Search results

Figure 1 summarizes the study selection process. A total of 704 studies were retrieved in the initial search, and 616 were retained after removing the duplicates. Subsequently, 504 studies were deemed irrelevant and excluded after screening the titles and abstracts. Next, we carefully reviewed the full text of 112 studies, of which 91 were excluded for various reasons. Finally, 21 studies were included in the systematic review.

Fig. 1Study characteristics

Table 1 summarizes the features of the included studies published between 2006 and 2022. The sample sizes of the included studies ranged from 149 to 4906 individuals. All data were from 18 countries, with about 50% of the studies conducted in Europe (n = 12), 5 in the Americas, 3 in Asia, and 1 in Africa. Most were cross-sectional studies (n = 18), 2 were pre-test/post-test intervention studies, and 1 was a case–control study. The 21 studies included in the analysis focused on FA, but the measurement tools used were not identical, and the measurement methods were mostly self-reported questionnaires or interviews. Among them, the most commonly used is the FA scale developed by Lampic in 2006. The questionnaire mainly used different response scales and a format of true and false, multiple choice, or open-ended questions. None of the included studies reported global reproductive awareness scores. The topics explored included fertility risk factors, age-related fertility decline, infertility definition, intended behavior in the event of infertility, in vitro fertilization (IVF) treatment knowledge, and factors influencing FA.

Overall FA

A total of 10 studies explicitly reported the level of FA among college students. In comparison, seven studies reported a marked lack of awareness of fertility issues among college students and low levels of FA [11, 12, 14, 16,17,18, 20, 25], and two studies reported high levels of FA [10, 26]. The remaining studies reported college students’ knowledge of human fertility and their knowledge of assisted reproductive technologies (ARTs).

Specific dimensions of FAAge-related fertility decline

A total of 16 studies analyzed the level of awareness of fertility declining with age. Among these, 14 reported low FA, indicating that college students overestimated the chances of having children at an older age [6, 7, 10,11,12,13,14, 16,17,18,19, 22,23,24], and only 2 had high FA, indicating that college students had a realistic view of fertility [25, 26].

Typically, there is a general lack of age-related awareness among students about declining human fertility. For example, research in Argentina showed that 36.2% of female students believe that female fertility declines between the ages of 45 and 50 years, 33.2% between the ages of 40 and 45 years, and 25.9% between the ages of 35 and 40 years; 57% of male students believed that male fertility does not decline with age [6]. A study in China showed that students overestimated the age of optimal fertility (69% of men, 79% of women), and they greatly overestimated the age at which female fertility began to decline (91% of men, 93% of women) [17]. Only a few participants realized that a slight decline in female fertility began before 30, and a significant decrease occurred in the late 30 s [7]. The two studies that reported high fertility awareness were conducted on medical students, with the majority of women in the US study (59%) with accurate knowledge that fertility peaked between the ages of 20 and 24 years, and 51% correctly identifying the period of significant fertility decline between the ages of 35 and 39 years [25]. About 75% of participants in a European study precisely indicated the optimal age for childbearing and the age at which fertility declined significantly [26].

Fertility risk factors

Five studies reported students’ awareness of fertility risk factors. These studies showed that college students had some understanding of fertility risk factors and could answer most of the risk factors correctly [6, 10, 16, 21, 26]. Most people are highly aware of the dangers of smoking and alcohol as bad habits for fertility [6, 10, 16, 21, 26]. At the same time, other lifestyle options (overeating, prolonged physical exertion, and irregular sleep patterns) were significantly less chosen. There is substantially less awareness of child-damaging behaviors, such as an unbalanced diet, excessive physical effort, and irregular sleep [21]. Two studies mentioned that students ranked age as a significant factor in fertility [6, 26]. A study in Argentina showed that students also recognized drug use (79.2%) and sexually transmitted infections (43%) as seriously affecting fertility [6]. Two studies identified the genetic disease factor [16, 21]. In summary, we observed that the level of awareness of students regarding fertility risk factors varies from medium to high.

Infertility definition and intended behavior in the event of infertility

Four studies assessed University students’ knowledge of the definition and related understanding of infertility. They found that they generally had limited knowledge of infertility problems and treatment and little sense of the intention of infertility and the associated causes of the disease [12, 15]. Many students (45.6%) answered that 40–60% of couples might experience difficulties conceiving, while 33.8% said it could be a problem for 20–40% [6]. 55% of women and 42% of men are aware of the prevalence of infertility [7].

A total of 12 studies investigated the intended behavior in the event of infertility. The study participants in the USA and European countries remained open to ARTs and were willing to undergo in vitro fertilization (IVF); no significant differences were observed between the sexes [7, 10,11,12, 20, 22, 23, 26]. Participants also reported the global trends in child adoption, with young people in Nigeria and Mexico and women in South Korea believing adoption is better than pursuing IVF [18, 24, 26]. In the case of infertility, the proportion of childless lifestyle choices is lower, and studies have shown that both men and women are less comfortable living childless [7, 10, 12, 23]. Surprisingly, younger people in Hong Kong are more likely to choose to remain childless and less likely to seek medical treatment or adoption than sample populations from the USA and Europe [17].

Knowledge about IVF treatments

Ten studies assessed University students’ knowledge of ARTs [6, 7, 9, 10, 17,18,19, 22,23,24]. The study showed that young people have a specific understanding of ARTs, such as IVF, with 26.8% of students saying they know what ART is, 39.2% saying that the probability of success of a single IVF cycle is < 40% and the majority (90%) said they understood the meaning of egg freezing [6].

However, young people were unable to assess the success rate of ART and showed undesirable confidence in the ability of fertility treatment to deliver positive results. A study in Saudi Arabia showed that only 22% of students overestimated the success rate of ART treatment [19], and 25% of young people in a Spanish study correctly answered the possibility of having a child through IVF [23]. Other studies were unsatisfactory, with 50% [23] to 75% [24] of participants overestimating the success rate of IVF and IVF with different techniques. In some countries with strong religious beliefs, ART is relatively unpopular.

Influencing factors of FAGender

Six studies have shown that female students are more aware of fertility than male students, age-related fertility decline, and factors affecting fertility [7, 9, 10, 14, 21, 26]. Among these, a Swedish study showed that although women perceive fertility problems accurately, they are also likely to overestimate the chances of getting pregnant at ovulation and receiving a child through IVF [7]. Another four studies concluded that students generally lacked awareness of fertility issues, had low fertility awareness, and had no apparent differences between the sexes [11, 20, 23, 24].

Major

Five studies explored the differences in levels of FA among students in different majors [10, 12, 19, 21, 26]. Three of these studies compared the awareness of fertility issues between medical and non-medical students. They showed that medical students had higher levels of FA than students from other disciplines [10, 21, 26]. However, a study in Saudi Arabia showed that medical students were less aware of fertility, as only 52 (33.1%) of medical students believed that women had the easiest time having children at the age of 15–25 compared to 68.6% (P = 0.001) in other health professions [19]. Another study showed that science students are more aware of fertility than humanities students and have a more realistic view of fertility issues [12].

Education

Since this systematic review was on FA among college students, there was little difference in the educational level of the participants. Two studies compared the differences in the ranks of FA between undergraduate and graduate students, suggesting that years of schooling affect FA; people with high education had high levels of FA [21, 25].

Age

Only one study discussed the effect of age on FA, and the results showed that older participants had higher FA and a deeper understanding of fertility issues than younger participants [14].