Dr. Eliran Mor

 160.Hernández Guerrero CA, Bujalil Montenegro L, de la Jara Díaz J, Mier Cabrera J, Bouchán Valencia P. Endometriosis and deficient intake of antioxidants molecules related to peripheral and peritoneal oxidative stress. Ginecol Obstet Mex. 2006;74:20–8. [PubMed] [Google Scholar]

 164.Zheng X, Lin D, Zhang Y, Lin Y, Song J, Li S, Sun Y. Inositol supplement improves clinical pregnancy rate in infertile women undergoing ovulation induction for ICSI or IVF-ET. Medicine (Baltimore). 2017;96(49):e8842. [DOI] [PMC free article] [PubMed] [Google Scholar]

 165.Pundir J, Psaroudakis D, Savnur P, Bhide P, Sabatini L, Teede H, Coomarasamy A, Thangaratinam S. Inositol treatment of anovulation in women with polycystic ovary syndrome: a meta-analysis of randomised trials. BJOG. 2018;125(3):299–308. [DOI] [PubMed] [Google Scholar]

 167.Genazzani AD, Lanzoni C, Ricchieri F, Santagni S, Rattighieri E, Chierchia E, Monteleone P, Jasonni VM. Acetyl-L-carnitine (ALC) administration positively affects reproductive axis in hypogonadotropic women with functional hypothalamic amenorrhea. J Endocrinol Invest. 2011;34(4):287–91. [DOI] [PubMed] [Google Scholar]

 168.Samimi M, Jamilian M, Ebrahimi FA, Rahimi M, Tajbakhsh B, Asemi Z. Oral carnitine supplementation reduces body weight and insulin resistance in women with polycystic ovary syndrome: a randomized, double-blind, placebo-controlled trial. Clin Endocrinol (Oxf). 2016;84(6):851–7. [DOI] [PubMed] [Google Scholar]

 176.Lyngsø J, Ramlau-Hansen CH, Bay B, Ingerslev HJ, Hulman A, Kesmodel US. Association between coffee or caffeine consumption and fecundity and fertility: a systematic review and dose-response meta-analysis. Clin Epidemiol. 2017;9:699–719. [DOI] [PMC free article] [PubMed] [Google Scholar]

 178.James JE. Maternal caffeine consumption and pregnancy outcomes: a narrative review with implications for advice to mothers and mothers-to-be. BMJ Evidence-Based Medicine. [Internet] 2020; [cited 2021 Apr 10]. Available from: https://ebm.bmj.com/content/early/2020/09/01/bmjebm-2020-111432, [DOI] [PMC free article] [PubMed] [Google Scholar]

 181.Fan D, Liu L, Xia Q, Wang W, Wu S, Tian G, Liu Y, Ni J, Wu S, Guo Xet al. Female alcohol consumption and fecundability: a systematic review and dose-response meta-analysis. Sci Rep. 2017;7(1):13815. [DOI] [PMC free article] [PubMed] [Google Scholar]

 Many recent societal trends have led to the need for fertility education, including the age at which individuals become parents, the development of new reproductive technologies, and family diversity. Fertility awareness has emerged as a concept very recently and is increasingly gaining recognition. However, fertility education is often neglected as there is no consensus on the appropriate content, target populations, or on who should provide it. This article attempts to provide an overview of the use of interventions to improve fertility education. We emphasize the importance of delivering evidence-based information on fertility and reproductive health through various methods while providing guidelines for their standardization and systematization. Recommendations are provided to aid the development and implementation of fertility education tools, including: the establishment of a comprehensive understanding of the target populations; the incorporation of theories of behavioural change; the inclusion of the users’ perspectives and the use of participatory research; and the use of specific guidelines for increasing engagement. By following these recommendations, it is expected that fertility education resources can contribute to improving fertility literacy, empowering individuals and couples to make informed reproductive decisions, and ultimately reducing the incidence of infertility and need for fertility treatment.

 Profound sociodemographic changes occurred within the last few decades: gender roles are more fluid, families are more diverse and smaller, and parents are older than previously. Developments in ART have accompanied these changes with increasing possibilities of parenting a child (Inhorn and Birenbaum-Carmeli, 2008), and legislation across different countries is adjusting to these changes. The number of fertility treatment cycles undertaken increases every year around the world (Wyns et al., 2022). While medically assisted reproduction (MAR) accommodates new ways of forming families, the leading cause behind the rise in infertility is the increasing age of parenthood in high income countries (Kuhnt and Passet-Wittig, 2022). The chance of conception is largely (female) age dependent (Raymer et al., 2020), but many individuals and couples feel shocked by a diagnosis of age-related infertility and regret not having been educated about this earlier on (Lee, 2019).

 The World Health Organization (WHO) recently recognized the need for fertility education. The term ‘fertility awareness’ was included in the latest revision of the International Glossary on Infertility and Fertility Care and defined as ‘the understanding of reproduction, fecundity, fecundability, and related individual risk factors (e.g. advanced age, sexual health factors such as sexually transmitted infections (STIs), and lifestyle factors such as smoking, obesity) and non-individual risk factors (e.g. environmental and workplace factors); including the awareness of societal and cultural factors affecting options to meet reproductive family planning, as well as family building needs’ (Zegers-Hochschild et al., 2017). The need to improve fertility awareness was demonstrated in a systematic review, which revealed that fertility knowledge is in general low to moderate and that neither age nor child wish predict higher levels of fertility awareness (Pedro et al., 2018). There is also strong evidence that individuals overestimate the probability of pregnancy (Ekelin et al., 2012), the age at which fertility declines (Delbaere et al., 2020), and the success rates of treatments (Conceição et al., 2017).

 Although fertility awareness is essential for making informed reproductive decisions, fertility education is still omitted in reproductive health guidelines (Bakkensen and Goldman, 2021; Practice Committee of the American Society for Reproductive Medicine and Practice Committee of the Society for Reproductive Endocrinology and Infertility, 2022). Furthermore, school sex education programmes focus on how to reduce the risk of STIs and unintended pregnancy (Haberland and Rogow, 2015), but fertility education remains ignored (Harper et al., 2021). Similarly, family planning is mainly directed at contraception and reducing fertility (Cleland et al., 2006; Frayne, 2017), but few preconception health programmes exist (Berglund and Lindmark, 2016). While the need for fertility education and infertility prevention has been emphasized (Bakkensen and Goldman, 2021; Harper et al., 2021), we have yet to implement it.

 The International Reproductive Health Education Collaboration (IRHEC), formerly known as the International Fertility Education Initiative (IFEI), adopted as one of its missions to improvereproductive health literacy. Educational resources that effectively increase fertility health literacy or awareness are pivotal to enable informed reproductive decisions, and prevent and manage subfertility and infertility. Still, there is no consensus on the contents of such resources, who they should target or who should provide them (Berglund and Lindmark, 2016; Ojukwu et al., 2016).

 Since health education can have many definitions (Liu et al., 2020), it is essential to start by defining fertility education. Adopting the widely accepted WHO definition of health education (World Health Organization, 2020), fertility education is hereby defined as the use of communication strategies and materials to inform and influence decisions and actions to improve fertility literacy or awareness. Fertility education should lead to greater fertility awareness and enable competences to be gradually built into everyday activities, social interactions and across generations (Nutbeam and Muscat, 2021) to inform and facilitate reproductive decision-making. This includes fertility education tools or resources to deliver evidence-based information on fertility and reproductive health effectively. Methods to convey such information may involve traditional forms of communication (e.g. doctor–patient communication in a family planning consultation; lectures in school; brochures at a primary health care centre) and/or digital forms of communication (e.g. website, fertility patient app, video, social media account). The more accessible, understandable, and of practical value for the intended target population, the more effective these tools will be (World Health Organization, 2020).

 Digital fertility literacy solutions are of particular interest because they can enable a more active role from the user or patient (Conard, 2019). Digital health literacy is the most significant social determinant of health (Sieck et al., 2021), but most digital health tools are not evidence-based (Jandoo, 2020). More than ever, patients bring their own information to consultations with their doctor, primarily from the Internet (Tan and Goonawardene, 2017). Guiding people to reliable sources of information may reduce the potential damage of inaccurate information, decrease shame in requesting information (Parikh et al., 1996), and lead to better decision-making skills (Conard, 2019).

 This article attempts to describe the process of developing fertility education tools, thereby contributing to the effort in standardising and systematizing best-practice guidelines in this field. Recently many noteworthy resources have been developed (for a detailed list, see www.eshre.eu/IRHEC) based on the fact that infertility may be preventable if potentially modifiable factors, such as lifestyle, are considered. However, estimates show that research results can take up to 17 years until effective implementation by health professionals (Morris et al., 2011). Practice guidelines can bridge this gap (Car et al., 2019) and, for that reason, their publication and implementation are increasing (Rod and Høybye, 2015). It is important to notice that fertility education resources, like any other health education tools, are developed to provide information that enables individuals to make positive behaviour changes that improve reproductive outcomes (Kumar and Preetha, 2012). Conversely, strategies to improve fertility knowledge at a population level usually involve cross-sectoral or cross-government approaches and aim to change policies and patterns of consumption (Kumar and Preetha, 2012) and are out of the scope of this article. We believe that the following recommendations can increase the feasibility and efficacy of implementation of resources designed to increase fertility awareness and/or prevent infertility.

 Fertility education aims include increasing knowledge about fertility for children and adolescents; promoting informed reproductive decisions for adults (including if and when to have children and whether to undergo fertility preservation); and facilitating decision-making about fertility treatments if facing infertility or if in a same-sex relationship or considering single parenthood. Thus, the goal of fertility education varies depending on stage of reproductive life, and a framework can be adapted accordingly (Fig. 1).

 While it was first considered that fertility education interventions should target women intending to have children, we now know that such interventions can induce anxiety (Maeda et al., 2018) as they intensify the societal pressure on women to have children. Based on research that shows that men want children as much as women do and that their understanding of fertility is low (Hammarberg, 2017), contemporary approaches to fertility education also target men. Additionally, fertility education needs to consider those who do not wish to have children to ensure they can avoid unplanned pregnancy. Regardless of the target population, the focus of fertility care interventions should always be on empowering people to make informed decisions, assisting ‘individuals and couples to realize their desires associated with reproduction and/or to build a family’ (Zegers-Hochschild et al., 2017).

 Health and education professionals are also important targets for fertility education. These are indirect recipients and are not depicted in Fig. 1 because interventions must first consider who the patients or users are. They include primary health providers, family planning nurses, gynaecologists and urologists, counsellors, and teachers. Interventions for professionals should focus on developing training-specific skills or increasing knowledge regarding communication in a particular age-range or problem.

Eliran Mor MD

 Understanding the population goes beyond knowing what education people need at the different reproductive life stages and involves a deep understanding of the context in which the intervention will occur. Context is a core element to consider when developing any complex intervention (Skivington et al., 2021). Within fertility education, approaches need to be adapted to the context of the target population. For example, a fertility education intervention to increase literacy in reproductive rights needs to consider the legislation in the country or region where it takes place. Likewise, interventions to support medical help-seeking for people with fertility difficulties must consider the options that realistically are available to them.

 The type of the educational tool will, of course, depend on population and context. While online training may be suitable for educating specialised nurses on how to talk about fertility education with young adults, a social media resource may be effective in improving adolescents’ fertility knowledge directly.

 Theories provide a valuable framework for understanding the complex factors that might influence and/or change individuals’ knowledge, attitudes, or behaviours regarding fertility. Only by testing the directional relationships between concepts, i.e. establishing a hypothesis, will a researcher or practitioner know if an intervention is effective in changing what it was intended to change (Moullin et al., 2020). Moreover, theory-driven interventions are known to be more effective than interventions lacking a theoretical basis (Davis et al., 2015), and there is evidence that suboptimal use of frameworks in both research and practice leads to wasted resources, errors in implementation methods and data analyses, and erroneous conclusions (Moullin et al., 2020).

 While, to the authors’ knowledge, a specific theoretical model postulated for fertility awareness does not exist, there are health behaviour models that can help. Developing a tool to improve fertility awareness can rely on theories or models of health behaviour, which seek to explain why individuals engage in (or fail to engage in) health-related behaviours (Noar, 2004). In general, the premise of these theories is that an individual’s intentions and behaviours will determine their actions (Tarkang and Zotor, 2015). Hence, one can identify the causal factors that determine change in intentions and behaviours. The most common variables assessed are knowledge, attitude, and efficacy (Record et al., 2021).

 The choice of health behaviour theory is not always evident and, in most conditions, the literature does not provide clear empirical support for researchers and health educators on the most appropriate model (Noar, 2004). However, several studies have successfully applied health behaviour models to fertility education interventions. Here, we describe three of the most used theories and provide examples from existing fertility education efforts.

 The Theory of Reasoned Action (TRA) (Fishbein and Ajzen, 1977) and its extension, known as the Theory of Planned Behaviour (TPB) (Ajzen, 1991), are widely used in health education (Sharma et al., 2021), and numerous interventions have been developed using these theories (Tyson et al., 2014; Lareyre et al., 2021). In TPB, behaviour is determined by behavioural intention, which is dependent on attitude, subjective norm, and perceived behavioural control. Attitude is defined as favourable or unfavourable feelings towards the behaviour, determined by behavioural belief and outcome evaluations. Subjective norm is determined by normative beliefs (i.e. perceived social pressure from important people) and motivation to comply (i.e. the degree to which a person would like to adopt the behaviour of the important people). Perceived behavioural control is determined by control belief (i.e. beliefs about factors that may affect the performance of the behaviour) and perceived power (i.e. perception about the difficulties involved in performing the behaviour). TPB is a well-established theory to predict various healthy behaviours (Armitage and Conner, 2001; McEachan et al., 2011).

 The TPB has been employed to understand fertility decisions such as childbearing (Ajzen and Klobas, 2013; Li et al., 2019), contraceptive use (Der et al., 2021) and elective egg freezing (Caughey et al., 2021). Using ‘freezing eggs’ as an example of a behaviour, the intention to freeze one’s eggs would depend on attitude (how favourable or unfavourable the person feels about freezing their eggs), subjective norms (e.g. important others will support the person freezing their eggs), and perceived behavioural control (e.g. ‘Whether or not I freeze my eggs is entirely up to me’). Since these constructs of the TPB were proven to be predictors of intentions to freeze eggs, interventions designed to develop a positive attitude towards egg freezing, gain approval from important others, and increase the perception of personal control would likely increase the uptake of egg freezing (Caughey et al., 2021).

 Whereas several TPB-based educational programmes have been developed to improve pregnancy health (Lee et al., 2016; Khani Jeihooni et al., 2021), the use of TPB in fertility education is still limited. Kariman et al. (2020) developed a TPB-based fertility education intervention, which included information about the effects of the decline in population growth on the family and the society, as well as medical facts. They showed positive effects of the intervention on knowledge, attitude, perceived behavioural control, and behavioural intention regarding fertility.

 Social cognitive theory (SCT), developed by Bandura (1986), is one of the most frequently applied theories of health behaviour (Baranowski et al., 2002). SCT has often been called a bridge between behavioural and cognitive learning theories since it focuses on the interaction between internal factors, such as thinking and symbolic processing (e.g. attention, memory, motivation), and external determinants (e.g. rewards and punishments) in determining behaviour. Individuals are viewed as active agents that both influence and are influenced by their environment. SCT may contribute to understanding how individuals develop their life goals, including childbearing and parenthood intentions, and how their behaviour is directed to that goal attainment. It also considers how environmental factors (e.g. social, familial, work, and others) influence their behaviour.

 A central tenet of SCT is the concept of self-efficacy, which is an individuals’ belief in their capability to perform a behaviour (Bandura, 1977). Self-efficacy is essential for action and regulates motivation and the definition of life goals and will determine how people persist in a specific type of behaviour. The concept of self-efficacy has been widely used in studies focusing on the experience of infertility, mainly as a moderator between internal factors and the impact of fertility treatments (e.g. Khalid and Dawood, 2020, Mirzaasgari et al., 2022). Indeed, when an individual perceives themselves as capable of dealing with a stressful situation, such as infertility, a better emotional adjustment is expected (Cousineau et al., 2006). Less attention has been paid to the role of self-efficacy in fertility awareness and fertility-related behaviour. Packer et al. (2020) have recently studied the role of self-efficacy in childbearing plans, highlighting the importance of developing and implementing SCT-based interventions in fertility awareness and behaviour.

 Furthermore, SCTs emphasizes that individuals learn from one another via observation, imitation, and modelling. Even when fertility intentions have not yet been formulated, automatic and deliberative brain processes that form emotionally laden images of self, family, childbearing, and childrearing can be evoked by a relevant cue in the environment. Intentions, by contrast, are formed through deliberative processes that consciously weigh these emotion-laden images and calculate a desired course of action. Because these calculations are costly for the brain, cognitive theory suggests that they will be formed only when circumstances demand or motivate it, for example when people confront new situations, like marriage. The effects of short-term exposure to fertility-related concepts, such as career aspirations (mainly for women), may vary with more durable, but still environmentally conditioned, aspects of social identity such as religiosity (Marshall and Shepherd, 2018).

 To our knowledge, to date no SCT-based fertility education interventions have been implemented or evaluated. Paradoxically, SCT is the theory most frequently used in interventions to promote contraceptive use, often in conjunction with another model of behaviour change (Lopez et al., 2009).

 The Health Belief Model (HBM) (Rosenstock, 1974) is a psychological theory of health behaviour change that posits that individuals are more likely to change their health behaviour if they feel they are personally susceptible to a health risk, that the health risk is severe and if they believe there are more benefits than barriers to engage in the behaviour or preventative behaviour (Michie et al., 2017). According to this model, cues to action trigger behaviour change.

 In fertility awareness, the HBM helps us understand that individuals need to feel susceptible to fertility problems/infertility to change their behaviour/engage in preventative action (e.g. starting to try to become pregnant, freezing their eggs, etc.). There must be a benefit to taking action and changing their behaviour (e.g. being able to have children in the future). As such, through an HBM lens, to be most effective, fertility awareness interventions should target individuals’ sense of susceptibility to the risk of fertility problems along with the benefits and barriers of postponing childbearing (Glanz et al., 2015). Such interventions can include risk assessment and personalized advice.

 One example is The Fertility Assessment and Counselling Clinic in Denmark (FAC; Hvidman et al., 2015), that includes an individualised assessment of one’s risk of fertility problems. Researchers from the FAC clinic have used the HBM to explain the mechanisms of attending FAC clinic in that it serves as a ‘cue to action’ wherein women and men make choices such as pursuing fertility treatment or ending a relationship with a partner who is not ready to have children after attending the FAC clinic (Sylvest et al., 2018; Koert et al., 2020). Another example is described below with partnered women who want children.

 These three theoretical models, as with many other health behaviour theories, are based on the premise that an individual weighs the potential risks and benefits of changing a behaviour, considers how others will respond, and calculates the likelihood of success of that change (Ryan et al., 2014). The choice of which model to apply depends on the target population (see point 1). For example, adolescents hardly perceive themselves as susceptible to infertility, as has been largely demonstrated before with STIs (Samkange-Zeeb et al., 2011). However, the fear of being unable to conceive is an essential motivator for adults with a child wish. Hence, interventions with adolescents could be based on SCT, and interventions for people with a child wish can formulate hypotheses informed by the TPB.