The other side of the fertility coin: a comparison of childless men’s and women’s knowledge of fertility and assisted reproductive technology

The other side of the fertility coin: a comparison of childless men’s and women’s knowledge of fertility and assisted reproductive technology Judith C. Daniluk, Ph.D., and Emily Koert, M.A. University of British Columbia, Vancouver, British Columbia, Canada

Objective: To determine childless men’s knowledge about fertility and assisted reproductive technology (ART) treatments and family building options, compared to knowledge of a sample of childless women. Design: Self-report questionnaire comprising 2 self-ratings and 20 knowledge questions related to later childbearing and ART. Setting: Online survey. Patient(s): A total of 599 presumed fertile, childless men between the ages of 20 and 50 years. Intervention(s): None. Main Outcome Measure(s): Knowledge of fertility and ART as measured by the male version of the Fertility Awareness Survey. Result(s): The majority of participants rated themselves as having some knowledge or being fairly knowledgeable about fertility and ART. However, on the 20 knowledge questions, overall knowledge was limited, with more than 50% of the sample answering correctly only 4 of 20 knowledge questions. The men demonstrated even less knowledge of fertility and ART than childless women. Conclusion(s): Given that the childless men in our study had no coherent body of knowledge regarding age-related fertility and ART treatment and family-building options, men may be contributing to the trend to delay childbearing. If they are to be effective in supporting informed fertility and childbearing Use your smartphone decisions, education programs must target both women and men. (Fertil SterilÒ 2013;99: to scan this QR code 839–46. Ó2013 by American Society for Reproductive Medicine.) and connect to the Key Words: Fertility knowledge, ART knowledge, delayed childbearing Discuss: You can discuss this article with its authors and with other ASRM members at http:// fertstertforum.com/danilukjc-fertility-knowledge-delayed-childbearing/

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he trend to delay childbearing is pervasive across the globe as more men and women elect to wait until their 30s, 40s, and even 50s before having children (1–3). In Canada, where this study was conducted, the age at first birth continues to increase, with the highest birth rates being seen for women in the 30–34 year-old age range. The birth rate for women in the 40–44 year-old

age range has more than doubled between 1988 and 2008 in Canada (4). In countries, such as the United Kingdom (5), it has more than tripled. Statistics on men’s age at first birth are lacking; however, there is some evidence that average paternal age at first birth is also increasing (6). The growing social trend toward delayed childbearing can be attributed to a number of factors. Changing social

Received September 4, 2012; revised October 15, 2012; accepted October 17, 2012; published online November 10, 2012. J.C.D. received support for travel to meetings from the Canadian Institutes for Health Research. E.K. has nothing to disclose. Supported by a grant from Canadian Institutes of Health Research and Assisted Human Reproduction Canada #PAH-103594, 2009/10. Reprint requests: Judith C. Daniluk, Ph.D., Department of Educational and Counselling Psychology, University of British Columbia, 2125 Main Mall, Vancouver, BC, Canada V6T 1Z4 (E-mail: [email protected]). Fertility and Sterility® Vol. 99, No. 3, March 1, 2013 0015-0282/$36.00 Copyright ©2013 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2012.10.033 VOL. 99 NO. 3 / MARCH 1, 2013

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norms regarding the ideal age for parenthood and the pursuit of education and career goals are commonly cited factors in the decision to delay childbearing. The widespread availability of assisted reproductive technologies (ART) also appears to contribute to decisions to delay childbearing, based on the belief that IVF can compensate for age-related fertility declines (1, 7–14). Partner readiness and suitability, relationship duration, and relationship stability have been identified as critical factors influencing women’s childbearing decisions (10, 12, 15–23). Indeed, most women expect and prefer to have children within a traditional family structure. Those women who lack a suitable and willing partner frequently defer motherhood beyond the ideal reproductive age range—resulting in an 839

ORIGINAL ARTICLE: MENTAL HEALTH, SEXUALITY, AND ETHICS increasing percentage of women finding themselves faced with pursuing a pregnancy on their own using a known or anonymous donor and becoming sole support mothers, or facing permanent, unintentional childlessness (12, 15, 24–26). It would appear that a majority of men, like women, intend to have children at some time in their lives (e.g., 9, 11, 13, 27, 28). However, similar to the current cohort of women, recent research on men’s fertility intentions suggests that many men also intend to delay childbearing (13, 28) for many of the same reasons as women: finding a suitable partner, educational attainment, career and financial stability, personal maturity, and perceived readiness (13, 28). Similar to women, men may support delaying childbearing until they feel they have achieved an adequate level of career and financial stability, and feel personally ready to become fathers (13, 28). Family planning research suggests that men are influential in heterosexual couples’ reproductive decisions, particularly in terms of the timing and postponement of parenthood (12, 23, 29). Fertility beliefs and knowledge also inevitably play an important role in couples’ decisions regarding the timing of childbearing. Although recent studies have assessed the fertility knowledge and beliefs of adult women and younger populations such as university students (e.g., 10, 12, 30–34), relatively little is known about childless adult men’s knowledge and beliefs about fertility, later childbearing, and the costs and limitations of ART procedures and treatments. This study aimed to address this gap.

for a group of 500 childless men and 1,006 women between the ages of 20 and 45 years. The researchers did not measure the participants’ self-assessed level of knowledge, but included questions related to maternal age-related risks of childbearing, knowledge of risks associated with suboptimal infant outcomes, and knowledge of infertility and treatment. Knowledge of risk factors related to advanced paternal age was not assessed. Although more than half (64.7%) of the men in this study knew that the likelihood of becoming pregnant varies with a woman’s age, only 35.6% knew that the risk of stillbirth also varies with a woman’s age. The men had poor understanding of ART success rates and the costs of fertility treatments. In terms of gender differences, overall Tough et al. (21) found that the childless men in their study were less knowledgeable than the women about the range of risks associated with delayed childbearing, with lower education and income being correlated with less knowledge. The limited available literature suggests that men may lack adequate knowledge of the risks associated with later childbearing (e.g., 21), and may be overly optimistic about the ability of ART and in particular IVF to compensate for age-related fertility declines (9, 11). Following from our recent study assessing the fertility knowledge of 3,345 presumed fertile, childless women (31), the purpose of this study was to assess the fertility and ART knowledge of a demographically and geographically diverse sample of childless, presumed fertile Canadian men, and to compare their fertility and ART knowledge to that of the women in our previous study.

LITERATURE REVIEW

MATERIALS AND METHODS

A small number of research studies have assessed men’s general fertility awareness and knowledge of the maternal, fetal, and infant risks associated with delayed childbearing (e.g., 9, 11, 21, 35–38). Only two studies included questions about ART (21, 35). Considerably less attention has been paid to men’s knowledge of the male fertility lifespan and the impact of paternal age on pregnancy and infant outcomes. There is some evidence that younger men have an overall lack of awareness of age-related fertility declines and ART success rates (9, 11). For example, a recent study conducted by Peterson et al. (11) surveyed the fertility knowledge of 246 American undergraduates (108 men, 138 women). The researchers found that these university-aged men overestimated the age at which women’s fertility experiences a marked decline (81% of sample). They also overestimated the likelihood of achieving a pregnancy through IVF (64% of sample). These findings are consistent with results from previous research conducted on university-aged men and women in Sweden (9). In the study by Lampic et al. (9) of 222 female and 179 male university students, the majority of the men in the study overestimated both the age at which women’s fertility experiences a marked decline (63% of sample thought it declined after age 40 þ years), and the success rates of achieving a pregnancy through IVF (53% of sample). Similar knowledge gaps were found in research on a community-based sample of men (21, 28). Tough et al. (21) examined the childbearing intentions and extent of knowledge of the risks associated with delayed childbearing

Measures

840

The Fertility Awareness Survey (FAS) developed by the researchers to assess childless women’s fertility beliefs and intentions, and knowledge about later childbearing and ART (31) was adapted for use with men (FAS-M). The FAS-M included a number of demographic questions (e.g., age, sexual orientation, current relationship status, ethnicity, income, and employment status), and two self-ratings on fertility knowledge and knowledge of AHR procedures and treatment options. Minor changes were made to the language of some of the questions on fertility intentions and motivations to make them more gender-appropriate for men, without changing the specific context, content, or focus of the question. For example, the question ‘‘If you had difficulties becoming pregnant, how likely is it that you would consider using in vitro fertilization (IVF)?’’ was changed to ‘‘If you and your partner had difficulties becoming pregnant.’’; and ‘‘If you and your partner were not able to produce a child using his sperm.’’ was changed to ‘‘If you and your partner were not able to produce a child using your sperm.’’ Also, to the original 16 knowledge questions in the FAS, we added 4 questions specific to male fertility (Table 1, questions 17 through 20). For anonymity and convenience to participants, and ease of data collection and analysis, the survey was only available online. Due to funding limitations, the FAS-M was available only in English. The reader is directed to Daniluk et al. (31) for a full discussion of the findings on the female participants’ knowledge of later childbearing and ART. VOL. 99 NO. 3 / MARCH 1, 2013

VOL. 99 NO. 3 / MARCH 1, 2013

TABLE 1 FAS-M ART knowledge item distribution, means, and SD. ART knowledge items

593

F

2.9

16.0

23.8

48.4

8.9

3.4

0.96

595

F

5.7

20.8

31.4

34.1

7.9

3.2

1.03

593 586

T F

21.1 .9

18.7 7.0

26.5 34.1

14.8 46.1

18.9 11.9

2.9 3.6

1.39 0.82

591 590

F T

7.4 2.2

20.0 9.7

54.6 16.9

14.6 45.6

3.4 25.6

2.9 3.8

0.87 0.99

594

T

1.0

8.6

21.2

42.8

26.4

3.9

0.94

590

F

2.7

9.8

49.2

34.4

3.9

3.3

0.80

591

T

2.7

7.4

42.5

40.9

6.4

3.4

0.83

587

T

1.5

9.4

25.9

37.1

26.1

3.8

0.99

592

T

8.8

26.4

23.3

32.4

9.1

3.1

1.14

590 588

T T

3.9 12.1

24.9 33.5

44.1 41.7

24.9 10.5

2.2 2.2

3.0 2.6

0.86 0.91

589

F

8.3

29.5

42.3

18.3

1.5

2.8

0.90

591

T

3.2

11.0

39.6

39.9

6.3

3.4

0.88

589 587

T F

4.4 1.5

18.8 7.7

28.4 50.8

34.8 35.9

13.6 4.1

3.3 3.3

1.07 0.74

590

T

5.3

18.0

34.4

36.3

6.1

3.2

0.98

587

T

0.9

3.7

18.1

40.9

36.5

4.1

0.88

590

T

5.4

21.0

46.4

23.4

3.7

3.0

0.90

Note: SPSS software was used to calculate descriptive data. ART ¼ assisted reproductive technology; F ¼ false; FAS-M ¼ Fertility Awareness Survey-Men; ICSI ¼ intracytoplasmic sperm injection; T ¼ true. Daniluk. Men’s and women’s fertility and ART knowledge. Fertil Steril 2013.

SD

841

Fertility and Sterility®

1. For women >30 y, overall health and fitness level is a better indicator of fertility than age 2. Taking birth control pills for >5 y negatively affects a woman’s fertility 3. A woman’s eggs are as old as she is 4. Prior to a woman reaching menopause, ART (e.g., IVF) can help most women to have a baby using their own eggs 5. The total cost of one cycle of IVF is <$5,000.00 6. There is a progressive decrease in a woman’s ability to become pregnant after the age of 35 y 7. The rates of miscarriage are significantly higher for women in their 40s than for women in their 30s, even for physically fit women in excellent health 8. Most Canadian fertility clinics will not provide treatment to women more than age 45 y 9. Egg freezing before the age of 35 y can significantly prolong a woman’s fertility 10. Sexually transmitted diseases (e.g., chlamydia, gonorrhea) significantly increase the risk of later infertility 11. A man’s age is an important factor in a couple’s chances of becoming pregnant 12. The use of IVF poses health risks for a woman 13. Children conceived through the use of ART, such as IVF and ICSI, have more long-term health problems than children conceived without the use of these fertility treatments 14. The majority of fertility conditions are caused by problems with the woman’s fertility 15. Most couples have to go through IVF more than once to have a baby 16. A woman’s weight affects her chances of conceiving a child 17. The upper age limit for a man to be treated at most Canadian fertility clinics is 55 y of age 18. There is a significant decline in the quality of a man’s sperm before the age of 50 y 19. Smoking cigarettes or marijuana can reduce the quality of a man’s sperm 20. Children born to fathers >45 y have higher rates of learning disabilities, autism, schizophrenia, and some forms of cancer

Mean of 5 No. of respondents True/false % definitely not % probably not % uncertain % probably % definitely possibilities

ORIGINAL ARTICLE: MENTAL HEALTH, SEXUALITY, AND ETHICS Recruitment This study received approval by the Behavioral and Research Ethics Board at the University of British Columbia. Because of limited funds and time remaining in our original grant, we elected to use a survey company to gather data from a sample of 600 childless Canadian men between the ages of 20 and 50 years who believed they were fertile and who were open to the possibility of having children in the future. A significant portion (59.7%) of the female sample in our original study had been recruited through the same survey company. The male sample was recruited from across Canada and roughly matched our previous female sample based on age and education level. The participants were self-selected from the survey company’s pool of respondents. If they met the inclusion criteria and were interested in responding to our survey, respondents were invited by the survey company to log on to our site and complete the questionnaire. The funding source for the study was clearly identified and confidentiality was assured.

Participants A total of 599 childless men from 20–50 years of age (mean, 33.9; SD, 8.99) completed and submitted the FAS survey online. Most identified as heterosexual (92.4%) with 53.2% being married or living common law. More than half of this well-educated sample had completed college or university (64.7%), or had a postgraduate degree (8.5%), whereas 24.7% indicated secondary school as their highest level of education. The majority of respondents identified as White/Caucasian (79.9%), whereas the remaining identified as Asian/ South East Asian (10.1%), Black (4.0%), or ‘‘other’’ (6.0%). The men reported an annual, combined gross household income of less than $50,000 (40.8%), between $51,000 and $100,000 (36.1%), or more than $101,000 per year (23.1%), respectively. Fifty-nine percent of the participants were employed full-time, or part-time (7.5%), and 18.7% were students. The remainder indicated that they were currently unemployed (14.8%)—some due to illness or disability.

Data Analysis Using SPSS, data analysis included analyzing FAS-M selfratings and knowledge items individually for variance within the responses. Descriptive statistics were computed for each item (i.e., means, SD, and proportions). Summative scales were then developed using Cronbach’s alpha to determine the reliability and internal consistency of the two scales. Oblique factor analysis assessed the internal structure of the 20item knowledge scale. Factor analysis was used to examine relationships among the self-rated and actual knowledge scales and the demographic variables (e.g., age, level of education), to determine their ability to predict the participants’ knowledge level.

RESULTS The participants were asked to rate their current fertility knowledge and their knowledge of ART on a scale from 1–4, with 1 indicating ‘‘no knowledge,’’ 2 indicating ‘‘some 842

knowledge,’’ 3 indicating ‘‘fairly knowledgeable,’’ and 4 indicating ‘‘very knowledgeable.’’ In response to the question ‘‘Overall, how would you rate your current fertility knowledge?’’ the majority of men in this study rated themselves as having ‘‘some’’ fertility knowledge (51.9%) or as being ‘‘fairly’’ knowledgeable about fertility (26.8%). Interestingly, a fair number of these men acknowledged having ‘‘no knowledge’’ of fertility (16.7%), whereas only 4.6% assessed themselves as being ‘‘very’’ knowledgeable about fertility (mean, 2.2; SD, 0.76). Similarly, in response to the question ‘‘Overall, how would you rate your current knowledge of Assisted Human Reproduction (AHR) procedures and fertility treatments’’ the majority of the respondents rated themselves as having ‘‘some’’ knowledge (53.6%) or being ‘‘fairly’’ knowledgeable (12.8%) (mean, 1.9; SD, 0.73). However, the percentage of respondents who rated themselves as having ‘‘no knowledge’’ of ART (30.7%) was almost double those who claimed to have ‘‘no knowledge’’ of fertility (16.7%). Only 2.9% of these men believed they were ‘‘very’’ knowledgeable about ART. Correlations were calculated to determine the strength of the relationship between the two self-report scores. Although the respondents assessed themselves as significantly more knowledgeable about fertility than ART fertility procedures and treatments (t ¼ 12.59, df ¼ 574, P¼ .000), the two items correlated highly (r ¼ 0.67, P¼ .000). The scores were averaged to produce an overall knowledge self-assessment score (mean, 2.0; SD, 0.68), with a relatively high Cronbach’s alpha for a two-item scale of 0.801. For the 20 knowledge items, respondents were asked to answer questions on a 5-point Likert scale based on their pre-existing knowledge (i.e., 1 ¼ definitely not, 2 ¼ probably not, 3 ¼ uncertain, 4 ¼ probably, 5 ¼ definitely) (Table 1). As a scale, these knowledge items showed very low reliability or internal consistency (Cronbach’s alpha ¼ 0.743). Looking at the distribution of responses across the items, many had a mean of approximately 3 (‘‘uncertain’’) and an SD around 1, suggesting that for most respondents the answer to the questions hovered around uncertainty or a weak guess in one direction or another. This uncertainty was also demonstrated by low percentages in the ‘‘definitely’’ and ‘‘definitely not’’ categories, suggesting a general uncertainty in responding to each item. A factor analysis of these 20 items failed to rotate in 25 iterations to produce a pattern matrix, whereas the scree plot of eigenvalues reflected the pattern expected from more-or-less random numbers. Based on the assumption that the 5-point Likert scale responses reflected strength of knowledge, the 20 knowledge items were scored in the direction of incorrect as low and correct as high, then averaged to produce an overall knowledge scale score (mean, 3.2; SD, 0.27). The correlation between the overall knowledge scale and the overall self-assessment of knowledge scale—self-assessment item of fertility knowledge, self-assessment item of ART knowledge, and overall self-assessment of knowledge—were all low and not statistically significant, at 0.099, 0.080, and 0.105, respectively. These findings indicate that the men’s perceived fertility and ART knowledge did not relate to their actual knowledge. Also, although different VOL. 99 NO. 3 / MARCH 1, 2013

Fertility and Sterility® respondents may have known different individual facts about fertility and ART, knowing one fact was not related to knowing others. These findings support the conclusion that the respondents possessed no clear, coherent body of knowledge regarding fertility or ART. Correlations were also calculated between relevant demographic variables (age, education, income) and both self-reported knowledge of fertility and ART, and actual knowledge as measured by the 20 knowledge questions. All correlations were very weak, suggesting that age, level of education, and income were not correlated with the participants’ levels of fertility or ART knowledge.

Men’s Fertility and ART Knowledge For the purposes of reporting the findings, ‘‘definitely not’’ and ‘‘probably not’’ were considered a ‘‘no’’ response, and ‘‘probably’’ and ‘‘definitely’’ were considered a ‘‘yes’’ response. A response of ‘‘uncertain’’ was interpreted as indicating that the participant did not know the answer to the question. It is important to note that in determining whether a question was considered true or false, the researchers relied on the fee schedules for Canadian fertility clinics at the time when the survey was developed, and on the current available research data regarding, for example, age-related declines in fertility and women and men. Consistent with their perceptions of having ‘‘no knowledge’’ or only ‘‘some knowledge’’ about fertility (68.6%) and ART (84.3%), using the ‘‘yes,’’ ‘‘no,’’ and ‘‘don’t know’’ classification system, 50% or more of the respondents answered only 4 of the 20 knowledge items correctly, for an overall correct response rate of only 20%. As is apparent from Table 1, at least 50% of the childless men in this study knew that a woman’s fertility declines after age 35 years (71.2%), that rates of miscarriage are significantly higher for women in their 40s even for fit and healthy women (69.2%), and that sexually transmitted diseases, such as chlamydia and gonorrhea, significantly increase the risk of later infertility (63.2%). However, 50% or more of these men did not know or were unsure about the remaining 16 of 20 questions specific to fertility in general, later childbearing, and ART. It was striking to note that more than 80% of the men in this study wrongly believed that for women more than 30 tears, overall health and fitness level is a better indicator of fertility than age (81.1%). These men also were under the inaccurate assumption that prior to menopause ART can help most women to have a baby using their own eggs (92.1%). Specific to male fertility, the majority of respondents knew that smoking cigarettes or marijuana can reduce the quality of a man’s sperm (77.4%). However, 72.8% of men did not know that children born to fathers more than age 45 years have higher rates of learning disabilities, autism, schizophrenia, and some forms of cancer. Many men were not aware that there is a significant decline in the quality of a man’s sperm before the age of 50 years (57.7%), and the majority (90.8%) wrongly assumed that there is an upper age limit of 55 years for men to be treated at most Canadian fertility clinics. VOL. 99 NO. 3 / MARCH 1, 2013

Men’s Versus Women’s Fertility and ART Knowledge In comparing the fertility and ART knowledge self-ratings of the men in this study with the self-ratings of the women in our previous study (31), the majority of the men and women rated themselves as having ‘‘some’’ fertility knowledge or being ‘‘fairly’’ knowledgeable about fertility (male = 78.7; female ¼ 89.8%). However, a larger percentage of the childless men in this study rated themselves as having ‘‘no’’ fertility knowledge (16.7%) compared to the childless women in our previous study (4.6%). Specific to knowledge of ART procedures and treatments, similar to the women in our previous study (75.6%), the majority of men (66.4%) assessed themselves as having ‘‘some’’ knowledge or being ‘‘fairly’’ knowledgeable about ART procedures and treatments. The percentage of men (30.7%) who acknowledged having ‘‘no’’ knowledge of ART was only somewhat higher than the relatively large percentage of childless women in our previous sample who claimed to have no ART knowledge (22.4%). A comparison between the levels of knowledge of the 599 childless men in this study versus the 3,345 women in our previous study (31) can be found in Table 2. The table is limited to the 16 knowledge items that were included on the original FAS and on the version of the scale adapted for men (FASM). Using the categories discussed previously (‘‘definitely not’’ and ‘‘probably not’’ ¼ ‘‘no’’; ‘‘probably’’ and ‘‘definitely’’ ¼ ‘‘yes’’; ‘‘uncertain’’ ¼ ‘‘don’t know’’), it is interesting to note that the correct response rate for more than 50% of the childless women was 6 of 16 items (37.5%) compared to a correct response rate of only 3 of the original 16 knowledge items for the men in this study (18.7%). Specifically, 51.7% of women knew that egg freezing before the age of 35 years can significantly prolong a woman’s fertility, 66.1% knew that most couples have to go through IVF more than once to have a baby, and 66.2% knew that a woman’s weight affects her chances of conceiving—facts that fewer than 50% of the men knew to be true. Both women and men were overly optimistic about the ability of ART to assist most women to have a baby using their own eggs up until menopause (W ¼ 90.9%; mean, 92.1%). These women and men wrongly believed that IVF poses no health risks for a woman (W ¼ 69.5%; mean, 72.9%), and that overall health and fitness level is a better indicator of fertility than age for women more than 30 years (W ¼ 72.9%; mean, 81.1%). These findings indicate the lack of a coherent and consistent body of fertility and ART knowledge on the part of the currently childless men in this study, and the childless women in our previous study.

DISCUSSION The findings of our study may be limited by the online nature of the data collection and our use of a professional survey company to recruit the male participants. However, there were no significant differences between the responses or knowledge levels of the women in our previous study (31) based on whether they self selected to complete the FAS (N ¼ 1,345) or were recruited by the same survey company who recruited our male sample (N ¼ 2,000). We also 843

ORIGINAL ARTICLE: MENTAL HEALTH, SEXUALITY, AND ETHICS

TABLE 2 Male versus female 16-item ART knowledge item comparison. Male ART knowledge items

True/false

1. For women >30 y, overall health and fitness level is a better indicator of fertility than age 2. Taking birth control pills for >5 y negatively affects a woman’s fertility 3. A woman’s eggs are as old as she is 4. Prior to a woman reaching menopause, ART (e.g., IVF) can help most women to have a baby using their own eggs 5. The total cost of one cycle of IVF is <$5,000.00 6. There is a progressive decrease in a woman’s ability to become pregnant after the age of 35 y 7. The rates of miscarriage are significantly higher for women in their 40s than for women in their 30s, even for physically fit women in excellent health 8. Most Canadian fertility clinics will not provide treatment to women >45 y 9. Egg freezing before the age of 35 y can significantly prolong a woman’s fertility 10. Sexually transmitted diseases (e.g., chlamydia, gonorrhea) significantly increase the risk of later infertility 11. A man’s age is an important factor in a couple’s chances of becoming pregnant 12. The use of IVF poses health risks for a woman 13. Children conceived through the use of ART, such as IVF and ICSI, have more long-term health problems than children conceived without the use of these fertility treatments 14. The majority of fertility conditions are caused by problems with the woman’s fertility 15. Most couples have to go through IVF more than once to have a baby 16. A woman’s weight affects her chances of conceiving a child

No

Uncertain

Female Yes

Percentage

No

Uncertain

Yes

Percentage

a

F

18.9

23.8

57.3

81.1

27.1

15.7

57.2

72.9a

F

26.5

31.4

42.1

73.5a

46.9

20.5

32.6

53.1a

T F

39.8 7.9

26.5 34.1

33.7 58.0

66.3a 92.1a

31.2 9.1

19.8 25.7

49.0 65.2

68.8a 90.9a

F T

27.4 11.9

54.6 16.9

18.0 71.2

72.7a 71.2b

49.9 4.0

34.7 5.7

15.4 90.3

50.1a 90.3b

T

9.6

21.2

69.2

69.2b

5.9

10.4

83.7

83.7b

F

12.5

49.2

38.3

87.5a

10.2

49.0

40.8

89.8a

T

10.1

42.5

47.4

52.6a

11.2

37.0

51.7

51.7b

T

10.9

25.9

63.2

63.2b

4.9

13.0

82.1

82.1b

T

35.2

23.3

41.5

58.5a

39.4

17.7

42.9

57.1a

T T

28.8 45.6

44.1 41.7

27.1 12.7

72.9a 87.3a

31.4 62.7

38.1 29.8

30.5 7.5

69.5a 92.5a

F

37.8

42.3

19.9

62.2a

46.4

36.6

17.0

53.6a

T

14.2

39.6

46.2

53.8a

13.5

20.5

66.1

66.1b

T

23.2

28.4

48.4

51.6a

17.5

16.3

66.2

66.2b

Note: Male (N ¼ 599); female (N ¼ 3,345). a Percentage uncertain or incorrect. b Percentage correct. Daniluk. Men’s and women’s fertility and ART knowledge. Fertil Steril 2013.

acknowledge that the answers to some of the knowledge questions remain controversial—for example, questions 18 and 20—due to a current lack of sufficient and incontrovertible evidence. However, in the case of both of these questions, the mean hovered around 3.0, indicating that at best the respondents were uncertain about the answers to these questions. With these potential limitations in mind, the findings appear to provide unequivocal evidence of a lack of fertility and ART knowledge among these presumed fertile childless Canadian men. Respondents were largely unaware of the consequences of delayed childbearing, including the effect of paternal age on pregnancy and infant outcomes, the availability and costs of ART, and the effectiveness of these treatments in overcoming the consequences of age-related fertility decline. Contrary to the findings by Tough et al. (21) that lower levels of education and income were correlated with less knowledge, the men in our study demonstrated the lack of a coherent body of knowledge related to fertility and ART, irrespective of their age or level of education. Scores on the 20 knowledge items on the FAS-M indicated that knowing one fact about fertility or ART was not related to 844

knowing another. In addition, responses suggested a general uncertainty about fertility and ART given that answers generally tended to cluster around the middle of the scale with a mean of 3 (‘‘uncertain’’), and an SD of 1. Similar to the women in our previous study (31), the men in our study were unrealistically confident about the ability of ART treatments (e.g., IVF) to compensate for age-related fertility declines, and were largely unaware of the costs, availability of, and health risks associated with ART. Also, despite growing public awareness of the effects of paternal age on pregnancy and infant outcomes (39–45), our findings indicate that these men lacked important knowledge about declines in male fertility and the implications of delayed fatherhood in terms of the health of their future offspring. Like the women in our previous study (31), the men in this study also overestimated their knowledge of fertility and ART. Close to 75% of the sample rated themselves as having ‘‘some knowledge’’ or being ‘‘fairly’’ or ‘‘very knowledgeable’’ about fertility and ART procedures and treatments. However, the men’s perceived fertility and ART knowledge did not relate to their actual knowledge given that of 20 knowledge items, VOL. 99 NO. 3 / MARCH 1, 2013

Fertility and Sterility® 50% or more of the male respondents answered only 4 items correctly. Consistent with the significant gaps in fertility and ART knowledge that have been identified in previous studies (e.g., 9, 11, 21, 36), these findings suggest that childless men may well believe they know more about age-related declines in female and male fertility, and the implications of later mothering and fathering in terms of the health of their future offspring, than they actually know. The men in this study had even less knowledge than the childless women in our previous study (31), on which to base their family planning decisions. These results are sobering and of particular concern, given men’s influence on women’s decisions regarding the timing of childbearing (12, 29, 23). Taken together with the findings of other studies (9, 12, 21, 37, 32–34, 36–38), the results of this and our previous study (31) suggest that there may well be an alarming gap in fertility and ART knowledge among currently childless adult men and women. Accurate information on the fertility life span and the costs and limitations of ART treatment and family building options is essential, if women and men are to make informed childbearing decisions. In light of the considerable psychosocial and health consequences of delaying childbearing, there appears to be an urgent need for targeted public education programs to enhance fertility and ART awareness. Given that men appear to play an important role in childbearing decisions and the timing of childbearing (e.g, 12, 23, 29), public education targeted at both women and men is warranted. To that end, we have developed and launched an educational website, MyFertilityChoices.com, in an effort to begin to address these knowledge gaps and to support informed reproductive decision-making.

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