Table 2 Themes on barriers and enablers to a healthy lifestyle in people with infertility

Psychological capability

Memory, attention and decision processes; Knowledge

Managing whole-body health and disease

B: Difficult to follow healthy lifestyle with comorbidities

In the last two and a half months I haven’t been able to exercise. I got injured in my lower back. (M2)

There’s been times where I had depression and stuff, and when COVID lockdowns and stuff, I didn’t do a lot. I just ate; drank and ate, and didn’t really focus on that then. (W5)

B: Difficult to follow healthy lifestyle with risks and side effects of fertility treatment

When I’m giving myself injections, I don’t feel like running on the treadmill. (W5)

You want to do the exercise because you know that you shouldn’t be putting on that much weight, but then it’s hard because the medicine actually makes you put on weight. (W4)

But there were also times where they said, you’re probably best if you don’t exercise because it might cause torsion. (W2)

E: Healthy lifestyle to manage comorbidities

I’ve had reflux and gallstones so I know that both of them are affected by diet and that is long term benefits of healthy eating and exercise. (W2)

I feel like having a healthy diet for myself would be beneficial because it would help potentially with my underlying PCOS, which then will hopefully help with fertility. (W9)

E: Healthy lifestyle to manage risks and side effects of fertility treatment

Especially if you’re going through the IVF process where you’re already having to inject yourself with lots and lots of hormones and that and you’re already feeling uncomfortable so it’s better to try and eat healthier. (W4)

It would be nice if they put some exercises or some stretches together because when you’re going through it (fertility treatment), sometimes you get cramps… it’s painful and maybe they’ve got some ideas, maybe some stretches or something to help. (W4)

I have to do anaesthetic. I don’t want to be in a high-risk category, so I need to keep my weight within the limits and everything. (W4)

Knowledge

Understanding the mechanisms and pathophysiology

B: Insufficient evidence on lifestyle

I wish there was more information on it. I wish there were more studies. (W8)

B: Uncertainty of conception probability after lifestyle change

Maybe that’s why our doctors don’t talk about it, because there hasn’t been anything specific where it’s like, yes, if you stop A then you will get pregnant, or if you eat B then you’ll get pregnant. (W8)

You see people that eat takeout all the time and are just not healthy, and they have babies so easily, and then you’re, yeah—I still don’t really understand why. (W7)

B: Vulnerable population for misinformation

I think as much as you’ve got conscious mind of where the credible information is, the subconscious and being led by emotion could lead you down a different path and probably open you up to be more accepting of certain information as well, despite the less strong evidence. (W6)

E: Baseline knowledge of relationship between lifestyle factors and pregnancy outcomes

It’s like if you don’t eat healthy or you don’t exercise, well, if you consume alcohol and tobacco and all that, that has a big impact on the sperm quality. (M2)

E: Want information from evidence-based sources on lifestyle and fertility

(I go to) reputable sites. Obviously, your Better Health, NHMRC for example, Healthy Guide. (W6)

Physical opportunity

Environmental context and resources

Limited time, resources and money

B: Higher cost of health foods

Sometimes I’m broke and mightn’t be able to afford the foods that I want to buy. (W1)

Salmon is whatever is it now, 35 per kilo as it is, and then you get a free-caught wild one, and that’s suddenly $60 per kilo. I mean, how am I going to live? (W5)

I can get healthy food fairly easily, but I can get all the unhealthy stuff a lot more easily. (W2)

B: No scope to delay fertility treatment

They’re like, no, you’re running out of time, you need to do it now, you need to do it now, and, no, there’s no time to lose weight first, no, there’s no time for this first, just do the best you can and we’ll try and get it to work (W2)

B: Time constraints

I opt for speed and convenience versus really thorough cooking. (M1)

I’m just sometimes finding a struggle in finding the time in the day. Also, what I traditionally did sports for was for my figure, and so if I do cardio or work out at the gym, that has more effect than yoga. So, if I can only do either/or, because the day has so many hours, then I traditionally had tried to do more intense sessions. (W5)

B: Work commitments

When I come home from work, I didn’t want to go and do more stuff and exercise. I just wanted to rest. (W1)

E: Finding lifestyle strategies that require minimal time and resources

I just have to plan a little bit and if I’m too busy with work or I’m really tired, what I’ve been doing is actually prepacking my meals. (W4)

E: Flexible working arrangements

The majority of the time we can still work from home. That has given me the flexibility to prepare meals ahead. (W4)

E: Putting lifestyle management into perspective

(A healthy lifestyle) takes time and money you’ve got. That’s nothing compared to what all the fertility stuff takes. (W2)

I don’t buy into this whole thing of, healthy eating is more expensive. Yes, the organic part, yes, but I’m not saying that eating healthy is more expensive than eating McDonald’s. McDonald’s is relatively expensive. (W5)

Unmet needs from the healthcare system

B: Health professional refusal to provide lifestyle care

The other ones (gynaecologists) have just not wanted to talk about it (lifestyle). (W2)

The nurses– they’re like, oh, that’s not me. You’d have to talk to the fertility specialist. I’m like, well, but they don’t talk to me anymore. They’ve talked to me at the beginning, when they wanted my business, and then there’s no other sessions, so when am I – and then the embryologist obviously has their own little niche. They’re like, oh, no, I only look at the embryo, but then if I ask a question that’s beyond, they’re like, ooh, that’s not my – you need to talk to the nurse. (W5)

B: Inconsistent messaging from siloed information sources

I don’t know quite who to believe, how important it is. (W2)

She (acupuncturist) wasn’t a fan of IVF as such, I guess, and that’s what I’m finding in this journey, that some of the medicines, traditional versus alternative, they’re very anti each other. So, I find from the – and it’s not complementary at all. The IVF people do not care whatsoever about nutrition. (W5)

B: Perfunctory lifestyle advice with a one-size-fits-all approach

Maybe there was a line in one of the paperwork that one gets from the IVF clinic, that says, make sure you eat healthy and drink enough water. I’m not saying that that wasn’t there. Maybe that was there, but for somebody who’s not educated in food, or who doesn’t make it a passion, what does that even mean for them, right? (W5)

B: Privatisation compromises quality of care

I guess it’s an industry now, and everybody loves to make money out of it. (W5)

Optimal intervention strategies

E: Clear advice with practical strategies

Getting provided examples of some healthy meals or things you can add into your diet would be great, and maybe some exercise programs or things you can do at home would be really good. (W9)

E: Engaging information provision

It has to be a bit more eye catching, bit more of an interesting read. (W6)

E: Inclusive program to accommodate individual needs

It would have to be something that would be catered to, or that would accommodate my veganism. (M1)

We’ve all got different things that work for us and I don’t think I’d participate if it was really prescriptive. (W2)

E: Qualified allied health professionals integrated into fertility treatment

But, because they have the embryologist and the fertility specialists, they have all these specialties, but if nutrition is very important, which we know it is, then they should probably hire somebody in that capacity, who you can call, and also, who calls you. What I’m struggling with a little bit is the lack of proactive, from their side. (W5)

They will get a psychologist to screen you beforehand. There will be a police check beforehand. I think maybe it’s also worthwhile having a health coach as part of that beforehand, just to have a chat to you about overall, not just about fertility but about nutrition when you fall pregnant, the risk of gestational diabetes for example, pre-eclampsia. Maybe also chatting about how the journey, like the IVF journey could impact on somebody’s health and weight. (W6)

E: Support with motivation and accountability

It would have to be fairly motivating because I find motivation pretty difficult. (W2)

I think the weigh-in would be helpful because at least then it gives you something to track on so that you know that you’re not putting on weight, at least. (W4)

Social opportunity

Social influences

Interpersonal dynamics

B: Misunderstood role of the male partner

There’s always been like such a focus on women. It would be good if men were involved in it more too but it’s so patchy for them to talk about that. (W7)

B: Social obligations while navigating sensitive nature of infertility

It’s not something that you really broadcast widely, or I didn’t, that we were trying. (M1)

They’re like, oh, what do you want to diet for? What’s the point in eating all that good stuff? (W2)

E: Independence and resilience

I’m not really swayed by what other eat. (W9)

We are responsible for ourselves. (M2)

E: Support from family, peers and friends

She (partner) was definitely very, very supportive and did everything she could to take us on that journey together. (M1)

I had a workmate and she had diabetes, and I said, oh, let’s have lunch together and let’s bring food in that is salad-based. (W3)

E: Sensitivity in communication from health professionals

Just providing that information and that safe space to have a chat would be good – without feeling judged. (W9)

Reflective motivation

Social/professional role and identity, goals, intentions, beliefs about capabilities

Considering the stage of behaviour change

B: Difficulty sustaining lifestyle change throughout fertility journey

They keep saying my chances would be better if I was in a healthy weight range and I haven’t got back to that. I almost did but then had a failed attempt and was not really doing the best stuff so it went back up again. (W2)

B: Negative self-perceptions

They’re running around, doing five kilometre runs a day. I’m not doing that because I’m totally unfit right now. (W4)

E: Confident in skills required to maintain healthy behaviours

From conceiving point of view, I haven’t changed much my approach to exercising or sporting because I always considered that I’m fairly active. (M2)

E: Internalising responsibility for lifestyle to optimise fertility treatment outcome

If we start an IVF treatment and we just dedicate to drink and watch movies all the time and not consider an active lifestyle, we know that we are jeopardising our chances. There is an important element there, which is we are responsible of ourselves. (M2)

Beliefs about consequences

Valuing the broader benefits of a healthy lifestyle

E: Health benefits whether trying to conceive or not

If it’s going to make you healthier overall in general, then why not? (W7)

E: Offset gestational weight gain

But it does sound like a good idea doing it (weight loss) first because then whenever it happens, you’re going to be pregnant and putting on weight and stuff. So probably prior sounds better. (W1)

E: Prepare body for healthy pregnancy and raising children

It keeps me fit. Then when baby comes afterward, I’m a lot stronger to look after her. (W3)

E: Promote offspring health

It’s not just about just passing on legacy in terms of finance or this and that, but health is so important. Health is the best thing you can give a child and that sets them up on going. (W6)

Automatic motivation

Emotion

Interplay between lifestyle and emotional state

B: Mental toll of making lifestyle changes

The disadvantage is that it’s another mental load that you have to think about that most people who, for example, naturally conceive, don’t really think about it. (W8)

B: Stressful circumstances impede healthy lifestyle behaviours

I get really down and just don’t feel like going anywhere and so I don’t really exercise because I don’t want to go out. (W2)

E: Healthy lifestyle promotes feelings of wellbeing

I found that by doing exercise, by going for a walk every single day, it helps you clear your mind so that you’re not as stressed. (W4)

E: Making space for a flexible approach to lifestyle management

I might add a few junk foods into it but it’s still mostly there. (W2)

I would love for somebody to tell me, if I eat pizza once a month, I’m okay, I don’t have to – because then you feel bad, right? (W5)

E: Perseverance despite stressful circumstances

I just keep going with that as that’s the long-term choice, even when things get a bit more stressful. (W2)

E: Taking control of lifestyle empowers patients

I think knowing that I do the right thing makes me feel a lot better. (W6)