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Research Article
Revised

Knowledge, attitudes, and practices regarding male infertility: A cross-sectional study among infertile couples visiting fertility clinics in Indonesia’s urban areas

[version 2; peer review: 1 approved]
Yusuf Mushlih1, Imam Adli1, Leo Alfath Araysi1, [...] Kemal Akbar Suryoadji1, Rinaldo Indra Rachman
https://orcid.org/0000-0003-4666-805X
2,3, Ghifari Nurullah3, Roberto Bagaskara Indy Christanto
https://orcid.org/0000-0002-5980-0657
1,3, Missy Savira
https://orcid.org/0000-0002-3492-432X
1-3, Rupin Shah2,4, Ashok Agarwal2,5, Indah Suci Widyahening
https://orcid.org/0000-0002-7952-2893
6, Gita Pratama
https://orcid.org/0000-0001-5626-1283
7, Gede Wirya Kusuma Duarsa2,8, Ricky Adriansjah
https://orcid.org/0000-0002-9733-3092
2,9, Dyandra Parikesit
https://orcid.org/0000-0001-5779-2713
2,10, Widi Atmoko
https://orcid.org/0000-0002-7793-7083
2,3,10, Nur Rasyid
https://orcid.org/0000-0003-4473-755X
2,3, Ponco Birowo2,3
Yusuf Mushlih1, Imam Adli1, [...] Leo Alfath Araysi1, Kemal Akbar Suryoadji1, Rinaldo Indra Rachman
https://orcid.org/0000-0003-4666-805X
2,3, Ghifari Nurullah3, Roberto Bagaskara Indy Christanto
https://orcid.org/0000-0002-5980-0657
1,3, Missy Savira
https://orcid.org/0000-0002-3492-432X
1-3, Rupin Shah2,4, Ashok Agarwal2,5, Indah Suci Widyahening
https://orcid.org/0000-0002-7952-2893
6, Gita Pratama
https://orcid.org/0000-0001-5626-1283
7, Gede Wirya Kusuma Duarsa2,8, Ricky Adriansjah
https://orcid.org/0000-0002-9733-3092
2,9, Dyandra Parikesit
https://orcid.org/0000-0001-5779-2713
2,10, Widi Atmoko
https://orcid.org/0000-0002-7793-7083
2,3,10, Nur Rasyid
https://orcid.org/0000-0003-4473-755X
2,3, Ponco Birowo2,3
PUBLISHED 21 Jul 2025
Author details Author details
OPEN PEER REVIEW
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Abstract

Background:

In many countries, the stereotype that women are to blame for infertility in relationships remains prevalent, even though approximately half of the cases are caused by male factors. This study aimed to determine the knowledge, attitudes, and practices of infertile couples in urban areas with regard to male infertility.

Methods:

A web-based survey was conducted among infertile couples who visited fertility clinics in three cities in Indonesia. Sociodemographic information and knowledge, attitudes, and practices regarding male infertility were obtained through self-reported questionnaires.

Results:

A total of 378 participants completed the questionnaire (201 men and 177 women); 66.9% had good knowledge, 72.5% had positive attitudes, and 70.1% had good practices related to male infertility. Knowledge moderately correlated with attitudes (r = 0.280, p = 0.016), whereas the correlation with practices was not significant (r = 0.140, p = 0.186). The correlation between attitudes and practices was moderate (r = 0.251, p = 0.031). Among all participants, 82% visited an obstetrician-gynecologist first. A total of 39.9% of fertility examinations were conducted first on the wife, 11.4% on the husband, and 48.7% on both.

Conclusion:

Most participants in our study at fertility clinics in urban areas visited an obstetrician-gynecologist first rather than a urologist, despite having good knowledge, attitudes, and practices regarding male infertility.

Keywords

male infertility, infertile couples, infertility knowledge, fertility, stigma, misperception

Corresponding author: Ponco Birowo
Competing interests: No competing interests were disclosed.
Grant information: This work was supported by Hibah PUTI 2022 Universitas Indonesia (NKB-428/UN2.RST/HKP.05.00/2022; to PB). The funder did not participate in designing the study, data extraction, analysis, or manuscript writing.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Copyright:  © 2025 Mushlih Y et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Mushlih Y, Adli I, Araysi LA et al. Knowledge, attitudes, and practices regarding male infertility: A cross-sectional study among infertile couples visiting fertility clinics in Indonesia’s urban areas [version 2; peer review: 1 approved]. F1000Research 2025, 12:1334 (https://doi.org/10.12688/f1000research.136305.2) First published: 16 Oct 2023, 12:1334 (https://doi.org/10.12688/f1000research.136305.1) Latest published: 21 Jul 2025, 12:1334 (https://doi.org/10.12688/f1000research.136305.2)

Revised Amendments from Version 1

We've added more discussion about the stigma of women being blamed for infertility and the lack of attention given to male infertility in paragraphs 4–6. We also revised our abstract based on feedback from peer review. Additionally, we revised some of our references and added English translations for our Indonesian references.

To read any peer review reports and author responses for this article, follow the "read" links in the Open Peer Review table.

Introduction

Infertility is defined as the absence of pregnancy for one year or more after regular unprotected sexual intercourse.1 Male infertility is a common health concern globally. It affects 15% of couples worldwide.2 About 40–50% of infertility cases are caused by male factor infertility.3 One in eight couples encounter problems attempting to conceive their first child, and one in six couples encounter difficulties trying to conceive subsequently.4 In 40–50% of infertility cases, abnormalities in the semen parameter were found.5

The stereotype that women are to blame for infertility in a relationship remains prevalent worldwide. This stigma causes many women to be depressed and self-deprecating.6 In the United States, women continue to be the focus of infertility workups even though male factors contribute to 50% of infertility cases.7 In Pakistan, women are often blamed for infertility despite the fertility status of their partner being unknown,6 because the public lacks an accurate understanding of infertility. Male infertility is not given enough attention, as evidenced by the lack of mainstream literature and media on the subject. Infertility as a social construct focuses on women because they are considered the carriers of conception and pregnancy; men are considered secondary participants.8 A survey conducted in Indonesia revealed that 93.4% of participants living in an urban area (Jakarta) indicated both the husband and wife should be evaluated for infertility, whereas only 55.4% of participants living in a rural are (East Sumba) indicated both husband and wife should be evaluated.9

A lack of knowledge about what can contribute to infertility can lead to incorrect perceptions of male infertility, which could have an effect on clinical presentations at the first clinic visit. The Andrology Research Consortium recently conducted a North American survey on the characteristics of 4335 men seeking an infertility consultation. The average age of men seeking consultation was 37, and 74% had no previous male fertility evaluation. Interestingly, 6% of couples underwent intrauterine insemination (IUI), and 10.9% of couples underwent in vitro fertilization (IVF) before evaluation for possible male factor infertility.10

Among infertile males who presented at an andro-urology clinic in an urban hospital, 53% exhibited azoospermia.11 In contrast, the European Association of Urology guidelines indicated that approximately 10% of male infertile patients were diagnosed with azoospermia.12 This difference in percentages suggests the possibility of misdiagnosis and that non-azoospermic causes may have been underdiagnosed, which could result in undertreated cases. Male patients with a more severe spectrum of infertility may require surgical sperm retrieval and assisted reproductive technology (ART) to obtain offspring. These are expensive procedures, and the success rate varies between 21.6% and 94%.13

Few studies have examined the knowledge, attitudes, and practices of married couples in Indonesia regarding male infertility. Societal and cultural norms and attitudes, and medical treatment and stereotypes regarding male infertility, can affect help-seeking and the treatment couples receive. In this regard, the aim of the present study was to determine the knowledge, attitudes, and practices regarding male infertility in infertile couples in urban areas of Indonesia.

Methods

Ethical considerations

Ethical approval was obtained from the Health Research Ethics Committee, Faculty of Medicine, Universitas Indonesia and Cipto Mangunkusumo National General Hospital (40/UN2.F1/ETIK/PPM.00.02/2022) on January 17th, 2022. Informed consent was obtained from the participants through an online informed consent form before completing the questionnaire.

Study design and sampling

This cross-sectional study was conducted in Indonesia with couples who visited fertility clinics in Jakarta, Bandung in West Java, and Denpasar in Bali between May and August 2022. Participants were recruited using a consecutive sampling technique, and all data were collected using a self-reported questionnaire through Google Forms. The sample size of 375 participants was determined using a Raosoft sample size calculator with a 5% margin of error, a 95% confidence interval, and a response distribution of 50%. The questionnaire was completed voluntarily and anonymously. The inclusion criteria were heterosexual couples who could not conceive after one year of unprotected sexual intercourse, visited a fertility clinic, and indicated their consent to participate in this study. The exclusion criteria were those with low cognitive function and those who did not understand Indonesian or English. The participants provided written informed consent to participate in the study. To avoid duplicate data, participants were asked whether they had already participated in the study. Participants’ personal data (including full name, email address, and telephone number) were not recorded so as to maintain confidentiality. The study was conducted and reported based on STROBE guidelines for cross-sectional studies.

Measurement tool and data management

The questionnaire was developed through a literature search and previously validated questionnaire,9,14–16 which was modified and translated into Indonesian (backward and forward translation) by three of the authors. Validity was assessed in two stages: face validity and a pilot test. Face validity was assessed by two experts to determine the adequacy and appropriateness of the questionnaire. A pilot study was conducted with 30 participants to improve item comprehension and assess validity. Cronbach's alpha test was conducted on the variables of knowledge, attitude, and behavior, resulting in values of 0.607 for knowledge, 0.669 for attitude, and 0.774 for behavior. No changes were made to the questionnaire after conducting the pilot survey.

The questionnaire was divided into four parts: (1) sociodemographic characteristics, (2) knowledge of male infertility, (3) attitudes toward male infertility, and (4) practices regarding male infertility. Sociodemographic data included gender, age, education, monthly income, health insurance, first clinic visited to treat infertility, first to be tested for infertility, and history of IVF. Gender on the survey exclusively denote the biological sex assigned at birth. The participants' sex was determined based on self-reported information provided in the questionnaire. Participants’ ages were grouped into two categories, ≥ 35 years and < 35 years, based on the effect of age on male and female infertility.17,18 Education was classified into middle school, high school, and higher education (academic, diploma, and vocational degrees). Education and occupation were categorized according to the Central Bureau of Statistics of Indonesia (BPS) classification.19 Monthly income was divided into three categories: low (<Rp 5 million), middle (Rp 5–10 million), and high (>Rp 10 million).20 Health insurance was divided into four categories: no insurance, national health insurance, private insurance, and national and private insurance.

All study questions were required to be answered before the questionnaire could be submitted to reduce the potential for missing or incomplete data. Participants’ knowledge was assessed using 14 questions regarding the risk factors for male infertility. Responses included “true” or “false.” Each question had a score of zero or one point, with a total possible score of 14. Participants’ attitudes were assessed using 21 questions that included their views on the effects of male infertility, treatment, quality of life, and divorce. The attitude assessment used a five-point Likert scale ranging from “strongly agree” to “strongly disagree”, with a maximum score of 105 points. Ten questions were used to assess practices. The questions were divided into two sections: six about the husbands’ practices and four about the couples’ practices related to male infertility. Questions included drug usage, smoking, alcohol cessation, lifestyle changes, first clinic visit, IVF history, and whether the couple had ever adopted a child. We used only the men’s practices section for scoring. Each question had a score of zero or one point, with a total possible score of 6 points for men’s practices. Any mention of the word “practices” in this study referred to the men.

Data analysis

Data storage and processing were done using MS Excel® for Office 365 MSO ver. 2018 (Microsoft Corporation, Redmond, WA, 2018), and data analysis was conducted using SPSS 25.0 (IBM, Armonk, NY). Analysis was conducted by taking into account factors that can affect the level of knowledge, attitudes, and practices. Demographic data were calculated in a tabular form as frequency and percentage. Subsequently, the data were subjected to a bivariate analysis based on the measurement scale and assessed variables.

Participants’ knowledge, attitudes, and practice levels were classified as poor, moderate, and good using Bloom’s cutoff ratio (<60% = poor, 60–79% = moderate, 80–100% = good);21 a “good” score indicated adequate knowledge, positive attitudes, and good practices. The Goodman-Kruskal gamma bivariate correlation test was used to determine the correlation between knowledge, attitudes, and practices. Logistic regression analysis was used to examine the relationships between sociodemographic factors (gender, age, education, income, occupation, and health insurance) and knowledge, attitudes, and practices. Correlations (r-values) were assessed based on the 1992 Rea and Parker classification, and a p-value < 0.05 indicated statistical significance.22

Results

Sociodemographic data

The characteristics of the participants are summarized in Table 1. Of the 378 participants, 201 (53.2%) were male. Most participants were over 35 years of age (70.9%). Approximately 91% had a higher level of education. The highest proportion of participants had an occupation in the private sector (37.3%), with the most significant proportion having a monthly income of more than 10 million rupiah (45.2%), or approximately 666 USD (1 USD = Rp 15,000). In addition, most of the participants had national health insurance (BPJS [Badan Penyelenggara Jaminan Sosial/Social Security Administrator for Health]).

Table 1. Characteristics of the participants (N = 378).

Characteristic n (%)
Gender
 Male201 (53.2)
 Female177 (46.8)
Age group
 ≥35 years268 (70.9)
 <35 years110 (29.1)
Education level
 Middle school2 (0.5)
 High school33 (8.7)
 Higher education343 (90.7)
Occupation
 Private sector employee141 (37.3)
 Civil servant/armed forces/policeman/employee at a state-owned enterprise106 (28)
 Entrepreneur53 (14.0)
 Other46 (12.2)
 Unemployed25 (6.6)
 Student6 (1.6)
 Laborer/driver/housemaid1 (0.3)
Monthly income
 <5 million rupiah72 (19.0)
 5–10 million rupiah135 (35.7)
 >10 million rupiah171 (45.2)
Health insurance
 National health insurance (BPJS)146 (38.6)
 Private health insurance56 (14.8)
 Both BPJS and private health insurance149 (39.4)
 Do not have health insurance27 (7.1)

Male infertility-related knowledge, attitudes, and practices of couples visiting fertility clinics

The adequacy of knowledge of male infertility was between 55.8% and 97.1% for each question, as shown in Table 2. More than 80% of the participants knew that hormonal imbalance, smoking, excessive alcohol consumption, psychological stress, and recreational drugs were relevant to male infertility; however, age, high temperature, and urinary tract infections were less known. We found no significant differences between men and women in the statements regarding knowledge of male infertility.

Table 2. Summary of male infertility knowledge of couples visiting fertility clinics (N = 378).

StatementAdequate knowledge
Total n (%)Men n (%)Women n (%)
History of urinary tract infection is related to male infertility271 (71.7)156 (77.6)115 (65.0)
Hormonal imbalance is related to male infertility367 (97.1)197 (98.0)170 (96.0)
Constant high temperature around the male genitalia is related to male infertility279 (73.8)149 (74.1)130 (73.4)
History of sexually transmitted diseases is related to male infertility350 (92.6)182 (90.5)168 (94.9)
Age is related to male infertility211 (55.8)121 (60.2)90 (50.8)
Smoking is related to male infertility331 (87.6)176 (87.6)155 (87.6)
Excessive alcohol consumption is related to male infertility343 (90.7)179 (89.1)164 (92.7)
Obesity is related to male infertility347 (91.8)181 (90.0)166 (93.8)
Chronic diseases (diabetes, hypertension, and cardiovascular diseases) are related to male infertility326 (86.2)173 (86.1)207 (68.8)
Psychological stress and mental disorders are related to male infertility332 (87.8)177 (88.1)155 (87.6)
History of recreational drug use is related to male infertility345 (91.3)182 (90.5)163 (92.1)
Supernatural causes are related to male infertility342 (90.5)276 (87.6)166 (93.8)
Black magic is related to male infertility350 (92.6)175 (87.1)175 (98.9)
Regular exercise is related to male infertility349 (92.3)185 (92)264 (92.7)

Responses indicative of positive attitudes toward male infertility varied between 12.2% and 96.3% as shown in Table 3. Among the items, infertility as a disability was the least endorsed attitude (12.2%). Less than half of the participants (45%) agreed that male infertility was a disease. However, most participants agreed that couples experiencing infertility needed to be treated and were given treatment (96.3%). There were no significant differences between men and women regarding attitudes toward male infertility.

Table 3. Summary of attitudes toward male infertility of couples visiting fertility clinics (N = 378).

ItemPositive attitudes
Total n (%)Men n (%)Women n (%)
Male infertility is a disease170 (45.0)94 (46.8)76 (42.9)
Couples experiencing infertility need to be treated and given treatment364 (96.3)193 (96)171 (96.6)
Male infertility can be cured339 (89.7)178 (88.6)161 (91.0)
Male infertility is a serious medical problem265 (70.1)143 (71.1)122 (68.9)
Treatment of infertility in men is dangerous297 (78.6)151 (75.1)146 (82.5)
Infertility in men should be treated medically359 (95)188 (93.5)171 (96.6)
If a couple has had a child once, it will be more difficult for the couple to have another child326 (86.2)172 (85.6)154 (87.0)
The ability to have children is greatly affected by health358 (94.7)191 (95.0)167 (94.4)
The ability to have children is greatly affected by the partner’s health347 (91.8)182 (90.5)165 (93.2)
Infertility can reduce my quality of life178 (47.1)104 (51.7)74 (51.8)
Having children is the right of every human being332 (87.8)177 (88.1)155 (87.6)
The community is responsible for helping couples who do not have children137 (36.2)84 (41.8)53 (29.9)
Infertility is a disability46 (12.2)36 (17.9)10 (5.6)
The wife should be the first to check for infertility in infertile couples187 (49.5)92 (45.8)95 (53.7)
The husband should be the first to be checked for infertility in infertile couples176 (46.6)84 (41.8)92 (52.0)
In infertile couples, the husband and wife must simultaneously check for infertility.362 (95.8)188 (93.5)174 (98.3)
The wife’s inability to have children/infertility is a valid reason for divorce.341 (90.2)176 (87.6)165 (93.2)
The wife’s inability to have children/infertility is a valid reason for husbands to remarry/have a second wife.330 (87.3)167 (83.1)163 (92.1)
The husband’s inability to have children/infertility is a valid reason for divorce.341 (90.2)175 (87.1)166 (93.8)
Women are more often to cause infertility in couples than men.338 (89.4)174 (86.6)164 (92.7)
Men are more likely to cause infertility in couples than women.333 (88.1)172 (85.6)161 (91.0)

Many male participants tried to quit smoking (89.2%) or drinking alcohol (94.7%) to have children ( Table 4). In addition, most men had a healthy lifestyle, including nutritious food consumption (86.8%). More than half of the men (58.5%) had not tried traditional or alternative medicine. Most men tried to change their lifestyle to be healthier and have children (89.7%).

Table 4. Summary of husband’s male infertility practices in couples visiting fertility clinics (N = 378).

ItemGood practices n (%)
Not use traditional/alternative medicine221 (58.5)
No/quit smoking337 (89.2)
No/quit drinking alcohol358 (94.7)
Adequate consumption of nutritious foods328 (86.8)
Adopted healthier lifestyle339 (89.7)
No using drugs without prescription268 (70.9)

Table 5 shows that approximately 82% of participants visited an obstetrician-gynecologist before visiting a urologist. Approximately 48% of participants underwent fertility checks simultaneously with their partner. Most participants had a history of IVF (67%) and no history of child adoption (96.6%).

Table 5. Practices of couples visiting fertility clinics regarding infertility (N = 378).

Item (couple’s practices)n (%)
The first physician visited to treat infertility
 Obstetrician-gynecologist 310 (82.0)
 Urologist68 (18.0)
The first to be tested for infertility
 Husband43 (11.4)
 Wife151 (39.9)
 Together184 (48.7)
History of in-vitro fertilization
 Yes124 (67.2)
 No254 (32.8)
History of child adoption
 Yes13 (3.4)
 No365 (96.6)

The results on level of insight into the knowledge, attitudes, and (men’s) practices are presented in Table 6. Scores were divided into good, moderate, and poor categories, with a “good” score indicating adequate knowledge, positive attitudes, and good practices. The results indicated that the majority of the participants had good knowledge (66.9%), attitudes (72.5%), and practices (70.1%) regarding male infertility.

Table 6. Level of insight regarding male infertility (N = 378).

ItemLevel of insight
Poor n (%)Moderate n (%)Good n (%)
Knowledge17 (4.5)108 (28.6)253 (66.9)
Attitudes2 (0.5)102 (27.0)274 (72.5)
Husband’s practices34 (9.0)79 (20.9)265 (70.1)

Table 7 shows that moderate correlations were observed between knowledge and attitudes (r = 0.280, p = 0.016), and attitudes and practices (r = 0.251, p = 0.031). No significant correlation was found between knowledge and practices.

Table 7. Correlations between knowledge, attitudes, and practices of couples visiting fertility clinics.

Relationshipr-value p
Knowledge and attitudes0.2800.016
Knowledge and husband’s practices0.1400.186
Attitudes and husband’s practices0.2510.031

The logistic regression analysis on the relationship between the sociodemographic factors and knowledge, attitudes, and practices is presented in Table 8. The primary factor significantly associated with good knowledge was a monthly income of ≥ 10 million rupiah (OR = 1.93, 95% CI = 1.21–3.06). In addition, the higher-income groups had more positive attitudes (OR = 1.611, 95% CI = 0.99–2.63), and a higher level of education was associated with better practices compared to a lower level of education (OR = 1.91, 95% CI = 0.92–3.98).

Table 8. Associations between sociodemographic factors and knowledge, attitudes, and practices toward male infertility using logistic regression.

Characteristicn (%)“Good” level of
KnowledgeAttitudesHusband practices
OR (95% CI) p OR (95% CI) p OR (95% CI) p
Gender
 Male201 (53.2)0.91 (0.58–1.42)0.670.79 (0.49– 1.27)0.330.72 (0.45–1.14)0.16
 Female†177 (46.8)
Age group
 ≥35 Years268 (70.9)0.89 (0.54–1.45)0.630.97 (0.57–1.62)0.891.18 (0.70–1.95)0.53
 <35†110 (29.1)
Education level
 Higher education343 (90.7)0.72 (0.33–1.58)0.421.74 (0.83–3.66)0.141.91 (0.92–3.98)0.08
 Lower education†35 (9.2)
Monthly income
 ≥10 million rupiah171 (45.3)1.93 (1.21–3.06)0.011.61 (0.99–2.63)0.0561.14 (0.714–1.83)0.58
 <10 million rupiah†207 (54.7)
Health insurance
 Have health insurance351 (92.9)0.61 (0.24–1.51)0.280.70 (0.27–1.80)0.451.21 (0.52–2.82)0.65
 Do not have health insurance†27 (7.1)

† Indicates used as reference.

Discussion

The findings of this study indicated that infertile couples who visited fertility clinics in urban areas in Indonesia usually first consulted with an obstetrician-gynecologist and had good knowledge, attitudes, and practices regarding male infertility. Furthermore, a higher level of income and education was associated with better knowledge, more positive attitudes, and better practices by men related to infertility. These findings were supported by a positive correlation between knowledge and attitudes toward male infertility.

The levels of participants’ knowledge, attitudes, and practices were assessed and categorized into three groups: poor, moderate, and good. This classification was determined using Bloom’s cutoff ratio, where a score below 60% was considered poor, a score between 60% and 79% was categorized as moderate, and a score of 80% to 100% was deemed good. Bloom’s cutoff ratio is the most used and cited standard for knowledge, attitude and practice (KAP) study.21,23–25 This approach allowed for a comprehensive evaluation of the participants’ proficiency in these areas, providing insights into the varying degrees of understanding, outlook, and implementation within the studied population.

In Indonesia, few studies have examined knowledge, attitudes, and practices regarding male infertility. Several studies have explored infertility in general and female infertility; however, none have focused on measuring people’s understanding of male infertility.9,26 Furthermore, despite the fact that approximately half of infertility cases are due to male factors, women are often prioritized in discussions related to the cause, diagnosis, and treatment of the condition.6–8 About 50% of infertile male patients who visited the fertility clinic at Dr. Cipto Mangunkusumo Hospital in Jakarta had azoospermia; however, azoospermia occurs in just 10% of all infertile patients,11,12 implying many cases of male infertility may be misdiagnosed and undertreated. Additionally, the issue of male infertility and azoospermia have received increasing attention, with the findings of meta-analyses and recent studies indicating that progressive sperm and semen quality is decreasing globally.27–30 This may contribute to high rates of azoospermia as a diagnosis. To add to its urgency, a global survey on mostly childbearing-aged women of almost 17,500 participants from 10 countries revealed poor fertility and reproductive biology knowledge.31

Despite the presence of clear guidelines from the AUA, there are certain limitations in the management of male infertility.32 The true epidemiological data for male infertility in Indonesia is still unknown. Data on male infertility are limited to only a few hospitals and there is no official national registry that collects information about male infertility. Because of this, the true burden of male infertility in Indonesia remains unclear. Unfortunately, this problem is found all over the world such as in the United States.33 Another problem is that Assisted Reproductive Technology (ART) facilities, semen analysis services, and access to urologists in Indonesia remain concentrated in major provinces like Jakarta, West Java, and East Java.34 Knowledge gaps about the importance of male infertility and its diagnosis is still prevalent, even among medical professionals around the globe.33,35,36 Government and health regulations, especially in Indonesia, have several policies regarding infertility, though none directly focus on male infertility.37,38 Moreover, despite the increasing prevalence, infertility problems have not yet been included in national insurance coverage.39 These issues increase our concerns about the need to measure people’s understanding of male infertility in Indonesia, especially in couples who visit fertility clinics.

The findings of this study suggest that level of education plays a significant role in having knowledge regarding male infertility, which can reduce the social stigma related to infertility, particularly in women. It is noteworthy that a vast majority (90.7%) of participants had a diploma or higher degree, suggesting that individuals with higher levels of education possess better knowledge about infertility treatment and are more likely to seek treatment at a fertility clinic. These results are consistent with those of Swift et al.40 who demonstrated a relationship between education and fertility awareness. Similarly, a study in Pakistan revealed 80% of participants with higher education tended to seek gynecologists as the primary reference for treatment.6 Lastly, we also found that higher education was a positive predictor of men’s fertility practices.

Most participants went to an obstetrician-gynecologist first (82%) rather than a urologist (18%), although almost all of the participants (95.8%) agreed that both partners should be tested for infertility simultaneously. Approximately 39.9% chose to test the wife first for infertility, while only 11.4% opted to test the husband first. These findings are surprising, considering the high level of education, adequate knowledge, positive attitudes, and good practices that characterize the sample in this study. The high percentage of participants choosing to seek help from an obstetrician-gynecologist and test the wife first suggests the reluctance for men to seek medical attention and undergo examinations to treat infertility.41–43 These findings also support the belief that women are the primary cause of infertility remains prevalent, similar to earlier findings.6–8,18 This belief may lead to women being blamed, depressed, or even subjected to violence from their partners. A meta-analysis by Sharifi et al.44 revealed that 14–88% of infertile women experienced domestic violence. Another reason that could explain these findings is the disparity of urologists relative to obstetrician-gynecologist in Indonesia, with a ratio of approximately 1:8.5. The number of urologists is also limited to around 2.4 per 1 million people, a stark contrast to developed nations like the US with 42.1 per 1 million people.34,45 Nevertheless, we can conclude that knowledge, attitudes, and men’s practices regarding male infertility did not necessarily affect a couple’s decision on which type of doctor to see or who should get examined first. Multiple factors, such as knowledge of infertility as a whole, knowledge about female infertility, lack of awareness among health care providers, and lack of access to male infertility health services, could be the catalysts for why most participants went to an obstetrician-gynecologist first. Therefore, further studies are required to compare these factors. Along these lines, education remains a powerful tool for combating infertility stigma. A study suggested that education, peer support, and self-help could be used to reduce stigma.46 The government must implement public education initiatives and policy changes related to infertility because they can increase knowledge and minimize stigma, particularly regarding male infertility and the pressure and violence experienced by women in infertile couples. Additionally, there is a need to increase and evenly distribute the number of urologists to offer patients greater access to male infertility examinations and treatment.

Most of the participants had good knowledge (66.9%), attitudes (72.5%), and practices (70.1%). This could be attributed to the study setting, an urban fertility clinic, where more than 90% of the participants had higher education and are generally more knowledgeable and aware of health problems than rural residents, especially regarding infertility.9,47 In addition, participants with higher monthly incomes showed better results, which is consistent with Almeida-Santos et al.’s48 study indicating that higher-income individuals had better knowledge of infertility. The income disparity may lead to different infertility treatment options and facilities, especially where male infertility examination and procedure can cost around three times the average Indonesian monthly income while IVF can cost up to 20 times the monthly average.49,50 An equitable distribution of health workers, health facilities, and wider national health insurance coverage must be implemented to overcome the effect of the disparity between urban and rural areas. Education on male infertility that focuses on lower-income populations should also be implemented to increase their level of knowledge.

Fertility plays a significant role in marital and sexual satisfaction. The pressure to have children, complicated pregnancy programs, and infertility treatment can negatively affect the marital relationship and sexual functioning of married couples. Although infertility could be a factor in divorce, most studies suggest that infertility is not the primary cause of divorce in married couples.51–53 Our results support this statement, with only 9.8% of participants considering divorce as a solution for their husbands’ or wives’ infertility problem, which is lower than that reported in studies from Chennai, India and Jeddah, Saudi Arabia where 64.4% and 57.6% of the participants saw divorce as a solution to infertility, respectively.14,16

The results indicated that more than half of the husbands had not used traditional or alternative medicine for the problem with fertility. This finding was surprising considering their level of education, good knowledge, and positive attitudes. However, it was in line with a previous study in Pakistan in which 28% of the participants sought alternative treatment for infertility as their first choice, and 75% sought it as their second choice.6 The common reasons for utilizing alternative medicine are dissatisfaction with conventional medicine, favorable past experiences, and belief in the advantages of alternative medicine.54 Commonly used herbal medicines in Indonesia, such as bee pollen, royal jelly, cinnamon, and ginger, have limited or inconclusive evidence in treating infertility.54–59 This could lead to the misuse of herbal remedies and pose a danger to the patient.

The results of this study indicated a moderate correlation between knowledge and attitudes, as well as attitudes and practices regarding male infertility. No significant correlation was found between knowledge and practices. It is possible that confounding variables, such as cultural and economic differences among participants, could restrict the strength of the relationship. No previous studies have demonstrated a direct correlation among knowledge, attitudes, and practices related to male infertility. However, a systematic review60 revealed that awareness of male infertility was related to education level. This awareness can be explained from the observation that individuals with a high level of education are more likely to have general knowledge of male infertility and informed attitudes toward infertility conditions in men. These findings further reinforce our statement that individuals who have a low level of education are most in need of interventions to increase knowledge and raise awareness about infertility and reduce social stigma around infertility. It is suggested that teaching the public about male infertility has the potential to positively impact attitudes and practices related to infertility within the community, including among couples who seek treatment at clinics for infertility issues.

This study has several strengths and limitations. First, there was limited sample size and an imbalance in the number of participants based on sampling location. The majority of the participants were from Jakarta (over three-quarters of the participants), and those from Bandung accounted for less than 5%. Consequently, this limits the generalizability of our results and makes subgroup analysis impossible. Further research must assess the knowledge, attitudes, and practices regarding male infertility in larger, more diverse Indonesian populations. Second, this research was conducted in urban areas and included only clinically infertile couples. However, other studies have demonstrated differences in knowledge and attitudes toward infertility between urban and rural populations,9 and the insights of the general population could not be assessed. Third, this study did not explore the psychological aspects of male infertility, as multiple studies have revealed a connection between male infertility and mental disorders.61,62 Moreover, additional uncontrolled confounding variables could have affected our results.

Nevertheless, a strength of this study is that it is the first to evaluate knowledge, attitudes, and practices regarding male infertility in urban couples in Indonesia. Consequently, it offers a knowledge base and reference for institutions, clinicians, and policymakers to develop effective strategies to address male infertility. In addition, it raises public awareness about male infertility and reduces the negative stigma associated with female infertility.

Conclusion

Our study revealed that most participants at fertility clinics in urban areas visited an obstetrician-gynecologist first rather than a urologist, despite having good knowledge, attitudes, and practices regarding male infertility. In addition, we found that having knowledge about male infertility was associated with positive attitudes, and that positive attitudes related to the husband’s practices regarding male infertility. However, the results suggest that social stigma about infertility may (still) exist, especially for women. Health education on reproduction and further public health efforts regarding infertility that focus on low-income populations need to be implemented by the government to reduce the negative stigma and misperceptions about infertility.

Data availability

Underlying data

Open Science Framework: DATA - Knowledge, Attitudes, and Practices Regarding Male Infertility; A Cross-Sectional Study Among Infertile Couples Visiting Fertility Clinics in Indonesia’s Urban Areas. https://doi.org/10.17605/OSF.IO/AS6Y3.63

This project contains the de-identified underlying data of the survey (Raw Data – Knowledge Attitudes and Practice Regarding Male Infertility.xlsx).

Extended data

Open Science Framework: DATA - Knowledge, Attitudes, and Practices Regarding Male Infertility; A Cross-Sectional Study Among Infertile Couples Visiting Fertility Clinics in Indonesia’s Urban Areas. https://doi.org/10.17605/OSF.IO/AS6Y3.63

This project contains the following extended data:

  • - STROBE checklist

  • - Blank questionnaire

  • - Descriptive table

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

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Mushlih Y, Adli I, Araysi LA et al. Knowledge, attitudes, and practices regarding male infertility: A cross-sectional study among infertile couples visiting fertility clinics in Indonesia’s urban areas [version 2; peer review: 1 approved]. F1000Research 2025, 12:1334 (https://doi.org/10.12688/f1000research.136305.2)
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Hong-Jun Li, Department of Urology, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China 
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https://doi.org/10.5256/f1000research.185199.r399672
The authors have revised the paper carefully. In my opinion, the research (even though simple and incomplete) was important and meaningful. Many original information concerning male infertility was collected and discussed from the local infertile couples. I have no other ... Continue reading
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Li HJ. Reviewer Report For: Knowledge, attitudes, and practices regarding male infertility: A cross-sectional study among infertile couples visiting fertility clinics in Indonesia’s urban areas [version 2; peer review: 1 approved]. F1000Research 2025, 12:1334 (https://doi.org/10.5256/f1000research.185199.r399672)
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Hong-Jun Li, Department of Urology, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China 
Approved with Reservations
VIEWS 57
https://doi.org/10.5256/f1000research.149442.r216784
This article aims to determine the knowledge, attitudes, and practices of infertile couples by a web-based survey in urban areas regarding male infertility through self-reported questionnaires. The authors found that most participants in their study at fertility clinics in urban ... Continue reading
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Li HJ. Reviewer Report For: Knowledge, attitudes, and practices regarding male infertility: A cross-sectional study among infertile couples visiting fertility clinics in Indonesia’s urban areas [version 2; peer review: 1 approved]. F1000Research 2025, 12:1334 (https://doi.org/10.5256/f1000research.149442.r216784)
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