Fertility Awareness and Subclinical Infertility Among Women Trying to Get Pregnant at Home&nbsp;

doi:10.21203/rs.3.rs-153000/v1

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Fertility Awareness and Subclinical Infertility Among Women Trying to Get Pregnant at Home

https://doi.org/10.21203/rs.3.rs-153000/v1

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published 20 Feb, 2022

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Background: Recent studies on fertility awareness in the reproductive population have reported the lack of accurate knowledge about fertility and assisted reproductive technologies. However, these researches were conducted among university students or fertility patients. Therefore, there was little information among women trying to get pregnant at home on the following aspects: (i) the presence of adequate fertility knowledge, (ii) the prevalence of subclinical infertility, and (iii) reasons for not visiting the clinic to identify the possibility of infertility. The aim of this study was to explore fertility awareness and subclinical infertility among women trying to get pregnant at home.

Methods: A total of 2,084 Japanese women responded to this online survey. We selected 1,541 women according to the study criteria. By the results of 61 questions, we evaluated knowledge about fertility, prevalence of subclinical infertility, and reasons for visiting the clinic.

Results: Despite the desire of the participants to get pregnant, they had an apparent tendency to overestimate the age limit of childbearing. A total of 338 (21.9%) women thought that those aged over 45 years could have children. Approximately 40% of the women had a possibility of subclinical infertility, despite being unaware of the fact. In addition, about 70% of the women considered themselves to suffer from infertility problems. Women who were informed about the possibility of infertility hesitated to visit the clinic for the following reasons: unfamiliarity with a gynecologist or clinic and apprehensions about the gynecologic examination.

Conclusions: Several women require treatment for infertility. Nonetheless, they hesitate to visit the clinic. Sexual health education, together with proper accessibility to gynecology clinics are necessary to avoid involuntary childlessness.

Internal Medicine

Preventive Medicine

Fertility knowledge

subclinical infertility

education

involuntary childlessness

Japanese

The average age of first pregnancy has increased in most countries since the 1980s¹. This delay in childbearing has been attributed to changes in womens’ social and economic environments, namely, higher education, social progress, and the rise of effective contraception¹. Although the decision of a delayed marriage or pregnancy influences the lifestyle of women, it leads to several health problems. Older mothers have a higher risk of both obstetric and fetal complications, including gestational diabetes, placenta previa, placental abruption, hypertensive disorders of pregnancy, and fetal congenital anomalies¹.

Moreover, recent studies on fertility awareness in the reproductive population have reported the lack of accurate knowledge about fertility and assisted reproductive technologies (ARTs) ^1–14. The proportion of women having accurate knowledge about fertility is particularly low in Japan, compared to other industrial countries¹. The importance of health literacy and fertility education has been emphasized in the Japanese society, similar to other countries. Furthermore, the number of websites or applications disseminating information on fertility have rapidly increased in the last decade. Moreover, portable telephone applications that inform about the approximate ovulation day from the menstrual cycle are extremely convenient. They have been distributed among women who wish to have a child.

Thus, women are able to access fertility information more easily than before. However, the number of infertile patients has been increasing. In addition, the age at first delivery is substantially high in Japan¹. The above-mentioned facts suggest the presence of other problems, apart from the lack of fertility knowledge or circumstances surrounding the women.

We aimed to explore fertility awareness and action among women trying to get pregnant at home. Most of the previous studies on fertility-related knowledge were conducted among university students^1–9. University students generally do not want to bear children at a young age. Therefore, most of them would not realistically consider fertility and infertility at the time of the survey. The differences in the environment and awareness between university students and women trying to get pregnant at home necessitated a survey on the latter. This, in turn, would prevent situations wherein women are forced to abandon the idea of having a child because of poor knowledge about fertility. Furthermore, other studies targeted clinical patients. Therefore, there was little information on the following aspects: (i) the presence of adequate fertility knowledge, (ii) the prevalence of subclinical infertility, and (iii) reasons for not visiting the clinic to identify the possibility of infertility. We performed an online research in Japan regarding the knowledge on fertility, potential infertility, and reasons for visiting the clinic among women who used the pregnancy-assisting application at home.

Participants and procedures

We conducted the study on an application that comprised the user information, including women’s health, fertility, and ovulation prediction (MTI, Tokyo, Japan) in September 2018¹. The time frame that collected the names of participants who wanted to have children was shown for 13 days. At the beginning of the session, the purpose and methods of this study were presented to all participants. After obtaining informed consent, the participants had to answer several questions on fertility and action for childbearing on the application site. The questionnaire comprised 61 questions. Each participant took about 50 min to fill in the questionnaire.

A total of 2,084 women responded to this survey. The first question was as follows: “Do you want to have children now?” We obtained a negative response from 114 women who responded to the remaining questions. Of the 1,970 women who wanted to have children, 272 were under treatment for infertility, 146 did not respond to the question on infertility treatment, and 11 were undergoing hormone therapy. We eventually analyzed 1,541 participants who completed the questionnaire (Fig. 1).

Measures

The questionnaire consisted of five domains as follows: 1) participants’ demographic information (31 items); 2) menstrual information (10 items); 3) intention and behavior for childbearing (6 items); 4) awareness of fertility and infertility (5 items); and 5) partner’s demographic information (9 items). All domains contained yes-or-no, open-ended, and multiple choice questions for which the participants could select one or several categories from the list.

Statistical analysis

We analyzed the differences in age between each group using one-way analysis of variance, followed by Tukey’s multiple comparison tests. The unadjusted and multivariable-adjusted odds ratios were calculated using logistic regression analyses. We calculated the odds ratios (OR) and 95% confidence interval (CI) in the multivariate analysis after simultaneously controlling for the potential confounders, that is, age, body mass index (BMI), history of smoking, delivery status, experience of abortion or miscarriage, as well as age, BMI, and history of smoking of partner. Statistical analyses were performed using the SPSS software package, version 22.0 (SPSS Inc., Chicago, IL, USA). A P value < 0.05 was considered statistically significant.

Participant characteristics

Table 1 summarizes the characteristics of the participants. The largest age group was 30–34 years (37.1%). Most of the participants had a moderate BMI. Nearly 80% of the women had a job (full-time: 57.6%, part-time: 20.8%). A total of 1,247 (80.9%) women were married. In addition, 582 (37.8%) women had children.

Table 1
Participant characteristics (N = 1,541)
		N (%)
Age (years)	16–29	500 (32.4)
	30–34	571 (37.1)
	35–39	314 (20.4)
	40–44	128 (8.3)
	45–50	28 (1.8)
Body mass index (kg/m²)	< 18.5	225 (14.6)
	18.5–24.9	1,040 (67.6)
	25-29.9	198 (12.9)
	≥ 30	76 (4.9)
Smoking	Never smoked or former smoker	1,307 (84.8)
Smoking	Current smoker	234 (15.2)
Social status	Full-time job	888 (57.6)
	Part-time job	320 (20.8)
	Housewife/jobless	323 (21.0)
	student	10 (0.6)
Marital status	Single	294 (19.1)
Marital status	Married	1,247 (80.9)
Reproduction	Have children	582 (37.8)
Reproduction	Experience of abortion or miscarriage	305 (19.8)

Fertility knowledge

Table 2 presents the fertility knowledge of the participants. These results highlight the apparent tendency of most participants to overestimate the possible age of childbearing. Approximately 338 (21.9%) women believed that women over 45 years of age could have children. In addition, 47.7% of the participants selected the 40–44 years category as the upper age limit to have children.

Table 2
Fertility knowledge
Question	Age (years)	N (%)^a
What do you think is the upper age to have children? (select one)	< 35	55 (3.6)
	35–39	412 (26.8)
	40–44	735 (47.7)
	≥ 45	338 (21.9)
^a: distribution of responses calculated excluding missing data.

Behaviors for childbearing

Table 3 summarizes the participants’ actions and the period for childbearing. About three-quarters (74.4%) of the women used the ovulation prediction service, presented by the application. The number of women whose sterile period was less than 1 year, 1 year, 2 years, 3 years, and 4 years or more was 746 (48.4%), 267 (17.3%), 159 (10.3%), 94 (6.1%), and 222 (14.4%), respectively.

Table 3
Behavior for childbearing
Question		N (%)
What are you doing to become pregnant? (select one)	Self-timing therapy with application service	1146 (74.4)
	Self-timing therapy without application service	50 (3.2)
	Nothing in particular	345 (22.4)
Since how long are you having intercourse without contraception? (select one)	< 1 year	746 (48.4)
	1 to < 2 year	267 (17.3)
	2 to < 3 year	159 (10.3)
	3 to < 4 year	94 (6.1)
	≥ 4 year	222 (14.4)
	No response	53 (3.4)

Awareness and attitude for infertility

Approximately 70% of the women referred to their potential infertility (Table 4). Over half of the 1,362 women, who had never been examined for infertility, were conscious of the necessity for an infertility examination. The primary reasons for not visiting the clinic were as follows: (i) “no time” (22.5%), (ii) “hesitation to know the truth” (22.4%), and (iii) “an absence of a familiar gynecologist or clinic (22.3%).” Other reasons behind this hesitancy included the following: (i) “the fear of gynecologic examination” (12.7%), (ii) “an uncooperative partner” (7.9%), and (iii) “the hesitation to let other person know about their infertility (89%).” Fig. 2 shows the awareness of infertility and sterile period. Each category of the awareness of infertility corresponds to the results of the first question in Table 4. More than 40% women had a sterile period over one year among those who gave negative response to the question on potential infertility (Never, Almost never).

Table 4
Awareness of and attitude towards infertility
Question		N (%)
Do you think you are infertile? (select one)	Never	121 (7.9)
	Almost never	342 (22.2)
	Possibly	651 (42.2)
	Likely	306 (19.9)
	Most likely	118 (7.7)
	No response	3 (0.2)
Do you think you should be examined for infertility? (select one)	Yes	718 (46.6)
	No	644 (41.8)
	I have been examined before.	179 (11.6)
Why haven’t you visited a clinic for infertility examination?^a (select any number)	There is no time.	307 (22.5)
	I am afraid of the gynecologic examination.	173 (12.7)
	I feel afraid of discovering the truth.	305 (22.4)
	Partner is not cooperative.	107 (7.9)
	I don’t know a familiar gynecologic doctor/clinic.	304 (22.3)
	If I would be infertile, I don’t want other person to know it.	89 (6.5)
	Nothing in particular.	415 (30.5)
^a: this question was asked to women without an experience of a prior infertility examination (n = 1,362)

The proportion of potentially sterile women among those who thought that infertility was a “possibility”, “likely”, and “most likely” were 43.8%, 58.2%, and 71.2%, respectively.

Relationships between infertility and risk factors

Table 5 summarizes the unadjusted and multivariable-adjusted ORs of infertility for demographic characteristics and fertility experiences. Among the 1,541 women, 742 (48.2%) were infertile with sterile periods over one year. According to the multi-variable analysis, multiparous women (OR, 1.408; 95% CI, 1.128–1.757, P = 0.003) and male partners with smoking habits (OR, 1.316; 95% CI, 1.053–1.646; P = 0.016) were significant risk factors for infertility. Furthermore, the two groups, namely those aged 30–39 (OR: 1.473, 95% CI: 1.094–1.982, P = 0.011) and 40–49 (OR: 1.776, 95% CI: 1.226–2.575, P = 0.002) years each had a significantly higher risk of infertility, compared to the group aged 16–29 years. Nonetheless, women’s age, BMI, smoking status, abortion or miscarriage, and BMI of male partners were not significant risk factors for infertility.

Table 5
The odds ratio of infertility by demographic characteristics and fertility experiences
	Unadjusted odds ratio			Multivariable-adjusted odds ratio^a
	OR	95% CI	p	OR	95% CI	p
Age(years) 16–29 30–34 35–39 40–44 45–50	1.0 1.222 1.332 1.861 2.367	- 0.960–1.555 1.003–1.768 1.255–2.758 1.071–5.230	- 0.104 0.048 0.002 0.033	1.0 0.962 0.893 1.119 1.408	- 0.725–1.275 0.634–1.257 0.702–1.783 0.605–3.276	- 0.785 0.517 0.637 0.427
Body mass index (kg/m²) < 18.5 18.5–24.9 25-29.9 ≥ 30	1.0 0.950 1.083 1.756	- 0.712–1.268 0.739–1.587 1.032–2.988	- 0.729 0.681 0.038	1.0 0.883 0.898 1.494	- 0.654–1.193 0.598–1.348 0.858–2.601	- 0.419 0.603 0.156
Smoking Never or former smoker Current smoker	1.0 1.391	- 1.052–1.840	- 0.021	1.0 1.150	- 0.847–1.561	- 0.372
Delivery status Nullipara Have children	1.0 1.607	- 1.306–1.978	- 0.000	1.0 1.408	- 1.128–1.757	- 0.003
Experience of abortion or miscarriage No Yes	1.0 1.525	- 1.184–1.964	- 0.001	1.0 1.283	- 0.980–1.681	- 0.070
Age of partner (years) 18–29 30–39 40–49 50–64	1.0 1.503 1.961 1.817	- 1.167–1.936 1.443–2.664 0.887–3.722	- 0.002 0.000 0.103	1.0 1.473 1.776 1.467	- 1.094–1.982 1.226–2.575 0.681–3.161	- 0.011 0.002 0.328
Body mass index of partner (kg/m²) < 18.5 18.5–24.9 25-29.9 ≥ 30	1.0 0.724 0.837 1.302	- 0.433–1.213 0.487–1.438 0.664–2.551	- 0.220 0.520 0.442	1.0 0.721 0.773 1.139	- 0.425–1.223 0.444–1.348 0.570–2.276	- 0.225 0.364 0.713
Smoking of partner Never or former smoker Current smoker	1.0 1.459	- 1.189–1.791	- 0.000	1.0 1.316	- 1.053–1.646	- 0.016
OR: odds ratio, CI: confidence interval.
a: Adjusted for age, body mass index, smoking, delivery status, experience of abortion or miscarriage, age of partner, body mass index of partner, and smoking of partner.

This was the first epidemiologic study to focus on women who are trying to get pregnant at home. Moreover, this was the first study to make an investigation into fertility knowledge and the prevalence of subclinical infertility in Japan.

The number of women who need infertility treatment has been recently increasing in several countries¹. Among all infertility treatments, ARTs creates significant economic, mental, and physical burden on the women. Furthermore, it has a considerable impact on their daily lives¹. The increasing number of women with infertility can be attributed to changes in their lifestyle, such as higher education, social progress, and late marriage¹. Moreover, several epidemiological investigations from various countries reported about the poor knowledge about infertility among numerous women of reproductive age. Furthermore, they overestimate their reproductive lifespan^1–14. This subsequently increases the number of women unexpectedly requiring infertility treatment. The issue of poor fertility awareness is particularly important in some developed countries where declining birth rate is a serious social issue¹.

The apparent tendency of overestimating the age limitation of childbearing was consistent with previously published results. Several people can obtain correct medical information through the internet in recent times. However, the dissemination of knowledge on fertility and infertility is inadequate for women needing them. Certain background factors, such as the tendency to sensitively deal with infertility problems and late child-bearing by celebrities also create a significant impact. Hence, imparting sex education would effectively resolve the problem of insufficient knowledge on fertility.

The hesitancy of visiting a clinic was attributed to a lack of familiarity with the gynecologist or clinic and fear of the gynecologic examination. In other words, women faced difficulty in visiting gynecology clinics, although it may be a problem characteristic to Japan. One reason for the aforementioned problem is that women rarely visit gynecology clinics before getting pregnant in Japan. The administration of human papilloma virus vaccines or recognition of women’s health care would enhance their familiarity with a gynecology clinic.

Multivariate analysis indicated “multipara” as a significant risk factor for infertility. Such women may lack sufficient awareness on secondary infertility because of a previous pregnancy. Despite being overlooked for secondary infertility, such women should be aware of infertility in case of a long period of sterility.

Our study had several limitations. First, the participants were selected from those who used a particular application, thus raising the possibility of a selection bias. The above-mentioned application presented information about pregnancy and helped them get pregnant. Thus, the participants could have a stronger desire of bearing a child, compared to ordinary women. Second, we conducted the study among Japanese women who often have negative and sensitive ideas about infertility. Hence, this tendency may have influenced our results. Third, our investigation lacked information about the place of residence of the selected participants. There are several infertility clinics in a city, compared to the few in the countryside. This uneven distribution of infertility clinics may have also influenced the thought of infertility treatment. Thus, the differences in this study could not be clarified.

According to our investigation there may be more than a few patients with subclinical infertility among those trying to get pregnant at home. Furthermore, these women generally hesitate to visit the clinic for several reasons. In addition, our results also indicate the experience of giving birth previously being a possible risk factor for secondary infertility.

The dissemination of correct knowledge about fertility and infertility is insufficient. The presence of a gynecologist who could provide medical advice at an appropriate time would effectively resolve the problems. Our study was small-sized with limited participants. This calls for the need of large-scale studies in various countries.

ARTs

assisted reproductive technologies

odds ratios

confidence interval

BMI

body mass index

Ethical approval and consent to participate

Our study was approved by the research ethics committee of the Hirosaki University with approval number 2018-1041. Participation in this study was voluntary, and informed consent was obtained from all participants on line.

Consent for publication

Not applicable

Availability of data and materials

The data used and/or analyzed during this study are available from the corresponding author on reasonable request.

Competing interests

Kaori Iino, Rie Fukuhara, Megumi Yokota, and Yoshihito Yokoyama have nothing to disclose.

Funding

There was no financial support in this study.

Authors’ contributions

KI, RF, MY, and YY contributed to the conception and design of the study, analysis and interpretation of data, and revising it critically for important intellectual content and providing final approval of the version to be submitted. KI and YY contributed to acquisition of the data and finally KI contributed to drafting the article. All authors read and approved the final version of the manuscript.

Acknowledgments

The authors thank the MTI staff for their cooperation in conducting the questionnaire.

Human rights statements and informed consent

All procedures were performed in accordance with the ethical standards of the relevant committees on human experimentation (institutional and national) and the Helsinki Declaration of 1964 and its later amendments. Informed consent was obtained from all patients included the study.

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No competing interests reported.

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You are reading this latest preprint version

Fertility Awareness and Subclinical Infertility Among Women Trying to Get Pregnant at Home

Status:

Journal Publication

Version 1

Abstract

Figures

Background

Material And Methods

Participants and procedures

Measures

Statistical analysis

Results

Participant characteristics

Fertility knowledge

Behaviors for childbearing

Awareness and attitude for infertility

Relationships between infertility and risk factors

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1