Journey of infertile couples: scoping the barriers for infertility care among infertile women in Morocco

Article information

Obstet Gynecol Sci. 2025;68(3):186-197

Publication date (electronic) : 2025 March 25

doi : https://doi.org/10.5468/ogs.24259

Meriem Ouadrhiri, PhD^,1,2, Chaymae Rochdi, PhD³, Rachida Archou, PhD^2,4, Mounia Amazian, PhD^5,6, Mustapha Boucetta, PhD^2,4, Nawal Mouhoute, PhD^5,7, Nisrine Mamouni, MD, PhD^1,8, Kamelia Amazian, PhD^2,9

¹Biomedical and Translational Research Laboratory, Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University, Fez, Morocco

²Laboratory of Health Sciences, Care and Techniques, Higher Institute of Nursing Professions and Health Techniques, Fez, Morocco

³Maternal-Child and Mental Health Research Laboratory, Faculty of Medicine and Pharmcy, Mohammed First University, Oujda, Morocco

⁴Clinical Neuroscience Laboratory, Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University, Fez, Morocco

⁵Higher Institute of Nursing Professions and Health Techniques, Rabat, Morocco

⁶Research Laboratory in Management Sciences, Mohammed V University, Rabat, Morocco

⁷Communication Department, CHU Hassan II, Fez, Morocco

⁸Obstetrics and Gynaecology Service, Hassan II University Hospital, Fez, Morocco

⁹Human Pathology, Biomedicine and Environment Laboratory, Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University, Fez, Morocco

Corresponding author: Meriem Ouadrhiri, PhD Biomedical and Translational Research Laboratory, Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University, Fez 30000, Morocco E-mail: meriem.ouadrhiri@usmba.ac.ma

Received 2024 September 22; Revised 2025 January 5; Accepted 2025 March 4.

Abstract

Introduction

Inequality and inequity in health and access to infertility care are pervasive in Morocco, an assessment of the current state of infertility care provision shows a wide gap between theory and practice, stated objectives and their application on the ground. For example, a significant gap has emerged between the availability of essential components, such as obstetrics and family planning care, and access to infertility services, including assisted reproductive technology (ART) [1]. Infertility is defined as a disease characterized by the failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse [2]. Infertility care encompasses several medical methods and procedure from ovulation induction to ART which eggs or embryos are manipulated [3], including intrauterine inseminations (IUI), in vitro fertilization (IVF) and intra cytoplasmic sperm injection (ICSI).

Infertility affects millions of people of reproductive age worldwide, with approximately 10-15% of couples affected. Experience with infertility can have a negative effect on an individual’spsychological and social health [4]. The impact of infertility generates individual or marital, emotional and sexual problems (negative feelings, frustration and relief, divorce, and gestational failure) [5]. More alarming, when infertility is present, there are many potential barriers to treatment, leading to inequity of access [6].

Recent reports from Moroccan society of reproduction medicine have shown that 15% of all couples frequently experience infertility, however the average duration to infertility treatment seeking at primary healthcare setting is estimated to be 5 years [1,7].

An in-depth review of the literature shows that disparities in access to infertility are well documented in developed countries. Indeed, treatment seeking is influenced by several factors including internalized stigma, having access limited by professional careers, low or no social support supporting treatment seeking and negative perceptions of the clinical environment [8], poor understanding of treatment options and inadequate referral patterns of primary care providers [9]. In addition, delays to initial consultation and treatment for infertile couple were significantly associated with reported supportive services offerings by healthcare professionals [10]. However, in Morocco previous studies of infertility are often focused on prevalence, causes and risk factors of either female or male infertility, the epidemiological and clinical profile of infertile couples who attended the ART in different regions of the country [11]. To our knowledge, no study targeting infertile couples has been conducted regarding barriers to infertility treatment seeking whether at primary health care setting or tertiary health facilities.

Acknowledging and understanding these barriers will enable to make recommendations which could help to prevent inequity of access to infertility care and bridging the gap between the various components of sexual and reproductive health (SRH) including infertility topic. The purpose of this study was to explore factors and barriers to ART care among women who experience infertility in Morocco.

Materials and methods

This is a cross-sectional analytical study relies on prospective data collected through a standardized questionnaire, was carried out in January-June 2023. The target population concerned infertile women attending outpatient Department of Obstetrics and Gynecology in a private clinic in the region of Fez-Meknes Morocco, having at least 1 year of infertility and being able to understand and answer the questionnaire. The inclusion criteria were females of a reproductive age, that is, 18-49 years, who met the medical definition for primary or secondary infertility, and those who were followed during the mentioned period and receiving treatment for infertility. Women who first visit and those who have started infertility treatment for less than 3 months were excluded from the study.

For this study we propose a theoretical framework to approach the problem of access to infertility care, inspired by the "pathway model" of the World Health Organization (WHO) Commission on Social Determinants of Health, it states that health inequalities are the result of complex interactions between multiple factors at global, national and local levels. As mentioned in Fig. 1, the theoretical framework proposed in our study, adapted to the Moroccan context classifies the determinants into two categories: structural determinants of health which are related to the political and socio-economic context of the country and intermediate determinants of health status relate to physical, psychosocial, biological and genetic factors, behavior and the role of access to the health system [12,13].

Fig. 1.

Theoretical framework on factors influencing the treatment-seeking process of Moroccan women experiencing infertility based on the who conceptual framework for action on CSDH adapted to the Moroccan context [12]. SRH, national strategy for sexual and reproductive health 2021-2030; ART, assisted reproductive technology; HCP, healthcare professionals; CSDH, commission on social determinants of health.

Thus, by referring to this theoretical framework, it was possible to identify a set of factors that align with structural and intermediary determinants. Each category of factors refers to a set of variables, and each variable was selected after a thorough review of both international and local literature.

Structural determinants refer to political, social, economic and environmental context and cultural factors (law 47-14, National Health Plan 2025, SRH strategy….) and position in society (employment, education, residence: urban/rural, income, social economic level….).

As regards intermediate determinants, they influence material circumstances (ack of financial means, distance from a fertility care.…), behavior and psychosocial factors (marital relationship, social pressure, stigma/guilt/pity….), genetic and biological and clinical factors (age, marriage span, duration of infertility….) and journey of care, infertility medical treatment including ART, barriers to ART, cost and financial sources.

Data were entered in Microsoft Excel 2019 (Microsoft Corp., Redmond, WA, USA) then analyzed using SPSS ver 25 software (IBM Corp., Armonk, NY, USA). A first descriptive analysis of the sample was carried out. Quantitative variables were expressed as means, standard deviations, and medians, and qualitative variables as numbers and frequency. Quantitative variables were expressed as means, standard deviations, medians, and while qualitative variables as numbers and frequency.

Multivariate logistic regression models were used to identify independent factors associated with access to ART. Variables included in the multivariate analysis are those that were found to be significant in the bivariate analysis at a level of P≤0.2. The statistical significance was set at P≤0.05.

Results

110 infertile women were included in this study, socio-economic and demographic characteristics are found in Table 1. The mean age of women was 31.99±6.79 years with extreme ages of 20 and 47 years and the median time of marriage was 7.70±4.92 years. The majority (74.5%) of women had a low socioeconomic level with a monthly household income of less than 5,000 MAD, 38.2% came from rural areas and 19.1% were illiterate. The highest proportion of respondents reporting coverage by AMO tadomone insurance (58.2%) and over half were unemployed (59.1%).

Table 1.

Socio-economic and demographic characteristics of study participants

For the overall respondent population, 80.9% had primary infertility and 19.1% had secondary infertility. The mean time experiencing infertility was 6.53±4.69 years and the length of time experiencing infertility before seeking initial consultation was 2.03±1.08 years. Among infertile couples, 34.5% had a female factor, 31.8% had a male factor, 18.2% had both male and female factors and in 15.5% of couples, the cause of infertility was undetermined.

Regarding the search for infertility treatment, 70.0% of infertile couples have used the private sector at the first consultation. Almost all (92.7%) of the women reported that they faced difficulties during their ART journey and 86.4% have tried alternative treatment to get pregnant, especially medicinal plant, and infertility meal and traditional massage (Table 2).

Table 2.

Women's distribution based on their clinic characteristics and care path

1. Barriers, self-perceived and announced psychosocial factors, cost and financial sources

As summarized in Fig. 2, the descriptive results have demonstrated several barriers to access to care that are evoked by women suffering from infertility such as: cost and lack of financial means (90.00%), distance from a fertility care (81.80%), tiring treatment (80.00%), accommodation during the care journey (78.20%), failed attempts (70.00%), type of insurance sheme (38.20%), condition of privacy care (35.50%), lack of time (34.50%), and spousal refusal (14.50%).

Fig. 2.

Obstacles encountered by women facing infertility issues barriers.

It was determined that 67.3% of women seeking infertility treatment experienced social pressure; among them, half felt pity from their surroundings, 27.3% felt guilty, 41.8% faced marital tensions, and 24.5% had a fear of divorce. Besides, almost half (50.9%) of the sample reported that they did not receive any psychological support from the nurses during their care pathway and 35.5% were unsatisfied with the management (Table 3). Couples use various strategies to cover for treatment expenses, they often resort family loans (43.60%), bank credit (30.90%), finding additional work in their free time (27.30%), sale of property (19.10%), and seeking help from the family members (14.50%) (Fig. 3).

Table 3.

Psychosocial factors perceived by women during ART journey

Fig. 3.

The financial sources sought by couples to cover the costs of ART. ART, assisted reproductive technology.

Thus, only 42.7% had undertaken at least a single attempt of ART, 57.3% underwent ovulation induction, 30.9% IUI and only 11.8% had received IVF/ICSI cycle (Fig. 4).

Fig. 4.

Use of ART by infertile women and average cost of a single attempt (MAD) & type of treatment received. IUI, intrauterine inseminations; FIV/ICSI, in vitro fertilization/intracytoplasmic sperm injection; ART, assisted reproductive technology.

2. Factors associated to ART

On bivariate analysis findings suggest there are multifactorial barriers that influence treatment seeking: the age (P=0.02), marriage span (P=0.02), duration of infertility (P=0.0001), length of time experiencing infertility before seeking initial consultation (P=0.05), monthly household income (P=0.03), education level (P=0.05), and profession (P=0.02) (Table 4).

Table 4.

Individual and socio-demographic factors associated with access to ART

On multivariable logistic analysis, age over 35 years old (odds ratio [OR], 3.36; 95% confidence interval [CI], 1.07-10.65; P=0.004) and the duration of infertility over 10 years (OR, 5.59; 95% CI, 1.24-25.24; P=0.003) remained significantly associated with women who had undertaken an attempt of ART (Table 5).

Table 5.

Multivariate analysis for access to ART

Discussion

Findings from our research suggest that there are multiple factors and barriers that influence access to ART, synthesized using the theoretical framework aforementioned in the context of infertile women in Morocco. It encompasses physical and financial barriers; individual, clinical, biological and psychosocial factors.

Firstly, financial and physical barriers were commonly reported among this population. On one side, almost all women, reported cost and lack of financial means as a barrier to care, indeed the average cost of a single attempt was 51,866±44,408 MAD who is approximately equivalent to 5,127.47 USD given that nearly three quarters of participants reported they had a monthly income of not more than 5,000 MAD (494.50 USD), in this case couples use various strategies to cover for treatment expenses, such as family loans, bank credit or seeking help from family members. Knowing that ART is very expensive in Morocco, a single IVF cycle in the private sector can cost between 25,000 and 45,000 MAD in out of-pocket costs [14]. These results have been confirmed in several studies where women reported that the cost was the most barrier to care, regardless of their race or ethnicity, education level, and insurance status [6,15]. These findings are in consistent with other studies that assert that cost, lower socioeconomic status and median income, coverage by health insurance were all the most identified barriers to both initiating and continuing ART [16]. In our Moroccan context, a study conducted among infertile couples showed that coverage of the expenses of ART was the first barrier on the way to infertility care because of the high cost of treatments and therapeutic solutions [14]. In fact, ART techniques cost 100 times as much as the average annual drug consumption per capita in Morocco, which is roughly 450 MAD [17]. As other results documented in developing countries where the cost of one IVF cycle is generally in excess of half the average annual income [18].

In other side, it was confirmed that all women had health insurance, and despite their affiliation to various insurance schemes, none of them covers the expenses of ART. Except for some medicines that have recently been refunded, the reimbursement remains partial [19]. However, in France, ART procedures are fully covered by health insurance, with coverage limited to a maximum of six IUI and four IVF attempts [20], the reimbursement policy in Belgium is identical, with a maximum of six IVF cycles per patient over their lifetime, which minimizes the financial burden on patients. Thus, 17,191 IVF/ICSI cycles were performed for a population of 11.3 million inhabitants, corresponding to 1,513 attempts per millions. Conversely, it is striking that ART remain accessible to less than 1% of the African population [21].

Indeed, a multi-country survey carried out in Africa has demonstrated there is a shortage of ART procedures in the public sector, ART’s utilization is low and it is inversely correlated with the value of copayments. Tunisia reported the highest use of public ART (>500 cycles per year), with the lowest co-payments, while ART centers in other countries, such as Algeria, Benin, Cameroon and Nigeria, perform fewer than 500 cycles annually [22]. The WHO revealed that only 16.4% of people in South Africa, one of the few higher middle-income countries in the region, had insurance coverage [23]. It appears that health systems in developing countries do not appear to meet their responsibilities regarding infertility patients [24].

In fact, still infertility prevention and management services are not included in the health insurance schemes, putting universal health coverage (UHC) progress at risk [1]. In other terms, they are not included in the current SRH package. In terms of Moroccan strategic policy perspective, access to care, especially SRH has been ranked as a priority of the ministry of health. Indeed, several reforms, strategies and action were adopted to enhance access to care including the National Health Plan 2025, the National SRH 2021-2030 and UHC.

However, infertility remains neglected, access to infertility care faces many barriers, infertility care is underserved. Indeed, some SRH components, such as infertility prevention and management services, although they were mentioned in the national reproductive health strategy 2010-2019, yet their translation into actions and interventions at health facilities was not well accomplished [25].

In order to support ART services, policy and legislation, appropriate funding, and good health service infrastructure are the essential enablers [22]. This requires the implementation of accessible, low-cost fertility clinics in in low- and middle-income countries, with affordable, effective, safe, and standardised diagnostic and therapeutic procedures in addition to the integration of infertility management into SRH care programmes with a particular focus on family planning and maternal care [26].

Besides, there was a variation in the provision of infertility care services in high, middle, and low-income countries. For instance, in Iran, insurance companies have been required to cover diagnostic and therapeutic tests, subsidizing medication costs, and expanding public infertility clinics, making infertility treatment more accessible. The National Health Service in the United provides infertility care for women with age restrictions (eligible couples may receive up to three full cycles of IVF if the woman is between 18 and 39 and one cycle for where the woman is aged 40-42 years) [27].

Un other barrier to access to ART care was distance from a fertility care, this factor was mentioned by the majority of infertile women whether they live in urban or rural areas and it is requirement for them to find an accommodation during de care journey. Data from the literature review confirmed this finding, women who lived within 15 km of a fertility clinic were 21% more likely to undergo ART treatment and 68% more likely to undergo IUI treatment than those who lived further than 60 km away [28]. Infertility care in Morocco is concentrated in the private sector, where the majority of ART centers are located in the center of Morocco. Despite the existence of ART departments in three university teaching hospitals (Rabat, Oujda, and Marrakech), they are unable to meet the needs of infertile couples in Morocco which currently has 12 regions. Indeed, geographical location as a barrier to accessing ART, can inflect in different ways such as a proximity to a fertility clinic, the number and location of fertility clinics and the city that the couple live [16,29].

In contrast, an unexpected result was that, nearly half of women have undergone ART despite their monthly income not exceeding 5,000 MAD witch equivalent to 493.71 USD. These data clearly demonstrate that women, despite their precarious status, the physical barriers they encounter and the constraints of healthcare system, are compelled to make substantial efforts and sacrifices to achieve their parental goals due to other factors which will be explained below.

In summary, similar result are not only observed in Morocco but also globally, reported that medical accessibility is influenced by physical and financial obstacles which represent geographical disparities of medical facilities, travel logistics and financial strain due to long distances from facilities [30].

Secondly, concerning individual clinical and biological factors, there were other factors to accessing ART include the age, the duration of infertility and marriage; the length of time experiencing infertility before seeking initial consultation; education level and profession. These results are consistent with the results of other studies where the patient individual-level characteristics comprised the most identified barriers to accessing [31,32].

Indeed, in our study almost half infertile women who had undergone infertility services were over 35 years old that can be explained by the fear of not achieving the parental objective given that the ability to reproduce is closely associated with age, particularly in women. The age of the woman is a crucial factor in predicting treatment success in ART, for women who were 44 or older, the live birth per embryo transfer was 1.7% [33]. In other side women who are under 35 years old of age were less likely to underwent ART, therefore they need to be sensitized on the issue of fertility notably the biological clock, given that ART is not a panacea, it is conditioned by several factors for its success. This situation becomes more complicated when combined with the duration of infertility in couples. The Hung study confirmed this, stating that when the duration of infertility was more than 5 years, the clinical pregnancy rate of women younger than 35 years old decreased with the increase of infertility duration [34]. Indeed, our multivariate analysis showed that a duration of infertility over 10 years was correlated positively with ART utilization. However, the relationship between duration of infertility and access to ART has not been extensively explored in other studies. In contrast the connection between duration of infertility and ART success was investigated, for example the number of motile spermatozoa and women age are factors with the highest impact on pregnancy after IUI treatment in women with infertility for over 10 years [35], moreover the incidence of IVF decreased for women who had infertility that was greater than 4.8 years [36] and when the duration of infertility was more than 5 years, the clinical pregnancy rate decreased with the increase of infertility duration [34]. What has already been reported by a preliminary systematic review and meta-analysis suggesting that extending the duration of infertility reduces the chances of obtaining a pregnancy in IVF [37].

The length of time experiencing infertility before seeking initial consultation initial consultation was significantly associated with access to ART care which is inconsistent with the data of others studies, which report that women’s timing of their initial presentation to gynaecologists were not found to be barriers to timely access to infertility care [16].

Finaly, concerning psychosocial factors, the psychological status and effects on the patient were shown to act as a barrier to both initiating and continuing ART [6], barriers to quality fertility care include social stigmas [31], psychological stress and anxiety about pregnancy outcome [33]. In our study women seeking infertility treatment face social pressure and experienced stigma, guilt and pity. Also, nearly half faced marital tensions, and one-quarter had a fear of divorce. Data from other studies state that women suffer from guilt, intimate partner violence, fear of divorce, divorce and abandonment of the partner, a husband’s second marriage, social stigma, family pressure for a male child, emotional stress, depression, anxiety and low self-esteem [38]. Infertility had also a negative effect on the marital relationships of the infertile persons who attended the public health facility such as the sexual life, communication in the marital relationships as well as the psychological well-being of the participants was strained as a consequence of infertility [39].

Besides, almost half of the sample reported that they did not receive any psychological support from the nurses during their care pathway and around a third were dissatisfied with the management, while delays to initial consultation and treatment for infertile couple were significantly associated with reported supportive service offerings by healthcare professionals [10]. In a systematic review common barriers that influence treatment seeking for infertility were low or no social support supporting treatment seeking and negative perceptions of the clinical environment, while high social support encouraging treatment was among facilitators [8].

In conclusion, the WHO recognized infertility as a disease and emphasized universal access to high-quality prevention, diagnosis and treatment of infertility as a fundamental component of reproductive health. Addressing infertility is important for achieving the health equality targets of the 2030 Sustainable Development Goals. This study has demonstrated that in Morocco, infertile women confront economic barriers, social pressure, and constraints related to health systems. Women over the age of 35 with the duration of infertility exceeding 10 years are struggling to access ART due to these barriers. Indeed, the social pressure related to infertility often compels infertile women to seek infertility treatment despite multidimensional barriers of accessing care, notably high ART cost and funding. More than half of the women were unable to follow an ART protocol, and those who started the treatment had benefited from IUI in most cases.

Likewise, to other barrier is important to take into account age an important factor to the realization of parental projects, given that the biological clock represents a major challenge for women, which becomes more intricate when the duration of infertility is extended. Indeed, an anarchic recourse to these ART procedures reduces the efficiency of care and complicates the history of infertility.

In light of this analysis, policy-makers must to take into account these barriers and factors to ensure efficient access to ART. This means the right to equitable and equal access to infertility care notably the opportunity to receive quality fertility care and a chance of several attempts in a regular manner. This indicates that it is imperative to ensure an equitable distribution of healthcare services between the public and private sectors and across the different regions of Morocco, expand ART facilities in rural areas, reduce the costs of medical procedure and infertility medications, ensure a full coverage of ART expense, guarantee the ongoing training of health care professional in the area of infertility, organize educational programs for physicians and patients’ various fertility-related topic [40] and more specifically raise infertile couples’ awareness of fertility problems and the biological clock. These finding will encourage us to conduct a more in-depth study to elucidate the association between these barriers, factors and the outcomes of ART.

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