Socio-demographic profiles, motivations and perspectives of women undergoing publicly funded elective fertility preservation: a nationwide multicenter study in France.

A total of 351 survey responses were recorded, originating from 49 of the 96 French residential metropolitan departments. 27/31 CECOS centers reported participating in the study. As shown in Table  1 , 306 of the 351 participants were aged 33 years or older (87.2%). Most of these women were not in a relationship at the time of EFP (62.9%, n  = 220) and were childless (98%, n  = 344). Regarding the level of education, 333 participants had a high level of education (95.4%). Most of the participants had already undergone EFP (OC + : 61.1%, n  = 214 versus OC-: 38.9%, n  = 136). Of the 136 participants who had not yet completed the EFP process (OC- group), 61.8% (84/136) had already attended a prior consultation, while 38.2% (52/136) were attending a consultation for the first time. During the inclusion period, an average of 110.8 consultations for EFP were carried out per center. This corresponds to an estimated response rate of 4.5% among women who had not yet undergone EFP. Responses to questions about motivations showed that the main reasons for undergoing an EFP process were the absence of a partner (50.7%, n  = 178); no desire for an immediate pregnancy (30.8%, n  = 108); and a partner without immediate desire of children (16.0%, n  = 56). Only a few participants expressed interest in postponing their pregnancy due to financial (12.3%, n  = 43) or professional (14.0%, n  = 49) reasons. Women were asked to identify the initial sources of information that led them to the EFP procedure (Table  1 ). Family members and friends were the main source of information (37.6%, n  = 132), followed by healthcare professionals (29.3%, n  = 103), and the media/social networks (27.1%, n  = 95). The questionnaire also assessed these women’s awareness of the French bioethics law. Only 32.6% ( n  = 114) of the respondents correctly identified the legal age limit for oocyte use, i.e. 45 years old (Table  1 ). Stratifying by stage of care revealed significant differences in the proportion of correct responses regarding the legal age limit. Only 13.5% (7/52) of the women attending the consultation for the first time answered this question correctly. Among women who had undergone a prior consultation or oocyte cryopreservation, 45.2% (38/84) and 32.2% (OC + : 69/214), respectively, answered correctly. This indicates a progressive loss of information following counseling ( p  < 0.01). Among women who had considered oocyte donation, 57.0% (187/328) knew about the bioethics law allowing individuals conceived through ART with gamete donation to access the donor's identity once they reach 18 years old in France. The first items in the questionnaire regarding the perspectives on the future use of oocytes explored patients’ intentions to use their frozen oocytes for conception, the family context in which they planned to do so and their anticipated timeline (Fig.  2 ). Of the 349 respondents to this item, 68.5% ( n  = 239) believed it was likely or very likely that they would need to use their cryopreserved oocytes to conceive a child. The intended family model for using these oocytes (multiple choices question) was primarily a heterosexual couple (82.9%, n  = 291). However, 46.2% of the respondents ( n  = 162) also considered using them as single woman, while 6.3% ( n  = 22) considered using them as part of a same-sex couple. Regarding the age limit for using cryopreserved oocytes, 49% of the respondents set an age limit, with 86.8% setting the limit at 40 years or older. In the event of non-self use of the cryopreserved oocytes (multiple-choice question), 65.8% ( n  = 231) of participants would like to donate them to another woman or couple, and 57.5% ( n  = 202) would like to donate them for research purposes (Fig.  2 ). Fig. 2 Perspectives of the women participants to the questionnaire about: A their intended Family Model if they plan to use their oocytes by ICSI, B the chance of issue of their cryopreserved oocytes if they do not use for themselves. A and B are based on multiple-choice questions Perspectives of the women participants to the questionnaire about: A their intended Family Model if they plan to use their oocytes by ICSI, B the chance of issue of their cryopreserved oocytes if they do not use for themselves. A and B are based on multiple-choice questions A multiple correspondence analysis (MCA) revealed two distinct clusters of women respondents to the survey (Fig.  3 , Supplemental Table 2). These clusters significantly differed in terms of the likelihood of using cryopreserved oocytes, the stage of the medical process (OC +/OC-), the motivation for undergoing EFP, and the intended parental model. The first cluster consisted of 48.1% of the respondents (169/351). The women in this cluster had more often already completed EFP (OC + : 72.8%), expressed a desire to become pregnant despite not having a partner (93.5%), and considered using cryopreserved oocytes as single women (59.2%). In contrast, the second cluster (44.7%, 157/351) included mainly women who had not undergone EFP (OC-: 48.4%), who either did not want to become pregnant immediately (57.0%) or whose partners did not want to have children at that time (35.0%). Moreover, within this cluster, 90.5% of respondents would like to use cryopreserved oocytes within a heterosexual couple, despite 29.9% not knowing whether the use of oocytes will be necessary. Fig. 3 A multiple correspondence analysis (MCA) followed by hierarchical classification explored relationship between prespecified variables ( A ), the first two dimensions (Dim 1 and Dim 2) represent the main axes summarizing associations among the studied factors. Two clusters of 169 and 157 participants were identified ( B ) based on their distribution in the factorial map. Variables contributing significantly to cluster 1 (black) or cluster 2 (red) are shown in panel ( A ). All variables plot coordinates are listed on Supplemental Table 2 A multiple correspondence analysis (MCA) followed by hierarchical classification explored relationship between prespecified variables ( A ), the first two dimensions (Dim 1 and Dim 2) represent the main axes summarizing associations among the studied factors. Two clusters of 169 and 157 participants were identified ( B ) based on their distribution in the factorial map. Variables contributing significantly to cluster 1 (black) or cluster 2 (red) are shown in panel ( A ). All variables plot coordinates are listed on Supplemental Table 2

This nationwide, multicenter descriptive study was conducted from November 2023 to June 2024 within the French national CECOS network (31 French centers authorized to perform EFP). This study is based on the results of an anonymous online survey targeting women involved in an EFP process at these centers. The ethics committee of Clermont-Ferrand University Hospital approved the study on July 24, 2023 (2023-CF094). The 351 women included in this study met the criteria for EFP defined by the 2021 bioethics law [ 26 ], namely, they were being between 29 and 37 years old at the time of the procedure, and they did not have diseases or undergo treatments affecting ovarian reserve that would qualify them for medical FP [ 27 ]. Only the women who participated in the study were considered. Women who had not yet undergone oocyte cryopreservation (OC) were asked to participate in the study when they came to the center for an EFP consultation. All consultations were conducted within a CECOS reference center, in accordance with national clinical regulations [ 28 ], which define the obligatory content and methodology of counseling, including information on age limits, legal restrictions, and donation policies. At that time, a medical doctor gave them a document with a QR code and an email address to access the online questionnaire. Women who had already undergone OC were invited retrospectively to participate in the study via email (Fig.  1 ). Fig. 1 Study flowchart. One woman did not respond about her current stage in the medical process. OC + the questionnaire was proposed by email to the women after procedure of oocyte cryopreservation was achieved. OC- the questionnaire was proposed to the women during the counseling before oocyte freezing for EFP. EFP: Elective Fertility Preservation. OC: Oocyte cryopreservation Study flowchart. One woman did not respond about her current stage in the medical process. OC + the questionnaire was proposed by email to the women after procedure of oocyte cryopreservation was achieved. OC- the questionnaire was proposed to the women during the counseling before oocyte freezing for EFP. EFP: Elective Fertility Preservation. OC: Oocyte cryopreservation The clinico-biological team at the assisted reproductive technology (ART) unit of Clermont-Ferrand University Hospital designed and approved the online questionnaire consisting of 17 questions (open-ended, multiple-choice with single or multiple answers) and requiring five minutes to be completed. The women could skip questions if they wanted to. To ensure anonymity, no questions about their identity were asked; only their department of residence in France was requested. Participants reported their stage of the oocyte cryopreservation process allowing the formation of two groups: those who had not yet undergone oocyte cryopreservation (OC-) and those who had (OC +) (Fig.  1 ). Women in the OC- group must specify whether or not they have already attended a consultation. This allowed us to analyze responses based on the stage of the process. Three main themes were then analyzed: socio-demographic profiles and motivations; levels of knowledge about EFP; and the perspectives on the potential future use of cryopreserved oocytes (Supplemental Table  1 , at the bottom of the manuscript before the bibliography). Information and related documents for this study were given to CECOS network to ensure nationwide deployment. Table 1 Socio-demographic profiles, motivation and levels of knowledge of women participating to the survey about elective fertility preservation % (n) Socio-demographic profiles Age group (y) ( n  = 351)  29–32 12.8% (45)  33 +  87.2% (306) Marital status ( n  = 350)  Single 62.9% (220)  Married/In a relationship 37.1% (130) Family status ( n  = 351)  Children—Yes 2.0% (7)  Children—No 98.0% (344) Education level ( n  = 349)  Up to high school diploma 4.6% (16)  Higher education graduate 95.4% (333) Motivation ( n  = 351)  Desire for pregnancy but no partner 50.7% (178)  No desire for pregnancy 30.8% (108)  Partner does not want pregnancy 16.0% (56)  Waiting for financial stability 12.3% (43)  Waiting for professional stability 14.0% (49) Knowledge Sources of information a ( n  = 351)  Social circle 37.6% (132)  Healthcare professionals 29.3% (103)  Media 27.1% (95)  Others (personal research, profession) 6.0% (21) Knowledge of the bioethics law ( n  = 350) Correct response (45 yo)  All participants 32.6% (114)  First consultation ( n  = 52) 13.5% (7)  Consultation carried out ( n  = 84) 45.2% (38)  EFP completed ( n  = 214) 32.2% (69) yo years old a multiple-choice question Socio-demographic profiles, motivation and levels of knowledge of women participating to the survey about elective fertility preservation yo years old a multiple-choice question Due to the survey-based design, no formal sample size calculation was performed. However, according to previous studies [ 29 – 31 ], the sample size allowed robust estimation of proportions and the identification of meaningful participant profiles using multivariate exploratory methods. To identify the key determinants influencing decision-making, the relationships between socio-demographic characteristics, the motivations, the level of knowledge about EFP, and perspectives of women opting for EFP were first examined using the Chi-squared test or Fisher's exact test. Subsequently, a multiple correspondence analysis (MCA) followed by hierarchical classification was conducted. The objectives were to further explore the relationships among the prespecified variables, and to identify groups of patients sharing similar response patterns. While significance testing with Chi-squared or Fisher’s exact tests only indicates whether pairwise associations exist, MCA provides a broader framework by showing how multiple categorical variables are interrelated. Variables included in the MCA were selected based on univariate results and their epidemiological relevance. All analyses were performed using Stata software (version 15, StataCorp, College Station, TX, USA) and R ( https://cran.r-project.org/ ). For inferential analyses, a two-sided type I error rate of 5% was considered statistically significant. Declaration of generative AI and AI-assisted technologies in the writing process. During the preparation of this work the authors used DeepL Write AI tool in order to improve language and readability. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

Our study is the first multicenter study within the CECOS network to investigate EFP three years after its authorization and reimbursement by the French health system. Our study identified two different clusters of women. One cluster consisted of women who desired pregnancy and considered single motherhood. The other cluster consisted of women who were concerned about their fertility, did not want to become pregnant immediately, and prioritizing a heterosexual family model. A larger-scale prospective study with the fate of cryopreserved oocytes will be necessary to complement this analysis. Finally, the low level of understanding of the regulatory framework governing the procedure among these women, as revealed by the questionnaire, underscores the importance of addressing this issue in greater depth during the medical counseling.

Our multicenter study aimed to assess the sociodemographic profiles, motivations, knowledge and perspectives on the future use of cryopreserved oocytes of women undergoing EFP, using a survey distributed through the French public network CECOS. This study was conducted in France, three years after EFP was legally authorized in a healthcare system that covers procedure costs. The women undergoing EFP in our study were primarily single and childless with high levels of education. These findings are consistent with those of a previous monocentric French study [ 32 ] and other European data [ 17 , 21 , 33 – 35 ]. Indeed, Murugesu et al . (2023) demonstrated that the majority (89.5%) of women who underwent social egg freezing were single at the time of the procedure, which they considered to be a motivating factor [ 35 ]. For these women, the quest for EFP was primarily driven byconcerns about a future decline in their fertility. Our national analysis revealed two distinct participant profiles. The first and largest group consisted of women who sought EFP because they wanted to become mothers but did not have a partner. Although these women generally favored the traditional family model, they remained open to becoming single mothers through sperm donation. This confirms the study by Kanters et al. (2022), showing that women preferred motherhood with a committed partner, yet still viewed solo motherhood as a viable alternative [ 17 ]. The second cluster contained women without immediate desire of pregnancy, but who were actively seeking information or securing their reproductive options for the future. For these women, EFP may be a long-term strategic decision rather than an immediate response to current circumstances. Therefore, our multicentric study confirms the two clusters reported by Chehimi et al. (2024) in their monocentric study of French women [ 32 ], with some participants perceiving EFP as a part of a broader approach to advancing reproductive planning. During the counseling, the information is provided in accordance with French regulations governing assisted reproductive technologies and fertility preservation. These regulations define the mandatory content, including age limits, legal restrictions, and donation policies [ 28 ]. Therefore, this information should be retained for several years. However, our study reveals that fewer than half of the respondents were able to answer questions correctly about key aspects of the EFP procedure in France, such as the age limit for using cryopreserved oocytes through ICSI or the legal context of oocyte donation. This suggests a discrepancy between the information provided during the consultation and what the women ultimately understand or remember. To address this issue, we propose implementing a follow-up counseling session that revisits important information, such as the legal age limit for oocyte use and options in the event of non-self use. Providing a comprehensive explanation and emotional support throughout the EFP process is crucial, as misunderstanding the advice has been shown to increase regret about the decision after ART [ 36 ]. In France, EFP is fully covered by the national healthcare system for women between 29 and 37 years of age [ 26 ]. Other countries do not set an age limit on the possibility of undergoing EFP, opening an ethical debate on this policy. In previous studies without age restrictions, most participants expressed interest in cryopreserving their oocytes on average before turning 38 [ 35 ]. In our study, most respondents were women aged 33 or older. This may be related to the fact that the survey was conducted three years after EFP was authorized in France, which could explain the observed age range. Women who choose EFP at a younger age for non-medical reasons are more likely to conceive naturally. As a result, they may ultimately never need to use their cryopreserved oocytes [ 37 , 38 ]. As previously published by Hagege et al. (2024), the majority of French women who responded to our questionnaire were highly educated (95.4% had graduated from higher education compared to 51.9% of women aged 25–44 in the general population [ 39 ]), suggesting a high socioeconomic status, although educational attainment was the only available marker. Often, highly educated women face demanding career paths and extended years of study, which can lead to delayed family planning. This may be one reason for the increased demand for non-medical oocyte storage [ 40 ]. Furthermore, because most women view education and careers as essential, delaying pregnancy becomes inevitable [ 41 ]. Theoretically, reimbursement by the French national healthcare system eliminates financial barriers that continue to restrict access for women of lower socioeconomic status elsewhere [ 35 ], including in Europe, where most countries offer little to no financial coverage. According to a Belgian study, women felt a sense of injustice due to the lack of reimbursement for EFP [ 42 ]. These contrasts highlight how national policies influence both access to and perceptions of EFP. Although we might have expected that the reimbursement of EFP to make it accessible to all social classes, the results of our studies indicate otherwise, as the majority of respondents were highly educated. This raises the questions about how French women are currently being informed about the EFP. In our study, many participants learned about EFP through personal networks, followed by healthcare professionals. Similarly, a previous French study found that only 30% of the participants from were informed by healthcare professionals, while most heard about it from friends or family [ 11 ], revealing a gap in physician–patient communication. Notably, young women in France receive limited information about the age-related fertility decline. Indeed, neither schoolteachers nor general medical doctors provide adequate education on this topic. To address this gap, the French government launched an information campaign in 2025 through the official health insurance website to raise awareness about infertility and the decline of fertility with age. Providing preventive counseling between the ages of 25 and 30 may also help address this gap by offering fertility assessments and raising awareness about age-related fertility decline. This approach could promote informed reproductive choices and encourage young women to reflect on family planning earlier. Furthermore, integrating this counseling into routine preventive care could normalize fertility discussions, dispel misconceptions, and promote a proactive approach to reproductive health. By contrast, the media accounted for just a quarter of the reported information sources, suggesting a mismatch between the platforms used for public messaging and how the target audience consumes media. Broader campaigns, such as television advertisements or posters in public spaces, could help to bridge this gap. Meanwhile, the media should take a more responsible approach to fertility communication. Frequent portrayals of celebrities conceiving at advanced ages may create unrealistic expectations. Thus, balanced, evidence-based messaging is essential to promoting an accurate understanding of reproductive aging. In our study, most respondents believed that it was likely or very likely that they would use their cryopreserved oocytes at an ART unit to conceive after turning 40. The predominant intended family model was within a heterosexual couple. However, nearly half of them also considered using their oocytes as single women. Since the survey was anonymous, the actual outcomes are unknown. It would be valuable to plan a prospective study to clarify this issue. The response rate to our survey was 4.5% but may be underestimated due to the approximate estimation of the number of women who were invited to participate in the survey. However, this is comparable to the response rates reported in another large health survey [ 43 ]. Furthermore, the fact that our results are consistent with those of other French studies [ 11 , 32 ] on the same subject reassures us as to the representativeness of our samples. In perspective, the follow-up of a larger cohort with an accurate census of the patients surveyed would help determine the usage rate of cryopreserved oocytes. Finally, another limitation of our study is that patients in the two clusters are at different stages of the decision-making process. This may affect comparability, as some women who have had a consultation may discontinue the procedure before undergoing egg freezing. However, a study in the United States reported that fewer than 10% of patients enrolled in an EFP process choose to stop the procedure [ 44 ]. As treatment options in this country are expensive, it is likely that this number is even lower in France, which would reinforce the comparability of our two clusters. Most participants expressed willingness to donate their oocytes to another woman or for research if they did not intend to use them. Thus, despite the absence of financial compensation, these French women showed strong support for oocyte donation, contrasting with findings from countries where monetary compensation is permitted [ 45 ]. Although decisions about egg donation are complex and follow an individual thought process [ 46 ], this may reflect an increased awareness of fertility issues and exposure to information about oocyte donation during their medical journey. Having already undergone the physically and emotionally demanding retrieval process may lower psychological barriers to donation as no further intervention is required [ 47 ]. Therefore, unused oocytes could help alleviate the shortage of donor oocytes, despite practical challenges, such as the need for additional screening and counseling. Eligibility for donation could be discussed during EFP counseling. However, there are some ethical concerns, including issues of informed consent and appropriate compensation [ 48 ]. Many participants expressed a willingness to donate, but our study highlights that few were familiar with the legal framework surrounding access to donor information, underscoring the need to improve public and professional education.

Oocyte vitrification is now a well-established fertility preservation (FP) procedure. Initially intended for medical reason, primarily for patients facing cancer therapies [ 1 ], it is also proposed for benign conditions that may affect ovarian reserve, such as endometriosis [ 2 ] or autoimmune disorders [ 3 ]. Due to its effectiveness, this procedure has been extended to women who wish to delay childbearing for personal, professional, or social reasons. In such cases, this practice is referred to as ‘elective fertility preservation’ (EFP) [ 4 , 5 ]. For over a decade, EFP has been widely available in different countries, offering women the option to extend their reproductive window [ 6 , 7 ]. Indeed, intracytoplasmic sperm injection (ICSI) with warmed oocytes yields comparable results to those obtained with fresh oocytes [ 8 ], but achieving a live birth is not guaranteed [ 7 ] and remains strongly age-dependent [ 6 ], as confirmed by a recent meta-regression analysis. This study revealed that the future conception rate following EFP ranges from 19 to 52% for women aged 40 or under 35, respectively [ 9 ], with the best outcomes being observed in the 30–34 age group [ 6 , 10 ]. Although EFP is a promising alternative for mitigating age-related infertility, performing it too early may increase the risk of not using the cryopreserved oocytes [ 11 ]. In many countries, access to EFP remains largely dependent on financial resources. In the USA, two oocyte-retrieval-cycles, which are often required to obtain 15–20 mature oocytes, cost approximately $15,000 [ 12 ]. In most countries, reimbursement for the procedure is indication-based, with EFP being rarely reimbursed, particularly given the relatively low utilization rate of oocytes [ 13 ]. Importantly, women who choose to delay motherhood are often financially stable, have a partner, and/or are career-driven [ 14 , 15 ]. EFP allows women to proactively manage their fertility, which contributes to reproductive autonomy and promotes gender equality [ 16 – 19 ]. Beyond healthcare policy, EFP has sparked feminist debates about the tension between medical and commercial influence and reproductive autonomy. A recent study, showed that most of the American women interviewed pursued EFP in hopes of having a genetically related child, rather than prioritizing their careers, framing this choice as an act of "responsible" reproductive planning [ 20 ]. In France, the 2021 bioethics law legalized EFP for women aged 29 to 37 without limiting the number of oocyte retrieval cycles. France is also the first country to offer public reimbursement for EFP-related clinical and biological procedures associated, excluding annual storage fees. Only public centers, mainly within the CECOS (Centre Etude et Conservation des Œufs et Sperme humain) network are authorized to perform the EFP procedure. Based on the principle of social justice, this policy aimed to eliminate income-based disparities and ensure equitable access to EFP. This development raises important questions about whether the reimbursement framework influences the demographic profile of women accessing these services [ 21 ]. Worldwide, the use of cryopreserved oocytes remains low: between 8.4 and 38% of women who freeze their oocytes ultimately use them via ICSI [ 6 , 7 , 22 , 23 ], and a recent meta-analysis of 17 international studies revealed that 26% of women undergoing EFP were willing to donate their oocytes [ 24 ], with a higher likelihood of donation after family completion [ 25 ]. In France, women who have undergone EFP are contacted by the CECOS center to decide whether to continue storage, donate their oocytes anonymously, give them to research, or end storage. In this context, the aim of our study is to conduct a comprehensive national analysis of EFP three years after its legal authorization and reimbursement in France. By examining the socio-demographic profiles, the motivations, the levels of knowledge about EFP and perspectives of women who opt for EFP, this study seeks to identify the key determinants that influence their decision-making processes. The findings of this study will likely improve women’s care, optimize counseling strategies and refine EFP procedures, to better align with women’s needs and expectations.

Supplementary Material 1. Supplementary Material 1.