Infertility is defined as 12 months of unprotected intercourse without successful conception. There are more than 186 million people worldwide who suffer from infertility, accounting for 8%–12% of couples of reproductive age (Inhorn and Patrizio, 2015). In vitro fertilization (IVF)-embryo transfer (ET), a widely adopted assisted reproductive technology (ART), solves the problem of infertility to a certain extent and offers hope for infertile patients (De Geyter, 2019). ET is the most critical and important link in the process of IVF-ET treatment. Medical staff have also done a lot of propaganda and education work before IVF-ET, but patients are still full of expectation and fear and accompanied by great psychological pressure. Some patients also have abdominal pain, lower back pain, insomnia, and other physical symptoms after this very minimally invasive surgery, which may affect the success rate of patients to a certain extent. The psychological wellbeing of patients undergoing IVF-ET procedures varies significantly, which may be influenced by the knowledge, attitude, and practice (KAP) of ET among infertile patients (Yang et al., 2021). Therefore, it is crucial to understand the KAP level of ET among infertile individuals undergoing IVF-ET procedures, as this will assist in optimizing ART treatment plans and improving the success rates of ART procedures while also considering the overall health and wellbeing of the patient.

KAP study, as a valuable survey methodology, has been widely applied in gaining insight into patients’ perceptions, emotions, and behaviors regarding specific medical topics (Moon and Hyun, 2019; Pandey et al., 2020; Tahani and Manesh, 2021). Past research has predominantly focused on the fields of medicine and biology, with a focus on technological advancements and healthcare professionals’ experiences (Justin et al., 2022). However, as the patient’s level of KAP plays a crucial role in the outcomes of the treatment process, it is crucial to take into account this aspect. Unfortunately, previous studies have primarily focused on knowledge and attitude regarding ART, and most of these surveys are outdated (more than 20 years old) (Braverman et al., 1998), limited in size (Anaman-Torgbor et al., 2021), targeted to specific populations (Brandão et al., 2023), or conducted in other countries (Szalma and Bitó, 2021). Currently, there is a lack of in-depth understanding of KAP about ET among patients undergoing IVF-ET, which poses a significant challenge for precise adjustment of treatment regimens and establishment of patient support systems. Therefore, this study aimed to investigate the KAP of ET among women who underwent IVF-ET.

The results demonstrated that women who underwent IVF-ET had inadequate knowledge and negative attitudes but proactive practices toward ET. Anxiety, income, and reasons for IVF were associated with KAP toward ET. Moreover, knowledge significantly affected attitude, and attitude had a significant positive effect on practice. These findings may provide critical insights into how medical practitioners could develop and implement appropriate interventions and policies to improve KAP levels of ET among women who underwent IVF-ET.

In this study, the average total knowledge score was 19.46 ± 5.06, which was less than 70% of the total knowledge dimension score, suggesting inadequate knowledge regarding ET among the respondents. Previously, knowledge and attitudes of fertility and ART have been investigated among different populations, such as infertile couples/women (Afshani et al., 2016; Rabiei et al., 2022), the general public (Ahmadi and Bamdad, 2017), and university students (Jurkowski et al., 2021). Similar to the present study, most of the respondents in these surveys lacked sufficient information about fertility or ART knowledge. Specifically, the items with low “Very well-known” rates were related to the process of ET, the reason for holding your urine before the transfer, and dietary precautions taken after the transfer. These areas of knowledge deficits should be addressed in future health education or preoperative counseling regarding ET. According to previous reports (Hope and Rombauts, 2010; Daniluk and Koert, 2015; Mori et al., 2021), measures to improve respondents’ knowledge of ET may include online fertility education, educational DVD or brochures, and patient education and care programs.

In terms of the attitude dimension, the average total score of 39.41 ± 5.20 was also below 70% of the total attitude dimension score, indicating the respondents' negative attitude toward ET. Inconsistent with this result, Fauser et al. (2019) demonstrated a positive attitude toward IVF and gamete donation among European men and women. It may be attributed to the different items used to assess attitudes toward ET in the present survey. In addition, differences in the survey populations may be another reason for the conflicting results of the two studies, as only 10% of the people in their studies received IVF treatment. By analyzing the distribution of the attitude dimension, although most respondents recognized the importance of communicating with healthcare professionals about ET treatment and the warm words of healthcare professionals, more than 80% of respondents were still concerned about the success of implantation and delivery of the baby during the IVF-ET procedure. Excessive worry about the outcome of IVF-EMT may lead to adverse psychological emotions, and several studies have shown that some women and families suffer from anxiety, depression, and sleep disorders during IVF-ET treatment. Importantly, the levels of psychophysiological stress before and during treatment may influence the outcome of IVF-ET (Maia Bezerra et al., 2021). Therefore, there is a need for educational and psychosocial interventions to support women and their families physically and psychologically during IVF-ET treatment (Huang et al., 2019).

Different from the knowledge and attitude scores, the respondents showed proactive practice toward ET in the present survey. More than 70% of the respondents rarely or never had sex-related dreams, pain in lower limbs, cold sweats, insomnia, etc., and 30% of the patients had somatic symptoms such as sexual dreams, lower abdominal pain, and insomnia after ET. These findings indicated that the respondents in this survey had low levels of anxiety and active practice after Et. Nevertheless, a survey conducted by Anaman-Torgbor et al. (2021) found that the women undergoing ART were anxious, stressed, exhausted, and financially burdened and that 30% of the women undergoing ART had somatic symptoms such as sexual dreams, lower abdominal pain, and insomnia after Et. This difference may be due to the fact that the time of investigation for their study was when women were seeking ART services, whereas, in the present study, the women were enrolled after ET. In fact, previous studies (Massarotti et al., 2019; Capuzzi et al., 2020) have shown that there is a higher anxiety level among women undergoing infertility treatment before IVF-ET treatment, while women who resorted to IVF could have less perinatal depressive symptoms as the result of a positive outcome of the technique and the satisfaction of the desire to become mothers.

It was noteworthy that these results showed that the respondents’ KAP levels of ET differed by sociodemographic factors. Although some of these influencing factors are non-modifiable (e.g., reasons for performing IVT-ET and years of infertility), other factors may serve as a breakthrough to improve infertile patients’ KAP levels of ET. Specifically, individuals with lower education or income levels had less knowledge about ET, indicating that patients with low income or low education levels are a priority population in need of educational interventions. It does not mean that high-income or high-education patients do not need education, but that they are more likely to already have better knowledge and attitude than the less favored patients. These results are similar to prior research investigating the association between sociodemographic factors and knowledge level of IVF or infertility among women of childbearing age or community residents (Ahmadi and Bamdad, 2017; Arhin et al., 2022). Those results are also supported by the observation that a higher socioeconomic status (which includes education, work, and income, among others, is associated with better health literacy (Svendsen et al., 2020). Interestingly, the practice scores illustrated that lower practice was associated with living or working noise/decoration/chemical pollution environment in the last year and currently suffering from the underlying disease. Nevertheless, the multivariable analysis showed that the independent influencing factors of practice only included attitude score and anxiety score. This may be because, in the univariable analyses, the association between these factors and the level of practice was influenced by other factors and may be a “false association,” which can be easily adjusted and disappear in a multivariable analysis. In combination with the results of correlation analysis and SEM, knowledge significantly affected attitude, and attitude had a significant positive effect on practice and anxiety. Consequently, patient-centered education about ET knowledge may facilitate the development of a positive attitude and a decrease in anxiety for women who underwent IVF-ET.

This study is subject to several limitations that require acknowledgment. Firstly, due to the cross-sectional study design, it is not possible to draw conclusions regarding the effects of influencing factors on improving the KAP levels of respondents. Secondly, the sociodemographic characteristics of participants were not comprehensively included in the analysis, making it difficult to determine the extent to which other factors, such as marital status, may have influenced the responses in this survey. Additionally, it is difficult to generalize the findings of this study to represent all opinions on questionnaire questions, as respondents may have different educational backgrounds, lived in different cities, and had different accents, which may have affected their responses and understanding of questionnaire questions. Finally, the causes of infertility among the participants were mainly tubal infertility or oligozoospermic conditions, but the perception of the male partner with an oligozoospermic condition and its influence on the women’s KAP toward IVF-ET were not analyzed.

In conclusion, women who underwent IVF-ET had inadequate knowledge and negative attitudes but proactive practice toward ET, which were affected by anxiety, income, and reasons for IVF. Moreover, knowledge significantly affected attitude, and attitude had a significant positive effect on practice. Medical professionals should conduct targeted education to improve the awareness of ET-related knowledge among women who underwent IVF-ET to improve the patient’s compliance and enhance their mental health.

The manuscript titled “Knowledge, Attitude, and Practice of Embryo Transfer among Women who Underwent In Vitro Fertilization-Embryo Transfer” investigated the knowledge, attitude, and practice (KAP) of embryo transfer among women who underwent IVF-ET. The study was conducted using a cross-sectional design and surveyed using a self-designed questionnaire from 614 women who underwent IVF-ET between May and November 2023. The results indicated inadequate knowledge and negative attitude but proactive practice toward embryo transfer. The KAP was influenced by anxiety, income, and reasons for IVF. Structural equation modeling and multivariable linear regression analyses revealed significant associations between KAP dimensions and various demographic factors. Specifically, anxiety, income, and reasons for IVF were independently associated with knowledge, while income and number of embryo transfer cycles were associated with attitude. In addition, attitude and anxiety were associated with practice. The study underscores the importance of continuing patient education to enhance their KAP toward embryo transfer. These findings contribute to understanding the factors influencing IVF-ET outcomes and highlight the need for targeted interventions to improve patient education and support.