Title: Patients’ and Providers’ Perspectives on Non-Urgent Egg Freezing Decision-making: a
Thematic Analysis
Version: 1 Date: 20 Oct 2022
Reviewer:  Tessa Copp
Reviewer's report:
Thank you for the opportunity to review this beautifully written manuscript with important
insights and well described methods. My main concern with the manuscript is regarding the
discussion around ovarian reserve testing. Many sentences in the results and discussion refer
to providers believing AMH is an indicator of success for ART live birth rates. However, the
evidence is far from clear. Although AMH is associated with the number of eggs obtained, this
does not necessarily translate to higher birth rates (see Broer et al, 2013; Broekmans et al, 2006).
As such, ASRM guidelines are clear that AMH test results should not be used as a criterion
for the use of ART (ASRM 2015). It is also not clear that people with low AMH have a lower
chance of achieving a pregnancy spontaneously later in life (Steiner 2017). Although associated
with menopause timing at a population level, predictions have an 8—12 year range, making the
test result uninformative for individual women (Depmann et al 2018; De Kat et al 2021). Given
the unreliability of AMH test results, the discussion could reflect on how this evidence contrasts
to the views of your participant providers, and why it is concerning they are using the AMH test
to deem patients ineligible for treatment.
Further suggestions or points to consider are outlined below:
Abstract
- Suggest removing “No study has explored perspectives on EF from both providers and patients”
as there are many studies providing patient perspectives on EF and you did not interview patient-
clinician dyads.
Introduction
- Thank you for stating the costs, however, you could also add how the costs are likely higher
for some women due to the need of having more than one cycle to get a good enough number
of eggs.
- The aims sound like you interviewed patient-clinician dyads. Please correct.
Results
- Do you have data on whether patients were currently in a relationship? Please add to Table
A if so.
- The results suggest you conducted a content analysis however the methods state you undertook
thematic analysis.
- Figure A is a great addition to the manuscript.
- Suggest italicizing quotes in addition to quotation marks so it is immediately clear to the reader
they are the participants’ own words.
- Was there any discussion around what patients perceived the likelihood of success of using
frozen eggs was, if required? Research has found the general public and IVF patients tend to
over-estimate their likelihood of success. This could perhaps in part explain how participants
appeared less concerned about the likelihood of failure if they did end up using their frozen eggs.
Discussion
- Please soften your wording about interviewing ‘patients and their providers’ as you did
not interview actual patient-clinician dyads. This could account for some of the incongruous
findings.
- I agree AMH should not be a factor in determining eligibility for treatment, but rather used
a guide for how many eggs may be collected and how many cycles may be required for a
good chance of success if those egg stores are to be used. You could also discuss how patients
misunderstood the reason for AMH testing (thought it was related to their ability to conceive
now), and how they need more accurate, evidence-based information about what the test can tell
them, including the substantial limitations in interpretation.
- The limitation of the study sample not including women who consider but don’t decide to
freeze their eggs is well described, however you could also discuss how the sample was highly
educated, although this is likely because they are the population who can afford egg freezing.
Future research should aim to capture the perspectives of women who consider egg freezing
but choose not to.
- Whilst egg freezing can indeed give women more options, the responsibility of maximising
reproductive potential is yet again placed on individual women, many of whom cannot afford
this option. There is no discussion of how society could be doing better to facilitate women in
pursuing their careers whilst also having children when they are biologically able.