Title: Patients’ and Providers’ Perspectives on the Decision to Undergo Non-Urgent Egg
Freezing: A Needs Assessment
Version: 0 Date: 06 Feb 2023
Reviewer:  Giuliana Fuscaldo
Reviewer's report:
Dear Editors
Re: TITLE: Patients’ and Providers’ Perspectives on the Decision to Undergo Elective Egg
Freezing: A Needs Assessment
Thank you for the opportunity to review this manuscript. The focus of the paper is Egg freezing,
and the views of women making decision about whether to undertake egg freezing. The topic is
current and particularly interesting given that the uptake of egg freezing has grown enormously
in the last 5 years.
There have been a number of papers exploring women’s experiences of egg freezing but this
paper could makes a unique contribution in that the authors attempt to identify the factors that
might make decision making about egg freezing difficult, and to develop a decision making
framework, based on the Ottawa Decision Support Framework.
While the topic is interesting and the paper generally well written, there are some areas that
could be improved with revision and editing. The rationale for the paper may not be supported
with refence to the literature cited. The method of data analysis is not clearly described and while
comparisons are referred to (with ODSF and between participants, professional and providers)
they are not clearly reported.  There are several problems with the results section which make
that section difficult to understand. There are some claims made in the discussion that do not
seem to relate to the results and are not fully supported.
I offer the following comments (in blue) in response to passages in the paper, to assist with the
revision of this manuscript to make its findings clearer.
Rationale:
From page 2.
With an increased recognition of age-related fertility decline and advancements in freezing
techniques, there has been a rise in interest in proactive oocyte cryopreservation.- It might be
beneficial to clarify this term and to compare this to say medical and non medical –
Using the eggs in a future IVF cycle has additional costs of $1500- $5000; one IVF cycle is
covered by provincial funding in Ontario. The authors might explain for international readers
what this means- is it partly, wholly publicly funded? Criteria?
Assessing the need for decisional support in shared decision-making is the first step to improving
decisional quality. Prior studies have identified that whether or not to pursue EF is a difficult
decision for patients
Perhaps I am not across all the literature but I am not aware of these studies making this claim-
or of any that actually address how women find the decision making- rather – the studies you cite
refer to difficulties in undergoing the EF process or describe factors that motivate the decision
eg fear and guilt
If there is evidence that women need or would benefit from decisional support specifically for
EF it would be good to add this and make this clear- Or perhaps the authors are suggesting that
– in general- many decisions about health care and future reproduction are difficult and that it
would be beneficial to see if a decision-making aid facilitated decision making about EF??
and involves the consideration of many personal values (Baldwin, 2018; Baldwin et al., 2019;
de Groot et al., 2016; Esfandiari et al., 2019). Similarly, prior studies suggest that providers may
not fully understand the decisional difficulty and how to improve upon counselling (14,15).
It is not clear why some citations are in text and some are numbered
Thus, the literature supports the identification of decisional supports for this complex shared
decision. Again, the Sando paper does not refer to providers understanding of the difficulties in
making decision about EF, but rather to medical paternalism and the difficulties that providers
have in accepting women’s decisions. The Yu paper focuses on knowledge, attitudes and
intentions that US obstetrics and gynecology residents have toward discussing age-related
fertility decline, and does not really refer to women’s decisional difficulties
I am not sure what the literature has to say about decisional support specifically for EF or whether
women find this decision difficult and what would help. Nevertheless it is true that a decision
aid could help, and in some circumstances it has been demonstrated that they do help, but the
authors should clarify the basis for their idea and the rationale for the paper
The ODSF maintains that decision aids which address decisional needs ultimately improve
decision quality (Hoefel et al., 2020).
The authors might want to clarify what is meant by decision quality and what makes it better-
- it is about better understanding about the options or risks etc or   feeling better about making
the decision etc
Interviews were conducted using two populations selected by purposive and convenience
sampling: (1) English-speaking patients over 18 attending an academic fertility clinic, Mount
Sinai Fertility, in Toronto, Ontario who were considering EF as a reproductive option,
It’s a shame that only English speakers were included as I imagine decision making might be
even harder for people from culturally and linguistically diverse backgrounds. This might be
addressed and/or added as a limitation of the study.
…physicians, nurse practitioners, reproductive counsellors) across Canada who participate in
counselling women about EF as a reproductive option.
Is counselling compulsory for all patients prior to EF, or standard or elective?
Data Analysis and Results
I suggest that the results section needs some major revision- there are some awkward sentences-
headings that do not seem to follow, and it is not clear what codes were identified, and how
themes relate to the ODSF. The authors state that “Codes were compared to ODSF concepts” but
there is no detail about how this was done. Further, the way that the authors present the data does
not distinguish between what the participants said and how this was interpreted by the authors.
Ie there are no examples of how quotes gave rise to codes and themes which makes it hard for
the reader to be confident of the themes reported. It would also help the reader if the authors
clarified what questions the participants are responding to- and who is responding – sometimes
it is participants, sometimes counsellors, or specialists or providers, but these are all intertwined
and so it is hard to make send of who said what. There are many good examples of how to report
qualitative data that might be used as a template to clarify reporting the data collected in this
study. Some examples of the need for revision are given below
From page 4:
Two interviewed patients were ultimately excluded from analysis as they were undergoing EF
for medical indications.
The authors should state inclusion and exclusion about and a rational- it is not clear why the
authors exclude people seeking medical
Factors contributing to decisional difficulty
1) Multiple reproductive options with different views regarding importance  \
Is this a theme? If so, how does it relate to a factor that gives rise to decisional difficulties?
Reproductive options considered by patients and providers are outlined in Figure 1.
Interestingly, patients primarily saw their options as “egg freeze” or “do not egg freeze”. This
was because of the significant impact of the value placed on reproductive autonomy this sentence
is not clear- . are you suggesting there are other choices or ?? Patients ultimately were only
considering options that allowed them to conceive with a partner they met in the future. They
were looking at EF as true fertility preservation, rather than ensuring they would have a child
or a live birth in the future.
This paragraph is not clear- it would be helpful if the authors reported what the participants
indicated- or stated or chose- rather than what the authors think the women  ‘were looking at’
or considering-
In keeping with this, only 2/12 patients considered “embryo freezing with donor sperm” and
only 3/12 patients considered adoption.
This is not clear- perhaps the authors can indicate what questions that are being addressed
Given the motivation of patients to pursue EF now, they were not considering options that
allowed them to conceive in the future due to other life values.
This sentence does not make sense.
Further, is it possible that other options were considered, but rejected?
As one patient described, “The obvious options are to freeze or not freeze. Then I also considered
whether to have a child now [but] I have to rule [that] out right away. I’m still in school, I have
no income. I have no partner, so I mean that’s sort of a very theoretical option. That was never
really an option.” In contrast, providers counselled patients on reproductive options that could
be utilized throughout their life or were more likely to result in a live birth including “embryo
freezing with donor sperm” (8/13) or “donor eggs in the future” (5/13).
This section is not clear- I think what the authors are suggesting is that the option to fertilise eggs
and freeze embryos was not articulated by this participant- but it is not clear what the authors
are saying about counsellors- is it that counsellors provide information about more options, but
participant’s do not remember them or reject them ?  Further it is not clear what question this
quote is in response to
Decision made under the pressure of reproductive aging ? is this a theme or code- it reads more
like a summary of  types of decision made.
Patients needed to make this decision under the pressure of reproductive aging. One patient
shared, “I’ll be 35 soon and then I keep hearing that this has to be done by 35 and after that it’s
going to be a big impact on your reserve so I would say I was a little bit stressed there.”
It is not clear what the authors make of this quote re decision making difficulties - but it seems
to me that a possible interpretation of this quote is that one factor that makes decision making
difficult is the belief that it needs to be made by age 35
Decision timing also impacted the recruitment of patients for this study. Only patients who chose
to pursue EF were recruited. Our observation was that women presenting for EF consultation
were not ready to have a child at that time and were therefore only considering options that
would allow them to delay this decision and maintain reproductive autonomy, mainly EF now
as opposed to conception with donor gametes or embryo freezing. Is it possible that they did
indeed consider all options but rejected some- it si not clear what the authors intend here.
2) Uncertainty surrounding technology itself
Reproductive counsellors, in contrast to REI specialists, also brought up specific considerations
about what happens to the genetic material in the event it is not used in the future and the cultural
and religious acceptance of children produced via assisted reproductive technology (ART).
Relevance not clear - is this a comparison of what REI and counsellors said about something??
3) Financial burden of EF
These decisions carried both a financial and emotional burden. Strikingly, all patients and
practitioners brought up the financial burden associated with this decision which decision?
4) Voiced uncertainty
Patients generally were unsure about which option to choose, worried about what could go wrong
if they made a choice, wanted to delay the decision, questioned what was important to them, felt
distressed or upset, wavered between the choices they faced, constantly thought about options
and felt physically stressed. Interviews also identified uncertainty in deliberation amongst the
multiple options, financial and emotional investment, potential for decisional regret and the
physical risk of intervention and medication. There are many factors here relevant to the question
of what makes decision making difficult which are all thrown in a single sentence and could
separated and elaborated on -
5) Differing perceptions of decisional roles
Although all participants agreed that this was ultimately a patient-led decision, there was a
mismatch in perceived decisional roles. While 5/12 patients looked to providers to share the
decision with them, only 4/13 providers actually felt that this was their role. Most REI specialists
viewed their primary role as providing information and support to patients and specifically felt
uncomfortable helping patients with their value judgements Who is suggesting that specialists
should help with value judgement? What is intended here? Is this something participants said?
DISCUSSION
This study is the first of its kind to compare and contrast both patient and provider views on the
decision of whether or not to undergo EF.
Perhaps more could be said about why this comparison is useful- And how it was done – which
is not clear from the way the findings are reported in the results section of this   study
Our research has also echoed several additional survey-based and cross-sectional studies, which
have identified a lack of knowledge about the options, costs, benefits and risks of EF (24),
discussed the need for detailed and individualized information on the procedure and possible
outcomes for women considering EEF (25), and recognized the need for greater support in the
decision-making process (26)
Would be good to clarify how this study adds to what is known.
The results of the present study further demonstrate that despite being provided the basic
information, women have trouble understanding the applicability of the benefits and risks in
concordance with their personal values.
This sentence is not clear - what is intended?
However, providers interviewed in our study indicated that due to the significant financial
burden of EF, they were even more hesitant to engage in shared decision-making as they did not
want to present EF as a solid option for patients if they truly could not afford it. These findings
of incongruency between patients and providers represent potential significant barriers to shared
decision-making in the context of EF, and highlight the importance of developing rapport and
a strong therapeutic relationship early on in the patient encounter, as well as having discussions
around patients’ values and future goals.
This is an interesting finding which also suggests a degree of paternalism in providers approach
to what inflormation participants should receive or can handle.
The separate finding that patients and providers differ in what they perceive as available
reproductive options for patients furthermore indicates that these types of value-based
discussions are not readily occurring; It  is not clear how the authors came to this conclusion-
They were less likely to be considering other options due to other values that they held – for
example, reproductive autonomy.This is not clear – the study was not exploring what options
participants considered- or why they did not consider them- rather it was addressing factors that
make decision making difficult. The (repeated) claim that ‘other values’ impact decision making
does not seem to be relevant or have any baring on what facilitates decision making
CONCLUSIONS
In conclusion, our study has explored the decisional needs of patients and providers in
considering EF and has identified that decisional support is required. This conclusion is
somewhat exaggerated- the study may have identified factors that make decision making
difficult and authors may suggest that a decision-making support could be useful- but there is
no evidence that the support is REQUIRED
Specific factors that can support this decision and aid in shared decision-making between
patients and providers include    reviewing patient values in the context of the complex medical
information. Again the reference to patient values is not clear- what is mean by ‘reviewing
patient values’, where did this claim come from- how does help decision making ?
The heading for   figure 1 is not clear- what is being reported- is it – participants intended choice?
Is it a response to question 3 ? 3. Thinking about this decision, what were the options that you
had?
I do not understand what the providers options are- is this showing providers response to question
3?   very confusing