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.