There were nine key themes identified in the analysis. Figure 3 presents these themes and their possible inter-relationships. The themes ‘stage of trying for a baby’, ‘knowing about my fertility’ and ‘best age’ were linked to pregnancy planning. The themes ‘time to ask for help’ and ‘fertility assessment tools’ were linked to knowledge and experience of products aimed at improving fertility and supporting conception. ‘New knowledge’ and ‘concerns’ were linked to views on a novel IUD aimed at assessing and improving fertility assessment. Below, each theme is briefly described along with illustrative quotes from participants.
Fertility and conception
Stage of trying for a baby. Current stage of trying for a baby seemed to be central for women’s opinions and experience regarding various aspects of fertility and conception. Women who had not started trying yet were more likely to assume natural conception and had limited knowledge about their fertility. Those who already started were more aware of fertility issues and appeared more likely to try various methods of fertility assessment, should they have problems conceiving naturally within certain timeframe (generally 6-12 months). Stage for trying for a baby seemed to be linked to participants’ age and life stage and had impact on knowledge about fertility, fertility assessment tools, and their opinions about the novel device.
Knowing about my fertility. Generally, women described a low awareness of their own fertility as well as its indicators.
I don’t think you can ever really know. I think it’s very difficult to know if you’re somebody who’s very fertile or not fertile. [Participant 9]
However, some participants believed that they could draw conclusions about their fertility in the context of age, general health, having healthy lifestyle, lack of family history of fertility problems and lack of negative symptoms.
I think it would be really shocking if I couldn’t get pregnant. I think I’m just assuming, naturally that I’m going to have no problems with it … I consider myself a relatively healthy person, and Josh is a relatively healthy person and there has been, as far as I’m aware, no problems in our families. So, I think it would be a bit of a shock, and my opinion might change if I found out that I couldn’t get pregnant, because I’m so desperate for children. [Participant 11]
Best age. The perceived ‘ideal age’ for trying to have a baby was much lower than the ‘realistic age’, which was often linked to having a stable relationship, career and financial situation.
Participants linked age to prediction of possible conception difficulties, as one of them explained: I don’t want my biological clock to run out [Participant 7]. There was also a minority voice that there was no ‘best age’. Some of the participants declared that age was one of the factors that would determine whether they sought medical help for trying to get pregnant.
Time to ask for help. Most participants saw conception as a ‘physiological’ process and that falling pregnant should preferably be achieved naturally. Self-help methods to enhance fertility known by participants included herbal/dietary supplements, having regular intercourse around ovulation time, and using acupuncture. Most participants did not know what their fertility chances were and were unsure when to ask for professional help.
But, yeah, in all honesty I wouldn’t know whether or not (I’m fertile) unless we’d, you know, had that check before… [Participant 2]
I think I don't really know that much about that (my fertility). I think when I saw my gynaecologist, but it was a couple of years ago, he said that I'm healthy and should be okay. [Participant 4]
A third of participants said that they would seek medical help if they had been unsuccessful in conceiving after specific time (mostly one year or six months) of trying. Participants who had passed their perceived ‘best age’ or who have medical histories would consider seeking help much earlier, even before actively trying to conceive. The GP was the first person they would contact. Participants felt that intrusive tests are necessary only if fertility issues become apparent once the couple starts trying. There was also a voice that adoption may be an alternative option.
I mean I want a child in my life…but I wouldn’t be averse at all to adopting... So, I would say within a year I’d be more likely to go down the adoption route rather than any kind of invasive methods. [Participant 11]
Fertility assessment tools. Participants’ knowledge about available products to assess fertility or support conception was limited. Most of participants were not aware of commmonly available methods of assessing fertility.
All I basically know is like old wives’ tales and over-the-counter things, but I’ve never really taken that seriously. I don’t know if that actually has any effect. [Participant 1]
Of the very few participants who mentioned ovulation kits, majority reported lack of knowledge regarding how they worked, but most knew that they played a role in assessment of ovulation time. A few participants used these kits or knew someone who had. Several participants mentioned ovulation apps, using the Internet sources, observing physiological changes over the cycle, or tracking cycles to determine the ovulation time and to enhance chances of getting pregnant. One of the participants’ partners had used an off the shelf ‘sperm count’ kit. Others were aware of additional medical tests which may be available on referral to a fertility specialist.
Novel intrauterine sensor fertility device
The opinions about the device seemed to be impacted mainly by the current stage of trying for a baby and participants’ knowledge about fertility assessment tools. Participants generally perceived an intrauterine novel device monitoring the womb environment as acceptable and potentially valuable in the fertility assessment. The majority of participants would only consider the device after a period of trying to conceive and had been unsuccessful, “I guess it seems a bit drastic if you haven’t tried to conceive yet because it’s almost like an extra level of detail you don’t really need to know” [Participant 9]. As described earlier, participants felt that pregnancy and conception should ideally be ‘natural’. ‘Medicalising the process’ is generally considered appropriate only when problems arise.
Concerns. Concerns about the novel device focused on discomfort, pain, safety and invasiveness. Participants were particularly concerned about pain and discomfort around the time of the device insertion and removal. Participants also felt that size of the device was important factor affecting acceptability. Participants preferred shorter durations of insertion, i.e. days rather than weeks/months, as they felt that this would minimise the potential risks. Participants perceived increased acceptability if the procedure for insertion/removal was quick, was done in an outpatient setting and/or performed by a medical professional. As one participant said:
If it’s not really having an impact on your life, it’s not a big procedure, then I think that would be a lot more acceptable to women and their partners in that situation. [Participant 9]
Participants expressed a need to be reassured about the safety of the device and had concerns surrounding potential risks (e.g. infection, damage to the integrity of the womb) and risks to their future pregnancies/babies. Participants compared the device to an intrauterine contraceptive device and recognised that the proposed novel device was an ‘invasive tool’. They had concerns that the device (perceived as a ‘foreign body’ by some), would ‘interfere’ with physiology or translate to a higher degree of risk than other ‘non-invasive methods’. However, one participant felt that the nature of the device was ‘less invasive’ than current methods of assessment:
“Well it’s less invasive than an exam, I guess at the moment, the other option is to have a camera on a stick…having something (device) up there for a couple of days, you’ll get a lot more information” [Participant 16]
New knowledge
Participants expressed a need to understand/be reassured about the relative added benefit compared to conventional methods. The potential addition of ‘new knowledge’ from this novel device was attractive and there was the expectation that the information obtained would complement current investigations, e.g. a blood test or scan. They were interested in the accuracy and the translational benefit of the result specific to the individual, particularly when there are problems with conception or maintaining a pregnancy. Interestingly, most participants did not grasp what factors the novel IUD would measure to determine the womb environment. Some suggestions included the ‘thickness of the womb’, ‘damage to the womb’, ‘hormones’, ‘timing of ovulation’, ‘various chemicals’, ‘ph’ and ‘temperature’. Participants felt that measurement of the womb parameters by the use of the local device is more valuable.
It may be that if it’s (the device is) inside, it’s getting better readings and accurate results… maybe because it’s in a specific area, you’re looking at more specific information. [Participant 15]
Participants generally expected the results generated from the novel device to be interpreted, and translated to clinical relevance and then communicated to the couple by a doctor or medical professional. Participants were more likely to find the idea of the device acceptable and useful the device if obtaining new knowledge from the device was going to help with treatment decisions or options; they saw benefits or potentially more streamlined and personalised care.
I think if it could give accurate results and those results were helpful in solving problems that women had, I think it could be a good idea. [Participant 15]
It was evident that the decision whether or not to accept the use of the novel device was a balance between the perceived benefits and risks.