Abstract
Purpose
Few options are available for preserving female fertility to postpone childbirth. Although egg freezing with successful thawing is now possible, women’ attitudes towards its use or the circumstances under which this technique may be considered remain unclear.
Methods
This study is a cross-sectional online survey. From November 2020 to January 2021, 848 questionnaires were collected through the Questionnaire Star Network platform, and a total of 750 valid answers were obtained.
Results
For more than 40% of the interviewees, the level of knowledge about egg freezing was only 0–25%; 36.9% of the interviewees supported elective egg freezing, and the main factor affecting their approval was major; approximately 60% of interviewees believed that being married should not be a condition for freezing eggs; and 56.7% of the interviewees supported the establishment of an egg bank in China, and the main factor affecting their acceptance was the place of residence.
Conclusion
College students generally have a high level of recognition regarding elective egg freezing and the establishment of an egg bank, but their level of knowledge about egg freezing is low. Relevant knowledge must be strengthened to help college students achieve a correct understanding of elective egg freezing and egg bank establishment and then guide college students in developing a scientific dialectical attitude towards this technology.
Keywords: Assisted reproduction, Oocyte cryopreservation, Female fertility, Oocyte banking, College students
Introduction
According to data released by the China National Bureau of Statistics, in 2021, the annual birth population will be 10.62 million, a decrease of 1.4 million compared with 2020. The natural growth rate of China’s population was 0.34‰, a decrease of 1.11 thousand points compared with 2020. The continued slowdown in population growth is mainly due to two factors. First, the number of women of childbearing age continues to decrease, which may be related to China’s one-child policy since 1980. The second is that the age of first marriage and childbirth has been delayed due to the change of fertility concept and the increase of fertility costs, and the fertility level has continued to decline. Even after the one-child policy was terminated on January 1, 2016, the number of births in China continued to decrease.
With the advancement of the social economy and the popularization of education, the social status and functions of women have undergone considerable changes, and women’s ages at marriage and childbirth have been continuously delayed. Fertility survey data in 2017 showed that the average age of Chinese women at first marriage has risen from 23.6 to 26.5 years in the past 10 years, and the total first marriage rate has dropped from more than 0.9 to 0.6 [1]. The age at first childbirth among Chinese women of childbearing age rose to 26.73 in 2017 from 24.63 in 2011, reflecting a delay of 2.1 years [2]. This trend is also evident in the USA. The average age of women at childbearing was 27.7 years in 2011, which rose to 29.0 years by 2018 [3]. Nevertheless, the decline in oocyte quality in older women and increases in fertility risks have caused many women to lose the opportunity for parenthood. Preserving women’s fertility using existing technology may be the key to its solution.
Oocyte cryopreservation can preserve women’s fertility and prolong fertility time. It was initially used for patients with clear medical indications that would impair fertility (i.e., medically frozen eggs) and has since become the choice of women who want to delay childbirth for nonmedical reasons (i.e., elective egg freezing, social egg freezing) [4]. The most commonly used technique for egg freezing is vitrification, which yields pregnancy rates not significantly different from those of fresh eggs. According to the current law, frozen eggs can be stored for at least 10 years [5]. Elective egg freezing can provide an opportunity to delay childbirth for women of childbearing such that they can have sufficient preparation time with respect to age, economics, psychology, and partner selection [6].
Regardless of the advantages of egg freezing technology in protecting female fertility, due to the commercial nature and the beautification of public opinions of egg freezing, many women underestimate the speed at which female fertility declines, and the possibility of overcoming age-related infertility through IVF is highly overestimated [7]. Although egg freezing allows healthy women to preserve their fertility, as a technology under development, controversies remain regarding its safety, effectiveness, commerciality, and especially ethical issues [8]. Proponents of elective egg freezing believe that this option gives women reproductive autonomy, reduces reproductive pressure and anxiety, and provides women with more free choices. Those who do not support elective egg freezing believe that the use rate of egg freezing is low and that problems such as excessive medical treatment and a benefit/cost imbalance exist. At the same time, this possibility may give women a false sense of security due to its commercial beautification [8, 9].
In 2012, the American Society for Reproductive Medicine removed the label “experimental” from egg freezing, rendering it available as a means of fertility preservation for women hoping to delay childbearing [10]. Many developed countries, such as the UK, the USA, and Japan, use egg freezing to support corresponding medical purposes and have gradually allowed this technology for nonmedical purposes for the public on the premise of not violating social ethics and related legislation [11]. Europe, the USA, Canada, and other countries have already surveyed people’s awareness and attitudes towards egg freezing. However, these studies mostly used online surveys to explore knowledge and influencing factors supporting elective egg freezing, and the results suggest that most people support medical egg freezing, but the overall support rate for elective egg freezing is slightly lower [6]. The reasons among those who supported elective oocyte cryopreservation were concluded to include age, marital status, children (yes or no), full-time employment (yes or no), and difficult pregnancy (yes or no) [12].
Currently, egg freezing is allowed only for medical reasons in China. According to China’s current laws and regulations, egg freezing is performed only in the following two situations: for couples undergoing in vitro fertilization (IVF), the man cannot provide sperm in time or has no sperm or dead sperm; and for young women who wish to preserve their fertility prior to cancer treatment. An egg bank is an institution that uses egg freezing technology to cryopreserve healthy eggs collected. At the end of 2008, the world’s first egg bank was established at the University of Wisconsin in the USA. In China, there are still many difficulties to overcome in the development of the egg bank. However, over the past 30 years, Chinese sperm banks have become routine. Ayo Wahlberg emphasized in his research on Chinese sperm banks that sperm banking and artificial insemination with donated sperm have become an integral part of China’s population management goals [13]. The important reasons for the above situation are Chinese law allows all men (including unmarried men) to electively freeze sperm, but prohibits the implementation of human-assisted reproductive technology (including artificial insemination, in vitro fertilization-embryo transfer, and derived egg freezing) for single women. Disputes over the legal issues of frozen eggs have existed in China for a long time, and individual public figures choose frozen egg technology abroad due to their personal fertility needs. In addition, China’s IVF technology is relatively mature [14], and both embryo banks and egg donation are limited to married couples who comply with national population and family planning laws and regulations. In China, current research focuses on addressing the benefits and ethical issues of egg freezing [15], and investigations regarding perceptions and attitudes towards selecting egg freezing are limited. And there is also a lack of surveys on Chinese people’s perceptions of egg bank.
Under the influence of historical processes such as social expansion, marketization of economic activities, and diversification of stakeholders, contemporary Chinese college students have strong independent thinking skills and yearn for economic independence [16]. Regarding the concept of fertility among college students, the proportion of fertility purposes in pursuit of self-improvement and spiritual value has gradually increased, highlighting the characteristics of individualism [17]. Under the current policy background in China, the perception and willingness to accept elective egg freezing among college students, who are the main sources of future fertility, and which factors may affect this group’s willingness to accept egg freezing are unknown. Therefore, this study selects college students in Hefei, an eastern city in China, as the research object to explore college students’ perception and attitude towards egg freezing technology and their attitude towards establishing egg bank in China and to explore the main factors affecting their willingness to accept it. This study provides evidence for the application and promotion of egg freezing technology in China.
Materials and methods
The questionnaire survey was carried out between November 2020 and January 2021 in Hefei, Anhui, in eastern China. Five comprehensive universities were selected by convenience sampling. The following inclusion criteria were applied: (1) aged 17–35 years; (2) full-time college students at regular institutions of higher education; (3) school located in Hefei; and (4) informed consent and voluntary participation. The exclusion criteria were as follows: (1) non-Chinese students; (2) pregnancy; and (3) having children.
Questionnaire scope and content
The aim of this study was to explore university students’ knowledge of, perceptions of, and attitudes towards elective egg freezing using a self-administered online questionnaire. A questionnaire was constructed using a similar structure to that previously used in studies regarding attitudes towards oocyte cryopreservation in Australia and Italy [4, 18] and was adapted to the purpose of the study and actual national conditions in China. The questionnaire was reviewed by an ART doctor and an assistant professor experienced in questionnaire design, and changes were applied according to feedback provided by these experts. The questionnaire was tested on 100 random samples, and 30 of 100 samples were retested after 1 week, resulting in a Cronbach’s α coefficient of 0.949 and a test–retest reliability of 0.766.
The content of the questionnaire included the following: (1) sociodemographic variables: sex, age, major, grade (education), place of residence, and paternal education level and maternal education level (7 items total); (2) attitudes and perceptions: perceptions on marriage or childbearing (optimal ages for marriage and childbearing); the degree of understanding of egg freezing (advantages, harm, technology, economic cost, success rate, etc.); (3) willingness to freeze eggs (attitudes towards delaying childbirth and elective egg freezing, and consideration of using egg freezing excluding safety and economic costs, 4 items); (4) attitudes towards ethical aspects (whether fertility is an obstacle to women’ success in the workplace and views on single women choosing egg freezing, 16 items); and (5) attitudes towards the establishment of oocyte banking (attitudes, reasons for supporting and not supporting oocyte banking, 3 items).
The questionnaire was set by questionnaire star. The questionnaires were administered by distributing the corresponding link to the college students via social networking sites (including WeChat and QQ) and inviting the students to complete and share the questionnaire after the researchers received training to become familiar with the research procedure, the contents of the questionnaires, and matters requiring attention.
We took several steps to ensure the quality of the data collected in this online survey: (1) Each IP address set in the background of the questionnaire could submit the questionnaire only once; (2) Participants had to answer all items to submit the questionnaire; (3) Questionnaires with obvious logical errors were eliminated; and (4) Participants whose response time was less than 3 min or more than 10 min were excluded.
Ninety-eight invalid questionnaires were excluded because of incomplete data, attendance at a school not located in Hefei, and a response time of less than 3 min or more than 10 min, and the final sample included 750 questionnaires, with an effective sample rate of 88.44%.
Statistical analyses
For continuous variables, the results conforming to a normal distribution are described as the mean ± standard deviation, while those not conforming to normal distribution are presented as the interquartile range (IQR). Categorical data are summarized as numbers or percentages. Differences in the perception of elective egg freezing between groups with different characteristics were compared using chi-squared tests. Factors with significant differences (independent variables) were submitted to bivariate logistic regression to explore factors influencing college students’ attitudes towards elective egg freezing and the establishment of an oocyte bank in China (dependent variable, coded as 0 = oppose and 1 = support). The inspection level was alpha = 0.05. Statistical analyses were performed using SPSS software (version 24.0).
Results
Sociodemographic characteristics
Table 1 describes the population of respondents included in the analysis (n = 750). The ages of the participants ranged from 17 to 35 years, with an average age of 20.36 ± 3.34.
Table 1.
Sociodemographic characteristics of the study population (n = 750)
| Characteristic | N | % |
|---|---|---|
| Gender | ||
| Male | 318 | 42.4 |
| Female | 432 | 57.6 |
| Major | ||
| Medicine | 155 | 20.7 |
| Nonmedicine | 595 | 79.3 |
| Grade | ||
| Junior college students | 86 | 11.5 |
| Undergraduate students | 518 | 67.1 |
| Graduate students | 146 | 19.4 |
| Place of residence | ||
| Rural | 324 | 43.2 |
| Urban | 426 | 56.8 |
| Paternal education level | ||
| Middle school education or lower | 377 | 50.3 |
| High school education or higher | 373 | 49.7 |
| Maternal education level | ||
| Middle school education or lower | 407 | 54.3 |
| High school education or higher | 343 | 45.7 |
Perception and attitudes
Perceptions about marriage and childbirth
More than 60% of the participants had referred to the age ranges of 25–30 as the best ages for marriage (67%, 504/750) and childbirth (69%, 518/750). Forty-six percent (345/750) of participants considered childbirth to be the barrier existing in the workplace.
The level of knowledge about egg freezing
Participants’ understanding of egg freezing technology, the degree of understanding of the advantages of freezing eggs, and the understanding of the dangers of freezing eggs of 0–25% were 49.6% (375/750), 44% (330/750), and 60.4% (453/750), respectively. Among them, the understanding of frozen egg technology is the overall level of frozen egg technology. Respondents can comprehensively estimate their understanding of other frozen egg technology in the questionnaire (including its role, process, probability of success, cost, development status).
Attitudes towards egg freezing
When all participants were asked about their attitude towards elective egg freezing, 36.9% (277/750) of the participants replied that they accepted it, 29.1% (218/750) replied that they did not accept it, and 34% (255/750) replied that they were uncertain. Assuming that the safety of egg freezing is guaranteed and the cost is affordable, 46% (345/750) of all interviewees said that they would choose egg freezing, 16.9% (127/750) still insisted on not considering egg freezing, and the remaining 37.1% (278/750) respondents chose “unsure.” A total of 432 of the 750 participants were women who were asked if they would choose to delay childbirth; 28.0% (121/432) responded “yes,” 29.6% (128/432) responded “no,” and 42.4% (184/432) were uncertain.
Attitudes towards the ethics of freezing eggs
A total of 65.2% (489/750) of the participants believed that being married should not be a condition for judging whether to freeze eggs. When asked whether they would have negative opinions about single women who choose to freeze their eggs, 17.1% of the participants responded “yes,” 59.5% responded “no,” and the rest were uncertain.
Attitudes towards the establishment of oocyte banking in China
A total of 56.7% (425/750) of participants held a supportive attitude towards the establishment of oocyte banking in China, 16.8% (126/750) said that they did not support it, and another 26.5% (199/750) said that they were uncertain. The reasons for whether participants supported the establishment of oocyte banking are shown in Table 2. Among the participants who did not support oocyte banking, the most vital reason was the risk of illegal transactions due to poor supervision (37.8%).
Table 2.
Reasons to support or oppose egg freezing
| Reasons | N (%) |
|---|---|
| Reason for support | |
| A more convenient and effective method for preserving the fertility | 259 (30.9) |
| A more convenient method for donating eggs to an infertile couple | 284 (33.9) |
| Convenience for unified management of frozen eggs | 247 (29.5) |
| Others | 48 (5.7) |
| Reason for opposition | |
| Prone to illegal transactions due to unfavorable supervision | 139 (37.8) |
| High costs and low returns | 95 (25.8) |
| Imperfect related biological science and technology | 87 (23.6) |
| Others | 47 (12.8) |
Analysis of influencing factors
Influencing factors of college students’ attitudes towards elective egg freezing
In our study, significant differences were found between different characteristics of females with regard to proportions reporting attitudes towards egg freezing to delay childbirth. Significant differences were found in major, grade, place of residence, paternal education level, maternal education level, and level of knowledge about egg freezing (p < 0.001). Medical students, those whose mothers have a junior high school education level and below, and those with a 50% to 100% understanding of egg freezing were aware of elective egg freezing at a 21.5% higher rate than nonmedical students, a 14.6% higher rate than those with a high school education level, and a 30.8% higher rate than those with a comparative understanding of 0–50%.
Relatively smaller differences were found between various characteristics in males with regard to proportions reporting attitudes towards elective egg freezing to delay childbirth. Significant differences were found in major, grade, and the level of knowledge about freezing eggs (p < 0.001).
Explanatory variables were found to be statistically significant in chi-squared tests when females were entered into the binary logistic regression analysis. The results show that the most important factor in female attitudes towards elective egg freezing is major, followed by the level of knowledge about egg freezing (Table 3).
Table 3.
Regression analysis of factors influencing attitudes towards elective egg freezing among females (N = 278)
| Characteristic | Attitudes towards elective egg freezing | |
|---|---|---|
| OR (95% CI) | p value | |
| Major | ||
| Medicine | 5.24 (2.23–12.33) | <0.001 |
| Nonmedicine | 1 | |
| Grade | ||
| Junior college and undergraduate students | 2.29 (1.06–4.95) | 0.035 |
| Graduate students | 1 | |
| Place of residence | ||
| Rural | 1.04 (0.53–2.05) | 0.904 |
| Urban | 1 | |
| Paternal education level | ||
| Middle school education or lower | 0.24 (0.14–0.41) | <0.001 |
| High school education or higher | 1 | |
| Maternal education level | ||
| Middle school education or lower | 0.24 (0.12–0.46) | <0.001 |
| High school education or higher | 1 | |
| Level of knowledge about egg freezing | ||
| 0 ~ 50% | 2.75 (1.31–5.79) | 0.008 |
| > 50% | 1 | |
| Do you think that fertility is a barrier for women in the workplace? | ||
| Yes | 0.32 (0.18–0.59) | <0.001 |
| No | 1 | |
Regarding the analysis of the factors affecting male attitudes towards elective egg freezing, the analysis method was the same as above, and the results show that all factors are not statistically significant.
Factors influencing college students’ perceptions of “building oocyte banking in China”
As shown in Table 4, sex, major, grade, place of residence, paternal and maternal education levels, and the level of knowledge about egg freezing were factors influencing perceptions of “building oocyte banking in China.” Specifically, college students who were in support of building oocyte banking in China were more likely to be female, pursuing nonmedical majors, junior college and undergraduate students, and urban residents and to have a father with a higher education level, a mother with a lower education level, and lower levels of knowledge about egg freezing. Among them, female recognition was 20.8% higher than that of males, and junior college and undergraduate students’ recognition was 28.2% higher than that of graduate students.
Table 4.
Attitudes towards the establishment of oocyte banking in China
| Characteristic | Attitudes towards the establishment of oocyte banking in China | χ2 | p | ||
|---|---|---|---|---|---|
| Support | Oppose | Uncertainty | |||
| Gender | |||||
| Male | 142 (44.7) | 66 (20.8) | 110 (34.6) | 32.708 | < 0.001 |
| Female | 283 (65.5) | 60 (13.9) | 89 (20.6) | ||
| Major | |||||
| Medicine | 102 (65.8) | 26 (16.8) | 27 (17.4) | 68.975 | < 0.001 |
| Nonmedicine | 323 (54.3) | 100 (16.8) | 172 (28.9) | ||
| Grade | |||||
| Junior college and undergraduate students | 387 (61.0) | 89 (14.0) | 158 (24.9) | 42.636 | < 0.001 |
| Graduate students | 38 (32.8) | 37 (31.9) | 41 (35.3) | ||
| Place of residence | |||||
| Rural | 222 (68.5) | 40 (12.3) | 62 (19.1) | 32.902 | < 0.001 |
| Urban | 203 (47.7) | 86 (20.2) | 137 (32.2) | ||
| Paternal education level | |||||
| Middle school education or lower | 119 (52.8) | 61 (16.2) | 117 (31.0) | 36.826 | < 0.001 |
| High school education or higher | 226 (60.6) | 65 (17.4) | 82 (22.0) | ||
| Maternal education level | |||||
| Middle school education or lower | 237 (58.2) | 60 (14.7) | 110 (27.0) | 35.570 | <0.001 |
| High school education or higher | 188 (54.8) | 66 (19.2) | 89 (25.9) | ||
| The level of knowledge about egg freezing | |||||
| 0 ~ 50% | 354 (59.7) | 90 (15.2) | 149 (25.1) | 47.984 | < 0.001 |
| > 50% | 71 (45.2) | 36 (22.9) | 50 (31.8) | ||
We performed the bivariate analysis using logistic regression to identify associations between the independent variable (IV: perceptions of “building oocyte banking in China”) and dependent variables (DVs: sex, major, grade, place of residence, paternal and maternal education levels, the level of knowledge about freezing eggs, and the belief that fertility is an obstacle for females in the workplace). The results showed that urban residence was the factor that most influenced this variable, followed by female sex (Table 5).
Table 5.
Regression analysis of factors influencing attitudes towards the establishment of oocyte banking in China (N = 278)
| Characteristic | Attitudes towards the establishment of oocyte banking in China | |
|---|---|---|
| OR (95% CI) | p value | |
| Gender | 0.001 | |
| Male | 2.19 (1.46–3.28) | <0.001 |
| Female | 1 | |
| Major | ||
| Medicine | 1.22 (0.75–1.97) | 0.433 |
| Nonmedicine | 1 | |
| Grade | 0.001 | |
| Junior college and undergraduate students | 0.24 (0.14–0.39) | <0.001 |
| Graduate students | 1 | |
| Place of residence | 0.001 | |
| Rural | 2.35 (1.54–3.58) | <0.001 |
| Urban | 1 | |
| Paternal education level | ||
| Middle school education or lower | 1.07 (0.72–1.59) | 0.754 |
| High school education or higher | 1 | |
| Maternal education level | ||
| Middle school education or lower | 0.72 (0.48–1.07) | 0.108 |
| High school education or higher | 1 | |
| Level of knowledge about egg freezing | ||
| 0 ~ 50% | 0.58 (0.38–0.90) | 0.015 |
| > 50% | 1 | |
| Do you think that fertility is a barrier for women in the workplace? | ||
| Yes | 1.25 (0.84–1.87) | 0.271 |
| No | 1 | |
Discussion
To our knowledge, this is the first study to investigate perceptions and attitudes towards elective egg freezing among college students in China. We surveyed a group of college students from Hefei to determine their views on marriage and childbirth, their level of knowledge about egg freezing, their willingness to freeze eggs, and their attitudes towards the ethics of egg freezing and the establishment of oocyte banking in China. We also explored the influencing factors of college students’ attitudes towards elective egg freezing and their attitudes towards the establishment of oocyte banking in China. This study fills the gap in research on perceptions and attitudes towards elective egg freezing in China, provides relevant data on the acceptance of new fertility technologies and ethical considerations by college students who are the main source of fertility in China, and provides a reference for the subsequent adjustment of relevant laws regarding oocyte cryopreservation.
Approximately half of the participants thought that fertility was an obstacle to female success in the workplace. Fertility’s labor market theory generally recognizes that a negative correlation exists between female reproductive behavior, especially child care, and female career development [19]. Worldwide, women often postpone/reject pregnancy due to gender discrimination in the workplace [20]. More than 60% of the respondents believe that the best age for marriage and childbirth is 25–30 years old. From a physiological point of view, the best female reproductive age is between 25 and 30 years old, which is conducive to improvement of the physical health of the next generation [21]. This shows that most college students have a correct understanding of the appropriate ages for marriage and childbirth. A study from Mexico in 2020 showed that 44% of female college students and 29% of male college students chose 25–30 years old as the best reproductive age [22], which is lower than that in this study. Differences in findings may be attributable to the high rate of adolescent pregnancies caused by poverty and the lack of sex education in Mexico [23].
The results revealed that approximately 50% and 60.4% of interviewees reported a 0–25% level of knowledge of the advantages and hazards of freezing eggs, respectively. Prior results show that 34.3% of Italian female college students [18] and 36.4% [24] Singaporean medical students had heard about oocyte cryopreservation, and these rates were lower than those reported in a study comparing attitudes between Danish and British women in 2012 [12] and in a study with medical students at Northwestern University in Chicago (USA) [25], where 89% and 99% of respondents had heard about oocyte cryopreservation, respectively. The lack of knowledge of egg freezing may affect female use of this technology [26]. Whether women consider or undertake egg freezing is based on the correct understanding of relevant knowledge and reasonable consultations [6, 7]. Therefore, the awareness rate of fertility preservation and egg freezing knowledge among Chinese college students requires further strengthening.
All interviewees were asked about their attitudes towards elective egg freezing, and 37.5% of the female participants considered it acceptable. Our results are slightly lower than those for female medical students (43%) in Chicago [25] and female college students (48.9%) in Singapore [24] but higher than the results for female college students (19.5%) in Italy [18]. When safety and economic costs are not considered, the acceptance rate of elective egg freezing rises to 46%, and the proportion of those who did not approve of elective egg freezing decreased by 12.2%, indicating that safety and economic costs are important influencing factors in elective egg freezing for individuals. Existing literature suggests that oocyte cryopreservation is least cost-effective between ages 25 and 30, with a cost of $366,824–$698,722 [27]. This high economic cost has become an obstacle for most women with respect to egg freezing technology. In studies in Australia, the UK, and Denmark, more than half of the respondents said that the cost of egg freezing is high, which is a major obstacle to choosing this reproductive technology [4, 12].
According to the results of influencing factor analysis on elective egg freezing, participants whose major was medicine, maternal education level was middle school education or lower, and level of knowledge about freezing eggs was higher than 50% and who believed that fertility is not a barrier for women in the workplace are more willing to select eggs freezing, which is consistent with Tozzo et al.’s research showing that medical students seem more open to freezing their eggs [18]. On the one hand, the academic time faced by medical students is significantly longer than that of students pursuing other majors, rendering female medical students more likely to face delayed childbirth. The study performed by Ikhena-Abel et al. suggests that women who feel childbearing pressure are more likely to choose to freeze their eggs [25]. On the other hand, due to the particularity of the medical profession, medical students have a better understanding of marriage, childbirth, and egg freezing than the general population, which increases acceptance of elective egg freezing. We speculate that people with a high level of knowledge about egg freezing may have a higher demand for elective egg freezing, which has led to a high degree of acceptance for elective egg freezing. Interestingly, respondents with more educated mothers had lower acceptance of elective egg freezing. Although this may be an accidental finding, the reason may be that children of more educated mothers are likely to have higher education due to the intergenerational transmission of education. In society nowadays, highly educated women bear more burdens and expectations when giving birth and raising children. In the absence of a sound legal system and regulatory, highly educated women are more likely to suspect that the development of egg freezing technology is the product of capital push [28]. In addition, the study results suggested that respondents who agree that “fertility is a barrier for females in the workplace” will not increase their approval ratings for elective egg freezing but will negatively impact approval ratings. Previous studies have also shown that women have lower acceptance of elective egg freezing due to career development plans [4, 12]. The reasons for this may be that postponing or even forgoing childbirth is a choice rather than a necessity due to personal reasons such as professional development in the current social climate. This choice is described as a negative egoist choice [4]. Because all the influencing factors in the analysis of males’ attitudes (n = 318) towards elective egg freezing were not statistically significant, we did not discuss the male data. The reason for the lack of significant influencing factors may be that women are primarily responsible for the choice of egg freezing, while most male college students are not married and have not considered the issue of fertility; thus, the possibility of considering egg freezing is even smaller.
The results showed that approximately 60% of interviewees agreed that being married should not be a condition for egg freezing and did not have a negative view of women who choose to freeze eggs. Discussing whether marriage should be a condition for egg freezing entails whether reproductive rights belong to the category of personality or identity. A considerable number of scholars agree that reproductive rights are a right of personality, indicating that approximately 60% of college students are more inclined to agree that reproductive rights are a right of personality and that single women have the right to choose to freeze their eggs. However, considering the legal rights of minors born in the future, chaos in the sale of eggs and reproductive ethical issues may occur after blindly relaxing restrictions [29]. China currently allows medical egg freezing only within the scope of the law. The discussion on the legal and ethical issues surrounding egg freezing within Chinese academic circles is still ongoing, and laws and regulations on elective egg freezing should be appropriately adjusted in accordance with technological development and public opinion in the future.
The proportion of respondents who supported the establishment of oocyte banking in China was 56.7%. In the statistical analysis, factors showing significant associations were sex, major, grade, place of residence, paternal and maternal education levels, and the level of knowledge about freezing eggs. Among them, sex, grade, and place of residence are important influencing factors. The reasons may be that women are more inclined to support the establishment of oocyte banking due to their own needs for eggs. As shown in previous studies, female students are more willing to donate their eggs than male students. People with higher education are less inclined to support oocyte banking, which may be related to their rich social experience and concerns about the technology, law, and ethics of oocyte banking in China. Our results are contradictory to the results of a survey on people’s attitudes towards donation to biobanks conducted in the USA, where younger people with higher educational levels were more willing to donate eggs. The difference in the results is understandable due to variation in the use of biobanks and oocyte banking in different countries [30]. College students who live in urban areas are more inclined to support the establishment of oocyte banking. This association may be attributed to the fact that people living in urban settings may have easier access to knowledge about egg freezing, facilitating acceptance of egg freezing and oocyte banking.
Limitations
This study reveals the cognition and attitude of Chinese college students towards elective frozen eggs, but there are also some limitations. First of all, there will be a certain degree of selection bias in this survey through QQ and WeChat group chat questionnaires. Female respondents are more likely to complete our questionnaire. Secondly, the scope of this survey is limited to five comprehensive universities in Hefei City, Anhui Province. It has geographical restrictions and may not represent the cognition and attitude of Chinese college students. In the future, on-site or online surveys of multi-regional college students can be considered to clarify the cognition of Chinese college students on issues related to frozen eggs and the impact of regional differences on cognition.
Conclusion
The current study fills the gap in the scientific literature on perceptions and attitudes towards elective egg freezing and establishing egg bank among Chinese college students. The college students in this study have a low level of knowledge about freezing eggs but are more willing to freeze eggs, are more open to the ethics of egg freezing, and have more positive attitudes towards oocyte banking. The results suggest that college students have the potential willingness to electively freeze eggs, although actual conditions do not meet their willingness. Issues regarding people’s willingness, ethical principles, legal systems, and technological development are crucial factors to consider regarding whether the country should allow elective egg freezing. Therefore, improving technical safety and reducing the cost of egg freezing will be the focus of future technological development. Various forms of education for popular science knowledge on egg freezing, egg donation, and egg banking are discussed to improve people’s awareness such that people can make informed fertility decisions.
Author contribution
All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Baoxin Zhang, Qinghong Leng, Shuheng Ou, Renxiang Yu, and Kaixuan Zhang. The first draft of the manuscript was written by Yi Zhou and Xing Li. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Fenfen Xie and Lunfang Xie were responsible for the supervision and edition of the study.
Funding
The present work was supported by the National Natural Science Foundation of China (82101716), National Innovation and Entrepreneurship Training Program for College Students (202010366020), Natural Science Research Project of Universities in Anhui Province (KJ2020A0198), Open Project of Anhui Province Key Laboratory of Reproductive Health and Genetics (RHG-2020–8), and Provincial College Students Innovation and Entrepreneurship Training Program (S202010366105).
Data availability
Data and supplementary materials are available upon request.
Declarations
Ethics approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Bioethics Committee of Anhui Medical University (No. PJ2020-07–22)(2020–06-11).
Consent to participate
Informed consent was obtained from all individual participants included in the study.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher's note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Yi Zhou and Xing Li contributed equally to this work.
Contributor Information
Lunfang Xie, Email: 527548725@qq.com.
Fenfen Xie, Email: xff2005024@126.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data and supplementary materials are available upon request.