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Human Fertility
an international, multidisciplinary journal dedicated to furthering
research and promoting good practice
ISSN: 1464-7273 (Print) 1742-8149 (Online) Journal homepage: http://www.tandfonline.com/loi/ihuf20
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: https://doi.org/10.1080/14647273.2018.1486514
Published online: 10 Jul 2018.
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ORIGINAL ARTICLE
Fertility-related knowledge and perceptions of fertility education among
adolescents and emerging adults: a qualitative study
Jacky Boivin
a
, Amea Sandhu
a
, Kate Brian
b
and China Harrison
a
a
School of Psychology, Cardiff University, Cardiff, Wales, UK;
b
Royal College of Obstetricians and Gynaecologists, London, UK
ABSTRACT
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, n¼19) and emerging
adults (21–24 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.
ARTICLE HISTORY
Received 11 February 2018
Accepted 21 May 2018
KEYWORDS
Fertility knowledge;
education; qualitative;
adolescents; emerging
adults; fertility awareness
Introduction
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
ıa
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 boivin@cardiff.ac.uk School of Psychology, Cardiff University, Tower Building, Park Place, Cardiff, Wales, CF10 3AT, UK
ß2018 The British Fertility Society
HUMAN FERTILITY
https://doi.org/10.1080/14647273.2018.1486514
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 16–18 years) and emerg-
ing adults (aged 21–24 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
Participants
Eligible participants were aged 16–18 (adolescent
group) and 21–24 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 Women’s 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.
Materials
A‘focus group discussion guide’consisting 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 Fertility’see
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 brochure’examined 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
2 J. BOIVIN ET AL.
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.
scarletdesign.com).
Procedure
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 Fertility’and instructed that they had
15–20 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/women’s health issues, data not pre-
sented in the present paper. The School of Psychology
ethics committee (Cardiff University) provided ethical
review (Reference number: EC.16.03.08.4472GR2A3)
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 taker’s
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.
Results
Participants
A total of 33 adolescents (n¼19, six boys, 13 girls)
and emerging adults (n¼14, 4 men, 10 women),
participated.
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 adults’had poor knowledge of fertility.
Participants evidenced a lack of knowledge about fer-
tility ‘very little’[A], ‘I’m 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 I’m lacking. My knowledge doesn’t
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 don’t learn a lot’
[A], ‘there seems to be lots of myths around about fer-
tility’[A].
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
HUMAN FERTILITY 3
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. It’s 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’
[A-M].
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: ‘I’ve 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 can’t 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 don’t 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] I’d be like I don’t
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 I’m going to be infertile. It’sa
big unknown it’s 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 I’m really scared
about my future’[EA] or from learning the prevalence
of infertility ‘I was surprised at how many people it
affects because I don’t 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 low’the 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 didn’t real-
ise …10 cigarettes a day isn’t…that 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 ‘I’d 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
4 J. BOIVIN ET AL.
to ovarian reserve ‘I don’t 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 wouldn’t even know
[to know]’[F-EA]; ‘… to think more deeply about fer-
tility. I didn’t realise it affected so many people’[A-M],
especially in younger people for whom fertility would
not be that relevant ‘I doubt I’d [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]; ‘it’sa
good piece of statistics …to prevent people from
doing things you don’t 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 you’ll 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 don’t want to get to an age
where it’s 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 women’s bodies’[A].
Feasibility and acceptability of the Guide. The gen-
eral consensus in both age groups was that ‘A Guide
to Fertility’was 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 doctors’surgeries 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 ‘it’s 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-
…that’s 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]’/‘
…that’s a lot if they all fertilise’/‘…you don’t have
all these eggs coming out of you’/‘…only 1 can be
ovulated’/‘…how are we losing them (eggs)?’/‘you
don’t 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’/‘they’re
maybe just decomposing in you’/‘what does bad
quality mean? Does that mean you’ll have a bad
quality child’[Researcher interrupts to clarify]
HUMAN FERTILITY 5
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
don’t think I’d 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’/
‘it’s not telling you to stop drinking …it’s telling you
not to have six glasses of wine a week’/‘I think that’s
better than [what] we do, going out and drinking
loads at once …’/‘not for me …useful for someone
else’/‘the menopause for me that’s…the really big
thing …because I’ve 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 can’t ignore it’
Finally, information in the guide could be mislead-
ing: ‘…people could be making decisions on this kind
of information (in Guide) …it’s 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 one’s 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? …wasn’t 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 it’s,
well I kind of assume it’s just the woman’). Some com-
ments arose due to the education brochure being
focused on women ‘I was surprised that there weren’t
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 can’t make those choices for her because I’m
not physically carrying out that action (having IVF)’
[EA-M].
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 wouldn’t…generally don’t
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 isn’t just about
your fertility there’s 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
aman’.
Discussion
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
6 J. BOIVIN ET AL.
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
‘subfecund’due 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. yourfertility.org; 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
HUMAN FERTILITY 7
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 taker’s 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.
Acknowledgements
Thanks to Emily Koert, Toni Harris, Kate Parker, Allysha
Perryman and Lorna O’Shea 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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