Abstract
Over the last century, most industrialized countries have experienced a progressive increase in maternal age at first pregnancy and a reduction of fertility rate, with important social and economic consequences. Moreover in Italy a very restrictive law on assisted reproductive technologies was introduced in 2004, limiting its effectiveness and causing a strong public debate that unfortunately focused more on the political and ethical implications of the law than on the medical and technical aspects of assisted reproduction. The present study performed an epidemiological investigation among the students of Turin University in the year 2006/07 in order to assess three aspects: the factors affecting the decision to become parents, their level of consciousness about human reproduction and their level of knowledge about the legal rules that regulate assisted reproduction in Italy. The study also wanted to clarify how the sex (male or female) and the type of education (sciences or humanities) could affect their opinions and knowledge in this area. It was observed that young people consider parenthood an important part of their life, but knowledge about human fertility and legal rules regulating assisted reproduction is rather poor, regardless of sex and type of education.
Keywords
Introduction
Over the last century, a progressive increase in maternal age at first pregnancy and a simultaneous reduction of fertility rate (number of children per woman during fertile age) has been observed in most industrialized countries. In Europe, the lowest fertility rates are reported in Lithuania, Hungary, Poland, Portugal, Romania and Slovakia (1.25–1.35) (
EUROSTAT, 2009
, EUROSTAT, 2009. Luxemburg, European Commission. Available from: <http://epp.eurostat.ec.europa.eu/portal/page/portal/population/>.
Ledger, 2009
). The social and economic consequences of this trend are of great importance.As far as Italy is concerned, the slight increase in the fertility rate observed in recent years (from 1.18 to 1.40 from 2000 to 2008) is probably due to births occurring among couples moving to Italy from the developing world; in fact, 15.3% of the newborns in Italy now belong to foreign mothers, whereas the birth rate among Italians in the same time period did not increase (
ISTAT, 2009
). According to epidemiological data from the Italian national database, the mean maternal age at the birth of the first child was 28 years in 1995 and it is now slightly over 31 years (ISTAT, 2009
). In the study centre’s obstetric unit (which hosts more than 9000 deliveries per year), the mean age at the first delivery has increased significantly from 26.3 years in 1970 to 32.4 years in 2008. This demographic situation is rather alarming if one considers that women have the highest fertility potential (approximately 30% probability of conceiving per month of unprotected sexual activity) at around age 20. Moreover, it is well known that female fertility declines from the age of 30 (pregnancy chance 25% per month) and more sharply decreases after 35 years of age, reaching an annual cumulative conception chance that does not exceed 20% after age 40 (ASRM, 2008
, Baird et al., 2005
, Hassan and Killick, 2003
).Over the past few decades, the use of assisted reproductive technology has greatly spread all over the world. It has been estimated that the number of treatment cycles in the world rose from 89,000 in 1989 to 600,000 in 2006 (extimated data based on
Nyboe Andersen et al., 2009
, - Nyboe Andersen A.
- Goossens V.
- Bhattacharya S.
- et al.
Assisted reproductive technology and intrauterine inseminations in Europe, 2005: results generated from European registers by ESHRE: ESHRE. The European IVF Monitoring Programme (EIM), for the European Society of Human Reproduction and Embryology (ESHRE).
Hum. Reprod. 2009; 24: 1267-1287
Sunderam et al., 2009
, Zegers-Hochschild et al., 2009
). However, the value given is likely to be underestimated because the registers only include data from the USA and Europe. The rapid diffusion of the technology and its continuously increasing effectiveness are abundantly reported by the media and probably induce great expectations among people. However, despite a continuous improvement in results, the obstacle to conception represented by the woman’s age has not been overcome, at least in homologous treatments. In fact, the cumulative probability of having a baby by IVF is around 50% when the woman undergoes the procedure at 30 years, but it drops to only around 5–10% when she is age 40 (Leridon, 2004
).Are these data known by people in general? Recently, epidemiological investigations aimed at understanding the degree of awareness of fertility among young people and the importance they give to becoming parents were carried out in Sweden, the USA and Canada (
Lampic et al., 2006
, Martinez et al., 2006
, Tough et al., 2006
). Other epidemiological studies investigated the level of knowledge among young people about other aspects of reproduction: contraception and undesired pregnancy (Rasch et al., 2001
), medical consequences of delayed childbearing (Tough et al., 2006
) and infertility risk factors other than advanced age (Bunting and Boivin, 2008
). These studies showed quite clearly that although young people attribute a noticeable importance to parenthood, knowledge about human fertility is surprisingly poor. Furthermore, a survey among general practitioners in the USA clearly showed that even physicians may not be well informed about human fertility (Ceballo et al., 2009
).The present study conducted an epidemiological investigation among students of the University of Turin in order to assess their consciousness about fertility, their level of knowledge about human reproduction and the legal rules regulating assisted reproduction in Italy (
Benagiano and Gianaroli, 2004
). To this purpose, it must be considered that the Italian law on assisted reproductive technology introduced in 2004 was modified a few months ago by the Italian Constitutional Court, which cancelled some key parts of the text allowing procedures in Italy to be similar to that of many other countries. At the time of this study, however, the law had its original text (Benagiano and Gianaroli, 2004
) and in particular the following content: (i) no more than three oocytes could be used for fertilization, regardless of the woman’s age or the man’s sperm characteristics; (ii) any type of embryo selection was forbidden; (iii) it was mandatory to transfer in utero all obtained embryos (embryo cryopreservation was not allowed); (iv) any clinical or experimental research on embryos was forbidden; and (v) any type of heterologous technique was forbidden. This study also aimed at clarifying how the sex (male or female) and the type of education (sciences or humanities) could affect this knowledge and their feelings about parenthood.Materials and methods
This epidemiological investigation included students of the University of Turin in the year 2006/07 attending at the following schools: Agricultural Sciences, Medicine, Veterinary Medicine, Physics/Mathematics/Biological Sciences and Pharmacy (sciences schools) and Literature/Philosophy, Political Sciences and Law (humanities schools). The investigation protocol was approved both from the local ethical committee (St Anna Academic Hospital) and from each of the schools involved.
The students were randomly recruited immediately after a formal lesson and were asked to answer individually and anonymously to a questionnaire divided into three sections: (i) knowledge of human fertility; (ii) personal projects about family planning; and (iii) knowledge about assisted reproductive technology and the Italian law regulating it. All fulfilled questionnaires were immediately collected by the same researcher and stored.
At the end of the phase of questionnaire collection, a statistical evaluation was performed, during which the answers were grouped and analysed according to sex (males versus females) and type of education (sciences versus humanities) by means of the Chi-squared test. The level of significance was fixed at P < 0.05.
The questionnaire is available on request from the authors for further similar studies.
Results
A total number of 958 questionnaires were collected (76–150 per school). Among them, 607 (63.4%) belonged to females and 351 (36.6%) to males, a proportion that reflects the total population of students in the University of Turin (which in that year included 37,567 students, 62% of which were females) (Table 1). The students’ mean age in the study population was 22.1 years (range 19–37) for females and 21.9 years (range 19–34) for males. Among the students enrolled in the study, 559 (58.4%) were attending a sciences school, while 399 (41.6%) were attending a humanities school (Table 1). The proportion of subjects recruited in each single school ranged from 7.9% (Veterinary Medicine) to 16.7% (Political Sciences) of the total sample and was proportioned to the overall number of students attending each school.
Table 1Total student population and recruited study population at the University of Turin in the year 2006/07 with respect to gender and school of study.
| Characteristic | No. of recruited students (%) | Total no. of students |
|---|---|---|
| Gender | ||
| Male | 351 (36.6) | – |
| Female | 607 (63.4) | – |
| Total | 958 (100.0) | – |
| Sciences school | ||
| Agricultural Sciences | 77 (8.0) | 1612 |
| Physics/Mathematics/Biological Sciences | 142 (14.8) | 5668 |
| Pharmacy | 114 (11.9) | 1761 |
| Medicine | 150 (15.7) | 5954 |
| Veterinary Medicine | 76 (7.9) | 1029 |
| Total | 559 (58.4) | 16,024 |
| Humanities school | ||
| Literature/Philosophy | 106 (11.1) | 7569 |
| Law | 133 (13.9) | 6879 |
| Political Sciences | 160 (16.7) | 7125 |
| Total | 399 (41.6) | 21,573 |
| Overall total | 958 (100.0) | 37,597 |
The students’ answers to the part of the questionnaire regarding knowledge about fertility are shown in Table 2. Although students know that female fertility declines with age and about half of them thought that the decline starts between 30 and 34 years, the age at which female fertility sharply declines is considered to be 45–55 years by 53.1% of females, 36.9% of males, by 58.7% of humanities students and 48.8% of sciences students. The monthly pregnancy rate of an optimally fertile, young couple also appears overestimated: 58.2% of females and 41.2% of males indicated that the monthly pregnancy rate of an optimally fertile couple ranges between 50 and 100%. Overall, data on human fertility showed a lack of knowledge in both sexes and both type of education, with significantly lower knowledge in particular for most fertile age among females and humanities students (P < 0.0001 and <0.005, respectively) and for the starting age of female fertility decline among female students (P < 0.05). Females were more aware than males of the prevalence of couple’s infertility in Italy: the actual prevalence (around 20%) is known by 72% of female students, but by only 52% of male students. No significant difference had been outlined comparing humanities versus sciences students on this topic.
Table 2Questions and answers about human fertility, according to gender and school of study.
| Question | Answer (years) | Gender | School | ||||
|---|---|---|---|---|---|---|---|
| Female | Male | P-value | Humanities | Sciences | P-value | ||
| Which is the most fertile age in women? | 15–19 | 11.6 | 19.5 | <0.0001 | 12.0 | 16.4 | 0.005 |
| 20–24 | 68.8 | 59.6 | 66.1 | 64.9 | |||
| 25–29 | 18.9 | 19.8 | 20.6 | 18.2 | |||
| 30–44 | 0.7 | 1.2 | 1.3 | 0.5 | |||
| When does a slow decline in female fertility start? | 15–24 | 0.3 | 0.3 | <0.05 | 0.8 | 0.0 | NS |
| 25–29 | 6.6 | 10.1 | 4.3 | 10.6 | |||
| 30–34 | 52.0 | 45.7 | 48.1 | 50.7 | |||
| 35–49 | 41.1 | 43.9 | 46.8 | 38.7 | |||
| When does a sharp decline in female fertility start? | 25–34 | 0.0 | 0.6 | NS | 0.2 | 0.2 | NS |
| 35–39 | 9.4 | 10.8 | 9.1 | 10.4 | |||
| 40–44 | 37.5 | 35.8 | 31.9 | 40.5 | |||
| 45–55 | 53.1 | 36.9 | 58.7 | 48.8 | |||
| Which is the monthly pregnancy rate of an optimally fertile couple (woman <25 years)? | 0–29% | 7.5 | 10.0 | NS | 6.8 | 9.6 | NS |
| 30–39 | 13.4 | 21.2 | 13.2 | 18.4 | |||
| 40–49 | 20.9 | 27.6 | 21.6 | 24.5 | |||
| 50–100 | 58.2 | 41.2 | 58.4 | 47.5 | |||
Values are percentages or P-values based on Chi-squared test, unless otherwise stated.
NS = not statistically significant.
Questions about family planning showed how almost all students wish to have children in the future; the ideal number of children is considered between one and three by both sexes, with a significant trend towards two or three children for females and one or two for males (Table 3). The age at which most students desire to have the first child ranged between 25 and 34 years; women were more often oriented toward age 25–29 (59.7%), men toward age 30–34 (50.3%). These differences reached strong statistical significance (female versus male, P = 0.001), which was maintained after adjusting for the type of academic education (humanities versus sciences, P < 0.0001).
Table 3Questions and answers about family planning, according to gender and school of study.
| Question | Answer | Gender | School | ||||
|---|---|---|---|---|---|---|---|
| Female | Male | P-value | Humanities | Sciences | P-value | ||
| How many children do you wish to have? | 1 | 3.7 | 6.5 | 0.001 | 3.8 | 5.3 | <0.0001 |
| 1–2 | 26.4 | 34.6 | 29.3 | 29.3 | |||
| 2 | 23.9 | 18.4 | 21.4 | 22.3 | |||
| 2–3 | 33.6 | 25.5 | 33.2 | 28.8 | |||
| 3 | 7.7 | 6.5 | 7.4 | 7.4 | |||
| >3 | 4.7 | 8.4 | 4.9 | 6.9 | |||
| At which age do you wish to have the first child? | <23 | 0.5 | 0.6 | 0.001 | 0.3 | 0.8 | <0.0001 |
| 23–24 | 3.5 | 1.5 | 2.2 | 3.2 | |||
| 25–29 | 59.7 | 40.4 | 53.5 | 52.2 | |||
| 30–34 | 34.3 | 50.3 | 39.6 | 40.4 | |||
| 35–39 | 1.8 | 5.9 | 3.6 | 3.0 | |||
| >39 | 0.2 | 1.2 | 0.8 | 0.4 | |||
Values are percentages or P-values based on Chi-squared test.
When prompted with the hypothesis of future infertility and the choice of either undergoing treatment, adopting a child or refraining from becoming parents, participants reported a global tendency towards using treatment or adopting. This trend is maintained even when analysing data by sex or by type of study. About a third of the interviewed students were amenable to undergoing treatment or adoption. Only a small proportion of participants expressed acceptance to remain childless (data not shown).
The most important conditions to decide to become parents were having a stable relationship, sharing responsibility with a partner, feeling mature enough, having social assistance for children and having a stable job (data not shown). Economical issues (such as flexible working hours, a suitable home and good income) and having obtained graduation were not considered conditions sine qua non; however, they were considered important, in particular by females of both humanities and sciences groups. Having friends with children, having the possibility of a successful career and having led a carefree life for enough time before forming a family were considered not important. There was a general opinion that having babies would not impair the possibility of having a career, especially among males and sciences students.
The third section, knowledge about assisted reproductive technology, showed a generally limited knowledge about infertility problems and treatment (Table 4). Effectiveness, expressed as pregnancy rate, was better known by male students. Humanities students showed the tendency to overestimate the maternal and fetal risks linked to treatment and to underestimate its effectiveness. They considered: the drugs used as unsafe or doubtfully safe (75% of the replies), the fetal risks increased or doubtfully increased (72% of the replies) and the success rate per assisted reproductive technology cycle to be below 20% (more than 50% of the replies). The opinion of sciences students was more optimistic: 40.1% of them considered treatment to be devoid of significant fetal risks and about 60.1% of them estimated IVF effectiveness to be 20–39% for each attempt.
Table 4Questions and answers about the knowledge of assisted reproduction techniques, according to gender and school of study.
| Question | Answer | Gender | School | ||||
|---|---|---|---|---|---|---|---|
| Female | Male | P-value | Humanities | Sciences | P-value | ||
| Are the hormonal drugs used in assisted reproductive technology safe? | Yes | 29.1 | 24.9 | NS | 25.2 | 29.4 | 0.005 |
| No | 19.2 | 19.5 | 15.9 | 19.2 | |||
| Don’t know | 51.7 | 55.6 | 58.8 | 49.0 | |||
| Are fetal risks increased in assisted reproductive technology? | Yes | 8.5 | 6.1 | NS | 9.1 | 6.7 | 0.0002 |
| No | 33.1 | 38.2 | 27.6 | 40.1 | |||
| Don’t know | 58.4 | 55.7 | 63.2 | 53.2 | |||
| What is the pregnancy rate of one assisted reproductive technology (IVF) attempt? | 1–19% | 47.1 | 27.2 | <0.0001 | 50.8 | 32.2 | <0.0001 |
| 20–29% | 31.5 | 36.5 | 30.0 | 35.7 | |||
| 30–39% | 17.5 | 27.5 | 16.3 | 24.4 | |||
| 40–100% | 3.7 | 8.8 | 2.9 | 7.4 | |||
| No answer | 0.2 | ||||||
Values are percentages or P-values based on Chi-squared test.
NS = not statistically significant.
The knowledge of Italian law on assisted reproductive technology was poor overall, although in general it was perceived as severe and restrictive (Table 5). Interestingly, about 15% of the students thought that IVF had become illegal in Italy and about 12% were doubtful about its legality. More than half of the enrolled students in both sciences and humanities groups considered research on human gametes illegal or doubtfully legal, even if the question was formulated stressing that gametes are spermatozoa and non-fertilized oocytes. About 50% of students (in both sciences and humanities groups) did not know what to answer to the question about embryo cryopreservation; only about 45% of the students in both sciences and humanities groups were aware of the legal regulation of preimplantation genetic diagnosis. The answer regarding the maximum number of embryos that could be generated in a single IVF cycle had the highest proportion of correct replies regardless the type of school attended (about 65% of cases), only 21% of the students being convinced that there was no limit.
Table 5Questions and answers about the knowledge of the Italian Law regulating assisted reproductive technology.
| Question | Answer | Gender | School | ||||
|---|---|---|---|---|---|---|---|
| Female | Male | P-value | Humanities | Sciences | P-value | ||
| Is IVF legal in Italy? | Yes | 78.5 | 65.9 | <0.0001 | 76.0 | 72.4 | NS |
| No | 12.9 | 17.3 | 13.8 | 15.1 | |||
| Don’t know | 8.6 | 16.8 | 10.2 | 12.5 | |||
| Is research on oocytes and spermatozoa legal in Italy? | Yes | 22.2 | 24.9 | NS | 22.7 | 23.5 | NS |
| No | 55.7 | 52.9 | 57.4 | 52.8 | |||
| Don’t know | 22.0 | 22.2 | 19.9 | 23.7 | |||
| What is the maximal number of embryos obtainable in one IVF attempt in Italy? | One | 11.3 | 13.9 | NS | 13.5 | 11.5 | 0.04 |
| Three | 69.1 | 63.1 | 68.5 | 64.9 | |||
| No limits | 19.5 | 21.9 | 16.9 | 23.6 | |||
| Is embryo cryostorage legal in Italy? | Occasionally | 24.9 | 29.7 | 0.02 | 24.4 | 28.4 | NS |
| Never | 29.5 | 21.2 | 27.9 | 25.4 | |||
| Don’t know | 45.6 | 49.0 | 47.7 | 46.0 | |||
| Is preimplantation genetic diagnosis legal in Italy? | Yes | 9.4 | 13.9 | 0.002 | 7.7 | 13.7 | 0.02 |
| No | 48.7 | 37.7 | 46.5 | 43.2 | |||
| Don’t know | 41.8 | 48.4 | 45.8 | 43.0 | |||
Values are percentages or P-values based on Chi-squared test.
NS = not statistically significant.
Discussion
The sample of students enrolled in the present investigation can be considered representative of the entire population of academic students in Turin since the schools that agreed to join the study include over 60% of the total number of university students. It is questionable if the results of the present investigation could be extended to the entire Italian academic population, as profound differences might be present among different geographic areas of Italy that traditionally have heterogeneous cultures.
There were 150 medical students in the study sample, 27 from the Dental School and the others from the Medical School. None of them had yet attended the obstetrics and gynaecology lessons. It is therefore likely that they had no specific information about human reproduction.
Rather surprisingly, about 90% of the students who received the questionnaire returned it correctly completed. This did not happen in the Swedish study (
Lampic et al., 2006
), in which the questionnaire was sent by ordinary mail and around 40% of the interviewed students failed to return it. The high response rate in this study’s population probably depends on the direct collection of the questionnaires by the interviewer.In general, the results of the section on fertility knowledge showed an overestimation of the reproductive potential of human beings. Both the monthly pregnancy chance of couples below 25 years of age with unprotected regular sexual intercourse (
ASRM, 2008
, Baird et al., 2005
) and the pregnancy chance per year for women between 35 and 40 (ASRM, 2008
, Baird et al., 2005
, Hassan and Killick, 2003
) are much lower than estimated in this study.Overestimation of fertility may be one factor contributing to the finding that a large proportion of female students expressed the will to postpone the first pregnancy to after age 30 or even after age 35. The same concept was even more stressed among male students. This trend on family planning is apparently in contrast with the concept, quite widespread among students, that female fertility is higher between 20 and 24 years of age but is compatible with the idea that female fertility persists until advanced ages.
Analysing data by the type of education (sciences versus humanities schools) did not find any socially relevant, significant difference. The opinion of sciences students about the age-linked fertility reduction in women was slightly more realistic than that of humanities students, but still much more optimistic than reality. In line with previous studies (
Lampic et al., 2006
), females were more aware of the biological clock than males. In any case, there was a dramatic overestimation of fertility even by female students, which was even more marked among female students attending schools with courses of longer duration (e.g. Medicine).Data on family planning showed a striking contrast between the desire of a family before 30–35 years of age and the social needs considered as indispensable requirements to build a family. Having social assistance for children and a stable job were the strongest requirements and a flexible job, a suitable home and a good income were considered important. These needs are not currently easily attainable, at least in Italy; they should be taken into consideration by institutional organizations taking care of social and economic planning.
The questions on assisted reproduction therapies outlined a general lack of knowledge about the procedures and the drugs used. Drugs were considered with a certain degree of fear, particularly in relation to the potential onset of malformations in the newborn; this opinion was more widespread among humanities students than among sciences students. The most recent literary reviews do not confirm any significant increment in malformations among babies born with assisted reproduction techniques, even when they are considered at 3-year follow-up (
Basatemur and Sutcliffe, 2008
, Ceelen et al., 2008
, Elizur and Tulandi, 2008
). Conversely, sciences students expressed a more marked general trust and optimistic view about the effectiveness of IVF techniques. Overall, however, in spite of the lack of knowledge there was a global positive attitude towards assisted reproduction treatment, paralleled by the high proportion of participants answering that they would find it difficult to remain childless and would chose to undergo treatment instead of adopting a child.The answers about Italian law on assisted reproductive technology showed a general lack of knowledge, which was rather surprising as 93.4% of the interviewed students had already reached the legal age for voting at the time of the public consultation on assisted reproduction, which took place on June 2005. Interestingly, when only 24.5% of people voted at this public consultation, the very low participation was interpreted as the will to avoid changing the rules, whereas it was rather a sign of the general lack of interest and information on the subject (
Benagiano, 2005
).In conclusion, the results of this investigation are comparable to those obtained in Sweden in 2006 (
Lampic et al., 2006
) and probably reflect the opinion of university students of all industrialized countries. The results presented herein are alarming with respect to a probable delay of parenthood among university students, which is linked to social reasons but also to a lack of awareness of age-related decline in human fertility. The importance of information about fertility is self-evident; information should be markedly improved to get a more conscious decision about life planning by young people. This kind of information should be given already during compulsory schooling in order to reach those that will not attend university and should be reinforced by general practitioners, gynaecologists and nurses during the first meetings with young girls at the beginning of their reproductive life. Moreover, institutional bodies should take care when giving specific information on human fertility to the media or in seminars at schools, as has been done in the recent past for contraception.References
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Article info
Publication history
Published online: April 26, 2010
Accepted:
March 10,
2010
Received in revised form:
January 4,
2010
Received:
September 1,
2009
Declaration: The authors report no financial or commercial conflicts of interest.Footnotes
Valentina Rovei completed her medical studies and her specialization training in Obstetrics and Gynaecology at the University of Turin, Italy. Now she is attending the PhD course at the Reproductive Medicine and IVF Unit, Department of Obstetrical and Gynaecological Sciences, University of Turin. Her fields of special interest ad research are polycystic ovary syndrome, embryo transfer techniques and epidemiological studies in human reproduction.
Identification
Copyright
© 2010 Reproductive Healthcare Ltd. Published by Elsevier Inc. All rights reserved.
