Social egg freezing: Motivations, treatment experiences and the impact of Covid-19 - a single-center experience.

SM, MMC, M‐YT and TB‐M developed the concept of this study, carried out the data collection and analysis. BPJ, SS, RF, JP and JN were involved in questionnaire design and review of the article.

The response rate to the study invitation was 46.6%; a total of 191 responses were received from 410 eligible participants. Of the 191 responses, 26 were excluded and thus a total of 165 participants were included in the study analysis. The reasons for exclusion varied: 11 were excluded as they did not confirm that they had undergone SEF at Lister Fertility Clinic, five were excluded because, despite confirmation of SEF at the clinic, no further questions were answered, and three were excluded because they did not answer any further questions beyond demographic information. Finally, a cohort of seven women were excluded because they had undergone oocyte preservation for social reasons as well as medical reasons; this included treatment prior to chemotherapy ( n  = 4), prior to ovarian excision surgery due to endometriosis ( n  = 1), endometriosis diagnosis ( n  = 1) and recurrent granulosa cell tumors. Table  1 outlines the demographic features of women who underwent SEF and participated in this study. Demographic and egg freezing cycle characteristics. Sample size may not add up to 165 due to incomplete responses. The average age of women during their first SEF cycle was 36.6 ± 3.0 years (mean ± standard deviation) and at survey time was 39.8 ± 4.2 years. In all, 42.3% of women were 35–37 years and 16.6% were <35 years during their first SEF cycle. The mean follow‐up period at the time of the survey was 3.2 years. Of the participants, 48.5% underwent multiple (two or more) oocyte cryopreservation cycles; these women were significantly more likely to have a final number of cryopreserved oocytes >20 compared with women who underwent one cycle (χ 2 , p  20 oocytes. Women aged younger than 35 at first SEF cycle were significantly more likely to have a final number of cryopreserved oocytes >20 compared with women aged 35 or older at first SEF cycle (χ 2 , p  < 0.05). The majority of women were single at the time of SEF (86.0%). Analysis of the ethnicity of participants found 86.6% were white. Of the participants, 96.3% had completed an undergraduate degree or postgraduate degree, 62.0% of participants earned an annual household income >£75 000 and 69.5% were in full‐time employment. A total of 160 women answered whether they cryopreserved oocytes during the COVID‐19 pandemic; 92 (57.5%) did not cryopreserve oocytes during the COVID‐19 pandemic (before March 2020) and 68 (42.5%) cryopreserved oocytes during the pandemic (from March 2020 onwards). Figure  1 outlines the motivations to undergo SEF. In all, 93.9% of participants were influenced to undergo SEF by a concern for age‐related fertility decline (strongly agreed or agreed) (Figure  1A ). In contrast, the majority of women reported that they were not influenced (strongly disagreed or disagreed) by medical advice due to age (50.3%) (Figure  1B ) or low anti‐Müllerian hormone (AMH; 73.3%) (Figure  1C ). Participant age impacted receptivity to medical advice influencing SEF decision‐making; women aged 35 or older were significantly more likely to respond positively to being influenced by medical advice due to age than were women younger than 35 (χ 2 , p  < 0.05). Influences on the decision to undergo social egg freezing (SEF). (A) Concern of age‐related decline in fertility ( n  = 165); (B) medical advice of healthcare professional due to age ( n  = 165); (C) medical advice of healthcare professional due to AMH/egg reserve ( n  = 165); (D) goal to become financially independent ( n  = 165); (E) focus on career ( n  = 165); (F) employer coverage and/or encouragement ( n  = 165); (G) not being in a relationship ( n  = 142) (this question was applicable only to women who were not in a relationship at time of SEF); (H) partner not ready to have children ( n  = 23) (this question was applicable only to women who were in a relationship at time of SEF). Motivations in relation to career goals showed that a large proportion of participants strongly disagreed that the decision to undergo SEF was influenced by the aim to become more financially independent (43.6%) (Figure  1D ), an aim to focus on career (41.2%) (Figure  1E ) and employer coverage and/or encouragement (73.9%) (Figure  1F ). Questions related to career as an influencing factor to undergo SEF revealed that the majority of women strongly disagreed that their decision to undergo SEF was influenced by a goal to become more financially independent (43.6%), an aim to focus on career (41.2%) and employer coverage and/or encouragement (73.9%) (Figure  1D–F ). Of the participants, 89.5% were not in a relationship at the time of SEF and regarded their relationship status as an influencing factor in committing to the procedure (Figure  1G ). Of the cohort of women who were in a relationship at the time of SEF, the majority (52.2%) were influenced by their partner's position of not wanting to have children (Figure  1H ). Responses to questions regarding motivation (Figure  1 ) did not differ significantly in women who cryopreserved oocytes during the COVID‐19 pandemic and those who did not cryopreserve oocytes during the COVID‐19 pandemic. Table  2 outlines participant knowledge before and during SEF treatment. Women were asked to identify all the initial sources of information that led them to SEF. The most common source of information was own research (60.5%, n  = 98), followed by family member/friends (58.0%, n  = 94), media/social media (20.4%, n  = 33), healthcare professionals (16.0%, n  = 26), workplace (1.2%, n  = 2), other (0.6%, n  = 1) and partner (0.0%, n  = 0); 40.1% ( n  = 65) reported multiple sources of information. Knowledge before and during SEF treatment. Statement 1 (Table  2 ) explored the length of time that women considered oocyte cryopreservation prior to undergoing the procedure. The most common answer was 1–2 years (31.5%) and 18.2% of women considered SEF for ≥5 years before actually undergoing a cycle. Women who underwent multiple egg freezing cycles were more likely to have considered oocyte cryopreservation for more than 2 years compared with women who underwent one cycle (χ 2 , p  < 0.01). The majority of the participants (76.4%) were informed (strongly agreed or agreed) on the three knowledge‐related statements at the time of SEF (Statement 2: I was aware that my chances of giving birth depended on my age and number of eggs frozen; Statement 3: I was aware that this would not guarantee pregnancy and a live birth; Statement 4: I was confident of my knowledge of SEF process and potential side effects) (Table  2 ). No participants strongly disagreed with Statements 2 or 3; 2.4% ( n  = 4) strongly disagreed with Statement 4. Figure  2 shows the mean concern ratings for five aspects of SEF of participants both prior to and following completion of treatment. Participants were asked to evaluate their level of concern about specific aspects of SEF on a Likert scale of 1 “not concerned” to 5 “very concerned”. The results demonstrate a fall in mean levels of concern following completion of SEF in all aspects questioned. Statistical analysis revealed that concern decreased significantly after treatment for (A) “number of eggs collected” ( p  < 0.05, Mann–Whitney U test), (B) “egg collection procedure”, (C) “side effects of medication” and (E) “number of appointments/time involved” ( p  < 0.001, Mann–Whitney U test). The distributions of concern ratings for five aspects of social egg freezing (SEF). Bars represent the mean value for concern before starting SEF and after completion of SEF. Aspects ranked on a scale of 1 “Not concerned” to 5 “Very concerned”. NS corresponds to no significance. Mean values were calculated using only participants who replied to all questions ( n  = 160). (A) Number of eggs collected; (B) egg collection procedure; (C) side effects of medication; (D) negative opinion of family and friends; (E) number of appointments/time involved. Figure  3 outlines the results on questions focusing on SEF treatment experience and feelings of regret. Of the participants, 39.0% experienced treatment side effects which “interfered with my work and social life” (Figure  3A ). Data derived from the survey showed that women were significantly more likely to experience side effects if they underwent multiple oocyte cryopreservation cycles rather than one cycle (χ 2 , p  < 0.01). The data also showed that side effects were significantly more frequent if the SEF treatment occurred during the COVID‐19 pandemic than if the cycles occurred prior to the pandemic (χ 2 , p  < 0.05). Treatment experience and feelings of regret. (A) I experienced side effects which interfered with my work and social life ( n  = 164). (B) The cost of egg freezing reduced the number of cycles I completed ( n  = 162). (C) I wish I froze my eggs at a younger age ( n  = 164). (D) I am satisfied with the total number of eggs frozen ( n  = 164). (E) I regret freezing my eggs ( n  = 158); Sample size may not add up to 165 due to incomplete responses. Questions were asked exploring the impact of cost on patient journeys (Figure  3B ). Almost half of the participants (47.5%) reported that cost was a limiting factor impacting the total number of cycles completed; this was the most common factor selected by participants. Women whose household income was ≤£75 000 were significantly more likely to report cost being a limiting factor to further cycles than were those whose annual household income was >£75 000 (χ 2 , p  < 0.05). The later questions in this section focused on participants’ feelings of satisfaction and regret following the SEF procedure (Figure  3C–E ); 64.0% reported “I wish I froze my eggs at a younger age” and this was significantly more likely to be reported by women over the age of 37 than those younger at the first SEF cycle (χ 2 , p  < 0.001). Despite this, 48.2% of the total participants were “satisfied with the total number of eggs frozen” (agreed or strongly agreed) (Figure  3D ). Again, the age of first SEF cycle had a significant impact on post‐procedure satisfaction; women aged ≤37 years at first cycle were significantly more likely to be satisfied (χ 2 , p  20 cryopreserved oocytes were significantly more likely to be satisfied compared with those who cryopreserved ≤20 oocytes (χ 2 , p  < 0.01). The majority of women (96.2%) strongly disagreed or disagreed about feeling regret following SEF (Figure  3E ). The responses regarding satisfaction and regret did not vary significantly in participants who cryopreserved oocytes during the COVID‐19 pandemic and those who did not. A subset of women who underwent SEF during the COVID‐19 pandemic were asked specific questions about how their experience was shaped by the pandemic; this cohort included a total of 68 participants (Figure  4 ). Of these women, 48.5% agreed that “the COVID‐19 protocols made the procedure more difficult”; 44.1% disagreed with this statement (disagreed or strongly disagreed) (Figure  4A ); and 57.4% disagreed with “the stress of my treatment being cancelled due to contracting COVID‐19, negatively impacted my treatment experience” (disagreed or strongly disagreed) (Figure  4B ). The impact of the COVID‐19 pandemic on treatment experience and factors influencing decision to undergo social egg freezing (SEF) ( n  = 68). This section was applicable only to women who froze their eggs during the COVID‐19 pandemic. (A) During my treatment, the COVID‐19 protocols made the procedure more difficult (eg required to take COVID‐19 test before attending egg freezing clinic). (B) The stress of my treatment being canceled due to contracting COVID‐19, negatively impacted my treatment experience. (C) Concern of being exposed to COVID‐19 by going to the clinic delayed my decision to undergo SEF. (D) COVID‐19 government‐imposed restrictions reduced my chances of meeting a partner while socializing. (E) Overall, COVID‐19 pandemic made me more willing to freeze my eggs. (F) Working from home due to the COVID‐19 pandemic, reduced my chances of meeting a suitable partner. The majority of participants (82.3%) disagreed with the statement “concern of being exposed to COVID‐19 by going to the clinic delayed my decision to undergo SEF” (disagreed or strongly disagreed) (Figure  4C ). Also, 55.9% of participants agreed with the statement “COVID‐19 government‐imposed restrictions reduced my chances of meeting a partner while socializing” (agreed or strongly agreed) (Figure  4D ). Agreement with the restrictions impacting ability to meet a partner was significantly more common from women who were single at the time of SEF (Fisher's exact test, p  < 0.001). Of the participants, 44.1% agreed “Overall, COVID‐19 pandemic made me more willing to freeze my eggs” (agreed or strongly agreed); 38.2% disagreed with this statement (disagreed or strongly disagreed) (Figure  4E ). Agreement with the impact of COVID‐19 increasing the motivation to undergo SEF was significantly more common in women who were not in a relationship during their oocyte cryopreservation cycles (Fisher's exact test, p  < 0.01). More than half of participants (51.4%) did not consider working from home a factor reducing their chance of meeting a suitable partner (Figure  4F ). This opinion was significantly more commonly reported by participants who were in a relationship than by those who were not in a relationship at the time of SEF (Fisher's exact test, p  < 0.05). Table  3 outlines participants’ responses to statements relating to usage of oocytes and future plans. A total of 66.0% agreed with the statement that oocyte cryopreservation offered the opportunity for more time to find a suitable partner (agreed or strongly agreed) (Statement 1) and 56.0% agreed with the statement “egg freezing has given me the flexibility to conceive at a more appropriate time for me” (agreed or strongly agreed) (Statement 2). The agreement with these statements were influenced by age; those who were <35 years at first SEF cycle were statistically more likely than those ≥35 years to agree with Statement 1 (Fisher's exact test, p  < 0.05) and Statement 2 (χ 2 , p  < 0.01). Usage and future plans. Note : Sample size may not add up to 165 due to incomplete responses. This question was applicable only to women who attempted to conceive since freezing their eggs. The majority of participants (82.4%) considered egg freezing a back up to conceiving naturally. Although 37.1% responded that they would consider using a sperm donor to conceive in the future, 38.4% disagreed that they would consider sperm donors when trying to conceive in the future. Women who were not in a relationship at the time of SEF cycle were significantly more likely to agree that they would consider the use of a sperm donor to conceive than were those that were in a relationship (χ 2 , p  < 0.001). Similarly, participants who underwent oocyte cryopreservation during the COVID‐19 pandemic were significantly more likely to agree that they would consider the use of a sperm donor to conceive than were those who underwent SEF prior to the pandemic (χ 2 , p  < 0.05). Since oocyte cryopreservation, 31.4% (50/159) of participants have attempted to conceive; 68% (34/50) reported having successfully conceived and had children since their SEF treatment. The cohort of women who tried to conceive was significantly more likely to have been in a relationship during their first SEF cycle (χ 2 , p  < 0.01). Figure  5 outlines the methods used by participants who attempted to conceive following their oocyte preservation treatment; those who have been successful and unsuccessful are presented separately for each method of attempted conception. Natural conception was the most frequently used method to try to conceive; 56.0% (28/50) had used this method alone; 20.0% (10/50) had used only cryopreserved autologous oocytes with either partner ( n  = 4) or donor sperm ( n  = 6) (six of these were successful in having a child since SEF); 12% (6/50) attempted to conceive using multiple methods, of which three had used their autologous cryopreserved eggs alongside other methods. Therefore in the cohort of 50 women who had gone on to try to conceive, 26% had used their store of cryopreserved oocytes in their process of attempted conception. Method of attempted conception of women who underwent social egg freezing (SEF). Results are stratified by whether women have had children since freezing eggs ( n  = 50). This question was applicable only to women who attempted to conceive.

To our knowledge, this is the first study to evaluate the impact of the COVID‐19 pandemic on patient experience of SEF. This study is a broad and thorough examination of patient motivations and knowledge prior to SEF, treatment experience, feelings of regret, future plans and usage of cryopreserved autologous oocytes with a cohort who have since tried to conceive, and a specific analysis of how the COVID‐19 pandemic has impacted each of these factors. A low proportion of women (16.6%) underwent their first egg freezing cycle aged 20 oocytes than were women >35 years, including those who had multiple cycles. Cobo et al. found that women aged 36–40 years yielded a significantly lower number of oocytes per cycle compared with those aged 31–35 years, a reflection of egg reserve (AMH) reducing with age. 36 Moreover, the literature has shown that older women need to cryopreserve more oocytes to have similar live‐birth success rates 21 ; cryopreservation of 10 oocytes at 35 years of age and 61 oocytes at 42 years of age are required for a 75% chance of at least one live birth. This is a reflection of increased aneuploidy rates with increased maternal age. This data demonstrates that older women should be recommended to cryopreserve a larger number of oocytes to have similar live‐birth outcomes compared with women who undergo oocyte cryopreservation at a younger age. We found that 72.7% of women considered SEF for more than a year before actually undergoing the oocyte cryopreservation process. Most commonly, they were introduced to the concept of SEF by family member, friends or own research; in contrast, only a small proportion were signposted to SEF via medical professionals. The role played by healthcare professionals in influencing the decision for SEF is variable in the literature. 15 , 37 Our findings support the notion that there is a need for improvement in female education regarding age‐related fertility decline and fertility options. This may be addressed by healthcare professionals such as General Practitioners and specialists in family planning clinics, 38 or an earlier introduction to the concept in the national school curriculum to ensure the concept is introduced at some point to all, thus allowing the conversation to be opened earlier for people to consider this option when planning their future families. We identified that, at the time of SEF, the majority of women had a good understanding of the process in accordance with the literature. 16 Studies have shown that people are aware that there is a particular age at which fertility is highest. 37 However, the significance of age‐related fertility decline and impact on pregnancy success rates is a concept which is less well understood; 15 in particular, the fact that the age at which SEF occurs is inversely correlated to the chances of achieving at least one live birth given age and total number of oocytes cryopreserved. 16 The need to educate the general public on age‐related fertility decline has been highlighted by a number of studies 39 , 40 and, in addition to this, there is a need to educate healthcare professionals better. 41 In this cohort of women undergoing SEF, the major influencing factor was age‐related fertility decline, which is in keeping with previous studies. 15 The other main motivation was not being in a relationship at time of SEF; similar findings have been reported in previous studies. 15 , 16 , 42 A higher percentage of participants considered undergoing SEF due to their partner's wish to have a child later on in life compared with previous studies. 16 , 43 A less common influencing factor on the choice to undergo SEF was derived from medical advice, either due to age (42.4%) or low AMH (21.2%). SEF is a self‐funded procedure and thus may not be accessible for all women. 44 The potential for employers to support SEF coverage has raised ethical debate. In favor of employer grants to cover SEF costs is the facilitation of supporting an individual's choice to delay childbearing, which in many cases would then allow more time to focus on developing their career. However, this implies that, by providing the opportunity to undergo SEF, the individual should take part in the process and also that they may then feel an obligation to continue working for their employer. 45 Studies have shown that female university students would be more likely to consider SEF if covered by their future employer. 46 , 47 In this study, employer cost coverage was only considered by 3.6% of women as a motivating factor. Additionally, the aim to establish economic stability and focus on career were not major factors influencing the decision, consistent with the literature. 14 , 16 This may be due to most women undergoing SEF already receiving a high annual income. 16 , 48 Economic factors do play a pivotal role in SEF pathways, as 47.5% of women considered procedure cost to be a factor limiting the number of oocyte cryopreservation cycles; women earning <£75,000 were more likely to have this opinion. SEF can be a stressful experience and studies have highlighted the importance of emotional support. 15 , 49 In this study, 39.0% of women reported experiencing side effects which interfered with work and social life, highlighting the necessity for emotional support. Particularly, women undergoing multiple egg freezing cycles were significantly more likely to experience side effects that interfered with work and social life, compared with women who completed one cycle. Concern regarding time spent in clinic prior to commencement of SEF may arise due to multiple clinic visits for consultations, blood tests and ultrasound scans for SEF treatment. 50 The aim to collect a satisfactory number of oocytes was the major concern of participants both before and after completion of SEF. The significant decrease in concern following SEF treatment completion suggests satisfaction and reassurance from the number collected. Similar to views reported in previous studies, 64.0% of participants wished to have cryopreserved oocytes at a younger age. 14 , 31 Analysis showed that participants aged ≤37 years were significantly more likely to be satisfied with total number of oocytes and age at which oocytes were cryopreserved. This likely reflects the inverse relation between age and number of oocytes collected from women in their 30s and 40s; older women being less satisfied and having a stronger desire to cryopreserve more oocytes. Despite this, the majority of women (96.2%) did not regret the decision to undergo SEF, in keeping with previous studies 16 , 37 The impact of the COVID‐19 pandemic on the likelihood of women in the general public considering SEF in future was assessed by Huttler et al. 51 They reported that the COVID‐19 pandemic altered the likelihood of 15.2% respondents to consider SEF: both an increase and a decrease in likelihood to consider SEF were observed. This study found that for the majority of participants, the COVID‐19 pandemic did not act as a deterring factor. Overall, the COVID‐19 pandemic made 44.1% of women more willing to cryopreserve their oocytes. This study has demonstrated that the COVID‐19 pandemic may augment stress experienced by women. Of the participants, 55.9% agreed that government‐imposed restrictions reduced the chance of meeting a suitable partner through socializing. This limitation during the height of the COVID‐19 pandemic will have added to the pressure associated with finding a partner previously explored in literature. 31 Huttler et al. found that more time spent working remotely due COVID‐19 pandemic made women significantly more likely to consider SEF. 51 Further demonstrating the increased pressure felt by women with regard to a partner, participants were more likely to consider donor sperm for later conception if they underwent SEF during the pandemic. Women not in a relationship at the time of SEF were significantly more likely to consider the COVID‐19 pandemic a motivating factor. Almost half (48.5%) of participants felt that COVID‐19 protocols such as COVID‐19 testing made the oocyte cryopreservation process more difficult. Furthermore, during the pandemic, women were more likely to experience treatment‐associated side effects which affected social and work life; future studies should explore possible reasons for this increased impact, such as the additional emotional stress during the pandemic. Studies have shown that women may perceive SEF as a method of optimizing the potential to conceive at a later age and to prevent feelings of regret associated with not cryopreserving oocytes. 31 , 52 In this study, 66.0% of participants stated that egg freezing has given them more time to find a suitable partner and 56.0% that SEF allowed for greater flexibility to conceive at a more appropriate time. This highlights the importance of providing women with realistic probabilities of future success stratified by age at which SEF occurs and the number of oocytes collected, as well as the additional risks associated with pregnancy at advanced maternal age to prevent false reassurance. Understanding of the impact of advanced maternal age on pregnancy outcomes, is something to consider for future studies of patients opting to undergo SEF. In this study, 31.4% proceeded to conceive and have a live birth following SEF. Only 8.2% of women returned to use autologous cryopreserved oocytes. Previous studies have similarly shown that a small percentage of women return to use cryopreserved oocytes within the study time frame 16 , 29 , 37 but that women who have not yet used cryopreserved oocytes may plan to do so in the future. 16 In this study, 41.2% (68/165) of participants had undergone SEF within 2 years of analysis, and thus future usage percentage in this cohort is likely to increase significantly with a longer follow‐up time period. Of the participants in this study, 82.4% considered SEF to be a backup option to natural conception and most women attempted to conceive naturally, in accordance with other studies showing patient preference for natural conception over IVF. 16 , 37 Notably, 60% (6/10) of participants who solely used cryopreserved oocytes to try to conceive had had children following SEF. The literature shows similar success rates with vitrified autologous oocytes and fresh oocytes. 7 This study has identified and addressed gaps in literature with regard to patient motivations and treatment experiences of SEF, and the impact of COVID‐19 pandemic. However, limitations have been identified. The response rate of 46.6% was similar to that of previous studies 14 , 37 but lower than others. 16 , 29 A longer study duration may have afforded higher response rates. Women with more positive or negative experiences associated with SEF treatment may have been more inclined to participate in the survey and share their experience, giving rise to participation bias. Due to anonymity of responses, an analysis of demographic and treatment differences between responders and non‐responders was not feasible. Another limitation is that the patients all underwent SEF in one large UK clinic, and results regarding knowledge at time of SEF and treatment experience may vary with other clinics both within the UK and globally. Further limitations of the study arise from use of close‐ended questions, chosen to allow for quantitative statistical analysis. However, the design of these questions are restrictive and do not allow the opportunity for elaboration of the patient perspective. Furthermore, a participant may misunderstand questions, which may then lead to a reinterpretation of those questions or incomplete responses. Future work via use of qualitative studies will allow for clarification of questions and further exploration of factors such as the impact of the COVID‐19 pandemic on willingness to undergo SEF.

Overall, the main motivation of women to undergo SEF is concern regarding age‐related fertility decline, followed by relationship status where women are not in a relationship. The majority of women who underwent SEF were aged ≥35 years and not in a relationship. Most of the participants reported that they were not influenced by the medical advice of healthcare professionals and it is clear that the majority wished that they had undergone SEF at a younger age; thus there is a role for improved education of women on age‐related fertility decline and fertility options such as SEF. This public health intervention should be aimed at women from a young age, potentially as part of the school curriculum or within a family planning setting, in order to allow delivery of accurate information and give the individual the possibility to consider oocyte cryopreservation at an earlier age than the current mean, thus improving the chance of collecting a higher number of oocytes with fewer cycles. This study demonstrates that most women do not regret the decision to undergo SEF but the majority wished that they had cryopreserved oocytes at a younger age. The pandemic made women who were not in a relationship more willing to undergo SEF. The egg freezing process can be stressful, women may have concerns around SEF and unprecedented situations such as the COVID‐19 pandemic alter treatment experience.

Gender equality has progressed significantly since the mid‐20th century, with educational and professional opportunities increasing for women worldwide. In the UK, female employment rates have increased over recent decades. 1 The impact is reflected in an increase in age of mothers in England and Wales, where the maternal age has increased from an average of 26.4 years in 1973 to 30.7 years in 2019. 2 , 3 However, with advancing age there is a decline in ovarian reserve and oocyte quality, with this decline accelerating significantly in women aged 35 or above. 4 Therefore, the trend of deferring motherhood for “social” reasons carries risk and has been associated with involuntary childlessness. 5 Oocyte cryopreservation involves initial stimulation of ovaries to produce oocytes, followed by a trans‐vaginal egg collection procedure to generate multiple mature oocytes which are then frozen and stored for future use. 6 , 7 , 8 , 9 The demonstration of similar pregnancy and live birth rates between vitrified and fresh oocytes, 10 has cemented the concept of pausing the clock and electively collecting oocytes for use at a later age when oocyte quality would otherwise have declined. The development of vitrification and demonstration of its successful outcomes have led to a more than 10‐fold increase in the number of egg freezing cycles in the UK from 2009 to 2019. 11 The concept of social egg freezing (SEF) refers to the storage of autologous oocytes, specifically for women who wish to preserve their fertility for non‐medical reasons. 12 , 13 , 14 Studies have demonstrated that the main motivating factors for women choosing to undergo SEF are concerns regarding age‐related fertility decline 15 and not having a partner. 16 Studies evaluating the perception of the general public regarding SEF, demonstrate that career planning , 17 particularly in younger women , 18 and lack of a suitable partner 19 are considered to be possible motivating factors to undertake SEF. The chance of a successful outcome from SEF will vary depending on two factors: the number of oocytes frozen and the maternal age at which oocytes are frozen. 20 , 21 Goldman et al. 21 demonstrated that the success rate of achieving at least one live birth was 90% in women aged 34 years who had at least 20 oocytes cryopreserved. This outcome decreased to 75% at 37 years and fell further to 37% at 42 years. A meta‐analysis has confirmed the impact of maternal age at time of SEF, indicating that the live birth rate is greater in women aged <36 compared with women aged 36 or older. 22 Despite these data highlighting the impact of maternal age at the time of SEF, analysis from the Human Fertilization and Embryology Authority on 2016 data has shown that the most common age for oocyte cryopreservation was 38. 23 The caveat to SEF is that is it does not guarantee conception and live birth. 16 Further to this, using SEF as a method to postpone pregnancy, carries the obstetric risks of advanced maternal age, which include gestational diabetes and fetal growth restriction. 24 , 25 In addition, the process of SEF treatment has medical risks such as intra‐abdominal bleeding following oocyte retrieval 26 and ovarian hyperstimulation syndrome (OHSS), with severe cases of OHSS requiring hospitalization. 26 , 27 In the majority of cases, SEF is self‐funded, with a cost of approximately £5000 per cycle, 28 with multiple cycles potentially required to ensure storage of an adequate number of oocytes. There is an additional required annual storage cost of £200–£400. 28 Women who opt to undergo oocyte cryopreservation at a younger age for non‐medical reasons have an increased chance of natural conception, given a larger window of time from a younger age potentially to conceive spontaneously , 5 and thus may not return to use previously frozen eggs. 29 However, despite treatment costs, it has been shown that most women do not regret their choice to undergo SEF. 30 , 31 In July 2020, the UK storage limit of cryopreserved oocytes from SEF was extended a further 2 years from the initial 10 years (UK Human Fertilization and Embryology Act 1990) to allow more time for storage due to temporary suspension of certain fertility treatments during the COVID‐19 pandemic. From July 1, 2022, a transitional period was instituted, extending the maximum storage limit of SEF to 55 years (UK Human Fertilization and Embryology Act Regulations 2020). This study aims to assess motivations and treatment experiences of women who have gone through SEF. This study assesses the effect of the COVID‐19 pandemic on motivations, decision‐making and women's SEF experience. Further to this, the study aims to understand knowledge before and during SEF treatment, usage of oocytes and future plans.

None.

An in‐depth survey investigating patients’ perspectives of SEF was designed based on previously published questionnaires 32 , 33 , 34 and a systematic review was performed on SEF. 35 Feedback was obtained on the questionnaire and content validation on the questionnaire was performed by the SEF team at The Lister Fertility Clinic, London, who determined whether the questionnaire addressed the topic overall. The survey allowed participants to skip questions which were not relevant to their experience, with a maximum number of questions ranging from 47 to 60 questions. Closed‐ended multiple‐choice questions, Likert scale or rating scale questions and fewer open‐ended questions were included, which allowed for qualitative analysis. There were six sections to the questionnaire: (1) demographic information, (2) motivations, (3) egg freezing knowledge, before and during treatment, (4) treatment experience, (5) impact of COVID‐19 pandemic and (6) usage and future plans. The study participants were women who had undergone egg freezing at the Lister Fertility Clinic. The inclusion criteria for this study were women who had undergone oocyte cryopreservation for social reasons between January 2011 and December 2021. At the time of treatment, these individuals had, consented to being contacted in the future for research. The questionnaire was answered anonymously. The questionnaire was created and accessed online, using QUALTRICS software, with an estimated completion of 10 min. The Qualtrics survey link was circulated to 410 eligible participants via email. A reminder email was sent 2 weeks later to those who had not yet completed the survey. The online survey was open and accessible to invited participants for approximately 3 weeks between March 15 and April 4, 2022. Software SPSS version 28 was used to carry out statistical analysis. Comparison of categorical data was analyzed using Pearson's Chi‐square (χ 2 ) test or Fisher's exact test, where appropriate. Distribution of rating scale questions was assessed using the Shapiro–Wilk test of normality. Comparison of rating scale questions was performed by Mann–Whitney U tests. Statistical significance level was established at p  < 0.05. Ethical approval was provided by “London Riverside Research Ethics Committee” (Research Ethics Committee (REC) reference: 17/LO/1491) on September 4, 2017.