Barriers and enablers to a healthy lifestyle in people with infertility: a qualitative descriptive study.

This is a qualitative descriptive study [ 25 ] with a pragmatic research paradigm. Pragmatism involves a pluralist and flexible approach to ontology that is context dependent and focuses on the practical consequences of ideas. Its epistemological stance is underpinned by acquisition of knowledge via experience, acknowledging that knowledge evolves over time [ 26 ]. Ethical approval was obtained from Monash University Human Research Ethics Committee (Project ID 38759) prior to the recruitment of the first participant. This study is reported in accordance with the Consolidated criteria for reporting qualitative research (COREQ) checklist [ 27 ] (Supplementary Table S1). The eligibility criteria were: males and females with infertility (≥ 12 months of attempting conception as per the WHO definition [ 1 ]), using or seeking fertility treatment, living in Australia and ≥ 18 years. Participants were recruited using purposive sampling through social media platforms (Facebook and Twitter/X) and the Victorian Assisted Reproductive Treatment Authority (VARTA) website, as well as snowball sampling through participant social networks. To overcome the quality limitations of online recruitment [ 28 ], measures were taken to verify the authenticity of responses (e.g., geolocating IP addresses, valid Australian phone number required). Participants provided written informed consent (REDCap (Research Electronic Data Capture) [ 29 ]) and were reimbursed for their time with an electronic store voucher valued at 40 Australian Dollars upon study completion. The concept of information power was considered when determining the moderate sample of 10–15 participants [ 30 ]. The information power of our study is enhanced by a narrow aim (barriers and enablers to lifestyle management in people with infertility), purposive sampling of participants specific to the research aim (people with infertility), use of theory (BCW, COM-B and TDF) to underpin data collection and clear communication between researchers and participants. All interviews were conducted by S.T., a postgraduate student and dietitian with experience in qualitative research. No other researchers were present during the interview. Prior to the interview S.T. informed all participants about her credentials, role in this research, as well as the aims for the interview. L.M., S.C. and S.T. analysed the data. L.M. and S.C. are dietitians and experienced qualitative researchers with doctoral qualifications. None of the researchers had any contact with any of the research participants prior to their recruitment in the study. As dietitians who value and utilise patient-centred approaches to elicit behaviour change all three researchers lean towards a constructivist ontology, recognising that healthy lifestyle may be viewed as a socially constructed concept shaped by personal meaning, emotions and sociocultural factors. Demographic information was collected via an online survey (Qualtrics Insight Platform) prior to the interviews (Supplementary Table S2) and included questions related to anthropometric measures, ethnicity, level of education, employment status, infertility aetiology, details of any fertility treatment and parity. The interview guide, developed by L.M, S.C and S.T., explored barriers and enablers to lifestyle change while attempting conception from the perspective of people with infertility. Interview questions were designed to cover all domains of the COM-B model, including questions related to capability (e.g. knowledge of lifestyle strategies that improve infertility, and cognitive or physical skills required to improve health behaviours), opportunity (e.g. availability of social and professional support, access to accurate information, and adequate time or finances required to utilise health services) and motivation (e.g. confidence in abilities needed to change lifestyle behaviours, priorities to improve diet and physical activity, and perceived advantages/disadvantages of lifestyle modification) (Supplementary Table S3). Interview guides were pilot tested and iteratively refined by the research team. Semi-structured interviews were conducted and audio recorded via a video conferencing platform (Zoom) between October 2023 and March 2024. Participants were encouraged to choose a private location where they felt comfortable to fully express their experiences and perspectives. Only the researcher and participant were present during interviews. The duration of each interview was between 45 and 60 min. Descriptive statistics were calculated using Microsoft Excel (Office 2019). Categorical variables were reported as frequency (relative frequency), and continuous variables were reported as median (quartiles). The reported postcode of residence was used to determine state of residence and Rural, Remote and Metropolitan Area classification (using the Health Workforce Locator [ 31 ]) for each participant. Body mass index for each participant was calculated as the reported weight in kilograms divided by the square of the reported height in meters. Audio recordings were transcribed verbatim by a secure, ISO 9001 and ISO 27001 certified, third-party transcription company (Pacific Transcription). All transcripts were then analysed using template analysis [ 32 ] in NVivo Release 1.3 QSR International Pty Ltd Software. Template analysis is a flexible form of thematic analysis which involves developing a structured coding template which is iteratively refined as data is analysed. Template analysis allows for both a priori themes which are informed by existing knowledge as well as new themes identified during analysis, and hence prioritises maximising practical application of data, aligning with the focus on practical problem-solving in pragmatism. After familiarisation with the transcripts, S.T. inductively coded 100% of transcripts and L.M. and S.C. each independently coded 9% of transcripts (18% independent coding). Codes were checked for congruity and any discrepancies were resolved by discussion (between L.M., S.C. and S.T.). Codes were identified and organised into meaningful clusters, which were then examined alongside the results from our systematic review which aimed to evaluate barriers and enablers to lifestyle change in people with infertility [ 23 ] to develop the initial coding template. The coding template was then refined through an iterative process by L.M., S.C. and S.T., where new themes were inserted and existing themes were redefined or merged to better reflect the meaning of the data. The coding template was finalised and applied to the entire data set by S.T., from which supporting quotes were generated. These themes were subsequently mapped against the COM-B constructs and TDF domains in order to identify the individual and environmental factors relating to lifestyle change in people with infertility when trying to conceive. To facilitate future intervention development, these COM-B components were matched to the relevant intervention functions and policy categories as guided by the BCW. Targeted interventions were then developed by applying the APEASE (acceptability, practicability, effectiveness and cost-effectiveness, side effects and safety and equity) framework [ 33 ], and by identifying behaviour change techniques (using BCT taxonomy version 1) to deliver practical and specific recommendations [ 34 ]. To verify whether the study findings resonated with participants’ experiences, synthesised member checking was utilised [ 35 ], by which all participants were provided with a plain language summary of the results via email, and were given the opportunity to provide feedback using their preferred method of communication (email, phone or video conferencing). Synthesised member checking was chosen as it allows participants to voice their perspectives on the interpretation of the data, hence maximising its utility, and is less likely to produce discomfort compared to other methods of member checking such as transcript review [ 36 ]. To help prompt their responses, we posed a series of questions including how accurately they felt the findings captured their experience, what could be added to the findings to capture their experience better, and if there was anything they feel should be removed and why. Participants were informed that any discrepancies or additional insights would be incorporated into the final analysis. Quotations are presented in a deidentified format. Each quotation is followed in parenthesis by a letter representing the participant’s gender (W for women and M for men), followed by a unique number for each participant.

Our eligibility screening survey received 106 responses. Of these, 95 were not interviewed due to not meeting eligibility criteria ( n  = 66), not answering our contact attempts ( n  = 21), not providing any valid contact details ( n  = 6), being a duplicate response ( n  = 1) or declining to participate ( n  = 1). Eleven participants (nine women and two men) were interviewed, with a median age of 38 years and BMI of 24.3 kg m −2 (Table 1 ). The majority of participants resided in a metropolitan area (91%), were born in Australia (64%), completed university education (82%), had unexplained infertility (64%) and had used IVF (55%). All participants spoke English as their main language at home and no participants identified as Aboriginal or Torres Strait Islander. Table 1 Demographic characteristics of sample Demographic variable Summary statistics Gender, n (%)  Woman 9 (82%)  Man 2 (18%) Age (years), median (quartiles) 38 (33, 42) Body mass index (kg m −2 ), median (quartiles) 24.3 (22.8, 25.9) State of residence, n (%)  New South Wales 6 (55%)  Queensland 2 (18%)  Tasmania 1 (9%)  Victoria 2 (18%) Rural, Remote and Metropolitan Area classification, n (%)  Metropolitan 10 (91%)  Rural 1 (9%) Location of birth, n (%)  Australia 7 (64%)  Asia 2 (18%)  Europe 1 (9%)  South America 1 (9%) Years since migration to Australia, n (%)  11 to 15 2 (18%)  16 or more 2 (18%)  Not applicable (born in Australia) 7 (64%) Highest level of education, n (%)  High school 1 (9%)  Diploma 1 (9%)  University 2 (18%)  Postgraduate degree 7 (64%) Ethnic or cultural background a  Australian (excluding Indigenous Australian) 5 (45%)  North-East Asian 1 (9%)  North-West European 3 (27%)  South American 1 (9%)  South-East Asian 3 (27%) Main language spoken at home  English, n (%) 11 (100%) Identity as Aboriginal or Torres Strait Islander  No, n (%) 11 (100%) Diagnosed cause of infertility, n (%) a  Anovulation 1 (9%)  Endometriosis 1 (9%)  Low anti-Mullerian hormone 1 (9%)  Male factor 1 (9%)  Polycystic ovary syndrome 1 (9%)  Tubal factor 1 (9%)  Unexplained 7 (64%) Duration of attempting conception (months), median (quartiles) 13 (12, 37) Fertility treatment used a  None 5 (45%)  In vitro fertilisation 6 (55%)  Intrauterine insemination 1 (9%) a Participants could select multiple; hence, total exceeds 100% Demographic characteristics of sample a Participants could select multiple; hence, total exceeds 100% Thematic analysis revealed 9 themes with 46 corresponding subthemes, mapped to five COM-B components and 10 TDF domains (Table 2 ). Following synthesised member checking, no participants voiced any disagreement with the results, and this process therefore did not result in any changes to the results. Table 2 Themes on barriers and enablers to a healthy lifestyle in people with infertility COM-B TDF Themes Barriers (B) and enablers (E) Supporting quotes 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) Themes on barriers and enablers to a healthy lifestyle in people with infertility 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) 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) 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) 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) 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) 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) 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) (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) 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) 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) 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) 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) 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) 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) I’m not really swayed by what other eat. (W9) We are responsible for ourselves. (M2) 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) 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) Mental health disorders, physical injury and fertility treatment side effects introduced challenges to following a healthy lifestyle. While musculoskeletal injuries impeded participants’ ability to exercise, depression made it difficult to prioritise healthy behaviours. Some participants also raised concerns about jeopardising eating disorder recovery. Fertility treatment side-effects, including increased appetite, mood disturbances and pain, resulted in weight gain and made it challenging to adopt healthy behaviours such as exercise, with one participant explaining “I got pain when I was trying to move” (W4). Women were also concerned about the risk of ovarian torsion with exercise following fertility treatment, and were unsure of what types of exercise to avoid. Understanding the role that diet and/or physical activity have in the management of concurrent medical conditions was a key enabler to improving lifestyle habits. Participants with these comorbidities felt there were clear mechanisms for improving pathophysiology which helped them to understand the benefits of a healthy lifestyle. To manage fertility treatment side effects, women wanted to learn exercises or stretches to reduce pain and choose healthy foods to minimise discomfort. Additionally, women recognised that higher weight increased risks associated with fertility treatment, providing additional motives beyond improving chances of conception to manage their weight. Participants felt uncertain about how effective lifestyle is at promoting conception in infertility, and acknowledged the limited evidence on lifestyle and fertility. This ambivalence was further compounded by noticing people with unhealthy lifestyles finding it easy to have babies. They were also frustrated with the generic lifestyle information promoted by credible sites, lacking for example the geographical context, specific infertility aetiology and safe exercise recommendations. Participants felt strongly that they were a vulnerable population for misinformation, explaining that “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). Misinformation sources included social media influencers and unsolicited advice from friends and family. Participants wanted evidence-based resources and were very engaged and interested in learning more about the role of lifestyle in fertility management. This was a key enabler to encourage greater uptake of healthy behaviours preconception, as is evident in their sophisticated understanding of the influence of lifestyle factors on pregnancy outcomes, including excessive gestational weight gain and high-risk foods for food poisoning. Limited time to focus on lifestyle change was a major barrier for participants, with increased work hours to save money for their growing family and the time burden of fertility treatments making it difficult to prioritise diet and physical activity. Time constraints were pronounced for those with secondary infertility who also balanced parenting responsibilities. Consequently, participants opted for convenience in favour of the nutritional value of foods, and found it difficult to engage in regular physical activity Participants also felt there was a lack of opportunity to delay fertility treatment for lifestyle management, which was driven by a sense of urgency from health professionals, with a participant explaining a doctor told her “you’re running out of time; you need to do it (fertility treatment) now; there’s no time to lose weight first” (W2) despite her voicing concerns that previous cycles of fertility treatment did not result in conception. Affordability of health foods marketed to participants attempting to enhance fertility, such as organic products that limit pesticide exposure, were described as a key deterrent for making dietary changes, with participants voicing that unhealthy foods were substantially easier to access than healthy foods. Exhaustion and lack of energy to engage in exercise and meal preparation were also associated with the demands and pressure of their increased workloads and with navigating infertility services. To overcome these barriers, participants valued lifestyle strategies which required minimal time and resources, such as exercises which do not require equipment, preparing nutritious meals in advance and purchasing healthy convenience foods. Participants with flexible working arrangements found it easier to integrate lifestyle changes into their daily routines, though acknowledged that this is not a feasible option for everyone. Additionally, putting lifestyle management into perspective by recognising it as a relatively inexpensive and time-efficient management strategy helped to overcome any apprehensions about allocating time, resources and money towards lifestyle management. Participants recognised that lifestyle management was cheaper and less time consuming than fertility treatment, and felt that it was a comparably small sacrifice to make if it improved their treatment outcomes. Participants experienced refusal from health professionals delivering fertility services to provide lifestyle care, who participants stated have “just not wanted to talk about it (lifestyle management)” (W2). This paired with a lack of integration of nutrition and exercise professionals in fertility clinics led to siloed and inconsistent messaging on what participants viewed as important topics, such as weight loss. When lifestyle advice was provided, this was often viewed as perfunctory. Health professionals provided vague instructions to “eat healthy” (W2), without information on the rationale or how to implement the recommendations. Additionally, participants who were within the healthy weight range did not receive a thorough evaluation of their health status, and were assumed by health professionals to be living a healthy lifestyle, despite the possibility that they “could be eating Maccas (abbreviation for the fast food restaurant McDonalds) every second day” (W6). Participants discussed how the privatisation of fertility services compromised the quality of care provided. Given the high costs of IVF services, they were disappointed by the lack of lifestyle advice, and felt there was an inappropriate allocation of clinic resources. Participants consequently sought information from alternative sources such as online programs/forums and complementary medicine practitioners, which were prone to charging exorbitant prices, spreading misinformation and providing inappropriate advice, with a vegetarian being advised by an acupuncturist to consume red meat and liver. Online lifestyle programs marketed to improve fertility were expensive and viewed as “money-making situations” (W8) by many. Participants felt that the provision of lifestyle information would be more engaging and relevant if it provides clear advice with practical strategies (e.g., exercise examples, healthy food swaps, meal plans, recipe suggestions, problem solving, goal setting), explains the mechanism of effects, and accommodates individual needs using an inclusive, tailored and flexible approach that considers their dietary restrictions, baseline lifestyle and infertility aetiology. In regards to the program structure and delivery, it was important for the male partner to be invited to lifestyle consultations for heterosexual couples, where information would be provided on the effects of lifestyle for both male and female fertility, and for the program to be adapted to accommodate same-sex couples and single individuals. Participants emphasised that they needed a scalable approach with a flexible duration and opportunities for bite-sized module-based learning. They also felt that a lifestyle program “should be part of the (fertility) treatment” (W5), with appropriately qualified health professionals (e.g. dietitians) delivering the program. Participants emphasised the importance of sensitivity in communication which recognised that weight loss can be difficult. Finally, participants emphasised the role of the fertility clinic in reinforcing motivation and accountability, voicing that they struggled with procrastination when making lifestyle changes. One participant felt that regular weigh-ins at the fertility clinic could help to prevent treatment-related weight gain. Participants felt that the role of the male partner was largely overlooked and misunderstood, with fertility clinics engaging women in communication to a greater extent than their male partners. Some women viewed their male partners as unsupportive and resistant to making healthy changes of their own. If male partners were supportive, their role was viewed as secondary, with the female partner taking the lead in information seeking. Social obligations while navigating the sensitive nature of infertility were also a challenge, with participants wishing to keep pregnancy intentions private while being questioned on their lifestyle decisions. Participants also found it difficult to fit healthy eating into social occasions and experienced social pressure to eat unhealthy foods. Many participants recognised that support from family, friends and peers played a large role in their success to achieve lifestyle change. Participants specifically highlighted strategies such as collaborating with their partner in lifestyle management, joining online peer support groups, nominating a friend with similar goals as a healthy lifestyle buddy, surrounding themselves with friends who are supportive of the fertility journey and viewing family members who made healthy lifestyle changes as positive role models. Conversely, some participants felt that their ability to be independent and assertive contributed to their successful lifestyle management. These participants preferred solo exercise, were not “swayed by what others eat” (W9) and stated “we are responsible for ourselves” (M2). This perspective contrasts with the majority belief that social supports should form an integral component of lifestyle interventions, highlighting that for some individuals, interventions should foster autonomy and self-advocacy. Participants found it difficult to sustain healthy lifestyle behaviours throughout the fertility journey, with fluctuating levels of confidence as well as relapses into unhealthy behaviours triggered by not conceiving after IVF cycles. People additionally had negative self-perceptions which impeded healthy lifestyle behaviours, such as perceiving themselves as “unfit” and “lazy” (W4). Conversely, people who had established healthy lifestyle behaviours before attempting conception felt self-assured in their capability to maintain a healthy diet and regular exercise without relapse, even when faced with the pit-falls and uncertainty of their fertility journey. Finally, people who viewed it as their own responsibility to optimise their chances of successful conception following fertility treatment felt motivated to sustain healthy lifestyle behaviours during the fertility journey. People valued the importance of a healthy lifestyle not only preconception, but also continuing this into pregnancy and postpartum for the health and betterment of their future children, stating that a healthy lifestyle produces “positive changes for your overall wellbeing” (M2). Women wanted to prepare their bodies for a healthy pregnancy, including weight management to offset gestational weight gain. People were aware of the developmental origins of health and disease, emphasising the importance of good nutrition and avoiding vitamin deficiencies before and during pregnancy to promote offspring health. They also discussed the concept of healthy ageing during parenthood, to reduce the risk of health complications that affect longevity and pose challenges for parenting. Lastly, they valued the importance of setting a good example and providing a positive role model for their children to learn and replicate healthy behaviours. Some people described a bi-directional relationship between their inability to make lifestyle changes and the mental toll of infertility treatment. For these people, the additional pressure and burden associated with making lifestyle changes exacerbated the mental strain of fertility treatment, and reciprocally the mental strain of fertility treatment made lifestyle change difficult. This bi-directional relationship further intensified after failing to conceive, often leading to episodes of emotional and dysregulating eating. In contrast, some people felt that lifestyle changes helped them feel “more in control” (W9) and provided them with feelings of empowerment, which was helpful in contrast to the uncertainty experienced during infertility. For these people, it was the ability to choose strategies which supported their mental health, coupled with the use of flexible and moderate approaches, that helped them succeed in making positive changes. They were able to find joy in exercise, incorporated mindfulness strategies during walking, and recognised the meditative benefits of yoga. Exercising self-compassion by allowing themselves flexibility with exercise targets and learning how to enjoy discretionary foods in moderation helped to reduce feelings of guilt. Table 3 details all of the intervention functions (education, persuasion, training, environmental restructuring, modelling and enablement), policy categories (communication/marketing, service provision and environmental/social planning) and BCTs ( n  = 37) used to inform our suggested intervention strategies. Figure  1 illustrates examples of suggested intervention strategies for different target populations (people with infertility, health professionals and policy) mapped to COM-B components. Table 3 Suggested intervention strategies targeting barriers and enablers to a healthy lifestyle in people with infertility COM-B TDF Themes Barriers (B) and enablers (E) Intervention functions & policy categories BCTs Example methods to deliver BCTs (BCT numbers) Psychological capability Memory, attention and decision processes; Knowledge Managing whole-body health and disease B: Difficult to follow healthy lifestyle with comorbidities B: Difficult to follow healthy lifestyle with risks and side effects of fertility treatment E: Healthy lifestyle to manage comorbidities E: Healthy lifestyle to manage risks and side effects of fertility treatment Intervention functions: education, training enablement Policy categories : Service provision 3.1 Social support (unspecified) 4.1 Instruction on how to perform the behaviour 9.1 Credible source 11.1 Pharmacological support 11.2 Reduce negative emotions Interdisciplinary approach to enable management of comorbidities and treatment side effects and hence reduce barriers to healthy eating and physical activity (9.1) Pharmacist, physician or nurse practitioner led education on medications for comorbidity management which are safe during preconception and can enable healthy lifestyle behaviours (e.g. safe analgesia for those with musculoskeletal comorbidities affecting ability to exercise) (4.1, 9.1, 11.1) Physiotherapist or exercise physiologist led education and training on appropriate physical activity strategies which can enable managements of comorbidities and reduce fertility treatment side effects without increasing risks of ovarian torsion where applicable (e.g. stretches to reduce pain during fertility treatment) (4.1, 9.1) Psychologist led management of mental health conditions using evidence-based strategies such as cognitive behavioural therapy (3.1, 9.1) and education and training on stress management strategies (11.2) to enable healthy lifestyle Dietitian led education and training on medical nutrition therapy (4.1, 9.1) to enable management of comorbidities and fertility treatment side effects Knowledge Understanding the mechanisms and pathophysiology B: Insufficient evidence on lifestyle B: Uncertainty of conception probability after lifestyle change B: Vulnerable population for misinformation E: Awareness of lifestyle factors which can influence pregnancy outcomes E: Want to learn more about lifestyle and fertility Intervention functions: education, training enablement Policy categories: service provision, communication/marketing, guidelines 3.1 Social support (unspecified) 4.1 Instruction on how to perform the behaviour 5.1 Information about health consequences 9.1 Credible source Educate on available health services to support lifestyle change (3.1, 9.1) Provision of authoritative evidence-based apps (e.g. Ask Fertility) (9.1) and resources with information to educate on the effects of lifestyle on fertility (5.1), debunk common myths (5.1) and train people on how to implement lifestyle recommendations (4.1) Develop up-to-date repositories endorsed by credible organizations that aggregate evidence-based materials in a simplified easy to use format that is public facing (4.1, 5.1, 9.1) Increase visibility of credible nutrition information on social platforms by promoting content through recognised accredited health professionals and bodies with a large social media following (4.1, 5.1, 9.1) Physical opportunity Environmental context and resources Limited time, resources and money B: Difficulty affording health foods B: No scope to delay fertility treatment B: Time constraints B: Work commitments E: Finding lifestyle strategies that require minimal time and resources E: Flexible working arrangements E: Putting lifestyle management into perspective Intervention functions: education, training, environmental restructuring, enablement Policy categories: Communication/marketing, service provision 4.1 Instruction on how to perform the behaviour 5.1 Information about health consequences 5.6 Information about emotional consequences 9.1 Credible source 9.2 Pros and cons 12.1 Restructuring the physical environment 12.5 Adding objects to the environment Education on cost-efficient healthy foods (4.1, 5.1) Use a shared decision tool outlining the pros and cons of delaying fertility treatment to implement preconception lifestyle changes, in order to enable shared decision making between patients and clinicians (9.1, 9.2) Education to health professionals about effect of delaying fertility treatment on pregnancy outcomes (5.1) Education and training on communication strategies to request flexible working arrangements (4.1) Discuss pros and cons of managing time by reducing work hours or other time commitments to enable balanced decision making (9.2) Educate on how to use an active commute (e.g. parking further from destination, using public transport, walking or cycling) (4.1) and persuade that this is a time-efficient way to receive the physical and mental health benefits of physical activity (5.1, 5.6) Educate on how to use environmental restructuring to keep freezer and pantry stocked with healthy and convenient foods (e.g. frozen vegetables, canned tuna) and either remove discretionary foods or keep discretionary foods in an inconvenient location (12.1, 12.5) Unmet needs from the healthcare system B: Health professional refusal to provide lifestyle care B: Inconsistent messaging from siloed information sources B: Perfunctory lifestyle advice with a one-size-fits-all approach B: Privatisation compromises quality of care Intervention functions: education, persuasion, training, environmental restructuring Policy categories: Communication/marketing, service provision, environmental/social planning, guidelines 2.2 Feedback on behaviour 4.1 Instruction on how to perform the behaviour 4.4 Behavioural experiment 5.1 Information about health consequences 5.3 Information about social and environmental consequences 6.3 Information about others’ approval 9.1 Credible source 10.1 Material incentive (behaviour) 12.1 Restructuring the physical environment 12.2 Restructuring the social environment Environmental restructuring of fertility clinics to include allied health professionals (9.1, 12.1, 12.2) Use education and persuasion to inform fertility clinics that offering paid nutrition and exercise services could increase revenue (5.3, 10.1) Education and training to fertility clinic staff on how to deliver individualised patient-centred lifestyle care and provide appropriate referrals (4.1, 9.1) Educate fertility clinic staff on lifestyle risk factors beyond weight which affect pregnancy outcomes and train them on how to assess these risk factors (4.1, 5.1) Educate and persuade clinics to implement feedback mechanisms (e.g. patient surveys, suggestion boxes), which can reprioritise services valued by patients (e.g. lifestyle add-on packages), reduce low-value services (2.2, 5.3, 6.3) and test the value of implementing a lifestyle add-on package (4.4) Optimal intervention strategies E: Clear advice with practical strategies E: Engaging information provision E: Inclusive program to accommodate individual needs E: Qualified allied health professionals integrated into fertility treatment E: Support with motivation and accountability Intervention functions: training, restriction, environmental restructuring, enablement Policy categories: communication/marketing, service provision 1.1 Goal setting (behaviour) 1.3 Goal setting (outcome) 1.4 Action planning 2.2 Feedback on behaviour 2.3 Self-monitoring of behaviour 2.4 Self-monitoring of outcomes of behaviour 2.7 Feedback on outcomes of behaviour 3.1 Social support (unspecified) 4.1 Instruction on how to perform the behaviour 5.1 Information about health consequences 7.1 Prompts/cues Provide education and training using clear advice with practical strategies (4.1) Deliver lifestyle education using engaging media (e.g. short videos, infographics) and with explanations of the mechanism by which lifestyle improves fertility (5.1) Use active listening and motivational interviewing to understand individual needs (e.g. dietary restrictions, cultural practices, time constraints) and tailor lifestyle education accordingly (3.1) Use motivational interviewing to enable motivation and accountability (3.1), provide feedback on progress (2.2, 2.7) and train patients on strategies including self-monitoring (2.3, 2.4), goal setting (1.1, 1.3), action planning (1.4) and using prompts (7.1) Social opportunity Social influences Interpersonal dynamics B: Misunderstood role of the male partner B: Social obligations while navigating sensitive nature of infertility E: Independence and resilience E: Support from family, peers and friends E: Sensitivity in communication from health professionals Intervention functions: education, training, environmental restructuring, modelling, enablement Policy categories: communication/marketing, service provision 3.1 Social support (unspecified) 3.2 Social support (practical) 4.1 Instruction on how to perform the behaviour 6.1 Demonstration of the behaviour 7.5 Remove aversive stimulus 8.1 Behavioural practice/rehearsal 8.2 Behaviour substitution Encourage fertility clinics to actively involve male partner in lifestyle discussions and enable collaboration between partners (3.2) Education and training on strategies to fit healthy eating into social occasions (e.g. choosing nutritious meals at restaurants) (4.1) Encourage to choose social activities which do not involve food and drinks, particularly those which promote physical activity and wellbeing (e.g. social sports, walks with friends) (8.2) Social marketing campaigns to enable reduction of stigma of male-factor infertility and hence improve service utilisation (7.5) Education and training on communication strategies when encountering social pressure to eat foods which are unconducive to goals (e.g. via demonstration and role play) (4.1, 6.1, 8.1) Encourage to find a healthy lifestyle buddy for reciprocal modelling of healthy lifestyle behaviours (3.2) Encourage to use environmental restructuring to surround self with supportive friends and limit time with unsupportive friends (3.1) Health professional training (e.g. via demonstration and role play (4.1, 6.1, 8.1)) on sensitivity in communicating about lifestyle and fertility (3.1) 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 B: Negative self-perceptions E: Confident in skills required to maintain healthy behaviours E: Internalising responsibility for lifestyle to optimise fertility treatment outcome Intervention functions: education, persuasion, training Policy categories: communication/marketing, service provision 3.1 Social support (unspecified) 8.7 Graded tasks 13.5 Identity associated with changed behaviour 15.1 Verbal persuasion about capability 15.3 Focus on past success 15.4 Self-talk Overcome negative self-perceptions by educating and training on ways to incrementally improve diet (e.g. gradually reducing consumption of discretionary foods) and physical activity (e.g. gradually increasing physical activity targets) to build self-efficacy (8.7) Overcome negative self-perceptions using persuasion to elicit confidence in abilities (15.1) using motivational interviewing techniques (3.1), including encouraging reflection on previous times they successfully made lifestyle change (15.3) and practicing positive self-talk Use persuasion to encourage to identify themselves as a person who exercises and eats healthily (13.5) Beliefs about consequences Valuing the broader benefits of a healthy lifestyle E: Health benefits whether trying to conceive or not E: Offset gestational weight gain E: Prepare body for healthy pregnancy and raising children E: Promote offspring health Intervention functions: education, persuasion Policy categories: communication/marketing, service provision 5.1 Information about health consequences 5.3 Information about social and environmental consequences 5.6 Information about emotional consequences 13.1 Identification of self as role model 13.2 Framing/reframing Educate about the physical and mental health benefits of healthy eating and physical activity (5.1, 5.6) Persuade to reframe the preconception period as an opportunity to establish healthy habits which continue into parenthood, supporting healthy role modelling (5.3, 13.1, 13.2) Automatic motivation Emotion Interplay between lifestyle and emotional state B: Mental toll of making lifestyle changes B: Stressful circumstances impede healthy lifestyle behaviours E: Healthy lifestyle promotes feelings of wellbeing E: Making space for a flexible approach to lifestyle management E: Perseverance despite stressful circumstances E: Taking control of lifestyle empowers patients Intervention functions: education, persuasion, training, environmental restructuring Policy categories: communication/marketing, service provision 4.1 Instruction on how to perform the behaviour 8.2 Behaviour substitution 11.2 Reduce negative emotions 11.3 Conserving mental resources 12.1 Restructuring the physical environment 12.4 Distraction 13.2 Framing/reframing Persuade patients to reframe healthy lifestyle behaviours as self-care strategies (13.2) Persuade patients to reframe healthy lifestyle behaviours as empowerment through taking control of their health (13.2) Educate about the appropriate portion of discretionary food (4.1) to reduce guilt surrounding consumption of discretionary foods (11.2) Education and training on ways to manage and distract from the urge for comfort eating by doing an alternative activity (e.g. taking a bath or going for a walk) (8.2, 12.4) Encourage to use environmental restructuring to remove foods typically overconsumed in comfort eating from the home (12.1) Intervention functions within example methods to deliver BCTs are indicated in bold font Fig. 1 Suggested interventions strategies targeting barriers and enablers to a healthy lifestyle in people with infertility Suggested intervention strategies targeting barriers and enablers to a healthy lifestyle in people with infertility B: Difficult to follow healthy lifestyle with comorbidities B: Difficult to follow healthy lifestyle with risks and side effects of fertility treatment E: Healthy lifestyle to manage comorbidities E: Healthy lifestyle to manage risks and side effects of fertility treatment Intervention functions: education, training enablement Policy categories : Service provision 3.1 Social support (unspecified) 4.1 Instruction on how to perform the behaviour 9.1 Credible source 11.1 Pharmacological support 11.2 Reduce negative emotions Interdisciplinary approach to enable management of comorbidities and treatment side effects and hence reduce barriers to healthy eating and physical activity (9.1) Pharmacist, physician or nurse practitioner led education on medications for comorbidity management which are safe during preconception and can enable healthy lifestyle behaviours (e.g. safe analgesia for those with musculoskeletal comorbidities affecting ability to exercise) (4.1, 9.1, 11.1) Physiotherapist or exercise physiologist led education and training on appropriate physical activity strategies which can enable managements of comorbidities and reduce fertility treatment side effects without increasing risks of ovarian torsion where applicable (e.g. stretches to reduce pain during fertility treatment) (4.1, 9.1) Psychologist led management of mental health conditions using evidence-based strategies such as cognitive behavioural therapy (3.1, 9.1) and education and training on stress management strategies (11.2) to enable healthy lifestyle Dietitian led education and training on medical nutrition therapy (4.1, 9.1) to enable management of comorbidities and fertility treatment side effects B: Insufficient evidence on lifestyle B: Uncertainty of conception probability after lifestyle change B: Vulnerable population for misinformation E: Awareness of lifestyle factors which can influence pregnancy outcomes E: Want to learn more about lifestyle and fertility Intervention functions: education, training enablement Policy categories: service provision, communication/marketing, guidelines 3.1 Social support (unspecified) 4.1 Instruction on how to perform the behaviour 5.1 Information about health consequences 9.1 Credible source Educate on available health services to support lifestyle change (3.1, 9.1) Provision of authoritative evidence-based apps (e.g. Ask Fertility) (9.1) and resources with information to educate on the effects of lifestyle on fertility (5.1), debunk common myths (5.1) and train people on how to implement lifestyle recommendations (4.1) Develop up-to-date repositories endorsed by credible organizations that aggregate evidence-based materials in a simplified easy to use format that is public facing (4.1, 5.1, 9.1) Increase visibility of credible nutrition information on social platforms by promoting content through recognised accredited health professionals and bodies with a large social media following (4.1, 5.1, 9.1) B: Difficulty affording health foods B: No scope to delay fertility treatment B: Time constraints B: Work commitments E: Finding lifestyle strategies that require minimal time and resources E: Flexible working arrangements E: Putting lifestyle management into perspective Intervention functions: education, training, environmental restructuring, enablement Policy categories: Communication/marketing, service provision 4.1 Instruction on how to perform the behaviour 5.1 Information about health consequences 5.6 Information about emotional consequences 9.1 Credible source 9.2 Pros and cons 12.1 Restructuring the physical environment 12.5 Adding objects to the environment Education on cost-efficient healthy foods (4.1, 5.1) Use a shared decision tool outlining the pros and cons of delaying fertility treatment to implement preconception lifestyle changes, in order to enable shared decision making between patients and clinicians (9.1, 9.2) Education to health professionals about effect of delaying fertility treatment on pregnancy outcomes (5.1) Education and training on communication strategies to request flexible working arrangements (4.1) Discuss pros and cons of managing time by reducing work hours or other time commitments to enable balanced decision making (9.2) Educate on how to use an active commute (e.g. parking further from destination, using public transport, walking or cycling) (4.1) and persuade that this is a time-efficient way to receive the physical and mental health benefits of physical activity (5.1, 5.6) Educate on how to use environmental restructuring to keep freezer and pantry stocked with healthy and convenient foods (e.g. frozen vegetables, canned tuna) and either remove discretionary foods or keep discretionary foods in an inconvenient location (12.1, 12.5) B: Health professional refusal to provide lifestyle care B: Inconsistent messaging from siloed information sources B: Perfunctory lifestyle advice with a one-size-fits-all approach B: Privatisation compromises quality of care Intervention functions: education, persuasion, training, environmental restructuring Policy categories: Communication/marketing, service provision, environmental/social planning, guidelines 2.2 Feedback on behaviour 4.1 Instruction on how to perform the behaviour 4.4 Behavioural experiment 5.1 Information about health consequences 5.3 Information about social and environmental consequences 6.3 Information about others’ approval 9.1 Credible source 10.1 Material incentive (behaviour) 12.1 Restructuring the physical environment 12.2 Restructuring the social environment Environmental restructuring of fertility clinics to include allied health professionals (9.1, 12.1, 12.2) Use education and persuasion to inform fertility clinics that offering paid nutrition and exercise services could increase revenue (5.3, 10.1) Education and training to fertility clinic staff on how to deliver individualised patient-centred lifestyle care and provide appropriate referrals (4.1, 9.1) Educate fertility clinic staff on lifestyle risk factors beyond weight which affect pregnancy outcomes and train them on how to assess these risk factors (4.1, 5.1) Educate and persuade clinics to implement feedback mechanisms (e.g. patient surveys, suggestion boxes), which can reprioritise services valued by patients (e.g. lifestyle add-on packages), reduce low-value services (2.2, 5.3, 6.3) and test the value of implementing a lifestyle add-on package (4.4) E: Clear advice with practical strategies E: Engaging information provision E: Inclusive program to accommodate individual needs E: Qualified allied health professionals integrated into fertility treatment E: Support with motivation and accountability Intervention functions: training, restriction, environmental restructuring, enablement Policy categories: communication/marketing, service provision 1.1 Goal setting (behaviour) 1.3 Goal setting (outcome) 1.4 Action planning 2.2 Feedback on behaviour 2.3 Self-monitoring of behaviour 2.4 Self-monitoring of outcomes of behaviour 2.7 Feedback on outcomes of behaviour 3.1 Social support (unspecified) 4.1 Instruction on how to perform the behaviour 5.1 Information about health consequences 7.1 Prompts/cues Provide education and training using clear advice with practical strategies (4.1) Deliver lifestyle education using engaging media (e.g. short videos, infographics) and with explanations of the mechanism by which lifestyle improves fertility (5.1) Use active listening and motivational interviewing to understand individual needs (e.g. dietary restrictions, cultural practices, time constraints) and tailor lifestyle education accordingly (3.1) Use motivational interviewing to enable motivation and accountability (3.1), provide feedback on progress (2.2, 2.7) and train patients on strategies including self-monitoring (2.3, 2.4), goal setting (1.1, 1.3), action planning (1.4) and using prompts (7.1) B: Misunderstood role of the male partner B: Social obligations while navigating sensitive nature of infertility E: Independence and resilience E: Support from family, peers and friends E: Sensitivity in communication from health professionals Intervention functions: education, training, environmental restructuring, modelling, enablement Policy categories: communication/marketing, service provision 3.1 Social support (unspecified) 3.2 Social support (practical) 4.1 Instruction on how to perform the behaviour 6.1 Demonstration of the behaviour 7.5 Remove aversive stimulus 8.1 Behavioural practice/rehearsal 8.2 Behaviour substitution Encourage fertility clinics to actively involve male partner in lifestyle discussions and enable collaboration between partners (3.2) Education and training on strategies to fit healthy eating into social occasions (e.g. choosing nutritious meals at restaurants) (4.1) Encourage to choose social activities which do not involve food and drinks, particularly those which promote physical activity and wellbeing (e.g. social sports, walks with friends) (8.2) Social marketing campaigns to enable reduction of stigma of male-factor infertility and hence improve service utilisation (7.5) Education and training on communication strategies when encountering social pressure to eat foods which are unconducive to goals (e.g. via demonstration and role play) (4.1, 6.1, 8.1) Encourage to find a healthy lifestyle buddy for reciprocal modelling of healthy lifestyle behaviours (3.2) Encourage to use environmental restructuring to surround self with supportive friends and limit time with unsupportive friends (3.1) Health professional training (e.g. via demonstration and role play (4.1, 6.1, 8.1)) on sensitivity in communicating about lifestyle and fertility (3.1) B: Difficulty sustaining lifestyle change throughout fertility journey B: Negative self-perceptions E: Confident in skills required to maintain healthy behaviours E: Internalising responsibility for lifestyle to optimise fertility treatment outcome Intervention functions: education, persuasion, training Policy categories: communication/marketing, service provision 3.1 Social support (unspecified) 8.7 Graded tasks 13.5 Identity associated with changed behaviour 15.1 Verbal persuasion about capability 15.3 Focus on past success 15.4 Self-talk Overcome negative self-perceptions by educating and training on ways to incrementally improve diet (e.g. gradually reducing consumption of discretionary foods) and physical activity (e.g. gradually increasing physical activity targets) to build self-efficacy (8.7) Overcome negative self-perceptions using persuasion to elicit confidence in abilities (15.1) using motivational interviewing techniques (3.1), including encouraging reflection on previous times they successfully made lifestyle change (15.3) and practicing positive self-talk Use persuasion to encourage to identify themselves as a person who exercises and eats healthily (13.5) E: Health benefits whether trying to conceive or not E: Offset gestational weight gain E: Prepare body for healthy pregnancy and raising children E: Promote offspring health Intervention functions: education, persuasion Policy categories: communication/marketing, service provision 5.1 Information about health consequences 5.3 Information about social and environmental consequences 5.6 Information about emotional consequences 13.1 Identification of self as role model 13.2 Framing/reframing Educate about the physical and mental health benefits of healthy eating and physical activity (5.1, 5.6) Persuade to reframe the preconception period as an opportunity to establish healthy habits which continue into parenthood, supporting healthy role modelling (5.3, 13.1, 13.2) B: Mental toll of making lifestyle changes B: Stressful circumstances impede healthy lifestyle behaviours E: Healthy lifestyle promotes feelings of wellbeing E: Making space for a flexible approach to lifestyle management E: Perseverance despite stressful circumstances E: Taking control of lifestyle empowers patients Intervention functions: education, persuasion, training, environmental restructuring Policy categories: communication/marketing, service provision 4.1 Instruction on how to perform the behaviour 8.2 Behaviour substitution 11.2 Reduce negative emotions 11.3 Conserving mental resources 12.1 Restructuring the physical environment 12.4 Distraction 13.2 Framing/reframing Persuade patients to reframe healthy lifestyle behaviours as self-care strategies (13.2) Persuade patients to reframe healthy lifestyle behaviours as empowerment through taking control of their health (13.2) Educate about the appropriate portion of discretionary food (4.1) to reduce guilt surrounding consumption of discretionary foods (11.2) Education and training on ways to manage and distract from the urge for comfort eating by doing an alternative activity (e.g. taking a bath or going for a walk) (8.2, 12.4) Encourage to use environmental restructuring to remove foods typically overconsumed in comfort eating from the home (12.1) Intervention functions within example methods to deliver BCTs are indicated in bold font Suggested interventions strategies targeting barriers and enablers to a healthy lifestyle in people with infertility Key intervention strategies required to enhance capability include education on the mechanisms by which lifestyle can impact on fertility outcomes, for example via communication and marketing of centralized online repositories for evidence-based lifestyle information endorsed by credible bodies. To enable lifestyle change by removing barriers, strategies should also optimise the management of comorbidities and mitigate fertility treatment side effects through improved service provision by an interdisciplinary care team and regular communication with other providers. The majority of barriers and enablers identified by participants were mapped to opportunity and indicated a high demand for environmental restructuring of fertility care via the service provision of integrated lifestyle services. These services should be delivered by allied health professionals who can use motivational interviewing to enable accountability and support people to make practical and tailored lifestyle changes, and should be coupled with engaging content using communication and marketing to deliver high-quality multimedia. It is essential to enable males to actively engage in lifestyle strategies, including by communication and marketing which addresses the stigma of male-factor infertility. In addition, it is important to educate health professionals about the importance of shared decision making when choosing to delay fertility treatment during lifestyle intervention, such as by using shared decision aid tools. Intervention strategies to enhance motivation intersect with previous recommendations for capability and opportunity. They highlight a need to educate about the benefits of lifestyle management beyond fertility, including improvements in overall health that continue into parenthood and positive role modelling for future children using communication and marketing of engaging content. They can also persuade and educate on overcoming negative self-perceptions and promote more flexible and reaffirming lifestyle strategies as part of improved service provision of lifestyle services.

This is the first primary study to use behaviour change theory to explore the lived experience of people with infertility when trying to change their lifestyle behaviours. We applied the BCW model to explore the lived experience of men and women with infertility when implementing healthy lifestyle changes during the preconception period. The identified barriers and enablers were mapped to intervention functions, policy categories and BCTs and will inform the development of targeted lifestyle interventions to improve fertility treatment outcomes. While participants highly valued the benefits of a healthy lifestyle during preconception, the infertility journey introduced major barriers on both the individual level (e.g. mental health difficulties impacting their ability to sustain healthy lifestyle behaviours and time and financial burdens associated with fertility care) and contextual level (e.g. lack of evidence-based resources, inadequate support from the healthcare system and the complex social dynamics introduced when navigating the sensitive nature of infertility). To improve capability people highlighted the importance of education to improve their knowledge of disease pathophysiology and mechanisms underpinning the effects of lifestyle on disease outcomes. Participants were well informed about risk factors affecting pregnancy outcomes, and understood the complex pathophysiology underpinning their comorbidities (e.g. PCOS and hyperlipidaemia). This ability to interpret health information and critically evaluate risks and benefits indicates a high level of health literacy, which may be related to education status [ 37 , 38 ]. The majority of participants in our study had tertiary qualifications, which is reflected in research showing that people with higher educational attainment and occupational status are more likely to seek fertility care [ 6 ]. People seeking fertility treatment have a high level of health literacy, are eager to expand their knowledge about lifestyle and fertility, and yet are frustrated by the lack of reliable and evidence-based information. In-line with previous research, participants largely relied on self-directed sourcing of information via social media [ 39 ]. The stressful and uncertain circumstances surrounding infertility clouded their ability to critically appraise these information sources despite high levels of knowledge. This is consistent with previous findings in preconception women, where participants identified as a vulnerable population for misinformation, and felt overwhelmed and stressed by conflicting advice [ 40 ]. Our intervention suggestions reflect the importance of using education at the systems level to shape the landscape of online information by communicating and promoting credible and authoritative information, such as evidence-based resources which correct common misperceptions. Participants were disheartened by the limited lifestyle support provided by fertility care services and some felt that their lifestyle behaviours were overlooked if they were within the healthy weight range. Many participants felt strongly that to improve their opportunity for successful lifestyle change, lifestyle services should be integrated into fertility clinics. Importantly, lifestyle advice should focus on practical and actionable lifestyle strategies that are appropriately tailored to patients’ situations and considers sensitivity in communication, rather than overemphasising weight which may be viewed as stigmatising [ 41 ]. Participants in our study were using or seeking fertility treatment in Australia, where fertility care is largely privatised, similarly to many countries globally [ 42 ]. Privatised health care service delivery may be influenced by profit-driven motives that can prioritise high-margin services and neglect less profitable areas of care like lifestyle management. It can also lead to a further fragmentation of care where referrals to external services, such as allied health, are not encouraged [ 43 ]. Fertility clinic staff also experience challenges including time constraints and concerns about patients’ expectations of care, which limit their capacity to deliver lifestyle care [ 44 ]. This compromised quality of care was a concern voiced not only by the participants in our study, but also in previous research on information and support needs in men with male-factor infertility [ 45 ]. Strategies that integrate lifestyle services into existing models of care while having a neutral or positive impact on business viability are crucial. For example, over three-quarters of fertility clinics in Australia and New Zealand advertise add-ons [ 46 ], and lifestyle services could be advertised as an evidence-based add-on, allowing for integration into fertility services and an additional revenue stream. Additionally, clinics could employ feedback mechanisms such as patient surveys or suggestion boxes to reprioritise high-value services and streamline low-value services. While private clinics are unlikely to shift away from a fee-for-service volume-based model towards patient centred-outcome driven care, employing meaningful patient consultation alongside cost analysis will help to reprioritise services [ 47 ]. Finally, while this would require substantial policy and organisational changes, government funding for public services to facilitate a two-tiered system would encourage coordination and integration of care across organisations. These systems-level changes to restructure service provision are applicable both in Australia and internationally, particularly countries which have private fertility clinics. While participants valued the broader benefits of a healthy lifestyle beyond its impact on fertility outcomes, they also struggled to maintain motivation for change throughout the fertility journey due to the mental toll of fertility treatment. Participants unanimously perceived a healthy lifestyle as beneficial whether trying to conceive or not. There is strong evidence supporting the broad-reaching health benefits of appropriate nutrition and physical activity, including reductions in all-cause mortality [ 48 ] and improvements in mental health [ 49 ]. The evidence on these outcomes is stronger than evidence on the effects on fertility [ 19 ], and should be harnessed as a motivating factor for lifestyle change. While motivating patients to commit to lifestyle modification is an important stage of behaviour change, sustaining motivation proves more challenging. Infertility and fertility treatment are stressful experiences [ 50 ], and participants often struggle with emotional eating (e.g. Porter 2008) and relapses triggered by the uncertainty of fertility treatment. Conversely, adopting healthy lifestyle behaviours induces feelings of empowerment to counter the unpredictability of the infertility journey, hence reducing feelings of helplessness and improving self-efficacy. Consequently, our suggested intervention strategies emphasise the importance of service provision from appropriately qualified health professionals to enable improvements in self-efficacy and encourage reframing healthy lifestyle behaviours as self-care strategies for individuals experiencing infertility. Our study has several strengths. Firstly, we undertook measures to assure the authenticity of responses, in accordance with published guidelines [ 28 ]. Additionally, our use of online recruitment and interviews allowed us to include participants from outside of our geographical area, as well as those who had time constraints that would preclude a face-to-face interview. We also used evidence-based frameworks to inform data collection and analysis, with member checking to confirm findings, hence enhancing the robustness of our findings. Our findings should be considered in light of the limitations of this study. We did not collect data on lifestyle behaviours and are therefore unable to ascertain whether people who meet current recommendations for lifestyle behaviours experience different enablers and barriers to people who do not meet lifestyle recommendations. While we met recruitment targets of 10–15 people and included people from a range of ethnic backgrounds, locations of birth and education levels, the sample size remained small, and further research is needed to capture the diverse experiences of people with infertility including those from minority groups. Additionally, there was an underrepresentation of men, which likely reflects our findings that men are often not engaged in fertility care and the onus of treatment lies on the female partner in heterosexual couples [ 51 ]. Findings also were unable to capture the perspectives of people living in remote areas, though again this reflects the population demographics of people accessing fertility services. This underrepresentation therefore does not necessarily limit the transferability of our findings, but rather highlights systemic issues related to the unfair distribution of services and/or disengagement with fertility care [ 6 , 52 ]. While no participants voiced disagreement with our results in synthesised member checking, there is a possibility that their decision not to voice disagreement may be influenced by the time and effort required to respond or by their perception of uneven power dynamics [ 36 ].

These findings identified several interacting factors influencing lifestyle in people with infertility, and will underpin behaviour change strategies to assist people with infertility to successfully implement lifestyle change. Changes at the organisational and policy levels are needed to address identified barriers to focus on improved access to online information provision that can counteract misinformation and equip people with a thorough understanding of the mechanisms by which lifestyle affects fertility. Additionally, organisational changes which promote values-based care through improved resource allocation towards lifestyle services and integration of allied health services will further support people with infertility to successfully implement lifestyle change. Increased government funding for public services could further support a model of care conducive to integration of lifestyle support. Future research should qualitatively explore factors affecting integration of lifestyle services into existing fertility care using theory such as the Consolidated Framework for Implementation [ 53 ] to explore constructs at the policy/government level (e.g. funding, market pressures, societal pressures) and health organisation level (e.g., culture, physical infrastructure, incentive systems). It should also use the findings of this study to co-design resources both for online and in-clinic use.

Infertility, defined as the inability to achieve a clinical pregnancy after 12 months of unprotected intercourse, is a widespread health condition affecting 1 in 6 couples globally [ 1 , 2 ]. It is estimated that 40% of cases of infertility are caused by female factors (including tubal, ovulatory and uterine factors), 40% of cases are caused by male factors (including abnormalities in sperm count, motility and structure), and the remaining 20% are caused by a combination of male and female factors [ 3 – 5 ]. Approximately half of people with infertility will seek medical treatment [ 6 ], which may involve ovulation induction, intrauterine insemination or assisted reproductive therapies such as in vitro fertilisation (IVF). While these treatments increase the chances of pregnancy for people with infertility, they impose substantial physical, psychological and financial burdens on patients which may lead to treatment discontinuation before fulfilling reproductive goals [ 7 ]. Modifiable factors, such as lifestyle, which can influence fertility and the outcome of fertility treatment are therefore essential to consider in the context of reproductive health. Optimising lifestyle behaviours, including diet and physical activity, can improve both male and female fertility, and is recommended in many clinical guidelines for infertility management [ 8 – 10 ]. However, some indications for fertility treatment are unrelated to diet and physical activity; these include relationship status (e.g. same-sex couples and single individuals), previous sterilisation (e.g. tubal ligation or vasectomy) and damage to reproductive organs (e.g. due to sexually transmitted infections) [ 11 – 13 ]. A healthy lifestyle can improve female fertility through mechanisms including improving ovulation, correcting hormonal imbalances and enhancing endometrial receptivity [ 14 , 15 ]. In males, a healthy lifestyle can improve fertility by improving sperm quality and motility [ 16 ]. However, similarly to the general population [ 17 ], many people with infertility have suboptimal lifestyle behaviours, including alcohol use, physical inactivity and inadequate fruit and vegetable consumption [ 18 ]. Further, systematic reviews investigating effects of diet and physical activity on fertility outcomes report mixed findings. This highlights the need to identify intervention characteristics that optimise success [ 19 , 20 ]. To understand how to improve lifestyle in this population, it is essential to gain a thorough understanding of the unique barriers and enablers affecting their uptake of lifestyle behaviours. Findings can be used to directly inform the design of targeted lifestyle interventions and ultimately improve intervention outcomes. When aiming to investigate factors influencing lifestyle behaviours, the behaviour change wheel (BCW) method is an evidence-based and systematic method to inform collection and analysis of data [ 21 ]. At the core of the BCW, the Capability, Opportunity and Motivation of Behaviour (COM-B) model posits that behaviours are influenced by interacting capabilities, opportunities and motivation to perform a behaviour of interest. Each component of the COM-B model is further subdivided into domains of the theoretical domains framework (TDF), which consists of 14 domains that identify specific psychological, social and environmental influences on the desired behaviour [ 22 ]. By using the BCT researchers can determine which intervention functions (broad behavioural change strategies including education, persuasion, incentivisation and environmental restructuring) are most likely to be effective, and which policy categories (population or organizational level approaches that address the social, economic or institutional factors effecting behaviour change) can be targeted to create a more enabling environment. Lastly, Behaviour Change Techniques (BCTs) are used to develop targeted interventions by providing specific, practical strategies for implementing the broad approaches defined by the intervention functions and policy categories. By aligning BCTs with the underlying behavioural determinants and contextual factors, interventions are more effective and sustainable. A mixed-methods systematic review published in 2024 used the BCW method to evaluate factors affecting lifestyle management of infertility [ 23 ]. The review included 27 studies (3931 people with infertility,372 health professionals) and identified unique factors affecting preconception lifestyle management in people with infertility, including emotional eating driven by the stress of not conceiving, the importance of partner support and engagement with lifestyle change and awareness of lifestyle risk factors affecting not only fertility but also pregnancy outcomes. However, one of the key findings from this review was the paucity of qualitative research on this topic, with only six of the included studies using a qualitative study methodology [ 23 ]. Qualitative research is crucial in intervention design as it uncovers the needs, perspectives, and lived experiences of individuals, ensuring the intervention is relevant, effective, and responsive to the target population. Therefore, further qualitative research is needed to address this evidence gap and hence ensure that lifestyle interventions meet the unique needs of people with infertility. The aim of this study is to understand the enablers and barriers affecting uptake of lifestyle intervention in people with infertility who are using or seeking fertility treatment, using the BCW method to inform the development of targeted behavioural change strategies. While lifestyle is a broad term that addresses biological, psychological, social, spiritual and ecological aspects of health, and hence encompasses a range of different behavioural interventions [ 24 ], this study defines lifestyle interventions as those designed to improve dietary intake or physical activity through appropriate behavioural support.

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