Abstract
Background. Infertility is a major reproductive health concern, and barriers to accessing and utilizing infertility treatment services may lead to significant individual and societal consequences. This study aimed to identify the barriers to accessing and utilizing infertility treatment services among infertile women and to propose policy options to address these challenges.
Methods. This policy brief was developed based on a multi-phase study employing a mixed (quantitative-qualitative) approach, which included a narrative review study of the available evidence, a descriptive cross-sectional study examining the status of infertile women referring to public and private infertility treatment centers in Tehran (n = 450), and finally, a focus group discussion study aimed at obtaining the opinions of experts in the field of infertility.
Results. The major barriers identified included financial constraints and inadequate insurance coverage, geographic accessibility limitations, challenges related to service delivery, insufficient awareness among couples, certain shortcomings in service quality, and individual and cognitive factors affecting treatment continuation. Based on these findings, four policy options were proposed: expanding insurance coverage for infertility services, developing infertility treatment centers, improving the quality of infertility care, and strengthening educational and awareness-raising programs.
Conclusion. The findings of this study suggest that treatment costs and inadequate financial support are among the most significant barriers to accessing and utilizing infertility treatment services among infertile women in Tehran. Policy interventions focusing on enhanced insurance coverage, improved geographic access, better quality of care, and increased awareness may help reduce these barriers and improve the utilization of infertility services.
Research Insights
· Infertility is one of the important issues in reproductive health, and barriers to access to and utilization of treatment services can have considerable individual and social consequences.
· Sufficient evidence was lacking regarding the barriers to access to and utilization of infertility treatment services by infertile women, as well as effective policy options for addressing them.
· This study, employing a mixed-methods approach, identified the main barriers (financial, insurance-related, geographical, service quality, awareness, and individual factors) and presented four policy options to address them.
· By documenting the identified barriers and providing specific policy recommendations, this article filled the scientific gap at the level of problem recognition and solution provision, although it did not assess the effectiveness of the implementation of these policies.
Extended Abstract
Background
Infertility has become an increasingly significant public health issue in Iran, with notable demographic implications. Recent population trends indicate a declining fertility rate alongside a growing proportion of elderly citizens, raising serious concerns among policymakers. In response, national and international policy documents such as Iran's 2014 General Population Policies and the sustainable development goals (SDGs) emphasize equitable access to infertility treatment as a key component of reproductive health and demographic sustainability. Despite Iran's scientific and technological advances in assisted reproductive technologies (ARTs) and its recognized regional leadership in infertility treatment, many infertile couples continue to face barriers to accessing and utilizing these services. This policy brief, derived from a multi-phase mixed-methods study conducted in Tehran, aimed to identify barriers to access and utilization of infertility treatment services among infertile women and to propose evidence-informed policy options to improve service equity and coverage.
Methods
This policy brief was developed based on a multi-phase study employing a mixed (quantitative-qualitative) approach conducted in Tehran, Iran, between 2022 and 2023. The keywords included the following: infertility, barriers to healthcare access, service utilization, health policy stratifies, effective interventions and related combinations. The inclusion criteria comprised studies published from 2000 onward in Persian or English that investigated barriers to accessing, utilizing, or continuing infertility treatment, as well as relevant strategies to address these barriers. The exclusion criteria also included purely clinical studies without reference to access barriers, animal or laboratory studies, articles lacking full text or available only as abstracts, studies with irrelevant target populations.
In the first phase, evidence on access to and utilization of infertility treatment services was reviewed through searches of PubMed, Scopus, Web of Science, Semantic Scholar, and relevant national documents.
In the second phase, a descriptive-analytical study was conducted among 450 infertile women attending public and private infertility treatment centers in Tehran. Eligible participants were Iranian, Persian-speaking women with a confirmed diagnosis of primary or secondary infertility who had been married for at least one year and had undergone infertility treatment for a minimum of six months. Women who declined further participation or submitted incomplete questionnaires were excluded. Data were collected through structured interviews using a questionnaire assessing six dimensions of access (affordability, geographic accessibility, accommodation, awareness, availability, and acceptability) and three dimensions of utilization (personal and cognitive factors, service quality, and interpersonal communication). Data were analyzed in SPSS version 26 using descriptive statistics and Spearman's correlation test.
In the third phase, the perspectives of 20 experts—including health policymakers (n = 4), infertility specialists (n = 6), healthcare managers (n = 5), psychologists ( n = 2) and health economists (n = 3) were obtained through four expert panel discussions to inform the development of policy recommendations.
Results
Financial barriers emerged as the most critical constraint to access and utilization. Out-of-pocket expenditure accounted for an average of 84% of treatment costs, while insurance coverage accounted for only 16%. Many participants reported difficulty affording medications, travel, and accommodation, particularly those residing outside Tehran. Geographic barriers included the limited distribution of infertility centers, long travel times, and inadequate public transportation. Organizational barriers such as complex referral pathways, long waiting times, and limited clinic hours further restricted access. Inadequate awareness of available services, insufficient patient education, and poor communication with healthcare providers were also identified as major challenges. In addition, personal and psychosocial factors including stigma, emotional distress, and lack of family support adversely affected treatment adherence and continuity.
Policy Options
Four main policy options were proposed to address these barriers:
1. Expanding insurance coverage for infertility diagnosis and treatment to reduce out-of-pocket expenditures and improve equity of access.
2. Developing and decentralizing infertility centers across provinces to improve geographic accessibility and relieve pressure on referral facilities.
3. Enhancing service quality through improved clinical standards, staff training, and patient-centered communication.
4. Increasing public awareness and education about infertility causes, treatment options, and available services through targeted media and community-based programs.
Conclusion
High treatment costs and inadequate insurance coverage remain the primary obstacles preventing infertile women from accessing and benefiting from infertility care in Iran. Coordinated policies involving the Ministry of Health, insurance organizations, and the private sector can significantly reduce these disparities. Strengthening financial protection, expanding service networks, improving quality of care, and promoting awareness will collectively help overcome access barriers, support national population policies, and advance reproductive health equity.
Practical Implications of Research
The findings of this study can inform the development and implementation of evidence-based interventions to improve access to and utilization of infertility treatment services among infertile women. The results highlight the need for policymakers and health system managers to prioritize strengthening financial protection mechanisms and expanding insurance coverage for infertility care. In addition, the equitable expansion of infertility treatment centers, improved service quality, streamlined service delivery processes, and targeted educational and awareness-raising programs for infertile couples may help reduce existing barriers. Incorporating these findings into policy and decision-making processes could enhance equity in reproductive health and improve the responsiveness of the health system to the needs of infertile couples.