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. 2014 Dec 5;30(2):353–363. doi: 10.1093/humrep/deu328

Fertility awareness online: the efficacy of a fertility education website in increasing knowledge and changing fertility beliefs

JC Daniluk 1,*, E Koert 1
PMCID: PMC4287305  PMID: 25480922

Abstract

STUDY QUESTION

How effective is online education in increasing knowledge of fertility and assisted reproductive technologies (ART), and changing beliefs about the timing of parenthood?

SUMMARY ANSWER

Exposure to an online educational intervention resulted in immediate changes in participants' beliefs about the ideal timing of parenthood, and a significant increase in their knowledge of fertility and ART treatments and options; most of these changes were not sustained over time, particularly for men.

WHAT IS KNOWN ALREADY

Research has identified significant gaps in men's and women's knowledge of fertility and ART, contributing to the trend to delay childbearing. Effective educational programs need to be developed, to support informed fertility and child-timing decisions.

STUDY DESIGN, SIZE, DURATION

Pre-post intervention study of 199 currently childless men and women, and a 6-month follow-up of 110 of these participants.

PARTICIPANTS/MATERIALS, SETTING, METHODS

One hundred and ninety-nine childless participants between the ages of 18 and 35 were asked to complete 4 beliefs and 22 knowledge questions prior to, and immediately after, reading 10 online posts related to: fertility testing and preservation, fertility history and lifespan, the effects of health and fitness on fertility, and assisted reproduction. Six months later, 110 of the original sample repeated the 26-item survey.

MAIN RESULTS AND THE ROLE OF CHANCE

Participants' fertility and ART knowledge scores increased significantly immediately after the intervention, as did their confidence in their fertility and ART knowledge. Participants' beliefs about the ideal and latest age a woman or man should consider producing a child decreased. However, 6 months later, participants' beliefs and knowledge levels largely returned to their pre-intervention levels, particularly for the men in the study.

LIMITATIONS, REASONS FOR CAUTION

The sample size and the recruitment methods may limit the generalizability of these findings.

WIDER IMPLICATIONS OF THE FINDINGS

Previous studies have demonstrated the short-term efficacy of online educational approaches to increase fertility knowledge and support informed family planning decisions. Web-based approaches have the benefit of being easily and conveniently accessed by individuals worldwide. However, the findings of the current study call into question the long-term efficacy of online fertility education, and suggest that variables such as gender and relevance need to be considered in assessing the efficacy of online fertility education strategies.

STUDY FUNDING/COMPETING INTERESTS

This research was funded through a Canadian Institutes of Health Research Knowledge Translation Grant #KTB-117428. No competing interests.

Keywords: fertility knowledge, reproductive decision-making, delayed childbearing, online fertility education

Introduction

The trend to delay childbearing is an international phenomenon in developed countries in the world with the average first age at birth now around 30 years of age for women (Bewley et al., 2005; ESHRE, 2005; Nicoletti and Tanturri, 2005; National Vital Statistics Reports, 2013; Statscan, 2013). In Canada, where this study was conducted, the birth rate for women having their first child in their 30s and 40s has more than tripled over the last 20 years (Statscan, 2013). Unfortunately, delayed childbearing is associated with higher rates of infertility, greater reliance on reproductive technologies, more risks of adverse maternal, fetal, and infant outcomes, smaller family sizes than intended, and increased permanent, unintentional childlessness (Leridon, 2004; Schoen and Rosen, 2009; de Graaff et al., 2011; Schmidt et al., 2012). These outcomes inevitably increase the burden on our health care system, and contribute to a range of social and personal challenges.

The literature suggests that the decision to delay parenthood is a complex process, involving many social, economic and personal factors. These include the financial costs of raising a child; the availability of quality and affordable childcare; the economic consequences of career interruptions for childbearing and childrearing; cultural and ethnic norms and mandates; individual beliefs regarding the context within which children should be raised; perceptions of personal readiness for parenthood; relationship status; and partner suitability and readiness (Hammarberg and Clarke, 2005; Abma and Martinez, 2006; Proudfoot et al., 2009; Cooke et al., 2010; Mills et al., 2011). Research also indicates that men and women may be making decisions to delay parenthood based on a lack of accurate information about the fertility life span and the consequences of delaying parenthood (e.g. Adashi et al., 2000; Benzies et al., 2006; Lampic et al., 2006; Tough et al., 2006, 2007; Bunting and Boivin, 2008; Maheshwari et al., 2008; Proudfoot et al., 2009; Bretherick et al., 2010; Hashiloni-Dolev et al., 2011; Ekelin et al., 2012; Peterson et al., 2012; Bunting et al., 2013; Hammarberg et al., 2013; Lundsberg et al., 2014).

Studies have found a belief among many women that they can rely on IVF to help them become pregnant if they wait too long to start their families (Adashi et al., 2000; Benzies et al., 2006; Lampic et al., 2006; Maheshwari et al., 2008; Bretherick et al., 2010; Hashiloni-Dolev et al., 2011; Daniluk et al., 2012; Ekelin et al., 2012; Peterson et al., 2012). Men appear to share this belief about the ability of IVF to compensate for age-related fertility declines, and underestimate the risks associated with fathering children later in life (Peterson et al., 2012; Daniluk and Koert, 2013). In our previous study of currently childless, presumed fertile Canadians between the ages of 20 and 50, 50% or more of the 3345 women responded correctly to only 6 of 16 questions related to the consequences of delaying parenting, as well as the availability, costs and effectiveness of ART treatments (Daniluk and Koert, 2012; Daniluk et al., 2012). The knowledge levels of the 599 men were even lower, with 50% or more responding correctly to only 4 of 20 knowledge questions (Daniluk and Koert, 2013). The findings confirmed that there was no coherent body of fertility and ART knowledge among the respondents, irrespective of their sex, age or level of education.

In light of the significant psychosocial and health consequences associated with delayed childbearing and later parenthood, medical and mental health professionals and researchers have underscored the urgent need for public education to enhance awareness and increase fertility knowledge (Benzies et al., 2006; Friese et al., 2006; Bunting and Boivin, 2008; Maheshwari et al., 2008; Bretherick et al., 2010; Schmidt, 2010; Boivin et al., 2013; Daniluk and Koert, 2013). While we cannot change the economic and social realities faced by the current generation of women and men, we can try to ensure they have ready access to accurate information about fertility and assisted human reproduction (ART)—information that is essential to making informed fertility decisions.

Unfortunately, recent educational initiatives to enhance awareness of the consequences of delayed childbearing, such as the ‘Protect Your Fertility’ campaign by the American Society for Reproductive Medicine (Reynolds, 2009), the 2010 ‘Manicures and Martinis’ campaign by the American Fertility Association, and more recently the ‘Get Britain Fertile’ campaign, have been met with public criticism for focusing on women's waning fertility and for encouraging women to have children before they are economically, socially or personally ready. There are several online educational strategies committed to providing information about the fertility lifespan, as well as parenthood timing and family building options (e.g. www.YourFertility.org.au; www.nhs.uk/livewell/fertility; www.MyFertilityChoices.com). However, to date, there have been very few empirical examinations of the effectiveness of online strategies in increasing fertility knowledge or impacting family planning decisions.

One exception is the recent study by Wojcieszek and Thompson (2013). In this pre-post intervention study of 137 male and female undergraduate students, online exposure to a brief fertility brochure containing information on fertility, ART and delayed childbearing, resulted in a significant increase in fertility knowledge for those in the experimental group, and a decrease in intended age at first birth. These findings provide preliminary evidence that online education may be an effective approach to increase fertility knowledge. However, given there was no long-term follow-up, we do not know whether this information was retained over time.

Indeed, the internet has rapidly become a primary vehicle for those seeking health information (Rice and Katz, 2001; Webb et al., 2010), including information on fertility and family planning (Epstein and Rosenberg, 2005; Daniluk and Koert, 2013). In recognition of the fact that ‘the Internet offers far-reaching benefits for health… and is increasingly being used to eliminate geographical barriers to health,’ the World Health Organization has recently developed an ‘eHealth’ program (WHO, 2014).

The results of two meta-analyses indicate that online interventions can positively impact health behaviors. In their review of 85 studies on internet-based health interventions, Webb and colleagues (2010) found a statistically small but significant effect on health-related behavior. Similarly, in a review of 20 studies, internet-based interventions were seen to moderately increase knowledge levels and change behaviors (Wantland et al., 2004). Thus online health information may provide a cost-effective way of disseminating fertility and family planning information to help inform child timing decisions. However, according to Wantland et al. (2004), the long-term impact of such interventions warrants further attention. In the case of fertility knowledge and beliefs, it is as yet unclear the extent to which online education results in sustained knowledge retention, or whether demographic variables such as age, sex or relationship status may mediate the effectiveness of online education.

Purpose of the study

The purpose of this study was to evaluate the effectiveness of an online approach to fertility education. The goal was to assess the extent to which exposure to 10 posts from the ‘fertility information’ section of the website MyFertilityChoices.com, would result in changes to participants' beliefs about the ideal ages for producing children, and would increase their fertility and ART knowledge, immediately after the intervention, and 6 month post-intervention. It was expected that reading this information would result in a significant reduction in participants' beliefs regarding the ideal ages for women and men to have their first and last child. It was further expected that there would be a significant increase in participants' self-assessed fertility and ART knowledge, and in their actual fertility and ART knowledge. We were curious as to whether these changes would be sustained over time, and whether demographic variables such as sex, age or current relationship status would be related to changes in beliefs and increased fertility knowledge, post-intervention and 6 months later.

Materials and Methods

Design and procedure

In this study participants were asked to complete sections of the Fertility Awareness Survey (Daniluk et al., 2012; Daniluk and Koert, 2013) prior to, and again immediately after reading 10 posts from the ‘Fertility Information’ section of the MyFertilityChoices.com website. The posts were in a question and answer format and related to: fertility history and lifespan (How long can men safely wait to father a child? How long can women safely wait to bear a child? Will having been treated for a sexually transmitted infection affect my chances of being able to have children?); fertility testing and preservation (Is there a way to test my current fertility? How can I preserve my fertility so I can have kids when I'm ready?); the effects of health and fitness on fertility (Are good health and fitness a better indicator of fertility than age? What is the relationship between weight and fertility? What lifestyle factors can impact male fertility?); and ART (What are the treatment options for a low sperm count? How is IVF done, and what are the risks and possible side effects of the medications?).

The sections of the Fertility Awareness Survey that participants completed prior to, and immediately following reading the 10 posts included four questions regarding their beliefs about the ideal and latest age for a woman and a man to reproduce, two self-assessment questions related to their perceived fertility knowledge and their knowledge of ART procedures and treatments, and 20 questions assessing their general fertility knowledge. The pre-intervention survey also included seven demographic questions from the Fertility Awareness Survey (age, ethnicity, sexual orientation, education, occupation, annual household income, relationship status).

This online survey was set up to ensure that participants completed all questions in the pre-survey before being directed to the 10 online posts. They were free to spend as much time as they wished reading the material, after which they were asked to complete the four beliefs, two fertility and ART knowledge self-assessments, and the 20 knowledge questions. During the survey, participants were not provided access to the entire website—only the information contained in the 10 posts on fertility information. Six months later, all of the original participants were invited to complete the 26-item post-survey, to assess the extent to which pre-post changes were sustained over time and reflected an actual increase in fertility and ART knowledge.

Participants

After receiving approval from the Behavioral and Research Ethics Board at the University of British Columbia, we enlisted a national survey company to recruit 200 women and men from across Canada for this study. Participation was restricted to childless individuals between 18 and 35 years of age, as women and men in this age group typically have time to use the information on the site to inform their fertility preservation and childbearing decisions. Participation was also limited to individuals who claimed they had not previously completed the Fertility Awareness Survey (Daniluk et al., 2012; Daniluk and Koert, 2013), and had never visited the MyFertilityChoices.com website.

One hundred and ninety-nine individuals completed the initial study (151 women; 48 men). Participants ranged in age from 18 to 35 with a mean age of 28. The majority self-identified as Caucasian (80.4%), and Asian/South East Asian (14%). Most were currently single (52.8%) or married (45.2%), and identified as heterosexual (92.5%). Participants were relatively well educated, with the majority having completed College/University (67.3%) and 9% having attained graduate degrees. Only 23.1% listed high school as their highest level of education. Participants were primarily employed full-time (58.3%) or part-time (9.5%). Twenty-four percent were students. Participants' gross annual household income ranged from $15 000 to over $200 000 (mean = $63 391).

Participants in the 6-month follow-up included 81 women and 29 men—55% of the original sample. The 110 participants in the 6-month follow-up were demographically representative of, and similar to, the original sample of 199 participants. Their mean age was 29 years, 84% were Caucasian, 90% identified as heterosexual and 55% were currently single. A majority were employed full-time (58.2%), or part-time (11%), while 24% were students. Sixty-nine percent had completed College or University. Participants' mean annual household income was $68 418.

Data analysis

Using SPSS, paired t-tests were conducted on the pre-post scores of the initial sample, for the four questions related to their fertility beliefs, the two self-assessments of their overall fertility and ART knowledge, and the 20 knowledge questions. Descriptive statistics were computed for each item (i.e. means, standard deviations and proportions). Two-tailed t-tests comparisons were run by gender, relationship status (single versus partnered) and age (18–29 versus 30–35), to determine if there were significant differences in the beliefs and knowledge scores of the participants based on these demographic factors.

The identification numbers of the 110 participants who completed the 6-month follow-up survey were matched with their pre- and post-intervention scores from the initial phase of the study. Paired t-tests were conducted to determine the extent to which the participants' current beliefs about the ideal age for women and men to have their first and last child, their self-assessed knowledge, and their actual knowledge, differed from their original scores prior to the online educational intervention. Comparisons were also conducted separately for the 81 women and the 29 men.

Results

Although a significant decrease was evident in participants' beliefs about the ideal ages for having children immediately after the educational intervention, their ideal age perceptions at the 6-month follow-up had returned to their pre-intervention levels. Participants' perceptions of ‘the ideal age for a woman to give birth to her first child,’ initially dropped from 26.87 to 25.87 (P < .001, t = 4.562), but increased to 27.19 at the 6-month follow-up. This trend was similar for their beliefs regarding ‘the latest age a woman should consider bearing a child,’ which initially dropped significantly from 40.27 to 38.71 (P < .001, t = 5.133), but rebounded to 39.85. Participants' beliefs regarding ‘The latest age a man should consider fathering a child,’ dropped more than a year following the intervention, from 43.88 to 42.07 (P < .001, t = 4.572), but then also returned to pre-intervention levels at 43.81 years. It is interesting to note that there were no significant differences between the three time periods, in response to the question ‘What is the ideal age for a man to father his first child.’ (29.01; 28.51; 29.04). Changes in participants' beliefs did not differ significantly based on their sex, relationship status (partnered versus single) or age (18–29 versus 30–35).

Participants' were asked to assess their fertility and ART knowledge levels at the three survey points on a scale from 1 to 4 (1 = no knowledge, 2 = some knowledge, 3 = fairly knowledgeable, 4 = very knowledgeable): ‘Overall, how would you rate your current fertility knowledge’ and ‘Overall, how would you rate your current knowledge of Assisted Human Reproduction (ART) procedures and fertility treatments.’ Irrespective of their sex, age or relationship status, participants' assessed their fertility and ART knowledge levels to be significantly higher immediately after reading the 10 posts (fertility knowledge: P < .001, t = 6.493; ART knowledge: P < .001, t = 11.195). When comparing their pre-intervention self-assessed knowledge levels with their self-assessments 6 months later, participants' continued to rate their fertility knowledge levels (P < .001; t = −3.444) and their ART knowledge levels (P < .071, t = 1.826) as being higher than their pre-intervention levels.

In turning to knowledge levels, as is evident from Table I, there were significant changes in participants' scores on 14 of the 20 knowledge questions immediately after reading the 10 posts, with the number of correct responses increasing from 8 to 13 questions for at least 50% of the sample. Consistent with their significantly increased self-assessed fertility and ART knowledge ratings, the percentage of uncertain responses decreased for all but the second knowledge question. However, for the 110 participants who participated in the 6-month follow-up, there were significant changes from participants' original pre-intervention knowledge scores on only four questions (see Table II), albeit in the direction of a higher percentage of correct answers. The number of questions answered correctly by 50% or more of the respondents did not change, with the same 10 questions being answered correctly prior to reading the 10 posts and 6 months later. Interestingly, again there was a reduction in the percentage of ‘uncertain’ answers on 14 of the 20 questions. Of those 14 questions, the percentage of correct answers increased for 11 questions.

Table I.

ART knowledge item distribution pre- and post-online education intervention.

ART knowledge items True (T) False (F) Pre-MFC
 Post-MFC
 P-value
No Uncertain Yes No Uncertain Yes
1. For women over 30, overall health and fitness level is a better indicator of fertility than age. F 16.1 18.6 65.3 63.8 7.5 28.6 .000*
2. Taking birth control pills for >5 years negatively affects a woman's fertility. F 32.2 27.6 40.2 25.1 29.1 45.7 .020*
3. A woman's eggs are as old as she is. T 33.7 16.6 49.7 11.1 8.5 80.4 .000*
4. Prior to a woman reaching menopause, the assisted reproductive technologies (e.g. in vitro fertilization, also known as IVF) can help most women to have a baby using their own eggs. F 4.5 23.1 72.4 7.0 16.6 76.4 .759
5. The total cost of one cycle of in vitro fertilization (IVF) is under $5000.00. F 49.2 33.7 17.1 56.8 21.6 21.6 .625
6. There is a progressive decrease in a woman's ability to become pregnant after the age of 35. T 6.5 12.6 80.9 2.5 10.1 87.4 .015*
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. T 3.5 14.1 82.4 3.5 8.0 88.4 .134
8. Most Canadian fertility clinics will not provide treatment to women over the age of 45. F 17.6 44.2 38.2 11.6 38.2 50.3 .001*
9. Egg freezing before the age of 35 can significantly prolong a woman's fertility. T 9.5 32.2 58.3 7.5 18.6 73.9 .001*
10. Sexually transmitted diseases (e.g. chlamydia, gonorrhea) significantly increase the risk of later infertility. T 9.5 17.1 73.4 16.1 13.6 70.4 .127
11. A man's age is an important factor in a couple's chances of becoming pregnant. T 30.2 17.1 52.8 5.5 9.0 85.4 .000*
12. The use of in vitro fertilization (IVF) poses health risks for a woman. T 18.6 45.7 35.7 20.6 29.6 49.7 .000*
13. Children conceived through the use of assisted reproductive technologies such as IVF and ICSI have more long-term health problems than children conceived without the use of these fertility treatments. T 52.3 34.7 13.1 30.7 33.2 36.2 .000*
14. The majority of fertility conditions are caused by problems with the woman's fertility. F 38.7 32.7 28.6 42.2 20.6 37.2 .455
15. Most couples have to go through IVF more than once to have a baby. T 10.6 29.1 60.3 7.0 20.1 72.9 .002*
16. A woman's weight affects her chances of conceiving a child. T 12.6 14.6 72.9 6.0 7.5 86.4 .000*
17. The upper age limit for a man to be treated at most Canadian fertility clinics is 55 years of age. F 8.0 64.3 27.6 9.5 35.2 55.3 .000*
18. There is a significant decline in the quality of a man's sperm before the age of 50. T 23.1 36.2 40.7 11.6 12.1 76.4 .000*
19. Smoking cigarettes or marijuana can reduce the quality of a man's sperm T 1.5 9.5 88.9 3.0 9.0 87.9 .436
20. Children born to fathers over the age of 45 have higher rates of learning disabilities, autism, schizophrenia and some forms of cancer. T 18.6 48.2 33.2 8.5 14.1 77.4 .000*
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Values are percentages of sample N = 199; females: n = 151; males: n = 48.

*P < .05.

Table II.

ART knowledge item distribution pre- and 6 months following online fertility education.

ART knowledge items True (T) False (F) Pre-intervention
 6-month follow-up
 P-value
No Uncertain Yes No Uncertain Yes
1. For women over 30, overall health and fitness level is a better indicator of fertility than age. F 17.3 17.3 65.5 30.9 20.0 49.1 .001*
2. Taking birth control pills for >5 years negatively affects a woman's fertility. F 31.8 29.1 39.1 35.5 25.5 39.1 .625
3. A woman's eggs are as old as she is. T 30.9 15.5 53.6 20.9 10.9 68.2 .002*
4. Prior to a woman reaching menopause, the assisted reproductive technologies (e.g. in vitro fertilization, also known as IVF) can help most women to have a baby using their own eggs. F 5.5 20.9 73.6 9.1 16.4 74.5 .731
5. The total cost of one cycle of in vitro fertilization (IVF) is under $5000.00. F 53.6 31.8 14.5 51.8 32.7 15.5 .747
6. There is a progressive decrease in a woman's ability to become pregnant after the age of 35. T 6.4 10.9 82.7 2.7 5.5 91.8 .030*
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. T 3.6 14.5 81.8 2.7 10.0 87.3 .264
8. Most Canadian fertility clinics will not provide treatment to women over the age of 45. F 17.3 47.3 35.5 10.9 45.5 43.6 .070
9. Egg freezing before the age of 35 can significantly prolong a woman's fertility. T 10.9 30.9 58.2 11.8 31.8 56.4 .731
10. Sexually transmitted diseases (e.g. chlamydia, gonorrhea) significantly increase the risk of later infertility. T 11.8 11.8 76.4 6.4 11.8 81.8 .103
11. A man's age is an important factor in a couple's chances of becoming pregnant. T 28.2 14.5 57.3 21.8 14.5 63.6 .199
12. The use of in vitro fertilization (IVF) poses health risks for a woman. T 15.5 46.4 38.2 18.2 36.4 45.5 .538
13. Children conceived through the use of assisted reproductive technologies such as IVF and ICSI have more long-term health problems than children conceived without the use of these fertility treatments. T 50.0 33.6 16.4 49.1 37.3 13.6 .815
14. The majority of fertility conditions are caused by problems with the woman's fertility. F 39.1 33.6 27.3 46.4 28.2 25.5 .383
15. Most couples have to go through IVF more than once to have a baby. T 8.2 30.0 61.8 8.2 23.6 68.2 .348
16. A woman's weight affects her chances of conceiving a child. T 8.2 13.6 78.2 6.4 9.1 84.5 .171
17. The upper age limit for a man to be treated at most Canadian fertility clinics is 55 years of age. F 9.1 64.5 26.4 8.2 48.2 43.6 .008
18. There is a significant decline in the quality of a man's sperm before the age of 50. T 24.5 34.5 40.9 20.0 30.9 49.1 .183
19. Smoking cigarettes or marijuana can reduce the quality of a man's sperm T 0.9 10.0 89.1 4.5 6.4 89.1 .417
20. Children born to fathers over the age of 45 have higher rates of learning disabilities, autism, schizophrenia and some forms of cancer. T 20.0 41.8 38.2 15.5 35.5 49.1 .034*
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Values are percentages of sample N = 110; females: n = 81; males: n = 29.

*P < .05.

Changes in participants' knowledge did not differ significantly based on their relationship status (partnered versus single) or age (18–29 versus 30–35). However, when changes in knowledge scores based on sex were examined for the original sample of 48 male and 151 female participants (see Table III), significant differences were found in the pre-post intervention scores on 13 questions for the women, and 9 questions for the men. Notably, the number of questions answered correctly by 50% or more of the women after reading the 10 online posts increased from 10 to 14, while for the men there was an increase in correct answers from 7 to 13. The percentage of ‘uncertain’ responses decreased on 18 of the 20 knowledge questions for the women and on 17 of the questions for the men, perceptions that were largely justified by the increases in the percentage of correct scores on these questions (15 of 18 for the women; 12 of 17 for the men).

Table III.

Comparison of male and female ART knowledge pre- and post-online fertility education.

ART knowledge items True (T) False (F) Females
 Males
No Uncertain Yes t-score P-value No Uncertain Yes t-score P-value
1. For women over 30, overall health and fitness level is a better indicator of fertility than age. F 17.2 17.9 64.9 10.053 .000* 12.5 20.8 66.7 5.378 .000*
67.5 5.3 27.2 52.1 14.6 33.3
2. Taking birth control pills for >5 years negatively affects a woman's fertility. F 33.8 25.2 41.1 −1.465 .145 27.1 35.4 37.5 −2.296 .026*
27.8 27.8 44.4 16.7 33.3 50.0
3. A woman's eggs are as old as she is. T 30.5 17.9 51.7 7.273 .000* 43.8 12.5 43.8 3.513 .001*
8.6 6.6 84.8 18.8 14.6 66.7
4. Prior to a woman reaching menopause, the assisted reproductive technologies (e.g. in vitro fertilization, also known as IVF) can help most women to have a baby using their own eggs. F 4.6 19.2 76.2 .716 .475 4.2 35.4 60.4 −1.844 .071
8.6 15.2 76.2 2.1 20.8 77.1
5. The total cost of one cycle of in vitro fertilization (IVF) is under $5000.00. F 54.3 30.5 15.2 −.095 .924 33.3 43.8 22.9 1.095 .279
58.9 20.5 20.5 50.0 25.0 25.0
6. There is a progressive decrease in a woman's ability to become pregnant after the age of 35. T 7.3 11.3 81.5 2.281 .024* 4.2 16.7 79.2 .903 .371
2.0 9.9 88.1 4.2 10.4 85.4
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. T 4.0 11.9 84.1 1.956 .052 2.1 20.8 77.1 −0.227 .821
2.6 6.0 91.4 6.3 14.6 79.2
8. Most Canadian fertility clinics will not provide treatment to women over the age of 45. F 13.9 44.4 41.7 −1.780 .077 29.2 43.8 27.1 −3.763 .000*
10.6 40.4 49.0 14.6 31.3 54.2
9. Egg freezing before the age of 35 can significantly prolong a woman's fertility. T 9.9 29.8 60.3 2.866 .005* 8.3 39.6 52.1 1.533 .132
7.3 17.2 75.5 8.3 22.9 68.8
10. Sexually transmitted diseases (e.g. chlamydia, gonorrhea) significantly increase the risk of later infertility. T 7.9 15.2 76.8 −2.080 .039* 14.6 22.9 62.5 .727 .471
17.2 11.9 70.9 12.5 18.8 68.8
11. A man's age is an important factor in a couple's chances of becoming pregnant. T 29.8 19.9 50.3 7.682 .000* 31.3 8.3 60.4 3.853 .000*
6.0 7.9 86.1 4.2 12.5 83.3
12. The use of in vitro fertilization (IVF) poses health risks for a woman. T 18.5 42.4 39.1 5.664 .000* 18.8 56.3 25.0 .659 .513
17.9 27.8 54.3 29.2 35.4 35.4
13. Children conceived through the use of assisted reproductive technologies such as IVF and ICSI have more long-term health problems than children conceived without the use of these fertility treatments. T 57.6 29.8 12.6 6.946 .000* 35.4 50.0 14.6 1.300 .200
29.8 29.8 40.4 33.3 43.8 22.9
14. The majority of fertility conditions are caused by problems with the woman's fertility. F 41.1 29.1 29.8 .254 .800 31.3 43.8 25.0 −2.160 .036*
47.7 17.9 34.4 25.0 29.2 45.8
15. Most couples have to go through IVF more than once to have a baby. T 9.9 25.8 64.2 2.109 .037* 12.5 39.6 47.9 2.915 .005*
7.3 18.5 74.2 6.3 25.0 68.8
16. A woman's weight affects her chances of conceiving a child. T 10.6 12.6 76.8 4.067 .000* 18.8 20.8 60.4 1.944 .058
4.0 6.0 90.1 12.5 12.5 75.0
17. The upper age limit for a man to be treated at most Canadian fertility clinics is 55 years of age. F 5.3 66.9 27.8 −4.856 .000* 16.7 56.3 27.1 −1.873 .067
7.9 33.8 58.3 14.6 39.6 45.8
18. There is a significant decline in the quality of a man's sperm before the age of 50. T 23.8 37.1 39.1 5.864 .000* 20.8 33.3 45.8 4.025 .000*
13.2 11.3 75.5 6.3 14.6 79.2
19. Smoking cigarettes or marijuana can reduce the quality of a man's sperm T 2.0 9.9 88.1 .192 .848 0.0 8.3 91.7 −1.631 .110
2.6 7.9 89.4 4.2 12.5 83.3
20. Children born to fathers over the age of 45 have higher rates of learning disabilities, autism, schizophrenia and some forms of cancer. T 17.9 48.3 33.8 7.964 .000* 20.8 47.9 31.3 3.693 .001*
7.9 11.9 80.1 10.4 20.8 68.8
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Upper values in columns represent pre-knowledge items, and lower values represent post-knowledge items.

Values are percentages of total sample: N = 199; females: n = 151; males: n = 48.

*P < .05.

As is evident from Table IV, when the pre-intervention knowledge responses of the 110 participants who took part in the follow-up were compared with their responses 6 months later, significant changes were apparent in their knowledge scores on only six questions for the 81 women, and on only one question for the 29 men. There were no changes in the number of questions answered correctly by 50% or more of the women at the 6-month follow-up (10 questions), while for the men the number of correct responses increased from seven to eight. Consistent with their 6-month self-assessments of their fertility and ART knowledge levels, there was a decrease in the percentage of ‘uncertain’ responses on 14 of the 20 knowledge questions for the women, and on 12 of the questions for the men. Of these questions, there was indeed an increase in the percentage of correct responses on 11 of 14 questions for the women and 9 of 12 questions for the men.

Table IV.

Comparison of male and female ART knowledge pre- and 6 months following online fertility education.

ART knowledge items True (T) False (F) Females
 Males
No Uncertain Yes t-score P-value No Uncertain Yes t-score P-value
1. For women over 30, overall health and fitness level is a better indicator of fertility than age. F 18.5 16.0 65.4 3.228 .002* 13.8 20.7 65.5 1.000 .326
35.8 16.0 48.1 17.2 31.0 51.7
2. Taking birth control pills for >5 years negatively affects a woman's fertility. F 35.8 25.9 38.3 .865 .390 20.7 37.9 41.4 −0.465 .646
40.7 23.5 35.8 20.7 31.0 48.3
3. A woman's eggs are as old as she is. T 27.2 13.6 59.3 2.965 .004* 41.4 20.7 37.9 1.294 .206
14.8 12.3 72.8 37.9 6.9 55.2
4. Prior to a woman reaching menopause, the assisted reproductive technologies (e.g. in vitro fertilization, also known as IVF) can help most women to have a baby using their own eggs. F 6.2 17.3 76.5 .266 .791 3.4 31.0 65.5 .226 .823
9.9 12.3 77.8 6.9 27.6 65.5
5. The total cost of one cycle of in vitro fertilization (IVF) is under $5000.00. F 59.3 29.6 11.1 −.910 .365 37.9 37.9 24.1 .779 .442
53.1 33.3 13.6 48.3 31.0 20.7
6. There is a progressive decrease in a woman's ability to become pregnant after the age of 35. T 8.6 9.9 81.5 3.114 .003* 0.0 13.8 86.2 −1.000 .326
2.5 1.2 96.3 3.4 17.2 79.3
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. T 4.9 12.3 82.7 .869 .387 0.0 20.7 79.3 .812 .424
8.6 46.9 44.4 17.2 41.4 41.4
8. Most Canadian fertility clinics will not provide treatment to women over the age of 45. F 16.0 45.7 38.3 −1.442 .153 20.7 51.7 27.6 −1.154 .258
10.6 40.4 49.0 14.6 31.3 54.2
9. Egg freezing before the age of 35 can significantly prolong a woman's fertility. T 12.3 24.7 63.0 −.660 .511 6.9 48.3 44.8 .465 .646
11.1 33.3 55.6 13.8 27.6 58.6
10. Sexually transmitted diseases (e.g. chlamydia, gonorrhea) significantly increase the risk of later infertility. T 8.6 9.9 81.5 .376 .708 20.7 17.2 62.1 2.069 .048*
7.4 9.9 82.7 3.4 17.2 79.3
11. A man's age is an important factor in a couple's chances of becoming pregnant. T 25.9 17.3 56.8 1.182 .241 34.5 6.9 58.6 .532 .599
22.2 11.1 66.7 20.7 24.1 55.2
12. The use of in vitro fertilization (IVF) poses health risks for a woman. T 14.8 42.0 43.2 3.957 .001* 17.2 58.6 24.1 1.652 .110
18.5 37.0 44.4 17.2 34.5 48.3
13. Children conceived through the use of assisted reproductive technologies such as IVF and ICSI have more long-term health problems than children conceived without the use of these fertility treatments. T 56.8 27.2 16.0 .000 1.00 31.0 51.7 17.2 −0.528 .602
53.1 34.6 12.3 37.9 44.8 17.2
14. The majority of fertility conditions are caused by problems with the woman's fertility. F 44.4 29.6 25.9 1.242 .218 24.1 44.8 31.0 −0.328 .745
53.1 27.2 19.8 27.6 31.0 41.4
15. Most couples have to go through IVF more than once to have a baby. T 8.6 27.2 64.2 .779 .438 6.9 37.9 55.2 .528 .602
9.9 18.5 71.6 3.4 37.9 58.6
16. A woman's weight affects her chances of conceiving a child. T 7.4 9.9 82.7 1.354 .180 10.3 24.1 65.5 .493 .626
3.7 8.6 87.7 13.8 10.3 75.9
17. The upper age limit for a man to be treated at most Canadian fertility clinics is 55 years of age. F 6.2 70.4 23.5 −3.357 .001* 17.2 48.3 34.5 .000 1.00
4.9 48.1 46.9 17.2 48.3 34.5
18. There is a significant decline in the quality of a man's sperm before the age of 50. T 27.2 33.3 39.5 1.315 .192 17.2 37.9 44.8 .386 .702
22.2 28.4 49.4 13.8 37.9 48.3
19. Smoking cigarettes or marijuana can reduce the quality of a man's sperm T 1.2 8.6 90.1 −0.893 .374 0.0 13.8 86.2 .000 1.00
4.9 6.2 88.9 3.4 6.9 89.7
20. Children born to fathers over the age of 45 have higher rates of learning disabilities, autism, schizophrenia and some forms of cancer. T 21.0 40.7 38.3 2.242 .028* 17.2 44.8 37.9 .465 .646
14.8 34.6 50.6 17.2 37.9 44.8
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Upper values in columns represent pre-knowledge items, and lower values represent post-knowledge items.

Values are percentages of sample N = 110; females: n = 81; males: n = 29.

*P < .05.

Discussion

There were a number of interesting and surprising findings that merit discussion and have implications for future research and fertility education efforts. Changes in participants' beliefs and knowledge levels immediately after reading the online posts were not maintained 6 months later. Although age (18–29 versus 30–35) and relationship status (partnered versus single) were not robust factors in changes in beliefs or knowledge levels, sex differences were apparent from pre-to-post, and at the 6-month follow-up. The initial knowledge levels of the participants in this study were also noteworthy, when compared with the knowledge levels of a large sample of childless Canadians who completed a similar survey in 2011 (Daniluk et al., 2012; Daniluk and Koert, 2013).

Beliefs

Reductions in participants' beliefs regarding the ideal ages for women and men to have children were not maintained at the 6-month follow-up. The initial drop in ideal ages may have been an immediate reaction to reading the information contained in the 10 posts, specific to age-related fertility decline and the risks of delayed parenting. That these changes were not sustained over time may reflect the fact that we were actually tapping into ‘perceptions’—which are typically much less firmly held than beliefs, and more subject to change and influence. With beliefs being informed over time by cultural, familial and social values, it is unlikely that a single exposure to this type of fertility information would have been sufficient to result in actual changes in participants' beliefs about the ideal timing of parenting.

Knowledge

Similar to Wojcieszek and Thompson's (2013) findings, there was a significant increase in the percentage of correct responses to the 20 knowledge questions for the participants in our study immediately after the online intervention. However, the changes were not maintained 6 months later, calling into question whether the participants actually learned from being exposed to the intervention, or simply remembered the information they had just read. Consistent with the claims of Wantland and colleagues (2004), future efforts to determine the extent to which online fertility education is effective in increasing knowledge and changing behaviors, will require longitudinal assessments and follow-up.

Sex differences

In our study the knowledge levels of the women were higher at all assessment points, when compared with those of the men. Given women's shorter fertility lifespan and greater responsibility for birth control throughout their lives, information about fertility, pregnancy and birth control is more relevant and pressing during their fertile years. Given men's longer fertility lifespan, fertility information may not yet have been of concern or interest to the men in this study (mean = 29 years). These findings suggest that fertility information may be sought, retained and acted upon based on personal relevance and need. For fertility education efforts to be successful, information needs to be readily accessible so that individuals can seek answers to questions as they become relevant to their lives. Online fertility education may be a particularly promising approach, given that it is a convenient and easily-accessible vehicle for those seeking health information, and can be accessed as needed and desired (Rice and Katz, 2001; Wantland et al., 2004; Webb et al., 2010).

Self-assessed knowledge levels

The men and women in this study rated their fertility and ART knowledge as being greater after reading the online posts, and at the 6-month follow-up. Indeed, on many of the knowledge questions, there were increases for both sexes in the percentage of correct answers 6 months after the intervention. It would appear that even brief exposure to this type of information may serve to increase women's and men's confidence in their fertility and ART knowledge. What is not clear, is whether this leads to future information seeking, and how this confidence informs their fertility and family planning decisions.

Pre-intervention knowledge levels

It is interesting to note that, when compared with our previous samples of childless and presumed fertile Canadian women and men (Daniluk et al., 2012; Daniluk and Koert, 2013), even prior to reading the 10 fertility information posts, the women and men in the current study were considerably more knowledgeable. The participants were recruited by the same national survey company, and other than age range (18–50 versus 18–35), shared a similar heterogeneous demographic profile. Perhaps the higher knowledge levels of the participants in the current, study is a reflection of the increased attention paid in the media over the last few years to the risks of delayed childbearing. Or, it may reflect the recent accessibility of educational websites dedicated to providing information about the fertility lifespan, parenthood timing and family planning options (e.g. www.YourFertility.org.au; www.nhs.uk/livewell/fertility; www.MyFertilityChoices.com).

Limitations

The findings of this study may be limited by the relatively small sample size and recruitment method. For that reason, the findings cannot be considered representative of the general population of currently childless, presumed fertile men and women between the ages of 18 and 35. However, the sample was heterogeneous in terms of level of education and economic status.

Conclusion

As highlighted by Nyboe Andersen and Hvidman (2013), there is a need for fertility education for men and women who are delaying childbearing and are concerned about their future fertility. The results of the current study point to the need for long-term follow-up in assessing the efficacy of online fertility education strategies. Findings also suggest that men and women may need to be targeted differently in order for the information to be relevant and timely. Future research should assess the primary sources of women's and men's fertility knowledge, and determine if, and how, increased knowledge translates into action. It will also be important to determine whether increased knowledge of fertility and family planning options reduces the growing trend toward delayed childbearing and later parenting, and results in more informed and satisfying reproductive decision-making.

Authors' roles

J.C.D. was the principal investigator on this Canadian Institutes of Health Research (CIHR) funded study and was involved in every stage of the study. J.C.D. oversaw and contributed to the research design, execution, analysis and results, manuscript drafting and editing. E.K. assisted with every stage of the research design, execution, discussion of analysis and results, manuscript drafting and editing.

Funding

This research was entirely funded from a CIHR Knowledge Translation Grant #KTB-117428. No other financial interests or sponsorships were involved.

Conflict of interest

None declared.

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