From “Infertility Knowledge and Attitudes in Urban High School Students”
by.1 Clifford Librach and Susan Quach
Adapted by Naomi Louder for Creating Families (Fall 2009)
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Where infertility is concerned, we usually think of the reproductive-age couples affected, and we focus on the treatments that are available rather than on prevention. Several common causes of infertility are easily preventable, and many organizations on the front lines of infertility awareness – IAAC among them – are working to raise awareness, especially among youth, in order to prevent future problems. But don’t young people already know enough from sex education classes, the Internet, and all the other resources available to today’s generation? According to a recent Canadian study, the answer is a resounding “No!”
The study in question, “Infertility Knowledge and Attitudes in Urban High School Students,” was published in 2008, in Fertility and Sterility. It assessed attitudes and knowledge of factors that can affect future fertility in a diverse Toronto high school population. Led by noted fertility specialist Dr. Clifford Librach, reproductive endocrinologist at Sunnybrook Health Sciences Centre, and co-investigator Susan Quach, MSc, the study surveyed 772 eleventh and twelfth grade students to gauge their knowledge and attitudes about infertility.
When asked to list some actions they could take to protect their fertility, some students suggested incorrect actions like using tampons, drinking milk, using birth control pills, not masturbating, and not drinking Mountain Dew soda. More than 94% of students were unable to identify a single sexually transmitted infection (STI) that causes infertility. Students were also remarkably ignorant of other common and preventable factors that affect fertility such as being overweight or underweight, smoking, drug and alcohol use, injuries to the groin area (male), and waiting too long to have kids. In many cases, these factors are preventable, and it is essential to educate young people as they begin to make lifestyle choices that may determine the course of their adult life.
Teens at high risk
STI are perhaps the most urgent fertility risk for teens. Chlamydia or Gonorrhea infection, which can lead to PID (pelvic inflammatory disease) and tubal blockage in women, are most common among teens and young adults between 15 and 24 years old. When these infections are detected early enough and treated with antibiotics, they are relatively minor. But in the case of Chlamydia, for example, there are often no symptoms, or symptoms so mild they are easily ignored, especially by teens who are often too embarrassed to seek medical attention. When left untreated, a significant proportion of these infections in women and girls cause scarring in the fallopian tubes, potentially leading to infertility.
And there are several other areas that pose a high risk to teens’ future fertility. In boys, sports injuries affecting reproductive health are most likely to occur in high school or college athletics. Eating disorders develop most frequently among adolescent girls, and habits of overeating or under-eating developed in adolescence often persist or even worsen in adulthood. Finally, we see many people nowadays choosing to start their families in their late thirties or forties. To teenagers, especially teenage girls, this begins to look like the norm. It is important to inform the new generation about the potential drawbacks of waiting too long to start a family. Quach and Librach’s study surveyed the largest school board of the greater Toronto area, and a total of 772 eleventh and twelfth grade students from 18 schools participated. In order to get as clear a picture as possible of teens’ fertility awareness, the survey questions were distributed during math and English classes, rather than during health or sex education. Parts of the test were aimed at gauging students’ demographic groups; other questions aimed to assess their knowledge and understanding of fertility issues and asked them to rate how important they felt it was to protect their fertility.
Risk assessment and student demographic
The vast majority of teens knew the meaning of the words fertility or infertility, but more than 80% underestimated the infertility rate. Most female students knew that age is a factor, but 34% of them were unaware that smoking could affect fertility, and almost a quarter of students did not know that drug and alcohol use are harmful to fertility. Perhaps most important, almost half (43%) of students were unaware that STIs can cause infertility. The majority of students – 81% – did not know what pelvic inflammatory disease was. When asked to name an STI that could cause infertility, only 6% of students named Chlamydia, and 5% named Gonorrhoea; female students were significantly more aware, however, than males.
Although many students were unable to name STDs that cause infertility, the survey structure may have posed an additional challenge: the questions relied on students’ memories rather than giving them a list to choose from. Other studies have shown that students have a somewhat greater awareness of the different STIs that can jeopardize fertility, possibly because these studies provided the names of infections and students simply had to select them; or because the studies were performed in clinics where subjects had been exposed to more information through contact with doctors and nurses. However, it seems clear from this study that the students’ knowledge of risk from STIs – and other factors – is inadequate.
Another disquieting discovery related to the difference in awareness between demographic groups. Although the study was done in an urban centre, representing students from a wide variety of cultural backgrounds and experience, a distinction was made between the students from schools with low socio-economic status (SES) ¬ in other words, schools in poorer neighbourhoods ¬ and high SES schools, in more affluent areas. The students in the high SES schools had significantly more correct responses on the survey than the low SES students, although there was plenty of room for improvement in the high SES group as well. The lack of knowledge in the low SES group is especially disturbing, since members of this group will also be less likely able to pay for quality fertility treatment as adults under the current system, where only a fraction of Ontarian infertility cases are covered by provincial healthcare. Where there’s a will there’s a way?
This study found one encouraging factor: in the majority of cases, high school students value their fertility, and would like to protect it. Roughly 70% of the teen respondents affirmed that protecting their fertility was important to them. This indicates that a prevention-oriented approach to infertility awareness is appropriate. If youth were ambivalent or apathetic about their fertility, it would be even more difficult to reach them. The proportion who claimed they would be embarrassed to ask for information about fertility (18%) is an even greater indication that initiatives must be taken to reach these students – they’re not going to go looking for the information on their own. And about 20% of boys and 14% of girls still stated that they would not take part in STD screening.
Health education for fertility prevention
The sex or health education curriculum in Ontario could benefit from greater emphasis on STI-related infertility. While STI education is mandatory for grade 9 and 12 students, the curriculum does not explicitly draw the connection between these infections and infertility. Students are told how the infections are transmitted, and how to prevent them, but not that an untreated infection can lead to scarring and tubal blockage. This should certainly be addressed. Without clear knowledge of the risks these infections pose, many students will leave infections untreated, too embarrassed to seek medical attention. Teens also need to be aware that the “biological clock” is no myth and that waiting too long to start a family can also have a significant effect on their fertility. Having this information early on can help women with family planning when they are in their twenties and early thirties. Too often, infertility specialists hear the lament, “I only wish I’d been educated in my youth about the risks of waiting too long to start a family.”
Only a few initiatives have been implemented so far in North America with the specific aim of educating teenagers about their fertility, and this study shows that more education is needed. While youth express a clear desire to protect their fertility, the current health education curriculum in Ontario does not adequately help them to do so. Those teens who are knowledgeable or cautious enough to see the need for STI screening may find out about fertility risks from doctors or nurses when they visit a clinic. But it’s clear that there should be more healthcare and health education in infertility prevention specifically targeted to teens. Anyone experiencing infertility, working with those on the journey or looking at the figures that represent the cost of a single cycle of IVF will agree that anything that can be done to prevent infertility should be done – before it’s too late.
1. Quach S., Librach C. Infertility knowledge and attitudes in urban high school students. Fertility and Sterility. 2008:90(6);2099-106.
Dr. Clifford Librach completed his medical school and ob/gyn residency training at the University of Toronto, and a fellowship in reproductive endocrinology and infertility (REI) at the University of California, San Francisco. Dr. Librach is a board certified Reproductive Endocrinologist and Infertility Specialist. He is currently an Associate Professor at the University of Toronto, chief of the division of Reproductive biology at the Sunnybrook Health Sciences Centre and the Women’s College Hospital in Toronto, and director of Create Fertility Centre. His research focuses are related to stem cells derived from the umbilical cord and reproductive immunology. Dr Librach is frequently interviewed on television, radio and in newspapers and magazines and serves on various national committees related to reproductive technologies. Susan Quach completed her epidemiology training at the University of Calgary, where she also studied at the Western Regional Training Centre for Health Services Research. She is an epidemiologist with research interests in infertility, influenza, critical care medicine, risk adjustment and cardiovascular disease surveillance. Currently, she is working on developing a national cardiovascular disease surveillance at the Public Health Agency of Canada. In her spare time, she enjoys playing the piano and learning various styles of dance.
Naomi Louder has edited Creating Families on a contractual basis since February 2008. She is a freelance writer and certified translator (French to English, McGill University). Besides medical writing, her interests include sociology, environmental science and human rights.