Awareness and Decisions Regarding Elective Oocyte Cryopreservation (EOC) in Greece: A Cross-Sectional Study on Generation Z

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Esteemed Authors and Editors,

In my opinion this is a very interesting topic to have chosen and a valuable manuscript. The theme of elective oocyte preservation is still young, but it will gain more ground in the future.

 

I have several suggestions for the authors:

• Line 57 – “ a woman's age and the number of retrieved oocytes is critical factors” – correct to “are critical factors”.
• In the Results section, data should be provided either as text or as tables/figures. please remove all duplicate information.
• In the Discussions sections, when discussing the correlation between education and fertility preservation choices we may speculate these women are more likely surrounded by people who support their decision (family, peers, partner).
• I would also comment that clearly the personal history of gynaecologic pathology, especially with ovarian involvement, is deemed to render patients more aware, hopefully by medical advice primarily. And secondly given their own care and preoccupation.

At the same time, having peers experiencing infertility issues, especially age related, could also a strong factor influencing the initiative to plan one’s family planning and adopt cryopreservation as a viable option.

• I think a comparative analysis between “older” and “newer” studies could be added, since the social context of fertility awareness and planning has changed much in the past 20 years, as well as the perception of fertility preserving options, women’s roles in society and even cryopreservation methods who now favor vitrification.

As a result, I support the publication of the current manuscript following the minor changes suggested.

Author Response

Comment 1: "In the Results section, data should be provided either as text or as tables/figures. Please remove all duplicate information."

• Response: We thank the reviewer for this suggestion. We have thoroughly reviewed the Results section and removed redundant numerical data from the text that was already clearly presented in the tables. The text now focuses on highlighting key trends and significant findings.

Comment 2: "Discussion: Speculate on the correlation between education and fertility preservation (social support/peers)."

• Response: We agree that the social environment plays a crucial role. We have added a section in the Discussion speculating that highly educated women are likely part of social circles (peers, family, partners) that are more informed and supportive of reproductive autonomy and EOC.

Comment 3: "Discussion: Gynaecologic history and peer infertility as factors."

• Response: Excellent point. We have added a paragraph discussing how personal gynaecologic history acts as a "medical wake-up call," often supported by direct medical advice. We also included the impact of "vicarious experience" through peers facing age-related infertility.

Comment 4: "Comparative analysis between 'older' and 'newer' studies (vitrification/social context)."

• Response: We have included a brief comparative analysis. We highlight that older studies focused on "slow-freezing" and medical necessity, whereas newer studies (including ours) reflect the "vitrification era" and a shift toward social egg freezing and career-oriented reproductive autonomy.

Reviewer 2 Report

Comments and Suggestions for Authors

Currently, many countries only subsidize medical egg freezing. In the future, to reduce the low birth rate, social egg freezing could be encouraged and subsidized.

I agree with conducting a survey on this intention among young women. Knowing their intentions would allow for targeted encouragement of egg freezing at a young age.

1. The core issue explored is the impact of Selective Oocyte Cryopreservation (EOC) on Gen Z women.The study aims to answer the following questions:

• Investigate these young women's familiarity with the technology and the proportion of them potentially willing to use this fertility-preserving technique in the future.
• In-depth analysis of demographic and psychosocial factors that influence women's reproductive decisions. This includes examining how education level, living environment, reproductive health history (such as ovarian disease or surgery), and complex factors such as anxiety about declining fertility, family and social expectations, and financial considerations affect their decisions.
• Identify common social characteristics among women considering selective oocyte freezing to build a predictive model that understands their decision-making processes, values, and social roles.
• One of the ultimate goals of the study is to provide practical guidance to healthcare professionals (such as midwives and obstetricians) through these findings, helping them develop optimal preconception education and counseling strategies for young women considering oocyte freezing.

2. The literature clearly points out that while numerous studies have explored women's awareness and motivation regarding selective egg freezing (EOC) with the increasing prevalence of egg freezing technology, a significant gap remains in the discussion of the perspectives of "young women (i.e., the next generation of mothers)." This study aims to fill this gap, specifically focusing on Generation Z women (primarily 18-25 years old) to understand their potential acceptance of this technology and their decision-making motivations before facing actual fertility pressures.Relevance and Original Contribution: The significance and originality of this study are primarily reflected in the following aspects:

• As more and more women delay childbearing for non-medical reasons (such as career development or lack of a partner), this study helps to expand the broad knowledge of the complex relationship between reproductive technology and "women's reproductive autonomy."
• The study goes beyond simply investigating intentions; through cross-analysis of factors such as young women's education level, living environment, gynecological history, and psychological anxiety, it establishes for the first time a multi-dimensional predictive profile for this group of young women who "may freeze their eggs in the future."
• The ultimate contribution of this study, after filling this gap, lies in its clinical application. The findings can directly help medical professionals (such as midwives and related health educators) develop more comprehensive and targeted preconception counseling strategies and best practices for young women.

3. Compared to other published literature, this study's contributions to the fields of reproductive medicine and sociology are primarily reflected in the following core aspects:

• While a wealth of literature has explored women's awareness and motivations regarding selective egg freezing (EOC), a significant gap remains in the discussion of the perspectives of "next-generation mothers" (i.e., young women). This study, specifically targeting Generation Z women, successfully fills this gap, allowing us to understand the forward-looking attitudes of this younger generation in the face of actual fertility pressures.
• This study goes beyond simply investigating intentions; it also establishes a concrete predictive model (visualized through a radar chart) using multivariate logistic regression analysis. This innovative contribution reveals how demographic characteristics, reproductive health history (such as past surgical history), and psychosocial factors (such as independence in student housing) intertwine and collectively shape women's reproductive decisions.
• The results confirm that "higher education levels are more likely to lead to the pursuit of fertility preservation strategies," which is highly consistent with existing literature exploring the impact of education level. Furthermore, this study found that the tested group had an extremely high level of awareness about egg freezing (93.1%), which echoes the findings of a 2016 literature study comparing the attitudes of women in Denmark and the UK. The contribution of this study lies in extending and applying the conclusions of these existing studies to younger populations who are not yet facing immediate pressure to have children.
• This study significantly expands the broad knowledge of the link between assisted reproductive technology and women's reproductive autonomy. Its significant practical contribution is that the findings can directly assist medical professionals in developing optimal practical and preconception counseling strategies for young women considering egg freezing, and provide policymakers with clear direction, advocating for the use of financial support mechanisms to promote equality and empowerment in reproductive decisions.

4. Based on the limitations and future directions of this study, the authors suggest the following specific methodological improvements to enhance the rigor and applicability of the research:

• The current study employs a cross-sectional design, which only observes states at specific points in time and cannot establish definitive causal relationships between variables. Future research should consider using a longitudinal tracking design to observe how women's attitudes towards fertility and egg freezing evolve over time and life stages.
• The reproductive health variables in the study (e.g., menstrual cycle characteristics, gynecological history) were all self-reported by participants and have not been clinically validated. This can easily lead to reporting bias or subjective interpretation errors. Future research could consider incorporating objective medical record data to improve accuracy.
• The current sample is predominantly composed of young women of Greek origin, which may limit the applicability of the results to other cultures or socioeconomic backgrounds. Future research should expand the sample size to include a more diverse population of different nationalities and ethnicities to gain a more comprehensive understanding of the true attitudes of women worldwide towards selective egg freezing.

This study primarily focuses on the current "willingness and awareness" of young women. To better reflect reality, future research methods should incorporate assessments of long-term outcomes, such as exploring the long-term emotional and psychological impacts of selective egg freezing, and actually tracking women's "post-operative satisfaction," "regret," and "actual utilization rate of frozen eggs." This research on young women's intentions regarding egg freezing can provide a reference for future government policies.

Author Response

We sincerely thank the reviewer for the comprehensive summary and for recognizing the originality of our study, particularly the use of the radar chart and the focus on Generation Z in Greece. We have reinforced the "Future Directions" section to include the longitudinal designs and the use of objective medical records as suggested.

Reviewer 3 Report

Comments and Suggestions for Authors

The overall manuscript is well presented in a logical comperhensive way of studying the awareness of the young generation Gen Z regarding the elective oocyte freezing. However, a few key points could be of added value:

1. Title: consider awareness instead of attitude, add the geographic area (Greece)
2. Abstract: The OR of logistic multivariate analysis was not mentioned.
3. Methodology: the data collection period in the methods is different from that in the abstract (maintain consistant time period of data collection)
4. Introduction: More clinical applications of early fertility awareness from a clinical perspective.
5. Methods: No response rate of the online questionnaire was reported.
6. Results: for the OR for living with a partner was 0.07, a strong protective factor against the idea of having the EOC. However, living with a partner OR 0.07 with CI 0.01–1.43 has a wide range which crosses 1, meaning an insignificant outcome.
7. Discussion: kindly consider more description of the limitations in the form of financial, legal, and social perspectives.
8. Conclusion: Try to be more neutral, less prescriptive tone

Author Response

Comment 1: "Title: Consider 'awareness' instead of 'attitude', add 'Greece'."

• Response: Accepted. The title has been revised to reflect both the focus on awareness and the geographic location.

Comment 2: "Abstract: Mention OR of logistic multivariate analysis."

• Response: We have updated the Abstract to include the specific Odds Ratios (OR) and 95% CI for the most significant predictors (e.g., education level and student housing).

Comment 3: "Consistency in data collection period."

• Response: We apologize for the oversight. The dates have been synchronized throughout the manuscript to "November 2024 to February 2025."

Comment 4: "Methods: Report response rate."

• Response: We have now included the response rate.

Comment 5: "Results: OR 0.07 for living with partner (insignificant outcome)."

• Response: The reviewer is correct. While the OR was low, the 95% CI [0.01,1.43] and p-value of 0.086 indicate that this did not reach statistical significance. We have corrected the text to describe this as a "non-significant trend" rather than a definitive protective factor.

Comment 6: "Discussion: Limitations in financial, legal, and social perspectives."

• Response: We have expanded the limitations section to discuss the high cost of EOC in Greece and the current legal framework, which primarily favors medical over social freezing in terms of subsidies.

Comment 7: "Conclusion: Be more neutral."

• Response: We have revised the conclusion to be more balanced, avoiding prescriptive language.