In a general context, fertility awareness incorporates information on fertility and human reproduction, such as the menstrual cycle, timing and occurrence of pregnancy, likelihood of getting pregnant from having unprotected sexual intercourse at various times during the menstrual cycle, and the role of male fertility and sperm survival (1). It can also include how specific methods of family planning work, how to use them and how they affect fertility (2). Fertility awareness also includes the ability to effectively apply reproductive health information to one’s life to achieve personal, desired outcomes (3). This requires individual knowledge and skills, personal experience, and a family and wider community environment that empowers people to take action and make their own fertility-related decisions (4). Good fertility awareness can empower and enable men and women to make strategic life choices relating to their fertility and reproductive health. The international glossary on infertility and fertility care (5) defines fertility awareness as:
“the understanding of reproduction, fecundity, fecundability, and related individual risk factors (e.g. advanced age, sexual health factors such as sexually transmitted infections, and life style factors such as smoking, obesity) and non-individual risk factors (e.g. environmental and work place factors); including the awareness of societal and cultural factors affecting options to meet reproductive family planning, as well as family building needs”.
In clinical settings, fertility awareness covers more in-depth knowledge of fertility awareness-based methods (FABMs) for family planning, used in achieving birth control (6). Examples of such methods include the Billings Ovulation Method, Cycle Beads Method, Two Day method, Standard Day Method, Temperature Methods and the Symptothermal Method (STM) (6–10). These methods typically involve an assessment of signs associated with ovulation and being fertile, such as the observation and characterisation of cervical secretions, basal body temperature, monitoring of cycle days (6,8–12) and use of this information for family planning.
A marked increase in childbearing at advanced maternal and paternal age has recently been observed in many high-income countries (13). Since earning potential generally tends to increase with age, delaying parenthood is a rational economic strategy and one of the reasons frequently cited for delaying childbearing. Economic reasons such as studying, employment and career progression are not the only motivators for a delay in family building but are collectively cited as the most important reasons (14, 15). Changing social norms on the ideal age for parenthood (16), education, availability of contraception and ARTs (17) are also contributing factors. It has been suggested that social advantage could reduce some impact of advanced maternal age (18). Moreover, a higher happiness score is reported in children of mature parents (19). Some studies also reveal greater satisfaction and less stress in older parents (20) (19). Indeed, patients should not be judged when they initially attend clinics.
Overall, the demographic shift towards delayed childbearing and family building is of increasing public health and clinical concern due to elevated risks of poor outcomes for mother and baby (21, 22). Although many remain childless by choice (23–25) and most women will be able to conceive naturally if they do so by the age of 35 (26), for those who have difficulty conceiving, poor outcomes increase rapidly (27). Improvement of fertility knowledge and awareness continues to be a crucial component of public health initiatives for preventing involuntary childlessness and achieving desired family building intentions (28–31).
Clinics should not assume that patients have adequate fertility knowledge. Studies reveal a common misconception that most women will conceive immediately after they begin to try. Years of education focus on how to prevent pregnancy rather than how to attain it, thus promoting the perception that pregnancy is inevitable if contraception is not used. This idea is reinforced by pill usage, where “just missing one pill can result in pregnancy” making women believe that they are more fertile than they really are (32). In reality, the incidence of conception, especially with increasing maternal age, is quite low compared to common estimates. As such, there has been a growing debate and concern amongst health and education professionals about the general lack of knowledge on fertility and reproductive health globally. Additionally, there have been several campaigns across Europe aimed at improving fertility awareness (33), especially on topics such as age-related fertility decline, knowledge of menstrual cycle and overestimation of assisted reproductive technology (ART) success rates. Significant advances in ART are also evident. However, this also focuses on potential solutions such as IVF and social egg freezing rather than on the possible root causes, which may include a lack of fertility awareness of potentially modifiable factors.
Clinics must recognise the importance of fertility awareness for general health. Improvements in cancer treatments such as chemotherapy and radiotherapy have significantly increased survival rates. Unfortunately these cancer treatments can adversely affect other aspects of a patient’s health, including reproductive health (34–40). Studies have shown that approximately one in ten cancer cases are diagnosed in men and women of reproductive age (41) and the loss of fertility is one of the long-term effects of prolonged cancer treatments (36,40). Evidence shows that cancer patients have significant concerns regarding the effect of cancer treatment on their fertility. Cryopreservation (freezing) of men’s sperm or women’s oocytes or embryos may give people with cancer or other medical treatments causing premature infertility the option to try and have children in the future.
Although many obese men and women experience normal fertility, obesity and being overweight, both of which are preventable, can have negative consequences, not only on general health, but also on reproductive health (42). Research highlights poor knowledge of the implications of obesity on reproductive health outcomes (43) such as menstrual irregularities, PCOS (polycystic ovary syndrome) (44), infertility (45), reduction in conception rates (46), lowered response to fertility treatments (47–51) and sexual dysfunction in women. It can also contribute to miscarriages and various other maternal and perinatal complications (42, 52–56).
Finally, various chronic health conditions can affect fertility. Diabetes in pregnant women is associated with an increased risk of stillbirth, miscarriage, complications, metabolic, developmental and growth abnormalities of the foetus and pre- and post-natal complications for the mother (54, 57–60). Women who develop gestational diabetes are also more likely to develop type 2 diabetes later in life (61). These issues are discussed in further detail in chapter 2.4 on diet and nutrition. Clinic staff should be aware of the range of health conditions that will affect individual fertility needs.