Determinants of infertility treatment from the point of couples referring to infertility treatment center in Southern Iran

Abstract

Infertility and attempts to treat it are associated with stress for couples. In Iran, infertility is a problem associated with many challenges. The present study was conducted to Explaining effective factors of infertility treatment from the point of view of the participants of the infertility treatment center in Bandar Abbas City. This research is a qualitative content analysis research. The data were collected through in-depth semi-structured interviews with 36 men and women. A purposive sampling was used with maximum variety of Gender, Number of years of infertility, education, Economic situation different geographical regions and History of underlying disease. The interviews continued until data saturation. All the verbal interactions of the participants were recorded using a digital voice recorder and analyzed using qualitative-oriented content analysis. MAXQDA version 10 software was used to manage codes and facilitate data analysis. The average age of female participants was 36.5 and the average age of male participants was 41 years. Data analysis led to the identification of 7 main categories of determinants including (1) individual, (2) environmental, (3) religious, and psychological, (4) legal and regulatory, (5) socio-cultural, (6) economic s, and (7) therapeutic. Further, a total of 43 subcategories were identified. effective factors of infertility treatment identified in this study can help planners and policymakers in treating infertility and increasing the Iranian population which is on the decline.

Introduction

Infertility is a major health challenge for approximately 8–10% of couples across the globe¹ In the developed world, the problem of infertility is increasing and has become a social concern. This problem was described in 1988 at the international conference in Bangkok as a global health problem with sexual, and psycho-social dimensions², which exposes affected people to a lot of family pressures³. From a clinical point of view, infertility refers to the failure to conceive after 12 months of regular unprotected intercourse, although some couples conceive without treatment⁴.

In Iran, 11.3% of people experience infertility at some point in their lives, while 3.7% are currently infertile. Looking at specific types of infertility, 18.3% experience primary infertility (infertility in couples who have never conceived) and 2.5% experience secondary infertility (infertility in couples who have conceived at least once before)⁵. In recent years, changing the trend of demographic policies towards increasing the birth rate in Iran has put infertility policies on the agenda of the health sector⁶.

In some developing countries, including Iran, having children is a deeply ingrained social value for married women⁷. Consequently, couples facing infertility often experience significant psychological distress, including depression, anxiety, low self-esteem, and dissatisfaction^8–10. These emotional burdens can strain interpersonal, social, and marital relationships, sometimes even leading to divorce or relationship breakdown¹¹. The infertility treatment process itself can be physically, mentally, and emotionally demanding, placing considerable stress on couples, often described in the literature as an “infertility crisis”¹².

Hormozgan province, located in southern Iran, presents a unique context for studying infertility. This region faces significant challenges regarding access to healthcare and treatment facilities. Prior to 2018, Hormozgan lacked a dedicated infertility center^13,14, further complicating the experiences of couples struggling with infertility. This limited access, coupled with the substantial financial burden of treatment, the potential physical side effects of medications and procedures, and the emotional toll, can lead to treatment discontinuation^15,16. Given the importance of childbearing and population growth in Iran’s national priorities¹⁷, understanding the factors influencing successful infertility treatment is crucial.

Quantitative infertility research provides valuable prevalence data but often overlooks the complexity of individual experiences¹⁸. This qualitative study addresses this gap by exploring the experiences of participants at the Bandar Abbas infertility treatment center. Focusing on subjective meanings, challenges, and facilitators, this research offers rich insights into the psychosocial and contextual factors influencing treatment journeys. Understanding these nuances is crucial for developing culturally sensitive interventions and improving support, especially in Hormozgan, where access to specialized care has been limited.

Therefore, this study aimed to explore the effective factors in infertility treatment from the perspective of participants at the Bandar Abbas infertility treatment center in Hormozgan province, contributing valuable insights to improve support and care for couples navigating this challenging experience.

Methods

Study design

The present study is a type of qualitative content analysis with a conventional approach. The research population included people who were undergoing infertility treatment at the infertility treatment center affiliated to Hormozgan University of Medical Sciences (HUMS). Inclusion criteria were couples who started treatment in 2024 and were willing to share their experiences with the interviewers. By phone or face-to-face participants were invited to an interview. These people filed a case at the infertility center affiliated with HUMS and started their treatment and wanted to participate in the study. 76 couples were invited to participate in the study. 42 accepted the invitation, but some of them did not attend the interview day, and ultimately 36 were interviewed. A total of 20 women and 16 men were included in the study. These people were completely free to leave the study whenever they wanted. Interviews were conducted face-to-face. To select participants to explore their different life experiences, first, a purposive sampling was conducted to ensure a diverse sample of participants in terms of place of residence (urban or rural), socio-economic status, gender, education level, treatment method in Different stages of treatment and different age groups be included. Participants were people who went to the said medical centers for examination and treatment. Semi-structured in-depth interview, which is the most common method in qualitative research, was used to collect data. This type of interview is suitable for qualitative research due to its flexibility and explore the depths of people’s experiences. In this method, the researcher started with general questions about the concept and continues the interview with deeper questions. In this research, an interview guide was used, in which the questions mainly focused on encouraging the interviewees to present their impressions of the experience, mention problems, and express their views regarding determinants of infertility treatment.

Data collection

At the beginning, complete explanations about the study, objectives, implementation method and also the arrangements that were considered to keep the information confidential were presented to the participants verbally and in writing. In case of agreement, a written informed consent form was signed by the participants. The time and place of the interview were determined according to the opinion of the participants and previous arrangements with them. Then, using the opinions and guidance of experts knowledgeable about the subject, its validity was confirmed. To prepare a guide for the questions, a preliminary guide was first prepared, and to determine its acceptability (validity), the interview guide was reviewed and reviewed by some experts familiar with the qualitative research method. The questions started about “the number of years that have passed since the beginning of cohabitation” and continued with “how many years have you been trying to get pregnant” and finally with a question about “why did you finally go to treatment centers for your infertility treatment?“. In the continuation of the interview process, probing questions (such as “Please explain more”, what did you mean by this sentence you said?” “Why do you have such an opinion?” and “How did you come to this belief” “And” and” also” were also used. The interviews continued until the data was saturated. All discussions were recorded using a digital device. The duration of the discussions was between 30 and 45 min and at the end of the discussion The way to contact the participant was determined so that, if necessary, the possibility of further communication for questions or possible additional explanations is provided. The interviews were conducted on the second floor of the Infertility Treatment Center of Hormozgan University of Medical Sciences in a room with complete silence and privacy. The initial questions were designed with the help of a gynecologist and infertility specialist and a psychologist. The interview began with general questions about the number of years the couple had been married and the number of years since the couple attempted to have children, and continued with a series of designed questions, reaching saturation based on the responses of the interview participants. The initial and following questions included:

1. How many years have you been married?

2. How long have you been trying to have a baby?

3. What are the determinants of infertility treatment in your opinion?

4. Why did you turn to infertility treatment centers for your infertility treatment?

5. What factors do you consider effective in your infertility?

6. How did you come to believe this?

Qualitative data analysis method

In this research, the content analysis method of Granheim and Lundman was used to analyze the qualitative data. The steps taken in this method include: writing the entire interview immediately after each interview, reading the entire interview text to get a general understanding of its content, determining meaning units and primary codes, classifying similar primary codes into more comprehensive classes, determining the content It lies in the data and extraction of the main theme¹⁷. The software used at this stage is MAXQDA version 10. Our strategies for minimizing self-report bias in this study were creating a safe and non-judgmental environment for interviews and ensuring the confidentiality of participants’ information, reviewing the interview transcripts by some participants to confirm the accuracy of our interpretation of the individuals’ words, using professional interviewers and analysts, and collaborative coding in collaboration with the research team, and using the triangulation method by combining different data sources (interviews, observations, documents)¹⁹.

Rigor and trustworthiness

Guba and Lincoln evaluation criteria were used to check the trustworthiness of the findings²⁰. To substantiate the validity of the findings, the researcher’s self-review technique, incorporate observations and clinical records analysis was used in data collection and analysis as well as a peer check during which the codes were provided to two participants to resolve misunderstandings. To substantiate the reliability of findings, inter and intra-rater reliability exams were used. To this aim, the recorded and their transcribed conversations were given to two experts for review. After analyzing the data, they were re-analyzed by colleagues. The next step was documentation to test the comprehensibility and accuracy of the procedures, and the underlying mechanisms of errors.

Ethics approval and consent to participate

The present study was approved by the ethics committee of HUMS with the ethics code IR.HUMS.REC.1403.373. To ensure voluntary participation in the study, informed consent forms were signed by the participants and permission was obtained to record their voices. The interview files (typed files and recorded interviews) were considered confidential and kept in a separate folder that was encrypted. The interviewees were free to withdraw from the interview at their request. The authors confirm that all methods were performed in accordance with the relevant guidelines and regulations. In addition, at the beginning of each interview, the interviewer fully explained that this study has received the code of ethics from HUMS and that all your information and experiences will remain confidential, and you can discontinue your participation at any time if you do not wish to do so.

Results

According to the findings of the present study, the average age of the participants was 38.75 ± 10.73 years. 20 women and 16 men. Their demographic features are described in Table 1.

Table 1.

Demographic characteristics of the participants.

Variable		Frequency	Percentage
Age	Man Mean (SD)	38.75 (10.73)
Gender	Man	16	44/4
	Woman	20	55/6
Number of years of infertility	Under three years	8	22/2
	Between three and seven years	15	41/7
	Over seven years old	13	36/1
Education	Under diploma	18	50
	Diploma to bachelor	14	38/9
	Above bachelor’s degree	4	11/1
Economic situation	Weak	20	55/6
	Average	10	27/8
	Good and very good	6	16/7
Residence	City	27	75
	The village	9	25
History of underlying disease	Yes	32	88/9
	No	4	11/1

Data analysis led to the identification of 7 main categories of determinants including (1) individual, (2) environmental, (3) religious, and psychological, (4) legal and regulatory, (5) socio-cultural, (6) economic s, and (7) therapeutic. Further, a total of 43 subcategories were identified (Table 2).

Table 2.

Factors affecting in the treatment of infertile couples.

Categories	Sub-categories
Individual determinants	Inadequate health literacy about healthy pregnancy Ignorance of the principles of sexual hygiene Lack of sexual hygiene Low education and literacy of couples Embarrassment and shame in treatment Poor-quality oocytes and sperm varicocele Mutual understanding of spouses Low health literacy in the area of ​​infertility in couples Lack of perceived sensitivity getting older Unhealthy lifestyle
Environmental determinants	Access and limited medical facilities Commuting problems and then distance The climate of the region Lack of sports facilities
Religious and psychological	Hope and trust in God Trying to end depression Belief in luck Infertility in men and low sense of masculinity feeling guilty
Legal and regulatory determinants	Inefficient rules Late response A history of illegal abortion: and its impact on future infertility
Socio-cultural determinants	Fear of early pregnancy The stigma of impotence, especially in men Influence of significant others Lack of education before marriage Spouse’s child: afraid of sexual intercourse / non-activation of the oocyte Divorce and widowhood: delay the reproductive age People’s words and judgments The lack of importance of the issue in society Covering local-indigenous people
Economic determinants	Unemployment and inappropriate and insufficient income poverty The high cost of treatment and tests
Therapeutic determinants	Insurance problems The pain of ovum transplant and embryo transfer operation A sick man is not comfortable with a female doctor underlying diseases Type of infertility center Stress and pain of operation Native and traditional treatment

Individual determinants

The first category of individual determinants includes sub-categories: insufficient health literacy about healthy pregnancy, ignorance of the principles of sexual hygiene, non-observance of sexual hygiene, age, education and literacy of couples, embarrassment and shame in treatment, Poor-quality oocytes and sperm, varicocele, being literate Spouse, mutual understanding of spouse—decrease of spouse’s attention, infertility health literacy in couples, lack of perceived sensitivity, increasing age, high weight, influence of lifestyle.

Inadequate health literacy about healthy pregnancy

“We had little information about oocyte health and fertility and everything in general. There is not much talk about gestational age and high-risk pregnancy and healthy fertility in society” (Participant number 3, a 38-year-old woman).

“Everything we learned was from friends and acquaintances, for example, I didn’t know what to take during those years when I took birth control pills or if it would have a negative effect on my future pregnancy. We used to go to the pharmacy and buy pills” (Participant No. 8, a 33-year-old woman).

Ignorance and non-observance of sexual hygiene principles

“I wish they would force both women and men to attend classes related to health issues. I think my wife did not follow sexual hygiene well, or maybe she didn’t know, and I kept getting infections” (Participant No. 14, a 40-year-old woman).

Low education and literacy of couples

“I didn’t study until the 5th grade of primary school. I didn’t even go to university. They didn’t tell us anything about how to have a baby and what to do if it doesn’t work. We don’t have internet literacy either. It took 4–5 years before we realized that we had a problem and that it was serious” (Participant number 21, a 44-year-old man).

Embarrassment and shame in treatment

“From the first year of marriage, we felt that we had a problem, but we were ashamed to share it with our families” (Participant No. 30, 34-year-old woman).

“We didn’t tell anyone in our family because we didn’t want our family to know that we had a problem, especially when we found out that the problem was with my husband. I know that it would be really embarrassing for others to tell us that the problem is with him” (Participant No. 35, a 38-year-old woman).

Poor-quality oocytes and sperm

“The doctor said that my sperm count is low, that’s why we haven’t had a baby yet” (Participant number 5, a 35-year-old man).

“We are three sisters, all three of us will not have children. The doctor said that your oocytes are not good. I was followed up for pregnancy, but my older sister was not” (Participant number 11, a 39-year-old woman).

Varicocele

“I had a varicocele problem since I was young, and I didn’t know that this problem would cause infertility in the future” (Participant number 23, a 40-year-old man).

Mutual Understanding of spouses

“I am so upset that I have a problem, then the only thing that calms me down is when my husband tells me not to worry, even if we don’t have children, I am behind you” (Participant number 6, a 29-year-old woman).

Low health literacy in the area of infertility in couples

“We didn’t know what infertility was at all? We didn’t even know which doctor we should go to for this problem. Gynecologist or urologist? When we sat in the doctor’s office, they told us where it was and where it was good…” (Participant no. 20 women, 41 years old).

“When people understand that someone is infertile, they quickly say that the problem is with the woman, they don’t know that the problem can also be with the man” (Participant number 2, a 33-year-old woman).

“When we came to this center, we just realized that we have to do tests and do a bunch of things. We didn’t know anything before” (Participant number 10, a 39-year-old man).

Lack of perceived sensitivity

“Early on, we didn’t think it was serious. We didn’t worry about it until I saw that two years had passed and they were asking us if we were going to have children? It just became serious for us” (Participant No. 13, a 35-year-old woman).

Getting older

“If I had taken action earlier, I would have had more luck. I am 43 now. I am disappointed” (Participant No. 22, a 43-year-old woman).

Unhealthy lifestyle

“I have ovarian laziness. My doctor insists that I exercise to lose some weight, but I really don’t feel like exercising and losing weight” (Participant number 1, a 33-year-old woman).

“Even though my test is good, but the embryo transfer is negative, the doctor said this time that you should exercise and be careful about your nutrition. Because I like fast food, I don’t exercise, maybe that’s why” (Participant No. 16, a 37-year-old woman).

Environmental determinants

The second category was environmental determinants includes sub-categories: access and limited medical facilities, transportation problems, and then distance, climate of the region, and lack of sports facilities.

Access and limited medical facilities

“Before, everyone went to other cities like Yazd for treatment because there were few treatment facilities here. We didn’t go because we couldn’t afford to go. Maybe if the clinic here was better equipped, we would have gotten results sooner” (Participant No. 26, a 42-year-old man).

Commuting problems and then distance

“It’s really difficult for us to travel from the village to the city for treatment. We don’t have a car ourselves” (Participant number 34, a 39-year-old man).

The climate of the region

The climate of the region was extracted from one of the Environmental determinants category.

“In winter, I lost ten kilos by walking because the doctor said, but because the weather in Bandar Abbas is very hot, it really won’t be for three or four months because of the heat, I got fat again” (Participant number 27, a 29-year-old woman).

Lack of sports facilities

“I have no choice but to exercise because of my weight, but there are no good parks around us to exercise” (Participant number 17, a 39-year-old woman).

Religious and psychological

The third religious and spiritual class includes sub-categories: trust in God, hope, trying to end depression, belief in luck, infertility in men and a sense of low masculinity, feeling guilty.

Hope and trust in god

“During the entire treatment, I was hoping to God that something good would happen and we would have children too” (Participant No. 25, a 38-year-old woman).

Trying to end depression

“Without a child, our life does not feel good, we love it. We are sure that if we have a child, this unhappiness will end” (Participant No. 31, a 39-year-old woman).

Belief in luck

“Luck plays a big role in my opinion, because someone doesn’t want a child, he will have a child unintentionally. Those of us who have been waiting for a child for years got unlucky and it is not clear whether we will get a child or not” (Participant number 4, a 43-year-old man).

Infertility in men and low sense of masculinity

“We tried for two years when we saw that we couldn’t have a baby. My husband said don’t worry, you’ll be fine. He thought it was my problem. He couldn’t believe that he saw the problem after taking the sperm test. Even now, he’s very sad and told us not to tell our family under any circumstances. Me too. I said that it is my problem that my husband is not humiliated in front of others. They know that it is very bad for a man not to have children” (Participant number 17, a 34-year-old woman).

Feeling guilty

“At first, my wife was sure that the problem was with me, but when we did the test and it turned out that the problem was with her, she felt guilty. She tells me that it’s probably because of the food we eat. She wants to please me” (Participant No. 33, a 37-year-old woman).

“My husband is the first child in the family and his family is waiting for us to bring their first grandchild, but what should I do? We haven’t taken action in 5 years. I really feel bad for them” (Participant No. 24, a 35-year-old woman).

Legal and regulatory determinants

The fourth category of legal and regulatory determinants includes sub-categories: ineffective laws, non-cooperation, history of illegal abortion and the effect it has on infertility in the future. Since abortion in Iran has strict laws for religious and political reasons, some determinants of infertility referred to individuals’ previous experiences with home and illegal abortions. On the other hand, the need to pass laws and implement them regarding greater cooperation between medical centers and their support for couples with infertility problems can be helpful in continuing treatment for these couples.

Inefficient rules

“I think the government can help a lot to solve the infertility problem of couples, both in the field of financial support and advertising on radio and television” (Participant number 32, a 36-year-old man).

Late response

Some infertile couples need the cooperation of the agencies that work there to pursue their treatment. However, due to the lack of legal support and specific guidelines in this regard, cooperation with these people is not possible.

“If the government sends a letter to related departments to cooperate with infertile couples so that they can take leave for treatment and hospitalization, our stress would be reduced” (Participant number 28, a 34-year-old woman).

A history of illegal abortion and its impact on future infertility

“I had a history of miscarriage before. We took medicine ourselves and injected it at home, and then I was so bothered that I had to have a curettage. I think this caused me to be infertile now, but I didn’t tell anyone except my doctor” (Participant No. 24, a 32-year-old woman).

Socio-cultural determinants

The fifth category of social determinants includes sub-categories: fear of early childbearing, the stigma of being asexual, especially in men, being influenced by significant others, not having pre-marriage education, children of the spouse: having a fear of sexual intercourse/ovulatory inactivity, divorce and widowhood: it postpones the reproductive age, people’s words and judgments are not important in the society.

Fear of early pregnancy

“We didn’t want children for the first one or two years, that means no one wants children at first, then everything we tried didn’t work” (Participant number 7, a 40-year-old man).

The stigma of impotence, especially in men

“People’s words bothered me a lot, they even told my husband to go and find another woman, because we had told everyone that the problem was mine so that my husband would not be disappointed” (Participant No. 28, a 42-year-old woman).

Influence of significant others

“My husband and his family are educated, they give good suggestions and guidance, they told me that this infertility center is open and we could come for treatment” (Participant number 25, a 38-year-old woman).

Lack of education before marriage

“Everyone should be taught about women’s menstrual cycle and its effect on premarital pregnancy, we are not taught to only ask about anemia and…” (Participant No. 20, a 41-year-old woman).

Spouse’s child: afraid of sexual intercourse/non-activation of the oocyte

“It was customary in our village that a girl should get married early. We should get married at the age of 10–11. They expect us to have a child in a year. Not at all” (Participant No. 1, a 33-year-old woman).

Divorce and widowhood: delay the reproductive age

“I had an unsuccessful marriage before. Divorce and the period after it and the specific marriage itself took a lot of time and made me older and my chances of pregnancy decreased” (Participant No. 28, a42-year-old woman).

People’s words and judgments

“We were tired of people’s words, everyone saw us at every party and everywhere they asked: Don’t you have children?” (Participant No. 31, a 39-year-old woman).

“Everyone was asking me so many questions and why don’t you have children or they were giving different suggestions, go to this doctor, go to that doctor, that I didn’t even go out for a while without anyone seeing me” (Participant No. 28, a 42-year-old woman).

“People’s words bothered me a lot, they even told my husband to go and get another woman, she can’t bring you children” (Participant No. 24, a 32-year-old woman).

The lack of importance of the issue in society

“They are now maneuvering on the issue of population increase, but there is less talk about the problems we have, as if infertility is not a very important issue” (Participant number 25, a 38-year-old woman).

Coverage of local-indigenous people

“We can’t exercise at all because of the bandari clothes. We got used to these clothes. Even with these tight skirts, you can’t walk, let alone exercise.” (Participant No. 1, a 33-year-old woman).

Economic determinants

The sixth class of economic determinants includes sub-categories: inappropriate and insufficient job and income, unemployment, poverty, high cost of treatment and tests. Most of the participants were interested in the fact that the treatment of infertility is completely dependent on the income and budget of the people.

Unemployment and inappropriate and insufficient income

“My husband is a taxi driver, he doesn’t have a stable job, I have a house because I am unemployed most of the time, there is no money for IVF” (Participant number 17, a 34-year-old woman).

Poverty

“We have so much trouble to provide the necessities of life that we don’t have money for infertility treatment” (Participant number 30, a 34-year-old woman).

The high cost of treatment and tests

“The tests are very expensive, there are many ultrasounds, and it is difficult for us to get medicine and treatment” (Participant number 9, a 35-year-old man).

Therapeutic determinants

The seventh class of treatment determinants includes sub-categories: insurance problems, stress and pain of operation, male patient not being comfortable with a female doctor, underlying diseases, type of infertility center.

Insurance problems

“If the insurance had helped and covered the costs a few years ago when I was younger, I wouldn’t have bothered now at this old age. It would have been better at the time” (Participant No. 22, a 43-year-old woman).

“Many insurance companies do not support, my people do not follow up if the cost is high” (Participant number 15, a 40-year-old man).

The pain of ovum transplant and embryo transfer operation

“I am very afraid of the embryo transfer procedure. Sometimes I feel nauseous because of the stress.” (Participant No. 27, 29-year-old woman).

“I am afraid of the procedure. I have been afraid of the hospital since I was a child. They also say that stress has a bad effect on pregnancy. I don’t know what to do.” (Participant No. 25, 38-year-old woman).

A sick man is not comfortable with a female Doctor

“My husband doesn’t like to come to see female doctors, he can’t do it, he’s embarrassed. He says I’m not comfortable” (Participant No. 14, a 40-year-old woman).

Underlying diseases

I think that because I have diabetes, my infertility problem cannot be treated (Participant No. 30, a 34-year-old woman).

Type of infertility center

“One doesn’t get an answer from the center, but he gets an answer from another center and another doctor. It happened to me because their work, their diagnoses, even their devices were different” (Participant No. 13, a 35-year-old woman).

“We did not trust private centers at all, because we heard that they sell sperm and oocytes and do illegal work” (Participant number 29, a 38-year-old man).

Stress and pain of operation

“I’m just afraid of oocyte retrieval and embryo transfer. Sometimes I feel nauseous due to stress” (Participant No. 27, 29-year-old woman).

“I’m afraid of the operation. I was afraid of the hospital since I was a child. They say stress has a bad effect on pregnancy, I don’t know what to do” (Participant No. 25, a 38-year-old woman).

Native and traditional treatment

“When we first doubted after marriage and saw that it was too late and we didn’t have children, we tried everything the people around us said. We bought and consumed many herbal medicines from the apothecaries, but there was no cure and all the money was wasted” (Participant No. 24, Mrs. 35 years old).

“My husband and I decided to go to the doctor for treatment, but they kept telling us that the medicines have side effects and they scared us and we connected with several people on the internet. We took a series of herbal medicines with palm tree pollen, honey and… But we didn’t get an answer” (Participant No. 31, 39-year-old woman).

Discussion.

This study investigated the effective factors and determinants of infertility treatment in infertile couples in south of Iran at 2024. Our findings show that infertile couples face many determinants (personal, environmental, religious and psychological, legal and regulatory, socio-cultural, economic and therapeutic) to treat their infertility. These factors draw attention to the complexities in navigating the issue of infertility in this demographic group. This study sought to provide a comprehensive multi-dimensional description and conceptualization of the experiences of infertile couples visiting an infertility clinic.

Infertile couples often stated the needs and individual determinants that affect infertility treatment, such as obesity, health literacy, and increasing age were among the individual determinants of infertility in this study. Aaker’s (2024) study, which focused on assessing the relationship between health literacy and quality of life in women undergoing infertility treatment, also shows that health literacy acts as a determining factor in improving the outcomes of infertility treatment, the quality of life, 40% reduction in treatment anxiety and a 35% increase in adherence to treatment plans of these women²¹. These findings are also consistent with the research of Aslan H and Tokat (2023), who emphasized the role of health literacy in reducing the social stigma of infertility²². Another study conducted by Sahakian and colleagues in Lebanon shows that improving public literacy can lead to positive changes in attitudes and behaviors related to infertility²³. People with higher levels of education are more accepting of scientific methods such as in vitro fertilization (IVF) or adoption and are more willing to use modern treatments and they are less influenced by traditional beliefs and local legends that often attribute infertility to women. Also, the findings of Gilbert et al.‘s qualitative study with healthcare providers regarding infertility barriers showed that language barriers, low health literacy, and cultural differences were important individual barriers²⁴. This suggests that addressing these individual health factors, possibly through targeted interventions like weight management programs and improved health education, could positively impact treatment outcomes.

Another important class identified in our study was the environmental determinants such as the lack of limited medical facilities, transportation problems, and then distance, the weather of the region, and the lack of sports facilities. The women in our study were located in an area where, due to population growth policies, the government covers infertility treatments, but many participants did not know about this issue and therefore postponed their treatment. Also, this center was in the capital of the province (Bandar Abbas) and it was a long distance from many cities. These women faced more barriers to treatment evaluation due to insufficient knowledge of resources and limited social support. This was obvious because many of them were not evaluated within 12 months of infertility symptoms, which is the gold standard of treatment²⁵. In another study, service-related barriers such as limited, timely, and affordable access to health services Specialization and lack of appropriate reproductive services were recognized as effective factors in infertility treatment. The lack of modern facilities and equipment required for infertility investigations, the limited number of local infertility specialists, and the distance to fertility-related healthcare centers, especially for rural communities, were among the environmental barriers identified in the studies²⁴. Environmental barriers such as access to services in other cities of the province and providing facilities and vehicles for villagers can be effective in treating infertility. This underscores the need for improved public awareness campaigns to educate couples about available resources and support as well as the need for decentralized services and improved infrastructure to bridge the gap between urban centers and remote communities.

Belief and spiritual determinants were other known determinants in this study. Trusting in God, hope, trying to end depression, and believing in luck were among these things.

A study in Africa showed that infertility in African society is often related to supernatural and spiritual causes, and the use of indigenous medicine was beyond the medicinal effect in their opinion²⁶. Despite the availability of modern treatment methods, some women believe that treating infertility with indigenous methods is preferable²⁷. This highlights the importance of incorporating culturally sensitive approaches that acknowledge and respect individual belief systems when providing care and support.

The psychological impact of infertility, including depression, stress, and anxiety, is well documented^28,29. Our findings confirm these experiences and highlight the need for integrated mental health support within infertility treatment programs. However, within the Iranian context, these psychological burdens are likely exacerbated by prevailing cultural norms and expectations surrounding childbearing. In Iran, as in many other developing countries, having children is a deeply ingrained social value for married women⁷. A woman’s identity and social standing are often closely tied to her ability to bear children, and infertility can therefore lead to feelings of inadequacy, shame, and social isolation. The social pressure to conceive can be immense, with infertile couples facing judgment, pity, or even ostracism from family and community members. This pressure can be particularly acute for women, who may bear the brunt of the blame for infertility, regardless of the actual cause. As our findings indicate, the stigma of infertility, particularly in men (related to perceived masculinity), can further compound the psychological distress experienced by both partners. Men may experience feelings of emasculation and shame, while women may struggle with guilt and self-blame. The combination of these cultural pressures and personal emotional struggles creates a unique and challenging psychological landscape for infertile couples in Iran. Therefore, culturally sensitive mental health interventions, such as counseling that addresses these specific social and cultural factors, are crucial for supporting infertile couples in Iran. As Read et al. suggest, couple counseling and educational materials can be valuable resources, but these should be tailored to the Iranian cultural context³⁰. Furthermore, public awareness campaigns aimed at reducing stigma and promoting empathy towards infertile couples could also play a significant role in alleviating their psychological burden.

Legal and regulatory determinants were among the issues raised in this study. Many ambiguities and legal issues were raised among the participants due to the cultural and traditional context of the region. Some studies have considered infertility as a reproductive rights issue and thus support fertility treatments as part of supporting these rights²⁴, while consistently addressing barriers to providing ART in low-resource countries. It is noted that the importance of reproductive autonomy of individuals, as emphasized by the World Health Organization, requires that efforts should be made to ensure that people have the right to decide when, and how many. and how to have children³¹. It is suggested that to remove legal and regulatory obstacles, health service providers and other related institutions should properly and effectively inform infertile couples about the laws.

Due to the cultural and traditional context of this region, which regards reproduction as a social and cultural phenomenon rather than a biological phenomenon, socio-cultural determinants were one of the most important and effective factors from the participant’s point of view, such as stigma and people’s judgment, among others. The most important of these was previous studies also highlight the stigmatizing nature of infertility and other worrisome psychosocial issues and show that people generally do not have the psychosocial capacities to deal with traditional perceptions of unusual medical and psychological problems^32,33. A study showed that the feeling of stigma related to sexual health is more obvious in men²⁴. Other studies have also shown that this stigma affects related care^34–36 because infertility is generally considered a women’s problem. Men’s participation in the diagnosis and treatment of infertility seems limited³⁷. In the present study, infertile couples faced several important problems, including stigma, rejection, etc. It seems that raising people’s awareness, health literacy and social literacy is effective and people think rationally instead of worrying about “what others say”.

Due to economic problems and inflation in the country, economic determinants were another important factor issues such as the high cost of treatment and tests, unemployment, and poverty were mentioned as important issues, which were consistent with another study²⁴, while the cost of IVF treatment varies among countries, it is generally an expensive treatment^38,39. As a result, very high costs, problems with insurance and medicine coverage, and the lack of support programs double the couple fights in the treatment of infertility and livelihood, and conflicts will inevitably arise that threaten the foundations of people’s common life and social relationships.

Therapeutic determinants were among the issues raised in this study. Studies show the importance of reducing infertility treatment barriers at the clinical level²⁸. Primary care providers are known as the gatekeepers of referrals to specialized care⁴⁰. It seems that a comprehensive and multi-dimensional program is needed to successfully treat infertility and not leave incomplete treatment, which is one of the problems of infertility treatment. Doubt and disappointment in the treatment process can shake the foundation of a couple’s life. In a study, couples had special expectations from medical personnel that were not met, for this reason, in addition to medical treatment, they may resort to unusual treatments as well⁴¹.

Strengths and limitations

The use of a qualitative approach and data saturation enabled us to gather more in-depth information, particularly related to the study objectives⁴². The inclusion of actual quotes from the participants has enhanced the trustworthiness of the data. This study was conducted in a government clinic in the center of the province, and it is suggested that future studies be conducted in private clinics and other cities of the province. While an attempt was made to use diverse samples in the study to enable the collection of a diverse range of views, however, a greater proportion of female participants, with low education and poor economic status, were living in the city, and this should be should be considered in the interpretation of the results and its generalizability should be done with caution. Further, triangulation was not used in our study and future researchers can use a mixed methods approach. However, qualitative study is intended to understand a phenomenon and not to analyze the relationship between variables.

Future suggestions

This study strongly suggests that future studies should examine the psychological barriers and psychological determinants of individuals. This study also suggests that future studies should examine the determinants of appropriate behavior for pursuing treatment by infertile individuals and examine the mental barriers of individuals. Our study is the first to use such an approach in southern Iran, and few qualitative studies have previously examined this issue in southern Iran. Therefore, this study suggests conducting infertility intervention studies, especially in the field of psychology. Discovering the experiences of male infertility and eliminating the stigma of this group, as it seems to overshadow their masculinity, requires a more detailed study. Strategies to eliminate stigma and encourage couples, especially men with infertility problems, to participate in qualitative, cross-sectional, and interventional studies are strongly recommended. and examining the impact of cultural, geographical, and occupational factors, etc., in future studies.

Conclusions

The findings of this study can be used by policymakers and planners to take an important step to reduce the problems of these people and ultimately increase the population according to the determinants identified in this study. It can also improve the reproductive health of infertile couples improve their mental health, social and family status, and reduce the catastrophic costs of infertility care. This study improves the insight of decision-makers regarding the importance of fundamental factors in the formulation of policies, the participation of stakeholders in creating the policy prioritization process, and the state of evidence and documentation in decision-making and policy innovation. The present study provided an in-depth view of the effective factors in the treatment of infertile couples and can be used as a basis for future planning. The capacities and obstacles of medical centers to meet the needs and expectations of infertile couples should be given more attention. Also, the findings show the need for more studies to investigate effective factors in the treatment of infertile couples, taking into account specific aspects of infertility, such as the duration and causes of infertility, as well as issues related to male or female factors.

Author contributions

R.T conceptualized and designed the project, R.ER and M.SH wrote and developed the manuscript, M.AK. and A.Y. performed the critical review. All authors have read and approved the manuscript.

Funding

This study received no support for study design, data collection and analysis processes were developed independently by authors.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The present study was approved by the ethics committee of Hormozgan University of Medical Sciences with the ethics code IR.HUMS.REC.1402.373 to ensure voluntary participation in the study, informed consent forms were signed by the participants and permission was obtained to record their voices. The interview files (typed files and recorded interviews) were considered confidential and kept in a separate folder that was encrypted. The interviewees were free to withdraw from the interview at their request.

Competing interests

The authors declare no competing interests.