: first, most healthcare providers held a reluctant attitude towards oocyte cryopreservation; second, perceived risks had direct effects on attitudes towards oocyte cryopreservation; and third, familiarity with oocyte cryopreservation had indirect effects on attitudes towards oocyte cryopreservation.
Most Chinese healthcare providers held a reluctant attitude towards oocyte cryopreservation, especially towards non-medical reasons for oocyte cryopreservation. In line with our findings, a survey among American obstetric and gynaecology resident physicians indicated that there was less likelihood for residents to support oocyte cryopreservation with patients pursuing careers, while the chance of discussing oocyte cryopreservation with cancer patients was relatively higher.9 Differences in culture and national conditions might have effects on reluctant attitudes of Chinese healthcare providers, as the practice of oocyte cryopreservation for non-medical reasons still raises several ethical and sociocultural issues.11 Our previous qualitative interviews with Chinese healthcare providers (unpublished) revealed that due to the uniformity of health policies throughout the country, coupled with varying health needs of people from different socioeconomic backgrounds, Chinese healthcare providers are concerned about potential repercussions of the government’s endorsement of unrestricted oocyte cryopreservation among women.
In the present study, Chinese healthcare providers were more concerned about the perceived risks to offspring compared with women’s reproductive health. As reported, the frozen-thaw cycle could cause sublethal impairments on oocytes, including DNA fragmentation and epigenetic risks.12 Besides, the frozen-thaw cycle survival oocyte rate was shown to be around 70%, but the euploid rate was only around 30%, decreasing with maternal age.13 Although in the latest decade, with the vitrification technology becoming mature and being widely introduced into clinical practice,14 evidence showed that the clinical pregnancy rate and live birth rate of planned oocyte cryopreservation were more promising, and pregnancies using frozen oocytes had no difference in fertilisation and ongoing pregnancy rate when compared with fresh oocyte pregnancies.15 16 Still, there is a lack of long-term follow-up studies on children born under this procedure because oocyte cryopreservation has yet not been used for a long time as a non-experimental clinical technique.17 This insufficiency of evidence might lead healthcare providers to worry about the future uncertainty of these offspring. To ensure the health of offspring as far as possible, equipment and expertise for the routine application of the advanced technique are needed, and a more standard and nationally unified oocyte frozen-thaw cycle protocol is required, along with extensive long-term follow-up studies in the future.
As the impact of age on female fertility decline is underestimated and the success rate of ART is overestimated by the general public,18 approval of oocyte cryopreservation for non-medical reasons might postpone their first birth age even further, which might subsequently decrease their chances to conceive and increase the risks of gestational complications.19 In addition, the utilisation of frozen oocytes is quite low, turning out that most women after oocyte cryopreservation achieved pregnancy without frozen oocytes or were unwilling to have a child without a partner.20 More information from reliable institutions should be available for women seeking oocyte cryopreservation before they make up their minds, to avoid the effort for oocyte retrieval and storage in vain. As healthcare providers are still considered to be a top source of information on fertility and reproductive health,4 it is essential to manage individual discussions between physicians and patients on fertility preservation in outpatient services.
Healthcare providers in the present study showed a perceived shortage of knowledge about oocyte cryopreservation, which is also suggested in other studies that only around 30% of residents were familiar with the oocyte cryopreservation procedure.9 21 22 In China, getting an internship in the reproductive department is hard for residents from other specialties. Thus, their knowledge about oocyte cryopreservation might only come from a short chapter in the textbook or on social media like the general public. Media messages tend to be persuasive rather than informative and can be biased on the benefits and risks,23 which might cause healthcare providers to misunderstand the technique and deprive them of the leadership in disseminating this knowledge.
Other than these concerns discussed above, we believe there are three more important issues need attention. The first is the patient informed consent in oocyte cryopreservation. Protecting patient informed consent in oocyte cryopreservation is crucial. By taking appropriate measures to ensure that patients are fully informed of all the potential risks and consequences of this process, we can promote patients' right to make autonomous decisions while upholding the credibility and ethical standards of the medical profession. The second is the standardised protocols for counselling. The decision to freeze eggs is complex, and detailed, unbiased information is needed. Therefore, a two-step systematic counselling protocol24 that guide healthcare providers to offer prospective egg freezing in patients with a systematic and comprehensive pre-procedure counselling can be helpful. The third is the regulated donation of unused surplus frozen eggs. Any kind of commercial egg donation is illegal in China. Only women who have had eggs taken during a human-assisted reproductive treatment procedure can donate their unused surplus frozen eggs. Local egg donation cases are very limited, and relevant laws and regulations may not be perfect. Thus, several vital issues, including donor anonymity, refund medical fees for donation genetic screening of donors, should be addressed.25
These findings should be viewed in the context of the study’s limitations. First, we did not collect specific reasons for individuals on the decision for each question listed in table 2. To study the underlying reasons for healthcare providers’ attitudes, qualitative interviews might be a great option in the future. Second, the current study only presents the voices of healthcare providers. As oocyte cryopreservation turns out to be not only a medical topic but also a social topic, voices from other stakeholders like lawyers and patients are wanted to enrich our findings. Third, we are uncertain about the participants’ opinions regarding the socioeconomic impact of oocyte cryopreservation. While some may agree with the technique of oocyte cryopreservation, they may not support its reimbursement by society for non-medical fertility preservation. This question is crucial to consider when assessing the feasibility of oocyte cryopreservation for non-medical purposes.
Conclusion
The present study found that the majority of healthcare providers held a reluctant attitude towards oocyte cryopreservation for non-medical reasons, which might relate to their worries about the risks to offspring’s health and lack of knowledge about a reproductive technique. To respect individual patient autonomy as well as help patients make the most informed reproductive decision, extensive cooperation from multiple social roles is required, in which healthcare providers should play the key role.
Data availability statement
Data are available upon reasonable request. The data underlying this article is available from the corresponding author under reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by The study was approved by the Ethics Committee of Zhejiang University (ZGL202011-7#). Participants gave informed consent to participate in the study before taking part.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors JJL and ZCW conceived and designed the study. ZCW acquired the data and is
responsible for the overall content as the guarantor. All authors contributed to the analysis and interpretation of data. All authors drafted or revised the article critically and approved the final version.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests The authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.