Title: Patients’ and Providers’ Perspectives on Non-Urgent Egg Freezing Decision-making: a
Thematic Analysis
Version: 1 Date: 02 Nov 2022
Reviewer's report:
Review of Patients’ and Providers’ Perspectives on Non-Urgent Egg Freezing Decision-making:
a Thematic Analysis
Initial and Overall impression
Thank you for the opportunity to review this manuscript on an important and growing topic.
Summary: The authors describe the findings from a series of 25 interviews exploring women’s
and clinicians’ perspectives about elective egg freezing decisions. The authors report 4 primary
themes (focus on backup plan,  views of ovarian reserve testing, social acceptance, and peer
resources) and note differences between patients' and clinicians' perspectives.
Importance: This topic is timely and increasingly important in terms of growing incidence,
substantial gaps in evidence, high costs to women, ethical concerns, and both cultural differences
in decision-making and racism disparities in practice. The publication of high-quality formative
studies should be encouraged to address the gaps in evidence that are needed to accelerate the
transition to high-value health care (improving outcomes that matter to all patients), patient/
relationship-centered care, shared decision making solutions, policy, and funding.
Content & Contribution to the Literature: This study focuses specifically on identifying potential
decision-making values of women and clinicians considering elective egg freezing, which
echoes findings of similar studies in oncofertility and direct-to-consumer fertility preservation
technologies.
Readability:  Overall, the manuscript is well-organized and clean.  The Introduction could
be worded stronger, especially if the link to equity and high-value health care are addressed.
Harmonization is needed across the sections to ensure readers can clearly understand how the
methods address the objectives and the findings emerged from the interviews.  Addressing the
grammar typos would improve readability.
Major issues (changes that you think are required or essential)
1. Background: In the last sentence re the study purpose of the study, were the four concepts
proposed a priori?  As written, they appear to be repetitive of the Findings in the Abstract and
on page 7, which gives the impression that the objectives have been adjusted after the study to
suit the findings. Please clarify (this could be a simple as saying they were a priori, dropping
that sentence, or describing the conceptual framework that informed the selection of those four
topics - and not other topics).
2. Continuity: Similarly, there seems to be gaps between the rationale, purpose, methods, and
findings. The Background focuses on women’s decision-making values (i.e., the key factors
driving their decisions) at a general level. The purpose statement narrows in on 4 specific values
(ovarian reserve testing, acceptance, peer support) but it isn’t clear why. The interview guide
does not assess decision-making values at all, but rather asks briefly about knowledge recall,
barriers, and a few of the features that could be desirable for a decision support program. The
Findings seem to jump back to the four concepts in the purpose statement, but do not report
the primary themes regarding barriers and desirable features.  Please harmonize and clarify how
responses to those interview questions resulted in those primary themes.
3. Addressing Equity: Significant disparities exist in women’s fertility care worldwide, making
addressing equity essential for all papers in this area. While this study was not designed to
address disparities, at minimum, describe the rationale for not including the standard questions
assessing participants’ race/ethnicity, as well as well-known drivers of fertility decisions such
as culture, religion, and family beliefs. Without that data, what boundaries should readers put
on the application of these findings? For example, how might the same study find different
primary themes if participants were Québécoise or from indigenous cultures? What additional
work would you recommend to ensure shared decision-making solutions prioritize equity?
4. Methods:  More is needed regarding the approaches chosen for qualitative data collection and
analysis – please clarify. For example:
a. What was the expertise of the study team and were patient advisors consulted in the design
of the study and interview guide, or only clinicians?
b. How was the interview guide developed and pilot-tested prior to use (there may be concerns
about ordering effects and plain language for inclusiveness of all patients)?
c. Why weren’t the standard decision support program development methods used (https://
bmcmedinformdecismak.biomedcentral.com/articles/10.1186/1472-6947-13-S2-S2), or the
standard Decisional Needs Assessment interview guide (Jacobsen & O’Connor 1999, https://
decisionaid.ohri.ca/resources.html)?
d. Was speaking English an inclusion criterion?
e. Were interviews taped and transcribed? Who did the transcription?
f. Were field notes taken, compared, and discussed?
g. What were the criteria for saturation in each group?
h. How was reflexivity addressed? Was member checking done?
i. Which Thematic Analysis approach was used and why (eg, Strauss and Corbin)? How was
the codebook developed and evolved?
j. What does “four prominent themes were further explored” mean? Additional interviews? Re-
interviewing participants? Re-coding and analyzing transcripts?
k. Were any subthemes identified?
5. Findings:
a. In the participant characteristics, report the numbers of patient participants who were a)
considering a decision, b) had made a decision, or c) had made a decision and undergone elective
egg freezing. The mention that these three groups were included immediately made me wonder
whether responses differed, but no findings or discussion followed. Strongly recommend at least
one sentence addressing whether or not responses were similar, as this may be informative for
counseling and decision aid design.
b. Where are the findings for the other two sections of the interview guide re barriers and
desirable features of a decision support program?  As currently written, it appears as if much
of the analysis is missing.
c. Delete the sentence, “Although markers of ovarian reserve, including AMH, have been shown
to be an effective way to predict the number of retrievable eggs (3), views on what these markers
mean to providers and patients have not been explored previously.”  There’s an extant literature
on clinical perceptions of the validity and use of ORT measures, studies of patient perceptions
of social egg freezing that include the role of testing, and at least one study I know by Moira
Kyweluk that specifically focuses on perspectives of women considering direct-to-consumer
technologies.
Minor issues
The following suggestions are truly minor and offered solely to improve the manuscript, with
respect for the authors and in support of this important and much-needed work.  I have no interest
in being a “reviewer 2”, but rather am sincerely interested in seeing your work disseminated
and presented as robust and readable as possible.  Please use or discard at your discretion.  No
response is needed.
Overall:
• I couldn’t discern the theoretical framework that guided the study in the text.  The interview
guide contains topics that relates to shared decision making, but they are not in the usual wording/
format and there are several key gaps.
• If you have data in the interviews about what health outcomes (note: not processes or
experiences) matter most to women considering elective egg freezing, it could be a strong point
to address in the Discussion - how understanding the outcomes that matter to women is an
essential step in the progression towards providing high-quality, high-value health care.  As
opposed to simply reducing costs or improving processes, high-value health care centers on
improving the outcomes that matter to each and all patients (Teisberg & Porter 2016, Redefining
Health Care). As such, it also focuses on relationship-centered care that supports both the patient
and the care team, including facilitating shared decision making for preference-sensitive topics.
If your data is mostly processes and experiences, then I hope you will consider a value-based
framework to guide your next studies so that they truly transform care and produce value for
women, not just incremental improvement.
• There are quite a few grammar typos that could be addressed to improve readability of the
manuscript.
Abstract:
• Guidelines for readability and for effective broad dissemination of study findings call for
minimizing field-specific acronyms, especially in the abstract and for key terms. For example,
EF is a common acronym in health care and may cause cognitive dissonance for many people
in the desired audience.
• Abstract, Results: The phrase “the decisional role of” was distracting since it usually refers to
a person in shared decision making.  You can drop it and just say that “providers viewed ovarian
reserve testing as essential, while …”
• Recommend using MeSH terms for the keywords so that the article can be easily found for
systematic reviews.  Also maximize the variability of terms in the title, abstract, and keywords
to maximize search engine optimization (ability of the article to be found in the most searches).
Background:
• I found myself distracted by confirming which types of egg freezing the paper was focused on
(non-oncological, non-urgent, non-medical, elective egg freezing, etc).  All seem relevant so I’d
choose one phrase to use consistently (eg, egg freezing) and define it to include the others in the
intro.  For example, … Although egg freezing has become increasingly common (insert annual
incidence), elective egg freezing (eg, without an urgent oncological or other medical necessity),
remains controversial due to a lack of high-quality evidence, high costs to patients, and ethical
concerns. [then add at least one sentence describing these three things – gap, costs, concerns –
before changing the subject to reasons. You might even restructure this paragraph to set up your
rationale for why you compared patients’ and clinicians’ perspectives.]
• The opening paragraph can be more crisp and compelling for such an important topic (e.g., the
“only” is confusing in the first sentence).  You could skip it entirely and start with the second
paragraph to jump into the real issue. Also, add the incidence to the first sentence of that second
paragraph.
• Citations needed re the description of shared decision making,
especially since it focuses on the role of the physician rather
than the mutual exchange of information described by the international
guidelines (http://www.ipdas.ohri.ca/resources.html) or the Cochrane Collaboration
review (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001431.pub5/full?
highlightAbstract=aids%7Cdecision%7Cdecis%7Caid).
Methods
• Guidelines emphasize the importance of describing informed consent as a process, not just the
form signed.  Consider rephrasing to the standard template language: eg, “All study participants
provided initial and ongoing informed consent”.
Results & Findings
• Consider changing the header to Findings or Results and Findings, as results typically refers
to quantitative studies.
• While I agree with contemporary perspectives that reporting numbers is less relevant in
qualitative studies, clarity would be helpful in understanding how you determined what were
primary themes and what “several people” meant, given he small samples in each group.
• It would be helpful to note whether any latent concepts were observed in your thematic analysis.
They don’t seem to be clearly mentioned in the Findings; however, there are additional concepts
referred to in the Discussion.
• Is the statement that patients approach were some of the first seen for elective egg freezing at
this clinic intended to focus on the potential impact of being years out from their decision (if
it’s been done a while there) or in the first cohort at this clinic? How might being in the first
cohort impact the findings and interpretation (don’t want readers to decide this is a reason to
ignore the manuscript at this point).
• Decisional Role of ORT: Decisional role refers to the role a person wants to play in the
Definition, Deliberation, Determination processes of making a shared medical decision. It seems
that in these paragraphs that you are describing the disconnect of clinicians realizing that ovarian
reserve testing is not a top decision-making value for women. I would recommend switching
terms so it’s not confusing for readers.
• Also, it is very notable that the clinicians articulated the logic problems in using ORT at either
extreme to guide decisions. The problems with the various ORT measures have been well-
articulated in the literature, and yet the culture of practice continues to place high decision-
making value on ORT.  That would be a good point for the Discussion and for relating these
interviews to the existing literature.  One possibility is that clinicians are carrying over decision-
making values from medically-indicated fertility preservation to these elective discussions,
while women do not have that "burden of knowledge" - hence the difference in perspectives
and communication.
• Acceptance: The quotes provided focus on early awareness and education more than
acceptance.  Do you have other quotes?  If not, might want to reframe or clarify why you chose
the concept acceptance here over the other concepts.
Discussion
• The first two sentences aren’t necessary; strongly recommend replacing them with a clear
summary of the key findings and how to use them, as many readers review the abstract and first
paragraph of the Discussion to decide whether to read the rest.
• Multiple concepts are mentioned in the quotes and Discussion. While I understand the sample
size was small in each group, it would be more robust to report primary themes and subthemes
in the usual qualitative format.
• It may be worth discussing how many of these findings echo or parallel similar studies
of fertility preservation decision-making values of reproductive-aged women diagnosed with
cancer and oncofertility clinicians.  There is value in sharing knowledge across siloes so that we
do not re-invent the wheel when developing decision support programs. If you are considering
developing a patient decision aid, I recommend reaching out to Dr. Terri Woodard at MD
Anderson who created the wonderful Pathways website, which is validated and could be easily
adapted for elective decisions.
Again, these comments are offered with full respect of your authorship as suggestions for
strengthening the manuscript.