By Macy Rupprecht, DO
August 14, 2019

Editor’s Note: This is a review of research[i] published in 2018 by Pedro et al in Upsala Journal of Medical Sciences titled, “What do people know about fertility? A systematic review on fertility awareness and its associated factors.” Dr. Macy Rupprecht reviewed the study and wrote this article as part of a two-week online elective taught by FACTS executive director, Dr. Marguerite Duane, at Georgetown University College of Medicine. The study brings to light various factors that may impact the effectiveness of fertility awareness education and guide future research.

Introduction
In recent years, there have been concerns regarding insufficient fertility awareness among people of reproductive age, especially with the trend toward postponing childbearing to later in life. This study by Pedro et al provides a systematic review of current research available about fertility awareness. It examines and summarizes available evidence regarding fertility awareness education and attempts to identify gaps in the literature and in education based on studies conducted worldwide.

Methodology
A search of 13 electronic databases identified 7,961 studies. Of those, 71 studies were included in the study and evaluated by two separate reviewers (a third reviewer resolved conflicts that arose). The following inclusion criteria were used: 1) used quantitative data regarding fertility awareness, 2) used a fertility awareness specific measure or provided detailed description of the questions assessed.

The study assessed overall fertility awareness, including knowledge of the definition of infertility, age-related fertility decline, fertility parameters, infertility risk factors, and consequences of delayed childbearing. It also attempted to identify any differences in fertility awareness based on gender, age, education, and reproductive status.

Results
Most of the studies reviewed (n=41) included women and men of reproductive age, with the following populations comprising the majority of groups studied: college/secondary education students, people trying to conceive and/or seeking fertility treatment, and women under gynecologic care. The study identified that, in general, people of reproductive age have inadequate fertility awareness regarding fertility, infertility, and the consequences of delaying childbearing. The participants reported low to moderate fertility awareness.

Generally, people were aware that age poses a risk for reduced fertility; however, the specifics of this risk factor were not well understood. It was generally believed that the age-related decline of fertility starts later than it does, and they overestimated the chances of having a successful pregnancy later in life, whether spontaneously or through fertility treatment.

There was a relatively high awareness of the risks associated with sexually transmitted infections (STI’s) and fertility as well as individual female lifestyle risk factors. However, awareness regarding the impact of higher female age on birth outcomes, including premature delivery, low birth weight, and the need for Cesarean delivery was poorly understood. Additionally, there was low awareness of the birth outcomes on the offspring due to men’s advanced age, including learning disabilities, autism, schizophrenia, and some cancers.

The study identified certain groups that demonstrated higher levels of fertility awareness, including those with higher levels of education, people with difficulty conceiving, individuals who planned their pregnancies, and women. The level of awareness was not related to having or desiring children.

Inconsistent associations were found between age and level of fertility awareness. Some studies showed that older women had higher levels of fertility awareness, whereas other studies suggested younger females were more aware. Still other studies showed no association between age and level of fertility awareness.

Discussion
This review article, which is the first of its kind, sought to obtain the best available evidence regarding fertility awareness through a rigorous review process. Although the sample size is small, the results and challenges discovered may help guide future research. The studies assessed included data from five continents with many different populations, which provided a more global view of the topic at hand. Summarizing the findings was challenging due to different sample sizes as well as the heterogeneity of the samples studied. Also, the various discrepancies within the data examined may be a reflection of different ways of assessing fertility awareness, and only a small proportion of the studies applied psychometrically validated instruments.

Most of the samples were from Europe, followed by America and Asia; future research will need to attempt to minimize the impact of cultural bias. More research is needed to determine who needs fertility awareness and to establish during which phases of reproductive life this knowledge should be imparted to individuals. Future research will need to utilize more reliable, validated fertility awareness instruments.

The results of this study suggest that specific populations may require targeted education regarding fertility awareness. It is likely the best strategy will not be a generalized approach that seeks to target all individuals with the same message. Rather, a patient-centered approach will likely be more effective and more acceptable to people. Although written materials like handouts and pamphlets provide an opportunity to increase one’s knowledge, they do not necessarily lead to behavior change. Some evidence suggests that web-based educational interventions can impact health behaviors in a positive way.

This article clearly supports the notion that fertility awareness in individuals of reproductive age remains an area in need of greater attention. Yet, it does not appear that a single approach to reach everyone is necessarily the best way to bridge this educational gap. Developing new and creative ways to meet the educational needs of different populations and raise their fertility awareness will be essential.

Editor’s Note: At FACTS, we recognize the need for both fertility awareness education and ongoing research in this rapidly evolving field in women’s health. As interest in female technology (fem-tech) continues to grow, fertility awareness based methods are the foundation not only to fill educational gaps about fertility and reproductive health but also for emerging technologies in women’s health. For this reason, this year’s theme for our FACTS annual meeting is Fertility Awareness and Fem-Tech: Synergy for the 21st Century. Find out more and register for our November 3, 2019 conference HERE!

References
[i] Pedro, J., Brandao, T., Schmidt, L., Costa, ME., & Martins, MV. “What do people know about fertility? A systematic review on fertility awareness and its associated factors.” Upsala Journal of Medical Sciences. 2018, https://www.ncbi.nlm.nih.gov/pubmed/29957086.

Author Bio: Macy Rupprecht, DO is a family medicine physician who completed residency training at the Via Christi Family Medicine Residency Program in Wichita, KS. She earned her medical degree at the Edward Via College of Osteopathic Medicine and was chosen as a National Health Service Corps (NHSC) Scholar. She is excited to join the Eastern Shore Rural Health System at the Onley Community Health Center in Onley, VA, where she will complete her NHSC service commitment. Dr. Rupprecht participated in an FABM elective during residency and completed the Creighton Model NFP Medical Consultant training in 2018. She looks forward to using FABMs in her practice to empower women and couples to take ownership of their fertility and gain a better understanding of their reproductive system.

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