Assessing the quality of decision-making for planned oocyte cryopreservation

Purpose This survey study aims to examine the quality of planned oocyte cryopreservation (POC) decision-making in the domains of decision change, decision difficulty, decision regret and informed choice.

Of the 224 women who completed at least one POC cycle between 2012 and 2018 at a Canadian academic IVF centre, 198 were reachable by email for anonymous survey participation.

Ninety-eight questionnaires were returned (response rate 49.5%). Of these, 86 fully completed questionnaires were analyzed for this study. Eighty-eight percent of respondents stated that it was a ‘good decision’ to cryopreserve oocytes, in retrospect. Despite this, 31% found the decision-making process to be ‘difficult’. Three in five (61%) would have made ‘exactly the same’ decision without any change, yet slightly over a third (35%) would have made a ‘similar’ decision, but with option-related changes and process-related changes. A negative correlation between ‘decision regret’ and ‘informed choice’ was found (p < .005). Those who stated that they would have made exactly the ‘same’ POC decision were found to have a significantly higher ‘informed choice’ score compared to others who would have made a ‘similar’ or ‘completely different’ decision, in retrospect (p < .001). Respondents with lesser ‘decision regret’ were significantly more likely to appraise their decision as a well-informed choice (p < .001).

Our findings show that high-quality POC decision-making is accompanied by the perception of being able to make an informed choice, which can be achieved by providing patients with adequate information and individualized counselling to help patients set realistic expectations of cycle outcomes.

Fertility preservation, Oocyte cryopreservation, Planned egg freezing, Planned oocyte cryopreservation, Social egg freezing, Assisted reproduction

Oocyte cryopreservation through vitrification is a fertility preservation option for women anticipating the threat of age-related fertility decline, and whose social and personal circumstances are not conducive to beginning motherhood during their prime reproductive years. The latest US data show that the live birth rate per in vitro fertilization (IVF) cycle for women aged over 42 years is only 3.4% compared to 51.6% for women younger than 35 [1]. This procedure mitigates the deleterious effects of age on oocyte quality by allowing women to cryopreserve healthy oocytes for later reproductive use [2, 3]. Reproductive medicine societies around the globe have found the use of oocyte cryopreservation ethically acceptable for women wanting to guard against age-related fertility decline [4–7]. The American Society of Reproductive Medicine (ASRM) advocates the use of neutral and non-judgemental terminology to describe oocyte cryopreservation as a ‘planned’ strategy to avoid stigmatizing women who are interested in this service [4]. Large-scale surveys conducted in Belgium [8], Canada [9], Denmark and the UK [10], Sweden [11] and the USA [12, 13] identified favourable public attitudes toward women using planned oocyte cryopreservation (POC) to delay childbearing for social reasons. Research among physicians and medical trainees found similar positive attitudes towards POC. Between 46 and 70% of female medical trainees would consider using POC themselves to manage career demands [14–16]. Not surprisingly, POC is an appealing fertility preservation option for women whose biological schedule does not align with their life circumstances to begin motherhood [2]. A Canadian survey found that over half of 500 childless women aged 18–38 would consider POC if they found themselves in social circumstances that were not conducive to begin motherhood [9]. To date, most POC research on women who had undertaken the procedure focuses primarily on evaluating their characteristics, life circumstances, intentions, experience and future utilization plans [17–21]. The influential role of decision regret has only been explored briefly in a few qualitative [23, 24] and quantitative [18, 24, 25] studies, and more in-depth in a US-based single-site follow-up survey study [26]. Existing data, although limited, have revealed that some women cryopreserved their oocytes in order to avoid later regret for not making use of cryopreservation technology when it is available and feasible, or remorse for their inaction if they subsequently found themselves having fertility difficulties [18, 24]. Regret is a negative emotion involving elements of remorse, distress and self-blame. It occurs when decision-makers believe that a more favourable outcome ‘would’, ‘could’ or ‘might’ have occurred had they made a different choice [27–29]. Health research has shown that people are more likely to experience regret through inaction than through action. Therefore, the fear of future regret for not taking a certain action is a powerful motivating factor impacting decision-making [30]. Nonetheless, the decision to undergo POC should be an informed choice, after carefully evaluating its risks and benefits in accordance with the woman’s circumstances, preferences and personal values. Women should not feel obligated to cryopreserve their oocytes based solely on their desire to avoid anticipatory regret, especially when success cannot be guaranteed [23]. A recent US study [26] that used a standardized Decision Regret Scale [31] to evaluate the quality of POC decisions found that the adequacy of information provision and higher patient-estimated chances of achieving a live birth with vitrified oocytes were associated with a reduced likelihood of post-decision regret. Interestingly, a lower number of cryopreserved oocytes was found to be a significant risk factor only in their univariate logistic regression analysis, but not in the multivariate model when other factors were considered. This study adds valuable information to the understanding of decision regret, providing evidence that decision quality could be augmented by providing high-quality POC information regarding chances of a live birth after use of the oocytes. Nevertheless, a systematic review found that regret is a difficult theoretical construct to measure comprehensively. They further concluded that existing standardized regret scales, including the Decision Regret Scale, have failed to capture the multiplicity and complexity of regret [32]. More research is needed to better understand the inextricable relationships of different factors influencing the quality of POC decision-making. This paper examines the POC decision-making process from the perspective of a cohort of healthy women who had undertaken POC at a Canadian academic IVF centre. It aims to identify factors influencing the decision to seek POC consultation, and issues that most concern women when deciding to undertake POC. Additionally, it seeks to better understand (1) how women appraised the quality of their POC decision after completing the process, (2) the interplay of different decision variables in influencing decision quality and (3) if they would have done anything differently if given a chance to revisit their POC decision.

This single-site retrospective anonymous survey was approved by the University of Toronto Research Ethics Board (#32951). IVF laboratory records were used to compile a list of patients who completed at least one POC cycle at our facility between 2012, the first year our facility fully implemented the vitrification protocol, and 2018. A study specific anonymous questionnaire, with free-text boxes for descriptive comments, was constructed based on a comprehensive review of published literature and the study’s team clinical experiences. Five clinicians with direct patient care experience in POC independently reviewed the questionnaire for face and content validity. The questionnaire was subsequently pilot-tested by seven young female volunteers recruited at an IVF clinic; minor revisions with regard to the wordings and sequence of questions were made based on their feedback. The quality of POC decision was appraised by four aspects related to the process: (1) decision difficulty, (2) informed choice, (3) decision regret and (4) decision change. A 5-question standardized subscale from the Treatment Decision Evaluation Scale [33] was used to appraise informed choice. Survey participation for this study was voluntary and anonymous. The online survey was implemented by SurveyMonkey® and was administrated twice: in June 2017 for patients who completed their first POC cycle between 2012 and 2016, and in April 2019 for patients who completed their first POC cycle between 2017 and 2018. An initial email invitation with a hyperlink to the online survey was sent to POC users for whom an email address was available in the patient registration database. A second invitation email was sent 2 weeks later, followed by a final reminder email after a further 4 weeks. Of the 224 women who underwent at least one POC cycle at our facility during the study period, 198 had a valid email address that enabled us to invite them to participate in the survey. Ninety-eight anonymous questionnaires were completed (response rate 49.5%), of which twelve were incomplete and were excluded. Therefore, a total of 86 completed questionnaires were used for the analysis. Free-text comments were imported to Excel spreadsheets for data management. The first (S.Y.) and second (C.V.G.) authors analyzed the comments independently to identify recurrent themes, underlying sub-themes and emergent categories using thematic analysis [34]. Investigator triangulation was achieved through an iterative process using constant comparative methods [35]. Differences were resolved through revision and discussion until consensus was reached. Quantitative data were analyzed by SPSS, version 26.0 (IBM Corp., Armonk, NY). Descriptive statistics were used to summarize the mean, standard deviation, frequency and percentage for each. Pearson correlation and Fisher’s exact test were used to examine the association of variables. Respondents were divided into two groups based on their desire for decision change (no decision change vs. other), for independent sample Student’s t-test analyses. All statistical tests were two-sided; p < .05 was considered statistically significant.

Socio-demographics The socio-demographic characteristics of the 86 respondents are summarized in Table 1. Their mean age at the time of their first POC cycle and survey completion was 35.7 ± 2.4 (range 27–43) and 37.7 ± 2.5 (range 28–45), respectively. The mean time lapse between respondents’ first cycle and the survey was 2.0 years ± 1.2 (range: 0–4 years). At the time of their POC cycle, 20 women were in a committed relationship (n = 6, 7.0%) or a non-committed relationship (n = 14, 16.3%), and only two respondents (2.3%) who were either single or in a common law relationship had a biological child. Table 1. | Sociodemographic characteristics | At the first POC cycle n (%) | At survey time n (%) | |---|---|---| | Age (n = 86) | || | < 30 | 1 (1.2) | 1 (1.2) | | 30–34 | 24 (27.9) | 5 (5.8) | | 35–39 | 55 (64.0) | 61 (70.9) | | 40–45 | 6 (7.0) | 19 (22.1) | | Sexual orientation (n = 86) | || | Heterosexual | - | 82 (95.3) | | Same sex | - | 2 (2.3) | | Bisexual | - | 2 (2.3) | | Racial or ethnic heritage (n = 86) | || | White | - | 57 (66.3) | | Non-white | - | 29 (33.7) | | Relationship status (n = 86) | || | Single | 54 (62.8) | 40 (46.5) | | Married/common-law | 6 (7.0) | 14 (16.3) | | Non-committed relationship | 14 (16.3) | 22 (25.6) | | Separated/divorced | 12 (14.0) | 10 (11.6) | | Biological children (n = 86) | || | No | 84 (97.7) | 79 (91.9) | | Yes | 2 (2.3) | 7 (8.1) | | Highest level of education (n = 85) | || | Community College | - | 6 (7.0) | | Undergraduate degree | - | 24 (27.9) | | Postgraduate degree | - | 46 (53.5) | | Doctorate degree or equivalent | - | 9 (10.5) | | Occupation (n = 86) | || | Homemaker | - | 1 (1.2) | | Freelancer | - | 2 (2.3) | | Business owner or entrepreneur | - | 8 (9.3) | | Skilled labourer | - | 3 (3.5) | | Skilled professional | - | 45 (52.3) | | Skilled professional in a highly specialized field | - | 20 (23.3) | | Other | - | 7 (8.1) | | Gross annual income (n = 86) | || | ≤ $30,000 | - | 1 (1.2) | | $30,001–$50,000 | - | 2 (2.3) | | 50,001–$70,000 | - | 12 (14.0) | | $70,001–$90,000 | - | 26 (30.2) | | > $90,000 | - | 38 (44.2) | | Prefer not to answer | - | 7 (8.1) | POC planned oocyte cryopreservation Decision considerations Table 2 shows respondents’ decision considerations during the POC process. From a list of eight factors influencing respondents’ decision to seek a POC consultation, the three items that were rated above ‘neutral’ were (a) wanting to have a back-up plan against age-related fertility decline (4.7 ± 0.7), (b) wanting to remove the biological clock pressure (4.6 ± 0.8) and (c) being single (4.1 ± 1.5). Sixteen respondents (18.6%) indicated that they had a pre-existing medical condition that would put their fertility at risk, including fibroids, endometriosis, PCOS and family history of early menopause and infertility. Twenty-six women (30.2%) sought POC from more than one IVF clinic before deciding where, and if, to cryopreserve their oocytes. Table 2. | I. Decision considerations during the POC process | n (%) or mean ± SD | | A. Number of fertility clinics consulted before deciding to freeze oocytes (n = 86) | | | One fertility clinic only | 60 (69.8) | | Two fertility clinics | 19 (22.1) | | Three or more fertility clinics | 7(8.1) | | B. The level of influence in deciding to seek a POC consultationa (n = 86) | | | a) I was not financially ready to have children | 2.3 ± 1.3 | | b) I had a busy career and was not ready to have children | 2.3 ± 1.2 | | c) I was not emotionally ready to have children | 2.4 ± 1.3 | | d) I knew someone who had done oocyte freezing | 2.8 ± 1.3 | | e) I knew someone who had infertility struggles | 3.4 ± 1.3 | | f) I was single | 4.1 ± 1.5 | | g) I wanted to take away the biological clock pressure of having children | 4.6 ± 0.8 | | h) I wanted to have a back-up plan against age-related fertility decline | 4.7± 0.7 | | C. The level of concern in deciding to undergo POCb (n = 86) | | | a) Use of IVF procedure for oocyte retrieval | 2.9 ± 1.3 | | b) Use of fertility drugs | 3.1 ± 1.3 | | c) Physical demands of an oocyte freezing cycle | 3.1 ± 1.2 | | d) Time commitment to completing an oocyte retrieval cycle | 3.1 ± 1.2 | | e) Health risks associated with an oocyte freezing procedure | 3.2 ± 1.3 | | f) Health risks of children born from frozen oocytes | 3.4 ± 1.4 | | g) Success rate of oocyte freezing based on clinical profile | 4.0 ± 1.1 | | h) Confidence in my fertility doctor/clinic | 4.1 ± 1.0 | | i) Cost of oocyte freezing | 4.2 ± 1.1 | | D. Ovarian reserve test result from medical screening (n = 83c) | | | Low—significantly lower compared to average for women of my age | 8 (9.6) | | Suboptimal—slightly lower compared to average for women of my age | 25 (30.1) | | Good—same as average for women of my age | 37 (44.6) | | Very good—higher compared to average for women of my age | 13 (15.7) | | E. Length of time it took to decide on POC following initial consultation (n = 86) | | | About 1 month | 51 (59.3%) | | About 3 months | 18 (20.9%) | | About 6 months | 7 (8.1%) | | About 1 year | 5 (5.8%) | | Over 1 year | 5 (5.8%) | | II. Quality appraisal of POC decision | n (%) or mean ± SD | | A. The level of decision difficulty in the process (n = 85) | | | It was an extremely easy process | 11 (12.9) | | It was a very easy process | 13 (15.3) | | It was quite an easy process | 28 (32.9) | | Neutral | 7 (8.2) | | It was quite a difficult process | 14 (16.5) | | It was a very difficult process | 9 (10.6) | | It was an extremely difficult process | 3 (3.5) | | B. The level of decision regret in retrospect (n = 86) | | | It was a good decision | 76 (88.4) | | It was a fair decision | 6 (7.0) | | Neutral | 1 (1.2) | | It was a bad decision | 3 (3.5) | | It was a very bad decision | 0 (0) | | C. The extent to which it was an informed choice (n = 86)d | | | a) I knew the pros and cons of oocyte freezing | 4.0 ± 0.7 | | b) I made a well-informed oocyte freezing choice | 4.1 ± 0.7 | | c) I was satisfied with the oocyte freezing information I received | 3.8 ± 1.0 | | d) I wanted to receive clearer advice on oocyte freezing | 2.9 ± 1.2 | | e) I wanted more information about the decision to freeze oocytes | 3.0 ± 1.2 | | Total score | 12.5 ± 2.4 | | D. The level of decision change in retrospect (n = 86) | | | Would have made exactly the same decision with no change | 52 (60.5) | | Would have made a similar decision but with some changes | 30 (34.9) | | Would have made a completely different decision | 4 (4.7) | POC planned oocyte cryopreservation a5-point Likert scale (1—‘strongly disagree’; 2—‘disagree’; 3—‘neutral’, 4—‘agree’; and 5—‘strongly agree’) b5-point Likert scale (1—‘not at all concerned’; 2—‘a little bit concerned’; 3—‘moderately concerned’, 4—‘very concerned’; and 5—‘extremely concerned’) cOne participant did not answer this question and two participants did not know the result d5-point standardized informed choice subscale (1—‘strongly disagree’ to 5—‘strongly agree’) of the Treatment Decision Evaluation Scale (Stalmeier et al. 2005). Revised words from the original instrument to better reflect the research topics are highlighted in italics. The last two items were reverse scored when calculating the total scores of the scale Two in five women indicated that the results from medical screening revealed suboptimal (n = 25, 30.1%) or low (n = 8, 9.6%) ovarian reserve compared to other women of their age. From a list of nine concerns related to undertaking POC, the top three issues about which respondents were ‘moderately’ or ‘very’ concerned were the cost (4.2 ± 1.1), confidence in their fertility doctor/clinic (4.1 ± 1.0) and their estimated success rate (4.0 ± 1.1). Three in five (n = 51, 59.3%) women reported spending about a month to make a POC decision post consultation, while one in five (n = 18, 20.9%) spent about 3 months in decision-making. Cycle outcomes The 86 respondents reported a total of 111 POC cycles; 67 (77.9%) completed a single cycle, and the others completed two (n = 15, 17.4%), three (n = 2, 2.3%) and four (n = 2, 2.3%) cycles. Respondents’ mean age at the time of undergoing their first POF cycle was 35.7 ± 2.4 (range: 27–43); only one (0.9%) underwent her first cycle before age 30 (Table 1). The most common age range to complete a POC cycle was 35–39 (71 cycles, 64.0%), followed by 30–34 (29 cycles, 26.1%), 40–43 (10 cycles, 9.0%) and < 30 (1 cycle, 0.9%). After excluding two cycles with unreported outcomes, the numbers of reported oocytes cryopreserved in each cycle were 0 (1 cycle, 0.9%), 1–5 (22 cycles, 20.2%), 6–10 (46 cycles, 42.2%), 11–15 (28 cycles, 25.7%), 16–20 (6 cycles, 5.5%), 21–25 (4 cycles, 3.7%) and 26–30 (2 cycles, 1.8%). Only three respondents were in the process of using (n = 2), or had used (n = 1), their cryopreserved oocytes, utilizing either partner sperm (n = 2) or donor sperm (n = 1), with no viable pregnancy reported yet. Quality appraisal of the POC decision Fifty-two respondents (61.2%) thought that the decision-making process was ‘easy’; the remainder considered it either ‘difficult’ (n = 26, 30.6%) or were ‘neutral’ (n = 7, 8.2%). Seventy-six respondents (88.4%) stated that they made a ‘good decision’ to cryopreserve their oocytes, and only three (3.5%) considered it a ‘bad decision’, in retrospect. On the ‘informed choice’ subscale, respondents felt fairly confident in their knowledge of the pros and cons of POC (4.0 ± 0.7), most believed they made a well-informed decision (4.1 ± 0.7) and most were fairly satisfied with the information they received (3.8 ± 1.0) (Table 2). When asked to reflect on their POC decision, the majority (n = 52, 60.5%) would have made exactly the same decision, and only four (4.7%) would have made a completely different decision. Thirty (34.9%) women would have made a similar decision but with some changes. The key themes extracted from these 30 respondents’ comments of the changes they would have made are highlighted in Table 3. They include (a) freeze oocytes earlier, (b) do another freezing cycle, (c) freeze both oocytes and embryos, (d) seek more social support, (e) seek more counselling and (f) be better prepared emotionally. Table 3. | Key themes | Categories | Illustrative quotes | |---|---|---| | a. Freeze oocytes earlier | Option-related change | ‘I would have done it earlier. I wish I had known that egg quality declines with age. There is so much misinformation out there, especially from an older generation of women who are not in the same position as women now because they had children young.’ | | b. Do another freezing cycle | Option-related change | ‘I did get a good number of eggs but would do another cycle if I could as extra assurance!’ | | c. Freeze both oocytes and embryos | Option-related change | ‘Perhaps taken half the eggs and tried to make embryos but probably didn’t have enough eggs and would have had to do another cycle. I think the success of frozen embryos vs eggs is apparently a lot higher so that’s my only hesitation with egg freezing.’ | | d. Seek more social support | Process-related change | ‘If I could change anything, I might have made more arrangements to have friends and family visit and stay with me during the process, since it was lonely at times and I also felt a lot of anxiety during the process.’ | | e. Seek more counselling | Process-related change | ‘I planned to have counseling support and I did see a counselor at one point during the process, but I might have felt better if I had been able to go more often.’ | | f. Be better prepared emotionally | Process-related change | ‘I would’ve been more gentle with myself and prepared for the emotions that it brought up. It was more emotionally challenging than I anticipated.’ | POC planned oocyte cryopreservation Respondents who would have made ‘exactly the same’ decision had a significantly higher ‘informed choice’ score (n = 52, M = 13.3 ± 1.8 vs. n = 34, M = 11.4 ± 2.7; t (84) = 6.1, p .05) and the number of cryopreserved oocytes between these two groups (p > .05). Table 4 shows correlations between ‘decision difficulty’, ‘decision regret’ and ‘informed choice’. The total score of the ‘informed choice’ scale was negatively correlated with ‘decision regret’ (r = − .57, p < .005). Table 4. | Decision difficultya | Decision regretb | Informed choicec | | |---|---|---|---| | Decision difficulty | 1 | .13 | − .17 | | Decision regret | .13 | 1 | − .57* | | Informed choice | − .17 | − .57* | 1 | aDecision difficulty variable is a 7-point Likert scale: a low score indicates an easy decision and a high score indicates a difficult decision bDecision regret variable is a 5-point Likert scale: a low score indicates a good decision with no regrets and a high score indicates a bad decision with regrets cThe total score of the Informed Choice subscale was used for analysis. A low total score indicates an uninformed choice and a high total score indicates an informed choice Seventy-six (88.4%) respondents reported that their pursuit of POC was self-empowering, five (5.8%) disagreed and another five (5.8%) felt neutral about it. Thirty-eight respondents believed there was ‘moderate’ (n = 24, 28.2%) or ‘high’ (n = 14, 16.5%) stigma associated with POC, 27 (31.4%) believed there was ‘a little bit’ and 20 (23.3%) believed there was ‘none’. The overwhelming majority would ‘absolutely’ (n = 62, 72.1%), or ‘most likely’ (n = 19, 22.1%), recommend POC to their friends and relatives.

This study was the first to investigate the experience of a cohort of Canadian women who had undertaken POC at an IVF centre. Reproductive medicine societies across the globe have recommended that women should be appropriately counselled about the costs, risks, benefits, efficacy, success rates and limitations of POC in order to make an informed decision [4–7]. Findings of this study will enhance clinicians’ understanding of how women appraise the quality of their POC decisions. This will facilitate the development of better supportive services, leading to higher quality POC decision-making. A latest systematic review of 17 psychosocial studies found that over 70% of women were single at the time of POC [21]. In our study, only 7% of respondents were in a committed relationship and 71% were ≥ 35 years old when undergoing their first POC cycle. Single status and a desire to remove pressure related to age-associated fertility decline were highly influential in their decision to seek POC consultation, suggesting that many of them were confronted by a reproductive barrier of lacking a committed partner, and they sought POC as a way to optimize their future motherhood chance. Furthermore, nearly one in five of respondents indicated that their fertility was threatened by an existing or a potential gynecologic condition that could increase their risk of infertility. Similar observations have been reported in other studies; between 13 and 22% of POC users were confronted by a non-acute gynecologic issue at the time of POC decision-making [18, 20]. The myth of women using POC to purposefully postpone childbearing for career reasons has been dispelled by the latest research [25, 36–38]. In consistent with the findings of Platts et al.’s [21] systematic review, our study found further evidence that many women opt for POC out of concern about the gradual exhaustion of their ovarian reserve due to age or a non-acute gynecologic issue, coupled with their single status, and a strong motherhood desire. A recent binational study [39] of women who had undertaken POC in the USA and Israel found that all of them were deeply concerned about the expense associated with POC, despite differences in their healthcare systems and economic structures. Other studies also reported that some women received financial help from their parents towards the costs of POC [22, 37]. In Canada, where this study took place, POC is an out-of-pocket medical procedure that is not funded by any provincial health plans. The procedural costs of POC, including fertility drugs, are at least $10,000 CAD per cycle. Not surprisingly, the cost of POC was rated as the most important concern by respondents when deciding to cryopreserve oocytes, despite 74% of respondents being high-income earners (>$70,000 CAD annually). The high treatment cost of POC was identified as a universal concern among women who had undertaken such procedure in different countries, and a barrier for accessing this service perceived by the general public [21]. Half (51%) of the women who participated in Greenwood et al.’s [26] study expressed no post-decision regret, although a third (33%) experienced mild regret. Using a similar study design, our questionnaire went a step further to investigate whether or not POC users would have made exactly the same, a similar, or a completely different decision, if given the chance; and if so, what they would have done. We found that three in five (61%) women would have made exactly the same POC decision, slightly over a third (35%) would have made a similar decision but with (1) option-related changes (e.g. cryopreserving their oocytes earlier, undertaking another POC cycle to cryopreserve more oocytes, cryopreserving both oocytes and embryos) and (2) process-related changes (e.g. seeking more social support and counselling, and being more emotionally prepared when undergoing the procedure). The desire for option-related decision change following POC has also been reported in other studies [19, 24]; some of their study participants wished they had undertaken POC at an earlier age or had cryopreserved more oocytes by going through additional cycles. Sixteen percent of respondents in Greenwood et al.’s [26] study had experienced moderate to severe decision regret following POC. However, the number of cryopreserved oocytes, a physiologic-dependent outcome which may not be modifiable, was not a significant risk factor of decision regret in their multivariate regression analysis. Their study sheds light on the importance of focusing on process-related factors to augment decision quality. In our study, a standardized informed choice scale was used to investigate the quality of POC decision-making. An inverse relationship between decision regret and informed choice was found. Furthermore, respondents with lesser decision regret were significantly more likely to appraise their decision as a well-informed choice. Those who stated that they would have made exactly the same POC decision were found to have a significantly higher informed choice score compared to others who would have made a similar or completely different decision. Health research has consistently shown that post-decision regret is associated with inadequate or suboptimal quality information provision, as well as lack of patient involvement in the decision-making process [40–43]. Our data further support the conclusion that high-quality POC decision is accompanied by perceptions of being able to make an informed choice, which can be achieved by providing patients with adequate information and individualized counselling to help them set realistic expectations of cycle outcomes [36]. Three in ten respondents (30%) found the decision-making process ‘difficult’, although 88% stated that it was a ‘good decision’ to cryopreserve oocytes proactively, suggesting that POC was inherently a difficult medical decision for a minority of women, although most of them felt it was a good decision in the end. Patient-centred POC care starts with understanding patients’ life circumstances, personal values, parenthood aspirations, treatment expectations and risk tolerance, while being respectful of their reproductive autonomy [36, 44, 45]. It is essential that women who are interested in POC have adequate information for decision-making, are made aware of their options when formulating a POC treatment plan and have adequate support to sustain the emotional stress throughout the process. Other assisted reproductive options such as donor sperm insemination for immediate conception, alternative options of cryopreserving embryos using partner sperm or donor sperm, as well as the process of utilizing cryopreserved oocytes in the future, should be discussed in advance to minimize future regret [5, 6]. Furthermore, POC is a medical process that requires a significant time commitment to attend clinic appointments. Previous studies have found that unpartnered women are more susceptible to the emotional challenge of POC when undertaking the process in couple-oriented IVF centres [36, 46]; women who were recently separated or divorced experienced a significantly higher negative treatment impact on their quality of life, compared to married or single women [47]. As POC is a service primarily utilized by single women without a supportive partner when undergoing the process, providing more individualized supportive services and offering more extensive counselling would make the process more emotionally and psychologically manageable for POC patients [21, 47]. This cross-sectional retrospective study design has several limitations that would limit the generalizability of the findings. First, retrospective reporting is always limited by recall bias. Second, participant anonymity did not allow us to make direct comparisons between study participants and non-participants. Third, response bias is possible due to voluntary participation. Patients with more favourable clinical experiences may have been more willing to participate. Fourth, findings from this single-site study may not reflect the POC experience of other Canadian fertility centres or other fertility centres worldwide. Despite these limitations, this study contributes important data to the paucity of research with regard to POC decision-making from patients’ perspective and adds to the limited understanding of factors influencing the quality of POC decision-making. Clinicians should provide patients with accurate POC information to improve their ability to make an informed decision, while taking into consideration their personal values and preferences. Providing individualized counselling augments the quality of POC decision-making by helping patients to set realistic expectations, thereby minimizing the chances of future regret.

The first author would like to thank Professor Eric Blyth, PhD (Emeritus Professor, University of Huddersfield) for critically reviewing the manuscript and providing insightful comments. Funding This research was funded by CReATe Fertility Centre from clinical earnings. It did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors. Declarations Conflict of interest 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.

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