What Do You Know about Reproductive Medicine? –
Results of a German Representative Survey
Yve Stoebel-Richter1*, Kristina Geue1, Ada Borkenhagen1, Elmar Braehler1, Kerstin Weidner2
1Department of Medical Psychology and Medical Sociology, University of Leipzig, Leipzig, Germany, 2Clinic and Polyclinic for Psychotherapy and Psychosomatics,
Medical Faculty Carl Gustav Carus, Dresden, Germany
Objective: The use of reproductive medical treatments has become increasingly routine in recent years. This paper reports
on a study of how different aspects of modern reproductive medicine are perceived by the German population.
Design: Findings from a nationally representative sample of 2110 men and women aged 18 to 50 are presented.
Participants responded to a questionnaire seeking self-report information about attitudes and knowledge regarding
different aspects of reproductive medicine.
Results: The majority of respondents had already heard or read something about reproductive medicine; knowledge gaps
were prevalent in men and individuals with lower levels of education. The decrease in female fertility usually was
underestimated, whereas both the number of involuntarily childless couples and the success rate of reproductive medical
treatment were overestimated. One-third of participants would make use of reproductive medicine to have their own child.
Conclusion: This study revealed inadequacies in the knowledge of the German general population regarding reproductive
medicine. Despite the low interest and poor knowledge of the topic, a broad acceptance of reproductive medical methods
was reported. The results illustrate the need for adequate information transfer regarding female fertility as well as success
rate and risks of reproductive medical interventions.
Citation: Stoebel-Richter Y, Geue K, Borkenhagen A, Braehler E, Weidner K (2012) What Do You Know about Reproductive Medicine? – Results of a German
Representative Survey. PLoS ONE 7(12): e50113. doi:10.1371/journal.pone.0050113
Editor: Qinghua Shi, University of Science and Technology of China, China
Received July 18, 2012; Accepted October 16, 2012; Published December 3, 2012
Copyright: ? 2012 Stoebel-Richter et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This research was funded by the Federal Ministry of Education and Research (BMBF), registration number: 01GP0205/0255. The funders had no role in
study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: email@example.com
Since the first successful use of IVF in 1978 , assisted
reproductive medicine has made great progress, has become
routine in the health care system , and is constantly developing
About 6–9% of all couples in central Europe remain
involuntarily childless and desire treatment [6,7]. Assessments of
lifetime risk of infertility suggest that 20–30% of all couples will be
affected by reduced fertility once in their life. In many cases,
couples associate modern reproductive methods with a reliable
possibility of achieving parenthood for almost an unlimited period
of time [8,9,10]. In contrast, previous studies have reported success
rates of IVF treatment of lower than 20% [3,11,12]. Many studies
demonstrate a relationship between the age of the woman treated
and treatment success of assisted reproductive medicine: the older
the women at treatment time, the lower the chance of success
[12,13,14]. The rapid decrease of gravidities in women older than
35 years who have IVF-treatment corresponds with the decline of
the general pregnancy probability in middle-aged women. Against
the background of the predominantly unsuccessful results of
assisted reproduction methods, patient-centered treatment re-
quires a careful consideration of risks and benefits of medical
treatment as well as the risks and benefits of nonmedical
alternatives like adoption or living without children [15,16,17,18].
Several studies have examined knowledge and attitudes towards
fertility or reproductive medicine in certain population groups. A
fundamentally positive attitude towards parenthood was found by
Lampic et al.  in a survey of 401 Swedish students. But half of
the female students envisioned their first-time parenthood as
occurring after age 35, unaware of their own decreasing fertility.
Approximately half of the participants supposed the time of
decline in fertility to begin some years later than in actuality.
Findings of the study by Tough et al.  also found that women
are not aware of risks associated with delayed parenthood. The
authors stated that participants’ postponement of first-time
parenthood is associated with insufficient knowledge about their
own reproductive capability. A study by Quach et al.  found
that 80% of 772 high school students underestimated the infertility
rate, and nearly all of the respondents believed that infertility
would be ‘curable’. Knowledge gaps were also reported by Rovei
et al.  in a study of Italian students (N=958) among whom
this information deficit was uncorrelated with sex and type of
education (humanities or science). Whereas the decline in female
fertility was underestimated, the pregnancy rate after either sexual
intercourse or IVF was overestimated. Rovei and collegues 
PLOS ONE | www.plosone.org1 December 2012 | Volume 7 | Issue 12 | e50113
recognized a better information level of people as an essential
element in decision-making concerning when to start a family. The
Finnish study by Heikkila ¨ et al.  exploring the attitudes towards
reproductive medicine of infertile women (N=189) and breast-
feeding mothers (N=84) demonstrated similar attitudes in both
groups. Infertile women, however, were even more liberal and
favored a popularization of reproductive medicine.
Only half of 205 surveyed American physicians (general
practitioners, internists, gynecologists) associated infertility with
women aged 35 and older . The majority of physicians
supposed European Americans with high income to be at the
highest risk for infertility (85%). In fact, this group makes the most
frequent use of reproductive medicine, which likely account for
this, selective perception on the part of these professionals. Ceballo
et al.  required a better education of non-experts regarding
infertility treatment. Papaharitou et al.  compared attitudes of
midwives with the general population and found no differences
between the groups. But there was an effect of age insofar as older
respondents favored stronger regulation of reproductive medicine.
The aforementioned studies indicate knowledge gaps or false
beliefs about fertility, infertility, and reproductive prospects among
both medical professionals and nonprofessionals, while the latter
consisting predominantly of young student samples. As an essential
criterion for deciding on political questions, Kalfouglou and
colleagues  highlighted knowledge of the attitudes of the
general population (e.g. a public information campaign). For
reproductive endocrinologists per se, knowledge about public
opinion leads to a better understanding of couples being treated
Our present study examined fertility-related knowledge and
acceptance of modern assisted reproductive techniques using a
large nationally representative sample of German adults aged
between 18 and 50 years. Furthermore, the study sought to clarify
how gender and level of education may influence these findings.
Materials and Methods
This representative survey was assigned by the University of
Leipzig and carried out by USUMA (Berlin), a market analysing
and opinion research institute. All participants were visited in
person, informed about the study procedures by a trained research
assistant, and signed an informed consent form prior to
assessment. All interviewers/researchers involved were aware of
the responsibility for confidentiality in respect to participants’
records. The data used were de-identified. The study adhered to
the ethical guidelines of the ICC/ESOMAR International Code of
Marketing and Social Research Practice. The present study posed
a low risk to the participants. Ethical approval was required and
obtained from the Ethic Committee by Leipzig University’s
Institutional Review Board.
Respondents were randomly selected according to the random-
route-procedure which first provided a target–home and after that
a target–person in every home. The sample was weighted
regarding sex and age to reflect the characteristics of the German
population. The selected individuals were personally approached
by the interviewer who collected the sociodemographic informa-
tion face-to-face. The self-report attitude questionnaire was filled
out by the respondents themselves in the presence of the
interviewer. With a response rate of 55%, 2110 interviews were
completed by persons aged 18 to 50 years.
Participants received a questionnaire which was designed to
collect self-report information about attitudes and knowledge of
different aspects of reproductive medicine. Several items were
developed for this study. All instruments were pretested in several
Participants were asked about various aspects of reproductive
medicine in general. Knowledge-based questions about female
fertility, the success rate of IVF, and childlessness in Germany
were presented with multiple-choice or estimation response
options. To find out about attitudes towards ethically controversial
aspects of reproductive medicine, a set of statements including pros
and cons was given. These items were related to the pushing of the
biological age limit, to the advantages of remaining childless, and
to moral conflicts. A five-point Likert scale was used to measure of
degree of agreement with each statement. At the end of the
questionnaire respondents were asked to evaluate the pros and
cons of reproductive medicine in general using a six-point scale.
Data were analysed with descriptive as well as inferential
statistical procedures. Significance levels of differences between
frequencies were assessed through Chi2-analysis.
The sample consisted of 929 males and 1181 females with an
average age of 35.8 years (SD 9.1). More than half of all
respondents (64.7%) were in a committed relationship and had at
least one child (60%). A small number of participants 1.3% had
themselves had infertility treatment (IVF 56%, hormonal treat-
ment 30%). More information is given in Table 1.
Participants’ Desire for Having Children
More than half of respondents (56.9%; N=1200) reported not
desiring to have (more) children at the time the survey was
conducted. Further, 19% (N=398) were undecided on this
question. More details are shown in figure 1. Of the total sample,
at least 10.0% had been referred for infertility.
Knowledge About Fertility and Reproductive Medicine
Participants were asked to estimate the age when female fertility
gradually starts to decrease. Three percent of participants
answered correctly, expecting the fertility decline to start at the
age of 25. 24% responded at age 35 and a further 28% of the
sample at age 40. One-third responded that female fertility starts
to decline at the age of 45 or after menopause (Table 2). Overall,
compared to female participants, males estimated that female
fertility starts to decrease at a higher age (p=.022). More highly
educated people rated the age of female fertility decline more
accurately than those less educated (p=.001).
The rate of involuntarily childless couples of all couples in
Germany was estimated to be 5 to 10% by more than one third of
participants (33.9%), while 31.5% expected 11 to 20% of couples
to be involuntary childless, and another 33% of interviewees
believed this rate to be higher than 20%. On average it was
estimated that 20% of all couples in Germany were involuntary
childless. No sex difference was found with regard to this response
(p=.111). More highly educated persons supposed the rate of
involuntary childless couples lower than less educated people
In-vitro fertilization (IVF) was associated with a success rate of
44% on average by respondents, although 10% estimated a
Reproductive Medicine in Germany
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success rate of less than 10% and 21.5% assumed that successful
pregnancy following IVF was achieved in 10 to 25% of cases.
About one third estimated the success rate as 25 to 50%, and one
third of participants estimated it as greater than 50%. Men
overestimated the success rate of IVF significantly more often than
The majority of respondents (70.9%) had already heard, seen or
read something about reproductive medicine at the time the
survey was conducted. Of this informed sub-sample, their own
knowledge about reproductive medicine was self-reported as either
excellent or good by 13.3%. 42% of participants rated their
knowledge as moderate while more than half reported having poor
knowledge. The most frequently used source of information
interviewees mentioned was TV (53%), weekly magazines (27%) as
well as professional journals or conversation with friends, relatives
and acquaintances (21% each). Female as well as more highly
educated participants, in comparison to male and less educated
respondents, reported having more often heard or read something
about reproductive medicine and having better knowledge in this
Attitudes Towards Assisted Reproductive Medicine
Interest in reproductive medicine was low among participants
(M 3.9, with a scale ranging from 1 ‘extremely interested’ to 5 ‘not
Table 1. Socio-demographic characteristics of the sample.
Total (N=2110) Female (N=1181)Male (N=929)
Age groups 18–25 years 367 (17.4%) 193 (16.3%)174 (18.7%)
26–35 years 609 (28.9%)343 (29.0%) 266 (28.6%)
36–45 years754 (35.7%) 433 (36.7%)321 (34.1%)
.45 years 380 (18.0%) 212 (18.0%)168 (18.1%)
Marital status Married, living together1138 (53.9%) 680 (57.6%) 458 (49.3%)
Married, separated29 (1.4%) 16 (1.4%)13 (1.4%)
Single 712 (33.7%) 328 (27.8%)384 (41.3%)
Divorced 194 (9.2%)127 (10.7%) 67 (7.2%)
Widowed37 (1.8%)30 (2.5%)7 (0.8%)
Partnershipyes 1365 (64.7%) 798 (67.6%)567 (61.0%)
low Less than 10th grade644 (30.5%) 346 (29.3%)298 (32.0%)
10th grade 974 (46.2%)589 (49.9%) 385 (41.5%)
high Student 20 (0.9%)6 (0.5%) 14 (1.5%)
High school 321 (15.2%) 186 (15.7%)135 (14.6%)
College/university degree 151 (7.2%) 54 (4.6%) 97 (10.4%)
Religion yes1576 (74.7%) 908 (77.0%) 668 (71.9%)
Children yes1275 (60.4%)803 (68.0%)472 (50.8%)
Used Assisted Reproductive
yes27 (1.3%)24 (2.0%)3 (0.3%)
Figure 1. Decision in favour for against having one (more) child.
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Table 2. Knowledge-based questions and results.
Kendall tau b
Kendall tau b
At what age does female fertility
start to gradually decline?
How many couples do you think remain
involuntarily childless in Germany, today?
What is your estimate of the likelihood
that a woman becomes pregnant following
one artificial insemination treatment cycle?
Have you ever heard, seen or read
anything about reproductive medicine
prior to this study?
How would you describe your knowledge
about reproductive medicine? 2. only
participants who answered ‘‘yes’’ to theprevious question
very low or none at all
*May not add up to 100% due to missing data.
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interested at all’). Of all respondents 5.8% reported being strongly
or extremely interested, and nearly one-third had no interest in
this topic (Table 3). Male and less educated participants reported
significantly lower interest than women and more highly educated
persons (p=.001; p=.001). A correlation between the interest in,
and the rating of one’s own knowledge of, reproductive medicine
was shown (Crame ´r-V.391; p=.001).
Participants were also asked questions designed to reveal their
values regarding various aspects of reproductive medicine. Asked
about what they would do if they desired children but were not
able to have them the ‘‘natural’’ way, one third of participants
(31.6%) would use all reproductive options. Remaining childless
was an option for one in five (22.2%) as was adopting a child
(21.8%). More men than women would accept their own
Approximately half (49.8%) of the participants agreed that
childless couples should use all available assisted reproductive
techniques for having biological children, while 17.6% disagreed
with this statement. Analyses did not reveal differences in sex or
education with regard to this opinion (p=.565; p=.414). A third
32.2% assumed that infertile couples used techniques of repro-
ductive medicine without being able to correctly evaluate
treatment risks whereas 27.1% did not agree with this supposition.
More highly educated people agreed with this statement more
often compared to the less-educated (p=.001).
About two-thirds (64.5%) of participants opposed allowing older
women to realize their desire for children by using reproductive
medicine, independent of their age-based biological limitation,
while 14.1% did not. Women were oppose4d to this more often
than men (p=.003).
Nearly a third (30.7%) associated ethical conflicts with
employing new reproductive medical techniques, while a quarter
(27.4%) did not. Ethical conflicts were more often seen by the
more highly educated compared to the less-educated (p=.031).
Being asked to generally evaluate advantages and disadvantages
of reproductive medicine, 25.6% reported a preponderance of
advantages. 26% associated reproductive medicine predominantly
with disadvantages, whereas one third (35.9%), saw it as more
balanced. A lower educational level was associated with greater
indecisiveness towards possible advantages or disadvantages in
comparison with higher educational level (p=.001).
This study sought to identify the knowledge and attitudes of the
German population towards reproductive medicine and to
evaluate any differences in knowledge and attitudes associated
with sex or educational level. The authors conclude that
reproductive medicine is a subject which is accessible to the
German population, though the results indicate some superficiality
in knowledge. For example the decline of in female fertility with
age was underestimated.
The age-related decline of female fertility was also underesti-
mated in student samples [19,21]. Bunting & Boivin  found
that bearing a child early was only seen as a protective factor for
fertility by four out of 149 students. In accordance with findings
from Rovei et al.  the success rate of reproductive medical
treatments was clearly overestimated in the present study.
Findings of other studies also indicate that the probability of
conceiving after unprotected intercourse was clearly overestimated
[19,25]. As Lampic et al.  and Rovei et al.  have shown,
women’s knowledge about reproductive medicine was better than
that of men. Further, more highly educated people more
accurately responded about aspects of general reproductive
medicine. The combination of deficient knowledge about female
fertility and overestimation of the probability of pregnancy
occurrence may help to explain why first-time parenthood is
being increasingly postponed.
In many cases this deferral might be explained by misinforma-
tion suggesting public information that having children can be
arbitrarily postponed. So one has to question if accurate concrete
knowledge would lead to a modification of behavior concerning
the significance of first-time parenthood, if the decision was made
earlier. Yet, the clear overestimation of involuntarily childless
couples indicates that there is already an awareness of the problem
of the unfulfilled wish for children in the German population. This
overestimation can be attributed to the perception of increasing
childlessness. But often the differentiation between voluntary and
involuntary childlessness is not made . The present study did
not ask participant’s views regarding the reasons for involuntarily
Knowledge gaps about reproductive medicine in the German
general population and the associated demand for better
education have also been reported elsewhere [20,21]. The sexual
education of young people has previously focused on other aspects,
including information about contraceptive methods and prevent-
ing sexually transmissible diseases. Certainly, removing the delay
of parenthood due to the misunderstanding of age-related decline
in female fertility will not be easy. The education of young women
about their own fertility done by treating gynecologists was
supposed to be an effective approach [21,27].
In spite of the low interest and state of knowledge regarding the
topic of reproductive medicine reported in this study, a broad
acceptance of reproductive medical techniques was found. Half
the participants stated that childless couples should make use of all
reproductive medical techniques to have biological children. In the
event of their own involuntarily childlessness, one-third of the
respondents were poised to utilize all possibilities provided by
reproductive medicine – women far more often than men.
Furthermore, the results showed that men were more able to
imagine remaining childless than women. An explanation of these
findings may be that involuntary childlessness is considered a
stressful life event [17,18,28,29]. By the principle of ‘leaving no
stone unturned’, reproductive medicine has become a promising
solution providing new options for persons concerned. The
primary goal of any treatment for infertility should always be to
augment spontaneous conception rates .
Studies have shown that involuntarily childless couples do not
differ from other couples (e.g. mental health), but that childless
couples are frequently confronted to explain their situation. This
might result in a sense of diminished self-worth as well as a
modification of their existing life plan . In contrast to older
studies [32,33] new findings indicate that both men and women
suffer from involuntary childlessness [34,35] including, primarily,
psychological impairment (depression and anxiety).
Although reproductive medical techniques are accepted by the
German population, one-third believes that couples concerned
were not able to correctly assess the risk of utilization. In particular
more highly educated people agreed with this statement. Rauprich
et al.  showed that German couples wishing to have children
were not informed about all relevant aspects of reproductive
medical techniques to reach a decision for treatment. Findings by
Porter et al.  demonstrated that most of the couples desiring
children were only interested in information that enhanced their
chances for having a baby, while disregarding reasons against a
treatment. Yet analyses by Stoebel-Richter et al.  and
Revermann & Hu ¨sing  showed that psychosocial counseling
within the reproductive medical context is still desirable.
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Table 3. Attitude-based questions and results.
Kendall tau b
Kendall tau b
How much are you interested in
none at all
Assuming that you and your partner
desire children and were not able to
have children the natural way, what
would you do?
use all poss. of ART
adopt a child
Involuntarily childless couples
should use all possibilities of
reproductive medicine for having
Infertile couples use techniques of
assisted medicine without having
correctly calculated treatment risks.
Older women should be able to
realize their desire for children by
using reproductive medicine,
independent of their age-based
biological age limitation.
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Table 3. Cont.
Kendall tau b
Kendall tau b
Application of new techniques of
reproductive medicine presents grave ethical
How would you appraise the advantages and
disadvantages of reproductive medicine as a
both adv. and disadv.
*May not add up to 100% due to missing data.
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Balancing the pros and cons of reproductive medicine in the
present study resulted in a very heterogeneous pattern showing
that advantages as well as disadvantages are noticed by the
population. As a result of evaluations, 3% of all children born in
Germany were produced with the aid of reproductive medicine
. By postponing first-time parenthood to a later age due to
changing social and economic conditions it is assumed that the
user group of reproductive medical treatment will enlarge in the
As a critical appraisal of methods, it should be noted that non-
standardized, self-designed items were used. According to the cited
studies, this is a common practice, but comparability and
generalizability of findings were hampered. Due to the cross-
sectional study design used, it remained unsolved, the question of
whether knowledge and attitudes change in the general population
over time remains unanswered.
Findings of this representative study point out that adequate
information transfer is needed concerning female fertility as well as
success rates and risks of reproductive medicine. Normally, couples
get their information about decreasing female fertility if their
desire for a child wish is renewed or they are already in fertility
treatment. Family planning and reproductive medicine aspects
should be an integral part of sex education at school – just like
education about contraception and prevention of sexually
transmitted diseases. It may be advisable to explore the use of
digital and interactive media to reach young people effectively.
Other possibilities for the clarification of young women about
female fertility and the success rates and risks of reproductive
medicine are conversations and the offer of relevant information
material during the gynaecological practice. Furthermore popu-
lation-wide education campaigns should be considered, which can
certainly allow an effective information transfer.
At this time, to inform patients’ effective balancing of the success
rates and risks of reproductive medical techniques in terms of
patient-centered treatment decision-making, broad education and
counseling both at a medical and psychosocial level are necessary
to address current knowledge deficiencies and attitudes of the
Conceived and designed the experiments: YSR EB. Performed the
experiments: YSR. Analyzed the data: YSR KG. Contributed reagents/
materials/analysis tools: YSR AB KW. Wrote the paper: YSR KG KW.
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