Chemotherapy, radiotherapy, certain medications for cancer, and some rheumatological and haematological diseases are gonadotoxic, which can jeopardise patients’ fertility, particularly that of young cancer survivors.1 With advancements in treatment, the 5-year survival rate of patients with cancer in childhood and adolescence has increased to over 80%.2 Thus, improving their quality of life and reducing their risk of infertility is an important aspect of their management plan.

International clinical guidelines, including the American Society of Clinical Oncology (ASCO),3 European Society for Medical Oncology (ESMO),4 and Royal College of Radiologists guidelines,5 suggest discussion of fertility preservation (FP) with patients of childhood and reproductive age during the course of cancer therapy. However, a study showed that fewer than half of oncologists routinely refer their patients to reproductive endocrinologists, and even fewer oncologists follow the guidelines, despite their willingness to discuss infertility in relation to cancer therapy.6 Moreover, a lack of awareness and related training about FP among clinicians may cause underutilisation of FP services worldwide, including in Canada, the US, and Hong Kong.7 8 9 In Hong Kong, clinicians and patients alike may consider FP as an expensive, privatised option without subsidisation.

In a previous cross-sectional study that evaluated the awareness, attitudes, and knowledge of FP among clinicians across different specialties in Hong Kong, only 45.6% of clinicians were familiar with FP.10 As current medical students will become our future clinicians, it is important to assess their level of understanding and awareness of fertility and FP, as this may greatly influence their future practice and consideration of appropriate interventions to improve affected patients’ outcomes. Cross-sectional studies have been conducted to assess college students’ awareness and knowledge of fertility in Canada,11 Serbia,12 and the US.13 These studies in Western populations showed knowledge inadequacy about age-related fertility decline and FP. However, to the best of our knowledge, there are no studies in a Chinese population that have aimed to investigate the awareness, knowledge gaps, and attitudes of medical students regarding fertility and FP. Therefore, the aims of this study were to evaluate the awareness of, attitudes towards, and knowledge regarding FP among Chinese medical students in Hong Kong.

This was a cross-sectional survey conducted from November 2018 to June 2019. The study population consisted of Chinese medical students from The Chinese University of Hong Kong. Chinese undergraduate students aged ≥18 years studying in the Medicine programme and capable of communicating in English were included. Those who were non-Chinese, under age 18 years, incapable of communicating in English, and those who refused to join the study were excluded.

Eligible participants were invited to complete a self-administered online survey. The online survey was sent to participants by internal mass email and social networking applications. Snowball sampling was done by encouraging medical students to send the online survey to their classmates to boost the response rate.

The online survey was developed on an electronic form (MyCUform). The self-administered survey included a brief explanation and was comprised of four parts: (1) baseline demographic data (Table 1); (2) awareness of FP; (3) knowledge about FP (Table 2); multiple choice questions consisting of five or six options on knowledge about fertility and FP; and (4) attitudes towards FP (Tables 3 and Table 4). It consisted of 38 questions and took approximately 15 minutes to finish. The survey was developed after reviewing the literature.14 15 16 It was assessed for logical validity by three physicians in the Department of Obstetrics and Gynaecology, who reviewed the accuracy of the contents. The survey was also piloted on a small number of doctors and medical students for content clarity and modified accordingly to incorporate the pilot participants’ feedback. The final version was then administered to the full study’s participants.

Statistical analysis was performed using SPSS (Windows version 24.0; IBM Corp, Armonk [NY], US). Continuous data were described as means, standard deviations, and percentiles. Categorical data were summarised as frequencies and percentiles. Subgroup analyses were performed between gender and year groups, with the medical students split into junior (year 1-4) and senior (year 5-6) year groups. Junior medical students had not completed the clinical attachments of the obstetrics and gynaecology module rotation (OB-GYN), whereas senior medical students had finished the OB-GYN module in year 5. The categorical data were tested by Pearson’s Chi squared test or Fisher’s exact test to check for significant differences between groups. Results with P values of <0.05 were considered statistically significant.

Approximately 700 Chinese medical students were approached through social networking applications and email, and 243 completed the online survey (response rate: 34.7%). Table 1 summarises the participants’ demographic data. In terms of age distribution, there was no significant difference (P=0.597) between the two groups.

Overall, 71.2% (n=173) of respondents were aware of FP strategies. Despite this, 77.8% (n=189) of respondents were not familiar with any clinics or specialists who provide FP services. Senior students showed better awareness than junior students of the above items (P<0.001). The majority (86.8%, n=211) had not heard of any regulations related to FP. Gamete and embryo freezing were the most well-known FP methods, with female students being significantly more aware than male students of those methods (P<0.003).

The majority (71.2%, n=173) responded that they would discuss the option of FP with their patients as future doctors, even if the treatment had a <30% chance of causing infertility. If a treatment had a ≥70% chance of causing infertility, nearly all (95.5%, n=232) students would discuss FP.

Table 2 shows the results of the questions that address knowledge about fertility and FP. Overall, there were no gender differences besides the response regarding the age range of a woman’s significant fertility decline: proportionally more female students answered that item correctly (45.7% vs 38.8%; P<0.05).

Knowledge regarding FP was mainly acquired from electronic media (58.4%, n=142), medical school (57.6%, n=140), and medical professionals (38.7%, n=94). More senior students than junior students acquired fertility knowledge through medical school education (81.4% vs 30.7%; P<0.0001) and medical professionals (54.3% vs 21.1%; P<0.0001).

Most of the responding students (86.4%, n=210) wished to know more about FP, with 80.7% (n=196) of the students agreeing that there is a need to incorporate FP material into the medical curriculum.

Regarding attitudes, 94.2% (n=229) of medical students agreed that establishing one or two dedicated clinics or centres for FP counselling is necessary. Subgroup analysis indicated that more male medical students would like to have two dedicated centres (75.0% vs 68.2%, P=0.021). More senior than junior students agreed that FP should be available solely as a public service (89.1% vs 71.9%; P=0.001). Overall, 97.9% (n=238) of participants thought that practice guidelines for FP should be required. More than half of respondents (59.7%, n=145) agreed that there should be an age limit for FP. More female than male students agreed to set an age limit for FP (65.7% vs 51.5%, P=0.025).

Among various factors considered by medical students to determine whether to recommend FP to patients, the desire to have children (51.0%, n=124), the prognosis of cancer or a medical condition (23.5%, n=57), and time available before gonadotoxic treatment (7.4%, n=18) were the most likely considerations.

Most participants (80.2%, n=195) responded that the government should subsidise FP in patients undergoing gonadotoxic treatment, with senior students expressing stronger support for subsidisation than junior students (86.0% vs 73.7%; P<0.02). More than half of the responding students agreed that the government should subsidise 30% to 50% of the cost of FP procedures including sperm (79.8%, n=194) and egg freezing (80.2%, n=195), and in vitro fertilisation (IVF) [67.9%, n=165]. More senior than junior students thought that the government should subsidise >70% of the cost of IVF (34.1% vs 20.1%; P<0.02).

Table 3 shows the respondents’ attitudes towards elective and medical gamete and embryo freezing. More male students than female students expressed agreement with FP provision to men because of having no suitable partner (34.0% vs 22.1%; P<0.05). Table 4 illustrates attitudes towards family planning among the responding medical students. More male than female students were determined not to delay their family planning (16.5% vs 7.9%, P=0.037).

With the advancement of technology, FP has become increasingly effective at enabling patients who have undergone gonadotoxic treatment to raise families. However, as shown by many previous studies on medical students’ understanding of FP, this study reflects an overall worldwide tendency towards a lack of awareness and knowledge about fertility and FP.11 12 13 To the best of our knowledge, this is the first study that has aimed to investigate the awareness, knowledge, and attitudes of Chinese medical students regarding fertility and FP, as well as identifying their knowledge gaps in the subject.

The majority of Chinese medical students in Hong Kong have heard of at least one FP strategy. Senior students had significantly greater awareness than junior students of FP, reproductive techniques, and the availability of specialty clinics, likely reflecting the knowledge and exposure gained during the clinical OB-GYN module in the fifth year of study. This suggests that appropriate and timely education can improve medical students’ awareness of FP.

Previous studies have shown that even brief educational interventions about FP to medical students and house staff have potential benefits.13 To provide quality service, ASCO and ESMO guidelines suggest that patients with cancer be informed of their potential fertility decline and referred to FP services after treatment.3 4 Most students responded that they would refer patients to FP services even if treatment had only a low risk of infertility, but they were not familiar with the actual practice of FP, including relevant regulations and referral methods. Downloadable fact sheets on the effects of cancer treatment on fertility, available options for FP, and a list of service providers with reference costs stated should be available and accessible for proper patient education and counselling.

There are several misconceptions among medical students regarding knowledge about fertility and FP. The responding medical students tended to overestimate the age of the female fertility peak and the success rate of IVF and underestimate the risk of infertility in women at age 45 years (Table 2). Overestimation of female fertility has also been observed in overseas studies.11 12 13 17 18 Medical students have better knowledge about female fertility than male fertility. This could be explained by the fact that there have been many more studies about the concern of female fertility decline with age. As sex education programmes at the secondary and university levels mainly emphasise pregnancy prevention education rather than infertility awareness, there may be a lack of knowledge about the impact of ageing on fertility among women.11 Fertility-related knowledge should be included in the undergraduate medical curriculum and ideally be integrated in high school education as well to enhance public education on this topic. Beyond patient care, medical students’ inadequate knowledge about this topic also has great implications for their future careers and personal lives. They may delay their own family planning for career reasons without sufficient consideration of their impending fertility decline or may have a false sense of security regarding the success rate of IVF. Therefore, more education about fertility is required, which was also supported by the respondents of our study.

Electronic media play a significant role in the promotion of FP, especially among junior students. In contrast, medical school was the main source of FP knowledge for senior students, followed by medical professionals and electronic media. This is consistent with findings in American medical students and house staff.13 Media reports of female celebrities undergoing FP procedures, particularly egg freezing, could explain the high prevalence of student familiarity with this procedure and their lack of knowledge about other, less popular options.19 Knowledge acquisition through both the medical curriculum and electronic media have proven to be significant, particularly in people who have not received formal education about FP. This can be applied to the general public, although it poses a risk of promoting misinformation: people could be misled into having a false sense of security regarding successful childbearing late in one’s reproductive life through the use of FP methods.11 Therefore, caution should be used to ensure that materials released through the media are accurate.

Most of the responding medical students would first consider the patient’s desire when referring patients for FP, while 41.3% of physicians would consider the patient’s prognosis first.10 This finding could be explained by the medical students’ lack of medical practice experience and doctors’ awareness of resource limitations, as it has been shown that junior doctors make judgements mostly based on their own assumptions, compared with the experience-based judgements made by senior doctors.20

The private sector is the only current provider of FP services in Hong Kong. More male than female medical students who responded to our survey had positive attitudes towards the establishment of related facilities. The cost of freezing gametes is at least US$7800 (US$1 to HK$7.8),21 and the median monthly household income of a 1-person family in Hong Kong is US$1282.22 There are currently no gamete freezing subsidy programmes available. Such high costs are unaffordable to many patients, and especially patients with cancer are already financially burdened by their current treatment. In this regard, most medical students agreed that the government should subsidise FP services to patients undergoing gonadotoxic treatment, with more than half agreeing that 30% to 50% is a reasonable subsidy proportion.

There has been an increasing trend towards elective FP in recent years, which has opened up a debate about the ethicality of FP for non-medical indications and whether FP should only be provided for medical reasons. Our study reflected overwhelming support for FP for medical reasons. However, the responding medical students’ opinions were mixed regarding elective freezing for non-medical indications. Only approximately half of the respondents agreed that FP should be provided to people because they have not found a suitable partner, or because they delay family planning for the sake of career development. Despite the mixed responses regarding elective freezing, Chinese medical students from Hong Kong were more supportive of elective freezing than undergraduates and medical students from the US.23 This finding may be driven by the higher cost of FP in the US compared with that in Hong Kong.23 Indeed, elective freezing has gained popularity in recent years. Still, the greater acceptance of FP for medical reasons echoes the healthcare-related perceptions and expectations of patients in Hong Kong: fertility is not a necessity, and FP healthcare is considered a luxury as opposed to a necessity for immediate physical well-being.

This study’s participants were more supportive of elective freezing for women than men. This is likely because of their awareness that women’s fertility declines relatively earlier than that of men. Moreover, women in Hong Kong are expected to have a predominantly domestic and childrearing role within their families,16 largely because of deeply rooted traditional Chinese familial constructs in which women tend to take on homemaking roles. However, the male medical students who responded were also concerned about their own family planning. This study’s results show that more male than female medical students were determined not to delay their family planning or stated their intent to have gametes frozen because they had no suitable partner.

Most medical students agree that their future fertility is important to them. Over half of the responding medical students stated their intent to delay family planning for career development, and the majority plan to have their first child between age 30 and 34 years (the average age of residency completion is 29 years). However, few responded that they would consider undergoing FP treatments. This paradoxical response is consistent with the results of another study on Hong Kong university students that showed low inclination to seek help in the event of fertility problems compared with Western counterparts.16 The taboo of childlessness in Chinese culture may be another reason why planning and conversation are discouraged in the event of infertility.16 Thus, students may view FP techniques as drastic and unconventional, preferring natural conception. As discussed earlier, the lack of correct knowledge about age-related female fertility decline could also lead to such results. Medical training is long, potentially delaying doctors from starting families during their most fertile years. Education is beneficial not only to future patients, but also to current and future physicians’ quality of life.

As a form of convenience sampling, the online survey method was chosen to efficiently distribute the survey throughout the large population of medical students. However, this inherently came with limitations, including low response rate, small sample size, selection bias, and the inability to characterise non-respondents. Ideally, students of other medical schools in Hong Kong should be included to make our study more comprehensive; however, this would be logistically difficult. Because of constraints on advertising, the study consisted of slightly more senior than junior students and more female than male respondents. Moreover, our study did not specifically ask about the educational background of students that may have influenced their knowledge. However, there was no significant difference in the age distribution between the junior and senior student groups. Information bias may have also affected the responses from students who had not completed the OB-GYN module.

In conclusion, this study revealed important aspects of FP from the perspective of Chinese medical students in Hong Kong. In particular, we highlighted that awareness and knowledge of FP are limited among medical students. There is a strong worldwide need to increase education about and exposure of FP in the curriculum to improve medical students’ knowledge. More involvement from the public sector and enhancement of facilities in terms of service provision and financial support for FP services are also needed. Given the variety of perspectives on childbearing among different cultures, this should be taken into account when doctors consider FP options for their patients and themselves. Only by increasing awareness and knowledge can more accepting attitudes towards FP arise among our doctors, allowing for better clinical outcomes and quality of life for future patients.

Concept or design: JPW Chung, EYL Ng.
Acquisition of data: All authors.
Analysis or interpretation of data: EYL Ng.
Drafting of the article: All authors.
Critical revision for important intellectual content: JPW Chung.

All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

As an editor of the journal, JPW Chung was not involved in the peer review process of the article. Other authors have no conflicts of interest to disclose.

The authors would like to thank the medical students at The Chinese University of Hong Kong for their kind participation in the study.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Ethical approval for the study was obtained from the Survey and Behavioural Research Ethics Committee (Ref SBRE-18-168).

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