The European Journal of Contraception & Reproductive

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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

To link to this article: https://doi.org/10.1080/13625187.2018.1526895

Published online: 25 Oct 2018.

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THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE
https://doi.org/10.1080/13625187.2018.1526895

REVIEW

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

D

esir

ee Garc
ıa, Amelia Rodr
ıguez and Rita Vassena
Eugin Clinic, Barcelona, Spain

ABSTRACT ARTICLE HISTORY

Objective: There is a strong body of published data corroborating the current lack of awareness Received 22 February 2018
of age-related fertility decline (ARFD), but few studies have evaluated specific interventions aimed Revised 23 August 2018
at increasing ARFD knowledge. Here, we review the literature examining the instruments devel- Accepted 17 September 2018
oped and the educational interventions performed to date. Published online 23 October
2018
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. KEYWORDS
Results: The instruments available comprise websites, paper brochures, slide presentations and Age-related infertility;
tailored information, mainly developed with the input of university students. The eight interven- educational interventions;
tions reviewed include surveys before and/or after a specific intervention, with and without a con- fertility awareness; fertility
trol group, in randomised and non-randomised designs. Overall, the interventions were effective in knowledge;
increasing ARFD knowledge and lowering the desired age for childbearing in the short term. health promotion
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.

Introduction for childbearing [22,23] and increased risk of involuntary

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 one’s
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
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.
Methods
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.
Results
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 rvassena@eugin.es Cl
ınica Eugin, Travessera de les Corts 322, 08029 Barcelona, Spain
ß 2018 The European Society of Contraception and Reproductive Health
2 D. GARC
IA ET AL.
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.
FertiSTAT
In 2010, Bunting and Boivin [34] developed FertiSTAT (fertis-
tat.com), 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 one’s 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 old’ was 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 Fertility’ campaign, 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 (yourfertility.org.au). 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 18–24) 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 (myfertilitychoices.com) 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 (þ71%) 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,
Table 1. Comparison of online instruments for fertility education.
Publication year/
Instrument (website) last update Authors/owner Country Format Main topics Target audience Aim Strengths
FertiSTAT (fertistat.com) 2010 [34]/ NA Laura Bunting and UK Online questionnaire Infertility risk factors: Women and couples To calculate an individ- Provides personalised
Jacky Boivin/ (infertility risk fac- age, lifestyle, med- planning to have ual’s or couple’s evaluation and
Cardiff University tor assessment) ical conditions children now or in FertiSTAT score advice
the future To give advice on how Supported by the
to protect fertility School of
Psychology of
Cardiff University
Available in English
and Portuguese
Your Fertility 2013 [1]/ 2018 Karin Hammarberg, Australia Online information pro- Fertility factors: age, Women, men, couples To promote awareness Variety of content in
(yourfertility.org.au) Tracey Setter, vided as text, fig- weight, smoking, and health care of factors that influ- accessible language
Robert J. Norman, ures, videos and alcohol, timing, professionals ence fertility so that Variety of materials
Carol A. Holden, animations other factors individuals and cou- (text, videos, anima-
Janet Michelmore Online questionnaires ples can make tions)
and Louise Johnson/ (fertility knowledge, informed and timely Assessment tools with
Fertility Coalition fertility potential, decisions regarding personalised advice
ovulation calculator) childbearing and to Expert information and
Specific materials for prevent infertility personal stories
professionals (webi- and involuntary Supported by the
nar, sheets, childlessness Australian govern-
presentations) ment
Updated contents
My Fertility Choices 2013 [39]/ 2015 Judith C. Daniluk and Canada Online information pro- Fertility information Women and men of To provide decision- Concise and clear infor-
(myfertilitychoices.com) Emily Koert/ vided as questions Readiness for child- all ages making resources to mation
Judith C. Daniluk and answers bearing make the best fertil- Easy to navigate web-
by topic Decision making ity choices site
Relationships To provide current Expert information and
information about personal stories
fertility testing, fer- Supported by the
tility preservation, Canadian govern-
infertility treatment ment and the
and family-build- University of
ing options British Columbia
NA: not applicable.
THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE
3
 4

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

Age
Study (range and/or Intervention Length of Response
Study Year Country Study population size Women n (%) Men n (%) mean ± SD) Design performed Instrument follow-up rate
Wojcieszek and Thompson [33] 2013 Australia Male and female 137 93 (67.9) 44 (32.1) 191 ± 3.2 Pre-/post-interven- Online brochure Questionnaire par- Immediately Not given
university tion survey tially based on after exposure
students Not RCT the Swedish
Awareness
D. GARC
IA ET AL.

Questionnaire
Stern et al. [31] 2013 Sweden Female univer- 299 299 (100) 0 23 ± 2.4 Pre-/post-interven- Tailored oral and Questionnaire par- 2 months 88%
sity students tion survey RCT written tially based on
information the Swedish
Awareness
Questionnaire
Williamson et al. [32] 2014 Canada Childless women 69 69 (100) 0 21 ± 3.7 Post-intervention Slide presentation Questionnaire spe- Immediately Not given
survey only RCT cifically after exposure
designed for
the study
Daniluk and Koert [28] 2015 Canada Childless men 199 151 (75.9) 48 (24.1) 18–35 (28) Pre-/post-interven- Online brochure Fertility Immediately after 55%
and women tion survey (My Awareness exposure and 6
Not RCT Fertility Survey months later
Choices)
Garc
ıa et al. [29] 2016 Spain Women in an 201 201 (100) 0 18–35 (23.5 ± 4.6) Pre-/post-interven- Tailored oral and Questionnaire par- 1–3 months 93.9%
oocyte dona- tion survey RCT written tially based on
tion information the Swedish
programme Awareness
Questionnaire
and on Bunting
and Boivin [13]
Maeda et al. [30] 2016 Japan General popula- 1455 729 (50.1) 726 (49.9) 20–39 Pre-/post-interven- Online brochure CFKS Immediately 67.8%
tion Medical tion survey RCT (Japanese after exposure
professionals version)
excluded
Conceiç~ao et al. [27] 2017 Portugal Male and female 173 140 (80.9) 33 (19.1) 20.2 ± 4.9 Pre-/post-interven- Video Questionnaire par- Immediately 93.9%
university tion survey RCT tially based on after exposure
students the Swedish
Awareness
Questionnaire
Anspach Will et al. [26] 2017 USA Male and female 53 47 (88.7) 6 (11.3) 20–40 Pre-/post-interven- Slide presentation Questionnaire spe- Immediately 81.5%
medical stu- tion survey cifically after exposure
dents and Not RCT designed for
health care the study
professionals
 THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE
Table 3. Outcomes and results of interventional studies.
Study Year Main outcome
Wojcieszek and Thompson [33] 2013 Fertility knowledge
IVF knowledge
Desired age for childbearing
Stern et al. [31] 2013 Fertility knowledge
Desired age for childbearing
Williamson et al. [32] 2014 Fertility knowledge
Intended age for childbearing
Daniluk and Koert [28] 2015 Fertility knowledge
ART knowledge
Desired age for childbearing
Garc
ıa et al. [29] 2016 Fertility knowledge
Intended age for childbearing
Maeda et al. [30] 2016 Fertility knowledge
Psychological burden
Conceiç~ao et al. [27] 2017 Fertility knowledge
Anspach Will et al. [26] 2017 ARFD knowledge
Social egg freezing
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 þ6.2% 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 brochure’s
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.
RCTs
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, þ27%
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
5
Results
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
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 women’s 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 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 “ageing” of 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 þ10.3% 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.
Conceiç~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 (þ6.92; 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: þ7.35 years
(p < .001) and þ2.61 years (p < .001), respectively. The
authors hypothesised that the presence of several ques-
tions in the test about women’s 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 (þ23.5%; p < .001) and in two specific questions
about ARFD (þ31.9%; p < .001).
Discussion
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 individuals’ intentions 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
 THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE
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.
7
Conclusion
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.
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