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Fertility-related knowledge and perceptions of fertility education among adolescents and emerging adults: a qualitative study



Research shows that young people do not know much about their fertility. In the present study, we examined fertility knowledge and perceptions of a fertility educational brochure (i.e. ‘A Guide to Fertility’) in five focus groups with adolescents (16–18 years, n = 19) and emerging adults (21–24 years, n = 14) who were childless, not currently pregnant (or for men partner not pregnant) or trying to conceive but intending to have a child in the future. Participants (n = 33) reported having poor knowledge of a range of fertility topics and feelings of surprise, fear and concern in response to the brochure, despite perceiving benefits of the provision of fertility education and feasibility of ‘A Guide to Fertility’. Comparison between age groups showed that adolescents lacked confidence in their fertility knowledge and emerging adults more frequently referred to gender and family planning issues when considering the fertility information. The findings show the need and importance of ensuring fertility education is tailored to different age groups for it to be integrated at specific stages of the life course and optimize its benefits over costs. Results point to educators and researchers working together to determine how best to disseminate fertility information to relevant age groups.
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Fertility-related knowledge and perceptions
of fertility education among adolescents and
emerging adults: a qualitative study
Jacky Boivin, Amea Sandhu, Kate Brian & China Harrison
To cite this article: Jacky Boivin, Amea Sandhu, Kate Brian & China Harrison (2018): Fertility-
related knowledge and perceptions of fertility education among adolescents and emerging adults: a
qualitative study, Human Fertility, DOI: 10.1080/14647273.2018.1486514
To link to this article:
Published online: 10 Jul 2018.
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Fertility-related knowledge and perceptions of fertility education among
adolescents and emerging adults: a qualitative study
Jacky Boivin
, Amea Sandhu
, Kate Brian
and China Harrison
School of Psychology, Cardiff University, Cardiff, Wales, UK;
Royal College of Obstetricians and Gynaecologists, London, UK
Research shows that young people do not know much about their fertility. In the present study,
we examined fertility knowledge and perceptions of a fertility educational brochure (i.e. A
Guide to Fertility) in five focus groups with adolescents (1618 years, n¼19) and emerging
adults (2124 years, n¼14) who were childless, not currently pregnant (or for men partner not
pregnant) or trying to conceive but intending to have a child in the future. Participants (n¼33)
reported having poor knowledge of a range of fertility topics and feelings of surprise, fear and
concern in response to the brochure, despite perceiving benefits of the provision of fertility edu-
cation and feasibility of A Guide to Fertility. Comparison between age groups showed that ado-
lescents lacked confidence in their fertility knowledge and emerging adults more frequently
referred to gender and family planning issues when considering the fertility information. The
findings show the need and importance of ensuring fertility education is tailored to different
age groups for it to be integrated at specific stages of the life course and optimize its benefits
over costs. Results point to educators and researchers working together to determine how best
to disseminate fertility information to relevant age groups.
Received 11 February 2018
Accepted 21 May 2018
Fertility knowledge;
education; qualitative;
adolescents; emerging
adults; fertility awareness
Fertility awareness concerns level of knowledge about
reproduction, fecundity and fecundability, risk factors
for reduced fertility, and the societal and cultural fac-
tors affecting family planning and building (Zegers-
Hochschild et al., 2017). Research to date shows that
young people (mean age <24 years) have poor know-
ledge on a range of these fertility topics (e.g.
Mogilevkina, Stern, Melnik, Getsko, & Tyd
en, 2016;
Rovei et al., 2010). There are costs to poor knowledge
even for young people including inadvertent exposure
to factors that reduce fertility (e.g. lifestyle, cultural
practices; Bunting, Tsibulsky, & Boivin, 2013) and
unnecessary exposure to painful, early onset symp-
toms that are normalized (e.g. severe menstrual pain,
heavy menstrual; Harlow & Campbell, 2004; Hudelist
et al., 2012). In the longer term, the lack of knowledge
is related to feelings of immunity to fertility problems,
to misconceptions about fertility being robust and to
beliefs that fertility is possible beyond its natural time
frame (Bunting & Boivin, 2008). These beliefs could
cause misinformed decision-making about when to
start a family or about postponing childbearing
(Virtala, Vilska, Huttunen, & Kunttu, 2011) and its
associated higher risk of reduced fertility, longer time
to pregnancy, inadvertent childlessness at end of life
and poor health in pregnancy (Schmidt et al., 2012).
In light of these findings, there has been a call for
the provision of accurate fertility information in school
curriculums in Britain with a call for research exploring
what the content of the new curriculum could be, and
how it could be integrated in schools and its effects
evaluated (Boivin, Bunting, & Gameiro, 2013; Boivin
et al., 2018; Harper et al., 2017; Littleton, 2014).
Research does show that provision of fertility informa-
tion increases knowledge (Garc
ıa, Vassena, Prat, &
Vernaeve, 2016; Maeda et al., 2016; Oliveira, 2015;
Williamson, Lawson, Downe, & Pierson, 2014;
Wojcieszek & Thompson, 2013) and that young people
have favourable attitudes toward the dissemination of
fertility information through social media and health
care providers such as general practitioners (Garc
et al., 2016; Hammarberg, Collins, Holden, Young, &
McLachlan, 2017; Hammarberg et al., 2017; Littleton,
2014). To date, reactions to fertility information have
not been examined among adolescents despite these
being the target of current fertility education initia-
tives in the UK (i.e. Fertility Education Initiative, Harper
et al., 2017).
CONTACT Jacky Boivin School of Psychology, Cardiff University, Tower Building, Park Place, Cardiff, Wales, CF10 3AT, UK
ß2018 The British Fertility Society
For fertility educational initiatives to be effective, an
understanding of the needs and interests of the target
population is required (Garc
ıa et al., 2016). According
to Bowen et al. (2009), qualitative methods are often a
more optimal methodology to elicit data on the feasi-
bility and acceptability of new interventions and proc-
esses. Indeed, an in-depth qualitative study of the
fertility knowledge of British teenage girls showed
them to know a fair amount about diverse fertility
topics (Littleton, 2014). However, the quality of the
knowledge possessed was often poor (inaccurate,
vague) and was poorly applied to life settings; limits
to fertility were disregarded and poorly integrated in
personal ambitions or sociocultural understandings
(e.g. older parenthood acceptable if in line with per-
sonal preference). As such, a qualitative approach to
reactions to fertility information might reveal positive
or negative evaluations of fertility information but also
how young people think they would apply this infor-
mation in the context of their own lives.
The aim of our research programme was to evalu-
ate the effect of fertility information on fertility-related
cognitions, emotions and knowledge acquisition in
male and female young people <24 years). We carried
out quantitative experimental work that compared the
effects of fertility information (A Guide to Fertility)
among adolescents and emerging adults (male and
female, Boivin et al. (2018)). The quantitative results
showed that provision of fertility information was
associated with benefits (increased knowledge in 21-
to 24-year olds) but also some costs (increase in infer-
tility threat for adolescents and emerging adults). The
aims of the present qualitative study were to explore
in more depth the fertility knowledge of another
cohort of adolescents (aged 1618 years) and emerg-
ing adults (aged 2124 years) and their perceptions of
the fertility educational brochure (A Guide to
Fertility). It was expected that the findings could help
inform the development (content, tailoring) of health
education initiatives to be used in school curriculums.
Materials and methods
Eligible participants were aged 1618 (adolescent
group) and 2124 years (emerging adults), childless,
not trying to conceive or currently pregnant (for men,
partner not pregnant), presumed fertile and intending
to have a child in the future. Convenience sampling
was used, and group composition determined from
those willing to participate. Young people from the
author affiliated university, secondary schools in the
same geographical region, and Birmingham and mem-
bers (<24 years) of the Womens Voices Involvement
Panel (WVIP, Royal College of Obstetricians and
Gynaecologists, London) were invited to participate in
the study. Secondary students were invited to the
study at their morning assembly, before the start of
classes, and were not offered incentive for participa-
tion on advice of their headmaster. University students
were recruited from the entry hall of the student
union, during lunchtime with the added incentive of
free pizza. Women in the WVIP were invited via email
and their travel expenses paid, offered tea and bis-
cuits, and given a £10 shopping voucher. The
Birmingham group was recruited from young people
known to one of the authors (AS) and not
offered incentives.
Afocus group discussion guideconsisting of 12 ques-
tions and a series of informal prompts was derived
from previous research and methods (Krueger &
Casey, 2000). The guide aimed to first aid discussions
about the amount, nature and source of current fertil-
ity knowledge, perceptions of factors that could
impact on fertility and the importance of fertility
topics at different ages. The discussion started with
general questions (e.g. what do you think the word
fertility means? what topics are most important in
terms of fertility? what factors could impact fertility?)
with necessary prompts based on replies (e.g. what is
normal? how would that factor affect fertility?).
Participants were then also encouraged to discuss
their perception of the provision and content of a fer-
tility education brochure (A guide to Fertilitysee
below). Questions focused on what they liked and dis-
liked about the brochure as well as what they had
learnt from it. General questions about the brochure
(e.g. what did you like about the brochure? what do
you feel you have learnt from it?) followed by specific
questions depending on replies (e.g. is X something
you would like to see in a health brochure?). At the
end of the focus group, participants were asked two
further questions which were what do you feel was
the most important topic discussed today?and why?,
to ensure that all important topics were captured.
The fertility education brochureexamined during
the focus groups was A Guide to Fertility(Boivin
et al., 2018). It was used to provide a concrete
example of what providing fertility information could
entail. The brochure contained four pages (3004
words) of information, divided into nine sections
concerned with fecundity, infertility and its risk factors,
signs and symptoms, and reproductive options)
derived from the information proposed to be relevant
in past fertility education studies and topics relevant
to fertility awareness (Zegers-Hochschild et al., 2017).
Each section comprised graphics to aid learning and
links to information sources (e.g. National Health
Service (NHS), Human Fertilisation and Embryology
Authority) where participants could receive more infor-
mation about the topic. The Guide also included a
glossary of terms. Graphic designers produced the
brochure to appeal to younger men and women
(aged <24 years) (Scarlett Design Agency, http://www.
Five focus groups were carried out in English, four
mixed-gender and one single-sex female group. For
the adolescents, focus groups were carried out during
school (January 23 and 27, 2017) morning sessions or
at the weekend in London and Birmingham (February
18, March 25, 2017, respectively). The mixed gender
groups had a maximum of six participants per focus
group, but the single-sex group had 11 (eight adoles-
cents and three emerging adults). At the start of the
focus group, any questions were answered and con-
sent forms were signed. Participants were provided
with a set of ground rules (e.g. confidentiality, feeling
free to express opinions even if it differed from others,
no right or wrong answers) and alerted to presence of
audio-recorders, as per consent. Following the discus-
sion of fertility topics, participants were given a copy
of A Guide to Fertilityand instructed that they had
1520 minutes to read through it and form a view of
the information provided. A general discussion of the
Guide followed. The procedure was the same for
emerging adults except that participation took place
during the afternoon in London and the authors affili-
ated university (January 25, 2017 and March 2, 2017).
The focus groups carried out in the educational insti-
tutions were approximately 45 min long (due to time
constraints of classes and courses), whereas the week-
end focus group was 2 h. Only the first hour covered
the topic of fertility and the second covered other
gynaecological/womens health issues, data not pre-
sented in the present paper. The School of Psychology
ethics committee (Cardiff University) provided ethical
review (Reference number: EC.
and approval for the study (including consent for
audio-recording of discussions).
Data management and analysis
The focus groups had digital recordings and were
transcribed for analysis. In one focus group, a tech-
nical error occurred and instead the note takers
record was used (note taker present in case of tech-
nical error). Data from all focus groups were com-
bined. Lower and higher level themes were extracted
using inductive coding (AS) and discussed between
two researchers (JB, KB). Differences among age
groups were also examined. Software was not used.
Illustrative quotes were used. Quotes for adolescents
and emerging adults were indicated with A and EA,
respectively, and those from men were indicated with
M, otherwise quotes were from women.
A total of 33 adolescents (n¼19, six boys, 13 girls)
and emerging adults (n¼14, 4 men, 10 women),
Data generation
Thematic analysis yielded seven broad themes: four
were shared across age groups and three unique to
the age groups.
Shared themes
Poor knowledge of fertility. Adolescents and emerg-
ing adultshad poor knowledge of fertility.
Participants evidenced a lack of knowledge about fer-
tility very little[A], Im not even sure if I could even
define to be honest[A-M], and the factors that may
affect fertility. The knowledge reported was limited
must admit Im lacking. My knowledge doesnt
expand much past there[A-M], and lacked depth and
precision, and often offered tentatively x-rays and
phones, probably[EA-M]. Participants were aware that
they did not know as much as they might or should
know about fertility at school you dont learn a lot
[A], there seems to be lots of myths around about fer-
When asked what factors were thought to affect
fertility, a diverse set was produced including health
risks that have general effects on health (e.g. smoking,
drinking) as well as specific fertility risks (e.g. radiation,
genetics, contraceptive pill, past abortion, sexual orien-
tation, cultural and religious practices). However, there
was variability in ability to explore these factors in any
depth. For example, participants mentioned that drugs
might have an impact on fertility, but their ability to
expand on this was limited or tentative hard drugs
like heroin?[A]. It was also noted that participants did
not have much knowledge surrounding fertility prob-
lems and how to protect their fertility. When asked for
signs that might indicate a problem with fertility, the
responses focused on the menstrual cycle missing a
period, erratic periods[A], [] changes in discharge
[EA] although they were aware that their age might
also impact on this it is hard when you are younger
because your periods can be all over the place[A].
There were other suggestions related to menopause
‘…bloating, hot flushes[EA].
Most frequently, acquisition of knowledge origi-
nated from subjects taught at school but respondents
were often unable to recall fully what had been learnt
I think I did it in the science section of general stud-
ies, briefly[EA]. Some knowledge was gleaned from
media I think I saw it on Hollyoaks [popular soap
opera] once a guy had to do it [semen analysis] into a
thing[A]. Another source of information for partici-
pants was friends and family My Mum. I can ask her
anything[A], talking to friends, discussion with
friends about things[A]. Some women were using fer-
tility apps to track their menstrual cycles that were
perceived as helpful I use an app that tracks your
cycle and lets you put in information about your
mood, PMT etc. Its good because it is personal to
you[A]. Few people in the group knew people with
fertility problems, and if mentioned, it was in relation
to use of reproductive technologies that were poorly
understood even though the child is older they got
various sets of eggs frozen lots of batches left
Emotional reactions to information. Feelings of sur-
prise, fear and concern for personal welfare were
expressed about the information presented in the
Guide. One piece of information elicited a consensus
reaction of surprise was the age at which family plan-
ning should begin. The Guide provided the Habbema
matrix of start ages according to desired number of
children, certainty of wanting to achieve that specific
parenthood goal and willingness to use in vitro fertil-
ization (IVF) if fertility problems were encountered
(Habbema, Eijkemans, Leridon, & te Velde, 2015). For
example, a woman would need to start trying to get
pregnant at the age of 23 years for 90% certainty to
have three children without fertility treatment, and
this age shocked participants: Ive got just under a
month left to start if I want to have three kids![EA].
There was clear concern about the dilemma they
would face in the future when trying to balance a car-
eer and having a family ‘…you need to get across
how little time you have got. That you cant wait. You
hear all the stories in the media about women and
fertility, but you never hear the facts[A]. The converse
could also be true: but here you can get to 32 and
still have like 90% chance (of having children) so I
thought that was quite nice[EA-M].
Concern about the worry that fertility information
could elicit was also expressed: I like the idea of
younger women getting this information but at the
same time you dont want to stress us out with this.
There is a bit of a danger in communicating some of
these things;[the Guide] is not scare-mongering
but it does elicit like a fear in you[EA]. There was
also some concern that fertility information could
cause fear-induced behaviour change: ‘… if I read
this [the Guide] in 6th form [college] Id be like I dont
have time to go to University I need to start a family;
like it would scare me[EA]. Finally, the information
could increase the perceived threat of fertility prob-
lems generally, ‘… that Im going to be infertile. Itsa
big unknown its not till you think about it that you
worry about it[EA], or due to personal circumstance
the menopause thing mum and my nan both had
a really early menopause so now Im really scared
about my future[EA] or from learning the prevalence
of infertility I was surprised at how many people it
affects because I dont personally know anybody that
(has) openly struggled with it[EA-M].
Two other facts were commented upon. First was
the limitation of reproductive technologies to over-
come fertility problems (e.g. how lowthe success
rates were). Second, the critical thresholds for the
effects of some behaviours such as smoking and alco-
hol consumption shocked many because participants
expected thresholds to be much higher: I didnt real-
ise 10 cigarettes a day isntthat much but it
can clearly have a significant effect on fertility[A-M].
Benefits of fertility education. There were several
perceived benefits. First, participants reported learning
new information Id say like 80% of stuff in that
(Guide) I didn't know about[EA-M] or reinforcing
vaguely known content. There were several new
pieces of information, namely some risk factors or
signs and symptoms of fertility problems (e.g. obesity,
mumps), facts about fertility (e.g. prevalence of infertil-
ity, typical time to pregnancy), and some uses of
reproductive options (e.g. to help gay people become
parents). The decline of fertility with age was dis-
cussed at length, especially areas of confusion related
to ovarian reserve I dont know where I thought
[eggs] came from all those eggs are in you from
birth![EA]. Information could also trigger recall of pre-
viously learnt information things that I might have
known like vaguely before[A].
A second benefit was the increased awareness of
fertility health stuff that you just wouldnt even know
[to know][F-EA]; ‘… to think more deeply about fer-
tility. I didnt realise it affected so many people[A-M],
especially in younger people for whom fertility would
not be that relevant I doubt Id [have] read it unless
I was given it[EA]. It was perceived that information
could also help to change modifiable risk factors
hearing that [alcohol] would affect my fertility would
definitely make me not have that amount[EA]; itsa
good piece of statistics to prevent people from
doing things you dont want them to do[EA].
Third, participants reported now feeling more com-
fortable talking about the subject of fertility[A-M].
The focus on contraception in current school educa-
tion on sex and relationships was raised, as it was felt
this gave an unrealistic idea of fertility everything you
hear at school is about how easily you fall pregnant
not that you might have problems[A], you end up
feeling that if you sit on a toilet youll fall pregnant,
but it can be hard[A]. There was surprise at the idea
of a male biological clock you seem to think that men
can carry on having babies into their eighties[A].
A fourth benefit was more informed decisions.
Participants felt reassured that if they had fertility
problems in the future then they could still possibly
achieve parenthood having fertility problems is not
the end of your chance of having a kid[A-M] because
of available reproductive technologies ‘… you get a
bit concerned [but] the back page [on reproductive
technologies] makes you feel a lot better about your-
self. You get hit with the bad news first …’ [A-M],
‘…seeing those statistics definitely puts things into
perspective. Like we dont want to get to an age
where its no longer a choice[EA-M]. Other partici-
pants felt that the Guide was a valuable document
that would benefit individuals in their decision-making
because its content was perceived to be generally
unknown. However, a discussion about the optimum
age to receive fertility education produced differing
views on whether it would be appropriate in primary
or secondary schools ‘…primary school might be too
young for this conversation, they might be too
immature[A], but they [young people] do need to
know some of it. Having access to this information is
good. It just has to be aimed at different ages[EA].
The idea that fertility education should be offered to
both sexes was also raised men need to know about
it too, about womens bodies[A].
Feasibility and acceptability of the Guide. The gen-
eral consensus in both age groups was that A Guide
to Fertilitywas informative, laid out well, accessible,
generally understandable and a good piece of health
documentation covering desirable fertility topics.
Participants commented on the usefulness and place-
ment of graphs and tables.
Nevertheless, some recommendations were made
to improve the brochure. First, it was considered to be
too wordy and described as different from typical
ones found at doctorssurgeries due to its length, cov-
ering of multiple topics and lack of pictures. The issue
of classification of body weight sparked some discus-
sion because body mass index (BMI) was not per-
ceived to be an effective measure of obesity (e.g.
weight differential with more muscular people), calling
into question its ability to detect effect of weight on
fertility. The need for a standard measure of weight
was nevertheless accepted. Participants concluded
that information regarding diet might be useful in the
brochure. Some liked the graphics and found these
helped them to understand its really informative,
I like it. All the statistics are good, very interesting and
the graphics are easy to understand [A],graphics
make it less numbers on a piece of paper”’ [A], but a
minority found the graphics confusing. In general, the
participants referred to the need for clarification for
example, complex terminology not defined (e.g. med-
ically assisted reproduction) or vague terminology that
could ignite concern (e.g. ‘…severe period pains-
thats very ambiguous[EA] especially when people
perceived the content to apply to them personally.
There was uncertainty about the information in the
Guide and how to best integrate it. The abbreviated
content of the guide increased participants desire to
seek out more fertility information but it could also
cause uncertainty about fertility facts. This exchange
among emerging adults illustrates this well (not all
discussion shown between start and end point):
‘…all those eggs are in you from birth/‘…like your
future child is in there/‘…like Russian dolls [M]/
thats a lot if they all fertilise/‘…you dont have
all these eggs coming out of you/‘…only 1 can be
ovulated/‘…how are we losing them (eggs)?/you
dont lose one at a time [M]/shedding of the uterus/
so where are all these others disappearing?/they
might still be there but really bad quality/theyre
maybe just decomposing in you/what does bad
quality mean? Does that mean youll have a bad
quality child[Researcher interrupts to clarify]
Similarly, lack of guidance caused uncertainty about
how to apply the fertility information provided to their
daily life, as illustrated in the discussion among these
emerging adults about their perceptions of the most
important issue discussed:
Preventable things/drinking is really common/I
dont think Id listen to that [M]/Maybe if I was trying
to get pregnant maybe I should stop smoking/now
you can still smoke 20 a day/‘…is that how it works/
its not telling you to stop drinking its telling you
not to have six glasses of wine a week/I think thats
better than [what] we do, going out and drinking
loads at once …’/not for me useful for someone
else/the menopause for me thatsthe really big
thing because Ive got (family history of early
menopause)/[researcher says: you would pay
attention to family history over the other factors of
smoking and drinking?]/yeah because I need to factor
that (menopause) in, I cant ignore it
Finally, information in the guide could be mislead-
ing: ‘…people could be making decisions on this kind
of information (in Guide) its fine I can freeze my
eggs or I can get IVF in the future not knowing
that they might not be able to (do this) because
(of) other factors (that) affect whether you can
have access[EA].
Themes unique to an age group
A lack of confidence in ones fertility knowledge
among adolescents. Adolescents and emerging adults
indicated a lack of confidence in their understanding
of fertility issues. However, insecurity was more preva-
lent in the adolescent groups, who frequently offered
content tentatively or looked at their peers for guid-
ance and reassurance before bringing up issues
Would you [looking to peers] count dolly the sheep
as being linked to fertility? wasnt it [checks with
peers] implanting like they do, all the cutting and
implanting[A-M]. Similarly, the adolescents often visu-
ally checked with the researcher to confirm whether
their responses were correct. Girls in the adolescent
group talked less than boys, whereas the reverse was
true in emerging adult group.
Gender issues among emerging adults. The emerg-
ing adults referred to gender when discussing fertility
awareness, more so than the adolescents I think
when you think of fertility you kind of just assume its,
well I kind of assume its just the woman). Some com-
ments arose due to the education brochure being
focused on women I was surprised that there werent
any signs [of infertility] for men[M]. However, gender
was also discussed in relation to explaining the
pressure participants perceived each gender to experi-
ence in reference to fertility: not being able to have a
baby, it is all tied up with the role of a woman[A], or
another I have not even considered men when I hear
about fertility I have just assumed it is all about the
woman because they are carrying the baby[A]. The
majority of girls had already thought about having a
family at some point in the future, and said that they
had started to think about having children from an
early age I was never asked much about my career,
about what I wanted to do. It was more questions
about my family role, being a mother[EA]. One man
stated he would defer the decision of using reproduct-
ive technologies to his partner, with agreement from
others: I cant make those choices for her because Im
not physically carrying out that action (having IVF)
The need to plan for fertility in emerging adults.
The emerging adults made more references to the
need to incorporate thinking about having a family
like the whole idea of fertility is a lot more complex
than I first thought, like I wouldntgenerally dont
really think about it.I feel like people should prob-
ably look into this before they seriously consider hav-
ing children it would help them make more
informed decisions …’ [M]. Reference was made to
the need for forward planning about age and financial
status [fertility education] gives people more time to
consider because like getting pregnant isnt just about
your fertility theres other factors involved in the deci-
sion to get pregnant: [e.g.] your financial status.
Participants expressed concern regarding how to fit in
a successful career alongside having children you
want a career and things as well) before the decline
of their fertility. Participants felt that women had a
considerably larger number of factors to consider
when planning their future fertility than men and
were definitely at a disadvantage compared to
The findings of this study provide useful insight into
the fertility knowledge of adolescents and emerging
adults and their perceptions of the provision of fertility
education. Adolescents and emerging adults welcome
the opportunity to learn about fertility but struggle
(particularly women) to integrate newfound know-
ledge at their stage of life without worrying about its
implications for them now or in the future. According
to these young people, fertility education should be
delivered but needs to be tailored to different age
groups to make it meaningful and optimize its bene-
fits over costs. Educators and researchers need to
work together to determine what fertility content
needs to be known at different ages and how best to
disseminate it to relevant age groups.
Young people in the present study had some fertil-
ity knowledge, but its nature, depth and coverage did
not suggest they would be able to make informed
decisions about their fertility, as found in other studies
(Heywood, Pitts, Patrick, & Mitchell, 2016; Littleton,
2014). The information in the Guide reflected the con-
tent tested in fertility education studies and what is
considered to be relevant to fertility awareness
(Zegers-Hochschild et al., 2017). Participant responses
to this material indicated they learnt new facts, critical
thresholds and found the information useful for the
planning of family. Nevertheless, young people ques-
tioned why they needed to know all the information
presented and how it should be integrated at a stage
of life not concerned with starting a family, as per
other studies (Heywood et al., 2016). Most young peo-
ple, including those participating in our focus group,
spent very little time thinking about their fertility
beyond the simple desire to have children
(Hammarberg, Collins, Holden, Young, & McLachlan,
2017). How and when parenthood goals should be
pursued is not tackled until people feel ready to actu-
ally start a family. This goal-orientated approach to
information means that information is difficult to inte-
grate when it is not yet needed or sought after. This
difficulty mirrors that reported for teenage girls strug-
gling to integrate the fertility information they
encounter in the course of everyday life
(Littleton, 2014).
Difficulty integrating fertility information and meth-
ods to achieve integration need to be identified in
future research. Difficulties could be due to, for
example, providing too much information (amount
problem) or information with varying levels of rele-
vance to the age group (topic problem), too much or
too little depth (depth problem) or lack of contextual-
ization to support relevance of information to specific
age groups (context problem). To illustrate, young
people might more easily integrate fertility informa-
tion if it was contextualized according to misconcep-
tions relevant to the specific age groups. Past
qualitative research showed that 30% of young het-
erosexual women (majority <24 years) with an
unplanned pregnancy believed themselves to be
subfecunddue to misconceptions about past repro-
ductive behaviours (e.g. abortion, use of hormonal
contraception), perceived fertility effects of medical ill-
nesses and inferences about non-pregnancy in previ-
ous episodes of unprotected intercourse (Frohwirth,
Moore, & Maniaci, 2013). Tailoring fertility information
to match the knowledge, beliefs, environment, past
experiences or gender has been done in some initia-
tives (e.g.; Hammerberg, Norman et al.,
2017), and has been shown to produce more informed
decision-making (Edwards et al., 2006), but has not yet
been done for specific age groups. Future research
also needs to examine what young people learn from
information provision. Our quantitative survey showed
short-term gains for 21- to 24-year olds could be
achieved (Boivin et al., 2018) but retention over the
longer term was not evaluated. Other methods of
engaging young people should also be investigated
(e.g. use of the arts).
The provision of information also raised more gen-
eral societal issues. Despite the significant shifts in
childbearing norms, societal and occupational support
for families and great strides in reproductive technolo-
gies, young women still worry about how best to sat-
isfy their desire and goals for education, career and
family. The provision of fertility information appeared
to ignite worries that not all of these would be satis-
fied. Women in the emerging adult groups in particu-
lar felt pressurized and made anxious by fertility
information, as per other quantitative research (Boivin
et al., 2018; Maeda et al., 2016) and felt it to be threat-
ening of their other goals (e.g. career). In research
with teenage girls, incongruence between fertility and
other goals was managed by disregarding bodily limi-
tations, for example declaring older parenthood
acceptable if it was what the woman wanted even
when knowing about age-related fertility decline
(Littleton, 2014). There is a rich and long history of
studies addressing motherhood and career decision-
making with different generations finding their own
ways of balancing these (Roy, Schumm, & Britt, 2014)
and one would expect millennials and generation Z to
do the same. In the present sample, people were
relieved that reproductive technologies could help
overcome some problems of family building, but sur-
prised by their low success rates and unsure about
accessibility. This uninformed willingness points to the
need for better information about using these techni-
ques, especially among emerging adults who were
more concerned about planning for a family.
About 27% (n¼9) of the sample was young men.
Men contributed significantly to the focus groups and
had similar reactions to women although some topics
seemed more often initiated by men (e.g. critical
thresholds for drinking) and others more by women
(e.g. career-family balancing); with so few participants,
these impressions are not conclusive. However, it can
be concluded that men were interested in the fertility
information, engaged with the discussions and
seemed concerned too about how to use fertility
information. As such they should be involved equally
to women in the initiatives to disseminate fertility
information. We did not specifically study gender dif-
ferences in reactions to the fertility information and
did not observe any major difference in content
between the mixed and female only group other than
that the latter discussed menstrual health in more
detail (e.g. heaviness and pain of periods). However,
we did notice that in the adolescent age-group girls
spoke less than boys, whereas in the older age group
the reverse was true (women spoke more than men).
This could be due to an age difference in ease and
confidence of talking about fertility in front of the
other gender, or to the specific composition of our
groups. One emerging adult man referred to deferring
decision-making about using ART to his partner, which
aligns with perceptions among adult male users of
ART. It could be that beliefs about responsibility for
reproductive choice start early in life. Future research
could address in more detail whether gender compos-
ition facilitates or hinders discussion of fertility topics.
Limitations of the study include convenience sam-
pling from diverse sources. There is a need for replica-
tion of the study with other populations of
adolescents and emerging adults. However, consist-
ency between the present study and past findings
(e.g. lack of knowledge) also adds weight to these
being substantive issues in the younger population.
Another limitation is the technical problem whereby
one of the focus group was not recorded. Analysis of
this group relied on the note takers detailed records
but we acknowledge that these would have been less
detailed than a recording (e.g. recording of pauses,
hesitations). Focus groups were between 45 and
60 min due to the constraints of young people having
to return to lessons, lectures or weekend activities. It
could be that more topics would have emerged with
a longer discussion time.
In conclusion, the current study shows young
adults want and benefit from the provision of fertility
information and shows poverty of knowledge applies
to adolescents and young men too. Young people
welcome fertility information but qualitative data illus-
trate the need for it to be tailored to specific age
groups to maximize its benefits and ensure young
people can integrate the information they need to
maintain reproductive health and make informed deci-
sions about future parenthood. Educators and
researchers need to work together to increase accessi-
bility of fertility information.
Thanks to Emily Koert, Toni Harris, Kate Parker, Allysha
Perryman and Lorna OShea for their helpful input in prepar-
ation of the study. We would also like to thank Maya Lane
and Christianah Olagunju for helping with the focus groups
in London.
Disclosure statement
No potential conflict of interest was reported by the authors.
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... It was concluded that information needs to be conveyed in a way that is engaging and helps young people integrate it at their current life stage, as suggested in research on risk awareness (Bunting & Boivin, 2010). A qualitative study from the same group and using the Guide, came to the same conclusion (Boivin, Sandhu, Brian, & Harrison, 2018) using a different sample. Results showed that adolescents perceived multiple benefits to fertility education (e.g., learning new information, increased awareness of fertility health and comfort in discussing it, more informed decision-making) but questioned why they needed to know fertility information at this stage of their life. ...
... UK teachers deliver sex education using a variety of tools including PowerPoint, animations, games, quizzes and written literature (Faculty of Sexual and Reproductive Healthcare (FSRH), 2018). This information is immediately relevant to most teenagers, whereas fertility education may not be something that young adults are thinking about (Boivin, Koert, et al., 2018;Boivin, Sandhu, et al., 2018;Heywood, Pitts, Patrick, & Mitchell, 2016). ...
... Past research has shown that the simple provision of information was not sufficient for adolescents to learn (Boivin, Koert, et al., 2018;Boivin, Sandhu, et al., 2018). Art has been used effectively in sex education (Roberts et al., 2017) and was considered a potentially engaging approach for fertility education. ...
The Fertility Education Initiative was established in 2016 to provide education on fertility, modern families and reproductive science for young adults, teachers, health professionals, parents and adults. We report on our study to determine the feasibility and acceptability of using the arts to delivery fertility education in schools. The evaluation was mixed methods: (i) two focus groups with young people aged 14–16 and 16–18 were conducted to investigate attitudes to fertility awareness; and (ii) seventeen 16–22 year olds were divided into two groups and each undertook a day of art workshops that consisted of two visual and two theatrical workshops and then completed questionnaires at the end of each workshop and at the end of the day. The artists were interviewed using a semi-structured interview. Young adults confirmed they were interested in learning about fertility, but current understanding varied. The majority thought that fertility education should be delivered in schools at ages 16–18. During the art workshops they learnt some facts but asked for more science and discussion. They felt using art was powerful and they wanted to hear the artists personal stories. Tools using a number of platforms need to be developed that can be taken into schools nationally and evaluated for their engagement.
... Consistent with previous research on attitudes towards fertility Six-year follow-up of fertility assessment/counselling education (e.g. Boivin et al., 2018b), when speaking about fertility education more broadly the participants cautioned that receiving fertilityrelated information may increase individuals' distress. The few studies that have examined this specifically provide some preliminary support for an increase in subjective anxiety or worry after exposure to a fertility education intervention without personalized information (e.g. ...
... Maeda et al., 2016;Boivin et al., 2018a,b). Boivin et al. (2018b) suggested distress may increase when fertility information feels threatening to other goals (e.g. career). ...
Full-text available
STUDY QUESTION What are women’s perceptions and experience of fertility assessment and counselling 6 years after attending a Fertility Assessment and Counselling (FAC) clinic in Denmark? SUMMARY ANSWER Women viewed the personalized fertility knowledge and advice they received as important aids to decision-making and they felt the benefits outweighed the risks of receiving personalized fertility information. WHAT IS KNOWN ALREADY Many young people wish to become parents in the future. However, research demonstrates there is a gap in women’s and men’s knowledge of fertility and suggests they may be making fertility decisions based on inaccurate information. Experts have called for the development of interventions to increase fertility awareness so that men and women can make informed fertility decisions and achieve their family-building goals. Since 2011, the FAC clinic in Copenhagen, Denmark has provided personalized fertility assessment and guidance based on clinical examination and evaluation of individual risk factors. Available qualitative research showed that attending the FAC clinic increased fertility awareness and knowledge and was experienced as a catalyst for change (e.g. starting to conceive, pursuing fertility treatment, ending a relationship) in women 1-year post-consultation. STUDY DESIGN, SIZE, DURATION The study was a 6-year follow-up qualitative study of 24 women who attended the FAC clinic between January and June 2012. All women were interviewed during a 2-month period from February to March 2018 at Rigshospitalet, their home or office, in Copenhagen, Denmark. Interviews were held in English and ranged between 60 and 94 min (mean 73 min). PARTICIPANTS/MATERIALS, SETTING, METHODS Invitations to participate in an interview-based follow-up study were sent to 141 women who attended the FAC clinic in 2012. In total, 95 women read the invitation, 35 confirmed interest in participating and 16 declined to participate. Twenty-five interviews were booked and 24 interviews held. Interviews followed a semi-structured format regarding reasons for attending the FAC clinic, if/how their needs were met, and perceptions of fertility assessment and counselling. Data were analysed using thematic analysis. MAIN RESULTS AND THE ROLE OF CHANCE At the follow-up interview, women were on average 39.5 years old. Ten were currently single or dating and 14 were married/cohabiting. All were childless when they attended the FAC clinic. At the follow-up interview, 21 women were parents (14 women with one child; 6 with two children; 1 with three children) and the remaining three women intended to have children in the future. The most common reason for originally attending the FAC clinic was to determine how long they could delay childbearing. Most of the women now believed their needs for attending had been met. Those who were dissatisfied cited a desire for more exact (‘concrete’) information as to their remaining years of fertility, although acknowledged that this was likely not realistic. Women stated that they had felt reassured as to their fertility status after attending the FAC clinic whilst receiving the message that they could not delay childbearing ‘too long’. Women viewed personalized fertility knowledge as an important aid to decision-making but cautioned about developing a false sense of security about their fertility and chance of conceiving in the future based on the results. Although women were generally satisfied with their experience, they wished for more time to discuss options and to receive additional guidance after their initial meeting at the FAC clinic. LIMITATIONS, REASONS FOR CAUTION Participants were from a group of Danish women attending the FAC clinic and interviews were conducted in English, which means they are not representative of all reproductive-aged women. Nevertheless, the study group included a broad spectrum of women who achieved parenthood through different means (heterosexual/lesbian relationship, single parent with donor, co-parent) with various family sizes, and women who were currently childless. WIDER IMPLICATIONS OF THE FINDINGS Our study provides support for an individualized approach to fertility education, assessment and counselling provided at a time when the information is relevant to the individual and their current fertility decision-making. The findings suggest that although satisfied with their visit to the FAC clinic, the women wished for more information and guidance after this visit, suggesting that the current intervention may need to be expanded or new interventions developed to meet these additional needs. STUDY FUNDING/COMPETING INTEREST(S) E.K. was funded by an ESHRE Travel/Training grant by ReproUnion, co-financed by the European Union, Interreg V OKS. J.B. reports that the risk evaluation form used at the Fertility Assessment Clinic was inspired by the Fertility Status Awareness Tool FertiSTAT that was developed at Cardiff University for self-assessment of reproductive risk. J.B. also reports personal fees from Merck KGaA, Merck AB, Theramex, Ferring Pharmaceuticals A/S and a research grant from Merck Serono Ltd outside the submitted work. A.N.A. has received personal fees from both Merck Pharmaceuticals and Ferring and grants from Roche Diagnostics outside the submitted work. The other authors report no conflicts of interest.
... Two further papers of note in this issue are those published by Prior, Lew, Hammarberg, and Johnson (2019) and Boivin, Sandhu, Brian, and Harrison (2019) which each examine different aspects of fertility knowledge and plans of young people. The first (Prior et al., 2019) surveyed over 1000 university students in Australia about their intentions and expectations for future parenthood and found, perhaps unsurprisingly, that most were inadequately informed about the impact of age on fertility and many significantly over-estimated what life goals they would be able to achieve before their fertility was affected. ...
... The first (Prior et al., 2019) surveyed over 1000 university students in Australia about their intentions and expectations for future parenthood and found, perhaps unsurprisingly, that most were inadequately informed about the impact of age on fertility and many significantly over-estimated what life goals they would be able to achieve before their fertility was affected. Similarly, interviewing a smaller number of young people in the United Kingdom, Boivin et al., (2019) found that adolescents lacked confidence in their fertility knowledge which suggested that would not be able to make informed decisions about their fertility. ...
... Moreover, the attitudes toward marriage and roles of wife, motherhood, and even domestic work have been changed, which in some ways have been excluded from the priority of women's lives. This change of attitude has spread from feminist thinking and Western societies to other countries, including Iran (Boivin et al. 2019). In a study, the gap between marriage and childbearing was clearly affected by social pressure, but it was not related to social support. ...
Full-text available
This study was conducted to explain the contextual factors associated with total fertility rate (TFR) decline to help policymakers. A qualitative approach and Leichter contextual analysis framework were applied to conduct this study. The participants were selected using purposive sampling method, and also the interviews continued until data saturation was reached. Individuals with knowledge and perspectives on population policies were included in the study to improve the research credibility. The data validity was achieved by applying the maximum variety in selecting the sample. The results were classified into four groups, including situational, structural, cultural, and environmental factors. Situational factors included political sanctions, drought, and road accidents. Structural factors involved government policies, the absence of monitoring, paying no attention to the required conditions, housing status, employment status, economic status, and other issues. Cultural factors were classified into the seven categories, including divorce, socio-economic development, women's employment, marriage age, urbanization, and other issues and factors included international treaties, and the western influence. Policymakers and administrators in the field of demographic policies can make more accurate strategies to increase TFR by recognizing the causes that reduce fertility with the help of providing the possibility to understand better the factors affecting the TFR decline.
... More-educated women tend to marry later, have a week orientation towards having families [25]. However, the need and importance of ensuring fertility education is tailored to different women [26]. Less-educated women may be left ill-equipped to make informed choices about their reproductive lives and relationships [27]. ...
Full-text available
Purpose To assess the association between maternal education level and live birth after in vitro fertilization (IVF). Methods We studied women who underwent the first cycle of fresh or frozen-thawed embryo transfer between 2014 and 2019. Women were divided into four educational categories according to the level of education received (elementary school graduate or less, middle school graduate, high school graduate, college graduate or higher). The live birth rate was compared between different education level groups. We used logistic regression to analyze the association between maternal education level and live birth after IVF. Results We studied 41,546 women, who were grouped by maternal educational level: elementary school graduate or less (n = 1590), middle school graduate (n = 10,996), high school graduate (n = 8354), and college graduate or higher (n = 20,606). In multivariable logistic regression analysis, we did not demonstrate a statistically significant relationship between educational level and live birth in middle school graduate (adjusted odds ratio [AOR] 0.96; 95% confidence interval [CI], 0.84–1.09), high school graduate (AOR 1.01; 95% CI, 0.87–1.14) or college graduate or higher (AOR 1.01; 95% CI, 0.88–1.14) patients, with elementary school graduate or less as the reference group. Conclusions Maternal educational level was not associated with the likelihood of live birth in patients undergoing fresh or frozen embryo transfer.
... The Priority Setting Partnership for Infertility (Duffy et al., 2020) placed understanding male infertility as a priority for fertility research. However, the rates of male participation in this specific field of health research are disproportionately low compared to those of women (Boivin et al., 2019; Almeida-Santos et al., 2017) with ratios of 9 female participants for every male participants reported in survey research (e.g., Bunting, et al., 2013), more so in research with men not in fertility treatment (Culley et al., 2013). This occurs despite similarity between men and women in desire for children and factors that affect readiness to parent (Boivin et al., 2018a). ...
... Fertility-awareness messages have been criticised for not being sufficiently tailored This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (, which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. (Boivin, Sandhu, et al., 2019;Maeda et al., 2016) and for putting a disproportionate amount of reproductive responsibility on the woman (Campo-Engelstein, 2014; Cutas et al., 2018). Further, many believe that emotional stress per se is a risk factor for infertility (Bodin et al., 2018;Daumler et al., 2016;Ekelin et al., 2012;Mu et al., 2019). ...
Full-text available
Being aware of factors that affect fertility can help people make informed decisions about their reproductive futures. To some, however, fertility information leads to worry and self-blame. In this paper, we explore how people from different generations discuss fertility and reproductive decision-making, along with their perceptions of fertility information. The study was conducted in southern Sweden with 26 focus-group discussions that included a total of 110 participants aged 17–90 years. The material was analysed thematically. Our results show that fertility knowledge and openness to talking about fertility problems have increased over generations. Participants who were assigned female at birth were more often concerned about their fertility than those who were not, and fertility concerns were transferred from mothers to daughters. While age-related fertility concerns had been uncommon in older generations, participants aged 25–40 often expressed these concerns. Young adults appreciated being knowledgeable about fertility but simultaneously expressed how fertility information could lead to distress. Our conclusion is that fertility information was best received by high-school students, and efforts to improve fertility education in schools are therefore recommended.
... These educational interventions improve fertility awareness, both in the short term (Daniluk and Koert, 2015;Wojcieszek and Thompson., 2013;Maeda et al., 2016) and even two years after exposure (Maeda et al., 2018). However, interest in future pregnancy and fertility education is often limited, as is the ability to integrate fertility information into everyday life (Boivin et al., 2018b;Maeda et al., 2018). It is therefore necessary to continue developing strategies to encourage people to participate in their fertility, particularly strategies that can be delivered efficiently to large populations. ...
Research Question What are the effects of using a fertility education chatbot (i.e., automatic conversation program) on knowledge, intentions to improve preconception behaviour, and anxiety? Design A three-armed, randomized, controlled trial was conducted using an online social research panel. Participants included 927 women aged 20–34 years who were randomly allocated to one of three groups: a fertility education chatbot (intervention group, IG), a document about fertility and preconception health (control group 1, CG1), or a document about an irrelevant topic (control group 2, CG2). Participants’ scores on the Cardiff Fertility Knowledge Scale and the State-Trait Anxiety Inventory, their intentions to optimise preconception behaviours (e.g., taking folic acid), and the free-text feedback provided by chatbot users were assessed. Results A repeated-measures analysis of variance showed significant fertility knowledge gains after the intervention in the IG (+9.1 points) and CG1 (+14.9 points) but no significant change in CG2 (+1.1 points). Post-test increases in the intentions to optimise behaviours were significantly higher in the IG than in CG2 and were similar to those in CG1. Post-test state anxiety scores were significantly lower in the IG than in CG1 and CG2. User feedbacks about the chatbot suggested technical limitations (e.g., low comprehension of users’ words) and pros and cons of using the chatbot (e.g., convenient versus coldness). Conclusions Providing fertility education using a chatbot improved fertility knowledge and intentions to optimise preconception behaviour without increasing anxiety, but the improvement in knowledge was small. Further technical development and exploration of personal affinity for technology is required.
... The claim that women are unfamiliar with EF is not surprising as many studies have identified that people of reproductive age have a poor understanding of fertility and of the capacity of ARTs to overcome problems with infertility. 5,23,[43][44][45] In addition, the information available to individuals through ART clinic websites may not be accessible to the lay public. Recent audits of ART clinic websites indicated the quality of information provided is poor and often not up to industry standards. ...
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Egg freezing (EF) technology has improved significantly over the last decade, giving women more choice over their reproductive futures. Despite this advance, EF brings forth contentious ethical and regulatory issues. Policies controlling access to EF vary around the world and there is a lack of consensus about who should have access and what criteria are relevant in making these decisions. This study aimed to identify views of women about access to EF for both “medical” and “non-medical” risks to infertility. An online survey was administered to women aged between 18 and 60 years in Victoria, Australia between April and May 2018. A total of 1,066 individuals initiated the survey. The median age of the participants was 28 years and 81% were <40 years old. Almost all participants (98%) supported access to medical EF in situations where treatments (e.g. chemotherapy) or illnesses threaten fertility. Support for access to EF for non-medical indications was lower; 75% supported EF for “lack of suitable partner”, followed by “financial insecurity to raise a child” (72%) and “career/educational advancement” (65%). Older respondents (aged ≥40 years) were less likely than their younger counterparts to support all indications for non-medical EF. Our findings indicate broad support for EF. However, the variation in support between indications for non-medical EF suggests that individuals do not think about access to EF simply in terms of medical necessity. To reflect public views, future policy may need to consider access to EF beyond the medical/non-medical distinction.
This study was designed to evaluate the extent to which school-based ovulatory-menstrual (OM) health interventions facilitate the Health Outcome Model’s domains of health literacy. Electronic databases and gray literature sources were searched from 1980 to 2019. Findings from 16 studies of school-based OM health interventions (n = >8800 adolescents aged 13–16 years) were collated. The results indicate that OM health education addresses the domains of health literacy to various degrees; critical health literacy skills are least often addressed. Future programs would benefit from positive teaching about the cycle as a health monitor and from engaging parents and healthcare providers.
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Study question: Does the provision of fertility (compared to control) information affect fertility-related knowledge, perceived threat of infertility, anxiety, physical stress and fertility plans in adolescents and emerging adults? Summary answer: The provision of fertility information was associated with increased fertility knowledge (emerging adults) and greater infertility threat (adolescents and emerging adults). What is known already: According to fertility education research, adolescents and emerging adults know less than they should know about fertility topics. Fertility knowledge can be improved through the provision of information in older adults. Study design, size, duration: Experimental design. Secondary and university students completed pre-information questionnaires, were randomly assigned via computer to an experimental group, read either fertility (FertiEduc group) or healthy pregnancy information (Control group), and completed post-information questionnaires. Data were collected in group sessions via an online portal. Participants/materials, setting, methods: Eligible participants were aged 16-18 (adolescents) or 21-24 years (emerging adults), childless, not currently pregnant (for men, partner not pregnant) or trying to conceive, presumed fertile and intending to have a child in the future. Of the 255 invited, 208 (n = 93 adolescents, n = 115 emerging adults) participated. The FertiEduc group received 'A Guide to Fertility', four online pages of information about fertility topics (e.g. 'When are men and women most fertile?') and the Control group received four online pages from the National Health Service (NHS) pregnancy booklet 'Baby Bump and Beyond'. Participants completed a questionnaire (fertility knowledge, perceived threat of infertility, anxiety, physical stress and fertility plans, moderators) prior to and after the provision of information. Mixed factorial analysis of variance was used to examine the effects of information provision and hierarchical multiple regression to assess potential moderators of knowledge. Main results and the role of chance: The FertiEduc and Control groups were equivalent on age, gender, disability, relationship status and orientation at baseline. Results showed that fertility information significantly increased fertility knowledge for emerging adults only (P < 0.001) and threat of infertility for emerging adults and adolescents (P = 0.05). The moderators were not significant. Participation in the study was associated with an increase in feelings of anxiety but a decrease in physical stress reactions. Adolescents had more optimal fertility plans compared to emerging adults due to being younger. Limitations, reasons for caution: This was an experimental study on a self-selected sample of men and women from selected educational institutions and only short term effects of information were studied. Wider implications of the findings: Provision of fertility information can have benefits (increased fertility knowledge) but also costs (increase potential threat of infertility). Adolescents find fertility information positive but do not learn from it. Fertility education should be tailored according to age groups and created to minimise negative effects. Longitudinal examination of the effects of fertility information in multi-centre studies is warranted and should include measures of perceived threat of infertility. Study funding/competing interest(s): Cardiff University funded this research. All authors have no conflicts of interest to declare.
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Study question: Can a consensus and evidence-driven set of terms and definitions be generated to be used globally in order to ensure consistency when reporting on infertility issues and fertility care interventions, as well as to harmonize communication among the medical and scientific communities, policy-makers, and lay public including individuals and couples experiencing fertility problems? Summary answer: A set of 283 consensus-based and evidence-driven terminologies used in infertility and fertility care has been generated through an inclusive consensus-based process with multiple stakeholders. What is known already: In 2006 the International Committee for Monitoring Assisted Reproductive Technologies (ICMART) published a first glossary of 53 terms and definitions. In 2009 ICMART together with WHO published a revised version expanded to 87 terms, which defined infertility as a disease of the reproductive system, and increased standardization of fertility treatment terminology. Since 2009, limitations were identified in several areas and enhancements were suggested for the glossary, especially concerning male factor, demography, epidemiology and public health issues. Study design, size, duration: Twenty-five professionals, from all parts of the world and representing their expertise in a variety of sub-specialties, were organized into five working groups: clinical definitions; outcome measurements; embryology laboratory; clinical and laboratory andrology; and epidemiology and public health. Assessment for revisions, as well as expansion on topics not covered by the previous glossary, were undertaken. A larger group of independent experts and representatives from collaborating organizations further discussed and assisted in refining all terms and definitions. Participants/materials, setting, methods: Members of the working groups and glossary co-ordinators interacted through electronic mail and face-to-face in international/regional conferences. Two formal meetings were held in Geneva, Switzerland, with a final consensus meeting including independent experts as well as observers and representatives of international/regional scientific and patient organizations. Main results and the role of chance: A consensus-based and evidence-driven set of 283 terminologies used in infertility and fertility care was generated to harmonize communication among health professionals and scientists as well as the lay public, patients and policy makers. Definitions such as 'fertility care' and 'fertility awareness' together with terminologies used in embryology and andrology have been introduced in the glossary for the first time. Furthermore, the definition of 'infertility' has been expanded in order to cover a wider spectrum of conditions affecting the capacity of individuals and couples to reproduce. The definition of infertility remains as a disease characterized by the failure to establish a clinical pregnancy; however, it also acknowledges that the failure to become pregnant does not always result from a disease, and therefore introduces the concept of an impairment of function which can lead to a disability. Additionally, subfertility is now redundant, being replaced by the term infertility so as to standardize the definition and avoid confusion. Limitations, reasons for caution: All stakeholders agreed to the vast majority of terminologies included in this glossary. In cases where disagreements were not resolved, the final decision was reached after a vote, defined before the meeting as consensus if passed with 75%. Over the following months, an external expert group, which included representatives from non-governmental organizations, reviewed and provided final feedback on the glossary. Wider implications of the findings: Some terminologies have different definitions, depending on the area of medicine, for example demographic or clinical as well as geographic differences. These differences were taken into account and this glossary represents a multinational effort to harmonize terminologies that should be used worldwide. Study funding/competing interests: None. Trial registration number: N/A.
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Awareness among people of reproductive age about the factors that influence fertility and reproductive outcomes, including medically assisted reproduction outcomes, is generally low. To improve awareness about the potentially modifiable factors that affect fertility and reproductive outcomes, ‘Your Fertility’, a fertility health promotion programme funded by the Australian Government, was established in 2011. This paper describes the development and evaluation of the reach of the Your Fertility programme from its inception in 2011 to June 2016. Systematically recorded outcomes for the programme’s key focus areas and Google Analytics data were collated. Key achievements include developing and maintaining an internationally renowned website that experiences high growth and demand for fertility-related information; by 2016, over 5 million users had viewed more than 10 million webpages, and over 96,000 users had engaged in programme messages across social media. Programme messages have reached more than 4 million Australian social media users, and a potential audience of 150 million through media coverage across more than 320 media features. More than 4200 education and health professionals have completed online learning modules, and external partnerships have been established with 14 separate organizations. Data collected over 5 years indicate that the Your Fertility programme meets a need for targeted, evidence-based, accessible fertility-related information.
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Women and men globally are delaying the birth of their first child. In the UK, the average age of first conception in women is 29 years. Women experience age-related fertility decline so it is important that men and women are well-informed about this, and other aspects of fertility. A group of UK stakeholders have established the Fertility Education Initiative to develop tools and information for children, adults, teachers, parents and healthcare professionals dedicated to improving knowledge of fertility and reproductive health.
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Objective: This paper reports on fertility knowledge and intentions to have children among a national sample of students in years 10-12. Method: Data were from the Fifth National Survey of Australian Secondary Students and Sexual Health. Students identified factors that could affect fertility, if they wanted children and at what age. Results: Most students wanted to have children (77%). Of those who wanted children or were unsure (n=1,780), 54% were able to identify six of eight factors that could affect fertility. Male students had poorer knowledge than females. Poorer knowledge was also reported by male students who were born overseas or used marijuana and by female students who were sexually active or religious. More than half the students (59%) wanted their first child aged 25-29, while 19% wanted their first child after 30. Intentions to have children at an earlier age were associated with being religious, sexually active (females), and using marijuana (males). Students not exclusively attracted to the opposite sex were more likely to want children at an older age. Conclusions and implications: Most students typically want children in their late 20s. Many were unaware of factors that could affect their fertility and there was a mismatch between intentions and likely behaviour. These factors could be addressed as part of relationship education.
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STUDY QUESTION What are the effects of fertility education on knowledge, childbearing desires and anxiety? SUMMARY ANSWER Providing fertility information contributed to greater knowledge, but increased anxiety. WHAT IS KNOWN ALREADY Past studies have found that exposure to educational material improved fertility awareness and changed desires toward childbearing and its timing. Existing educational websites with evidence-based medical information provided in a non-judgmental manner have received favorable responses from reproductive-aged men and women. STUDY DESIGN, SIZE, DURATION This three-armed (one intervention and two control groups), randomized controlled trial was conducted using online social research panels (SRPs) in Japan in January 2015. PARTICIPANTS/MATERIALS, SETTING, METHODS A total of 1455 participants (726 men and 729 women) between 20 and 39 years of age who hoped to have (more) children in the future were block-randomized and exposed to one of three information brochures: fertility education (intervention group), intake of folic acid during pregnancy (control group 1) or governmental financial support for pregnancy and childbirth (control group 2). Fertility knowledge was measured with the Japanese version of the Cardiff Fertility Knowledge Scale (CFKS-J). Knowledge, child-number and child-timing desires, subjective anxiety (i.e. whether participants felt anxiety [primary outcome]), and scores on the State-Trait Anxiety Inventory were assessed immediately after exposure. Non-inferiority comparisons were performed on subjective anxiety with non-inferiority declared if the upper limit of the two-sided 95% confidence interval (CI) for risk difference did not exceed a margin of 0.15. This test for non-inferiority was only performed for subjective anxiety; all the other variables were tests of superiority. MAIN RESULTS AND THE ROLE OF CHANCE Posttest scores on the CFKS-J (mean, SD) were higher in the intervention group than that of the control groups: intervention versus Control 1 and versus Control 2: 52.8 (28.8) versus 40.9 (26.2) (P< 0.001) versus 45.1 (27.1) (P = 0.003) among men and 64.6 (26.0) versus 50.8 (26.9) (P< 0.001) versus 53.0 (26.4) (P< 0.001) among women. The percentage of participants who felt subjective anxiety after exposure to the intervention brochure was significantly higher than that of the control groups: intervention versus Control 1 and versus Control 2: 32.6 versus 17.8% (risk difference [RD] = 0.149, 95% CI: 0.073–0.225) versus 14.5% (RD = 0.182, 95% CI: 0.108–0.256) among men, and 50.2 versus 26.3% (RD = 0.239, 95% CI: 0.155–0.322) versus 14.0% (RD = 0.362, 95% CI: 0.286–0.439) among women. Non-inferiority of the intervention was inconclusive (i.e. the CI included 0.15) among men whereas inferiority was declared among women. The incidence of anxiety was higher in the intervention group than that of the control groups especially among men aged 30 and older and among women aged 25 and older. No difference existed in childbearing desires between groups after exposure. LIMITATIONS, REASONS FOR CAUTION The possibility of selection bias associated with the use of SRPs (higher socioeconomic status and education) and volunteer bias toward those more interested in fertility may limit the generalizability of these findings. WIDER IMPLICATIONS OF THE FINDINGS In addition to education targeting a younger generation, psychological approaches are needed to alleviate possible anxiety caused by fertility information. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by National Center for Child Health and Development, Seiiku Medical Study Grant (24-6), the Daiwa Foundation Small Grants and Grant-in-Aid for JSPS Fellows (26-1591). No competing interest declared. TRIAL REGISTRATION NUMBER UMIN Clinical Trials Registry. Trial registration number, 000016168. TRIAL REGISTRATION DATE 13 January 2015. DATE OF FIRST PATIENT'S ENROLMENT 15 January 2015.
Background: The increasingly common practice in high-income countries to delay childbearing to the fourth and fifth decades of life increases the risk of involuntary childlessness or having fewer children than desired. Older age also increases the risk of age-related infertility, the need for ART to conceive, and obstetric and neonatal complications. Existing research relating to childbearing focusses almost exclusively on women, and in public discourse declining fertility rates are often assumed to be the result of women delaying childbearing to pursue other life goals such as a career and travel. However, evidence suggests that the lack of a partner or a partner willing to commit to parenthood is the main reason for later childbearing. Objective and rationale: To better understand men's contributions to childbearing decisions and outcomes, the literature pertaining to men's fertility-related knowledge, attitudes and behaviours was reviewed. Search methods: The electronic databases of Medline, Embase and PsycINFO were searched to identify investigations of men's knowledge, attitudes and behaviours relating to fertility, infertility, reproductive health or childbearing using relevant fertility keyword search terms. Studies were included if they had investigated factors associated with men's fertility-related knowledge, attitudes and behaviours, had been conducted in a high-income country and were published in an English language peer-reviewed journal between January 2005 and August 2016. Outcomes: The search yielded 1349 citations. Of these, 47 papers representing 43 unique studies were included in the review. Where response rate was reported, it ranged between 13 and 94%. Studies varied in terms of research design; inclusion and exclusion criteria; recruitment strategies; adequacy of sample size; recruitment and retention rates and data collection tools. However, findings were consistent and indicate that men almost universally value parenthood, want and expect to become fathers, and aspire to have at least two children. Yet most men have inadequate knowledge about the limitations of female and male fertility and overestimate the chance of spontaneous and assisted conception. Perceptions of ideal circumstances in which to have children included being in a stable and loving relationship, having completed studies, secured a permanent job and a dependable income, having achieved personal maturity, and having a partner who desires children and is 'suitable' as a potential co-parent. Although all studies were conducted in high-income countries, between-country social and cultural differences may have influenced the findings relating to attitudes. Wider implications: Men aspire to parenthood as much as women do but have limited knowledge about the factors that influence fertility. The gap between ideal biological and ideal social age for having children appears to be widening, narrowing the time frame in which parenthood can be achieved. This may lead to unfulfilled parenthood aspirations. The findings can inform government policies and public education strategies aimed to support childbearing during the most fertile years, reduce the personal and societal cost of infertility and ART use, and allow people to fulfil their parenthood goals.
Over the past century fertility patterns in the United States have fluctuated and the age of first-time parents has generally increased. With greater family planning resources women have also had the opportunity to delay both marriage and childbearing in pursuit of their education and careers. Later life childbearing has indirectly reduced total birth rates in the United Sates, Asian and many European countries. This chapter describes trends in ages of new parents and societal influences that have impact on these trends are discussed. Geographical differences are also highlighted as many trends differ across different regions. The chapter concludes with concerns that need to be addressed by future research and the need for more family supportive public policy.
Objectives: The aim of our study was to investigate Ukrainian medical students' intentions and attitudes in relation to future parenthood, and their knowledge about fertility. Methods: A classroom survey was carried out of randomly selected groups among 3568 Russian-speaking medical students. The response rate was 88.8%; 858 were female and 407 were male; the mean age was 20.6 (standard deviation [SD] 2.4) years. Results: One in four male and 16% of female respondents did not want to have children, 3.3% had children and 17% wanted one child only. Female respondents wished to have their first child when they were 24.4 (SD 2.4) years of age, and male respondents when they were 26.8 (SD 3.4) years of age. Around 60% of respondents reported there was a pronounced decline in female fertility after the age of 45 years. Conclusions: The desire to have children in the future is not apparent among medical students, especially not among men. Gaps in students' knowledge about fertility need to be addressed by sexual and reproductive education.