Sei sulla pagina 1di 9
The European Journal of Contraception & Reproductive Health Care ISSN: 1362-5187 (Print) 1473-0782 (Online) Journal
The European Journal of Contraception & Reproductive Health Care ISSN: 1362-5187 (Print) 1473-0782 (Online) Journal

The European Journal of Contraception & Reproductive Health Care

ISSN: 1362-5187 (Print) 1473-0782 (Online) Journal homepage:

Actions to increase knowledge about age-related fertility decline in women

Désirée García, Amelia Rodríguez & Rita Vassena

To cite this article: Désirée García, Amelia Rodríguez & Rita Vassena (2018): Actions to increase knowledge about age-related fertility decline in women, The European Journal of Contraception & Reproductive Health Care, DOI: 10.1080/13625187.2018.1526895

Published online: 25 Oct 2018.  

Published online: 25 Oct 2018.

Submit your article to this journal
Submit your article to this journal
View Crossmark data
View Crossmark data

Full Terms & Conditions of access and use can be found at




CARE REVIEW Actions to increase knowledge about age-related fertility

Actions to increase knowledge about age-related fertility decline in women

D esir ee Garc ıa, Amelia Rodr ı guez and Rita Vassena

Eugin Clinic, Barcelona, Spain


Objective: There is a strong body of published data corroborating the current lack of awareness of age-related fertility decline (ARFD), but few studies have evaluated specific interventions aimed at increasing ARFD knowledge. Here, we review the literature examining the instruments devel- oped and the educational interventions performed to date. Methods: We carried out a narrative review based on a literature search in PubMed, Web of Science, PsycINFO and Scopus between January 2010 and December 2017. Results: The instruments available comprise websites, paper brochures, slide presentations and tailored information, mainly developed with the input of university students. The eight interven- tions reviewed include surveys before and/or after a specific intervention, with and without a con- trol group, in randomised and non-randomised designs. Overall, the interventions were effective in increasing ARFD knowledge and lowering the desired age for childbearing in the short term. These results were not always maintained, however, in the long term, possibly due to a lack of perceived risk of future infertility among those studied. Conclusion: Further interventions need to be targeted to both young people and health care pro- viders, and should be as personalised as possible. A greater number of validated instruments are also needed to reliably measure the effectiveness of any intervention.


Received 22 February 2018 Revised 23 August 2018 Accepted 17 September 2018

Published online 23 October



Age-related infertility; educational interventions; fertility awareness; fertility knowledge; health promotion


Despite a general awareness of age-related fertility decline (ARFD) in the population, specific facts about ARFD in women (e.g., when female fertility starts to decline) are less well known. On the one hand, the general population [1 , 2 ] and university students [ 3 5 ] have been shown to be gen- erally unaware of ARFD. On the other hand, health care professionals have both limited knowledge [ 6 ,7 ] and scarce resources [ 8 ] to discuss ARFD with their patients. The most significant decrease in fertility occurs in women from the mid- to the late 30s [ 9 11 ], age over 35 being the main risk factor for infertility [ 12 ]. Unfortunately, while university students recognised that age over 40 was a significant infertility risk [13 ], age over 35 was barely rec- ognised as such [13 , 14 ]. A woman s degree of fertility loss before reaching her 40s is evident through both natural and medically assisted reproduction [15 17 ]. Half of all women are sterile by their mid-40s [17 ] and unable to give birth to a genetically related child, even through in vitro fertilisation (IVF) [16 ]. Moreover, there is an overconfidence in the population of what assisted reproductive technologies (ART) can achieve when it comes to having a child at an older age [ 18, 19 ]:

pregnancy chances are often overrated, gamete donation is usually unknown and there is a general overoptimism about late childbearing. An immediate consequence of erroneous perceptions about fertility and age is a false idea of control over ones own reproduction [ 20 ], enhanced by an overconfidence in the success of ART at any age [ 21 ]. Insufficient fertility knowledge has been associated with delayed intended age

for childbearing [ 22 ,23 ] and increased risk of involuntary childlessness [24 ]. The age of the subfertile population and the demand for ART are also increasing [ 25 ]. Despite the large number of studies highlighting the lack of accurate fertility knowledge among the general population, and its consequences, few instruments have been developed and even fewer interventional studies pro- posed to date. The objective of this narrative review is to describe relevant published studies and provide input for future interventions.


The publications included in this review were selected by searching for studies evaluating fertility knowledge pub- lished in PubMed, Web of Science, PsycINFO and Scopus, and further complemented by a selection of interventions performed to increase ARFD knowledge and the instru- ments used in those interventions. Relevant publications included: (1) articles that evaluated interventions aimed at increasing fertility knowledge, particularly ARFD knowledge and (2) articles that described the development of the instruments used in the previous studies. This review was performed in January 2018 and covers the period from January 2010 to the end of December 2017.


We describe the development and use of three instruments available online (FertiSTAT, Your Fertility and My Fertility Choices) and eight interventional studies [ 26 33 ], five of

CONTACT Rita Vassena

studies [ 26 – 33 ], five of CONTACT Rita Vassena Cl ı nica Eugin,

– 33 ], five of CONTACT Rita Vassena Cl ı nica Eugin, Travessera de les

Cl ı nica Eugin, Travessera de les Corts 322, 08029 Barcelona, Spain

2018 The European Society of Contraception and Reproductive Health


2 D. GARC IA ET AL. which were randomised controlled trials (RCTs) [ 27 , 29


which were randomised controlled trials (RCTs) [ 27 ,29 32 ].

A comparison of the three instruments developed is pro-

vided in Table 1 , whereas the main characteristics of the interventional studies are presented in Table 2 , and their outcomes and results summarised in Table 3.


In 2010, Bunting and Boivin [34] developed FertiSTAT (fertis-, the first online tool for evaluating infertility risk fac- tors (including age, lifestyle and medical conditions) in women and heterosexual couples, providing personalised

advice on how to protect ones fertility. FertiSTAT evaluates

22 items with regard to age, time trying to get pregnant,

reproductive history and lifestyle. The infertility risk factor evaluation gives a score accompanied by personalised advice;

ARFD after the age of 34 years is also always pointed out. FertiSTAT was used in the International Fertility Decision-Making Study (IFDMS) [35 , 36 ], which aimed to evaluate the role of fertility knowledge using the Cardiff Fertility Knowledge Scale (CFKS) and infertility risk factor

awareness in the decision-making process to have a child, and what to do in case of infertility. The IFDMS is the larg- est non-interventional study in number of participants and countries involved ever performed with the objective of evaluating fertility knowledge, including 10,045 partici- pants, both men and women trying to have a baby, from

79 countries. Among the high-risk factors evaluated were

being aged between 35 and 39 years old, being aged between 40 and 44 years old and being aged over 45 years old. Overall, the mean fertility knowledge score was 56.9%, ranging from 14.1% in Turkey to 79.0% in New Zealand. The authors observed that people overestimated natural fertility, making it hard to regard infertility as a risk of delaying childbearing. Of note, being aged over 45 years oldwas correctly identified as the main infertility risk factor, but being aged between 35 and 39 years old was the least recognised risk factor. Fulford et al. [36 ], in a fol- low-up study of the same cohort, found that intentions to take action to improve fertility among women younger than 35 years depend on three factors: fertility knowledge, infertility risk and feeling of vulnerability to infertility. FertiSTAT also inspired the risk evaluation form used in the Fertility Assessment and Counselling clinic (an inde- pendent unit of the Fertility Clinic of Copenhagen) in a programme for improving fertility prediction and protec- tion [37 ]. In this programme, fertile women and men received free individualised reproductive counselling. Although it was not offered in the context of a research study measuring the effect of any intervention, the initia- tive was considered useful and was reported to increase fertility knowledge in most individuals attending the clinic between 2011 and 2014 [37 ]. Moreover, the prediction of longer time to achieve pregnancy obtained in the Fertility Assessment and Counselling clinic could be used by fertility experts to counsel individuals on how to implement their reproductive life plan (see below) [38 ].

Your fertility

In 2013, in the context of the Australian public education

Your Fertilitycampaign, and from the answers obtained

by a telephone interview with 462 women and men of reproductive age, Hammarberg et al. [1 ] devised the web- site of the same name ( The website includes information on four factors affecting fertility (age, BMI, smoking and menstrual cycle) and provides printable materials for both lay people and health care professionals. The online format was especially appreciated by the youngest participants (age 1824) and by men, while women aged 35 45 preferred to speak directly to a health care professional. The usefulness of this site was supported by a recent qualitative investigation on information-seeking

behaviour among reproductive-age people [18 ] and by an anonymous survey addressed to nurses working in primary health care [8 ]. Although its efficacy in increasing fertility knowledge has never been evaluated in the context of an interventional study (namely an RCT), this is the most com- plete and updated online material of the three evaluated

in this study.

My fertility choices

Daniluk and Koert [39 ] developed the Canadian educational website My Fertility Choices ( to address the knowledge gaps found in their previous inves- tigations and the finding that women and men expect to

become parents significantly later in life than they believe

is ideal (5.6 years of difference for women and 7.3 years for

men) [ 21 ,40 ]. The authors developed this website in order to help couples and individuals to make fertility choices and to provide information about family-building options, fertility testing, fertility treatments and fertility preservation. This material was used in a further study described in the next section [ 28 ].

Non-randomised interventions

In 2013, Wojcieszek and Thompson [33 ] performed the first interventional study evaluating the effectiveness of educa- tional interventions in increasing fertility knowledge. These authors analysed exposure to an online information bro- chure about ARFD, delayed childbearing and IVF effective- ness (vs. a brochure about home ownership) among university students in Queensland, Australia. They carried out a non-randomised controlled trial (computer-generated alternate allocation) and performed a pre-test/post-test comparison between groups. They found that exposure to

a brief brochure significantly increased participants fertility and infertility knowledge (þ 71%) and IVF knowledge ( þ61%) ( p < .001), and moderately decreased the desired age for having the first and last child ( 0.83 and 1.24 years, respectively; p < .001). These findings were valid at least in the short term, since the post-test was adminis- tered immediately after exposure. In 2014, Daniluk and Koert [28 ] evaluated the effective- ness of the exposure to the My Fertility Choices website, presented above, on increasing fertility and ART know- ledge. The effectiveness of the intervention was evaluated immediately and 6 months after, using the Fertility Awareness Survey [21 , 39 , 40 ]. The intervention was shown to be effective in increasing overall knowledge and advanc- ing childbearing ideals in the short term but the improve- ment was not maintained in the long term; for example,

Provides personalised evaluation and advice Supported by the School of Psychology of Cardiff University Available in English and Portuguese Variety of content in accessible language Variety of materials (text, videos, anima- tions) Assessment tools with personalised advice Expert information and personal stories Supported by the Australian govern- ment Updated contents Concise and clear infor-

mation Easy to navigate web- site Expert information and personal stories Supported by the Canadian govern- ment and the University of British Columbia


To calculate an individ-

To provide decision- making resources to make the best fertil- ity choices To provide current information about fertility testing, fer- tility preservation, infertility treatment and family-build- ing options

To promote awareness of factors that influ- ence fertility so that individuals and cou- ples can make informed and timely decisions regarding childbearing and to prevent infertility and involuntary childlessness

ual s or couples FertiSTAT score To give advice on how to protect fertility


Women, men, couples and health care professionals

Women and couples planning to have children now or in

Women and men of all ages

Target audience

the future

age, lifestyle, med- ical conditions

Infertility risk factors:

Fertility factors: age, weight, smoking,

Fertility information Readiness for child- bearing Decision making Relationships


Main topics

alcohol, factors


Online information pro- vided as text, fig- ures, videos and animations Online questionnaires (fertility knowledge, fertility potential, ovulation calculator) Specific materials for professionals (webi- nar, sheets, presentations)

Online information pro- vided as questions and answers by topic

Online questionnaire (infertility risk fac-

tor assessment)






Karin Hammarberg, Tracey Setter, Robert J. Norman, Carol A. Holden, Janet Michelmore and Louise Johnson/ Fertility Coalition

Judith C. Daniluk and Emily Koert/ Judith C. Daniluk

Laura Bunting and Jacky Boivin/ Cardiff University


Table 1. Comparison of online instruments for fertility education.

Publication year/

2013 [ 39]/ 2015

2013 [ 1]/ 2018

2010 [34]/ NA

last update

My Fertility Choices (

FertiSTAT (

Your (

Instrument (website)

NA: not applicable.





Not given

Not given









Immediately after exposure and 6 months later

after exposure

after exposure

after exposure

after exposure

after exposure

Length of







13 months

2 months

Questionnaire par- tially based on the Swedish Awareness Questionnaire Questionnaire par- tially based on the Swedish Awareness Questionnaire Questionnaire spe-

Questionnaire par- tially based on the Swedish Awareness Questionnaire Questionnaire spe-

Questionnaire par- tially based on the Swedish Awareness Questionnaire and on Bunting and Boivin [13] CFKS (Japanese version)

cifically for

cifically for



the study

the study





Slide presentation

Slide presentation

Online brochure (My Fertility Choices) Tailored oral and written information

Tailored oral and written information

Online brochure

Online brochure




Post-intervention survey only RCT

Pre-/post-interven- tion survey RCT

1835 (23.5 ± 4.6) Pre-/post-interven- tion survey RCT

Pre-/post-interven- tion survey RCT



Pre-/post-interven- tion survey RCT


tion survey

tion survey

tion survey





Age (range and/or mean ± SD)

18 35 (28)

20.2 ± 4.9

191 ± 3.2

23 ± 2.4

21 ± 3.7



Men n (%)

726 (49.9)

33 (19.1)

48 (24.1)

44 (32.1)

6 (11.3)




Women n (%)

140 (80.9)

151 (75.9)

729 (50.1)

201 (100)

299 (100)

47 (88.7)

93 (67.9)

69 (100)




299 69





Table 2. Main characteristics of interventional studies included in the review.

Study population

tion Medical professionals excluded Portugal Male and female

Male and female medical stu- dents and health care professionals

Wojcieszek and Thompson [ 33] 2013 Australia Male and female

Childless women

Women in an oocyte dona- tion programme

General popula-

sity students

Female univer-

and women

Childless men






2013 Sweden













Anspach Will et al. [ 26]

Daniluk and Koert [ 28]

Williamson et al. [ 32]

~Conceic¸ao et al. [ 27]

Maeda et al. [ 30]

Garcı a et al. [ 29]

Stern et al. [31 ]



a l . [ 2 7 ] Maeda et al. [ 30 ] Garc ı a


Table 3. Outcomes and results of interventional studies.






Main outcome


Wojcieszek and Thompson [33]


Fertility knowledge IVF knowledge Desired age for childbearing Fertility knowledge Desired age for childbearing Fertility knowledge Intended age for childbearing Fertility knowledge ART knowledge Desired age for childbearing

Fertility knowledge: increase IVF knowledge: increase Desired age for childbearing: decrease Fertility knowledge: increase Desired age for childbearing: decrease Fertility knowledge: increase Intended age for childbearing: no change Overall knowledge: increase in short term, no change in long term Specific ARFD knowledge: increase in short term, higher increase in long term Desired age for childbearing: decrease in short term, no change in long term Fertility knowledge: increase Intended age for childbearing: no change Fertility knowledge: increase Psychological burden: increase Fertility knowledge: increase ARFD knowledge: increase Social egg freezing: increase

Stern et al. [ 31]


Williamson et al. [ 32]


Daniluk and Koert [28 ]


Garc ı a et al. [ 29]


Fertility knowledge Intended age for childbearing Fertility knowledge Psychological burden Fertility knowledge ARFD knowledge

Maeda et al. [ 30]


Conceic¸~ao et al. [ 27] Anspach Will et al. [ 26]




Social egg


the ideal age for a woman to have her first and last child (initially 26.9 and 40.3 years) dropped 1 and 1.5 years immediately after the intervention (to 25.9 and 38.7 years; p < .001), but returned to pre-intervention values after 6 months (27.2 and 39.9 years). Although more questions were correctly answered by more than half of participants immediately after the intervention than after 6 months (14 vs. four correct answers), respondents presented higher results at follow-up, with evident differences between the sexes. For instance, the sentence There is a progressive decrease in a woman s ability to become pregnant after the age of 35 was correctly rated as true immediately after the intervention by þ6.6% women ( p ¼ .024) and þ 6.2% of men ( p ¼ .37) vs. þ14.8% of women ( p ¼ .003) and 6.9% of men (p ¼ .33) after 6 months. These results suggest, first, that most participants could remember the brochures information for a short while but, afterwards, it was not always retained (learnt). Second, they suggest that fertility information should be provided differently to women and men, since retention noticeably depends on personal rele- vance and need.


Stern et al. [31 ] carried out the first RCT evaluating the effectiveness of educational interventions in increasing fer- tility knowledge in young women attending a health centre for contraceptive counselling in Sweden. In addition, oral and written information based on the reproductive life plan were provided in the intervention group (vs. informa- tion about folic acid intake in the control group). The reproductive life plan is a counselling tool used in the deci- sion-making process of childbearing in relation to personal goals during one s lifetime, using a set of questions about having or not having children, and giving advice on the family planning methods to be used accordingly [ 41 ]. Stern et al. [31 ] demonstrated that the tailored oral and written information provided to participants had a positive effect on their reproductive knowledge (p < .001) and childbear- ing intentions ( p < .05) 2 months later. Specifically, þ 27% acknowledged a marked fertility decline at age 35, and pre- ferred age at last child was lowered by 1 year on average. Moreover, the majority of women appreciated the

intervention and considered that midwives should routinely discuss a reproductive life plan with their patients. A second RCT was carried out by Williamson et al. [32 ]. In this study, childless women at a Canadian university campus were exposed to a slide presentation about fertility (vs. alcohol consumption in the control group) and its effect on their fertility knowledge was evaluated in a post- test-only design. Participants exposed to the fertility pres- entation obtained a fertility knowledge score of 3.8 vs. 1.7 in the control group (p < .001). In particular, 100% of women in the fertility information group correctly identi- fied the biologically optimal age for childbearing (20 25 years), compared with 88.2% in the control group (p ¼ .04); and 88.6% vs. 32.4% ( p < .001), respectively, correctly iden- tified the age when female fertility starts to decline (32 years, among the options 16, 28, 32 and 40). The intended age at first birth was, however, not significantly different between groups. Williamson and Lawson [20 ] further studied young womens intentions to delay childbearing, concluding that the perception of control of fertility was mainly founded on a false perception of long-lasting fertil- ity and significantly contributed to their intentions to delay motherhood. Garc ıa et al. [29 ] carried out an RCT in Spain. It com- prised three arms (no intervention, untailored written infor- mation and tailored oral and written information) in a population of healthy women aged < 36 years (oocyte donors) from different backgrounds, more representative of reproductive-age women than selected populations of uni- versity students. The effect of the intervention was eval- uated in a follow-up visit on average 2 months later. The tailored intervention resulted in an increase ( þ25%) in fer- tility knowledge compared with baseline that was signifi- cantly higher than that of the control group ( p < .001). The tailored intervention also resulted in a reduction of 2.1 years in the intended age for childbearing reported at baseline, although this result was not statistically signifi- cant. In particular, correct answers to the questions related to ARFD in women increased by þ28.9% (best time for childbearing before age 25; p ¼ .045), þ32% (marked fertil- ity decrease at age 35; p ¼ .031) and þ62.8% (identification of > 35 years old as a strong infertility risk factor; p < .001). The authors concluded that the oral tailored intervention was effective in increasing ARFD knowledge, while written


6 D. GARC IA ET AL. standard brochures, although somewhat effective, did not elicit sufficient interest


standard brochures, although somewhat effective, did not elicit sufficient interest if not accompanied by individual- ised information. Maeda et al. [ 30] carried out an RCT evaluating the immediate effects of providing an online brochure about fertility in a representative sample of 20- to 39-year-old Japanese men and women. The authors also evaluated for the first time the psychological burden of the intervention. The RCT had three arms: information on fertility, informa- tion on folic acid intake and information on financial and social support. The brochure about fertility addressed the ARFD thorough the paragraphs entitled Both men and women are affected by reproductive ageing, What is the ideal age for women to conceive and give birth? and What is ageingof the ovum? The effect of the interven- tion on fertility knowledge was measured by the Japanese version of the CFKS [35 ], while the effect on anxiety was measured by the Japanese version of the State-Trait Anxiety Inventory (STAI) [ 42 ] and by the question How do you feel about the brochure just presented?rated on a five-point Likert scale. The intervention resulted in a signifi- cant increase in fertility knowledge of þ15.1% in women (p < .001) and þ 10.3% in men ( p < .001). The authors con- cluded that fertility information, even when neutral in its presentation and evidence-based, increased knowledge but also induced anxiety among the reproductive-age popula- tion. The authors suggested that educational interventions should be performed earlier, in younger generations who had time enough to make informed decisions about their reproductive health. Conceic¸~ao et al. [ 27 ] performed an RCT among male and female university students in Portugal. This study com- pared the short-term (10 min later) effect of exposure to an educational video about reproductive health and infertility compared with no exposure. The effect of the intervention was measured using a questionnaire based on that of Lampic et al. [3 ]. The authors observed a significant increase in ARFD knowledge in the intervention group regarding identification of the most fertile age and the age when there is a slight fertility decrease (þ 6.92; p < .001), which was not observed in the control group. Participants in both arms, however, gained knowledge on the age when a marked fertility decrease occurs: þ 7.35 years (p < .001) and þ 2.61 years ( p < .001), respectively. The authors hypothesised that the presence of several ques- tions in the test about womens age might have influenced the answers also in the control group.

Intervention in health care professionals

Finally, in 2017, Anspach Will et al. [ 26 ] carried out an inter- ventional study among, for the first time, medical students and health care professionals in Connecticut, USA. The intervention consisted of a slide presentation about ARFD and social egg freezing. The presentation lasted 45 min and was followed by 15 min of questions. The pre-test/post-test comparison immediately after the intervention showed a significant improvement in overall score in the six ques- tions (þ 23.5%; p < .001) and in two specific questions about ARFD ( þ31.9%; p < .001).


Findings and interpretation What information should be provided?

Considering the gaps in knowledge found in the literature, any instrument used in educational interventions about fer- tility should include the following information related to reproductive ageing: the decrease in fertility with age in both women and men, the specific age intervals when the most important changes in women occur, the success rates of different ART techniques at different ages, and the need for donated gametes in ART at older ages. It is important to point out, however, that ARFD is not the only factor preventing women from conceiving, and we have found other important gaps in fertility knowledge in our literature review. Therefore, the inclusion of informa- tion about modifiable lifestyle factors such as alcohol con- sumption, smoking and sexually transmitted diseases in these materials is also desirable. Good examples of instru- ments comprising a variety of fertility-relevant factors are the previously described FertiSTAT, My Fertility Choices and Your Fertility.

How should information be provided?

Participants in the focus group of the study by Hammarberg et al. [ 18 ] investigating fertility knowledge and information-seeking behaviour among people of repro- ductive age reported that the most effective ways to edu- cate reproductive-age people about fertility should be through primary health care providers (especially general practitioners), mass media and social media. The focus group especially valued printed information (posters, bro- chures) available at clinics; we draw attention to those materials easily accessible online. In light of the studies reviewed, instruments such as FertiSTAT, Your Fertility and My Fertility Choices seem appropriate means to spread fer- tility knowledge. In addition, interventions should be targeted to their audience, wherever possible, since tailoring to the intended target produces the greatest effects [ 29 ,31 , 37 ]. It is essen- tial to mention that individualsintentions to take action to protect their fertility rely on their reproductive knowledge and their real and perceived infertility risk [36 ]; thus, per- sonalised risk assessment for infertility is more likely to result in a behavioural change compared with general information [43 , 44 ]. Health care professionals need to increase their knowledge to provide their patients with realistic information. For instance, health care professionals can make use of online courses [ 45 ] and evidence-based online instruments [18 ] such as Your Fertility. It is worth mentioning that some studies, although not comprising an intervention, induced participants to ask for more fertility information [21 , 46 48 ]. This suggests that sometimes a survey can itself mediate an intervention.

When should education be provided?

Reproductive education is essential in counselling patients with childbearing intentions [ 49 ]. As seen in the IFDMS [ 36 ], women <35 years were more likely to intend to take action when they were both knowledgeable and felt vul- nerable to infertility, while there was no such association in


JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE 7 older women. Some authors recommend the early 20s


older women. Some authors recommend the early 20s for providing information about the risks and benefits of delaying childbearing [20 , 50 , 51 ], while others suggest intro- ducing discussions about fertility protection even earlier in life [ 30 , 52 55 ]. Early education could also prevent the asso- ciated psychological burden of the provision of ARFD infor- mation at an older age [ 30 ].

Which instruments can measure improvement?

Validated instruments are needed to reliably measure fertil- ity knowledge before and after interventions and then assess their efficacy. In the studies included in this review, only one validated instrument was used to measure fertility knowledge before and after the intervention in the general population (i.e., excluding medical professionals): the CFKS [30 , 35 ]. More recently, the Fertility and Infertility Treatment Knowledge Score [ 56 ] was created and validated as a measurement tool for use in the general population and also among health care professionals, a population of spe- cial interest in disseminating fertility knowledge. Finally, the effectiveness of the interventions should be evaluated not only immediately after the intervention but also in the long term. It is worthwhile to assess the effect- iveness of measuring the impact of the intervention on reported ideal ages for childbearing, childbearing inten- tions and actual age at first childbirth.

Limitations of the study

The main limitation of this study is inherent to its design as a narrative review. We could not directly search for interventions to increase ARFD knowledge because this subject is too specific and we wanted to avoid overlooking relevant articles. Therefore, publications were selected by searching for studies evaluating fertility knowledge, and then looking for those measuring ARFD knowledge after an intervention. We argue that such interventions necessarily measure ARFD knowledge, and the associated articles may be found using this search strategy. Interpretation of the results may also be rather subject- ive in a narrative review. For this reason we evaluated whether each intervention increased ARFD knowledge, and whether it advanced the desired age for childbearing in the study participants. Further, we could not compare the quantification of the increase/advancement achieved among studies because the interventions and the measure- ment tools were almost unique to each of them.

Unanswered questions and future research

This review indicates that there are few studies evaluating the impact of educational interventions on ARFD know- ledge in the long term. Similarly, we found that only three tested instruments are currently accessible to the general population. Two of these resources are available only in English and one in English and Portuguese. Since insuffi- cient ARFD knowledge is a global problem [ 35 ], educa- tional resources available in other languages are needed.


We have shown that educational interventions using online instruments, paper brochures, slide presentations and vid- eos can increase ARFD knowledge, especially when infor- mation is personalised to the participants. A greater number of validated instruments are needed to reliably measure the usefulness of the interventions, which should be targeted to specific populations such as young people and health care professionals.

Disclosure statement

No potential conflict of interest was reported by the authors.


















Hammarberg K, Setter T, Norman RJ, et al. Knowledge about

factors that influence fertility among Australians of reproduct- ive age: a population-based survey. Fertil Steril. 2013;99:

502 507.

Vassard D, Lallemant C, Nyboe Andersen A, et al. A population- based survey on family intentions and fertility awareness in women and men in the United Kingdom and Denmark. Ups J Med Sci. 2016;121:244 251. Lampic C, Svanberg AS, Karlstrom P, et al. Fertility awareness,

intentions concerning childbearing, and attitudes towards par- enthood among female and male academics. Hum Reprod. 2006;21:558 564. Sabarre KA, Khan Z, Whitten AN, et al. A qualitative study of Ottawa university studentsawareness, knowledge and percep- tions of infertility, infertility risk factors and assisted reproduct- ive technologies (ART). Reprod Health 2013;10:41. Virtala A, Vilska S, Huttunen T, et al. Childbearing, the desire to have children, and awareness about the impact of age on female fertility among Finnish university students. Eur J Contracept Reprod Health Care. 2011;16:108 115. Revelli A, Razzano A, Delle Piane L, et al. Awareness of the effects of postponing motherhood among hospital gynecolo- gists: is their knowledge sufficient to offer appropriate help to patients? J Assist Reprod Genet. 2016;33:215 220. Yu L, Peterson B, Inhorn MC, et al. Knowledge, attitudes, and intentions toward fertility awareness and oocyte cryopreserva- tion among obstetrics and gynecology resident physicians. Hum Reprod. 2016;31:403 411. Hammarberg K, Collison L, Johnoson L, et al. Knowledge, atti- tudes and practices relating to fertility among nurses working in primary health care. Aust J Adv Nurs. 2016;34:613. Eijkemans MJ, van Poppel F, Habbema DF, et al. Too old to have children? Lessons from natural fertility populations. Hum Reprod. 2014;29:13041312. Menken J, Trussell J, Larsen U. Age and infertility. Science. 1986;233:1389 1394. Schwartz D, Mayaux MJ. Female fecundity as a function of age:

results of artificial insemination in 2193 nulliparous women with azoospermic husbands. Federation CECOS. N Engl J Med. 1982;306:404 406. Crawford NM, Steiner AZ. Age-related infertility. Obstet Gynecol Clin North Am. 2015;42:1525. Bunting L, Boivin J. Knowledge about infertility risk factors, fer- tility myths and illusory benefits of healthy habits in young people. Hum Reprod. 2008;23:1858 1864. Machado MD, Alves MI, Couceiro L, et al. Birth rate and fertility:

knowledge and expectations. Analysis of 3585 university stu- dents. Acta Med Port. 2014;27:601 608. Portuguese. Gonzalez-Foruria I, Penarrubia J, Borras A, et al. Age, independ- ent from ovarian reserve status, is the main prognostic factor in natural cycle in vitro fertilization. Fertil Steril 2016;106:

342 347.

Habbema JD, Eijkemans MJ, Leridon H, et al. Realizing a desired

family size: when should couples start? Hum Reprod. 2015;30:

2215 2221.





Leridon H. Can assisted reproduction technology compensate


for the natural decline in fertility with age? A model assess- ment. Hum Reprod. 2004;19:15481553. Hammarberg K, Zosel R, Comoy C, et al. Fertility-related know- ledge and information-seeking behaviour among people of reproductive age: a qualitative study. Hum Fertil. 2017;20:


8895. Hashiloni-Dolev Y, Kaplan A, Shkedi-Rafid S. The fertility myth:


Israeli studentsknowledge regarding age-related fertility decline and late pregnancies in an era of assisted reproduction technology. Hum Reprod. 2011;26:3045 3053. Williamson LEA, Lawson KL. Young womens intentions to delay



childbearing: a test of the theory of planned behaviour. J Reprod Infant Psychol. 2015;33:205 213. Daniluk JC, Koert E, Cheung A. Childless womens knowledge


of fertility and assisted human reproduction: identifying the gaps. Fertil Steril. 2012;97:420 426. Cooke A, Mills TA, Lavender T. Advanced maternal age: delayed


childbearing is rarely a conscious choice. A qualitative study of womens views and experiences. Int J Nurs Stud. 2012;49:

Hammarberg K, Clarke VE. Reasons for delaying childbearing


a survey of women aged over 35 years seeking assisted repro- ductive technology. Aust Fam Physician. 2005;34:187 188, 206. Kemkes-Grottenthaler A. Postponing or rejecting parenthood:


results. J Biosoc Sci. 2003;35:213 226. de Graaff AA, Land JA, Kessels AG, et al. Demographic age shift

a randomised pre-test/post-test study. Eur J Contracept Reprod



toward later conception results in an increased age in the sub- fertile population and an increased demand for medical care. Fertil Steril. 2011;95:6163. Anspach Will E, Maslow BS, Kaye L, et al. Increasing awareness


of age-related fertility and elective fertility preservation among medical students and house staff: a pre- and post-intervention analysis. Fertil Steril. 2017;107:1200 1205. Conceic¸~ao C, Pedro J, Martins MV. Effectiveness of a video


intervention on fertility knowledge among university students:

Health Care. 2017;22:107113. Daniluk JC, Koert E. Fertility awareness online: the efficacy of a


fertility education website in increasing knowledge and chang- ing fertility beliefs. Hum Reprod. 2015;30:353 363. Garc ıa D, Vassena R, Prat A, et al. Increasing fertility knowledge


and awareness by tailored education: a randomized controlled trial. Reprod Biomed Online. 2016;32:113 120. Maeda E, Nakamura F, Kobayashi Y, et al. Effects of fertility edu-


cation on knowledge, desires and anxiety among the repro- ductive-aged population: findings from a randomized controlled trial. Hum Reprod. 2016;31:20512060. Stern J, Larsson M, Kristiansson P, et al. Introducing reproduct-


ive life plan-based information in contraceptive counselling: an RCT. Hum Reprod. 2013;28:2450 2461. Williamson LEA, Lawson KL, Downe PJ, et al. Informed repro-


ductive decision-making: the impact of providing fertility infor- mation on fertility knowledge and intentions to delay childbearing. J Obstet Gynaecol Can. 2014;36:400 405. Wojcieszek AM, Thompson R. Conceiving of change: a brief

intervention increases young adultsknowledge of fertility and the effectiveness of in vitro fertilization. Fertil Steril. 2013;100:


Bunting L, Boivin J. Development and preliminary validation of the fertility status awareness tool: FertiSTAT. Hum Reprod.



Bunting L, Tsibulsky I, Boivin J. Fertility knowledge and beliefs


about fertility treatment: findings from the International Fertility Decision-Making Study. Hum Reprod. 2013;28:385 397. Fulford B, Bunting L, Tsibulsky I, et al. The role of knowledge and perceived susceptibility in intentions to optimize fertility:

findings from the International Fertility Decision-Making Study (IFDMS). Hum Reprod. 2013;28:32533262.





Hvidman HW, Petersen KB, Larsen EC, et al. Individual fertility assessment and pro-fertility counselling; should this be offered to women and men of reproductive age? Hum Reprod. 2015; 30:9 15. Birch Petersen K, Maltesen T, Forman JL, et al. The fertility assessment and counseling clinic does the concept work? A

prospective 2-year follow-up study of 519 women. Acta Obstet Gynecol Scand. 2017;96:313 315. Daniluk JC, Koert E. The other side of the fertility coin: a com- parison of childless men s and womens knowledge of fertility and assisted reproductive technology. Fertil Steril. 2013;99:

839 846.

Daniluk JC, Koert E. Childless Canadian men s and womens

childbearing intentions, attitudes towards and willingness to use assisted human reproduction. Hum Reprod. 2012;27:

2405 2412.


ier reproductive outcomes: recommendations for the routine care of all women of reproductive age. Am J Obstet Gynecol. 2008;199:S280 S289. Spielberger CD, Gorsuch RL, Lushene R, et al. Manual for the State-Trait Anxiety Inventory. Palo Alto (CA): Consulting

Psychologists Press; 1983. Bavan B, Porzig E, Baker VL. An assessment of female university students attitudes toward screening technologies for ovarian reserve. Fertil Steril. 2011;96:11951199. Tremellen K, Savulescu J. Ovarian reserve screening: a scientific and ethical analysis. Hum Reprod. 2014;29:26062614. Whittington K, Cook J, Barratt C, et al. Can the internet widen participation in reproductive medicine education for professio- nals?. Hum Reprod. 2004;19:1800 1805. Ekelin M, Åkesson C, Ångerud M, et al. Swedish high school students knowledge and attitudes regarding fertility and family building. Reprod Health. 2012;9:6. F ugenerJ, Matthes A, Strauß B. Knowledge and behaviour of young people concerning fertility risks results of a question- naire. Geburtsh Frauenheilk. 2013;73:800 807. Garc ıa D, Vassena R, Trullenque M, et al. Fertility knowledge and awareness in oocyte donors in Spain. Patient Educ Couns. 2015;98:96 101.

[49] American College of Obstetricians and Gynecologists








Moos MK, Dunlop AL, Jack BW, et al. Healthier women, health-








Committee on Gynecologic Practice and Practice Committee. Female age-related fertility decline. Committee opinion no. 589. Fertil Steril. 2014;101:633634. Maeda E, Nakamura F, Boivin J, et al. Fertility knowledge and the timing of first childbearing: a cross-sectional study in Japan. Hum Fertil. 2016;19:275 281. Maheshwari A, Porter M, Shetty A, et al. Womens awareness

and perceptions of delay in childbearing. Fertil Steril. 2008;90:

1036 1042.

Heywood W, Pitts MK, Patrick K, et al. Fertility knowledge and

intentions to have children in a national study of Australian secondary school students. Aust NZ J Public Health. 2016;40:

462 467.

Macintosh KL [Internet]. Teaching about the biological clock:

age-related fertility decline and sex education; 2015 [cited 2017 Jan 13]. Available from:

Mogilevkina I, Stern J, Melnik D, et al. Ukrainian medical students attitudes to parenthood and knowledge of fertility. Eur J Contracept Reprod Health Care. 2016;21:189 194. Sauer MV. Reproduction at an advanced maternal age and maternal health. Fertil Steril. 2015;103:1136 1143. Kudesia R, Chernyak E, McAvey B. Low fertility awareness in U.S. reproductive-aged women and medical trainees: creation and validation of the Fertility & Infertility Treatment Knowledge Score (FIT-KS). Fertil Steril 2017;108:711717.