Beauty has no age. Fertility does’. These sentences were oneof the slogans used in 2016 to mark Fertility Day in Italy.Although this campaign was highly controversial, it reflectscurrent concerns regarding the trend of postponing child-bearing to later ages (1) and the lack of sufficient fertilityawareness within the reproductive-age population.The determinants and consequences of delaying preg-nancy have been analysed and discussed by gynaecologists,public health experts, psychologists, demographers, and poli-ticians (2–5). Studies have shown that the decision to havechildren is multifaceted and determined not only by individ-ual, social, and economic factors but also by social policies(2,3,5). Hence, delaying parenthood is not always a consciousprocess (6), and it seems to make an important contributionto the incidence of infertility (7). Infertility is a public healthproblem (8,9) that affects people around the world. Althoughnot all infertility problems can be prevented, some importantrisk factors are preventable (10). Advanced female age isrelated to fewer and poorer-quality follicles (11,12) as well asa higher risk of miscarriage (12–14), obstetric morbidity, andperinatal complications (15). Female and male ages are bothassociated with an increased time to pregnancy (16,17). Arecent study estimated that if a couple desires to have twochildren without making use of fertility treatments, theyshould start trying to conceive when the woman is 27 yearsold to have a 90% chance of success (18).In addition to age, other modifiable factors include sexu-ally transmitted infections (STIs) (19), smoking (20,21), alcoholconsumption (22,23), and obesity or low weight (21,24,25);for a full review of these and other risk factors, see (26–28).Further, in less developed countries unsafe abortions, preg-nancy-related infections, and insufficient delivery care areimportant risk factors for secondary infertility (29). In add-ition, some myths and misconceptions concerning fertility,reproduction, and fertility treatments remain, which mightdelay help-seeking behaviours and negatively affect repro-ductive plan management (30,31).Together with the increasing evidence regarding infertilityrisk factors, the trend towards childbearing postponementhas stimulated researchers to assess fertility awareness (FA)—a concept recently defined in The International Glossary onInfertility and Fertility Care as‘the understanding of eproduction, fecundity, fecundability, and related individualrisk factors (e.g. advanced age, sexual health factors such assexually transmitted infections, and life style factors such assmoking, obesity) and non-individual risk factors (e.g. environ-mental and work place factors); including the awareness ofsocietal and cultural factors affecting options to meet repro-ductive family planning, as well as family building needs’(32).A majority of studies focused on FA suggests that youngadults of reproductive age desire to have children (33,34)butthey are not sufficiently informed about age-related fertilitydecline and infertility risk factors (33,35–37). This lack of know-ledge led to the emergence of public FA campaigns. However,some of these campaigns were not well accepted by the pub-lic, with media reactions stating that the reproductive-agepopulation felt pressure to have (more) children (e.g.‘Advancing age decreases your ability to have children’,USASeattle News and Events, 9 October 2006;‘Even the best marks-man could miss the target’,Strait Times, 5 February 2016;‘Swimming too slowly?’,Independent, 2 June 2016 (38–40)).Consistent with this finding, education programmes haverevealed mixed results regarding their effectiveness on increas-ing FA (41–44), with side effects such as increases in anx-iety (45).This systematic review aims to: 1) summarize and examineglobally the available evidence regarding FA and its relatedindividual risk factors; and 2) identify the gaps in the litera-ture based on studies conducted worldwide. This knowledgewill help both researchers and clinicians to develop moresuccessful and well-accepted campaigns targeting specificgroups in need of fertility-related information.Specifically, this review attempts to answer two questions:1) Are reproductive-age people informed about fertility andindividual infertility risk factors? and 2) Do differences exist inFA based on gender, age, education, and reproductive status
Study screening, selection, and data extraction
We followed the Preferred Reporting Items for SystematicReviews and Meta-Analyses (PRISMA) guidelines for reportingthe data analysed (46). All records were stored in a databaseusing Endnote X6. Manual inspection was independently per-formed by the first and second authors, and disagreementsat each stage of screening and selection were resolved by athird reviewer. The initial search identified 7961 studies.Additionally, 21 studies were found through other sources(Figure 1). During the initial screening, 3476 articles/studieswere excluded based on the title and after 84 were excludedbased on the abstract. Afterwards, full-text articles (n¼103)were independently examined and were included if they metthe following criteria: 1) used quantitative data regarding FA(e.g. awareness concerning the fertile period, definition ofinfertility, factors affecting fertility and lifestyle risk factors,chances of pregnancy, age-related fertility decline, the suc-cess rates of medically assisted reproduction treatments[MAR], including allin vitro[e.g.in vitrofertilization, IVF] andin vivotreatment methods [e.g. intra-uterine insemination,IUI], and the risks of postponing pregnancy and infertilitytreatments); 2) used a FA-specific measure or provided adetailed description of the questions assessed. The first andsecond authors independently examined the included stud-ies, and the first author extracted the relevant data, whichwas cross-checked by the second author. The data extractedincluded the author, year, and country of publication, samplesize, sample characteristics, outcome measures, instrumentsused, and main results. To meet the second goal of thisreview, we recorded the associations between FA and age,gender, education, and reproductive status. A narrative synthe-sis approach was used to conduct this review
ResultsStudy characteristicsSeventy-one studies
were included in this review.Supplementary Table A1(available online) summarizes theparticipant characteristics and the main findings. The studieswere published between 1994 and 2017. The data originatedfrom 26 countries, and most studies were conducted inEurope (n¼27), 16 in America, 12 in Asia, seven in Oceaniaand four in Africa. Five articles used data from more thanone country. The sample sizes ranged from 20 to 7036 indi-viduals. The majority of the studies (n¼41) included bothmen and women of reproductive age and focused on one ofthree populations: university/college/secondary educationstudents (n¼28); people trying to conceive, those seekingfertility treatment, or both (n¼11); or gynaecology patients(n¼9). The remaining 22 studies used convenience samples.Participants were primarily in their early 20s and 30s, exceptthose in five studies that assessed adolescents (48–52). Themajority of studies were cross-sectional (n¼64). Five studieswere pre/post-test intervention studies (41–43,45,53), andtwo were longitudinal studies (54,55). The baseline or firstmoment of evaluation data were extracted from the interven-tion and longitudinal studies and included in this reviewOf the 71 studies included, 49 investigated the relationshipbetween FA and variables such as age, education, gender,and reproductive status. Although all of the studies focusedon FA, they varied in the way that this awareness was meas-ured. FA was measured using specific self-report question-naires or interviews.Supplementary Table A1(availableonline) gives the measures used by each study. A minority ofstudies provided only a total FA score (n¼8), with theremaining studies reporting the results for each item separ-ately. The included quantitative questionnaires used differentresponse scales and formats composed of true/false, mul-tiple-choice, or open-ended questions. Only 11 studies pre-sented data regarding the psychometric properties of theused instruments, with the majority reporting Cronbach’salpha of>0.70 or‘satisfactory’reliability (30,37,45,56–62),and one reporting a 0.52 reliability (63). The response rateranged from 15% to 100%, but this value was only reportedby 63% (n¼37) of the 59 studies that could have provided aresponse rate.Quality assessmentBecause the answer to our second research question requiresstatistical inference, we performed quality assessment on thestudies investigating the relationship between FA and theother variables (n¼49). Using a standardized quality frame-work for non-intervention studies (64) used for previousreviews (65,66), two researchers independently evaluated thestudies. Most of the studies were rated as high quality(scores>4), and only one was rated as having low quality(67). Numerous studies failed to garner a positive scoreregarding the study methodology because detailed informa-tion indicating the measures used or the procedures/instru-ments developed, adapted, or validated was missing
***
References1.
Sobotka T, Zeman K, Potancokova M, Eder J, Brzozowska Z,Beaujouan E, et al. Fertility datasheet 2015. 2015.2. Balbo N, Billari FC, Mills M. La f econdit e dans les soci et esavanc ees: un examen des recherches. Eur J Popul. 2013;29:1–38.3. Mills M, Rindfuss RR, McDonald P, te Velde E. Why do peoplepostpone parenthood? Reasons and social policy incentives. HumReprod Update. 2011;17:848–60.4. Schmidt L, Sobotka T, Bentzen JG, Andersen AN. Demographicand medical consequences of the postponement of parenthood.Hum Reprod Update. 2012;18:29–43.5. Waldenstr€om U. Postponing parenthood to advanced age. Ups JMed Sci. 2016;121:235–43.6. Cooke A, Mills TA, Lavender T.‘Informed and uninformed deci-sion making’—women’s reasoning, experiences and perceptionswith regard to advanced maternal age and delayed childbearing:a meta-synthesis. Int J Nurs Stud. 2010;47:1317–29.7. te Velde ER, Pearson PL. The variability of female reproductiveaging. Hum Reprod Update. 2002;8:141–54.8. Boivin J, Bunting L, Collins J, Nygren K. International estimates ofinfertility prevalence and treatment-seeking: potential need anddemand for infertility medical care. Hum Reprod.2007;22:1506–12.9. Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, StevensGA. National, regional, and global trends in infertility prevalencesince 1990: a systematic analysis of 277 health surveys. PLoSMed. 2012;9:1–12.10. Macaluso M, Wright-Schnapp TJ, Chandra A, Johnson R,Satterwhite CL, Pulver A, et al. A public health focus on infertilityprevention, detection, and management. Fertil Steril.2010;93:16.e1–10.11. Broekmans FJ, Knauff EAH, te Velde ER, Macklon NS, Fauser BC.Female reproductive ageing: current knowledge and futuretrends. Trends Endocrinol Metab. 2007;18:58–65.12. Djahanbakhch O, Ezzati M, Zosmer A. Reproductive ageing inwomen. J Pathol. 2007;211:219–31.13. Carolan M, Frankowska D. Advanced maternal age and adverseperinatal outcome: a review of the evidence. Midwifery.2011;27:793–801.14. Waldenstr€om U, Aasheim V, Nilsen ABV, Rasmussen S, PetterssonHJ, Shytt E. Adverse pregnancy outcomes related to advancedmaternal age compared with smoking and being overweight.Obstet Gynecol. 2014;123:104–12.15. Balasch J, Gratac os E. Delayed childbearing: effects on fertilityand the outcome of pregnancy. Fetal Diagn Ther.2011;29:263–73.16. Dunson DB, Baird DD, Colombo B. Increased infertility with agein men and women. Obstet Gynecol. 2004;103:51–6.17. Hassan MA, Killick SR. Effect of male age on fertility: evidence forthe decline in male fertility with increasing age. Fertil Steril.2003;79:1520–7.18. Habbema JDF, Eijkemans MJC, Leridon H, Te Velde ER. Realizinga desired family size: when should couples start? Hum Reprod.2015;30:2215–21.19. Ochsendorf FR. Sexually transmitted infections: impact on malefertility. Andrologia. 2008;40:72–5.20. Augood C, Duckitt K, Templeton AA. Smoking and female infertil-ity: a systematic review and meta-analysis. Hum Reprod.1998;13:1532–9.21. Lintsen AME, Pasker-de Jong PCM, DeBoer EJ, Burger CW, JansenCAM, Braat DDM, et al. Effects of subfertility cause, smoking andbody weight on the success rate of IVF. Hum Reprod.2005;20:1867–75.22. Hakim RB, Gray RH, Zacur H. Alcohol and caffeine consumptionand decreased fertility. Fertil Steril. 1998;70:632–7.23. Eggert J, Theobald H, Engfeldt P. Effects of alcohol consumptionon female fertility during an 18-year period. Fertil Steril.2004;81:379–83.24. Ohwaki K, Endo F, Yano E. Relationship between body massindex and infertility in healthy male Japanese workers: a pilotstudy. Andrologia. 2009;41:100–4.25. Hassan M, Killick S. Negative lifestyle is associated with asignificant reduction in fecundity. Fertil Steril. 2004;81:384–92.26. Anderson K, Nisenblat V, Norman R. Lifestyle factors in peopleseeking infertility treatment - a review: invited review. Aust NewZeal J Obstet Gynaecol. 2010;50:8–20.27. Homan GF, Davies M, Norman R. The impact of lifestyle factorson reproductive performance in the general population andthose undergoing infertility treatment: a review. Hum ReprodUpdate. 2007;13:209–23.28. Sharma R, Biedenharn KR, Fedor JM, Agarwal A. Lifestyle factorsand reproductive health: taking control of your fertility. ReprodBiol Endocrinol. 2013;11:66.29. Ombelet W, Cooke I, Dyer S, Serour G, Devroey P. Infertility andthe provision of infertility medical services in developing coun-tries. Hum Reprod Update. 2008;14:605–21.30. Abolfotouh M, Alabdrabalnabi A, Albacker R, Al-Jughaiman U,Hassan S. Knowledge, attitude, and practices of infertility amongSaudi couples. Int J Gen Med. 2013;6:563–73.31. Bunting L, Boivin J. Knowledge about infertility risk factors, fertil-ity myths and illusory benefits of healthy habits in young people.Hum Reprod. 2008;23:1858–64.32. Zegers-Hochschild F, Adamson GD, Dyer S, Racowsky C, deMouzon J, Sokol R, et al. The international glossary on infertilityand fertility care, 2017. Fertil Sterility. 2017;108:393–406.33. Ekelin M, Åkesson C, Ångerud M, Kvist LJ. Swedish high schoolstudents’knowledge and attitudes regarding fertility and familybuilding. Reprod Health. 2012;9:1–8.34. Vassard D, Lallemant C, Nyboe Andersen A, Macklon N, SchmidtL. A population-based survey on family intentions and fertilityawareness in women and men in the United Kingdom andDenmark. Ups J Med Sci. 201
0 Comments