From sex-ed to fertility-ed: a more holistic approach to reproductive education

This month’s F&S Reports features two articles on the reproductive knowledge of nonmedical graduate students regarding natural fertility, oocyte cryopreservation (OC), and family planning goals. The first study, by Cardozo et al., evaluated whether employer coverage of OC affects willingness to consider OC and subsequent family planning (1). The second study, by Bernardi et al., demonstrated that nonmedical graduate students (both male and female) are not truly aware of what the biological clock means and how it affects their chance of success (2). Notably these students tended to overestimate both natural fertility and success rates with treatment—misconceptions which could set them up for disappointment later on. Both articles chose to look at graduate students, an ideal population because they are highly educated and career oriented without necessarily a focus in medicine. Bernardi et al. point out, however, that studies done in obstetrics and gynecology residents similarly found gaps in fertility knowledge (3). Although these gaps in knowledge are alarming, considering how irreversible age-related infertility actually is, this lack of fertility education is hardly their fault. In the Cardozo et al. study, most women had indeed heard of OC but fewer than 3% of them learned of OC from a medical provider. This implies that we are not in control over how this information is disseminated and thus there is no consistent message being relayed.

Starting as early as fourth grade, students are introduced to “sex-ed,” where they are taught about safe sex practices, i.e., how to avoid sexually transmitted diseases and prevent pregnancy. Obstetrician-gynecologists take up the reins and continue this emphasis on preventing pregnancy using various methods of contraception well into a woman’s 20s and 30s. Because the risk and ramifications of unintended pregnancy are high during this time, it makes sense that this should be one of the primary counseling points. But this is unfortunately where the conversation ends for most women. “Sex-ed” never fully evolves into “fertility-ed” until it is frequently too late. And then the treatment that she was depending on to help her overcome her struggles is not as successful as she had originally anticipated. The only true treatment for age-related infertility is prevention. As obstetrician-gynecologists, we need to make this loud and clear, particularly generalists, as they have regular contact points with patients for annual gynecologic exams, Pap smears, and contraception. Family planning should include planning for a family. If not actively having a family by age 35, then OC. This recommendation requires not a single test, just a conversation.

When is the ideal time for “fertility-ed”? As demonstrated by these studies, graduate students have many misconceptions regarding both natural fertility (overestimating fecundability at all ages) as well as fertility treatment success rates as women get into their 40s. Should there be a class or seminar for students who are at a higher risk of needing to delay family building secondary to professional goals? Or does this education about the age-related fertility decline need to start even earlier in college? Is it contradictory to be teaching sex-ed and fertility-ed together? Or would they complement each other and give students a more well rounded view of reproductive health?

What would happen if a college included as part of its health benefits to graduate students an opportunity to freeze eggs? Much like the tech industry, which offers these benefits as a way of attracting talent, would a graduate program attract the most motivated students? The Bernardi et al. (2) paper delved into the question of coverage by looking at how employer coverage of egg freezing affects reproductive decisions of graduate students. Most participants in this study stated that they would consider OC if it were covered by their employer; cost was the main reason to not pursue OC. Some have suggested that insurance coverage for egg freezing might be an attempt to “persuade” employees/students to delay childbearing (4), but this study showed that most would not alter their plans for timing of childbearing even if OC was a covered benefit. Others have made similar observations, that employee coverage does not persuade women to delay childbearing, but instead gives them more control over timing and adds to her sense of empowerment (4). Decisions about when to pursue childbearing are also influenced by maternity leave policies, something that many women are not truly aware of until they are ready to conceive. It seems that a good education in sex-ed followed by fertility-ed followed by maternity-ed would really be the most ideal for a woman to have full control over her reproductive choices.

Coverage for OC is a frequently noted obstacle that prevents more women from taking advantage of this opportunity. But there are some potential financial benefits to OC; it is just hard to predict who will and will not need to use them. and this is primary argument against it. Sixty percent of the total in vitro fertilization population is aged ≥35 years, and it is anticipated that the trend toward delaying childbearing will continue, thus increasing the need for assisted reproductive services. On an individual level, elective OC at a younger age has the potential to save women (and insurance companies) money in the future. Newer insurance companies, such as Progyny, do offer egg freezing benefits, and ∼10% of their cycles are egg-freezing cycles. When I inquired how much of a financial benefit we think egg freezing incurs, patients who freeze their eggs at age 35 and then use them at age 40 would save ∼28%, or $17,000, in fertility treatments costs. They estimated this based on average costs quoted by Fertility IQ and taking into consideration costs of egg freezing, storage, embryology, and fertility medication. And it’s obvious why—fewer cycles would be necessary at age 35 to achieve an even higher chance of success then at age 40. Most importantly, we may not be successful by age 40. So while we cannot predict the future and determine who ultimately will need to use their eggs, it may be better to have them and not need them than to need them and not have them.