Factors Associated With Willingness To Donate Oocytes Among Female Students In A Tertiary Institution

Background: The shortage of oocyte donors in the face of increasing demand for infertility treatment globally has become a concern for stakeholders involved in assisted reproduction. Local research on oocyte donation is relatively limited in Ghana and tends to neglect female university students who constitute a large donor group for oocyte donation. Objective: This research sought to investigate the knowledge and attitude of female university students towards oocyte donation in assisted reproduction. Method: A questionnaire-based, cross sectional study was conducted among 295 female undergraduate students. The outcome variable was willingness to donate an oocyte or not. Factors investigated were socio-demographic characteristics, knowledge and attitude towards oocyte donation. Knowledge items were measured on a binary scale, where a correct response scored ‘1’ and an incorrect response scored ‘0’. Knowledge was rated as either high (score >3) or low (score £3). Attitude items were measured on a 5-point Likert scale and rated as positive (score >24) or negative (score £24). Descriptive and inferential statistics were computed with STATA version 15, assuming statistical signicance at p<0.05. Results: Majority of the students, 278 (94.2%), were Christians and had a low level of knowledge about oocyte donation (61%). Fifty-two percent and 44% of students showed a positive attitude towards oocyte donation and were willing to donate oocytes respectively. Being a Christian [AOR = 0.24, 95% CI: 0.07-0.92], spending between GhC500-1000 a month [AOR = 2.47, 95% CI: 1.48-4.11] and having a positive attitude towards oocyte donation [AOR = 2.12, 95% CI: 1.30-3.34] were associated with willingness to donate oocytes. Conclusion: The low levels of knowledge among the female university students highlights the need for information regarding oocyte donation in assisted reproduction. Existing barriers can be addressed through further research, public education by health academia of infertile was relatively high compared to an earlier study. The desire to help couples was the main motivation to donate eggs. Students who were Christians, those whose monthly expenditure ranged between GhC500 to GhC1000 and had a positive attitude were more willing to donate oocytes compared to their counterparts. The paucity of knowledge about human egg donation to assist reproduction calls for education in the target group and general public. Further research and dialogue between health authorities, academia and religious leaders could be potentially benecial in addressing the plight of infertile couples.


Introduction
Infertility is recognized as a problem of public health importance globally [1]. This is because it is associated with a signi cant social, psychological and economic burden [1]. However, it assumes a higher signi cance in settings where procreation is accorded greater cultural and social value. It is estimated that about 8-12% of couples worldwide are infertile [2]. The rate is even higher in sub-Saharan Africa, where the prevalence has been estimated as 30% [3]. The World Health Organisation (WHO) considers an infertility rate exceeding 15% as a public health problem [4]. In Ghana, it has been reported that the infertility rate among women of childbearing age is 15% [5] or slightly higher at 15.8% [6].
Although these reported rates halve the average rate reported for the sub-Saharan African region, there is signi cant social stigma [7], physical trauma [8] and psychological distress [9] associated with infertility which negate the gains. Infertility and adverse consequences associated with it have been neglected in Ghana due to the overarching menace of overpopulation and unmet need for contraception [8].
The scienti c breakthrough and availability of in vitro fertilization (IVF) in low-income countries offers hope and relief to infertile couples. In Ghana, since the rst IVF baby was born in 1995, a growing number of IVF clinics, mostly private, have emerged offering IVF and other forms of assisted reproduction [10]. In a typical IVF procedure, an infertile female undergoes ovarian hyperstimulation to produce oocytes.
These oocytes are fertilized in a laboratory ("in vitro") and develop into one or more embryo(s), which are transferred to the uterus. However, in some situations the use of donor oocytes may be the only potential option for a couple to have a baby through IVF. The most obvious indication for accessing this service is poor ovarian reserve due to ageing. Sub-fertility increases as the woman ages and becomes signi cant after the age of 35 years, as ovulatory cycles and quality of oocytes decreases leading to diminished ovarian reserve [11]. The growing desire by women to achieve higher career goals and the global trend towards modernization often results in the choice of a single woman or a couple to delay pregnancy until they are in their late 30s or early 40s, often unaware of a risk of decreasing fertility [10].
Paramount among potential reasons for limited access to donor oocytes include lack of awareness, negative religious and cultural perspectives [12]. Other reasons may include ethical, medical and other complications associated with the process [13]. A few studies have explored the effect of knowledge and attitudes towards oocyte donation among the donors [14][15][16], but there is a dearth of local studies. Although the number of potential recipients is continuously increasing at fertility clinics, there is a shortage of donors available to ensure the establishment of successful oocyte donor programs in Ghana.
As young women, and female university undergraduates in particular, are increasingly being recruited to become oocyte donors, the present study seeks to identify gaps in knowledge and attitudes towards oocyte donation that can be addressed through appropriate education and referral [17].

Study design
An analytic cross-sectional study employing a quantitative method was used for the study. A questionnaire-based survey was conducted from 29 th April, 2019 to 10 th June, 2019. The survey was carried out on a university campus which was chosen on the basis that university students are a major donor pool for fertility centers and oocyte donor recruitment agencies. Additionally, the university offers the advantage of accessibility to the study population as it had large numbers of undergraduate female students.

Study setting and population
The university campus which is situated in Legon, Accra, has four colleges, nineteen schools, ve institutes and eleven centers of learning. It is the largest of the university's three campuses. Currently, the student population exceeds 40,000; of which 85.4% are undergraduates. The main campus consists of 14 halls of residence and 2 hostels. All the halls of residence house both sexes, excluding two halls that each accommodate only males and only females.
The target population for the study consists of female undergraduate students between the ages of 18-30 years. This group was selected on the basis that most fertility centers prefer this age group for oocyte donation as they are in their peak fertility years [18] and able to provide informed consent. Additionally, high IVF success rates have been associated with the use of oocytes from younger patients. Further, it is believed that the limited nancial resources coupled with a greater nancial burden associated with university education makes the nancial compensation offered to oocyte donors a valuable source of income for the students [19].

Sample size estimation and sampling
The sample size was determined using the formula for estimating a single population proportion. The proportion for substitution in the formula (23%) was based on a previous study on the willingness of female college students to donate an oocyte when given the opportunity [17]. A precision of 0.05, a con dence level of 95% and a non-response rate of 10% were assumed and a nal sample size of 300 was computed.
A multi-stage sampling was employed. The rst stage involved selection of the residential halls. A list of all halls of residence with female undergraduates was obtained from the university's computing system. This yielded 14 halls of residence from which 12 were selected to participate in the study. Of the two halls that were excluded, one hall each provided accommodation to only male students and only foreign students respectively. Each hall formed a stratum from which the survey respondents were selected.
The second stage involved the selection of survey respondents. The total population of female undergraduate students in each of the selected halls was obtained with the aim of selecting equal numbers of female students (25) to obtain a total of 300 respondents. In each hall of residence, a list of all the room numbers with female occupants was obtained. The numbers were coded and a computergenerated random sampling of 10 rooms was obtained. Students from the rooms selected were approached with the questionnaires and those who consented to participate were given questionnaires.
The selected rooms were visited one after the other until the total number of 25 students were obtained. The process was repeated in all halls to attain the required samples size.

Data Collection
Structured questionnaires were administered to eligible students who consented to participate in the study. The questionnaires consisted of closed ended, open-ended questions and Likert type questions. The questions were divided into four main sections namely: socio-demographic characteristics (7 items), knowledge about egg donation (11 items), attitude towards egg donation (18 items), and personal choices (11 items). Questions in the sections on knowledge about oocyte donation were adapted from [17] and Bernsen [20], whereas items in the sections on attitude towards oocyte donation and personal choices were adapted from [21] and [17].
Twelve research assistants, each representing a hall of residence, were trained in data collection procedures and good ethical conduct. A pretest was conducted in a different tertiary institution to ascertain clarity of the questions and anticipate any practical di culties. Data collection took place in the halls of residence, mostly in the late afternoon, evenings and weekends as most students were available at these times. Returned questionnaires were scrutinized to eliminate errors and ensure completeness prior to data entry and analysis. Questionnaires with several missing entries were eliminated.

Study variables and data processing
The responses to the question "Will you be willing to donate oocytes (eggs) for in-vitro fertilization (IVF) if you were approached?" were 'Yes/No' indicating willingness and unwillingness to be an oocyte donor respectively. This was the outcome variable and it was dichotomous. Demographic characteristics of respondents were age, sex, college of study as a proxy of the program of study, marital status, monthly expenditure in Ghana cedis as a proxy of income levels, occupation and place of residence when outside the campus. Other variables included knowledge of oocyte donation within the context of assisted reproductive technology (ART) and the attitude towards oocyte donation.
Knowledge was assessed as a composite variable made up of seven items. Each question was scored '0' for an incorrect answer and '1' for a correct answer, resulting in a minimum score of zero and a maximum score of seven. To assess the overall knowledge score, a score above three was interpreted as a high level of knowledge and a score of three or less, denoted a low level of knowledge.
Respondents' attitude, ethical stance and concerns regarding oocyte donation were assessed using 18 questions measured on a 5-point Likert scale, divided into three subscales namely: (i) General attitude towards egg donation (9 items), (ii) Ethical aspects of egg donation such as cash rewards for donors (2 items) and (iii) Issues of anonymity (7 items). A Cronbach's alpha reliability co-e cient was used to assess the level of internal consistency between the questions within each subscale. Satisfactory values of 0.67, 0.80 and 0.78 were obtained respectively. Among the subscales, 'General attitude' was used as an indication of overall attitude towards oocyte donation, with scores ranging from 9 to 45. A respondent's attitude was categorized as positive if the sum of scores was greater than 24 and deemed negative if a score of less than or equal to 24 was obtained.

Statistical Analysis
Descriptive statistics generated for socio-demographic characteristics of respondents included frequencies, percentages, mean and standard deviation. The Pearson's chi-square test, Fischer's exact test and logistic regression analysis were used to determine association between willingness to donate an oocyte or not (outcome variable), and socio-demographic characteristics, level of knowledge about oocyte donation and the attitude towards oocyte donation (explanatory variables). Crude and adjusted odds ratios were presented with the 95% con dence limits constructed around the estimates.

Results
In all, 300 students were surveyed out of which 295 correctly responded to the questionnaires resulting in a non-response rate of 1.7%. The mean age of the respondents was 20.20(±1.63) years. Most of the respondents, 155 (52.5%) were aged between 20 years and 22 years, single 288 (97.6%), Christians 278 (94.2%) and had monthly expenditure below GhC500, 186 (63.1%). The background characteristics of the respondents are summarized in Table 1.  The main sources of information on oocyte donation were the internet (41.1%), television advertisements (24.8%) and friends (21.7%). Other sources were relatives, newspapers and the radio (  Table 3 lists items used to assess respondents' attitude towards oocyte donation. Only 24 (8.1%) respondents indicated they will strongly support a friend to donate oocytes (referred to in the instrument as 'human eggs') and 29 (9.8%) stated they would support a friend to receive donated oocytes. Approximately 10.2% of respondents strongly agreed that oocyte donation is a good way of helping childless couples. One hundred and seven respondents (36.3%) agreed that advertising via media is good method to recruit women for oocyte donation. Although 10.2% of respondents strongly supported oocyte donors having some relationship with the receiving couples, majority of respondents valued anonymity. This was evident as 25.1% and 20% of respondents strongly agreed and agreed respectively to the statement that "Women who donate oocytes and the couple receiving should be anonymous to each other". Overall, 51.5% of respondents had a positive attitude towards oocyte donation based on the scoring system.    about oocyte donation compared to peers in the US study. It is important to recognize that although these studies are nearly a decade apart, the levels of knowledge were still low. Media advertisements have been used for donor recruitment in the United States, therefore it would have been expected that college students would have relatively more knowledge about oocyte donation. The actual practice of oocyte donation appeared to be low as only 5% of respondents in the present study knew a friend or relation who had been an oocyte donor. On the other hand, none of the respondents in another study donated oocytes despite the widespread practice of donor recruitment among college students in the USA [20].
The primary source of information on oocyte donation was the internet, which differed from a previous study in Ohio where the television was mentioned as the major source of information [20]. In the United States, egg donation has been practiced for many years with clear guidelines and regulations. However, information on oocyte donation is not widely discussed on radio and television in Ghana, therefore most students rely on the internet for information about the procedure. Nonetheless, the present study found no association between level of knowledge and willingness to donate an oocyte. This nding supports other studies that demonstrate that the level of knowledge about oocyte donation does not appear to limit an individual's intent to donate oocytes [24][25][26][27].
According to Ajzen's Theory of Planned Behaviour, an individual's intention to perform a certain behaviour is largely in uenced by his/her beliefs about the expected outcome of the behaviour as well as the worthiness of the expected outcome [28]. It further posits that the attitude of a person is often shaped by cultural normative beliefs and reinforced by religion [28]. Thus, the importance placed on oocyte donation by an individual will be largely in uenced by the societal constructs of third-party involvement in reproduction and religious views about the concept. The present study revealed that 52% of female students studied showed a positive attitude towards oocyte donation. This a rms earlier studies which showed that about 50-90% of non-patient respondents exhibit a positive attitude towards oocyte donation [20][21][22][29][30][31]. In contrast, a few studies in Africa have reported poor attitude towards egg donation [12,32]. A potential explanation for the positive attitude reported in the present study could be a higher level of education which might have in uenced them to take a less conservative stance oocyte donation than might be expected from the general population. It is not certain whether women with relatively less exposure to western education might have a similar attitude. A comparative study could elucidate with a larger sample size. Another probable explanation for the positive attitude, in spite of the low level of knowledge about oocyte donation, could be the worthiness of the expected outcome as posited in Ajzen's theory.
Anonymity in oocyte donation is the phenomenon where the identity of the oocyte donor is not revealed to the recipient and the offspring. In the UK for instance, the Human Fertility and Embryology Authority (HFEA), the body that regulates the practice of assisted reproduction in the United Kingdom, passed a law in 2005 that makes it mandatory for donors to disclose their identity. Following the passage of this law, 17% of non-patient women surveyed considered donating an oocyte as opposed to nearly 34% who demonstrated a positive attitude prior to the removal of anonymity in the same group [16,33,34].
Counterintuitively, similar studies in Sweden revealed that a greater proportion of participants studied preferred a non-anonymous donation to an anonymous donation [21,35]. In the present study, majority of respondents supported an anonymous oocyte donation (strongly agreed=25%; agreed=20%). Further exploration of the wider public's stance on anonymity is necessary to inform practice. Finally, this study demonstrated that students who showed a positive attitude towards oocyte donation were more willing to donate oocytes compared to their counterparts with a negative attitude which is consistent with literature.
The high proportion of respondents who were willing to donate an oocyte obtained in this study could be due to a simplistic view of oocyte donation. This is based on Svanberg's assertion that college students tend to hold a more simplistic view on oocyte donation than older individuals [21].
Consistent with earlier studies, the main motivation to donate an oocyte in the present study was a desire to assist an infertile couple as well as nancial reward [17,36,37]. Various studies have cited nancial compensation and altruism as the two most common factors that motivate potential egg donors to donate [36]. Majority of potential donors in most studies cite altruism as their major motivation which is consistent with the present study were 70% of students would donate oocytes to help an infertile couple [17,37]. This desire to assist an infertile couple by oocyte donation is probably linked to traditional values that African place on fertility. This has been demonstrated by certain sociocultural practices aimed at helping an infertile relative. Some of these practices include child gift, adoption, and heterosexual woman to woman marriages [12]. Although the role of traditional values was not explored in the present study, it can be considered in future studies on this subject.
Among the socio-demographic factors under investigation, religion and monthly expenditure of GhC500-1000 per month had a signi cant effect. Religion has been associated with willingness to donate oocytes in previous studies, with Christians generally more likely to demonstrate an intention to donate oocytes compared to Muslims [24,31]. The present study found that Muslim students were less willing to donate an egg to a couple which is consistent with literature. It is believed that Islamic laws forbid third party assisted conception and it is less well accepted [22,38]. Apart from the desire to help an infertile couple, nancial motivation in uenced willingness to be an oocyte donor. Tertiary level education imposes nancial demands on students, therefore it is expected that nancial compensation would be an important consideration in the decision about oocyte donation. Other factors investigated such as age, programme of study and marital status did not have any association with willingness to donate oocytes.
However, previous studies have reported that age and marital status were positively associated with willingness to donate oocytes [39,40]. It is possible that the smaller sample size studied could be the reason why similar ndings were not observed in this study.
Based on the key ndings in the study, recommendations were proposed to healthcare providers, academia and religious leaders. Healthcare providers involved in fertility treatment should extend and intensify education regarding oocyte donation to the general public, taking into cognizance major sources of information reported herein. Community engagement through focus group discussions can help to motivate people towards oocyte donation as well as highlight concerns that need to be addressed. Qualitative studies can be conducted in collaboration with academia to explore in more depth potential barriers and facilitators of oocyte donation. Oocyte donation may require a broad discussion among religious bodies in collaboration with health care institutions. This will provide holistic information to guide intent and choices about oocyte donation to relieve the plight of and provide support to infertile couples.
This study had some limitations. No standardized tool was available to the authors for assessing the level of knowledge of the respondents about oocyte donation. Though the method used to assess knowledge was adapted from other studies, the lack of uniformity and standardization makes it di cult to compare effectively across studies. Future efforts may need to be directed at designing and testing to generate a standardized tool. The results herein may not re ect attributes in the general population, rather those of a speci c group of donors, therefore local studies targeting various donor groups in assisted reproduction are urgently required.

Conclusion
The present study demonstrated that knowledge about egg donation as a form of ART among female undergraduate students was low. The proportion of students willing to donate oocytes was higher than reported elsewhere. A good attitude and nancial motivation were associated with willingness to donate oocytes. Religion also had a signi cant effect which was consistent with earlier studies.
Recommendations include targeted and public education to address identi ed gaps in knowledge and involvement of religious bodies, healthcare providers and academia in efforts to improve the plight of infertile couples.

Abbreviations
ART Assisted Reproductive Technology

GHS-ERC Ghana Health Service Ethical Review Committee
HFEA Human Fertilization and Embryology Authority IVF In-vitro fertilization Declarations EAU participated in the proposal development, contributed to manuscript writing and reviewed the manuscript. All authors read and approved the nal manuscript.

Funding
No funding was received for the conduct of the study.
Availability of data and materials The dataset used and analyzed in the present study are available from the corresponding author upon reasonable request.

Figure 1
Source of information about oocyte donation Knowledge of respondents about oocyte donation Reasons for unwillingness to donate an oocyte