Abstract
Purpose
To evaluate the prevalence and factors associated with decision regret following oocyte cryopreservation (OC) in women with diminished ovarian reserve (DOR) and/or age-related fertility decline (ARFD).
Methods
A cross-sectional survey study was conducted to five hundred fifty-two women with DOR and/or ARFD who underwent OC between 2014 and 2019 in two private-assisted reproductive units in Istanbul, Turkey. Decision regret was measured using the validated Decision Regret Scale (DRS).
Results
The median and mean DRS scores were 10 (interquartile range: 25) and 13.4 (SD: 13.2, range 0–70), respectively. Eighty-five (52.5%) women reported mild regret and 26 (16%) had moderate to severe regret. Decision regret was inversely associated with the belief in fate regarding childbearing and trust in the efficacy of OC.
Conclusions
The prevalence of severe decision regret among patients with DOR and/or ARFD undergoing OC is low. Women who had belief in fate and trusted in the efficacy of oocyte cryopreservation had significantly lower decisional regret.
Keywords: Oocyte cryopreservation, Diminished ovarian reserve, Decision regret, Egg freezing, Fertility preservation
Introduction
Oocyte cryopreservation (OC) is the second most established fertility preservation technique after embryo cryopreservation. Although initially OC was reserved for cancer patients undergoing gonadotoxic therapies, now it is most commonly used for elective indications [1].
In Turkey, OC has been legal for only medical indications until October 2014, after which the scope of the legislation was broadened to include women with diminished ovarian reserve (DOR) and/or a family history of early menopause [2]. As older women face age-related fertility decline (ARFD) regardless of their ovarian reserve, they also benefit from OC under this regulation; however, elective/planned OC in young patients with normal or high ovarian reserve and the use of donor gametes are not allowed. Under the same legislation, intrauterine insemination, in vitro fertilization (IVF), and the use of frozen oocytes can be offered only to married heterosexual couples.
Diminished ovarian reserve is characterized by reduced number of oocytes [3–5], but there is lack of consensus regarding the diagnostic criteria [3]. Although DOR in women older than 38 is accompanied by an increase in aneuploidy rate which is interpreted as fertility decline due to age (ARFD) (4–6), accelerated reduction in oocyte quality in young women with DOR is debatable [6–9]. While some studies show increased miscarriage and decreased live birth rates in women with DOR [10], others show similar rates compared with women with normal ovarian reserve [11]. Even if the latter is the case, when these women postpone childbearing, they have the risk of infertility related to further reduction in both oocyte number and quality due to the advanced age [12]. Therefore, especially in women without a partner or a plan of imminent pregnancy, future consequences related to infertility and early menopause urge women with DOR and/or ARFD to take action to cryopreserve their oocytes.
Oocyte cryopreservation is one of the difficult health-care decisions which have potential physical, psychological, and financial burdens. As it may happen in every decision, women may later regret their choice that they have made after OC [13]. Regret has been associated with lower satisfaction with medical decision making, poorer health outcomes, and negative experiences with the healthcare system [14, 15]; however, little is known about decision regret and its predictors [15]. In a recent systematic review of 44 studies from different clinical populations, overall regret was low after making a variety of health-care decisions [16]. In two recent studies that evaluated decision regret among women who had undergone elective OC, it was also reported to be none [17] or very low [13]. In the later study by Greenwood, which included more than 200 subjects, the researchers also found that women who banked ≤ 10 oocytes had increased regret compared with women who banked more oocytes [13]. Conversely, the third and more recent study did not find any association between regret levels and the mean number of banked oocytes [18]. The factors apart from the number of banked oocytes such as perceived adequacy of information prior to OC, adequacy of emotional support during OC, patient-estimated probability of achieving a live birth using their banked eggs, and financial expense were evaluated in these studies as well.
Given the conflicting results on the association of the number of frozen oocytes and regret levels, and the lack of data assessing decision regret following OC in women with DOR and/or ARFD, we aimed to evaluate the prevalence of decision regret in this population and identify the factors associated with decision regret following OC. As our patient population undergoing OC in Turkey consists of women with DOR and ARFD, which is different than the population undergoing elective OC in the rest of the world, we believe our results will be important when counseling patients regarding their expectations and regret after the procedure.
Material and methods
From October 2014 to May 2019, all women with DOR defined as women having an AMH level of ≤ 1.3 ng/ml or a total AFC of ≤ 7 regardless of age, and/or ARFD which includes women ≥ 38 years of age who underwent OC at two private assisted reproduction units (American Hospital and Bahceci IVF Centre in Istanbul, Turkey) were surveyed. Women who froze their oocytes for medical indications such as impending radio/chemotherapy for cancer were excluded. Following Institutional Review Board approval from the Koc University School of Medicine Committee of Human Research (2019.209.IRB1.032), women were contacted by phone and asked whether they would be willing to participate in an online questionnaire to evaluate the presence of decision regret, their satisfaction level, relationship, and reproductive status, and attitude towards oocyte banking for future reproductive planning following OC. Microsoft Forms was used to form an online survey. An Internet link to the survey site along with an accompanying survey invitation was sent by email to all women who had undergone OC and willing to participate in the survey. Each mailed survey was self-addressed and accompanied by a cover letter explaining the objectives of the study. To increase the response rate, surveys were sent twice. Since the responses were anonymously received and recorded to the system, the investigators were blinded to which treated patients did or did not participate in the survey and no data was available for non-respondents.
We evaluated the extent of decision regret which was categorized as no, mild, or moderate to severe decision regret. The primary outcome of the study was the prevalence of moderate to severe decision regret. Decision Regret Scale (DRS) which was validated in different patient populations and described extensively elsewhere was used [15, 16, 19]. It is proved to discriminate between patients who have high and low levels of decisional regret, and also found to be psychometrically robust due to showing significant correlations with other instruments that measure patients’ physical, mental, and social well-being [20]. DRS included five questions. Three of these were whether regret was felt to be present, whether the decision was right for the patient, and whether the patient would make the same decision again under the same circumstances. The remaining two items were about whether the decision was a wise one and whether the decision had resulted in harm. The scoring algorithm yields scores from 0 to 100, with 0 indicating absent regret and 100 indicating extreme regret. DRS scores were interpreted as follows: 0, no regret; 1–25, mild regret; and > 25, moderate to severe regret [19].
To determine associated factors with decision regret after OC, additional questions specific to sociodemographic characteristics of the Turkish population were developed by a panel of experts including reproductive specialists and a sociologist, and after a thorough literature review [21, 22]. Questions were particularly focused on factors likely to be associated with decision regret. The following fields were examined in 45 items: demographics (14 questions), preparation for OC (2 questions), future reproductive planning (6 questions), and desire for parenthood (7 questions), treatment satisfaction (11 questions), and decision regret (5 questions). The survey was designed to be completed in less than 10 min and was tested thoroughly in a small sample of volunteer patients and topic experts before distribution. Answering every question was not a prerequisite to increase compliance with the survey.
Collected demographics included current age, age at the time of OC, education level, occupation, monthly income, sexual orientation, relationship status during and after OC, smoking status, family history of premature menopause or breast cancer, and serum anti-Mullerian hormone (AMH) levels. The number of total oocytes frozen and the time between considering and undergoing OC were also asked. Religious identity or ethnic identity were not asked due to the sensitivity of such topics in the contemporary political environment of the country characterized by polarization; however, it might be helpful to note that the society is predominantly Sunni Muslim populated.
Preparedness for OC was evaluated using Likert-type scales (e.g., strongly agree to strongly disagree) for perceived adequacy of information when at the initiation of the treatment and emotional support provided during the process. Besides, emotional and financial difficulties were inquired.
Reproductive planning was determined by asking the latest age that the woman may consider childbearing, the likelihood of using frozen oocytes (from 0 to 100%), and the perceived chances of live birth in the event of such a practice (from 0 to 100%), whether they had delivered a baby since OC, and, if so, the method by which the pregnancy was achieved.
The desire for parenthood and attitude towards other childbearing methods were measured by using a Likert-type scale (e.g., strongly agree to strongly disagree). Participants were asked whether being a parent is a more important goal than having a satisfying career, whether they have always desired to be a parent, and whether they believed that having a child is a matter of fate. The word ‘fate’ has religious implications. It is widely used in colloquial language and was included in the survey following the findings of a much smaller qualitative study in which some Turkish women referred to fate concerning their expectations about the future use of frozen oocytes [22]. Other methods to have a child (adoption, egg/sperm donation, and using frozen oocytes outside of matrimony) were also sought out by using a Likert-type scale (e.g., strongly agree to strongly disagree) in four questions.
To assess satisfaction by using Likert-type scales (e.g., strongly agree to strongly disagree), survey participants answered the following questions: “I feel like I have more control over my reproductive future,” “I feel like I have more flexibility in planning a family,” “I feel like I have more options for planning a family,” “If I never use my oocytes to get pregnant, I will still be happy I did it,” “I trust in the efficacy of OC,” “I feel regretful because I lost my virginity during the procedure.” To compare the emotional state of the patients before deciding to undergo OC, after the procedure, and at the time of the survey, their feelings (comfortable, anxious, strong/safe, alone, regretful) were asked as well.
Statistical analysis
Descriptive data were presented using numbers and percentages. The relationship between age and the number of oocytes frozen with DRS scores was assessed by the Spearman’s rank correlation. Likert-type scale responses, considered as possible predictors, were coded from a scale of 1–5 with 1 denoting strong disagreement and 5 denoting strong agreement. Percent estimations, considered in 10% intervals from 0 to 100%, were coded from 0 to 10. Since DRS score > 25 was indicative of moderate to severe regret, it was considered as a dichotomous rather than a continuous dependent variable. Univariate logistic regression analysis was used to identify factors associated with the primary outcome of moderate to severe decision regret. Multivariate regression models were generated using factors meeting the significance of p < .10 in the univariate analysis. The multivariate regression model was established by choosing input variables that were not highly correlated with one another (multi-collinearity) [23]. The emotional status among different treatment stages was analyzed using the Friedman test. Statistical analyses were performed using Microsoft Excel and SPSS software (Statistical Package for the Social Sciences, Version 20; SPSS Inc., Chicago, IL). Correction for multiple comparisons was not performed, given the exploratory nature of this analysis.
Results
A total of 552 women who completed at least one OC cycle from 2014 to 2019 were asked to participate in the study. Of these, 38 could not be reached by phone, 30 declined to participate, and 16 e-mails were undeliverable. A total of 468 surveys were delivered of which 162 (34.6%) were fully responded.
The demographics of the respondents are shown in Table 1. The mean age of women at the time of the survey was 40.4 years (SD: 5). At the time of OC, 76% of the respondents were above 35 years, and the mean age was 37.8 (SD: 5). The mean serum AMH level was 0.68 ng/ml (range: 0.01–3.1) and 36.4% of those reporting had a family history of early menopause and/or breast cancer. The mean number of oocytes frozen was 7.4 (SD: 3.9). The mean number of cycles per patient was 1.6 (range: 1–8). The majority of women (70%) were able to bank < 10 oocytes (71% for those > 35 years) and 28% had < 5.
Table 1.
Demographic characteristics of survey respondents
| Variables | N = 162 |
|---|---|
| Current age, year | 40.4±5 |
| Age at the time of OC, year | |
| ≤30 | 37.8 ± 4.6 |
| 31–35 | 13 (8%) |
| 36–39 | 24 (15%) |
| 40–43 | 67(41%) |
| ≥ 44 | 44 (27%) |
| Education level at the time of OC | |
| Less than 11th grade | 0 |
| High school graduate | 6(4%) |
| University graduate | 68(42%) |
| Master degree | 63(39%) |
| Postgraduate | 25(15%) |
| Household income at the time of OC | |
| < 2000 TL | 9 (5.5%) |
| 2000–7000 TL | 66 (41%) |
| > 7000–10,000 TL | 34 (21%) |
| > 10,000–20,000 TL | 26 (16%) |
| > 20,000–30,000 TL | 10 (6%) |
| > 30,000 TL | 4 (2.5%) |
| Prefer not to state | 13 (8%) |
| Sexual orientation | |
| Heterosexual | 147 (91%) |
| Lesbian | 0 |
| Bisexual | 1 (0.5%) |
| Other | 10 (6%) |
| Prefer not to state | 2 (1%) |
| Sexual status at the time of OC | |
| Active | 107 (66%) |
| Inactive | 45 (28%) |
| Prefer not to state | 10 (6%) |
| Relationship status at the time of OC | |
| No partner | 102 (63%) |
| Involved with a partner | 31 (19%) |
| Married | 7 (4%) |
| Divorced | 20 (12%) |
| Relationship status, at the time of survey | |
| No partner | 98 (60.5%) |
| Involved with a partner | 43 (26.5%) |
| Married | 13 (8%) |
| Divorced | 7 (4%) |
| Smoking status at the time of OC | |
| None | 97 (60%) |
| 1–10 cigarettes/day, < 5 years | 13 (8%) |
| 1–10 cigarettes/day, > 5 years | 27 (16.5%) |
| 11–20 cigarettes/day, < 5 years | 1 (0.5%) |
| 11–20 cigarettes/day, > 5 years | 19 (11.5%) |
| > 20 cigarettes/day, < 5 years | 1 (0.5%) |
| > 20 cigarettes/day, > 5 years | 4 (3%) |
| AMH level at the time of OC, ng/ml | Response rate: 58/162 |
| Mean (min–max) | 0.68 (0.01–3.1) |
| Time between considering and undergoing OC | |
| 0–3 months | 82 (51%) |
| 4–6 months | 18 (11%) |
| 7–12 months | 19 (12%) |
| 1–2 years | 23 (14%) |
| > 2 years | 20 (12%) |
| Number of eggs cryopreserved | |
| < 5 | 46 (28%) |
| 5–9 | 67 (41%) |
| 10–15 | 33 (20%) |
| > 15 | 14 (9%) |
| Family history in 1st degree relatives | |
| Premature menopause | 41 (25%) |
| Breast cancer | 13 (8%) |
| Both | 5 (3%) |
| Have you had a baby since you had frozen your eggs? | |
| Yes | 7 (4.5%) |
| No | 155 (95.6%) |
| How did you get pregnant? | N = 7 |
| Naturally | 6 |
| Needed a medication or insemination | 0 |
| Using my frozen eggs | 1 |
| Via oocyte donation | 0 |
The majority of respondents were highly educated; 96% of them had a university degree or more; however, only 24.5% reported a monthly household income of more than one OC cycle including medications (approximately 10,000 TL) (Table 1). The time between considering and undergoing OC was 3 months in 50.5% of the respondents; 27% underwent OC 1 year after counseling. The mean interval from OC to survey submission was 2.1 years. Most women were sexually active (66%) and heterosexually oriented (90.7%); 63% did not have a sexual partner at the time of OC. During the interval from OC to survey submission, twelve additional women found a sexual partner, and 6 additional women got married increasing the marriage rate from 4 to 8% (13 women). Among respondents, seven women got pregnant resulting in live births and only one in seven got pregnant by using their frozen oocytes.
Perceived adequacy of information and emotional support
Most women (76.5%) agreed they were adequately counseled prior to deciding OC (Table 2). While 42.5% of the women stated that they received adequate emotional support, 27% were not content with the emotional support that was provided (Table 2).
Table 2.
Preparedness for oocyte cryopreservation and reproductive planning
| Variables | N = 162 |
|---|---|
| Adequate information when deciding to pursue OC | |
| Strongly disagree | 1 (0.5%) |
| Disagree | 16 (10%) |
| Neutral | 21 (13%) |
| Agree | 81 (50%) |
| Strongly agree | 43 (26.5%) |
| Adequate emotional support during the OC | |
| Strongly disagree | 10 (6%) |
| Disagree | 34 (21%) |
| Neutral | 33 (20.5%) |
| Agree | 60 (37%) |
| Strongly agree | 25 (15.5%) |
| Emotional difficulty during oocyte freezing process | |
| Strongly disagree | 33 (20.5%) |
| Disagree | 51 (31.5%) |
| Neutral | 17 (10%) |
| Agree | 37 (23%) |
| Strongly agree | 21 (13%) |
| Financial difficulty during oocyte freezing process | |
| Strongly disagree | 10 (6%) |
| Disagree | 47 (29%) |
| Neutral | 20 (12%) |
| Agree | 52 (32%) |
| Strongly agree | 33 (20%) |
| The latest age that you consider childbearing | |
| 30–35 | 8 (5%) |
| 36–40 | 14 (8.5%) |
| 41–43 | 18 (11%) |
| 44–46 | 59 (36.5%) |
| 47–50 | 36 (22%) |
| > 50 | 11 (7%) |
| I don’t know | 11 (7%) |
| Likelihood of using your frozen oocytes | |
| 0% | 8 (5%) |
| 25% | 33 (20.5%) |
| 50% | 72 (44.5%) |
| 75% | 31 (19%) |
| 100% | 18 (11%) |
| Perceived chances of live birth by using frozen oocytes | |
| 0% | 7 (4.5%) |
| 25% | 31 (19%) |
| 50% | 69 (42.5%) |
| 75% | 43 (26.5%) |
| 100% | 12 (7.5%) |
Reproductive planning
For the majority of women (66%), the latest age at which they could see themselves having a baby was 44 years. According to 22% and 7% of the respondents, ages 47–50 and > 50 years, respectively, were the maximum ages for having a baby (Table 2). Of the respondents, 44.5% estimated that they had a 50% chance of returning to use their banked oocytes. Other estimates varied widely (range 0–100%). While 43% of the women estimated that they have a 50% chance of conceiving if they ever used their banked oocytes, the corresponding rate for women who believed that they have a 100% chance of conceiving was 8% (Table 2).
Desire for parenthood
Being a parent was more important than having a satisfying career for 50% of the respondents. The majority of women (67%) agreed with the quotation: “I wanted to be a parent as long as I can remember” (Table 3).
Table 3.
Desire for parenthood
| Variables | N = 162 |
|---|---|
| For me, being a parent is a more important goal than having a satisfying career | |
| Strongly disagree | 6 (4%) |
| Disagree | 31 (19%) |
| Neutral | 44 (27%) |
| Agree | 49 (30%) |
| Strongly agree | 32 (20%) |
| I wanted to be a parent as long as I can remember | |
| Strongly disagree | 3 (2%) |
| Disagree | 16 (10%) |
| Neutral | 34 (21%) |
| Agree | 63 (39%) |
| Strongly agree | 46 (28%) |
| I can consider child adoption | |
| Strongly disagree | 12 (8) |
| Disagree | 26 (16%) |
| Neutral | 73 (45%) |
| Agree | 36 (22%) |
| Strongly agree | 15 (9%) |
| I can consider oocyte donation | |
| Strongly disagree | 29 (18%) |
| Disagree | 27 (17%) |
| Neutral | 49 (30%) |
| Agree | 41 (25%) |
| Strongly agree | 16 (10%) |
| I can consider sperm donation to use my frozen oocytes | |
| Strongly disagree | 22 (13.5%) |
| Disagree | 17 (10%) |
| Neutral | 48 (30%) |
| Agree | 43 (26.5%) |
| Strongly agree | 23 (14%) |
| I can consider using my frozen oocytes without marriage | |
| Strongly disagree | 6 (4%) |
| Disagree | 15 (9%) |
| Neutral | 18 (11%) |
| Agree | 56 (34.5%) |
| Strongly agree | 67 (41%) |
| I have belief that having a child is matter of fate | |
| Strongly disagree | 8 (5%) |
| Disagree | 7 (4%) |
| Neutral | 18 (11%) |
| Agree | 63 (39%) |
| Strongly agree | 65 (40%) |
Among the respondents, 31% stated that they would consider adoption as an alternative to OC. Respective rates for oocyte donation and sperm donation with frozen eggs were 35% and 40%. Furthermore, 76% said that they would consider using their cryopreserved oocytes outside of matrimony (Table 3). While the majority of the women (79.5%) agreed with the statement that having a child is a matter of fate, 9.5% disagreed and 11% were neutral (Table 3). Of those who agreed with this statement, only 13% had moderate to severe regret.
Satisfaction
Qualitative attitudes reflecting satisfaction following OC were queried. One hundred thirty women (80%) perceived increased control and 84 (52%) perceived increased flexibility over reproductive planning (Table 4). Similarly, 85 (52.5%) felt they had more options for planning a family following OC. One hundred thirty-six respondents (83%) were satisfied with the choice of freezing their oocytes, even if they never use them (Table 4).
Table 4.
Satisfaction
| Variables | N = 162 |
|---|---|
| I feel like I have more control over my reproductive future | |
| Strongly disagree | 4 (2.5%) |
| Disagree | 6 (3.5%) |
| Neutral | 22 (13.5%) |
| Agree | 81 (50%) |
| Strongly agree | 49 (30%) |
| I feel like I have more flexibility in planning a family | |
| Strongly disagree | 9(5.5%) |
| Disagree | 36 (22%) |
| Neutral | 33 (20%) |
| Agree | 59 (36%) |
| Strongly agree | 25 (15%) |
| I feel like I have more options for planning a family (such as sperm donation) | |
| Strongly disagree | 12 (7.5%) |
| Disagree | 32 (20%) |
| Neutral | 32 (20%) |
| Agree | 55 (34%) |
| Strongly agree | 30 (18.5%) |
| If I never use my oocytes to get pregnant, I will still be happy I did it | |
| Strongly disagree | 2 (1.5%) |
| Disagree | 9 (5.5%) |
| Neutral | 15 (9%) |
| Agree | 69 (42%) |
| Strongly agree | 67 (41%) |
| I trust in the efficacy of OC | |
| Strongly disagree | 0 |
| Disagree | 1 (0.5%) |
| Neutral | 30 (18.5%) |
| Agree | 62 (38%) |
| Strongly agree | 67 (41%) |
| I feel regretful because I lost my virginity during the course of the procedure | |
| Strongly disagree | 108 (66.5%) |
| Disagree | 31 (19%) |
| Neutral | 6 (3.5%) |
| Agree | 1 (0.5%) |
| Strongly agree | 2 (1%) |
The majority of women (80%) agreed with the statement: “I trust in the efficacy of oocyte freezing”, 19% were neutral and only one woman disagreed.
Almost half of the women stated that they had both emotional (46%) and financial (52%) difficulties during the OC process.
The emotional state was evaluated in three stages; before deciding to undergo OC, after the procedure, and at the time of the survey (Fig. 1). During this timeline, comfortable feelings gradually increased from 23% before the decision to 47.5% after freezing and finally to 55% at the time of the survey. Furthermore, there was also a sharp decrease in anxiety during this period (50%, 10%, 9%) (p < 0.001). Three women (2%) and one woman (0.6%) felt regretful before deciding on and after freezing their oocytes, respectively. Loss of virginity was not a major factor for regret as only 1.5% of those declared that they felt regretful regarding this issue; this finding is in line with a qualitative study which shows that several virgin Turkish women did not experience decisional conflict concerning OC via transvaginal procedure [22] (Table 4).
Fig. 1.
Change in emotional status of participants at different stages of the treatment
Decision regret
Of the 162 respondents, 51 (31.5%) had no decision regret, 85 (52.5%) had mild, and 26 (16%) had moderate to severe decision regret (Fig. 2). The median and mean DRS scores were 10 (interquartile range: 25) and 13.4 (SD: 13.2, range: 0–70), respectively, indicating a low score of regret. When we subcategorized women based on the number of frozen oocytes, the mean DRS scores of the women who had < 10 and ≥ 10 eggs frozen were 14 and 11.7, respectively (p = 0.51). There was no significant correlation between DRS scores with age (rho: − 0.27, p = 0.736) and number of oocytes cryopreserved (rho: 0.111, p = 0.163).
Fig. 2.
Decision Regret Scale (DRS) scores after oocyte cryopreservation. Increasing scores indicate higher levels of regret. Regret categories are indicated as follows: 0, no regret; 1–25, mild regret; and > 25, moderate to severe regret; dashed lines, category thresholds
Univariate logistic regression analysis identified moderate to severe decision regret (DRS score > 25) associated with the following variables: belief in fate regarding childbearing, trust in the efficacy of OC, and emotional difficulty (Table 5). Age during OC, current age, number of oocytes frozen, perceived adequacy of information when deciding to pursue OC, perceived adequacy of emotional support during the OC process, the likelihood of using the frozen oocytes, predicted chances of live birth when using the frozen oocytes, latest age for considering childbearing, attitude towards other childbearing methods (sperm/oocyte donation, child adoption), financial difficulty during OC, and the emotional status at different stages of the treatment were not associated with decision regret.
Table 5.
Univariate and multivariate logistic regression analysis of variables associated with severe decision regret
| Univariate model (unadjusted) | Multivariate model (adjusted) | |||
|---|---|---|---|---|
| OR (95% CI) | P value | OR (95% CI) | P value | |
| Age at the time of OC | 0.9 (0.8,1.0) | 0.10 | ||
| Age at the time of survey | 0.9 (0.8,1.0) | 0.06 | 0.9 (0.8,1.1) | 0.6 |
| Monthly income | 1.3 (0.9,1.8) | 0.18 | ||
| Current relationship status | 1.5 (0.6, 3.4) | 0.38 | ||
| Oocytes frozen | 0.8 (0.5,1.3) | 0.42 | ||
| Adequacy of information prior to OC | 0.6 (0.2, 1.2) | 0.24 | ||
| Adequacy of emotional support during OC | 1.3 (0.7, 2.4) | 0.41 | ||
| Likelihood of using oocytes | 0.5 (0.1, 2.9) | 0.5 | ||
| Likelihood of live birth when using frozen oocytes | 0.5 (0.1,3.0) | 0.5 | ||
| Latest age of considering childbearing | 0.9 (0.8,1.0) | 0.22 | ||
| Attitude towards other childbearing methods | ||||
| Sperm donation | 1.0 (0.6 | 0.88 | ||
| Oocyte donation | 0.8 (0.5 | 0.62 | ||
| Child adoption | 0.9 (0.5 | 0.67 | ||
| Belief in fate regarding childbearing | 4.4 (1.7,11.5) | 0.002 | 3.8 (1.4,10.8) | 0.01 |
| Trust in the efficacy of OC | 7.5 (2.9,19.0) | < 0.001 | 6.1 (2.3,16.3) | < 0.001 |
| Emotional difficulty during OC | 1.7 (0.9,3.1) | 0.07 | 1.5 (0.8,3.1) | 0.2 |
| Financial difficulty during OC | 0.9 (0.9,1.7) | 0.72 | ||
| Emotional status | ||||
| Before deciding to undergo OC | 1.1(0.7 | 0.75 | ||
| After freezing oocytes | 1.4 (0.9 | 0.10 | ||
| At the time of survey | 1.1 (0.8 | 0.42 | ||
The multivariate logistic regression model included all the factors with a significance level of P < .10 in the univariate analysis (Table 5). Of these factors, belief in fate regarding childbearing and trust in the efficacy of OC had a statistically significant association with regret. With an increasing level of agreement in belief in fate regarding childbearing, on average 4 times lower decision regret was observed (OR: 3.8, 95% CI 1.4–10.8, P = 0.01). Furthermore, women who trusted in the efficacy of OC were 6 times less regretful compared with women who did not trust it (OR: 6.1, 95% CI 2.3–16.3, P < 0.001).
Discussion
This study is the first to evaluate decision regret following OC in patients with DOR and/or ARFD. According to our findings, although 68% of the participants reported some degree of decision regret, the prevalence of moderate to severe regret in women with DOR undergoing OC was low (16%). Those who had a belief in fate and trusted in the efficacy of OC had significantly lower decisional regret.
Similar to women undergoing elective/planned OC in the literature [24–32], our study population included mostly single (75%), highly educated women (96%) with a mean age of 37.8 (SD: 5), the majority working either as professionals or managers. The prevalence of moderate to severe regret in our patient population was similar to what was shown in a previous study among women with normal ovarian reserve undergoing elective OC (16% for both) [13]. However, if we consider overall regret including mild, moderate, and severe, a higher prevalence of regret was observed (52% mild and 16% moderate to severe) in our patient population compared with women undergoing elective OC in the study by Greenwood et al (33% mild and 16% moderate to severe). In that study, the majority of women (66%) were < 38 years of age at the time of OC and had good ovarian reserve [the median number of frozen oocytes were 15 (IQR: 11–21)] [13], whereas less than half (41%) of our study participants were < 38 years of age with seventy percent having less than 10 oocytes cryopreserved with a median number of 6 (SD: 3.9, range 1–16). Despite the difference in mean age, number of oocytes cryopreserved and indication of OC, mean DRS scores for women with DOR in both studies were low; 13.4 (range: 0–70) in the current study, and 10 (range: 0–90) for women undergoing elective OC in the study by Greenwood et al. These results indicate a low prevalence of severe regret which can be interpreted as; irrespective of age at the time of OC and indication, the procedure does not seem to cause high decisional regret.
In contrary to the similar prevalence of severe regret in both patient populations, the associated factors related to regret were different in women undergoing OC electively or due to DOR. Decision regret is commonly associated with the risk factors that may help healthcare professionals to anticipate and prevent in their practice settings. Accordingly, in the study by Greenwood et al., in addition to the number of banked oocytes, perceived adequacy of information and emotional support during the treatment process, and the patient-estimated probability of achieving a live birth using their banked eggs were associated with decision regret [13]. Interestingly, none of these factors were associated with regret in our patient population; instead, the significant associations with regret were related to the sociological questions added based on our experience and the previous sociological studies reporting oocyte freezing experiences of women in Turkey [21, 22]. Those were the items questioning belief in fate regarding childbearing and trust in the efficacy of OC. According to our study, with an increasing level of agreement in belief in fate regarding childbearing, on average 4 times lower decision regret was observed. Furthermore, women who trusted in the efficacy of OC were 6 times less regretful compared with women who did not trust it.
Sociological studies on OC in Turkey argue that belief in fate and God’s will help women cope with uncertainty and give meaning to their experiences; hence, belief in fate helps women to reconcile with the low number of frozen eggs and to keep their hopes high [21]. We can similarly interpret that belief in fate may help women experience less decisional regret. In the context of a belief in fate from an Islamicate cultural perspective, women with DOR undergoing OC do whatever they can including the experience of a stressful and costly medical procedure and leave the rest to God’s will. Such an understanding of fate does not deny agency, nor does it mean passive submission to God’s will [33]. Furthermore, we see that belief in fate and use of reproductive technologies do not conflict, as also shown by sociological and anthropological studies on OC [21, 34]. This may be thanks to the fact that Islamic religious authorities approve assisted reproductive technologies including the use of OC for both married and unmarried women [34]. It appears that in the setting of a medical and an emotional conflict such as DOR, women trust in both divine and medical interventions, and this trust decreases the likelihood of regret. Given our results, the majority of women in our study sample probably have what is called “belief-based expectations” [21], something like: “if it is in my fate, pregnancy can occur even with one frozen egg” and it is physician’s role to retrieve and freeze that one egg, and they have trust in that.
In our questionnaire, there were two different questions related to emotional perception; one regarding the perceived emotional support and the other whether they had emotional difficulty during OC. Although we did not find a correlation between decision regret and emotional support, experiencing emotional difficulty was associated with decision regret in the univariate, but abolished in the multivariate analysis. The perceived adequate emotional support (52.5%) in our patient population is lower than women undergoing OC electively (69%) in the study by Greenwood et al. [13]. This is what we were expecting because DOR is generally interpreted as low fertility or impending infertility [13]. Additionally, women facing an acute, unexpected diagnosis of DOR, even when they had no plans for future childbearing, have no clear explanation of why they have a low ovarian reserve. Identifying a reason upon facing a stressful life event is a well-known contributor to better emotional adjustment and resilience [35]. Nevertheless, not having an answer may be one of the explanations for lower perceived emotional support and having higher emotional difficulty during OC in patients with DOR. Therefore, women with DOR may benefit from additional support before or during the treatment by either their physicians or the nurses following their treatment.
Furthermore, adverse emotions such as anxiety, sadness, and feeling alone are often associated with regret and women experience a variety of emotions while deciding to pursue OC. Our findings showed that the emotional status of participants was progressively changing throughout the treatment. In the long term and after completing the OC procedure, the positive emotions including feeling comfortable and strong/safe increased, while adverse emotions including anxiety and loneliness decreased (Fig. 1).
The participants’ satisfaction with the decision was qualitatively assessed with the queries focusing on the control over the reproductive future. According to the responses, most of the women perceived increased control over reproduction and increased flexibility with family planning which showed they were quite satisfied with their decision.
Oocyte cryopreservation offers more than a chance of future pregnancy: for instance, relief from time pressure, avoiding potential future regret for not having made use of such an opportunity, holding on to something women feel like they are about to lose by aging or by premature menopause, etc [22]. These are in accordance with our results as for only half of the women in our study population being a parent was a more important goal than having a satisfying career and 67% indicated that they have wanted to be parents as long as they remembered (Table 3).
The most striking findings in our study were the unrealistic expectations of women regarding pregnancy success rates with the use of their banked oocytes. The mean estimated probability of achieving a live birth with their banked eggs was 53%, which indicated a positive but unrealistic expectation of OC. Although the mean age of the women was high and the number of oocytes frozen was low, 78% of the respondents overestimated by more than 50% the chance of having a child with the utilization of their frozen oocytes. Despite adequate and extensive counseling, some women even believed that their chance of conception was 100%. This is following our previous study results on the awareness of fertility and reproductive aging in women seeking OC due to DOR [36]. Even though most of them remained unpartnered at the time of the survey, and hardly any of them had returned for their frozen eggs, it is also notable that most women were still confident in the future efficacy of their frozen eggs, which is in line with many other studies on OC [13, 28, 29].
The other unexpected finding that was apparent in our study population was the positive consideration of childbearing options other than OC by almost one-third of the women. When considering Turkish sociodemographic characteristics and legal restrictions, these results were higher than expected; 35% and 40% of the women said they would consider oocyte and sperm donation as alternative options for childbearing and 76% said they would consider using their frozen oocytes outside of matrimony. As noted in the introduction, the uses of donor gametes and of IVF outside matrimony are not legally allowed in Turkey, and such restrictions might be pushing some women to turn to OC. On the other hand, Cyprus has been an important travel destination for the Turkish citizens who want to pursue assisted reproductive technologies not accessible in Turkey. This phenomenon has led to Turkish legislative steps to ban travel for third-party reproductive assistance; however, such travel is still reported [37] The survey finding then appears meaningful vis-à-vis the opportunities for reproductive travel and future uncertainty.
The strengths of our study include evaluating decision regret with a validated decision regret scale in a large number of participants of a specific group (DOR/ARFD) of women undergoing OC. As this was an online survey and the responses were anonymously received, we assume the answers to the questions related to social norms and beliefs reflect the participants’ honest opinions. As social norms and beliefs play important roles in the process of decision making in our lives, adding questions related to these parameters strengthened our study.
Besides the strengths, the current study has several limitations, one of them being the low response rate (35%) to the survey. Some women who may have experienced negative emotions towards the procedure may have been overrepresented among the non-responders. The relatively short and variable follow-up duration of the study is another limitation that decreases our ability to evaluate the regret of women who attempted pregnancy. In addition, a positive change in relationship status, and certainly a pregnancy in the interim, would be considered as a limitation that impacts regret. However, in this period, only very few of the women who banked their oocytes came back to use them and got pregnant, and 3.8% of the respondents had since noted significant changes in relationship status, which did not make any change in our results.
To conclude, the present study is the first to examine the prevalence and associated factors of decision regret among women with DOR undergoing OC. The findings of this study indicate that although more than half of the patients expressed some degree of regret, the prevalence of moderate to severe regret among patients with DOR and/or ARFD undergoing OC is low which might be explained by the increased belief-based expectations in our study population. Regret is decreased when expectations are balanced with an increased belief in fate. However, our study does not answer the question of how women will respond if these expectations are unmet in the long term. Appropriate consultation of patients and efforts to increase emotional support in the decision-making process and during the procedure is of paramount importance to decrease regret in the long term. Of note, these results should be interpreted cautiously as the number of women who return to use their cryopreserved oocytes is low, which restricts our ability to assess the impact of failure to achieve a live birth on regret scores. Further prospective studies with longer follow-up periods evaluating the decision regret in women who planned but did not freeze their oocytes and in those who did not conceive after using their frozen oocytes are necessary.
Acknowledgements
We are grateful to all of the physicians and embryologists of the two IVF centers for contributing their patients and their help in extracting patient files. Also, we thank all of the women who had undergone oocyte cryopreservation and responded to our survey.
Code availability
Not applicable.
Data availability
Available.
Declarations
Ethics approval
2019. 209. IRB1.032 (IRB approval number).
Consent to participate
Available.
Consent for publication
Available.
Conflict of interests
The authors declare no competing interests.
Footnotes
Key messages
Regret in women with diminished ovarian reserve undergoing oocyte cryopreservation is low. Women who had belief in fate and trusted the efficacy of oocyte cryopreservation had significantly lower regret levels.
Publisher’s note
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