Effect of Virtual Educational Program on Female Faculty Nursing Students' Perception toward Egg Freezing Technology and their Fears regarding it

: As nursing students are the future health care providers, they should acquire knowledge regarding egg freezing technology (EFT) to serve themselves first and others. Aim of the study: Evaluate the effect of virtual educational program on female faculty nursing students' perception toward egg freezing technology and their fears regarding it. Subjects and Method: A quasi-experimental research design was used. Setting: The study was conducted at Faculty of Nursing, Tanta University. Subjects: A cluster random sample of 320 female nursing students were selected. Four tools were used: Tool (I) : A structured questionnaire which included: Part 1: Socio demographic characteristics, Part 2: Knowledge regarding EFT. Tool (II): Attitudes of the female nursing students regarding EFT. Tool (III): Opinion of the female nursing students about if they would personally consider undertaking EFT in the future and their reasons. Tool (IV): Fears of undergoing egg freezing among the female nursing students. Results: The total knowledge score of the participants significantly improved among half of them and more than two-thirds of the participants had positive attitude toward EFT three months post-program with a highly statistically significant difference. The main reported fears of undergoing EFT among the participants were; the high cost involved and religious rejection. Conclusion: The virtual educational program achieved a significant improvement in female faculty nursing students' knowledge and had a positive effect on their attitudes toward EFT. Recommendations: Reapplication of the study for all faculties nursing students. Online distribution of an Arabic PDF about EFT among all specialties.


Egg
freezing technology (EFT) is one of the most recent innovative approaches in the assisted reproductive techniques. (1)It is also known as oocyte cryopreservation.EFT is defined as a technique used to preserve female's fertility through freezing and storing their healthy eggs for a subsequent chance of future pregnancy or infertility treatment. (2)Despite the well-established evidence that fertility declines with female advanced age, many females in the developing countries delay their childbearing. (3)As a result, those females may experience the threat of age-related infertility when they desire to get pregnant. (1,4)Hence, egg freezing has emerged as a technology mean to plan ahead for the anticipated loss of female fertility, thus keep open the possibility of using their own eggs for conception (5,6) .Egg freezing technology is known to be offered for medical or non-medical reasons.Medical egg freezing is indicated for women who were exposed to premature infertility due to diseases as; severe endometriosis which compromises the ovary, primary ovarian insufficiency from a genetic predisposition, possible damage to the ovaries during upcoming surgeries, or chemotherapy treatments for cancer that had a negative impact on future fertility. (7,8)Also, it can be offered to healthy women, with the intention to postpone their motherhood for non-medical reasons mostly for continuing education and career, lack of a husband, reproductive autonomy,anticipated age-related fertility decline, or for reasons beyond their control. (9-11)It is believed that female's fertility decline over the course of her life time beginning with a slight decrease after the age of 32 years and become more evident after the age of 37 years. (12,13)So, according to the clinical practice, the most suitable age for EFT range between 20 to 30 years of age.The most significant contributing factors to the success of EFT includes; the age of woman at time of egg freezing, the number of eggs collected and frozen, along with the chosen clinic"s and the physician"s expertise level in egg freezing technique. (9,14,15) Additionally, hormonal stimulation of the ovaries before transabdominal or transvaginal healthy, viable eggs retrieval is very essential.][21] However, EFT are associated with risks including ovarian hyperstimulation syndrome which manifested by swelling or pain in the ovaries and abdomen, bloating, nausea, vomiting, and diarrhea. In addition to, the post-frozen-thawed eggs risks especially at an advanced age such as; pregnancy-induced hypertension, preterm delivery with low birth weight infant, and multiple pregnancy.However, these risks vary widely, depending on the woman"s health status, and increase with maternal age at delivery. (19,23)espite the benefits of EFT, many fears may affect the females' decision to undergo EFT as; lack of information, negative attitudes, cultural and religious beliefs regarding it.][26] With the advent and development of Internet technology during the 1990s, a powerful new tool called virtual education was provided to universities and research institutes at the top of the curricula to help students achieve their goals and create new dynamic learning and teaching environments. (27)It is a form of education where teacher and student are separated by time or space, or both, and the teacher provides course content through course management applications, multimedia resources, the Internet, and videoconferencing.Virtual learning can be convenient, flexible, affordable and address issues as increasing the demand for higher education, the high cost of education, the need for students to access noncontent, their time and space restrictions and issues related to mandatory and timely classroom attendance. (28,29)ignificance of the study In Egypt, the infertility ratio among the married couples has been estimated to be 10.4%.Moreover, the age of marriage has been progressively rising over the past few decades. (1,30,31)This will increase the incidence or risks of developing abnormal embryos and fetal loss as well as less opportunities for the eggs to become fertilized as the female fertility window is narrower and gradually continues to decline beyond the mid-thirties annually until the menopause compared to the male. (32)Thus nowadays, an emerging egg freezing technology can offer some protection for women against the loss of fertility with ageing and may be suggested or recommended as a cure or remedy for infertility problems. (1,26)Since, the majority of women reported that the health care provider is the preferred and most reliable information source regarding their reproductive health choices. (24)Thus, the future obstetric or community nursing students health care providers should be updated with new practices and evidence-based medicine and technologies to enhance their knowledge and attitudes regarding EFT to serve themselves first and serve others. (19)So the current study was conducted to evaluate the effect of virtual educational program on female faculty nursing students' perception toward egg freezing technology and their fears regarding it as they are the future health care providers.-The researchers selected a cluster random sample of around ten percent (10%) of the total student number which was 320 students.Tools of data collection: Four tools were used by the researchers in ordered to obtain the necessary data as follow: -Tool (I): A structured questionnaire.This tool was constructed by the researchers after reviewing the relevant recent literatures which included three parts: This tool was designed by the researchers after reviewing the related literatures (1,2, 24) .It was intended to assess nursing students' attitudes toward EFT.It consisted of 31 items, 14 items were negatively worded and other 16 items were positively worded.The studied nursing students' attitudes were measured using a three-point Likert scale which ranged between zero (disagree), one (uncertain), and two (agree).The score of the studied nursing students' attitudes were obtained by summing up the students" responses for all items taking into consideration the revise of negatively worded items.

The scoring system
The total attitudes scores ranged between ( 0-62 The evaluation was conducted two times, before and three months after the implementation of the virtual program.

Statistical analysis:
The collected data was organized, tabulated, and statistically analyzed using Statistical Package for the Social Sciences (SPSS) software, version 25.Frequencies of correct knowledge answers and various attitudes were described.Correlation between variables was evaluated using Pearson's correlation coefficient.Significance was adopted at P<0.05 for interpretation of results of tests of significance.

Discussion
Egg freezing technology now allows women to freeze and store oocytes with a realistic chance of future pregnancy, with in vitro fertilization (IVF) pregnancy rates now similar to those achieved with fresh oocytes.A better understanding of EFT is crucial to optimize the appropriate use of fertility preservation by it. (3,33) his study aimed to determine the effect of a virtual educational program on knowledge, attitudes and opinions among faculty nursing students regarding EFT.The results revealed improvement in female faculty nursing students' knowledge, attitudes and opinions regarding EFT.This result support study hypothesis "Female faculty nursing students' perception regarding egg freezing technology are anticipated to be improved after the implementation of the virtual educational program".The results of the present study revealed that; the age of the studied female faculty nursing students ranged from 19-24 years with mean 21.01 1.284 years.As regards their academic year, they were as follow: an equal percent of less than one-fifth in the first and fourth year, and an equal percent of one-third in the second and third year.The majority of the studied nursing students were single, twothirds of them were living in rural areas and all of them didn't attend any training program about EFT., mentioned that two thirds of the studied bridging program, nursing students has a positive attitude regarding EF.This finding is consistent with results from USA, and Brazil which predominantly reported favorable attitudes towards EFT. (39,42){Ikhena-Abel D et al. (2017) (39) and Santo E et al., (2017) (42) } Meanwhile, finding of the current study disagree with several descriptive studies including; the study of Ng E et al.,(2020) (43) which highlights the negative attitudes of FP among Chinese medical students, and the study of the nursing/midwifery students in Izmir, Turkey which found that the students"attitudes toward EFT was negative.Daşıkan Z & Taner A (2020) (44)  ), and a sample comprised of participants across both the United Kingdom (UK) and Denmark (Milman L et al., (2017) (46) .From the researchers' point of view, support for EFT remains relatively low on the whole.Regarding the opinion of the studied female faculty nursing students about if they would personally consider undertaking EFT in the future; half of them mentioned that they would consider it preprogram ,and that percent increased to more than two thirds of them three months post program.This finding is consistent with the published article in Al-Ahram Weekly on the occasion of International Women"s Day, in 2023and looked into the rising number of Egyptian women opting to freeze their eggs.It revealed that despite prior controversies among supporters and opponents of the practice, EFT has been growing in popularity among Egyptian women. (47); O'Brien Y et al., (2017) (17) .Conversely, in the survey of Singaporean study, 70% of medical student participants initially reported that they would consider using EF, which decreased to 48.9% after an educational intervention regarding EF.Tan S et al. (2014) (41) .Another study of American medical students echoed a decrease in likelihood to freeze following educational intervention in participants who were originally neutral regarding their intention to use EFT.Milman L et al., (2017) (46) .Also, Mahesan A et.al (2019) (50) , revealed that most undergraduate and medical students would not consider EFT at the present time.who reported that only (18.5%) of women from the general population would undertake EFT for career reasons.Also ,concur with other studies assessing acceptance of EFT for social reasons in other countries : we found in a study by Tozzo P et al. (2019 ) (40) in Italy that only (19.5%) of women would accept freezing their eggs for social reasons and this percentage is similar to that reported in a study by Milman L et al., (2017) (46) , in the study comparing attitudes of Danish and British women .Moreover, the present findings is similar with a study done by Tan S et al. (2014) (41) in Singapore which found that only one fifth of medical students would accept EFT for social reasons and slightly lower than that in a previous Belgian study by Stoop D et al., (2011) (45) .While , the findings of the present study disagree with Mahesan A et.al (2019) (50) in their study in Eastern Virginia who found that less than half of students would consider EFT for medical reasons, two thirds of students would consider EFT for career reasons, and only one third would consider it for social reasons.Also, Ng E et al., (2020) (43) mentioned that medical students showed overwhelming support towards EFT for medical reasons among most of them but had mixed responses about EFT for career reasons among nearly two thirds of them.Moreover, Wennberg A-L et al., (2016) (52) found that less than half of women were positive towards EFT for medical reasons.The findings of a study in USA published by Ikhena-Abel D et al. (2017) (39) revealed that career progression has been shown to have little effect on decision-making regarding EFT.Platts S et al. (2021) (3) in their systematic review, revealed that career advancement was not found to be a direct motivating factor in studies of known or potential EFT users.Will E et al., (2017) (33) , Jones B et al., (2020) (53) , Baldwin K et al., (2019) (54) .From the researchers' point of view, these findings highlight the dynamic nature of reproductive aspirations and choices among student populations and general public.In relation to, the Fears of undergoing EFT among the studied female faculty nursing students; the high cost involved, religious rejection and social stigma represents the main fears among (61.1%,55.6% and 47.3% respectively) of the studied nursing students.Followed by fears of; effect of EFT on virginity before marriage, potential health implications, and future husband rejection among (41.4%,33.7% and 32.5% respectively) of the studied nursing students.And, followed by fear of future regrets and fear of taking responsibility among (25.2%-, and 22.2% respectively) of the studied nursing students.These finding agrees with several studies which indicated that the cost of EFT is the limiting factor in women"s ability to undergo the procedure.{Bavan B et al., (2011) (55) ; Goldman R et al., (2017) (56) ;  (49) ;Hurley E et al. (2018) (51) ;Carroll K& Kroløkke C (2018) (58) } Other findings indicated that women would be more inclined to undergo EFT procedures if the cost was reduced or subsidized {Tozzo P et al. (2019 ) (40) and Tan S et al. (2014) (41) } Regarding religious rejection, there was no other studies that mentioned it but Egypt's Dar El-Iftaa, the country's Islamic institution responsible for issuing religious edicts, released a statement in 2019 saying that EFT is permissible if four conditions are met: the frozen eggs are only to be used within the context of marriage using the husband's sperm; the eggs are to be well-secured so as not to get mixed up with another women's eggs; the eggs should not be fertilized in another woman's womb; and the procedure should not negatively affect, or cause any birth defects, to the embryo. (59)Hasab Allah M et al., (2021) (1) and Hodes-Wertz B et al., (2013) (60) agree that there to be social stigma surrounding EFT.Will E et al., (2017) (33) agree with the present study finding in regard to the perceived potential health implications as a barrier to undertaking EFT.While, interestingly, the present study finding disagree with one German study which rated financial costs as one of the least important reasons in considering EFT {Schick M et al.,(2017) (61) }Also, the present study finding disagree with Daniluk J & Koert E (2016) (62) , finding which revealed that perceived risk was among women's highest-rated considerations regarding EFT.Meanwhile, Baldwin K et al.,(2019) (54) and de Groot M et al., (2016) (63) agreed in their studies that women were not too concerned about possible risks of the intervention, and such concerns were overruled by the desire for pregnancy.Moreover, in Fahmy S & Mohamed M (2021) (24) study, about four quarters of studied bridging program nursing students consider fear of future husband refusing as a barrier to perform EFT.In addition, Fear of future regret" was identified as a motivating factor to undertake EFT by women in a number of studies.{Sandhu S et al. (2023) (48) ; de Groot M et al., (2016) (63) ; Baldwin K& Culley L( 2020) (64) }From the researcher's point of view, this agreement between countless number of studies across the world that fear of high cost is the main barrier to EFT uses, might be due to the recent jump in the dollar exchange rate.Another obstacle to the demand for EFT could be specific to the student population in the present study that the subject of high cost is always a sensitive topic among them because they worry about future earning potential.Concerning the correlation between the studied female faculty nursing students' total knowledge score and their total attitude score regarding EFT, there was a statistical significant correlation between them pre and three month after the application of the virtual educational program.These findings are consistent with Rashed A et al., (2018) (35) and Hasab Allah M et al., (2021) (1) .While, Mansour S & Hassan S (2021) (38) revealed that there was significant association between the post-intervention total knowledge and attitude level among the nurses only.Concerning the correlation between the studied female faculty nursing students' total knowledge score regarding EFT and their age, and academic year, there was a statistical significant correlation between them pre and three month after the application of the virtual educational program.These findings agree Hasab Allah M et al., (2021) (1) findings which found a highly statistical significant relation between students' total knowledge about oocyte cryopreservation and their age, in both pretest and posttest.Also, Abbass E et al., (2023) (2) , indicated that there was a statistically significant relationship between the overall amount of knowledge that students had acquired about ova cryopreservation before and after the implementation of the educational program and their age.Relating to the correlation between the studied nursing students' total attitude score regarding EFT and their age, and academic year, there was a statistical significant correlation between them pre and three month after the application of the virtual educational program.These findings agree with Hasab Allah M et al., (2021) (1) findings who found a statistically significant relation between students' total attitudes toward oocyte cryopreservation and their age, in pretest, posttest.Stoop D et al., (2011) (45) and Daniluk J & Koert E (2016) (62) studies found that societal attitudes towards EFT appear to be influenced by age., O'Brien Y et al., (2017) (17) }.

Conclusion
The virtual educational program achieved a significant improvement in female faculty nursing students' knowledge and had a positive effect on their attitudes toward EFT.Also, the main reported fears of undergoing EFT among the female faculty nursing students were the high cost involved, religious rejection and fear of social stigma.So, the aim of this study has been achieved and the study hypothesis has been supported.

Figure ( 1 ):
Figure (1): Total knowledge score of the studied female faculty nursing students toward EFT pre, and three months post virtual educational program (n=320).

Figure ( 2
Figure (2): Total attitude score of the studied female faculty nursing students toward EFT pre, and three months post virtual educational program (n=320).

Figure ( 3 ):
Figure (3): Opinion of the studied female faculty nursing students about if they would personally consider undertaking EFT in the future pre, and three months post virtual educational program (n=320).
Also, in Italy and Belgium participants typically had more negative views towards EFT {Tozzo P et al. (2019) (40) and Stoop D et al., (2011) 45) }.Moreover, in a Singaporean sample, majority of women indicated a more negative towards EFT (Tan S et al. (2014) (41) Ikhena-Abel D et al. (2017) (39) and Santo E et al., (2017) (42) } Moreover, a number of studies reported that a high proportion of women would personally consider undertaking EFT in the future.Platts S et al. (2021) (3) ; Santo E et al., (2017) (42) ; Sandhu S et al. (2023) (48) ; Hickman L et al. (2018) Will E et al., (2017) (33) ; Tozzo P et al. (2019) (40) ;Hurley E et al. (2018) (51) }.From the researchers' point of view, there is divided opinion about the EFT in Egypt and across the world.Concerning the reasons of potential users for EFT the studied female faculty nursing students; medial reason was among more than two thirds of them , career progression reason was among 16.9% of them and social reasons was among 15.4% of them.The findings of this study concur with O'Brien Y et al.,

The aim of this study was to
Study Design: A quasi-experimental research design was used in the present study.Setting: This study was conducted at Faculty of Nursing, Tanta University.Subjects -A cluster random sampling was used to obtain the sample size for the academic year 2022-2023 of undergraduate female nursing students at Faculty of Nursing, Tanta University.The number of the nursing students in the first, second, third and fourth academic years were as follows; 550, 1049, 1048, and 550 students respectively.

IV): Fears of undergoing egg freezing among the female nursing students. It
At the beginning of this phase; the researchers conduct the first online meeting using Microsoft teams program on the free time for each sample according to their academic year, introduced themselves, and explained the purpose of the study to the participants, Then, an online self-administered questionnaire link which included the four tools was distributed on students through Microsoft teams program and the nursing students WhatsApp groups to collect the baseline data about EFT as a preprogram assessment.
evaluation phase were used to achieve the aim of the study.These phases were completed over a 6-months period. Assessment phase (Pre-test):  Planning and Implementation phase: Based on the findings from the assessment phase, the researchers developed the virtual educational program sessions content material.The total students' numbers (55,105,105,55) were divided into 6 groups each group about 55 nursing students according to their academic year and available time to help the students' attends for the sessions.The content of the sessions were delivered to the students in the form of online symposium and group discussion on Microsoft teams that constructed for faculty theoretical lectures utilizing online audiovisual aids as; PowerPoint presentations, graphics, videos, and Arabic PDF for enhancing students' knowledge , attitudes and opinions regarding EFT.To implement the content of the virtual educational program, The virtual online program was given in 3 sessions.Each session took about 45 minutes.Implementing the virtual educational sessions continued over a period of 6 weeks.The first session: This session aimed to establish a relationship with the studied nursing students and orient them about the importance of the educational program, its sessions and expectations of each session and provided them with information about fertility preservation for female, and methods of Vol. 31.No. 4 (Suppl 1) ,November 2023 woman's fertility preservation.egg freezing, duration of storage of frozen egg, as well as legality of EFT under law.In addition open discussion for any questions and inquires about EFT.Evaluation phase: This phase aimed to evaluate the effectiveness of the virtual educational program on the studied nursing student"s knowledge, attitudes and opinion using Tool (I) part 2, Tool II and Tool (III).

1):Socio-demographic characteris- tics of the studied female faculty nursing students.
It shows that the studied female nursing students 'age ranged from 19-24 years with mean 21.0  1.284 years.Regarding to academic year, the study subjects were as the following: first year (17.2%), second year (32.8%), third and fourth year (32.8%) and (17.2%) respectively.The majority (84.4%) of the subjects were single and two-thirds (64.4%) of them were living in rural areas.The entire subjects didn't attend any training program about egg freezing.

Table ( 2): Mean and standard deviation of Knowledge of the studied female faculty nursing students toward EFT pre and 3- months post virtual educational program.
It shows that, there was a significant improvement in the total knowledge score of the studied female nursing students related to all items about EFT pre, and three months post program.P = (<0.001),where the mean score of their knowledge increased from 17.38  6.163 pre-program to 36.31  7.768 three months post-program.This difference was a statistically significant t = (56.04).

Table ( 4): Correlations between total knowledge score ,total attitude score toward EFT among the studied female faculty nursing students and their age, and academic year pre and 3-month post virtual educational program (n=320).
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